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BOF: 61

An elderly lady has features of osteoporosis. She appears to have lost height due to osteoporotic collapse of the vertebrae but she does not know what her former height was. Which measurement will give an indication of her former height?

a)      Length of manubrium sterni

b)      Distance between the costal margin and the iliac crest

c)      Diameter of the rib cage

d)      Waist measurement

e)      Arm span

Answer:

e)

In an adult the arm span and height are approximately equal. In osteoporotic collapse of the vertebrae, the arm span becomes greater than the height.

Osteoporosis

BOF: 62

In osteoporotic collapse of the vertebra:

a)      The absence of precipitating stress makes it less likely

b)      The absence of severe pain will make the diagnosis less likely

c)      The pain is very well localised and the absence of this symptom will exclude the

diagnosis

d)      The vertebrae are tender to percussion and the absence of this sign will exclude

the diagnosis

e)      Frequently occurs without symptoms

Answer:

e)

Osteoporotic collapse of the vertebrae frequently occurs without symptoms

 Osteoporosis

BOF: 63

The three main sites at which osteoporotic fractures occur are:

a)      Vertebrae, pelvis, femoral neck

b)      Vertebrae, femoral neck, forearm

c)      Vertebrae, forearm, pelvis

d)      Vertebrae, femoral neck, humerus

e)      Vertebrae, forearm, ribs

Answer:

b)

The commonest sites of osteoporotic fracture are vertebrae, femoral neck, forearm

Osteoporosis  BOF: 64

In contrast to other forms of osteoporosis, steroid induced osteoporosis affects the:

a)      Skull

b)      Forearm

c)      Vertebrae

d)      Pelvis

e)      Femoral neck

Answer:

a)

Osteoporosis is thought not to affect the skull except in steroid induced osteoporosis.

 Osteoporosis

BOF: 65

A 45-year-old female is admitted with a subarachnoid haemorrhage. She initially, makes satisfactory progress but 5 days later her level of consciousness begins to deteriorate. The most likely cause of the deterioration is:

a)      Bacterial meningitis complicating lumbar puncture

b)      Cerebral abscess

c)      Coning of the medulla

d)      Acute hydrocephalus

e)      Dural sinus thrombosis

Answer:

d)

Organised blood in the subarachnoid space may cause obstruction to the flow of cerebrospinal fluid and result in hydrocephalus.

 

BOF: 66

A 67-year-old man presents with a history of falls. He has difficulty in reading and

coming down stairs. He has dysarthria, and akinesia and rigidity can be demonstrated.

Power of the muscles is normal, reflexes are brisk. What physical sign will help to make

the diagnosis?

a)      Jaw jerk

b)      Romberg’s sign

c)      Tandem walking

d)      Eye movements

e)      Plantar response

Answer:

d)

The patient has progressive supranuclear palsy and demonstration of impairment of voluntary gaze will allow one to make a diagnosis

 BOF: 67

A 25-year-old female has recently had a forceps delivery. She complains of pain in the groin and on examination she has weakness of adduction and internal rotation of the hip.

There is sensory impairment over the medial aspect of the thigh. The affected nerve is the:

a)      Femoral nerve

b)      Sciatic nerve

c)      Lateral cutaneous nerve of the thigh

d)      Tibial nerve

e)      Obturator nerve

Answer:

e)

The obturator nerve supplies gracilis, adductor longus and brevis, adductor magnus, obturator externus and the skin over the lateral aspect of the thigh

BOF: 68

A 20-year-old male presents with wasting and weakness of the muscles of the pelvic

girdle. There is evidence of generalised muscular hypertrophy. His maternal grandfather

had a similar disorder. The mode of inheritance is

a)      Autosomal dominant

b)      Autosomal recessive

c)      X-linked recessive

d)      Polygenic inheritance

e)      X-liked dominant

Answer:

c)

The patient has benign x-liked muscular dystrophy (Becker type)

 BOF: 69

Myotonia aggravated by cold is a feature of:

a)      Myotonia dystrophica

b)      Myotonia congenita

c)      Chondrodystrophic myotonia

d)      Paramyotonia

e)      Hypothyroidism

Answer:

d)

Myotonia appearing on exposure to cold occurs in Paramyotonia. Chondrodystrophic myotonia causes choking on cold drinks.

 

BOF: 70

In myasthenia gravis the tendon reflexes are:

a)      Brisk

b)      Absent

c)      Depressed

d)      Delayed

e)      Pendular

Answer:

a)       

In myasthenia gravis the tendon reflexes are characteristically brisk. If the reflexes are depressed or absent one should think of Eaton-Lambert syndrome.

BOF: 71

A 25-year-old male who is known to have ankylosing spondylitis presents with a painful, aching, photophobic red eye. Examination shows cells floating in the anterior chamber and precipitated on the back of the cornea. In this patient treatment should be commenced with:

a)      High dose oral steroids

b)      Broad spectrum antibiotics

c)      Local steroids

d)      Local steroids and dilator

e)      Local steroids and a constrictor

Answer:

d)

The patient has anterior uveitis. Treatment should be with local steroids and a dilator to break adhesions to the lens and allow the iris to remain mobile.

Ankylosing Spondylitis

BOF: 72

In diabetes mellitus eye. complications that do not result in visual impairment are:

a)      Cataract

b)      Lipaemia retinalis

c)      Rubeosis iridis

d)      Retinal vein occlusion

e)      Diabetic retinopathy

Answer:

b)

Lipaemia retinalis is seen in association with hypertriglyceridaemia and reverses with

metabolic control. All other complications impair vision. Rubeosis iridis can result in

glaucoma by neovascularistion of the drainage channels of the aqueous in the anterior

chamber.

 BOF: 73

A 27 year old female presents with abdominal pain, weight loss, diarrhoea and mouth ulcers. On clinical examination apart from mouth ulcers no abnormality is detected. Full blood count reveals normocytic normochromic anaemia, inflammatory markers are raised, and biochemical investigation reveals a raised alkaline phosphatase. Barium follow through shows terminal ileal inflammatory disease. In this patient long term remission may be maintained by the use of:

a)      Low dose prednisolone

b)      Mesalazine

c)      Azathioprine

d)      Infliximab

e)      Elemental diet

Answer:

c)

The patient has Crohn’s disease. Induction of remission of Crohn’s disease may be achieved by the use of steroids, elemental diet, surgery or Infliximab. Mesalazine may maintain remission if induction has been achieved by surgery and if an 8-week course of metronidazole is administered. In other cases the most useful drug to maintain remission is azathioprine.

Crohn's Disease

BOF: 74

An 80-year-old man has had a stroke and has a poor swallow. He keeps pulling his

nasogastric tube out and is not adequately nourished. He develops diarrhoea. Stools were

examined and show the presence of Clostridium difficile toxin. He has not been treated

with antibiotics. In this patient the next course of action should be:

a)      Arrange a colonoscopy

b)      Arrange a barium enema

c)      Treat with metronidazole

d)      Treat with Loperamide

e)      Treat with Cholestyramine

Answer:

c)

Infection with Clostridium difficile is usually established upon exposure to antibiotics.

However, it may also occur in debilitated patients who have not been exposed to

antibiotics.

BOF: 75

A 50-year-old male presents with haematemesis and melaena. He gives a history of alcohol abuse of several years duration. On examination he has bilateral parotid enlargement, spider naevi, Dupuytren’s contracture, jaundice and ascites. Whilst awaiting endoscopy the initial management of this patient should be:

a)      Administration of intravenous pantoprazole

b)      Administer terlipressin

c)      Insert a Sengstaken tube

d)      Nasogastric tube and aspiration to decompress the stomach

e)      Administer sucralfate

Answer:

b)

The patient has clinical evidence of cirrhosis of the liver (features of portal hypertension and features of hepatocellular failure). The likely cause of the haematemesis and melaena is bleeding oesophageal varices. Until endoscopy and definitive treatment one should attempt to reduce portal venous pressure with terlipressin.

BOF: 76

The cardinal manifestation of acute hepatic failure is:

a)      Jaundice

b)      Prolonged prothrombin time

c)      Hepatic encephalopathy

d)      Ascites

e)      Elevated ALT

Answer:

c)

Cerebral disturbance (hepatic encephalopathy) is the cardinal manifestation of acute

hepatic failure.

 BOF: 77

A 45-year-old female who is known to have autoimmune hepatitis, which has progressed to cirrhosis of the liver documented on liver biopsy, complains of breathlessness. The breathlessness is better when she lies down and gets worse when she is upright. Her arterial oxygen saturation is reduced on standing. The condition that this patient suffers from is an:

a)      Indication for treatment with carvedilol

b)      Indication for treatment digoxin

c)      Indication for liver transplantation

d)      Indication for home oxygen treatment

e)      Indication for oral beta agonists

Answer:

c)

Breathlessness on standing relieved by lying down (platypnoea) together with decreased arterial oxygen saturation on standing (orhtodeoxia) are features of the hepato-pulmonary syndrome which is an indication for liver transplantation

BOF: 78

A 26-year-old female who has been on the contraceptive pill presents with abdominal

pain and distension of 5 days duration. On examination she has no stigmata of chronic

liver disease. She has distended veins over the anterior abdominal wall with flow of

blood in a caudal to cephalic direction .She also has ascites, an enlarged tender liver with

absent hepato-jugular reflux. Her lower limbs are oedematous.

In this patient the oedema of the lower limbs is due to:

a)      Hypoalbuminaemia

b)      Hepato-renal syndrome

a)      Inferior vena cava thrombosis

b)      Portal venous thrombosis

c)      Lymphatic obstruction

Answer:

c)

Budd-Chiari syndrome is thrombosis of the hepatic veins. Lower limb oedema could

occur due to associated thrombosis of the inferior vena cava.

BOF: 79

A 40-year-old male presents with a history of intermittent, but slowly progressive dysphagia for both solids and liquids. He experiences pain on swallowing and has regurgitation of food swallowed several hours earlier. He has no heartburn but has anorexia and weight loss.

Ba swallow demonstrates proximal dilatation of the oesophagus and failure of relaxation of the lower oesophageal sphincter.

In this patient good medium to long term relief of symptoms may be obtained by:

a)      Oesophageal myotomy

b)      Amyl nitrite

c)      Amlodipine

d)      Intrasphincteric botulinum toxin

e)      Oesophageal bouginage

Answer:

a)

The patient has achalasia of the cardia, which is a functional obstruction at the lower oesophageal sphincter caused by a failure of relaxation. Oesophageal myotomy (Heller’s operation) and balloon dilatation give good medium to long-term results. Bouginage is not used. Drug therapy does not achieve medium to long-term relief.

BOF: 80

A 22-year-old female of Irish descent has been admitted under the care of the surgeons

with a history of abdominal pain. They have concluded that the patient has non-specific

abdominal pain, which they define as abdominal pain that cannot be treated by an

operation. No abnormality has been detected clinically or by routine investigation. They

wish to discharge the patient but would welcome your opinion. You agree to see the

patient in clinic following discharge but request that they perform an investigation prior

to discharge. This investigation would be:

a)      B12 and folate levels

b)      Urine for porphyrins

c)      ANCA screen

d)      Mesenteric angiogram

e)      Anti gliaden and anti endomysial antibodies

Answer:

e)

Coeliac disease presents with abdominal pain and a coeliac screen would be a good

screening test for this condition