MCEM Clinical Knowledge MCq

MCEM CLINICAL KNOWLEDGE MCQ

1. Wound infection (a) Infections occur in approximately 7 to 10 percent of traumatic wounds repaired in EDs True FalseInfections occur in approximately 3 to 5 percent of traumatic wounds repaired in EDs (b) Crush injuries are less at risk of wound infection. True FalseCrush injuries are more at risk of wound infection. (c) Puncture are more at risk of wound infection. True FalsePunctures are more at risk of wound infection. (d) Avulsion wounds are more at risk of wound infection. True FalseAvulsion wounds are more at risk of wound infection. (e) Amoxicillin-clavulinic acid is a reasonable choice for prophylaxis against wound infections. True FalseAs most non-bite wound infections are due to staph or strep.

2. Hyponatremia causes: (a) Hyperlipidaemia. True FalsePseudohyponatremia.(b) Hepatic Cirrhosis. True FalseOedema and water retention. (c) Lithium therapy. True FalseCauses a water diuresis in excess of Na(anti-ADH).(d) Diarrhoea. True False

(e) Diabetes Insipidus. True False

3. Fainting or Syncope: (a) Causes loss of consciousness due to cerebral ischaemia True FalseThis is the definition of the condition (b) May be cerebral in origin True FalseAs in psychological vasovagal syncope(c) May be cardiac in origin True FalseDue to abnormal rhythm or brief asystole(d) Is more likely in cold rather than hot environments True FalseHeat favours vasodilation and a drop in blood pressure. (e) Results from sympathetic vasoconstriction in skeletal muscles True FalseSympathetic vasodilation is the vaso of vasovagal

4. Heart failure (a) Patients with breathlessness at rest have NYHA heart failure class 1 True FalsePatients with breathlessness at rest have NYHA heart failure class IV, Class 1 = No breathlessness, Class 2 = Breathlessness on severe exertion, Class 3 = Breathlessness on mild exertion (b) Patients with breathlessness at mild exertion have NYHA heart failure class 2 True FalseClass 1 = No breathlessness, Class 2 = Breathlessness on severe exertion, Class 3 = Breathlessness on mild exertion, Class 4 = breathlessness at rest (c) Patients with breathlessness at severe exertion have NYHA heart failure class 3 True FalseClass 1 = No breathlessness, Class 2 = Breathlessness on severe exertion, Class 3 = Breathlessness on mild exertion, Class 4 = breathlessness at rest (d) There is a higher BNP increase in women than men. True FalseThere is a higher BNP increase in women than men.(e) BNP decreases with age True FalseBNP increases with age.

5. Mitral Stenosis (a) Murmur is decrescendo diastolic True False

(b) Atrial fibrillation is uncommon True False

(c) Features of RVH on ECG are common True False

(d) Rheumatic heart disease is the commonest cause True False


(e) The most common symptom is exertional dyspnoe True FalseMITRAL STENOSIS Aetiology - Rheumatic heart disease most common, others congenital, SLE (Libman's Sacks) Pathophysiology - 1. obstruction to L atrial emptying (L atrial hypertrophy, AF (80%), pulmonary hypertension, RVH), 2. Impaired L ventricular filling Symptoms - exertional dyspnea (80%), hemoptysis, fatigue Signs - malar flush, AF, raised JVP with prominent a waves, tapping apex, R venticular heave, loud P2 Murmur - low pitched rumbling mid diastolic murmur with presystolic accentuation (if in SR) best heard in the mitral area on the left side after exercise with no radiation and associated with a loud 1st S1 and an opening snap. ECG - AF/broad bifid p waves, RVH (upright QRS in V1, RAD) CXR - LA enlargement, mitral valve calcification, upper lobe vascular redistribution, Kerley B lines

6. The Spinal Cord: (a) There are 31 pairs of spinal nerves. True FalseThere are 31 pairs of spinal nerves. (b) There is usually 1 pair of coccygeal nerves. True FalseThere is usually 1 pair of coccygeal nerves. (c) There are 5 pairs of sacral nerves. True FalseThere are 5 pairs of sacral nerves.(d) There are 11 pairs of thoracic nerves. True FalseThere are 12 pairs of thoracic nerves. (e) There are 7 pairs of cervical nerves. True FalseThere are 8 pairs of cervical nerves. The spinal cord gives rise to 31 pairs of spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal

7. Lateral medullary syndrome: (a) Is caused by infarction of the posterior inferior cerebellar artery. True FalseLateral medullary syndrome is caused by infarction of the posterior inferior cerebellar artery. (b) Is characterised by contralateral pain and temperature abnormality. True FalseLateral medullary syndrome is characterised by contralateral pain and temperature abnormality. (c) Is characterised by ipsilateral loss of gag, hoarseness and swallowing difficulties. True FalseLateral medullary syndrome is characterised by ipsilateral loss of gag, hoarseness and swallowing difficulties. (d) Nausea, nystagmus and vomiting are not a feature. True False

(e) Has a contralateral horners syndrome associated. True FalseLateral medullary syndrome is caused by infarction of the posterior inferior cerebellar artery.Is characterised by contralateral pain and temperature abnormality(spinothalamic tract) and ipsilateral loss of gag, hoarseness and swallowing difficulties(glossopharyngeal and vagus )Nausea, nystagmus and vomiting are a feature(vestibulocochlear dysfunction) and ipsilateral horners syndrome(descending sympathetic disruption).

8. Leukaemia classification; acute and chronic lymphoblastic leukaemia; acute and chronic myeloid leukaemia (a) Blast cells usually do not show any evidence of differentiation to granulocytes in AML. True FalseBlast cells usually show some evidence of differentiation to granulocytes in AML (b) CLL affects males to females in a ratio of 4:1 True FalseCLL affects males to females in a ratio of 2:1 (c) In CLL the leucocytosis is usually from the T lymphocytes True FalseIn CLL the leucocytosis is usually from the B lymphocytes (d) Anaemia and thrombocytopenia are early developments in CLL True FalseAnaemia and thrombocytopenia are late developments in CLL (e) There is a mean survival of 10 years in CGL True FalseThere is a mean survival of 4 years in CGL

9. Pattern Of Breathing:(a) In a large consolidation chest wall movement is reduced on the affected side, , there is mediastinal displacement away from the affected side, the percussion note is dull, breath sounds are bronchial,

True False


and fine carackles may be heard.In a large consolidation chest wall movement is reduced on the affected side, , there is no mediastinal displacement, the percussion note is dull, breath sounds are bronchial, and fine carackles may be heard. (b) In a pleural effusion ( >500 ml ) chest wall movement is reduced on the affected side, the mediastinum is deviated away from the lesion, the percussion note is stony dull, breath sounds may be vesicular reduced or absent, and there are no added sounds.

True False

In a pleural effusion ( >500 ml ) chest wall movement is reduced on the affected side, the mediastinum is deviated away from the lesion, the percussion note is stony dull, breath sounds may be vesicular reduced or absent, and there are no added sounds. (c) In a large pneumothorax chest wall movement is reduced on the affected side, the mediastinum is deviated away from the lesion, the percussion note is hyperresonant, breath sounds are reduced or absent, and there prolonged expiratory wheeze.

True False

In a large pneumothorax chest wall movement is reduced on the affected side, the mediastinum is deviated away from the lesion, the percussion note is hyperresonant, breath sounds are reduced or absent, and there is no added sounds. (d) In Asthma chest wall movement is reduced on both sides, there is no mediastinal displacement, the percussion note is hyperresonant, breath sounds may reveal a prolonged expiration and there may be expiratory polyphonic wheeze.

True False

In Asthma chest wall movement is reduced on both sides, there is no mediastinal displacement, the percussion note is normal, breath sounds may reveal a prolonged expiration and there may be expiratory polyphonic wheeze (e) In COPD chest wall movement normal, there is no mediastinal displacement, the percussion note is normal, breath sounds may reveal a prolonged expiration and there may be expiratory polyphonic wheeze and coarse crackles.

True False

In COPD chest wall movement is reduced on both sides, there is no mediastinal displacement, the percussion note is normal, breath sounds may reveal a prolonged expiration and there may be expiratory polyphonic wheeze and coarse crackles.

10. Optic Neuritis(a) Is a rare cause of visual reduction due to optic nerve disease in the 20-40 age group. True FalseIs a common cause of visual reduction due to optic nerve disease in the 20-40 age group (b) Pain is no worse with eye movement. True FalsePain is worse with eye movement. (c) The affected eye will see darker shades of red in comparison to the unaffected eye. ( when looking at the same red object one eye at a time )

True False

The affected eye will see lighter shades of red in comparison to the unaffected eye. ( when looking at the same red object one eye at a time ) (d) There is sometimes an afferent pupillary defect on the unaffected eye. True FalseThere is an afferent pupillary defect of the affected eye. (e) All patients should be started on steroids without delay as this improves visual outcome at 1 year. True FalseThere is no difference in visual outcome at 1 year if patients are treated with steroids or not.

11. Reflexes (a) Biceps jerk-C5/C6 True False

(b) Triceps Jerk-C7 True False

(c) Abdominal Reflex T8-T12 True False

(d) Ankle Jerk L1-L2 True FalseAnkle Jerk S1-S2 (e) Bulbocavernosus reflex S1-S2 True False

12. Causes of encephalitis include:(a) Mumps virus True False

(b) Coxsackie virus True False


(c) Influenza A virus True False

(d) Hepatitis A virus True False

(e) Adenovirus True FalseThe usual organisms cultured include from adults include herpes simplex, echo, coxsackie, mumps, and EBV. Adenoviruses, varicella zoster, influenza, measles and others are rarer causes. Clinical features include fever, headache, mood change and drowsiness, and these may be accompanied by focal neurological signs, seizures and coma.

13. The following bacteria are associated with food poisoning: (a) Helicobacter pylori. True False

(b) Clostidium perfringes. True FalseAssociated with meat based foods. (c) Staphylococcus aureus. True FalseMediated by enterotoxins which are secreted into the food. (d) Pseudomonas aeruginosa. True FalsePseudomonas may cause food spoilage but are not associated with acute food poisoning.(e) Bacillus Cereus. True FalseBacillus cereus is associated with re-heated rice.

14. The oxyhaemoglobin dissociation curve: (a) Is shifted to the right in chronic anaemia. True FalseThe oxyhaemoglobin dissociation curve is shifted to the right in chronic anaemia.(b) Is shifted to the left in pulmonary capillaries. True FalseThe oxyhaemoglobin dissociation curve is shifted to the left in pulmonary capillaries. (c) Is shifted to the left in hypoventilation. True False

(d) Is unaffected by temperature. True False

(e) Is shifted to the right in carbon monoxide poisoning. True FalseThe oxyhaemoglobin dissociation curve is shifted to right if increase in acidity, PCO2 ,temp, 2,3 DPG(chronic anaemia), altitude.

15. Patients with anorexia nervosa should be admitted in the following circumstances: (a) Weight loss >30% in 3 months. True False

(b) BMI < 15. True FalseBMI is not a criteria for determining admission usually however BMI <13 is used in some jurisdictions as an arbitory cut off for admission for consideration of refeeding. (c) Bradycardia. True False

(d) Brittle hair and nails. True FalseThis may be longstanding. (e) Pedal or pretibial oedema. True FalseAgain this may be longstanding.


The glasgow coma scale (a) Motor response is scored at 2 out of 6 if the patient has decorticate posturing. False ? (b) Motor response is scored at 3 out of 6 if the patient has decerebrate posturing. False ? (c) Verbal response is scored at 4 out of 5 if the patient is speaking nonsensically. False ? (d) Eye opening is scored at 4 out of 5 if eye opening is to speech False ? (e) Motor response is scored at 5 out of 6 if the patient localises to pain. True ? Motor Response 1 = No Response, 2 = Decerebrate extension, 3 = Decorticate flexion, 4 = Movement or withdrawal to pain, 5 = Localizes to pain, 6 = Follows Commands Verbal Response 1 = No Response, 2 = Moans or unintelligible, 3 = speaking but nonsensical, 4 = Disorientated conversation, 5 = Alert and Orientated Eye Opening 1 = No Response, 2 = To Pain, 3 = To speech, 4 = Spontaneous


Which of the following are true: (a) The aortic opening in the diaphragm is posterior to the median arcuate ligament and transmits the azygous but not the hemiazygous vein. False ?The aortic opening in the diaphragm is posterior to the median arcuate ligament and transmits the azygous and hemiazygous veins (b) The caval opening transmits the thoracic duct. False ?The aortic opening transmits the thoracic duct. (c) The origin of the coeliac axis is at T12 True ?The origin of the coeliac axis is at T12 (d) L4 is crossed by the transpyloric plane of addison ( half way between the suprasternal notch and the symphysis pubis.) False ?L1 is crossed by the transpyloric plane of addison ( half way between the suprasternal notch and the symphysis pubis.) (e) The vagi pierce the diaphragm at T12 along with the oesophagus False ?The vagi pierce the diaphragm at T10 along with the oesophagus


Diarrhoea: (a) The incubation period for salmonella is up to 48 hours. True ?The incubation period for salmonella is up to 48 hours. (b) Verotoxin producing strains of E Coli may cause bloody diarrhoea. True ?Verotoxin producing strains of E Coli may cause bloody diarrhoea (c) Vibrio Cholerae is associated with bloody diarrhoea. False ?This usually causes an enteritis which does not cause blood. (d) Campylobacter jejuni infection may present with blood and mucus pr. True ?Severe cases may present with blood and mucus (e) Giardia Lamblia usually causes bloody diarrhoea. False ?Infection is confined to the duodenum and jejenum in giardia lamblia.


Anatomical considerations: (a) T1 is the first clearly palpable spinous process. False ?C7 is the first clearly palpable spinous process. (b) The superior border of the scapula is at T1 False ?The superior border of the scapula is at T2 (c) The suprasternal notch is at the level of T1/2 False ?The suprasternal notch is at the level of T2/3 (d) The end of the oblique fissure of the lung is at the spine of T2 False ?The end of the oblique fissure of the lung is at the spine of T3 (e) The pharynx becomes the oesophagus at C4 False ?The pharynx becomes the oesophagus at C6


Contraindications to Immediate Excercise Stress Testing: (a) Ischaemic ECG changes True ?Ischaemic ECG changes, and obvious unstable angina are contraindications. (b) Uncontrolled Hypertension True ?Uncontrolled Hypertension is a contraindication (c) Uncompensated Heart Failure True ?Uncompensated Heart Failure is a contraindication (d) Aortic Stenosis is not a contraindication. False ?Aortic Stenosis is a contraindication (e) Dysrhythmias True ?


Leukaemia ? classification; acute and chronic lymphoblastic leukaemia; acute and chronic myeloid leukaemia (a) The neoplastic cell in AML is the megakaryocyte precursor cell. False ?The neoplastic cell in AML is the granulocyte/monocyte precursor cell. (b) There is a 50% cure rate in AML with standard chemotherapy False ?There is a 20-25% cure rate in AML with standard chemotherapy (c) There is a 50% cure rate in AML with allogenic bone marrow transplant. True ?There is a 50% cure rate in AML with allogenic bone marrow transplant. (d) Blast cells usually show some evidence of differentiation to megakaryocytes in AML False ?Blast cells usually show some evidence of differentiation to granulocytes in AML (e) AML is the rarest form of leukaemia in adults False ?AML is the commonest form of acute leukaemia in adults


Back Pain:Lumbar Spinal/Lateral recess stenosis (a) Pain is worse on walking True ? (b) Straight leg raising is positive False ?Negative (c) Is usually associated with CNS signs False ?Few CNS signs (d) The normal lateral recess is 3-5mm True ?And in spinal stenosis this is narrowed to 2mm or less (e) Corsets work by prevention of the exaggeration of lumbar lordosis on standing True ?


In cerebrovascular disease: (a) Stroke mortality rates increases with age. True ?Geometric progression. (b) Cerebrovascular disease is more common in social classes four and five than in higher social classes. True ?Several studies using different study designs and various definitions of socioeconomic status have shown that stroke incidence increases with decreasing socioeconomic status. Kurth T, Berger K, The Socioeconomic Stroke Puzzle Stroke. 2007;38:4-5 (c) Following a stroke, death usually occurs within 4 or 5 days when unconsciousness is prolonged. True ?Poor prognosis when consciousness is not regained. (d) The presence of polycythaemia is a predisposing factor for stroke. True ?Other factors include diabetes mellitus and hypertension. (e) TIA's with motor symptoms are more likely to progress to stroke. True ?Also the age of the patient and duration of symptoms.


Hypercalcaemia: Signs and Symptoms (a) Diarrhoea False ?Hypercalcaemia is a cause of constipation. (b) Urinary retention False ?Thirst and polyuria. (c) Confusional state True ? (d) Carpopedal spasm False ?Carpopedal spasm is associated with hypocalcaemia. (e) Tetany False ?Tetany is associated with hypocalcaemia and is most commonly seen in CRF patients after elective subtotal parathyroidectomy.


Infective Endocarditis ( IE ) : (a) Patients with a VSD are particularly susceptible to endocarditis affecting the right side of the heart. False ?IV drug abusers are particularly susceptible to endocarditis affecting the right side of the heart as are patients with nutritionally deficient states. (b) Coxiella burnetti is a likely organism to cause infective endocarditis soon after prosthetic valve surgery. False ?Coagulase negative staph is the most likely organism to cause infective endocarditis soon after prosthetic valve surgery. (c) A typical antibiotic regime for IE caused by strep viridans is ciprofloxacin and vancomycin False ?A typical antibiotic regime for IE caused by strep viridans is gentamicin and benzylpenicillin (d) A typical antibiotic regime for IE caused by staphylococci is gentamicin and benzylpenicillin. False ?A typical antibiotic regime for IE caused by staphylococci is gentamicin and flucloxacillin (e) For penicillin allergic patients a typical regime may be vancomycin and gentamicin. True ?For penicillin allergic patients a typical regime may be vancomycin and gentamicin


The lumbar plexus: (a) The femoral nerve originates from the lumbar plexus from L1 and L2 False ?The lumbar plexus is formed by the anterior rami of the upper four lumbar nerves.The femoral nerve originates from the lumbar plexus from L2, L3 and L4 (b) The obturator nerve originates from L2, L3 and L4 True ?The obturator nerve originates from L2, L3 and L4 (c) It is situated within the iliacus muscle. False ?It is situated within the psoas muscle (d) The obturator nerve innervates the abductors of the thigh and the skin on the medial surface of the thigh. False ?The obturator nerve innervates the adductors of the thigh and the skin on the medial surface of the thigh. (e) The lumbar plexus is formed by the anterior rami of the upper three lumbar nerves. False ?The lumbar plexus is formed by the anterior rami of the upper four lumbar nerves.


Beta Blocker Overdose (a) Ipecacuanha derivatives should be used immediately on suspicion of beta blocker overdose. False ?Emetics should not be used as cognitive decline can lead to aspiration. (b) Glucagon takes about 1 minute to reach maximum serum concentration. True ?Glucagon takes about 1 minute to reach maximum serum concentration. (c) The half life of glucagon is about 6 minutes True ?The half life of glucagon is about 6 minutes (d) Glucagon is an anti-emetic. False ?Nausea and vomiting are the commonly reported side effects of glucagon. Glucagon relaxes the lower oesphageal tone and this may be the cause. (e) 3-10mg for a 70kg man is a typical initial dose of glucagon in beta blocker toxicity. True ?3-10mg for a 70kg man is a typical initial dose of glucagon in beta blocker toxicity. This may be followed by a glucagon infusion.


Hypercalcaemia: (a) Can cause malaise, psychosis and occasionally coma. True Hypercalcaemia can cause malaise, psychosis and occasionally coma. (b) Can cause weakness and hyporeflexia. True Hypercalcaemia can cause weakness and hyporeflexia. (c) Does not involve the renal system. False (d) Is associated with pancreatitis. True Hypercalcaemia is associated with pancreatitis. (e) Can cause a long QT interval on ECG. False Clinical features of hypercalcaemia: 1.Psychic Moans- malaise, psychosis, coma 2.Muscle Tones-weakness and hyporeflexia. 3.Renal Stones- polyuria,polydipsia, nephrocalcinosis. 4.Abdominal Groans-Nausea, vomiting,pancreatitis, peptic ulcer disease. 5.Painful Bones- osteolysis 6.QT- short QT, bradyarrhythmias,sensitization to digitalis toxicity.


Seizures: (a) Diazepam has a high lipid solubility and therefore an ability to rapidly cross the blood-brain barrier. True ?Diazepam IV should not be given at a rate faster than 2.5mg/min. This is true as faster infusion rates carry a risk of sudden apnoea. Diazepam has a high lipid solubility and therefore an ability to rapidly cross the blood-brain barrier. It is highly effective in rapidly terminating seizures when administered at doses of 0.1 to 0.3 mg/kg intravenously. (b) A maximum of 40 mg diazepam can be given. True ?A maximum of 40 mg diazepam can be given. (c) Lorazepam is more likely to cause respiratory depression. False ?Lorazepam is less likely to cause respiratory depression. (d) A total of 8mg IV lorazepam can be given in 2mg to 4mg doses. True ?A total of 8mg IV lorazepam can be given in 2mg to 4mg doses. (e) In alcoholics there is a risk of precipitating Wernicke's encephalopathy by a glucose load. True ?So it is recommended to give IV pabrinex first of all.


Eye Trauma (a) A flat anterior chamber suggests a ruptured globe True ?A flat anterior chamber suggests a ruptured globe (b) A hyphema suggests significant ocular trauma True ?A hyphema suggests significant ocular trauma (c) Restricted upgaze suggests blow-out fracture with entrapment. True ?Restricted upgaze or lateral gaze suggests a blow out fracture with entrapment. (d) The sensation of the inferior orbital nerve is tested below the eye and on the ipsilateral side of the nose. True ?The sensation of the inferior orbital nerve is tested below the eye and on the ipsilateral side of the nose. (e) The pupil can be constricted or dilated after sustaining trauma. True ?The pupil can be constricted or dilated after sustaining trauma.


Abbreviated mental status includes: (a) Age. True ? (b) Time(to the nearest hour). True ? (c) Recall. True ? (d) Year. True ? (e) Name of hospital. True ? Also recognition of two people,date of birth,year of 1st world war,name of present monarch, count backwards from 20 to 1.


Neurological manifestations of hypothyroidism include (a) Woltmans sign True Woltmans sign is delayed deep tendon reflexes (b) Paranoia True Myxoedema madness (c) Cerebellar syndrome True Lancet 1960; ii:225 (d) Hoffmans syndrome True Muscle aches with myotonia in myxoedema (e) Deafness to high tones True Called trotters syndrome Trotter WR Br med bull 1960 16:92


Ureters (a) The blood supply in the upper end is supplied by the superior vesical artery. False ?The upper end is supplied by the renal arteries, the middle is supplied by the testicular or the ovarian artery and the inferior end is supplied by the superior vesical artery. (b) Stones are likely to become obstructed at the pelvic brim True ?Ureteric stones frequently arrest where the renal pelvis joins the ureter, where the ureter is kinked as it passes the pelvic brim and where the ureter pierces the bladder wall. (c) Lymph drainage is to the inguinal nodes. False ?Lymph drainage is to the lateral aortic and iliac nodes. (d) Each ureter measures approximately 25cm ( 10 inches ) in length True ?Each ureter measures approximately 25cm ( 10 inches ) in length (e) Each ureter passes into the posterior surface of the urinary bladder. True ?Each ureter passes into the posterior surface of the urinary bladder.


Type's of drug Reactions: (a) Type II reactions may cause fever, urticaria, arthropathy, lymphadenopathy and proteinuria. False ?Type III reactions may cause fever, urticaria, arthropathy, lymphadenopathy and proteinuria.Type II reactions because of a drug reacting with a circulating or membrane bound protein to cause production of an IgG or IgM antibody with subsequent complement activation. (b) Type III reactions do not cause eosinophilia False ?Type III reactions cause eosinophilia (c) Type II reactions activate the complement system via IgG and IgM True ?Type II reactions activate the complement system via IgG and IgM (d) Type I reactions cause coombs positive haemolytic anaemia. False ?Type II reactions cause coombs positive haemolytic anaemia. (e) Type I reactions are cell mediated hypersensitivity reactions caused by the formation of an antigen-protein complex and subsequent lymphocytic reaction. False ?Type IV reactions are cell mediated hypersensitivity reactions caused by the formation of an antigen-protein complex and subsequent lymphocytic reaction.


If the ulnar nerve is interrupted at the wrist the following muscles are not affected: (a) The first lumbrical True ?The first and second lumbricals are innervated by the median nerve. (b) The second lumbrical True ?The first and second lumbricals are innervated by the median nerve. (c) Opponens pollicis True ?Opponens pollicis is innervated by the median nerve. (d) Palmaris brevis . False ?Palmaris brevis is innervated by the superficial terminal branch of the ulnar nerve in the hand. (e) Abductor pollicis brevis True ?Abductor pollicis brevis is innervated by the median nerve.


IV fluid infusion: (a) If pressure of approximately 300mmHg is added to a bag of fluids which is running through an 18G cannula then the rate of fluids is approximately 100ml/min False ?If pressure of approximately 300mmHg is added to a bag of fluids which is running through an 18G cannula then the rate of fluids is approximately 120-180ml/min (b) If pressure of approximately 300mmHg is added to a bag of fluids which is running through an 16G cannula then the rate of fluids is approximately 150ml/min False ?If pressure of approximately 300mmHg is added to a bag of fluids which is running through an 16G cannula then the rate of fluids is approximately 200-250ml/min (c) If pressure of approximately 300mmHg is added to a bag of fluids which is running through an 14G cannula then the rate of fluids is approximately 200ml/min False ?If pressure of approximately 300mmHg is added to a bag of fluids which is running through an 14G cannula then the rate of fluids is approximately 250-300ml/min (d) If a pressure of approximately 300mmHg is added to a bag of fluids which is running through an 8.5 Fr central venous line up to 500ml of fluid can be infused per minute. True ?If a pressure of approximately 300mmHg is added to a bag of fluids which is running through an 8.5 Fr central venous line up to 500ml of fluid can be infused per minute. (e) If no pressure apart from gravity is added to a bag of fluids which is running through an 8.5 Fr central venous line about 200ml/min can be infused. True ?If no pressure apart from gravity is added to a bag of fluids which is running through an 8.5 Fr central venous line about 200ml/min can be infused.


The Brachial Plexus: (a) The musculocutaneous nerve is made up from C5 , C6 , C7 , and C8 False ?The musculocutaneous nerve is made up from C5 , C6 , and C7 (b) The medial cord and the lateral cord form the median nerve True ?The medial cord and the lateral cord form the median nerve (c) The dorsal scapular nerve ( C5 ) supplies the rhomboid muscles True ?The dorsal scapular nerve ( C5 ) supplies the rhomboid muscles. (d) The ulnar nerve is largely made up from C5 and C6 fibres. False ?The ulnar nerve is largely made up from C8 and T1 fibres. (e) The axillary nerve is given off by the medial cord. False ?The axillary nerve is given off by the posterior cord.


Pisiform Fractures: (a) It is a sesamoid bone within the flexor carpi ulnaris tendon. True ?It is a sesamoid bone within the flexor carpi ulnaris tendon. (b) There is tenderness at the base of the hypothenar eminence. True ?There is tenderness at the base of the hypothenar eminence. (c) Treatment consists of a volar splint at 30 degrees flexion with ulnar deviation to relieve tension on the tendon. True ?Treatment consists of a volar splint at 30 degrees flexion with ulnar deviation to relieve tension on the tendon. (d) Pisiform fractures may involve a direct blow to the ulnar aspect of the wrist. True ?Pisiform fractures may involve a direct blow to the ulnar aspect of the wrist. (e) Pisiform fractures may involve forceful hyperextension, as in a fall on an outstretched hand. True ?Pisiform fractures may involve forceful hyperextension, as in a fall on an outstretched hand. Pisiform fractures usually involve either a direct blow to the ulnar aspect of the wrist or forceful hyperextension, as in a fall on an outstretched hand. On clinical examination, the diagnosis is suggested by pain and tenderness with direct palpation of the pisiform.


Delirium Tremens: (a) Diazepam is an inappropriate agent for management of alcohol withdrawals. False ?Long acting benzodiazepines such as diazepam/ chlordiazepoxide are the most commonly used agents for the management of alcohol withdrawals. (b) DTs have a mortality rate of 50% if untreated. False ?35% mortality rate in the untreated. (c) DT's have a mortality rate of 1% if treated. False ?Mortality rate is 5 % even when treated. (d) There is no role for the use of antipsychotics in the management of the DT's False ?Antipsychotics can be very useful in severe cases especially haloperidol. (e) Formication is a described feature of delerium tremens. True ?Formication is the tactile hallucination of insects crawling under ones skin.


Vertebrae (a) The vertebral arch is made up of two pedicles, two laminae, and seven processes True ?The vertebral arch is made up of two pedicles, two laminae, and seven processes (one spinous, two transverse, and four articular). (b) Each disk consists of a peripheral annulus fibrosus and a central nucleus pulposus True ?Each disk consists of a peripheral annulus fibrosus and a central nucleus pulposus (c) The annulus fibrosus is composed of fibrocartilage. True ?The annulus fibrosus is composed of fibrocartilage. (d) The nucleus pulposus is made of water and cartilage fibers. True ?The nucleus pulposus is made of water and cartilage fibers. (e) With increasing age the porportion of fibrocartilage to water increases. True ?With increasing age the porportion of fibrocartilage to water increases.


In dental abscess (a) Toothache is throbbing. True ?And severe, possibly with fever. (b) The tooth is sensitive to cold but not to hot stimuli. False ?It is sensitive to both. (c) Cervical lymph glands may become enlarged and tender. True ?And the face is swollen on the affected side. (d) NSAIDS are ineffective as analgesics. False ?They will help relieve the pain. (e) A suitable antibiotic to use would be amoxicillin. True ?Or flucloxacillin.


Panic Disorder (a) Has a lifetime prevalence of 10% False ?Has a lifetime prevalence disorder of 3-4% (b) Symptoms usually begin in the teens 20's and 30's True ?Symptoms usually begin in the teens 20's and 30's. Women are 2-3 times more likely than men to be affected. (c) Symptoms often peak at 1 hour False ?Symptoms often peak at 10 min. (d) Somatic symptoms include paraesthesia. True ?Shortness of breath, palpitations, chest pain, weakness, nausea. (e) Chlordiazepoxide is short acting benzodiazepine. False ?Chlordiazepoxide is a long acting benzodiazepine.


Cyanosis (a) Is visible when the deoxyhaemoglobin is 2 g/dL. False ?Cyanosis is characterisitically thought to be evident when the deoxyhaemoglobin is 5g/dL. (b) Because cyanosis reflects the amount of deoxyhaemoglobin then a low overall Hb will make cyanosis more difficult to detect. True ?Because cyanosis reflects the amount of deoxyhaemoglobin then a low overall Hb will make cyanosis more difficult to detect( if the Hb available is bound to oxygen )The amount of oxygenated blood is of little value. (c) The tongue is considered one of the most sensitive sites for observing central cyanosis. True ?The tongue is considered one of the most sensitive sites for observing central cyanosis. (d) The skin is affected in peripheral cyanosis but the mucous membranes are not. True ?The skin is affected in peripheral cyanosis but the mucous membranes are not. (e) Central cyanosis is seen under conditions where there is abnormal haemoglobin. True ?Central cyanosis is seen under conditions where there is abnormal haemoglobin or where the haemoglobin is not saturated.


Congestive heart failure in end stage renal disease (a) Peritoneal dialysis is a useful treatment inpateints with pulmonary oedema and fluid overload False ? (b) Is most commonly caused by causes other than uraemic cardiomyopathy True ? (c) ACE inhibitors are contraindicated False ? (d) Frusemide is a useful treatment for pulmonary oedema even if urine output is minimal True ? (e) The presence of pulmonary oedema always indicates fluid overload False ? There are many causes for congestive heart failure in ESRD with hypertension and IHD both being more common than uremic cardiomyopathy. Fluid overload in ESRD is a common cause of congestive heart failure but not always a requirement for pulmonary edema. Management follows similar lines to standard treatment in non-ESRD patients. Frusemide is effective even in patients with minimal urine output because of its pulmonary vasodilator effect. Hemodialysis is the ultimate treatment for fluid overload (Peritoneal dialysis is ineffective) other options include phlebotomy.


NICE Guidelines: The following are considered dangerous mechanisms of injury when assessing for the requirement for cervical spine films (a) Fall of 4 steps. False ?A fall of 5 steps or 1 metre is considered a dangerous mechanisms of injury when assessing for the requirement for cervical spine films. (b) Diving. True ?Diving causes an axial load to head. (c) Rollover motor vehicle accident. True ?A rollover or a high speed motor vehicle accident. (d) Bicycle collision. True ? (e) Accident involving motorised recreational vehicles. True ?


Heart Murmurs (a) Mitral stenosis is a rumbling mid diastolic murmur with an opening snap True ? (b) Mitral valve prolapse has a late systolic murmur True ? (c) Aortic Regurgitation has a collapsing pulse True ? (d) Aortic regurgitation has a wide pulse pressure True ? (e) Aortic Regurgitation has a high pitched early diastolic murmur True ?


Endotoxin (a) Is a lipopolysaccharide. True ?Endotoxin is a lipopolysaccharide. (b) Is found in the cell wall of gram positive bacteria False ?Is found in the cell wall of gram negative bacteria. (c) Can cause intravascular coagulation True ?Endotoxin can cause intravascular coagulation. (d) Listeria produces an endotoxin-like toxins. True ? (e) Endotoxin can cause hypotension. True ?Endotoxin can cause hypotension. Endotoxin is a lipopolysaccharide (LPS) in the cell wall of gram negative bacteria. It is reponsible for many of the features of septicaemic shock, namely hypotension, fever , intravascular coagulation. The effects of endotoxin are mediated through the release of tumor necrosis factor.


Hyphaema: (a) Traumatic hyphemas usually are the result of bleeding from a ruptured iris root vessel. True ?Traumatic hyphemas usually are the result of bleeding from a ruptured iris root vessel. (b) Are never spontaneous. False ?Hyphaemas may be spontaneous or secondary to trauma.Spontaneous are associated with clotting diseases. (c) The pupils should not be dilated. False ?Dilating the pupil will avoid recurrent dilating and constriction in response to the changing light. (d) Topical alpha adrenergic antagonists may be used to control intra ocular pressure. False ?Topical alpha adrenergic agonists may be used to control intra ocular pressure. (e) Rebleeding rarely occurs. False ?Rebleeding can occur up to 5 days later in 30% of cases. Topical medications work either by increasing aqueous outflow (alpha adrenergic agonists, miotics, epinephrine compounds, and prostaglandins) or by decreasing aqueous production (alpha adrenergic agonists, beta adrenergic blockers, and carbonic anhydrase inhibitors).


Heart Sounds (a) ASD's are associated with fixed splitting of the second heart sound True ? (b) Mitral stenosis is associated with a loud S1 True ? (c) Pulmonary stenosis is associated with revered splitting of the second heart sound False ? (d) S2 is due to mitral and tricuspid valve closure False ? (e) Pulmonary hypertension is associated with a loud P2 True ? Heart sounds S1 is due to mitral and tricuspid valve closure. Splitting is usually not detectable but may occur with RBBB. Increased intensity occurs with stenosis of either valve. Mitral regurgitation is associated with a soft S1. S2 is due to aortic and pulmonary valve closure with P2 following A2. This splitting is best heard in the pulmonary area and normally increases with inspiration. A2 and P2 will be loud in systemic and pulmonary hypertension respectively or stenosis of the associated valve. A2 is quiet in aortic incompetence. Increased splitting occurs if there is delayed RV emptying (eg RBBB and pulmonary stenosis). Reverse splitting (P2 before A2 and increased on expiration) occurs if there is delayed left ventricular emptying (eg LBBB and aortic stenosis). Fixed splitting occurs if there is equalization of pressure between the right and left atria (eg ASD). S3 is a low pitched mid-diastolic sound and S4 a more high pitched late diastolic sound. A physiological S3 can occur in the young, S4 is always pathological. Both are due to poor compliance of the ventricle and indicate ventricular dysfunction. S4 only occurs in the presence of atrial contraction. They are appreciated as a gallop or quadruple rhythm.


In subarachnoid haemorrhages (a) 20% of patients with subarachnoid bleeds are bending or lifting heavy objects at onset of symptoms. False 10% of patients. (b) Early focal neurological signs are rare. False Such signs are not rare and if there is a third nerve palsy it suggests involvement of a posterior communicating artery aneurysm. (c) Aneurysms account for 90 % of cases False Aneurysms account for 70%.? (d) The cause is unknown in up to 20% of cases. True Aneurysms: 70% A-V Malformation:5% Unknown cause in up to 20% Rare causes include clotting disorder, tumour, vasculitis, associated with polycystic kidney disease. (e) Hunt and Hess scale is used to grade severity and has prognostic value. True It is a scale of 5 grades 1-5. Prognosis is best in grade 1 with mortality of < 5%, worst in grade 5 (mortality 50-70%)


In aortic dissection medical therapy is to be considered for (a) Medical therapy is to be considered for new, stable dissections False Medical therapy is to be considered for old stable dissections (>2 weeks) (b) Isolated arch dissections True ? (c) Medical therapy is to be considered for uncomplicated dissection of ascending aorta False Uncomplicated dissection of Descending aorta (d) 66% of tears occur in the ascending aorta True ? (e) 33% of tears in the descending aorta False 20% of tears occur in the descending aorta


Veins of the Upper Limb: (a) The cephalic vein originates from the postero-lateral aspect of the venous network on the dorsum of the hand. True ?The cephalic vein originates from the postero-lateral aspect of the venous network on the dorsum of the hand. (b) The cephalic vein passes upwards along the medial border of the forearm anterior to the head of the radius False ?The cephalic vein passes upwards along the lateral border of the forearm anterior to the head of the radius (c) The veins in the upper limb do not possess valves. False ?All veins in the upper limb possess valves. (d) In the upper arm the cephalic vein ascends on the medial aspect of the biceps brachii to the groove between the deltoid and pectoralis major False ?In the upper arm the cephalic vein ascends on the lateral aspect of the biceps brachii to the groove between the deltoid and pectoralis major (e) The basilic vein begins on the lateral side of the venous network on the dorsum of the hand. False ?The basilic vein begins on the medial side of the venous network on the dorsum of the hand.


Epilepsy and driving (a) Following a first seizure a patient is still permitted to drive False ?Following a first seizure a patient is not permitted to drive for 1 year with a medical review before starting driving again (b) If an epileptic patient only has seizures in there sleep they are permitted to drive False ?If they had a seizure in there sleep more than 3 years ago (c) HGV driving regulations specify that patients on treatment should not have had an attack in 5 years False ?10 years and off treatment (d) HGV driving regulations specify that patients on treatment should not have had an attack in 10 years False ? (e) HGV driving regulations specify that patients should not have had an attack in 10 years and be off all treatment True ?


The scaphoid bone: (a) The scaphoid lies at the radial border of the proximal carpal row. True ?The scaphoid lies at the radial border of the proximal carpal row. (b) The scaphoid articulates with the radius, lunate, capitate, trapezoid, and trapezium. True ?The scaphoid articulates with the radius, lunate, capitate, trapezoid, and trapezium. (c) Nearly the entire surface is covered by hyaline cartilage. True ?Nearly the entire surface is covered by hyaline cartilage. (d) Vessels may enter only at the sites of ligamentous attachment. True ?Vessels may enter only at the sites of ligamentous attachment. (e) The dorsal and volar branches of the radial artery provide the blood supply to the scaphoid. True ?The dorsal and volar branches of the radial artery provide the blood supply to the scaphoid. The scaphoid lies at the radial border of the proximal carpal row, but its elongated shape and position allow bridging between the 2 carpal rows because it acts as a stabilizing rod. The scaphoid articulates with the radius, lunate, capitate, trapezoid, and trapezium. As a result, nearly the entire surface is covered by hyaline cartilage. Vessels may enter only at the sites of ligamentous attachment: the flexor retinaculum at the tubercle, the volar ligaments along the palmar surface, and the dorsal radiocarpal and radial collateral ligaments along the dorsal ridge. The dorsal and volar branches of the radial artery provide the blood supply to the scaphoid. The primary blood supply comes from the dorsal branch of the radial artery, which divides into 2-4 branches before entering the waist of the scaphoid along the dorsal ridge. The branches course volar and proximal within the bone, supplying 70-85% of the scaphoid. The volar scaphoid branch also enters the bone as several perforators in the region of the tubercle; these supply the distal 20%-30% of the bone.


Neisseria: (a) The main pathogenicity determinant of N meningitides is the gonococcal pili. False ?The main pathogenicity determinant of N meningitides is the antiphagocytic polysaccharide capsule. (b) If neisseria meningitis is present it almost always causes infection. False ?Carriage of Neisseria meningitis is common (c) Antigenic variation of the gonococcal pili of neisseria means recovery provides no immunity. True ?Antigenic variation of the gonococcal pili of neisseria means recovery provides no immunity (d) Quinolones are not active against neisseria gonorrhoea. False ?Ciprofloxacin is active against neisseria gonorrhoea (e) Epidemics of Neisseria meningitides occur every 10-12 years True ?Epidemics of Neisseria meningitides occur every 10-12 years


Necrotising fasciitis (a) IV drug use is not a risk factor. False ?Smoking, DM, PVD and IV drug use are risk factors. (b) Is frequently caused by group A strep. True ?Is caused by group A strep or there is also a polymicrobial form. (c) Most cases start in the lower extremities. True ?And may go on to involve the upper extremities, perineum, head, trunk and buttocks. (d) If polymicrobial commonly involves anaerobes. True ? (e) The mortality exceeds 25% True ?The mortality is reported to be in the region of 25-50%.


Cellulitis (a) Enterobacter should be considered in diabetic patients. True ?Enterobacter should be considered in diabetic patients. (b) Needle aspiration of the leading end of an area of cellulitus identifies the causative bacteria in few cases (<10%) True Needle aspiration of the leading end of an area of cellulitus identifies the causative bacteria in few cases (<10%) (c) Haemophilus is a leading cause in children. True ?Haemophilus is a leading cause in children. (d) Lymphangitis is almost always involved. False ?Lymphangitis is sometimes involved. (e) There is almost always lymphadenopathy. False ?There is sometimes lymphadenopathy but not 'almost always'


NICE Guideline: Selection of adults for CT Brain post head injury. (a) Amnesia of events 10 min beforehand requires a CT brain. False ?Amnesia of events >30 min beforehand requires a CT brain. (b) Any amnesia since the trauma always requires a CT brain scan. False ? (c) Age >65 always require a CT brain. False ? (d) A patient with a coagulopathy ( on warfarin ) always requires a CT brain. False ? (e) A fall of >5 stairs or >1m is considered a dangerous mechansim of injury. True ?A fall of >5 stairs or >1m is considered a dangerous mechansim of injury. http://www.nice.org.uk/guidance


Causes of splenomegaly (a) Gauchers disease True ? (b) Autoimmune haemolytic anaemia True ? (c) Haemachromatosis False ? (d) Filariasis False ? (e) Cirrhosis True ? Myeloproliferative Disorders( myelofibrosis, chronic myeloid leukaemia, PRV, Essential thrombocythaemia ), Portal Hypertension (cirrhosis, congestive cardiac failure), Bacterial Infection (e.g. typhoid fever and brucella and TB), Collagen Disease, Chronic Haemolytic Anaemia ( autoimmune haemolytic anaemia, cold haemagglutinin disease, hereditary spherocytosis, haemoglobinopathies) Lymphoproliferative disorders ( most lymphomas, chronic lymphocytic leukaemia, hairy cell leukaemia) Tropical ( malaria, kala-azar)


Spondylolisthesis (a) Is caused by osteoarthritis of posterior facet joints True ? (b) Is caused by spondylolysis True ? (c) Is caused by congenital malformation of the articular processes True ? (d) Onset of pain is usually in later life False ?Usually in adolescence (e) Diagnosis is only by MRI False ?Plain films can diagnose this condition Spondylolisthesis is displacement(usually forward) of one lumbar vertebra on the lumbar vertebrae below it


Pancreatitis (a) The incidence of acute pancreatitis ranges between 5 and 80 per 100,000 population True ?The incidence of acute pancreatitis ranges between 5 and 80 per 100,000 population (b) Mild edematous pancreatitis occurs in about 80% of presentations, and the mortality rate is below 1%. True ?Mild edematous pancreatitis occurs in about 80% of presentations, and the mortality rate is below 1%. (c) Because the pancreas is located in the retroperitoneal space with no capsule, inflammation can spread easily True ?Because the pancreas is located in the retroperitoneal space with no capsule, inflammation can spread easily (d) The inflammatory process can cause systemic effects because of the presence of cytokines, such as LCF and haemolayse False ?The inflammatory process can cause systemic effects because of the presence of cytokines, such as bradykinins and phospholipase A (e) Fat necrosis may cause hypocalcemia True ?Fat necrosis may cause hypocalcemia http://www.emedicine.com/emerg/topic354.htm


Marijuana, clinical features. (a) Tachycardia. True ? (b) Conjunctival injection. True ? (c) Impaired motor coordination. True ? (d) Duration of action 6-8 hours False ?Duration of action is 2-4 hours. (e) Hallucinations True ? Marijuana is a cannabinoid which binds cannabinoid receptors. The typical dose is 5-15mg of THC. The duration of action is 2-4 hours. Clinical features include tachycardia, conjunctival injection and impaired motor coordination. Complications are rare. Treatment is supportive and possibly with benzodiazepines


Hand Infections (a) Deep space infections involve the webbed space only. False ?Deep space infections involve the webbed space or the midpalmer space. (b) In deep space infections dorsal and volar swelling of the web space with separation of the affected digits is noted. True ? (c) Midpalmer space infection always occurs from spread of a flexor tenosynovitis. False ?Midpalmer space infection occurs from spread of a flexor tenosynovitis or from a penetrating wound to the palm causing infection in the radial or ulnar bursa of the hand. (d) Flexor tenosynovitis is suggested by a flexed position of the involved digit. True ? (e) Flexor tenosynovitis is suggested by symmetric swelling over the finger. True ? Flexor tenosynovitis is suggested by tenderness over the flexor tendon sheath. Flexor tenosynovitis is suggested by symmetric swelling over the finger. Flexor tenosynovitis is suggested by pain with passive extension. Flexor tenosynovitis is suggested by a flexed position of the involved digit. Deep space infections involve the webbed space or the midpalmer space In deep space infections dorsal and volar swelling of the web space with separation of the affected digits is noted. Midpalmer space infection occurs from spread of a flexor tenosynovitis or from a penetrating wound to the palm causing infection in the radial or ulnar bursa of the hand.


CT Brain in Adults post head injury: NICE Guidelines (a) Amnesia of events >20 min beforehand requires a CT Brain False ?Amnesia of events >30 min beforehand requires a CT Brain (b) Post event LOC always requires a CT Brain scan. False ? (c) Age >65 is not an absolute indication for CT brain True ? (d) A coagulopathy is not an absolute indication for a CT Brain. True ? (e) A fall of 2 stairs is considered a dangerous mechanism of injury. False ?A fall of >5 stairs or >1 m is considered a dangerous mechansim of injury http://www.nice.org.uk/guidance


Anaphylaxis in the Emergency Department: (a) In anaphylaxis IM adrenaline is given at a dose of 3-5mg ( 3-5 ml of 1:1000 dilution ) False ?In anaphylaxis IM adrenaline is given at a dose of 0.3-0.5mg ( 0.3-0.5 ml of 1:1000 dilution ) (b) About 50% of anaphylactic mortality occurs within the first hour True ?About 50% of anaphylactic mortality occurs within the first hour (c) The recurrence rate for anaphylaxis from insect stings is about 10% False ?The recurrence rate for anaphylaxis from insect stings is about 50% (d) In anaphylaxis mediators are released from mast cells and basophils and this reaction is dependent on IgE. True ?In anaphylaxis mediators are released from mast cells and basophils and this reaction is dependent on IgE. (e) It is appropriate to observe patients who suffer anaphylaxis for a period of 48 hours as they may have a reoccurrence because of a second round of mediator release. False ?It is appropriate to observe patients who suffer anaphylaxis for a period of 4 hours as they may have a reoccurrence because of a second round of mediator release.


Lesions of the Optic Nerve: (a) Fibres for the light reflex from the optic chiasm finish in the inferior colliculus. False ?Fibres for the light reflex from the optic chiasm finish in the superior colliculus (b) Fibres from the temporal half of the retina cross in the optic chiasm False ?Fibres from the nasal half of the retina cross in the optic chiasm (c) The temporal visual field corresponds to the temporal half of the retina False ?The temporal visual field corresponds to the nasal half of the retina (d) Fibres from the upper part of the retina are found in the inferior part of the chiasm. False ?Fibres from the lower part of the retina are found in the inferior part of the chiasm. (e) The optic nerve is mostly sensory but has some motor fibres to the retina. False ?The optic nerve is purely sensory.


The following are true with regard to evaluation of chest pain: (a) The chest pain of myocarditis can be pleuritic. True ?The chest pain of myocarditis can be pleuritic and it can also mimic the chest pain of myocardial ischaemia. (b) A large area of extension of chest pain increases the likelihood that the pain is due to myocardial ischaemia. True ?A large area of extension of chest pain increases the likelihood that the pain is due to myocardial ischaemia. (c) A length of years without progression of the chest pain makes it more likely that the pain is functional. True ?A length of years without progression of the chest pain makes it more likely that the pain is functional. (d) Myocardial ischaemia is more likely to occur in the afternoon than the morning. False ?Myocardial ischaemia is more likely to occur in the morning than the afternoon.As there is a higher sympathetic tone in the morning.


Causes of electro mechanical dissociation(Pulseless Electrical Activity): (a) Hypovolaemia. True ?Hypovolaemia, hypoxia, hypothermia and hypo/hyperkalaemia. (b) Tension pneumothorax. True ?Tension pneumothorax, tamponade, toxins, and thrombosis. (c) Hypothermia. True ? (d) Cardiac tamponade True ? (e) Drug intoxication. True ?


Epistaxis (a) At least two adequate attempts at direct pressure should be made before moving to cautery or packing. True ?At least two adequate attempts at direct pressure should be made before moving to cautery or packing.These should be for 10-15 minutes and timed. (b) The patient should not blow there nose before insertion of a vasoconstrictive agent as this may remove pre-formed clot. False ?The patient should blow there nose before insertion of a vasoconstrictive agent to remove any clot and allow the agent to come into contact with the bleeding mucosa. (c) A 5 cm length preformed nasal tampon should be used for a posterior nasal bleed. False ?A 10 cm length preformed nasal tampon should be used for a posterior nasal bleed. A 5 cm length preformed nasal tampon should be used for a anterior nasal bleed (d) Discharge instructions should include not to use aspirin for 3-4 days. True ?Discharge instructions should include not to use aspirin for 3-4 days. (e) Phenylephrine may be used as a vasoconstrictive agent. True ?Adrenaline, phenylephrine, or oxymetolazine may be used with lignocaine.


Cardiovascular Disease: (a) Pericardial tamponade, tension pneumothorax and pulmonary embolism are associated with PEA. True ?Pericardial tamponade, tension pneumothorax and pulmonary embolism are associated with PEA. (b) Only approximately 20 percent of all cardiac arrest victims survive to leave the hospital without neurological sequelae. False ?Only approximately 7 percent of all cardiac arrest victims survive to leave the hospital without neurological sequelae. (c) In Brugada syndrome there is horizontal ST elevation in leads V1 and V2. False ?In Brugada syndrome there is downsloping ST elevation in leads V1 and V2 and a QRS complex resembling a right bundle branch block. (d) Anorexia, hypokalaemia and hypermagnesemia are associated with a prolonged QT interval. False ?Anorexia, hypokalaemia and hypomagnesemia are associated with a prolonged QT interval. (e) The half life elimination of adenosine is <10 seconds. True The onset of action of adenosine is rapid. Metabolism: Blood and tissue to inosine then to adenosine monophosphate (AMP) and hypoxanthine.The half-life elimination is <10 seconds.


Gross anatomy of the testis (a) The testes drain to the para-aortic lymph nodes while the scrotum drains to the inguinal lymph nodes. True ?The testes drain to the para-aortic lymph nodes while the scrotum drains to the inguinal lymph nodes. (b) The testis develops in the anterior abdominal wall of the embryo. False ?The testis develops in the posterior abdominal wall of the embryo. (c) The testes is almond shaped and measures about 2 cm by 3 cm by 2.5 cm in dimension. False ?The testes is almond shaped and measures about 5 cm by 3 cm by 2.5 cm in dimension. (d) The testicular vein drains to the inferior vena cava on the left and to the right renal vein on the right. False ?The testicular vein drains to the inferior vena cava on the right and to the left renal vein on the left. (e) The blood supply to the scrotum is from the internal pudendal artery which is a branch of the internal iliac artery. True ?The blood supply to the scrotum is from the internal pudendal artery which is a branch of the internal iliac artery.


Suicide Risk Assessment (a) Patients with pesonality disorders are at higher risk of completing suicide True ? (b) Males are at higher risk than females True ? (c) Individuals who have a history of substance abuse have a higher risk True ? (d) Individuals who have chronic medical problems are at higher risk True ? (e) Married individuals are at higher risk than single ones False ? S sex M>F A age <19 or >45 years D depression, major depression, hopelessness P psychiatric history, personality disorder E excessive alcohol and substance abuse R rational thinking loss, psychosis, organic brain syndrome, delusions S single, separated, socially isolated O organized attempt N no supports, unemployed homeless S states future intent


Streptococci: (a) Because of transplacental transfer of antibodies children under 1 year are relatively resistant to infection from acute pneumonia with S pneumoniae. False ?Children under 1 year of age are especially susceptible to acute pneumonia from S. pneumoniae. (b) The cell surface protein hyaluronidase is the main pathogenicity determinant of S. pneumoniae. False ?The capsule is the main pathogenicity determinant of S. pneumoniae. (c) Acute otitis media, sinusitis and acute pneumonia are the most common infections related to strep pneumonia True ?Acute otitis media, sinusitis and acute pneumonia are the most common infections related to strep pneumonia (d) S. Pneumonia is generally resistant to tetracycline. False ?S. Pneumonia is generally sensitive to rifampicin and tetracycline. (e) Dogs and Humans are the only hosts of S. pneumoniae and most carriage is asymptomatic False ?Humans are the only host of S. pneumoniae and most carriage is asymptomatic


Erythromycin: (a) Is a first line therapy in the treatment of mycoplasma pneumonia. True ?Is a first line therapy in the treatment of mycoplasma pneumonia. (b) Binds to the 30S ribosome to interfere with protein synthesis. False ?Erythromycin binds to the 50S ribosome to interfere with protein synthesis. (c) Is a first line therapy in the treatment of haemophilus influenza. False ?Many strains of haemophilus influenza are resistant to erythromycin. (d) Is a first line therapy in the treatment of legionella pneumonia. True ?Rifampicin may be added to erythromycin in serious cases. (e) Is active against bacteroides. False ?Erythromycin is not active against bacteroides but is active against many other anaerobes.


Local Anaesthetic: (a) Lignocaine is an amide local anaesthetic. True ?Lignocaine is an amide local anaesthetic.Procaine is an ester local anaesthetic (b) Procaine is an ester local anaesthetic. True ?Lignocaine is an amide local anaesthetic.Procaine is an ester local anaesthetic (c) 1% lignocaine is 10mg/ml True ?1% lignocaine is 10mg/ml (d) The maximum dose of lignocaine which can be given with epinephrine/adrenaline is higher than the maximum dose of lignocaine which can be given without epinephrine/adrenaline. True ?The maximum dose of lignocaine which can be given with epinephrine/adrenaline is higher than the maximum dose of lignocaine which can be given without epinephrine/adrenaline. (e) The duration of action of lignocaine is 4-5 hours. False ?The duration of action of lignocaine is 30-60min.


In Deep Vein Thrombosis: (a) Being on the combined oral contraceptive pill increases risk by 2-4 times. True ?Being on the combined oral contraceptive pill increases the risk of suffering a deep vein thrombosis 2-4 fold. (b) Risk factors include obesity. True ?Obesity is a risk factor for DVT. (c) Risk factors include post myocardial infarct. True ?Post myocardial infarct is a risk factor for deep vein thrombosis. (d) Risk factors include polycythaemia ruba vera. True ?Polycythaemia ruba vera is a risk factor for deep vein thrombosis. (e) D dimers have a specificity of 95% and sensitivity of 45% for DVT's False ?


Eye manifestations of rheumatoid arthritis include: (a) Iritis. False ? (b) Scleritis. True ? (c) Episcleritis. True ? (d) Ptosis. False ? (e) Sjogrens syndrome. True ? Episcleritis, scleritis, scleromalacia, keratoconjunctivitis sicca, sjogrens syndrome


Pericardial Tamponade Secondary to Trauma (a) Pressure in the pericardium increases slowly as small increments of fluid accumulate. False ?Pressure in the pericardium increases sharply as small increments of fluid accumulate. (b) Almost never occurs because of blunt compressive forces. False ?Cardiac Tamponade may occur because of blunt or penetrating injuries. (c) Will cause tracheal deviation. False ?The fact that cardiac tamponade does not cause tracheal deviation helps distinguish it from tension pneumothorax. (d) The ECG is unaffected. False ?The amplitude of the ECG is decreased. (e) As little as 150ml-200ml of fluid in the pericardial sac may result in pericardial effusion. True ?As little as 150ml-200ml of fluid in the pericardial sac may result in pericardial effusion.


Non Q Wave MI: (a) Have a higher rate of subsequent heart failure. False ?Smaller infarcts with less myocardial damage. (b) Less frequently have post infarct angina. False ?More frequently as there is viable myocardium with a reduced blood supply. (c) There is a higher incidence of early recurrent infarct. True ?40% Vs 8%. (d) Have a lower one year mortality. False ?Higher ,65% Vs 35%. (e) Have a lower in hospital mortality. True ?


Back Pain: (a) May be caused by a duodenal ulcer. True ?May result from any retroperitoneal disease eg pancreatic cancer, aortic aneursym. Be cautious if spine movements are pain free and full. (b) Lumbar discs are the most likely to prolapse. True ?Sciatica may occur if the herniated nucleus pulposus compresses a nerve root. (c) S1 root compression may cause loss of ankle jerk. True ?S1 root compression may cause loss of ankle jerk and calf pain, weak planter flexion and decreased sensation over the sole of the foot. (d) S1 root compression may cause loss of sensation over the anterior shin. False ?S1 root compression may cause loss of ankle jerk and calf pain, weak planter flexion and decreased sensation over the sole of the foot. (e) S1 root compression may cause weak planter extension False ?


In an unconscious patient the following clinical signs suggest a cervical cord injury: (a) Hypotension with bradycardia. True ?Neurogenic shock caused by loss of sympathetic tone. (b) Diaphragmatic breathing. True ?Diaphragmatic breathing may be seen after cervical cord injury. (c) Priaprism. True ?Priaprism may be seen after cervical cord injury. (d) Flaccid arreflexia of the limbs. True ?In the acute phase of spinal shock the patient will have flaccid arreflexia. But ultimately the patient will develop spasticity. (e) A fixed, dilated pupil. False ?


Factors which increase suicide risk include: (a) Male gender. True ?Male gender increases the risk of suicide. (b) Rural dweller. False Risk is higher in urban dwellers. (c) Alcohol abuse. True ? (d) Married status. False Higher rates reported in separated and divorced individuals. (e) Socio economnic class 1. False Suicide rates are higher in socio economic class 3 and 4.


Swallowed Foreign Body: (a) Most adult obstructions occur in the proximal oesophagus False ?Most paediatric obstructions occur in the proximal oesophagus (b) The majority of children presenting with foreign bodies are caught in the distal oesophagus. False ?The majority of adults presenting with foreign bodies are caught in the distal oesophagus (c) The majority of adults who present with meat stuck in the oesophagus have an abnormal oesophagus secondary to a pathological process. True ?The majority of adults who present with meat stuck in the oesophagus have an abnormal oesophagus secondary to a pathological process. (d) Objects are likely to have the most difficulty traversing the ileum. False ?Objects are likely to have the most difficulty traversing the pylorus (e) About 30% of swallowed objects require intervention False ?About 10% of swallowed objects require intervention


Features of opiate withdrawal include: (a) Tachycardia. True ?Tachycardia is a feature of opiate withdrawal. (b) Sneezing. True ?Sneezing is a feature of opiate withdrawal. (c) Goosebumps. True ? (d) Lilliputian hallucinations. False Occur in alcohol withdrawal. (e) Muscular pain. True Muscular pain is seen in opiate withdrawal. Opiate withdrawal is characterised by increased blood pressure and pulse, lacrimation, rhinorhea, sneezing, goosebumps, arthralgia, abdominal pain, muscular pain.


Torsion of the testes: (a) Peak incidence is between the ages of 13 and 16 years. True ?The peak age group is between the ages of 13 and 16 years but no age group is immune. (b) Cannot develop during sleep. False ?Many cases of testicular torsion occur during sleep. (c) Can be excluded if the patient also complains of dysuria or frequency. False ?dysuria or frequency are more suggestive of inflammation but do occur in some torsions. (d) Patients may give a history of previous 'warning' attacks of pain. True ?One in 3 have had minor episodes previously. (e) Must not be reduced by manipulation. False ?Worth a try but will recur so still admit for surgery.


Distinguishing JVP from carotid pulsation. (a) Inspiration causes arterial pulsation to fall. False ?Inspiration causes venous pulsation to fall. (b) The venous pulsation is not palpable. True ? (c) The height of the JVP is affected by the position of the patient. True ? (d) The venous pulsation normally has 2 peaks in its pulsation. True ?


Hiccups (a) The reflex serves the useful purpose of expelling secretions. False ?The cough reflex serves the useful purpose of expelling secretions, not hiccups. (b) The effect is brought about by the phrenic nerve, the recurrent laryngeal branch of the vagus nerve, and the motor nerves to the anterior scalene and intercostal muscles. True ?The effect is brought about by the phrenic nerve, the recurrent laryngeal branch of the vagus nerve, and the motor nerves to the anterior scalene and intercostal muscles. (c) Can be initiated by a sudden change in environmental temperature. True ?Hiccups can be inititiated by sudden gastric distension, alcohol, excessive smoking , a change in environmental temperature or a 'fright'. (d) Persistent hiccups should lead to an inspection of the external auditory canal. True ?Persistent hiccups should lead to an inspection of the external auditory canal as a foreign body in the external auditory canal can irritate the vagus nerve. (e) Chlorpromazine IV is a useful treatment. True ?Chlorpromazine, metoclopramide, nifedipine, valproic acid, and baclofen may be tried to control hiccups.


Scaphoid Fracture; (a) Scaphoid is the most common carpal fracture. True ?Scaphoid is the most common carpal fracture. (b) The patient is usually tender in the anatomical snuff box. True ?The patient is usually tender in the anatomical snuff box. (c) The wrist radiograph is commonly negative. True ?The wrist radiograph is commonly negative. (d) 12% of scaphoid fractures are associated with other fractures. True ?12% of scaphoid fractures are associated with other fractures. (e) In adults, 70% of scaphoid fractures involve the waist; 10-20%, the distal pole; 5-10%, the proximal pole; and 5%, the tubercle. True ?In adults, 70% of scaphoid fractures involve the waist; 10-20%, the distal pole; 5-10%, the proximal pole; and 5%, the tubercle. http://www.emedicine.com/radio/topic747.htm


Features of delirium tremens include: (a) Autonomic overarousal. True ? (b) Delusions. True ? (c) Mood instability. True ? (d) Hallucinations. True ? (e) Pyrexia. True ?


The following are true regarding the vertebral column: (a) There are seven cervical vertebrae. True ?There are seven cervical vertebrae. (b) There are 12 thoracic vertebrae. True ?There are 12 thoracic vertebrae. (c) There are five lumbar vertebrae. True ?There are five lumbar vertebrae. (d) There are five sacral vertebrae fused to form the sacrum. True ?There are five sacral vertebrae fused to form the sacrum. (e) There are four coccygeal vertebrae which are usually fused. True ?There are four coccygeal vertebrae which are usually fused.


Fecal impaction in elderly patients: (a) Diagnosis will always be confirmed by digital rectal examination. False ?Sometimes masses will only be palpable on abdominal examination. (b) May present with diarrhoea. True ?Spurious diarrhoea or soiling. (c) Is more likely to occur in the immobile. True ?Whatever the cause of the immobility. (d) Contraindicates the use of purgatives. False ?Will help, though avoid harsh purgatives in elderly patients. (e) Is as likely to be successfully cleared by one or two as by a serious of enemas. False ?Will need daily enemas for 5 to 7 days for colon clearance.


With regard to sinus bradycardia: (a) Usually requires treatment if less than 60 BPM. False (b) Atropine 0.5mg should be given as a single dose only. False (c) Atropine can be repeated every 3-5 minutes up to a total of 3mg IV. True (d) Transcutaneous cardiac pacing can be used in patients refractory to atropine. True (e) Adrenaline has no role in sinus bradycardia treatment. False Sinus bradycardia usually does not require treatment unless the heart rate is less than 50BPM and there is evidence of hypoperfusion. Initial therapy should be 05mg IV atropine and repeated every 3-5 minutes up to a total of 3mg IV. Transcutaneous cardiac pacing can be used in patients refractory to atropine. Adrenaline 2-10ug/min or dopamine3-10ug/kg/min IV may be used if external pacing is not available. Internal cardiac pacing may be required with symptomatic recurrent or persistent sinus bradycardia due to sick sinus syndrome.


Signs of upper motor neurone lesion include (a) Marked muscle wasting False ?Muscle wasting is a feature of lower motor neurone lesions. (b) Exaggerated tendon reflexes True ?Loss of tendon reflexes occurs in lower motor neurone lesions. (c) Loss of abdominal reflexes True ? (d) Cog-wheel rigidity False ? (e) Extensor plantar response True ? Also in UMN lesions there may be drift of an upper limb, increase in tone, and normal electrical excitability of muscle.


In cerebrovascular disease: (a) Stroke mortality rates increases with age. True ?Geometric progression. (b) Cerebrovascular disease is more common in social classes four and five, than in higher social classes. False ?Affects all social classes equally, unlike CAD. (c) Following a stroke, death usually occurs within 4 or 5 days when unconsciousness is prolonged. True ?Poor prognosis when consciousness is not regained. (d) The presence of polycythaemia is a predisposing factor for stroke. True ?Other factors include diabetes, hypertension and stroke. (e) TIA's with motor symptoms are more likely to progress to stroke. True ?Also the age of the patient and duration of symptoms.


The following medications are associated with pancreatitis: (a) Estrogens. True ?Estrogens are associated with pancreatitis. (b) Sulfasalazine. True ?Sulfasalazine is associated with pancreatitis. (c) Lisinopril. True ?Lisinopril is associated with pancreatitis (d) Simvastatin. True ?Simvastatin is associated with pancreatitis (e) Didanosine. True ?Didanosine is associated with pancreatitis. With regard to Ransons the presence of 1 to 3 criteria represents mild pancreatitis. The mortality rate rises significantly with four or more criteria. Ransons criteria is noted at 0 and at 48 hours. At 0 hours age, WBC count, glucose, LDH and AST are noted. Age over 55 years, WBC count greater than 16000/mm3, glucose >11.1mmol/L, LDH > 350 U/L, and AST > 250 U/L all score one point. At 48 hours the criteria include haematocrit, blood urea nitrogen, serum calcium, PO2, base deficit and fluid sequestration. A haematocrit fall >10%, a BUN increase > 1.8 mmol/L, a serum calcium <2 mmol/L, a PO2 <60mmHg, a base deficit >4 mEq/L, and >6L of fluid sequestration all score a point.


Parkinsons Disease: (a) Patients have increased dopaminergic receptors in the substantia nigra. False ?Patients have reduced dopaminergic receptors in the substantia nigra. (b) Unilateral resting tremor worsens with intentional movement. False ?Unilateral resting tremor improves with intentional movement. (c) Benztropine is used in the treatment of tremor. True ?Benztropine is used in the treatment of tremor. (d) Cells in the substantia nigra show eosinophilic spherical inclusions. True ?Cells in the substantia nigra show eosinophilic spherical inclusions(Lewy Bodies) (e) Occurs in 1 per 1000 adults. True ?Parkinsons Disease occurs in 1 per 1000 adults and 1 per 200 over the age of 65 years.


The lung may be ventilated but not perfused in the following conditions ( Va/Q >1 ) (a) Pulmonary Embolism True ?Pulmonary Embolism is a cause of ventilation perfusion mismatch where the lung is ventilated but not perfused. (b) Fibrosing Alveolitis True ?Fibrosing Alveolitis is a cause of ventilation perfusion mismatch where the lung is ventilated but not perfused(loss of capillary bed). (c) Pulmonary Arteritis True ?In Pulmonary Arteritis there is lung ventilation but not perfusion. (d) Disease of the chest Wall False ?In disease of the chest wall there is perfusion but no ventilation. (e) Loss of elastic tissue. False ?In diseases which cause loss of elastic tissue ( emphysema ) there may be perfusion but no ventilation.


The lumbar plexus: (a) The obturator nerve originates from L2, L3 and L4 True ?The obturator nerve originates from L2, L3 and L4 (b) The obturator nerve innervates the adductors of the thigh and the skin on the lateral surface of the thigh. False ?The obturator nerve innervates the adductors of the thigh and the skin on the medial surface of the thigh. (c) The lumbar plexus is formed by the anterior rami of the upper five lumbar nerves. False ?The lumbar plexus is formed by the anterior rami of the upper four lumbar nerves. (d) It is situated within the gluteus muscle False ?It is situated within the psoas muscle (e) The femoral nerve originates from the lumbar plexus from L2, L3 and L4 True ?The femoral nerve originates from the lumbar plexus from L2, L3 and L4


Conduction problems (a) Bifasicular block consists of left anterior hemiblock and right bundle branch block. True ?Left anterior hemiblock is characterised by a marked left axis with deep S waves in II and III. (b) Complete heart block usually has a rate of about 60 bpm. False ?Complete heart block usually has a rate of less than 50 bpm. (c) Complete heart block usually has narrow complexes. False ?Complete heart block usually has broad complexes. (d) Left bundle branch block usually has inverted T waves in the lateral leads. True ?Inverted T waves in I,VL,V5-V6. (e) In mobitz type 2 there is a progressive PR lengthening then non-conducted P wave, and then repetition of the cycle. False ?The above question describes the Wenckebach, mobitz type 1.


Irritable bowel syndrome is associated with: (a) Abdominal distension. True ?Irritable bowel syndrome is associated with abdominal distension and borborygmi. (b) Heartburn. True ?Irritable bowel syndrome is associated with heartburn and nausea. (c) Pain relieved by passing flatus. True ?Irritable bowel syndrome is associated with pain relief by passing flatus or defecating. (d) Pain worsened by drinking alcohol. True ?Irritable bowel syndrome is associated with aggravation after alcohol or by eating. (e) Bleeding per rectum. False ?Not a feature.


In the management of paracetamol overdose: (a) Consider giving N-acetyl cysteine to overdoses > 12 g who present within 24-72 hours False Recommendations are that all overdoses greater than 10g who present within 24- 72 hours should be given N-acetyl cysteine . (b) Give vitamin K IV 10mg True In case body stores are depleted.?Oxford Handbook of Acute Medicine (c) Give FFP if there are signs of liver failure. False Avoid giving FFP as it may make management decisions more difficult e.g liver transplantation (d) The high-risk treatment line on the paracetamol level v's time graph should be used with someone who is alcohol dependent. True ? (e) The high-risk treatment line on the paracetamol level v's time graph should be used with someone who is on lithium. False Lithium is not hepatically metabolised. The high-risk treatment line on the paracetamol level v's time graph should be used with someone who is on enzyme inducing medications or those who are malnourished.


Stroke prognosis (a) Between 33% and 50% will die in the first month following a stroke. True ? (b) Early mortality is lower for stroke from intracerebral haemorrhage than from thromboembolic infarction. False ?Around 75% mortality for ICH in comparison to 25% mortality for a thromboembolic infarction. (c) A poor outcome is likely when there is a defect in conjugate gaze. True ?A poor outcome is likely when there is a coma, a defect in conjugate gaze or a severe hemiplegia. (d) Recurrent strokes are rare. False ?Of those who survive a stroke about 33% return to independent mobility and 33% have severe disability requiring permanent institutional care. (e) Many patients die subsequently of a myocardial infarction True ?


The following are associated with regular heavy drinking: (a) Peripheral neuropathy occurs in 20% of heavy drinkers. False Peripheral neuropathy occurs in 10% of heavy drinkers. (b) Worsening of psoriasis. True ? (c) Avascular necrosis of the femoral head. True ? (d) Alcoholic cardiomyopathy which usually presenting as arrhythmia. False Alcoholic cardiomyopathy usually presents as cardiac failure. (e) Resistance to osteoporosis in men. False In postmenopausal women moderate alcohol consumption may delay development of osteoporosis.


The radial artery: (a) Early in its course the radial artery crosses anterior to the biceps tendon to lie posterior to the supinator muscle. False ?Early in its course the radial artery crosses anterior to the biceps tendon to lie on the supinator muscle. (b) The radial artery lies superficial to brachioradialis in the forearm False ?The radial artery lies deep to brachioradialis in the forearm (c) The radial artery lies deep to flexor carpi radialis in the forearm True ?The radial artery lies deep to flexor carpi radialis in the forearm. (d) The superficial branch of the radial nerve lies medial to the radial artery in the forearm. False ?The superficial branch of the radial nerve lies lateral to the radial artery in the forearm (e) The radial artery arises at the level of the neck of the radius True ?The radial artery arises at the level of the neck of the radius


Chondromalacia patellae (a) Is associated with trauma False ? (b) Is treated by vastus medialis strengthening exercises True ? (c) Treatment is usually ineffective False ?Vastus medialis can be strengthened by and this relieves pain in 80% of cases (d) Pain is felt after prolonged sitting True ? (e) Pain is usually on the medial side of the patella True ?Also pain is felt on patellofemoral compression


The following statements are true: (a) The prognosis for extradural haematoma is worse than for subdural haematoma. False ?The prognosis for extradural haematoma is better than for subdural haematoma. (b) Subdural haematomas usually come from a venous source. True ?Bridging veins between brain and venous plexus. (c) A skull vault fracture significantly increases the risk of haematoma. True ?A skull vault fracture significantly increases the risk of haematoma. (d) A basal skull fracture significantly increases the risk of intracranial haematoma. True ?A basal skull fracture significantly increases the risk of intracranial haematoma. (e) An open skull fracture implies the dura mater is torn. True ?An open skull fracture implies the dura mater is torn.


Surface Anatomy of the Anterior Forearm: (a) The pulsations of the ulnar artery are recognised lateral to the pisiform bone. True ?The pulsations of the ulnar artery are recognised lateral to the pisiform bone (b) In the area of the wrist and hand the ulnar artery is superficial to the palmer aponeurosis. False ?In the area of the wrist and hand the ulnar artery is covered by the palmer aponeurosis. (c) The brachial artery divides into the radial and ulnar arteries just above the line of the elbow joint. False ?The brachial artery divides into the radial and ulnar arteries just below the line of the elbow joint. (d) The radial artery lies in a groove between the flexor carpi ulnaris and the anterior border of the radius. False ?The radial artery lies in a groove between the flexor carpi radialis and the anterior border of the radius. (e) The radial artery can be palpated on the lateral side of the scaphoid in the anatomical snuff box. True ?The radial artery can be palpated on the lateral side of the scaphoid in the anatomical snuff box.


CRP and ESR: (a) CRP is produced by the liver and gall bladder. False ?CRP is produced by the liver and produced by adipocytes. (b) CRP rises within 6 hours of an event. True ?CRP rises within 6 hours of an event. (c) CRP rises with trauma. True ?CRP rises with temperature, with inflammatory conditions and after trauma. (d) The ESR rises with age and is higher in females than in males. True ?The ESR rises with age and is higher in females than in males. (e) CRP is low in patients with polycythaemia and high in patients with anaemia. False ?ESR is low in patients with polycythaemia and high in patients with anaemia(not CRP)


Drug Reactions: (a) Type II reactions may mimic SLE. False ?Type III reactions may mimic SLE (b) Sulphonmamides and streptomycin are associated with type II reactions. False ?Penicillin?s, sulphonmamides and streptomycin are associated with type III reactions (c) Carbimazole and prophylthiouracil are associated with type III reactions True ?Carbimazole and prophylthiouracil are associated with type III reactions (d) Type I reactions present several days following the initiation of therapy False ?Type III reactions present several days following the initiation of therapy (e) Type IV reactions ( arthrus, serum sickness or immune complex ) is caused by the formation of antibody-antigen complexes which lodge in the small blood vessels of the skin, kidney, and joints. False ?Type III reactions ( arthrus, serum sickness or immune complex ) is caused by the formation of antibody-antigen complexes which lodge in the small blood vessels of the skin, kidney, and joints.


Myocardial Infarction: (a) NSTEMI have been shown to benefit from thrombolysis. False NSTEMI have not been shown to benefit from thrombolysis. (b) NSTEMI have a high one year mortality. True ?NSTEMI have a one year mortality of 65%. (c) Temporary pacing is indicated in anterior MI complicated by CHB. True ?Temporary pacing is indicated in anterior MI complicated by CHB. This presentation is associated with a high mortality due to extensive myocardial damage. (d) The left circumflex artery gives branches to the SA and AV nodes more frequently than the RCA. False ?The RCA gives branches to the SA and AV nodes more frequently than the LCA. The RCA is dominant in 85% of cases. (e) Cardiac rupture is usually seen 4-10 days post MI. True ?Cardiac rupture is usually seen 4-10 days post MI.


The clinical features of hypothermia include: (a) Hyponatremia due to haemodilution. False (b) Body core temp <34 degrees C. True (c) Areflexia and absent pupillary responses. True (d) ECG shows tachycardia with pronounced u waves. False (e) Asymptomatic acute pancreatitis and lactic acidaemia. True Hypothermia is defined as a core temperature below 35?C (95?F), and can be further classified by severity ;mild hypothermia - core temperature 32 to 35?C (90 to 95?F) moderate hypothermia - core temperature 28 to 32?C (82 to 90?F) , severe hypothermia - core temperature below 28?C (82?F). Under usual circumstances, resuscitative efforts should be continued indefinitely (occasionally for several hours) until the temperature is 32 to 35?C (90 to 95?F) because of the neuroprotective effects of hypothermia.


Carriage of O2 and CO2 in blood: (a) In type II respiratory failure the PaO2 is less than 10 kPa and the PaCO2 is >6.0kPa False ?In type II respiratory failure the PaO2 is less than 8 kPa and the PaCO2 is >6.0kPa (b) The normal pressure of CO2 in the blood is 4.8-6.0 kPa True ?The normal pressure of CO2 in the blood is 4.8-6.0 kPa (c) Ventilation of about 6 L/min carries 600ml/min of CO2 out of the body. False ?Ventilation of about 6 L/min carries 9mmol/min of CO2 (= 200ml/min ) out of the body. (d) In type I respiratory failure the PaO2 is less than 10 kPa and the PaCO2 is <6.0kPa. False ?In type I respiratory failure the PaO2 is less than 8 kPa and the PaCO2 is <6.0kPa. (e) The pulmonary blood flow of 5L/min carries about 22mmol/min of Oxygen ( = 500ml/min) from the lungs to the tissues. False ?The pulmonary blood flow of 5L/min carries about 11mmol/min of Oxygen ( = 250ml/min) from the lungs to the tissues.


Disorders predisposing to the development of hypothermia include: (a) Addisons disease. True (b) Hypothyroidism. True (c) Hepatic cirrhosis. True (d) Hypoglycaemia. True (e) Drug overdose. True Hypothermia is defined as a core temperature below 35?C (95?F), and can be further classified by severity ;mild hypothermia - core temperature 32 to 35?C (90 to 95?F) moderate hypothermia - core temperature 28 to 32?C (82 to 90?F) , severe hypothermia - core temperature below 28?C (82?F). Under usual circumstances, resuscitative efforts should be continued indefinitely (occasionally for several hours) until the temperature is 32 to 35?C (90 to 95?F) because of the neuroprotective effects of hypothermia.


ECG Interpretation: (a) The usual recording rate is 25mm/sec True ?The usual recording rate is 25mm/sec (b) 1 small square is equal to 0.04 sec True ?1 small square is equal to 0.04 sec and 1 large square is 0.2 seconds (c) The rate can be calculated by dividing 200 by the number of large squares in one R-R interval. False ?The rate can be calculated by dividing 300 by the number of large squares in one R-R interval. (d) QRS complexes in I and II should both be predominantly negative. False ?QRS complexes in I and II should both be predominantly positive. (e) A widened bifid P wave suggests right atrial hypertrophy False ?A widened bifid P wave suggests left atrial hypertrophy


Ankle Injuries (a) Fracture of the ankle or mid-foot occurs in less than 5% of those presenting with acute traumatic ankle injuries. False ?The management of ankle sprains is daily routine at emergency departments, and although most patients undergo radiography, fracture of the ankle or mid-foot occurs in less than 15% (b) The mid-foot assessment in the ottawa ankle rules covers the ability to walk and notes localised tenderness of the navicular or the base of the fifth metatarsal. True ?The mid-foot assessment in the ottawa ankle rules covers the ability to walk and notes localised tenderness of the navicular or the base of the fifth metatarsal. (c) The ankle assessment in the ottawa ankle rules covers the ability to walk one step (immediately after the injury or at the emergency department) and notes localised tenderness of the posterior edge or tip of either malleolus False ?The ankle assessment covers the ability to walk four steps (immediately after the injury or at the emergency department) and notes localised tenderness of the posterior edge or tip of either malleolus (d) The ottawa ankle rules have a high specificity but a low sensitivity False ?The ottawa ankle rules have a high sensitivity but a low specificity. (e) Tenderness over the cuboid bone is an indication for X Ray according to the Ottawa ankle rules False ?Tenderness over the navicular bone but not the cuboid bone is an indication for X Ray according to the Ottawa ankle rules.


NICE Guideline: Selection of adults for CT Brain post head injury (a) Postauricular ecchymosis is an indication for CT Brain True ?Battle's sign infers a base of skull fracture. (b) CSF leakage from the nose but not from the ears is an indication for CT Brain False ?CSF leakage from the nose or from the ear indicates a base of skull fracture and should be investigated with CT Brain. (c) Seizures after a head injury in adults are common and do not require investigation with CT Brain. False Seizures after a head injury in adults require investigation with CT Brain. (d) If a focal neurological deficit is restricted to one cranial nerve it does not require CT brain after head injury. False ?Any focal neurological deficit after head injury requires investigation with CT Brain. (e) >1 episode of vomiting always requires a CT brain according to the NICE guidelines. True ?>1 episode of vomiting always requires a CT brain according to the NICE guidelines.


Possible Kidney Stone Composition (a) Xanthine True ?1% and radiolucent (b) Calcium oxalate True ?25% (c) Mixed Calcium oxalate and phosphate True ?40% (d) Urate True ?10% (e) Cystine True ?2%


Classification of Anemias (a) Decreased MCV is seen in anaemia of chronic disease. True ?Decreased MCV is seen in chronic iron deficiency anaemia, thalassaemia and anaemia of chronic disease. (b) Increased MCV is seen in B12 or folate deficiency, alcohol abuse, and liver disease. True ?Increased MCV is seen in B12 or folate deficiency, alcohol abuse, and liver disease. (c) New reticulocytes should begin to appear in the blood within 24 hours. False ?New reticulocytes should begin to appear in the blood within 3 to 7 days. (d) Warfarin therapy will cause a reduced platelet number. False ?Warfarin therapy increases PT. (e) The percentage of reticulocytes in the blood is normally 0.5-2.5% True ?The percentage of reticulocytes in the blood is normally 0.5-2.5%


Back Pain (a) Straight leg raising stretches the sciatic nerve True ? (b) If straight leg raising is less the 60 degrees lasegues sign is said to be positive False ?If straight leg raising is less the 45 degrees lasegues sign is said to be positive (c) Kidney cancer frequently metastasizes to bone True ?Breast, bronchus, kidney,thyroid and prostate are the commonest malignancies to metastasize to bone (d) Alkaline phosphatase is high in paget's disease and tumors True ? (e) The cervical spine is usually lordosed True ?As is the lumbar spine


Neurological manifestations of rheumatoid arthritis: (a) Peripheral neuropathy. True ? (b) Mononeuritis multiplex. True ? (c) Carpal tunnel syndrome. True ? (d) Cervical myelopathy. True ? (e) Optic neuritis. False ?


Temporomandibular joint problems: (a) Dislocation is characterised by an open mouth in the forward position. True ?Dislocation is characterised by an open mouth in the forward position. (b) TMJ syndrome is not tender. False ? (c) TMJ syndrome pain is worse when the mouth is open. True ?TMJ syndrome pain is worse when the mouth is open. (d) To reduce a TMJ dislocation the mandible is manipulated down and back. True ?To reduce a TMJ dislocation the mandible is manipulated down and back. (e) After reduction of the TMJ joint dislocation the patient is recommended to eat soft diet for a week. True ?Also may be prescribed muscle relaxants.


Bell's palsy (a) Only effects the lower face and there is an equal sex ratio. False ?Bell's palsy affects the upper and lower face but there is an equal sex ratio. (b) The obicularis muscle is rarely involved in bell's palsy. False ?The obicularis muscle's are frequently involved resulting in incomplete closure of the eyelids. (c) HSV-1 is a frequent cause of bell's palsy. True ?HSV-1 is a frequent cause of bell's palsy. (d) Most commonly occurs in the 3rd decade of life False ?Bell's palsy most commonly occurs to middle aged people. (e) CN VII controls the lacrimal gland secretory function. True ?CN VII controls the lacrimal gland secretory function, nerve to stapedius, sensory sensation to the anterior 2/3rd's of the tongue and the muscles of facial expression.


The femoral vein,artery and nerve: (a) The femoral vein is lateral to the femoral nerve. False ?The femoral vein is medial to the femoral nerve. (b) The femoral nerve is lateral to the femoral artery. True ?The femoral nerve is lateral to the femoral artery. (c) The femoral canal is on the lateral side of the femoral artery in the femoral triangle. False ?The femoral canal is on the medial side of the femoral artery in the femoral triangle. (d) In the femoral triangle the femoral nerve is medial to the femoral artery. False ?In the femoral triangle the femoral artery is related laterally to the femoral nerve and medially to the femoral nerve and femoral canal. (e) The femoral artery is a continuation of the internal iliac artery and lies midway between the anterior superior iliac spine and the pubic symphysis False ?The femoral artery is a continuation of the external iliac artery and lies midway between the anterior superior iliac spine and the pubic symphysis


Commonest causes of CRF (a) Diabetes True ?Diabetic nephropathy 25% (b) Chronic Glomerulonephritis True ?15% (c) Hypertension True ?15% (d) Chronic pyelonephritis True ?12%. Most often due to reflux nephropathy (e) Alports Syndrome False ?Rare


The following are red flags with regard to back pain and warrant further investigation (a) Age >55 years True ?Also <20 years (b) Non-mechanical pain True ? (c) Thoracic pain True ? (d) On Steroid medication True ? (e) HIV True ?Also weight loss, history of carcinoma, widespread neurology and structural deformity


In electrocardiography: (a) A potassium ion gradient is mainly responsible for the electrical potential difference across the cell membrane. True ?A potassium ion gradient is mainly responsible for the electrical potential difference across the cell membrane. (b) An electrode records an upward deflection when the depolarization current is flowing away from it. False ? (c) The PR interval is reduced in first degree heart block. False ?The PR interval is prolonged in first degree heart block. (d) The QT interval is reduced in hypocalcaemia. False ?The QT interval is prolonged in hypocalcaemia. (e) The T wave is produced by ventricular repolarization. True ?The T wave is produced by ventricular repolarization.


Abbreviated mental test score includes: (a) Name of monarch/Prime Minister. True ? (b) Age. True ? (c) Count backwards from 20 to 1. True ? (d) Date of birth. True ? (e) Year of first world war. True ? Also time(to the nearest hour), recall, year, name of hospital.


CCF: (a) Proteinuria and granular casts may be evident in the urine of patients with CCF. True ?Proteinuria and granular casts may be evident in the urine of patients with CCF. (b) Patients with CCF are more likely to present with weight loss than weight gain. False ?Usually present with weight gain due to retention of salt and water. (c) An elevated urea and creatinine are present in 90 % of patients presenting with congestive heart failure. False ?The majority of patients have normal renal function on presentation. (d) CCF may produce pyoderma gangrenosum. False ?No association. (e) Right ventricular failure may cause hepatomegaly. True ?Hepatic dysfunction occurs also.


Le Fort's fractures: (a) Are fractures along midfacial fracture lines. True ? (b) Result from blunt trauma. True ? (c) The jaw is free floating. True ? (d) Type I is a horizontal maxillary fracture. True ?Type I is a horizontal maxillary fracture. (e) Type II is a pyramidal fracture. True Type II is a pyramidal fracture and type III is craniofacial dysfunction, with a fracture line extending from the frontozygomatic sutures, across the orbits and through the base of the nose and the ethmoid bones.


Wernicke's encephalopathy includes: (a) Confusion. True ? (b) Ataxia. True ? (c) Opthalmoplegia. True ? (d) Tremor. False ? (e) Headache. False ? Wernicke's encephalopathy (WE) is a common, acute neurologic disorder caused by thiamine deficiency . It is manifested by a clinical triad of encephalopathy, oculomotor dysfunction, and gait ataxia.


Wrist Injuries (a) The space between the scaphoid and the lunate bones is usually more than 3mm False ?The space between the scaphoid and the lunate bones is usually more than 3mm if there is scapholunate dissociation (b) Scapholunate dissociation is almost always treated conservatively. False ?Early referral for ligamentous repair is indicated. (c) The most common carpal bone dislocation is scaphoid dislocation. False ?The most common carpal bone dislocation are lunate and perilunate. (d) With a lunate dislocation the lunate dislocates posterior to the radius, but the remainder of the carpus aligns with the radius. False ?With a lunate dislocation the lunate dislocates anterior to the radius, but the remainder of the carpus aligns with the radius. (e) There is no evidence of lunate dislocation on PA radiographs. False ?On PA radiographs the lunate has a triangular shape , which is the pathognomonic " piece of pie " sign. Lateral radiograph reveals the lunate to be displaced and tilted palmarly ( " spilled teacup sign " )


Haemoptysis (a) Mild haemoptysis is considered less than 100ml's in 24 hours. False ?Mild haemoptysis is considered less than 20ml in 24 hours. (b) Moderate haemoptysis is considered less than 600ml's in 24 hours True ?Moderate haemoptysis is considered between 20 and 600 ml's in 24 hours. (c) Severe haemoptysis is considered more than 1000ml in 24 hours False ?Severe haemoptysis is considered more than 600ml's in 24 hours. (d) Neoplasm is a common cause of haemoptysis. True ?Neoplasm accounts for 25% of cases of haemoptysis. (e) Congestive cardiac failure accounts for 25% of cases of haemoptysis. False ?Congestive cardiac failure accounts for 3% of cases of haemoptysis.


Leukaemia ? classification; acute and chronic lymphoblastic leukaemia; acute and chronic myeloid leukaemia (a) In 40% of cases of CML there is progression to a more aggressive phase due to the dominance of a more malignant type of myeloid cell False ?In 70% of cases of CML there is progression to a more aggressive phase due to the dominance of a more malignant type of myeloid cell (b) CML with the philadelphia chromosome has a mean survival of 14 years. False ?CML with the philadelphia chromosome has a mean survival of 4 years. (c) CML is characterised in 80% of cases by the philadelphia chromosome within the haemopoietic stem cells False ?CML is characterised in 95% of cases by the philadelphia chromosome within the haemopoietic stem cells (d) The philadelphia chromosome is a reciprocal translocation of the long arm of 22 with the long arm of chromosome 11 False ?The philadelphia chromosome is a reciprocal translocation of the long arm of 22 with the long arm of chromosome 9 (e) CML occurs most frequently between the ages of 40 and 60 years True ?CML occurs most frequently between the ages of 40 and 60 years


The following injuries are more commonly associated with rear-end motor vehicle crashes than head on motor vehicle crashes. (a) Anterior Subluxations False ?More associated with head-on motor vehicle crashes. (b) Facet joint dislocations False ?More associated with head-on motor vehicle crashes. (c) Vertebral compression fractures False ?More associated with head-on motor vehicle crashes. (d) Spinous process avulsions False ?More associated with head-on motor vehicle crashes. (e) Atlas fractures True ? Rear-end motor vehicle crashes often cause hyperextension of the neck, associated with atlas fractures, extension teardrop fractures, posterior arch fractures, laminar fractures, hyperextension dislocations, and traumatic spondylolisthesis.


The Ear (a) The vagus nerve carries sensation from the external auditory canal. False ?The trigeminal and the facial nerves carries sensation from the external auditory canal. (b) The vestibulocochlear nerve carries sensory input from the middle ear structures. False ?The glossopharyngeal nerve and the auricular branch of the vagus nerve carry sensory input from the middle ear structures. (c) Referred otalgia may come from the nasopharynx, oropharynx, throat, and neck. True ?Referred otalgia may come from the nasopharynx, oropharynx, throat, and neck. (d) Tinnitus does not have a gender imbalance. True ?Tinnitus does not have a gender imbalance. (e) The most common cause of sudden hearing loss is idiopathic. True ?Other causes include ototoxic drugs infection, vascular causes, trauma, and metabolic disturbances.


Common tendon ruptures include (a) Achilles tendon. True ?Sudden pain is felt at the back of the ankle during running or jumping as the tendon ruptures. (b) Supraspinatus. True ? (c) Quadriceps expansion. True ?The quadriceps expansion encloses the patella and inserts into the tibial tubercle by the patellar tendon.Injury may be direct(eg a blow) or indirect( eg stumbling and causing sudden forced contraction) (d) Triceps. False ?This is uncommon. (e) Brachoradialis False ?This is uncommon. Extensor tendon rupture of the fingers and long head of biceps rupture are also common.


Regional Anaesthesia (a) The total volume of the anesthetic agent should not exceed 4 mL for a digital nerve block True ?The total volume of the anesthetic agent should not exceed 4 mL for a digital nerve block (b) The sural nerve is blocked between the medial malleolus and the Achilles tendon False ?The sural nerve is blocked between the lateral malleolus and the Achilles tendon. (c) The sural nerve lies just posterior to the short saphenous vein. False ?The sural nerve lies just anterior to the short saphenous vein. (d) The saphenous nerve is blocked between the medial malleolus and the anterior tibial tendon. True ?The saphenous nerve is blocked between the medial malleolus and the anterior tibial tendon. (e) The posterior tibial nerve is blocked by injecting the local anaesthetic between the posterior tibial artery and achilles tendon. True ?The posterior tibial nerve is blocked by injecting the local anaesthetic between the posterior tibial artery and achilles tendon.


Neck and Thoracolumbar pain: (a) Cervical disc prolapse is more common in women. False ?Cervical disc prolapse is more common in men. (b) Cervical disc prolapse occurs most commonly during the 6th decade of life. False ?Cervical disc prolapse is most common in the 4th decade of life. (c) The most commonly involved level is C7 T1. False ?The most commonly involved levels are C5 and C6 ( C6 root;20%) and C6 and C7 ( C7 root 70%). (d) The C7 nerve root is the most commonly involved. True ?The C7 nerve root is the most commonly involved(70%). (e) Thoracic compression fractures are most commonly seen in the 5th decade. False ?Thoracic compression fractures are most commonly seen in those with advanced age, especially in elderly females with osteoporosis.


Renal Physiology and Urine Production: (a) 100L of water and unbound small molecular weight constituents of blood are ultrafiltrated each day. False ?170-180L of water and unbound small molecular weight constituents of blood are ultrafiltrated each day. (b) 90% of filtered water and sodium are reabsorbed in the proximal tubule. False ?60-80% of filtered water and sodium are reabsorbed in the proximal tubule. (c) Almost all potassium, bicarbonate, glucose and amino acids are reabsorbed in the proximal tubule. True ?Almost all potassium, bicarbonate, glucose and amino acids are reabsorbed in the proximal tubule. (d) The plasma protein oncotic pressure exerted at the glomerulus is approximately 50 mmHg. False ?The plasma protein oncotic pressure exerted at glomerulus is approximately 25 mmHg (e) The GFR is approximately 60-70ml/min/1.70m 2 in adults. False ?The GFR is approximately 120-130ml/min/1.70m 2 in adults.


Giant Cell (cranial/temporal) arteritis (GCA) (a) Is associated with polymyalgia in 10% of people False ?Is associated with polymyalgia in 25% of people (b) About 33% of cases occur in the under 55's False ?Temporal arteritis is very rare in the under 55's (c) Platelets are characteristically decreased False ?Platelets are characteristically increased (d) Alkaline Phosphatase is characteristically decreased False ?Alkaline Phosphatase is characteristically increased.


Causes of hyperpigmentaion include (a) Nelsons syndrome True ? (b) Primary sclerosing cholangitis False ? (c) Addisons disease True ? (d) Uraemia True ? (e) Ectopic ACTH True ? Suntan, Race, uraemia, haemochromatosis, primary biliary cirrhosis, ectopic ACTH, Porphoria cutanea tarda, nelsons syndrome, malabsorption syndromes


The following are true: (a) The joints of the feet are the most commonly affected by suppurative arthritis False ?Large joints eg the knee are most commonly affected by suppurative arthritis (b) In children the onset of suppurative arthritis is usually slower and more insidious than the onset in adults. False ?In children the onset of suppurative arthritis is usually faster than the onset in adults (c) In children the metaphyses of the long bones ( femur, tibia and humerus ) are most commonly involved by osteomyelitis. True ?In children the metaphyses of the long bones ( femur, tibia and humerus ) are most commonly involved by osteomyelitis (d) Staphylococcus Aureus accounts for 50% of cases of osteomyelitis False ?Staphylococcus Aureus accounts for 90% of cases of osteomyelitis (e) 95% of cases of suppurative arthritis are due to staphylococcus aureus and S saprophyticus. False ?95% of cases of suppurative arthritis are due to staphylococcus aureus and S pyogenes


The Vertebral Column: (a) The cervical vertebrae normally have a posterior concavity while the thoracic region has a posterior convexity. True ?The cervical vertebrae normally have a posterior concavity while the thoracic region has a posterior convexity. (b) Flexion and extension of the vertebral column is extensive in the cervical and lumbar regions but limited by the thoracic region. True ?Flexion and extension of the vertebral column is extensive in the cervical and lumbar regions but limited by the thoracic region. (c) Lateral flexion of the body is restricted by the lumbar section of the vertebral column. False ?Lateral flexion of the body is restricted by the thoracic section of the vertebral column because of the rib cage. (d) Rotation ( twisting of the vertebral column ) of the body is least extensive in the thoracic region. False ?Rotation of the body is least extensive in the lumbar region. (e) There is normally 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, and 5 sacral vertebrae, and 4 coccygeal vertebrae. True ?There is normally 7 cervical vertebrae, 12 thoracic vertebrae, 5 lumbar vertebrae, and 5 sacral vertebrae, and 4 coccygeal vertebrae.


Typical causes of hypernatremia include: (a) Hypothyroidism. False ? (b) Diabetes Insipidus. True ? (c) Conn's Syndrome. True ? (d) Lithium. True ? (e) Addisons Disease. False ? HYPERNATREMIA [Na]>150 mmol/L Posm>295 mmol/L Classified according to whether net water loss or net sodium gain has occurred. Most cases are due to net water loss in excess of sodium with resultant decrease ECF (sodium gain is associated with increase ECF). Those with water gain can be sub-classified as to whether renal compensatory factors are intact (small volume concentrated urine) or renal factors are responsible (large volume dilute urine) AETIOLOGY 1. Water Depletion (hypovolemic) Extrarenal UNa>20, Uosm>295, Uvol 500 ml/day - decreased intake, infancy, coma, dementia - GIT losses - insensible losses, sweating, burns Renal Uosm<275 - osmotic diuresis - mineralocorticoid/glucocorticoid excess - Diabetes Insipidus i) central (decreased ADH secretion) - post traumatic - pituitary surgery - tumors - CNS infection - granulomatous disease - vascular: aneurysms, thrombosis Sheehan syndrome - idiopathic ii) nephrogenic (decreased response to ADH) - hypercalcemia - hypokalemia - renal diseases - drugs: lithium, amphotericin B 2. Sodium Gain (Hypervolemic) - NaHCO3, Hypertonic saline


NICE Guideline: Selection of adults for CT Brain post head injury (a) Postauricular ecchymosis is not an indication for CT Brain False ?Postauricular ecchymosis is an indication for CT Brain as it implies a base of skull fracture ( Battle's Sign ) (b) CSF leakage from the nose or from the ear indicates a base of skull fracture and should be investigated with CT Brain. True ?CSF leakage from the nose or from the ear indicates a base of skull fracture and should be investigated with CT Brain. (c) Seizures after a head injury in adults require investigation with CT Brain. True ?Seizures after a head injury in adults require investigation with CT Brain. (d) Any focal neurological deficit after head injury requires investigation with CT Brain. True ?Any focal neurological deficit after head injury requires investigation with CT Brain. (e) 1 episode of vomiting always requires a CT brain according to the NICE guidelines. False ?>1 episode of vomiting always requires a CT brain according to the NICE guidelines.


Regarding needlestick injuries: (a) Possible transmissible infective agents include diptheria. True Possible transmissible infective agents include diptheria. (b) The risk of acquiring hepatitis B from a carrier is around 3-10%. False The risk of acquiring hepatitis B has been estimated to be 2-40%. Risk of hepatitis C transmission from a carrier is around 3-10%. In contrast, HIV risk is much lower ? around 0.2-0.5% (c) Transmission risk is increased with hollow needles more than with solid needles. True Transmission risk is increased with hollow needles more than with solid needles. (d) The risk of acquiring HIV from a carrier is related to the volume of injected material. True Risk of HIV transmission is increased if significant volumes have been injected.


Beta Blockers (a) Sotalol causes a prolonged QT interval which may deteriorate to ventricular arrhythmias. True ?Sotalol causes a prolonged QT interval which may deteriorate to ventricular arrhythmias. (b) Toxicity may cause seizures. True ?CNS beta blocker toxicity may present with an altered mental status, confusion, or seizures. (c) Co-ingestion with another drug such as TCA's rarely complicates the clinical picture. False ?Co-ingestion with another drug such as TCA's is amonst the most helpful indicators of a bad outcome. (d) Beta blockers can cause oesophageal spasm but this is rare. True ?Beta blockers can cause oesophageal spasm but this is rare. (e) Sotalol is a Vaughan-Williams class III anti-arrhythmic medication. True ?Sotalol is a Vaughan-Williams class III anti-arrhythmic medication.


Splenomegaly is a feature of (a) Hepatitis A infection False ? (b) Malaria True ?Though splenic enlargement may be minimal or difficult to appreciate in early cases (c) Typhoid True ?Though splenic enlargement may be minimal or difficult to appreciate in early cases (d) Infectious mononucleosis True ?Present in nearly half of patients (e) Schistosomiasis True ?Due to portal hypertension and chronic immuological stimulation


Triceps rupture: (a) Triceps rupture usually occurs as a result of a direct blow to the olecranon. True ?Triceps rupture usually occurs as a result of a direct blow to the olecranon. (b) Triceps rupture may occur because of a fall on an outstretched hand causing a forceful flexion of an extended forearm. True ?Triceps rupture may occur because of a fall on an outstretched hand causing a forceful flexion of an extended forearm. (c) There is commonly an associated olecranon avulsion fracture. True ?There is commonly an associated olecranon avulsion fracture. (d) Swelling and tenderness is noted proximal to the olecranon. True ?Swelling and tenderness is noted proximal to the olecranon. (e) Extension of the forearm is weak. True ? Triceps rupture usually occurs as a result of a direct blow to the olecranon or a fall on an outstretched hand causing a forceful flexion of an extended forearm. There is commonly an associated olecranon avulsion fracture. Swelling and tenderness is noted proximal to the olecranon. Extension of the forearm is weak.


Therapeutic Hypothermia: (a) Includes ice packs to the groin, axillae, neck. True ?Therapeutic hypothermia includes ice packs to the groin, axillae, neck. (b) Includes 2 litres of ice cold saline. True ?Therapeutic hypothermia includes 2 litres of ice cold saline. (c) Includes intravenous magnesium. True ?It is used for vasodilation. (d) Includes exposing the patient. True ? (e) Hypothermia causes a rightward shift of the oxyhaemoglobin dissociation curve. False ?Hypothermia causes a leftward shift of the oxyhaemoglobin dissociation curve.


Hamate fracture: (a) Is often sustained in racket sports. True ? (b) Usually involve the body of the hamate. False ?Usually involve the hook of the hamate. (c) Nondisplaced hamate hook fractures and nondisplaced hamate body fractures are both treated conservatively and immobilized with a cast for 6 weeks. True ?Nondisplaced hamate hook fractures and nondisplaced hamate body fractures are both treated conservatively and immobilized with a cast for 6 weeks. (d) The mechanism of hamate injury usually involves direct trauma to the volar aspect of the hand. True ?The mechanism of hamate injury usually involves direct trauma to the volar aspect of the hand. (e) The hook is palpable in the soft tissue of the radial aspect of the hypothenar eminence. True ?The hook is palpable in the soft tissue of the radial aspect of the hypothenar eminence.


Biceps Rupture: (a) Patients complain of pain at the anterior shoulder most frequently . The rupture may be accompanied by a snap or pop. True ?Patients complain of pain at the anterior shoulder most frequently . The rupture may be accompanied by a snap or pop. (b) The rupture is more commonly proximal than distal. True ?The rupture is more commonly proximal than distal. (c) Biceps rupture after a sudden or prolonged contraction against resistance. True ?Biceps rupture after a sudden or prolonged contraction against resistance. (d) Rupture of the long head of the biceps is more common than rupture of the short head. True ?Rupture of the long head of the biceps is more common than rupture of the short head. (e) The distally retracted biceps is visable as a ball in the middle of the arm when the elbow is flexed. True ?The distally retracted biceps is visable as a ball in the middle of the arm when the elbow is flexed. Rupture of the long head of the biceps is more common than rupture of the short head. Biceps rupture after a sudden or prolonged contraction against resistance Patients complain of pain at the anterior shoulder most frequently . The rupture may be accompanied by a snap or pop. The distally retracted biceps is palpable as a ball in the middle of the arm. The rupture is more commonly proximal than distal.


The Brachial Plexus: (a) The roots of the brachial plexus emerge into the posterior triangle behind the scalenus anterior and the scalenus medius. False ?The roots of the brachial plexus emerge into the posterior triangle between the scalenus anterior and the scalenus medius. (b) The root of the ventral ramus of C7 makes the middle trunk of the brachial plexus True ?The root of the ventral ramus of C7 makes the middle trunk of the brachial plexus (c) The brachial plexus is sequentially divided into the roots, the trunks , the divisions, and the cords. True ?The brachial plexus is sequentially divided into the roots, the trunks , the divisions, and the cords. (d) The posterior divisions of the upper and middle trunk make up the lateral cord. False ?The anterior divisions of the upper and middle trunk make up the lateral cord. (e) Behind the clavicle each root divides into the anterior and posterior division False ?Behind the clavicle each trunk ( not root ) divides into the anterior and posterior division


Acute iritis (acute uveitis): (a) Is commonly relapsing. True (b) Slit lamp examination may reveal hypopyon. True Hypopyon refers to pus in the anterior chamber. (c) Talbot?s test is positive when pain is increased in the affected eye by shining a light into the ?good? eye. False This is a sign of acute iritis. However, Talbot?s test is positive when there is an increase in pain with eye convergence and pupil reaction to accommodation. (d) Reduced visual acuity, epiphoria and ?floaters? are common symptoms. True Other common symptoms are acute onset pain and photophobia.


Adverse Drug Reactions: (a) Quinine is associated with Type I reactions causing thrombocytopaenia False ?Quinine is associated with Type II reactions causing thrombocytopaenia (b) Agranulocytosis and marrow aplasia are associated with a type III reaction. False ?Agranulocytosis and marrow aplasia are associated with a type II reaction. (c) Type III reactions because of a drug reacting with a circulating or membrane bound protein to cause production of an IgG or IgM antibody with subsequent complement activation False ?Type II reactions because of a drug reacting with a circulating or membrane bound protein to cause production of an IgG or IgM antibody with subsequent complement activation (d) The most common target for Type III reactions is the haematological system ( resulting in Coombs positive haemolytic anaemia or thrombocytopaenia False ?The most common target for Type II reactions is the haematological system ( resulting in Coombs positive haemolytic anaemia or thrombocytopaenia (e) Methyldopa and Pencillin?s are associated with Type II reactions causing Coombs positive haemolytic anaemia. True ?Methyldopa and Pencillin?s are associated with Type II reactions causing Coombs positive haemolytic anaemia.


Antibiotics: (a) Aminoglycosides act by preventing peptidoglycan cross linking. False ?Aminoglycosides act by preventing translation of mRNA into protein (b) Glycopeptides are given intravenously to treat severe infection with C. Difficile. False ?Glycopeptides are given orally to treat pseudomembranous colitis. They are not absorbed orally ( Vancomycin ) (c) Erythromycin binds to the 50S ribosome, interfering with protein synthesis. True ?Erythromycin binds to the 50S ribosome, interfering with protein synthesis, (d) Tetracyclines interfere with protein synthesis by locking tRNA to the septal site of mRNA True ?Tetracyclines interfere with protein synthesis by locking tRNA to the septal site of mRNA (e) Trimethoprim and sulphonamides inhibit bacterial DNA gyrase. False ?Trimethoprim and sulphonamides inhibit the synthesis of tetrahydrofolate


Cavernous Sinus Syndrome:Structures passing through the cavernous sinus include (a) CN III True ? (b) CN IV True ? (c) CN VI True ? (d) Maxillary division of CN V. True ?Maxillary and opthalmic division of CN V (e) Internal carotid artery. True ?


Head Injury (a) Mild traumatic brain injury ( TBI ) patients are never amnesic of events. False ?Mild TBI = GCS 14 or more = 80% of patients (b) Mild TBI patients do not have a history of loss of consciousness. False ?Mild TBI patients may be asymptomatic with only a history of head trauma or they may be confused and amnestic of the event. They may have experienced brief loss of consciousness. (c) Mild TBI patients do not suffer from nausea or vomiting. False ?Mild TBI patients may complain of a diffuse headache , nausea and vomiting. (d) Those over 45 with a mild TBI constitute a high risk group. False ?High risk mild TBI patients include with a skull fracture, focal neurological signs, coagulopathy, age >60 years, drug or alcohol intoxication. (e) Moderate TBI patients have a GCS between 7 and 13. False ? Mild TBI = GCS 14 or more = 80% of patients Moderate TBI = GCS 9 to 13 ( inclusive ) = 10% of patients. Severe TBI = GCS 8 or less = 10% of patients.


Back Pain (a) With prolapse of the intervertebral disc between L5 and S1 weak hallux extension is seen False ?With prolapse of the intervertebral disc between L4 and L5 weak hallux extension is seen (b) With prolapse of the intervertebral disc between L5 and S1 sensation is decreased over the sole of the foot True ? (c) With prolapse of the intervertebral disc between L5 and S1 there is absence of the ankle jerk True ? (d) With prolapse of the intervertebral disc between L5 and S1 there is weak planter flexion True ? (e) With prolapse of the intervertebral disc between L4 and L5 there is a decrease in sensation over the lateral dorsum of the foot True ?If lumbar discs prolapse centrally cauda equina may occur


Lesions of the Optic Nerve: (a) An upper quadrant homonymous hemianopia is associated with a temporal lobe lesion. True ?An upper quadrant homonymous hemianopia is associated with a temporal lobe lesion. (b) A lower quadrant homonymous hemianopia is associated with a parietal lobe lesion. True ?A lower quadrant homonymous hemianopia is associated with a parietal lobe lesion. (c) A homonymous hemianopia may be caused by a pituitary tumor or a sella meningioma. False ?A bitemporal hemianopia may be caused by a pituitary tumor or a sella meningioma (d) A bitemporal hemianopia is caused by a lesion of the optic tract to the occipital cortex. False ?A homonymous hemianopia is caused by a lesion of the optic tract to the occipital cortex. (e) An incomplete lesion of the optic tract is associated with macular ( central ) vision sparing. True ?An incomplete lesion of the optic tract is associated with macular ( central ) vision sparing


Photosensitivity rashes: (a) Treatment with topical steroids is contraindicated. False ?This is an effective treatment. (b) About 1 per cent of patients treated with penicillin will develop such a rash. False ?Very rare with penicillin but more frequently with sulphonamides and tetracycline. (c) There is an association with SLE. True ?There is an association with SLE. (d) Patients with photosensitivity rashes are more likely to have a contact allergy to multiple allergens. True ?Particularly plants, cosmetics and other common contact allergens. (e) The rash will be helped by the wearing of any clothing over the affected area. False ?It is not widely appreciated that light may penetrate a number of different fabrics, particularly in thin loosely-woven clothing.


Mechanical Back Pain: (a) Should avoid stooping, bending, lifting and low chairs True ?Avoid stress on back (b) Does not vary with activity False ?Mechanical back pain is brought on by activity and relieved by rest (c) Is usually associated with focal bony tenderness False ?This is a sinister symptom (d) Is not usually associated with bladder or bowel dysfunction True ? (e) Physiotherapy during the acute phase can reduce spasm. True ?Physiotherapy during the acute phase can help reduce pain and spasm. During convalesence the patient can be educated on heavy lifting and given exercises to strengthen the back muscles.


Adult respiratory distress syndrome(ARDS): (a) Can be caused by methadone. True ?In patients with ARDS the protein percentage in the interstitiium of the lung parenchyma is greater than 60% of the plasma value. The onset of ARDS is often within 2 hours of the precipitating event. (b) Can be caused by aspiration of gastric contents. True ? (c) Can be caused by frusemide. False ? (d) Can be caused by oxygen toxicity. True ? (e) Can be caused by pancreatitis. True ? ARDS can be caused by overdose of aspirin, cocaine, opioids, phenothiazines, and tricyclic antidepressants. Reactions to protamine, nitrofurantoin, and certain chemotherapeutic agents, occasionally precipitate ARDS after therapeutic doses. Radiologic contrast media can also provoke ARDS in susceptible individuals . Alcohol abuse has been shown to increase the risk of ARDS due to other causes (eg, sepsis, trauma), although it does not cause ARDS itself.


Causes of pleural effusion: (a) Glomerulonephritis. True ?Glomerulonephritis usually causes a transudate effusion. (b) Liver cirrhosis. True ?Liver cirrhosis usually causes a transudate effusion. (c) Nephrotic syndrome. True ?Nephrotic syndrome usually causes a transudate effusion. (d) Pulmonary embolus. True ?Pulmonary embolus usually causes an exudate effusion. (e) Rheumatoid arthritis. True ?Rheumatoid arthritis usually causes an exudate effusion.


Spontaneous Pneumothorax (a) Is twice as common in men than in women False ?Is 5 times more common in men than in women. (b) Smokers are twice as likely to suffer a spontaneous pneumothorax than non smokers. False ?Smokers are more than 10 times as likely to suffer a pneumothorax than non smokers. (c) Subpleural bleb's which rupture are frequently located in the lower lobes. False ?Subpleural bleb's which rupture are frequently located in the upper lobes. Baumann MH, Strange C: The clinician's perspective on pneumothorax management. Chest 112:822, 1997. (d) AIDS sufferers are more likely to suffer a spontaneous pneumothorax. True ?AIDS sufferers are more likely to suffer a spontaneous pneumothorax and this can be related to PCP. (e) Dyspnoea is associated with larger pneumothorax's. True ?Dyspnoea is associated with larger pneumothorax's.


Accelerated and malignant hypertension: (a) Has a diastolic blood pressure >120mmHg. True ? (b) Is characterised by acute microvascular changes. True ?This is most easily seen in the retina but occurs in all organs. (c) Presentation is with headache and visual loss. True ?And varying degrees of confusion. (d) The diastolic BP should be lowered as quickly as possible. False ?Should be lowered by 15-20mmHg over 24 hours. (e) Hypertensive retinopathy grade I is characterised by flame-shaped haemorrhages and cotton wool exudates. False ?Grad I-Silver wiring(tortuous retinal arteries), Grad II-AV nipping, Grade III-flame shaped haemorrhages and cotton wool exudates, Grade IV - papilloedema.


The clinical features of heat syncope include: (a) Headache. True (b) Postural hypotension. True (c) Fever. False (d) Warm dry skin. False (e) Nausea and vertigo. True Syncopal episodes are frequently induced by prolonged standing, venipuncture (experienced or witnessed), heat exposure, painful or noxious stimuli, fear of bodily injury, or exercise. However, some patients have recurrent episodes without an identifiable cause.


The following antibiotics inhibit the formation of folic acid: (a) Sulphonamides. True ?Sulphonamides inhibit the formation of folic acid. (b) Trimethoprim. True ?Trimethoprim inhibits the formation of folic acid. (c) Flucloxacillin. False ? (d) Gentamicin. False ?Gentamicin is a protein synthesis inhibitor. (e) Clindamycin. False ?Clindamycin binds to the 50s ribosomal subunit.


Which of the following treatment strategies are of proven benefit? (a) Lactulose for hepatic encephalopathy True ?Lactulose for hepatic encephalopathy is a useful treatment strategy. (b) High flow oxygen for cluster headaches True ?High flow oxygen can relieve the pain of cluster headaches. (c) Prednisolone with acyclovir for Bell's palsy True ?Prednisolone with acyclovir for Bell's palsy is of proven benefit. (d) Therapeutic hypothermia for out of hospital cardiac arrest True ?Therapeutic hypothermia for out of hospital cardiac arrest is a useful treatment strategy and improves survival. (e) Steroids for bacterial meningitis. True ?


Oropharyngeal airway: (a) Eliminates the possibility of an upper airway obstruction. False ?Incomplete airway obstruction can occur despite an oropharyngeal airway. (b) It eliminates the need to position the head of an unconscious patient. False ?You must still maintain proper head position in an unconscious patient when an oropharyngeal airwat is inserted. (c) It is of no value once a tracheal tube is inserted. False ? (d) It may stimulate vomiting or laryngospasm if inserted in the semiconscious patient. True ?A semiconscious patient may maintain their gag reflex. (e) Holds the tongue from the back of the pharynx in an unconscious patient. True ?


The ottawa ankle rules: (a) Have a high specificity but a low sensitivity. False Have a high sensitivity but a low specificity. (b) Do not include wheather a patient is weight bearing or not. False If a patient is not weight bearing it is an indication for an X Ray. (c) If a patient is tender over the base of the 5th metatarsal it is an indication for an X Ray. True If a patient is tender over the base of the 5th metatarsal it is an indication for an X Ray. (d) Tenderness over the tip but not over the posterior part of the medial malleolus is an indication for an X Ray. False Tenderness over the tip and over the posterior part of the medial malleolus is an indication for X Ray. (e) Tenderness over the tip and over the posterior part of the lateral malleolus is an indication for X Ray. True Tenderness over the tip and over the posterior part of the lateral malleolus is an indication for X Ray.


With regard to airway management in the emergency department: (a) An uncuffed size 5 (5mm internal diameter) endotracheal tube is appropriate for a 4-year-old male. True The formula for endotracheal tube sizing in children is the age divided by 4 then add 4 in mm. Uncuffed tubes should be used up until the age of 12 as the narrowest part of the upper airway is the cricoid ring until puberty. (b) A size 4 laryngeal mask airway cuff should be inflated with a 50mL volume of air following correct positioning. False The recommended volume is 30mL. The general formula for this is the size of the LMA minus 1 times 10 in mL. (c) The best head and neck position for direct laryngoscopy is extension of the neck with maximal flexion at the occipito-atlantal joint. False The most effective position is with flexion of the neck and extension at the occipitoatlantal joint ? the so called ?sniffing the morning air? position. (d) Sellick?s manoeuvre is used to prevent aspiration when the patient is vomiting during attempted endotracheal intubation. False Cricoid pressure should be released if the patient is actively vomiting otherwise an oesophageal rupture may occur.


Control mechanisms of respiration: (a) The strongest stimulant to ventilation is a rise in PaCO2. True ?The strongest stimulant to ventilation is a rise in PaCO2. (b) In COPD patients PaO2 is the chief stimulus to respiratory drive. True ?In COPD patients PaO2 is the chief stimulus to respiratory drive. (c) DKA causes a fall in PaCO2 because of increased ventilation and deep sighing breathing. True ?DKA causes a fall in PaCO2 because of increased ventilation and deep sighing breathing. (d) The repiratory centre is depressed by severe hypoxaemia. True ?The repiratory centre is depressed by severe hypoxaemia. (e) Aspirin in large doses stimulates the respiratory centre. True ?Aspirin in large doses stimulates the respiratory centre.


In community acquired pneumonia: (a) The most common microbe is Staph Aureus. False (b) Less than 20% of patients will have chest pain. False (c) In the elderly ,features of cerebral dysfunction may be the only presenting feature. True (d) Chest X Ray is necessary for diagnosis. False (e) Initial antibiotic choice is ciprofloxacin. False Streptococcus pneumoniae, haemophilus, and mycoplasma are the most common organisms in CAP. 65% have chest pain, with more than 70% with cough, breathlessness and sputum.In the elderly signs cerebral dysfunction may be the only presenting sign such as confusion, incontinence or falls. Chest X ray is not necessary for diagnosis of CAP. The initial choice of antibiotic should be amoxicillin or erythromycin for five to seven days.


Low voltage ECGs are caused by: (a) Left bundle branch block(LBBB). False ? (b) Pulmonary emphysema. True ? (c) Pericardial effusion. True ? (d) Severe obesity. True ? (e) Myxoedema. True ? This is seen in pulmonary emphysema, pericardial effusion, myxoedema, severe obesity, cardiomyopathies , global ischaemia and amyloid.


Orbital Cellulitis (a) Orbital cellulitis is infection deep to the orbital septum. True ?Orbital cellulitis is infection deep to the orbital septum. Peri-orbital cellulitis is pre-septal. (b) Staph Aureus is the most common pathogen. True ?Staph Aureus is the most common pathogen. (c) E Coli is a common pathogen in young children. False ?Haemophilus is a common pathogen in young children. (d) Polymicrobial infection is uncommon. False ?Polymicrobial infection is common. (e) Extension from paranasal sinus infection is the most common source. True ? Extension from paranasal sinus infection is the most common source.


When assessing chest pain: (a) Oesophageal pain is provoked by exertion. True ?Oesophageal pain is provoked by exertion. (b) Pneumonia is a cause of pleuritic chest pain. True ?Pneumonia is a cause of pleuritic chest pain. Other causes include pulmonary embolism, pleurisy, and pneumothorax. (c) Pain relief with GTN spray is helpful in distinguishing cardiac from non cardiac chest pain. False ?Pain relief with GTN spray is not helpful in distinguishing cardiac from non cardiac chest pain. (d) The pain of pericarditis is often aggravated by sitting up and leaning forwards. False ?The pain of pericarditis is often relieved by sitting up and leaning forwards.


Features of cocaine intoxication frequently include (a) Bradycardia False Tachycardia and ventricular arrhythmias are common features- cardio respiratory failure ca occur but is not common. (b) Schizophrenia False Paranoia and psychosis can occur acutely with high doses or with chronic use but these are differentials to be excluded before a diagnosis of schizophrenia is made (c) Skin pallor True Cocaine is a vasoconstrictor. (d) Seizures True This is a common feature. In epiletics seizures can occur at recreational doses however in non epileptics presentation in status epilepticus usually indicates a very severe overdose with poor prognostic outcome. (e) Hypertension True Cocaine is a vasoconstrictor.


In diabetic retinopathy (a) Background retinopathy is the most common cause of visual loss False Diabetic maculopathy is (b) Diabetic maculopathy is more common in type one rather than type two diabetes True ? (c) Features of proliferative retinopathy include cotton woll spots, venous changes and large deep haemorrhages False These are features of preproliferative retinopathy. (d) Diabetic retinopathy is present in 20% of type II patients at diagnosis False Present in 10% at diagnosis (e) Diabetic retinopathy is present in 50% of type II patients after 10 years True Present in 80% after 20 years. It is unusual in type 1 diabete until 10years after diagnosis


Anterior spinal artery occlusion: (a) Causes a contralateral hemiparesis. True Anterior spinal artery occlusion causes a contralateral hemiparesis. (b) Involves the cortico-spinal tract. True Anterior spinal artery occlusion involves the cortico-spinal tract. (c) Causes a ipsilateral loss of discrete touch, proprioception and vibration. False (d) Does not affect the tongue. False (e) Causes an ipsilateral hemiparesis. False Anterior spinal artery occlusion causes a medial medullary syndrome characterised by contralateral hemiparesis caused by involvement of the cortico-spinal tract, contralateral loss of discrete touch, proprioception and vibration caused by involvement of the medial lemniscus and tongue dysfunction caused by hypoglossal involvement.


The vagus nerve ( CN X ) (a) Is the afferent pathway for the gag reflex False ?The vagus nerve is largely motor. It supplies the striated muscle of the pharynx ( efferent pathway of the gag reflex) , the larynx ( including the vocal cords via the recurrent laryngeal nerve) and the upper oesophagus. (b) Supplies the larynx True ?There are also sensory fibers from the larynx. (c) Supplies the upper oesophagus True ? (d) Supplies the sympathetic supply to the heart False ?Parasympathetic fibers supply the heart. (e) Supplies parasympathetic fibers to the abdominal viscera. True ?Parasympathetic fibers supply the abdominal viscera.


Appropriate pharmacological management of an acutely agitated 70 year old man with no history of mental illness may include: (a) Haloperidol 10mg False ?Caution must be exercised with use of antipsychotics in the elderly ( >65). Recommended dosing for this age group is 0.5- 1.5mg po/ im. (b) Olanzapine 5 mg False ?There is a warning out re the use of Olanzapine and Risperidone in patients over the age of 65. The is an increased risk of cerebrovascular accident. (c) Risperdone 1mg False ? (d) Lorazepam 0.5mg True ? (e) Chlorpromazine 25mg True ?


Hip Injuries (a) Hip fracture incidence doubles for each decade after 50. True ? (b) Hip fracture incidence is 5 to 6 times higher in women than in men. False ?Hip fracture incidence is 3 to 4 times higher in women than in men. (c) The affected leg in a hip fracture is classically shortened and internally rotated. False ?The affected leg in a hip fracture is classically shortened and externally rotated. (d) Complications of a hip fracture include non-union. True ? (e) Extracapsular hip fractures may be subcapital. False ? Hip fracture incidence doubles for each decade after 50. Hip fracture incidence is 3 to 4 times higher in women than in men. The affected leg in a hip fracture is classically shortened and externally rotated. Intracapsular hip fractures involve the femoral head and femoral neck. Extracapsular hip fractures may be intertrochanteric or subtrochanteric.


Leukaemia ? classification; acute and chronic lymphoblastic leukaemia; acute and chronic myeloid leukaemia: (a) CLL is the most common leukaemia of adults comprising about 10% of all leukaemias. False ?CLL is the most common leukaemia of adults comprising about 30% of all leukaemias.(CLL comprises 30% [not 10% as stated in the question]) (b) CLL affects males to females in a ratio of 4:1. False ?CLL affects males to females in a ratio of 2:1. (c) CLL is much less aggressive than other leukaemias and patients commonly survive for more than 10 years. True ?CLL is much less aggressive than other leukaemias and patients commonly survive for more than 10 years. (d) Secondary autoimmune haemolytic anaemia develops in 20% of patients with CLL. False ?Secondary autoimmune haemolytic anaemia develops in 10% of patients with CLL. (e) Neutropaenia, lymphopaenia and thrombocytopaenia are very common in the chronic phase of CML. False ?Neutropaenia, lymphopaenia and thrombocytopaenia are not common in the chronic phase of CML.


Epilepsy: (a) Auras with no loss of consciousness represent complex partial seizures. False This is associated with SIMPLE partial seizures. (b) Pseudoseizures (Non epileptic seizures) by definition are not associated with episodes of incontinence. False Incontinence is not a common feature of pseudoseizures but does occur and certainly does not exclude the diagnosis. (c) Pseudoseizures are usually more prolonged than normal seizures. True ? (d) Prolactin levels are usually raised after seizures. True Generally this is the case but prolactin levels are not usually raised in FRONTAL seizures. (e) Temporal lobe epilepsy is associated with episodes of psychosis. True There are two types of psychosis associated with TLE- 1. Post ictal psychosis 2.Long standing TLE with psychosis developing interictally.


Common Microbes: (a) Staph haemolyticus is a common cause of UTI?s in young women. False ?Staph Saprophyticus is a common cause of UTI?s in young women. (b) Gamma haemolytic streptococcus have incomplete haemolysis while alpha haemolytic streptococcus have complete haemolysis. False ?Streptococcus is divided into colonies which are distinguished by the type of haemolysis. Alpha haemolytic streptococcus have incomplete haemolysis while beta haemolytic streptococcus have complete haemolysis. (c) Streptococcus Pyogenes is carried asymptomatically in the pharynx in 5-30% of the population True ?Streptococcus Pyogenes is carried asymptomatically in the pharynx in 5-30% of the population (d) Infection with streptococcus pyogenes is most common old age. False ?Infection with streptococcus pyogenes is most common in children (e) Staphylococcus Saprophyticus is the most common agent of osteomyelitis and septic arthritis. False ?Staphylococcus Aureus is the most common agent of osteomyelitis and septic arthritis.


Hip Fractures (a) Subtrochanteric fractures are usually seen in young people after minor injuries. False ?Subtrochanteric fractures are usually seen in elderly osteoporotic patients or in young patients after major trauma. (b) Subtrochanteric fractures are associated with small amounts of blood loss. False ?Subtrochanteric fractures may present hypotensive secondary to blood loss into the soft tissue of the thigh. (c) With greater trochanteric fractures pain is inducible with adduction and flexion of the leg. False ?With greater trochanteric fractures pain is inducible with abduction and extension of the leg. (d) Greater trochanteric fractures almost always require operative fixation. False ?Greater trochanteric fracture treatment is contoversial. Some patients are managed conservatively, others are fixed operatively. (e) Lesser trochanteric avulsions are most common in elderly osteoporotic patients. False ?Lesser trochanteric avulsions are most common in young athletes after avulsion secondary to a forceful contraction of the iliopsoas muscle.


Myocarditis: (a) Most solitary myocarditis cases are caused by viral infections True ?Most solitary myocarditis cases are caused by viral infections (b) Brucellosis is not a cause of myocarditis. False ?Brucellosis and rickettsia can cause myocarditis. (c) In myocarditis the ECG may show upward curved elevated ST segments. False ?In myocarditis the ECG may show T wave inversion, prolongation of the PR or QRS interval, extrasystoles or heart block. Upward curved elevated ST segments are a feature of pericarditis. (d) Myocarditis is not associated with a treponin rise. False ?Any cause of damage to the myocardium can cause a treponin rise. (e) Myocarditis is caused by the coxsackie, echo and adenoviruses most frequently. True ?Myocarditis is caused by the coxsackie, echo and adenoviruses


Angina (a) Patients who suffer from decubitus angina usually have preserved left ventricular systolic function False ?Patients with decubitus angina( that occurring on lying down) usually have impaired left ventricular systolic function. (b) Variant (prinzmetal) angina is usually provoked by exertion. False ?Variant ( Prinzmetal ) angina occurs wihout provocation, usually at rest, as a result of coronary artery spasm. (c) ST segment elevation may occur on the ECG during prinzmetal angina. True ? (d) Resting ECG between attacks is normal. True ? (e) ST segment depression of > 1 mm during an exercise ECG suggests myocardial ischaemia. True ?Particularly if typical chest pain occurs at the same time.


The following are causes of sinus bradycardia: (a) Acute inferior myocardial infarction. True (b) Decreased intracranial pressure. False (c) Carotid sinus massage. True (d) Hyperthyroidism. False (e) Sick sinus syndrome. True There are physiological causes(vagal tone), pharmacological causes(B Blockers, digoxin and calcium channel blockers) and pathological causes ( Hypothyroidism, sick sinus syndrome, increased intracranial pressure, acute inferior MI, carotid sinus hypersensitivity).


Cervical Vertebrae and position of Structures: (a) The body of hyoid is at the level of C3 True ?The body of hyoid is at the level of C3 (b) The bifurcation of the common carotid arteries is at C4 True ?The bifurcation of the common carotid arteries is at C4 (c) The upper border of the thyroid cartilage is at C5 False ?The upper border of the thyroid cartilage is at C4 (d) The cricoid cartilage is at the level of C7 False ?The cricoid cartilage is at the level of C6 (e) The larynx becomes the trachea at C6 True ?The larynx becomes the trachea at C6


Testes, Epididymis and Spermatic Cord: (a) The deep inguinal ring transmits the teticular branch of the genitofemoral nerve. False ?The deep inguinal ring transmits the genital branch of the genitofemoral nerve. (b) The round ligament terminates in the fibrofatty tissue of the labium majus. True ?The round ligament terminates in the fibrofatty tissue of the labium majus. (c) The internal spermatic fascia is derived from the external oblique aponeurosis. False ?The internal spermatic fascia is derived from the transversalis fascia. (d) The cremasteric fascia containing the cremasteric muscle is derived from the transversalis fascia. False ?The cremasteric fascia containing the cremasteric muscle is derived from the internal oblique muscle (e) The external spermatic fascia is derived from the aponeurosis of the external oblique muscle True ?The external spermatic fascia is derived from the aponeurosis of the external oblique muscle


The characteristic features of acute mountain sickness(AMS) include: (a) Onset at 1500m above sea level. False AMS is usually seen in unacclimated people making a rapid ascent to over 2000m ( 6600 ft ) above sea level. (b) Hyporeninaemia hypoaldosteronism. False Increased sympathetic nervous system activity is associated with decreased urine output, mediated by increased renin- angiotensin, aldosterone, and ADH. (c) Headache nausea and vomiting. True Symptoms similar to a hangover may develop within 6 hours after arrival at altitude. These include headache, anorexia, nausea, weakness and fatigue. (d) Pulmonary and cerebral oedema. True High altitude pulmonary oedema and high altitude cerebral oedema are an extreme progression of acute mountain sickness. (e) Hypocoagulation states. False No association.


In the elderly, opiates: (a) Have a decreased half life. False (b) Preclude driving. True (c) Should always be used in short acting preparation form. False (d) Rarely cause true addiction. False (e) Are contraindicated in patients with cardiac failure. False In the elderly, opiates have an increased half life and possibly a greater analgesic effect than in younger pt's.Opiate preparations should be used in continuous preparations for continuous pain. True addiction is far less common in the elderly than in younger patients.


Gastrointestinal Bleeding: (a) In lower GI bleeding, not from haemorrhoids, the most common aetiologies are diverticular disease and angiodysplasia. True ?In lower GI bleeding, not from haemorrhoids, the most common aetiologies are diverticular disease and angiodysplasia. (b) Angiodysplasia is more common in patients with hypertension. True ?Angiodysplasia is more common in patients with hypertension. (c) PUD causes about 40% of all upper GI bleeds. False ?PUD causes about 60% of all upper GI bleeds. (d) About 30% of duodenal bleeds will re-bleed within 24 -48 hours. False ?About 10% of duodenal bleeds will re-bleed within 24 -48 hours. (e) A Mallory weiss tear occurs in the distal oesophagus due to a tear in the mucosa from repeated vomiting. True ?A Mallory weiss tear occurs in the distal oesophagus due to a tear in the mucosa from repeated vomiting.


Viral Croup In Children (a) Children 6 months to 3 years of age are most commonly affected with viral croup, with a peak incidence between 1 and 2 years of age. True ?Children 6 months to 3 years of age are most commonly affected with viral croup, with a peak incidence between 1 and 2 years of age. (b) A 1mm amount of oedema in an infant may cause a reduction of 50% of the cross-sectional area True ?A 1mm amount of oedema in an infant may cause a reduction of 50% of the cross-sectional area (c) Rhinovirus virus types I, II and III are the most common causes of viral croup. False ?Parainfluenza virus types I, II and III are the most common causes of viral croup. (d) The incubation period of the most common virus to cause viral croup is less than 6 days and the shedding period is about 2 weeks. True ?The incubation period of the most common virus to cause viral croup is less than 6 days and the shedding period is about 2 weeks. (e) Croup is always associated with a low grade fever and the cough is usually worse in the evening and at night-time. False ?Croup is sometimes associated with a low grade fever and the cough is usually worse in the evening and at night-time.


Helpful dietary tips for diabetic patients include: (a) Drink at least 2 portions of fruit a day. False (b) As far as possible a eat foods labelled 'for diabetics'. False (c) Where possible eat wholegrain cereals and breads. True (d) Eat at least 3 meals a day. True (e) Never eat chocolate sweets or biscuits. False Fruit has a high natural sugar content and therfore diabetics should limit themselves to 1 portion of fruit juice per day. It is unneccessary to eat foods labelled 'for diabetics' as far as possible as this is expensive. Good diet does not ban foods but should limit unhealthy ones.


Lunate Fracture (a) Is not at risk of avascular necrosis False ?A lunate fracture is at risk of avascular necrosis.The etiology of avascular necrosis of the lunate or Kienb?disease has long been debated. The arterial blood supply of the lunate is variable, and it may be predominately derived from a single vessel (b) Occupies 1/3 rd of the articular surface of the radius. False ?The lunate bone occupies 2/3 rd's of the articular surface of the radius. (c) Tenderness is present distal to the rim of the radius at the base of the 5th metacarpal. False ?Tenderness is present distal to the rim of the radius at the base of the 3rd metacarpal. This is the lunate fossa. (d) Treatment consists of a volar resting splint and orthopaedic referral. False ?Treatmant consists of a thumb spica splint and orthopaedic referral. (e) The mechanism of lunate fracture involves either chronic repetitive trauma leading to multiple microfractures or a direct traumatic blow resulting in a primary fracture True ? The mechanism of lunate fracture involves either chronic repetitive trauma leading to multiple microfractures or a direct traumatic blow resulting in a primary fracture. The etiology of avascular necrosis of the lunate or Kienb?disease has long been debated. The arterial blood supply of the lunate is variable, and it may be predominately derived from a single vessel. More recent evidence suggests that venous stasis may be more of an etiologic factor than an inadequate arterial supply. The diagnosis should be suspected in the patient who reports central dorsal wrist pain, loss of motion at the wrist, and diminished grip strength. Tenderness is demonstrated with direct palpation of the dorsal aspect of the lunate.


Class 2 hypovolaemic shock (a) Urine output 35ml/hour False ? (b) Blood loss 2500ml in 70kg man False ? (c) Pulse rate 110bpm True ? (d) Respiratory rate 15 bpm False ? (e) Blood loss of 40% of blood volume False ? Class 1, blood loss < 15% (up to 750 ml/70 KG), PR<100, BP N, PP N, UO>30 Class 2, blood loss 15-30% (750-1500 ml/70 KG), PR>100, hypotension, PP dec, UO 20-30 Class 3, blood loss 30-40% (1500-2000 ml/70 KG), PR>120, hypotension, PP dec, UO 5-15 Class 4, blood loss >40% (>2000 ml/70 KG), PR>140, hypotension, PP dec, UO nil


Antibiotics in clinical use: (a) Erythromycin does not cross the placenta False ?Erythromycin crosses the placenta (b) Erythromycin is excreted by the kidneys. False ?Erythromycin is excreted in the bile (c) Quinolones inhibit bacterial DNA gyrase True ?Quinolones inhibit bacterial DNA gyrase (d) Quinolones are more active than fluoroquinolones against pseudomonas and Chlamydia. False ?Fluoroquinolones are more active than quinolones against pseudomonas and Chlamydia (e) Erythromycin is active against gram negative cocci, many anaerobes not including bacteroides, mycoplasma and Chlamydia False ?Erythromycin is active against gram positive cocci, many anaerobes not including bacteroides, mycoplasma and Chlamydia


Myocarditis: (a) There is no evidence of myocarditis on a CXR. False ?There may be elevation of the cardiac enzymes and cardiomegaly on the CXR in myocarditis. (b) Myocarditis is caused by the coxsackie, echo and adenoviruses but not mycoplasma or rubella. False ?Myocarditis is caused by the coxsackie, echo and adenoviruses. Rubella and mycoplasma can cause myocarditis also. (c) Most solitary myocarditis cases are caused by brucellosis and rickettsia. False ?Most solitary myocarditis cases are caused by viral infections (d) Treatment for myocarditis is with infliximab. False ?Treatment for myocarditis is supportive. (e) In myocarditis the ECG caharacteristically shows 1st degree heart block with a positive R wave in AVR. False ?In myocarditis the ECG may show T wave inversion, prolongation of the PR or QRS interval, extrasystoles or heart block


Lower Leg Arteries: (a) At the ankle the anterior tibial artery has the tendon of extensor digitorum longus on it?s medial side False ?At the ankle the anterior tibial artery has the tendon of extensor digitorum longus on it?s lateral side (b) The posterior tibial artery is accompanied by the tibial nerve. True ?The posterior tibial artery is accompanied by the tibial nerve. (c) At the ankle the anterior tibial artery has the tendon of the extensor hallucis longus on it?s lateral side False ?At the ankle the anterior tibial artery has the tendon of the extensor hallucis longus on it?s medial side (d) The anterior tibial artery finishes it?s course as the profunda artery. False ?The anterior tibial artery finishes it?s course as the dorsalis pedis artery. The profunda artery is in the thigh. (e) The anterior tibial artery arises at the bifurcation of the peroneal artery. False ?The anterior tibial artery arises at the bifurcation of the popliteal artery in the popliteal fossa.


Urinary Retention: (a) Infrequent ejaculation can lead to secondary prostatic congestion and worsen symptoms of outlet ejaculation. True ? (b) Men void less completely when sitting down to void. True ? (c) Bladder spasm frequently accompanies an indwelling catheter. True ? (d) Postobstructive diuresis is more common in chronic rather than acute obstruction. True ? (e) After catheterisation prophylactic antibiotics should be considered if the catheter is to remain indwelling for prolnged periods. True ?


Thrombolysis (a) Thrombolysis results in a higher earlier CPK rise but a lower total CPK rise. True ?Thrombolysis results in a higher earlier CPK rise but a lower total CPK rise. (b) May be given for up to 10 hours in the context of continuing pain or deteriorating condition. False ?May be given for up to 12 hours in the context of continuing pain or deteriorating condition. (c) Recanalisation without thrombolysis occurs in 15%. True ?Recanalisation after thrombolysis occurs in 70% (d) Is contraindicated if the patient has had head trauma within 12 months. False ?Is contraindicated if the patient has had head trauma within 2 weeks. (e) Is contraindicated if the patient has a proven haemorrhagic stroke or cerebral infarction within the last 12 months. False ?Is contraindicated if the patient has a proven haemorrhagic stroke or cerebral infarction within the last 2 months.


The diaphragm and it's orifices: (a) The left phrenic nerve pierces the diaphragm lateral to the central tendon at the level of T8 True ?The left phrenic nerve pierces the diaphragm lateral to the central tendon at the level of T8 (b) The right phrenic nerve pierces the diaphragm with the IVC at T8 True ?The right phrenic nerve pierces the diaphragm with the IVC at T8 (c) The sternoxiphisternal joint is at the level of T6/7 False ?The sternoxiphisternal joint is at the level of T8/9 (d) The oesophageal opening in the diaphragm is at the level of T12 False ?The oesophageal opening in the diaphragm is at the level of T10 (e) Branches of the left gastric vessels go through the diaphragm at T10 True ?Branches of the left gastric vessels go through the diaphragm at T10


Staphylococcus Species: (a) Asymptomatic carriage of Staph Aureus is found in 80% of healthy people, in the skin, axilla or perineum False ?Asymptomatic carriage of Staph Aureus is found in 40% of healthy people, in the skin, axilla or perineum (b) Staphylococcus Aureus possesses the enzyme fibrinase which catalyses the conversion of fibrinogen to fibrin. False ?Coagulase catalyses the conversion of fibrinogen to fibrin (c) Staph Aureus produces extracellular lytic enzymes ( e.g lipase ) which break down host tissues True ?Staph Aureus produces extracellular lytic enzymes ( e.g lipase ) which break down host tissues (d) Staphylococcus pneumonia is cavitating. True ?Staphylococcus pneumonia follows influenza, progresses rapidly, is cavitating and has a high mortality (e) Staphylococcus Saprophyticus is the most invasive species of staphylococcus. False ?Staphylococcus Aureus is the most invasive species of staphylococcus and is differentiated from other species by possessing the enzyme coagulase


If a patient presents with a loss of consciousness admission is usually indicated if: (a) The JVP is raised. True ?This may suggest a diagnosis oftamponade,PE, or pulmonary hypertension. (b) There are signs of significant valvular disease. True ?This may suggest aortic stenosis. (c) There are signs of significant cardiac failure. True ?This may suggest a ventricular tachycardia. (d) Abnormal ECG. True ? (e) Known cardiomyopathy. True ?


A prolonged QTc (rate corrected QT interval): (a) Can result from quinidine therapy. True Other drugs that may prolong the QTc include tri-cyclic antidepressants. (b) Occurs during sleep. True It may also be due to acute MI, hypothermia or hypocalcaemia. (c) May predispose to ?torsades de pointes?. True Torsades de pointes is an uncommon form of polymorphic VT with a constantly changing electrical axis resulting in a constantly changing QRS complex amplitudes, associated with hypokalaemia or hypomagnesaemia with a prolonged QT interval. (d) Is seen in digoxin toxicity. False Digoxin and hypercalcaemia shorten the QTc. (e) May be caused by TCAs. True


The following are true with regard to delirium: (a) Features can include auditory hallucinations. True ? (b) Features can include visual hallucinations. True ? (c) Impaired concentration is an early feature, often arising before any other discernable features. True ? (d) Tearfulness suggests a functional psychiatric illness is a more likely diagnosis. False Lability of mood is a common feature of delirium. (e) In patients over the age of 65 if antipsychotic treatment is necessary atypicals are the class of choice. False There is a warning on atypical antipsychptics and patients over the age of 65 due to increased risk of cerebrovascular accident. Typical agents e.g haloperidol are safer- though should only be used when other measures practical measures- nurse in well lit room, orientate etc and benzodiazepines have failed.


ECG changes with hyperkalaemia include: (a) High peaked T waves. True ? (b) A narrow QRS complex. False ? (c) A prolonged QT interval. False ? (d) Sine wave. True ? (e) ST segment depression. True ? A tall peaked T wave with shortened QT interval is the first change seen on the ECG in a patient with hyperkalemia. This is followed by progressive lengthening of the PR interval and QRS duration. The P wave may disappear, and ultimately the QRS widens further to a "sine wave". Ventricular standstill with a flat line on the ECG ensues with complete absence of electrical activity. Ventricular fibrillation or standstill are the most severe consequences. A variety of other conduction disturbances, including right bundle branch block, left bundle branch block, bifascicular block, and advanced atrioventricular block may also be seen . There is large interpatient variability in the actual potassium level leading to progression of ECG changes with worsening hyperkalemia, in part related to the presence or absence of concomitant hypocalcemia, acidemia, or hyponatremia. Thus, monitoring of the ECG is essential.Rose BD et al;Clinical manifestations and treatment of hyperkalemia;www.uptodate.com


Pain in the knee (a) In chondromalacia patellae the pain is usually felt on the lateral aspect of the knee False ?Medial. There is a condition called excessive lateral pressure syndrome where the pain is felt laterally and exercise provokes pain (b) Bipartite patella is usually extremely painful False ?Usually an incidental finding. May give pain (c) The patella usually subluxes laterally True ?This gives medial pain and causes the knee to give way. (d) Patella subluxation is commoner in girls True ?Because of valgus knees (e) Patellar tendon transfer procedures are frequently used in the treatment of patella subluxation False ?1st line is vastus medialis excercises.


Brain Stem Function: (a) In a comatose patient whose brain stem is intact doll?s eye?s movement will not be present. False ?In a comatose patient whose brain stem is intact the eyes will rotate relative to the orbit. Doll?s eye?s movement will be present. (b) Ice cold water in the right ear causes nystagmus with the fast component to the right. False ?Ice cold water in the left ear causes nystagmus with the fast component to the right. (c) Warm water in the right ear causes nystagmus with the fast movement to the left. False ?Warm water in the left ear causes nystagmus with the fast movement to the left. (d) Spinal reflexes may be present in the presence of brain death. True ?Spinal reflexes may be present in the presence of brain death. (e) The oculocephalic reflex is present if when the head is moved from side to side the eyes move with the head and therefore remain stationary relative to the orbit. False ?The oculocephalic reflex is absent if when the head is moved from side to side the eyes move with the head and therefore remain stationary relative to the orbit.


The following are indicators of patients who are most at risk of stroke in the first 7 days after a TIA. (a) Age over 55 years False ?In the Rothwell et al risk scoring system (ABCD; age, blood pressure, clinical features, duration)the cut off age for a score is 60 years. (b) Diastolic Blood Pressure greater than 85mmHg on arrival False ?In the Rothwell et al risk scoring system (ABCD; age, blood pressure, clinical features, duration)the blood pressure values are 140mmHg systolic or 90 mmHg diastolic on arrival. (c) A duration of symptoms of greater than 60 minutes True ?A duration of symptoms of greater than 10 minutes gives a score of one while a duration of symptoms of greater than 60 minutes gives a score of 2. (d) Sensory symptoms are of more predictive value than motor symptoms. False ?Motor symptoms are of more predictive value than sensory symptoms.Speech disturbance scores one while motor disturbance scores two. Patients are most at risk of stroke in the first 7 days after a TIA (up to 10% of patients with a TIA will have a stroke in this time, most in the first 2 days)


Myocardial Infarction: (a) The RCA gives branches to the SA and AV nodes more frequently than the Left Circumflex Artery. True ?The RCA gives branches to the SA and AV nodes more frequently than the LCA.The RCA is dominant in 85% of cases. (b) Temporary pacing is indicated in anterior MI complicated by complete heart block. True ?Temporary pacing is indicated in anterior MI complicated by complete heart block.This presentation is associated with a high mortality due to extensive myocardial damage. (c) NSTEMI have a low one year mortality. False ?NSTEMI have a high one year mortality ( 65% ). (d) NSTEMI have not been shown to benefit from thrombolysis. True ? (e) Inferior infarctions have a higher re-infarction rate. True ?


After a loss of consciousness admission is usually indicated if: (a) The patient has had a previous myocardial infarction. True ?As this makes a diagnosis of ventricular tachycardia more likely. (b) The patient has a known cardiomyopathy. True ?As this makes a diagnosis of ventricular tachycardia more likely. (c) The patient has associated chest pain. True ?As serious cardiovascular causes of collapse are more likely. (d) There was an associated abrupt headache. True ??SAH (e) The patient is a known epileptic and the history is similar on this presentation. False ?


Pulmonary Mechanics: (a) Lung compliance is the change in lung volume brought about by a unit change in transpulmonary pressure ( L/kPa) True ?Lung compliance is the change in lung volume brought about by a unit change in transpulmonary pressure ( L/kPa) (b) The ribs move upwards and outwards on inspiration under the influence of the intercostal muscles. True ?The ribs move upwards and outwards on inspiration under the influence of the intercostal muscles. (c) The inspiratory capacity is also called the inspiratory reserve volume. False ?The inspiratory capacity is the tidal volume and the inspiratory reserve volume. (d) The vital capacity is the tidal volume and the expiratory reserve volume. False ?The vital capacity is the inspiratory reserve volume, the tidal volume and the expiratory reserve volume. (e) At the end of quiet expiration the volume in the lungs is known as the residual volume. False ?At the end of quiet expiration the volume in the lungs is known as the functional residual capacity


Hip Dislocations (a) The Allis maneuver may be used to reduce posterior dislocations True ?The hip is flexed to 90 degrees and then internally and externally rotated. (b) Posterior dislocations may be reduced with the stimson maneuver. True ?Patient prone, with the leg hanging over the edge of the stretcher, and application of gentle traction. (c) Anterior dislocations occur during forced abduction. True ? (d) 90% of hip dislocations are anterior. False ?90% of hip dislocations are posterior. (e) 10% of hip dislocations are posterior. False ?90% of hip dislocations are posterior.10% of hip dislocations are anterior.


Severe Mitral Regurgitation is clinically evident because of the following: (a) The loudness of the murmur False ?The loudness of the murmur is of no clinical significance. (b) A soft S1 True ?A soft S1 is reflective of severe disease. (c) An S3 True ?An S3 is reflective of severe disease as this indicates rapid ventricular filling and thus negates any significant mitral stenosis. (d) Degree of displacement of the apex beat. True ?The apex is laterally displaced and hyperdynamic.


Head Injury: (a) Children do not recover as well as adults from head injury. False ?Recovery is actually much better because of better neuroplasticity. (b) The brain has more room in the cranial vault with age and is therefore more likely to rupture vessels with an impact. True ?The brain has more room in the cranial vault with age and is therefore more likely to rupture vessels with an impact. (c) Minor primary brain injury is known as concussion. True ?Minor primary brain injury is known as concussion. (d) Head injuries account for 0.5-1% of all deaths. True ?Head injuries account for 0.5-1% of all deaths. (e) Brain injury is less likely in the presence of a skull fracture. False ?Much more likely.


Veins of the Upper Limb: (a) The cephalic vein becomes the axillary vein. False ?The basilic vein becomes the axillary vein. (b) The cephalic vein passes upwards along the lateral border of the forearm anterior to the head of the radius True ?The cephalic vein passes upwards along the lateral border of the forearm anterior to the head of the radius (c) The median antebrachial vein commonly joins the cephalic vein. False ?The median antebrachial vein commonly joins the median cubital vein (d) The cephalic vein originates from the medial aspect of the venous network on the dorsum of the hand. False ?The cephalic vein originates from the postero-lateral aspect of the venous network on the dorsum of the hand. (e) The median cubital vein unites the axillary and basilic veins. False ?The median cubital vein unites the cephalic and basilic veins.


The following are true statements regarding alcoholic liver disease: (a) Peak incidence of alcoholic liver cirrohsis is at 30-45 years. False Peak incidence of alcoholic liver cirrohsis is at 40-55 years. (b) 50% of patients attending alcohol treatment units in the UK have abnormal liver histology False 70% of patients attending alcohol treatment units in the UK have abnormal liver histology. (c) Fatty liver can lead to liver failure and jaundice. False It is benign and reversible. (d) The most reliable indicators of poor hepatic function are the serum transaminases. False Raised prothrombin time and albumin are the most reliable. (e) The 5-year survival following diagnosis of alcoholic cirrhosis is good if the patient abstains from alcohol. True The majority of patients who abstain are alive at 5 years.


Diagnostic Tests for the Confirmation of Brain Death: (a) In brain stem death there is an irreversible loss of the capacity for consciousness sometimes combined with an irreversible loss of the capacity to breath. False ?In brain stem death there is an irreversible loss of the capacity for consciousness (always ) combined with an irreversible loss of the capacity to breath. (b) It is not necessary to perform an EEG to diagnose brain stem death. True ?It is not necessary to perform an EEG to diagnose brain stem death. (c) There may be a motor response in the cranial nerve territory to painful stimuli in the presence of brain death. False ?There is no motor response in the cranial nerve territory to painful stimuli in the presence of brain death. (d) There is no gag or cough reflex in response to pharyngeal or laryngeal stimulation in the presence of brain death but there may be a response to tracheal stimulation. False ?There is no gag or cough reflex in response to pharyngeal, laryngeal or tracheal stimulation in the presence of brain death. (e) The examination should be performed and repeated after a few hours by two doctors of senior status a minimum of 6 hours after the onset of coma. True ?The examination should be performed and repeated after a few hours by two doctors of senior status a minimum of 6 hours after the onset of coma.


Mitral Regurgitation (a) The apex beat is laterally displaced and hyperdynamic True ?The apex beat is laterally displaced and hyperdynamic (b) S1,the first heart sound, is soft. True ?S1,the first heart sound, is soft.P2 is loud if there is pulmonary hypertension. (c) The loudness of the murmur indicates more severe disease. False ?The loudness of the murmur is of no significance. (d) The pulse may be of small volume and chaotic. True ?The pulse may be of small volume and chaotic. (e) Severe disease is indicated by a soft S1 and an S3 with a large degree of displacement of the apex and dyspnoea. True ?Severe disease is indicated by a soft S1 and an S3 with a large degree of displacement of the apex and dyspnoea.


The following suggest a dissecting thoracic aorta on CXR (a) Widening of the superior mediastinum to >5cm False ?Widening of the superior mediastinum to >8cm (b) Depression of the left main bronchus to an angle of <20 degree's with the trachea. False ?Depression of the left main bronchus to an angle of <40 degree's with the trachea. (c) Tracheal shift to the left. False ?Tracheal shift to the right. (d) Well defined aortic outline. False ?Blurring of the aortic outline. (e) Obliteration of the medial aspect of the left upper lobe. True ?This is also called pleural capping. Opacification of the angle between the aorta and the left pulmonary artery and lateral displacement of nasogastric tube in the oesophagus are also consistent with a dissecting aortic aneursym.


Mitral Regurgitation (a) Infective Endocarditis is more common with with mitral regurgitation than mitral stenosis. True ?Infective Endocarditis is more common with with mitral regurgitation than mitral stenosis. (b) The apex is laterally displaced and hyperdynamic. True ?The apex is laterally displaced and hyperdynamic. (c) S1 is loud False ?S1 is soft. (d) The loudness of the murmur is of no significance. True ?The loudness of the murmur is of no significance.


Spinal Stability:The Denis three-column system for classification of thoracolumbar injuries (a) The anterior column consists of the anterior vertebral body, the anterior annulus fibrosis, the anterior longitudinal ligament True ?The anterior column consists of the anterior vertebral body, the anterior annulus fibrosis, the anterior longitudinal ligament (b) The middle column consists of the posterior vertebral body, the posterior annulus fibrosis, and the posterior longitudinal ligament. True ?The middle column consists of the posterior vertebral body, the posterior annulus fibrosis, and the posterior longitudinal ligament. (c) The posterior column consists of the vertebral arch structure and the posterior ligamentous complex. True ?The posterior column consists of the vertebral arch structure and the posterior ligamentous complex. (d) For a fracture to be unstable there must be injury to 1 or more columns. False ?For a fracture to be unstable there must be injury to 2 or more columns. (e) If a vertebral body is compressed by 40% the fracture is considered to be unstable. False ?It a vertebral body is compressed by 50% or more the fracture is considered to be unstable.


Bell's Palsy: (a) Affects the upper and lower face and there is equal sex ratio. True ?Bell's palsy is a facial nerve palsy affecting the upper and lower face. (b) The obicularis muscle's are frequently involved resulting in incomplete closure of the eyelids. True ?The obicularis muscle's are frequently involved resulting in incomplete closure of the eyelids. (c) HSV-1 is a frequent cause of bell's palsy. True ?HSV-1 is a frequent cause of bell's palsy. (d) Bell's palsy most commonly occurs to middle aged people. True ?Bell's palsy most commonly occurs to middle aged people. (e) CN VII controls sensory sensation to the posterior 2/3rd's of the tongue. False ?CN VII controls the lacrimal gland secretory function, nerve to stapedius, sensory sensation to the anterior 2/3rd's of the tongue and the muscles of facial expression. There is no race, geographic, or gender predilection, but the risk is three times greater during pregnancy, especially in the third trimester or in the first postpartum week . There is an 8 to 10% incidence of recurrence either on the ipsilateral or contralateral side . Diabetes is present in about 5 to 10% of patients.


Temporomandibular joint problems: (a) TMJ dislocation is usually after opening the mouth widely. True ?TMJ dislocation is usually after opening the mouth widely. (b) TMJ syndrome is usually bilateral. False ?TMJ syndrome is usually unilateral. (c) TMJ syndrome is a sharp pain. False ?TMJ syndrome is a dull pain. (d) TMJ syndrome is relieved by opening the mouth. False ?TMJ syndrome is exacerbated by opening the mouth. (e) TMJ syndrome usually has a clicking sound. True ?TMJ syndrome usually has a clicking sound.


Anaphylaxis in the Emergency Department: (a) Adrenaline given with beta agonists may cause hypertension due to unopposed alpha adrenergic stimulation. False ?Adrenaline given with beta blockers may cause hypertension due to unopposed alpha adrenergic stimulation. (b) Most adults do not need more than a single dose of IM adrenaline. True ?Most adults do not need more than a single dose of IM adrenaline. (c) It is unhelpful to check histamine levels post a suspected anaphylactic reaction as they are elevated for about half an hour post reaction are often returning to normal levels by the time the patient presents to the ED. True ?It is unhelpful to check histamine levels post a suspected anaphylactic reaction as they are elevated for about half an hour post reaction are often returning to normal levels by the time the patient presents to the ED. (d) Tryptase is released in response to mast cell degranulation and may be helpful to confirm a suspected diagnosis of anaphylaxis. True ?Tryptase is released in response to mast cell degranulation and may be helpful to confirm a suspected diagnosis of anaphylaxis. (e) In anaphylaxis IM adrenaline is given at a dose of 0.3-0.5mg ( 0.3-0.5 ml of 1:100,000 dilution ) False ?In anaphylaxis IM adrenaline is given at a dose of 0.3-0.5mg ( 0.3-0.5 ml of 1:1000 dilution )


Differentiating between acute confusional state and dementia: (a) Attention is impaired in dementia. False ?In acute confusional state it is. (b) Symptoms are worse at nighttime in acute confusional state. True ? (c) Hallucinations are more associated with dementia. False ?Acute confusional state. (d) Speech is often incoherent in dementia. False ?Difficulty finding words in dementia but speech usually preserved. (e) There is clouding of consciousness in dementia. False ?In acute confusional state.


Acute Mountain Sickness:Symptoms and Signs: (a) Headache. True ? (b) Vomiting. True ? (c) Postural Hypotension. True ? (d) Peripheral Oedema. True ? (e) Facial Oedema. True ? Symptoms: Headache, vomiting, anorexia, weakness, fatigue, dyspnoea. Signs: Postural Hypotension, peripheral and facial oedema, localised rales in 20% of cases, on fundoscopys tortuous and dilated veins may be noted, at altitudes of over 5000 m retinal haemorrhages may occur.


In carbon monoxide poisoning (a) Patients present cyanotic and hypoxic False Patients present with signs of hypoxia without cyanotic.? (b) Skin and mucosa may present cherry red. True (c) Levels of COHb 30%- 40% produce syncope, tachypnoea, tachycardia and fits. False Such symptoms are associated with levels of 50-60%.Levels below 30% cause only headache and dizziness. (d) Management includes an arterial blood gas and subsequent monitoring of oxygen with a pulse oximeter. False Pulse oximetry is unhelpful since it will not distinguish HbO2 and COHb (Hence the oxygen reading will be falsely high) (e) Sites at particular risk of damage are the cerebral, cerebellar or mid brain. True E.g. Parkinsonism and akinetic-mutism; the myocardium, with ischaemia and infarction: skeletal muscle, causing rhabdomyolysis and myoglobinuria: skin involvement ranges from erythema to severe blistering.


Indications for urgent dialysis in ARF: (a) Pulmonary oedema. True ? (b) Uraemic pericarditis. True ? (c) Severe Acidosis(pH < 7.1). True ? (d) Creatinine >350. False ?Severe uraemia is an indication for dialysis. Symptoms of uraemia include vomiting and encephalopathy. Creatinine on it's own is not an indication for dialysis. (e) K > 6.0. False ?Potassium greater than 6.5 is an indication for dialysis. The threshold for dialysis due to high potassium is less if there is ECG changed.


Ottawa Ankle Rules:Indications for X Ray (a) Base of the 5th metacarpal. False ?Base of the 5th metatarsal tenderness is an indication for X Ray. http://www.bmj.com/cgi/content/full/326/7386/417#F1 (b) Tenderness over the cuboid bone False ?Tenderness over the navicular bone is an indication for X Ray. (c) If the patient is able to weight bear at the scene of the accident but unable to weight bear when reviewed in the emergency department then there is no indication to X Ray. False ?If the patient cannot weight bear in the department then their ankle should be X Rayed. (d) Tip of medial malleolus bone tenderness. True ?Tip of medial malleolus bone tenderness is an indication for X Ray. (e) Posterior edge of medial malleolus bone tenderness. True ?Posterior edge of medial malleolus bone tenderness.


The following are true: (a) LBBB is demonstrated by an RsR' pattern in V1. False ?LBBB is demonstrated by an RsR' pattern in V6 (b) RBBB is demonstrated by an RsR' pattern in V6. False ?RBBB is demonstrated by an RsR' pattern in V1 (c) The normal duration of the qrs complex is 0.05sec-0.11sec. True ?The normal duration of the qrs complex is 0.05sec-0.11sec (d) S in V2 and R in V5 greater than 35mm suggests LVH. True ?S in V2 and R in V5 greater than 35mm suggests LVH (e) Q waves may be normal in III, aVR and V1. True ?Q waves may be normal in III, aVR and V1. Q waves in I, II, aVF and aVL are abnormal if >0.04 seconds or greater than half the height of the subsequent R wave.


Emergency complications of malignancy (a) The untreated mortality of neutropaenic ( <500ul ) bacteraemic patients is 50% True ?The untreated mortality of neutropaenic ( <500ul ) febrile patients is 50% (b) In neutropaenic patients the usual findings of infection are augmented. False ?Due to an impaired inflammatory response the usual findings of infection are not as prominent. (c) Granulocytopenia may preclude development of a visible infiltrate on chest X Ray True ?Granulocytopenia may preclude development of a visible infiltrate on chest X Ray and so the clinician may need to rely on physical findings. (d) The incidence of meningitis is increased in neutropenic patients. False ?The incidence of meningitis is not increased with neutropenia. (e) Bacteremia is most frequently due to anaerobic bacteria. False ?Bacteremia is most frequently due to aerobic gram-positive cocci or aerobic gram-negative bacilli.


Clinical features of migraine that would support a diagnosis of migraine rather than tension headache: (a) Pressure or band like pain. False ?Suggests tension, migraine headache is pulsating. (b) Aggravated by routine activities. True ?With tension patient is usually able to function normally. (c) Associated with photophobia. True ? (d) Unilateral. True ?Tension headache tends to be bilateral. (e) Gets worse during the day. False ?Tension headache can last for days and can get worse during the day.


Urine Dipstix Testing: (a) Tamm-Horsfall glycoprotein is a normal constituent of urine. True ?Tamm-Horsfall glycoprotein is a normal constituent of urine. (b) Pyrexia, exercise and the upright posture all increase urinary protein output. True ?Pyrexia, exercise and the upright posture all increase urinary protein output. (c) Increased urinary specific gravity may be caused by diabetes insipidus. False ?Increased urinary specific gravity may be associated with dehydration, diarrhea, emesis, excessive sweating, glucosuria, renal artery stenosis, hepatorenal syndrome, decreased blood flow to the kidney (as a result of heart failure), and excess of antidiuretic hormone caused by Syndrome of inappropriate antidiuretic hormone. (d) A urine stix test is positive for microscopic blood if 10 or more red cells are visible under the high-power field of a light microscope and can not distinguish between blood and free haemoglobin. False ?A urine stix test is positive for microscopic blood if 2 or more red cells are visible under the high-power field of a light microscope and can not distinguish between blood and free haemoglobin. (e) Urine stix test for protein react primarily with albumin. True ?Urine stix test for protein react primarily with albumin.


In COPD patients with exacerbations, the following are indications to consider admission to hospital: (a) Green sputum. False ?But may be an indication for an antibiotic. (b) Sudden development of resting dyspnoea. True ?Or other marked increase in intensity of symptoms. (c) Significant co-morbidities. True ?Of diagnostic uncertainty. (d) No response to oral prednisolone. True ?Or other failure of response to initial therapy. (e) New onset of peripheral oedema. True ?Or new onset cyanosis, confusion.


Cranial Nerve Examination: (a) Tunnel Vision ( concentric diminution ) can be caused by papilloedema. True ?Tunnel Vision ( concentric diminution ) can be caused by papilloedema, glaucoma and syphilis. (b) Normal visual acuity is present when the line on the snellen chart marked 6 can be read from 6 feet away. False ?Normal visual acuity is present when the line on the snellen chart marked 6 can be read from 6 metres away. (c) Fibres from the optic radiation pass through the posterior part of the internal capsule and finish in the visual cortex in the parietal lobe. False ?Fibres from the optic radiation pass through the posterior part of the internal capsule and finish in the visual cortex in the occipital lobe. (d) Fibres serving the upper quadrants course through the parietal lobe while fibres serving the lower quadrants traverse the temporal lobe. False ?Fibres serving the lower quadrants course through the parietal lobe while fibres serving the upper quadrants traverse the temporal lobe. (e) The fibres from the optic chiasm concerned with the light reflex travel in the optic tract to the lateral geniculate body. False ?The fibres from the optic chiasm concerned with vision travel in the optic tract to the lateral geniculate body. The light fibre reflex fibres travel to the superior colliculus.


Urine and Plasma Electrolytes: (a) The serum urea and creatinine do not rise above the normal range until there is a reduction of 20% in the GFR. False ?The serum urea and creatinine do not rise above the normal range until there is a reduction of 50-60% in the GFR. (b) Serum urea levels will rise in infection and will decrease with corticosteroid therapy. False ?Serum urea levels will rise in infection and in corticosteroid therapy due to increased production. (c) The thin descending limb of the loop of henle is permeable to sodium and impermeable to water. False ?The thin descending limb of the loop of henle is permeable to water and impermeable to sodium. (d) The ascending limb of the loop of henle is impermeable to sodium but permeable to water. False ?The ascending limb of the loop of henle is impermeable to water but permeable to sodium. (e) Filtered bicarbonate is largely reabsorbed and hydrogen ions are excreted mainly buffered by phosphate. True ?Filtered bicarbonate is largely reabsorbed and hydrogen ions are excreted mainly buffered by phosphate.


Head Injury: (a) Mild traumatic brain injury patients always have a GCS 15 out of 15. False ?Mild traumatic brain injury patients are those with a GCS of greater than or equal to 14 out of 15. (b) A GCS of 14 out of 15 would be considered a moderate traumatic brain injury. False ?A GCS of 14 out of 15 would be considered a mild traumatic brain injury. (c) A GCS of 9 out of 15 would be considered a moderate traumatic brain injury. True ?Moderate traumatic brain injury is a GCS between 9 and 13. (d) Moderate traumatic brain injury accounts for 30% of all head injury cases. False ?Moderate traumatic brain injury accounts for 10% of all head injury cases. (e) Severe traumatic brain injury accounts for 33% of all head injury cases. False ?Severe traumatic brain injury accounts for 10% of all head injury cases. Mild = GCS 14 or more Moderate = GCS 9 to 13 ( inclusive ) Severe = GCS 8 or less


Leukaemia ? classification; acute and chronic lymphoblastic leukaemia; acute and chronic myeloid leukaemia (a) There is a 75% cure rate in adults with chemotherapy in ALL False ?There is a 35% cure rate in adults with chemotherapy (b) There is a 80% cure rate in adults with ALL with allogenic bone marrow transplant. False ?There is a 50% cure rate in adults with ALL with allogenic bone marrow transplant. (c) 80% of ALL are in children under 14 years False ?90% of ALL are in children under 14 years (d) The highest incidence of ALL in children is at 10-11 years. False ?The highest incidence of ALL in children is at 3-4 years. (e) There is a up to 75% cure rate in children aged 2-9 years (in ALL ) True ?There is a up to 75% cure rate in children aged 2-9 years


Benign intracranial hypertension: (a) Is associated with papilloedema. True ? (b) Rarely causes visual symptoms. False ?Usually causes visual symptoms. (c) CSF pressure is raised. True ? (d) Can be caused by vitamin A. True ? (e) Can be caused by nitrofurantoin. True ?Other drugs that can cause it include OCP, steroids, tetracycline, vitamin A, nitrofurantoin and naladixic acid.


Fractures of the clavicle: (a) Are the second most common fracture in children. False ?Are the most common fracture in children. (b) The most common mechanism is a direct blow to the shoulder that causes buckling of the clavicle. True ?The most common mechanism is a direct blow to the shoulder that causes buckling of the clavicle. (c) Medial third fracures are the most common. False ?Medial third fractures account for 5%. (d) Distal third fractures are the least common. False ?Distal third factures account for 15%. Medial third are the least common ( 5% ) (e) Marked initial displacement is a risk factor for non-union. True ?And shortening is another risk factor for non union.


Radial Head Fractures (a) The radial head articulates with the capitellum. True ?The radial head articulates with the capitellum. (b) The most common mechanism of injury for a radial head fracture is fall on an outstretched hand. True ?The most common mechanism of injury for a radial head fracture is fall on an outstretched hand with the radial head being driven into the capitellum. (c) Are associated with medial epicondyle avulsion fractures. True ? (d) The radial head stabilises against valgus forces. True ?Valgus forces are forces away from the midline. (e) Is the second most common elbow fracture after intercondylar fractures. False ?Radial head fractures are the commonest elbow fractures.


Antibiotics in clinical use: (a) Penicillin half life is increased by probenecid as it slows absorption in the gut. False ?Penicillin half life is increased by probenecid as it competes for secretion in the kidney. (b) Glycopeptides are usually given orally for blood stream infection. False ?Glycopeptides ( vancomycin and teicoplanin ) are not absorbed orally. May be given orally for C Diff. (c) Penicillin does not cross the blood brain barrier in normal uninfected patients True ?Penicillin does not cross the blood brain barrier in normal uninfected patients ( it only crosses the BBB if the meninges are inflamed ) (d) Oral cephalosporins have a mainly gram positive spectrum True ?Oral cephalosporins have a mainly gram positive spectrum (e) Flucloxacillin is degraded by penicillinase False ?Flucloxacillin is a penicillinase resistant penicillin


Causes of small pupil(miosis) (a) Age True ?Senile miosis (b) Horners Syndrome True ? (c) Pilocarpine True ? (d) Opiates True ? (e) Myotonic Dystrophy True ? Also Argyl-Robertson pupils which are bilateral (but may be asymmetrical) small irregular pupils which do not react to light but accommodate normally


Bier's Block (a) Duration of action is 30-60min True ?Duration of action is 30-60min (b) A standard blood pressure cuff is adequate. False ?A standard blood pressure cuff may result in systemic leakage of local anaesthetic. A double-cuff tourniquet with a constant gas source is required. (c) A history of cardiac dysrhythmias is a contraindication. True ?As is PVD and hypertension. (d) Lignocaine or prilocaine with adrenaline is used. False ?Lignocaine or prilocaine without adrenaline is used. (e) Peripheral vascular disease is a contraindication. True ?


IV Lines: (a) An 18G peripheral IV line can infuse fluids at an approximate rate of 100ml/min with the pressure of gravity only. False ?An 18G peripheral IV line can infuse fluids at an approximate rate of 50-60ml/min with the pressure of gravity only. (b) A 16G peripheral IV line can infuse fluids at an approximate rate of 200ml/min with the pressure of gravity only. False ?A 16G peripheral IV line can infuse fluids at an approximate rate of 90-125ml/min with the pressure of gravity only. (c) A 14G peripheral IV line can infuse fluids at an approximate rate of 250-300ml/min with the pressure of gravity only. False ?A 14G peripheral IV line can infuse fluids at an approximate rate of 125-160ml/min with the pressure of gravity only. (d) An 8.5 Fr central venous introducer can infuse fluids at an approximate rate of 200ml/min with the pressure of gravity only. True ?An 8.5 Fr central venous introducer can infuse fluids at an approximate rate of 200ml/min with the pressure of gravity only. (e) If a pressure of approximately 300mmHg is added to a bag of fluids which is running through an 18G IV line approximately 120ml-180ml/min of fluids can be infused. True ?If a pressure of approximately 300mmHg is added to a bag of fluids which is running through an 18G IV line approximately 120ml-180ml/min of fluids can be infused.


Streptococci and Clostridia (a) The streptococcus milleri group of organisms colonise small bowel. False ?The streptococcus milleri group of organisms colonise the mouth (b) Tetanus infection is caused by deep wounds with aerobic conditions. False ?Tetanus infection is caused by wounds deep enough to produce anaerobic conditions (c) Tetanospasmin prevents the release of the inhibitory transmitter GABA True ?Tetanospasmin prevents the release of the inhibitory transmitter GABA (d) In tetanus infection isolation of the organism is diagnostic. False ?In tetanus infection isolation of the organism is not diagnostic ( diagnosis is based on history and clinical features ) (e) Streptococcus agalactiae is likely to cause PID if found in the female genital tract. False ?Streptococcus agalactiae is a normal gut commensal and may be found in the female genital tract.


In a depressed patient the risk of suicide is increased when: (a) There is no close supportive relationship. True (b) Patient is a rural dweller. False Living in city increases risk of completed suicide- ie urban dwelling. (c) Female gender. False (d) Old age (>65). True (e) There is associated heavy alcohol consumption. True Poor physical health, hopelessness, isolation, homelessness, substance abuse and previous suicidal behaviour are other indicators.


Streptococci: (a) Streptococcus pyogenes is not a cause of impetigo. False ?Streptococcus pyogenes may cause impetigo and necrotising fasciitis. (b) Streptococcus pyogenes does not cause erysipelas. False ?Streptococcus pyogenes may cause cellulitis and erysipelas. (c) Erythema nodosum is a post infectious immune mediated manifestation of streptococcus pyogenes True ?Erythema nodosum is a post infectious immune mediated manifestation of streptococcus pyogenes where the antibodies cross react with the host tissue. (d) Glomerulonephritis may be caused by a post infectious manifestation of streptococcus pyogenes where the antibodies cross react with host tissue. True ?Glomerulonephritis may be caused by a post infectious manifestation of streptococcus pyogenes where the antibodies cross react with host tissue. (e) Streptococcus agalactiae is the most common bacterial cause of pharyngitis False ?


The Shoulder Joint: (a) Abduction of the shoulder joint is achieved by the deltoid and the supraspinatus. True ?Abduction of the shoulder joint is achieved by the deltoid and the supraspinatus. (b) Lateral rotation of the shoulder joint is contributed to by the deltoid muscle. True ?Lateral rotation of the shoulder joint is contributed to by infraspinatus, deltoid and teres minor. (c) Flexion of the shoulder joint is achieved by the pectoralis major ( both the clavicular head and the sternocostal head ) and the anterior fibres of the deltoid True ?Flexion of the shoulder joint is achieved by the pectoralis major ( both the clavicular head and the sternocostal head ) and the anterior fibres of the deltoid (d) Adduction of the shoulder joint is achieved by pectoralis major, latissimus dorsi, subscapularis, teres major and minor, and infraspinatus. True ?Adduction of the shoulder joint is achieved by pectoralis major, latissimus dorsi, subscapularis, tere major and minor, and infraspinatus. (e) Extension of the shoulder joint is achieved by the deltoid and latissimus dorsi alone. False ?Extension of the shoulder joint is achieved by the deltoid, teres major and latissimus dorsi.


ECG interpretation: (a) The height of the ST segment is measured at a point 2 boxes after the end of the QRS complex. True ?The height of the ST segment is measured at a point 2 boxes after the end of the QRS complex. (b) ST segment elevation is considered significant if it exceeds 1 mm in a limb lead or 2 mm in a precordial lead. True ?ST segment elevation is considered significant if it exceeds 1 mm in a limb lead or 2 mm in a precordial lead. (c) ST segments may remain elevated when ventricular aneurysm develops. True ?ST segments may remain elevated when ventricular aneurysm develops. (d) ST segment depression is most suspicious of ischaemia if the ST segment is horizontal. False ?ST segment depression is most suspicious of ischaemia if the ST segment is downsloping. (e) ST segment depression can be caused by a fast heart rate. True ?ST segment depression can be caused by ischemia, digitalis, rapid heart rate, and temperature or electrolyte abnormality. It can also be a ?reflected? or reciprocal ST elevation (showing an inverted view of what?s happening at another place in the heart).


Temporal Arteritis (a) Affects branches of the external carotid artery. True ? (b) Men are affected more commonly than women. False ?Women are affected more commonly than men. (c) Fever and weight loss are features. True ?Other systemic features include malaise, anorexia, diplopia, blurred vision, and polymyalgia. (d) The temporal artery is not tender palpation False ?The temporal artery is usually very tender to palpation. (e) Vision loss is secondary to retinal haemorrhage. False ?Vision loss is secondary to ischaemic optic neuritis.


After removing a foreign body from the eye (a) You should use an antibiotic cream. True ?This should be used for 24 hours. (b) Always pad the eye. False ?Use an eyepad if near bedtime, if there was significant pain or if removal of the foreign body was difficult. (c) You should always use a slit lamp to outrule an intraocular foreign object. False ?Use a slit lamp if you suspect an intraocular foreign body, but not if there is a non penetrating foreign body. (d) You should instil fluorescein to check there is no corneal ulcer. False ?Do this as part of the examination if there is no obvious foreign body. (e) You should follow up all patients the next day. False ?Not if there is minimal pain, the foreign body is small and easily removed and vision is good.


The Lumbar Plexus: (a) The femoral nerve supplies the skin on the anterior surface of the thigh True ?The femoral nerve supplies the skin on the anterior surface of the thigh (b) The femoral nerve supplies the skin on the medial side of the leg and foot. True ?The femoral nerve supplies the skin on the medial side of the leg and foot. (c) The obturator nerve supplies the cremaster muscle False ?The genitofemoral nerve supplies the cremaster muscle (d) The obturator nerve originates from L2, L3 and L4 and supplies the adductor muscles of the thigh. True ?The obturator nerve originates from L2, L3 and L4 and supplies the adductor muscles of the thigh. (e) The femoral nerve originates from the lumbar plexus from L2, L3 and L4 True ?The femoral nerve originates from the lumbar plexus from L2, L3 and L4


Peak Flow Rates: (a) In a man in his 20's who is approx 6 ft tall should be in the region of 600l/min. True ?In a man in his 20's who is approx 6 ft tall should be in the region of 600l/min. (b) In a man in his 70's who is approx 5ft 6" tall should be in the region of 480l/min. True ?In a man in his 70's who is approx 5ft 6" tall should be in the region of 480l/min. (c) Gets progressively worse with age. True ?Peak flow rates gets progressively worse with age. (d) Is not significantly effected by height. False ? (e) Can be used to assess degree of asthma attack severity. True ?


DIC may occur in: (a) Amniotic fluid embolus. True ? (b) Acute promyelocytic anaemia. True ? (c) Falciparum malaria. True ? (d) Haemolytic transfusion reaction. True ? (e) Thrombotic thrombocytopaenic purpura. False ? Disseminated intravascular coagulation (DIC) is a systemic process producing both thrombosis and haemorrhage. It consists of the following components exposure of blood to procoagulants , formation of fibrin in the circulation , fibrinolysis , depletion of clotting factors , end-organ damage. Disseminated intravascular coagulation is a complication of underlying illness occurring in approximately one% of hospital admissions. Treatment of DIC is supportive, with platelet transfusion and clotting factor replacement therapy.


The pancreas: (a) The pancreas comprises only 0.1% of total body weight. True ?The pancreas comprises only 0.1% of total body weight. (b) When a meal is ingested VIP, GRP, secretin, CCK, and encephalins stimulate enzymatic release into the pancreatic duct. True ?When a meal is ingested, the vagal nerves, VIP, GRP, secretin, CCK, and encephalins stimulate enzymatic release into the pancreatic duct. (c) The overall mortality rate of patients with acute pancreatitis is 3-4%. False ?The overall mortality rate of patients with acute pancreatitis is 10-15%. (d) Pancreatitis is more common in caucasian people than black people. False ?Pancreatitis is more common in black people. (e) Approximately 50% of the gross weight of the pancreas supports exocrine function, while the remaining 50% is involved with endocrine function. False ?Approximately 80% of the gross weight of the pancreas supports exocrine function, while the remaining 20% is involved with endocrine function.


With regard to Mortons Metatarsalgia: (a) There is usually limping between attacks. False ?The patient may well limb during an attack but does not usually limb between attacks. (b) There is usually agonising pain between the first and second toes. False ?There is usually agonising pain around the middle 3 toes, most often third and fourth. (c) There is usually relief of pain after removing the shoes and resting the foot. True ?While moving about in closed footwear exacerbates the problem. (d) There may be acute tenderness on pressure applied upwards and backwards in a web space. True ?Usually the web space between the third and fourth toes. (e) Responds better after medical rather than surgical treatment. False ?Adequate neurectomy is extremely effective.


Jugular venous pulse: (a) Has three waves('a','c', and 'v'). True ? (b) Has two descents ('x', 'y'). True ? (c) The neck should not be supported when assessing the JVP. False ?The sternocleidomastoid muscles should be relaxed by supporting the neck with pillows. (d) Is measured in vertical height from the angle of Louis and is normally 3-5 cm. True ?JVP is measured in vertical height from the angle of Louis and is normally 3-5 cm. (e) Is a reflection of pressure in the right atrium. True ?The JVP is a reflection of pressure in the right atrium.


Back Pain: Sinister Pathology (a) Pain brought on by activity and relieved by rest False ?Constant pain is more likely to be sinister than pain brought about by activity and relieved by rest (b) Localised bony tenderness True ? (c) Bilateral signs of nerve root tension True ? (d) A normal ESR False ?A raised ESR is a valuable screening test for sinister pathology (e) Urinary symptoms True ?Suggest Cauda Equina


Spontaneous Pneumothorax (a) Baring complications a 25% pneumothorax will take about 3 weeks to resolve if managed conservatively. True ?Baring complications a 25% pneumothorax will take about 3 weeks to resolve if managed conservatively. Approximately 1% of pleural air is reabsorbed each day. (b) Approximately 25% of patients managed conservatively will go on to require a chest drain insertion. True ?Approximately 25% of patients managed conservatively will go on to require a chest drain insertion. (c) Catheter aspiration may be attempted in the second intercostal space in the mid clavicular line. True ?Or in the 4th or 5th intercostal space in the anterior axillary line. (d) Re-expansion pulmonary oedema is more commonly seen in older patients. False ?Re-expansion pulmonary oedema is more commonly seen in younger patients. (e) Spontaneous pneumothorax may occur in 10% of patients. False ?Spontaneous pneumothorax may occur in up to 30% of patients.


The femoral artery: (a) The femoral artery is a continuation of the external iliac artery and lies midway between the anterior superior iliac spine and the pubic symphysis True ?The femoral artery is a continuation of the external iliac artery and lies midway between the anterior superior iliac spine and the pubic symphysis. (b) The femoral artery is lateral to the femoral nerve. False ?VAN..from medial to lateral. The femoral vein is medial, the femoral artery is next and then the femoral nerve is most lateral. (c) The femoral canal is on the lateral side of the femoral artery in the femoral triangle. False ?VAN..from medial to lateral. The femoral vein is medial, the femoral artery is next and then the femoral nerve is most lateral. (d) The femoral nerve is medial to the femoral artery in the femoral canal. False ?The femoral nerve is lateral to the femoral artery in the femoral canal. (e) The femoral vein is medial to the femoral nerve. True ?The femoral vein is medial to the femoral nerve.


Neck and Thoracolumbar Pain (a) Thoracic vertebral compression fractures are usually associated with neurologic compromise. False ?Thoracic vertebral compression fractures seldom cause neurologic compromise. (b) Thoracic compression fractures rarely cause distressing pain. False ?Thoracic compression fractures are extremely painful. Fractures may be due to direct trauma, osteoporosis, or hyperflexion. (c) The rate of neurologic compromise observed with lumbar bony injuries is increased. False ?The rate of neurologic compromise observed with lumbar bony injuries is decreased. This is because the size of the spinal canal is larger than in the thoracic region. (d) Cervical disc prolapse is most common in the 6th decade of life False ?Cervical disc prolapse is commonest in the 4th decade of life and levels C5/C6 and C6/C7 are involved most frequently. (e) In 85% of cases of back pain no definite source of pain is identified. True ?


Bier's Block: (a) Duration of action is 2 hours. False ?Duration of action is 30-60min. (b) A standard blood pressure cuff may result in systemic leakage of local anaesthetic. True ?A double-cuff tourniquet with a constant gas source is required. (c) A history of cardiac dysrhythmias is a contraindication to Bier's block. True ?Others include PVD,cardiac dysrhythmias, severe hypertension, raynaud's syndrome, sickle cell disease, methaemoglobinaemia, children < 7 years, uncooperative or confused patients, and procedures lasting more than 30 minutes. (d) Lignocaine or prilocaine without adrenaline is used. True ?Lignocaine or prilocaine without adrenaline is used. Lignocaine may be more likely than prilocaine to cause toxic effects. (e) Hypertension is a contraindication. True ?Others include PVD,cardiac dysrhythmias, severe hypertension, raynaud's syndrome, sickle cell disease, methaemoglobinaemia, children < 7 years, uncooperative or confused patients, and procedures lasting more than 30 minutes.


Admission is often indicated in a pateint presenting with loss of consciousness if: (a) The loss of consciousness is associated with exertion. True ? (b) There is palpitations with the loss of consciousness. True ? (c) The patient is taking amiodarone. True ?Amiodarone is associated with torsade de pointes. (d) The patient is taking sotalol. True ?Associated with torsade de pointes. (e) There is significant postural hypotension(decrease in systolic BP >20mmHg). True ?


The following are true: (a) Most patients with aortic dissection have a pulse deficit. False ?Most patients with aortic dissection do not have a pulse deficit. (b) Many patients with fibromyalgia have tenderness over the second costochondral junctions. True ?Many patients with fibromyalgia have tenderness over the second costochondral junctions. (c) Hypertensive lower oesophageal sphincter occurs when the resting pressure is above 45 mmHg. True ?Hypertensive lower oesophageal sphincter occurs when the resting pressure is above 45 mmHg. (d) Chest pain and dysphagia is more suggestive of an oesophageal motility disorder than heartburn. True ?Chest pain and dysphagia are more suggestive of an oesophageal motility disorder than heartburn.


Acute gout: (a) Is associated with negatively birefringent crystals in joint aspirate. True Is associated with negatively birefringent crystals in joint aspirate. (b) Early radiological signs include punched out lesions in the periarticular bone. False Early radiological signs include soft tissue swelling. Punched out lesions appear later. (c) Is treated with allopurinol and NSAIDs. False Initial therapy does not include allopurinol. NSAIDs or colchicine are used in acute gout. (d) Most commonly affects the 1st MTP joint of the foot in men. True Most commonly affects the 1st MTP joint of the foot in men.


Acute asthma attack; Markers of severe attack: (a) PaCO2 >6 kPa. True ? (b) PaO2 < 8 kPa. True ? (c) pH <7.35. True ? (d) SpO2 <95%. False ?SpO2 <92%. (e) HR >110/min. True ?Also RR>25, PEF <60% predicted or best,and unable to talk in sentences.


In heat exhaustion: (a) Water loss 6-8 litres is typical. True Water loss 6-8 litres is typical. (b) Headache, nausea and the absence of thirst are characteristic. True Headache, nausea and the absence of thirst are characteristic. (c) The skin is hot and dry. False (d) Progression to heat stroke is avoidable with effective therapy. True Progression to heat stroke is avoidable with effective therapy. (e) Predominant water depletion is more common in the unacclimatised. False Heat stroke is defined as a core body temperature in excess of 40.5?C (105?F) with associated central nervous system dysfunction in the setting of a large environmental heat load that cannot be dissipated. Frequently encountered complications include acute respiratory distress syndrome (ARDS), disseminated intravascular coagulation, renal or hepatic failure, hypoglycemia, rhabdomyolysis, and seizures. Classic heat stroke affects individuals with underlying chronic medical conditions that either impair thermoregulation or prevent removal from a hot environment. Exertional heat stroke generally occurs in young, otherwise healthy individuals who engage in heavy exercise during periods of high ambient temperature and humidity.


In Cyanide poisoning. (a) HCN gas can lead to cardiorespiratory arrest and death within a few minutes. True ? (b) Onset of effects after ingestion are generally very quick False Onset of effects whether by ingestion or skin contamination are generaaly much slower than the onset of cardiorespiratory arrest (up to several hours). (c) Early signs include cyanosis. False Cyanosis is not a feature. (d) Lactic acidosis is a common feature of severe poisoning True Acidosis indicates severe poisoning (e) The smell of bitter almonds is detected by over 70% of people. False This is an unhelpul feature as it is genetically determined and 50% of observers don't detect it.


If the median nerve is severed at the wrist the following muscles would not be innervated: (a) The first lumbrical True ?The first and second lumbricals are innervated by the median nerve (b) The second lumbrical True ?The first and second lumbricals are innervated by the median nerve (c) Flexor carpi ulnaris False ?Flexor carpi ulnaris is innervated by a branch of the ulnar nerve in the forearm. (d) Medial head of flexor digitorum profundus. False ?Medial head of flexor digitorum profundus is innervated by a branch of the ulnar nerve in the forearm. (e) Palmaris brevis False ?Palmaris brevis is innervated by the superficial terminal branch of the ulnar nerve in the hand.


Peripheral Nerves: (a) The lateral plantar nerve is composed of fibres from L5 and S1 False ?The lateral plantar nerve is composed of fibres from S1 and S2 (b) The deep peroneal nerve is composed of fibres from L3 and L4. False ?The deep peroneal nerve is composed of fibres from L4, L5, S1 and S2 (c) The superficial peroneal ( fibular ) nerve is composed of fibers from L5, S1 and S2 True ?The superficial peroneal ( fibular ) nerve is composed of fibers from L5, S1 and S2 (d) The common peroneal (fibular ) nerve is composed of fibers from L4, L5, S1, and S2 True ?The common peroneal (fibular ) nerve is composed of fibers from L4, L5, S1, and S2 (e) The medial plantar nerve is composed of fibres from S1 and S2 False ?The medial plantar nerve is composed of fibres from L4 and L5


Features of delirium include: (a) Paranoia. True Delirium is associated with any psychiatric symptom. (b) Visual Hallucinations. True ?A common feature of delirium which can be very distressing and evoke a marked emotional response. (c) Lability of mood. True Delirium is associated with any psychiatric symptom. (d) Low mood. True Delirium is associated with any psychiatric symptom. (e) Incidious onset. False Onset is usually acute with fluctuating severity of symptoms.


Ureteric Colic (a) Calculi usually are formed from magnesium ammonium and phosphate False ?Calculi usually consist of calcium oxalate and calcium phosphate (b) There is an equal incidence in men and women. False ?The male to female ratio is 2:1 (c) Blood on stix testing is present in 99% of cases with proven stones. False ?Blood on stix testing is present in >80% of cases with proven stones. (d) 90% of urinary calculi are radio-opaque True ?90% of urinary calculi are radio-opaque (e) X Ray is 50% sensitive and 70% specific True ?X Ray is 50% sensitive and 70% specific


Which of the following are correct: (a) The right phrenic nerve pierces the diaphragm with the IVC at T10 False ?The right phrenic nerve pierces the diaphragm with the IVC at T8 (b) The sternoxiphisternal joint is at the level of T10/11 False ?The sternoxiphisternal joint is at the level of T8/9 (c) The oesophageal opening in the diaphragm is at the level of T10 True ?The oesophageal opening in the diaphragm is at the level of T10 (d) Branches of the left gastric vessels go through the diaphragm at T12 False ?Branches of the left gastric vessels go through the diaphragm at T10 (e) The left phrenic nerve pierces the diaphragm lateral to the central tendon at the level of T10 False ?The left phrenic nerve pierces the diaphragm lateral to the central tendon at the level of T8


Massive (>8 cm) splenomegaly occurs in the following conditions. (a) Portal hypertension secondary to cirrhosis False Associated with moderately ( 4- 8 cm) enlarged spleen. (b) Lymphoproliferative disorder False Associated with moderately ( 4- 8 cm) enlarged spleen (c) Gauchers disease True ? (d) Infectious hepatitis False Associated with just palpable spleen? (e) Infectious mononucleosis False Associated with just palpable spleen. Massively enlarged spleen is associated with Myelofibrosis, chronic myeloid leukaemia, malaria, kala-azar, Gauchers disease. moderately enlarged spleen is associated with portal hypertension secondary to cirrhosis, lymphoprliferative disorders such as hodgkins disease. Common conditions which are associated with a just palpable spleen: Lymphoproliferative disorders, portal hypertension secondary to cirrhosis, infectious hepatitis, glandular fever, subacute endocarditis, sarcoid, rheumatoid arthritis, collagen disease, ITP, congential spherocytosis, polycythaemis ruba vera.


MIs: (a) A posterior MI may present with a tall R wave in V1-V2. True ?A posterior MI may present with a tall R wave in V1-V2. (b) A posterior MI may present with ST segment depression in V1-V3. True ?A posterior MI may present with ST segment depression in V1-V3. (c) Persisting ST segment elevation 1 month post MI suggests RV aneursym. False ?Persisting ST segment elevation 1 month post MI suggests a LV aneursym. (d) A Q wave should be 50% of the size of the R wave. False ?25-33% the size of the corresponding R wave. (e) A true Q wave should be 0.02 seconds in duration. False ?0.04.


Tibial Plateau Fractures: (a) The medial plateau is more commonly fractured. False ?The lateral plateau is more commonly fractured. (b) There is rarely ligamentous instability. False ? (c) Common symptoms include pain, swelling of the knee and decreased range of motion. True ?Common symptoms include pain, swelling of the knee and decreased range of motion. (d) Commonly result from varus or valgus forces combined with axial loading. True ?Commonly result from varus or valgus forces combined with axial loading. (e) Are usually treated conservatively with casting and immobilisation. False ?Early orthopaedic consultation is necessary due to the need for precise reconstruction of the articular surface.


In lithium toxicity (a) Lithium levels of over 1 mmol/L are associated with features of toxicity. False Toxicity is associated with levels greater than 1.5 mmol/L. (b) Diarrohea is a common feature of toxicity True Diarrohea is both a risk factor for the development of lithium toxicity and a symptom of toxicity. (c) Fine tremor is a good indicator of toxicity False Fine tremor is a common side effect of theraputic lithium -however the development of a new, especially a coarse tremor can indicate toxicity. (d) Thirst and polyuria are features True Theraputic lithium is associated with thirst and polyuria but these symptoms worsen / appear for the first time when lithium becomes toxic. (e) Hypertonia is a feature True ? Lithium has a low therautic index and toxicity can dose occur much more frequently than deliberate self administration. Toxicity is commonly precipitated by administration of diuretics or intercurrent dehydration e.g. vomiting or a febrile illness. Levels > 4mmol/l will require haemodialysis.


The anatomy of the thorax: (a) The sternum runs from T6 to T10 False ?The sternum runs from T5 to T8 (b) The upper border of the liver is usually at T2 False ?The upper border of the liver is usually at T6 (c) The inferior angle of the scapula is at T7 True ?The inferior angle of the scapula is at T7 (d) The IVC goes through the diaphragm at T8 True ?The IVC goes through the diaphragm at T8 ( along with the right phrenic nerve ) (e) The start of the arch of the aorta is at T1/T2 False ?The start of the arch of the aorta is at T4/T5


Regarding the modified SAD PERSON score in assessing suicide risk: (a) A total score <8 indicates that it may be safe to discharge the patient. False A score <6 may suggest safe discharge while a score 6 ? 8 indicates that psychiatric consultation should be arranged. (b) A total score >8 probably requires hospital admission. True (c) The age range that indicates an increased suicide risk is 19 - 45 years. False The high risk age group includes those aged <19 years or >45 years. (d) Excessive alcohol or drug use is one of the risk factors. True Risk factors also include: Male gender, age <19 or >45 years, depression or feeling of hopelessness, previous suicide attempts or psychiatric care, loss of rational thinking, separated/widowed/divorced, organised or serious attempt, lack of social support and stated future intent.

MCEM Clinical Knowledge MCq

Documents

Transcript of MCEM Clinical Knowledge MCq