LUSAKA APEX MEDICAL UNIVERSITY

FINAL 310 MEDICAL EXAMS- TIME 3 HOURS

PAPER 1

24th November, 2014

COMPUTER NUMBER.

INSTRUCTIONS:

There are 100 multiple choice questions, please answer all the questions on the answer sheet provided.

Mark T (TRUE) OR F (FALSE) against the options provided.

NOTE: CORRECT ANSWER ONE MARK, WRONG ANSWER NEGATIVE HALF MARK, UNANSWERED ZERO
MARK

This paper consists of 19 pages.

1
1. The pulse:
a. In pulsus paradoxus the rate slows during inspiration.
b. Corrigans sign support a diagnosis of aortic stenosis.
c. A collapsing pulse may be noticed in thyrotoxicosis.
d. Pulsus alternans indicates a poorly functioning left ventricle.

2. The jugular venous pressure

a. Is raised if it is 2 cm from sternal angle with the patient seated at 450
b. Tall a waves may be seen in pulmonary hypertension.
c. Irregular cannon waves indicate complete heart block
d. Giant v waves and a pulsatile liver indicate tricuspid stenosis

3. The following would help distinguish between a kidney and a spleen in the left upper
quadrant:
a. Dull to percussion over the mass.
b. A well localized notched lower margin
c. Moves with respiration
d. A ballottable mass

4. The following would suggest an upper rather than a lower motor neuron lesion:
a. Fasciculation
b. Increased tone
c. An absent plantar reflex
d. Clonus

5. The face:
a. A malar flush may indicate mitral valve disease or hypothyroidism
b. A butterfly rash in the face is seen in dermatomyositis
c. An expressionless face and drooling could indicate Parkinsons disease
d. Bells palsy can cause ptosis due to paralysis of orbicularis oculi

6. Hand signs:
a. Clubbing may be caused by uncomplicated chronic bronchitis
b. Koilonychias usually indicates liver disease
c. Oslers nodes and Heberdens nodes both occur in osteoarthritis
d. Splinter hemorrhages are due to embolic rather than immunological phenomena

2
7. Paracetamol overdose:
a. Ipecacuana followed by oral methionine is effective for most patients who are
just over the treatment line
b. Can cause renal failure
c. Intravenous N-acetylcysteine frequent causes anaphylaxis
d. Causes liver failure

8. Leukemia:
a. The common presenting triad is infection, bleeding, and fatigue
b. Acute Myeloid Leukemia (AML) may result spontaneously
c. The usual development of chronic lymphocytic leukemia is a transformation to
acute lymphoblastic leukemia
d. A platelet count of 40 109/L would not normally give rise to spontaneous
bleeding

9. For self-poisoning:
a. Gastric lavage is recommended for most drugs up to 12hours after ingestion
b. Naloxone is the specific antidote for benzodiazepine overdose
c. Patients with tricyclic antidepressant overdose need cardiac monitoring for up to
48 hours
d. Pinpoint pupils could indicate opiate overdose

10. The following are causes of a pan-systolic murmur:

a. Mitral regurgitation
b. Aortic regurgitation
c. Tricuspid regurgitation
d. Aortic stenosis

11. The following are signs of coarctation of aorta

a. Radiofemoral delay in the pulse
b. Rib notching
c. Bruits heard over the scapula
d. Ankle edema

3
12. Cardiac causes of clubbing are as follows:
a. Uncomplicated atrial septal defect
b. Chronic infective endocarditis
c. Atrial fibrillation
d. Acute endocarditis
13. Ptosis may be a feature of:
a. Myotonic dystrophy
b. Horners syndrome
c. Abducens nerve palsy
d. Myasthenia gravis

14. Causes of polyneuropathy include:

a. Diabetes
b. Gullain Barre syndrome
c. Renal failure
d. Amyloid

15. Brainstem death may be confirmed by:

a. Absent corneal reflexes
b. Absent tendon reflexes
c. A Flat EEG
d. Absent dolls eye reflexes

16. Which of the following is dependent on bile salts for its absorption:
a. Vitamin A
b. Vitamin B
c. Vitamin C
d. Vitamin D

17. The following precipitate portal-systemic encephalopathy:

a. Infection
b. Diarrhoea
c. Gatrointestinal bleeding
d. Use of opioid drugs

4
18. Pleural aspiration is useful in the following situations:
a. Pleural tuberculosis
b. Empyema
c. In diagnosing mesothelioma
d. Viral pleurisy

19. With respect to lumbar puncture:

a. Coagulation is a contraindication
b. Papilloedema is an absolute contraindication
c. Can be therapeutic by reducing intracranial pressure
d. The less CSF is removed, the less likely coning is to occur

20. Diagnostic criteria for the systemic inflammatory syndrome (SIRS) include:
a. Temperature > 380C or <360C
b. Respiratory rate >30/ min
c. Heart rate >90/min
d. White cell count >12 000

21. Causes of bleeding in liver disease include,

a. Decreased synthesis of procoagulant proteins
b. Peptic ulceration
c. Increased synthesis of Protein C and S
d. Impaired absorption and metabolism of vitamin K

22. Features of salicylate poisoning include

a. Cerebral oedema
b. Pulmonary oedema
c. Hyperpyrexia
d. Tinnitus

23. About Parkinsonism,

a. Mainly result from reduction of dopaminergic transmission within the basal ganglia
b. Intentional tremor and akinesia help in diagnosis
c. Family history is a risk factor
d. Neuropsychiatry symptoms might be present

5
 24. In organophosphate poisoning,
a. RBCs transketolase activity can be useful in monitoring treatment
b. Fasciculation is a result of overwhelming muscarinic receptors response
c. Patient may present as Parkinsonism later in life
d. Death is due to respiratory failure

25. About lymphoid malignancies,

a. HIV infection is a risk factor for developing Hodgkins disease
b. Epstein-Barr virus infection in infancy is protective for Burkitts leukemia
c. Chronic hepatitis C virus infection has been associated with lymphoplasmacytic
lymphoma
d. Reed-Sternberg cell is found in Hodgkins disease

26. Macrocytic anaemia may be found in

a. Pernicious anaemia
b. Folate deficiency
c. Bleeding diathesis
d. Patient on Zidovudine

27. Causes of haemolytic anaemia include

a. Sickle Cell Disease
b. Glucose-6-phosphate dehydrogenase deficiency
c. Pyruvate kinase deficiency
d. Hereditary spherocytosis

28. In Sickle Cell Anaemia

a. Disorders are due to the production of abnormal alpha chains
b. Percentage of Fetal haemoglobin is more compared to one without the disorder
c. HBS polymerizes when deoxygynated
d. Electrophoresis distinguishes SS, AS states, and other Hb variants

29. Which of the following on urinalysis is most likely in keeping with acute glomerulonephritis
a. Proteinuria
b. Erythrocyte casts
c. Granular casts
d. Hyaline cast

6
30. A 32 year old man has trace proteinuria on dipstick urinalysis. Which of the following
statements concerning proteinuria is correct?
a. Persistent proteinuria should be investigated
b. Can be caused by fever
c. Always caused by tubular secretion
d. In systemic disease, it has no prognostic value

31. A 60 year old woman with heart failure and renal function has been on Lasix 60mg for 4
weeks with a very good diuretic response. She comes in with improved heart failure
symptoms, but has significant fatigue and muscle weakness. What are possible
explanations for her condition?
a. Dehydration
b. Hyperkalemia
c. Anemia
d. Hypokalemia

32. Hypokalemia can result in,

a. Paralytic ileus
b. Rhabdomyolysis
c. Cardiac repolarization abnormalities
d. Peak T waves on ECG

33. The following is correct,

a. Maximum concentrated urine depends on Anti-Diuretic Hormone
b. Erythropoietin deficiency contributes to Anemia in Chronic Kidney Disease
c. Hyperkalemia is a feature of SIADH
d. The largest volume of water is reabsorbed in the nephron at the proximal
convoluted tubule

34. Ebola is,

a. Caused by a virus
b. Can cause Multiple organ failure
c. Can cause a bleeding diathesis
d. Can be prevented by vaccination

7
35. Cushing syndrome:
a. Causes osteoporosis
b. The diagnosis is made by a high dose dexamethasone suppression tests
c. Serum adrenocorticotrophic hormone (ACTH) is important in diagnosing the
underlying cause
d. Can only be cured by bilateral adrenalectomy

36. Causes of primary adrenocortical insufficiency include

a. Hemochromatosis
b. Autoimmune adrenalitis
c. Tuberculosis
d. Sarcoidosis

37. Typical features of primary adrenocortical insufficiency include

a. Anorexia, weight loss and diarrhea
b. Only new scars become pigmented
c. Vitiligo, weakness and hypotension
d. Amenorrhoea and loss of body hair

38. In hepatitis C (HCV)

a. A chronic carriage rate of above 50% is the rule
b. The infecting agent is an RNA flavivirus
c. The disease does not progress to a chronic hepatitis
d. Most patient experience symptoms of acute hepatitis

39. The typical features of acute cholecystitis include

a. Jaundice, nausea and vomiting
b. Murphys sign
c. Air in the biliary tree on plain radiograph
d. Peripheral leukocytosis

8
40. The following is true of viral hepatitis:
a. Hepatits C commonly presents with jaundice.
b. Hepatitis E is fatal particularly in pregnant women.
c. Hepatitis BeAg is a marker of viral replication.
d. Hepatitis A is a risk factor for hepatoma.

41. The following drugs cause jaundice:

a. Methotrexate.
b. Flucloxacillin.
c . Metronidazole.
d. Isoniazid

42. The following gastrointestinal disease are associated with the renal conditions listed:
a. Crohns disease and renal amyloidosis.
b. Hepatitis B and glomerulonephitis.
c. Gastric ulcer and nephritic syndrome.
d. Pancreatic neuroendocrine tumours and polycystc kidney disease.

43. Chronic pancreatitis:

a. Is a cause of diabetes mellitus
b. Can result from alcohol ingestion in moderate amount.
c. May be hereditary in a minority of cases.
d. Can be diagnosed by raised serum amylase.

44. The following are indications for liver biopsy

a. Unexplained abnormal liver enzymes.
b. Pyrexia of unknown origin with normal liver enzymes
c. Cirrhosis suspected on an ultrasound scan
d. Raised alkaline phosphatase in teenagers with acholurix jaundice

45. The following drugs cause cholestatic jaundice

a. Rifampicin
b. Isoniazid
c. Erythromycin
d. Halothane

9
46. The following are features of urinary infections in elderly people:
a. Patients usually complains of dysuria
b. They may present with falls
c. They may present with constipation
d. Estrogen supplements may reduce their frequency in post-menopausal women

47. The following statements are true of ascites;

a. A high protein content in ascites is usual in alcoholic liver disease.

b. Ascites resistant to diuretic is characteristic of hepatic vein thrombosis.
c. Ascites is something associated with pleural effusion.
d. Ascites is a risk factor for bacterial peritonitis.

48. The following precipitate portal-systemic encephalopathy;

a. Infection
b. Diarrhoea.
c. Gastrointestinal bleeding
d. Use of opioid drugs.

49. Acute renal failure is a likely complication of the following;

a. Sepsis or sepsis syndrome
b. Polycystic kidney disease
c. Major arterial surgery
d. Retroperitoneal tumours.

50. In patients with acute renal failure;

a. Sodium bicarbonate should be given routinely.
b. Most patients with acute renal failure need a long-term dialysis.
c. Skin turgor is a reliable guide to the need for i.v. fluid therapy.
d. Urinary catheterization is sometimes needed to monitor the response to therapy.

51. The following are causes of chronic renal failure;

a. Gout
b. Atherosclerosis
c. Analgesic abuse
d. Non-insulin-dependent diabetes.

10
52. The following may cause the nephrotic syndrome;
a. Minimal change disease
b. Treatment with beta- blockers
c. Rheumatoid arthritis
d. Diabetic mellitus

53. With respect to lumbar puncture;

a. Coagulopathy is a contraindication
b. Papilloedema is an absolute contraindication
c. The procedure may cause meningitis
d. The less CSF is removed, the less likely coning is to occur

54. Outcome from the bacterial meningitis relates to;

a. Age of patient.
b. Time to first administration of antibiotic
c. CSF concentration of antibiotics
d. Development of antibiotics resistance during therapy

55. Prognosis in diabetes;

a. Cardiovascular mortality is higher in diabetic than in non- diabetic people up to
the age of 80
b. Diabetic patients with proteinuria have a higher cardiovascular risk than those
without it.
c. When sulfonylureas became available, there was a noticeable improvement in
cardiovascular mortality
d. Good glycaemic control, on the balance of available evidence, can reduce
cardiovascular mortality in both type 1 and type 2 DM.

56. Diabetic retinopathy;

a. Characteristically causes arterio-venous nipping
b. Should be referred to an ophthalmologist only if the patient have visual
symptoms
c. Inevitably causes blindness
d. May cause cotton wool spots (soft exudates)

11
57. In insulin treatment;
a. Pen injectors are reserved for the small minority who take four or more injections
per day
b. Only patients who cannot be controlled with once- daily insulin should have two
or more injections
c. Insulin should be started without delay in a thin hyperglycaemic patient with
ketonuria
d. Insulin may sometimes be needed during short periods of illness in patients with
type 2 DM.

58. Hypertension in diabetes;

a. Is more prevalent in type 1 than in type 2
b. Its treatment slows the deterioration of nephropathy in type 1 DM
c. Thiazide diuretic should not be used in diabetes
d. Increase the risk of stroke in diabetes

59. Biochemical findings in Primary hypothyroidism include;

a. Decreased serum free T4 and decreased serum TSH concentration
b. Increased serum prolactin concentration
c. Inappropriate ADH secretion
d. Increased serum cholesterol concentration

60. About polycythemia vera ,

a. Massive splenomegaly may be the initial presenting sign
b. Aquagenic pruritus is a symptom
c. Systolic hypertension may be a feature
d. Red cell mass determination is very helpful in diagnosis

61. Complication of polycythemia vera include,

a. Erythromelalgia
b. Intravascular thrombosis
c. Myelofibrosis
d. Hyperuricaemia

12
62. Disorders of coagulation leading to bleeding may occur in,
a. Vitamin K intoxication
b. Factor IX deficiency
c. Protein S deficiency
d. Factor VIII deficiency

63. Following splenectomy for trauma

a. Thrombocytopenia is typical
b. Pneumococcal vaccine should be given
c. Prophylactic penicillin is useful
d. Heinz bodies are characteristically seen on blood film

64. Features of salicylate poisoning include

a. Celebral oedema
b. Pulmonary oedema
c. Hyperpyrexia
d. Tinnitus

65. Infarction in the territory of the anterior cerebral artery

a. Causes more severe hand than shoulder weakness on the affected side
b. Produces predominant weakness of the lower limb
c. Is most frequently seen after SAH after berry aneurysm rupture
d. Causes transcortical motor aphasia when affecting the dominant hemisphere

66. About human haemoglobin

a. Red Cells appear at about 6 weeks after conception
b. Foetuses and newborns require beta chains but not alpha chains for normal
gestation
c. Sickle Cell Disease is a result of defective beta chain
d. Fetal haemoglobin tend to be high in some patients with SCD and Thalassemia

67. About Plummer Vinson syndrome (sideropenic dysphagia),

a. Plummer-Vinson syndrome presents with anaemia
b. Koilonychias is a sign of Plummer-Vinson syndrome
c. Glossitis is a sign of Plummer-Vinson syndrome
d. Dysphagia in Plummer-Vinson syndrome is due to postcricoid pharyngeal web

13
68. About Parkinsonism,
a. Mainly result from reduction of dopaminergic transmission within the basal ganglia
b. Intentional tremor and akinesia help in diagnosis
c. Family history is a risk factor
d. Neuropsychiatry symptoms might be present

69. Causes of absolute erythrocytosis include

a. Hypoxia
b. Hepatoma
c. Androgen therapy
d. Zidovudine thepapy

70. A 70 year old woman complains of sudden onset of weakness of left arm and leg,
she also experiences difficulties in speech and loss of vision in one eye. Although
these symptoms were frightening, they improved within 10 hours and she was
feeling well she came to the clinic. What is the likely diagnosis
a. Patient has a minor stroke
b. Patient has Motor neurone disease
c. Patient has Parkinsons disease
d. Patient has Transient Ischaemic attack

71. A young lady of 35 complains of dizziness and fainting attacks on several occasions.
She also complains of palpitation and gets tired very easily. She has noticed that her
monthly periods are prolonged and heavy in recent months. What could be the
problem?
a. The patient has anaemia
b. The patient may have fibroids
c. The patient has psychosis
d. The patient has neurofibromatosis

72. A 17 year old female patient presents with very severe bone pain. She is sweating
profusely. Her pulse rate is 108 beats per minute. Her BP id 90/60 mm Hg. This is the
third episode experienced in the past 6 months. Her sibling sister experiences similar
attacks. What could be the diagnosis?
a. Patient has Parkinsons disease
b. Patient has Hepatoma
c. Patient is in Sickle cell crisis
d. Patient has Myocardial Infarction

14
73. A 58 year old male nurse is admitted to Levy Mwanawasa general hospital
complaining of sudden onset of severe headache. He has nausea and has vomited
several times on his way to the hospital. He also had a seizure just before arriving at
the hospital. On examination he is found to be delirious, photophobic and has
temperature of 39 degrees Celcius, He has neck stiffness and positive kernigs sign.
What could be the cause?
a. Patient has cerebral malaria
b. Patient has subarachnoid haemorrhage
c. Patient Pontine haemorrhage
d. Patient has bacterial meningitis

74. Drugs cause immunohemolytic anemia by the following mechanism,

a. They induce a disorder identical in almost every respect to warm-antibody
immunohemolytic anaemia
b. More less like anaemia of chronic infection
c. They become associated as haptens with the RBC surface and induce formation of
antibody directed against the RBC drug complex
d. Suppressing the bone marrow

75. In vascular injury, the main process that contribute to bleeding arrest are
a. Vasoconstriction
b. Gap plugging by platelets
c. Nitric oxide production
d. Coagulation cascade

76. Coagulation disorders may be found in

a. Liver disease
b. Warfarin use
c. Von Willebrand
d. Disseminated intravascular Coagulation

77. In meningitis,
a. Diastolic hypertension is an early sign
b. Reduced pulse rate may signify increased intracerebral pressure
c. Petechiae rash may suggest meningococcus
d. Non infective meningitis may be caused malignant cells

15
78. Aseptic meningitis may be due to
a. viral infection
b. TB
c. Partly treated bacterial infection
d. Lyme disease

79. In a patient presenting with seizures

a. A screen for toxins may be indicated
b. Blood sugar is indicated
c. CSF studies is mandatory in HIV infected (if no contraindication), even in the
absence of symptoms or signs suggesting infection
d. Brain scan might be indicated

80. Differential diagnosis of seizure include,

a. Migraine
b. Syncope
c. Transit ischemic attack
d. Sleep walking

81. In Motor Neurone Disease

a. The pathological hallmark is death of lower and upper motor neurones
b. Dementia is a component of Amyotrophic Lateral Sclerosis
c. Ocular motility is a late sign in Amyotrophic Lateral Sclerosis (ALS)
d. No treatment arrests the underlying process in ALS

82. Regarding the Central Nervous System (CNS) in HIV infection

a. Cytomegalovirus is the most common viral infection
b. Highly Active Anti-Retroviral therapy significant improves the survival of patient
with Progressive Multifocal leukoencephalopathy
c. The target sign on CT is pathognomic for Tuberculoma
d. Gummas are the most frequent features of neurosyphilis

83. The following are true of CNS involvement in AIDS

a. HIV encephalopathy(HIVE) is the most common cause of neurological disease
b. Progressive Multi-focal Leukoencephalopathy is associated with Jacob Creutzfeldt
Papova virus (JC Virus).
c. CMV encephalitis is easily differentiated from HIVE by its imaging characteristics
d. Lumbar puncture is contraindicated in evaluating patient with AIDS and CNS
involvement

16
84. In the evaluation of a confused patient, following should be considered
a. Motor neurone disease
b. Drug intoxication
c. Cerebral Malaria
d. Post-Seizure event

85. Non-convulsive status epilepticus may present with

a. Aggression
b. Confusion
c. Dreamy derealisation
d. Odd behaviour

86. Hypercapnia is a typical feature of

a. Pulmonary embolism
b. Severe chest wall injury
c. Pulmonary fibrosis
d. Severe chronic bronchitis

87. Typical chest findings in right lower lobe collapse include

a. Decreased chest expansion
b. Stony dull percussion note
c. Bronchial breath sounds
d. Aegophony

88. A pleural effusion with a pleural fluid: serum protein ration of >0.5 would be typical
of
a. Congestive cardiac failure (CCF)
b. Renal failure
c. Pneumonia
d. Nephrotic syndrome

89. The following disorders characteristically produce type 1 respiratory failure

a. Kyphoscoliosis
b. Guillain-Barre polyneuropathy
c. Acute respiratory distress syndrome (ARDS)
d. Extrinsic allergic alveolitis

17
 90. A non-pneumococcal pneumonia should be considered if the clinical features include
a. Respiratory symptoms preceding systemic upset by several days
b. Lobar consolidation
c. The absence of a neutrophil leucocytosis
d. Palpable splenomegaly

91. The following features suggest a poor prognosis in pneumonia

a. Diastolic blood pressure of 90mmHg
b. Confusion
c. Respiratory rate of 20 breaths per minute
d. Blood urea of 9mmol/l

92. Recognised complications of post-primary tuberculosis include

a. Aspergilloma
b. Amyloidosis
c. Massive haemoptysis
d. Bronchiectasis

93. Recognised adverse reactions to antituberculous drugs include

a. streptomycin-renal failure
b. isoniazid-hypothyroidism
c. rifampicin-optic neuritis
d. pyrazinamide-hepatitis

94. Pulmonary infection with Aspergillus fumigatus is a recognised cause of the following
a. Bullous emphysema
b. Mycetoma
c. Necrotising pneumonitis
d. Bronchopulmonary eosinophilia

95. The following statements about spontaneous pneumothorax are true

a. Breathlessness and pleuritic chest pain are often present
b. Bronchial breathing is audible over the affected hemithorax
c. Absent peripheral lung markings on chest radiograph suggest tension
d. Surgical referral is required if there is a bronchoplural fistula

18
96. The following statements about thyroid hormones are true
a. T3 and T4 both stored in colloid vesicles as thyroglobulin
b. T4 is metabolically more active than T3
c. T3 and T4 are mainly bound to albumin in the serum
d. 85% of the circulating T3 arises from extra-thyroidal T4

97. The finding of reduced serum free T4 and thyroid-stimulating hormone (TBG)
concentrations is compatible with the following conditions
a. Hypopituitarism
b. Primary hypothyroidism
c. Nephrotic syndrome
d. Pneumonia

98. The following statements about thyrotoxicosis are true

a. Most patients have Graves disease
b. Multinodular goitre is more common than uninodular goitre
c. Amiodarone treatment should be considered as a possible cause
d. The thyroid gland is diffusely hyperactive in Graves disease

99. In treatment of thyrotoxicosis

a. Propranolol should not be given in atrial fibrillation
b. Carbimazole blocks the secretion of T3 and T4 by the thyroid
c. Persistent suppression of the serum TSH is an indication for surgery
d. Serum TSH receptor antibodies usually persist despite carbimazole

100. The clinical features of primary hypothyroidism include

a. Carpal tunnel syndrome and proximal myopathy
b. Cold sensitivity and menorrhagia
c. Deafness and dizziness
d. Puffy face

19