PROGRESS TEST - JUNE 1998

GENERAL

1 F GIVEN A patient is receiving a total of 120mg morphine by mouth for cancer pain each day. He becomes unable to swallow and you decide to prescribe subcutaneous diamorphine QUESTION The correct dose is 60mg daily 2F If a dying patient cannot swallow an intravenous infusion should be started 3T The daily requirement for fluid and electrolytes of an adult weighing 70Kg is 2500-3000mi of water, 150mmol of sodium and 60mmol of potassium 4T GIVEN A locum general practitioner confirms the fact of death in a patient expected to die of cancer. The locum has never seen the patient before QUESTION The patient's usual general practitioner is permitted to issue a Death Certificate without seeing the body 5F A Coroner's inquest will on:y be held if death occurred before the usual age of retirement 6T A standardised mortality ratio (SMR) can only be estimated if the age distribution of the population is known

HEART, LUNGS AND BLOOD

717M Thiazide diuretics decrease renal HC03- excretion

8FM The "c" wave of the jugular venous pulse is due to opening of the tricuspid valve

9FM Staphylococcus aureus is frequently implicated in an acute exacerbation of chronic bronchitis

10FM Nicotine-containing chewing gum is available on NHS prescriptions

11FM Cuses of a pleural effusion with a protein content of 50g11 include cardiac failure

12T GIVEN: A 26 year old man is known to have bronchial asthma. A peak flow measurement is taken, and is found to be less than 50% of the subject's usual peak flow measurement QUESTION: Oral steroid therapy should be given

13FM Magnetic resonance imaging is of value in assessment of severity of pulmonary emphysema

14FM Prostacyclin (PG12) is synthesised in mast cells

15FM A paradoxical embolus is one which arises as a thrombus in the area of greatest flow in the aorta

16T Some of the muscles of the anterior abdominal wall are supplied by intercostal nerves

17T Haemosiderin consists of aggregates of ferritin molecules

18T The inferior vena cava lies to the right of the abdominal aorta

19T Macrophages are antigen-presenting cells 20T GIVEN The renal clearance of benzylpenicillin is greater than that of gentamicin QUESTION Benzylpenicillin has a shorter plasma concentration half-time than gentamicin

21F Atrial systole is responsible for 80% of the blood flow into the left ventricle of the heart

22F Plasmin is essential for normal thrombus retraction 23F In a normal subject, sitting upright, apical and basal regions of the lungs receive approximately equal blood flows

24T Neutrophil polymorphonuclear leucocytes are typically seen at the site of acute inflammation

25F GIVEN Cardiomegaly and pulmonary congestion are characteristic radiological features of cardiac failure QUESTION These findings indicate that the patient has heart muscle disease (cardiomyopathy)

26F GIVEN A patient presents to the Accident and Emergency Department with a history of central crushing chest pain for a period of two hours QUESTION A normal electrocardiogram excludes myocardial infarction

27T GIVEN The incidence of myocardial infarction increases in women following the menopause QUESTION Hormone replacement therapy (HRT) can be regarded as a form of primary prevention for coronary artery disease

28F Dilated pupils are an important prognostic sign immediately after cardiac arrest

29T One dose of aspirin may prolong the bleeding time for some days

30T GIVEN A patient with pernicious anaemia will show red cell macrocytosis caused, indirectly, by a deficiency of intrinsic factor and consequent Vitamin B12 malabsorption QUESTION Intrinsic factor and Vitamin B12 given together by mouth will correct the anaemia and macrocytosis

31T GIVEN Vitamin K is a fat soluble vitamin and is required for the manufacture of certain fully functional coagulation factors QUESTION Obstructive jaundice potentially causes prolongation of prothrombin time which can be corrected by Vitamin K treatment

32T GIVEN A woman of 63 years reports to her general practitioner that she has been hoarse for 4 weeks QUESTION She should be referred to hospital for investigations

33F GIVEN Histological verification of lung cancer is usually by bronchoscopy and biopsy QUESTION Bronchoscopy is poorly tolerated, and therefore contraindicated, in patients over 70 years of age

34T Benzodiazepines can be used to alleviate dyspnoea in terminally ill patients

35F GIVEN An adult with a known allergy to nuts suddenly has a rash and difficulty in breathing QUESTION It is appropriate to treat with 1 mg of adrenaline by rapid intravenous injection

36T For anything other than the treatment of a life-threatening condition, a general anaesthetic should not be administered within six months of acute myocardial infarction

37F GIVEN Hypertension represents an increased perioperative risk. Before routine surgery, you are clerking a patient with known hypertension, for which he is receiving medication. You find that his blood pressure is 210/105mmHg QUESTION His operation should be cancelled immediately

38F A patient who has had a coronary artery bypass graft should be advised to inform their dentist that they will require antibiotic cover for surgical procedures

39T In patients with asthma, a fall in the peak expiratory flow rate (PEFR) to 60% of their bi~st value is an indication for oral steroid therapy 40T Theophylline toxicity can be precipitated by erythromycin

41 F In an adult, acute breathlessness occurring at night is most commonly due to left ventricular failure

42T On testing for pitting oedema, indentation lasting more than 30 seconds is suggestive of hypoproteinaemia

43F Expiratory crackles are typically heard in fibrosing alveolitis

44T Atenolol is less likely than propranolol to produce unpleasant dreams

45F Vitamin B12 'Slikely to be necessary for the treatment of anaemia after pregnancy

46T Pleural biopsy is the best method o f diagnosing pleural tuberculosis

47F GIVEN An unconscious 60 year old man is brought into the Accident and Emergency Department QUESTION A chest x-ray should be performed to exclude pneumothorax

48T GIVEN A patient with chronic obstructive airways disease suffers cardiac arrest QUESTION Oxygen should be prescribed at the highest possible delivery rate

49T Hyperventilation can compensate for mild metabolic acidosis

50F Patients travelling to malarious areas should not be given mefloquine

51F GIVEN The worldwide prevalence of tuberculosis is increasing, and resistance to antituberculous chemotherapy is increasing QUESTION Quadruple therapy is advised for the initial therapy of tuberculosis, pending susceptibility testing results

52F Pyrexia of unknown origin is defined as a fever of 3M or more on two occasions over three days, with a negative blood culture

53F The murmur of aortic incompetence is low pitched and therefore best heard using the bell of the stethoscope

54F Abdominal aortic aneurysm often presents with symptoms of peripheral embolism

55F Sickle cell anaemia causes splenomegaly in adults

56T A pigmented skin lesion should be removed if depigmentation occurs

57F Haemophilus influenzae type A is the commonest cause of post-influenzal pneumonia 58T The blood in glandular fever characteristically shows atypical lymphocytes

59F Infection with papilloma virus can be reliably detected on examination of a cervical smear

60T In a normal menstrual cycle the secretory phase of the cycle is of constant length

61 F X-linked Duchenne muscular dystrophy presents as floppiness at birth

62F Karyotype 46XX is present in testicular feminisation

63F The UK National Breast Cancer Screening Programme is less likely to detect slowly growing tumours than rapidly growing tumours

64F Children with sickle cell disease are usually symptomatic in early infancy

65T GIVEN Iron within the heme molecule needs to be in the reduced form to bind oxygen QUESTION Haemoglobin containing ferric iron is ineffective in oxygen transport

NUTRITION, METABOLISM AND EXCRETION

66FM Type 1 hypersensitivity is classically seen in tuberculosis

67FM In untreated diabetes mellitus, urine is usually alkaline

68FM Dopamine receptors in the renal vasculature mediate vasoconstriction

69TM Glomerular filtration rate increases when renal afferent arterioles dilate

70FM Intercurrent infection typically precipitates hypoglycaemic episodes in a diabetic patient

71 FM Secondary hype rpa rathyroid ism is a cause of hypercalcaemia

72FM The absorption of a drug taken by mouth is most likely to be complete when the drug molecule is soluble in water

73TM Clostridium difficile-associated diarrhoea may be confirmed by detecting toxin in faeces

74FM A patient's urine output is a satisfactory guide to the apparent volume of distribution of a drug

75FM Gastric carcinoma is a frequent complication of chronic gastric ulcer

76FM The majority of dietary iron is absorbed

77TM Pain complicating cancer may be reduced by non-steroidal anti-inflammatory drugs

78TM Gold injections (sodium aurothiomalate) are potentially nephrotoxic when given to a patient with normal renal function ,

79TM In England and Wales the incidence of prostatic cancer is increasing

80FM In acute appendicitis in adults, vomiting usually precedes the onset of pain

81TM In a jaundiced patient, percutaneous transhepatic cholangiography should be delayed until a coagulation screen has been completed

82T The action of insulin is mediated by membrane receptors which function as tyrosine kinases

83T Growth hormone increases blood glucose concentration 84F Tri-iodothyronine is formed mainly in plasma

85T The ability of the kidney to concentrate urine depends on the osmolality of renal medullary interstitial fluid

86F The initial action of the oral hypoglycaemic drug tolbutamide is to increase the synthesis of insulin

87T Vomiting in adults involves an increase in intra-abdominal pressure

88F Glucocorticosteroids unmask latent diabetes mellitus because they inhibit the secretion of insulin

89F Pancreatic juice contains maltase

9OF Glomerular filtration rate (GFR) decreases when plasma protein concentration decreases

91F T lymphocytes are the source of lgM in the plasma

92F GIVEN Thyroxine is a cardiac stimulant QUESTION Thyrotoxicosis does not cause cardiac failure

93T Core temperature can effect the response to defibrillation

94F Thyroid swellings often cause dysphagia for solids

95F GIVEN A patient present with clinically malignant lymph nodes in the neck QUESTION The primary tumour is most probably in the head and neck region

96F A hard lump in the anterior triangle of the neck could be a cervical rib

97F Clinical features will usually distinguish between a benign and malignant tumour of the parotid

98T Salivary calculi are most common in the submandibular gland

99F Radioactive iodine therapy is contraindicated in young women as it may lead to infertility

100T Screening tests for Cushing=s syndrome may be abnormal in alcoholism

101F Hypoglycaemia is uncommon in well controlled diabetes mellitus

102F Obese patients with type 2 diabetes are ideally treated with a sulphonylurea in the first instance

103F The visual disturbance usually associated with a pituitary tumour is a homonymous hemianopia

104T Patients with Cushings syndrome may complain of difficulty in climbing stairs

105T The insulin tolerance test can be used to diagnose cortisol deficiency 106T Osteoporosis is a consequence of hypogonadism in men

107F GIVEN A fit young person presents with a one week history of cough QUESTION The presence of purulent sputum is an indication that antibiotics should be prescribed

108T Bisphosphonate drugs are effective in correcting malignant hypercalcaemia

109T GIVEN Thiazide diuretics reduce urinary calcium excretion QUESTION Thiazides can be used to prevent renal stones in men with hypercalciuria

11OF All type 11 diabetic patients taking oral hypoglycaemic agents and due to have an operation under general anaesthesia should be switched to soluble insulin preoperatively

111F Catheterisation of the bladder is a safe way to obtain urine samples for microbiology from elderly patients

112T Acute pyelonephritis may be treated with ciprofloxacin

113F Chlamydia trachomatis is sensitive to amoxycillin

1 14T Dentures are the most common predisposing factor to oral candidal infection

115F Recurrent aphthous ulceration usually indicates an underlying haematological problem

116F GIVEN A patient aged 30 years presents with diarrhoea of six weeks duration. Hepatomegaly is found on examination QUESTION Crohn=s disease is the most likely diagnosis

117F Carcinoma of the lower rectum is typically a squamous cell carcinoma

118F In the treatment of peptic ulceration, omeprazole is less effective than cimetidine in suppressing gastric acid production

119T Uterine prolapse is associated with urinary incontinence

120F GIVEN An unconscious elderly lady is brought into the Accident and Emergency Department. The core body temperature is WC QUESTION One litre of warm normal saline should be given intravenously over a period of 10 minutes

121 T Water fluoridation gives reductions in dental caries of the order of 50%

122F Mouth pigmentation is a frequent accompaniment of alcoholic liver disease

123F Features of paralytic ileus which help to distinguish it from mechanical intestinal obstruction include severe electrolyte depletion

124T Anal fissure is associated with Crohn=s disease

125F Digoxin is potentially nephrotoxic when given to a patient with normal renal function

126T The product of the normal p53 gene promotes apoptosis

127F Postparturn hypopituitarism is associated with thick coarse skin

128T Constipation is a common cause of abdominal pain in childhood

FAMILIES AND CHILDREN

129FM Congenital hypertrophic pyloric stenosis causes bile stained vomitus

130FM Karyotype 46XX is present in a patient with Turner's syndrome

131 FM Physiological jaundice in the newborn is associated with a positive Coombs test

132TM Duchenne's muscular dystrophy is inherited in an X-linked recessive manner

133TM Emotional deprivation is a cause of short stature

134TM Polyhydramnios is associated with fetal renal agenesis

135FM Anti-D antibody is present in plasma of Rh negative blood from infancy

136TM The incubation period of rotavirus infection is less than a week 1 37TM Acute osteomyelitis can present with a complaint of limb paralysis

138TM Haematemesis is an important toxic effect when ferrous gluconate is accidentally ingested by a child

139TM In England and Wales childhood accidental injury is commonest amongst children of social class V

140FM School refusal is more common in children from social classes 1 and 11

141 FM Puerperal breast infection is best treated by aspiration

142FM In labour normal uterine contractions increase placental blood flow

143TM Sodium cromoglycate is poorly absorbed after oral administration

144T Foveal function determines the level of visual acuity

145T Ageing causes reduction in pupil size

146F The sympathetic supply of the pupil is activated by pilocarpine eye drops

147F Before birth the chief site of haemopoiesis is the spleen

148T In labour, normal uterine contractions originate at the uterotubal junction

149F Phenyiketonuria is inherited as an autosomal dominant trait

150F A mother breast-feeding her baby should be advised to offer each breast for 10 minutes every 3 to 4 hours, with boiled water in between if the baby seems thirsty

151T A high intake of pasteurised cows' milk can contribute to iron deficiency

152F The immunisation status of a 4 year old child in the United Kingdom should include prophylaxis against pertussis, measles, chicken pox and Haemophilus influenzae type B 153T GIVEN The mother of a 6 month old boy thinks she has noticed a Aglide in his left eye. Examination of the baby's eye is completely normal, with no evidence of a squint QUESTION The baby should be referred to an orthoptist

154T GIVEN A child aged 19 months is bottom shuffling but not weight bearing QUESTION The child should have blood taken for a creatine phosphokinase estimation

155F Precocious puberty in girls is defined as the onset of breast development before the age of 9 years

156T Physical maturation in childhood and adolescence can be assessed using a wrist radiograph

157F Luteinizing hormone stimulates Sertoli cells in the testis

158F ASmall for gestational age is a term applied to babies with a birth weight of below the 25th centile

159T The calcium and phosphorus contents of human milk cannot meet the metabolic requirements of preterm infants

160F GIVEN MMR vaccine contains live attenuated viruses QUESTION Children with cystic fibrosis should not be given the MMR vaccine

161 F Replacement treatment with glucocorticoid and mineralocorticoid is required in hypoadrenalism secondary to hypopituitarism

162F The commonest form of congenital adrenal hyperplasia is that due to 11-hydroxylase deficiency

163F The majority of girls with Turner=s syndrome are of normal stature

164T Children with precocious puberty are often tall for their age at presentation

165F A trial of avoidance of dairy products is worthwhile in the management of young children with eczema

166F Recurrent infection in the first three months of life is most likely due to antibody deficiency

167T Conjugated hyperbilirubinaemia may be a feature of neonatal sepsis

168F A high vaginal swab is the best specimen for diagnosing gonococcal infection in a premenopausal woman

169T HIV infection may lead to rapidly progressive periodontal disease

170T In infective exacerbations of cystic fibrosis, the usual infecting organism is Pseudomonas aeruginosa

171T Chronic retention of urine can be present in an asymptomatic patient

172T Stones in the common bile duct may cause acute pancreatitis

173T Use of sodium valproate in pregnancy is associated with a higher incidence of neural tube defects in offspring

174F GIVEN Drugs are most likely to produce fetal malformations when given in the first trimester of pregnancy QUESTION This is because drug transport from maternal to fetal plasma is greatest in the first trimester 175T In cerebral palsy, signs may be absent in the first few months of life

176F GIVEN A boy aged 6 weeks old is brought to hospital with a history of irritability, anorexia and profuse vomiting for 24 hours. There are no other relevant features in the history and full examination reveals a weak cry, dehydration, lethargy and a body temperature of 39.60C QUESTION Antibiotics would be suitable treatment

177F Cancer of the breast typically arises from a fibroadenoma

178F GIVEN A pregnant patient presents with an antepartum haemorrhage QUESTION The absence of fetal heart sounds suggests that placenta praevia is the cause of the haemorrhage

179T Cardiac arrhythmias are an important toxic effect when imipramine is accidentally ingested by a child

180T HIV viraemia is greatest after seroconversion and in the terminal stages of AIDS

181 F A patient with acute epiglottitis can be safely managed on a general paediatric ward

182T Ultrasonography at 16 to 18 weeks of gestation is able to establish gestational age to within an accuracy of two weeks

183F Seminoma of the testis occurs in a younger age group than teratoma of the testis

184T In postmenopausal women, the introduction of hormone replacement therapy (HRT) can lead to the return of regular periods

185T Fragile X syndrome is one of the most common causes of mental retardation in boys

186F Appendicitis does not occur under the age of 5 years

187T In a child with abdominal distension and faecal retention, Hirschsprung=s disease should be considered

188F GIVEN A child with severe cerebral palsy has difficulty in exploring the environment QUESTION This will not affect language development

COGNITION, SPECIAL SENSES, LOCOMOTION

189F Post herpetic neuralgia pain is triggered by touching the face, cold air or shaving

19OF Agoraphobia is an abnormally intense dread of situations in which other people are present

19 1 FM Euphoria is a feature of Parkinson's disea se

192FM In cognitive behavioural counselling, the counsellor discourages the client from viewing negative beliefs as hypotheses to be tested 193FM Aspirin overdose is characterised by metabolic alkalosis

194FM In those over 75 years, dementia usually requires neuroleptic medication

195FM Renal failure is a common feature of paracetamol overdose

196FM Damage to Wernicke's area results in expressive dysphasia

197TM The most common form of intracranial haemorrhage in boxers is a subdural haematoma

198TM Patients with carotid stenosis may benefit from antiplatelet therapy

199FM Retrograde memory loss following head injury usually recovers completely

20OTM Amaurosis fugax is associated with atrial fibrillation

201TM Magnetic resonance imaging is of value in suspected prolapsed intervertebral disc

202TM The sympathetic supply of the pupil is reduced in Horner's syndrome

203TM In petit mal epilepsy, the electroencephalogram characteristically shows a spike and wave pattern with a frequency of 3 per second

204FM Atropine may be appropriate in the treatment of acute angle closure glaucoma

205FM Cerebellar disease is commonly associated with tremor at rest

206T Sexual dysfunction is a common side effect of selective serotonin reuptake inhibitors (SSR1s)

207F GIVEN A tricyclic antidepressant is prescribed for a man with depression QUESTION The drug should be discontinued three months after recovery

208F GIVEN A man hits a nurse in the Accident and Emergency Department QUESTION The duty psychiatrist should be urgently called to assess the man

209T Patients with personality disorder can be detained under the Mental Health Act (1983) in the absence of mental illness

21OF Psychodynamic psychotherapy is the most effective treatment of agoraphobia in young women

211 F GIVEN A 47 year old man is seen in the Accident and Emergency Department. He is speaking rapidly and is restless QUESTION The presence of delusions favours a diagnosis of acute confusional state

212T Sleep reversal is common in delirious patients

213F Mental health services have little therapeutic role in patients with advanced Alzheirrier=s disease

214T Approximately one in five octogenarians suffers from dementia

215T GIVEN Patients with schizophrenia are at higher risk of relapse if they live with relatives who show high expressed emotion QUESTION Full-time attendance at a day hospital may reduce the risk of relapse in schizophrenia

216T The physical health of people with chronic schizophrenia is significantly worse than that of the general population 217F GIVEN A young woman with schizophrenia smokes cannabis several times each week QUESTION This is very unlikely to have any effect on her mental state

218T GIVEN A patient who has recently stopped drinking alcohol has become disorientated in time, person and place QUESTION This patient requires immediate medical treatment

21 9T GIVEN A patient has carried out several acts of non-fatal deliberate self-harm Question: He is at higher risk of eventually killing himself than someone who has attempted self-harm only once

220T GIVEN A 69 year old man is seen after taking an overdose of ten aspirin tablets Question: This history strongly suggests that he is depressed

221 F Given: An elderly woman with depression has low mood in the morning Question: Her mood is likely to worsen during the day

222F Given: A patient presents with short-term memory loss. Her husband says that this problem started six months ago Question: The diagnosis is likely to be delirium

223T The presence of skin tenderness may indicate a psychogenic element to chronic back pain

224T Cognitive behaviour psychotherapy is effective in treating depressed patients

225F In the management of osteoarthritis non-steroidal anti-inflammatory drugs (NSAIDs) are the drugs of first choice

226T Lack of insight is a common feature of schizophrenia

227F Wernicke-Korsakoff syndrome leads to agnosia

228F Airway assessment is part of the Glasgow coma scale (GCS)

229T GIVEN A previously well child aged 2 years is found unconscious QUESTION Overdose of drugs or alcohol is a likely diagnosis

230T The commonest long term complication of total hip replacement is aseptic loosening of implant

231 T GIVEN Osteomyelitis results in bone death QUESTION Osteomyelitis results in new bone formation

232F The best way of avoiding osteomyelitis after open fracture is to give antibiotics

233T Depressive illness should be considered in the differential diagnosis of nihilistic delusions 234F In petit mal epilepsy, the treatment of choice is phenytoin

235T Hip fractures often cause external rotation and shortening of the affected limb

236F Retrobulbar neuritis is characterised by preservation of visual acuity

237T The commonest cause of visual impairment in AIDS is cytomegalovirus (CMV) retinitis

238F Disc swelling is a typical feature of the optic disc in chronic glaucoma

239T Temazepam increases the risk of a fall in an 82 year old subject

240F GIVEN Patients with Parkinson=s disease move and turn more slowly than healthy elderly people QUESTION Patients with Parkinson=s disease are less likely to fall over

241 F A hemiparesis is usually a sign of a cervical cord lesion

242T Myasthenia gravis often causes drooping of the eyelids and double vision

243T Subdural haematoma in infancy is associated with apnoeic episodes

244T Low levels of endogenous oestrogens is a recognised feature of anorexia

245F Hypertension is a complication of spinal injuries in men

246T Brain tumours in children are most often in the posterior fossa

247F Raised intracranial pressure stops the production of cerebrospinal fluid

248T lritis is associated with ankylosing spondylitis

249F Amblyopia may follow palsy of the third cranial nerve in an adult

250F Occlusion of the squinting eye is a common treatment in childhood squint