1. A 70-year-old woman has a history of dyspnoea and palpitations for six
months.An ECG at that time showed atrial fibrillation. She was given digoxin,
diuretics, and aspirin.She now presents with two short lived episodes of
altered sensation in the left face, left arm, and leg. There is poor coordination
of the left hand. ECHO was normal as was a CT head scan.Which of the
following is the most appropriate next step in management?
A. Clopidogrel
B. No action
C. Corticosteroid treatment
D. Anticoagulation
E. Carotid endarterectomy
Answer: D
Explanation: Key learning points
Cardiology, Pharmacology, Stroke
● There is an increased risk of strokes in patients with atrial fibrillation and
hence with the given symptoms formal anticoagulation with warfarin should be
considered.
Explanation
This patient is having symptoms of transient ischaemic attacks most likely due to a
cardiac source of emboli.
A normal echocardiogram (ECHO) or computerised tomography (CT) scan head
does not rule out thromboembolic events.
There is an increased risk of strokes in patients with atrial fibrillation and hence with
the given symptoms formal anticoagulation with warfarin should be considered.
2. A 67-year-old man is reviewed in oncology following surgery to remove a
gastrointestinal stromal tumour (GIST). He had been losing weight over the past few
months, suffering from night sweats, nausea, and early satiety, and an endoscopy
had identified the tumour. A decision is made to commence adjuvant imatinib
therapy.
Which of the following represents the mode of action of imatinib?
, A. Nucleoside analogue
B. Tyrosine kinase inhibitor
C. Alkylating agent
D. Serine threonine kinase inhibitor
E. mTOR inhibitor
Answer: B
Key learning points
Pharmacology
● Imatinib is a Bcr-Abl inhibitor originally developed for CML, but now has an
extended role across a number of haematological malignancies, including
gastric MALtoma.
Explanation
The answer is Tyrosine kinase inhibitor. Imatinib is a small molecule protein-tyrosine
kinase inhibitor that inhibits the activity of the Bcr-Abl tyrosine kinase (TK), as well
the KIT and PDGFR receptors. It was primarily developed for the treatment of
chronic myeloid leukaemia, although now it has also proved useful in the treatment
of a range of other myeloproliferative disorders including gastrointestinal stromal
tumours. Studies suggest that in high risk patients it may reduce rate of recurrence
after surgery.
Examples of alkylating agents include chlorambucil and cyclophosphamide, used as
part of conventional chemotherapy regimens but not classically in the treatment of
GISTs.
Nucleoside analogues interfere with DNA replication and are primarily used as
anti-virals including in the treatment of HIV, Hepatitis B and C.
mTOR inhibitors are also used in the treatment of cancer, an example is everolimus,
which is most commonly used in combination with exemestane for the treatment of
metastatic breast cancer.
A number of serine threonine kinase inhibitors are currently in development for the
treatment of various malignancies.
Further reading
,3. In a study of the utility of serum procalcitonin level for early diagnosis of
bacteraemia, 100 consecutive febrile patients admitted to hospital were tested for
serum procalcitonin and culture of bacteria.
It was reported that serum procalcitonin level above 0.5 microgram/L had a
sensitivity of 85% in detecting bacteraemia.
Which of the following statements is correct?
A. 85% of the patients who have bacteraemia would be expected to have serum
procalcitonin level above 0.5 microgram/L
B. Sensitivity will be higher if 200 patients instead of 100 patients were tested
C. 15% of the patients who do not have bacteraemia would be expected to have
serum procalcitonin level above 0.5 microgram/L
D. 15% of the patients who have serum procalcitonin level above 0.5
microgram/L would be expected not to have bacteraemia
E. 85% of the patients who have serum procalcitonin level above 0.5
microgram/L would be expected to have bacteraemia
Answer: A
Explanation: Key learning points
Statistics
● Sensitivity and specificity can be remembered using the acronym Spin and
Snout. Spin stands for ‘Specific test when Positive rules IN the disease’.
Snout is the acronym for ‘Sensitive test when Negative rules OUT the
disease’.
Explanation
Eighty five per cent of the patients who have bacteraemia would be expected to have
serum procalcitonin level above 0.5 microgram/L.
This is the correct interpretation of sensitivity, which is the proportion of diseased
cases that are tested positive.
The number of patients will not affect sensitivity.
, 4. Which of the following antibodies are typically found in auto-immune adrenalitis
(Addison's disease)?
A. Antinuclear antibody
B. Anti-tryptophan hydroxylase antibody
C. Anti-rho antibody
D. Anti-21 hydroxylase antibody
E. Anti-thyroid peroxidase antibody
Answer: D
Explanation: Key learning points
Endocrinology
● Anti-21-hydroxylase antibody is found in 80% of patients with autoimmune
adrenalitis.
Explanation
21 hydroxylase is the enzyme involved in the cholesterol steroid pathway and has
been found to be present in approximately 80% of cases.
Anti-nuclear antibody suggest an autoimmune disease is present though is positive
in many.
Anti-thyoroid peroxidase antibody is associated with Hashimoto's thyroiditis.
Anti-rho antibody is associated with Sjogren's syndrome.
5. A 29-year-old male presents to you seeking advice regarding starting a family.
He has common variable immunodeficiency and wants to know what is the risk of
passing this on to his children?
A. 50%
B. 25%
C. over 70%
months.An ECG at that time showed atrial fibrillation. She was given digoxin,
diuretics, and aspirin.She now presents with two short lived episodes of
altered sensation in the left face, left arm, and leg. There is poor coordination
of the left hand. ECHO was normal as was a CT head scan.Which of the
following is the most appropriate next step in management?
A. Clopidogrel
B. No action
C. Corticosteroid treatment
D. Anticoagulation
E. Carotid endarterectomy
Answer: D
Explanation: Key learning points
Cardiology, Pharmacology, Stroke
● There is an increased risk of strokes in patients with atrial fibrillation and
hence with the given symptoms formal anticoagulation with warfarin should be
considered.
Explanation
This patient is having symptoms of transient ischaemic attacks most likely due to a
cardiac source of emboli.
A normal echocardiogram (ECHO) or computerised tomography (CT) scan head
does not rule out thromboembolic events.
There is an increased risk of strokes in patients with atrial fibrillation and hence with
the given symptoms formal anticoagulation with warfarin should be considered.
2. A 67-year-old man is reviewed in oncology following surgery to remove a
gastrointestinal stromal tumour (GIST). He had been losing weight over the past few
months, suffering from night sweats, nausea, and early satiety, and an endoscopy
had identified the tumour. A decision is made to commence adjuvant imatinib
therapy.
Which of the following represents the mode of action of imatinib?
, A. Nucleoside analogue
B. Tyrosine kinase inhibitor
C. Alkylating agent
D. Serine threonine kinase inhibitor
E. mTOR inhibitor
Answer: B
Key learning points
Pharmacology
● Imatinib is a Bcr-Abl inhibitor originally developed for CML, but now has an
extended role across a number of haematological malignancies, including
gastric MALtoma.
Explanation
The answer is Tyrosine kinase inhibitor. Imatinib is a small molecule protein-tyrosine
kinase inhibitor that inhibits the activity of the Bcr-Abl tyrosine kinase (TK), as well
the KIT and PDGFR receptors. It was primarily developed for the treatment of
chronic myeloid leukaemia, although now it has also proved useful in the treatment
of a range of other myeloproliferative disorders including gastrointestinal stromal
tumours. Studies suggest that in high risk patients it may reduce rate of recurrence
after surgery.
Examples of alkylating agents include chlorambucil and cyclophosphamide, used as
part of conventional chemotherapy regimens but not classically in the treatment of
GISTs.
Nucleoside analogues interfere with DNA replication and are primarily used as
anti-virals including in the treatment of HIV, Hepatitis B and C.
mTOR inhibitors are also used in the treatment of cancer, an example is everolimus,
which is most commonly used in combination with exemestane for the treatment of
metastatic breast cancer.
A number of serine threonine kinase inhibitors are currently in development for the
treatment of various malignancies.
Further reading
,3. In a study of the utility of serum procalcitonin level for early diagnosis of
bacteraemia, 100 consecutive febrile patients admitted to hospital were tested for
serum procalcitonin and culture of bacteria.
It was reported that serum procalcitonin level above 0.5 microgram/L had a
sensitivity of 85% in detecting bacteraemia.
Which of the following statements is correct?
A. 85% of the patients who have bacteraemia would be expected to have serum
procalcitonin level above 0.5 microgram/L
B. Sensitivity will be higher if 200 patients instead of 100 patients were tested
C. 15% of the patients who do not have bacteraemia would be expected to have
serum procalcitonin level above 0.5 microgram/L
D. 15% of the patients who have serum procalcitonin level above 0.5
microgram/L would be expected not to have bacteraemia
E. 85% of the patients who have serum procalcitonin level above 0.5
microgram/L would be expected to have bacteraemia
Answer: A
Explanation: Key learning points
Statistics
● Sensitivity and specificity can be remembered using the acronym Spin and
Snout. Spin stands for ‘Specific test when Positive rules IN the disease’.
Snout is the acronym for ‘Sensitive test when Negative rules OUT the
disease’.
Explanation
Eighty five per cent of the patients who have bacteraemia would be expected to have
serum procalcitonin level above 0.5 microgram/L.
This is the correct interpretation of sensitivity, which is the proportion of diseased
cases that are tested positive.
The number of patients will not affect sensitivity.
, 4. Which of the following antibodies are typically found in auto-immune adrenalitis
(Addison's disease)?
A. Antinuclear antibody
B. Anti-tryptophan hydroxylase antibody
C. Anti-rho antibody
D. Anti-21 hydroxylase antibody
E. Anti-thyroid peroxidase antibody
Answer: D
Explanation: Key learning points
Endocrinology
● Anti-21-hydroxylase antibody is found in 80% of patients with autoimmune
adrenalitis.
Explanation
21 hydroxylase is the enzyme involved in the cholesterol steroid pathway and has
been found to be present in approximately 80% of cases.
Anti-nuclear antibody suggest an autoimmune disease is present though is positive
in many.
Anti-thyoroid peroxidase antibody is associated with Hashimoto's thyroiditis.
Anti-rho antibody is associated with Sjogren's syndrome.
5. A 29-year-old male presents to you seeking advice regarding starting a family.
He has common variable immunodeficiency and wants to know what is the risk of
passing this on to his children?
A. 50%
B. 25%
C. over 70%
