1 FGIVEN a Patient Is Receiving a Total of 120Mg Morphine by Mouth for Cancer Pain Each

PROGRESS TEST JUNE 1998

GENERAL

1 FGIVEN A patient is receiving a total of 120mg morphine by mouth for cancer pain each

day. He becomes unable to swallow and you decide to prescribe subcutaneous

diamorphine

QUESTION The correct dose is 60mg daily

2FIf a dying patient cannot swallow an intravenous infusion should be started

3TThe daily requirement for fluid and electrolytes of an adult weighing 70Kg is 25003000mi

of water, 150mmol of sodium and 60mmol of potassium

4TGIVEN A locum general practitioner confirms the fact of death in a patient expected to die

of cancer. The locum has never seen the patient before

QUESTION The patient's usual general practitioner is permitted to issue a Death

Certificate without seeing the body

5FA Coroner's inquest will on:y be held if death occurred before the usual age of retirement

6TA standardised mortality ratio (SMR) can only be estimated if the age distribution of the

population is known

HEART, LUNGS AND BLOOD

717MThiazide diuretics decrease renal HC03 excretion

8FMThe "c" wave of the jugular venous pulse is due to opening of the tricuspid valve

9FMStaphylococcus aureus is frequently implicated in an acute exacerbation of chronic bronchitis

10FMNicotinecontaining chewing gum is available on NHS prescriptions

11FMCuses of a pleural effusion with a protein content of 50g11 include cardiac failure

12TGIVEN: A 26 year old man is known to have bronchial asthma. A peak flow measurement is taken, and is found to be less than 50% of the subject's usual peak flow measurement

QUESTION: Oral steroid therapy should be given

13FMMagnetic resonance imaging is of value in assessment of severity of pulmonary emphysema

14FMProstacyclin (PG12) is synthesised in mast cells

15FMA paradoxical embolus is one which arises as a thrombus in the area of greatest flow in the aorta

16TSome of the muscles of the anterior abdominal wall are supplied by intercostal nerves

17THaemosiderin consists of aggregates of ferritin molecules

18TThe inferior vena cava lies to the right of the abdominal aorta

19TMacrophages are antigenpresenting cells

20TGIVEN The renal clearance of benzylpenicillin is greater than that of gentamicin QUESTION Benzylpenicillin has a shorter plasma concentration halftime than gentamicin

21F Atrial systole is responsible for 80% of the blood flow into the left ventricle of the heart

22FPlasmin is essential for normal thrombus retraction

23FIn a normal subject, sitting upright, apical and basal regions of the lungs receive approximately equal blood flows

24TNeutrophil polymorphonuclear leucocytes are typically seen at the site of acute inflammation

25FGIVEN Cardiomegaly and pulmonary congestion are characteristic radiological features of cardiac failure

QUESTION These findings indicate that the patient has heart muscle disease (cardiomyopathy)

26FGIVEN A patient presents to the Accident and Emergency Department with a history of central crushing chest pain for a period of two hours

QUESTION A normal electrocardiogram excludes myocardial infarction

27TGIVEN The incidence of myocardial infarction increases in women following the menopause

QUESTION Hormone replacement therapy (HRT) can be regarded as a form of primary prevention for coronary artery disease

28FDilated pupils are an important prognostic sign immediately after cardiac arrest

29TOne dose of aspirin may prolong the bleeding time for some days

30TGIVEN A patient with pernicious anaemia will show red cell macrocytosis caused, indirectly, by a deficiency of intrinsic factor and consequent Vitamin B12 malabsorption

QUESTION Intrinsic factor and Vitamin B12 given together by mouth will correct the anaemia and macrocytosis

31TGIVEN Vitamin K is a fat soluble vitamin and is required for the manufacture of certain fully functional coagulation factors

QUESTION Obstructive jaundice potentially causes prolongation of prothrombin time which can be corrected by Vitamin K treatment

32TGIVEN A woman of 63 years reports to her general practitioner that she has been hoarse for 4 weeks

QUESTION She should be referred to hospital for investigations

33FGIVEN Histological verification of lung cancer is usually by bronchoscopy and biopsy QUESTION Bronchoscopy is poorly tolerated, and therefore contraindicated, in patients over 70 years of age

34TBenzodiazepines can be used to alleviate dyspnoea in terminally ill patients

35FGIVEN An adult with a known allergy to nuts suddenly has a rash and difficulty in breathing QUESTION It is appropriate to treat with 1 mg of adrenaline by rapid intravenous injection

36TFor anything other than the treatment of a lifethreatening condition, a general anaesthetic should not be administered within six months of acute myocardial infarction

37FGIVEN Hypertension represents an increased perioperative risk. Before routine surgery, you are clerking a patient with known hypertension, for which he is receiving medication. You find that his blood pressure is 210/105mmHg

QUESTION His operation should be cancelled immediately

38FA patient who has had a coronary artery bypass graft should be advised to inform their dentist that they will require antibiotic cover for surgical procedures

39TIn patients with asthma, a fall in the peak expiratory flow rate (PEFR) to 60% of their bi~st value is an indication for oral steroid therapy

40TTheophylline toxicity can be precipitated by erythromycin

41 FIn an adult, acute breathlessness occurring at night is most commonly due to left ventricular failure

42TOn testing for pitting oedema, indentation lasting more than 30 seconds is suggestive of hypoproteinaemia

43FExpiratory crackles are typically heard in fibrosing alveolitis

44TAtenolol is less likely than propranolol to produce unpleasant dreams

45FVitamin B12 'Slikely to be necessary for the treatment of anaemia after pregnancy

46TPleural biopsy is the best method o f diagnosing pleural tuberculosis

47FGIVEN An unconscious 60 year old man is brought into the Accident and Emergency Department

QUESTION A chest xray should be performed to exclude pneumothorax

48TGIVEN A patient with chronic obstructive airways disease suffers cardiac arrest QUESTION Oxygen should be prescribed at the highest possible delivery rate

49THyperventilation can compensate for mild metabolic acidosis

50FPatients travelling to malarious areas should not be given mefloquine

51FGIVEN The worldwide prevalence of tuberculosis is increasing, and resistance to antituberculous chemotherapy is increasing

QUESTION Quadruple therapy is advised for the initial therapy of tuberculosis, pending susceptibility testing results

52FPyrexia of unknown origin is defined as a fever of 3M or more on two occasions over three days, with a negative blood culture

53FThe murmur of aortic incompetence is low pitched and therefore best heard using the bell of the stethoscope

54FAbdominal aortic aneurysm often presents with symptoms of peripheral embolism

55FSickle cell anaemia causes splenomegaly in adults

56TA pigmented skin lesion should be removed if depigmentation occurs

57FHaemophilus influenzae type A is the commonest cause of postinfluenzal pneumonia

58TThe blood in glandular fever characteristically shows atypical lymphocytes

59FInfection with papilloma virus can be reliably detected on examination of a cervical smear

60TIn a normal menstrual cycle the secretory phase of the cycle is of constant length

61 F Xlinked Duchenne muscular dystrophy presents as floppiness at birth

62FKaryotype 46XX is present in testicular feminisation

63FThe UK National Breast Cancer Screening Programme is less likely to detect slowly growing tumours than rapidly growing tumours

64FChildren with sickle cell disease are usually symptomatic in early infancy

65TGIVEN Iron within the heme molecule needs to be in the reduced form to bind oxygen QUESTION Haemoglobin containing ferric iron is ineffective in oxygen transport

NUTRITION, METABOLISM AND EXCRETION

66FMType 1 hypersensitivity is classically seen in tuberculosis

67FMIn untreated diabetes mellitus, urine is usually alkaline

68FMDopamine receptors in the renal vasculature mediate vasoconstriction

69TMGlomerular filtration rate increases when renal afferent arterioles dilate

70FMIntercurrent infection typically precipitates hypoglycaemic episodes in a diabetic patient

71 FM Secondary hype rpa rathyroid ism is a cause of hypercalcaemia

72FMThe absorption of a drug taken by mouth is most likely to be complete when the drug molecule is soluble in water

73TMClostridium difficileassociated diarrhoea may be confirmed by detecting toxin in faeces

74FMA patient's urine output is a satisfactory guide to the apparent volume of distribution of a drug

75FMGastric carcinoma is a frequent complication of chronic gastric ulcer

76FMThe majority of dietary iron is absorbed

77TMPain complicatingcancer may be reduced by nonsteroidal antiinflammatory drugs

78TMGold injections (sodium aurothiomalate) are potentially nephrotoxic when given to a patient with normal renal function ,

79TMIn England and Wales the incidence of prostatic cancer is increasing

80FMIn acute appendicitis in adults, vomiting usually precedes the onset of pain

81TMIn a jaundiced patient, percutaneous transhepatic cholangiography should be delayed until a coagulation screen has been completed

82TThe action of insulin is mediated by membrane receptors which function as tyrosine

kinases

83TGrowth hormone increases blood glucose concentration

84FTriiodothyronine is formed mainly in plasma

85TThe ability of the kidney to concentrate urine depends on the osmolality of renal medullary interstitial fluid

86FThe initial action of the oral hypoglycaemic drug tolbutamide is to increase the synthesis of insulin

87TVomiting in adults involves an increase in intraabdominal pressure

88FGlucocorticosteroids unmask latent diabetes mellitus because they inhibit the secretion of insulin

89FPancreatic juice contains maltase

9OFGlomerular filtration rate (GFR) decreases when plasma protein concentration decreases

91F T lymphocytes are the source of lgM in the plasma

92FGIVEN Thyroxine is a cardiac stimulant

QUESTION Thyrotoxicosis does not cause cardiac failure

93TCore temperature can effect the response to defibrillation

94FThyroid swellings often cause dysphagia for solids

95FGIVEN A patient present with clinically malignant lymph nodes in the neck

QUESTION The primary tumour is most probably in the head and neck region

96FA hard lump in the anterior triangle of the neck could be a cervical rib

97FClinical features will usually distinguish between a benign and malignant tumour of the parotid

98TSalivary calculi are most common in the submandibular gland

99FRadioactive iodine therapy is contraindicated in young women as it may lead to infertility

100T Screening tests for Cushing=s syndrome may be abnormal in alcoholism

101FHypoglycaemia is uncommon in well controlled diabetes mellitus

102FObese patients with type 2 diabetes are ideally treated with a sulphonylurea in the first instance

103FThe visual disturbance usually associated with a pituitary tumour is a homonymous

hemianopia

104TPatients with Cushings syndrome may complain of difficulty in climbing stairs

105TThe insulin tolerance test can be used to diagnose cortisol deficiency

106TOsteoporosis is a consequence of hypogonadism in men

107FGIVEN A fityoung person presents with a one week history of cough

QUESTION The presence of purulent sputum is an indication that antibiotics should be

prescribed

108TBisphosphonate drugs are effective in correcting malignant hypercalcaemia

109TGIVEN Thiazide diuretics reduce urinary calcium excretion

QUESTION Thiazides can be used to prevent renal stones in men with hypercalciuria

11OFAll type 11 diabetic patients taking oral hypoglycaemic agents and due to have an operation under general anaesthesia should be switched to soluble insulin preoperatively

111FCatheterisation of the bladder is a safe way to obtain urine samples for microbiology from elderly patients

112TAcute pyelonephritis may be treated with ciprofloxacin

113FChlamydia trachomatis is sensitive to amoxycillin

1 14T Dentures are the most common predisposing factor to oral candidal infection

115FRecurrent aphthous ulceration usually indicates an underlying haematological problem

116FGIVEN A patient aged 30 years presents with diarrhoea of six weeks duration.

Hepatomegaly is found on examination

QUESTION Crohn=s disease is the most likely diagnosis

117FCarcinoma of the lower rectum is typically a squamous cell carcinoma

118FIn the treatment of peptic ulceration, omeprazole is less effective than cimetidine in suppressing gastric acid production

119TUterine prolapse is associated with urinary incontinence

120FGIVEN An unconscious elderly lady is brought into the Accident and Emergency

Department. The core body temperature is WC

QUESTION One litre of warm normal saline should be given intravenously over a period of

10 minutes

121 T Water fluoridation gives reductions in dental caries of the order of 50%

122FMouth pigmentation is a frequent accompaniment of alcoholic liver disease

123FFeatures of paralytic ileus which help to distinguish it from mechanical intestinal obstruction include severe electrolyte depletion

124TAnal fissure is associated with Crohn=s disease

125FDigoxin is potentially nephrotoxic when given to a patient with normal renal function

126TThe product of the normal p53 gene promotes apoptosis

127FPostparturn hypopituitarism is associated with thick coarse skin

128TConstipation is a common cause of abdominal pain in childhood

FAMILIES AND CHILDREN

129FM Congenital hypertrophic pyloric stenosis causes bile stained vomitus

130FM Karyotype 46XX is present in a patient with Turner's syndrome

131 FM Physiological jaundice in the newborn is associated with a positive Coombs test

132TM Duchenne's muscular dystrophy is inherited in an Xlinked recessive manner

133TM Emotional deprivation is a cause of short stature

134TM Polyhydramnios is associated with fetal renal agenesis

135FM AntiD antibody is present in plasma of Rh negative blood from infancy

136TM The incubation period of rotavirus infection is less than a week

1 37TM Acute osteomyelitis can present with a complaint of limb paralysis

138TM Haematemesis is an important toxic effect when ferrous gluconate is accidentally ingested by a child

139TM In England and Wales childhood accidental injury is commonest amongst children of social class V

140FM School refusal is more common in children from social classes 1 and 11

141 FM Puerperal breast infection is best treated by aspiration

142FM In labour normal uterine contractions increase placental blood flow

143TM Sodium cromoglycate is poorly absorbed after oral administration

144TFoveal function determines the level of visual acuity

145TAgeing causes reduction in pupil size

146FThe sympathetic supply of the pupil is activated by pilocarpine eye drops

147FBefore birth the chief site of haemopoiesis is the spleen

148TIn labour, normal uterine contractions originate at the uterotubal junction

149FPhenyiketonuria is inherited as an autosomal dominant trait

150FA mother breastfeeding her baby should be advised to offer each breast for 10 minutes every 3 to 4 hours, with boiled water in between if the baby seems thirsty

151TA high intake of pasteurised cows' milk can contribute to iron deficiency

152FThe immunisation status of a 4 year old child in the United Kingdom should include prophylaxis against pertussis, measles, chicken pox and Haemophilus influenzae type B

153TGIVEN The mother of a 6 month old boy thinks she has noticed a Aglide in his left eye.

Examination of the baby's eye is completely normal, with no evidence of a squint

QUESTION The baby should be referred to an orthoptist

154TGIVEN A child aged 19 months is bottom shuffling but not weight bearing QUESTION The child should have blood taken for a creatine phosphokinase estimation

155FPrecocious puberty in girls is defined as the onset of breast development before the age of 9 years

156TPhysical maturation in childhood and adolescence can be assessed using a wrist radiograph

157FLuteinizing hormone stimulates Sertoli cells in the testis

158FASmall for gestationalage is a term applied to babies with a birth weight of below the 25th centile

159TThe calcium and phosphorus contents of human milk cannot meet the metabolic requirements of preterm infants

160FGIVEN MMR vaccine contains live attenuated viruses

QUESTION Children with cystic fibrosis should not be given the MMR vaccine

161 FReplacement treatment with glucocorticoid and mineralocorticoid is required in hypoadrenalism secondary to hypopituitarism

162FThe commonest form of congenital adrenal hyperplasia is that due to 11hydroxylase deficiency

163FThe majority of girls with Turner=s syndrome are of normal stature

164TChildren with precocious puberty are often tall for their age at presentation

165FA trial of avoidance of dairy products is worthwhile in the management of young children with eczema

166FRecurrent infection in the first three months of life is most likely due to antibody deficiency

167TConjugated hyperbilirubinaemia may be a feature of neonatal sepsis

168FA high vaginal swab is the best specimen for diagnosing gonococcal infection in a premenopausal woman

169THIV infection may lead to rapidly progressive periodontal disease

170TIn infective exacerbations of cystic fibrosis, the usual infecting organism is Pseudomonas aeruginosa

171TChronic retention of urine can be present in an asymptomatic patient

172TStones in the common bile duct may cause acute pancreatitis

173TUse of sodium valproate in pregnancy is associated with a higher incidence of neural tube defects in offspring

174FGIVEN Drugs are most likely to produce fetal malformations when given in the first trimester of pregnancy

QUESTION This is because drug transport from maternal to fetal plasma is greatest in the first trimester

175TIn cerebral palsy, signs may be absent in the first few months of life

176FGIVEN A boy aged 6 weeks old is brought to hospital with a history of irritability, anorexia and profuse vomiting for 24 hours. There are no other relevant features in the history and full examination reveals a weak cry, dehydration, lethargy and a body temperature of 39.60C

QUESTION Antibiotics would be suitable treatment

177FCancer of the breast typically arises from a fibroadenoma

178FGIVEN A pregnant patient presents with an antepartum haemorrhage

QUESTION The absence of fetal heart sounds suggests that placenta praevia is the cause of the haemorrhage

179TCardiac arrhythmias are an important toxic effect when imipramine is accidentally ingested by a child

180THIV viraemia is greatest after seroconversion and in the terminal stages of AIDS

181 F A patient with acute epiglottitis can be safely managed on a general paediatric ward

182TUltrasonography at 16 to 18 weeks of gestation is able to establish gestational age to within an accuracy of two weeks

183FSeminoma of the testis occurs in a younger age group than teratoma of the testis

184TIn postmenopausal women, the introduction of hormone replacement therapy (HRT) can lead to the return of regular periods

185TFragile X syndrome is one of the most common causes of mental retardation in boys

186FAppendicitis does not occur under the age of 5 years

187TIn a child with abdominal distension and faecal retention, Hirschsprung=s disease should be considered

188FGIVEN A child with severe cerebral palsy has difficulty in exploring the environment QUESTION This will not affect language development

COGNITION, SPECIAL SENSES, LOCOMOTION

189FPost herpetic neuralgia pain is triggered by touching the face, cold air or shaving

19OFAgoraphobia is an abnormally intense dread of situations in which other people are present

19 1 FM Euphoria is a feature of Parkinson's disea se

192FM In cognitive behavioural counselling, the counsellor discourages the client from viewing negative beliefs as hypotheses to be tested

193FM Aspirin overdose is characterised by metabolic alkalosis

194FM In those over 75 years, dementia usually requires neuroleptic medication

195FM Renal failure is a common feature of paracetamol overdose

196FM Damage to Wernicke's area results in expressive dysphasia

197TM The most common form of intracranial haemorrhage in boxers is a subdural haematoma

198TM Patients with carotid stenosis may benefit from antiplatelet therapy

199FM Retrograde memory loss following head injury usually recovers completely

20OTM Amaurosis fugax is associated with atrial fibrillation

201TM Magnetic resonance imaging is of value in suspected prolapsed intervertebral disc

202TM The sympathetic supply of the pupil is reduced in Horner's syndrome

203TM In petit mal epilepsy, the electroencephalogram characteristically shows a spike and wave pattern with a frequency of 3 per second

204FM Atropine may be appropriate in the treatment of acute angle closure glaucoma

205FM Cerebellar disease is commonly associated with tremor at rest