Borang Rasmi MSA - Cuti Musim Panas 2012

MCQ Clinical Year Part6/10 CVS

Choose only ONE answer

51. A young man comes to the A & E Department complaining of feeling unwell and palpitations. Supraventricular tachycardia is confirmed on ECG and he responds to carotid sinus massage. Subsequently, the ECG shows a PR interval of 0.09 sec, widened QRS complex in all leads with a slurred upstroke, dominant R wave in V1 and left axis deviation.

What is the most likely diagnosis?

Rheumatic fever

Wolff–Parkinson–White syndrome

Atrial fibrillation

ASD

Right bundle-branch block

The ECG features are typical of Wolff-Parkinson-White (WPW) syndrome. This condition is classically associated with a short PR interval (< 0.12 s). Slurring of the QRS complex is due to an extra wave called a delta wave. As the AV node and bypass tract have different conduction speeds and refractory periods, a re-entry circuit can develop, causing paroxysms of tachycardia. Carotid sinus massage or intravenous adenosine will often terminate an episode of this form of tachycardia. One of the features of myocarditis due to rheumatic fever is a prolonged PR interval. This occurs due to a first- or second-degree block. In atrial fibrillation, the ECG shows normal but irregular QRS complexes; there are no P waves but the baseline may show irregular fibrillation waves. A right bundle-branch block presents with wide QRS complexes, dominant R in lead V1, inverted T waves in V1 – V4 and a deep wide S wave in lead V6. Atrial septal defects are usually associated with a right bundle-branch block. This leads to an rSR pattern 

___________________________________________________________

52. An obese 50-year-old woman suddenly develops dyspnoea and hypotension 3.5 days after undergoing a total abdominal hysterectomy. There is mild jugular venous distension with prominent A waves. The lung fields are clear. ECG shows tachycardia with a right bundle-branch block and minor ST-segment changes.

What is the most likely diagnosis?

Acute myocardial infarction

Pulmonary embolism

Aspiration pneumonia

Aortic dissection

Pneumothorax

Pulmonary embolism presents with a raised jugular venous pressure (JVP) and right bundle-branch block due to acute right heart failure. Hypotension in an acute MI would cause gross ST-segment abnormalities on ECG. Clear lung fields on auscultation preclude a diagnosis of pneumonia. Aortic dissection would cause an MI or aortic regurgitation before causing respiratory distress.

___________________________________________________________

53. A patient presents with congestive heart failure.

Which drug may be effective in reducing mortality?

Enalapril

Aspirin

Digoxin

Frusemide

Lidocaine

Standard drugs like digitalis and diuretics have not been shown to improve survival rates. A number of studies have conclusively demonstrated that reduction in left ventricular afterload prolongs survival rates in congestive heart failure. Vasodilators such as angiotensin-converting enzyme (ACE) inhibitors are thus effective by inhibiting the formation of angiotensin II and thus affecting coronary artery tone and arterial wall hyperplasia. Lidocaine and other antiarrhythmic agents are useful only when there is arrhythmia associated with heart failure. Aspirin is indicated only in cases of coronary occlusion or myocardial infarction.

___________________________________________________________

54. A 20-week pregnant woman with a history of asthma is noted to have consistent blood pressure readings over 170/95 mmHg.

Which of the following antihypertensives would you initiate for this patient?

Nifedipine

Diltiazem

Bendrofluazide

Enalapril

Losartan

Dihydropyridines (eg nifedipine) are safe and effective in pregnancy, whereas the role of diltiazem is less clear. Bendrofluazide is relatively contraindicated, while ACE inhibitors and angiotensin receptor blockers are absolutely contraindicated.

___________________________________________________________

55. A 63-year-old man with known chronic heart failure is admitted with symptoms at rest. Examination reveals pitting oedema to his knees, elevated jugular venous pressure and basal crepitations. He is in sinus rhythm at a rate of 80 bpm and his blood pressure is 100/60 mmHg. Current medication includes bisoprolol 10 mg once daily, frusemide 80 mg once daily and ramipril 2.5 mg twice daily. Blood tests reveal a sodium concentration of 133 mmol/l, potassium 4.9 mmol/l and creatinine of 169 mmol/l. The admitting doctor commences him on iv frusemide 80 mg twice daily and increases his ramipril to 5 mg twice daily.

When you review him the following day what other drug would be most appropriate to add in?

Amiloride 5 mg od

Bendrofluazide 2.5 mg od

Bumetanide 2 mg bd

Metolazone 5 mg od

Spironolactone 25 mg od

This man has decompensated CHF with symptoms at rest (New York Heart Association class IV). Examination has revealed significant fluid retention. The initial management plan of changing to iv frusemide is sensible since coexistent gut wall oedema is likely to impinge on oral absorption. Increasing the vasodilators in the form of ramipril is again a sensible approach. The addition of a thiazide (inhibiting sodium reabsorption in distal tubule) may work in synergy with a loop diuretic; the same is true for metolazone. Spironolactone, an aldosterone antagonist, has been shown to improve the mortality rate and symptoms and reduce hospitalisation in patients with severe CHF already on conventional treatment. Benefits are in addition to its diuretic effect since aldosterone itself has adverse effects on myocardial structure and function. Clearly, careful monitoring of renal function and biochemistry is important in such patients.

___________________________________________________________

56. A 65-year-old man presents to casualty with severe chest pain. ECG shows anterior ST-segment elevation and he receives prompt thrombolysis with reteplase with good resolution of changes. He is commenced on aspirin, a b-blocker, an ACE inhibitor and a statin. His initial progress is complicated by further pain, worse with inspiration and movement and relieved by non-steroidal drugs. You are called to see him on day 5 postinfarct when he complains of shortness of breath on walking to the bathroom. He looks unwell with a cool periphery and resting tachycardia. Blood pressure is reduced at 90/50 mmHg. Jugular venous pressure is elevated to around 8 cm and rises with inspiration. His ECG shows preserved anterior R waves and anterolateral T-wave inversion together with sinus tachycardia. Chest X-ray shows an increase in the cardiothoracic ratio but clear lung fields.

What is the most likely complication to have developed to account for this deterioration?

Cardiogenic shock

Mitral regurgitation

Pericardial tamponade

Pulmonary embolism

Ventricular septal defect

Devastating complications still do occur following acute myocardial infarction. Cardiogenic shock tends to occur early following a large infarct (or in the presence of already impaired left ventricular function), typically in the first 24–48 hours. The development of acute mitral regurgitation or VSD is associated with severe pulmonary oedema. While they would give rise to an elevation of jugular venous pressure, Kussmaul’s sign would not be present (increase in JVP with inspiration). Although pericarditis is common following an MI, and in particular anterior MI, tamponade occurs relatively infrequently. Chest X-ray shows a large heart with normal pulmonary vasculature. Echocardiography is vital to assist in the management of such a patient and permits easy differentiation of the possible causes of haemodynamic collapse.

___________________________________________________________

57. A 65-year-old man is admitted via A&E with acute shortness of breath. His past medical history includes an anterior MI 5 years ago. He is usually short of breath after walking around 400 m (0.25 mile), but is not on regular treatment. Clinically he is distressed: respiratory rate 30/min, basal crepitations to mid-zones, saturations 90%, pulse rate 110 sinus, blood pressure 180/100 mm Hg. The casualty officer has already given iv diamorphine 5 mg, iv metoclopramide and iv frusemide 40 mg (twice) but the patient remains short of breath, although saturations have increased to 94% with high-flow oxygen. CXR confirms pulmonary oedema.

What further intravenous therapy would you commence?

Atenolol iv

 Dobutamine iv

Dopamine iv

GTN iv

Milrinone iv

This patient has severe pulmonary oedema. Initial treatment includes sitting the patient up and administering high-flow oxygen. High catecholamine levels and activation of the renin–angiotensin–aldosterone systems drive the peripheral vasoconstriction, which increases myocardial oxygen demand. Traditionally, treatment has been with diuretics, but the benefits probably relate to their vasodilatatory actions. Early use of more powerful vasodilators represents a more attractive strategy and includes iv diamorphine and iv GTN (short half-life). Early administration of an oral ACE inhibitor would also be recommended. Inotropic agents should be considered in the context of cardiogenic shock (low blood pressure with impaired tissue perfusion).

___________________________________________________________

58. A 50-year-old woman is referred to out-patients for a previously asymptomatic atrial septal defect (ASD). She is new to the area and was last seen around 6 years ago in her previous local hospital. She is a smoker but without other significant medical history. She now complains of shortness of breath on exertion, together with peripheral oedema. Clinical examination reveals her to be clubbed and cyanosed. Her pulse rate is 90 bpm and blood pressure 98/60 mmHg. Echo demonstrates a dilated right heart with an estimated right ventricular pressure of 90 mmHg and significant tricuspid and pulmonary regurgitation.

What is the likely diagnosis?

Cor pulmonale

Eisenmenger’s syndrome

Infective endocarditis

Primary pulmonary hypertension

Pulmonary emboli disease

This woman has developed massive irreversible pulmonary hypertension as a consequence of a previous left to right shunt. Pulmonary pressures have now reached systemic level. The reversal of a left to right shunt as a consequence of pulmonary hypertension is known as Eisenmenger’s syndrome, and is generally the result of a previously undiagnosed ASD, ventricular septal defect (VSD) or patent ductus arteriosus. It may also result from an incompletely corrected Fallot’s tetralogy or Ebstein’s anomaly. Prognosis is poor, although a few patients may be candidates for heart–lung transplantation. Symptomatic treatment is directed towards right heart failure. Complications include polycythaemia, bleeding disorders and cerebral embolism or abscess. Since there is a particularly high risk in those of childbearing age, patients should be given appropriate advice and information to avoid pregnancy.

___________________________________________________________

59. A 40-year-old man is referred by his GP for advice with regard to primary prevention of cardiovascular disease. He is a smoker with a strong family history of premature death from ischaemic heart disease. Following a period of lifestyle modification, his fasting cholesterol concentration is 7.2 mmol/l. On consultation of the local guidelines you find that his estimated 10-year risk of a coronary heart disease event is > 30%.

What would you advise?

Cholestyramine

Dietician advice

Fibrate

Nicotinic acid

Statin

The National Service Framework for Coronary Heart Disease (2000) and the Joint British Society Guidelines recommend targeting individuals with a 10-year risk of a coronary heart disease event of > 30%. Individuals should be offered interventions to address all modifiable risk factors, including dietary advice, smoking cessation advice and support, moderation of alcohol consumption and weight reduction where appropriate. In respect of lipid management, non-pharmacological and pharmacological interventions should be utilised to achieve a total cholesterol concentration < 5.0 mmol/l and an LDL cholesterol concentration of < 3.0 mmol/l. The results of several important trials support the use of statins in primary prevention, these include: WOSCOPS (pravastatin) AFCAPS/TEXCAPS (LEVASTATIN).

___________________________________________________________

60. Left bundle branch block is associated with which one of the following conditions?

Ischaemic heart disease

Mitral stenosis

Pericarditis

Pulmonary embolism

Tricuspid stenosis

Mitral stenosis, tricuspid stenosis and secondary pulmonary hypertension due to pulmonary embolism are associated with right ventricular strain and hypertrophy with partial or complete right bundle branch block. Pericarditis is not associated with bundle branch block.

Prepared by:

Kevin Wong

Anthony Chan

MCQ Clinical Year Part5/10

Choose only ONE answer

41. Best prognostic factor for head injury is:

A. Glassgow coma scale

B. Age

C. Mode of injury

D. CT findings

Ans: a.

42. Barrett’s esophagus shows:

A. Intestinal dysplasia

B. Intestinal metaplasia

C. Squamous cell metaplasia

D. Columnar cell metaplasia

Ans: b.

43. 50 year old male with positive family history of prostate cancer has come to you for a screening test. The most sensitive screening test to pickup prostate cancer is:

A. PR

B. PSA

C. PR + PSA

D. Endorectal Coil MRI with T1W and T2W images

Ans: c.

44. Which of the following colonic polyps has no risk for malignancy?

A. Juvenile polyps

B. Hamartomatous polyps associated with Peutz-Jegher’s syndrome

C. Juvenile polyposis syndrome

D. Famillial adenomatous polyposis syndrome

Ans: a.

45. Peutz Jeghers polyps present most commonly in –

A. rectum

B. colon

C. esophagus

D. jejunum

Ans: d.

46. Sister Mary Joseph nodule is most commonly seen with –

A. Ovarian cancer

B. Stomach cancer

C. Colon cancer

D. Pancreatic cancer

Ans: b.

47. Early post-operative complication of ileostomy in the post-operative period –

A. Obstruction

B. Necrosis

C. Diarrhea

D. Prolapse

Ans: b.

48. Hashimoto’s thyroiditis – true are A/E –

A. Follicular destruction

B. Increase in lymphocytes

C. Oncocytic metaplasia

D. Orphan Annie eye nuclei

Ans: d.

49. A man with blunt abdominal trauma with H/O pelvic fracture has presented to ER. He has passed only few drops of blood per meatus and no urine in the past 8 hrs. His bladder is palpable per abdomen. Which of the following is correct?

A. Anuria due to hemorrhagic shock

B. Urethral injury

C. Ureteral rupture leading to extravasation of urine in retroperitoneum

D. Bladder rupture

Ans: b.

50.  25 yr old male having fever & malaise since 2 weeks, arthritis of ankle joint and tender erythematous nodules over the shin. Diagnosis is –

A. Erythema nodosum

B. Hensen’s disease

C. Weber-Christian disease

D. Urticardial vasculitis

Ans: a.

Prepared by:

Kevin Wong

Anthony Chan

MCQ Clinical Year Part4/10

Choose only ONE answer

 31. Chikungunya is transmitted by

A. aedes

B. culex

C. mansonoides

D. anopheles

Ans: a.

32. Drug of choice for Zollinger-Ellison syndrome –

A. antihistaminics

B. Proton lump inhibitors

C. Dopamine agonists

D. Antacids

Ans: b.

33. Which one of the following drugs cause hypomagnesemia by increased excretion?

A. Frusemide therapy

B. Cisplatin

C. Digitalis

D. Aminoglycosides

Ans: a.

34. What is the mechanism of acute rheumatic fever –

A. cross reactivity with endogenous antigen

B. innocent by slender effect

C. due to toxin secretion by streptococci

D. release of pyrogenic cytokines

Ans: a.

35. Eisenmenger syndrome – True are A/E –

A. Pulmonary veins are not distended

B. RV & LV walls come back to normal size

C. Dilatation of central pulmonary artery

D. Peripheral pruning of pulmonary arteries

Ans: b.

36. All are signs of impending Eisenmenger except –

A. Increased flow murmur across tricuspid & pulmonary valve

B. Single S2

C. Loud P2

D. Graham steel murmur

Ans: a.

37. Which of the following is a component of pentalogy of Fallot –

A. ASD

B. PDA

C. Coarctation of aorta

D. LVH

Ans: a.

38. Commonest organ injured in blast injury is –

A. Lung

B. Liver

C. Spleen

D. Pancreas

Ans: a.

39. In blunt trauma abdomen what should be the approach for doing laparotomy –

A. Depends on organ injured

B. Always midline incision

C. Always transverse

D. Depends upon type of injury

Ans: b.

40. A well differentiated follicular carcinoma of thyroid can be best differentiated from a follicular adenoma by: -

A. Hurthle cell change

B. Lining of tall columnar and cuboidal cells

C. Vascular invasion

D. Nuclear features

Ans: c.

Prepared by:

Kevin Wong

Anthony Chan

MCQ Clinical Year Part3/10

Choose only ONE answer

21. True about hemochromatosis –

A. Is genetically heterogenous

B. Cannot be treated by phlebotomy

C. Completely penetrant

D. More common in females

Ans: a.

22. A child presents with recurrent episodes of lip and laryngeal edema and abdominal pain associated with stress levels of which of the following are reduced.

A. C3

B. C5a

C. C1 estease inhibitor

D. C9

Ans: c.

23. Best test for initial malabsorption –

A. D-xylose test

B. NBT-PABA Test

C. Fecal fatestimation

D. Schilling test

Ans: a.

24. Cardiovascular complications of HIV infection include all of the following except –

A. pericardial effusion

B. Cardiac tamponade

C. Cardiomyopathy

D. Aortic Aneurysm

Ans: d.

25. Most sensitive test for Treponema –

A. VDRL

B. RPR

C. FTA-ABS

D. Kahn

Ans: c.

26. A 65 yrs old man with H/O back pain since 3 months. ESR is raised. On examination marked stiffness and mild restriction of chest movements is found. On x-ray, syndesmophytes are present in vertebrae. Diagnosis is –

A. Ankylosing spondylitis

B. Degenerative osteoarthritis of spine

C. Ankylosing hypersteosis

D. Lumbar canal stenosis

Ans: a.

27. All are common cause of childhood blindness except

A. Malnutrition

B. Glaucoma

C. Ophthalmia neonatorum

D. Congenital dacryocystitis

Ans: d.

28. Which of the following feature of thyroid nodule on USG is not suggestive of malignancy?

A. Hyperechogenecity

B. Hypoechogenecity

C. Non-homogenous

D. Microcalcification

Ans: a.

29. Leprosy involves all except:

A. uterus

B. Ovary

C. Nerve

D. Eye

Ans: a.

30. Disease not transmitted by Lice is:

A. relapsing fever

B. Trench fever

C. Q-fever

D. epidemic typhus

Ans: c.

Prepared by:

Kevin Wong

Anthony Chan

Intervarsity Games Performances Audition

Rules and Regulations

Anyone interested, or anyone who has any questions, please contact Rolo Khor, or Sidhar Sharm, or Mofar Rahman. 
Our FB links:
Mofar: http://www.facebook.com/mofar.rahman
Sidhar: http://www.facebook.com/sidhar.sharm
RoloKhor: http://www.facebook.com/Rein.Weissritter

MCQ Clinical Year Part2/10

Choose only ONE answer

11. Radiological features of left ventricular heart failure are all, except:

A. kerly B lines

B. cardiomegaly

C. oligenic lung fields

D. increased flow in upper lobe veins

Ans: c.

12. Hypersensitivity vasculitis affects –

A. Post-capillary venules

B. Arterioles

C. Veins

D. Medium-zised arteries

Ans: a.

13. Hyperextensibility with normal elastic recoil is a feature of –

A. Ehlers Danlos syndrome

B. Pseudoxanthoma elasticum

C. Cutis laxa

D. Scleroderma

Ans: a.

14. Which of the following about artherosclerosis is true?

A. Intake of PUFA associated with decreased risk

B. Thoracic aorta involvement is more severe than abdominal aorta involvement

C. Extent of lesion in veins is same as that in arteries

D. Hypercholesterolemia does not always increase the risk of atherosclerosis per se

Ans: a.

15. A girl presented with severe hyperkalemia and peaked T waves on ECG. Fasted way of shifting potassium intracellularly is –

A. calcium gluconate IV

B. oral resins

C. insulin + glucose

D. Sodium bicarbonate

Ans: c.

16. Features of hypocalcemia are A/E –

A. numbness & tingling

B. circumoral & paresthesis

C. depressed tendon reflexes

D. skin irritability & sensitivity

Ans: c.

17. Cause of vasodilatation in spider nevi –

A. estrogen

B. testosterone

C. Hepatotoxins

D. FSH

Ans: a.

18. A patient presented with arthritis and purpura. Laboratory examination showed monoclonal and polyclonal cryoglobulins. Histopathology showed deposits of cryoglobins around the vessels. The patient should be tested for which of the following?

A. HBV

B. HCV

C. EBV

D. parvovirus

Ans: b

19. Rapid infusion of insulin causes –

A. hyperkalemia

B. hypokalemia

C. hypernatremia

D. hyponatremia

Ans: b.

20. Digitalis toxicity enhanced by A/E –

A. renal failure

B. Hyperkalemia

C. hypercalcemia

D. hypomagnesemia

Ans: b.

Prepared by:

Kevin Wong

Anthony Chan