STUDENT NAME: Student ID:

Ollscoil na hÉireann
Gaillimh

National University of Ireland,

Galway

Semester 2 Examination – May,

2016

Exam Code: 3MB3

Module Code: MD314

Examiners: ​Dr. Faisal Sharif

Dr. Gerard Flaherty Dr. John Lee Dr.
John O Donnell Dr. Kieran Kennedy
Dr. Michael Scully Prof. Anthony
O’Regan Prof. Eamon Mulkerrin
Prof. Joe Harbison (External
Examiner) Prof. Michael Kerin Prof.
Stewart Walsh Prof. Timothy
O’Brien

Instructions: Single Best Answer Multiple Choice

Questions.
Please answer each of the following questions by selecting the ​SINGLE ​best
answer

in each case. There is NO negative marking. Each question carries the

same

number of marks. Please record your answers (in block capitals, i.e. A, B, etc.) in
the
 box provided beside each question on the printed question/answer sheet AND
on

the computer. Do NOT bring the question sheet out of the examination hall.
Please

write your name and ID number in the space provided on the each page of
this

printed question/answer sheet.

Duration: 2 hours

Page ​1 ​of ​12 PTO

STUDENT NAME: Student ID:

1. An 85 year-old retired fisherman presents to the emergency department with shortness of

breath and bilateral lower limb swelling. His past medical history includes non-ST segment
myocardial infarction, type 2 diabetes mellitus and dyslipidaemia. In an effort to treat himself, he
recently restarted a course of calcium channel blockers prescribed years ago by his previous
cardiologist. Physical examination yields significant jugular venous distention, an S3 heart
sound and diffuse bibasal crackles. A chest X-ray reveals cardiomegaly, pulmonary oedema
and a small left-sided pleural effusion. Which of the following would be most effective in the
initial treatment of this patient?

a) Acetazolamide b)
Amiloride c) Frusemide
d) Hydrochlorothiazide e)
Mannitol

2. An orthopaedic surgeon on-call admits an 18 year-old college student with a bimalleolar

ankle fracture following a fall while ice skating. On examination, the surgeon notes the
presence of a heart murmur, but is uncertain about its exact aetiology. He requests a pre-
operative transthoracic echocardiogram and puts through a cardiology consult. Which of
 the following heart lesions is correctly matched with its associated auscultatory finding?

a) Atrial septal defect – paradoxical splitting b)

Bicuspid aortic valve – mid-systolic click c) Mitral
regurgitation – ejection systolic murmur d) Mitral
stenosis – loud S1 e) Pulmonary stenosis –
mid-diastolic murmur

3. The admitting cardiologist is called to the emergency department to see an elderly

patient with suspected acute coronary syndrome (ACS). On examination, the patient is
short of breath, anxious and profoundly diaphoretic but not in any chest pain.
Electrocardiography shows approximately 5mm of ST-segment elevation in leads V​2

through V​5​. Cardiac troponins

​ are twenty times the upper limit of normal. A diagnosis of
STEMI is made and the appropriate care pathway is initiated. To account for her lack of
chest pain, the patient’s past medical history will most likely reveal which of the following?

a) Chronic opiate use b)

Diabetes mellitus c)
Hypothyroidism d) Parietal
pleurectomy e) Recent
chemotherapy

Page ​2 ​of ​12 PTO

STUDENT NAME: Student ID:

4. A 65 year-old gentleman presents to the emergency department with increasing

shortness of breath. He has not seen a doctor in 10 years and reports no past medical
history. He is not on any medications. Which of the following laboratory investigations
would be most helpful in excluding heart failure as the cause of this gentleman’s
dyspnoea?

a) Angiotensin converting enzyme

b) B-type natriuretic peptide c)
CK-MB d) Lactate dehydrogenase
 e) Troponin T

5. A 32 year-old accountant presents to her family physician with malaise, fever and
orofacial pain following a procedure to remove an impacted wisdom tooth two weeks
earlier. In addition to new auscultatory findings, red-brown linear streaks are present in the
nailbed of her right index and middle fingers. Which of the following investigations will be
most useful in diagnosing this lady’s underlying condition?

a) Autoantibody screen b)
Blood cultures c) CT head
and neck d)
Orthopantomogram e)
Slit-lamp examination

6. An exceptionally tall 36 year-old gentleman presents to the emergency department with

severe central chest pain radiating to his midback. An emergent surgical procedure is
attempted by the cardiothoracic team, but sadly the patient dies in the operating theatre.
His medical files reveal a history of mitral valve prolapse, ectopia lentis and hindfoot valgus.
Which of the following is most likely to be found on the post-mortem histopathology report
of the aorta?

a) Cystic medial degeneration b)

Granulomatous inflammation c)
Hyaline arteriolosclerosis d)
Leukocytoclastic vasculitis e)
Necrotising arteriolitis

Page ​3 ​of ​12 PTO

STUDENT NAME: Student ID:
7. An 82 year-old gentleman is transferred to a community hospital for physical
rehabilitation following an elective aortic valve replacement (AVR) plus coronary artery
bypass grafting (CABG) procedure. The procedure was uncomplicated and the immediate
postoperative course was unremarkable. However, two days after his arrival, the patient
becomes unwell. He is febrile with a temperature of 40.1 ̊C. On examination there is
sternal instability and purulent discharge from the lower end of the wound. Preliminary lab
results indicate profound leukocytosis and elevated C-reactive protein. Which of the
following is the definitive treatment for this patient’s condition?

a) Bedside needle aspiration b) Change

to cell-based dressing c) Full-thickness
skin graft d) Surgical debridement and
washout e) Wound packing with
fine-mesh gauze

8. A 50 year old lady present to her General Practitioner with symptoms of fatigue and
pruritus. Examination is unremarkable. She does not have any past medical history nor
does she take any medications. She recently travelled to the UK to visit her daughter.
Blood tests show a Bilirubin of 30umol/L, ALP 1012IU/L, ALT 120IU/L, Albumin 39g/L.
Antimitochrondrial antibody was positive. ​What is the most likely diagnosis?

a) Alcoholic Liver Disease b) Non

Alcoholic Steatohepatitis c)
Primary Biliary Cirrhosis d)
Primary Sclerosing Cholangitis e)
Viral Hepatitis

9. A 25 year old male with a diagnosis of ulcerative colitis has just commenced
Azathioprine,
a purine anti-metabolite. Which of the following is a side effect of this
medication?

a) Acute pancreatitis b)
Bronchospasm c)
Oesophageal spasm d)
Psoriasis e)
 Thyrotoxicosis

Page ​4 ​of ​12 PTO

STUDENT NAME: Student ID:

10. When examining a 59 year old male patient with alcoholic liver disease you note that he
has a hepatic flap and foetor hepaticus. Which of the following is used in the management
of hepatic encephalopathy? a) Benzodiazepines b) Lactulose c) Low-fat diet d)
Spironolactone e) Terlipressin

11. A patient with persistent symptoms of achalasia attends the gastroenterology clinic. The
treatment options for Achalasia include which of the
following:

a) Heller myotomy b)
Nissen fundoplication c)
Oesophagectomy d) Oral
botulin toxin e) Proton
Pump Inhibitor

12. A 45 year old patient is complaining of bilateral shoulder pain 24 hours after
laparoscopic
cholecystectomy. What is the likely cause of this
pain?

a) Bile leak b) Bleeding c) CO2 gas irritating

the diaphragmatic nerves d) Postoperative
infection e) Pulmonary Embolism
 13. A male patient with obstructive jaundice underwent unsuccessful ERCP two days ago.
His liver function tests are deteriorating. Which of the following treatment options would you
recommend to decompress his biliary system?

a) Gastro-jejunostomy b) Magnetic resonance

cholangiopancreatography c) Oesophago-gastro
duodenoscopy d) Percutaneous transhepatic
cholangiography e) Pyloroplasty

Page ​5 ​of ​12 PTO

STUDENT NAME: Student ID:

14. In the management of perforated gastric ulcer which of the following is

true?
a) Endoscopy is the diagnostic tool of choice b) Gastric adenocarcinoma should be
considered c) It is not necessary to take biopsy of ulcer edges during operation d)
The absence of air under the diaphragm excludes the presence of a perforated
ulcer e) Triple therapy is not indicated

15. A 73 year old gentleman attends the geriatric medicine outpatient department
with
cognitive impairment. He is accompanied by his wife, who asks if her husband’s
cognitive impairment is ‘reversible’? Which of the following is not a cause of
‘reversible’ dementia?

a) Depression b) Hyperthyroidism c)
Normal pressure hydrocephalus d)
Subdural haematoma e) Vitamin
B12 deficiency
 16. . A 74 year old man is found lying on the floor of his home by his daughter, and tells her
that
he had a fall 6 hours previously. Which of the following is not typically seen as part
of a ‘long lie’?

a) Aspiration pneumonia b)
Dehydration c) Fever d)
Pressure sores e)
Rhabdomyolysis

17. A 64 year old woman returns to the geriatric medicine outpatient clinic to discuss the
results of DEXA bone densitometry of the hip, that was ordered at her previous clinic
review, as you were concerned that she may have osteoporosis. Which of the following
results confirms your suspicion of osteoporosis?

a) T-score 0 b)
T-score -0.75 c)
T-score -1.5 d)
T-score 2.5 e)
T-score -3.0

Page ​6 ​of ​12 PTO

STUDENT NAME: Student ID:

18. A 58 year old male presents to the emergency department with acute onset of
weakness of the left arm, leg and neglect. The registrar in the emergency department
completes the National Institutes of Health Stroke Scale (NIHSS). Which of the following
pairings is incorrect?
 a) NIHSS 0 and no stroke b)
NIHSS 10 and moderate stroke c)
NIHSS 24 and severe stroke d)
NIHSS 3 and minor stroke e)
NIHSS 5 and minor stroke

19. A 78 year old gentleman attends the geriatric medicine outpatient clinic as his family
are concerned that he is drowsy throughout the day, despite sleeping well at night. His past
medical history is significant for hypertension, diabetes mellitus, chronic kidney disease,
rheumatoid arthritis, chronic obstructive pulmonary disease and parkinsonism. He attends
outpatient clinics with multiple specialities across two hospital sites. Which of the following
factors may reduce the risk of drug interactions?

a) Attending a single pharmacy b) Chronic kidney disease

which may modify drug clearance c) Consumption of
high-risk drugs including warfarin, digoxin d) Increased
medication consumption e) Visiting multiple prescribers

20. A 66 year old woman is admitted to hospital with an ischaemic stroke, after presenting
with unilateral weakness, aphasia and neglect. She receives thrombolysis and is managed
on the acute stroke unit. With respect to secondary prevention of stroke, which of the
following is inappropriate?

a) Anticoagulation in patients with atrial fibrillation b) Carotid

endarterectomy in those with high-grade carotid stenosis (>70%) c) Dual
antiplatelet therapy d) Systolic blood pressure reduction with ACE
inhibitor or ARB e) Treatment of hyperlipidaemia with statin therapy
 Page ​7 ​of ​12 PTO
STUDENT NAME: Student ID:

21. A 65 year old woman with a history of ovarian cancer presents with associated
shortness of breath that developed gradually over the last two weeks. She has had no
hemoptysis, palpitations or lower extremity edema. Exam reveals normal vital signs. She
has decreased breath sounds over her right hemithorax, with stony dullness on percussion
and decreased tactile fremitus. What is the most likely diagnosis?

a) Empyema b) Lobar Community

Acquired Pneumonia c) Malignant Pleural
Effusion d) Pneumothorax e) Pulmonary
Embolism

22. A 59 year old woman presents to your clinic with worsening shortness of breath over
the
last six months. She has never smoked cigarettes or travelled outside of Ireland. She
works in hotels. She has no pets. Her exam reveals oxygen saturation of 92%, bilateral
fine crackles 1/3 of the way up, no jugular venous distention and no lower extremity
edema. The most likely diagnosis is

a) COPD b) Interstitial lung disease c)

Motor Neuron Disease d) Pulmonary
hypertension e) Squamous Cell
Carcinoma of the lung
 23. Which of the following is not used to calculate the
CURB-65?
a) Confused Mental Status
b) Creatinine > 140 c)
Patient Age d) Respiratory
Rate > 30 e) Urea >7

Page ​8 ​of ​12 PTO

STUDENT NAME: Student ID:

24. A 29 year old woman with a history of chronic sinusitis presents to your office with
complaints of streaky hemoptysis for the last two weeks. She reports that she has lost 5 kg
in the last two months and describes lethargy and malaise. She has noticed that her urine
is reddish brown on and off for the last five months. She has lived in Ireland her whole life,
and has only travelled to the UK five months ago, for a training workshop for her job as an
administrator at Google. She has no pets, birds, and smoked a half a pack of cigarettes a
day for two years in her early twenties. On exam, you note that her vital signs and
cardiopulmonary exam are all normal. CXR shows a cavitating lesion in right lower lung
zone. The next appropriate diagnostic step includes:

a) c-ANCA b) CTPA c) Interferon

Gamma Release Assay d) PFTs with
Diffusion Capacity e) Sputum Culture

25. A 29 year old patient is referred to your clinic with worsening dyspnea on exertion. He
has
done Pulmonary Function Tests which reveal the following results. FEV1/FVC Ratio
89% FEV1 of 66%, FVC of 70% predicted. His TLC is 69%. DLCO is 87% predicted.
 Which of the following is most consistent with these PFT findings? a) Asthma with
fixed obstruction b) COPD c) Cystic Fibrosis d) Obesity e) Pulmonary Hypertension

26. A 55 year old woman presents with increased sputum production, fever of 39.3,
and
shortness of breath. She is diagnosed with Community Acquired Pneumonia.
Sputum culture is most likely to grow: a) Escherichia coli b) Haemophilus influenza
c) Pneumocystis Jiroveci d) Pseudomonas aeruginosa e) Staphylococcus aureus

27. . Which of the following is NOT a recognised cause of reduced DLCO on PFT
testing?

a) Anaemia b) Cystic Fibrosis c)

Emphysema d) Idiopathic
pulmonary fibrosis e) Pulmonary
hypertension

Page ​9 ​of ​12 PTO

STUDENT NAME: Student ID:

28. The following signs are found on examination of a male patient’s airway. Which of
them
suggests difficulty with tracheal intubation?

a) A beard

b) A thyromental distance of 8 cm

c) Ability by the patient to protrude the lower incisors beyond the upper
incisors

d) Cormack-Lehane grade 1

e) Mallampati score of 4

29. A 60-year -old man presents for a hemicolectomy for bowel cancer. He has a
history of
atrial fibrillation and is on warfarin for the same. His last dose of warfarin was three
days ago and his INR today is 1.6. With respect to postoperative analgesia:
 a) A combination of Intravenous paracetamol and rectal diclofenac is a sufficient
analgesic
regimen b) Epidural anaesthesia is contraindicated because of persistent effect of warfarin
c) Fentanyl patch is a comfortable choice for the first three postoperative days d)
Multimodal regimen is best avoided as interactions and side-effects are more common
e) Spinal morphine is a suitable alternative in this patient

30. A 25-year old woman who is pregnant for the first time requested epidural
labour
analgesia:

a) An epidural top-up cannot be used for Caesarean section because of the slow
onset of
action b) Spinal anaesthesia is the preferred choice for labour analgesia c) The correct
position of the needle is confirmed by the appearance of the cerebrospinal
fluid d) The epidural needle must be inserted below the third lumbar vertebra e) The
most common regimen includes a combination of local anaesthetic and opioid

31. A 55-year old patient presents to the pre-assessment clinic before an urgent
nephrectomy
for renal carcinoma. He is a smoker with a history of a laryngeal carcinoma that was
treated with radiotherapy. On examination of his airways, he has very limited mouth
opening (1 finger breadth) and Mallampati score of 4.

a) A fibre-optic bronchoscope is used as a guide for endotracheal tube

insertion b) A gum elastic bougie is an adjunct of choice for securing the
airway c) An Laryngeal Mask Airway is the airway device of choice d) Rapid
sequence induction is the method of choice to secure difficult airways e) The
surgery can be performed under the regional anaesthesia

Page ​10 ​of ​12 PTO

STUDENT NAME: Student ID:

32. A 75-year old patient had been producing 75ml/hour of urine before developing
complete
 anuria on the first post-operative day after an urgent nephrectomy for renal carcinoma.
He has a urinary catheter in situ.

a) A bolus of gelofusine 500 ml over 30 minutes is indicated

immediately b) A conservative approach with a careful observation is
sufficient c) Blocked urinary catheter is the most likely cause d)
Haemodialysis should be undertaken immediately e) Red blood cell
transfusion is indicated for suspected haemorrhage

33. A 42-year old man is treated in the Emergency Department for urinary tract infection
and
septic shock:

a) Dobutamine is the vasopressor of choice in this patient b) Fluid resuscitation

should be limited to 1500 ml of crystalloids and 500 ml of colloids c) Supplemental
oxygen is not indicated in this patient as his SpO2 is 96% d) The patient should be
transfused urgently to achieve a haemoglobin of 10 g/dl to
improve tissue oxygen delivery e) The single most important
intervention is to give IV antibiotics

34. You are called to see a 70-year old man on the day care unit who has had a
lower GI
endoscopy under sedation. He is known to suffer from ischaemic heart disease and he
is now complaining of severe central chest pain, nausea and shortness of breath. On
arrival he appears sweaty and pale. His BP is 160/100, pulse 125 bpm, respiratory rate
25 per minute and SpO2 on room air is 88%. There is evidence of pulmonary oedema
on the chest X-ray.

a) Adrenaline infusion should be started to increase the myocardial contractility

(positive
inotropic effect) b) An intravenous bolus of a loop diuretic is indicated c) Aspirin 75 mg is
indicated d) Elevations of ST segments in V3-V6 indicate an acute inferior MI e) The
patient is in cardiogenic shock and requires immediate intubation and mechanical
ventilation

35. A 69 year old man with type 2 DM controlled by oral agents is having low blood
 sugars.
Which of the following is likely to be causing episodes of
hypoglycaemia?

a) Sitagliptin b)
Pioglitazone c)
Metformin d)
Gliclazide e)
Acarbose

Page ​11 ​of ​12 PTO

STUDENT NAME: Student ID:

36. A 67 year old man is found to have a serum calcium of 2.9mmol/L (normal range
2.15-2.55) when being evaluated after a wrist fracture. Serum Parathyroid Hormone is
86ng/L (normal range 10-65ng/L). When considering management of this condition, which
of the following would be considered indications for surgery?

a) Age >75 years b) Hypertension c) Low

urine calcium d) Lumbar spine bone
density T-score -3.5 e) PTH > 65ng/L

37. Which of the following associations is

incorrect?

a) Corrigan’s Sign and Aortic Regurgitation b)

Lhermitte’s Sign and Multiple Sclerosis c)
Ramsey Hunt Syndrome and Herpes Zoster
d) Schamroth’s Sign and Clubbing e)
Virchow’s node and Lung cancer

38. You are the Acute Medicine Unit Intern. Your patient is a 42 year old man who
describes
sudden onset of a very severe headache unlike anything he has felt before. “It felt like I
was hit with a baseball bat”. He is afebrile and has neck stiffness on examination. The
most likely diagnosis is:
 a) Bacterial meningitis b)
Classic migraine c) Cluster
headache d) Subarachnoid
haemorrhage e) Viral meningitis

39. The preferred option for a thyroid nodule that is considered suspicious for
malignancy
on Fine Needle Aspiration Bioposy is: ​a)
Excision of the nodule b) Lobectomy c)
Repeat Ultrasound and FNAB in 6 months d)
Repeat ultrasound only to monitor size e)
Total thyroidectomy

40. Which of the following is a favourable prognostic factor in breast

cancer?

a) ER receptor positivity b) Grade III tumour c)

Herceptin-2 oestrogen receptor overexpression d)
Lymph node involvement e) Lymphovascular
invasion present

Page ​12 ​of ​12 PTO