BOF: 21

A 33-year-old female who has had multiple resections of the small bowel has been left
with 90 cms of eunum anastamosed to the colon! "he is maintained on a diet hi#h in
polysaccharides and mana#es well on this diet! "he is admitted to the ward with ata$ia%
blurred &ision% ophthalmople#ia and nysta#mus!
'he li(ely cause of this complication is
a) 'hiamine deficiency
b) *itamin B 12 deficiency
c) +a#nesium deficiency
d) , -.) lactic acidosis
e) / --) ,actic acidosis
Answer:
e)
0n patients with a short small bowel and an intact colon% ener#y is absorbed from the
colon by bacterial fermentation of polysaccharides to short chain fatty acid% which can be
absorbed by the colonocytes! 0n rare instances mono and oli#osaccharides may be
metabolised to / --) lactic acid by abnormal bacteria! 'he normal lactic acid produced by
man is , -.) lactic acid! Absorption of / --) lactic acid results in ata$ia% blurred &ision%
ophthalmople#ia and nysta#mus! 'reatment is with broad-spectrum antibiotics such as
neomycin or &ancomycin% thiamine and a chan#e in diet to one hi#h in polysaccharides
and low in mono and oli#osaccharides!
BOF: 22
A 21-year-old male presents with a painful swollen (nee! 2e feels #enerally unwell and
has fe&er! 2e has a psoriasiform rash on his #lans penis and he also complains of low
bac(ache!
"i$ wee(s pre&iously he has had a self-limitin# episode of diarrhoea!
0n this patient
a) 3rompt treatment will reduce the chance of recurrence
b) 2i#h dose steroids should be used without delay
c) 3rolon#ed antibiotic treatment will pre&ent the disease becomin# chronic
d) 0f the disease becomes chronic sulphasala4ine and methotre$ate are useful
second line a#ents
e) 2e has a #reater than 50 6 chance of de&elopin# erosi&e disease or spondylitis
Answer:
d)
'his patient has de&eloped reacti&e arthritis! 0f possible athrocenetesis should be
preformed to e$clude septic arthritis! 3rednisolone does help to control symptoms in
acti&e disease but is not the dru# of first choice! 7on-steroidal anti-inflammatory dru#s
should be used! Antibiotics should be used if acti&e infection is demonstrated but
prolon#ed therapy is of no benefit! +ore than 50 6 of patients will e$perience further
episodes! "ulphasala4ine and methotre$ate are useful second line a#ents if the disease
becomes chronic! About 15 6 of patients #o on to de&elop erosi&e disease or spondylitis!
BOF: 23
A 35-year-old female presents with a mutilatin# arthritis of the hands with associated
pittin# of the nails!
0n treatin# this patient
a) "ulphasala4ine is unli(ely to be effecti&e
b) +ethotre$ate is unli(ely to be effecti&e
c) Antimalarials are best a&oided
d) 'umour necrosis factor alpha anta#onists are not effecti&e
e) Oral corticosteroids should be the dru#s of first choice as they help the nail
condition as well
Answer:
c)

'he patient has psoriatic arthropathy! 'reatment is usually with non-steroidal anti-
inflammatory dru#s althou#h there is a ris( of worsenin# the psoriasis! "ulphasala4ine
and methotre$ate are useful in this condition! 'umour necrosis factor alpha anta#onists
are effecti&e but are e$pensi&e to use! "teroids are seldom needed and may pro&o(e
worsenin# of the psoriases on withdrawal! Antimalarials are best a&oided as they can
cause an acute psoriatic s(in reaction!
BOF: 28
A 85-year-old male presents with a sudden onset of pain and swellin# of the metatarso-
phalan#eal oint of the ri#ht bi# toe!
0n this patient
a) A normal serum uric acid concentration e$cludes the dia#nosis of #out
b) 'he $-ray chan#es would be characteristic
c) "yno&ial fluid analysis should be delayed to allow crystals to a##re#ate and
become easier to &isualise
d) Fe&er% leucocytosis and ele&ated 9": would su##est septic arthritis
e) 'he first attac( is seldom associated with residual disability
Answer:
e)
0n an acute attac( of #out serum uric acid is raised in only about ;0 6 of patients! "imilar
$-ray chan#es may occur in inflammatory and de#enerati&e arthritis! "yno&ial fluid
analysis should be underta(en immediately followin# aspiration of oint fluid! 'he
characteristic chan#es bein# the demonstration of needle shaped ne#ati&ely birefrin#ent
crystals of mono-sodium urate in syno&ial fluid neutrophils by polari4in# li#ht
microscopy! A raised 9": fe&er and leucocytosis can accompany &ery acute attac(s of
#out and do not necessarily indicate sepsis! 'he first attac( of #out is seldom associated
with residual disability!
BOF: 25
A si$ty fi&e year old male who is on treatment for chronic heart failure with diuretics%
an#iotensin con&ertin# en4yme inhibitors% beta-bloc(ers and spironolactone presents with
sudden onset of pain and swellin# of the metatarso-phalan#eal oint of his ri#ht bi# toe!
Aspiration of the oint demonstrates crystals of monosodium urate!
0n this patient
a) +oderate doses of aspirin would be beneficial
b) 7on-steroidal anti-inflammatory di#s would be the dru#s of first choice
c) 2i#hly selecti&e cycloo$y#enase 2 inhibitor should be used
d) <olchicine would be the best choice
e) 3arenteral colchicine may be safely used to counter nausea and diarrhoea
Answer:
d)

'his patient has #out! Aspirin unless used in hi#h doses causes uric acid retention! 7on-
steroidal anti-inflammatory dru#s would be contraindicated in &iew of the heart failure!
2i#hly selecti&e <O= 2 inhibitors may not be used with co-e$istin# heart failure!
0ntra&enous colchicine is potentially ha4ardous!
BOF: 2;
A 50-year-old female presents with a sudden onset occipital headache followed by a
decreased le&el of consciousness! On e$amination she has nec( stiffness and a positi&e
>erni#?s si#n! <' scannin# shows blood in the sub-arachnoid and intra&entricular space!
'he patient impro&es initially but 10 days followin# admission her le&el of consciousness
be#ins to deteriorate!
'he ne$t step in mana#ement would be:
a) /ecompression by lumbar puncture
b) ,umbar puncture followed by hi#h dose broad spectrum antibiotics until cultures
are a&ailable
c) 2i#h dose de$amethasone
d) <' scan followed by a &entricular u#ular shunt
e) <isternal puncture for decompression
Answer:
d)
'he patient has had a sub-arachnoid haemorrha#e! /eterioration comin# on after an
initial impro&ement is most li(ely due to the de&elopment of secondary hydrocephalus
due to bloc(a#e of <"F flow by blood! 'he mana#ement would be <' scan to confirm
the dia#nosis followed by a procedure to drain <"F!
BOF: 27
A ;0-year-old female presents with a se&ere left-sided temporal headache! 'he temporal
artery is tender% pulsation is lost and the o&erlyin# s(in is erythematous! 'he 9!"!:! is 10
mm in the first hour!
0n this patient
a) A short course of hi#h dose steroid should be prescribed
b) 'he 9!"!:! is not a reliable #uide to use when reducin# the dosa#e of steroids
c) 'he headache subsides within hours of commencin# the patient on hi#h dose
steroid
d) ,ifelon# steroid treatment will be re@uired
e) As steroids may be harmful in elderly patients% treatment should be delayed until
the results of temporal artery biopsy are a&ailable
Answer:
c)
The patient has temporal arteritis. The diagnosis is confirmed by biopsy but in
vie of the serious complications that may occur treatment ith high!dose
steroids should be started immediately. "eduction of steroid dosage is guided
by the fall in the #.$.". but the duration of treatment ould be several months
to years.
BOF: 2%
A 30-year-old female presents with a history of wea(ness and fati#ability of the ocular%
bulbar and limb muscles! On e$amination she has bilateral ptosis and e$tra-ocular muscle
wea(ness! :efle$es are preser&ed% there is no muscle wastin#! 'he 9drophonium test is
positi&e!
0n this patient
a) 'hymectomy has no lon# term benefit
b) 0f a thymoma is present the muscle wea(ness would impro&e
c) 0n non-thymoma patients impro&ement will be seen in ;0 6 of patients
d) 'he pro#nosis is worse as the patient is under 80 years of a#e
e) 'hymectomy should not be performed if the patient has positi&e receptor
antibodies
Answer:
c)
0n myasthenia #ra&is thymectomy offers lon#-term benefits! 0t impro&es the pro#nosis in
patients below 80 years% in those with positi&e receptor antibodies and in those who ha&e
had the disease for less than 10 years! Followin# thymectomy ;0 6 of non-thymoma
patients will impro&e! 0n thymoma althou#h sur#ery is necessary as the tumour is
potentially mali#nant% the myasthenia is unli(ely to impro&e!
BOF: 2%
A 30-year-old female presents with a history of wea(ness and fati#ability of the ocular%
bulbar and limb muscles! On e$amination she has bilateral ptosis and e$tra-ocular muscle
wea(ness! :efle$es are preser&ed% there is no muscle wastin#! 'he 9drophonium test is
positi&e!
0n this patient
a) 'hymectomy has no lon# term benefit
b) 0f a thymoma is present the muscle wea(ness would impro&e
c) 0n non-thymoma patients impro&ement will be seen in ;0 6 of patients
d) 'he pro#nosis is worse as the patient is under 80 years of a#e
e) 'hymectomy should not be performed if the patient has positi&e receptor
antibodies
Answer:
c)
0n myasthenia #ra&is thymectomy offers lon#-term benefits! 0t impro&es the pro#nosis in
patients below 80 years% in those with positi&e receptor antibodies and in those who ha&e
had the disease for less than 10 years! Followin# thymectomy ;0 6 of non-thymoma
patients will impro&e! 0n thymoma althou#h sur#ery is necessary as the tumour is
potentially mali#nant% the myasthenia is unli(ely to impro&e!
BOF: 29
A A0-year-old male is referred by his #eneral practitioner as he has had a stro(e! On
e$amination the patient has left sided complete third ner&e palsy with a contralateral
hemiple#ia! 'he lesion is li(ely to be in the
a) 'he pons
b) 'he medulla
c) 'he mid-brain at the le&el of the inferior colliculus
d) 'he mid-brain at the le&el of the superior colliculus
e) 'he thalamus
Answer:
d)
'he lesion in&ol&es the mid-brain at the le&el of the superior colliculus dama#in# the
third ner&e nucleus and the cerebral peduncles!
BOF: 3&
A 30-year-old male presents with a chronic cou#h producti&e of copious amounts of thic(
yellow sputum and occasional haemoptysis! 2e also complains of bad breath and
recurrent episodes of fe&er! On e$amination he has clubbin# and on auscultation o&er the
lun# bases coarse crepitations are heard!
'he test that would identify the cause of his condition would be:
a) "weat electrolytes
b) "inus $-ray
c) Bronchoscopy
d) 2i#h resolution <' scannin#
e) Broncho#raphy
Answer:
d)
'he patient has bronchiectasis! 2i#h resolution <' scannin# would be the in&esti#ation
of choice! 0t would show bronchial dilatation and wall thic(enin#!
BOF 3'
A ;1-year-old female patient is seen on the ward! "he complains of se&ere pain in her
ri#ht eye! 'here is blurrin# of &ision and she feels nauseated and has &omited se&eral
times! 9arlier in the day she has under#one colonoscopy for e&aluation of her lon#-
standin# <rohnBs disease! 'he endoscopist has made a comment that the e$amination was
difficult! Chat is the li(ely cause of her painful red eyeD
a) Anterior u&eitis
b) Acute conuncti&itis
c) 9piscleritis
d) "ub-conuncti&al haemorrha#e
e) Acute an#le closure #laucoma
(nser
e)
(nticholinergic agents are sometimes used during endoscopy to cause smooth
muscle rela*ation to aid e*amination hen difficulty is encountered. These
agents cause pupillary dilatation thus precipitating acute angle closure
glaucoma in susceptible patients. +n patients ith a history of glaucoma,
glucagon is used instead of anticholinergics.
BOF: 32
A ;5-year-old male presents with a chronic cou#h! 2e is a hea&y smo(er of o&er 80
ci#arettes a day! <=: shows a peripheral ri#ht-sided lesion% which on <' #uided lun#
biopsy% is shown to be s@uamous carcinoma! 7o re#ional lymph nodes are in&ol&ed! ,un#
function tests show a F9*1 of less than 1!5 litres!
'he treatment most li(ely to benefit this patient would be:
a) "ur#ery
b) <hemotherapy
c) 2i#h dose radiotherapy
d) <ombination chemotherapy and radiotherapy
e) <ombination chemotherapy and sur#ery
Answer:
c)
A F9*1 of less than 1!5 litres is not compatible with an acti&e life followin# sur#ery! 2i#h
dose radiotherapy can produce #ood results and is the treatment of choice in patients with
poor lun# function!
BOF: 33
A 85-year-old male homeless alcoholic has been referred to the medical ward after bein#
brou#ht in to casualty! 2e has a chronic cou#h producti&e of sputum% loss of wei#ht% and
ni#ht sweats! On e$amination he is un(empt and emaciated! 2is trachea is de&iated to the
left and there are crepitations o&er the ape$ of the left lun#! <=: shows fibrosis and
ca&itation in the left ape$!
'he in&esti#ation most li(ely to confirm the dia#nosis would be
a) "putum e$amination for acid and alcohol fast bacilli
b) 2i#h resolution <' scan
c) Fibreoptic bronchoscopy
d) +antou$ test
e) Eastric washin#s
Answer:
a)
'he patient has a producti&e cou#h! 'he chances are that AAFB will be identified in these
specimens! 0f sputum were not produced bronchoscopy would be preferred to #astric
washin#s!
BOF: 38
A fifty Ffi&e year old male presents with a history of anore$ia% nausea and &omitin# and
abdominal pain!
2is s(in is pi#mented with pi#mentation of palmar creases and sun e$posed areas! 2e has
a few patches of &itili#o! 2is blood pressure is low and there is a postural drop!
0n this patient the blood urea and electrolytes are li(ely to show the followin#
a) /ecreased 7a% /ecreased >% 7ormal Grea
b) /ecreased 7a% 0ncreased >% 0ncreased Grea
c) /ecreased 7a% 0ncreased > 7ormal Grea
d) 0ncreased 7a% /ecreased >% 0ncreased Grea
e) /ecreased 7a% /ecreased >% 0ncreased Grea
Answer:
b)
'he patient has Addison?s disease! 'he 7a will be low with and increase in > and
increase in blood urea!
BOF: 35
A si$ty-year-old female presents with a history of palpitations and swellin# in the nec(!
On e$amination of the pulse there is atrial fibrillation and in the nec( there is a lar#e
multinodular #oitre!
0n this patient which one of the followin# are li(ely
a) 9ye si#ns are common
b) 9ye si#ns are rare
c) "pontaneous remission is li(ely
d) ,on# term antithyroid dru#s are effecti&e in controllin# symptoms
e) 'hyro$ine will help to reduce the si4e of the #oitre
Answer:
b)
'his patient has to$ic multinodular #oitre! 0n this condition eye si#ns are rare unli(e
Era&e?s disease! "pontaneous remission is rare! Antithyroid dru#s will increase the si4e of
the #oitre and are only used as a temporary measure prior to definiti&e treatment!
'hyro$ine will not reduce the si4e of the #oitre!
BOF: 3;
A si$ty-year-old female presents with a history of nausea% lethar#y and depression!
2er s(in is pi#mented and there is &itili#o! 2er blood pressure is low and there is a
postural drop! 0n this patient which one of the followin# are true
a) 9osinopaenia is a feature
b) 'he 9": is decreased
c) 2yper#lycaemia is a feature
d) 'he heart si4e is small
e) 2ypo(alaemia would occur
Answer:
d)
'he patient has Addison?s disease! 0n this condition the heart si4e is small! 'he eosinophil
count may be ele&ated% the 9": may be hi#h% hypo#lycaemia may be a feature% and
hyper(alaemia would be a feature!
BOF: 3A
A si$ty-year-old man presents with a history of increased sweatin#! 2e also complains of
headaches!
On e$amination the patient has lar#e hands and the facial features are e$a##erated with
lar#e nose% prominent aw and thic( lips!
0n this patient which of the followin# may be used as a screenin# test
a) Erowth hormone le&el
b) Elucose 'olerance 'est
c) 3rolactin le&el
d) 3lasma 0nsulin-li(e Erowth Factor le&els
e) "erum calcium
Answer:
d)
'he patient has acrome#aly! 3lasma 0nsulin-li(e Erowth Factor may be used as a
screenin# test
BOF: 3%
A fifty-fi&e year old man is admitted with a history of fati#ue% wei#ht loss and aundice!
2is alcohol inta(e is si$ty units a wee(!
On e$amination he has clubbin#% /upuytren?s contracture% palmar erythema% flappin#
tremor% parotid enlar#ement% spider nae&i% #ynaecomastia% hepatosplenome#aly!
Chich of the followin# si#ns is indicati&e of a poor pro#nosis:
a) <lubbin#
b) 3arotid 9nlar#ement
c) Eynaecomastia
d) Flappin# 'remor
e) "plenome#aly
Answer:
d)
'he patient has alcoholic li&er disease with clinical e&idence of cirrhosis! 'he features of
a poor pro#nosis are hepatic encephalopathy% low serum albumin concentration% and low
serum sodium and prolon#ed prothrombin time!
BOF: 3-
A si$ty-year-old man who is (nown to ha&e ischaemic heart disease is admitted with a
history of sudden onset abdominal pain% followed by watery diarrhoea and subse@uent
profuse rectal bleedin#!
'he li(ely dia#nosis is
a) "mall bowel infarction
b) ,ar#e bowel infarction
c) *ol&ulus of the si#moid colon
d) <olon cancer with intussusception
e) Glcerati&e colitis
Answer:
b)
'he history of pain flowed by diarrhoea and bleedin# per rectum in a patient with (nown
macro &ascular disease is typical of lar#e bowel infarction% which occurs in the re#ion of
the splenic fle$ure!
BOF: .&
A thirty fi&e year old female has had a ri#ht hemicolectomy and resection of 30 cms of
terminal ileum for ileocaecal <rohn?s disease! "he has persistent diarrhoea% which is not
e$plosi&e! "he does not ha&e abdominal pain% bloatin#% or loss of wei#ht! 0n&esti#ations
ha&e failed to demonstrate e&idence of recurrent <rohn?s disease!
'reatment that would relie&e symptoms and #i&e a clue to the underlyin# dia#nosis
would be:
a) ,operamide
b) "teroids
c) <yclical antibiotics
d) <holestyramine
e) 'ricyclic antidepressants
Answer:
d)
'he patient has had resection of the terminal ileum and the cause of the diarrhoea is li(ely
to be Bile Acid +alabsorption -BA+)! 'reatment with a Bile Acid "e@uestrants such as
<holestyramine would relie&e symptoms and point to the dia#nosis!