QUESTION the Correct Dose Is 60Mg Daily

1

PROGRESS TEST JUNE 1998

1 GIVEN 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

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

3 The daily requirement for fluid and electrolytes of an adult weighing 70Kg is 25003000mi of water, 150mmol of sodium and 60mmol of potassium

4 GIVEN 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

5 A Coroner's inquest will only be held if death occurred before the usual age of retirement

6 A standardised mortality ratio (SMR) can only be estimated if the age distribution of population is known

7 Thiazide diuretics decrease renal HC03 excretion

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

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

10 Nicotinecontaining chewing gum is available on NHS prescriptions

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

12 GIVEN: 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

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

14 Prostacyclin (PG12) is synthesised in mast cells

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

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

17 Haemosiderin consists of aggregates of ferritin molecules

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

19 Macrophages are antigenpresenting cells

20 GIVEN The renal clearance of benzylpenicillin is greater than that of gentamicin

QUESTION Benzyl penicillin has a shorter plasma concentration halftime than gentamicin

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

22Plasmin is essential for normal thrombus retraction

23In a normal subject, sitting upright, apical and basal regions of the lungs receive

approximately equal blood flows

24Neutrophil polymorphonuclear leucocytes are typically seen at the site of acute

inflammation

25GIVEN Cardiomegaly and pulmonary congestion are characteristic radiological features of

cardiac failure

QUESTION These findings indicate that the patient has heart muscle disease

(cardiomyopathy)

26GIVEN 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

27GIVEN 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

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

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

30GIVEN A patient with pernicious anaemia will show red cell macrocytosis caused,

indirectly, by a deficiency of intrinsic factor and consequent Vitamin 13,2 malabsorption

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

anaemia and macrocytosis

31GIVEN 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

32GIVEN 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

33GIVEN 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

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

35GIVEN 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

36For anything other than the treatment of a lifethreatening condition, a general anaesthetic

should not be administered within six months of acute myocardial infarction
37GIVEN 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

38A 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

39In patients with asthma, a fall in the peak expiratory flow rate (PEFR) to 60% of their best

value is an indication for oral steroid therapy

40Theophylline toxicity can be precipitated byerythromycin

41In an adult, acute breathlessness occurring at night is most commonly due to left

ventricular failure

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

hypoproteinaemia

43Expiratory crackles are typically heard in fibrosing alveolitis

44Atenolol is less likely than propranolol to produce unpleasant dreams

45Vitamin B12 is likely to be necessary for the treatment of anaemia after pregnancy

46Pleural biopsy is the best method of diagnosing pleural tuberculosis

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

Department

QUESTION A chest xray should be performed to exclude pneumothorax

48GIVEN A patient with chronic obstructive airways disease suffers cardiac arrest

QUESTION Oxygen should be prescribed at the highest possible delivery rate

49Hyperventilation can compensate for mild metabolic acidosis

50Patients travelling to malarious areas should not be given mefloquine

51GIVEN 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

52Pyrexia of unknown origin is defined as a fever of 38% or more on two occasions over

three days, with a negative blood culture

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

of the stethoscope

54Abdominal aortic aneurysm often presents with symptoms of peripheral embolism

55Sickle cell anaemia causes splenomegaly in adults

56A pigmented skin lesion should be removed if depigmentation occurs

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

58The blood in glandular fever characteristically shows atypical lymphocytes

59Infection with papilloma virus can be reliably detectedon examination of a cervical smear

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

61Xlinked Duchenne muscular dystrophy presents as floppiness at birth

62Karyotype 46XX is present in testicular feminisation

63The UK National Breast Cancer Screening Programme is less likely to detect slowly

growing tumours than rapidly growing tumours

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

65GIVEN 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

66Type 1 hypersensitivity is classically seen in tuberculosis

67In untreated diabetes mellitus, urine is usually alkaline

68Dopamine receptors in the renal vasculature mediate vasoconstriction

69Glomerular filtration rate increases when renal afferent arterioles dilate

70Intercurrent infection typically precipitates hypoglycaemic episodes in a diabetic patient

71Secondary hype rpa rathyroid ism is a cause of hypercalcaemia

72The absorption of a drug taken by mouth is most likely to be complete when the drug

molecule is soluble in water

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

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

drug

75Gastric carcinoma is a frequent complication of chronic gastric ulcer

76The majority of dietary iron is absorbed

77Pain complicating cancer may be reduced by nonsteroidal antiinflammatory drugs

78Gold injections (sodium aurothiomalate) are potentially nephrotoxic when given to a patient

with normal renal function

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

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

81In a jaundiced patient, percutaneous transhepatic cholangiography should be delayed until

a coagulation screen has been completed

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

83 Growth hormone increases blood glucose concentration

84 Triiodothyronine is formed mainly in plasma

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

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

87 Vomiting in adults involves an increase in intraabdominal pressure

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

89 Pancreatic juice contains maltase

90 Glomerular filtration rate (GFR) decreases when plasma protein concentration decreases

91 T lymphocytes are the source of 19M in the plasma

92 GIVEN Thyroxine is a cardiac stimulant QUESTION Thyrotoxicosis does not cause cardiac failure

93 Core temperature can effect the response to defibrillation

94 Thyroid swellings often cause dysphagia for solids

95 GIVEN A patient present with clinically malignant lymph nodes in the neck QUESTION The primary tumour is most probably in the head and neck region

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

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

98 Salivary calculi are most common in the submandibular gland

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

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

101 Hypoglycaemia is uncommon in well controlled diabetes mellitus

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

103The visual disturbance usually associated with a hemianopia pituitary tumour is a homonymous

104Patients with Cushing=s syndrome may complain of difficulty in climbing stairs

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

106Osteoporosis is a consequence of hypogonadism in men

107GIVEN 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

108Bisphosphonate drugs are effective in correcting malignant hypercalcaemia

109GIVEN Thiazide diuretics reduce urinarycalcium excretion

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

110All type 11 diabetic patients taking oral hypoglycaemic agents and due to have an operation under general anaesthesia should be switched to soluble insulin preoperatively

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

112Acute pyelonephritis may be treated with ciprofloxacin

113Chlamydia trachomatis is sensitive to amoxycillin

114Dentures are the most common predisposing factor to oral candidal infection

115Recurrent aphthous ulceration usually indicates an underlying haematological problem

116GIVEN 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

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

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

119Uterine prolapse is associated with urinary incontinence

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

Department. The core body temperature is 350C

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

10 minutes

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

122Mouth pigmentation is a frequent accompaniment of alcoholic liver disease

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

124Anal fissure is associated with Crohn=s disease

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

126The product of the normal p53 gene promotes apoptosis

127Postpartum hypopituitarism is associated with thick coarse skin

128Constipation is a common cause of abdominal pain in childhood

129Congenital hypertrophic pyloric stenosis causes bile stained vomitus

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

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

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

133Emotional deprivation is a cause of short stature

134Polyhydramnios is associated with fetal renal agenesis

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

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

137Acute osteomyelitis can present with a complaint of limb paralysis

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

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

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

141Puerperal breast infection is best treated by aspiration

142In labour normal uterine contractions increase placental blood flow

143Sodium cromoglycate is poorly absorbed after oral administration

144Foveal function determines the level of visual acuity

145Ageing causes reduction in pupil size

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

147Before birth the chief site of haemopoiesis is the spleen

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

149Phenyiketonuria is inherited as an autosomal dcminant trait

150A mother breast~feeding 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

151A high intake of pasteurised cows' milk can contribute toiron deficiency

152The 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

153GIVEN 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

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

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

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

157Luteinizing hormone stimulates Sertoli cells in the testis

158ASmall for gestational age= is a term applied to babies with a birth weight of below the 25th centile

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

160GIVEN MMR vaccine contains live attenuated viruses

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

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

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

163The majority of girls with Turner's syndrome are of normal stature

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

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

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

167Conjugated hyperbilirubinaemia may be a feature of neonatal sepsis

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

169HIV infection may lead to rapidly progressive periodontal disease

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

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

172Stones in the common bile duct may cause acute pancreatitis

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

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

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

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

176GIVEN 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

177Cancer of the breast typically arises from a fibroadenoma

178GIVEN 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

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

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

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

182Ultrasonography at 16 to 18 weeks of gestation is able to establish gestational age to

within an accuracy of two weeks

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

184In postmenopausal women, the introduction of hormone replacement therapy (HRT) can

lead to the return of regular periods

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

186Appendicitis does not occur under the age of 5 years

187In a child with abdominal distension and faecal retention, Hirschsprung=s disease should

be considered

188GIVEN A child with severe cerebral palsy has difficulty in exploring the environment

QUESTION This will not affect language development

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

190Agoraphobia is an abnormally intense dread of situations in which other people are present

191Euphoria is a feature of Parkinson's disease

192In cognitive behavioural counselling, the counsellor discourages the client from viewing

negative beliefs as hypotheses to be tested

193Aspirin overdose is characterised by metabolic alkalosis

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

195Renal failure is a common feature of paracetamol overdose

196Damage to Wernicke's area results in expressive dysphasia

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

198Patients with carotid stenosis may benefit from antiplatelet therapy

199Retrograde memory loss following head injury usually recovers completely

200Amaurosis fugax is associated with atrial fibrillation

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

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

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

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