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Which of the following would be expected to reduce maternal mortality when given in

eclampsia?

Available marks are shown in brackets

1 ) Insulin and dextrose infusion [!

" ) #ow dose dopamine infusion [!$ ) %agnesium infusion [1!

& ) 'henytoin infusion [!

( ) albutamol infusion [!

********************************************************************************

+omments,

%agnesium has been shown to significantly reduce maternal mortality in eclampsia and afavourable outcome may also be expected in pre*eclampsia- .one of the other agents has

been associated with a reduced mortality in eclampsia-

********************************************************************************In most cardiac arrest situations 1mg of adrenaline /epinephrine) is given intravenously

every $ minutes- What is the correct volume and concentration of the adrenaline?


1 ) -1ml of 1 in 1 [!" ) 1ml of 1 in 1 [!

$ ) 1ml of 1 in 1 [!

& ) 1ml of 1 in 10 [!

( ) 1ml of 1 in 10 [1!

********************************************************************************+omments,A 1mg dose of adrenaline /epinephrine) would be administered with answers A0 and 2-

3owever0 1 ml is considered the optimum volume of adrenaline during cardiac arrest-

********************************************************************************

In malignant hyperpyrexia,

Available marks are shown in brackets1 ) A mortality rate of "4 may be expected [!

" ) 2levation of serum creatine kinase and myoglobinuria is diagnostic [!

$ ) %uscle biopsy may be histologically normal [1!& ) 5he only available specific treatment is sodium dantrolene0 which has a neutral p3

[!

( ) 5he predisposing gene is thought to be on chromosome 6 [!

********************************************************************************

+omments,

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%alignant hyperpyrexia /%3) is characterised by increased temperature and muscle

rigidity during anaesthesia0 which results from abnormal skeletal muscle contraction and

increased metabolism- 5he predisposing gene is thought to be on chromosome 160 closeto the gene for the ryanodine 7 dihydropyridine receptor complex- 8nown triggering

agents include the volatile anaesthetic agents and suxamethonium- 'atients show different

sensitivity to the triggering agents and the reaction can be delayed by several hours-Intravenous dantrolene /up to 1mg78g) is the only available specific treatment- 5he

solution has a p3 of 6 to 1- 5he prognosis is good when the appropriate treatment is

instigated early0 mortality being 9(4 /prior to dantrolene the mortality was :4)- erumcreatine kinase elevation and myoglobinuria are suggestive but not diagnostic of %3-

%yoglobin and creatine kinase are both known to increase after giving suxamethonium to

normal patients- +ontracture tests using caffeine and halothane are the investigations of

choice- %uscle biopsies may appear histologically normal-

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A 1; year old girl presents after having ingested fifty of her mother C (-6)

bicarbonate $" mmol7# /"" * ">)

Which one of the following is a recognised cause of this acid*base disorder?

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1 ) Amitriptyline overdose [!

" ) +ushingDs syndrome [!$ ) 3epatic failure [!

& ) 'regnancy [1!

( ) alicylate poisoning [!

********************************************************************************

+omments,5his patient has a mild metabolic alkalosis with what appears to be respiratory

compensation as reflected by the elevated p+E"- Amitriptyline overdose is associated

with acidosis as is salicylate poisoning- 3epatic failure usually presents with acidosis-

5his type of picture is associated with prolonged vomiting /as in pregnancy)0 diarrhoea0diuretic therapy and in +ushing

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5he average score for this Guestion is ;(-&4 /answered $$(( times)

youth worker0 aged &0 presents to Accident and 2mergency with vomiting- En detailed

Guestioning0 he admits to having taken $> paracetamol tablets " hours previously- 3e is

vomiting profusely with a ' of 67>- Which of the following measures would be mostappropriate?

Available marks are shown in brackets1 ) 'aracetamol levels [!

" ) oral methionone [!

$ ) IH .*acetyl cysteine [!

& ) IH fluids [1!( ) +oagulation screen [!

********************************************************************************

+omments,5he most pressing issue in this patient is resuscitation as he is vomiting and hypotensive-

It is too early to carry out paracetamol levels as these should be carried out at & hours0and certainly too early to instigate treatment with .A+ or methionine- An I.@ gives an

indication of hepatocellular damage and again this will not be seen at presentation of

paracetamol overdose-

********************************************************************************

5he average score for this Guestion is (;-&4 /answered &&(& times)

A $ year old man is admitted three hours after taking an overdose of amitriptyline and

diaBepam- En examination he was drowsy with a lasgow +oma cale of :0 he had apulse of 1& beats per minute0 a blood pressure of 11&7:: mm3g and dilated pupils- 3is

oxygen saturation was 64 on room air- What is the most appropriate initial action for

this patient?


1 ) activated charcoal [!" ) +5 head scan [!

$ ) 2+ [1!

& ) IH atenolol [!( ) IH flumaBenil [!

********************************************************************************+omments,

Faft Guestion really- 5he most appropriate initial action would be to get the investigations

done as Guickly as possible C arterial blood gases and 2+ as the latter may show @

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widening and merit treatment- 5hen0 the next step would be gastric decontamination with

lavage and activated charcoal- 5reatment with bicarbonate is also advocated as this

patient displays features of severe 5+A overdose- 3e doesn

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5he following are seen in +rohnDs disease,

A dermatitis herpetiformis

f steatorrhoea

t

+ pyoderma gangrenosumtrue

F haemolytic anaemia following sulphasalaBine treatment

true

2 erythema nodosumtrue

********************************************************************************

+omments,Fermatitis herpetiformis is a manifestation of coeliac disease- =at malabsorption may be

afeature of crohnDs with 2rythema nodosum and pyoderma gangrenosum being cutaneousmanifestations- Eligoarthritis with acroilitis and iritis may also feature- ulphasalaBine

can produce a number of haematological problems in particular thrombocytopaenia0

leucopaenia but haemolysis can occur-

********************************************************************************

$ year old caucasian male presents with a six month history of weight loss0 abdominalpain0 and diarrhoea- En examination you note finger clubbing- Which of the following

diagnoses is least likely-


1 ) +rohnDs disease [!

" ) lcerative colitis [!$ ) +oeliac disease [!

& ) WhippleDs disease [!

( ) Ileo*caecal 5 [1!

********************************************************************************

+omments,

Ileo*caecal 5 is the only condition mentioned not associated with clubbing and wouldbe very rare in a young caucasian in the 8-

********************************************************************************

5he average score for this Guestion is $:-"4 /answered

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& ) primary liver cancer [!

( ) spontaneous bacterial peritonitis [1!

********************************************************************************

+omments,

5he high white cell count in the ascites makes spontaneous bacterial peritonitis /')much more likely than udd +hiari yndrome /+)0 'H50 3++0 or a ruptured

pancreatic pseudocyst- Abdominal pain is often only mild0 or even absent in '0 with

patients often presenting with otherwise unexplained hepatic decompensation->(*year*old man is referred with abnormal liver function and undergoes a liver biopsy-

Which of the following count against hepatic cirrhosis?


1 ) =ibrous septa formation [!

" ) ranuloma formation [1!

$ ) #iver cell necrosis [!& ) .odular regeneration [!

( ) ubendothelial fibrosis [!

********************************************************************************

+omments,

ranuloma formation is not classically seen in cirrhosis0 which can be micro or

macronodular in type- In the micronodular form0the nodules are less than $mm across

with uniform liver involvement * seen in alcohol or biliary disease- In the macronodularform0 there are larger nodules0 classically seen in chronic viral hepatitis-)

********************************************************************************

A >(*year*old man is referred with abnormal liver function and undergoes a liver biopsy-Which of the following count against hepatic cirrhosis?

Available marks are shown in brackets1 ) =ibrous septa formation [!

" ) ranuloma formation [1!

$ ) #iver cell necrosis [!& ) .odular regeneration [!

( ) ubendothelial fibrosis [!

********************************************************************************

+omments,

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ranuloma formation is not classically seen in cirrhosis0 which can be micro or

macronodular in type- In the micronodular form0the nodules are less than $mm across

with uniform liver involvement * seen in alcohol or biliary disease- In the macronodularform0 there are larger nodules0 classically seen in chronic viral hepatitis-)

********************************************************************************

&& year old male with +hildDs grade + cirrhosis presented with haematemesis- Which one

of the following drugs0 administered intravenously0 would be the most appropriate0immediate0 treatment?


1 ) Isosorbide dinitrate- [!" ) EmepraBole- [!

$ ) 'ropranolol [!

& ) omatostatin [1!

( ) 5ranexamic acid- [!

********************************************************************************+omments,

5he suggestion is that this patient is at particularly high risk of oesophageal varices-

+hild"-;4 /answered ;&(1 times)

A routine ultrasound at 1: weeks gestation in a diabetic mother reveals a male foetus with

an endocardial cushion defect- Ether abnormalities include increased nuchal thickeningand a Mdouble bubbleM sign- Which of the following conditions is most likely to have

contributed to this set of findings,


1 ) %aternal use of A+2 inhibitor [!

" ) %arfan syndrome [!$ ) %aternal folate deficiency [!

& ) 5risomy "1 [1!

( ) +ongenital syphilis [!

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********************************************************************************

+omments,

Fiabetic mothers are more likely to have children with congenital abnormalitiesdepending on pre*conception0 and first trimester blood sugar control- &4 of FownDs

syndrome babies have atrioventricular septal defects as in this foetus- 5he double bubble

sign suggests duodenal atresia which again suggests FownDs syndrome- I malformationsoccur in >4 of FownDs patients * most commonly duodenal atresia and 3irschphrungs

disease-

********************************************************************************

A (" year old man with a diagnosis as a child of coeliac disease had been asymptomatic

despite poor dietary compliance- 3e presents with a one month history of intermittent0

colicky0 central abdominal pain and $ kilogram weight loss and positive faecal occultbloods- What is the most appropriate investigation?

Available marks are shown in brackets1 ) Anti*endomysial antibody- [!

" ) +olonoscopy- [1!$ ) +5 scan of abdomen- [!

& ) Fistal duodenal biopsy- [!

( ) mall bowel enema- [!

********************************************************************************

+omments,

.ew*onset weight loss0 with positive faecal occult bloods and central abdo pain in a ("*

year*old man must be assumed to be colonic carcinoma until proven otherwise-

+olonoscopy is the best way to check for this and would also demonstrate inflammatorybowel disease if present- If the colonoscopy were negative0 then an EF would be

needed to check for upper I malignancy-

********************************************************************************

5he average score for this Guestion is ((->4 /answered >>6> times)

( year old ex*footballer with a long history of alcohol excess presents with epigastric

pain- Which of the following suggests a diagnosis of peptic ulceration rather than chronic

pancreatitis?


1 ) ack pain [!

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" ) 2xacerbation with alcohol [!

$ ) #oose stool [!

& ) @elieved by food [1!( ) Weight loss [!

********************************************************************************+omments,

@elief with food suggests peptic /and specifically) duodenal ulceration- It is likely thatfood would precipitate the pain of chronic pancreatitis-

#oose stool is suggestive of pancreatitis7malabsorption- 'ain referred to the back occurs

in both situations and hence not suggestive-

Weight loss can occur in both gastric ulcers and pancreatitis and not very suggestive-Alcohol may well exacerbate both types of pain-

********************************************************************************

5he average score for this Guestion is :&-$4 /answered >&( times)

A "& year old woman was referred with tiredness and intermittent bloody diarrhoea and a

past history of cerebral venous thrombosis-En examination0 the sclera of the right eye was inflamed0 and multiple mouth ulcers were

noted- At the colonoscopy0 which confirmed colitis0 two large vulval ulcers were noted-

Which is the most likely diagnosis?

Available marks are shown in brackets1 ) ehcetDs disease- [1!

" ) +rohnDs disease- [!

$ ) 3IH infection [!

& ) yphilis [!( ) lcerative colitis- [!

********************************************************************************+omments,

A classical description of the presentation of ehcetDs0 with oral and genital ulceration0colitis and scleritis-

********************************************************************************

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1 ) In non*familial cases0 gene mutations in the cancer cells are unusual [!" ) In familial cases the inheritance pattern is typically autosomal recessive [!

$ ) It occurs most commonly in the ascending colon [!

& ) It is a characteristic feature of the 'eutB*Legher syndrome [!( ) In familial polyposis coli the increased cancer risk is due to inheritance of a mutated

suppressor gene [1!

********************************************************************************

+omments,

A C uantitative and Gualitative alterations in gene expression accumulate in colorectal

cancer cells- 5hese include alterations of pro*oncogene expression and chromosomalabnormalities /deletions at 1;p and 1:G are seen in ;4 of colorectal carcinomas)- C

oth familial polyposis coli and ardnerDs syndrome are autosomal dominant- + C 5he

rectum and sigmoid colon are the commonest sites- F C 'eutB*LegherDs syndrome is

dominantly inherited pigmentation of skin and mucuous membranes0 and harmatomatouspolyps in the stomach and larger intestine- 5he polyps only rarely undergo malignant

change- 2 C An allelic deletion of a putative tumour suppressor gene on (p-A > year old man presents with a ( day history of lower abdominal pain and diarrhoea-

3e has a history of chronic obstructive airways disease and has had numerous acute

infective exacerbations over the last $ months-

En examination he was dehydrated0 with a temperature of $:-> O+0 a blood pressure of

1"7;" mm3g and has a distended0 tender abdomen- Which of the following is the most

appropriate investigation for this patient?

Available marks are shown in brackets1 ) +hest K*ray [!

" ) 'lain abdominal K*ray [!

$ ) igmoidoscopy and biopsy [1!& ) tool microscopy [!

( ) ltrasound scan of the abdomen [!

********************************************************************************+omments,

5his is pseudomembranous colitis due to +lostridium Fifficile secondary to Antibiotic

usage for his +EAF- 'lain AK@ is useful for diagnosing toxic dilatation but does notestablish the diagnosis- tool microscopy has no value but stool toxin assay is useful- A

'atient with diarrhoea normally has involvement of the distal colon and rectum and

sigmoidoscopy with biopsy is helpful for rapid diagnosis- 'atients with involvement ofright colon usually have little or no diarrhoea

&> year old man with a family history of haemochromatosis presented to outpatients for

advice- Investigations revealed-

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serum ferritin &($ug7# /1( C $)

serum iron "6 umol7# /1" C $)

serum iron binding capacity &> umol7# /&( C ;()iron saturation >$ per cent /" C ()

What is the most appropriate next step in management?

Available marks are shown in brackets1 ) arrange for F.A analysis [1!

" ) begin a venesection programme [!

$ ) monitor his serum ferritin regularly [!

& ) take no action unless the iron saturation exceeds 6 per cent [!( ) undertake a liver biopsy [!

********************************************************************************

+omments,5his man is likely to have hereditary heamochromatosis /33+)- 3omoBygous mutation

/+":"N mutation) of the 3uman Iron gene /3=2 gene) accounts for over :4 of cases of33+- 5he diagnosis is made on F.A analysis- If the diagnosis is confirmed then

treatment with venesection to achieve and maintain a ferritin of (*1Pg7l is indicated-

A liver biopsy is not reGuired to make the diagnosis of 33+ although may be indicatedfor prognostic reasons if cirrhosis is suspected-

********************************************************************************

5he average score for this Guestion is &&-(4 /answered ;(:& times)

A (> year old female is referred to clinic by her ' who notes hepatomegaly- ix yearsago she was diagnosed with diabetes mellitus and takes metformin ( mg tds and

gliclaBide :mg bd- he drinks approximately 1( units of alcohol weekly amd stopped

smoking 1 years ago-

En examination she has a %I of $>-" kg7m0 no stigmata of liver disease are evident but

she has > cm hepatomegaly-

Investigations disclose,

5otal bilirubin 11 micromol7# /1 * "")Alkaline phosphatase 1&( 7# /&( * 1()

A5 1 7# /1 *$1)

A#5 1( 7# /( * $()Albumin & g7# /$; * &6)

=erritin &$& mg7# /1( * $)

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ltrasound of the abdomen reveals an echobright appearance of the liver and gallstones

in the gallbladder-

What is the most cause of her liver disease?


1 ) Alcoholic liver disease [!

" ) Frug induced hepatitis [!$ ) allstone disease [!

& ) 3aemochromatosis [!

( ) .on*alcoholic steatohepatitis /.A3) [1!

********************************************************************************

+omments,

5he patient has a hepatitic picture in contrast to +holestasis- =erritin level is not too high

to be considered for haemochromatosis and is an acute phase reactant being typicallyincreased in any inflammatory process- .A3 is very common and is typically

encountered in Ebese patients0 presenting with a hepatitic picture with or withoutJaundice- 2cho bright liver suggests fatty change in the liver seen in .A3-It was

previously termed Idiopathic decompensated hepatitis and if not treated in terms of

lowering %I and reducing fat intake can lead onto irreversible cirrhosis- allstones area distraction in this history-

********************************************************************************

5he average score for this Guestion is &(-$4 /answered $":1 times)

(" year*old male is admitted with haematemesis and melaena- 2xamination reveals that

he is icteric0 confused with a flapping tremor0 has signs of chronic liver disease0 a pulse

rate of 11 bpm and blood pressure of 17; mm3g- Abdominal examination reveals

ascites- An urgent endoscopy reveals small oesophageal varices0 without evidence ofbleeding but an ooBing portal hypertensive gastropathy- Which of the following measures

would be the most appropriate treatment for this patient?


1 ) endoscopic banding [!

" ) endoscopic inJection of adrenaline [1!$ ) endoscopic inJection of ethanolamine [!

& ) oral propranolol [!

( ) intravenous vitamin 8 [!

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