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Question 1
Correct
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A 42 year old man presents with end stage renal failure and is prepared to receive a kidney from his best friend. HLA testing showed that they are not a 100% match and he is given immunosuppressant therapy for this. Three months later when his renal function is assessed, he showed signs of deteriorating renal function, with decreased renal output, proteinuria of +++ and RBCs in the urine. He was given antilymphocyte globulins and his condition reversed. During the crisis period the patient is likely to be suffering from?
Your Answer: Acute rejection
Explanation:This patients is most likely experiencing an acute rejection. It is a cell mediated attack against the organ that has been transplanted. Antigens are either presented by blood borne cells with in the graft or antigen presenting cells in the body may be presenting class I and class II molecules that have been shed by the graft. Class I will activate CD8 and class II, CD4 cells, both of which will attack the graft.
Chronic rejection is a slow process which occurs months to years after the transplant. The exact mechanism is not very well understood but it probably involves a combination of Type III and Type IV hypersensitivity directed against the foreign MHC molecules which look like self-MHC presenting a foreign antigen.
Hyperacute Transplant Rejection occurs almost immediately and is often evident while you are still in surgery. It is caused by accidental ABO Blood type mismatching of the donor and recipient which almost never happens anymore. This means the host has preformed antibodies against the donated tissue.
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This question is part of the following fields:
- Inflammation & Immunology; Renal
- Pathology
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Question 2
Incorrect
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After a severe asthma attack, a 26-year-old woman is left in a markedly hypoxic state. In which of the following organs are the arterial beds most likely to be vasoconstricted due to the hypoxia?
Your Answer: Kidney
Correct Answer: Lungs
Explanation:Hypoxic pulmonary vasoconstriction is a local response to hypoxia resulting primarily from constriction of small muscular pulmonary arteries in response to reduced alveolar oxygen tension. This unique response of pulmonary arterioles results in a local adjustment of perfusion to ventilation. This means that if a bronchiole is obstructed, the lack of oxygen causes contraction of the pulmonary vascular smooth muscle in the corresponding area, shunting blood away from the hypoxic region to better-ventilated regions. The purpose of hypoxic pulmonary vasoconstriction is to distribute blood flow regionally to increase the overall efficiency of gas exchange between air and blood.
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 3
Correct
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Leukotrienes normally function during an asthma attack and work to sustain inflammation. Which of the following enzymes would inhibit their synthesis?
Your Answer: 5-lipoxygenase
Explanation:Leukotrienes are produced from arachidonic acid with the help of the enzyme 5-lipoxygenase. This takes place in the eosinophils, mast cells, neutrophils, monocytes and basophils. They are eicosanoid lipid mediators and take part in allergic and asthmatic attacks. They are both autocrine as well as paracrine signalling molecules to regulate the body’s response and include: LTA4, LTB4, LTC4, LTD4, LTE4 and LTF4.
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This question is part of the following fields:
- Inflammation & Immunology
- Pathology
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Question 4
Correct
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A 15-day old male baby was brought to the emergency department with sweating and his lips turning blue while feeding. He was born full term. On examination, his temperature was 37.9°C, blood pressure 75/45 mmHg, pulse was 175/min, and respiratory rate was 42/min. A harsh systolic ejection murmur could be heard at the left upper sternal border. X-ray chest showed small, boot-shaped heart with decreased pulmonary vascular markings. He most likely has:
Your Answer: Tetralogy of Fallot
Explanation:The most common congenital cyanotic heart disease and the most common cause of blue baby syndrome, Tetralogy of Fallot shows four cardiac malformations occurring together. These are ventricular septal defect (VSD), pulmonary stenosis (right ventricular outflow obstruction), overriding aorta (degree of which is variable), and right ventricular hypertrophy. The primary determinant of severity of disease is the degree of pulmonary stenosis. Tetralogy of Fallot is seen in 3-6 per 10,000 births and is responsible for 5-7% congenital heart defects, with slightly higher incidence in males. It has also been associated with chromosome 22 deletions and DiGeorge syndrome. It gives rise to right-to-left shunt leading to poor oxygenation of blood. Primary symptom is low oxygen saturation in the blood with or without cyanosis at birth of within first year of life. Affected children ay develop acute severe cyanosis or ‘tet spells’ (sudden, marked increase in cyanosis, with syncope, and may result in hypoxic brain injury and death). Other symptoms include heart murmur, failure to gain weight, poor development, clubbing, dyspnoea on exertion and polycythaemia. Chest X-ray reveals characteristic coeur-en-sabot (boot-shaped) appearance of the heart. Treatment consists of immediate care for cyanotic spells and Blalock–Taussig shunt (BT shunt) followed by corrective surgery.
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This question is part of the following fields:
- Cardiovascular
- Physiology
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Question 5
Correct
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Some substances, such as Chromium-51 and Technetium-99, are freely filtered but not secreted or absorbed by the kidney. In these cases, their clearance rate is equal to:
Your Answer: Glomerular filtration rate
Explanation:If a substance passes through the glomerular membrane with perfect ease, the glomerular filtrate contains virtually the same concentration of the substance as does the plasma and if the substance is neither secreted nor reabsorbed by the tubules, all of the filtered substance continues on into the urine. Glomerular filtration rate (GFR) describes the flow rate of filtered fluid through the kidney.
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This question is part of the following fields:
- Fluids & Electrolytes
- Physiology
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Question 6
Correct
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The neurotransmitters adrenaline, noradrenaline and dopamine are derived from which amino acid?
Your Answer: Tyrosine
Explanation:Tyrosine is the precursor to adrenaline, noradrenaline and dopamine. Tyrosine hydroxylase converts tyrosine to DOPA, which is in turn converted to dopamine, then to noradrenaline and finally adrenaline.
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This question is part of the following fields:
- Endocrine
- Physiology
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Question 7
Correct
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A 54-year-old woman with amyotrophic lateral sclerosis is diagnosed with respiratory acidosis. The patient’s renal excretion of potassium would be expected to:
Your Answer: Fall, since tubular secretion of potassium is inversely coupled to acid secretion
Explanation:Respiratory acidosis is a medical emergency in which decreased ventilation (hypoventilation) increases the concentration of carbon dioxide in the blood and decreases the blood’s pH (a condition generally called acidosis). Secretion of acid and potassium by the renal tubule are inversely related. So, increased excretion of H+ during renal compensation for respiratory acidosis will result in decreased secretion (or increased retention) of potassium ions, with the result that the body’s potassium store rises. An increase in K+ excretion would be associated with renal compensation for respiratory alkalosis. The filtered load of K+depends only on K+ plasma concentration and glomerular filtration rate, not on plasma pH.
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This question is part of the following fields:
- Physiology
- Renal
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Question 8
Correct
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Abnormal breathing is noticed in a of victim of a road traffic accident, who sustained a head injury. The breathing pattern is characterised by alternate periods of waxing and waning tidal volumes with interspersed periods of apnoea. This breathing pattern is known as:
Your Answer: Cheyne–Stokes breathing
Explanation:Cheyne-Stokes breathing is an abnormal breathing pattern with breathing periods of gradually waxing and waning tidal volumes, with apnoeic periods interspersed. It is usually the first breathing pattern to be seen with a rise in intracranial pressure and is caused by failure of the respiratory centre in the brain to compensate quickly enough to changes in serum partial pressure of oxygen and carbon dioxide. The aetiology includes strokes, head injuries, brain tumours and congestive heart failure. It is also a sign of altitude sickness in normal people, a symptom of carbon monoxide poisoning or post-morphine administration. Biot’s respiration (cluster breathing) is characterized by cluster of quick, shallow inspirations followed by regular or irregular periods of apnoea. It is different from ataxic respiration, which has completely irregular breaths and pauses. It results due to damage to the medulla oblongata by any reason (stroke, uncal herniation, trauma) and is a poor prognostic indicator. Kussmaul breathing, also known as ‘air hunger’, is basically respiratory compensation for metabolic acidosis and is characterized by quick, deep and laboured breathing. It is most often seen in in diabetic ketoacidosis. Due to forced inspiratory rate, the patients will show a low p(CO2). Ondine’s curse is congenital central hypoventilation syndrome or primary alveolar hypoventilation, which can be fatal and leads to sleep apnoea. It involves an inborn failure to control breathing autonomically during sleep and in severe cases, can affect patients even while awake. It is known to occur in 1 in 200000 liveborn children. Treatment includes tracheostomies and life long mechanical ventilator support.
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 9
Correct
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Which of these conditions causes haematuria, hypertension and proteinuria in children, usually after a streptococcal infection?
Your Answer: Acute nephritic syndrome
Explanation:Nephritic syndrome (or acute nephritic syndrome) is a syndrome comprising of signs of nephritis. Children between 2 and 12 are most commonly affected, but it may occur at any age. Predisposing factors/causes include:
Infections with group A streptococcal bacteria (acute post-streptococcal glomerulonephritis).
Primary renal diseases: immunoglobulin A nephropathy, membranoproliferative glomerulonephritis, idiopathic rapidly progressive crescentic glomerulonephritis.
Secondary renal diseases: subacute bacterial endocarditis, infected ventriculo–peritoneal shunt, glomerulonephritis with visceral abscess, glomerulonephritis with bacterial, viral or parasitic infections.
Multisystem diseases.
By contrast, nephrotic syndrome is characterized by only proteins moving into the urine.
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This question is part of the following fields:
- Physiology
- Renal
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Question 10
Correct
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Which of the following variables are needed to calculate inspiratory reserve volume of a patient?
Your Answer: Tidal volume, vital capacity and expiratory reserve volume
Explanation:Vital capacity = inspiratory reserve volume + tidal volume + expiratory reserve volume. Thus, inspiratory reserve volume can be calculated if tidal volume, vital capacity and expiratory reserve volume are known.
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 11
Correct
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After finding elevated PSA levels, a 69-year-old man undergoes a needle biopsy and is diagnosed with prostatic cancer. What is the stage of this primary tumour?
Your Answer: T1c
Explanation:The AJCC uses a TNM system to stage prostatic cancer, with categories for the primary tumour, regional lymph nodes and distant metastases:
TX: cannot evaluate the primary tumour T0: no evidence of tumour
T1: tumour present, but not detectable clinically or with imaging T1a: tumour was incidentally found in less than 5% of prostate tissue resected (for other reasons)
T1b: tumour was incidentally found in more than 5% of prostate tissue resected
T1c: tumour was found in a needle biopsy performed due to an elevated serum prostate-specific antigen
T2: the tumour can be felt (palpated) on examination, but has not spread outside the prostate
T2a: the tumour is in half or less than half of one of the prostate gland’s two lobes
T2b: the tumour is in more than half of one lobe, but not both
T2c: the tumour is in both lobes
T3: the tumour has spread through the prostatic capsule (if it is only part-way through, it is still T2)
T3a: the tumour has spread through the capsule on one or both sides
T3b: the tumour has invaded one or both seminal vesicles
T4: the tumour has invaded other nearby structures.
In this case, the tumour has a T1c stage.
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This question is part of the following fields:
- Pathology
- Urology
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Question 12
Correct
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A 34-year-old woman with pelvic inflammatory disease is administered ceftriaxone. The subclass of antibiotics that ceftriaxone belongs to is:
Your Answer: Third-generation cephalosporins
Explanation:Ceftriaxone is a third-generation cephalosporin antibiotic. It has a broad spectrum of activity against Gram-positive and Gram-negative bacteria. Its indications include middle ear infections, endocarditis, meningitis, pneumonia, bone and joint infections, intra-abdominal infections, skin infections, urinary tract infections, gonorrhoea, and pelvic inflammatory disease.
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This question is part of the following fields:
- Pathology
- Pharmacology
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Question 13
Correct
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Which of the following is responsible for the maximum increase in total peripheral resistance on sympathetic stimulation?
Your Answer: Arterioles
Explanation:Arterioles are also known as the resistance vessels as they are responsible for approximately half the resistance of the entire systemic circulation. They are richly innervated by the autonomic nervous system and hence, will bring about the maximum increase in peripheral resistance on sympathetic stimulation.
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This question is part of the following fields:
- Cardiovascular
- Physiology
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Question 14
Correct
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Question 15
Correct
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QT interval in the electrocardiogram of a healthy individual is normally:
Your Answer: 0.40 s
Explanation:QT interval extends from beginning of the QRS complex till the end of he T-wave and normally lasts for 0.40 s. It is important in the diagnosis of long-QT and short-QT syndrome. The QT interval varies on the basis of heart rate and may need to be corrected.
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This question is part of the following fields:
- Cardiovascular
- Physiology
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Question 16
Correct
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A 70-year-old male who has smoked since his teens complains of progressive shortness of breath and a persistent cough. He is diagnosed with COPD. Which of the following abnormalities is most likely to be present in his pulmonary function tests?
Your Answer: Increased residual volume
Explanation:Chronic obstructive pulmonary disease (COPD) is a type of obstructive lung disease characterized by long-term poor airflow. The main symptoms include shortness of breath and cough with sputum production. The best diagnostic test for evaluating patients with suspected chronic obstructive pulmonary disease (COPD) is lung function measured with spirometry. Key spirometrical measures may be obtained with a portable office spirometer and should include forced vital capacity (FVC) and the normal forced expiratory volume in the first second of expiration (FEV1). The ratio of FEV1 to forced vital capacity (FEV1/FVC) normally exceeds 0.75. Patients with COPD typically present with obstructive airflow. Complete pulmonary function testing may show increased total lung capacity, functional residual capacity and residual volume. A substantial loss of lung surface area available for effective oxygen exchange causes diminished carbon monoxide diffusion in the lung (DLco) in patients with emphysema. Tobacco smoking is the most common cause of COPD, with factors such as air pollution and genetics playing a smaller role.
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 17
Correct
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A 65-year-old man complains of headaches, weakness, cramps, and confusion; blood tests reveal he has severe hyponatremia. The most likely cause is:
Your Answer: Severe diarrhoea or vomiting
Explanation:Hyponatraemia occurs when the sodium level in the plasma falls below 135 mmol/l. Hyponatraemia is an abnormality that can occur in isolation or, more commonly as a complication of other medical illnesses. Severe hyponatraemia may cause osmotic shift of water from the plasma into the brain cells. Typical symptoms include nausea, vomiting, headache and malaise. As the hyponatraemia worsens, confusion, diminished reflexes, convulsions, stupor or coma may occur. The cause of hyponatremia is typically classified by a person’s fluid status into low volume, normal volume, and high volume. Low volume hyponatremia can occur from diarrhoea, vomiting, diuretics, and sweating.
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This question is part of the following fields:
- Fluids & Electrolytes
- Physiology
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Question 18
Correct
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A 58-year-old woman diagnosed with deep vein thrombosis had been using warfarin for 10 days. When she presented to the doctor she had haemorrhagic bullae and necrotic lesions in her lower limbs and buttocks. Deficiency of which of the following proteins may have caused the necrotic skin lesions?
Your Answer: Protein C
Explanation:Warfarin-induced skin necrosis is a rare complication of anticoagulant therapy that requires immediate drug cessation. The most common cutaneous findings include petechiae that progress to ecchymoses and haemorrhagic bullae. Warfarin inactivates vitamin K-dependent clotting factors II, VII, IX, and X and vitamin K-dependent proteins C and S. The concentration of protein C falls more rapidly than other vitamin K-dependent factors because they have a shorter half-lives. Skin necrosis is seen mainly in patients with prior protein C deficiency.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 19
Correct
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A 23-year-old woman decides to donate a kidney through a kidney chain. Which of the following indices would be expected to be decreased in the donor after full recovery from the operation?
Your Answer: Creatinine clearance
Explanation:Since medication to prevent rejection is so effective, donors do not need to be similar to their recipient. Most donated kidneys come from deceased donors; however, the utilisation of living donors is on the rise. Most problems encountered with live donation are associated with the donor. Firstly, there are the potentially harmful investigative procedures carried out in the assessment phase, the most hazardous being renal angiography, where there is cannulation of the artery and injection of a radio-opaque dye to determine the blood supply to the kidney. Secondly, there are the short-term risks of nephrectomy surgery. According to the literature, there is a mortality rate of between 1 in 1600 and 1 in 3000, but this is no more than is associated with any anaesthetic. In the initial postoperative period creatinine clearance may be decreased but this recovers fully over a few weeks to months. Long-term complications include prolonged wound pain.
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This question is part of the following fields:
- Physiology
- Renal
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Question 20
Correct
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The bronchial circulation is a part of the circulatory system that supplies nutrients and oxygen to the pulmonary parenchyma. What percentage of cardiac output is received by bronchial circulation?
Your Answer: 2%
Explanation:The bronchial circulation is part of the systemic circulation and receives about 2% of the cardiac output from the left heart. Bronchial arteries arise from branches of the aorta, intercostal, subclavian or internal mammary arteries. The bronchial arteries supply the tracheobronchial tree with both nutrients and O2. It is complementary to the pulmonary circulation that brings deoxygenated blood to the lungs and carries oxygenated blood away from them in order to oxygenate the rest of the body.
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 21
Incorrect
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A 48-year-old man smoker presented to the doctor complaining of a persistent cough and shortness of breath. A chest X-ray indicated the presence of a right upper lung mass. Biopsy of the mass revealed the presence of pink cells with large, irregular nuclei. What is the most probable diagnosis?
Your Answer: Bronchial carcinoid
Correct Answer: Squamous cell carcinoma
Explanation:Squamous cell carcinoma, is a type of non-small cell lung cancer that accounts for approximately 30% of all lung cancers. The presence of squamous cell carcinoma is often related with a long history of smoking and the presence of persistent respiratory symptoms. Chest radiography usually shows the presence of a proximal airway lesion. Histological findings include keratinisation that takes the form of keratin pearls with pink cytoplasm and cells with large, irregular nuclei.
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This question is part of the following fields:
- Pathology
- Respiratory
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Question 22
Incorrect
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Low molecular weight heparin (LMWH) has less side effects than heparin and is used in the prophylaxis and treatment of venous and arterial thrombotic disorders. Which of the following is LMWHs mechanism of action?
Your Answer: Inhibition of antithrombin III
Correct Answer: Inhibition of factor Xa
Explanation:Low molecular weight heparin (LMWH) is a anticoagulant that differs from normal heparin in that it has only short chains of polysaccharide. LMWH inhibits thrombin formation by converting antithrombin from a slow to a rapid inactivator of coagulation factor Xa.
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This question is part of the following fields:
- Haematology
- Pathology
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Question 23
Incorrect
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Increased resistance to flow of blood in cerebral vessels is most likely seen in:
Your Answer: Epileptic seizure
Correct Answer: Elevation in systemic arterial pressure from 100 to 130 mmHg
Explanation:Constant cerebral blood flow is maintained by autoregulation in the brain, which causes an increase in local vascular resistance to offset an increase in blood pressure. There will be an increase in cerebral blood flow (and decrease in resistance to cerebral blood flow) with a decrease in arterial oxygen or an increase in arterial CO2. Similarly, a decrease in viscosity will also increase the blood flow. Due to increased brain metabolism and activity during a seizure, there will also be an increase in the cerebral blood flow.
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This question is part of the following fields:
- Cardiovascular
- Physiology
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Question 24
Incorrect
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The renal tubule is the portion of the nephron that contains the fluid that has been filtered by the glomerulus. Which of the following substances is actively secreted into the renal tubules?
Your Answer: Sodium
Correct Answer: Potassium
Explanation:The renal corpuscle filters out solutes from the blood, delivering water and small solutes to the renal tubule for modification. In normal circumstances more than 90% of the filtered load of K is reabsorbed by the proximal tubules and loops of Henlé and almost all K appearing in the urine has been secreted by the late distal tubules and collecting tubules. So the rate of excretion is usually independent of the rate of filtration, but is closely tied to the rate of secretion and control of K excretion, largely accomplished by control of the secretion rate. Around 65–70% of the filtered potassium is reabsorbed along with water in the proximal tubule and the concentration of potassium in the tubular fluid varies little from that of the plasma.
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This question is part of the following fields:
- Fluids & Electrolytes
- Physiology
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Question 25
Incorrect
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Congenital anomalies of genitourinary tract are more common than any other system. Which of the following anomalies carries the greatest risk of morbidity?
Your Answer: Unilateral renal agenesis
Correct Answer: Bladder exstrophy
Explanation:Bladder exstrophy is the condition where the urinary bladder opens from the anterior aspect suprapubically. The mucosa of the bladder is continuous with the abdominal skin and there is separation of the pubic bones. The function of the upper urinary tract remains normal usually. Treatment consists of surgical reconstruction of the bladder and returning it to the pelvis. There can be a need for continent urinary diversion along with reconstruction of the genitals.
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This question is part of the following fields:
- Pathology
- Renal
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Question 26
Correct
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Which type of thyroid tumour represents 75 - 80% of thyroid cancer cases? This type is predominant in children and in patients who have had a previous history of head or neck radiation.
Your Answer: Papillary carcinoma
Explanation:Papillary thyroid carcinoma is the most common thyroid cancer. This cancer has a high cure rate with 10-year survival rates for all patients with papillary thyroid cancer estimated at 80% to 90%.
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This question is part of the following fields:
- Neoplasia
- Pathology
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Question 27
Incorrect
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If a catheter is placed in the main pulmonary artery of a healthy 30-year-old woman, which of the following will be its mean pulmonary arterial pressure?
Your Answer: 5 mmHg
Correct Answer: 15 mmHg
Explanation:The pulmonary artery pressure (PA pressure) is a measure of the blood pressure found in the main pulmonary artery. The hydrostatic pressure of the pulmonary circulation refers to the actual pressure inside pulmonary vessels relative to atmospheric pressure. Hydrostatic (blood pressure) in the pulmonary vascular bed is low compared with that of similar systemic vessels. The mean pulmonary arterial pressure is about 15 mmHg (ranging from about 13 to 19 mmHg) and is much lower than the average systemic arterial pressure of 90 mmHg.
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 28
Incorrect
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If the blood flow is constant, oxygen extraction by tissues will show the greatest decrease due to which of the following interventions?
Your Answer: Exercise
Correct Answer: Tissue cooling
Explanation:With a constant blood flow to a given tissue bed, there will be an increase in oxygen extraction by the tissue with the following; an increase in tissue metabolism and oxygen requirements: warming (or fever), exercise, catecholamines and thyroxine. With cooling, the demand for oxygen decreases, leading to decreased oxygen extraction.
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This question is part of the following fields:
- Cardiovascular
- Physiology
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Question 29
Incorrect
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Acute respiratory distress syndrome (ARDS) is a medical condition that occurs in critically ill patients, and can be triggered by events such as trauma and sepsis. Which of the following variables is most likely to be lower than normal in a patient with ARDS?
Your Answer: Alveolar–arterial pressure difference
Correct Answer: Lung compliance
Explanation:Acute (or Adult) respiratory distress syndrome (ARDS) is a medical condition occurring in critically ill patients characterized by widespread inflammation in the lungs. The development of acute respiratory distress syndrome (ARDS) starts with damage to the alveolar epithelium and vascular endothelium, resulting in increased permeability to plasma and inflammatory cells. These cells pass into the interstitium and alveolar space, resulting in pulmonary oedema. Damage to the surfactant-producing type II cells and the presence of protein-rich fluid in the alveolar space disrupt the production and function of pulmonary surfactant, leading to micro atelectasis and impaired gas exchange. The pathophysiological consequences of lung oedema in ARDS include a decrease in lung volumes, compliance and large intrapulmonary shunts. ARDS may be seen in the setting of pneumonia, sepsis, following trauma, multiple blood transfusions, severe burns, severe pancreatitis, near-drowning, drug reactions, or inhalation injuries.
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This question is part of the following fields:
- Physiology
- Respiratory
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Question 30
Incorrect
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Chest X-ray of a 45-year old gentleman with a week history of pleurisy showed a small pneumothorax with moderate-sized pleural effusion. Arterial blood gas analysis showed p(CO2) = 23 mmHg, p(O2) = 234.5 mmHg, standard bicarbonate = 16 mmol/l. What are we most likely dealing with?
Your Answer: Compensated respiratory acidosis
Correct Answer: Compensated respiratory alkalosis
Explanation:Normal pH with low p(CO2) and low standard bicarbonate could indicate either compensated respiratory alkalosis or a compensated metabolic acidosis. However, the history of hyperventilation for 5 days (pleurisy) favours compensated respiratory alkalosis. Compensated metabolic acidosis would have been likely in a diabetic patient with fever, vomiting and high glucose (diabetic ketoacidosis).
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This question is part of the following fields:
- Physiology
- Respiratory
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SESSION STATS - PERFORMANCE PER SPECIALTY
