1. A 19 year old intravenous drug user presents to the emergency
department with a fever of 38.5 degree celsius, dyspnoea and right
sided pleuritic chest pain. Bilateral cavitating lesions are seen in
both lungs on his chest x ray. What is the most likely diagnosis?
A. Aspiration pneumonia
B. Endocarditis of the tricuspid valve
C. Pneumocystis jirovecii pneumonia (PCP)
D. Pulmonary embolic disease
E. Pulmonary tuberculosis
Answer: B. endocarditis of the tricuspid valve
Explanation: PCP can be excluded as it does not present in this manner.
Aspiration pneumonia is more likely to show a single abscess cavity
rather than multiple bilateral lesions. The patient is certainly at higher
risk of TB and this is difficult to exclude without additional information
regarding constitutional symptoms (weight loss, night sweats, etc).
Pulmonary embolism could arise in this situation but the chest
radiograph is typically normal in that situation. If PEs do result in any
change on CXR it is usually in the form of wedge shaped infarcts.
The best answer, therefore, is that these cavities are due to septic
emboli arising from infection on the tricuspid valve. Systemic
embolisation occurs in 20-50% of cases on infective endocarditis and
can involve the lungs, central nervous system, coronary arteries, spleen,
bowel and extremities. This highest incidence of emboli is seen with
aortic and mitral valve infections, due to S.aureus, Candida, HACEK and
Abiotrophia. Most occur within the first 2-4 weeks of therapy.
Respiratory medicine: systemic embolisation occurs in 20-50% of cases
of infective endocarditis and can involve the lungs, central nervous
system,coronary arteries, spleen, bowel and extremities.
2. One of the phlebotomists at your surgery sustains a needle stick injury
while taking blood from a patient. What is the single, most appropriate,
immediate management?
A. Administer prophylactic hepatitis B immunoglobulin regardless of
vaccine status
B. Exclude the nurse from performing exposure-prone procedures for
three-months until a negative HIV antibody test has been obtained.
, C. Immediately take the nurse’s blood to test for antibodies to
hepatitis B, hepatitis C and HIV
D. Prompt administration of antiretroviral therapy
E. Wash the wound with soap under running water
Answer: E
Explanation:
First line management of needlestick injuries includes immediate
washing of the affected area under running water. All incidents should
be reported to the occupational health department and have a careful
risk assessment. HBIG is given only if donor is known hepatitis B
positive and victim is non-immune. Antiretroviral therapy is given, after
counselling, if the donor is known HIV positive and the exposure is
deemed high risk.
3. In the treatment of psoriasis, which of the following statements is
correct?
A. Etarnercept is not effective in psoriatic arthritis
B. Infliximab is associated with tuberculosis
C. PUVA is ineffective
D. Retinoids are the most useful monotherapy in psoriatic patients
E. Vitamin D analogues are associated with cutaneous atrophy.
Answer: B.
Explanation
Psoralen and ultraviolet light(PUVA) Is an effective treatment for
psoriasis, but has been related to increased risk of squamous cell
carcinoma and possibly malignant melanoma.
Retinoids are most effective in combination therapy especially with UVB
phototherapy and PUVA. part of the attraction of vitamin D analogues
over steroids is that they do not cuase cutaneous atrophy, whereas
steroids do. The combinat tumour necrosis factor and receptor fusion
protein, etanercept, has demonstrated considerable beneficial effects on
psoriatic arthropathy in placebo controlled, double blind studies.
,Infliximab is associated with tuberculosis by reactivation of latent
disease. Thus it is advised that patients who are to be treated with
infliximab are tuberculin tested and if required receive chest radiography.
Dermatology: infliximab is associated with tb by reactivation of latent
disease. Thus it is advised that patients who are to be treated with
infliximab are tuberculin tested and if required receive chest radiography.
4. A 75 year old man presents with severe central crushing chest pain.
ECG shows evidence of an inferior myocardial infarction(MI). He
receives primary stenting to the proximal right coronary artery. Four
hours after the initial presentation, he starts feeling dizzy and breathless.
His pulse is 30 bpm regular, BP 70/50 mmhg. Heart sounds are soft and
chest clear to auscultation. ECG shows 2:1 AV block with broad QRS
and T wave inversion inferiorly. IV atropine was administered but had no
effect. Which is the next most important treatment?
A. Emergency insertion of a permanent pacemaker
B. Emergency temporary transvenous pacing wire
C. Iv dopamine
D. Iv isoprenaline
E. Monitor his progress
Answer: B
Explanation
This patient has had an inferior MI which is commonly associated with
conduction abnormalities. He now develops heart block which leaves
him bradycardic, symptomatic and with a low BP, simply monitoring
progress is not appropriate. Isoprenaline is contraindicated in acute MI
due to its positive inotropic effects and arrhythmogenic potential. IV
dopamine is an inotrope which will not treat conduction blok. A
temporary wire would deal with the situation until the inferior MI has fully
resolved. Conduction block can recover in the next few days so a
permanent pacemaker may not be required.
Cardiology: a temporary wire is an appropriate measure until inferior MI
has fully resolved.
, 5. A 55-year-old woman on treatment for longstanding rheumatoid
arthritis has recently become dyspnea on mild exertion and developed a
dry cough. The oxygen saturation was found to be 87% on air. The chest
x-ray showed a diffuse bilateral interstitial infiltrate. An extensive
infection screen was negative and her symptoms were thought to be
drug-induced. Which drug is most likely to have caused this adverse
effect?
A. Azathioprine
B. Cyclosporin
C. Hydroxychloroquine
D. Methotrexate
E. Sulfasalazine
Answer: D
Explanation:
Methotrexate is a well recognised cause of acute pneumonitis and
interstitial lung disease. It is a rare complication of methotrexate therapy
but is often fulminant and can be fatal. Azathioprine can lead to bone
marrow suppression and infection. Cyclosporin toxicity can cause
neurological and visual disturbances. Hydroxychloroquine can lead to
abdominal pain as well as visual disturbances in toxicity. Sulfasalazine
can affect liver function tests and cause marrow suppression so
monitoring is required.
6. A 22-year-old man suffers a deep laceration to the forearm resulting in
transection of the median nerve. Following this injury, the nerve will
undergo which of the following pathological processes?
A. Chronic inflammation
B. Coagulative necrosis
C. Fibrinoid necrosis
D. Segmental demyelination
E. Wallerian degeneration
Answer: E
Explanation:
Wallerian degeneration is degeneration of the portion of the nerve distal
to the injury. It occurs following axonal injury in both the peripheral and
central nervous systems and usually begins within 24-36 hours of injury.
Coagulative necrosis is cell death following ischaemia or infarction. It is
department with a fever of 38.5 degree celsius, dyspnoea and right
sided pleuritic chest pain. Bilateral cavitating lesions are seen in
both lungs on his chest x ray. What is the most likely diagnosis?
A. Aspiration pneumonia
B. Endocarditis of the tricuspid valve
C. Pneumocystis jirovecii pneumonia (PCP)
D. Pulmonary embolic disease
E. Pulmonary tuberculosis
Answer: B. endocarditis of the tricuspid valve
Explanation: PCP can be excluded as it does not present in this manner.
Aspiration pneumonia is more likely to show a single abscess cavity
rather than multiple bilateral lesions. The patient is certainly at higher
risk of TB and this is difficult to exclude without additional information
regarding constitutional symptoms (weight loss, night sweats, etc).
Pulmonary embolism could arise in this situation but the chest
radiograph is typically normal in that situation. If PEs do result in any
change on CXR it is usually in the form of wedge shaped infarcts.
The best answer, therefore, is that these cavities are due to septic
emboli arising from infection on the tricuspid valve. Systemic
embolisation occurs in 20-50% of cases on infective endocarditis and
can involve the lungs, central nervous system, coronary arteries, spleen,
bowel and extremities. This highest incidence of emboli is seen with
aortic and mitral valve infections, due to S.aureus, Candida, HACEK and
Abiotrophia. Most occur within the first 2-4 weeks of therapy.
Respiratory medicine: systemic embolisation occurs in 20-50% of cases
of infective endocarditis and can involve the lungs, central nervous
system,coronary arteries, spleen, bowel and extremities.
2. One of the phlebotomists at your surgery sustains a needle stick injury
while taking blood from a patient. What is the single, most appropriate,
immediate management?
A. Administer prophylactic hepatitis B immunoglobulin regardless of
vaccine status
B. Exclude the nurse from performing exposure-prone procedures for
three-months until a negative HIV antibody test has been obtained.
, C. Immediately take the nurse’s blood to test for antibodies to
hepatitis B, hepatitis C and HIV
D. Prompt administration of antiretroviral therapy
E. Wash the wound with soap under running water
Answer: E
Explanation:
First line management of needlestick injuries includes immediate
washing of the affected area under running water. All incidents should
be reported to the occupational health department and have a careful
risk assessment. HBIG is given only if donor is known hepatitis B
positive and victim is non-immune. Antiretroviral therapy is given, after
counselling, if the donor is known HIV positive and the exposure is
deemed high risk.
3. In the treatment of psoriasis, which of the following statements is
correct?
A. Etarnercept is not effective in psoriatic arthritis
B. Infliximab is associated with tuberculosis
C. PUVA is ineffective
D. Retinoids are the most useful monotherapy in psoriatic patients
E. Vitamin D analogues are associated with cutaneous atrophy.
Answer: B.
Explanation
Psoralen and ultraviolet light(PUVA) Is an effective treatment for
psoriasis, but has been related to increased risk of squamous cell
carcinoma and possibly malignant melanoma.
Retinoids are most effective in combination therapy especially with UVB
phototherapy and PUVA. part of the attraction of vitamin D analogues
over steroids is that they do not cuase cutaneous atrophy, whereas
steroids do. The combinat tumour necrosis factor and receptor fusion
protein, etanercept, has demonstrated considerable beneficial effects on
psoriatic arthropathy in placebo controlled, double blind studies.
,Infliximab is associated with tuberculosis by reactivation of latent
disease. Thus it is advised that patients who are to be treated with
infliximab are tuberculin tested and if required receive chest radiography.
Dermatology: infliximab is associated with tb by reactivation of latent
disease. Thus it is advised that patients who are to be treated with
infliximab are tuberculin tested and if required receive chest radiography.
4. A 75 year old man presents with severe central crushing chest pain.
ECG shows evidence of an inferior myocardial infarction(MI). He
receives primary stenting to the proximal right coronary artery. Four
hours after the initial presentation, he starts feeling dizzy and breathless.
His pulse is 30 bpm regular, BP 70/50 mmhg. Heart sounds are soft and
chest clear to auscultation. ECG shows 2:1 AV block with broad QRS
and T wave inversion inferiorly. IV atropine was administered but had no
effect. Which is the next most important treatment?
A. Emergency insertion of a permanent pacemaker
B. Emergency temporary transvenous pacing wire
C. Iv dopamine
D. Iv isoprenaline
E. Monitor his progress
Answer: B
Explanation
This patient has had an inferior MI which is commonly associated with
conduction abnormalities. He now develops heart block which leaves
him bradycardic, symptomatic and with a low BP, simply monitoring
progress is not appropriate. Isoprenaline is contraindicated in acute MI
due to its positive inotropic effects and arrhythmogenic potential. IV
dopamine is an inotrope which will not treat conduction blok. A
temporary wire would deal with the situation until the inferior MI has fully
resolved. Conduction block can recover in the next few days so a
permanent pacemaker may not be required.
Cardiology: a temporary wire is an appropriate measure until inferior MI
has fully resolved.
, 5. A 55-year-old woman on treatment for longstanding rheumatoid
arthritis has recently become dyspnea on mild exertion and developed a
dry cough. The oxygen saturation was found to be 87% on air. The chest
x-ray showed a diffuse bilateral interstitial infiltrate. An extensive
infection screen was negative and her symptoms were thought to be
drug-induced. Which drug is most likely to have caused this adverse
effect?
A. Azathioprine
B. Cyclosporin
C. Hydroxychloroquine
D. Methotrexate
E. Sulfasalazine
Answer: D
Explanation:
Methotrexate is a well recognised cause of acute pneumonitis and
interstitial lung disease. It is a rare complication of methotrexate therapy
but is often fulminant and can be fatal. Azathioprine can lead to bone
marrow suppression and infection. Cyclosporin toxicity can cause
neurological and visual disturbances. Hydroxychloroquine can lead to
abdominal pain as well as visual disturbances in toxicity. Sulfasalazine
can affect liver function tests and cause marrow suppression so
monitoring is required.
6. A 22-year-old man suffers a deep laceration to the forearm resulting in
transection of the median nerve. Following this injury, the nerve will
undergo which of the following pathological processes?
A. Chronic inflammation
B. Coagulative necrosis
C. Fibrinoid necrosis
D. Segmental demyelination
E. Wallerian degeneration
Answer: E
Explanation:
Wallerian degeneration is degeneration of the portion of the nerve distal
to the injury. It occurs following axonal injury in both the peripheral and
central nervous systems and usually begins within 24-36 hours of injury.
Coagulative necrosis is cell death following ischaemia or infarction. It is
