Davidson Practice of Medicine Questions Chapter 18 to 20

Based on all the chapters of  Davidson’s Medicine- Fleshandbones Candidates  preparing for competitive examinations are recommended to read the appropriate chapter from the text books  and then to asses themselves using these questions.  Otherwise it seems to difficult. Try to record your reasoning before checking the correct answer.

CHAPTER – 18

Question 1. Bilirubin is

• derived exclusively from the breakdown of haemoglobin (False)
• Explanation: Also from catabolism of other haem-containing proteins (e.g. myoglobin)
• bound in the unconjugated form to plasma ß-globulin (False)
• Explanation: Bound to albumin
• conjugated in the microsomes of the hepatocytes (True)
• Explanation: By enzymes of the smooth endoplasmic reticulum
• reabsorbed in the small bowel as bilirubin diglucuronide (False)
• Explanation: Only reabsorbed after metabolism to stercobilinogen
• normally excreted as stercobilinogen in the faeces and as urobilinogen in the urine (True)
• Explanation: And as the oxidation products stercobilin and urobilin

Question 2. The concentration of conjugated bilirubin in the

• serum in haemolytic anaemia is typically increased (False)
• Explanation: Unconjugated hyperbilirubinaemia
• urine of healthy subjects is typically undetectable (True)
• Explanation: As almost all bilirubin is unconjugated and albumin-bound
• serum normally constitutes most of the total serum bilirubin (False)
• Explanation: Most of the serum bilirubin is unconjugated
• serum in Gilbert’s syndrome is typically increased (False)
• Explanation: Unconjugated bilirubin is increased
• urine in viral hepatitis parallels that of urobilinogen (False)
• Explanation: Urobilinogen is an unreliable indicator of hepatobiliary disease

Question 3. The serum alanine aminotransferase (ALT) concentration is

• derived from a microsomal enzyme specific to hepatocytes (False)
• Explanation: Neither ALT nor AST is specific to the liver
• typically more than six times normal in alcoholic hepatitis (False)
• Explanation: Not usually > three times normal
• usually normal in both obstructive and haemolytic jaundice (False)
• Explanation: May be elevated in either
• likely to rise and fall in parallel with the serum bilirubin in viral hepatitis (False)
• Explanation: Changes in serum ALT precede changes in the serum bilirubin
• likely to increase in response to enzyme-inducing drug therapy (False)
• Explanation: Only the gamma-glutamyl transferase levels increase

Question 4. The serum alkaline phosphatase concentration is

• derived from the liver, bone, small bowel and placenta (True)
• Explanation: Therefore not specific to liver disease
• typically increased to more than six times normal in viral hepatitis (False)
• Explanation: Not usually > 2.5 times normal
• derived mainly from hepatic sinusoidal and canalicular membranes (True)
• Explanation: Excess synthesis in cholestasis
• of particular prognostic value in chronic liver disease (False)
• Explanation: No prognostic value
• increased more in extrahepatic than in intrahepatic cholestasis (False)
• Explanation: No site-specific pattern

Question 5. In the investigation of suspected liver disease

• ultrasonography reliably distinguishes solid from cystic masses (True)
• ultrasonography reliably excludes liver disease (False)
• Explanation: May appear normal in disease
• normal liver function values exclude significant liver disease (False)
• Explanation: May be normal in 10-15% of patients with cirrhosis
• the mortality rate of percutaneous liver biopsy is about 5% (False)
• Explanation: Approximately 0.05%
• ascitic protein concentrations > 25 g/l are compatible with a diagnosis of carcinomatosis (True)
• Explanation: And tuberculosis and hepatic vein obstruction; protein concentration < 30 g/l = transudate

Question 6. Characteristic features of Gilbert’s syndrome include

• an autosomal recessive mode of inheritance (False)
• Explanation: Typically autosomal dominant
• decreased hepatic glucuronyl transferase activity (True)
• Explanation: Causing failure of bilirubin conjugation
• unconjugated hyperbilirubinaemia < 100 µmol/l (True)
• Explanation: And no abnormality of other liver function tests
• serum bilirubin concentration increased by fasting (True)
• Explanation: Sometimes used as a diagnostic test
• increased serum bile acid concentrations (False)
• Explanation: Unconjugated hyperbilirubinaemia is the sole abnormality

Question 7. Characteristic features of cholestatic jaundice include

• dark green stools (False)
• Explanation: Typically pale stools-steatorrhoea
• dark brown urine (True)
• Explanation: Due to conjugated bilirubinuria
• unconjugated hyperbilirubinaemia (False)
• Explanation: Conjugated hyperbilirubinaemia
• serum alkaline phosphatase concentration > 2.5 times normal (True)
• Explanation: Diagnostic feature
• increased serum bile acid concentrations (True)

Question 8. Typical causes of extrahepatic cholestatic jaundice include

• sclerosing cholangitis (False)
• Explanation: Intrahepatic
• primary biliary cirrhosis (False)
• Explanation: Intrahepatic
• cystic fibrosis (True)
• Explanation: Common bile duct obstruction from chronic pancreatitis
• alcoholic cirrhosis (False)
• Explanation: Intrahepatic
• non-alcoholic steatohepatitis (False)
• Explanation: Rarely causes jaundice

Question 9. The following features suggest extrahepatic cholestasis rather than viral hepatitis

• a palpable gallbladder (True)
• Explanation: E.g. pancreatic carcinoma
• right hypochondrial tenderness (False)
• Explanation: Also common in acute hepatitis
• serum alkaline phosphatase concentration > 2.5 times normal (True)
• pruritus and rigors (True)
• Explanation: Suggests obstruction with cholangitis
• peripheral blood polymorph leucocytosis (True)
• Explanation: Sometimes relative lymphocytosis in viral hepatitis

Question 10. The typical causes of macrovesicular steatosis include

• alcohol misuse (True)
• Explanation: Often asymptomatic
• pregnancy (False)
• Explanation: Microvesicular steatosis
• Reye’s syndrome (False)
• Explanation: Microvesicular steatosis
• severe malnutrition (True)
• Explanation: Steatohepatitis (macrovesicular steatosis with hepatocyte necrosis) can be serious
• diabetes mellitus (True)
• Explanation: Common and benign

Question 11. The typical features of type A viral hepatitis (HAV) include

• picornavirus infection spread by the faecal-oral route (True)
• an incubation period of 3 months (False)
• Explanation: 2-4 weeks
• a greater risk of acute liver failure in the young than in the old (False)
• Explanation: But children are more frequently infected
• right hypochondrial pain and tenderness (True)
• Explanation: Non-specific findings of acute hepatitis
• progression to cirrhosis if cholestasis is prolonged (False)
• Explanation: Chronic hepatitis does not occur

Question 12. The following statements about type A viral hepatitis are true

• persistent viraemia produces the post-hepatitis syndrome (False)
• Explanation: Viraemia is only transient in hepatitis A
• relapsing hepatitis usually indicates a poorer prognosis (False)
• Explanation: Spontaneous recovery is the typical outcome
• the virus is not usually transmitted via infected blood (True)
• Explanation: But a recognised rarity
• drug-induced acute hepatitis produces similar liver histology (True)
• Explanation: Serological investigations should help distinguish
• travellers given immune serum globulin are protected for 3 months (True)
• Explanation: Some will have natural endogenous protection

Question 13. Circulating hepatitis B surface antigen (HBsAg) is

• detectable during the prodrome of acute type B hepatitis (True)
• Explanation: A reliable marker of hepatitis B infection
• a DNA viral particle transmissible in all body fluids (True)
• Explanation: A DNA hepadna virus
• likely to persist in about 50% of adults following acute type B hepatitis (False)
• Explanation: Chronic carriage occurs in 5-10% of adults
• invariably present in a patient with jaundice attributable to type B hepatitis infection (False)
• Explanation: Alternative serological evidence of infection should be sought
• commoner in asymptomatic subjects in the Western rather than the Eastern hemisphere (False)
• Explanation: Carriage rates are highest in the Middle East and Far East

Question 14. The typical features of type B viral hepatitis (HBV) include

• an incubation period of 1 month (False)
• Explanation: Average incubation 3 months
• history of exposure to unsafe sex or drug misuse (True)
• Explanation: Or other exposure to blood or blood products
• prodromal illness with polyrtharalgia (True)
• Explanation: May cause serum sickness
• hepatitic illness more severe than with type A virus (True)
• Explanation: Hepatitis A is usually a mild illness
• absence of progression to chronic hepatitis (False)
• Explanation: And hepatic cirrhosis also occurs

Question 15. In hepatitis C (HCV)

• a chronic carriage rate of > 50% is the rule (True)
• Explanation: With varying degrees of severity
• the infecting agent is an RNA flavivirus (True)
• the disease does not progress to chronic hepatitis (False)
• Explanation: Hepatitis C may progress to chronic disease
• most patients experience the symptoms of acute hepatitis (False)
• Explanation: Most patients are asymptomatic; incubation period is 2-26 weeks
• the virus is responsible for 90% of all post-transfusion hepatitis (True)
• Explanation: Although serological screening methods have greatly reduced this

Question 16. The typical features of acute (fulminant) hepatic failure include

• onset within 8 weeks of the initial illness (True)
• Explanation: Without evidence of pre-existing liver disease
• hepatosplenomegaly and ascites (False)
• Explanation: Suggest chronic liver disease
• encephalopathy and fetor hepaticus (True)
• Explanation: With confusion and asterixis (liver flap)
• nausea, vomiting and renal failure (True)
• Explanation: Renal failure is an ominous development
• cerebral oedema without papilloedema (True)
• Explanation: Occurs late, if at all

Question 17. Typical liver function values in acute hepatic failure include

• hypoalbuminaemia (False)
• Explanation: Serum albumin has a long half-life
• hypoglycaemia (True)
• Explanation: Impaired hepatic gluconeogenesis
• prolonged prothrombin time (True)
• Explanation: Useful in determining prognosis
• serum alkaline phosphatase > 6 times normal (False)
• Explanation: Typically not so elevated, unlike the serum transaminases
• peripheral blood lymphocytosis (False)
• Explanation: May be a polymorphonuclear leucocytosis

Question 18. The clinical features of autoimmune hepatitis include

• an association with autoimmune thyroiditis (True)
• Explanation: Type I autoimmune liver disease is associated with Graves’ disease and Hashimoto’s thyroiditis
• acute onset simulating viral hepatitis in 25% of patients (True)
• Explanation: Occurs in 25% of patients but symptoms and signs then persist
• arthralgia, fever and amenorrhoea (True)
• Explanation: And fatigue, anorexia and jaundice
• spider telangiectasia and hepatosplenomegaly (True)
• Explanation: And other signs of chronic liver disease
• Cushingoid facies, hirsutism and acne (True)
• Explanation: Altered steroid hormone metabolism

Question 19. The typical features of hepatic cirrhosis include

• a small shrunken liver (True)
• Explanation: Liver size reduces as disease progresses
• painful splenomegaly (False)
• Explanation: Painless splenomegaly due to portal hypertension
• peripheral blood macrocytosis (True)
• Explanation: Particularly in alcoholic liver disease
• parotid gland enlargement (True)
• Explanation: Particularly in alcoholic cirrhosis
• central cyanosis (True)
• Explanation: Hepatopulmonary syndrome associated with pulmonary telangiectasia

Question 20. Typical features of hepatic encephalopathy include

• disordered sleep and loss of concentration (True)
• Explanation: Grade 1
• aggressive behaviour and personality change (True)
• Explanation: Grade 2
• yawning and hiccuping (True)
• Explanation: And asterixis (hepatic flap)
• drowsiness and disorientation (True)
• Explanation: Grade 3
• confusion progressing to coma (True)
• Explanation: Grade 4

Question 21. Causes of ascites in the absence of intrahepatic liver disease include

• congestive cardiac failure (True)
• Explanation: Also constrictive pericarditis-transudate
• nephrotic syndrome (True)
• Explanation: Also protein-losing enteropathy-transudate
• peritoneal tuberculosis (True)
• Explanation: Also carcinomatosis-exudate
• lymphatic obstruction (True)
• Explanation: Chylous effusion
• Budd-Chiari syndrome (True)
• Explanation: Transudate associated with hepatic vein occlusion

Question 22. In the management of ascites due to hepatic cirrhosis

• the dietary sodium intake should be restricted to 140 mmol/day (False)
• Explanation: Restriction < 40 mmol/day is usually required
• paracentesis and parenteral albumin replacement improve the survival rate (False)
• Explanation: A palliative, symptomatic measure with no prognostic value
• the daily calorie intake should be restricted to 1500 calories (False)
• Explanation: Calorie restriction is neither required nor desirable
• diuretic therapy should achieve a daily weight loss of at least 2.5 kg (False)
• Explanation: Daily weight loss > 1 kg may precipitate renal impairment and/or encephalopathy
• the protein intake should be at least 40 g/day unless encephalopathy is suspected (True)
• Explanation: Restriction may be necessary to control encephalopathy

Question 23. Causes of portal hypertension include

• alcoholic cirrhosis (True)
• Explanation: Intrahepatic parenchymal
• myeloproliferative disease (True)
• Explanation: Intrahepatic pre-sinusoidal
• hepatic schistosomiasis (True)
• Explanation: Intrahepatic pre-sinusoidal; also sarcoidosis
• abdominal trauma (True)
• Explanation: Extrahepatic pre-sinusoidal (portal vein thrombosis)
• hepatic vein obstruction (Budd-Chiari syndrome) (True)
• Explanation: Extrahepatic post-sinusoidal

Question 24. Complications of portal hypertension include

• variceal haemorrhage (True)
• Explanation: Oesophageal, gastric, stomal and rectal varices
• congestive gastropathy (True)
• Explanation: Associated with hypergastrinaemia
• hepatorenal failure (True)
• Explanation: Associated with reduced renal blood flow
• hepatic encephalopathy (True)
• ascites (True)
• Explanation: And hypersplenism

Question 25. In the management of acute variceal bleeding due to hepatic cirrhosis

• the priority is to restore normovolaemia (True)
• Explanation: Untreated, shock dramatically reduces liver blood flow and liver function
• pharmacological therapy is more effective than variceal banding or sclerotherapy (False)
• Explanation: Local measures stop bleeding in 80% of patients
• somatostatin (octreotide) and vasopressin both reduce portal venous pressure (True)
• Explanation: Constrict splanchnic arterioles; glyceryl trinitrate is given to reduce vasoconstriction
• balloon tamponade is best undertaken after endoscopic confirmation of bleeding varices (True)
• Explanation: Unless the patient is exsanguinating; 20% of patients are bleeding from non-variceal causes
• transjugular intrahepatic portosystemic stent shunting (TIPSS) is contraindicated in hepatic failure (False)
• Explanation: TIPSS is used when local measures fail and has replaced emergency shunt surgery

Question 26. Prevention of recurrent variceal bleeding is achievable using

• somatostatin (octreotide) therapy (False)
• Explanation: Somatostatin may be useful in acute bleeds
• TIPSS (True)
• Explanation: Also used in acute variceal bleeding
• ß-adrenoceptor antagonist (ß-blocker) treatment (True)
• Explanation: ß-blockers reduce portal pressure
• variceal banding (True)
• Explanation: Better than sclerotherapy in the elective situation
• sclerotherapy (True)
• Explanation: Easier than banding in the emergency situation

Question 27. In primary biliary cirrhosis

• middle-aged males are affected predominantly (False)
• Explanation: Middle-aged females
• pruritus is invariably accompanied by jaundice (False)
• Explanation: May precede jaundice by months or years
• osteomalacia and osteoporosis both occur as the disease progresses (True)
• Explanation: Vitamin D malabsorption and hepatic osteodystrophy
• rigors and abdominal pain are presenting features (False)
• Explanation: Suggests obstruction of large bile duct
• smooth muscle antibodies are present in high titres in the serum (False)
• Explanation: High titres of antimitochondrial antibody

Question 28. The typical features of primary haemochromatosis include

• association with an autosomal dominant pattern of inheritance (False)
• Explanation: Inherited as an autosomal recessive gene located on chromosome 6
• male predominance (True)
• Explanation: 90% are males; females may be protected by menstruation and pregnancy
• hepatic cirrhosis and diabetes mellitus (True)
• Explanation: ‘Bronzed diabetes’
• congestive cardiomyopathy (True)
• Explanation: May be a congestive cardiomyopathy
• grey skin pigmentation due to ferritin deposition (False)
• Explanation: Melanin not iron deposition

Question 29. The typical features of Wilson’s disease include

• haemolytic anaemia (True)
• Explanation: Sometimes accompanying an acute hepatitis in children
• acute hepatitis and chronic hepatitis (True)
• Explanation: Or acute hepatic failure or cirrhosis
• parkinsonian syndrome and hepatic cirrhosis (True)
• Explanation: A variety of extrapyramidal syndromes may be seen
• Kayser-Fleischer rings (True)
• Explanation: Kayser-Fleischer rings are an important diagnostic clue
• renal tubular acidosis (True)
• Explanation: Copper is deposited in the liver and kidneys

Question 30. The typical features of alcoholic liver disease include

• microvesicular steatosis (False)
• Explanation: Macrovesicular steatosis is the earliest stage when abstinence will achieve a good prognosis
• acute hepatitis and chronic hepatitis (True)
• Explanation: 33% mortality if liver dysfunction is severe
• hepatic cirrhosis (True)
• Explanation: 50% 5-year survival after the initial presentation if abstinent
• cholestatic jaundice (True)
• Explanation: Often associated with tender hepatomegaly and abdominal pain
• alcohol intake > 30 g/day for > 5 years (True)
• Explanation: Usually associated with at least 50 g/day for at least 10 years

Question 31. The typical features of hepatocellular carcinoma include

• fever, weight loss and abdominal pain (True)
• Explanation: Abdominal pain and a cirrhotic liver suggest hepatoma
• ascites and intra-abdominal bleeding (True)
• Explanation: Tumours are vascular and spread locally
• arterial bruit over the liver (True)
• Explanation: There may also be a hepatic rub
• rising serum a-fetoprotein titre (True)
• Explanation: Rises in 90% of cases
• surgically resectable disease in 50% of patients (False)
• Explanation: Only 10% are suitable for surgery

Question 32. Pyogenic liver abscess is a recognised complication of

• ascending cholangitis (True)
• Explanation: Secondary to biliary obstruction
• Crohn’s disease (True)
• Explanation: Secondary to portal pyaemia
• pancreatitis (True)
• Explanation: Acute pancreatitis
• septicaemia (True)
• Explanation: Infection via hepatic artery
• subphrenic abscess (True)
• Explanation: Direct local spread

Question 33. The typical features of pyogenic liver abscess include

• obstructive jaundice and pruritus (False)
• Explanation: Jaundice is usually mild and not often obstructive
• tender hepatomegaly without splenomegaly (True)
• Explanation: Splenomegaly suggests coexistent pathology
• pleuritic pain and pleural effusion (True)
• Explanation: May be right shoulder tip pain
• multiple abscesses, especially in ascending cholangitis (True)
• Explanation: Single lesions are more common in the right liver
• Escherichia coli, anaerobes and streptococci present in pus (True)
• Explanation: Multiple organisms in one-third of cases

Question 34. Gallstones are a recognised complication of

• obesity (True)
• Explanation: Increased hepatic cholesterol secretion
• pregnancy (True)
• Explanation: Increased hepatic cholesterol secretion and impaired gallbladder motility
• chronic haemolytic anaemia (True)
• Explanation: Pigment stones
• terminal ileal disease (True)
• Explanation: Pigment stones
• rapid weight loss (True)
• Explanation: Increased hepatic cholesterol secretion

Question 35. The typical clinical features of acute cholecystitis include

• jaundice, nausea and vomiting (False)
• Explanation: Jaundice occurs in less than 20% even in the absence of stones (Mirizzi’s syndrome)
• colicky abdominal pain in spasms lasting about 5 minutes (False)
• Explanation: Pain is typically continuous for up to 6 hours
• right hypochondrial tenderness worse on inspiration (True)
• Explanation: Murphy’s sign
• air in the biliary tree on plain radiograph (False)
• Explanation: May follow passage of a gallstone into intestine or biliary surgery
• peripheral blood leucocytosis (True)
• Explanation: May be absent in the elderly

Question 36. The post-cholecystectomy syndrome is characteristically associated with

• patients with previous acalculous cholecystitis (True)
• Explanation: Less common in patients with previous typical biliary colic and gallstones
• females with a history of abdominal pain > 5 years in duration (True)
• Explanation: Associated with the irritable bowel syndrome and functional dyspepsia
• retained stones in the common bile duct (True)
• Explanation: Hence the need to investigate this possibility
• dysfunction of the sphincter of Oddi (False)
• Explanation: This abnormality may not be causal and may in fact result from cholecystectomy
• early postoperative complications (True)
• Explanation: Suggest the possibility of a biliary stricture
• most patients aged < 55 years have an underlying peptic ulcer (False)
• Explanation: Only about 20%; most have reflux dyspepsia or functional dyspepsia
• 25% of duodenal ulcers relapse unless H. pylori has been eradicated (False)
• Explanation: 85% relapse if H. pylori has not been eradicated
• magnesium-containing antacids produce constipation (False)
• Explanation: Cause diarrhoea; aluminium-containing antacids cause constipation
• bismuth compounds should not be used for maintenance therapy (True)
• Explanation: Due to potential accumulation of bismuth, acid-lowering drugs are preferable
• gastric ulcers associated with NSAID therapy are less likely to be associated with H. pylori gastritis than gastric ulcers occurring in patients not taking NSAIDs (True)
• Explanation: 30% of gastric ulcers are not associated with H. pylori (NSAID-induced ulcers)

CHAPTER – 19

Question 1. Peripheral blood lymphocytosis would be an expected finding in

• brucellosis (True)
• Explanation: Often with neutropenia
• pneumococcal pneumonia (False)
• Explanation: Polymorphonuclear leucocytosis
• measles and rubella (True)
• Explanation: Non-specific feature of many viral infections
• Hodgkin’s disease (False)
• Explanation: Non-Hodgkin’s lymphoma
• chronic lymphatic leukaemia (True)
• Explanation: Predominantly small lymphocytes

Question 2. Peripheral blood neutrophil leucocytosis would be an expected finding in

• connective tissue disease (True)
• Explanation: Or may be neutropenia in systemic lupus erythematosus
• corticosteroid therapy (True)
• Explanation: And lithium therapy
• pregnancy (True)
• Explanation: Variable, increases at delivery
• whooping cough (False)
• Explanation: Typically lymphocytosis
• mesenteric infarction (True)
• Explanation: And myocardial infarction

Question 3. Platelets

• have a circulation lifespan of 10 hours in healthy subjects (False)
• Explanation: 10-day lifespan
• are produced and regulated under the control of thrombopoietins (True)
• Explanation: By the megakaryocytes
• contain small nuclear remnants called Howell-Jolly bodies (False)
• Explanation: Found in red blood cells
• decrease in number in response to aspirin therapy (False)
• Explanation: May increase
• release 5-hydroxytryptamine (5-HT, serotonin) and von Willebrand factor (vWF) (True)
• Explanation: 5-HT (delta granules), and vWF and fibrinogen (alpha granules)

Question 4. The following statements about red blood cell morphology are true

• hypochromia is pathognomonic of iron deficiency (False)
• Explanation: Seen in other disorders of haemoglobin synthesis (e.g. thalassaemia)
• polychromasia indicates active production of new red blood cells (True)
• Explanation: Residual ribosomal material is stained faintly
• poikilocytosis is invariably associated with anisocytosis (True)
• Explanation: Sign of dyserythropoiesis
• punctate basophilia is a typical feature of beta-thalassaemia (True)
• Explanation: And lead poisoning
• target cells are associated with hyposplenism and liver disease (True)
• Explanation: And haemoglobinopathies

Question 5. Peripheral blood findings in dietary iron deficiency include

• microcytosis (True)
• Explanation: Microcytosis is the first sign
• ovalocytosis (True)
• Explanation: Sometimes poikilocytosis
• mean corpuscular haemoglobin concentration < 50% of normal (False)
• Explanation: Only in severe anaemia; hypochromia is due to microcytosis
• Howell-Jolly bodies (False)
• Explanation: Suggests hyposplenism
• thrombocytosis (True)
• Explanation: Thrombocytosis occurs even in the absence of bleeding

Question 6. In the treatment of iron deficiency anaemia with iron

• folic acid should also be given if the anaemia is severe (False)
• Explanation: Only if coexistent deficiency demonstrated
• treatment is stopped as soon as haemoglobin normalises (False)
• Explanation: Continue for 3 months to replenish stores
• haemoglobin should rise by 1 g/l every 7-10 days (False)
• Explanation: 10 g/l every 10 days unless there is malabsorption, bleeding or poor compliance
• maximal reticulocyte count usually develops within 1-2 days (False)
• Explanation: Peak reticulocyte count at 7-10 days
• parenteral iron is usually more effective than oral iron (False)
• Explanation: Oral iron is usually effective

Question 7. Hypochromic microcytic anaemia is a recognised finding in

• haemolytic anaemia (False)
• Explanation: Macrocytic with polychromasia
• myelodysplastic syndrome (True)
• Explanation: Typically a dimorphic red cell population
• hypothyroidism (False)
• Explanation: Typically macrocytic
• beta-thalasaemia (True)
• Explanation: And other thalassaemias
• rheumatoid arthritis (True)
• Explanation: Or a normochromic normocytic picture

Question 8. Normocytic normochromic anaemia is an expected feature of

• alcoholic liver disease (False)
• Explanation: Typically macrocytic
• chronic renal failure (True)
• Explanation: Erythropoietin deficiency
• rheumatoid arthritis (True)
• Explanation: Typically macrocytic
• kwashiorkor (True)
• Explanation: Protein-energy malnutrition
• strict vegetarianism (False)
• Explanation: Anaemia is rare in modest reductions of dietary vitamin B12 intake

Question 9. Macrocytic anaemia is a typical finding in

• folic acid deficiency (True)
• Explanation: With megaloblastic marrow
• haemolytic anaemia (True)
• Explanation: With polychromasia
• alcohol misuse (True)
• Explanation: With or without cirrhosis
• primary sideroblastic anaemia (False)
• Explanation: Dimorphic, with microcytic population
• myelodysplastic syndrome (True)
• Explanation: But variable red cell morphology

Question 10. Typical haematological findings in megaloblastic anaemia include

• pancytopenia and oval macrocytosis (True)
• Explanation: Commonly due to vitamin B12 deficiency
• neutrophil leucocyte hypersegmentation (True)
• Explanation: Shift to the right in the nuclear segmentation count (Arneth count)
• anisocytosis and poikilocytosis (True)
• Explanation: And red cell fragmentation
• reticulocytosis and polychromasia (False)
• Explanation: Features of bleeding or haemolysis
• excess urinary urobilinogen and bilirubinuria (False)
• Explanation: Bilirubinuria is not a feature of any anaemia

Question 11. Folate and vitamin B12 deficiency both typically produce

• subacute combined degeneration of the spinal cord (False)
• Explanation: Feature of vitamin B12 deficiency only
• intermittent glossitis and diarrhoea (True)
• Explanation: Glossitis less common in folate deficiency
• mild jaundice and splenomegaly (True)
• Explanation: Mild haemolysis
• peripheral neuropathy (True)
• marked weight loss (True)
• Explanation: Partially dependent on underlying cause

Question 12. Characteristic features of Addisonian pernicious anaemia include

• onset before the age of 20 years (False)
• Explanation: Typically 45-65 years
• gastric parietal cell and intrinsic factor antibodies in the serum (True)
• Explanation: Found in 90% and < 50% respectively
• increased serum bilirubin and lactate dehydrogenase concentrations (True)
• Explanation: Mild haemolysis occurs
• four-fold increase in the risk of developing gastric carcinoma (True)
• Explanation: Associated gastric atrophy
• Schilling test usually reverts to normal with intrinsic factor (True)
• Explanation: Failure to correct suggests terminal ileal disease

Question 13. Causes of folic acid deficiency include

• vegetarian diet (False)
• Explanation: Caused by inadequate vegetable intake
• gluten enteropathy (True)
• Explanation: Characteristic finding
• pregnancy (True)
• Explanation: Increased requirements
• haemolytic anaemia (True)
• Explanation: Increased requirements
• antibiotic therapy (False)
• Explanation: Methotrexate and phenytoin may cause folate deficiency

Question 14. Characteristic features of primary aplastic anaemia include

• peak incidence in the elderly (False)
• Explanation: Peaks about 30 years of age
• normocytic normochromic anaemia with thrombocytosis (False)
• Explanation: Thrombocytopenia
• bone marrow trephine is required to confirm the diagnosis (True)
• Explanation: Diagnosis cannot be made on peripheral blood film alone
• splenomegaly indicating extramedullary erythropoiesis (False)
• Explanation: Splenomegaly occurs in under 10% of cases
• pancytopenia (True)
• Explanation: Typical

Question 15. Typical features suggesting intravascular haemolysis include

• bilirubinuria and haemoglobinuria (False)
• Explanation: Bilirubin is unconjugated therefore not found in urine
• methaemalbuminaemia and haemosiderinuria (True)
• Explanation: The latter always indicating intravascular haemolysis
• increased serum haptoglobin concentration (False)
• Explanation: Decreased serum haptoglobin
• increased plasma haemoglobin concentration (True)
• Explanation: Most is bound to serum haptoglobin
• splenomegaly (True)
• Explanation: Often with reticulocytosis

Question 16. Laboratory features suggesting haemolytic anaemia include

• increased serum lactate dehydrogenase (LDH) concentration (True)
• Explanation: Red cells are rich in LDH
• conjugated hyperbilirubinaemia and bilirubinuria (False)
• Explanation: Unconjugated hyperbilirubinaemia and excess urobilinogen in the urine
• peripheral blood neutrophil leucocytosis (True)
• Explanation: Also red cell abnormalities (e.g. spherocytes)
• peripheral blood polychromasia and macrocytosis (True)
• Explanation: Reflects reticulocytosis
• bone marrow erythroid hyperplasia (True)
• Explanation: With megaloblastic change if folate deficiency is also present

Question 17. Typical features of hereditary spherocytosis include

• splenomegaly (True)
• Explanation: Also pigment gallstones
• intravascular haemolysis (False)
• Explanation: Red blood cell destruction occurs in the spleen
• decreased red blood cell osmotic fragility (False)
• Explanation: Osmotic fragility is increased
• transient aplastic anaemia (True)
• Explanation: Often in association with parvovirus infection
• deficiency of red cell spectrin (True)
• Explanation: Red blood cell membrane protein

Question 18. The typical clinical features of sickle-cell anaemia include

• haemolytic and aplastic crises (True)
• Explanation: Often precipitated by viral infection
• neonatal spherocytic haemolytic anaemia (False)
• Explanation: Not until HbF levels fall after the age of 3 months
• pulmonary, splenic and mesenteric infarcts (True)
• Explanation: Causing pleuritic pain and also renal infarcts
• splenomegaly with hypersplenism (False)
• Explanation: Splenic atrophy and functional hyposplenism
• bone necrosis and osteomyelitis (True)
• Explanation: Painful bone infarcts

Question 19. In patients with sickle-cell disease, acute painful crises are likely to be precipitated by

• high altitude (True)
• Explanation: Decreased PaO2
• pregnancy (True)
• Explanation: May present as pseudo-toxaemia syndrome
• dehydration (True)
• Explanation: Rehydration is an essential component of therapy
• systemic infection (True)
• Explanation: Treat promptly to prevent sickle-cell crises
• hypoxia (True)

Question 20. The typical features of the beta-thalassaemias include

• macrocytic anaemia (False)
• Explanation: Typically hypochromic microcytic anaemia
• hepatosplenomegaly (True)
• Explanation: In the ‘major’ (homozygous) form
• pigment gallstones (True)
• Explanation: Pigment gallstones can be associated with chronic haemolysis
• neonatal haemolytic anaemia (False)
• Explanation: Not until HbF synthesis declines
• bone infarcts (False)
• Explanation: Unlike sickle cell disease

Question 21. The typical features of autoimmune haemolytic anaemia include

• peripheral blood spherocytosis and splenomegaly (True)
• Explanation: Characteristic
• haemoglobinuria and haemosiderinuria (True)
• Explanation: Suggesting intravascular haemolysis
• increased serum haptoglobin concentration (False)
• Explanation: Decreased serum haptoglobin concentration
• positive Coombs test (True)
• Explanation: Warm usually IgG, cold usually IgM
• association with lymphoproliferative disease (True)
• Explanation: Chronic lymphatic leukaemia, lymphoma and also systemic lupus erythematosus

Question 22. The typical features of polycythaemia rubra vera include

• peak prevalence aged > 40 years (True)
• splenomegaly, leucocytosis and thrombocytosis (True)
• Explanation: And elevated red cell mass
• headaches, pruritus and peptic ulcer dyspepsia (True)
• Explanation: But may be asymptomatic
• decreased leucocyte alkaline phosphatase score (False)
• Explanation: A feature of chronic myeloid leukaemia
• increased blood viscosity associated with vascular disease (True)
• Explanation: E.g. increased risk of stroke

Question 23. Acute lymphoblastic leukaemia (ALL)

• has a peak prevalence in patients aged 20-30 years (False)
• Explanation: Peaks in childhood
• typically produces cytoplasmic Auer rods in blast cells (False)
• Explanation: Acute myeloblastic leukaemia (AML)
• has a median survival of 30 months with chemotherapy (True)
• Explanation: AML has a 40% 5-year survival with chemotherapy
• is the most common of all acute leukaemias (False)
• Explanation: AML is four times more common than ALL
• is a typical complication of multiple myeloma (False)
• Explanation: May complicate myelofibrosis

Question 24. Clinical features of chronic myeloid leukaemia (CML) include

• painful splenomegaly (True)
• Explanation: Splenomegaly in 90% of cases
• gout and arthralgia (True)
• Explanation: Hyperuricaemia is often asymptomatic
• generalised lymphadenopathy (False)
• Explanation: Atypical feature
• tendency to bleeding and bruising (True)
• Explanation: Variable platelet dysfunction
• median survival of 15 years with chemotherapy (False)
• Explanation: Median survival 5 years

Question 25. The typical laboratory findings in chronic myeloid leukaemia include

• leucoerythroblastic anaemia and thrombocytosis (True)
• Explanation: Platelet count falls after blast transformation
• peripheral blood neutrophilia, eosinophilia and basophilia (True)
• chromosomal translocation q-22/q+9 (True)
• Explanation: Philadelphia chromosome
• increased neutrophil leucocyte alkaline phosphatase (LAP) score (False)
• Explanation: Usually decreased LAP score
• transformation to acute leukaemia (True)
• Explanation: Transformation results to either ALL (30%) or acute myeloid leukaemia (AML) (70%)

Question 26. Typical features of chronic lymphocytic leukaemia include

• onset in younger patients than in chronic myeloid leukaemia (False)
• Explanation: Peak age 65 years
• development of autoimmune haemolytic anaemia (True)
• Explanation: Typically warm antibody
• presentation with massive hepatosplenomegaly (False)
• Explanation: Mild organomegaly only
• lymphadenopathy associated with recurrent infections (True)
• Explanation: Bacterial more than viral
• median survival of 15 years following chemotherapy (False)
• Explanation: Overall median survival 6 years

Question 27. The typical laboratory features in chronic lymphocytic leukaemia include

• hyperuricaemia and thrombocytosis (False)
• Explanation: Mild thrombocytopenia with urate usually normal
• hypogammaglobulinaemia (True)
• Explanation: Associated with a paraproteinaemia in 5%
• peripheral blood lymphocytosis in the absence of lymphoblasts (True)
• Explanation: Total WCC typically 50-200 × 109/l
• positive Coombs test (True)
• Explanation: May be associated with haemolysis
• transformation to acute leukaemia (False)
• Explanation: Transformation is rare

Question 28. Allogeneic bone marrow transplantation is particularly useful in the treatment of

• multiple myeloma (True)
• Explanation: Also useful in acute myelofibrosis
• severe aplastic anaemia (True)
• alpha-thalassaemia (True)
• Explanation: All severe thalassaemias
• severe combined immunodeficiency disorder (True)
• chronic lymphocytic leukaemia (False)
• Explanation: But useful in most other acute and chronic leukaemias

Question 29. Complications of allogeneic bone marrow transplantation include

• acute graft-versus-host disease (True)
• Explanation: Usually occurs 2-3 weeks after the graft and is associated with infection
• severe infection (True)
• Explanation: A major problem, especially with viruses and atypical microorganisms
• infertility (True)
• Explanation: Important given the age of many of the patients
• pneumonitis (True)
• malignant disease during long-term follow-up (True)

Question 30. The presence of lymphadenopathy and splenomegaly would be expected findings in

• multiple myeloma (False)
• Explanation: Neither is characteristic
• chronic lymphocytic leukaemia (True)
• Explanation: Mild splenomegaly, generalised lymphadenopathy
• chronic myeloid leukaemia (False)
• Explanation: Moderate to massive splenomegaly, no lymphadenopathy
• infectious mononucleosis (True)
• Explanation: Usually both mild
• myelofibrosis (False)
• Explanation: Splenomegaly without lymphadenopathy

Question 31. Recognised clinical features of multiple myeloma include

• peak incidence between the ages of 30 and 50 years (False)
• Explanation: Peak prevalence in males aged 60-70 years
• secondary amyloidosis (True)
• Explanation: Amyloidosis occurs in 10% of cases
• median survival > 10 years with chemotherapy (False)
• Explanation: Median survival of 40 months
• recurrent infections and pancytopenia (True)
• Explanation: Reduction of normal plasma cells causes immunodeficiency
• increased serum calcium, urate and blood urea (True)
• Explanation: All of which may be asymptomatic

Question 32. In differentiating multiple myeloma from a benign monoclonal gammopathy, the following findings would favour the diagnosis of multiple myeloma

• monoclonal gammopathy with normal serum immunoglobulin levels (False)
• Explanation: Myeloma produces suppression of the other serum immunoglobulins
• bone marrow plasmacytosis of > 20% (True)
• Explanation: A diagnostic prerequisite
• bilateral carpal tunnel syndrome (True)
• Explanation: Amyloidosis also causes a restrictive cardiomyopathy
• Bence Jones proteinuria (True)
• Explanation: But the serum paraprotein may be undetectable
• multiple osteolytic lesions on radiograph (True)
• Explanation: Malignant infiltration is typically associated with a normal isotope bone scan

Question 33. The clinical features of Hodgkin’s disease include

• painless cervical lymphadenopathy (True)
• Explanation: Usually painless
• anaemia due to bone marrow involvement (False)
• Explanation: Unlike non-Hodgkin’s lymphoma
• impaired T-cell function in the absence of lymphopenia (True)
• Explanation: Lymphopenia suggests poor prognosis
• fever and weight loss (True)
• Explanation: Stage B
• median survival > 10 years (True)
• Explanation: Dependent on staging at presentation

Question 34. Typical characteristics of non-Hodgkin’s lymphoma include

• low-grade lymphomas rapidly produce symptoms due to high cell proliferation rates (False)
• Explanation: Indolent and often asymptomatic course with low cell proliferation rates
• bone marrow and splenic involvement are present from the onset (True)
• Explanation: Typically extranodal at diagnosis
• isolated involvement of gastric mucosa associated with Helicobacter pylori infection (True)
• Explanation: MALToma may be cured by H. pylori eradication
• the majority are T-cell rather than B-cell in origin (False)
• Explanation: 70% are B-cell tumours
• better prognosis in high-grade rather than low-grade lymphomas (True)
• Explanation: Prognosis is also stage- and age-dependent

Question 35. Recognised causes of thrombocytopenia include

• megaloblastic anaemia (True)
• Explanation: Often with leucopenia
• acquired immunodeficiency syndrome (True)
• Explanation: Primary, or secondary to superimposed infections
• disseminated intravascular coagulation (True)
• Explanation: Increased peripheral consumption of platelets
• von Willebrand’s disease (False)
• Explanation: The platelet count is normal
• aspirin therapy (True)
• Explanation: Also many commonly used drugs including heparin and ß-blockers

Question 36. Typical features of idiopathic thrombocytopenic purpura include

• IgG-mediated thrombocytopenia (True)
• Explanation: Can therefore be transmitted transplacentally
• peak prevalence in patients aged > 60 years old (False)
• Explanation: Usually the young and commoner in females
• prolongation of the bleeding time (True)
• Explanation: Other clotting tests normal
• splenomegaly (False)
• Explanation: Suggests other causes of thrombocytopenia
• prompt response to corticosteroid therapy (True)
• Explanation: Particularly in children

Question 37. The prothrombin time is typically prolonged in

• disorders of the intrinsic pathway (False)
• Explanation: The extrinsic pathway
• factor X deficiency (True)
• Explanation: The Stuart-Prower factor
• factor VII deficiency (True)
• Explanation: First factor in extrinsic pathway
• factor V deficiency (True)
• Explanation: Also affects the activated partial thromboplastin time
• factor XII deficiency (False)
• Explanation: Disorder of the intrinsic pathway

Question 38. The activated partial thromboplastin time (APTT) is typically prolonged in

• disorders of the extrinsic pathway (False)
• Explanation: The intrinsic pathway
• factor VII deficiency (False)
• Explanation: Detected by prothrombin time
• factor VIII or X deficiency (True)
• Explanation: Factor X also influences prothrombin time
• factor XIII deficiency (False)
• Explanation: Specific assay to measure
• factor IX, XI or XII deficiency (True)
• Explanation: Initial factors in the intrinsic system

Question 39. Disseminated intravascular coagulation is a complication of

• amniotic fluid embolism (True)
• Explanation: Initiated by thromboplastin
• incompatible blood transfusion (True)
• Explanation: An unusual complication
• hypovolaemic and anaphylactic shock (True)
• Explanation: Endothelial injury
• septicaemic shock (True)
• Explanation: Exogenous endotoxins
• carcinomatosis (True)
• Explanation: Commonly bronchial carcinoma

Question 40. The bleeding time is characteristically prolonged in

• ascorbic acid deficiency (False)
• Explanation: Bleeding time is normal but petechial haemorrhages may occur
• thrombocytopenia (True)
• Explanation: Irrespective of its cause
• haemophilia (False)
• Explanation: No vessel wall or platelet defect
• warfarin therapy (False)
• von Willebrand’s disease (True)
• Explanation: Secondary decrease in factor VIII level with a qualitative platelet defect

Question 41. The following statements about severe haemophilia A are true

• the disorder is inherited in an X-linked recessive mode (True)
• Explanation: Prenatal diagnosis is possible
• recurrent haemarthroses and haematuria are typical (True)
• Explanation: Usually not apparent until the age of 6 months
• activated partial thromboplastin time and prothrombin time are both prolonged (False)
• Explanation: Only the activated partial thromboplastin time is prolonged
• factor VIII has a biological half-life of about 12 days (False)
• Explanation: Half-life is 12 hours
• desmopressin therapy increases factor VIII concentrations (True)
• Explanation: Desmopressin (DDAVP) therapy is useful to limit exposure to blood products

Question 42. The following statements about von Willebrand’s disease are true

• the disorder is inherited in an X-linked recessive mode (False)
• Explanation: Autosomal dominant-gene locus on chromosome 12
• it is characterised by a prolonged bleeding time (True)
• Explanation: And secondary reduction in factor VIII levels
• the von Willebrand factor (vWF) is synthesised by both platelets and endothelial cells (True)
• vWF is a carrier protein which is bound to factor VIII (True)
• deficiency of vWF is best treated by desmopressin (True)
• Explanation: Desmopressin (DDAVP) therapy increases vWF concentrations

Question 43. Thrombophilia with a predisposition to recurrent venous thromboses is associated with

• the antiphospholipid antibody syndrome (True)
• Explanation: May present with recurrent spontaneous abortion
• antithrombin deficiency (True)
• Explanation: Decreased inactivation of factors IIa, VIIa, IXa, Xa, XIa, causing heparin resistance
• factor V Leiden (True)
• Explanation: Prolonged factor V activation; factor II Leiden increases plasma prothrombin levels
• polycythaemia rubra vera (True)
• Explanation: And chronic myeloid leukaemia-both are associated with thrombocytosis
• protein C deficiency (True)
• Explanation: And protein S deficiency-reduced inactivation of factors Va and VIIIa

Question 44. Indications for warfarin anticoagulation include

• venous thromboembolism (True)
• Explanation: Maintain the prothrombin ratio in the range 2.0-4.0
• arterial embolism (True)
• Explanation: Less effective in non-embolic peripheral vascular disease
• myocardial infarction (False)
• Explanation: Unless associated with mural thrombus
• atrial fibrillation (True)
• Explanation: Reduces the risk of arterial embolism
• mechanical prosthetic heart valves (True)
• Explanation: Reduces the risk of embolic clots and possibly endocarditis

Question 45. The hazards of blood transfusion include

• urticaria (True)
• Explanation: Allergic reaction
• cardiac failure (True)
• Explanation: Volume overload-in patients with previous CCF, give prophylactic diuretic therapy
• development of Rhesus antibodies in a Rhesus-negative patient (True)
• Explanation: Particularly important in women of child-bearing age
• fever (True)
• Explanation: Allergic reaction to one or more of the constituents of the transfusion
• acute intravascular haemolysis (True)
• Explanation: Major ABO incompatibility is the likeliest cause

Question 46. Clinical features suggesting an acute transfusion reaction include

• onset within an hour of starting the transfusion (True)
• Explanation: Delayed haemolytic transfusion reaction occurs 5-7 days after the transfusion
• rigors and fever (True)
• Explanation: Stop the transfusion immediately
• chest and back pain (True)
• sudden loss of consciousness (False)
• Explanation: Unlikely in the absence of other premonitory changes
• development of hypotension and shock (True)
• Explanation: May be problematic in anaesthetised patients

CHAPTER – 20

Question 1. The following diseases are associated with antinuclear and/or rheumatoid factor antibodies

• infective endocarditis (True)
• Explanation: Chronic infections (e.g. tuberculosis, leishmaniasis and schistosomiasis)
• autoimmune thyroiditis (True)
• Explanation: Also found in myasthenia gravis
• Sjögren’s syndrome (True)
• Explanation: And systemic lupus erythematosus, dermatomyositis and progressive systemic sclerosis
• fibrosing alveolitis (True)
• Explanation: And autoimmune hepatitis and sarcoidosis
• ankylosing spondylitis (False)
• Explanation: And, by definition, all the seronegative spondyloarthritides

Question 2. The biochemical features listed below characterise the following metabolic bone disorders

• increased serum calcium, serum phosphate and serum alkaline phosphatase-osteoporosis (False)
• Explanation: All three are normal in osteoporosis
• normal serum calcium and serum phosphate but increased serum alkaline phosphatase-Paget’s disease (True)
• Explanation: Occasionally the serum calcium may be elevated if immobilisation is prolonged
• normal serum calcium and serum alkaline phosphatase but decreased serum phosphate-osteomalacia (False)
• Explanation: All three may be normal (see E)
• decreased serum calcium, serum phosphate and serum alkaline phosphatase-metastatic bone disease (False)
• Explanation: Increased calcium, normal or low phosphate, and high serum alkaline phosphatase
• decreased serum calcium and serum phosphate but increased serum alkaline phosphatase-osteomalacia (True)
• Explanation: But all three may be normal

Question 3. Presentation with acute monoarthritis suggests the possibility of

• crystal arthritis (True)
• Explanation: Gout and pseudogout
• trauma (True)
• Explanation: Trauma usually obvious
• bacterial infection (True)
• rheumatoid arthritis (False)
• Explanation: Usually polyarticular in onset
• enteropathic arthritis (True)
• Explanation: Reactive arthritis following enterically or sexually acquired infection

Question 4. The following statements about infective arthritis are true

• the onset is typically insidious (False)
• Explanation: Onset usually acute, but less so in the elderly or the immunocompromised
• pre-existing arthritis is a recognised predisposing factor (True)
• Explanation: Also occurs after trauma or surgery
• small peripheral joints are involved more often than larger joints (False)
• Explanation: Large joints are most frequently affected
• Haemophilus influenzae is the commonest causative organism in adults (False)
• Explanation: H. influenzae is the main cause in children, streptococci and staphylococci in adults
• joint aspiration should be avoided given the risk of septicaemia (False)
• Explanation: Early joint aspiration is vital if the diagnosis is not to be delayed

Question 5. The following features of backache suggest mechanical or radicular pain rather than inflammatory pain

• radiation of pain down the back of one leg to the ankle (True)
• Explanation: Suggests lumbar nerve root compression
• an elevated C-reactive protein (CRP) (False)
• Explanation: Suggests an active inflammatory pathology
• localised tenderness over the greater sciatic notch (True)
• Explanation: Suggests lumbar nerve root compression
• gradual mode of onset in an elderly patient (False)
• Explanation: Suggests significant pathology even if there are no physical signs
• back pain and stiffness exacerbated by resting (False)
• Explanation: Suggests inflammatory disease

Question 6. The typical findings in fibromyalgia include

• elevation of the ESR (False)
• Explanation: A high ESR suggests another diagnosis
• symptoms of fatigue and an irritable bowel (True)
• Explanation: Typical of most psychosomatic disorders
• coexistent anxiety and depression (True)
• rapid, spontaneous resolution (False)
• Explanation: Often very chronic
• musculoskeletal pain without local tenderness (False)
• Explanation: Multiple tender points are characteristic

Question 7. Shoulder pain is a recognised feature of

• myocardial ischaemia (True)
• Explanation: Either alone or associated with central chest pain
• supraspinatus tendonitis (True)
• Explanation: With characteristic painful arc on shoulder abduction
• bronchial carcinoma (True)
• Explanation: Suggests extra-pleural spread or bony metastases
• pneumococcal pneumonia (True)
• Explanation: Classically due to diaphragmatic irritation secondary to pleurisy
• cervical spondylosis (True)
• Explanation: Due to cervical nerve root compression

Question 8. In a patient with neck pain

• aggravation by sneezing suggests cervical disc prolapse (True)
• Explanation: Disc prolapse may also produce upper or lower limb neurological signs
• radiation to the occiput suggests disease affecting the upper cervical vertebrae (True)
• Explanation: Common in tension headache
• associated bilateral arm paraesthesiae suggest angina pectoris as the most likely diagnosis (False)
• Explanation: Suggest cervical radiculopathy
• and otherwise normal joints, rheumatoid arthritis is excluded as a possible diagnosis (False)
• Explanation: Rheumatoid arthritis typically involves atlantoaxial articulations
• associated drop attacks suggest vertebral artery compression due to cervical spondylosis (True)

Question 9. The clinical features of primary (nodal) osteoarthrosis include

• joint pain aggravated by rest and relieved by activity (False)
• Explanation: More suggestive of an inflammatory arthritis such as rheumatoid arthritis
• proximal interphalangeal and metacarpal-phalangeal joint involvement (False)
• Explanation: Typically distal interphalangeal joint involvement
• involvement of the hip, knee and spinal apophyseal joints (True)
• a strong family history of Heberden’s nodes (True)
• microfractures of subchondral bone (True)

Question 10. Causes of secondary osteoarthritis include

• acromegaly (True)
• septic arthritis (True)
• Explanation: And any joint previously traumatised
• haemochromatosis (True)
• Explanation: Also chondrocalcinosis and Wilson’s disease
• Perthes’ disease (True)
• Explanation: And most hip dysplasias
• Ehlers-Danlos syndrome (True)
• Explanation: Also other causes of hypermobility

Question 11. Criteria for the diagnosis of rheumatoid arthritis include

• morning stiffness lasting more than 1 hour (True)
• Explanation: American Rheumatism Association criteria (1998)
• arthritis in both hip joints (False)
• Explanation: Arthritis affecting three or more joint areas
• the presence of rheumatoid nodules (True)
• Explanation: Pathognomonic
• symmetrical polyarthritis (True)
• Explanation: Diagnosis of RA requires four or more of the criteria
• radiological changes (True)
• Explanation: In significant titres

Question 12. Common extra-articular manifestations of rheumatological disorders include

• episcleritis and keratoconjunctivitis sicca in rheumatoid arthritis (True)
• erythema nodosum in enteropathic arthritis (True)
• enthesitis in ankylosing spondylitis (True)
• Explanation: And Reiter’s disease
• alopecia in systemic lupus erythematosus (True)
• Explanation: Also photosensitive skin rashes
• retinitis pigmentosa in psoriatic arthritis (False)

Question 13. Typical features of active rheumatoid arthritis include

• fever and weight loss (True)
• Explanation: These also occur with minimal joint symptoms, making diagnosis difficult
• macrocytic anaemia (False)
• Explanation: Anaemia is classically normochromic and normocytic
• anterior uveitis (False)
• Explanation: Anterior uveitis is specifically associated with the seronegative spondyloarthritides
• thrombocytopenia (False)
• Explanation: Modest elevation in platelet count is common
• generalised lymphadenopathy (True)
• Explanation: Most obvious in nodes draining actively inflamed joints

Question 14. The typical pattern of synovial disease in rheumatoid arthritis includes

• early involvement of the sacroiliac joints (False)
• Explanation: More suggestive of a seronegative spondyloarthritis such as ankylosing spondylitis
• symmetrical peripheral joint involvement (True)
• Explanation: Characteristic pattern of onset
• spindling of the fingers and broadening of the forefeet (True)
• Explanation: Involvement of the proximal interphalangeal and metatarsophalangeal joints respectively
• distal interphalangeal joint involvement of fingers and toes (False)
• Explanation: More suggestive of osteoarthrosis or psoriatic arthritis
• atlantoaxial joint involvement (True)
• Explanation: Often not obvious clinically but can produce cord compression

Question 15. The following statements about rheumatoid arthritis are true

• joint pain and stiffness are typically aggravated by rest (True)
• Explanation: Early morning stiffness is a characteristic feature of all inflammatory arthritides
• the rheumatoid factor test is positive in about 70% of patients (True)
• Explanation: May be absent at disease onset and is not specific to rheumatoid arthritis
• joint involvement is additive rather than flitting (True)
• Explanation: The usual pattern; in palindromic arthritis flitting episodes are typical
• associated scleromalacia typically produces painful red eyes (False)
• Explanation: Scleromalacia is a painless wasting of the sclera unlike the rarer scleritis
• sicca syndrome suggests the presence of an alternative diagnosis (False)
• Explanation: Common in rheumatoid arthritis

Question 16. The clinical features of Felty&apos;s syndrome include

• peak prevalence in the age group 20-30 years (False)
• Explanation: Peak prevalence in the age group 50-70 years
• previous long-standing rheumatoid arthritis (True)
• negative rheumatoid factor test (False)
• Explanation: Positive rheumatoid factor test
• lymphadenopathy and splenomegaly (True)
• Explanation: Characteristic
• recurrent infections and leg ulcers (True)
• Explanation: Characteristic

Question 17. In the treatment of rheumatoid arthritis

• bed rest should be avoided because of bony ankylosis (False)
• Explanation: Bed rest is of great value and without risk of bony ankylosis
• splinting of the affected joints reduces pain and swelling (True)
• Explanation: Reduces joint pain and may reduce contractures
• associated anaemia responds promptly to oral iron therapy (False)
• Explanation: Not usually iron-deficient and reflects disease activity
• systemic corticosteroids are contraindicated (False)
• Explanation: Low-dose steroids may lessen disease progression with only a small risk of side-effects
• non-steroidal anti-inflammatory drugs retard disease progression (False)
• Explanation: Not disease-modifying drugs, unlike gold, penicillamine and immunosuppressants

Question 18. Disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis include

• sulfasalazine (True)
• Explanation: 50% of patients respond in 3-6 months
• naproxen (False)
• Explanation: None of the NSAIDs are DMARDs
• D-penicillamine (True)
• Explanation: Benefit may not be apparent for 3 months
• sodium aurothiomalate (True)
• Explanation: Adverse effects are common (e.g. proteinuria and marrow suppression)
• azathioprine (True)
• Explanation: Reserved for life-threatening or unresponsive disease

Question 19. A poorer prognosis in rheumatoid arthritis is associated with

• insidious onset of rheumatoid arthritis (True)
• Explanation: An explosive onset confers a relatively better prognosis
• high titres of rheumatoid factor early in the course of the disease (True)
• Explanation: Especially within 12 months of onset
• early development of subcutaneous nodules and erosive arthritis (True)
• Explanation: Indicates seropositive disease
• extra-articular manifestations (True)
• onset with palindromic rheumatism (False)
• Explanation: The presence of periods of remission is a favourable sign

Question 20. Typical features of seronegative spondyloarthritis include

• asymmetrical oligoarthritis (True)
• Explanation: Axial joints are involved initially; only 10% of cases present with a peripheral arthritis
• involvement of cartilaginous joints (True)
• Explanation: E.g. the sacroiliac joints; involvement is rare in seropositive arthritides
• enthesitis of tendinous insertions (True)
• Explanation: Achilles tendonitis
• scleritis and episcleritis (False)
• Explanation: Typical ocular problem is acute anterior uveitis
• mitral valve disease (False)
• Explanation: An aortitis usually causing aortic regurgitation

Question 21. Features associated with ankylosing spondylitis include

• peak onset in the second and third decades (True)
• subcutaneous nodules (False)
• Explanation: Nodules suggest seropositive arthritis, especially rheumatoid arthritis
• HLA-B27 in at least 90% of affected patients (True)
• Explanation: Identical twins homozygous for HLA-B27 may, however, be discordant for the disease
• faecal carriage of specific Klebsiella species (True)
• Explanation: Klebsiella carry an antigen similar to HLA-B27, suggesting a possible aetiology
• family history of psoriatic arthritis and Reiter’s syndrome (True)
• Explanation: Familial aggregation of overlapping seronegative spondyloarthritides

Question 22. Features suggesting ankylosing spondylitis include

• early morning low back pain radiating to the buttocks (True)
• Explanation: Due to sacroiliitis and sometimes mistaken for lumbar disc disease
• persistence of lumbar lordosis on spinal flexion (True)
• Explanation: Lumbar lordosis may be lost in advanced disease
• chest pain aggravated by breathing (True)
• Explanation: Due to involvement of the costovertebral joints
• ‘squaring’ of the lumbar vertebrae on radiograph (True)
• Explanation: Leading to the ‘bamboo’ spine appearance
• erosions of the symphysis pubis on radiograph (True)
• Explanation: Involvement of cartilaginous joints is a hallmark of the disease

Question 23. In the treatment of ankylosing spondylitis

• systemic corticosteroid therapy is contraindicated (False)
• Explanation: Can be invaluable in acute iritis
• prolonged bed rest accelerates functional recovery (False)
• Explanation: In contrast to rheumatoid arthritis, the patient with ankylosing spondylitis stiffens with bed rest
• spinal radiotherapy modifies the course of the disease (False)
• Explanation: Only to improve symptoms
• spinal deformity is minimised with physiotherapy (True)
• Explanation: Education regarding appropriate back exercises is vital
• hip joint involvement augurs a poorer prognosis (True)
• Explanation: As does extra-articular disease

Question 24. The typical features of reactive arthritis include

• the development of anterior uveitis more often than conjunctivitis (False)
• Explanation: Conjunctivitis is the classical ocular manifestation
• non-specific urethritis and prostatitis (True)
• Explanation: Cause dysuria, frequency and suprapubic discomfort
• symmetrical small joint polyarthritis (False)
• Explanation: Arthritis is asymmetrical, involving large or small joints
• onset 1-3 weeks following bacterial dysentery (True)
• Explanation: Similar delay following sexually acquired infections
• keratoderma blenorrhagica and nail dystrophy (True)
• Explanation: Similar to psoriatic skin and nail disease

Question 25. In Reiter’s disease

• a peripheral blood monocytosis is commonly found (False)
• Explanation: Polymorphonuclear leucocytosis is typical in the acute phase
• sacroiliitis and spondylitis develop in most patients (False)
• Explanation: Occur in only 15% of patients
• Salmonella or Shigella species can be cultured from joint aspirates (False)
• Explanation: Organisms cause the preceding dysenteric illness
• calcaneal spurs are not apparent radiologically (False)
• Explanation: Appear on radiograph as a periostitis
• arthritis resolves within 3-6 months of onset (False)
• Explanation: 10% of patients have chronic active arthritis 20 years after onset

Question 26. Psoriatic arthritis is

• usually preceded by the development of psoriasis (True)
• Explanation: Occasionally there is no evidence of skin disease at onset
• likely to develop in 25% of patients with psoriasis (False)
• Explanation: Occurs in around 7% of patients
• commoner in patients with psoriatic nail changes (True)
• Explanation: Such as pitting and onycholysis
• associated with a poorer prognosis than rheumatoid arthritis (False)
• Explanation: Except for patients with arthritis mutilans
• likely to respond to hydroxychloroquine (False)
• Explanation: Should be avoided due to precipitation of an exfoliative dermatitis

Question 27. Recognised patterns of psoriatic arthritis include

• asymmetrical oligoarthritis of the fingers and toes (True)
• Explanation: Occurs in 40% of patients
• distal interphalangeal joint involvement with nail dystrophy (True)
• Explanation: Occurs in 15% of patients
• sacroiliitis and spondylitis (True)
• Explanation: Develops in 15% of patients-may be indistinguishable from ankylosing spondylitis
• rheumatoid-like symmetrical small joint arthritis (True)
• Explanation: Occurs in 25% of patients
• arthritis mutilans with telescoping of the digits (True)
• Explanation: Occurs in 5% of patients

Question 28. Diseases associated with seronegative spondyloarthritis include

• Sjögren’s syndrome (False)
• Explanation: Either as a primary disorder or in association with some connective tissue diseases
• Whipple’s disease (True)
• Explanation: Rare condition
• coeliac disease (False)
• Explanation: An association between coeliac disease and HLA-B8, DR17 and OQ2 but not HLA-B27
• ulcerative colitis (True)
• Explanation: Arthritis may precede evidence of ulcerative colitis or Crohn’s disease
• Behçet’s disease (True)
• Explanation: Suggested by orogenital ulceration and iritis (more common in Japan)

Question 29. Factors predisposing to hyperuricaemia and gout include

• hypothyroidism (True)
• Explanation: Diminished renal excretion of uric acid
• severe exfoliative psoriasis (True)
• Explanation: Increased purine turnover
• chronic renal failure (True)
• Explanation: Diminished renal excretion of uric acid
• polycythaemia rubra vera (True)
• Explanation: Increased purine turnover
• therapy with loop diuretic agents (True)
• Explanation: Diminished renal excretion of uric acid

Question 30. The clinical features of gout include

• precipitation of an acute attack by allopurinol (True)
• Explanation: Enzyme induction induces an acute attack
• cellulitis, tenosynovitis and bursitis (True)
• Explanation: Non-articular signs may predominate
• the abrupt onset of severe joint pain and tenderness (True)
• Explanation: Onset may be explosively sudden
• serum urate levels fall during an acute attack (False)
• Explanation: Serum urate is usually elevated but may be normal
• loin pain and haematuria (True)
• Explanation: Urate urolithiasis

Question 31. In the treatment of gout

• NSAID therapy increases urinary urate excretion (False)
• Explanation: Uricosuric drugs include probenecid, sulfinpyrazone and the NSAID azapropazone
• salicylates control symptoms and accelerate resolution of the acute attack (False)
• Explanation: Aspirin may worsen an acute attack by reducing renal urate excretion
• allopurinol inhibits xanthine oxidase and hence urate production (True)
• tophi should resolve with control of hyperuricaemia (True)
• allopurinol or probenecid should be given within 24 hours of onset of the acute attack (False)
• Explanation: Delay hypouricaemic therapy unless concomitant colchicine therapy is given

Question 32. In pyrophosphate arthropathy

• calcium pyrophosphate dihydrate crystals are deposited in the synovial cells (False)
• Explanation: Crystals are deposited in articular cartilage then shed into the joint space
• haemochromatosis is a recognised predisposing factor (True)
• the clinical appearances are similar to acute gout (True)
• Explanation: Hence ‘pseudogout’
• the findings on synovial aspiration are indistinguishable from acute gout (False)
• Explanation: Characteristic appearances of calcium pyrophosphate dihydrate (CPPD) crystals under polarising light microscopy
• intra-articular corticosteroid injections are contraindicated (False)
• Explanation: Such injections are often highly effective

Question 33. Osteoporosis is

• usually associated with normal serum calcium, phosphate and alkaline phosphatase (True)
• Explanation: Serum alkaline phosphatase may rise if fractures occur
• more likely to occur if menopause is early (True)
• Explanation: Accelerated bone loss occurs with oestrogen withdrawal
• commonly asymptomatic (True)
• Explanation: Pain only occurs after fracture
• a typical complication of untreated Addison’s disease (False)
• Explanation: Occurs in states of corticosteroid excess
• more common in patients with chronic high alcohol intake (True)
• Explanation: Also associated with cigarette smoking

Question 34. Risk factors for osteoporosis include

• gluten enteropathy (True)
• Explanation: All causes of malabsorption including liver disease
• rheumatoid arthritis (True)
• Explanation: And ankylosing spondylitis
• hyperparathyroidism (True)
• Explanation: Multifactorial
• anorexia nervosa (True)
• Explanation: Multifactorial
• hypogonadism (True)
• Explanation: Improved by androgen replacement therapy

Question 35. Therapies useful in preventing recurrent vertebral fractures in osteoporosis include

• regular exercise (True)
• Explanation: Excessive exercise may be associated with low body weight and osteoporosis
• oral phosphate supplementation (False)
• Explanation: Unless the patient is hypophosphataemic from severe malnutrition
• etidronate (True)
• Explanation: Bisphosphonate therapy is the most effective and best evaluated
• vitamin D and calcium supplementation (True)
• Explanation: But this is less effective than bisphosphonate therapy
• corticosteroid (False)
• Explanation: Causes osteoporosis; androgen and oestrogen therapy are both effective

Question 36. In osteomalacia

• the finding of a proximal myopathy suggests an alternative diagnosis (False)
• Explanation: Characteristic; patients may have difficulty in standing up or in climbing stairs
• bone involvement is characteristically painless (False)
• Explanation: Pain may be generalised and severe
• Chvostek’s sign indicates that the underlying diagnosis may be hyperparathyroidism (False)
• Explanation: Hypocalcaemia increases neuromuscular excitability (latent tetany)
• due to renal disease, 25-hydroxycholecalciferol therapy is recommended (False)
• Explanation: Give 1-a-hydroxycholecalciferol; renal 1-a-hydroxylation is impaired
• pseudofractures on radiograph are pathognomonic (True)
• Explanation: Looser’s zones are translucent bands seen on radiograph

Question 37. Typical features of Paget’s disease of bone include

• onset before the age of 40 years (False)
• Explanation: Onset usually over the age of 60 years
• increased serum alkaline phosphatase and urinary hydroxyproline excretion (True)
• Explanation: Increased bone turnover and osteoblast activity
• presentation with severe bone pain, especially in elderly patients (False)
• Explanation: Insidious asymptomatic progression; with nerve root and spinal cord compression
• delayed healing of fractures (False)
• Explanation: Fractures occur more commonly but usually heal normally
• risk of development of osteogenic sarcoma (True)
• Explanation: Rare complication suggested by bony expansion and localised pain

Question 38. In a male patient with prostate cancer and widespread metastatic bone disease

• osteolytic deposits are characteristic (False)
• Explanation: Prostatic secondaries are typically osteosclerotic
• the plasma parathyroid hormone (PTH) concentration is typically elevated (False)
• Explanation: Serum PTH is usually normal even when the serum calcium is high
• bone pain is invariably present (False)
• Explanation: Asymptomatic disease may be detected coincidentally on radiograph
• the alkaline phosphatase is only elevated if pathological fracture occurs (False)
• Explanation: Serum alkaline phosphatase is frequently elevated due to osteoblast activation
• cyproterone acetate retards progress of the disease (True)
• Explanation: Androgen deprivation therapy is of proven value in prostatic cancer

Question 39. Typical features of systemic lupus erythematosus (SLE) include

• a higher prevalence in Caucasian than in African women (False)
• Explanation: Afro-Caribbean females are particularly susceptible
• onset usually in the fourth and fifth decades (False)
• Explanation: Most commonly in the second and third decades
• impaired function of suppressor T lymphocytes (True)
• Explanation: Associated with polyclonal B lymphocyte activation
• increased prevalence in women compared with men (True)
• Explanation: Genetic factors appear to be of importance in aetiology
• presentation with Raynaud’s phenomenon in young men rather than young women (True)
• Explanation: And in women aged > 30 years

Question 40. Characteristic clinical features of SLE include

• Raynaud’s phenomenon (True)
• Explanation: Not, however, specific to SLE
• alopecia (True)
• Explanation: Occurs in at least 50% of patients
• an erythematous photosensitive facial rash (True)
• Explanation: Characteristic
• absence of renal complications (False)
• Explanation: Renal involvement is not infrequent and heralds a poor prognosis
• neuropsychiatric symptoms (True)
• Explanation: Especially depression and organic psychosis

Question 41. In the management of systemic lupus erythematosus, the following are of proven value

• NSAIDs for renal involvement (False)
• Explanation: NSAIDs may worsen renal function
• corticosteroid therapy for cerebral involvement (True)
• Explanation: High doses are often used initially, then reduced to as low a dose as possible on remission of disease
• plasmapheresis for immune complex disease (True)
• Explanation: Especially when combined with immunosuppressant drugs
• hydroxychloroquine for skin and joint involvement (True)
• Explanation: Beware retinal complications
• long-term corticosteroid therapy during periods of remission to prevent relapse (False)
• Explanation: Little evidence to suggest that this improves the long-term prognosis

Question 42. Recognised features of primary Sjögren’s syndrome include

• an increased incidence of lymphoma (True)
• dryness of the eyes, mouth and vagina (True)
• reduced lacrimal secretion rate (True)
• Explanation: Demonstrable with the Shirmer test
• more males affected than females (False)
• Explanation: More females than males
• a positive IgM rheumatoid factor in over 80% of patients (True)
• Explanation: Not diagnostic of primary Sjögren’s (sicca) syndrome

Question 43. The clinical features of progressive systemic sclerosis include

• presentation with Raynaud’s phenomenon (True)
• Explanation: Raynaud’s may precede other features by years
• reflux oesophagitis and dysphagia (True)
• Explanation: Gastrointestinal tract is involved in most patients
• fibrosing alveolitis (True)
• Explanation: Occurs in the majority of cases
• ulceration, atrophy and subcutaneous calcification of the fingertips (True)
• Explanation: ‘Sausaging’ of the fingers and sclerodactyly are also seen
• anti-DNA antibodies and decreased serum complement levels (False)
• Explanation: ANA only in 50%; anti-DNA antibodies are not seen and complement is normal

Question 44. In polymyositis

• a normal serum creatine kinase does not exclude the diagnosis (True)
• Explanation: Especially common in juvenile myositis
• antinuclear (DNA) antibodies are characteristically absent (True)
• Explanation: Similarly in polyarteritis nodosa
• electromyography is helpful in differentiation from peripheral neuropathy (True)
• underlying malignancy is usually present if weight loss is marked (False)
• Explanation: Weight loss may occur in the absence of malignancy
• an erythematous rash on the knuckles, elbows, knees and face is typical (True)
• Explanation: Cutaneous features suggest dermatomyositis (Gottron’s papules)

Question 45. Features of giant cell arteritis include

• a predominance in females > 60 years of age (True)
• pain in the jaw during eating (True)
• Explanation: Due to claudication of the masseters
• confluent involvement of affected arteries (False)
• Explanation: Histological involvement is characteristically patchy
• difficulty in rising from the seated position (False)
• Explanation: Suggests proximal myopathy
• weight loss with normochromic anaemia and high ESR (True)

Question 46. In polymyalgia rheumatica

• antinuclear and rheumatoid factor antibodies are present in high titre (False)
• Explanation: This finding would suggest an alternative diagnosis
• temporal artery biopsy usually confirms the diagnosis (False)
• Explanation: Biopsy is positive in < 40% of patients
• response to oral corticosteroids typically occurs within 7 days (True)
• Explanation: No such response should prompt a review of the diagnosis
• corticosteroid therapy should be withdrawn after 6 months (False)
• Explanation: Most patients require steroids for a minimum of 2 years
• sudden uniocular blindness suggests steroid-induced cataract (False)
• Explanation: Suggests acute ischaemic optic neuritis due to vasculitis and is a medical emergency

Question 47. The features of classical polyarteritis nodosa include

• increased prevalence in males (True)
• Explanation: Male to female ratio is 2:1
• an association with circulating immune complexes containing hepatitis B virus (True)
• Explanation: HBV markers may only become apparent on follow-up
• involvement of small arteries and arterioles (False)
• Explanation: Systemic vasculitis affecting medium-sized arteries
• multiple peripheral nerve palsies (True)
• Explanation: Due to arteritis of the vasa nervorum
• severe hypertension (True)
• Explanation: Especially in association with renal involvement.

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