MCQs

1. MCQs Dr. Prakruthi J MD,DNB Asst. Prof., Dept. of General Medicine

2. 1. All the following are true about peripheral vascular disease except : • Mechanism of injury may be thrombotic, thromboembolic, hemodynamic. • PAD affects the leg eight times more often than the arm • May present as intermittent claudication and critical limb ischaemia • Always present as chronic onset with slow progression

3. Answer D Speed of onset : • Where PAD develops slowly, a collateral supply will develop • Sudden occlusion of a previously normal artery is likely to cause severe distal ischaemia • Mechanism of injury • Haemodynamic • Thrombotic • Atheroembolic • Thromboembolic

4. 2. All of the following are true about Ankle Brachial Pressure index except: • the ratio between the (highest systolic) ankle and brachial blood pressures • Normal ABPI is > 1.0 • intermittent claudication 0.5-0.9 • Critical ischaemia < 0.2

5. ANSWER D • The presence and severity of ischaemia can be determined by clinical examination and measurement of the ankle:brachial pressure index (ABPI), • The ratio between the (highest systolic) ankle and brachial blood pressures. • In health the ABPI is > 1.0, in intermittent claudication typically 0.5-0.9, and in critical limb ischaemia usually < 0.5.

6. 3. Raynaud’s phenomenon which of the following is false: • Primary Raynaud’s is more common in females in >45 yrs. • characteristic sequence of digital pallor due to vasospasm, followed by cyanosis and then rubor. • Secondary Raynaud’s phenomenon is seen in CREST, thoracic outlet obstruction, vibration induced injury. • Sympathectomy may be considered in secondary causes.

7. Answer A • Primary Raynaud's phenomenon • This is also called Raynaud's disease and affects 5-10% of young women in temperate climates. • The condition is often familial and usually appears between the ages of 15 and 30 years. • It does not progress to ulceration or infarction and significant pain is unusual. No investigation is necessary and the patient should be reassured and advised to avoid exposure to cold, in the first instance.

8. Case Scenario A 50yr old male patient, an alcoholic and smoker presents with a 3 hour history of severe retrosternal chest pain and increasing shortness of breath. He started having this pain while eating, which was constant and radiated to the back and interscapular region. He was a known hypertensive. On examination, he was cold and clammy with a heart rate of 130/min, and a BP of 80/40mm Hg. JVP was normal. All peripheral pulses were present and equal. Breath sounds were decreased at the left lung base and chest x ray showed left pleural effusion. What is the most likely diagnosis?

9. 4. Most probable diagnosis : • Acute aortic dissection • Acute myocardial infarction • Rupture of the esophagus • Acute pulmonary embolism

10. Answer a • COMMON PRESENTATIONS • Incidental • On physical examination, plain X-ray or, most commonly, abdominal ultrasound • Even large AAAs can be difficult to feel, so many remain undetected until they rupture • Studies are currently under way to determine whether screening will reduce the number of deaths from rupture • Pain In the central abdomen, back, loin, iliac fossa or groin

11. Thromboembolic complications • Thrombus within the aneurysm sac may be a source of emboli to the lower limbs • Less commonly, the aorta may undergo thrombotic occlusion • Compression Surrounding structures such as the duodenum (obstruction and vomiting) and the inferior vena cava (oedema and deep vein thrombosis) • Rupture Into the retroperitoneum, the peritoneal cavity or surrounding structures (most commonly the inferior vena cava, leading to an aortocaval fistula)

13. 5. Factors predisposing for aortic dissection all except: • a. Hypertension • b. Collagen disorders • c. Female gender • d. Fibromuscular dysplasia

14. Answer c • Factors predisposing aortic dissection: • Hypertension (80% of cases) • Aortic atherosclerosis • Non-specific aortic aneurysm • Aortic coarctation • Collagen disorders (e.g. Marfan's syndrome, Ehlers-Danlos syndrome)

15. Fibromuscular dysplasia • Previous aortic surgery (e.g. CABG, aortic valve replacement) • Pregnancy (usually third trimester) • Trauma • Iatrogenic (e.g. cardiac catheterisation, intra-aortic balloon pumping) • The peak incidence is in the sixth and seventh decades of life but dissection can occur in younger patients, most commonly in association with Marfan's syndrome, pregnancy or trauma; men are twice as frequently affected as women.

16. 6. Which of the following statements is not true about abdominal aortic aneurysm? • Men are affected three times more commonly than women • The median age at presentation is 65 years for elective and 75 years for emergency cases • Ultrasound is the best way of establishing the diagnosis • AAA of >4cms should be considered for repair even if asymptomatic

17. Answer d • AAAs are present in 5% of men aged over 60 years and 80% are confined to the infrarenal segment. • Men are affected three times more commonly than women. The median age at presentation is 65 years for elective and 75 years for emergency cases. • About two-thirds of AAAs are sufficiently calcified to show up on a plain abdominal X-ray.

18. Ultrasound is the best way of establishing the diagnosis; an approximate size may be obtained, and the technique can be used to follow up patients with asymptomatic aneurysms that are not yet large enough to warrant surgical repair. • Until an asymptomatic AAA has reached a maximum of 5.5 cm in diameter, the risks of surgery generally outweigh the risks of rupture

19. 7. Which one of the following is a cause of Restrictive cardiomyopathy: • Alcohol • Amyloidosis • Histoplasmosis • SLE

20. Answer b • The three common causes of Restrictive cardiomyopathy: • Amyloidosis • Radiation • Myocardial fibrosis after open heart surgery • Amyloidosis is the most common cause of restrictive cardiomyopathy in the UK. However, other forms of infiltration (e.g. glycogen storage diseases), idiopathic perimyocyte fibrosis and a familial form of restrictive cardiomyopathy can present with this form of heart disease

21. 8. All the statements are true rregarding HOCM except: • Most common form of cardiomyopathy. • May present as sudden death • ECG is usually abnormal and may show the features of left ventricular hypertrophy with a wide variety of often bizarre abnormalities (e.g. pseudo-infarct pattern, deep T-wave inversion). • No genetic predisposition

22. Answer d • Hypertrophic ostructivecardiomyopathy is a genetic disorder with autosomal dominant transmission, a high degree of penetrance and variable expression. • In most patients, the disease appears to be due to a single point mutation in one of the genes that encode sarcomeric contractile proteins. There are three common groups of mutation with different phenotypes

23. May present as: • Angina on effort • Dyspnoea on effort • Syncope on effort • Sudden death

24. 9. All are true about HOCM except: • Beta agonists are useful • Asymmetrical hypertrophy of septum • Dynamic L.V. outflow obstruction • Double apical impulse

25. Answer a • Beta-blockers and the rate-limiting calcium antagonists (e.g. verapamil) can help to relieve angina and sometimes prevent syncopal attacks • Signs: • Jerky pulse • Palpable left ventricular hypertrophy • Double impulse at the apex (palpable fourth heart sound due to left atrial hypertrophy) • Mid-systolic murmur at the base • Pansystolic murmur (due to mitral regurgitation) at the apex

26. 10. All of the following are causes of dilated cardiomyopathy except: • Alcohol • Churg Strauss Syndrome • Duchenne Muscular dystrophy • Viral Myocarditis

27. Answer b

28. 11. All of the following combination of spinal level and vertebral body are true except: • Sacral segment ends at L1 • Upper cervical segmentSame as cord level • Lower cervical segment 1 level higher • Lumbar spinal segment T8 to T10

29. Answer D

30. 12. All are true regarding transverse section of the spinal cord except: • Lateral spinothalamic tract carries pain and temperature • Posterior column carries pressure, joint position, vibration sense • Fasciculus Gracilis carries sensation from the upper limb • Anterior horn cells are motor

31. Answer c

32. 13. All of the following are components of Brown Sequard syndrome except: • Ipsilateral extensor plantar response • Ipsilateral pyramidal tract involvement • Contralateral spinothalamic tract involvement • Contralateral posterior column involvement

33. Answer d • This consists of ipsilateral weakness (corticospinal tract) and loss of joint position and vibratory sense (posterior column), • with contralateral loss of pain and temperature sense (spinothalamic tract) one or two levels below the lesion. • Segmental signs, such as radicular pain, muscle atrophy, or loss of a deep tendon reflex, are unilateral. Partial forms are more common than the fully developed syndrome.

34. 14. All of the following statements about extramedullary tuomrs are true except: • These can lead to Brown Sequard syndrome • Radicular pain is often present • Early sacral sensory loss occurs • Spastic weakness in the legs is a feature

35. Answer a

36. 15. Which of the following is the root value of Knee jerk: • L2/L3 • L3/L4 • L4/L5 • L5/S1

37. Answer b • Ankle Jerk : L5/S1

38. 16. All of the following are true about Cervical Spondylotic Myelopathy except: • Affects Posterior one third of the cord • insidious and painless • Sensory loss in the upper limbs is common, producing tingling, numbness and proprioception loss in the hands, with progressive clumsiness • disturbance of micturition is a very late feature

39. Answer A • Dorsomedialherniation of a disc and the development of transverse bony bars or posterior osteophytes may result in pressure on the spinal cord or the anterior spinal artery which supplies the anterior two-thirds of the cord

40. 17. Painless burn in the hand is a characteristic feature of : • Syringomyelia • Thalamic syndrome • Cord compression • SLE

41. Answer a • The presentation is a central cord syndrome consisting of dissociated sensory loss (loss of pain and temperature sensation with sparing of touch and vibration) and areflexic weakness in the upper limbs.

42. 18. True about lumbar canal stenosis are all except: • congenital narrowing of the lumbar spinal canal • develop exercise-induced weakness and paraesthesia in the legs • absent of peripheral pulses with absent ankle reflexes • quickly relieved by a short period of rest

43. Answer C • The patients, who are usually elderly, develop exercise-induced weakness and paraesthesia in the legs (caudaequinaclaudication). • These symptoms progress with continued exertion, often to the point that the patient can no longer walk, but are quickly relieved by a short period of rest. • Physical examination at rest shows preservation of peripheral pulses with absent ankle reflexes. • Weakness or sensory loss may only be apparent if the patient is examined immediately after exercise.

44. 19. Which of the following are associated with abrupt onset of symptoms: • Glioma • Anterior spinal artery infarct • Syringomyelia • Hereditary Spastic paraplegia

45. Answer b

47. 20. Physical signs of root compression of C6 are all except: • Brachioradialis muscle weakness • Loss of Supinator reflex • Loss of Biceps reflex • Sensory loss over Lower lateral arm, thumb, index finger

48. Answer c

49. 21. Endocrine causes of secondary hypertension are all except: a. Acromegaly b. Primary hypothyroidism c. Thyrotoxicosis d. Hypoaldosteronism

50. Answer d CAUSES OF SECONDARY HYPERTENSION • Alcohol • Obesity • Pregnancy (pre-eclampsia) • Renal disease - Renal vascular disease - Parenchymal renal disease, particularly glomerulonephritis - Polycystic kidney disease • Drugs e.g. Oral contraceptives containing oestrogens, anabolic steroids, corticosteroids, non-steroidal anti-inflammatory drugs, carbenoxolone, sympathomimetic agents • Coarctation of the aorta (p. 637) The pathogenesis of essential hypertension is not clearly understood. Different