Of the following tumour markers, which has the highest specificity for the cancer indicated?
A. Beta-human chorionic gonadotrophin (β-hCG) and testicular cancer.
B. CA 125 and ovarian cancer.
C. CA 19-9 and pancreatic cancer.
D. CA 15-3 and breast cancer.
E. Carcinoembryonic antigen (CEA) and colon cancer
An immediate generalised reaction to which of the following drugs is most likely to be mediated by IgE (immunoglobulin E)?
A. Vancomycin.
B. Radiographic contrast media.
C. Aspirin.
D. Cephalothin.
E. Dextran.
A 52-year-old woman has been given a diagnosis of chronic fatigue syndrome (CFS) by her general practitioner. She meets Centres for Disease Control (CDC) criteria for this diagnosis. Which approach is most likely to be beneficial?
A. Referral to a CFS support group.
B. A graded exercise programme.
C. A selective serotonin reuptake inhibitor (SSRI) antidepressant.
D. Intravenous immunoglobulin.
E. Rest.
A 60-year-old man presents with nephrotic syndrome. He undergoes a renal biopsy. What is the most likely histological finding?
A. Minimal change nephritis.
B. Focal and segmental glomerulosclerosis.
C. IgA (immunoglobulin A) nephropathy.
D. Membranous glomerulonephritis.
E. Amyloidosis.
In addition to ondansetron and dexamethasone, the most effective strategy to reduce delayed chemotherapy nausea for someone receiving highly emetogenic chemotherapy is to add:
A. tropisetron.
B. haloperidol.
C. lorazepam.
D. aprepitant.
E. droperidol.
Which of the following factors is most predictive of future erosions in a patient with rheumatoid arthritis?
A. Sustained raised tender joint count.
B. Sustained prolonged early morning stiffness.
C. Sustained low serum C4 level.
D. Sustained raised C-reactive protein (CRP) level.
E. Expression of human lymphocyte antigen (HLA) - DR 3.
Oral medications, Drugs A and B, have the following properties in healthy individuals. Drug A Drug B Absorption 100% 100% Bioavailability 2% 90% Volume of distribution 350 L 50 L Renal Clearance 2 L/hr 1 L/hr Hepatic clearance 10 L/hr 2 L/hr Protein Binding 75% 25% Compared to healthy individuals, patients with cirrhosis have a much higher concentration of drug A than drug B. The best explanation for this is the difference in:
A. bioavailability.
B. volume of distribution.
C. renal clearance.
D. hepatic clearance.
E. protein binding
Which clinical feature of delirium is most useful for differentiating it from dementia?
A. Inability to count backwards from 30.
B. Failure to recall 3 items after a three-minute delay.
C. Disorientation in time and place but not person.
D. Paranoid delusions.
E. Sleep-wake disturbance with nocturnal wandering
A 56-year-old male presents with a three year history of progressive breathlessness on exercise with a dry unproductive cough. He works in a bank and has a ten pack year smoking history. His lung function is shown below. What is the most likely diagnosis?
A. Chronic bronchitis.
B. Interstitial fibrosis.
C. Emphysema.
D. Kyphoscoliosis.
E. Pulmonary embolism.
Which of the following cells is most important in the pathogenesis of vasculitis in temporal arteritis?
A. Multinucleate giant cell.
B. Macrophage.
C. CD8+ T cell.
D. CD4+ T cell.
E. Dendritic cell.
Which of the following parameters is most likely to decrease in the first trimester of pregnancy?
A. Total T4.
B. Free T4.
C. Total T3.
D. Free T3.
E. Thyroid stimulating hormone
Which of the following observations regarding a rare disorder would provide the best evidence of autosomal dominant inheritance?
A. Father and son affected.
B. Father and daughter affected.
C. Mother and son affected.
D. Mother and daughter affected.
E. Male and female cousins affected
A man with chronic renal failure is on the renal transplant waiting list. He is serologically cytomegalovirus (CMV) negative. If he is to receive a transplant from a CMV positive donor, which of the following is the most appropriate prophylactic regime for CMV disease?
A. Live attenuated CMV vaccination.
B. CMV hyperimmune globulin.
C. Oral acyclovir.
D. Intravenous ganciclovir.
E. Oral valganciclovir.
In idiopathic pulmonary arterial hypertension, an excess of which of the following mediators is most likely to be involved in the pathogenesis?
A. Nitric Oxide.
B. Vasointestinal Peptide.
C. Serotonin.
D. Endothelin 1.
E. Prostaglandin I2.
A defect in elimination of which of the following is most likely to occur post-splenectomy?
A. Polysaccharide antigens.
B. T cell-dependent antigens.
C. Intracellular microbes.
D. Protein antigens.
E. Staphylococcus aureus.
Which of the following cells is most likely to cause bony erosions in patients with rheumatoid arthritis?
A. T-Lymphocyte.
B. B-Lymphocyte.
C. Osteoclast.
D. Osteoblast.
E. Plasma cells.
For which of the following cancers is screening most strongly associated with improved survival?
A. Lung.
B. Prostate.
C. Ovarian.
D. Colon.
E. Melanoma.
A 42-year-old man with schizo-affective disorder and long-standing use of lithium presents with polyuria. Which of the following parameters is most suggestive of psychogenic polydipsia as the cause of his polyuria?
A. Serum osmolarity 287 mOsm/kg [285-295].
B. Serum creatinine 80 umol/l [< 120].
C. Serum sodium 130 mmol/l [135 – 145].
D. Urine osmolality 100mOsm/kg [700-1400].
E. Lack of response to Desamino-D-arginine-8 vasopressin (DDAVP).
A 40-year-old woman treated for Hodgkin’s disease in her early twenties with mantle radiotherapy is at highest risk of which of the following cancers?
A. Breast.
B. Lung.
C. Thyroid.
D. Lymphoma.
E. Sarcoma.
Diabetic neuropathic arthropathy is most likely to affect which of the following areas?
A. Knee.
B. Mid-foot.
C. 1st metatarsophalangeal joint.
D. Elbow.
E. Ankle.
Which one of the following patterns of electrolyte changes is most consistent with tumour lysis? Key to symbols: ↓ = decrease ↑ = increase
A
B
C
D
E
Liberation of dietary cobalamin from R-proteins would be most likely to be adversely affected by:
A. ileal resection.
B. pancreatic insufficiency.
C. coeliac disease.
D. Crohn’s disease.
E. Helicobacter pylori chronic gastritis.
A 48-year-old male presents with a six-month history of daytime somnolence. He worked as a shipbuilder and had previous asbestos exposure from replacing boiler lagging. He has a 15 pack year smoking history. His body mass index (BMI) is 39 kg/m2 [18-26], but otherwise examination is normal. His lung function tests and arterial blood gas are shown above. The most likely diagnosis is:
A. idiopathic pulmonary fibrosis.
B. obesity-hypoventilation syndrome.
C. asbestosis.
D. chronic obstructive pulmonary disease.
E. post-polio syndrome.
What is the most distinguishing feature of loss of imprinting of a growth-promoting imprinted gene?
A. Restoration of normal methylation patterns.
B. Inhibition of cell growth.
C. Reduced expression of the imprinted gene product.
D. Activation of the normally silent allele.
E. Ablation of biallelic gene expression.
A 73-year-old man is referred for assessment of testamentary capacity. There is a past history of excessive alcohol consumption and hypertension. Over the last six months, he has been more forgetful and irritable with occasional socially inappropriate behaviour. His speech is fluent and comprehension normal. There are no focal neurological findings. Testamentary capacity can be best established by which of the following?
A. Clinical assessment.
B. Neuro-imaging.
C. Formal neuropsychological testing.
D. Interview of family members.
E. Mini-mental state examination.
Which of the following best describes the toxicological mechanism of recurrent acute angioedema related to the use of angiotensin converting enzyme (ACE) inhibitors?
A. IgE (immunoglobulin E) mediated hypersensitivity.
B. Delayed-type hypersensitivity.
C. Enhancement of complement activation.
D. Disruption of endothelial tight junctions.
E. Impairment of bradykinin catabolism.
Which of the following drugs used in diabetes treatment is most likely to cause hypoglycemia?
A. Repaglinide.
B. Metformin.
C. Acarbose.
D. Rosiglitazone.
E. Orlistat.
In clinical research, which of the following best describes the meaning of the p value? The probability:
A. that the hypothesis is incorrect.
B. that the hypothesis is correct.
C. of observing a result at least this magnitude if the hypothesis is correct.
D. of observing a result at least this magnitude due to chance.
E. that the hypothesis is due to chance.
Hypomagnesemia is a common biochemical abnormality after renal transplantation and may cause serious cardiac arrhythmias. In this setting, it is most commonly due to:
A. persistent hyperparathyroidism.
B. vitamin D deficiency.
C. mycophenolate.
D. cyclosporin.
E. prednisolone.
A patient presents with weakness of the right hand and face, but sparing the leg. The most likely anatomic location of the stroke is:
A. cerebral cortex.
B. external capsule.
C. internal capsule.
D. pons.
E. medulla.
A 35-year-old man presents with several weeks of generalised unwellness, epigastric pain, vomiting and headaches. He has no past medical history of note. He has a smoking history of 15 pack years and uses daily cannabis. He has been holidaying at the beach for the summer and is tanned. He is mildly dehydrated. The rest of the physical examination is unremarkable. Blood tests show: sodium 139 mmol/L [138-145] potassium 5.4 mmol/L [3.5-5.2] corrected calcium 3.10 mmol/L [2.15-2.57] phosphate 1.50 mmol/L [0.87-1.45] urea 10.4 mmol/L [3.5-8.0] creatinine 0.32 mmol/L [0.05-0.12] parathyroid hormone 0.6 pmol/L [1.6-6.2] His chest X-ray is shown below. What mechanism best explains the hypercalcaemia?
A. Secretion of parathyroid hormone-related peptide (PTHrP).
B. Increased bone resorption.
C. Increased 1,25(OH)2-vitamin D synthesis.
D. Reduced renal clearance of calcium.
E. Mineralocorticoid deficiency.
In a patient with rheumatic mixed mitral valve disease, for which of the following procedures is there the strongest indication for antibiotic prophylaxis?
A. Flexible bronchoscopy.
B. Cardiac catheterisation.
C. Colonoscopy without biopsy.
D. Oesophageal dilatation.
E. Gastroscopy.
A test has a sensitivity of 95% and a specificity of 80%. It is used to screen for a condition with a prevalence of 1 in 100. What will the positive predictive value be nearest to?
A. 0.2%.
B. 0.5%.
C. 1%.
D. 2%.
E. 5%.
Arthritis in which of the following joints is most suggestive of haemachromatosis?
B. Ankle.
C. Distal interphalangeal.
D. Metacarpophalangeal.
E. Metatarsophalangeal.
Defects in the terminal attack elements of the complement system (C6, C7, C8) are most strongly associated with an increased risk of infection with which of the following pathogens?
A. Streptococcus pneumoniae.
B. Neisseria meningitidis.
C. Pneumocystis jiroveci.
D. Listeria monocytogenes.
E. Haemophilus influenzae.
Which of the following is the most appropriate tumour marker for follow-up of a person with medullary thyroid carcinoma?
A. Thyroglobulin.
B. Carcinoembryonic antigen.
C. Calcitonin.
D. Thyroid binding globulin.
E. Chromogranin.
During normal haemostasis, von Willebrand factor (vWF) plays a role in platelet adhesion/aggregation. During this process, which of the following is the primary binding site of vWF to platelets?
A. Collagen receptor.
B. Platelet glycoprotein Ib-IX-V.
C. Adenosine diphosphate receptor.
D. Platelet glycoprotein IIb-IIIa.
E. Ristocetin.
Which of the following is most predictive of variceal haemorrhage in a patient with oesophageal varices?
A. Portal vein pressure.
B. Child-Pugh score.
C. Variceal size.
D. Prolonged prothrombin time.
E. Thrombocytopenia.
Which of the following best explains why the jugular venous pressure (JVP) is raised in patients with congestive heart failure?
A. Pulmonary arterial pressure is increased.
B. Blood pools in the right heart because left heart output is reduced.
C. The failing right ventricle requires a higher distending pressure.
D. The enlarged left atrium compresses the right atrium.
E. The enlarged left ventricle compresses the right ventricle.
The 'number needed to treat' (NNT) to prevent one event is a clinically meaningful measure of the efficacy of treatment. When comparing event rates between two treatment groups in a clinical trial, the NNT is calculated as:
A. the ratio of the event rates.
B. the relative risk minus 1.
C. the absolute risk difference.
D. the reciprocal of the absolute risk difference.
E. the reciprocal of the relative risk.
An 18-year-old male develops a rash and becomes critically ill. The rash is demonstrated above. The most likely finding on blood cultures would be:
A. gram negative rods.
B. gram positive rods.
C. gram negative diplococci.
D. gram positive diplococci.
E. gram positive cocci.
Airline travel is undertaken by many patients with chronic cardio-respiratory disease. When travelling with standard international commercial airlines currently, the partial pressure of oxygen inflight approximates which sea-level FIO2 [Fraction of inspired oxygen]?
A. 5%.
B. 10%.
C. 15%.
D. 21%.
E. 25%.
A 36-year-old woman has a very strong family history of premature coronary disease. Physical examination is normal. Fasting lipid profile reveals: total cholesterol 9.5 mmol/L [2.5-5.2] high-density lipoprotein (HDL) cholesterol 1.5 mmol/L [0.9-1.8] triglycerides 2.00 mmol/L [0.10-1.85] Which abnormality is most likely to be present?
A. apoB 3500 mutation.
B. Cholesteryl ester transfer protein (CETP) deficiency.
C. Hypoalphalipoproteinaemia.
D. Low-density lipoprotein (LDL) receptor defect.
E. Lecithin:cholesterol acetyltransferase (LCAT) deficiency.
A 66-year-old man presents with numbness involving the right thumb and index finger, and the first dorsal webspace and dorsoradial forearm. There is no associated neck pain. On examination, power is normal. The biceps and triceps reflexes are normal and symmetrical. The brachioradialis reflex is reduced on the right. The most likely diagnosis is:
A. median neuropathy.
B. C6 radiculopathy.
C. radial neuropathy.
D. brachial plexopathy.
E. cortical stroke.
In which of the following does mannose binding lectin (MBL) have the most significant role?
A. Carbohydrate metabolism.
B. Fat metabolism.
C. Innate immunity.
D. Cardiovascular homeostasis.
E. Adaptive immunity.
The emergence of a pandemic strain of influenza is best explained by which of the following mechanisms?
A. Antigenic drift in H and N proteins of influenza A.
B. Antigenic shift in H and N proteins of influenza A.
C. Point mutations in the M proteins of influenza A.
D. Development of neuraminidase resistance.
E. Recombination of influenza A and B haemagglutinins.
A man is diagnosed with a rare autosomal recessive disorder. His pedigree is shown below. What is the best estimate of the risk of his cousin (indicated on the diagram by an arrow) developing the same disorder?
A. 1/2.
B. 1/4.
C. 1/8.
D. 1/16.
E. 1/32.
Which of the following is most likely to affect interpretation of the pulmonary artery occlusion pressure trace?
A. Right ventricular outflow tract obstruction.
B. Tricuspid regurgitation.
C. Mitral regurgitation.
D. Pulmonary vein obstruction.
E. Aortic stenosis.
The coupling of osteoblast and osteoclast function is mainly related to the action of which of the following factors?
A. Tumour Necrosis Factor (TNF).
B. Parathyroid hormone (PTH).
C. Receptor activator of NFKB (RANK) ligand.
D. 1,25 (OH)2 cholecalciferol.
E. Oestradiol.
Which one of the following statements is the best description of the molecular basis of a chimaeric protein (eg Bcr-Abl)?
A. Formation of disulphide bonds between cytosine residues on different peptides.
B. Post-transcription ligation of non-homologous messenger RNA (mRNA) molecules.
C. Hybrid messenger RNA (mRNA) synthesis from a bi-directional promoter.
D. Deletion of an exon from one gene.
E. In-frame ligation of the 5`-end of one gene to the 3`-end of another.
Which of the following best explains the morphological appearance of red cells pictured below? Red Cell Parameters Haemoglobin 103 g/L [122-170] Haematocrit 0.30 [0.36-0.49] Mean corpuscular volume 83 fL [80-97] Mean corpuscular haemoglobin 28.3 pg [26.0-34.0] Mean corpuscular haemoglobin concentration 340 g/L [311-352] Red blood cells 3.64 x 1012/L [4.00-5.70]
A. Abnormality of GPI-linked proteins.
B. Red cell enzyme deficiency.
C. Haemoglobin abnormality.
D. Red cell membrane abnormality.
E. Haematinic deficiency.
Of the following antiplatelet actions, which best describes the mechanism of clopidogrel?
A. Phosphodiesterase inhibition.
B. COX1 acetylation.
C. ADP receptor blocking.
D. GP IIb/IIIa blockade.
E. Factor Xa inhibition.
The primary factor leading to the accumulation of ascites in patients with chronic liver disease is?
A. Excessive abdominal lymph formation.
B. Splanchnic vasodilatation.
C. Hypoalbuminaemia.
D. Increased aldosterone secretion.
E. Expansion of plasma volume
The most common cause of treatment failure in pulmonary tuberculosis is:
A. co-existing chronic airways limitation.
B. presence of cavitatory disease.
C. poor adherence to therapy.
D. HIV (human immunodeficiency virus) co-infection.
E. isoniazid resistance.
High-altitude pulmonary oedema is a potentially fatal condition that can occur in 1-2% of individuals travelling to altitudes above 3000m. Which of the following physiological responses to altitude is the most likely cause of high-altitude pulmonary oedema?
A. Profound respiratory alkalosis (pH > 7.6).
B. Cheyne-Stokes respiration during sleep.
C. Hypoxic pulmonary vasoconstriction.
D. Hypoxia-induced left ventricular dysfunction.
E. Hypoxia-induced systemic hypertension.
Hepatic drug clearance is reduced in old age. Which of the following ageing changes is currently believed to have the biggest impact on hepatic drug metabolism?
A. Reduced expression of CYP (cytochrome P450) genes.
B. Oxidative (post-translational) injury to drug metabolizing enzymes.
C. Impaired protein binding and reduced serum albumin.
D. Diminished hepatic volume.
E. Diminished hepatic blood flow.
A boy and his maternal uncle have haemophilia A. Polymerase chain reaction (PCR) analyses of three exons of the gene responsible for haemophilia A, F8C, are shown in the figure below. The analyses included DNA from a normal male (lane 1), the affected boy (lane 2), his affected uncle (lane 3), and the boy’s mother (lane 4). What is the most likely explanation for the presence of a band corresponding to exon 4 in the mother? The mother:
A. has a deletion encompassing exon 4.
B. is a gonadal mosaic for a mutation in exon 4.
C. is a somatic mosaic for a mutation in exon 4.
D. inherited a normal F8C gene from her father.
E. has a polymorphism at a PCR primer site in exon 4.
In the general community, which of the following is the major pathogenic factor for reflux oesophagitis?
A. Excessive acid secretion.
B. Excessive transient lower oesophageal sphincter relaxations.
C. Presence of a hiatus hernia.
D. Impaired oesophageal motility.
E. Impaired gastric emptying.
Drugs A and B have the following properties in healthy individuals: In such healthy individuals, haemodialysis shortens the half-life of drug A much more than it shortens the half-life of drug B. This difference is best explained by which of the following characteristics of drug B?
A. Higher volume of distribution.
B. Much higher renal clearance.
C. Higher plasma protein binding.
D. Higher molecular weight.
E. Lower hepatic clearance.
Old age is associated with diminished pharmacodynamic response to beta adrenergic antagonists (beta blockers). Which of the following mechanisms best explains this?
A. Reduction in the hepatic clearance of beta blockers.
B. Decrease in renal clearance of active metabolites.
C. Decrease in density of beta-receptors.
D. Increase in blood levels of noradrenaline.
E. Decreased intracellular concentrations of cAMP (cyclic adenosine monophosphate).
The diagram below shows the time-course of a typical ventricular myocyte action potential (Figure 1a). Figure 1b shows the principal cation currents between the intra and extra-cellular space concurrent with phase 0-3 of the action potential shown in Figure 1a. The direction and size of the arrows in Figure 1b indicate whether the current is inward-directed or outward-directed and the relative current strengths of the ion identified by a letter at the base of the arrow.
The renal clearance of drugs that are weak bases and weak acids is affected by changes in the urine pH. The most accurate representation of how the pH changes clearance is:
Cholinesterase inhibitors are prescribed for Alzheimer's disease. Which of the following is a typical dose-dependent (type A) adverse drug reaction expected with this group of drugs?
A. Bradycardia.
B. Urinary retention.
C. Constipation.
D. Dry mucous membranes.
E. Extrapyramidal movements.
Which of the following is most characteristic of a patient with haemophilia A with 8% baseline factor VIII activity?
A. Spontaneous cutaneous purpura.
B. Spontaneous gastrointestinal haemorrhage.
C. Spontaneous deep muscle bleeds.
D. Spontaneous haemarthroses.
E. No spontaneous bleeding.
Following kidney transplantation, which of the following is the most likely manifestation of BK virus infection?
A. Aplastic anaemia.
B. Pulmonary infiltrates.
C. Nephropathy.
D. Progressive multifocal leucoencephalopathy.
E. Systemic vasculopathy
A patient presents with an anterior non-ST elevation myocardial infarction with transient T-wave inversion in V3-6. There is a typical rise in CK-MB (creatine kinase myocardial tissue) (2 x URL at 12 hr and 5 x URL at 24 hrs) and Troponin T (2 x URL at 12 hr and 20 x URL at 24 hrs). Levels are expressed as a multiple of the upper reference limit (URL). 72 hours after the onset of the first episode, the patient experiences recurrent chest pain. If present, which of the following BEST indicates that the patient has had a recurrent myocardial infarct?
A. The left anterior artery is occluded at angiography.
B. CK-MB (creatine kinase myocardial tissue) = 5 x URL 12 hrs after recurrent pain.
C. Troponin T = 10 x URL 12 hrs after recurrent pain.
D. Pain duration and intensity is similar to the first event.
E. The ECG now shows deep T-wave inversion in V3-6.
Which of the following is the primary mechanism of body iron regulation?
A. Shedding of duodenal enterocytes.
B. Regulation of enterocyte surface expression of transferrin receptor (TfR1).
C. Regulation of enterocyte ferritin content.
D. Renal haemosiderin excretion.
E. Alteration of Kuppfer cell iron metabolism gene expression
Resistance of gram-positive organisms to penicillin is most commonly mediated through which of the following mechanisms?
A. Antibiotic efflux.
B. Beta-lactamase production.
C. Alteration of the ribosomal target.
D. Modification of penicillin binding proteins.
E. Decreased outer membrane permeability
Which of the following findings is most specific for the diagnosis of pernicious anaemia?
A. Increased serum homocysteine.
B. Increased serum methylmalonate.
C. Positive gastric parietal cell antibodies.
D. Increased serum gastrin.
E. Positive intrinsic factor antibodies.
Which analgesic is most likely to lead to a serious drug interaction if combined with an MAO (monoamine oxidase) inhibitor (e.g. moclobemide)?
A. Morphine.
B. Indomethacin.
C. Tramadol.
D. Celecoxib.
E. Fentanyl.
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