Medicine MCQs for Medical Professional 3rd Edition

Medicine C

M Qs for Medical Professionals

Medicine C

M Qs for Medical Professionals Third Edition

Dr. Ajay Mathur

Professor of Medicine SMS Medical College and Hospital Jaipur, Rajasthan, India

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Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 2014, Jaypee Brothers Medical Publishers The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book. This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought. Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. Inquiries for bulk sales may be solicited at: [email protected] Medicine MCQ’s for Medical Professionals First Edition: 2007 Second Edition: 2010 Third Edition: 2013 Reprint: 2014 ISBN 978-93-5152-551-6 Printed at

Foreword







As a professional who has been practicing medicine for over four decades now, I appreciate the value this book brings to the table in times like today. As we move from a largely descriptive era to the bullet-point generation, this academic initiative appears even more relevant than its first two editions. Many refinements have been made in this book bearing in mind the reception it has received in the last few years. The book has been a reference point for many medical entrance examinations and has left an impact on medical professionals who look for high quality of academic material. Harrison’s Principles of Internal Medicine, published by The McGraw-Hill Companies, Inc. is an epic in the world of medical science. This book serves as a faithful companion to the epic by assisting the readers draw most out of it in the service of mankind. Knowledge is a more processed form of information. Prof. Ajay Mathur stays true to his pledge by presenting well-digested bytes of knowledge across different fields of medicine. He relies on good old word-of-mouth to make this book a success rather than blitzkrieg marketing. I recommend that you make this a must-have without a shadow of doubt. Dr Ramesh Roop Rai Professor & Head, Gastroenterology (Retd.) SMS Medical College & Hospital, Jaipur Past President, Indian Society of Gastroenterology (2008)

Preface Medicine, in all its vastness, needs to be understood in a way that makes most sense to how it is applied today. Memorizing each word is elusive and therefore, testing knowledge of a discipline remains an evergreen challenge. It is a widely accepted fact that taking a quiz soon after studying helps one retain information and knowledge better. The brain works in mysterious ways but a sure way of holding onto what the mind has already digested is to put lessons to test. Multiple Choice Questions are a quick and effective way of remembering the gist of the matter. This is precisely the reason why most examinations today follow this format. This book is committed to hone your skills for retaining knowledge; it is only axiomatic that excellence will follow when you acquire knowledge properly. In its third edition, this book incorporates the recent advances in medicine as well as my personal insights on how to learn better. Based on earlier and the 18th edition of Harrison’s Principles of Internal Medicine, published by The McGraw-Hill Companies, Inc., this book also comprises relevant studies from the leading medical journals from the world over. This book caters to medical professionals at all levels. Not only can this be used by aspiring doctors to prepare for medical entrance examinations but by seasoned medical professionals to update knowledge long after it has been acquired. The book is sign-posted with resources and references should the reader require elaboration on any given topic. Over ten thousand questions and still counting; I take it upon myself to continually refine the content of the book and chronicle the advances of medical science. Dr Ajay Mathur Professor of Medicine SMS Medical College & Hospital Jaipur

Contents



319



6. Endocrinology









8. Miscellaneous Genetics, HIV/AIDS, Tuberculosis, Malaria, Dengue, Typhoid, Syphilis, Skin, Rheumatoid arthritis, Leptospirosis, Rabies

389 523 643





7. Neurology





5. Gastroenterology



4. Nephrology

239



3. Respiratory

103





2. Cardiology

1





1. Hematology

827

Hematology 1

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Chapter 57. Anemia and Polycythemia 1

7

A.

0.2 to 0.4 %

B.

0.4 to 0.6 %

Harrison’s 18th Ed. 449

C.

0.6 to 0.8 %

A.

< 14 g/dL in men & < 13 g/dL in women

D.

0.8 to 1%

B.

< 13 g/dL in men & < 12 g/dL in women

C.

< 12 g/dL in men & < 11 g/dL in women

D.

< 11 g/dL in men & < 10 g/dL in women

According to WHO, anemia is defined as as a hemoglobin level of ?

Since the average red cell lives for 100 - 120 days, normal red cell production results in the daily replacement of 0.8 - 1% of all circulating red cells in the body,

8

A.

Erythroid / megakaryocyte progenitor

B.

Red cell destruction

Harrison’s 18th Ed. 448

C.

Organ responsible for red cell production

A.

D.

Red blood cell mass

Hematopoietic stem cell produce which of the following ? Red cells

B.

All classes of granulocytes

C.

Cells of the immune system

D.

All of the above

The organ responsible for red cell production is called “erythron” which consists of a rapidly proliferating pool of marrow erythroid precursor cells & the mass of mature circulating RBCs.

9

In the absence of erythropoietin (EPO), committed erythroid progenitor cells undergo ? A.

Stunted growth

B.

Halting of growth

C.

Programmed cell death (apoptosis)

D.

Change to other series of hematopoietic cell

10

Peptide hormone

B.

Glycoprotein hormone

C.

Steroid hormone

D.

None of the above

Erythropoietin is produced and released by ? Harrison’s 18th Ed. 448

A.

Glomerular capillaries

B.

Proximal tubular cells

How many mature red cells are produced from a pronormoblast ?

C.

Peritubular capillary lining cells of kidney

Harrison’s 18th Ed. 448

D.

All of the above

A.

1 to 16

B.

16 to 32

C.

32 to 48

D.

48 to 64

Physiologic regulator of RBC production, glycoprotein hormone EPO, is produced & released by highly specialized epithelial-like peritubular capillary lining cells within kidney.

11

Regulation of EPO production is linked to ? Harrison’s 18th Ed. 448

A.

O2

B.

CO 2

C.

Red cell mass

D.

Hemoglobin concentration

Erythropoietin is also produced by ? Harrison’s 18th Ed. 448

Pronormoblast undergoes 4 - 5 cell divisions resulting in the production of 16 - 32 mature RBC’s.

A.

Pancreas

B.

Spleen

C.

Hepatocytes

D.

Al of the above

A small amount of EPO is produced by hepatocytes.

12

Key to EPO gene regulation is ? Harrison’s 18th Ed. 448

The regulation of EPO production is linked to O 2 availability.

6

A.

EPO is a glycoprotein hormone that acts by binding to specific receptors on surface of marrow erythroid precursors, inducing them to proliferate & mature when iron is adequately available.

For RBC production, EPO is the regulatory hormone. It is required for maintenance of committed erythroid progenitor cells which undergoes programmed cell death (apoptosis) if EPO is absent.

5

Erythropoietin is a ? Harrison’s 18th Ed. 448

Harrison’s 18th Ed. 448

4

Term “erythron” best relates to ? Harrison’s 18th Ed. 448

Stem cells are capable of producing red cells, all classes of granulocytes, monocytes, platelets, and the cells of the immune system.

3

What percentage of all circulating RBC’s is replaced daily ? Harrison’s 18th Ed. 448

The World Health Organization (WHO) defines anemia as a hemoglobin level < 13 g/dL in men and < 12 g/dL in women.

2

A.

(HIF)-1

B.

(EIF)-1

Harrison’s 18th Ed. 448

C.

(RIF)-1

A.

Diameter is 8 µm

D.

(GIF)-1

B.

Anucleate

C.

Discoid in shape

D.

None of the above

Which of the following about mature red cell is false ?

Mature RBC is 8 µ in diameter, anucleate, discoid in shape, and extremely pliable for it to negotiate microcirculation successfully.

1 Cardiology

Key to EPO gene regulation is hypoxia-inducible factor (HIF)-1.

13

EPO production is increased in ? Harrison’s 18th Ed. 448

A.

Anemia

2

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Hypoxemia

C.

Renal artery stenosis

D.

All of the above

The fundamental stimulus for EPO production is the availability of O 2 for tissue metabolic needs. Anemia, hypoxemia, or renal artery stenosis can raise EPO production.

14

Harrison’s 18th Ed. 449

Harrison’s 18th Ed. 448

B.

10 to 15 % of total blood volume

A.

10 to 25 U/L

C.

15 to 20 % of total blood volume

B.

25 to 50 U/L

D.

20 to 25% of total blood volume

C.

50 to 75 U/L

D.

75 to 100 U/L

Signs of vascular instability appear with acute losses of 10 - 15% of the total blood volume.

21

A.

> 25 %

Harrison’s 18th Ed. 449 Figure 57-2

B.

> 30 %

A.

10 to 12 g/dL

C.

> 35 %

B.

8 to 10 g/dL

D.

> 40 %

C.

6 to 8 g/dL

D.

4 to 6 g/dL

Plasma EPO levels increase when hemoglobin falls below ?

If the volume of blood lost is >40% (>2 L in average-sized adult), signs of hypovolemic shock including confusion, dyspnea, diaphoresis, hypotension and tachycardia appear.

22

Intravascular hemolysis with release of free hemoglobin may be associated with ? Harrison’s 18th Ed. 449

In circulation, EPO has a half-clearance time of ?

A.

Acute back pain

Harrison’s 18th Ed. 448

B.

Acute pain in lower limbs

C.

Acute pain in upper limbs

D.

Acute headache

A.

1 to 3 hours

B.

3 to 6 hours

C.

6 to 9 hours

D.

9 to 12 hours

Intravascular hemolysis with release of free hemoglobin may be associated with acute back pain, free hemoglobin in the plasma and urine, and renal failure.

23

The mean hematocrit value for adult males is ? A.

42 %

B.

45 %

C.

47 %

D.

49 %

Mean hematocrit value for adult males is 47% (± SD 7) and for adult females is 42% (± 5).

Anemia is most often recognized by ? Harrison’s 18th Ed. 449

A.

Attendant symptoms

B.

Attendant signs

C.

Abnormal screening laboratory tests

D.

All of the above

O 2–hemoglobin dissociation curve relates to which of the following ? Harrison’s 18th Ed. 449

A.

Claude effect

B.

Bohr effect

C.

Charles effect

Which of the following may be associated with autoimmune hemolysis ? Harrison’s 18th Ed. 449

A.

Chronic lymphocytic leukemia

B.

Infection

C.

Rheumatoid arthritis

D.

All of the above

Chronic inflammatory states (infection, rheumatoid arthritis, cancer) are associated with mild to moderate anemia, whereas lymphoproliferative disorders (chronic lymphocytic leukemia and certain other B cell neoplasms) may be associated with autoimmune hemolysis.

24

If palmar creases are lighter in color than surrounding skin, hemoglobin level is usually ? Harrison’s 18th Ed. 449

Anemia is most often recognized by (incidental) abnormal screening laboratory tests.

19

Hypovolemic shock results if volume of blood lost is ? Harrison’s 18th Ed. 449

Harrison’s 18th Ed. 448

18

Signs of vascular instability appear with acute blood loss of ? 5 to 10 % of total blood volume

In circulation, EPO has a half-clearance time of 6 - 9 hours.

17

20

A.

When the hemoglobin level falls to 12 g/dL, plasma EPO levels increase logarithmically. When hemoglobin concentration falls below 10 - 12 g/dL, plasma EPO levels increase in proportion to the severity of anemia.

16

Bennet effect

Bohr effect refers to enhanced O 2 delivery through changes in O 2 –hemoglobin dissociation curve mediated by a decreased pH or increased CO 2.

Normal level of Plasma EPO is ?

Normal EPO level in plasma is 10 - 25 U/L.

15

D.

Hematology

A.

< 10 g/dL

B.

< 8 g/dL

C.

< 6 g/dL

D.

< 4 g/dL

If the palmar creases are lighter in color than the surrounding skin with hyperextended hand, the hemoglobin level is usually < 8 g/dL.

25

Femtoliters is the unit of expression of which of the following ? Harrison’s 18th Ed. 449

A.

Mean cell volume (MCV)

Hematology 3

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR 32

B.

Mean cell hemoglobin (MCH)

C.

Mean concentration of Hb per volume of RBCs (MCHC)

D.

None of the above

Which of the following reflects iron supply ?

RDW

D.

Polychromasia

Total iron-binding capacity (TIBC)

C.

Serum ferritin

A.

Older RBC’s

D.

All of the above

B.

Prematurely released reticulocytes

C.

Normoblasts

D.

Any of the above

33

“Shift” cells refer to ? Harrison’s 18th Ed. 453

Which of the following formula estimates MCV ? A.

(Hematocrit x 10) / (red cell count x 10 )

B.

(Hemoglobin x 10) / (red cell count x 106)

C.

(Hemoglobin x 10) / hematocrit

D.

(Hematocrit x 10) / hemoglobin

6

In anemia, polychromatophilic macrocytes in PBF represent prematurely released reticulocytes referred to as “shift” cells.

34

Erythroid cells take about how many days to mature ? Harrison’s 17th Ed. 359 Figure 58-13

A.

2.5

B.

3.5

Anisocytosis is related to which feature of RBC ?

C.

4.5

Harrison’s 18th Ed. 450

D.

5.5

A.

Size

B.

Shape

C.

Number

D.

Colour

Erythroid cells take ~4.5 days to mature. At normal hematocrit levels, they are released to the circulation with ~1 day left as reticulocytes.

35

Absolute reticulocyte count is calculated by ? Harrison’s 18th Ed. 452 Table 57–4

A.

Reticulocyte count x (Hemoglobin ÷ expected hemoglobin)

B.

Reticulocyte count x (Hemoglobin + Hematocrit)

Size

C.

Reticulocyte count x (Hemoglobin x Hematocrit)

B.

Shape

D.

Reticulocyte count / (Hemoglobin + Hematocrit)

C.

Number

D.

Colour

Poikilocytosis is related to which feature of RBC ? Harrison’s 18th Ed. 450

A.

36

RDW correlates with ? Harrison’s 18th Ed. 450

A.

Anisocytosis

B.

Poikilocytosis

C.

Polychromasia

D.

All of the above

37

Harrison’s 18th Ed. 450

B.

Blue

C.

Green

D.

Yellow

Reticulocytes are larger red cells, grayish blue in color on Wright-Giemsa stain, that are recently released from bone marrow & their color represents residual amounts of ribosomal RNA.

Red cells are larger than a small lymphocyte

B.

Well hemoglobinized red cells

C.

Often oval shaped

D.

None of the above

Howell-Jolly bodies best relate to which of the following ? Harrison’s 18th Ed. 451 Figure 57-6

Upon staining with supravital dye, reticulocytes are identified by what colour of punctate spots ? Red

A.

Macrocytes are red blood cells that are larger than a small lymphocyte and are well hemoglobinized. Often macrocytes are oval shaped (macro-ovalocytes).

Degree of anisocytosis correlates with increases in RDW or the range of cell sizes.

A.

Which of the following about macrocytes is false ? Harrison’s 18th Ed. 451 Figure 57-5

Variations in red cell shape is called poikilocytosis. Poikilocytosis suggests a defect in the maturation of red cell precursors in bone marrow or fragmentation of circulating red cells.

31

Reticulocyte count

C.

B.

Variations in red cell size is called anisocytosis.

30

B.

Serum iron

Harrison’s 18th Ed. 450 Table 57–2

29

EPO levels

A.

Serum iron, total iron-binding capacity (TIBC), and serum ferritin are measurements of iron supply.

28

A.

Reticulocyte count provides a reliable measure of red cell production.

Harrison’s 18th Ed. 450

27

Reliable estimate of red cell production is provided by ? Harrison’s 18th Ed. 452

Mean cell volume (MCV) - femtoliters, mean cell hemoglobin (MCH) - picograms per cell, and mean concentration of hemoglobin per volume of red cells (MCHC) - grams per liter.

26

3 Cardiology

A.

Uremia

B.

Nuclear remnants

C.

Foreign bodies in the circulation

D.

All of the above

Howell-Jolly bodies refer to tiny nuclear remnants that are not removed from red cells due to absence of a functional spleen (splenectomy) and and with maturation/dysplastic disorders (excess production). They remain as small homogeneously staining blue inclusions on Wright stain.

38

Teardrop-shaped red cells best relates to ? Harrison’s 18th Ed. 451 Figure 57-7

A.

Uremia

B.

Myelofibrosis

4

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Thalassemia

D.

Liver disease

Teardrop-shaped red cells are seen in myelofibrosis and extramedullary hematopoiesis.

39

40

45

Harrison’s 18th Ed. 453

A.

10 to 50 µg / dL

A.

Uremia

B.

50 to 150 µg / dL

B.

Myelofibrosis

C.

150 to 250 µg / dL

C.

Thalassemia

D.

250 to 450 µg / dL

D.

Acute hemolysis

Normal serum iron ranges from 50 - 150 µg/dL

46

Harrison’s 18th Ed. 453

Harrison’s 18th Ed. 451 Figure e17-13

A.

100 to 150 µg / dL

A.

Liver disease

B.

150 to 300 µg / dL

B.

Thalassemia

C.

300 to 360 µg / dL

C.

Hemoglobin C disease

D.

350 to 450 µg / dL

D.

All of the above

Normal TIBC is 300 - 360 µg/dL.

47

A.

Target cells

B.

Burr cells

C.

Howell-Jolly bodies

D.

Red cell fragmentation

48

B.

Acanthocytes

C.

Elliptocytes

D.

Spherocytes

Burr cells are also called echinocytes. Echinocytes have small, uniform, and evenly spaced membrane projections.

(Serum iron + TIBC) ÷ 100

C.

(Serum iron x 100) ÷ TIBC

D.

(Serum iron ÷ TIBC) x 100

Adult males have average serum ferritin levels of about ? A.

10 µg / L

B.

50 µg / L

C.

100 µg / L

D.

200 µg / L

Serum ferritin is used to evaluate total-body iron stores. Adult males have serum ferritin levels that average ~100 µg/L, corresponding to iron stores of ~1 gram. Serum ferritin level of 10 - 15 µg/L represents depletion of body iron stores.

49

Adult females have average serum ferritin levels of about ?

Echinocytes are found in patients with ?

Harrison’s 18th Ed. 453

Harrison’s 18th Ed. 451 Figure e17-16

A.

10 µg / L

A.

Severe uremia

B.

30 µg / L

B.

Glycolytic red cell enzyme defects

C.

60 µg / L

C.

Microangiopathic hemolytic anemia

D.

90 µg / L

D.

All of the above

Echinocytes are found in patients with severe uremia, in glycolytic red cell enzyme defects, and in microangiopathic hemolytic anemia.

44

(TIBC x 100) ÷ Serum iron

B.

Harrison’s 18th Ed. 453

Harrison’s 18th Ed. 451 Figure 57-10

Echinocytes

A.

Percent transferrin saturation is derived by dividing serum iron level (x 100) by TIBC. Normal transferrin saturation ranges from 25 - 50%.

Burr cells are also called ? A.

Percent transferrin saturation is calculated by ? Harrison’s 18th Ed. 453

Thermal injury may produce which of the following ?

Presence of foreign bodies in the circulation (mechanical heart valves), or thermal injury may cause red cell fragmentation.

43

The normal serum TIBC range is ?

Target cells are seen in ?

Harrison’s 18th Ed. 451 Figure 57-9

42

The normal serum iron range is ?

Harrison’s 18th Ed. 451 Figure 57-8

Target cells are recognized by the bull’s-eye appearance of the red cell. Small numbers of target cells are seen with liver disease & thalassemia. Larger numbers are typical of hemoglobin C disease.

41

Acanthocytes are contracted dense cells with irregular membrane projections that vary in length and width. Acanthocytes are present in severe liver disease, in patients with abetalipoproteinemia, and in rare patients with McLeod blood group.

Target red cells best relates to ?

Target red cells have a bull’s-eye appearance & are seen in thalassemia and liver disease.

Acanthocytes are present in which of the following conditions ? Harrison’s 18th Ed. 451 Figure e17-16

A.

Severe liver disease

B.

Abetalipoproteinemia

C.

Patients with McLeod blood group

D.

All of the above

Hematology

Adult females have serum ferritin levels averaging 30 µg/L, reflecting lower iron stores (300 mg).

50

Ferritin is also an ? Harrison’s 18th Ed. 453

A.

Enzyme

B.

Cytokine

C.

Chemokine

D.

Acute-phase reactant

Ferritin is also an acute-phase reactant.

Hematology 5 51

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Erythroblasts containing what are called sideroblasts ?

B.

Abnormalities in heme synthesis

Harrison’s 18th Ed. 454

C.

Abnormalities in globin synthesis

D.

Any of the above

A.

Hemosiderin

B.

Ferritin

C.

Residual RNA

D.

All of the above

Cytoplasmic maturation defects result from ‘severe’ iron deficiency or abnormalities in globin or heme synthesis.

58

In bone marrow smears, developing erythroblasts with small ferritin granules are sideroblasts.

52

Increased red cell mass is present when hematocrit in men is ? Harrison’s 18th Ed. 456

Hemolysis is most likely cause if reticulocyte production index is more than ?

A.

> 45 %

Harrison’s 18th Ed. 454

B.

> 50 %

A.

2.5

C.

> 55 %

B.

3.5

D.

> 60 %

C.

4.5

D.

5.5

PCV >60% in men & >55% in women are invariably associated with an increased red cell mass.

59

Reticulocyte production index of >2.5 indicates that hemolysis is most likely.

53

Gaisbock’s syndrome relates to ? Harrison’s 18th Ed. 456

A.

Spurious polycythemia

Harrison’s 18th Ed. 455

B.

High altitude polycythemia

A.

Hypoproliferative

C.

Ectopic EPO production

B.

Maturation Disorders

D.

Familial polycythemia

Which of the following anemias is most frequent ?

C.

Hemoglobinopathies

D.

Hemolytic

Gaisbock’s syndrome refers to spurious polycythemia due to a decrease in plasma volume.

60

EPO-producing neoplasms include ?

At least 75% of all cases of anemia are hypoproliferative in nature. Hemolytic disease is among the least common forms of anemia.

Harrison’s 18th Ed. 457

A.

Hepatoma

54

A hypoproliferative anemia can result from ?

B.

Uterine leiomyoma

Harrison’s 18th Ed. 455

C.

Cerebellar hemangiomas

D.

All of the above

A.

Marrow damage

B.

Iron deficiency

C.

Inadequate EPO stimulation

D.

All of the above

EPO-producing neoplasms include hepatoma, uterine leiomyoma, renal cancer or cysts and cerebellar hemangiomas.

Majority of hypoproliferative anemias are due to mild to moderate iron deficiency or inflammation. They result from marrow damage, iron deficiency or inadequate EPO stimulation.

55

Which of the following is the iron regulatory hormone ? Harrison’s 18th Ed. 455

Chapter 58. Bleeding and Thrombosis 61

Erythropoietin

B.

Transferrin

A.

C.

Hepcidin

B.

Platelet aggregation

D.

All of the above

C.

Fibrin clot formation

D.

All of the above

Nuclear maturation defects of RBC’s result from all except ? Harrison’s 18th Ed. 455

Harrison’s 18th Ed. 457

Platelet adhesion

In the human hemostatic system, procoagulant forces include platelet adhesion and aggregation and fibrin clot formation.

A.

Vitamin B12 deficiency

B.

Folic acid deficiency

C.

Iron deficiency

A.

Platelets, monocytes and red cells

D.

Methotrexate therapy

B.

Plasma proteins

Nuclear maturation defects result from vitamin B 12 or folic acid deficiency, drug damage (methotrexate or alkylating agents), myelodysplasia and alcohol.

57

In the human hemostatic system, procoagulant forces include ?

A.

Hepcidin is the iron regulatory hormone that is increased in inflammation.

56

Cytoplasmic maturation defects of RBC’s result from ? Harrison’s 18th Ed. 455

A.

Severe iron deficiency

5 Cardiology

62

The major components of the hemostatic system are ? Harrison’s 18th Ed. 457

C.

Vessel wall

D.

All of the above

Major components of the hemostatic system platelets & other formed elements of blood (monocytes & RBCs), plasma proteins (coagulation & fibrinolytic factors & inhibitors) and vessel wall.

6 63

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Formed element of blood that is not a component of the hemostatic system is ?

Surface of each platelet has how many GpIIb / IIIa binding sites ?

Harrison’s 18th Ed. 457

Harrison’s 18th Ed. 457

A.

Neutrophil

A.

~ 10,000

B.

Monocyte

B.

~ 25,000

C.

Red cell

C.

~ 50,000

D.

Platelet

D.

~ 100,000

Major components of hemostatic system are platelets, monocytes & red cells, plasma proteins (coagulation & fibrinolytic factors & inhibitors) and vessel wall itself.

64

69

Platelet adhesion is mediated primarily by ?

Surface of each platelet has ~50,000 GpIIb/IIIa binding sites.

70

von Willebrand factor (vWF)

B.

Gp IIb/IIIa

C.

Gp Ia/IIa

D.

Fibronectin

Tissue factor (TF) is present on ? Harrison’s 18th Ed. 458

Harrison’s 18th Ed. 457

A.

Hematology

A.

Subendothelial cellular components of vessel wall

B.

Circulating microparticles from monocytes

C.

Circulating microparticles from platelets

D.

All of the above

Platelet adhesion is mediated primarily by von Willebrand factor (vWF).

TF is expressed on surfaces of subendothelial cellular components of vessel wall (smooth-muscle cells & fibroblasts). TF is present in circulating microparticles shed from monocytes & platelets.

65

71

Which of the following is false about von Willebrand factor (VWF) ?

Harrison’s 18th Ed. 458

A.

Large multimeric protein

A.

III

B.

Present in plasma

B.

VIIa

C.

Present in extracellular matrix of subendothelial vessel wall

C.

IX

D.

X

D.

None of the above

von Willebrand factor (VWF) is a large multimeric protein present in both plasma & extracellular matrix of subendothelial vessel wall. It serves as the primary “molecular glue” to withstand high levels of shear stress that would detach platelets due to flow of blood.

66

TF binds serine protease factor VIIa and their complex (TF+VIIa) activates factor X to factor Xa. Factor IXa also activates factor X to factor Xa.

72

Which of the following is released from activated platelets ? A.

Epinephrine

B.

Thrombin

C.

Adenosine diphosphate

D.

All of the above

Platelet adhesion is followed by platelet activation and aggregation which is enhanced & amplified by humoral mediators in plasma (epinephrine, thrombin), mediators released from activated platelets (adenosine diphosphate, serotonin) & vessel wall extracellular matrix constituents that come in contact with adherent platelets (collagen, VWF).

73

B.

Gp Ib/IX

C.

Gp IIb/IIIa

D.

Gp VI

Va

B.

VIIa

C.

IX

D.

X

Which of the following in endothelial cells has antithrombotic effect ? Harrison’s 18th Ed. 458

Harrison’s 18th Ed. 457

Gp Ia/IIa

A.

Factor Xa converts prothrombin to thrombin, the pivotal protease of the coagulation system. The essential cofactor for this reaction is factor Va. Factor Va is produced by thrombin-induced limited proteolysis of factor V.

Most abundant receptor on the platelet surface is ? A.

Essential cofactor for conversion of prothrombin to thrombin is ? Harrison’s 18th Ed. 458

Harrison’s 18th Ed. 457

67

Which of the following is a serine protease factor ?

Harrison’s 18th Ed. 457

A.

Prostacyclin

B.

Nitric oxide

C.

EctoADPase/CD39

D.

All of the above

Platelet glycoprotein (Gp) IIb/IIIa (IIb3) complex is the most abundant receptor on platelet surface.

Prostacyclin, nitric oxide & ectoADPase/CD39 produced from endothelial cells act to inhibit platelet binding, secretion and aggregation.

68

74

Platelet surface receptor GpIIB / IIIa binds to ?

Anticoagulant factor produced by endothelial cells is ?

Harrison’s 18th Ed. 457

Harrison’s 18th Ed. 458

A.

Thrombospondin

A.

Heparan proteoglycans

B.

Fibrinogen

B.

Antithrombin

C.

Collagen

C.

Thrombomodulin

D.

All of the above

D.

All of the above

Platelet activation converts the normally inactive GpIIb/IIIa receptor into an active receptor enabling its binding to fibrinogen and vWF.

Endothelial cells produce anticoagulant factors like heparan proteoglycans, antithrombin, TF pathway inhibitor and thrombomodulin.

Hematology 7 75

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following produced by endothelial cells acts as an anticoagulant ?

81

Which of the following relates to protein S ? Harrison’s 18th Ed. 459

Harrison’s 18th Ed. 458

76

7 Cardiology

A.

Cofactor

A.

Plasminogen activator inhibitor

B.

Glycoprotein

B.

Thrombomodulin

C.

Vitamin K dependent posttranslational modification

C.

Prostacyclin

D.

All of the above

D.

Nitric oxide

Endothelial cells activate fibrinolytic mechanisms through the production of ? Harrison’s 18th Ed. 458-9

Glycoprotein Protein S is a cofactor that undergoes vitamin K dependent posttranslational modification. It accelerates the reaction of activated protein C with factors V and VIII.

82

Which of the following inhibits TF / FVIIa / FXa complex ? Harrison’s 18th Ed. 459

A.

Tissue plasminogen activator 1

A.

Activated protein C

B.

Urokinase

B.

Protein S

C.

Plasminogen activator inhibitor

C.

Tissue factor pathway inhibitor (TFPI)

D.

All of the above

D.

All of the above

Endothelial cells activate fibrinolytic mechanisms through the production of tissue plasminogen activator 1, urokinase, plasminogen activator inhibitor & annexin-2.

Tissue factor pathway inhibitor (TFPI) is a plasma protease inhibitor that regulates the TF– induced extrinsic pathway of coagulation. TFPI inhibits the TF/FVIIa/FXa complex.

77

83

Which of the following best relates to heparin ? Harrison’s 18th Ed. 459

Harrison’s 18th Ed. 459

A.

Antithrombin III

A.

Heparin

B.

Protein C

B.

Streptokinase

C.

Protein S

C.

Urokinase

D.

All of the above

D.

All of the above

Antithrombin III inhibits thrombin by forming inactivating complexes that increase several folds in the presence of heparin.

78

Which of the following becomes an anticoagulant when it is activated by thrombin ?

TFPI is bound to lipoprotein and can also be released by heparin from endothelial cells, where it is bound to glycosoaminoglycans, and from platelets.

84

Harrison’s 18th Ed. 459

Harrison’s 18th Ed. 459

Antithrombin III

A.

Arg460 - Val461

B.

Protein C

B.

Arg560 - Val561

C.

Protein S

C.

Arg660 - Val661

D.

Tissue factor pathway inhibitor (TFPI)

D.

Arg760 - Val761

Which of the following about thrombomodulin is false ? Harrison’s 18th Ed. 458-9

A.

Transmembrane proteoglycan binding site for thrombin on endothelial cell surface

B.

Thrombin-induced activation of protein C occurs physiologically on thrombomodulin

C.

Anticoagulant factor from endothelial cell

D.

None of the above

Thrombomodulin expressed on the surface of endothelial cells binds thrombin at low concentrations and inhibits coagulation through activation of the protein C pathway, leading to enhanced catabolism of clotting factors Va and VIIIa, thereby combating thrombus formation.

80

Plasminogen activators (tPA & uPA) cleave which bond of plasminogen to generate the active enzyme plasmin ?

A.

Protein C is a plasma glycoprotein that becomes an anticoagulant when activated by thrombin.

79

Tissue factor pathway inhibitor (TFPI) be released by ?

Plasminogen activators (tissue type plasminogen activator & urokinase type plasminogen activator cleave Arg560-Val561 bond of plasminogen to generate the active enzyme plasmin which is the major protease enzyme of the fibrinolytic system, acting to digest fibrin to fibrin degradation products.

85

“Fibrin specific” activity of plasmin is due to its ? Harrison’s 18th Ed. 459

A.

Arginine-binding sites

B.

Lysine-binding sites

C.

Valine-binding sites

D.

Leucine-binding sites

The lysine-binding sites of plasmin (and plasminogen) permit it to bind specifically to fibrin and therefore physiologic fibrinolysis is “fibrin specific”.

86

Physiologic regulation of fibrinolysis is done by ?

Activated protein C acts as an anticoagulant by cleaving and inactivating activated factor ?

Harrison’s 18th Ed. 460

Harrison’s 18th Ed. 459

B.

Thrombin-activatable fibrinolysis inhibitor (TAFI)

C.

 2-antiplasmin

D.

All of the above

A.

II

B.

V

C.

VI

D.

X

Activated protein C acts as an anticoagulant by cleaving & inactivating activated factors V & VIII.

A.

87

Plasminogen activator inhibitors (PAI-1 & PAI-2)

Which of the following antiplasmin inhibits plasmin ? Harrison’s 18th Ed. 460

A.

1 antiplasmin

8

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

2 antiplasmin

C.

Horse chestnut

C.

3 antiplasmin

D.

All of the above

D.

4 antiplasmin

PAI1 is the primary inhibitor of tPA & uPA and 2 antiplasmin is the main inhibitor of plasmin in human plasma, inactivating any nonfibrin clot associated plasmin.

88

Epistaxis is the most common symptom in ?

Coumarin containing herbs include Motherworth (Leonurus cardiaca), Chamomile (Matricaria recutita, Chamaemelum mobile), Horse chestnut (Aesculus hippocastanum) Red clover (Trifolium pratense) Fenugreek (Trigonella foenum-graecum).

94

Harrison’s 18th Ed. 460

A.

Hemophilia A

B.

Ehlers-Danlos syndrome

C.

Hereditary hemorrhagic telangiectasia

D.

Cushing’s syndrome

Epistaxis is the most common symptom in hereditary hemorrhagic telangiectasia & in boys with VWD.

89

Menorrhagia is a common symptom in women with ? Harrison’s 18th Ed. 460

90

Harrison’s 18th Ed. 461

A.

Liver disease

B.

Severe renal impairment,

C.

Hypothyroidism

D.

All of the above

Bruising or mucosal bleeding may be the presenting complaint in liver disease, severe renal impairment, hypothyroidism, paraproteinemias or amyloidosis & bone marrow failure.

95

All coagulation factors are synthesized in ?

VWD

Harrison’s 18th Ed. 461

B.

Factor XI deficiency

A.

Liver

C.

Symptomatic carriers of hemophilia A

B.

Kidney

D.

All of the above

C.

Lungs

D.

None of the above

Which of the following is called a “life-threatening site of bleeding” ?

All coagulation factors are synthesized in liver & hepatic failure results in combined factor deficiencies.

Harrison’s 18th Ed. 461

Which of the following coagulation factors is dependent on vitamin K for posttranslational modification ?

A.

Bleeding into oropharynx

Harrison’s 18th Ed. 461

B.

Bleeding into central nervous system

A.

Factor II

C.

Bleeding into retroperitoneum

B.

Factor VII

All of the above

C.

Factor IX

D.

All of the above

D.

Life-threatening sites of bleeding include bleeding into oropharynx, into central nervous system, and into retroperitoneum.

91

Bruising or mucosal bleeding may be the presenting complaint in ?

A.

Menorrhagia is a common symptom in women with underlying bleeding disorders. It is seen in majority of women with VWD & factor XI deficiency & in symptomatic carriers of hemophilia A.

Hematology

96

Which of the following about clopidogrel is false ?

97

Which of the following proteins is dependent on vitamin K for posttranslational modification ?

Harrison’s 18th Ed. 461

Harrison’s 18th Ed. 461

A.

Thienopyridine

A.

Protein C

B.

Inhibits ADP-mediated platelet aggregation

B.

Protein S

C.

Can precipitate or exacerbate bleeding symptoms

C.

Protein Z

D.

None of the above

D.

All of the above

Thienopyridines (clopidogrel and prasugrel) inhibit ADP-mediated platelet aggregation and like NSAIDs can precipitate or exacerbate bleeding symptoms.

Coagulation factors II, VII, IX, X and proteins C, S, and Z are dependent on vitamin K for posttranslational modification.

92

98

Herb with potential anti-platelet activity is ?

Harrison’s 18th Ed. 461

A.

Ginger

A.

50,000 to 100,000/µL

B.

Turmeric

B.

100,000 to 250,000/µL

C.

Garlic

C.

150,000 to 450,000/µL

All of the above

D.

250,000 to 550,000/µL

D.

Herbs with potential anti-platelet activity include Ginkgo, Garlic, Bilberry, Ginger, Dong quai, Feverfew, Asian, Siberian & American ginseng, Turmeric, Meadowsweet and Willow.

93

Normal blood platelet count is ?

Harrison’s 18th Ed. 461 Table 58–2

Which of the following is a Coumarin containing herb ? Harrison’s 18th Ed. 461 Table 58–2

A.

Motherworth

B.

Chamomile

Normal blood platelet count is 150,000 to 450,000/µL.

99

Thrombocytopenia results from ? Harrison’s 18th Ed. 461

A.

Decreased production of platelets

B.

Increased destruction of platelets

C.

Sequestration of platelets

Hematology 9 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Any of the above

D.

9 Cardiology

(PT ratio) International Sensitivity Index (ISI)

Thrombocytopenia results from decreased production, increased destruction, &/or sequestration.

International normalized ratio (INR) is calculated by the formula: INR = (PT patient/PTnormal mean)ISI.

100

106

Bleeding rarely occurs in isolated thrombocytopenia at counts ? Harrison’s 18th Ed. 461

Harrison’s 18th Ed. 462

A.

< 50000 / µL

A.

Factor VIII

B.

< 80000 / µL

B.

Factor IX

C.

< 100000 / µL

C.

Factor X

< 150000 / µL

D.

All of the above

D.

Bleeding rarely occurs in isolated thrombocytopenia at counts < 50000 / µL.

101

Most procedures can be performed in patients with a platelet count of ?

aPTT assesses the intrinsic & common coagulation pathways, factors XI, IX, VIII, X, V, II, fibrinogen, and also prekallikrein, high-molecular-weight kininogen & factor XII.

107

A.

< 50000 / µL

B.

< 80000 / µL

C.

< 100000 / µL

D.

< 150000 / µL

Most procedures can be performed in patients with a platelet count of 50,000/µL. For major surgery, a count of about 80,000/µL is likely to be sufficient.

108

B.

Hyperhomocysteinemia

C.

Dysfibrinogenemia

D.

Hormonal therapy

The major risk factor for arterial thrombosis is atherosclerosis. Risk factors for venous thrombosis are immobility, surgery, underlying medical conditions, malignancy, hormonal therapy, obesity, and genetic predispositions.

Uninodular

B.

Binodular

C.

Trinodular

D.

Quadrinodular

Cross-linking of the D domains on adjacent fibrinogen molecules is done by ? Harrison’s 18th Ed. 458 Figure 58-2

Harrison’s 18th Ed. 461

Atherosclerosis

A.

Fibrinogen is a trinodular structure consisting of 2 D domains and 1 E domain.

The major risk factor for arterial thrombosis is ? A.

Structure of Fibrinogen is ? Harrison’s 18th Ed. 458 Figure 58-2

Harrison’s 18th Ed. 461

102

Activated partial thromboplastin time (aPTT) assesses which of the following factors ?

A.

FX

B.

FXI

C.

FXII

D.

FXIIIa

Cross-linking of D domains on adjacent fibrinogen molecules is done by FXIIIa.

109

Which of the following about D-Dimers is false ? Harrison’s 18th Ed. 458

103

Most coagulation assays are performed in plasma anticoagulated with ? Harrison’s 18th Ed. 462

A.

Ethylenediamine tetraacetic acid (EDTA)

B.

Sodium citrate

C.

Heparin

D.

Any of the above

Most coagulation assays are performed in sodium citrate anticoagulated plasma that is recalcified for the assay.

104

Product of complete lysis of fibrin

B.

Released when plasmin acts on fibrin

C.

Relatively specific test of fibrin degradation

D.

Relatively specific test of fibrinogen degradation

D-Dimers are the product of complete lysis of fibrin, maintaining the cross-linked D domains. When plasmin acts on covalently cross-linked fibrin, D-dimers are released. D-dimers in plasma are as a relatively specific test of fibrin rather than fibrinogen degradation. D-Dimer assays are a sensitive marker of blood clot formation and coagulation activation.

110

Normal level of D-Dimer in blood is ? Harrison’s 17th Ed. 1653

PT assesses the factors except ? Harrison’s 18th Ed. 462

A.

< 500 pg/mL < 500 ng/mL

A.

Factor I

B.

B.

Factor II

C.

< 500 µg/mL

C.

Factor V

D.

< 500 mg/mL

D.

Factor VIII

PT assesses factors I (fibrinogen), II (prothrombin), V, VII, and X. PT only measures one aspect of hemostasis affected by liver dysfunction.

105

A.

Normal level of D-Dimer in blood is < 500 ng/mL.

111

Plasma level of D-Dimer is ? Harrison’s 17th Ed. Appendix Table 1

International normalized ratio (INR) is calculated by ?

A.

0.22 - 0.74 mg/mL

Harrison’s 18th Ed. 462

B.

0.22 - 0.74 µg/mL

A.

PT ratio x International Sensitivity Index (ISI)

C.

0.22 - 0.74 ng/mL

B.

PT ratio ÷ International Sensitivity Index (ISI)

D.

0.22 - 0.74 pg/mL

C.

PT ratio + International Sensitivity Index (ISI)

Plasma level of D-Dimer is 0.22 - 0.74 µg/mL.

10 112

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D-dimer levels increase in patients with ?

Harrison’s 16th Ed. 338

A.

Myocardial infarction

A.

vWF

B.

Pneumonia

B.

Fibrinogen

C.

II or III trimester of pregnancy

C.

Collagen

D.

All of the above

D.

All of the above

GpVI/Fc  RIIa binds collagen.

119

After leaving bone marrow, what proportion of platelets are sequestered in spleen ?

Platelet interaction with vascular collagen is stabilized by ?

Harrison’s 16th Ed. 673

Harrison’s 16th Ed. 337

A.

One-third

A.

Gp Ia/IIa

B.

One-half

B.

Gp VI

C.

Two-thirds

C.

von Willebrand factor (vWF)

D.

Three-fourths

D.

FcRg

120

von Willebrand factor (vWF) is an adhesive glycoprotein that allows platelets to remain attached to the vessel wall despite the high shear forces generated within the vascular lumen by stabilizing interaction between platelets with collagen.

114

Platelet surface receptor GpVI / FcRIIa binds to ?

Harrison’s 17th Ed. Chapter 256, 96, 292

D-dimer levels increase in myocardial infarction, pneumonia, intestinal ischemia, sepsis, cancer, postoperative state, initial infusion of human or humanized antibodies (rituximab, gemtuzumab, trastuzumab), and second or third trimester of pregnancy. D-dimer elevation is not as predictive of DVT in cancer patients as it is in patients without cancer.

113

118

Hematology

The life span of platelets in circulation is about ? Harrison’s 16th Ed. 673

A.

1 to 3 days

B.

3 to 5 days

Harrison’s 16th Ed. 338

C.

5 to 7 days

A.

vWF

D.

7 to 10 days

B.

Fibrinogen

C.

Collagen

D.

All of the above

Platelet surface receptor GpIb / IX binds to ?

After leaving bone marrow, ~one-third of platelets are sequestered in spleen, while the other two-thirds circulate for 7 to 10 days.

121

During menstrual cycle, platelet count rise at what time ? Harrison’s 16th Ed. 673

115

vWF forms a link between collagen fibrils & which of the following platelet receptor ?

A.

Harrison’s 16th Ed. 337, 338 Figure 53-2

At the onset of menses After completion of menstrual flow Before ovulation

A.

Gp Ia/IIa

B.

Gp Ib/IX

D.

C.

Gp VI

D.

All of the above

Formation of thromboxane A 2 (TXA 2) from arachidonic acid is mediated by enzyme ?

During menstrual cycle, platelet count fall at what time ? Harrison’s 16th Ed. 673

GpIb/IX complex binds vWF. Adhesion of platelets with vessel wall is stabilized by von Willebrand factor, which forms a bridge between collagen fibrils in the vessel wall & receptors on platelet glycoprotein Ib/IX. Similarly, platelet aggregation is mediated by fibrinogen, which links adjacent platelets via receptors on the platelet glycoprotein IIb/IIIa complex.

116

B. C.

122

Following ovulation

A.

Following ovulation

B.

At the onset of menses

C.

After completion of menstrual flow

D.

Before ovulation

Platelet count varies in menstrual cycle, rising following ovulation & falling at onset of menses.

Harrison’s 16th Ed. 338

123

Phospholipase C

B.

Phospholipase A2

C.

Cyclooxygenase

A.

Severe Iron deficiency

D.

All of the above

B.

Folic acid deficiency

C.

Vitamin B12 deficiency

D.

All of the above

Harrison’s 16th Ed. 673

Formation of TXA 2 from arachidonic acid is mediated by the enzyme cyclooxygenase.

117

Platelet counts are decreased in which of the following deficiencies ?

A.

Platelet surface receptor GpIa/IIa binds to ? Harrison’s 16th Ed. 338

A.

vWF

B.

Fibrinogen

C.

Collagen

D.

All of the above

GpIa/IIa binds collagen.

Platelet count are decreased in severe iron, folic acid or vitamin B12 deficiency.

124

Secondary or reactive thrombocytosis is due to which property of platelets ? Harrison’s 16th Ed. 674

A.

Hormonal

B.

Acute-phase reactant

C.

Enzymatic

Hematology 11 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

All of the above

Platelets are acute-phase reactants. Secondary or reactive thrombocytosis refers to an increase in platelet counts in patients with systemic inflammation, tumors, bleeding & mild iron deficiency.

125

D.

Chapter 59. Enlargement of Lymph Nodes & Spleen

Harrison’s 16th Ed. 674

IL-3

B.

IL-6

C.

IL-11

D.

All of the above

131

A.

Two or more

Harrison’s 16th Ed. 674

C.

Three or more

A.

Decreased bone marrow production

D.

Four or more

B.

Increased splenic sequestration

C.

Accelerated destruction

D.

All of the above

Generalized adenopathy is defined as involvement of three or more noncontiguous lymph node areas. Localized or regional adenopathy implies involvement of a single anatomic area.

132

TAR syndrome means ? A.

Thrombocytopenia with absent reticulocytes

B.

Thrombocytopenia with absent renin

C.

Thrombocytopenia with absent radii

D.

Thrombocytopenia with abnormal vessels

Congenital amegakaryocytic hypoplasia & thrombocytopenia with absent radii (TAR syndrome) produce a selective decrease in megakaryocyte production.

133

B.

Adults

C.

Elderly

D.

All of the above

AIDS

B.

Systemic lupus erythematosus (SLE)

C.

Mixed connective tissue disease

D.

All of the above

Occipital lymphadenopathy accompanies which of the following ? Harrison’s 18th Ed. 466

Harrison’s 16th Ed. 675

Children

A.

Generalized lymphadenopathy is frequently associated with infectious mononucleosis (EBV) or cytomegalovirus (CMV), toxoplasmosis, AIDS, systemic lupus erythematosus (SLE), and mixed connective tissue disease. Acute and chronic lymphocytic leukemias and malignant lymphomas also produce generalized adenopathy in adults.

Acute ITP is common in ? A.

Which of the following is a cause of generalized lymphadenopathy ? Harrison’s 18th Ed. 466

Harrison’s 16th Ed. 674

128

One or more

B.

Mechanism of thrombocytopenia include ?

Thrombocytopenia is caused by decreased bone marrow production or increased splenic sequestration or accelerated destruction of platelets.

127

Generalized adenopathy means involvement of how many noncontiguous lymph node areas ? Harrison’s 18th Ed. 466

Cytokines interleukin IL-3, IL-6 & IL-11 stimulate platelet production in acute inflammation.

126

Anti-CD22

Rituximab is an anti-CD20 monoclonal antibody. Efficacy is established in ITP. It eliminates normal B cells that produce antiplatelet antibody.

Which of the following cytokines interleukins stimulate platelet production in acute inflammation ? A.

11 Cardiology

A.

Scalp infection

B.

Ear infection

C.

Conjunctival infections

D.

Tooth infection

Occipital adenopathy often reflects infection of the scalp. Acute ITP is a severe thrombocytopenia following recovery from a viral exanthem or upper respiratory illness. It is common in children & is responsible 90% of pediatric cases of immunologic thrombocytopenia. >90% cases recover within 3 to 6 months.

129

Preauricular lymphadenopathy accompanies which of the following ?

Which of the following appear in the red cells of asplenic individuals ?

Harrison’s 18th Ed. 466

A.

Scalp infection

Harrison’s 16th Ed. 675

B.

Ear infection

C.

Conjunctival infections

D.

Tooth infection

A.

Macroovalocytes

B.

Basophilic stippling

C.

Howell-Jolly bodies

D.

Target cells

Howell-Jolly bodies are tiny nuclear remnants that are normally removed by spleen. They appear in blood after splenectomy & with maturation / dysplastic disorders.

130

134

Rituximab is what type of a monoclonal antibody ? Harrison’s 16th Ed. 676

Preauricular adenopathy accompanies conjunctival infections and cat-scratch disease.

135

Most frequent site of regional lymphadenopathy is ? Harrison’s 18th Ed. 466

A.

Axilla

B.

Neck Groin Abdominal

A.

Anti-CD19

C.

B.

Anti-CD20

D.

C.

Anti-CD21

Most frequent site of regional lymphadenopathy is neck.

12 136

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following about lymphadenopathy is false ? Harrison’s 18th Ed. 466

Which of the following is characteristic of enlarged lymph nodes in metastatic cancer ?

A.

Most frequent site of regional lymphadenopathy is neck

Harrison’s 18th Ed. 466

B.

Enlargement of supraclavicular and scalene nodes is always abnormal

A.

Hard

B.

Nonmovable

Virchow’s node is enlarged right supraclavicular node

C.

Nontender

Sarcoidosis can cause supraclavicular adenopathy

D.

All of the above

C. D.

Virchow’s node is an enlarged left supraclavicular node infiltrated with metastatic cancer from a gastrointestinal primary.

137

Metastases to supraclavicular nodes occur from ?

143

Harrison’s 18th Ed. 467

Lung

A.

Area

B.

Breast

B.

Volume

C.

Testis

C.

Ratio of long to short axis (L / S ratio)

D.

Any of the above

D.

Sonodensity

Which of the following is a cause of supraclavicular adenopathy ?

On Ultrasonography of cervical nodes, a ratio of long to short axis of 8 cm

B.

< 250 grams

C.

> 12 cm

C.

< 350 grams

D.

> 16 cm

D.

< 450 grams

Normal spleen weighs 8 cm in adult indicates splenic enlargement.

14 160

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR In Castell’s method, percussion in the lowest intercostal space is done in ?

167

Hematology

Term “splenosis” best relates to ? Harrison’s 18th Ed. 471

Harrison’s 18th Ed. 469

A.

Regression of systemic disease after splenectomy

A.

Midclavicular line

B.

Ultrafiltration of abnormal RBCs

B.

Anterior axillary line

C.

Iatrogenic splenic rupture

C.

Midaxillary line

D.

Ectopic spleen tissue

D.

Posterior axillary line

In Castell’s method, patient is supine, percussion is done in lowest intercostal space in anterior axillary line. A dull percussion note on full inspiration suggests splenomegaly.

At times in patients with splenic rupture, peritoneal seeding of splenic fragments can lead to splenosis i.e. presence of multiple collections of spleen tissue not connected to portal circulation. This ectopic spleen tissue may cause pain or gastrointestinal obstruction, as in endometriosis.

161

168

Massive splenomegaly is defined as spleen extending ? Harrison’s 18th Ed. 469

162

A.

> 2 cm below left costal margin

B.

> 4 cm below left costal margin

C.

> 6 cm below left costal margin

D.

> 8 cm below left costal margin

Massive splenomegaly is defined as spleen that weighs ? Harrison’s 18th Ed. 469

A.

> 250 gram

B.

> 500 gram

C.

> 750 gram

D.

> 1000 gram

Harrison’s 18th Ed. 471

Causes of massive splenomegaly include ? Harrison’s 18th Ed. 471 Table 59-3

164

165

A.

Chronic myelogenous leukemia

B.

Lymphomas

C.

Hairy cell leukemia

D.

All of the above

Iatrogenic splenic rupture

B.

Thrombocytopenia

C.

Presence of bone marrow failure

D.

Hairy cell leukemia

169

Chronic manifestations of splenectomy include ? Harrison’s 18th Ed. 471

A.

Howell-Jolly bodies

B.

Heinz bodies

C.

Basophilic stippling

D.

All of the above

Chronic manifestations of splenectomy include anisocytosis, poikilocytosis, presence of HowellJolly bodies (nuclear remnants), Heinz bodies (denatured hemoglobin), basophilic stippling.

170

Frequency of a serious infection following splenectomy is highest within ? Harrison’s 18th Ed. 471

A.

First 6 months

B.

First 1 year

Harrison’s 18th Ed. 471 Table 59-3

C.

First 3 years

A.

Myelofibrosis with myeloid metaplasia

D.

First 5 years

B.

Polycythemia vera

C.

Gaucher’s disease

D.

All of the above

Causes of massive splenomegaly include ?

Frequency of a serious infection following splenectomy is highest within first 3 years.

171

Which of the following is false in postsplenectomy period ? Harrison’s 18th Ed. 471

Causes of Massive splenomegaly include ?

A.

Increased susceptibility to capsulated bacterial infections

Harrison’s 18th Ed. 471 Table 59-3

B.

No increased risk of viral infection

A.

Chronic lymphocytic leukemia

C.

Increased susceptibility to babesiosis

B.

Sarcoidosis

D.

None of the above

C.

Autoimmune hemolytic anemia

D.

All of the above

Causes of massive splenomegaly fall into four main categories: infectious diseases such as chronic malaria, kala-azar, and leishmaniasis; infiltrative diseases such as Gaucher’s disease and Niemann-Pick disease; portal hypertension; and hematologic diseases, including myeloproliferative and lymphoproliferative disorders (N Engl J Med. 2001:345, 682).

166

A.

The only contraindication to splenectomy is the presence of marrow failure, in which the enlarged spleen is the only source of hematopoietic tissue.

Massive splenomegaly refers to spleen that extends >8 cm below left costal margin and/or weighs (drained) more than 1000 grams.

163

Which out of the following is a contraindication for splenectomy ?

‘Abscopal effect’ refers to ? Harrison’s 18th Ed. 471

A.

Ultrafiltration of abnormal RBCs

B.

Regression of systemic disease after splenectomy

C.

Increased tendancy of enlarged splenic rupture

D.

Peritoneal seeding of splenic fragments

172

In elective splenectomy, pneumococcal vaccine should be administered how many weeks before surgery ? Harrison’s 18th Ed. 471

A.

1 weeks

B.

2 weeks

C.

3 weeks

D.

4 weeks

Pneumococcal vaccine (23-valent polysaccharide vaccine) should be administered to all patients 2 weeks before elective splenectomy.

Hematology 15

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Chapter 60. Disorders of granulocytes & monocytes 173

Which of the following is a leukocyte ?

B.

5 days

C.

7 days

D.

10 days

15 Cardiology

Proliferation phase through the metamyelocyte takes ~1 week, while maturation phase from metamyelocyte to mature neutrophil takes ~1 week.

Harrison’s 18th Ed. 472

A.

Natural killer (NK) cell

B.

B lymphocyte

C.

Monocyte

D.

All of the above

179

Harrison’s 18th Ed. 472 Figure 60-2

Leukocytes include neutrophils, T and B lymphocytes, natural killer (NK) cells, monocytes, eosinophils, and basophils.

174

Which of the following statements about leukocytes is false ?

180

A.

Myeloblast

B.

Promyelocyte

C.

Myelocyte

D.

Metamyelocyte

Primary or azurophil granules are present in ?

Harrison’s 18th Ed. 472

Harrison’s 18th Ed. 472

A.

Derived from common stem cell in bone marrow

A.

Myeloblast

B.

Threefourths of nucleated cells of bone marrow are committed to leukocyte production

B.

Promyelocyte

C.

Myelocyte

C.

Their maturation in marrow is regulated by colonystimulating factors & interleukins

D.

All of the above

D.

None of the above

Leukocytes are derived from a common stem cell in bone marrow. Three-fourths of nucleated cells of bone marrow are committed to production of leukocytes. Leukocyte maturation in the marrow is under the regulatory control of colony-stimulating factors (CSFs) & interleukins (ILs).

175

Which of the following is the largest cell in size ?

Classic lysosomal granules called the primary or azurophil granules are found in promyelocyte.

181

Harrison’s 18th Ed. 472

Minimum number of stem cells necessary to support hematopoiesis is ? Harrison’s 18th Ed. 472

A.

100 to 200

B.

200 to 300

C.

300 to 400

D.

400 to 500

Primary or azurophil granules contain ? A.

Hydrolases

B.

Cathepsin G

C.

Myeloperoxidase

D.

All of the above

Primary granules contain hydrolases, elastase, myeloperoxidase, cathepsin G, cationic proteins, bactericidal/permeability-increasing protein & defensins.

182

Minimum number of stem cells necessary to support hematopoiesis is 400 - 500 at any one time.

Which of the following azurophil granules has broad antimicrobial activity against bacteria, fungi & certain enveloped viruses ? Harrison’s 18th Ed. 472

176

Colony-stimulating factors are produced by ?

A.

Hydrolases

Harrison’s 18th Ed. 472

B.

Cathepsin G

C.

Myeloperoxidase

D.

Defensins

A.

Monocytes

B.

Tissue macrophages

C.

Stromal cells

D.

All of the above

Human blood monocytes, tissue macrophages & stromal cells produce CSFs, hormones required for growth of monocytes & neutrophils in bone marrow.

Defensins in azurophil granules have a broad antimicrobial activity against bacteria, fungi, and certain enveloped viruses.

183

Specific or secondary granules are present in ? Harrison’s 18th Ed. 472

177

In a 80 kg person, how many neutrophils are produced by hematopoietic system per day ? Harrison’s 18th Ed. 472

A.

~ 0.3 x 1011

B.

~ 1.3 x 1011

C.

~ 2.3 x 1011

D.

~ 3.3 x 10

11

In a 80 kg person, ~1.3 x 10 11 neutrophils are produced by hematopoietic system per day.

178

Maturation from metamyelocyte to neutrophil takes how many days ? Harrison’s 18th Ed. 472

A.

2 days

184

A.

Myeloblast

B.

Promyelocyte

C.

Myelocyte

D.

All of the above

Secondary granules contain all except ? Harrison’s 18th Ed. 472

A.

Acid hydrolases

B.

Lactoferrin

C.

Vitamin B12 binding protein

D.

Histaminase

Myelocyte synthesises specific or secondary granules which contains lactoferrin, vitamin B 12

16

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

binding protein, membrane components of reduced nicotinamide-adenine dinucleotide phosphate (NADPH) oxidase, histaminase, and laminin. Secondary granules do not contain acid hydrolases.

185

Packaging of secondary granule contents during myelopoiesis is controlled by ? Harrison’s 18th Ed. 472

A.

CCAAT/enhancer binding protein-

B.

CCAAT/enhancer binding protein-

C.

CCAAT/enhancer binding protein-

D.

CCAAT/enhancer binding protein-

Circulating pool of neutrophils exists in two dynamic compartments: one freely flowing and one marginated. Freely flowing pool is ~half the neutrophils in basal state and is composed of those cells that are in the blood and not in contact with endothelium. Marginated leukocytes are those that are in close physical contact with endothelium. Due to extensive capillary bed (~1000 capillaries per alveolus) in pulmonary circulation, margination occurs because the capillaries are about the same size as a mature neutrophil.

191

Excessive segmentation of nucleus of neutrophils is a manifestation of ? Harrison’s 18th Ed. 473

Integrins

C.

Intercellular adhesion molecules

D.

Opsonins

B.

Iron deficiency

Harrison’s 18th Ed. 473

C.

Thalassemia

A.

Selectins

Repeated blood transfusion

B.

Integrins

C.

Intercellular adhesion molecules

D.

Opsonins

192

Which of the following is false about ‘Pelger-Huet anomaly’ ? A.

Benign disorder

B.

Majority of granulocytes are bilobed

C.

Nucleus has spectacle-like configuration

D.

None of the above

Under normal conditions, what proportion of neutrophil pool is in the bone marrow ? Harrison’s 18th Ed. 473

A.

~ 20 %

B.

~ 50 %

C.

~ 70 %

D.

~ 90 %

193

B.

~ 20 %

C.

~ 50 %

D.

~ 90 %

Normally, ~90% of the neutrophil pool is in bone marrow, 2 - 3% in circulation (freely flowing & marginated), & remainder in tissues.

Marginated leukocytes are maximum in ? Harrison’s 18th Ed. 473

A.

Lungs

B.

Spleen

C.

Liver

D.

Kidneys

A.

PECAM 1

B.

Anaphylatoxins

C.

Vascular endothelial growth factor (VEGF)

D.

Prostaglandins E & I

Process of migration into tissues is called diapedesis and involves crawling of neutrophils between postcapillary endothelial cells that open junctions between adjacent cells to permit leukocyte passage. Diapedesis involves platelet/endothelial cell adhesion molecule (PECAM) 1 (CD31) expressed on emigrating leukocyte & endothelial cells.

194

In the healthy adult, most neutrophils leave the body by ? Harrison’s 18th Ed. 475

Harrison’s 18th Ed. 473

~2%

Diapedesis involves which of the following ? Harrison’s 18th Ed. 474

Under normal conditions, what proportion of neutrophil pool is in the circulation ? A.

Neutrophils “stick” to the endothelium through ?

In response to chemotactic stimuli from injured tissues or bacterial products, neutrophil adhesiveness increases and they “stick” to the endothelium through integrins. Integrins are leukocyte glycoproteins that bind to specific endothelial receptors [intercellular adhesion molecules (ICAM) 1 & 2].

Pelger-Hüet anomaly is a benign inherited disorder. Majority of granulocytes are bilobed (hyposegmented neutrophils). Nucleus has a spectacle-like, or “pince-nez” configuration.

190

B.

Folate or vitamin B12 deficiency

Harrison’s 18th Ed. 473 Figure 60-5

189

Selectins

Selectins are glycoproteins expressed on neutrophils & endothelial cells and cause a lowaffinity interaction resulting in “rolling” of neutrophil along the endothelial surface.

Nucleus of neutrophils normally contains up to four segments. Excessive segmentation (>5 nuclear lobes) is seen in folate or vitamin B 12 deficiency & congenital neutropenia syndrome of warts, hypogammaglobulinemia, infections & myelokathexis (WHIM).

188

A.

A.

D.

187

“Rolling” of the neutrophil along the endothelial surface is a function of ? Harrison’s 18th Ed. 473

Packaging of secondary granule contents during myelopoiesis is controlled by CCAAT/enhancer binding protein- .

186

Hematology

A.

Migration through mucous membrane of GI tract

B.

Apoptosis

C.

Phagocytosis

D.

All of the above

In the healthy adult, most neutrophils leave the body by migration through the mucous membrane of the gastrointestinal tract.

195

N o r m a l l y, n e u t r o p h i l s s p e n d h o w m u c h t i m e i n circulation ? Harrison’s 18th Ed. 475

A.

2 to 3 hours

B.

6 to 7 hours

C.

12 to 24 hours

D.

24 to 36 hours

Normally, neutrophils spend a short time in circulation (half-life, 6 - 7 hours).

Hematology 17 196

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Senescent neutrophils are cleared from the circulation by macrophages in ?

Harrison’s 18th Ed. 476 Table 60–1

A.

Kidneys

A.

Carbamazepine

B.

Lung

B.

Clozapine

C.

GI tract

C.

Antithyroid drugs

D.

Thymus

D.

All of the above

Characteristic green color to pus is due to ? Harrison’s 18th Ed. 475

A.

Collagenase

B.

Elastase

C.

Myeloperoxidase

D.

All of the above

drugs cause neutropenia due to decreased production include alkylating agents (nitrogen mustard, busulfan, chlorambucil, cyclophosphamide), antimetabolites (methotrexate, 6-mercaptopurine, 5flucytosine), antibiotics (chloramphenicol, penicillins, sulfonamides), phenothiazines, tranquilizers (meprobamate), anticonvulsants (carbamazepine), antipsychotics (clozapine), certain diuretics, anti-inflammatory agents, antithyroid drugs.

203

Which of the following is not a group of chemokines ? Harrison’s 18th Ed. 475

A.

C

B.

CC

C.

CCC

D.

CXC

Susceptibility to infectious diseases increases sharply when neutrophil counts fall below ?

Phenylbutazone

C.

Mercurial diuretics

D.

All of the above

204

Which of the following is a cause of neutropenia due to peripheral pooling (Transient neutropenia) ? Harrison’s 18th Ed. 476 Table 60–1

205

A.

Overwhelming bacterial infection (acute endotoxemia)

B.

Hemodialysis

C.

Cardiopulmonary bypass

D.

All of the above

Congenital forms of neutropenia include ? Harrison’s 18th Ed. 476

A.

1000 cells/µL

A.

Kostmann’s syndrome

B.

2000 cells/µL

B.

Shwachman-Diamond syndrome

C.

3000 cells/µL

C.

WHIM syndrome

D.

4000 cells/µL

D.

All of the above

Inflammatory process is absent, when absolute neutrophil count (ANC) falls below ?

Congenital forms of neutropenia include Kostmann’s syndrome, cartilage-hair hypoplasia syndrome, Shwachman-Diamond syndrome, WHIM syndrome and hereditary cyclic neutropenia.

206

Kostmann’s syndrome is due to mutations in ?

Harrison’s 18th Ed. 476

Harrison’s 18th Ed. 476

A.

< 100 cells / µL

A.

Potassium voltage-gated channel gene KCNA1

B.

< 200 cells / µL

B.

PKD-1 gene

C.

< 500 cells / µL

C.

Anti-apoptosis gene HAX-1

< 1000 cells / µL

D.

GJB2 gene

D.

When absolute neutrophil count (band forms & mature neutrophils combined) is 30000 to 50000 / µL

C.

> 50000 to 75000 / µL

D.

> 75000 to 100000 / µL

Which of the following is false about leukemoid reaction ? Harrison’s 18th Ed. 477

A.

Neutrophil cell count > 30000 to 50000 / µL

B.

Circulating neutrophils are mature

C.

Circulating neutrophils are clonally derived

D.

None of the above

216

B.

Lithium

C.

Phenothiazines

D.

Phenylbutazone

217

A.

Autosomal dominant traits

B.

Inability of neutrophils to exit circulation

C.

Leukocytosis

D.

Increased susceptibility to infection

LAD 1 & 2 are autosomal recessive traits leading to inability of neutrophils to exit circulation to sites of infection, leukocytosis & increased susceptibility to infection.

Leukocyte adhesion deficiency 3 (LAD 3)

D.

None of the above

In neutrophils, which of the following is seen in severe acute bacterial infections ? A.

Toxic granulations

B.

Dohle bodies

C.

Large neutrophil vacuoles

D.

All of the above

Which of the following is false about ‘Dohle body’ ? A.

Discrete, blue-staining nongranular areas found in periphery of cytoplasm of neutrophils

B.

Found in infections and other toxic states

C.

Aggregates of rough endoplasmic reticulum

D.

None of the above

Döhle bodies are discrete, blue-staining nongranular areas found in periphery of cytoplasm of neutrophil in infections & toxic states. They are aggregates of rough endoplasmic reticulum.

218

For lymphocytes, “CD” stands for ? Harrison’s 16th Ed. 350

Which of the following about leukocyte adhesion deficiency (LAD) 1 & 2 is false ? Harrison’s 18th Ed. 477

C.

Harrison’s 18th Ed. 473 Figure Figure 60-3

Epinephrine, glucocorticoids, nonsteroidal anti-inflammatory agents, lithium, , granulocyte colonystimulating factor (G-CSF) can cause neutrophilia.

213

Leukocyte adhesion deficiency 2 (LAD 2)

In severe acute bacterial infection toxic granulations (immature or abnormally staining azurophil granules), Döhle bodies (cytoplasmic inclusions which are fragments of ribosome-rich endoplasmic reticulum) & large neutrophil vacuoles (pinocytosed or internalized membrane) are seen.

Harrison’s 18th Ed. 477 Table 60–2

Meprobamate

Leukocyte adhesion deficiency 1 (LAD 1)

B.

Harrison’s 17th Ed. 377

Which of the following drugs can cause neutrophilia ? A.

A.

LAD 2 is also known as congenital disorder of glycosylation IIc (CDGIIc) due to mutation in a GDP-fucose transporter (SLC35C1).

Persistent neutrophilia with cell counts of 30,000 - 50,000/µL is called a leukemoid reaction. In leukemoid reaction, circulating neutrophils are usually mature & not clonally derived.

212

Which of the following is called “Congenital disorder of glycosylation IIc (CDGIIc)” ? Harrison’s 18th Ed. 479

Harrison’s 18th Ed. 477

211

Hematology

219

A.

Clonal determinant

B.

Cluster determinant

C.

Capsule determinant

D.

Cell determinant

Which of the following is false about Chédiak-Higashi syndrome (CHS) ? Harrison’s 18th Ed. 479

A.

Autosomal recessive inheritance

B.

Defects in lysosomal transport protein LYST

C.

Abnormal packaging & disbursement of granules

D.

None of the above

CHS is a systemic disease with autosomal recessive inheritance due to defects in the lysosomal transport protein LYST required for normal packaging and disbursement of granules, encoded by the gene CHS1 at 1q42. Characterized by the presence of giant lysosomes within leukocytes.

Hematology 19 220

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Patients with Chédiak-Higashi syndrome (CHS) may have which of the following ? Harrison’s 18th Ed. 479

A.

Seizure

B.

Blindness

C.

Nystagmus

D.

Tremors

B.

Mobilizing leukocytes from bone marrow

C.

Activating lymphocytes & neutrophils

D.

All of the above

Functions of IL-1 include initiating fever in hypothalamus, mobilizing leukocytes from bone marrow and activating lymphocytes & neutrophils.

227

TNF-  duplicates the function of which of the following ? Harrison’s 18th Ed. 480

Patients with CHS have nystagmus, partial oculocutaneous albinism, and an increased frequency of infections. Patients may develop a severe disabling peripheral neuropathy in adulthood. Vitamin C supplementation is useful in Chédiak-Higashi syndrome. Hematopoietic cell transplantation can cure patients of CHS.

A.

IL-1

B.

IL-8

C.

IL-12

221

D.

IL-18

Leukocytes from patients with chronic granulomatous disease (CGD) have severely diminished production of ? Harrison’s 18th Ed. 479

A.

Hydrogen peroxide

B.

Nitric oxide

C.

IL-1

D.

TNF-alpha

TNF-  is a pyrogen that duplicates many actions of IL-1. It plays significant role in the pathogenesis of gram-negative shock.

228

Frequency of which of the following is increased in CGD ? Harrison’s 18th Ed. 480

223

A.

Immune thrombocytopenic purpura (ITP)

B.

Juvenile rheumatoid arthritis

C.

Discoid lupus

D.

All of the above

229

A.

Monoblasts

B.

Promonocytes

C.

Monocytes

D.

All of the above

A.

Acute infections

B.

Glucocorticoid therapy

C.

Aplastic anemia

D.

All of the above

Monocytopenia occurs with ? Harrison’s 18th Ed. 481

Mononuclear phagocyte system is composed of ? Harrison’s 18th Ed. 480

Monocytopenia occurs with ? Harrison’s 18th Ed. 481

Leukocytes from patients with CGD have severely diminished hydrogen peroxide production.

222

A.

Hairy cell leukemia

B.

Acute myeloid leukemia

C.

Stress

D.

All of the above

Monocytopenia occurs with acute infections, stress, glucocorticoid use, aplastic anemia, hairy cell leukemia, acute myeloid leukemia & use of myelotoxic drugs.

230

Monocytosis is associated with ? Harrison’s 18th Ed. 480

A.

Tuberculosis

Mononuclear phagocyte system is composed of monoblasts, promonocytes, monocytes and tissue macrophages.

B.

Brucellosis

C.

Subacute bacterial endocarditis

224

D.

All of the above

Monocytes have a half-life in the blood of ? Harrison’s 18th Ed. 480

A.

1 to 3 hours

B.

6 to 7 hours

C.

12 to 24 hours

D.

24 to 36 hours

231

“Big eaters” is the term used for ? Harrison’s 18th Ed. 480

A.

Neutrophils

B.

Monocytes

C.

Macrophages

D.

None of the above

Monocytosis is associated with ? Harrison’s 18th Ed. 480

Monocytes have a half-life in blood of 12 - 24 hours.

225

19 Cardiology

A.

Malaria

B.

Visceral leishmaniasis (kala azar)

C.

Hemolytic anemias

D.

All of the above

Monocytosis is associated with TB, brucellosis, SABE, Rocky Mountain spotted fever, malaria, visceral leishmaniasis (kala azar), leukemias, myeloproliferative syndromes, hemolytic anemias, chronic idiopathic neutropenias & granulomatous diseases like sarcoidosis & regional enteritis.

232

“TRAPS” stands for ? Harrison’s 18th Ed. 480

A.

Tumour associated periodic syndromes

B.

TNF- receptor associated periodic syndromes

Macrophages are called “big eaters”. They differentiate from blood monocytes that arrive in tissues.

C.

Thyroid associated periodic syndromes

226

D.

T receptor associated periodic syndromes

Function of macrophage secreted product - IL-1 is ? Harrison’s 18th Ed. 480

A.

Initiating fever in hypothalamus

Gain-of-function mutations in TNF- receptor cause TNF- receptor-associated periodic syndrome (TRAPS) characterized by recurrent fever without infection (persistent stimulation of TNF- receptor).

20 233

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Familial Mediterranean fever due to mutations in PYRIN is due to abnormal regulation of ?

239

234

A.

Arginine-rich protein content

A.

IL-1

B.

Histaminase activity

B.

IL-8

C.

Contain eosinophil peroxidase

C.

IL-12

D.

None of the above

D.

IL-18

Eosinophil granule contains arginine-rich protein in its crystalline core which has histaminase activity, eosinophil peroxidase that catalyzes oxidation by hydrogen peroxide.

240

Mutations in cold-induced autoinflammatory syndrome 1 (CIAS1) lead to ? A.

Neonatal-onset multisystem autoinflammatory disease

B.

Familial cold urticaria

C.

Muckle-Wells syndrome

D.

All of the above

Mutations in cold-induced autoinflammatory syndrome 1 (CIAS1) lead to neonatal-onset multisystem autoinflammatory disease, familial cold urticaria, and Muckle-Wells syndrome.

241

B.

Muckle-Wells syndrome

C.

Familial cold urticaria

D.

Familial Mediterranean fever

The syndrome of pyoderma gangrenosum, acne, and sterile pyogenic arthritis (PAPA syndrome) is caused by mutations in CD2BP1.

236

B.

Phospholipase

C.

Lysophospholipase

D.

Immunoglobulin E

Eosinophilia refers to how many eosinophils per microliter of blood ? A.

> 200

B.

> 300

C.

> 400

D.

> 500

Eosinophilia is the presence of >500 eosinophils per µL of blood.

242

Eosinophilia is due to allergic reaction which of the following drugs ? Harrison’s 18th Ed. 481

Which of the following is a TNF-  antagonist ? Harrison’s 18th Ed. 481

A.

Iodides

A.

Infliximab

B.

Aspirin

B.

Adalimumab

C.

Nitrofurantoin

C.

Etanercept

D.

All of the above

D.

All of the above

243

Eosinophilia is associated with which of the following diseases ? Harrison’s 18th Ed. 481

TNF-  antagonists are infliximab, adalimumab, certolizumab, and etanercept.

237

Hyaluronidase

Harrison’s 18th Ed. 481

Harrison’s 18th Ed. 481

PAPA syndrome

A.

Eosinophil cytoplasm contains Charcot-Leyden crystal protein which is a lysophospholipase.

Mutations in CD2BP1 cause which of the following ? A.

Charcot-Leyden crystal protein in eosinophil cytoplasm is ? Harrison’s 18th Ed. 481

Harrison’s 18th Ed. 480

235

Which of the following is false about eosinophil granule ? Harrison’s 18th Ed. 481

Harrison’s 18th Ed. 480

Diseases with abnormal IL-1 regulation leading to fever include familial Mediterranean fever due to mutations in PYRIN.

Hematology

Specific chemokine expressed by eosinophils is ? Harrison’s 18th Ed. 481

A.

Serum sickness

B.

Eczema Pemphigus All of the above

A.

Eotaxin

C.

B.

Eosinotaxin

D.

C.

Eosinophilotaxin

D.

All of the above

244

Eosinophilia is associated with which of the following malignancies ? Harrison’s 18th Ed. 481

Eosinophils express a specific chemokine EOTAXIN.

238

A.

Cancer pancreas

Which of the following is false about eosinophils ?

B.

Cancer ovary

Harrison’s 18th Ed. 481

C.

Cancer uterus

D.

All of the above

A.

Shorter half life than neutrophils

B.

Eosinophils can recirculate

C.

During most infections, eosinophils are not important

D.

Central role in defense against invasive helminthic infections

Eosinophils have a longer half life than neutrophils. Unlike neutrophils, tissue eosinophils can recirculate. During most infections, eosinophils are not important but plays a central role in host defense in invasive helminthic infections.

Eosinophilia occurs in allergic reaction to drugs (iodides, aspirin, sulfonamides, nitrofurantoin, penicillins & cephalosporins), allergies (hay fever, asthma, eczema, serum sickness, allergic vasculitis, & pemphigus), collagen vascular diseases (RA, eosinophilic fasciitis, allergic angiitis & PAN), malignancies (Hodgkin’s disease; mycosis fungoides; CML, Ca. lung, stomach, pancreas, ovary, uterus), Job’s syndrome & CGD, and helminthic infections.

245

Which of the following is the dominant eosinophil growth factor ? Harrison’s 18th Ed. 481

A.

IL-1

Hematology 21

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

IL-3

B.

Glucocorticoids

C.

IL-5

C.

Lithium

D.

All of the above

D.

All of the above

IL-5 is the dominant eosinophil growth factor.

246

Apart from recombinant G-CSF, androgens, glucocorticoids, lithium & immunosuppressive therapy are used to restore myelopoiesis in patients with neutropenia due to impaired production.

Which of the following is false about eosinophilia-myalgia syndrome ? Harrison’s 18th Ed. 481

247

21 Cardiology

A.

Eosinophil count > 1000/µL

B.

Caused by ingesting contaminants in L-tryptophan containing products

C.

Responds to glucocorticoids

D.

None of the above

Chapter 103. Iron Deficiency and Other Hypoproliferative Anemias 252

Which of the following is false about hypoproliferative anemias ? Harrison’s 18th Ed. 844

A.

Normocytic RBC’s

B.

Normochromic RBC’s

Cardiac arrhythmias

C.

Reticulocyte index < 2.0 - 2.5

B.

Myopathy

D.

None of the above

C.

Pulmonary fibrosis

D.

None of the above

Which of the following is an adverse effect of eosinopenia ? Harrison’s 18th Ed. 482

A.

There is no known adverse effect of eosinopenia.

Anemias associated with normocytic and normochromic red cells and an inappropriately low reticulocyte response (reticulocyte index < 2.0 - 2.5) are hypoproliferative anemias.

253

Which of the following is a hypoproliferative anemia ? Harrison’s 18th Ed. 844

248

Which of the following is false about hyperimmunoglobulin E–recurrent infection (HIE) syndrome ? Harrison’s 18th Ed. 482

A.

Also called Job’s syndrome

B.

‘Cold’ skin abscesses

C.

Kyphoscoliosis

D.

Obstructive lung disease

Hyperimmunoglobulin E - recurrent infection syndrome is also called Job’s syndrome, characterized by typical facies with broad nose, kyphoscoliosis, osteoporosis & eczema. Primary teeth erupt normally but do not deciduate requiring extraction. Patients develop recurrent sinopulmonary & cutaneous infections much less inflamed than expected (“cold abscesses”).

249

B.

Anemia of hypometabolic states

C.

Anemias from marrow damage

D.

All of the above

254

Most common anemia among hypoproliferative anemias is ? Harrison’s 18th Ed. 844

A.

Anemias associated with renal disease

Which of the following is performed to assess bone marrow reserves ?

B.

Anemias associated with chronic inflammation

C.

Anemias associated with cancer

Harrison’s 18th Ed. 482

D.

Anemias associated with hypometabolic states

A.

Steroid challenge test

B.

Epinephrine challenge test

C.

Endotoxin challenge test

D.

All of the above

anemia associated with chronic inflammation is the most common of the above mentioned hypoproliferative anemias. All these are characterized by an abnormal erythropoietin response to the anemia.

255

Which of the following is called iron transport protein ? Harrison’s 18th Ed. 844

A.

Ferritin

B.

Transferrin

Harrison’s 18th Ed. 482

C.

Divalent metal transporter 1 (DMT1)

A.

Rebuck skin window test

D.

All of the above

B.

Nitroblue tetrazolium (NBT) dye test

C.

Dihydrorhodamine (DHR) oxidation test

D.

All of the above

In vivo assessment of inflammation is done by ?

In vivo assessment of inflammation is done by Rebuck skin window test or skin blister assay, which measures the ability of leukocytes & inflammatory mediators to accumulate locally in skin. NBT & DHR tests are for detecting deficiencies of oxidative metabolism.

251

Anemia of acute and chronic inflammation

Hypoproliferative anemias include early iron deficiency, acute and chronic inflammation, renal disease, hypometabolic states (protein malnutrition & endocrine deficiencies), and anemias from marrow damage.

Assessment of bone marrow reserves of WBC’s is done by steroid challenge test. Epinephrine challenge test is for marginated circulating pool of cells & endotoxin challenge test is for their marginating ability.

250

A.

Which of the following drugs is useful to restore myelopoiesis in neutropenia due to impaired production ? Harrison’s 18th Ed. 482

A.

Androgens

Iron absorbed from the diet or released from stores circulates in the plasma bound to transferrin, the iron transport protein.

256

Turnover or half-clearance time of transferrin-bound iron is ? Harrison’s 18th Ed. 844

A.

5 - 10 minutes

B.

10 - 30 minutes

C.

30 - 60 minutes

D.

60 - 90 minutes

Turnover or half-clearance time of transferrin-bound iron is 60 - 90 minutes.

22 257

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following has the highest affinity for transferrin receptors ?

Harrison’s 18th Ed. 845

A.

1 mg

A.

Monoferric transferrin

B.

2 mg

B.

Diferric transferrin

C.

3 mg

C.

Apotransferrin

D.

4 mg

D.

All of the above

Each milliliter of red cells contains 1 mg of elemental iron.

264

A.

Stomach

Harrison’s 18th Ed. 844 Figure 103-1

B.

Proximal small intestine

A.

1 mg

C.

Distal small intestine

B.

2 mg

D.

Large intestine

C.

3 mg

D.

4 mg

Iron absorption takes place largely in proximal small intestinethrough a carefully regulated process.

265

During the last two trimesters of pregnancy, daily iron requirements increase to ?

A.

Duodenal hepcidin

B.

Duodenal ferroportin

Harrison’s 18th Ed. 845

C.

Duodenal hephaestin

D.

Duodenal cytochrome B (Dcytb)

A.

2 to 3 mg

B.

3 to 4 mg

C.

4 to 5 mg

D.

5 to 6 mg

Dietary inorganic iron traverses brush border membrane of duodenal enterocytes via DMT1 after reduction of ferric (Fe3+) to ferrous (Fe2+) iron by duodenal cytochrome B (Dcytb) - a ferrireductase.

266

Iron transport across the enteric absorptive cell membrane is accomplished by ? Harrison’s 18th Ed. 845

Transferrin-receptor complex is internalized via ?

A.

Duodenal cytochrome B (Dcytb)

Etharin-coated pits

B.

Hephaestin

B.

Megalin-coated pits

C.

Ferroportin

C.

Clathrin-coated pits

D.

Divalent metal transporter 1 (DMT-1)

D.

Azalin-coated pits

Harrison’s 18th Ed. 845

A.

Transferrin-receptor complex is internalized via clathrin-coated pits and transported to an acidic endosome, where iron is released at a low pH.

261

Reduction of ferric (Fe 3+ ) to ferrous (Fe 2+ ) iron at brush border membrane of duodenal enterocytes is done by ? Harrison’s 17th Ed. 3163 Figure 357-1

During the last two trimesters of pregnancy, daily iron requirements increase to 5 - 6 mg/day.

260

Iron absorption takes place largely in ? Harrison’s 18th Ed. 845

Daily requirement of dietary iron in adult man is ?

Normally, an adult male needs ~1 mg of elemental iron daily, while females in childbearing years need 1.4 mg/day.

259

Each milliliter of red cells contain how much elemental iron ?

Harrison’s 18th Ed. 844

Iron-transferrin complex in plasma interacts with specific transferrin receptors on marrow erythroid cell surface. Diferric transferrin has the highest affinity for transferrin receptors. Apotransferrin does not carry iron and has very little affinity for transferrin receptors.

258

263

In erythroid cell, excess iron binds to which of the following to form ferritin ?

Iron transport across enteric absorptive cell membrane is achieved by Divalent metal transporter 1 (DMT-1). DMT-1 is a general cation transporter and is also known as natural resistance macrophage-associated protein type 2 (Nramp 2) or DCT-1.

267

Apoferritin

B.

Transferritin

C.

Coferritin

D.

Endoferritin

Iron in gut cell is transported through its basolateral surface to plasma transferrin through ? Harrison’s 18th Ed. 845

Harrison’s 18th Ed. 845

A.

Hematology

A.

Duodenal cytochrome B (Dcytb)

B.

Hephaestin

C.

Ferroportin (FPN)

D.

Divalent metal transporter 1 (DMT-1)

In erythroid cell, excess iron binds to Apoferritin to form ferritin.

In gut cell, iron may be stored as ferritin or released at basolateral surface to plasma transferrin through membrane-embedded iron exporter, ferroportin (FPN).

262

268

What proportion of red cells turn over each day ? Harrison’s 18th Ed. 845

A.

0.2 to 0.4 %

B.

0.4 to 0.6 %

C.

0.6 to 0.8 %

D.

0.8 to 1.0 %

Normally, average RBC life span is 120 days. Thus, 0.8 - 1.0 % of red cells turn over each day.

Which of the following oxidizes iron to ferric form for transferrin binding at the basolateral surface of gut cell ? Harrison’s 18th Ed. 845

A.

Duodenal cytochrome B (Dcytb)

B.

Hephaestin

C.

Ferroportin

D.

Divalent metal transporter 1 (DMT-1)

Iron moves from enterocyte into circulation via a process requiring basolateral iron exporter ferroportin (FPN) & iron oxidase hephaestin (Heph) - which oxidizes iron to ferric form for transferrin binding.

Hematology 23 269

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Hephaestin is similar to which of the following ?

B.

15 to 20 %

Harrison’s 18th Ed. 845

C.

20 to 25 %

D.

25 to 30 %

A.

Ferritin

B.

Erythropoietin

C.

C-reactive protein

D.

Ceruloplasmin

Hephaestin is similar to ceruloplasmin, the copper-carrying protein.

270

271

276

Harrison’s 18th Ed. 846

A.

Impaired hemoglobin synthesis

A.

Bone marrow

B.

Microcytic RBCs first appear in PBF

B.

Liver

C.

Hyperchromic reticulocytes in circulation

C.

Duodenum

D.

Transferrin saturation between 15 to 20 %

D.

Spleen

Which of the following is called “iron regulatory hormone” ?

When transferrin saturation is between 15 to 20%, hemoglobin synthesis is impaired. This is a period of iron-deficient erythropoiesis. Peripheral blood smear reveals the first appearance of microcytic cells and hypochromic reticulocytes in circulation.

277

Ferritin

B.

Transferrin

A.

Negative iron balance

C.

Erythropoietin

B.

Iron-deficient erythropoiesis

D.

Hepcidin

C.

Iron-deficiency anemia

D.

All of the above

Harrison’s 18th Ed. 846

Hepcidin principally acts on which of the following ?

Hb synthesis is impaired in iron-deficient erythropoiesis and PBF shows microcytic RBCs and hypochromic reticulocytes.

A.

Duodenal cytochrome B (Dcytb)

B.

Hephaestin

C.

Ferroportin

Harrison’s 18th Ed. 846

D.

Divalent metal transporter 1 (DMT-1)

A.

Acute inflammation

B.

Chronic inflammation

C.

Gastrointestinal blood loss

D.

Blood malignancy

278

Hepcidin (principal iron regulatory hormone) is involved in regulation of iron uptake by enterocytes & iron release by RE cells. Hepcidin represses ferroportin at basolateral surface as well as iron release from macrophages & serves as a central regulator of body iron traffic. It is a crucial molecule in iron metabolism, linking body stores with intestinal iron absorption.

Hepcidin responds to signals mediated by ?

279

Iron deficiency in adult male usually means ? Harrison’s 18th Ed. 846

A.

HFE

A.

Inadequate iron in diet

B.

TfR2 (transferrin receptor 2)

B.

Inadequate iron absorption

C.

Hemojuvelin (HJV)

C.

Gastrointestinal blood loss

D.

All of the above

D.

All of the above

Aa a rule, iron deficiency in adult male means gastrointestinal blood loss until proved otherwise.

280

Bone marrow iron stores are absent when serum ferritin level is ? A.

< 15 µg/L

B.

< 25 µg/L

C.

< 35 µg/L

D.

< 45 µg/L

Bone marrow iron stores are absent when the serum ferritin level is 80 fL, MCH > 27 pg, normal Hb electrophoresis

D.

All of the above

B.

MCV > 90 fL, MCH > 27 pg, normal Hb electrophoresis

C.

MCV > 100 fL, MCH > 27 pg, normal Hb electrophoresis

Normal or increased serum iron & ferritin levels and transferrin saturation are characteristic of the thalassemias.

357

30

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

MCV > 110 fL, MCH > 27 pg, normal Hb electrophoresis

364

Patients with  -thalassemia trait have an elevated HbA2 of ? A. > 0.5 % B.

> 1.5 %

C.

> 2.5 %

D.

> 3.5 %

365

N Engl J Med 2005;353:1135-46

360

Serum ferritin

B.

Magnetic susceptometry (SQUID)

C.

Labile plasma iron estimation

D.

CT of liver

366

Hemolytic anemia

C.

Thalassemia

D.

Anemia

Which of the following should be avoided in an iron excess state ? A.

Vitamin C

B.

Vitamin E

C.

Folic acid

D.

Plant flavonoids

Heinz bodies is best related to ? N Engl J Med 2005;353:1135-46

A.

Precipitates of unpaired  globin chains

A unit (250-300 ml) of packed RBCs contains how much iron ?

B.

Precipitates of unpaired a globin chains

Harrison’s 18th Ed. 860

C.

Precipitates of unpaired a & b globin chains

D.

Any of the above

A.

50 - 100 mg

B.

100 - 150 mg

C.

150 - 250 mg

D.

250 - 300 mg

Precipitates of unpaired  chains form single large inclusions known as Heinz bodies.

367

Patients develop hemosiderosis after how many units of packed RBCs ? A.

> 50 units

B.

> 100 units

C.

> 200 units

D.

> 500 units

Which parameter in fetal ultrasound is used to assess risk of hemoglobin Bart’s hydrops fetalis ? A. Abdominal circumference B.

Harrison’s 18th Ed. 860

Nuchal translucency

C.

Cardiothoracic ratio

D.

Ventricular system of fetal brain

Cardiothoracic ratio in fetal ultrasound is used to assess risk of hemoglobin Bart’s hydrops fetalis (normal < 0.53).

368

Patients who receive >100 units of packed RBCs usually develop hemosiderosis.

362

B.

Vitamin C should not be supplemented in iron excess states because it generates free radicals.

A unit (250-300 ml) of packed RBCs contains 250 - 300 mg of iron (1 mg/mL).

361

Porphyria

Harrison’s 18th Ed. 861

Which of the following is not applicable for estimating iron overload in thalassemia patients ? A.

A.

Lucarelli classification assess risk factors that predict outcome & prognosis in thalassemia.

Patients with  -thalassemia trait have an elevated HbA2 of > 3.5 %.

359

Lucarelli classification is used to classify ? N Engl J Med 2005;353:1135-46

The finding of a normal MCV (>= 80 fL) with normal MCH (>= 27 pg) and normal Hb electrophoresis or HPLC rules out most cases of thalassemia and requires no additional thalassemia testing.

358

Hematology

Estimated 5-year survival rate following allogeneic bone marrow transplantation is ? Harrison’s 18th Ed. 861

A.

30 %

N Engl J Med 2005;353:1135-46

B.

50 %

A.

Deferoxamine

C.

70 %

B.

Deferiprone

D.

90 %

Which of the following is an not an oral iron-chelating agent ?

C.

Deferasirox

Estimated 5-year survival rate following allogeneic bone marrow transplantation is 90% if done

D.

None of the above

before they develop hepatomegaly or portal fibrosis and if given adequate iron chelation therapy.

Deferoxamine is iron-chelating agent & requires parenteral administration.

363

Chapter 105. Megaloblastic Anemias

Which of the following promotes high levels of HbF synthesis ? Harrison’s 18th Ed. 861

A.

Hydroxyurea

369

Element found at the center of corrin ring in cobalamin is ? Harrison’s 18th Ed. 862

B.

Butyrates

A.

Copper

C.

Cytarabine

B.

Cadmium

D.

All of the above

C.

Cobalt

D.

Calcium

Reestablishing high levels of HbF synthesis can ameliorate symptoms of thalassemia. Hydroxyurea & cytarabine promote high levels of HbF synthesis by stimulating proliferation of F cell progenitors. Butyrates also stimulate HbF production.

All forms of Cobalamin (vit. B 12) have a cobalt atom at the center of corrin ring.

Hematology 31 370

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which form of cobalamin is present in human plasma & in cell cytoplasm ?

376

31 Cardiology

Which of the following is a family of cobalamin-binding proteins ?

Harrison’s 18th Ed. 862

Harrison’s 18th Ed. 862

A.

Cobalamin

A.

Glucocorrins

B.

Methylcobalamin

B.

Enterocorrins

C.

Hydroxocobalamin

C.

Haptocorrins

D.

Adocobalamin

D.

All of the above

Cobalamin (vitamin B12) exists in a number of different chemical forms. Methylcobalamin is the form of cobalamin in human plasma & in cell cytoplasm.

Dietary cobalamin combines rapidly with a salivary glycoprotein that belongs to the family of cobalamin-binding proteins known as haptocorrins (HCs).

371

377

Methylcobalamin is the cofactor for ? Harrison’s 18th Ed. 862

In intestine, haptocorrin is digested by which of the following enzyme ?

A.

Cystathionine synthase

Harrison’s 18th Ed. 862

B.

Methionine synthase

A.

Pancreatic trypsin

C.

Serine - glycine hydroxymethylase

B.

Pancreatic amylase

D.

All of the above

C.

Pancreatic lipase

D.

Pancreatic colipase

Methylcobalamin is the cofactor for methionine synthase.

372

Which of the following about cobalamin is false ? Harrison’s 18th Ed. 862

A.

Copper atom is situated within a corrin ring

B.

Cannot be synthesized in human body

C.

Only dietary source is animal products

D.

Daily requirement is ~ 1 - 3 µg

Cobalamin is a complex organometallic compound in which a “cobalt” atom is situated within a corrin ring. It cannot be synthesized in human body & must be supplied in diet of animal products (meat, fish, and dairy products). Daily requirement for cobalamin is ~ 1 - 3 µg.

373

Body stores of cobalamin can suffice for how many years after supplies are completely cut off ?

IF is produced in ? Harrison’s 18th Ed. 862

A.

Gastric parietal cells

B.

Gastric chief cells

C.

Gastric endocrine cells

D.

Gastric enterochromaffin cells

IF is produced in the acid-secreting gastric parietal cells located in oxyntic gland of fundus & body of stomach. Its secretion parallels that of hydrochloric acid.

Name of the receptor that mediates intestinal absorption of cobalamin-IF complex is ?

A.

1 to 2 years

Harrison’s 18th Ed. 862

B.

2 to 3 years

A.

Spirulin

C.

3 to 4 years

B.

Humulin

D.

5 to 7 years

C.

Cubulin

D.

Cobalin

Deficiency of cobalamin is almost always due to ? Harrison’s 18th Ed. 862

379

Cubilin is a specific receptor on microvillus membrane of enterocytes. IF-cobalamin attaches to it and enters the ileal cell, where IF is destroyed..

380

Endocytic receptor protein related to cubulin is ? Harrison’s 18th Ed. 862

A.

Dietary deficiency

B.

Malabsorption

A.

Amnionless (AMN)

C.

Alcohol abuse

B.

Leptin receptor

Specific congenital enzyme deficiencies

C.

Asialo-GM1

D.

Glycophorin A

D.

Dietary intake of cobalamin is more than adequate for body’s requirements, except in complete vegetarians & their breast-fed infants. Deficiency of cobalamin is almost always due to malabsorption.

375

378

Harrison’s 18th Ed. 862

Body stores of 2 - 3 mg are sufficient for 3 - 4 years if supplies are completely cut off essentially due to enterohepatic cycle & size of liver stores. There is a permanent liver reserve of 1 mg.

374

In intestine, haptocorrin is digested by pancreatic trypsin to release cobalamin which is transferred to IF.

Normal active physiologic mechanism of cobalamin absorption occurs in ?

Cubulin acts through amnionless (AMN), an endocytic receptor protein that directs sublocalization and endocytosis of cubulin with its ligand IF-cobalamin complex.

381

Cubilin also is present in ?

Harrison’s 18th Ed. 862

Harrison’s 18th Ed. 862

A.

Buccal mucosa

A.

Cardiomyocyte

B.

Duodenal mucosa

B.

Renal proximal tubular epithelium

C.

Ileal mucosa

C.

Islet of Langerhans

D.

All of the above

D.

All of the above

Cobalamin absorption can be passive through buccal, duodenal & ileal mucosa. More efficient normal physiologic active mechanism is through ileum mediated by gastric intrinsic factor (IF).

Cubilin also is present in yolk sac and renal proximal tubular epithelium.

32 382

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Gastric R binder is found in which of the following secretions ?

Harrison’s 18th Ed. 863

A.

Saliva

A.

B.

Gastric juice

B.

Bone marrow

C.

Bile

C.

Spleen

D.

All of the above

D.

Kidney

Intrinsic factor (IF) catalyzes the conversion ? A.

Methionine to homocysteine

B.

Homocysteine to methionine

C.

Serine to glycine

D.

Glycine to serine

On entering the duodenum, the cobalamin-R binder complex is digested, releasing the cobalamin, which then binds to intrinsic factor (IF), a 50-kDa glycoprotein which catalyzes the conversion of homocysteine to methionine.

Most circulating cobalamin is bound to ?

Liver

Total-body folate in the adult is ~10 mg, liver containing the largest store.

389

Normally, minimum daily requirement of folic acid is about ? Harrison’s 18th Ed. 863

Harrison’s 16th Ed. 602

384

Which of the following is the major body store of folic acid ?

Harrison’s 16th Ed. 602

Cobalamin in food is released and forms a stable complex with gastric R binder that is found in secretions like saliva, milk, gastric juice and bile.

383

388

Hematology

A.

100 µg

B.

200 µg

C.

300 µg

D.

400 µg

Daily requirement is normally about 100 µg, but this may be increased several fold during periods of enhanced metabolic demand such as pregnancy, infancy, malignancy, increased hematopoiesis (chronic hemolytic anemias), chronic exfoliative skin disorders, hemodialysis.

390

Harrison’s 18th Ed. 862

Body stores of folate can suffice for how many months after supplies are completely cut off ? Harrison’s 18th Ed. 863

A.

Gastric R binder

A.

1 to 2 months

B.

Transcobalamin (TC) I

B.

2 to 3 months

C.

Transcobalamin (TC) II

C.

3 to 4 months

D.

Intrinsic factor (IF)

D.

5 to 7 months

TC I is derived from specific granules in neutrophils. Normally, it is ~ two-thirds saturated with cobalamin, which it binds tightly. TC I does not enhance cobalamin entry into tissues.

Total-body folate in adult is ~10 mg. Daily adult requirement is ~100 µg, so stores are sufficient for 3 - 4 months, if severe folate deficiency develops rapidly.

385

391

Which of the following is not related to “absorption” of cobalamin in humans ?

Harrison’s 18th Ed. 863

Harrison’s 18th Ed. 862

A.

Gastric R binder

B.

Intrinsic factor (IF)

C.

Transcobalamin (TC) I

D.

Transcobalamin (TC) II

Site of absorption of Folic acid is ? A.

Stomach

B.

Proximal jejunum

C.

Terminal Ileum

D.

Colon

Two main cobalamin transport proteins in human plasma are TC I & TC II. TC II carries cobalamin in plasma & gives up cobalamin to marrow, placenta, and other tissues.

Folates in food are largely conjugated to a chain of glutamic acid residues which impair its intestinal absorption. Conjugases (  -glutamyl carboxypeptidases) in gut lumen convert polyglutamates to mono- & diglutamates, which are readily absorbed in proximal jejunum.

386

392

The common name for pteroylmonoglutamic acid is ? Harrison’s 18th Ed. 863

All dietary folates are converted to which of the following before entering portal plasma?

A.

Folic acid

Harrison’s 18th Ed. 863

B.

Vitamin B12

C. D.

A.

N5-methyltetrahydrofolate

Ascorbic acid

B.

N10-methyltetrahydrofolate

Pyridoxine

C.

N15-methyltetrahydrofolate

D.

N20-methyltetrahydrofolate

Folic acid is the common name for pteroylmonoglutamic acid.

387

Which of the following is primary dietary source of folic acid ? Harrison’s 18th Ed. 863

Plasma folate is primarily in the form of N 5 -methyltetrahydrofolate. All dietary folates are converted to 5-methyl THF (5-MTHF) within small-intestinal mucosa before entering portal plasma.

393

N5-methyltetrahydrofolate is a type of ?

A.

Fruits and vegetables

B.

Eggs

A.

Monoglutamate

C.

Milk

B.

Diglutamate

D.

Meat

C.

Triglutamate

D.

Polyglutamate

Fruits and vegetables are the primary dietary source of folic acid. Folate concentrations is highest in liver, yeast, spinach, other greens, and nuts.

Harrison’s 18th Ed. 863

N 5 -methyltetrahydrofolate is a monoglutamate.

Hematology 33 394

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

The prime function of folate compounds is ? Harrison’s 18th Ed. 863

D.

5,10-methylene-THF is oxidized to DHF (dihydrofolate). Enzyme DHF reductase converts DHF to THF. Methotrexate, pyrimethamine, and trimethoprim inhibit DHF reductase that prevents formation of active THF coenzymes from DHF.

To transfer single-carbon moieties to organic compounds

B.

Factor for methionine synthase & methylmalonyl coenzyme A (CoA) synthase

C.

Conversion of methylmalonyl CoA to succinyl CoA

Harrison’s 17th Ed. 645

D.

Conversion of succinyl CoA to methylmalonyl CoA

A.

Caused by impaired DNA synthesis

B.

Hematopoietic precursors & GI epithelial cells affected

C.

Megaloblastic cells have increased DNA to RNA ratio

D.

Ineffective erythropoiesis

Gamma-glutamyl carboxypeptidases in gut lumen convert ? Harrison’s 16th Ed. 601

400

A.

Polyglutamates to mono & diglutamates

B.

Diglutamates to monoglutamates

C.

Polysaccharides to mono and disaccharides

D.

Disaccharides to monosaccharides

Which of the following about megaloblastic anemias is false ?

Megaloblastic anemias are caused by impaired DNA synthesis in cells with rapid turnover like hematopoietic precursors & gastrointestinal epithelial cells. Cell division becomes sluggish but cytoplasmic development progresses normally, so megaloblastic cells tend to be large, with an increased ratio of RNA to DNA. Megaloblastic erythroid progenitors are destroyed in marrow whose cellularity is increased but production of RBC is decreased (ineffective erythropoiesis).

401

In deficiencies of either folate or cobalamin, there is failure to convert ? Harrison’s 18th Ed. 864

A.

dUMP to dTMP

B.

dTMP to dUMP

Folate is essential for the de-novo synthesis of ?

C.

dUMP to dUTP

Harrison’s 16th Ed. 602

D.

dUTP to dUMP

Conjugases (  -glutamyl carboxypeptidases) in the gut lumen convert polyglutamates to monoand diglutamates, which are readily absorbed in the proximal jejunum.

396

All of the above

A.

Primary function of folate compounds is to transfer single carbon moieties such as methyl and formyl groups to various organic compounds. The sources of these 1-carbon moieties is usually serine which reacts with tetrahydrofolate to produce glycine and N 5,10 methylenetetrahydrofolate.

395

33 Cardiology

A.

Purines

B.

Deoxythymidylate monophosphate (dTMP)

C.

Methionine

D.

All of the above

In deficiencies of either folate or cobalamin, there is failure to convert deoxyuridine monophosphate (dUMP) to deoxythymidine monophosphate (dTMP), the precursor of dTTP because folate is needed as the coenzyme 5,10-methylene - THF polyglutamate for conversion of dUMP to dTMP.

402

Which of the following is a cobalamin-requiring reaction ? Harrison’s 16th Ed. 602

Folate is essential for the de novo synthesis of purines, deoxythymidylate monophosphate (dTMP), and methionine, serving as an intermediate carrier of 1-carbon fragments used in the biosynthesis of these compounds.

A.

Purines synthesis

B.

Deoxythymidylate monophosphate (dTMP) synthesis

397

Active form of folic acid is ?

C.

Methionine synthesis

Harrison’s 16th Ed. 602

D.

All of the above

A.

Dihydrofolate

B.

Trihydrofolate

C.

Tetrahydrofolate

D.

Pentahydrofolate

Active form of folate is tetrahydrofolate (THF).

398

Folate coenzymes are essential in which of the following biochemical reactions ?

THF acquires 1-carbon fragment from serine which is converted to glycine. For purine synthesis, the 1-carbon fragment is first oxidized to the level of formic acid, then transferred to substrate. For methionine synthesis, a cobalamin-requiring reaction, the 1-carbon fragment is first reduced to the level of a methyl group, then transferred to homocysteine. In these reactions the cofactor is released as THF, which can immediately participate in another 1-carbon transfer cycle. During the production of dTMP from dUMP, the 1-carbon fragment is reduced from formaldehyde to a methyl group during transfer reaction. Hydrogen atoms used for this reduction come from the cofactor, which is released, not as THF, but as dihydrofolate (DHF). To participate further in the 1-carbon transfer cycle, DHF has to be re-reduced to THF, a reaction catalyzed by dihydrofolate reductase.

403

Harrison’s 18th Ed. 863 Table 105–2

A.

Purine synthesis

B.

Pyrimidine synthesis

C.

Serine - glycine interconversion

D.

All of the above

Folate coenzymes are essential in Formate activation, Purine synthesis (formation of glycinamide ribonucleotide and formylation of aminoimidazole carboxamide ribonucleotide (AICAR), Pyrimidine synthesis (Methylation of deoxyuridine monophosphate (dUMP) to thymidine monophosphate (dTMP), Amino acid interconversion (serine - glycine interconversion, homocysteine to methionine and forminoglutamic acid to glutamic acid in histidine catabolism).

399

Which of the following drugs inhibit DHF reductase ? Harrison’s 18th Ed. 863

A.

Methotrexate

B.

Pyrimethamine

C.

Trimethoprim

Methylmalonyl CoA isomerization requires which of the following ? Harrison’s 18th Ed. 864

A.

Adocobalamin

B.

Methylcobalamin

C.

5-MTHF

D.

All of the above

Methylmalonyl CoA isomerization requires adocobalamin, and the methylation of homocysteine to methionine requires both methylcobalamin and 5-MTHF.

404

Which of the following abnormalities of folate metabolism occur in cobalamin deficiency ? Harrison’s 18th Ed. 864

A.

High serum folate

B.

Low cell folate

C.

Positive purine precursor aminoimidazole carboxamide ribonucleotide (AICAR) excretion

34

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

All of the above

Abnormalities of folate metabolism that occur in cobalamin deficiency include high serum folate, low cell folate and positive purine precursor aminoimidazole carboxamide ribonucleotide (AICAR) excretion.

405

Which of the following statements about megaloblastic anemia due to folate deficiency is true ? Harrison’s 16th Ed. 606

406

411

Autoantibodies to folate receptors

D.

Reduced activity of 5,10-methylene-THF reductase (MTHFR)

Deficiency of which of the following enzymes can cause homocystinuria ?

B.

Reduced serum methylmalonic acid, reduced homocysteine

C.

Normal serum methylmalonic acid, reduced homocysteine

A.

Methionine synthase

D.

Normal serum methylmalonic acid, elevated homocysteine

B.

MTHFR

C.

Cystathionine synthase

D.

All of the above

Harrison’s 18th Ed. 865, 869

Which of the following statements about megaloblastic anemia due to cobalamin deficiency is true ? Raised serum methylmalonic acid, elevated homocysteine

B.

Reduced serum methylmalonic acid, reduced homocysteine

C.

Raised serum methylmalonic acid, reduced homocysteine

D.

Reduced serum methylmalonic acid, elevated homocysteine

Severe homocystinuria may be due to deficiency of methionine synthase, MTHFR, or cystathionine synthase. Homocystinuria is a rare metabolic defect in the conversion of homocysteine to cystathionine. Folate deficiency is due to excessive utilization because of compensatory increased conversion of homocysteine to methionine.

412

Individuals with which of the following enzyme deficiency have an increased risk of vascular disease ? Harrison’s 18th Ed. 865

Most frequently affected tissues in cobalamin and folate deficiencies is ?

A.

Methionine synthase

B.

MHTFR

Harrison’s 18th Ed. 865

C.

Cystathionine synthase

A.

Epithelial cell surfaces of the mouth

D.

All of the above

B.

Bone marrow

C.

Peripheral nerves

D.

Epithelial cell surfaces of the small intestine

Children with deficiency of enzyme methionine synthase, MHTFR or cystathionine synthase have an increased risk of vascular disease.

413

Meta-analysis has suggested that folic acid supplementation reduces the risk of stroke by ? Harrison’s 18th Ed. 865

What dose of folic acid provides protective effect against Neural Tube Defects (NTDs) at conception ? Harrison’s 18th Ed. 865, 871

A.

4%

B.

8%

C.

18 %

D.

25 %

A.

0.1 mg daily

B.

0.2 mg daily

Meta-analysis has suggested that folic acid supplementation reduces the risk of stroke by 18%.

C.

0.3 mg daily

414

D.

0.4 mg daily

To prevent neural tube defects, folic acid supplements must be started at ? Harrison’s 18th Ed. 865

A.

Conception

B.

First 4 weeks of pregnancy

C.

First 8 weeks of pregnancy

D.

First 12 weeks of pregnancy

Prophylactic folic acid in pregnancy reduces subsequent incidence of which of the following ? Harrison’s 18th Ed. 865

0.4 mg daily of folic acid provides protective effect against NTDs at conception. Folic acid (400 µg daily, should be given as a supplement before and throughout pregnancy. In women who have had a previous fetus with a neural tube defect, 5 mg daily is recommended when pregnancy is contemplated and throughout the subsequent pregnancy.

409

C.

In NTD fetuses, reduced activity of the enzyme 5,10-methylene-THF reductase (MTHFR) has been identified as the maternal folate metabolic abnormality.

Most frequently affected tissue in cobalamin and folate deficiencies is the bone marrow followed by the epithelial cell surfaces of the mouth, stomach, and small intestine and the respiratory, urinary, and female genital tracts.

408

Mutations in serine - glycine hydroxymethylase

Raised serum methylmalonic acid, elevated homocysteine

A.

407

B.

A.

Harrison’s 16th Ed. 606

Hematology

A.

Acute lymphoblastic leukemia (ALL)

B.

Hodgekin’s lymphoma

C.

Astrocytoma

D.

Hemangioma

Prophylactic folic acid in pregnancy reduces the subsequent incidence of acute lymphoblastic leukemia (ALL) in childhood.

415

Clinical features of cobalamin deficiency involve which of the following ? Harrison’s 16th Ed. 603

A.

Blood

To prevent neural tube defects, folic acid supplements must be started at the time of conception and in the first 12 weeks of pregnancy. It reduces the incidence of neural tube defects (NTDs) (anencephaly, meningomyelocele, encephalocele, and spina bifida) in the fetus by 70%.

B.

Gastrointestinal tract

C.

Nervous system

410

D.

All of the above

In NTD fetuses, which of the following maternal folate metabolic abnormality has been identified ? Harrison’s 18th Ed. 865

A.

Mutations in methionine synthase

The clinical features of cobalamin deficiency involve the blood, the gastrointestinal tract, and the nervous system.

Hematology 35 416

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Hematologic manifestations of cobalamin deficiency are due to ?

Harrison’s 16th Ed. 605

A.

Anemia

A.

> 80 fL

B.

Leucopenia

B.

> 90 fL

C.

Thrombocytopenia

C.

> 100 fL

D.

All of the above

D.

> 110 fL

Which of the following pathological situations can be seen in cobalamin deficiency ? Harrison’s 16th Ed. 603

Significant and marked macrocytosis (MCV > 100 fL) suggests presence of a megaloblastic anemia. Macrocytosis is less marked with concurrent iron deficiency or thalassemia. Reticulocyte index is low, & leukocyte and platelet count may also be decreased, particularly in severely anemic patients. PBF shows marked anisocytosis & poikilocytosis, with macroovalocytes, which are large, oval, fully hemoglobinized erythrocytes typical of megaloblastic anemias.

423

Demyelination

Harrison’s 16th Ed. 605

B.

Axonal degeneration

A.

Hemolysis

C.

Neuronal death

B.

Aplastic anemia

All of the above

C.

Liver disease

D.

Hyperthyroidism

Initial pathology is demyelination, followed by axonal degeneration & eventual neuronal death.

Involvement of which of the following structures is uncommon in cobalamin deficiency ?

424

Harrison’s 16th Ed. 605

Peripheral nerves

A.

Hemolysis

B.

Spinal cord

B.

Pernicious anemia

C.

Cerebellum

C.

Myelodysplasia

D.

Cerebrum

D.

All of the above

Earliest neurologic manifestation of cobalamin deficiency is ?

Myelodysplasia produces a distinct morphologic picture most apparent in orthochromatic normoblasts in which a megaloblastic nucleus is associated with severely hypochromic cytoplasm. This variant is called “megaloblastoid” meaning presence of both nuclear & cytoplasmic maturation defects. “Megaloblastoid” does not mean “mildly megaloblastic.”

425

Megaloblastic anemia is seen in all except ?

A.

Numbness and paresthesia in extremities

B.

Motor weakness

A.

Hereditary TC I deficiency

C.

Ataxia

B.

TC II deficiency

D.

Sphincter disturbances

C.

Orotic aciduria

D.

Imerslund-Grasbeck disease

Signs and symptoms of cobalamin deficiency include numbness and paresthesia in the extremities (the earliest neurologic manifestations), weakness, and ataxia. There may be sphincter disturbances.

Harrison’s 16th Ed. 605

426

Neutrophils nucleus of >=6 lobes is suggestive of ? A.

Megaloblastic anemia

B.

CML

C.

AML

D.

Multiple myeloma

Hypersegmented nuclei of neutrophils is a characteristic finding of megaloblastic anemia. A single cell with a nucleus of six lobes or more raises suspicion of a megaloblastic anemia.

Which of the following provides evidence of ineffective erythropoiesis ? Harrison’s 18th Ed. 866

A.

Reduced haptoglobins

B.

Positive urine hemosiderin

C.

Raised serum lactate dehydrogenase

D.

All of the above

Raised urine urobilinogen, reduced haptoglobins and positive urine hemosiderin, and a raised serum lactate dehydrogenase provides evidence of ineffective erythropoiesis.

Which of the following is not a finding in bone marrow examination in folate or B12 deficiency megaloblastic anemia ? Harrison’s 16th Ed. 605

Harrison’s 16th Ed. 605

421

Megaloblastoid morphologic picture of RBC series is seen in ?

A.

Harrison’s 16th Ed. 603

420

Macrocytosis occurs in hemolysis, liver disease, alcoholism, hypothyroidism & aplastic anemia.

Harrison’s 16th Ed. 603

Sites of involvement include peripheral nerves; the spinal cord, where the posterior and lateral columns undergo demyelination; and the cerebrum itself.

419

Causes of macrocytosis include all except ?

A.

D.

418

What value of MCV is diagnostic of megaloblastic anemia ?

Harrison’s 16th Ed. 603

The hematologic manifestations are almost entirely the result of anemia, although very rarely purpura may appear, due to thrombocytopenia.

417

422

35 Cardiology

A.

Hypercellularity

B.

Increased myeloid / erythroid ratio

C.

Nuclear-cytoplasmic asynchrony in RBC precursors

D.

Fenestrated nuclear chromatin in RBC precursors

In B 12 deficiency megaloblastic anemia, bone marrow is hypercellular with decreased myeloid / erythroid ratio & abundant stainable iron. RBC precursors are abnormally large & have nuclei that appear much less mature than would be expected from the development of cytoplasm (nuclearcytoplasmic asynchrony). Nuclear chromatin is more dispersed & it condenses in a peculiar fenestrated pattern that is very characteristic of megaloblastic erythropoiesis. Abnormal mitoses may be seen. Granulocyte precursors are also affected appearing as giant bands and metamyelocytes. Megakaryocytes are decreased & show abnormal morphology.

427

Incidence of pernicious anemia is increased in ? Harrison’s 18th Ed. 867

A.

Graves’ disease

B.

Myxedema

C.

Thyroiditis

D.

All of the above

36 428

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Incidence of pernicious anemia is increased in ? Harrison’s 18th Ed. 867

A.

Addison’s disease

B.

Vitiligo

C.

Hypoparathyroidism

D.

All of the above

Abnormalities in gastric epithelium appear as cellular atypia that must be distinguished from cytologic abnormalities of gastric malignancy. Hypergastrinemia & pentagastrin-fast achlorhydria occur secondary to gastric atrophy. Incidence of gastric polyps & stomach cancer is increased.

434

Which of the following about pernicious anemia is false ? Harrison’s 18th Ed. 867

A.

Gastric atrophy does not affect antrum of stomach

B.

90% of patients have antiparietal cell antibody

C.

~80% of patients have anti-IF antibody

D.

None of the above

Which of the following about juvenile pernicious anemia is false ? Harrison’s 18th Ed. 867

Incidence of pernicious anemia is increased in patients with other diseases of immunologic origin like Graves’ disease, myxedema, thyroiditis, Addison’s disease, vitiligo & hypoparathyroidism.

429

A.

Gastric atrophy

B.

Achlorhydria

C.

Serum IF antibodies present

D.

Parietal cell antibodies present

In Juvenile PA, gastric atrophy, achlorhydria and serum IF antibodies are present, but parietal cell antibodies are usually absent.

435

Removal of what length of terminal ileum causes malabsorption of cobalamin ? Harrison’s 18th Ed. 868

~90% patients with PA have antiparietal cell antibody directed against H +,K +-ATPase, while IF antibodies are detected in gastric juice in ~80%. In patients with gastric atrophy without pernicious anemia, antiparietal cell antibody is found in 50%, but anti-IF antibody is usually absent. Antiparietal cell antibody is found in 10 - 15% of random patient population.

A.

0.2 meter

B.

0.5 meter

C.

0.8 meter

430

D.

1.2 meter

Which of the following about pernicious anemia is false ? Harrison’s 18th Ed. 867

A.

Hypergastrinemia

B.

Pentagastrin-fast achlorhydria

C.

Relatives have increased incidence of disease

D.

It is uncommon in patients with agammaglobulinemia

Removal of 1.2 meters of terminal ileum causes malabsorption of cobalamin.

436

Which of the following is false about pernicious anemia ? Harrison’s 18th Ed. 867

A.

Rare under the age of 30 years

B.

Average age of presentation is 60 years

C.

Men more affected than women

D.

Caused by the absence of IF

Stickler syndrome

B.

Imerslund-Gräsbeck Syndrome

C.

Cogan’s syndrome

D.

Menkes’ syndrome

437

Combined deficiencies of cobalamin and folic acid is seen in which of the following conditions ? Harrison’s 17th Ed. 648

A.

Gastric achlorhydria

B.

Tropical sprue

Which of the following about pernicious anemia is false ?

C.

Regional enteritis

Harrison’s 18th Ed. 867

D.

Pregnancy

A.

Unusually common in agammaglobulinemia

B.

Helicobacter pylori infection is infrequent

C.

Gastric atrophy spares the antrum

D.

None of the above

Pernicious anemia is unusually common in patients with agammaglobulinemia. Helicobacter pylori does not cause parietal cell destruction in pernicious anemia. Most characteristic finding in pernicious anemia is gastric atrophy affecting the acid- and pepsin-secreting portion of the stomach while sparing the antrum.

433

A.

Imerslund-Gräsbeck syndrome is a congenital disorder (autosomal recessive) of selective defect in cobalamin absorption accompanied by nonspecific proteinuria but renal functions are normal. Mutation occurs in cubulin receptor that mediates intestinal absorption of cobalamin-IF complex. Patients have normal amounts of IF & gastric acid as are other tests of intestinal absorption.

Pernicious anemia is the most common cause of cobalamin deficiency. It is caused by absence of IF, due to atrophy of gastric mucosa or autoimmune destruction of parietal cells. Ratio of incidence of PA in men and women among whites is 1:1.6. Average age of presentation is 60 (disease of elderly) & is rare < 30 years of age.

432

Disease due to mutation in cubulin receptor leading to selective defect in cobalamin absorption is ? Harrison’s 18th Ed. 868

PA is associated with hypogammaglobulinemia, with premature graying or blue eyes, and in persons of blood group A. Gastric output of hydrochloric acid, pepsin, and IF is severely reduced. Serum gastrin level is raised, and serum pepsinogen I levels are low.

431

Hematology

Combined deficiencies of cobalamin & folic acid is seen in tropical sprue. Gastric achlorhydria produces cobalamin deficiency by malabsorption due to defective release of cobalamin from food. Regional enteritis produces cobalamin deficiency by malabsorption due to terminal ileum malfunctioning. Pregnancy produces folate deficiency due to increased requirements.

438

Fish tapeworm - D. latum causes megaloblastic anemia due to ? Harrison’s 18th Ed. 868

A.

Defective release of cobalamin from food

Which of the following about pernicious anemia is false ?

B.

Inadequate production of intrinsic factor (IF)

Harrison’s 18th Ed. 867

C.

Competition for cobalamin

A.

Gastric epithelium atypia common

D.

Intestinal stasis

B.

Hypergastrinemia common

C.

Gastric polyps common

D.

None of the above

Megaloblastic anemia or cobalamin neuropathy is seen in persons heavily infested by fish tapeworm, Diphyllobothrium latum, due to competition by the worm for cobalamin. Individuals acquire the worm by eating raw or partly cooked fish. Destruction of the worm eliminates the problem.

Hematology 37 439

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Infestations by fish tapeworm “Diphyllobothrium latum” is common in which of the following countries ? Harrison’s 18th Ed. 868

A.

South East Asia

B.

Scandinavia

C.

South Africa

D.

South America

B.

Autoimmune hemolytic anemia

C.

Congenital spherocytosis

D.

All of the above

Folate deficiency frequently occurs in chronic hemolytic anemia, particularly in sickle cell disease, autoimmune hemolytic anemia, and congenital spherocytosis.

446

Alcohol causes folic acid deficiency by which of the following mechnism ?

Individuals acquire fish tapeworm, Diphyllobothrium latum by eating raw or partly cooked fish. Infestation is common around the lakes of Scandinavia, Germany, Japan, North America & Russia.

Harrison’s 18th Ed. 869

A.

Inadequate intake

440

Acute megaloblastic anemia can be seen after ?

B.

Increased requirements

Harrison’s 18th Ed. 869

C.

Malabsorption

D.

Impaired metabolism

A.

Nitrous oxide anesthesia

B.

Halothane anesthesia

C.

Chloroform anesthesia

D.

Ether anesthesia

Alcohol interferes with folate metabolism. Distilled spirits are devoid of folic acid, while beer and wine do not contain enough of vitamin for daily requirement.

447

Nitrous oxide irreversibly oxidizes methylcobalamin to an inactive precursor which inactivates methionine synthase.

441

Which of the following drugs is an inhibitor of dihydrofolate reductase ? Harrison’s 18th Ed. 870

A.

Zidovudine

Harrison’s 18th Ed. 869

B.

Methotrexate

A.

Salazopyrine

C.

Azathioprine

B.

Cholestyramine

D.

All of the above

C.

Triamterene

D.

All of the above

Malabsorption of folate is seen with which of the following drugs ?

448

Which of the following drugs is an inhibitor of dihydrofolate reductase ?

Malabsorption of folate occurs in patients receiving salazopyrine, cholestyramine & triamterene. Antifolate drugs include anticonvulsant drugs (phenytoin, primidone, barbiturates), sulphasalazine, Nitrofurantoin, and tetracycline.

Harrison’s 18th Ed. 870

442

Neonatal folate level falls rapidly to the lowest values at ? Harrison’s 18th Ed. 869

A.

6 weeks of age

B.

12 weeks of age

C.

24 weeks of age

D.

32 weeks of age

Neonatal folate level falls rapidly to the lowest values at about 6 weeks of age.

443

449

444

B.

Increased demand

C.

Malabsorption

D.

All of the above

Conditions that increase demand of folic acid are all except ? Harrison’s 18th Ed. 869

A.

Chronic hemolytic anemias

B.

Pregnancy

C.

Hemodialysis

D.

Tropical sprue

Pentamidine

B.

Trimethoprim

C.

Pyrimethamine

D.

All of the above

In megaloblastic anemia due to folate antagonists, which of the following is given ? Harrison’s 18th Ed. 870, 871

Harrison’s 18th Ed. 869

Inadequate intake

A.

Drugs that inhibit DHF reductase include methotrexate, pyrimethamine & trimethoprim. Methotrexate has the most powerful action against the human enzyme, whereas trimethoprim is most active against the bacterial enzyme and is only likely to cause megaloblastic anemia when used in conjunction with sulphamethoxazole in patients with preexisting folate or cobalamin deficiency. The activity of pyrimethamine is intermediate.

Folic acid deficiency is due to ? A.

A.

Folic acid

B.

Folinic acid

C.

Pyridoxine

D.

All of the above

Megaloblastic anemia due to folate antagonists that inhibit dihydrofolate reductase can be counteracted by folinic acid [5-formyl tetrahydrofolate (THF)] in a dose of 100 to 200 mg/day, which circumvents the block in folate metabolism by providing a form of folate that can be converted to 5,10-methylene THF. For the megaloblastic forms of sideroblastic anemia, pyridoxine in pharmacologic doses (~300 mg/day) can be tried. Folinic Acid (5-Formyl-THF) is a stable form of fully reduced folate. It is given orally or parenterally to overcome the toxic effects of methotrexate or other DHF reductase inhibitors.

450

The normal range of cobalamin in serum is ? Harrison’s 18th Ed. 870

A.

5 to 100 ng/L

The mechanism of folic acid deficiency in tropical sprue is malabsorption. Rest of the above conditions lead to increased folic acid requirements and cause megaloblastic anemia.

B.

100 to 200 ng/L

C.

160 to 1000 ng/L

445

D.

1000 to 2500 ng/L

Folate deficiency frequently occurs in which of the following ? Harrison’s 18th Ed. 869

A.

Sickle cell disease

37 Cardiology

The normal range of serum cobalamin in serum is 160 - 1000 ng/L. Values between 100 & 200 ng/L are regarded as borderline.

38 451

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Serum homocysteine is raised in all except ?

C.

WBC folate level

Harrison’s 18th Ed. 870

D.

Platelet folate level

A.

Chronic renal disease

B.

Hyperthyroidism

C.

Alcoholism

D.

Pyridoxine deficiency

Normal serum folic acid ranges from 6 to 20 ng/mL. Values 145 mmol/L.

The product of urine volume & osmolality is called solute excretion rate.

126

After administering ‘desmopressin’, urine osmolality should increase by how much in CDI ? Harrison’s 17th Ed 280

Nephrology 329

127

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

A.

At least 10 %

B.

At least 25 %

C.

At least 35 %

D.

At least 50 %

132

A.

At least 10%

B.

At least 25%

C.

At least 35%

D.

None of the above

Normally, ratio of ICF to ECF K+ concentration is ? Harrison’s 17th Ed 280

After administering ‘desmopressin’, urine osmolality should increase by how much in NDI ? Harrison’s 17th Ed 280

A.

28:1

B.

38:1

C.

48:1

D.

58:1

Normally, ratio of ICF to ECF K+ concentration is 38:1 due to resting membrane potential and is crucial for normal neuromuscular function.

133

The basolateral Na-K ATPase pump actively transports potassium in & sodium out of the cell in a ratio of ? Harrison’s 17th Ed 280

A.

1:2

CDI & NDI can be distinguished by administering AVP analogue desmopressin (10 µg intranasally) after careful water restriction. Urine osmolality should increase by at least 50% in CDI & will not change in NDI.

B.

2:3

C.

3:4

128

D.

4:5

In hypernatremia due to water loss, water deficit should be corrected in which of the following ways ?

The basolateral Na+, K+-ATPase pump actively transports K+ in and Na+ out of the cell in a 2:3 ratio, and the passive outward diffusion of K+ is quantitatively the most important factor that generates the resting membrane potential.

Harrison’s 18th Ed 350

A.

Rapidly

B.

Over 12 to 24 hours

C.

Over 24 to 36 hours

D.

Slowly over at least 48 to 72 hours

134

Drugs that either stimulate AVP secretion or enhance its action on the kidney includes all except ? Harrison’s 18th Ed 346 Table 45-1

A.

10 - 40 mmol/day

B.

40 - 120 mmol/day

C.

120 - 350 mmol/day

D.

350 - 550 mmol/day

K+ intake in an average western diet is 40 - 120 mmol/day, or approximately 1 mmol/kg per day, 90% of which is absorbed by the gastrointestinal tract.

A.

Chlorpropamide

B.

Clofibrate

C.

Carbamazepine

Harrison’s 17th Ed 280

D.

Phenytoin

A.

Dietary excess

B.

Dietary intake

C.

Dietary deficiency

D.

Daily requirement

135

Drugs that either stimulate AVP secretion or enhance its action on kidney are chlorpropamide, clofibrate, carbamazepine and NSAIDs.

130

K+ intake in an average western diet is ? Harrison’s 17th Ed 280

In hypernatremia due to water loss, water deficit should be corrected slowly over 48 - 72 hours.

129

329 Cardiology

Which of the following drugs is useful in NDI patients who have to take lithium ?

Potassium delivery to distal nephron approximates ?

K delivery to the distal nephron [DCT + cortical collecting duct (CCD)] approximates dietary intake. +

Harrison’s 18th Ed 350

136

A.

Amiloride

B.

Chlorpropamide

C.

Clofibrate

D.

Carbamazepine

Harrison’s 17th Ed 280

Amiloride is useful NDI patients who have to take lithium. Nephrotoxicity of lithium requires it to be taken up into collecting duct cells via amiloride-sensitive Na + channel.

Hypokalemia 131

Normal plasma potassium concentration inside cells is about ? Harrison’s 17th Ed 280

A.

50 mmol/L

B.

100 mmol/L

C.

150 mmol/L

D.

200 mmol/L

Normal plasma K+ concentration is 3.5 - 5.0 mmol/L, whereas that inside cells is about 150 mmol/ L. 5.0 mmol/L

C.

> 5.5 mmol/L

A.

Diabetes mellitus

D.

> 6.0 mmol/L

B.

Those receiving potasium sparing diuretics

Pseudohyperkalemia can result from ? A.

Prolonged use of tourniquet

B.

Hemolysis

C.

Marked leukocytosis

D.

All of the above

170

Intravascular hemolysis

B.

Tumor lysis syndrome

C.

Rhabdomyolysis

D.

All of the above

Pseudohyperkalemia refers to an artificially elevated “plasma” K+ concentration due to K+ movement out of cells on venipuncture in asymptomatic patient with no obvious underlying cause. Serum K+ concentration is normal. Prolonged tourniquet use, hemolysis & marked leukocytosis or thrombocytosis contribute to its occurrence. Intravascular hemolysis, tumor lysis syndrome, and rhabdomyolysis all lead to K+ release from cells as a result of tissue breakdown.

Which of the following regarding hyperkalemic periodic paralysis is false ?

Heparin can lead to severe hyperkalemia in patients with ? Harrison’s 17th Ed 283

C.

Those receiving ACE inhibitors

D.

All of the above

Heparin (UFH & LMWH) inhibits production of aldosterone by zona glomerulosa & can lead to severe hyperkalemia in those with renal disease, DM, on K+-sparing diuretics, ACE inhibitors or NSAIDs.

171

Pseudohypoaldosteronism is characterized by all except ? Harrison’s 17th Ed 283

Pseudohyperkalemia can result from ? A.

induced

ACE inhibitors block conversion of angiotensin I to II. Angiotensin receptor antagonists directly inhibit actions of angiotensin II on AT1 angiotensin II receptors and result in impaired aldosterone release. Patients at increased risk of ACE inhibitor or angiotensin receptor antagonist–induced hyperkalemia include those with diabetes mellitus, renal insufficiency, decreased effective circulating arterial volume, bilateral renal artery stenosis, or concurrent use of K+-sparing diuretics or NSAIDs.

Harrison’s 17th Ed 283

167

B.

A.

Harrison’s 17th Ed 283

166

Mild renal insufficiency

Harrison’s 17th Ed 283

Hyperkalemia is defined as a plasma K+ concentration >5.0 mmol/L

165

A.

Hyporeninemic hypoaldosteronism is seen in mild renal insufficiency, diabetic nephropathy or chronic tubulointerstitial disease.

Ideally, KCl is mixed in normal saline as dextrose solutions may initially exacerbate hypokalemia due to insulin-mediated movement of K + into cells.

164

Hyporeninemic hypoaldosteronism is seen in ? Harrison’s 17th Ed 283

The maximum concentration of administered K+ should be no more than 40 mmol/L via a peripheral vein or 60 mmol/L via a central vein.

163

Nephrology

172

A.

High renin & aldosterone levels

B.

End-organ resistance to aldosterone

C.

Renal sodium wasting

D.

Hypertension

Pseudohypoaldosteronism is characterized by all except ? Harrison’s 17th Ed 283

A.

Hyperkalemia

B.

Metabolic alkalosis

C.

Renal sodium wasting

D.

Hypotension

Pseudohypoaldosteronism is characterized by hyperkalemia, metabolic acidosis, renal Na+ wasting, hypotension, high renin and aldosterone levels, and end-organ resistance to aldosterone.

Harrison’s 17th Ed 283

Which of the following is a competitive mineralocorticoid antagonist ?

A.

Autosomal dominant disorder

Harrison’s 17th Ed 283

B.

Episodic weakness / paralysis precipitated by exercise

A.

Spironolactone

C.

Due to mutation in gene for skeletal muscle Na+ channel

B.

Amiloride

D.

None of the above

C.

Triamterene

D.

All of the above

Hyperkalemic periodic paralysis is an autosomal dominant disorder characterized by episodic weakness or paralysis, precipitated by stimuli that normally lead to mild hyperkalemia (exercise). Genetic defect is due to mutation in gene for skeletal muscle Na + channel.

173

Spironolactone is a competitive mineralocorticoid antagonist. Amiloride and triamterene block the apical Na+ channel of principal cell of kidney.

Nephrology 333 174

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following blocks the apical sodium channel of principal cell ?

180

333 Cardiology

The appropriate renal response to hyperkalemia is to excrete how much of K+ daily ?

Harrison’s 17th Ed 283

Harrison’s 17th Ed 284

A.

Amiloride

A.

At least 50 mmol

B.

Trimethoprim

B.

At least 100 mmol

C.

Pentamidine

C.

At least 200 mmol

D.

All of the above

D.

At least 300 mmol

Trimethoprim & pentamidine impair K+ secretion by blocking distal nephron Na+ reabsorption.

The appropriate renal response to hyperkalemia is to excrete at least 200 mmol of K+ daily.

175

181

Nephropathy associated with impaired potassium excretion include ? Harrison’s 17th Ed 283

Harrison’s 17th Ed 284

A.

Drug-induced interstitial nephritis

A.

5.5 mmol/L

B.

Lupus nephritis

B.

6.5 mmol/L

C.

Sickle cell disease

C.

7.5 mmol/L

All of the above

D.

8.5 mmol/L

D.

Nephropathies associated with impaired K + excretion include drug-induced interstitial nephritis, lupus nephritis, sickle cell disease and diabetic nephropathy.

176

Potentially fatal hyperkalemia occurs when plasma potassium concentration exceeds ?

Gordon’s syndrome includes all except ?

Potentially fatal hyperkalemia rarely occurs unless plasma K+ concentration exceeds 7.5 mmol/L.

182

In severe hyperkalemia, 10 mL of 10% calcium gluconate should be infused over ?

Harrison’s 17th Ed 284

Harrison’s 17th Ed 284

A.

Hyperkalemia

A.

Half to 1 minute

B.

Metabolic acidosis

B.

1 to 2 minutes

C.

Normal GFR

C.

2 to 3 minutes

D.

High renin

D.

5 to 10 minutes

Gordon’s syndrome is characterized by hyperkalemia, metabolic acidosis, normal GFR, volume-expansion with suppressed renin & aldosterone levels. It is refractory to kaliuretic effect of exogenous mineralocorticoids.

IV Calcium gluconate decreases membrane excitability. Usual dose is 10 mL of a 10% solution infused over 2-3 minutes. Its effect is short-lived (30-60 min). Dose can be repeated if no change in ECG is seen after 5-10 minutes.

177

183

The earliest ECG change in hyperkalemia is ? Harrison’s 17th Ed 284

178

A.

Increased T-wave amplitude

B.

Prolonged PR interval

C.

Prolonged QRS duration

D.

Loss of P waves

Sine wave pattern seen in severe hyperkalemia is due to merging of ?

Harrison’s 17th Ed 284

A.

184

Harrison’s 17th Ed 284

A.

P + QRS

B.

QRS + T

C.

P + QRS + T

D.

Any of the above

The earliest ECG changes in hyperkalemia include increased T-wave amplitude. More severe degrees result in prolonged PR interval and QRS duration, AV conduction delay and loss of P waves. Progressive widening of QRS complex and merging with T wave produces a sine wave pattern. The terminal event is ventricular fibrillation or asystole.

179

Severity of hyperkalemia is determined by ? Harrison’s 17th Ed 284

A.

Symptoms

B.

Plasma K+ concentration

C.

ECG abnormalities

D.

All of the above

Severity of hyperkalemia is determined by symptoms, plasma K+ & ECG abnormalities.

Which of the following is used for lowering potassium levels in severe hyperkalemia ? Insulin-glucose infusion

B.

Alkali therapy with IV NaHCO3

C.

 2 adrenergic agonists

D.

All of the above

Which of the following reduce plasma K+ levels by shifting K+ into cells ? Harrison’s 17th Ed 284

A.

Glucose - insulin therapy

B.

Alkali therapy with IV NaHCO3

C.

Beta2-adrenergic agonists

D.

All of the above

Alkali therapy with IV NaHCO3 shifts K+ into cells. 2-adrenergic agonists promote cellular uptake of K+.

185

Which of the following is false regarding sodium polystyrene sulfonate ? Harrison’s 17th Ed 284

A.

Anion-exchange resin

B.

One gram binds 1 mmol of K+ & releases 2-3 mmol of Na+

C.

Usual dose is 25-50 gram orally

D.

Can be administered as retention enema

Sodium polystyrene sulfonate is a cation-exchange resin that promotes the exchange of Na+ for K+ in the gastrointestinal tract. Each gram binds 1 mmol of K+ and releases 2–3 mmol of Na+. Usual dose is 25-50 grams in 100 mL of 20% sorbitol orally to prevent constipation. It can also be administered as a retention enema.

334 186

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR The most rapid & effective way of lowering plasma potassium concentration is ?

192

Harrison’s 17th Ed 285, Figure 47-1

A.

Increased tubular reabsorption of calcium by kidney

A.

Insulin-glucose infusion

B.

Resorption of calcium from bone

B.

Calcium gluconate infusion

C.

C.

Peritoneal dialysis

Stimulates renal 1,25(OH)2D production

D.

All of the above

D.

Hemodialysis

193

Harrison’s 17th Ed 285

A.

Hypercalcemia of malignancy

B.

Parathyroid adenoma

C.

Sarcoidosis

B.

Urine Osmolality

D.

Hyperthyroidism

C.

pH

D.

Serum K

Excess PTH production not appropriately suppressed by increased serum calcium concentrations occurs in primary neoplastic disorders of parathyroid glands like parathyroid adenomas, hyperplasia, or carcinoma.

194

Formula for calculating Transtubular Potassium Gradient (TTKG) is ? A. (PPotassium x U Potassium) / (P Osm x U Osm)

Harrison’s 17th Ed 285

PTH-related peptide (PTHrP)

B.

1,25(OH)2D

C.

Calcium sensor receptor (CaSR) mutations

C.

(POsm x U Potassium) / (P Potassium x U Osm)

D.

Exogenous calcium overload

D.

(PPotassium x U Osm) / (P Osm x U Potassium)

TTKG in a normal person on a normal diet is ? A. 2 - 4

Inappropriate PTH secretion for existing level of serum calcium occurs with heterozygous inactivating calcium sensor receptor (CaSR) mutations, which impair extracellular calcium sensing by parathyroid glands and kidneys, resulting in familial hypocalciuric hypercalcemia (FHH).

195

Which of the following is related to PTH-related peptide (PTHrP) ? Harrison’s 17th Ed 285

B.

4-6

A.

Hypercalcemia of malignancy

C.

6-7

B.

Milk-alkali syndrome

D.

8-9

C.

Familial hypocalciuric hypercalcemia (FHH)

D.

Sarcoidosis

Which of the following statements is false ? A. Hypokalemia should result in a TTKG < 2

Many solid tumors produce PTH-related peptide (PTHrP) which binds PTH receptor & mimicks effects of PTH on bone & kidney like PTHrP-mediated hypercalcemia of malignancy & suppression of PTH.

196

Enhanced conversion of 25(OH)D to 1,25(OH)2D leading to hypercalcemia is related to ?

B.

Hyperkalemia should result in a TTKG>10

C.

Hypokalemia not resulting in a TTKG10 suggests type I renal tubular acidosis

B.

Milk-alkali syndrome

D.

Hyperkalemia not resulting in a TTKG>10 suggests type IV renal tubular acidosis

Hypercalcemia 191

A.

(POsm x P Potassium) / (UPotassium x U Osm)

TTKG in a normal person on a normal diet is 8 - 9.

190

Which of the following is related to familial hypocalciuric hypercalcemia (FHH) ?

B.

Correct formula for TTKG is (POsm x UPotassium) / (PPotassium x UOsm). It is valid only when Uosm >300 & UNa >25.

189

Excess PTH production not appropriately suppressed by increased serum calcium concentrations occurs in ?

Which of the following parameter is not required in calculating TTKG ? A. Serum Osmolality

To calculate following parameters are required : Serum Osmolality (mOsm/kg), Urine Osmolality (mOsm/kg), Serum K (mEq/L) and Urine K (mEq/L).

188

Which of the following is the action of PTH ?

Harrison’s 17th Ed 284

The most rapid and effective way of lowering the plasma K+ concentration is hemodialysis. Peritoneal dialysis is only 15-20% as effective as hemodialysis.

187

Nephrology

C.

Familial hypocalciuric hypercalcemia (FHH)

D.

Sarcoidosis

Hypercalcemia in sarcoidosis or lymphomas is caused by enhanced conversion of 25(OH)D to potent 1,25(OH)2D that enhances intestinal calcium absorption resulting in hypercalcemia & suppressed PTH.

197

Hypercalcemia due to excess secretion of 1,25(OH)2 D occurs in which of the following ?

Decrease in serum calcium leads to ?

N Engl J Med 2005;352:373-9

Harrison’s 17th Ed 285, Figure 47-1

A.

A.

Increase in parathyroid hormone (PTH)

B.

Squamous-cell cancer

B.

Resorption of calcium from bone

C.

Ovarian cancer

C.

Stimulates renal 1,25(OH)2D production

D.

Lymphoma

D.

All of the above

Breast cancer

Some lymphomas secrete the active form of vitamin D, 1,25-dihydroxyvitamin D (1,25(OH) 2D), causing hypercalcemia as a result of the combination of enhanced osteoclastic bone resorption and enhanced intestinal absorption of calcium.

Nephrology 335 198

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Type of hypercalcemia associated with cancer is ?

Medication that may independently lead to hypercalcemia is ?

N Engl J Med 2005;352:373-9

N Engl J Med 2005;352:373-9

A.

Local osteolytic hypercalcemia

A.

Lithium

B.

Humoral hypercalcemia of malignancy

B.

Vitamin D

C.

1,25(OH)2D-secreting lymphomas

C.

Thiazides

D.

All of the above

D.

All of the above

In addition to the above three, ectopic hyperparathyroidism due to ectopic secretion of authentic PTH is a rare cause of hypercalcemia.

199

204

Hypercalcemia with suppressed PTH secretion in hyperthyroidism is due to ?

Medications that independently lead to hypercalcemia are lithium, calcitriol, vitamin D & thiazides.

205

Enhanced intestinal calcium absorption

B.

Increased calcium mobilization from bone

C.

PTHrP-mediated hypercalcemia

D.

Increased parathyroid cell mass

Hyperthyroidism or osteolytic metastases directly increase calcium mobilization from bone leading to hypercalcemia with suppressed PTH secretion.

While treating hypercalcemia, serum phosphorus level should be kept in the range of ? N Engl J Med 2005;352:373-9

Harrison’s 17th Ed 285

A.

335 Cardiology

206

A.

0.5 to 1.0 mg/dL

B.

1.0 to 2.0 mg/dL

C.

2.0 to 2.5 mg/dL

D.

2.5 to 3.0 mg/dL

While treating hypercalcemia, calcium - phosphorus product should be kept ideally below ? N Engl J Med 2005;352:373-9

200

Serum levels of calcium in mild hypercalcemia are upto ? Harrison’s 17th Ed 285

A.

7 - 8.5 mg/dL

B.

8 - 9.5 mg/dL

C.

9 - 10.5 mg/dL

D.

11 - 11.5 mg/dL

Serum levels of calcium in mild hypercalcemia is upto 11 - 11.5 mg/dL and is usually asymptomatic.

201

B.

10

C.

20

D.

30

207

Which of the following occurs in acute severe hypercalcemia (>12-13 mg/dL) ? Harrison’s 17th Ed 286

N Engl J Med 2005;352:373-9

A.

Pancreatitis

A.

11 mg/dL

B.

Peptic ulcer disease

B.

12 mg/dL

C.

Nephrolithiasis

C.

13 mg/dL

D.

All of the above

D.

14 mg/dL

Severe acute hypercalcemia (>12–13 mg/dL) may result in lethargy, stupor, coma or pancreatitis.

208

ECG changes in hypercalcemia include all except ? Harrison’s 17th Ed 286

True hypercalcemia refers to ? N Engl J Med 2005;352:373-9

A.

Bradycardia

A.

Elevated serum level of total calcium

B.

AV block

B.

Elevated serum level of nonionized calcium

C.

Short QT interval

C.

Elevated serum level of ionized calcium

D.

Prolonged PR interval

D.

Any of the above

Elevated serum level of ionized calcium is true hypercalcemia.

203

5

While treating hypercalcemia, serum phosphorus level should be kept in the range of 2.5 to 3.0 mg/ dL and the calcium - phosphorus product below 40, ideally in the range of 30.

Serum levels of calcium in severe hypercalcemia is more than ?

Serum levels of calcium in severe hypercalcemia is > 14.0 mg/dL.

202

A.

ECG changes in hypercalcemia include bradycardia, AV block& short QT interval.

209

Basic mechanism of true hypercalcemia is ?

Changes in serum calcium is preferrably monitored by which of the following in ECG ?

N Engl J Med 2005;352:373-9

Harrison’s 17th Ed 286

A.

Enhanced osteoclastic bone resorption

A.

Heart rate

B.

Enhanced renal tubular reabsorption of calcium

B.

QRS amplitude

C.

Enhanced intestinal absorption of calcium

C.

QT interval

D.

All of the above

D.

ST segment

True hypercalcemia is due to enhanced osteoclastic bone resorption (in local osteolytic hypercalcemia, humoral hypercalcemia of malignancy (HHM), 1,25(OH) 2 D secreting lymphomas, & ectopic hyperparathyroidism), enhanced renal tubular reabsorption of calcium (in HHM & ectopic hyperparathyroidism), and enhanced intestinal absorption of calcium (in 1,25(OH) 2D-secreting lymphomas & ectopic hyperparathyroidism).

Changes in serum calcium can be monitored by following the QT interval.

210

What percentage of serum total calcium is ionized ? Harrison’s 17th Ed 286

A.

10 %

336

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Nephrology

B.

25 %

C.

Hypercalcemia invariably leads to dehydration

C.

50 %

D.

None of the above

D.

80 %

~50% of total calcium is ionized & rest is bound principally to albumin.

Normally, plasma PTH level varies inversely with plasma calcium level. Ectopic secretion of authentic PTH is a rare cause of hypercalcemia, having been well documented in only eight patients to date.

211

217

With a decrease in serum albumin of 1.0 g/dL, what quantity should be added to serum total calcium ?

N Engl J Med 2008;358:1952-6

Harrison’s 17th Ed 286

A.

0.2 mg/dL

B.

0.4 mg/dL

C.

0.6 mg/dL

D.

0.8 mg/dL

Serum albumin levels are determined to obtain “correct serum calcium”. 0.8 mg/dL should be addd to total calcium for every decrement in serum albumin of 1.0 g/dL below the reference value of 4.1 g/dL for albumin, and conversely for elevations in serum albumin.

212

218

Hypercalcemia

B.

Metabolic alkalosis

C.

Impaired renal function

D.

All of the above

Initial therapy of significant hypercalcemia begins with ? Harrison’s 17th Ed 286

Chronic hypercalcemia is most commonly caused by ?

A.

Volume expansion with IV saline

Medication use

B.

Zoledronic acid

B.

Primary hyperparathyroidism

C.

Calcitonin

C.

Underlying malignancy

D.

Glucocorticoids

D.

Sarcoidosis

A.

Primary hyperparathyroidism is the most common cause of chronic hypercalcemia, followed by hypercalcemia due to an underlying malignancy.

Increases in PTH are often accompanied by ? A.

Hypokalemia

B.

Hyperphosphatemia

C.

Hypophosphatemia

D.

Hypernatremia

Initial therapy of significant hypercalcemia begins with volume expansion with saline (200 - 500 ml/ hour, depending on patient’s cardiovascular status & renal function) as hypercalcemia invariably leads to dehydration. Saline itself is calciuretic. Loop diuretics should not be administered until after full hydration has been achieved. Thiazide diuretics should not be used as they stimulate renal calcium reabsorption.

219

Harrison’s 17th Ed 286

Drug that inhibits bone resorption is ? Harrison’s 17th Ed 286

Increases in PTH are often accompanied by hypophosphatemia.

214

A.

Hypercalcemia, metabolic alkalosis & impaired renal function are classic laboratory findings in patients with milk alkali syndrome in those with excess oral intake of calcium and milk.

Harrison’s 17th Ed 286

213

Classic laboratory finding in milk alkali syndrome is ?

Lab. findings in primary hyperparathyroidism include ?

A.

Zoledronic acid

B.

Pamidronate

C.

Etidronate

D.

All of the above

Intravenous bisphosphonates are the best studied, safest and most effective agents for use in patients with hypercalcemia associated with cancer. They work by blocking osteoclastic bone resorption. Ibandronate and Clodronate are the other two besides the above three.

Harrison’s 17th Ed 286

A.

Elevated serum calcium

B.

Low serum phosphorus

C.

Increased PTH level

D.

All of the above

220

Harrison’s 17th Ed 286

If PTH level is increased with elevated serum calcium & low phosphorus, diagnosis is almost always primary hyperparathyroidism.

215

In familial hypocalciuric hypercalcemia calcium / creatinine clearance ratio is ?

(FHH),

Harrison’s 17th Ed 286

A.

< 0.01

B.

< 0.05

C.

< 0.1

D.

< 0.2

Which of the following statements is false ? Harrison’s 17th Ed 286, N Engl J Med 2005;352:373-9

A.

Normal serum calcium is 8.9 - 10.1 mg/dL

B.

Ectopic PTH secretion is extremely rare

A.

Malignancy

B.

Severe hyperparathyroidism

C.

Sarcoidosis

D.

Familial hypocalciuric hypercalcemia (FHH)

In patients with 1,25(OH)2D-mediated hypercalcemia, glucocorticoids are the preferred therapy, as they decrease 1,25(OH)2D production.

221

Pharmacologic therapy for hypercalcemia associated with cancer include ? N Engl J Med 2005;352:373-9

Calcium/creatinine clearance ratio (urine calcium/serum calcium divided by urine creatinine/serum creatinine) of 20 mmol/L

278

D.

None of the above

Which of the following is a metabolite of ethylene glycol ? Harrison’s 17th Ed 291

A.

Lactic acid

B.

Tricarboxylic acid

C.

Oxalic acid

D.

Hydrochloric acid

Uremic acidosis is characterized by reduced rate of NH4+ production & excretion due to decreased renal mass. [HCO3–] rarely falls to 20 mmol/L.

285

‘Extrarenal cause’ of acidosis is suggested by ? Harrison’s 17th Ed 292

A.

Negative urine anion gap (UAG)

Ethylene glycol (used in antifreeze) causes metabolic acidosis and damage to CNS, heart, lungs and kidneys. Its metabolites are oxalic acid, glycolic acid, and other organic acids.

B.

Positive urine anion gap

C.

Zero urine anion gap

279

D.

Any of the above

Under most physiologic conditions, osmotic pressure of blood is generated by ? Harrison’s 17th Ed 291

280

A.

Sodium

B.

Urea

C.

Glucose

D.

All of the above

The chemical name of ‘Fomepizole’ is ? Harrison’s 17th Ed 291

A.

2-methylpyrazole

B.

3-methylpyrazole

286

Urine anion gap (UAG) is calculated by the formula ? Harrison’s 17th Ed 292

A.

[Na+ + K+]u / [Cl-]u

B.

[Na+ + K+]u x [Cl-]u

C.

[Na+ + K+]u - [Cl-]u

D.

[Na+ + K+]u + [Cl-]u

Urinary NH4+ levels are estimated by urine anion gap (UAG) i.e. [Na+ + K+]u – [Cl–]u. When [Cl–]u > [Na+ + K+], the UAG is negative which indicates that urine ammonium level is appropriately increased, suggesting an extrarenal cause of the acidosis. When urine anion gap is positive, urine ammonium level is low, suggesting a renal cause of acidosis.

342 287

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Fanconi syndrome is characterized by ?

A.

2 mm Hg

Harrison’s 17th Ed 292

B.

4 mm Hg

C.

6 mm Hg

D.

8 mm Hg

A.

Glycosuria

B.

Generalized aminoaciduria

C.

Phosphaturia

D.

All of the above

294

Hypokalemia and alkalosis in a normotensive, nonedematous patient suggests ?

Fanconi syndrome refers to glycosuria, generalized aminoaciduria, and phosphaturia due to generalized proximal tubular dysfunction (type 2 RTA).

Harrison’s 17th Ed 293

A.

Magnesium deficiency

288

Typical findings in classic distal RTA (type 1 RTA) include ?

B.

Vomiting

Harrison’s 17th Ed 292

C.

Diuretic ingestion

D.

All of the above

289

A.

Hypokalemia

B.

Low urinary NH4+ excretion

C.

Urine pH > 5.5

D.

All of the above

295

The typical findings in classic distal RTA (type 1 RTA) include all except ?

A.

Bartter’s syndrome

B.

Gitelman’s syndrome

Harrison’s 17th Ed 292

C.

Exogenous alkali

D.

All of the above

A.

Hyperkalemia

B.

Hyperchloremic acidosis

C.

Low urinary NH4+ excretion

D.

High urine pH

Combination of hypokalemia & alkalosis in a normotensive, nonedematous patient can be due to Bartter’s or Gitelman’s syndrome, magnesium deficiency, vomiting, exogenous alkali, or diuretic ingestion.

296

Harrison’s 17th Ed 293

A.

Acidic urine, elevated [Na]u and [K]u, low [Cl]u

B.

Alkaline urine, low [Na]u and [K]u, low [Cl]u

B.

Metabolic alkalosis

C.

Acidic urine, low [Na] u and [K] u, low [Cl]u

C.

Respiratory acidosis

D.

Alkaline urine, elevated [Na]u and [K]u, low [Cl] u

D.

Respiratory alkalosis

If urine is alkaline, with elevated [Na+] & [K+] but low [Cl–], diagnosis is either vomiting or alkali ingestion.

297

A.

Prior vomiting

Harrison’s 17th Ed 292

B.

Posthypercapnic state

A.

Diabetes mellitus

C.

Prior diuretic ingestion

B.

Tubulointerstitial disease

D.

All of the above

C.

Renal insufficiency

D.

All of the above

If urine is acidic and has low concentrations of Na+, K+, and Cl–, the possibilities are prior vomiting, posthypercapnic state, or prior diuretic ingestion.

298

Metabolic alkalosis is manifested by all except ? A.

Elevated arterial pH

B.

Increase in serum [HCO3 ]

C.

Hyperchloremia

D.

Increase in PaCO2

-

Metabolic alkalosis manifests as elevated arterial pH, increased serum [HCO 3–] & increased PaCO2 due to compensatory alveolar hypoventilation. It is often accompanied by hypochloremia & hypokalemia.

The PaCO2 increases how much for each 10 mmol/L increase in [HCO3-] above normal ? Harrison’s 16th Ed. 267

Which of the following is false about Liddle’s syndrome ? Harrison’s 17th Ed 294

Harrison’s 17th Ed 292

293

Acid urine with low urinary Na+, K+, and Cl- suggest ? Harrison’s 17th Ed 293

Hyporeninemic hypoaldosteronism can be seen in ?

Hyporeninemic hypoaldosteronism causes hyperchloremic metabolic acidosis, in older adults with diabetes mellitus or tubulointerstitial disease and renal insufficiency.

292

Which of the following is true for urine in patients who are vomiting ?

Mnemonic “MUDPILES” is to remember cause of ? A. Metabolic acidosis

Useful to memorize causes of anion gap metabolic acidemias. Letters in MUDPILES represent methanol, uremia, diabetic & alcoholic ketoacidosis, paraldehyde, isoniazid (INH), lactic acidemia, ethylene glycol toxicity, and salicylates. Paraldehyde can be replaced with propylene glycol.

291

Hypokalemia and alkalosis in a normotensive, nonedematous patient suggests ? Harrison’s 17th Ed 293

Typical findings of classic distal RTA (type 1 RTA) include hypokalemia, hyperchloremic acidosis, low urinary NH4+ excretion (positive UAG, low urine [NH4+]), and high urine pH (pH > 5.5).

290

Nephrology

A.

Increased activity of collecting duct sodium channel

B.

Hypertension

C.

Hypokalemic alkalosis

D.

Elevated aldosterone levels

Liddle’s syndrome results from increased activity of collecting duct Na+ channel (ENaC) manifests as hypertension due to volume expansion leading to hypokalemic alkalosis & normal aldosterone levels.

299

Presentation of metabolic alkalosis is similar to ? Harrison’s 17th Ed 294

A.

Hypercalcemia

B.

Hypocalcemia

C.

Hyperkalemia

Nephrology 343 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

All of the above

Changes in central and peripheral nervous system function with metabolic alkalosis are similar to those of hypocalcemia.

300

High urine chloride metabolic alkalemia includes ? Disease-a-Month 2004;50:122-162

301

A.

Bartter syndrome

B.

Gitleman syndrome

C.

Liddle’s syndrome

D.

All of the above

307

302

303

304

B.

Cushing disease

C.

Bartter’s syndrome

D.

Liddle’s syndrome

B.

Vasodilatation

C.

Hyperviscosity

D.

Renal failure

Diagnosis of respiratory acidosis requires measurement of ? Harrison’s 17th Ed 295

Disease-a-Month 2004;50:122-162

Conn’s Syndrome

Vasoconstriction

In respiratory acidosis, papilledema is due to vasoconstriction secondary to loss of the vasodilator effects of CO 2.

High urine chloride metabolic alkalemia with hypertension includes all except ? A.

A.

343 Cardiology

A.

Pa CO2

B.

Pa O2

C.

[HCO3–]

D.

All of the above

Diagnosis of respiratory acidosis requires, by definition, measurement of PaCO2 & arterial pH.

308

In chronic respiratory alkalosis a 1-mm Hg fall in PaCO2 causes a drop in [HCO3–] of ? Harrison’s 17th Ed 295

High urine chloride metabolic alkalemia without hypertension includes all except ?

A.

0.1 to 0.2 mmol/L

B.

0.2 to 0.3 mmol/L

Disease-a-Month 2004;50:122-162

C.

0.3 to 0.4 mmol/L

D.

0.4 to 0.5 mmol/L

A.

Excess bicarbonate administration

B.

Gitelman syndrome

C.

Bartter’s syndrome

D.

Liddle’s syndrome

In chronic respiratory alkalosis a 1 mm Hg fall in PaCO2 causes a 0.4 to 0.5 mmol/L drop in [HCO3– ] and a 0.003 rise in pH.

309

In acute respiratory acidosis, [HCO3 ] levels increase by how much for every 10 mm Hg increase in PaCO2 ? -

[HCO3–] falls by how much for each 10-mmHg decrease in PaCO2 in acute hypocapnia ? Harrison’s 17th Ed 295

Harrison’s 17th Ed 294

A.

2 mmol/L

A.

1 mmol/L

B.

3 mmol/L

B.

2 mmol/L

C.

4 mmol/L

C.

3 mmol/L

D.

5 mmol/L

D.

4 mmol/L

310

In chronic respiratory acidosis, [HCO3 ] levels increase by how much for every 10 mm Hg increase in PaCO2 ? -

[HCO3–] falls by how much for each 10-mmHg decrease in PaCO2 in chronic hypocapnia ? Harrison’s 17th Ed 295

Harrison’s 17th Ed 294

A.

2 mmol/L

A.

1 mmol/L

B.

3 mmol/L

B.

2 mmol/L

C.

4 mmol/L

C.

3 mmol/L

D.

5 mmol/L

D.

4 mmol/L

In acute respiratory acidosis, there is an increase of 1 mmol/L of HCO 3– for every 10-mm Hg increase in PaCO2. In chronic respiratory acidosis (>24 hours), the [HCO3–] increases by 4 mmol/L for every 10-mmHg increase in PaCO2.

In acute hypocapnia, [HCO3–] falls by 2 mmol/L and 4 mmol/L for each 10-mmHg decrease in PaCO2 in acute and chronic hypocapnia respectively.

311

In pure respiratory alkalosis, plasma HCO3– is usually more than ? Harrison’s 17th Ed 295

305

In respiratory acidosis, serum HCO3– usually does not increase above ?

A.

12 mmol/L

B.

14 mmol/L

28 mmol/L

C.

16 mmol/L

B.

38 mmol/L

D.

18 mmol/L

C.

48 mmol/L

D.

58 mmol/L

Harrison’s 17th Ed 294

A.

In respiratory acidosis, serum HCO3– usually does not increase above 38 mmol/L.

It is unusual to see a plasma HCO3– < 12 mmol/L due to pure respiratory alkalosis.

312

Which of the following shift inside the cell in acute respiratory alkalosis ? Harrison’s 17th Ed 295

306

In respiratory acidosis, papilledema is due to ? Harrison’s 17th Ed 294

A.

Na +

B.

K+

344

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

PO 4–

D.

All of the above

Acute respiratory alkalosis causes intracellular shifts of Na , K , and PO 4 .Hypocapnia-induced hypokalemia is usually minor. +

313

+

–

Which of the following is an early finding in gram-negative septicemia ?

320

Fever

B.

Hypoxemia

C.

Respiratory alkalosis

D.

Hypotension

321

Most common acid-base disturbance in critically ill patients is ? Harrison’s 17th Ed 295

5 - 25 meq/day

B.

25 - 100 meq/day

C.

100 - 200 meq/day

D.

200 - 300 meq/day

Normal range of urine sodium is ? A.

10 - 60 meq/day

B.

60 - 100 meq/day

C.

100 - 260 meq/day

D.

260 - 460 meq/day

C.

Chronic respiratory acidosis

Harrison’s 17th Ed. Table 7

D.

Chronic respiratory alkalosis

A.

50 - 250 mg/day

B.

250 - 800 mg/day

C.

800 - 1800 mg/day

D.

1800 - 3000 mg/day

322

What is the anion gap in a patient if albumin is 2 gm/dL, Na+ is 140 mEq/L, Cl- is 100 mEq/L, and HCO3 is 20 mEq/L ? 323

Normal range of urine uric acid is ?

Normal range of urine urea nitrogen is ?

A.

15

Harrison’s 17th Ed. Table 7

B.

20

A.

6 - 17 g/day

C.

25

B.

17 - 37 g/day

30

C.

37 - 57 g/day

D.

57 - 87 g/day

Which of the following is an ineffective osmole ? 324

Normal range of urine osmolality is ?

A.

Inositol

Harrison’s 16th Ed. Table A-5

B.

Urea

A.

50 - 150 mosmol/kg

C.

Betaine

B.

150 - 300 mosmol/kg

D.

Glutamine

C.

300 - 900 mosmol/kg

D.

900 - 1500 mosmol/kg

For each decrease in blood pH of 0.10, the plasma potassium rises by ? Harrison’s 16th Ed. 264

319

A.

Acute respiratory alkalosis

Harrison’s 16th Ed. 252

318

Normal range of urine potassium is ?

B.

D.

317

2.6 - 3.0 g/day

Acute respiratory acidosis

Harrison’s 16th Ed. 265

316

2.2 - 2.6 g/day

D.

A.

Chronic respiratory alkalosis is the most common acid-base disturbance in critically ill patients.

315

C.

Harrison’s 17th Ed. Table 7

Respiratory alkalosis is often an early finding in gram-negative septicemia, before fever, hypoxemia, or hypotension develops.

314

1.6 - 2.2 g/day

Harrison’s 17th Ed. Table 7

Harrison’s 17th Ed 295

A.

B.

A.

0.5 mmol/L

B.

0.6 mmol/L

C.

0.7 mmol/L

D.

0.8 mmol/L

Chapter 277. Cellular and Molecular Biology of the Kidney 325

In kidneys, number of different cell types found is about ? Harrison’s 18th Ed 2280

Normal range of urine ammonia is ?

A.

10

Harrison’s 17th Ed. Table 7

B.

30

A.

10 - 30 meq/day

C.

50

B.

30 - 50 meq/day

D.

80

C.

50 - 100 meq/day

D.

100 - 150 meq/day

Normal range of urine creatinine is ?

Kidney is one of the highly differentiated organs in body containing nearly 30 different cell types.

326

How many glomeruli does each kidney contain in a normalbirth-weight adult ?

Harrison’s 17th Ed. Table 7

Harrison’s 18th Ed 2280

A.

A.

1.0 - 1.6 g/day

Nephrology

100,000

Nephrology 345 B.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

400,000

A.

Zero

C.

900,000

B.

10

D.

1200,000

C.

20

D.

30

There are ~900,000 glomeruli in each kidney in normal-birth-weight adults.

327

Contractile actin-myosin fibers are found in which of the following tissues of kidney ? Harrison’s 18th Ed 2280

Autoregulation of glomerular filtration is the result of ? Harrison’s 18th Ed 2281

B.

Mesangial cells

A.

Autonomous vasoreactive reflex in afferent arteriole

C.

Renal interstitium

B.

Tubuloglomerular feedback

D.

All of the above

C.

Angiotensin II mediated vasoconstriction of efferent arteriole

D.

All of the above

Which of the following about kidney structure is false ?

Autoregulation of glomerular filtration is the result of an autonomous vasoreactive (myogenic) reflex in the afferent arteriole, tubuloglomerular feedback, and angiotensin II mediated vasoconstriction of the efferent arteriole.

A.

Majority of nephrons are cortical

B.

Majority of glomeruli located in mid-to-outer cortex

Which of the following is the first line of defense against fluctuations in renal blood flow in autoregulation of glomerular filtration ?

C.

Cortical nephrons perform most of glomerular filtration

Harrison’s 18th Ed 2281

D.

None of the above

A.

Myogenic reflex in afferent arteriole

B.

Tubuloglomerular feedback

334

Which of the following about kidney structure is false ? Harrison’s 18th Ed 2281

C.

Angiotensin II mediated vasoconstriction of efferent arteriole

A.

Cortical nephrons have short loops of Henle

D.

None of the above

B.

Juxtamedullary nephrons have long loops of Henle

Myogenic reflex is a first line of defense against fluctuations in renal blood flow.

C.

Peritubular capillaries surrounding cortical nephrons are shared among adjacent nephrons

335

D.

None of the above

Majority of nephrons are cortical, with glomeruli located in mid-to-outer cortex. Cortical nephrons have short loops of Henle, whereas juxtamedullary nephrons have long loops of Henle. Peritubular capillaries surrounding cortical nephrons are shared among adjacent nephrons. Juxtamedullary nephrons use separate capillaries called vasa recta. Cortical nephrons perform most of the glomerular filtration & their afferent arterioles are larger than their respective efferent arterioles. Juxtamedullary nephrons create a hyperosmolar gradient that allows for production of concentrated urine.

330

333

Glomeruli

Harrison’s 18th Ed 2281

329

As the oncotic pressure rises along the length of the glomerular capillary, the driving force for filtration falls to zero before reaching the efferent arteriole.

A.

Glomerular capillaries are in the midst of a mesangial matrix and together form the Bowman’s capsule. Mesangial cells contain contractile actin-myosin fibers to maintain structural integrity.

328

345 Cardiology

Harrison’s 18th Ed 2281

336

Cortical nephron has how many capillary beds arranged in series ? 1

B.

2

C.

3

D.

4

Cortical nephron has two capillary beds arranged in series separated by efferent arteriole that regulates hydrostatic pressure in both capillary beds.

A.

Juxtaglomerular apparatus

B.

Macula densa

C.

Granular cells in the wall of afferent arteriole

D.

All of the above

Macula densa is located in which of the following ? Harrison’s 18th Ed 2281

Harrison’s 18th Ed 2281

A.

Tubuloglomerular feedback is mediated by ?

A.

Proximal tubule

B.

Thick ascending limb of the loop of Henle

C.

Distal tubule

D.

Collecting duct

Tubuloglomerular feedback is mediated by specialized cells in thick ascending limb of the loop of Henle called macula densa that act as sensors of solute concentration & flow of tubular fluid.

337

Which of the following blunts tubuloglomerular feedback ? Harrison’s 18th Ed 2282

331

What percentage of renal plasma flow is filtered into Bowman’s space ? Harrison’s 18th Ed 2281

A.

Angiotensin II

B.

Reactive oxygen species Nitric oxide Adenosine

A.

~ 20 %

C.

B.

~ 45 %

D.

C.

~ 60 %

D.

~ 80 %

~20% of the renal plasma flow is filtered into Bowman’s space.

Angiotensin II & reactive oxygen species enhance, while nitric oxide blunts tubuloglomerular feedback.

338

Juxtaglomerular apparatus is located in which of the following ? Harrison’s 18th Ed 2282

332

Driving force for glomerular filtration at efferent arteriole is ? Harrison’s 18th Ed 2281

A.

Afferent arteriole

346

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Efferent arteriole

C.

Cl –

C.

Distal tubule

D.

All of the above

D.

Collecting duct

Juxtaglomerular apparatus is located within the wall of afferent arteriole near macula densa and its granular cells release renin.

Nephrology

In kidney, movement by simple diffusion or passive transport occurs of water, K+, Na+, and Cl–.

345

Carriers or uniporters are related to ? Harrison’s 18th Ed 2283

339

Renin catalyzes the conversion of ?

A.

Active transport

Harrison’s 18th Ed 2282

B.

Passive transport

C.

Facilitated diffusion

D.

Secondary active transport

A.

Angiotensinogen to angiotensin I

B.

Angiotensin I to angiotensin II

C.

Angiotensin II to angiotensin III

D.

All of the above

346

Renin is a proteolytic enzyme that catalyzes conversion of angiotensinogen to angiotensin I.

340

Harrison’s 18th Ed 2283

A.

Active transport

Harrison’s 18th Ed 2282

B.

Passive transport

A.

Angiotensinogen to angiotensin I

C.

Facilitated diffusion

B.

Angiotensin I to angiotensin II

D.

Secondary active transport

C.

Angiotensin II to angiotensin III

D.

All of the above

Angiotensin-converting enzyme catalyzes conversion of ?

Angiotensin I is converted to angiotensin II by angiotensin-converting enzyme (ACE).

341

Leaky epithelia is present in ?

Facilitated diffusion is a specialized type of passive transport mediated by simple transporters called carriers or uniporters. Many transporters operate by translocating two or more ions/solutes either in the same direction (symporters or co-transporters) or in opposite directions (antiporters or exchangers) across the cell membrane.

347

A.

Proximal convoluted tubule

B.

Distal convoluted tubule

C.

Collecting duct

D.

All of the above

Proximal tubule contains leaky epithelia, whereas distal nephron segments, such as distal convoluted tubule & collecting duct contain tight epithelia with little water permeability.

Facilitated diffusion occurs through which of the following ? Harrison’s 18th Ed 2283

Aquaporin-1 present on apical & basolateral membranes

B.

Na+/K+-ATPase pump is on basolateral membranes

C.

Filtered bicarbonate is converted to carbonic acid in lumen

D.

Carbonic acid diffuses into the cell

Carbonic acid is metabolized by brush border carbonic anhydrase to water and carbon dioxide. Dissolved carbon dioxide diffuses into the cell, where by cytoplasmic carbonic anhydrase reforms carbonic acid which dissociates into H+ and bicarbonate anions. Bicarbonate exits the cell through a basolateral Na+/HCO3– co-transporter.

348

Which of the following drugs is not filtered at the glomerulus ?

Pumps

Harrison’s 18th Ed 2285

B.

Channels

A.

Penicillins

C.

Transporters

B.

Cephalosporins

D.

Co-transporters

C.

Salicylates

D.

All of the above

Ion-translocating ATPases include ? Harrison’s 18th Ed 2283

Penicillins, cephalosporins, and salicylates are not filtered at the glomerulus and are secreted by proximal tubule by specific transporters.

349

Which of the following is not a major segment of loop of Henle ? Harrison’s 18th Ed 2285

A.

Na+/K+-ATPase

A.

Descending thin limb

B.

H+-ATPase

B.

Descending thick limb

C.

Ca 2+ -ATPase

C.

Ascending thin limb

D.

All of the above

D.

Ascending thick limb

Ion-translocating ATPases that mediate active transport (“pumps”) are the ubiquitous Na +/K +ATPase, the H+-ATPases, and Ca2+-ATPases.

344

A.

A.

Movement of solutes & water across cell membranes is made possible by pumps (active transport), channels (passive transport), transporters (facilitated diffusion), and co-transporters (secondary active transport).

343

Which of the following statements is false ? Harrison’s 18th Ed 2287

Harrison’s 18th Ed 2282

342

Symporters or co-transporters, antiporters or exchangers are related to ?

Which of the following solute moves by simple diffusion or passive transport ? Harrison’s 18th Ed 2283

A.

K+

B.

Na +

Loop of Henle consists of 3 major segments - descending & ascending thin limb & ascending thick limb.

350

Site of action of loop diuretics is ? Harrison’s 18th Ed 2285

A.

Proximal convoluted tubule

B.

Loop of Henle

C.

Distal convoluted tubule

Nephrology 347 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

Collecting duct

347 Cardiology

All of the above

Site of action of loop diuretics is loop of Henle.

Potassium recycling contributes to a positive electrostatic charge in lumen relative to the interstitium.

351

357

Water-permeability is highest in ? Harrison’s 18th Ed 2285

Which of the following is a transmembrane protein located within the tight junction complex ?

A.

Descending thin limb

Harrison’s 18th Ed 2285

B.

Ascending thin limb

A.

Hensin

C.

Ascending thick limb

B.

Paracellin-1

D.

Proximal convoluted tubule

C.

Nedd4-2

D.

All of the above

Descending thin limb of loop of Henle is highly water-permeable due to dense expression of aquaporin-1 water channels. Water permeability is negligible in the ascending limb.

352

Which of the following is the primary target for loop diuretics ? Harrison’s 18th Ed 2285

A.

Na+/Cl– co-transporter

B.

Na+/K+/2Cl– co-transporter

C.

Na+/K+-ATPase

D.

Apical Ca++-selective channels (TRPV5)

Mutations in CLDN16 encoding paracellin-1, a transmembrane protein located within the tight junction complex, leads to familial hypomagnesemia with hypercalcuria and nephrocalcinosis.

358

Harrison’s 18th Ed 2286

The Na+/K+/2Cl– co-transporter is the primary target for loop diuretics.

353

Tubular concentration of K+ is ? Harrison’s 18th Ed 2285

B.

TRPM3 and TRPM4

C.

TRPM5 and TRPM6

D.

TRPM6 and TRPM7

~ 2 meq/L

B.

~ 4 meq/L

C.

~ 6 meq/L

A.

Hypotonic medullary interstitium

D.

~ 8 meq/L

B.

Hypertonic medullary interstitium

C.

Isotonic medullary interstitium

D.

Any of the above

Which of the following is an inherited disorder of the thick ascending limb ? Harrison’s 18th Ed 2285

359

A.

Gitelman’s syndrome

B.

Bartter’s syndrome

C.

Gordon’s syndrome

D.

Liddle’s syndrome

Loss-of-function mutations in which of the following can cause Bartter’s syndrome ? Harrison’s 18th Ed 2285

A.

NKCC2

B.

KCNJ1

C.

CLCNKB

D.

Any of the above

Loop of Henle and and vasa recta establishes a hypertonic medullary interstitium by phenomenon called countercurrent multiplication.

360

Harrison’s 18th Ed 2285

A.

Mg2+ reabsorption

B.

Ca2+ reabsorption

C.

Potassium recycling

Loss-of-function mutations of SLC12A3 encoding the apical Na+/Cl– co-transporter cause ? Harrison’s 18th Ed 2285

A.

Gitelman’s syndrome

B.

Bartter’s syndrome

C.

Gordon’s syndrome

D.

Liddle’s syndrome

Loss-of-function mutations of SLC12A3 encoding the apical Na+/Cl– co-transporter cause Gitelman’s syndrome - a salt-wasting disorder associated with hypokalemic alkalosis and hypocalciuria.

361

Mutations in genes encoding WNK kinases, WNK-1 & WNK-4 cause ? Harrison’s 18th Ed 2285

Loss-of-function mutations in genes encoding components of Na+/K+/2Cl– co-transporter (NKCC2), apical K + channel (KCNJ1) or basolateral Cl – channel (CLCNKB, BSND) can cause Bartter’s syndrome.

Positive electrostatic charge in the lumen relative to interstitium is caused by ?

“Countercurrent multiplication” leads to ? Harrison’s 18th Ed 2285

Bartter’s syndrome is an inherited disorder of thick ascending limb. It leads to a salt-wasting renal disease with hypokalemia & metabolic alkalosis.

356

TRPM1 and TRPM2

A.

Tubular concentration of K is similar to plasma i.e. about 4 meq/L.

355

A.

A molecular complex of TRPM6 and TRPM7 proteins is critical for Mg 2+ reabsorption in the thick ascending limb of Henle.

+

354

A molecular complex of which of the following proteins is critical for Mg2+ reabsorption in thick ascending limb of Henle ?

A.

Gitelman’s syndrome

B.

Bartter’s syndrome

C.

Gordon’s syndrome

D.

Liddle’s syndrome

Mutations in genes encoding WNK kinases, WNK-1 and WNK-4 cause pseudohypoaldosteronism type II or Gordon’s syndrome characterized by familial hypertension with hyperkalemia.

362

Which of the following about principal cells of cortical collecting duct is false ? Harrison’s 18th Ed 2286

A.

Main Na + reabsorbing cells

348

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Site of action of aldosterone

C.

Site of action of K -sparing diuretics

D.

None of the above

D.

+

369

Which of the following is true for type A intercalated cells of cortical collecting duct ? A.

Acid secretion & bicarbonate reabsorption

B.

Bicarbonate secretion & acid reabsorption

C.

Acid & bicarbonate secretion

D.

Acid & bicarbonate reabsorption

Which of the following is true for type B intercalated cells of cortical collecting duct ? A.

Acid secretion & bicarbonate reabsorption

B.

Bicarbonate secretion & acid reabsorption

C.

Acid & bicarbonate secretion

D.

Acid & bicarbonate reabsorption

370

Activating mutations occur in which of the following channels in Liddle’s syndrome ?

371

366

B.

K+

C.

Cl -

D.

HCO3-

372

Harrison’s 18th Ed 2286

Hypokalemia

B.

Hypernatremia

C.

Hypertension

D.

Metabolic alkalosis

In Liddle’s syndrome, activating mutations occur in epithelial Na + channel causing increase in Na + reclamation that produces hypokalemia, hypertension, and metabolic alkalosis.

367

C.

Aquaporin 3

D.

Aquaporin 4

Which of the following is false about renal natriuretic peptide (urodilatin) ? A.

Secreted by renal tubular epithelia

B.

Interacts with apical receptors on inner medullary collecting duct cells

C.

Attenuates net Na+ reabsorption

D.

None of the above

Urodilatin resembles which of the following ? A.

Atrial natriuretic peptide

B.

Aldosterone

C.

Renin

D.

PGE2

Which of the folowing TRPV channels is osmoreceptive ? Harrison’s 17th Ed 1747

All of the following are features of Liddle’s syndrome except ? A.

Aquaporin 2

Harrison’s 18th Ed 2286

Harrison’s 18th Ed 2286

Na +

Aquaporin 1

B.

Harrison’s 18th Ed 2286

Type A intercalated cells of cortical collecting duct mediate acid secretion and bicarbonate reabsorption. Type B intercalated cells mediate bicarbonate secretion and acid reabsorption.

A.

A.

Aquaporin 1 is active in all water-permeable segments of proximal & distal tubules, while aquaporins 2, 3, and 4 are regulated by vasopressin in the collecting duct.

Harrison’s 18th Ed 2286

365

Which of the following aquaporin is not regulated by vasopressin in the collecting duct ? Harrison’s 18th Ed 2286

Harrison’s 18th Ed 2286

364

Aquaporin-4

Inner medullary collecting duct cells have vasopressin-regulated water channels (aquaporin-2 on apical & aquaporin-3 & 4 on basolateral membrane). Aquaporin-1 water channels are densely expressed in descending thin limb of loop of Henle.

Principal cells are the main Na+ reabsorbing cells and the site of action of aldosterone, K+-sparing diuretics, and spironolactone.

363

Nephrology

A.

TRPV1+

B.

TRPV2+

C.

TRPV3+

D.

TRPV4+

Vanilloid receptors Transient receptor potential (TRPV) channels respond to changes in tonicity. TRPV4+ neuronal cells connected to supraoptic and paraventricular nuclei in hypothalamus are osmoreceptive. They modulate release of vasopressin by posterior lobe of the pituitary gland.

Extracellular protein hensin is best related to ?

373

Aldosterone leads to which of the following in principal cells of the collecting duct ?

Harrison’s 18th Ed 2286

Harrison’s 18th Ed 2288

A.

Principal cells

A.

Increase activity of apical membrane Na+ channel

B.

Intercalated cells

B.

Increase activity of apical membrane K+ channel

C.

Podocytes

C.

Increase activity of basolateral Na+/K +-ATPase

D.

Mesangial cells

D.

All of the above

In acidemia, kidneys uses type A intercalated cells to secrete excess H & generate more HCO3 . In bicarbonate excess with alkalemia type B intercalated cells predominate. Extracellular protein ‘hensin’ mediates this adaptation.

Aldosterone binds to cytoplasmic mineralocorticoid receptors in principal cells of collecting duct & increases activity of apical membrane Na+ channel, apical membrane K+ channel & basolateral Na+/ K+-ATPase.

368

374

+

–

Which of the following water channels “aquaporin” is not present in inner medullary collecting duct cells ?

Aldosterone mediates its effects by which of the following genes ?

Harrison’s 18th Ed 2286

Harrison’s 18th Ed 2288

A.

Aquaporin-1

A.

SLC2A2

B.

Aquaporin-2

B.

CLCN5

C.

Aquaporin-3

C.

SGK1

Nephrology 349 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

CASR

Aldosterone mediates its effects in part by serum/glucocorticoid-induced kinase 1 (SGK1).

Chapter 278. Adaption of the Kidney to Renal Injury 375

Chapter 279 & 280. Acute Kidney Injury & Chronic Kidney Disease 380

“Azo” means ? Harrison’s 18th Ed 2294

A.

Urea

B.

Ammonia

Harrison’s 18th Ed 2289

C.

Nitrogen

A.

Herbert Lubowitz

D.

Waste

B.

Neal Bricker

C.

Doris Rolf

D.

Fred Weisser

Whose name is associated with intact nephron hypothesis ?

Word azotemia is derived from “azo” meaning nitrogen.

381

Term azotemia is used mostly for ? Harrison’s 17th Ed. 1752

An exposition of the Intact Nephron Hypothesis was published by Bricker et. al. in American Journal of Medicine (1960). Dr. Bricker defined the "intact nephron hypothesis" that the number of functioning nephrons is reduced in chronic renal disease and that the remaining nephrons undergo adaptations that maintain renal homeostasis.

A.

Prerenal ARF

B.

Intrinsic ARF

C.

Postrenal ARF

376

D.

All of the above

Who proposed the “Hyperfiltration hypothesis” ? Harrison’s 18th Ed 2289

A.

JL Olson

B.

Timothy W. Meyer

C.

HG Rennke

D.

Barry Brenner

Prerenal acute renal failure is also called azotemia.

382

Abrupt & sustained decrease in renal function with retention of nitrogenous and non-nitrogenous waste products

B.

Acute & sustained increase in serum creatinine of 0.5 mg/ dL, if the baseline is < 2.5 mg/dL

C.

Increase in serum creatinine of > 20% if the baseline is > 2.5 mg/dL

D.

None of the above

A.

Calcium

B.

Phosphorus

C.

PTH

A.

Acute renal failure

D.

All of the above

B.

Chronic renal failure

C.

Glomerulonephritis

D.

Nephrotic syndrome

383

Urine specific gravity of 1.010 equals how many mosmol/L of urine osmolality ?

RIFLE system is used to classify ? Lancet 2005;365:417-430

Bricker’s trade-off hypothesis in 1972 is based on the effects of uremia on the balance between calcium, phosphorus & PTH levels. Elevations in PTH that occur in CKD restore calcium & phosphorus levels but lead to hyperplasia of parathyroid gland & secondary hyperparathyroidism (trade-off).

384

Which of the following about prerenal azotaemia is false ? Lancet 2005;365:417-430

Harrison’s 18th Ed 2291

A

A.

300

B.

Appropriate physiological response to renal hypoperfusion

B.

325

C.

Certain drugs can provoke acute prerenal failure

C.

350

D.

Persistent renal hypoperfusion leads to ischaemic ATN

D.

375

385

Urine specific gravity of 1.010 equals ~350 mosmol/L of urine osmolality.

379

A.

Bricker’s trade-off hypothesis best relates to ? Harrison’s 18th Ed 2289

378

Which of the following about acute renal failure is false ? Lancet 2005;365:417-430

Barry Brenner in his hyperfiltration hypothesis in 1982 demonstrated that alterations in glomerular hemodynamics associated with renal ablation are accompanied by structural lesions and suggest that sustained single nephron hyperfiltration (SNGFR) may have maladaptive consequences by damaging remnant glomeruli.

377

349 Cardiology

Integrity of renal tissue is disturbed

Typical histological features of human acute tubular necrosis include ? Lancet 2005;365:417-430

Delta metabolic acidosis occurs when GFR falls below ? Harrison’s 18th Ed 2292

A.

Loss of brush border in proximal tubular cells

A.

25 mL/minute

B.

Sloughing of tubular cells into the lumen

B.

40 mL/minute

C.

Interstitial oedema

C.

60 mL/minute

D.

All of the above

D.

75 mL/minute

When GFR falls below 25 mL/minute, organic acids accumulate producing a delta metabolic acidosis.

386

In kidneys, most of the blood supply is directed to ? Lancet 2005;365:417-430

A.

Renal cortex

350

387

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Outer medulla

C.

Medullary rays

D.

None of the above

394

Lancet 2005;365:417-430

388

Renal cortex

B.

Outer medulla

C.

Medullary rays

D.

None of the above

395

Lancet 2005;365:417-430

389

Angiotensin II

B.

Thromboxane A2

C.

Prostaglandin H2

D.

All of the above

396

Lancet 2005;365:417-430

390

Leukotrienes C4 and D4

B.

Endothelin 1

C.

Adenosine

D.

All of the above

397

391

B.

Urine osmolality > 500

C.

Fractional excretion of sodium (%) < 1

D.

Fractional excretion of urea (%) > 35

398

Lancet 2005;365:417-430

392

Urine sodium < 10 mmol/L

B.

Urine osmolality > 500

C.

Fractional excretion of sodium (%) > 2

D.

Fractional excretion of urea (%) < 35

399

Fractional excretion of urea (%) > 35

Which of the following about urine findings in renal ARF is false ? A.

Fractional excretion of uric acid (%) > 15

B.

Fractional excretion of Lithium (%) > 20

C.

High brush border enzyme levels

D.

None of the above

Biomarkers proposed for the early diagnosis of acute renal failure include ? A.

Urinary interleukin 18

B.

Intestinal form of alkaline phosphatase

C.

N-acetyl--glucosaminidase & alanine aminopeptidase

D.

All of the above

Biomarkers specifically higher in ischaemic ATN is ? Urinary interleukin 18

B.

Kidney injury molecule 1

C.

N-acetyl--glucosaminidase

D.

Alanine aminopeptidase

Agents that impair autoregulation of renal blood flow include ? A.

NSAIDs

B.

ACE inhibitors

C.

Angiotensin-II-receptor blockers

D.

All of the above

Oliguria is defined as ? Harrison’s 18th Ed. 2301

Which of the following about urine findings in pre-renal ARF is false ? Lancet 2005;365:417-430

393

Fractional excretion of sodium (%) < 1

D.

Lancet 2005;365:417-430

Which of the following about urine findings in pre-renal ARF is false ? A.

C.

A.

Lancet 2005;365:417-430

Specific gravity about 1.020

Urine osmolality > 300

Lancet 2005;365:417-430

Which of the following about urine findings in pre-renal ARF is false ? A.

Urine sodium > 20 mmol/kg

B.

Lancet 2005;365:417-430

Vasoconstrictors implicated in the reduced renal blood flow in acute tubular necrosis are ? A.

A.

Lancet 2005;365:417-430

Vasoconstrictors implicated in reduced renal blood flow in acute tubular necrosis are ? A.

Which of the following about urine findings in renal ARF is false ? Lancet 2005;365:417-430

In established acute tubular necrosis, selective reduction in blood supply occurs in ? A.

Nephrology

A.

Urine output < 100 mL/day with ECF overload

B.

Urine output < 200 mL/day with ECF overload

C.

Urine output < 300 mL/day with ECF overload

D.

Urine output < 400 mL/day with ECF overload

A.

Fractional excretion of uric acid (%) < 7

B.

Fractional excretion of Lithium (%) < 7

Oliguria is defined as urine output of 300

D.

C.

Fractional excretion of sodium (%) > 2

D.

Fractional excretion of urea (%) < 35

More severe or prolonged prerenal ARF (renal hypoperfusion) may lead to ischemic injury of kidneys leading to acute tubular necrosis (ATN).

Nephrology 351 401

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Prerenal ARF can complicate which of the following ?

C.

Diseases of renal microcirculation & glomeruli

Harrison’s 18th Ed. 2294

D.

All of the above

A.

Low cardiac output

B.

Systemic vasodilatation

C.

Selective intrarenal vasoconstriction

D.

All of the above

Intrinsic causes of ARF can be ischemic or nephrotoxic tubular injury, tubulointerstitial diseases, diseases of renal microcirculation & glomeruli and diseases of larger renal vessels.

408

C.

S3 segment of proximal tubule

D.

Cortical thick ascending limb of loop of Henle

A.

Sympathetic nervous system

B.

Renin-angiotensin-aldosterone system

C.

Release of arginine vasopressin

D.

All of the above

Ischemic renal injury is most prominent in S3 segment of PCT and in medullary portion of the thick ascending limb of the loop of Henle.

409

A.

Initiation

B.

Extension

Harrison’s 17th Ed. 1753

C.

Maintenance

A.

Increased biosynthesis of Prostaglandin E2

D.

Recovery

B.

Increased biosynthesis of prostacyclin

C.

Preferential constriction of efferent arterioles

D.

All of the above

Which of the following is an action of Angiotensin II ?

During maintenance phase that lasts for 1 - 2 weeks, urine output is lowest due to reduced GFR and uremic complications may appear.

410

A.

Initiation

B.

Extension

Harrison’s 17th Ed. 1753 Table 273-1

C.

Maintenance

A.

Nonsteroidal anti-inflammatory drugs

D.

Recovery

B.

Angiotensin-converting enzyme inhibitors

C.

Angiotensin II receptor blockers

D.

All of the above

Which of the following drugs cause impairment of renal autoregulatory responses ?

Diuresis occurs in the recovery phase.

411

Which of the following cause kidney injury through intrarenal vasoconstriction ? Harrison’s 17th Ed 1755

A.

Radiocontrast agents

B.

Cyclosporine

Harrison’s 17th Ed 1753

C.

Tacrolimus

A.

Prerenal ARF

D.

All of the above

B.

Intrinsic ARF

C.

Intratubular obstruction

D.

Postrenal ARF

Hepatorenal syndrome (HRS) is a form of ?

Radiocontrast agents (cyclosporine & tacrolimus) cause kidney injury through intrarenal vasoconstriction.

412

Which of the following is false about hepatorenal syndrome ? A.

Kidneys are structurally normal

B.

Kidneys fail due to intense renal vasoconstriction

C.

Type I HRS is the more aggressive form

D.

None of the above

Which of the following leads to intrinsic ARF ? Harrison’s 17th Ed 1754

A.

Ischemic or nephrotoxic tubular injury

B.

Tubulointerstitial diseases

Endogenous nephrotoxins include all except ? Harrison’s 17th Ed 1755

Harrison’s 17th Ed 1753

407

Diuretic phase occurs in which of the following phases of ischemic ATN ? Harrison’s 17th Ed 1754

Hepatorenal syndrome (HRS) is a unique form of prerenal ARF.

406

Urine output is lowest in which of the following phases of ischemic ATN ? Harrison’s 17th Ed 1754

Impairment of renal autoregulatory responses is caused by COX inhibitors (NSAID’s), ACE inhibitors & angiotensin II receptor blockers.

405

S1 segment of proximal tubule S2 segment of proximal tubule

Harrison’s 17th Ed. 1753

Angiotensin II increases biosynthesis of vasodilator prostaglandins (Pg E2 & prostacyclin) resulting in afferent arteriolar vasodilation. Angiotensin II also induces preferential constriction of efferent arterioles.

404

A. B.

Hypovolemia leads to activation of ?

Hypovolemia triggers neurohormonal responses that include activation of the sympathetic nervous system and renin-angiotensin-aldosterone system, and release of arginine vasopressin.

403

Ischemic renal injury is most prominent in ? Harrison’s 17th Ed 1754

Prerenal ARF can complicate any disease that induces hypovolemia, low cardiac output, systemic vasodilatation or selective intrarenal vasoconstriction.

402

351 Cardiology

413

A.

Calcium

B.

Magnesium

C.

Urate

D.

Oxalate

Which of the following is an endogenous nephrotoxin ? Harrison’s 17th Ed 1755

A.

Myoglobin

B.

Hemoglobin

C.

Myeloma light chains

D.

All of the above

Endogenous nephrotoxins include calcium, myoglobin, hemoglobin, urate, oxalate & myeloma light chains.

352 414

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Increased serum LDH is found in which of the following causes of acute renal failure ? Harrison’s 17th Ed. 1756 Table 273-2

A.

Renal artery thrombosis

B.

HUS / TTP

C. D.

D. 421

Nephrology

Elliptical-shaped

Hippurate crystal is best related with ? Harrison’s 17th Ed. 1758

A.

Envelope-shaped

Hemolysis

B.

Needle-shaped

All of the above

C.

Round-shaped

D.

Elliptical-shaped

Increased serum LDH is found in acute renal failure due to renal artery, HUS / TTP, thrombosis, hemolysis, acute urate nephropathy & tumor lysis syndrome.

Ethylene glycol toxicity causes oxalate (envelope-shaped) & hippurate (needle-shaped) crystals.

415

422

Eosinophilia is found in which of the following causes of acute renal failure ?

Harrison’s 17th Ed. 1758

Harrison’s 17th Ed. 1756 Table 273-2

A.

Renal artery thrombosis

B.

HUS / TTP

C.

Hemolysis

D.

Atheroembolic disease

Urine is strongly positive for heme by dipstick in ? A.

Hemoglobinuria

B.

Hematuria

C.

Myoglobinuria

D.

All of the above

Urine is strongly positive for heme by dipstick in hemoglobinuria, hematuria & myoglobinuria.

416

417

Hypocomplementemia is found in which of the following causes of acute renal failure ?

423

Lancet 2005;365:417-430

A.

Renal artery thrombosis

A.

B.

Ethylene glycol ingestion

[(urine sodium x plasma sodium)÷ (plasma creatinine x urine creatinine)] x 100

C.

Multiple myeloma

B.

D.

Atheroembolic disease

[(urine creatinine x plasma creatinine)÷ (plasma sodium x urine sodium)] x 100

C.

[(urine sodium x urine creatinine)÷ (plasma sodium x plasma creatinine)] x 100

D.

[(urine sodium x plasma creatinine)÷ (plasma sodium x urine creatinine)] x 100

Tamm-Horsfall protein is secreted by epithelial cells of ? Harrison’s 17th Ed. 1756

A.

Proximal convoluted tubule

B.

Loop of Henle

C.

Distal convoluted tubule

D.

All of the above

Tamm-Horsfall protein is secreted by epithelial cells of the loop of Henle.

418

FENa relates sodium clearance to creatinine clearance. Patients with prerenal ARF typically have a FENa of 1.0% in prerenal ARF if patients are on diuretics or with preexisting CKD, salt-wasting syndromes or adrenal insufficiency.

424

Harrison’s 17th Ed. 1758

A.

Hyperkalemia

A.

Prerenal ARF

B.

Hyperphosphatemia

B.

Ischemic or nephrotoxic ATN

C.

Hypocalcemia

C.

Postrenal ARF

D.

All of the above

D.

All of the above

Broad granular casts are characteristic of ?

Hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia and raised creatine kinase (MM isoenzyme) suggest a diagnosis of rhabdomyolysis.

425

Harrison’s 17th Ed. 1758

A.

Glomerular injury

B.

Acute tubulointerstitial nephritis

C.

Ischemic or nephrotoxic ATN

D.

Chronic kidney disease

Broad granular casts are characteristic of chronic kidney disease.

420

Presence of which of the following suggests a diagnosis of acute renal failure due to rhabdomyolysis ? Harrison’s 17th Ed. 1758

Pigmented “muddy brown” granular cast is characteristic of ?

Pigmented “muddy brown” granular cast is characteristic of ATN due to ischemic or nephrotoxic etiology.

419

Fractional excretion of sodium (FENa) is calculated as ?

Harrison’s 17th Ed. 1756 Table 273-2

Oxalate crystal is best related with ? Harrison’s 17th Ed. 1758

In acute renal failure, severe anemia in the absence of hemorrhage suggests ? Harrison’s 17th Ed. 1758

A.

Hemolysis

B.

Multiple myeloma

C.

Thrombotic microangiopathy

D.

Any of the above

In acute renal failure, severe anemia in the absence of hemorrhage suggests hemolysis, multiple myeloma, or thrombotic microangiopathy.

426

In acute renal failure, systemic eosinophilia suggests ?

A.

Envelope-shaped

B.

Needle-shaped

A.

Allergic interstitial nephritis

Round-shaped

B.

Atheroembolic disease

C.

Harrison’s 17th Ed. 1758

Nephrology 353

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

C.

Polyarteritis nodosa

D.

Any of the above

433

Acute renal failure impairs which of the following ? Harrison’s 17th Ed. 1758

A.

Renal excretion of sodium, potassium & water

B.

Divalent cation homeostasis

C.

Urinary acidification mechanisms

D.

All of the above

434

Harrison’s 17th Ed. 1758

Hyperphosphatemia

B.

Hypocalcemia

C.

Hypomagnesemia

D.

Metabolic acidosis

435

Harrison’s 17th Ed. 1759

Rhabdomyolysis

B.

Hemolysis

C.

Tumor lysis syndrome

D.

All of the above

Which of the following can occur during recovery phase of ARF ? Harrison’s 17th Ed. 1759

A.

Hypernatremia

B.

Hypokalemia

C.

Hypophosphatemia

D.

All of the above

Vigorous diuresis during recovery phase of ARF may lead to intravascular volume depletion causing hypernatremia, hypokalemia, hypomagnesemia, hypophosphatemia and hypocalcemia.

431

Cockcroft - Gault equation is used for estimation of ? Harrison’s 17th Ed. 1759

432

A.

Urinary anion gap

B.

Serum anion gap

C.

Glomeruler filtration rate (GFR)

D.

Fractional excretion of sodium

Modification of Diet in Renal Disease (MDRD) equation is used for estimation of ? Harrison’s 17th Ed. 1759

Rasburicase

D.

All of the above

Which of the following is an oral phosphate binder ? A.

Calcium carbonate

B.

Sevalamer

C.

Aluminum hydroxide

D.

All of the above

Uremic bleeding may respond to administration of ? A.

Desmopressin

B.

Estrogens

C.

Dialysis

D.

All of the above

Uremic bleeding may respond to desmopressin, estrogens or dialysis.

436

In acute renal failure, mortality is high when there is ? Lancet 2005;365:417-430

Hyperkalemia in acute renal failure may be severe in patients with rhabdomyolysis, hemolysis, and tumor lysis syndrome.

430

Forced alkaline diuresis

C.

Harrison’s 17th Ed. 1761

Hyperkalemia in acute renal failure is severe in ? A.

B.

Hyperphosphatemia can be controlled by oral phosphate binders like calcium carbonate, calcium acetate, sevalamer & aluminum hydroxide.

ARF is complicated by hyponatremia, hyperkalemia, hyperphosphatemia, hypocalcemia, hypermagnesemia and metabolic acidosis.

429

Allopurinol

Harrison’s 17th Ed. 1760

Which of the following is not a feature of acute renal failure ? A.

A.

Allopurinol, forced alkaline diuresis, Rasburicase, N-acetylcysteine help in preventing development of ARF due to various causes.

ARF impairs renal excretion of sodium, potassium, and water and perturbs divalent cation homeostasis and urinary acidification mechanisms.

428

Which of the following may prevent or attenuate ARF ? Harrison’s 17th Ed. 1759

In acute renal failure, systemic eosinophilia suggests allergic interstitial nephritis, atheroembolic disease or polyarteritis nodosa.

427

353 Cardiology

437

A.

Multiorgan failure

B.

High concentration of TNF-

C.

Low production of interleukin 10

D.

All of the above

Absolute indication for dialysis in ARF is ? Harrison’s 17th Ed. 1761

A.

Uremic syndrome

B.

Hyperkalemia

C.

Acidosis

D.

All of the above

Absolute indications for dialysis are symptoms or signs of uremic syndrome, refractory hypervolemia, hyperkalemia, or acidosis.

438

Classic pathologic features of ischemic ATN include ? Harrison’s 17th Ed. 1755

A.

Patchy & focal necrosis of tubular epithelium

B.

Normal glomeruli

C.

Normal renal vasculature

D.

All of the above

Classic pathologic features of ischemic ATN are patchy & focal necrosis of the tubular epithelium, detachment of cells from basement membrane and occlusion of tubule lumens. Glomeruli & renal vasculature is characteristically normal.

A.

Urinary anion gap

B.

Serum anion gap

C.

Glomeruler filtration rate (GFR)

A.

Anemia

D.

Fractional excretion of sodium

B.

Evidence of renal osteodystrophy

439

Which of the following suggests chronic kidney disease ? Harrison’s 17th Ed. 1755

354

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Small scarred kidneys

C.

5200

D.

All of the above

D.

5400

Nephrology

Findings that suggest chronic kidney disease include anemia, evidence of renal osteodystrophy (radiologic or laboratory) and small scarred kidneys.

Molecular weight of inulin is ~5200. It pass freely across glomerular filtration barrier, appearing at approximately the same concentration in Bowman’s space as in plasma.

440

447

Kidney size may be increased in which of the following chronic renal diseases ?

Which of the following is curve A-type solute ? Harrison’s 16th Ed 1640

Harrison’s 17th Ed. 1755

A.

Sodium

A.

Diabetic nephropathy

B.

Urate

B.

Amyloidosis

C.

Urea

C.

HIV associated nephropathy

D.

All of the above

D.

All of the above

Kidney size may be normal or increased in diabetic nephropathy, amyloidosis, polycystic kidney disease and HIV associated nephropathy.

Curve A-type solutes include urea and creatinine. These depend largely on glomerular filtration for urinary excretion. Their secretion contributes little to overall excretion. The clinical course of CRF usually also approximates curve A.

441

448

442

443

444

A persistent reduction in GFR to less than what level per minute per 1.73 m2 is defined as chronic kidney disease ?

Harrison’s 16th Ed 1640

Harrison’s 16th. Ed. 1653

A.

Phosphate (PO43-)

A.

60 ml

B.

Urate

B.

70 ml

C.

Potassium & Hydrogen ions

C.

80 ml

D.

All of the above

D.

90 ml

449

Harrison’s 16th Ed 1640

A.

Sodium

Lancet 2005;365:417-430

B.

Potassium

A.

Contrast nephropathy

C.

Hydrogen

B.

Uremic pericarditis

D.

None of the above

C.

Uremic encephalopathy

D.

All of the above

450

Which of the following is a curve C-type solute ? Harrison’s 16th Ed 1640

Most rapid way to remove potassium in severe hyperkalemia is ?

A.

Sodium

Lancet 2005;365:417-430

B.

Potassium

A.

Intravenous calcium

C.

Hydrogen

B.

Infusion of glucose & insulin

D.

Urate

C.

Na–K exchange resin (sodium polystyrene sulfonate)

D.

Haemodialysis

Decreased GFR occurs due to ?

In contrast to solutes of the curve A type, plasma levels of phosphate, urate, and potassium and hydrogen ions usually do not rise until the GFR falls to a small percentage of normal. With progressive renal failure this pattern of response (curve B) reflects the participation of tubule transport mechanisms in the excretion of these substances.

451

Plasma concentration of which of the following remains normal throughout the course of CRF ?

A.

Reduced Glomerular hydraulic pressure

B.

Elevated Bowman’s space hydraulic pressure

Harrison’s 16th Ed 1640

C.

Rise in Plasma colloid osmotic pressure

A.

Potassium

D.

All of the above

B.

Sodium

C.

Calcium

D.

Hydrogen

Decreased GFR occurs due to ? Harrison’s 16th Ed. 1639

446

Which of the following is not a curve B-type solute ?

In a case of CRF, oral acetylcysteine with hydration significantly lowers the risk of ?

Harrison’s 16th Ed. 1639

445

Which of the following are curve B-type solutes ?

A.

Reduced Glomerular blood flow

B.

Reduced Glomerular Permeability

C.

Diminished Filtration surface area

D.

All of the above

The molecular weight of inulin is about ? Harrison’s 16th Ed. 1639

A.

4800

B.

5000

For sodium chloride (NaCl), plasma concentrations remain normal throughout the course of CRF, despite unrestricted intake of these substances (curve C).

452

Site where AVP exerts its principal effect is ? Harrison’s 16th Ed 1641

A.

Proximal convoluted tubule

B.

Loop of Henle

C.

Distal convoluted tubule

D.

Cortical & papillary portions of collecting duct

Nephrology 355 453

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

What proportion of glomerular ultrafiltrate is reabsorbed in the proximal tubules ?

459

454

The principle site of action of Parathyroid hormone (PTH) is ? Harrison’s 16th Ed 1642

Harrison’s 16th Ed 1640

A.

Proximal convoluted tubule

A.

One third

B.

Loop of Henle

B.

One half

C.

Distal convoluted tubule

C.

Two third

D.

Collecting duct

D.

Three fourth

~ Two-thirds of glomerular ultrafiltrate is reabsorbed isosmotically in proximal tubule with little change in osmolality or sodium concentration of unreabsorbed fraction. With water absorption, sodium along with chloride & bicarbonate are absorbed actively to keep ultrafiltrate iso-osmotic.

355 Cardiology

460

Fluid that enters the distal convoluted tubule is always ? Harrison’s 16th Ed 1641

In earliest portion of proximal tubule, which of the following is the principal ion that accompanies the reabsorption of sodium ?

A.

Isoosmotic

B.

Hypoosmotic

C.

Hyperosmotic

D.

None of the above

Harrison’s 16th Ed 1640

A.

Chloride

B.

Bicarbonate

C.

Hydrogen

D.

Phosphate

461

N Engl J Med 2006;354:1065-72

In the earliest portion of PCT, bicarbonate is the principal anion that accompanies reabsorption of sodium. This process occurs via a Na/H exchanger at the luminal brush border and is dependent on the activity of carbonic anhydrase.

455

Early proximal convoluted tubule is the major site of reabsorption of ?

462

A.

Antacid overdose

B.

Ethylene glycol ingestion

C.

Blunt abdominal trauma

D.

Fat embolism

Each kidney contains how many glomeruli in the renal cortex ? N Engl J Med 2006;354:1387-401

Harrison’s 16th Ed 1640

A.

About 1 million

A.

Lactate

B.

About 2 million

B.

Amino acids

C.

About 3 million

C.

Glucose

D.

About 4 million

D.

All of the above

Glucose, amino acids, and organic solutes like lactate are extensively reabsorbed in the proximal tubule by cotransport mechanisms.

456

Calcium oxalate monohydrate crystals in the urinary sediment are typical of ?

463

N Engl J Med 2006;354:1387-401

Normally, in glomerulus, which of the following is true ? Harrison’s 16th Ed 1641

A.

Hydraulic pressure exceeds oncotic pressure

B.

Oncotic pressure exceeds hydraulic pressure

C.

Oncotic pressure equals hydraulic pressure

D.

Any of the above

Filtration barrier of capillary wall in glomerulus contains ?

464

A.

Fenestrated endothelium

B.

Glomerular basement membrane

C.

Interdigitating podocyte foot processes

D.

All of the above

Glomerular basement membrane has a thickness of ? N Engl J Med 2006;354:1387-401

A.

200 to 250 nm

At glomerulus, hydraulic pressure exceeds oncotic pressure favoring filtration.

B.

300 to 350 nm

457

Site of action of loop diuretics is ?

C.

400 to 450 nm

Harrison’s 16th. Ed. 1641

D.

500 to 550 nm

A.

Proximal convoluted tubule

B.

Thin ascending limb of Henle’s loop

C.

Medullary thick ascending limb of Henle

A.

Cortical collecting tubule

D.

All of the above

B.

Papillary collecting duct

C.

Terminal duct

D.

None of the above

465

Harrison’s 16th. Ed. 1642

Na:K:2Cl cotransporter is the site of action of the powerful loop diuretics in the medullary thick ascending limb of Henle, and its mutations give rise to Bartter’s syndrome.

458

Normally, major quantity of phosphate is reabsorbed in ? Harrison’s 16th Ed 1641

A.

Proximal convoluted tubule

B.

Loop of Henle

C.

Distal convoluted tubule

D.

Collecting duct

The terminal segment of the distal nephron is ?

466

Which of the following is a “salt-wasting nephropathy” ? Harrison’s 16th. Ed. 1642

A.

Chronic pyelonephritis

B.

Polycystic disease

C.

Medullary cystic disease

D.

All of the above

356 467

468

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

N Engl J Med 2003;348:2543-56

Chronic kidney disease (CKD) is divided into how many stages by National Kidney Foundation ?

A.

Type IV collagen

Harrison’s 17th Ed.

B.

Laminin

A.

3

C.

Nidogen

B.

4

D.

All of the above

C.

5

D.

6

Main components of glomerular basement membrane are ?

Pierson’s syndrome is a form of ? N Engl J Med 2006;354:1387-401

469

470

471

472

473

474

A.

Congenital nephrotic syndrome

B.

Congenital heart disease

C.

Congenital bone disease

D.

Congenital eye disease

475

Nephrology

CKD is divided into six stages by National Kidney Foundation [Kidney Dialysis Outcomes Quality Initiative (KDOQI)] according to the estimated GFR.

476

Harrison’s 17th Ed.

To convert the values for urea nitrogen to millimoles/liter, multiply by ? A. 0.157 B.

0.257

C.

0.357

D.

0.457

Chronic renal failure typically corresponds to which of the following CKD stages ? A.

1-3

B.

2-4

C.

3-5

D.

4-5

Term CRF applies to the process of continuing significant irreversible reduction in nephron number and typically corresponds to CKD stages 3 - 5.

477

End-stage renal disease denotes which stage of CKD ?

To convert the values for creatinine to micromoles/liter, multiply by ? A. 68.4

Harrison’s 17th Ed. 1762

B.

A.

2

B.

3

78.4

C.

4

C.

88.4

D.

5

D.

98.4

To convert the values for glucose to millimoles per liter, multiply by ? A. 0.4551

End-stage renal disease denotes stage 5 of CKD.

478

Modification of Diet in Renal Disease (MDRD) formula for estimating GFR (mL/min per 1.73 m2) is ? Harrison’s 17th Ed. 1762 Table 274-2

B.

0.5551

A.

1.56 x (PCr)–1.154 x (age) –0.203

C.

0.6551

B.

1.66 x (PCr)–1.154 x (age) –0.203

D.

0.7551

C.

1.76 x (PCr)–1.154 x (age) –0.203

D.

1.86 x (PCr)–1.154 x (age) –0.203

To convert the values for calcium to millimoles per liter, multiply by ? A. 0.150 B.

0.250

C.

0.350

D.

0.450

To convert the values for phosphorus to millimoles per liter, multiply by ? A. 0.1229 B.

0.2229

C.

0.3229

D.

0.4229

To convert the values for magnesium to millimoles per liter, multiply by ? A. 0.200 B.

0.300

C.

0.400

D.

0.500

479

Cockcroft-Gault equation for estimating creatinine clearance (ml/minute) is ? Harrison’s 17th Ed. 1762 Table 274-2

480

A.

(120-age x body weight in kg) / (72 x plasma creatinine)

B.

(130-age x body weight in kg) / (72 x plasma creatinine)

C.

(140-age x body weight in kg) / (72 x plasma creatinine)

D.

(150-age x body weight in kg) / (72 x plasma creatinine)

Middle molecules have a molecular mass between ? Harrison’s 17th Ed. 1762

A.

500 & 1500 Da

B.

1500 & 3000 Da

C.

3000 & 5000 Da

D.

5000 & 8000 Da

Compounds with a molecular mass between 500 & 1500 Da are middle molecules.

481

Normal annual mean decline in GFR with age is ? Harrison’s 17th Ed. 1762

A.

~1 mL/min per year per 1.73 m2

Nephrology 357

482

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

~1.5 mL/min per year per 1.73 m2

C.

~2 mL/min per year per 1.73 m2

D.

~2.5 mL/min per year per 1.73 m2

Mean value of GFR at the age of 70 years is ?

Uremic syndrome manifests as accumulation of toxins due to renal excretory failure, loss of fluid & electrolyte homeostasis & hormone regulation and progressive systemic inflammation with vascular & nutritional consequences.

488

70 mL/min per 1.73 m2

B.

80 mL/min per 1.73 m2

C.

90 mL/min per 1.73 m2

D.

100 mL/min per 1.73 m2

Normal annual mean decline in GFR with age is ~1 mL/min per year per 1.73 m2, reaching a mean value of 70 mL/min per 1.73 m2 at the age of 70 years.

483

484

489

End products of aliphatic amine metabolism

C.

End products of aromatic amino acid metabolism

D.

All of the above

Uremic “Toxins” include ? Urea

B.

Creatine

Harrison’s 17th Ed. 1762

C.

Urates and hippurates

A.

> 11 mg

D.

All of the above

B.

> 13 mg

C.

> 15 mg

D.

> 17 mg

Apart from the above ones, PTH is also a uremic toxin.

490

In adult females, persistence in urine of how much albumin per gram of creatinine signifies chronic renal damage ? A.

> 18 mg

B.

> 21 mg

C.

> 23 mg

D.

> 25 mg

491

< 15

B.

15 - 29

C.

30 - 59

D.

60 - 89

A.

Polyamines

B.

Myoinositol

C.

Phenols

D.

All of the above

Which of the following is a nitrogenous excretory product ? Harrison’s 16th Ed. 1654

What is the GFR value (mL/min per 1.73 m2) in stage 5 of chronic kidney disease (CKD) ? A.

Which of the following is a nitrogenous excretory product ? Harrison’s 16th Ed. 1654

Harrison’s 17th Ed. 1762 Table 274-1

492

A.

Benzoates

B.

Indoles

C.

Phenols

D.

All of the above

Plasma levels of which of the following hormones rise with renal failure ? Harrison’s 16th Ed. 1654

GFR in CKD (mL/min per 1.73 m ) - Stage 0 = >90, stage 1 = >=90, stage 2 = 60 - 89, stage 3 = 30 - 59, stage 4 = 15 - 29 and stage 5 = 17 mg of albumin per gram of creatinine in adult males and 25 mg albumin per gram of creatinine in adult females signifies CKD.

486

A.

Harrison’s 17th Ed. 1765

Harrison’s 17th Ed. 1762

485

Uremic “Toxins” include ? Harrison’s 16th Ed. 1654

Harrison’s 17th Ed. 1762

A.

357 Cardiology

Which of the following dysfunctions occur in uremic syndrome ? Harrison’s 17th Ed. 1763

A.

Renal excretory failure

B.

Progressive systemic inflammation

C.

Loss of hormone regulation

D.

All of the above

A.

Parathyroid hormone (PTH)

B.

Prolactin

C.

Luteinizing hormone

D.

All of the above

Clinical abnormalities in uremia that develop only after initiation of dialysis therapy are all except ? Harrison’s 17th Ed. 1763 Table 274-3

494

A.

Adynamic osteomalacia

B.

Dialysis disequilibrium syndrome

C.

Hypotension & arrhythmias

D.

Hypothermia

Clinical abnormalities in uremia that develop only after initiation of dialysis therapy are all except ? Harrison’s 17th Ed. 1763 Table 274-3

A.

Hepatitis

B.

Idiopathic ascites

C.

Peritonitis

D.

Muscular irritability

358 495

496

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Clinical abnormalities in uremia that develop only after initiation of dialysis therapy are all except ? Harrison’s 17th Ed. 1763 Table 274-3

Endocrine-metabolic disturbances in uremia that tends to persist or even progress, despite optimal dialysis & related therapy are all except ?

A.

Leukopenia

Harrison’s 17th Ed. 1763 Table 274-3

B.

Hypocomplementemia

A.

Increased Lp(a) level

C.

Muscle cramps

B.

Decreased high-density lipoprotein level

D.

Hypernatremia & hyponatremia

C.

Infertility and sexual dysfunction

D.

None of the above

Clinical abnormalities in uremia that improve with dialysis and erythropoietin therapy are all except ?

502

503

Harrison’s 17th Ed. 1763 Table 274-3

497

A.

Fatigue

B.

Impaired mentation

C.

Lethargy

D.

Sleep disorders

Clinical abnormalities in uremia that improve with dialysis and erythropoietin therapy are all except ? Harrison’s 17th Ed. 1763 Table 274-3

498

A.

Pallor

B.

Anemia

C.

Bleeding diathesis

D.

Leukopenia

Gastrointestinal disturbances in uremia that usually improve with optimal dialysis & related therapy are all except ? Harrison’s 17th Ed. 1763 Table 274-3

499

Harrison’s 17th Ed. 1763 Table 274-3

504

A.

Amenorrhea

B.

Impaired growth & development

C.

Infertility & sexual dysfunction

D.

None of the above

Neuromuscular disturbances in uremia that usually improve with optimal dialysis & related therapy are all except ? Harrison’s 17th Ed. 1763 Table 274-3

505

A.

Asterixis

B.

Muscular irritability

C.

Coma

D.

Sleep disorder

Neuromuscular disturbances in uremia that develops only after initiation of dialysis therapy are all except ?

Anorexia, nausea and vomiting

B.

Uremic fetor

A.

Muscle cramps

C.

Gastroenteritis

B.

Myoclonus

D.

Idiopathic ascites

C.

Dialysis disequilibrium syndrome

D.

Myopathy

Gastrointestinal disturbances in uremia that develop only after initiation of dialysis therapy are all except ?

Harrison’s 17th Ed. 1763 Table 274-3

506

Neuromuscular disturbances in uremia that improve with dialysis and erythropoietin therapy are all except ?

A.

Hepatitis

B.

Idiopathic ascites

A.

Fatigue

C.

Peritonitis

B.

Impaired mentation

D.

Uremic fetor

C.

Lethargy

D.

Asterixis

Endocrine-metabolic disturbances in uremia that develop only after initiation of dialysis therapy are all except ? Harrison’s 17th Ed. 1763 Table 274-3

501

Endocrine-metabolic disturbances in uremia that tends to persist or even progress, despite optimal dialysis & related therapy are all except ?

A.

Harrison’s 17th Ed. 1763 Table 274-3

500

Nephrology

Harrison’s 17th Ed. 1763 Table 274-3

507

Cardiovascular & pulmonary disturbances in uremia that usually improve with optimal dialysis & related therapy are all except ?

A.

Carbohydrate intolerance

B.

Adynamic osteomalacia

A.

CHF / pulmonary edema

C.

Secondary hyperparathyroidism

B.

Pericarditis

D.

Vitamin D-deficient osteomalacia

C.

Uremic lung

D.

Hypotension & arrhythmias

Endocrine-metabolic disturbances in uremia that usually improve with optimal dialysis & related therapy are all except ? Harrison’s 17th Ed. 1763 Table 274-3

Harrison’s 17th Ed. 1763 Table 274-3

508

Dermatologic disturbances in uremia that usually improve with optimal dialysis & related therapy are all except ?

A.

Carbohydrate intolerance

B.

Vitamin D-deficient osteomalacia

A.

Ecchymoses

C.

Hypothermia

B.

Uremic frost

D.

All of the above

C.

Pallor

D.

Pruritus

Harrison’s 17th Ed. 1763 Table 274-3

Nephrology 359 509

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following hypoaldosteronism ?

leads

to

hyporeninemic

Harrison’s 17th Ed. 1764

A.

Diabetes mellitus

B.

Obstructive uropathy

C.

Sickle cell nephropathy

D.

All of the above

D.

Which of the following growth patterns is seen when cell mass of parathyroid glands increases with CKD ? Harrison’s 17th Ed. 1764

All of the above

Phosphate binders are calcium acetate, calcium carbonate and Sevelamer.

515

Which of the following is a consequence of a very low PTH level ? Harrison’s 17th Ed. 1766

In CKD, potassium levels may rise out of proportion to decline in GFR in conditions that lead to hyporeninemic hypoaldosteronism like diabetes, obstructive uropathy & sickle cell nephropathy.

510

A.

Adynamic bone disease

B.

Fracture

C.

Ectopic calcification

D.

All of the above

In CKD, target PTH level should be between 150 and 300 pg/mL. Very low PTH levels cause adynamic bone disease, fracture and ectopic calcification.

A.

Diffuse hyperplasia (polyclonal)

B.

Nodular growth (monoclonal) within diffuse hyperplasia

Harrison’s 17th Ed. 1766

C.

Diffuse monoclonal hyperplasia (“adenoma” or tertiary autonomous hyperparathyroidism)

A.

Transthyretin

B.

Fetuin (AHSG)

Any of the above

C.

Albumin

D.

Fibrinogen

D.

359 Cardiology

516

Which of the following is not a negative acute-phase reactant ?

Owing to increased PTH production from parathyroid cells, its cell mass increases progressively with CKD. Growth patterns may be diffuse hyperplasia (polyclonal), nodular growth (monoclonal) within diffuse hyperplasia or diffuse monoclonal hyperplasia (“adenoma” or tertiary autonomous hyperparathyroidism).

Fetuin (AHSG), a glycoprotein is synthesized by hepatocytes & is present in the circulation. It has the highest capacity of inhibiting soft tissue calcification.

511

517

Brown tumor relates best with ? Harrison’s 17th Ed. 1765

A.

Subcuteneous tissue

B.

Bone

C.

Brain

D.

Liver

Bone histology in hyperparathyroidism may show bone cysts, at times with hemorrhagic elements giving it brown color, hence the term brown tumor.

512

Adynamic bone disease can result from ? Harrison’s 17th Ed. 1765

A.

Use of vitamin D preparations

B.

Excessive calcium-containing phosphate binders

C.

High-calcium dialysis solutions

D.

All of the above

Adynamic bone disease is a state of reduced bone volume & mineralization. It results from excessive PTH suppression from the use of vitamin D preparations or from excessive calcium exposure in the form of calcium-containing phosphate binders or high-calcium dialysis solutions.

513

Calciphylaxis is best related to which drug ? Harrison’s 17th Ed. 1765

Harrison’s 17th Ed. 1767

A.

Low blood pressure

B.

Reduced body mass index

C.

Hypolipidemia

D.

All of the above

In late-stage CKD, low BP, reduced BMI & hypolipidemia indicate the presence of a malnutritioninflammation state, with poor prognosis.

518

In CKD patients with diabetes or proteinuria > 1 gram/day, blood pressure should be reduced to ? Harrison’s 17th Ed. 1767

A.

110 / 70 mm Hg

B.

125 / 75 mm Hg

C.

135 / 85 mm Hg

D.

140 / 90 mm Hg

In CKD patients with diabetes or proteinuria > 1 gram/day, BP should be reduced to 125/75 mm Hg. Renoprotective effect of antihypertensive medications is gauged by consequent reduction of proteinuria.

519

Pericardial effusion is a side effect of ?

A.

Aspirin

Harrison’s 17th Ed. 1767

B.

Statins

A.

Prazosin

C.

Warfarin

B.

Minoxidil

All of the above

C.

Eplerenone

D.

Labetalol

D.

Calciphylaxis (livedo reticularis & ischemic necrosis) is seen almost exclusively in advanced CKD due to vascular occlusion secondary to extensive vascular calcification. Warfarin therapy decreases vitamin K–dependent regeneration of matrix GLA protein which prevents vascular calcification.

514

Which of the following is associated with poor prognosis in late-stage CKD patients ?

Which of the following is a phosphate binder ? Harrison’s 17th Ed. 1766

A.

Calcium acetate

B.

Calcium carbonate

C.

Sevelamer

Side effects of minoxidil include hypertrichosis and pericardial effusion.

520

Normocytic, normochromic anemia is almost always present by which stage of CKD ? Harrison’s 17th Ed. 1767

A.

Stage 1

B.

Stage 2

C.

Stage 3

360

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

Stage 4

527

A.

Guttate morphea

Primary cause of anemia in patients with CKD is ?

B.

Scleromyxedema

Harrison’s 17th Ed. 1767

C.

Linear scleroderma

D.

Diffuse fasciitis with eosinophilia

A.

Insufficient erythropoietin (EPO)

B.

Iron deficiency

C.

Anemia of chronic disease

D.

Bone marrow fibrosis

Nephrogenic fibrosing dermopathy, seen in CKD, is a progressive subcutaneous induration on arms & legs similar to scleromyxedema.

528

Primary cause of anemia in patients with CKD is insufficient production of erythropoietin (EPO) by the diseased kidneys.

522

Nephrogenic fibrosing dermopathy is similar to ? Harrison’s 17th Ed. 1769

Normocytic, normochromic anemia is almost always present by stage 4 of CKD.

521

Which of the following can precipitate nephrogenic fibrosing dermopathy ? Harrison’s 17th Ed. 1769

Abnormal bleeding time and coagulopathy in renal failure may be reversed temporarily with ?

A.

Vitamin D

B.

Metformin

Harrison’s 17th Ed. 1768

C.

Aluminum

D.

Gadolinium

A.

Desmopressin (DDAVP)

B.

IV conjugated estrogens

C.

Erythropoietin (EPO) therapy

D.

All of the above

Exposure to magnetic resonance contrast agent, gadolinium may precipitate nephrogenic fibrosing dermopathy or nephrogenic systemic fibrosis (NSF) between 5 & 75 days following exposure.

529

CKD is likely if bilateral kidney size is ?

Abnormal BT & coagulopathy in renal failure may be reversed temporarily with DDAVP, cryoprecipitate, IV conjugated estrogens, blood transfusions & EPO.

Harrison’s 17th Ed. 1770

A.

< 8.5 cm

523

B.

< 9.0 cm

C.

< 9.5 cm

D.

< 10 cm

Peripheral neuropathy of CKD becomes clinically evident after which stage of CKD ? Harrison’s 17th Ed. 1768

A.

Stage 1

B.

Stage 2

Finding of bilaterally reduced kidney size (65 - 70%

549

555

During each hemodialysis, patient is exposed to approximately how much water as dialysate ?

What level of KT/V per treatment, defines minimal standards for adequacy among ESRD patients ?

Harrison’s 18th Ed. 2323

Harrison’s 18th Ed. 2324

A.

80 L

A.

0.8

B.

120 L

B.

1.0

C.

180 L

C.

1.2

D.

250 L

D.

1.4

Patients are exposed to ~120 liters of water during each dialysis treatment.

Current target is body water–indexed clearance x time product (KT/V) above 1.2.

550

556

Blood flow rate in the extracorporeal circuit in hemodialysis machine ranges from ?

For the majority of patients with ESRD, how many hours of dialysis is required each week ?

Harrison’s 18th Ed. 2323

Harrison’s 18th Ed. 2324

A.

50 to 100 mL/min

A.

3 to 9 hours

B.

100 to 200 mL/min

B.

9 to 12 hours

C.

250 to 500 mL/min

C.

12 to 24 hours

D.

500 to 750 mL/min

D.

24 to 36 hours

Blood flow rate in extracorporeal circuit in hemodialysis machine ranges from 250 - 500 mL/ minute.

For the majority of patients with ESRD, between 9 and 12 h of dialysis are required each week, usually divided into three equal sessions.

551

557

‘Breschia - Cimino fistula’ is used for ?

Harrison’s 18th Ed. 2324

A.

Dialysis access

A.

Infection

B.

Ventriculo-atrial shunt

B.

Hypotension

C.

Peritono-caval shunt

C.

Anemia

Peripheral arterial bypass

D.

Anaphylactoid reactions

D.

In Brescia-Cimino fistula, cephalic vein is anastomosed end-to-side to radial artery for dialysis access.

552

Most common acute complication of hemodialysis is ?

Harrison’s 18th Ed. 2323

Most common dialysis access-related complication is ?

Hypotension is the most common acute complication of hemodialysis, particularly among diabetics.

558

In dialysate, presence of which of the following is a common cause of hypotension ?

Harrison’s 18th Ed. 2324

Harrison’s 18th Ed. 2324

A.

Infection

A.

Acetate

B.

Thrombosis

B.

Bicarbonate

C.

Embolism

C.

Calcium

D.

Perforation

D.

Aluminium

Most important complication of AV grafts is thrombosis of the graft & graft failure, due to intimal hyperplasia at anastomosis between graft & recipient vein.

Because of the vasodilatory & cardiodepressive effects of acetate, its use as buffer in dialysate is a common cause of hypotension.

Nephrology 363 559

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

In the management of hypotension during dialysis, administration of which of the following is useful ?

561

562

Harrison’s 16th Ed. 1666

A.

100 to 250 mL of isotonic saline

A.

Continuous arteriovenous hemodiafiltration with dialysis

B.

10 mL of 23 % saturated hypertonic saline

B.

Continuous arteriovenous hemodiafiltration without dialysis

C.

Salt-poor albumin

C.

Continuous veno-venous hemodiafiltration with dialysis

D.

All of the above

D.

All of the above

567

Harrison’s 16th Ed. 1667

A.

Continuous ambulatory peritoneal dialysis (CAPD)

Harrison’s 18th Ed. 2324

B.

Continuous cyclic peritoneal dialysis (CCPD)

C.

Nocturnal intermittent peritoneal dialysis (NIPD)

D.

All of the above

A.

Careful evaluation of dry weight

B.

Withholding of antihypertensive medications

C.

Avoiding heavy meals during dialysis

D.

All of the above

568

Harrison’s 16th Ed. 1667

A.

Dialysis solution is manually infused into peritoneal cavity

Harrison’s 18th Ed. 2324

B.

Dialysis solution remains in peritoneal cavity through night

C.

Drainage of spent dialysate is performed manually

D.

None of the above

A.

Ultrafiltration modeling

B.

Midodrine

C.

Cooling of dialysate during dialysis treatment

D.

All of the above

569

Which of the following statements is false ? Harrison’s 16th Ed. 1667

Which of the following may prevent muscle cramps during hemodialysis ?

A.

In CCPD, exchanges are performed in automated fashion

B.

In CCPD, the last exchange remains in abdomen

Reducing volume removal during dialysis

C.

In NIPD, the abdomen is left dry during the day

B.

Use of higher concentrations of sodium in dialysate

D.

None of the above

C.

Quinine sulfate before treatment

D.

All of the above

570

Preferred buffer in peritoneal dialysis solution is ? Harrison’s 18th Ed. 2325

In peritoneal dialysis, how much dextrose-containing solution is infused in the peritoneal cavity ?

A.

Lactate

B.

Bicarbonate

Harrison’s 18th Ed. 2325

C.

Acetate

A.

1 to 3 L

D.

All of the above

B.

4 to 6 L

C.

6 to 8 L

D.

10 to 12 L

Lactate is the preferred buffer in peritoneal dialysis solutions.

571

Additive to peritoneal dialysis solutions may be ? Harrison’s 18th Ed. 2325

In peritoneal dialysis, for how many hours dextrose-containing solution is allowed to remain in the peritoneal cavity ? Harrison’s 18th Ed. 2325

A.

Heparin

B.

Antibiotics

C.

Insulin

D.

All of the above

A.

1 to 2 hours

B.

2 to 4 hours

C.

4 to 6 hours

Additives to peritoneal dialysis solutions are heparin, antibiotics and insulin.

D.

6 to 8 hours

572

In peritoneal dialysis, 1.5 - 3 liters of a dextrose-containing solution is infused into peritoneal cavity & allowed for 2 - 4 hours.

565

Which of the following is false for CAPD ?

Hypotension during dialysis can be prevented by ?

A.

564

Which of the following is a type of ‘Peritoneal dialysis’ ?

Hypotension during dialysis can be prevented by ?

Harrison’s 18th Ed. 2324

563

Continuous renal replacement therapy (CRRT) techniques include ?

Harrison’s 18th Ed. 2324

Hypotension during dialysis is managed with discontinuing ultrafiltration, 100 - 250 mL of isotonic saline or 10 mL of 23% saturated hypertonic saline, and administration of salt-poor albumin.

560

566

363 Cardiology

Which of the following is a complication of peritoneal dialysis ? Harrison’s 18th Ed. 2326

A.

Peritonitis

B.

Weight gain

Harrison’s 18th Ed. 2325

C.

Residual uremia

A.

Better tolerated hemodynamically

D.

All of the above

B.

Gradual correction of biochemical abnormalities

C.

Highly effective in removing fluid

D.

All of the above

Advantage of Continuous renal replacement therapy (CRRT) over intermittent hemodialysis in ARF is ?

Complications of PD are peritonitis, catheter-associated nonperitonitis infections, weight gain, metabolic disturbances and residual uremia.

364 573

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR What value of peritoneal fluid leukocyte count denotes peritonitis ?

Harrison’s 18th Ed. 2334

A.

10 / mm

3

A.

Crucin

B.

40 / mm3

B.

Optimin

C.

80 / mm

C.

Megalin

D.

100 / mm3

D.

Reglin

3

Most common culprit organism in peritonitis as a complication of peritoneal dialysis is ? Gram-positive cocci

A.

PROP-1

B.

Gram-positive bacilli

B.

NPHS1

C.

Gram-negative cocci

C.

PAX-8

D.

Gram-negative bacilli

D.

PIT-1

Congenital nephrotic syndrome occurs due to mutations in NPHS1 (nephrin) and NPHS2 (podocin).

581

Glomerulonephritis refers to inflammation of ?

Nonperitonitis catheter-associated infections are termed as ?

Harrison’s 18th Ed. 2335

Harrison’s 18th Ed. 2326

A.

Glomerular capillaries

A.

Funnel infections

B.

Glomerular arterioles

B.

Tunnel infections

C.

Glomerular basement membrane (GBM)

C.

Channel infections

D.

All of the above

D.

Chamber infections

Inflammation of the glomerular capillaries is called glomerulonephritis.

Which of the following statements is false ?

582

In glomerulonephritis, cytokines & proteases damage which of the following ?

Harrison’s 16th Ed. 1667

Harrison’s 18th Ed. 2335

A.

Acetate in PD solution can accelerate peritoneal sclerosis

A.

Mesangium

B.

Bicarbonate in PD solution can precipitate calcium

B.

Capillaries

C.

Bicarbonate in PD solution can caramelize glucose

C.

GBM

D.

None of the above

D.

All of the above

Chemokines attract neutrophils, macrophages & T cells into glomerular tuft. These react with antigens & epitopes producing more cytokines & proteases that damage mesangium, capillaries, and/or GBM.

583

Number of glomerular capillary tufts in the two human kidneys is about ? A.

0.6 million

B.

1.2 million

C.

1.8 million

D.

2.4 million

About 1.8 million glomerular capillary tufts are found in the two human kidneys.

Pores in the glomerular basement membrane (GBM) and slitpore membranes have a radius of ?

Which of the following is associated with immune deposits along the GBM ? Harrison’s 18th Ed. 2335

Harrison’s 18th Ed. 2334

578

Congenital nephrotic syndrome occurs due to mutations in ?

A.

Chapter 283. Glomerular Diseases 577

580

Harrison’s 18th Ed. 2335

Nonperitonitis catheter-associated infections are often termed tunnel infections.

576

4000 to 9000 mg/day of albumin is filtered and is reclaimed by megalin and cubilin receptors along the proximal tubule.

Harrison’s 18th Ed. 2326

Most common culprit organisms in peritonitis as a complication of peritoneal dialysis are gram-positive cocci.

575

Which of the following is instrumental in reclaiming filtered albumin along the proximal tubule ?

Harrison’s 18th Ed. 2326

Peritonitis is defined by a raised peritoneal fluid leukocyte count (100/mm 3, 50% are PMN).

574

579

Nephrology

A.

Poststreptococcal glomerulonephritis

B.

Lupus nephritis

C.

Idiopathic membranous nephritis

D.

All of the above

Poststreptococcal glomerulonephritis, lupus nephritis, and idiopathic membranous nephritis typically are associated with immune deposits along the GBM.

584

Persistent glomerulonephritis that worsens renal function is always accompanied by ? Harrison’s 18th Ed. 2335

Harrison’s 18th Ed. 2334

A.

Interstitial nephritis

A.

2 nm

B.

Renal fibrosis

B.

4 nm

C.

Tubular atrophy

C.

6 nm

D.

All of the above

D.

8 nm

Pores in the GBM and slit-pore membranes have a radius of 4 nm.

Persistent glomerulonephritis that worsens renal function is always accompanied by interstitial nephritis, renal fibrosis, and tubular atrophy.

Nephrology 365 585

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Renal failure in glomerulonephritis best correlates histologically with the appearance of ?

Harrison’s 18th Ed. 2337

A.

A.

Tubulointerstitial nephritis

B.

Proteinuria during fever, emotional stress

B.

Papillary necrosis

C.

Proteinuria in UTI

C.

Cystic kidney disease

D.

Proteinuria in upright posture

D.

All of the above

Cause of microscopic hematuria is ? A.

Interstitial nephritis

B.

Papillary necrosis

C.

Cystic kidney diseases

D.

All of the above

Microscopic hematuria may appear with the onset of benign prostatic hypertrophy, interstitial nephritis, papillary necrosis, renal stones, cystic kidney diseases, or renal vascular injury.

592

593

B.

< 100 mg/day

C.

< 150 mg/day

D.

< 300 mg/day

A.

Focal segmental glomerulosclerosis

B.

Mesangioproliferative glomerulonephritis

C.

IgA nephropathy

D.

Subacute bacterial endocarditis

Which of the following can present with gross hematuria ? Harrison’s 18th Ed. 2339 Table 283-2

Harrison’s 18th Ed. 2337 Table 283-1

< 30 mg/day

Which of the following can present with gross hematuria ? Harrison’s 18th Ed. 2339 Table 283-2

Normal 24-hour urine protein is ? A.

Proteinuria in females

Benign, functional or transient proteinuria occurs in normal population, nonsustained, and 50% crescents on renal biopsy, serum creatinine >5.7 mg/dL or a need for dialysis.

Out of the following, which is the most common form of glomerulonephritis ? Harrison’s 18th Ed. 2342

A.

IgA nephropathy

B.

Focal sclerosing glomerulonephritis

C.

Rapidly progressive/crescentic glomerulonephritis

D.

Membranous glomerulonephritis

IgA nephropathy is the most common form of glomerulonephritis worldwide.

634

IgA nephropathy is also called ? Harrison’s 18th Ed. 2342

Harrison’s 18th Ed. 2342

629

Positive “oil droplet sign” in Alport’s syndrome pertains to ?

A.

Barratt disease

B.

Berger disease

C.

Tomino disease

D.

Glassock disease

IgA nephropathy (Berger disease) is a primary glomerular disease. Berger first described it in 1968.

635

Which of the following is false about IgA nephropathy ? Harrison’s 18th Ed. 2342

Patients of Goodpasture’s syndrome respond to which of the following treatments ?

A.

Female preponderance

Harrison’s 18th Ed. 2342

B.

Peak incidence in II & III decades of life

A.

Plasmapheresis

C.

Recurrent episodes of macroscopic hematuria

B.

Oral prednisone

D.

Between episodes, urinalysis is normal

C.

Cyclophosphamide

D.

All of the above

Patients of Goodpasture’s syndrome respond to plasmapheresis, accompanied by oral prednisone and cyclophosphamide therapy.

In IgA nephropathy, there is a male preponderance.

636

IgA nephropathy resembles which of the following diseases ? Harrison’s 18th Ed. 2342

A.

Wegener’s granulomatosis

Nephrology 369

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

Goodpasture’s syndrome

C.

Henoch Schonlein purpura

D.

All of the above

D.

638

643

Harrison’s 18th Ed. 2344

A.

Hematuria

Harrison’s 17th Ed. 1788

B.

Proteinuria

A.

Lymph node

C.

Significant lung disease or destructive sinusitis

B.

Bone marrow

D.

Renal involvement

C.

Spleen

D.

Liver

In IgA nephropathy, deposition of IgA occurs in ? A.

Glomerular capillaries

B.

Glomerular mesangium

C.

Glomerular basement membrane

D.

All of the above

Morphologically, IgA nephropathy is characterized by diffuse deposition of IgA in glomerular mesangium.

Deposits of IgA in glomerular mesangium are found in ? Harrison’s 18th Ed. 2342

640

Patients of microscopic polyangiitis are similar to those with Wegener’s granulomatosis, except that they rarely have significant lung disease or destructive sinusitis.

644

A.

Pulmonary infiltrates

B.

Peripheral eosinophilia

C.

Glomerulonephritis

D.

All of the above

Churg-Strauss Syndrome is a small-vessel vasculitis associated with peripheral eosinophilia, cutaneous purpura, mononeuritis, asthma, allergic rhinitis, hypergammaglobulinemia, elevated serum IgE, and rheumatoid factor.

645

Mesangiocapillary glomerulonephritis glomerulonephritis is also called ?

A.

Leprosy

B.

Crohn’s disease

C.

Chronic liver disease

A.

Focal segmental glomerulosclerosis

D.

All of the above

B.

Membranous glomerulonephritis

C.

Membranoproliferative glomerulonephritis

D.

Mesangioproliferative glomerulonephritis

Deposits of IgA in glomerular mesangium are found in ? A.

Ankylosing spondylitis

B.

Idiopathic interstitial pneumonia

C.

Sjögren’s syndrome

D.

All of the above

Which of the following is an ANCA-positive, pauci-immune glomerulonephritis ? Harrison’s 18th Ed. 2343

or

Membranoproliferative glomerulonephritis (MPGN) is also called mesangiocapillary glomerulonephritis or lobar glomerulonephritis.

646

Type I Membranoproliferative glomerulonephritis (MPGN) is associated with ? Harrison’s 18th Ed. 2344

A.

Persistent hepatitis C infections

B.

Lupus

C.

Neoplastic diseases

D.

All of the above

Type I MPGN is commonly associated with persistent hepatitis C infections, autoimmune diseases like lupus or cryoglobulinemia, or neoplastic diseases.

A.

Wegener’s granulomatosis

B.

Microscopic polyangiitis

C.

Churg-Strauss syndrome

A.

Type I membranoproliferative glomerulonephritis

D.

All of the above

B.

Type II Membranoproliferative glomerulonephritis

C.

Type III Membranoproliferative glomerulonephritis

D.

None of the above

647

Harrison’s 18th Ed. 2343

A.

Wegener’s disease

B.

Wegener’s syndrome

C.

Isolated Wegener’s granulomatosis

Which of the following is called “dense deposit disease” ? Harrison’s 18th Ed. 2344

Anti-PR3 antibodies are more common in Wegener’s granulomatosis & anti-MPO antibodies are more common in microscopic polyangiitis or Churg-Strauss syndrome..

Wegener’s granulomatosis presenting without renal involvement is termed ?

lobar

Harrison’s 18th Ed. 2344

Deposits of IgA in glomerular mesangium are found in chronic liver disease, Crohn’s disease, gastrointestinal adenocarcinoma, chronic obstructive bronchiectasis, idiopathic interstitial pneumonia, dermatitis herpetiformis, mycosis fungoides, leprosy, ankylosing spondylitis, relapsing polychondritis, and Sjögren’s syndrome. However, IgA deposition does not produce clinically significant glomerular inflammation or renal dysfunction.

642

Which of the following distinguishes Churg-Strauss Syndrome from other small-vessel vasculitis ? Harrison’s 18th Ed. 2344

Harrison’s 18th Ed. 2342

641

In microscopic polyangiitis, which of the following is uncommon ?

Most IgA deposited in the kidney are derived from ?

Harrison’s 18th Ed. 2342

639

Limited Wegener’s granulomatosis

Presentation without renal involvement is termed limited Wegener’s granulomatosis.

Clinical and laboratory evidence suggests close similarities between Henoch-Schönlein purpura and IgA nephropathy.

637

369 Cardiology

Low serum C3 & dense thickening of GBM containing ribbons of dense deposits and C3 characterize Type II MPGN, also called dense deposit disease.

648

Mesangioproliferative glomerulonephritis is seen in ? Harrison’s 18th Ed. 2344

A.

IgA nephropathy

B.

P. falciparum malaria

370

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Resolving postinfectious glomerulonephritis

D.

All of the above

Mesangioproliferative glomerulonephritis is seen in IgA nephropathy, P. falciparum malaria, resolving postinfectious glomerulonephritis, and Class II lupus nephritis.

649

650

Relapses occur in 70 - 75% of children after the first remission, and early relapse predicts multiple subsequent relapses.

655

Pathologic changes of focal segmental glomerulosclerosis (FSGS) are most prominent in glomeruli located at ? Harrison’s 18th Ed. 2345

Minimal change disease (MCD) is also called ? Harrison’s 18th Ed. 2345

A.

Corticomedullary junction

A.

Nil disease

B.

Outer cortex

B.

Lipoid nephrosis

C.

Middle cortex

C.

Foot process disease

D.

All of the above

D.

All of the above

Minimal Change Disease (MCD) is associated with ?

Nephrology

Pathologic changes of FSGS are most prominent in glomeruli located at corticomedullary junction.

Harrison’s 18th Ed. 2345

656

What value of protein:creatinine ratio indicates nephrotic range proteinuria ?

A.

Hodgkin’s disease

Harrison’s 17th Ed. 1790

B.

Allergies

A.

> 100 - 150 mg/mmol

C.

Use of nonsteroidal anti-inflammatory agents

B.

> 200 - 250 mg/mmol

D.

All of the above

C.

> 250 - 300 mg/mmol

D.

> 300 - 350 mg/mmol

MCD usually presents as a primary renal disease but can be associated with Hodgkin’s disease, allergies, or use of NSAIDagents.

A protein:creatinine ratio value > 300 - 350 mg/mmol indicates nephrotic range proteinuria.

651

657

Minimal Change Disease (MCD) on electron microscopy of renal biopsy consistently shows ?

Harrison’s 18th Ed. 2345

Harrison’s 18th Ed. 2345

A.

Mesangial proliferation

B.

Mesangial interposition

C.

Effacement of the foot process

D.

All of the above

MCD on electron microscopy of renal biopsy consistently shows an effacement of the foot process supporting epithelial podocytes with weakening of slit-pore membranes.

652

Majority of children with nephrotic syndrome are due to ?

658

A.

Minimal change disease (MCD)

B.

Focal and segmental glomerulosclerosis (FSGS)

C.

Membranous glomerulopathy

D.

Membranoproliferative glomerulonephritis (MPGN)

Most common cause of nephrotic syndrome in the elderly is ? Harrison’s 18th Ed. 2347

Which of the following is false about minimal change disease ? Harrison’s 18th Ed. 2345

A.

Minimal Change Disease (MCD)

B.

Focal segmental glomerulosclerosis (FSGS)

Known as nil lesion

C.

Membranous glomerulonephritis (MGN)

B.

Commonest cause of nephrotic syndrome in adults

D.

Mesangioproliferative glomerulonephritis

C.

Acellular urinary sediment

D.

Selective proteinuria

A.

MCD causes 70 - 90% of nephrotic syndrome in childhood but only 10 - 15% of nephrotic syndrome in adults. In MCD, proteinuria is selective and largely composed of albumin.

Membranous glomerulonephritis (MGN) is the most common cause of nephrotic syndrome in the elderly. It is rare in childhood.

659

Most common cause of nephrotic syndrome in black patients is ? Korbet SM et al. Am J Kidney Dis 1996;27:647-51

653

MCD patients with steroid resistance can develop ? Harrison’s 18th Ed. 2345

A.

Focal segmental glomerulosclerosis (FSGS)

B.

Mesangioproliferative glomerulonephritis

C.

Microscopic polyangiitis

D.

Any of the above

MCD patients with steroid resistance can develop FSGS on repeat biopsy.

654

A.

Minimal Change Disease (MCD)

B.

Focal segmental glomerulosclerosis (FSGS)

C.

Membranous glomerulonephritis (MGN)

D.

Mesangioproliferative glomeru2 €phritis

Membranous nephropathy is the most common cause of nephrotic syndrome in white, while FSGS is the most common cause in black patients.

660

Membranous glomerulonephritis (MGN) can be secondary to ?

In MCD, relapses occur in what proportion of children after the first remission ?

Harrison’s 18th Ed. 2347

A.

Solid tumors of breast, lung, colon

Harrison’s 18th Ed. 2345

B.

Hepatitis B

C.

Malaria

D.

All of the above

A.

10 - 20 %

B.

30 - 40 %

C.

50 - 60 %

D.

70 - 75 %

MGN can be secondary to solid tumors of breast, lung, colon, hepatitis B, malaria, schistosomiasis, & lupus.

Nephrology 371 661

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following causes of nephrotic syndrome has the highest incidences of renal vein thrombosis, pulmonary embolism, and deep vein thrombosis ? Harrison’s 18th Ed. 2347

A.

Minimal change disease (MCD)

B.

Focal segmental glomerulosclerosis (FSGS)

C.

Membranous glomerulonephritis (MGN)

D.

Diabetic nephropathy

Thrombotic complications occur in nephrotic syndrome. MGN has the highest incidence of renal vein thrombosis, pulmonary embolism & deep vein thrombosis. Risk of venous thrombosis is higher when serum albumin is 30 mg

B.

> 150 mg

C.

> 300 mg

D.

> 500 mg

1 - 2 years

B.

3 - 4 years

C.

5 - 7 years

D.

7 - 9 years

Dipstick positive level of proteinuria is > 300 mg albuminuria.

669

In diabetes, renal functions unrelentingly decline after what level of proteinuria ?

In Types 1 or 2 diabetes, microalbuminuria appears how many years after the onset of diabetes ?

Harrison’s 17th Ed. 1792

A.

> 500 mg/day

Harrison’s 18th Ed. 2348

B.

> 1000 mg/day

C.

> 1500 mg/day

D.

> 2500 mg/day

A.

2-5

B.

5 - 10

C.

10 - 15

D.

15 - 20

670

Which of the following histopathological findings occur in diabetic kidneys ? A.

Thickening of GBM

B.

Expansion of mesangial matrix

C.

Nodular glomerulosclerosis

D.

All of the above

From the earliest stages of microalbuminuria, it takes how many years to reach end-stage renal disease (ESRD)? Harrison’s 18th Ed. 2348

A.

5 - 10 years

B.

10 - 20 years

C.

20 - 30 years

D.

> 30 years

After proteinuria level of >500 mg/day, renal function decline relentlessly. From the stage of microalbuminuria, it usually takes 10 - 20 years to reach ESRD.

671

Kimmelstiel-Wilson lesion relates best with which of the following histopathological findings in diabetic kidney ?

Renal vein thrombosis is common in patients with nephrotic syndrome due to ? Harrison’s 17th Ed. 1792

Harrison’s 18th Ed. 2348

A.

Membranous glomerulopathy

A.

Thickening of GBM

B.

Membranoproliferative glomerulonephritis

B.

Expansion of mesangial matrix

C.

Amyloidosis

C.

Nodular glomerulosclerosis

D.

All of the above

D.

Hyaline arteriosclerosis

672

Kimmelstiel-Wilson nodules or nodular glomerulosclerosis are eosinophilic, PAS + nodules.

666

< 150 mg/day

B.

Harrison’s 18th Ed. 2348

Harrison’s 18th Ed. 2348

665

A.

Albuminuria in the range of 30 - 300 mg/day is called microalbuminuria.

In Types 1 or 2 diabetes, microalbuminuria appears 5 - 10 years after its onset.

664

In microalbuminuria, the range of albuminuria is ?

Harrison’s 18th Ed. 2348

Within 1 - 2 years after the onset of clinical diabetes, morphologic changes appear in the kidney.

663

nephropathy have diabetic retinopathy while only 60% of Type 2 diabetics with nephropathy have diabetic retinopathy.

How many years after the onset of clinical diabetes, morphologic changes appear in kidneys ? A.

Harrison’s 18th Ed. 2348

Natural history of diabetic nephropathy

B.

Renal biopsy findings

C.

Onset of microalbuminuria

D.

Presence of diabetic retinopathy

Renal biopsies from patients with Types 1 and 2 diabetes are largely indistinguishable. Natural history of diabetic nephropathy in patients with Types 1 and 2 diabetes is similar. Microalbuminuria appears 5 - 10 years after the onset of Types 1 or 2 diabetes. >90% of Type 1 diabetics with

Clinical features that suggest acute renal vein thrombosis include all except ? Harrison’s 16th Ed. 1684

Which of the following is different between Types 1 & 2 diabetes ? A.

371 Cardiology

673

A.

Sudden onset of flank or abdominal pain

B.

Gross hematuria

C.

Right-sided varicocele

D.

Acute decline in GFR

Congo red stains are positive ? Harrison’s 18th Ed. 2349

A.

AA & AL amyloidosis

B.

Fibrillary-Immunotactoid Glomerulopathy

372

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Light chain deposition disease

D.

All of thr above

680

Nephrology

Which of the following statements about ‘Nail–patella syndrome’ is false ? N Engl J Med 2006;354:1387-401, Harrison’s 18th Ed. 2351

AA and AL amyloid fibrils are detectable with Congo red.

A.

It an autosomal dominant disease

674

Which of the following best relates to Fabry’s Disease ?

B.

Abnormal gene is located on long arm of chromosome 9

Harrison’s 18th Ed. 2349

C.

Multiple osseous abnormalities primarily affect elbows and knees, and nail dysplasia

D.

None of the above

A.

Glucosylceramide

B.

Galactosylceramide

C.

Globotriaosylceramide

D.

Ceramide

681

N Engl J Med 2006;354:1387-401, Harrison’s 18th Ed. 2351

Fabry disease is an X-linked inborn error of globotriaosylceramide metabolism that results from mutations in the  -galactosidase gene leading to excessive intracellular storage of globotriaosylceramide.

675

A.

Glomerular basement membrane is thickened with splitting and fibrillar collagen deposits

Clinical manifestations of Fabry’s disease include all except ?

B.

Caused by loss-of-function mutations in LMX1B

Harrison’s 18th Ed. 3191

C.

LMX1B is expressed in kidney primarily by podocytes

D.

None of the above

A.

Angiokeratomas

B.

Corneal and lenticular opacities

C.

Small-vessel disease of the kidney

D.

Macrocephaly

682

Angiokeratomas is a clinical feature of ? Harrison’s 18th Ed. 3193 Table 361-1

677

~ 3 months

B.

~ 6 months

C.

~ 1 year

D

~ 2.5 years

Fabry’s disease

HIV-associated nephropathy begins ~ 2.5 years after HIV infection.

B.

-Mannosidosis

683

C.

Fucosidosis

D.

All of the above

A.

In Fabry’s disease, angiokeratomas are most dense ? A.

Over nape of the neck

B.

Over finger tips

C.

Between umbilicus and knees

D.

Over forehead

684

Harrison’s 18th Ed. 2350

Fabry’s disease

B.

-Mannosidosis

C.

Fucosidosis

D.

All of the above

685

Harrison’s 18th Ed. 3191

B.

Acute diffuse proliferative glomerulonephritis

C.

IgA nephropathy

D.

Membranous glomerulopathy

Term HIV-associated nephropathy (HIVAN) is used for ? A.

Aggresive focal segmental glomerulosclerosis

B.

Acute diffuse proliferative glomerulonephritis

C.

IgA nephropathy

D.

Membranous glomerulopathy

Which of the following is false for HIV-associated nephropathy (HIVAN) ? Harrison’s 18th Ed. 2353

In Fabry’s disease, electron microscopy of renal biopsy shows enlarged glomerular visceral epithelial cells packed with vacuoles containing globotriaosylceramide in parallel arrays called zebra bodies.

In Fabry’s disease, neutral glycosphingolipids accumulate in which orgenelle of glomerular cells ?

Aggresive focal segmental glomerulosclerosis

Harrison’s 18th Ed. 2353

“Zebra bodies” is a histopathological hallmark of ? A.

HIV infection is most commonly associated with which of the following glomerulopathies ? Harrison’s 18th Ed. 2353

In Fabry’s disease, angiokeratomas are most dense between umbilicus and knees ”the bathing suit area” but may occur anywhere, including mucosal surfaces.

679

A.

A.

Harrison’s 18th Ed. 3191

678

After what duration does HIV-associated nephropathy begin ? Harrison’s 17th Ed. 1796

Clinically, Fabry’s disease manifests as angiokeratomas (telangiectatic skin lesions), hypohidrosis, corneal and lenticular opacities, acroparesthesia, and small-vessel disease of kidney, heart, & brain.

676

Which of the following statements about ‘Nail–patella syndrome’ is false ?

686

A.

May be the first manifestation of HIV infection

B.

More common in blacks

C.

More frequent in intravenous drug abusers

D.

Slow clinical course

HIV patients with FSGS present with nephrotic-range proteinuria & hypoalbuminemia but without ?

A.

Mitochondria

Harrison’s 18th Ed. 2353

B.

Golgi apparatus

A.

Hypertension

C.

Lysosome

B.

Edema

D.

Nucleus

C.

Hyperlipidemia

D.

All of the above

Nephrology 373

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

HIV patients with FSGS typically present with nephrotic-range proteinuria and hypoalbuminemia, but without hypertension, edema, or hyperlipidemia.

687

Which of the following is an inflammatory glomerulopathy ? Harrison’s 16th Ed. 1674

693

Crescentic glomerulonephritis

A.

Immune-complex glomerulonephritis

All of the above

B.

Anti-GBM disease

C.

Pauci-immune glomerulonephritis

D.

None of the above

Harrison’s 16th Ed. 1680

Which of the following is false about inflammatory glomerulopathy ? 696

Serologic markers that predict the immunofluorescence microscopy findings in nephritic syndrome and RPGN include ?

A.

Nephrotic-type

B.

RBC in urine

C.

RBC cast in urine

A.

Serum C3 level

D.

Leucocyte in urine

B.

Titers of anti-GBM antibody

C.

Titers of ANCA

D.

All of the above

Harrison’s 16th Ed. 1680

Nephrotic-range proteinuria can be found in all except ? A.

Membranous glomerulopathy

B.

Minimal change disease (MCD)

C.

Focal proliferative glomerulonephritis

A.

Normal complement levels

D.

Focal and segmental glomerulosclerosis (FSGS)

B.

Negative anti-GBM serology

C.

Negative ANCA serology

D.

All of the above

697

Which of the following cells of kidney do not proliferate ? A.

Mesangial cells

B.

Endothelial cells

C.

Visceral epithelial cells

D.

All of the above

698

Infiltrating monocytes

B.

Proliferating parietal epithelial cells

C.

Fibrin

D.

All of the above

Which of the following is true for ‘pauci-immune glomerulonephritis’ ? Harrison’s 16th Ed. 1680

‘Crescents’ are composed of ? A.

Which of the following is true for Henoch Schonlein purpura ? Harrison’s 16th Ed. 1680

699

A.

Absent circulating anti-GBM autoantibodies

B.

Normal serum complement levels

C.

Circulating ANCA present

D.

All of the above

Which of the following is a type of pauci-immune glomerulonephritis ? Harrison’s 16th Ed. 1683

A.

Idiopathic renal-limited crescentic glomerulonephritis

Intrarenal vasoconstrictors include all except ?

B.

Microscopic polyangiitis nodosa (PAN)

Harrison’s 16th Ed. 1678

C.

Wegener’s granulomatosis

D.

All of the above

A.

Leukotrienes

B.

Nitric oxide

C.

Thromboxanes

D.

Platelet-activating factor

700

Which of the following statements is false ? Harrison’s 16th Ed. 1684

A.

Glomerular proteinuria results from leakage of plasma proteins through a perturbed glomerular filtration barrier

B.

Tubular proteinuria results from failure of tubular reabsorption of low-molecular-weight plasma proteins

C.

Overflow proteinuria results from filtration of proteins, usually immunoglobulin light chains, that are present in excess in circulation

D.

None of the above

Intrarenal vasoconstrictors include all except ? Harrison’s 16th Ed. 1678

694

Which of the following is least common among patients with RPGN ?

C.

Harrison’s 16th Ed. 1678

692

None of the above

Diffuse proliferative glomerulonephritis

Harrison’s 16th Ed. 1678

691

Pauci-immune glomerulonephritis

D.

B.

Harrison’s 16th Ed. 1674

690

C.

Focal proliferative glomerulonephritis

Harrison’s 16th Ed. 1674

689

Anti-GBM disease

A.

D. 688

695

373 Cardiology

A.

Endothelins

B.

Prostacyclin

C.

Thromboxanes

D.

Platelet-activating factor

Which of the following is most common in ‘acute nephritic syndrome’ ?

701

Which of the following statements is false ?

Harrison’s 16th Ed. 1680

Harrison’s 16th Ed. 1684

A.

A.

Immune-complex glomerulonephritis

Proteinuria > 150 mg per 24 h is abnormal

374

702

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Tubular proteinuria never exceeds 2 gram per day

C.

Sulfosalicylic acid precipitation test detects both albumin and light chains

D.

None of the above

709

Harrison’s 16th Ed. 1691

703

1 to 2 months

B.

2 to 4 months

C.

4 to 6 months

D.

6 to 8 months

710

Harrison’s 16th Ed. 1691

704

Rapidly progressive glomerulonephritis

B.

Pauci-immune necrotizing glomerulonephritis

C.

Focal segmental glomerulosclerosis

D.

Membranous glomerulopathy

711

Harrison’s 16th Ed. 1691

705

Rapidly progressive glomerulonephritis

B.

Pauci-immune necrotizing glomerulonephritis

C.

Focal segmental glomerulosclerosis

D.

Membranous glomerulopathy

712

Harrison’s 16th Ed. 1691

706

Rapidly progressive glomerulonephritis

B.

Pauci-immune necrotizing glomerulonephritis

C.

Focal segmental glomerulosclerosis

D.

Membranous glomerulopathy

MPGN

C.

IgA nephropathy

D.

Essential mixed cryoglobulinemia

HCV-induced immune-complex disease is associated with which of the following ? A.

Cryoglobulinemic proliferative glomerulonephritis

B.

MPGN

C.

Membranous glomerulopathy

D.

All of the above

Which of the following glomerulopathies is most commonly associated with Hodgkin’s lymphoma ? A.

FSGS

B.

MCD

C.

MPGN

D.

Membranous glomerulopathy

Amyloidosis is more frequent in patients of rheumatoid arthritis with ? Harrison’s 16th Ed. 1694

Morphologic lesion in rifampin induced glomerular disease is ? A.

Membranous glomerulopathy

B.

Harrison’s 18th Ed. 2345

Morphologic lesion in ciprofloxacin induced glomerular disease is ? A.

A.

Harrison’s 16th Ed. 1693

Renal biopsy typically reveals which of the following in patients with proteinuria following gold therapy ? A.

Which out of the following is the most common glomerular lesion associated with HBV infection ? Harrison’s 16th Ed. 1692

Proteinuria develops after what duration of gold therapy ? A.

Nephrology

A.

Long duration (> 10 years)

B.

Circulating rheumatoid factor

C.

Destructive arthropathy

D.

All of the above

Chapter 284. Polycystic Kidney Disease and Other Inherited Tubular Disorders

Morphologic lesion in warfarin induced glomerular disease is ? Harrison’s 16th Ed. 1691

707

708

A.

Rapidly progressive glomerulonephritis

B.

Pauci-immune necrotizing glomerulonephritis

C.

Focal segmental glomerulosclerosis

D.

Membranous glomerulopathy

713

Which of the following statements is false about polycystic kidney disease ? Harrison’s 18th Ed. 2355

A.

ADPKD is seen predominantly in childhood

B.

ARPKD is mainly a disease of adults

Morphologic lesion in thiazide induced glomerular disease is ?

C.

They infrequently cause kidney failure

Harrison’s 16th Ed. 1691

D.

All of the above

A.

Rapidly progressive glomerulonephritis

B.

Pauci-immune necrotizing glomerulonephritis

C.

Focal segmental glomerulosclerosis

D.

Proliferative glomerulonephritis with vasculitis

Glomerular lesion associated with HBV infection include ? Harrison’s 16th Ed. 1692

A.

Membranous glomerulopathy

B.

MPGN

C.

IgA nephropathy

D.

All of the above

Autosomal dominant polycystic kidney disease (ADPKD) is seen predominantly in adults, whereas autosomal recessive polycystic kidney disease (ARPKD) is mainly a disease of childhood. They frequently causes kidney failure.

714

Which of the following statements about ‘Autosomal dominant polycystic kidney disease (ADPKD)’ is false ? Harrison’s 17th Ed. 1797

A.

ADPKD-1 gene is on chromosome 16p13.3

B.

ADPKD-2 gene is on chromosome 4q21-23

C.

Cysts are distributed throughout cortex & medulla

D.

Erythropoietin production is low

Nephrology 375 715

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following statements about ‘Autosomal dominant polycystic kidney disease (ADPKD)’ is false ?

722

A.

>=1

A.

Standard diagnostic criteria is at least 3 to 5 cysts in each kidney

B.

>=2

B.

Cysts may be found in brain, thyroid

C.

>=3

C.

Mitral valve prolapse found in 25% of patients

D.

>=4

D.

Intracranial aneurysms present in 5 to 10 % of patients

Which of the following is a PKD-1 encoded protein ? Harrison’s 18th Ed. 2355

A.

Fibrocystin

B.

Polycystin-1

C.

Caveolin 3

D.

FMR-1 protein

Diagnostic criteria for ADPKD require two or more cysts in one kidney and at least one cyst in contralateral kidney in young subjects, but four or more in subjects older than 60 years.

723

In ADPKD, cyst formation begins ? Harrison’s 18th Ed. 2355

ARPKD-2

C.

PKHD1

D.

PKHD2

In utero In early childhood

C.

In adoloscence

A.

Nephrocystin

D.

In adulthood

B.

Inversin

C.

Fibrocystin

D.

Polycystin-3

724

Protein expressed by PKHD1 is termed ? Harrison’s 18th Ed. 2358

What percentage of total nephrons are involved in ADPKD ?

Protein expressed by PKHD1 is termed fibrocystin (polyductin).

A.

=3 in one & 2 cysts in other kidney

Nephronophthisis (NPHP) is the most common genetic cause of ESRD in childhood & adolescence.

376 728

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Senior-Loken syndrome, besides juvenile nephronophthisis, best relates to ?

734

729

A.

NKCC2

A.

Intracranial aneurysm

B.

ROMK

B.

Retinitis pigmentosa

C.

Barttin

C.

Colonic diverticulae

D.

All of the above

D.

All of the above

Presence of hyperuricemia and gout point towards the diagnosis of which of the following ?

Bartter’s syndrome is the result of mutations in ion transport proteins in TAL. Type 1 is due to apical loop-diuretic sensitive sodium-potassium-chloride co-transporter protein NKCC2, type 2 is due to apical potassium channel ROMK, type 3 is due to basolateral chloride channel ClC-Kb and Bartter type 4 results from mutations in barttin, an essential subunit of ClC-Ka and ClC-Kb that enables transport of the chloride channels to the cell surface.

Harrison’s 18th Ed. 2359

Which of the following electrical situations occur in Bartter’s syndrome ?

A.

Autosomal recessive polycystic kidney disease

Harrison’s 18th Ed. 2360

B.

Medullary cystic kidney disease 2

A.

Loss of lumen-positive electrical transport potential

C.

Bartter’s syndrome

B.

Loss of lumen-negative electrical transport potential

Nephronophthisis (NPHP)

C.

Loss of cell-positive electrical transport potential

D.

Loss of cell-negative electrical transport potential

D.

Most patients with medullary cystic kidney disease 2 (MCKD2) have severe hyperuricemia and precocious onset of gout.

730

Protein affected in Bartter’s syndrome is ? Harrison’s 18th Ed. 2360

Harrison’s 18th Ed. 2359

When juvenile NPHP has retinitis pigmentosa as an extrarenal manifestation, the syndrome is called Senior-Loken syndrome.

Nephrology

Renal tuberous sclerosis (TS) may occur in which of the following forms ? Harrison’s 18th Ed. 2360

A.

Renal cysts

B.

Renal angiomyolipomas

C.

Renal cell carcinoma

D.

All of the above

735

In Bartter’s syndrome, loss of lumen-positive electrical transport potential that normally drives paracellular reabsorption of sodium, calcium & magnesium causes NaCl wasting, hypercalciuria & mild hypomagnesemia.

736

Gitelman’s syndrome is due to mutations in ? Harrison’s 18th Ed. 2361

Renal TS occurs as renal cysts, renal angiomyolipomas & renal cell carcinoma.

A.

Apical loop-diuretic sensitive Na-K-Cl co-transporter

B.

Apical potassium channel

C.

Thiazide-sensitive Na-Cl co-transporter (NCCT)

D.

Basolateral chloride channel ClC-Kb

Gitelman’s syndrome is due to mutations in thiazide-sensitive Na-Cl co-transporter (NCCT) in DCT.

731

Deafness is invariably associated with which type of Bartter’s syndrome ?

737

Harrison’s 18th Ed. 2360

A.

Type 1

B.

Type 2

C.

Type 3

D.

Type 4

Gitelman’s syndrome is distinguished from Bartter’s syndrome by ? Harrison’s 18th Ed. 2361

A.

Hypokalemia

B.

Metabolic alkalosis

C.

Elevated renin and aldosterone levels

D.

Hypomagnesemia

Bartter type 4 is due to mutations in barttin which is also expressed in inner ear. Deafness is invariably associated with Bartter type 4.

Severe magnesium wasting occurs in Gitelman’s syndrome.

732

738

Which of the following is false for Bartter’s syndrome ? Harrison’s 18th Ed. 2360

A.

Inherited as autosomal recessive trait

B.

Due to abnormality in renal tubule transport proteins

A.

Hypokalemia

C.

Prostaglandin E production is low

B.

Metabolic alkalosis

D.

Metabolic abnormalities similar to diuretic abuse

C.

Elevated renin and aldosterone levels

D.

Hypocalciuria

In Bartter’s syndrome, RAS activation causes increased levels of cyclooxygenase 2 (COX-2) & marked overproduction of renal prostaglandins (PGE2).

733

Gitelman’s syndrome is distinguished from Bartter’s syndrome by ?

Hyperprostaglandin E syndrome is related to ?

Harrison’s 18th Ed. 2361

Gitelman’s syndrome is distinguished from Bartter’s syndrome by presence of severe hypomagnesemia & hypocalciuria. Hypercalciuria marked overproduction of renal prostaglandins (PGE2) occurs in Bartter’s syndrome.

Harrison’s 18th Ed. 2360

A.

Bartter’s syndrome

B.

Gitelman’s syndrome

C.

Liddle’s syndrome

D.

All of the above

Hyperprostaglandin E syndrome is a severe form of Bartter’s syndrome. Neonates present with pronounced volume depletion, fever, vomiting and diarrhea from PGE2 overproduction.

739

Carpopedal spasm, cramps & tetany are clinical features of ? Harrison’s 18th Ed. 2361

A.

Bartter’s syndrome

B.

Gitelman’s syndrome

C.

Liddle’s syndrome

D.

Von Hippel-Lindau Disease

Nephrology 377

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Gitelman’s syndrome is characterized by hypocalciuria, severe hypomagnesemia resulting in carpopedal spasm, cramps and tetany. Autosomal recessive familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC), autosomal recessive hypomagnesemia with secondary hypocalcemia (HSH), autosomal dominant hypomagnesemia, and autosomal dominant hypoparathyroidism can also produce such presentation.

740

741

746

Harrison’s 18th Ed. 2363

High plasma levels of vasopressin

B.

Hyponatremia

Harrison’s 18th Ed. 2363

C.

Polyuria

A.

Unregulated sodium reabsorption

D.

Seizures & mental retardation

B.

Overactive ENaC in cortical collecting duct

C.

Chloride-independent sodium reabsorption

D.

All of the above

Which of the following best relate to Liddle’s syndrome ?

Hereditary nephrogenic diabetes insipidus (NDI) presents in infancy with severe vasopressinresistant polyuria, dehydration, failure to thrive, and dilute urine despite the presence of hypernatremia.

747

Hypertension

B.

Hypokalemia

C.

High aldosterone levels

D.

Metabolic alkalosis

748

Liddle’s syndrome mimics a state of aldosterone excess. Features include early and severe hypertension, hypokalemia & metabolic alkalosis. Plasma aldosterone & renin levels are low.

744

1

B.

2

C.

3

D.

4

Serum anion gap is normal in which of the following renal tubular acidosis (RTA) type ? A.

1

B.

2

Harrison’s 18th Ed. 2363

C.

4

A.

Spironolactone

D.

All of the above

B.

Amiloride

C.

Triamterene

D.

All of the above

Which of the following drug is ineffective in treatment of Liddle’s syndrome ?

Inherited renal tubular acidosis presents as nonanion gap (hyperchloremic) metabolic acidosis from proximal tubular bicarbonate wasting or impaired distal net acid excretion.

749

Hereditary diseases that cause type 1 RTA include ? Harrison’s 16th Ed. 1699

A.

Ehler-Danlos syndrome

B.

Fabry’s disease

Harrison’s 18th Ed. 2361

C.

Wilson’s disease

A.

ADPKD

D.

All of the above

B.

Medullary cystic kidney disease (MCKD)

C.

Bartter’s Syndrome

Harrison’s 16th Ed. 1699

D.

Gitelman’s syndrome

A.

Sjogren’s syndrome

B.

Chronic active hepatitis

C.

Lupus

D.

All of the above

Polyuria is a prominent feature of all except ?

750

During antenatal period, fetal polyuria causes maternal polyhydramnios and premature labor in ? Harrison’s 18th Ed. 2361

Systemic disorder that cause type 1 RTA include ?

A.

ADPKD

B.

Medullary cystic kidney disease (MCKD)

C.

Bartter’s syndrome

Harrison’s 18th Ed. 2364

D.

Gitelman’s syndrome

A.

Wilson’s disease

B.

Cystinosis

C.

Glycogen storage disease type I

D.

All of the above

751

In antenatal period, fetal polyuria may cause maternal polyhydramnios & premature labor in Bartter’s syndrome.

745

A.

Harrison’s 18th Ed. 2363

Amiloride or triamterene block ENaC and, combined with salt restriction, provide effective therapy for hypertension and hypokalemia.

743

Which of the following renal tubular acidosis type is rare ? Harrison’s 18th Ed. 2363

Which of the following is false for Liddle’s syndrome ? Harrison’s 18th Ed. 2363

742

Which of the following is false about hereditary nephrogenic diabetes insipidus (NDI) ? A.

A.

ENaC best relates to ? Harrison’s 18th Ed. 2362 Table 284-3

A.

Amiloride-sensitive epithelial sodium channel

B.

Thiazide-sensitive Na-Cl co-transporter

C.

Na-K-2Cl co-transporter

D.

Sodium-bicarbonate co-transporter

ENaC is an amiloride-sensitive epithelial sodium channel.

377 Cardiology

Which of the following inherited disorders produce Type 2 (Proximal) RTA ?

Inherited disorders that produce Type 2 (Proximal) RTA are Wilson’s disease, cystinosis, tyrosinemia, galactosemia, hereditary fructose intolerance, glycogen storage disease type I, and Lowe’s syndrome.

752

Serum potassium is high in which of the following RTA ? Harrison’s 18th Ed. 2364

A.

1

B.

2

378

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

4

D.

All of the above

759

Drug-induced type 4 RTA is due to which of the following drugs ? Harrison’s 17th Ed. 1805

754

756

B.

Cystine

C.

Calcium oxalate

D.

Calcium phosphate

Increased proximal citrate absorption leads to hypocitraturia and together with hypercalciuria predisposes to nephrocalcinosis & calcium phosphate stone formation.

B.

ACE inhibitors

C.

Heparin

Harrison’s 18th Ed. 2364

D.

All of the above

A.

0.2 - 1 mmol/kg/day

B.

1 - 3 mmol/kg/day

C.

3 - 5 mmol/kg/day

D.

5 - 10 mmol/kg/day

760

Which of the following statements is false ? A.

Type 1 RTA is due to impaired H ion secretion or HCO3 reabsorption in distal nephron

B.

Type 2 RTA is due to impaired HCO3- reabsorption in proximal tubule

C.

Type 1 RTA may present as “marble-brain disease”

D.

None of the above

+

-

Bicarbonate replacement dose in Type 1 (Distal) RTA is ?

In Type 1 (Distal) RTA, bicarbonate replacement dose is 1 - 3 mmol/kg/day in divided doses. While, in Type 2 (proximal) RTA the dose is 5 - 15 mmol/kg/day along with supplemental potassium & vitamin D.

761

Renal glucosuria is due to mutations in which gene ? Harrison’s 18th Ed. 2364

A.

SLC6A19

Marble-brain disease consists of ?

B.

SLC5A2

Harrison’s 18th Ed. 2364

C.

SLC3A1

D.

SLC7A9

A.

Osteopetrosis

B.

Short stature

C.

Mental retardation

D.

All of the above

Renal isolated glucosuria with normal blood glucose concentration is due to mutations in SLC5A2 gene that encodes sodium-glucose co-transporter SGLT2 in the proximal renal tubule.

762

Low-molecular-weight proteinuria is a feature of ?

Marble-brain disease is due to mutations in ?

Harrison’s 18th Ed. 2365

Harrison’s 18th Ed. 2364

A.

Renal glucosuria

A.

CA2

B.

Hartnup Disease

B.

SLC3A1

C.

Cystinuria

C.

SLC6A19

D.

Dent’s disease

D.

CLCN5

Low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis and nephrolithiasis are features of Dent’s disease.

763

Cerebellar ataxia & pellagra-like skin lesions are a feature of ?

Which of the following is not a feature of Type 1 (Distal) RTA ?

Harrison’s 18th Ed. 2365

Harrison’s 18th Ed. 2364

A.

Renal glucosuria

A.

Hypokalemia

B.

Hartnup Disease

B.

Hypocitraturia

C.

Cystinuria

C.

Hypocalciuria

D.

Dent’s disease

D.

Rickets or osteomalacia

Type 1 (Distal) RTA presents as hypokalemia, hypocitraturia, hypercalciuria, nephrocalcinosis, nephrolithiasis. Chronic untreated acidosis may lead to rickets or osteomalacia.

758

Uric acid

NSAIDs

Marble-brain disease consists of osteopetrosis, short stature, and mental retardation with dRTA. It is due to mutations in CA2 (carbonic anhydrase II).

757

A.

A.

Harrison’s 18th Ed. 2364

755

Which of the following stone is formed in Type 1 (Distal) RTA ? Harrison’s 18th Ed. 2364

Type 4 RTA is acquired in association with moderate renal dysfunction & is characterized by hyperkalemia.

753

Nephrology

In Hartnup disease, tryptophan is retained in intestinal lumen & converted to indole compounds that are toxic to CNS. Consequent niacin deficiency leads to skin manifestations.

In Type 1 (Distal) RTA, patients fail to acidify urine to pH ?

Inherited systemic disorders associated with Fanconi syndrome include ?

Harrison’s 18th Ed. 2364

Harrison’s 18th Ed. 2365

A.

< 5.5

A.

Wilson’s disease

B.

< 6.5

B.

Galactosemia

C.

< 7.0

C.

Tyrosinemia

D.

< 7.5

D.

All of the above

In Type 1 (Distal) RTA, patients fail to acidify urine to pH 160/100 mm Hg) after 50 years of age, absence of family history of HTN, HTN with renal insufficiency, renal function worsens after administration of renin–angiotensin–aldosterone system blocker, HTN with repeated hospital admissions for heart failure, and drug-resistant hypertension.

775

Which of the following diagnostic imaging tests for renalartery stenosis provide best image quality & anatomical information ? N Engl J Med 2009;361:1972-8

Chapter 286. Vascular Injury to the Kidney 770

The clinical clues for the diagnosis of renal-artery stenosis include all except ?

Which of the following threaten blood supply of the kidney ?

A.

Duplex ultrasonography

B.

Magnetic resonance angiography

C.

Computed tomographic angiography

D.

Digital-subtraction angiography

Harrison’s 18th Ed. 2375

A.

Fibromuscular diseases

B.

Inflammatory disorders

C.

Primary hematologic disorders

D.

All of the above

776

Which of the following is termed as renal enzyme ? Harrison’s 17th Ed. 1811

A.

Serum aspartate aminotransferase (AST)

B.

Serum lactate dehydrogenase (LDH)

380

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Serum alkaline phosphatase

B.

Hemolytic uremic syndrome (HUS)

D.

All of the above

C.

Thrombotic thrombocytopenic purpura (TTP)

D.

All of the above

Renal enzymes elevated in renal infarction are aspartate aminotransferase (AST), lactate dehydrogenase (LDH), and alkaline phosphatase.

777

Most common cause of cholesterol crystal embolization in atheroembolic renal disease is ?

Flea-bitten appearance of kidneys is due to hemorrhages in surface capillaries.

783

A.

Vascular surgery

B.

Arteriography

C.

Anticoagulation with heparin

D.

Thrombolytic therapy

Arteriographic procedures are the most common cause of cholesterol crystal embolization in atheroembolic renal disease.

784

B.

Involves interlobular arteries

C.

Hyperplastic arteriolitis

D.

None of the above

In the natural course of malignant hypertension, death is almost always due to ? CHF

Harrison’s 17th Ed. 1812

B.

Ischemic heart disease

A.

Livedo reticularis

C.

Cerebrovascular accident

B.

“Purple” toes

D.

Uremia

C.

Toe gangrene

D.

Renal infarction

Malignant hypertension is a medical emergency. Its natural course includes a death rate of 80 - 90% within 1 year of onset, almost always due to uremia.

785

Lab. findings in cholesterol crystal embolization in atheroembolic renal disease include all except ? A.

Rising blood urea nitrogen & creatinine

B.

Eosinopenia

C.

Anemia

D.

Hypocomplementemia

Lab. findings in cholesterol crystal embolization in atheroembolic renal disease include rising BUN & creatinine, eosinophilia, eosinophiluria, leukocytosis, elevated ESR, anemia & hypocomplementemia.

Which of the following antibodies are strongly associated with scleroderma renal disease ? Harrison’s 17th Ed. 1814

A.

P-ANCA

B.

Smooth-muscle antibody (SMA)

C.

anti-Jo-1 antibody

D.

Anti-RNA POL3

Anti-RNA POL3 antibodies are strongly associated with scleroderma renal disease

786

Scleroderma renal crisis (SRC) includes ? Harrison’s 17th Ed. 1814

Which of the following approaches in atheroembolic renal disease is not beneficial ?

A.

Malignant hypertension

B.

Rapid deterioration in renal function

Harrison’s 17th Ed. 1812

C.

Microangiopathic hemolytic anemia

A.

Anticoagulation

D.

All of the above

B.

Cholesterol-lowering agents

C.

Steroid therapy

D.

All of the above

SRC is a rapid deterioration in renal function, usually accompanied by malignant hypertension, oliguria, proteinuria, fluid retention, microangiopathic hemolytic anemia, and CNS involvement.

787

Acute bilateral cortical necrosis is associated with ? Harrison’s 17th Ed. 1815

Withdrawal of anticoagulation may be beneficial.

781

Seen in malignant arteriolar nephrosclerosis

A.

Harrison’s 17th Ed. 1812

780

A.

Harrison’s 17th Ed. 1813

Which of the following is rare in cholesterol crystal embolization in atheroembolic renal disease ?

Renal infarction secondary to cholesterol embolization is rare.

779

Which of the following is false regarding “onion-skin lesion” ? Harrison’s 17th Ed. 1813

Harrison’s 17th Ed. 1812

778

A.

Septic abortion

B.

Abruptio placentae

Harrison’s 17th Ed. 1813

C.

Preeclampsia

A.

Afferent arterioles

D.

All of the above

B.

Capillaries

C.

Efferent arterioles

D.

All of the above

In ‘Benign arteriolar nephrosclerosis’ the characteristic pathology ‘Hyaline arteriolosclerosis’ is in ?

Acute bilateral cortical necrosis is associated with septic abortions, abruptio placentae & preeclampsia.

Chapter 287. Nephrolithiasis

Characteristic pathology of arteriolar nephrosclerosis is in afferent arterioles that have thickened walls & narrowing of vascular lumen due to deposition of homogeneous eosinophilic material (hyaline arteriolosclerosis) resulting in ischemic injury to glomeruli & tubules.

782

Nephrology

‘Flea-bitten appearance’ of kidneys is seen in ? Harrison’s 17th Ed. 1813

A.

Malignant arteriolar nephrosclerosis

788

The element in ‘Struvite’ is ? Harrison’s 17th Ed. 1815

A.

Calcium

Nephrology 381

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

Aluminium

B.

Multiple medullary calcifications

C.

Magnesium

C.

Multiple papillary calcifications

D.

Zinc

D.

Any of the above

The chemical formula of struvite is MgNH4PO4

Multiple papillary calcifications are called nephrocalcinosis.

789

796

Causes of ‘Hypercalciuria’ include all except ? Harrison’s 17th Ed. 1816 Table 281-1

Infection due to bacteria that possess enzyme urease can cause stones composed of ?

A.

Hypothyroidism

Harrison’s 17th Ed. 1817

B.

Cushing syndrome

A.

Calcium

C.

Sarcoidosis

B.

Cystine

Immobilization

C.

Struvite

D.

Uric acid

D. 790

Causes of ‘Hypercalciuria’ include ? Harrison’s 17th Ed. 1816 Table 281-1

A.

Vitamin D intoxication

B.

Rapidly progressive bone disease

C.

Paget’s disease

D.

All of the above

Infection due to bacteria that possess the enzyme urease can cause stones composed of struvite

797

Which of the following is false about ‘Struvite stones’ ? Harrison’s 17th Ed. 1816

798

Calcium content

C.

Zinc content

D.

Magnesium content

Urine may appear ‘milky’ due to which of the following ?

B.

Occur in patients with chronic bladder catheterization

A.

Uric acid crystals

C.

Due to UTI with urease-producing bacteria

B.

Cystine crystals

D.

May grow to produce a “staghorn” appearance

C.

Calcium oxalate crystals

D.

Calcium phosphate crystals

Basic constituents of most kidney stones include all except ? A.

Alumina

B.

Uric acid

C.

Cystine

D.

Struvite

Chapter 288. Urinary Tract Infections, Pyelonephritis, and Prostatitis 799

A.

Calcium

B.

Uric acid

C.

Cystine

D.

Struvite

Which of the following stone is radiolucent ?

Which of the following is not included in “Acute infections of upper urinary tract” ? Harrison’s 17th Ed. 1820

Urine crystals that are rectangular prisms and resemble ‘coffin lids’ are of ?

Harrison’s 17th Ed. 1816

A.

Cystitis

B.

Pyelonephritis

C.

Prostatitis

D.

Perinephric abscess

Acute urinary tract infections are either lower tract (urethritis & cystitis) or upper tract (acute pyelonephritis, prostatitis & intrarenal & perinephric abscesses) infection.

800

How many colony counts per mL grown from a properly collected midstream “clean-catch” urine sample indicates infection ?

A.

Calcium

B.

Cystine

A.

> 102

C.

Struvite

B.

> 103

D.

Uric acid

C.

> 104

D.

> 105

Calcium, cystine & struvite stones are radiopaque on standard x-rays. Uric acid stones are radiolucent.

795

B.

Harrison’s 16th Ed. 1711

Harrison’s 16th Ed. 1710

794

Sulfur content

Occur mainly in men

Harrison’s 16th Ed. 1710

793

A.

A.

Struvite stones occur mainly in women.

792

Radiopacity of Cystine stones is due to ? Harrison’s 16th Ed. 1710

Hyperthyroidism, Cushing syndrome, sarcoidosis, malignant tumors, immobilization, vitamin D intoxication, rapidly progressive bone disease, and Paget’s disease cause hypercalciuria.

791

381 Cardiology

Nephrocalcinosis best relates to ? Harrison’s 17th Ed. 1816

A.

Multiple cortical calcifications

Harrison’s 17th Ed. 1820

In UTI, a growth of >=105 organisms per milliliter from a properly collected midstream “clean-catch” urine sample indicates infection. In urine specimens obtained with indwelling catheter, colony counts of 102–104/mL indicates infection.

382 801

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR “Same-strain” recurrent infection evident within 2 weeks of cessation of therapy is due to ?

807

Nephrology

E. coli strains causing symptomatic UTIs in noncatheterized patients belong which of the following serogroups ?

Harrison’s 16th Ed. 1715

Harrison’s 17th Ed. 1822

A.

Unresolved renal or prostatic infection

A.

O

B.

Persistent vaginal infection

B.

K

C.

Persistent intestinal infection

C.

H

D.

All of the above

D.

Any of the above

“Same-strain” recurrent infections appearing within 2 weeks of cessation of therapy can be due to unresolved renal or prostatic infection (relapse) or of persistent vaginal or intestinal colonization.

Most E. coli strains that cause symptomatic UTIs in noncatheterized patients belong to a small

802

808

Symptom related to acute urethral syndrome is ? Harrison’s 17th Ed. 1820

Which of the following property of uropathogenic E.coli facilitates its infectivity ?

A.

Dysuria

Harrison’s 17th Ed. 1822

B.

Urgency

A.

Fimbriae

C.

Frequency

B.

Production of hemolysin

All of the above

C.

Production of aerobactin

D.

All of the above

D. 803

number of specific O, K, and H serogroups.

Which of the following is true for ‘acute urethral syndrome’ ? Harrison’s 17th Ed. 1820

A.

Insignificant bacteriuria

B.

Dysuria

C.

Urgency

D.

All of the above

Besides fimbriae, uropathogenic E. coli strains produce cytotoxins, hemolysin and aerobactin and are resistant to the bactericidal action of human serum.

809

Harrison’s 17th Ed. 1822

Symptoms of dysuria, urgency and frequency unaccompanied by significant bacteriuria is termed acute urethral syndrome.

804

Vaginal introitus & distal urethra are normally colonized by all except ? Harrison’s 17th Ed. 1821

A.

Renal angle tenderness

B.

Leukocyte casts in urine

C.

Hematuria

D.

All of the above

In the urine of acute pyelonephritis patients, leukocyte casts are pathognomonic.

A.

Streptococcal species

B.

Lactobacilli

C.

Staphylococcal species

Harrison’s 17th Ed. 1823

D.

Escherichia coli

A.

C. trachomatis

B.

U. urealyticum

810

Vaginal introitus & distal urethra are normally colonized by diphtheroids, streptococcal species, lactobacilli & staphylococcal species but not by enteric gram-negative bacilli that commonly cause UTIs.

805

Which of the following is pathognomonic for ‘Acute Pyelonephritis’ ?

Which of the following contributes to the ‘antibacterial properties of urine’ ?

Pyuria in the absence of bacteriuria (sterile pyuria) indicates infection with ?

C.

Mycobacterium tuberculosis

D.

All of the above

Pyuria in the absence of bacteriuria (sterile pyuria) may indicate infection with C. trachomatis, U. urealyticum, Mycobacterium tuberculosis or fungi.

Harrison’s 17th Ed. 1821

A.

Prostatic secretion

B.

High urine urea concentration

C.

High urine osmolarity

D.

All of the above

811

Harrison’s 17th Ed. 1822

High urea concentration & high osmolarity, prostatic secretions, cytokines & chemokines from bladder epithelial cells provide antibacterial properties to urine.

806

Predisposition to upper urinary tract infection during pregnancy is due to ? Harrison’s 17th Ed. 1821

“Sterile pyuria” may be demonstrated in ? A.

Nephrocalcinosis

B.

Vesicoureteral reflux

C.

Interstitial nephritis

D.

All of the above

Sterile pyuria may be seen in calculi, anatomic abnormality, nephrocalcinosis, vesicoureteral reflux, interstitial nephritis or polycystic disease.

812

Leukocyte esterase “dipstick” test is done for ? Harrison’s 17th Ed. 1822

A.

Decreased ureteral tone

B.

Decreased ureteral peristalsis

A.

Bacteriuria

C.

Temporary incompetence of vesicoureteral valves

B.

Pyuria

D.

All of the above

C.

Hematuria

D.

All of the above

During pregnancy, upper UTI is due to decreased ureteral tone, decreased ureteral peristalsis, and temporary incompetence of vesicoureteral valves.

Leukocyte esterase “dipstick” method is useful in identifying pyuria.

Nephrology 383 813

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Acute cystitis in pregnancy can be treated with ? Harrison’s 17th Ed. 1825

A.

Amoxicillin

B.

Nitrofurantoin

C.

Cephalosporin

D.

All of the above

D.

All of the above

Patients with diabetes, sickle cell disease, chronic alcoholism, and vascular disease are peculiarly susceptible to papillary necrosis.

815

Emphysematous pyelonephritis is most often due to ? Harrison’s 16th Ed. 1720

A.

E. coli

In pregnancy, acute cystitis can be managed with 7 days of treatment with amoxicillin, nitrofurantoin, or a cephalosporin.

B.

Proteus

C.

Klebsiella

814

D.

Pseudomonas

Patients of UTI susceptible to papillary necrosis include ? Harrison’s 16th Ed. 1720

A.

Diabetes mellitus

B.

Sickle cell disease

C.

Chronic alcoholism

383 Cardiology

Emphysematous pyelonephritis almost always occur in diabetics. It is characte-rized by high fever, leukocytosis, renal parenchymal necrosis and accumulation of fermentative gases in kidney & perinephric tissues. E. coli causes most cases.

Notes :

Answer

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

385

ANSWERS NEPHROLOGY 1 .................. D

36 ................ D

71 ................ B

106 .............. D

141 .............. D

176 .............. D

2 .................. D

37 ................ C

72 ................ B

107 .............. C

142 .............. D

177 .............. A

3 .................. A

38 ................ D

73 ................ A

108 .............. B

143 .............. D

178 .............. B

4 .................. A

39 ................ D

74 ................ C

109 .............. A

144 .............. B

179 .............. D

5 .................. B

40 ................ D

75 ................ B

110 .............. D

145 .............. C

180 .............. C

6 .................. D

41 ................ A

76 ................ C

111 .............. D

146 .............. D

181 .............. C

7 .................. D

42 ................ C

77 ................ A

112 .............. C

147 .............. D

182 .............. C

8 .................. A

43 ................ B

78 ................ B

113 .............. B

148 .............. B

183 .............. D

9 .................. A

44 ................ A

79 ................ D

114 .............. D

149 .............. D

184 .............. D

10 ................ D

45 ................ B

80 ................ B

115 .............. A

150 .............. D

185 .............. A

11 ................ C

46 ................ B

81 ................ D

116 .............. D

151 .............. D

186 .............. D

12 ................ B

47 ................ D

82 ................ B

117 .............. D

152 .............. D

187 .............. C

13 ................ C

48 ................ D

83 ................ D

118 .............. B

153 .............. D

188 .............. C

14 ................ D

49 ................ D

84 ................ A

119 .............. C

154 .............. C

189 .............. D

15 ................ D

50 ................ A

85 ................ A

120 .............. A

155 .............. D

190 .............. D

16 ................ D

51 ................ B

86 ................ A

121 .............. C

156 .............. D

191 .............. D

17 ................ C

52 ................ C

87 ................ A

122 .............. C

157 .............. D

192 .............. A

18 ................ C

53 ................ B

88 ................ D

123 .............. C

158 .............. D

193 .............. B

19 ................ C

54 ................ C

89 ................ C

124 .............. B

159 .............. A

194 .............. C

20 ................ D

55 ................ A

90 ................ D

125 .............. A

160 .............. A

195 .............. A

21 ................ A

56 ................ D

91 ................ D

126 .............. D

161 .............. A

196 .............. D

22 ................ A

57 ................ A

92 ................ C

127 .............. D

162 .............. B

197 .............. D

23 ................ A

58 ................ A

93 ................ D

128 .............. D

163 .............. A

198 .............. D

24 ................ D

59 ................ C

94 ................ D

129 .............. D

164 .............. B

199 .............. B

25 ................ D

60 ................ D

95 ................ D

130 .............. A

165 .............. D

200 .............. D

26 ................ B

61 ................ A

96 ................ D

131 .............. C

166 .............. D

201 .............. D

27 ................ C

62 ................ D

97 ................ D

132 .............. B

167 .............. D

202 .............. C

28 ................ D

63 ................ B

98 ................ B

133 .............. B

168 .............. D

203 .............. D

29 ................ D

64 ................ D

99 ................ A

134 .............. B

169 .............. C

204 .............. D

30 ................ C

65 ................ A

100 .............. B

135 .............. B

170 .............. D

205 .............. D

31 ................ D

66 ................ C

101 .............. C

136 .............. C

171 .............. D

206 .............. D

32 ................ D

67 ................ B

102 .............. C

137 .............. D

172 .............. B

207 .............. A

33 ................ D

68 ................ B

103 .............. C

138 .............. B

173 .............. A

208 .............. D

34 ................ A

69 ................ C

104 .............. D

139 .............. D

174 .............. D

209 .............. C

35 ................ A

70 ................ D

105 .............. C

140 .............. B

175 .............. D

210 .............. C

386

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Answer

ANSWERS NEPHROLOGY 211 .............. D

246 .............. D

281 .............. B

316 .............. B

351 .............. A

386 .............. A

212 .............. B

247 .............. C

282 .............. B

317 .............. B

352 .............. B

387 .............. B

213 .............. C

248 .............. D

283 .............. B

318 .............. B

353 .............. B

388 .............. D

214 .............. D

249 .............. D

284 .............. D

319 .............. A

354 .............. B

389 .............. D

215 .............. A

250 .............. A

285 .............. A

320 .............. B

355 .............. D

390 .............. D

216 .............. D

251 .............. C

286 .............. C

321 .............. C

356 .............. C

391 .............. C

217 .............. D

252 .............. D

287 .............. D

322 .............. B

357 .............. B

392 .............. D

218 .............. A

253 .............. D

288 .............. D

323 .............. A

358 .............. D

393 .............. D

219 .............. D

254 .............. D

289 .............. A

324 .............. C

359 .............. B

394 .............. C

220 .............. C

255 .............. A

290 .............. A

325 .............. B

360 .............. A

395 .............. D

221 .............. D

256 .............. C

291 .............. D

326 .............. C

361 .............. C

396 .............. D

222 .............. B

257 .............. D

292 .............. C

327 .............. B

362 .............. D

397 .............. B

223 .............. D

258 .............. C

293 .............. C

328 .............. D

363 .............. A

398 .............. D

224 .............. C

259 .............. B

294 .............. D

329 .............. D

364 .............. B

399 .............. D

225 .............. A

260 .............. A

295 .............. D

330 .............. B

365 .............. A

400 .............. B

226 .............. D

261 .............. A

296 .............. D

331 .............. A

366 .............. B

401 .............. D

227 .............. D

262 .............. D

297 .............. D

332 .............. A

367 .............. B

402 .............. D

228 .............. D

263 .............. D

298 .............. D

333 .............. D

368 .............. A

403 .............. D

229 .............. A

264 .............. D

299 .............. B

334 .............. A

369 .............. A

404 .............. D

230 .............. B

265 .............. A

300 .............. D

335 .............. B

370 .............. D

405 .............. A

231 .............. D

266 .............. C

301 .............. C

336 .............. B

371 .............. A

406 .............. D

232 .............. C

267 .............. C

302 .............. D

337 .............. C

372 .............. D

407 .............. D

233 .............. C

268 .............. D

303 .............. A

338 .............. A

373 .............. D

408 .............. C

234 .............. C

269 .............. D

304 .............. D

339 .............. A

374 .............. C

409 .............. C

235 .............. A

270 .............. A

305 .............. B

340 .............. B

375 .............. B

410 .............. D

236 .............. D

271 .............. D

306 .............. A

341 .............. A

376 .............. D

411 .............. D

237 .............. D

272 .............. C

307 .............. A

342 .............. C

377 .............. D

412 .............. B

238 .............. C

273 .............. A

308 .............. D

343 .............. D

378 .............. C

413 .............. D

239 .............. C

274 .............. B

309 .............. A

344 .............. D

379 .............. A

414 .............. D

240 .............. A

275 .............. A

310 .............. C

345 .............. C

380 .............. C

415 .............. D

241 .............. D

276 .............. A

311 .............. A

346 .............. C

381 .............. A

416 .............. D

242 .............. A

277 .............. D

312 .............. D

347 .............. D

382 .............. D

417 .............. B

243 .............. C

278 .............. C

313 .............. C

348 .............. D

383 .............. A

418 .............. B

244 .............. C

279 .............. D

314 .............. D

349 .............. B

384 .............. A

419 .............. D

245 .............. A

280 .............. C

315 .............. C

350 .............. B

385 .............. D

420 .............. A

Answer

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

387

ANSWERS NEPHROLOGY 421 .............. B

456 .............. A

491 .............. D

526 .............. C

561 .............. D

596 .............. C

422 .............. D

457 .............. C

492 .............. D

527 .............. B

562 .............. D

597 .............. B

423 .............. D

458 .............. A

493 .............. D

528 .............. D

563 .............. A

598 .............. D

424 .............. D

459 .............. A

494 .............. D

529 .............. A

564 .............. B

599 .............. D

425 .............. D

460 .............. B

495 .............. D

530 .............. D

565 .............. D

600 .............. D

426 .............. D

461 .............. B

496 .............. D

531 .............. D

566 .............. D

601 .............. D

427 .............. D

462 .............. A

497 .............. D

532 .............. D

567 .............. D

602 .............. C

428 .............. C

463 .............. D

498 .............. D

533 .............. D

568 .............. D

603 .............. D

429 .............. D

464 .............. B

499 .............. D

534 .............. D

569 .............. D

604 .............. A

430 .............. D

465 .............. B

500 .............. B

535 .............. C

570 .............. A

605 .............. B

431 .............. C

466 .............. D

501 .............. D

536 .............. D

571 .............. D

606 .............. D

432 .............. C

467 .............. D

502 .............. D

537 .............. D

572 .............. D

607 .............. D

433 .............. D

468 .............. A

503 .............. D

538 .............. C

573 .............. D

608 .............. A

434 .............. D

469 .............. C

504 .............. D

539 .............. D

574 .............. A

609 .............. A

435 .............. D

470 .............. C

505 .............. B

540 .............. D

575 .............. B

610 .............. B

436 .............. D

471 .............. B

506 .............. D

541 .............. B

576 .............. D

611 .............. D

437 .............. D

472 .............. B

507 .............. D

542 .............. B

577 .............. C

612 .............. A

438 .............. D

473 .............. C

508 .............. D

543 .............. B

578 .............. B

613 .............. B

439 .............. D

474 .............. D

509 .............. D

544 .............. D

579 .............. C

614 .............. A

440 .............. D

475 .............. D

510 .............. D

545 .............. B

580 .............. B

615 .............. A

441 .............. A

476 .............. C

511 .............. B

546 .............. B

581 .............. A

616 .............. C

442 .............. A

477 .............. D

512 .............. D

547 .............. D

582 .............. D

617 .............. C

443 .............. D

478 .............. D

513 .............. C

548 .............. D

583 .............. D

618 .............. C

444 .............. D

479 .............. C

514 .............. D

549 .............. B

584 .............. D

619 .............. D

445 .............. D

480 .............. A

515 .............. D

550 .............. C

585 .............. A

620 .............. D

446 .............. C

481 .............. A

516 .............. D

551 .............. A

586 .............. D

621 .............. D

447 .............. C

482 .............. A

517 .............. D

552 .............. B

587 .............. C

622 .............. C

448 .............. D

483 .............. D

518 .............. B

553 .............. C

588 .............. C

623 .............. A

449 .............. A

484 .............. D

519 .............. B

554 .............. D

589 .............. D

624 .............. C

450 .............. A

485 .............. A

520 .............. D

555 .............. C

590 .............. A

625 .............. D

451 .............. B

486 .............. A

521 .............. A

556 .............. B

591 .............. B

626 .............. D

452 .............. D

487 .............. D

522 .............. D

557 .............. B

592 .............. C

627 .............. B

453 .............. C

488 .............. D

523 .............. D

558 .............. A

593 .............. C

628 .............. D

454 .............. B

489 .............. D

524 .............. D

559 .............. D

594 .............. D

629 .............. D

455 .............. D

490 .............. D

525 .............. A

560 .............. D

595 .............. D

630 .............. A

388

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Answer

ANSWERS NEPHROLOGY 631 .............. B

666 .............. D

701 .............. D

736 .............. C

771 .............. C

806 .............. D

632 .............. A

667 .............. C

702 .............. C

737 .............. D

772 .............. B

807 .............. D

633 .............. A

668 .............. C

703 .............. D

738 .............. D

773 .............. B

808 .............. D

634 .............. B

669 .............. A

704 .............. B

739 .............. B

774 .............. A

809 .............. B

635 .............. A

670 .............. B

705 .............. A

740 .............. D

775 .............. D

810 .............. D

636 .............. C

671 .............. D

706 .............. A

741 .............. C

776 .............. D

811 .............. D

637 .............. B

672 .............. C

707 .............. D

742 .............. A

777 .............. B

812 .............. B

638 .............. B

673 .............. A

708 .............. D

743 .............. D

778 .............. D

813 .............. D

639 .............. D

674 .............. C

709 .............. A

744 .............. C

779 .............. B

814 .............. D

640 .............. D

675 .............. D

710 .............. D

745 .............. A

780 .............. A

815 .............. A

641 .............. D

676 .............. D

711 .............. B

746 .............. B

781 .............. A

642 .............. D

677 .............. C

712 .............. D

747 .............. C

782 .............. D

643 .............. C

678 .............. A

713 .............. D

748 .............. D

783 .............. D

644 .............. B

679 .............. C

714 .............. D

749 .............. D

784 .............. D

645 .............. C

680 .............. D

715 .............. B

750 .............. D

785 .............. D

646 .............. D

681 .............. D

716 .............. B

751 .............. D

786 .............. D

647 .............. B

682 .............. D

717 .............. A

752 .............. C

787 .............. D

648 .............. D

683 .............. A

718 .............. D

753 .............. D

788 .............. C

649 .............. D

684 .............. A

719 .............. D

754 .............. D

789 .............. A

650 .............. D

685 .............. D

720 .............. D

755 .............. D

790 .............. D

651 .............. C

686 .............. D

721 .............. A

756 .............. A

791 .............. A

652 .............. B

687 .............. D

722 .............. D

757 .............. C

792 .............. A

653 .............. A

688 .............. A

723 .............. C

758 .............. A

793 .............. D

654 .............. D

689 .............. C

724 .............. C

759 .............. D

794 .............. D

655 .............. A

690 .............. C

725 .............. D

760 .............. B

795 .............. C

656 .............. D

691 .............. D

726 .............. C

761 .............. B

796 .............. C

657 .............. A

692 .............. B

727 .............. D

762 .............. D

797 .............. A

658 .............. C

693 .............. B

728 .............. B

763 .............. B

798 .............. D

659 .............. B

694 .............. A

729 .............. B

764 .............. D

799 .............. A

660 .............. D

695 .............. B

730 .............. D

765 .............. D

800 .............. D

661 .............. C

696 .............. D

731 .............. D

766 .............. A

801 .............. D

662 .............. A

697 .............. D

732 .............. C

767 .............. B

802 .............. D

663 .............. B

698 .............. D

733 .............. A

768 .............. C

803 .............. D

664 .............. D

699 .............. D

734 .............. D

769 .............. C

804 .............. D

665 .............. C

700 .............. D

735 .............. A

770 .............. D

805 .............. D

Gastroenterology 389

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR D.

292 - Diseases of the Esophagus

389 Cardiology

Misdirection of food

Inhibition that precedes the peristaltic contraction is called deglutitive inhibition.

1

Dysphagia is defined as a sensation of “sticking” or obstruction of the passage of food through ?

7

Peristalsis that begins at the point of oesophageal distention and proceeds distally is called ?

Harrison’s 17th Ed. 237

Harrison’s 18th Ed. 297

A.

Mouth

A.

Primary peristalsis

B.

Pharynx

B.

Secondary peristalsis

C.

Esophagus

C.

Tertiary peristalsis

D.

All of the above

D.

Any of the above

Dysphagia is defined as a sensation of “sticking” or obstruction of the passage of food through the mouth, pharynx or esophagus.

Local distention of esophagus activates secondary peristalsis. It begins at the point of distention and proceeds distally as in gastroesophageal reflux.

2

8

Foreign body sensation localized in the neck is termed as ? Harrison’s 18th Ed. 297

Which of the following oesophageal contractions is nonperistaltic ?

A.

Odynophagia

Harrison’s 18th Ed. 297

B.

Globus pharyngeus

A.

C.

Transfer dysphagia

B.

Secondary peristalsis

Phagophobia

C.

Tertiary peristalsis

D.

Any of the above

D.

A foreign body sensation localized in the neck that does not interfere with swallowing & is sometimes relieved by swallowing is termed as “Globus pharyngeus”.

3

Which of the following is characteristic of oropharyngeal dysphagia ?

Tertiary esophageal contractions are nonperistaltic, disordered esophageal contractions that occur spontaneously during fluoroscopic observation.

Harrison’s 18th Ed. 297

Which of the following is a part of upper esophageal sphincter (UES) physiologically ?

A.

Odynophagia

Harrison’s 18th Ed. 298

B.

Globus pharyngeus

A.

C.

Transfer dysphagia

B.

Inferior pharyngeal constrictor

Phagophobia

C.

Proximal portion of cervical esophagus

D.

All of the above

D.

Transfer dysphagia frequently results in nasal regurgitation & pulmonary aspiration during swallowing and is characteristic of oropharyngeal dysphagia.

4

Whihc of the following may have a psychogenic cause of dysphagia ?

9

Harrison’s 18th Ed. 297

Innervation to the musculature acting on UES to facilitate its opening during swallowing comes from ?

A.

Globus pharyngeus

Harrison’s 18th Ed. 298

B.

Transfer dysphagia

A.

Fifth cranial nerve

C.

Phagophobia

B.

Seventh cranial nerve

D.

All of the above

C.

Twelfth cranial nerve

D.

All of the above

“Deglutitive inhibition” best relates to which of the following ? Harrison’s 18th Ed. 297

10

UES innervation is derived from the vagus nerve, whereas innervation to the musculature acting on UES to facilitate its opening during swallowing comes from fifth, seventh & twelfth cranial nerves.

11

Which of the following is involved in keeping UES closed at rest ?

A.

Smell

B.

Mastication

C.

Peristaltic contraction of esophagus

A.

Cricopharyngeus muscle

D.

Gastroesophageal reflux

B.

Inferior pharyngeal constrictor

C.

Proximal portion of cervical esophagus

D.

All of the above

Harrison’s 18th Ed. 298

Primary peristalsis refers to peristaltic contractions elicited in response to a swallow. It is an interplay of sequenced inhibition followed by contraction of the entire length of esophageal musculature. The inhibition that precedes peristaltic contraction is called deglutitive inhibition.

6

Cricopharyngeus muscle

Physiologically, UES consists of the cricopharyngeus muscle, the adjacent inferior pharyngeal constrictor, and the proximal portion of the cervical esophagus.

Phagophobia refers to fear of swallowing. Refusal to swallow thereby may be psychogenic.

5

Primary peristalsis

Deglutitive inhibition refers to ?

UES remains closed at rest due to its inherent elastic properties and neurogenically mediated contraction of cricopharyngeus muscle.

Harrison’s 18th Ed. 297

A.

Complete esophageal obstruction

B.

Difficulty in initiating a swallow

C.

Inhibition that precedes peristaltic contraction

12

Which of the following is a muscle of upper esophageal sphincter (UES) ? Harrison’s 17th Ed. 237

A.

Cricopharyngeus muscle

390

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Inferior pharyngeal constrictor muscles

B.

Pemphigoid

C.

Geniohyoid muscle

C.

Epidermolysis bullosa

D.

All of the above

D.

All of the above

UES consists of constrictor (cricopharyngeus and inferior pharyngeal constrictor muscles) and dilator muscles (suprahyoid muscles including geniohyoid).

13

Which of the following muscle is involved in opening UES during swallowing ?

Scleroderma, pemphigoid and epidermolysis bullosa can involve the esophagus.

19

Geniohyoid

B.

Mylohyoid

C.

Stylohyoid

D.

Styloglossus

UES opening during swallowing is due to relaxation of cricopharyngeus muscle (cessation of vagal excitation) and simultaneous contraction of suprahyoid & geniohyoid muscles.

14

Motor dysphagia refers to ? Weakness of peristaltic contractions

B.

Impaired deglutitive inhibition

C.

Impaired sphincter relaxation

D.

All of the above

Dysphagia caused by a large bolus or a narrow lumen is called structural dysphagia. Dysphagia due to weakness of peristaltic contractions or to impaired deglutitive inhibition causing nonperistaltic contractions & impaired sphincter relaxation is called propulsive or motor dysphagia.

15

A.

Stretch reflex

B.

Chemical reflex

C.

Vasovagal reflex

D.

All of the above

Gastric distention - evoked transient lower esophageal sphincter relaxation (tLESR) is a vagovagal reflex.

20

Agents that increase LES pressure are all except ? Harrison’s 17th Ed. 1847

Harrison’s 18th Ed. 298

A.

Gastric distention-evoked transient lower esophageal sphincter relaxation (tLESR) is a ? Harrison’s 17th Ed. 1847

Harrison’s 18th Ed. 298

A.

Gastroenterology

21

A.

Substance P

B.

Prostaglandin F2

C.

Secretin

D.

Gastrin

Agents that reduce LES pressure are all except ? Harrison’s 17th Ed. 1847

A.

Cholecystokinin

Length of adult esophagus is ?

B.

Secretin

Harrison’s 18th Ed. 298

C.

Dopamine

A.

12 - 16 cm

D.

Gastrin

B.

14 - 20 cm

C.

16 - 24 cm

D.

18 - 26 cm

22

Agents that reduce LES pressure are all except ? Harrison’s 17th Ed. 1847

A.

VIP

Adult esophagus is 18 - 26 cm in length. Anatomically, it is divided into cervical esophagus (from pharyngoesophageal junction to suprasternal notch) and thoracic esophagus (upto the diaphragmatic hiatus).

B.

Calcitonin gene-related peptide (CGRP)

C.

Prostaglandin E

16

D.

Prostaglandin F2

In an adult, esophageal lumen can distend up to ? Harrison’s 17th Ed. 238

A.

4 cm in diameter

B.

6 cm in diameter

C.

8 cm in diameter

D.

10 cm in diameter

In adult, esophageal lumen can distend up to 4 cm in diameter. When esophagus cannot dilate beyond 2.5 cm in diameter, dysphagia to normal solid food occurs. Dysphagia is always present when esophagus cannot distend beyond 1.3 cm.

17

Hallmark of oropharyngeal dysphagia is ? Harrison’s 18th Ed. 299

A.

Food impaction

B.

Odynophagia

C.

Nasal regurgitation

D.

Hoarseness

Agents that reduce LES pressure are all except ? Harrison’s 17th Ed. 1847

A.

Adenosine

B.

Dopamine

C.

Substance P

D.

Nitrates

Reduction in LES sphincter pressure occurs with phosphodiesterase-5 inhibitors (sildenafil) use, fatty meals, smoking, and beverages with high xanthine content (tea, coffee, cola), nicotine, betaadrenergic agonists, dopamine, cholecystokinin, secretin, vasoactive intestinal peptide (VIP), calcitonin gene–related peptide, adenosine, prostaglandin E, nitric oxide donors (nitrates). LES contraction occurs with GABA-B agonists (baclofen), muscarinic M2 and M3 receptor agonists, alpha-adrenergic agonists, gastrin, substance P & Pg F 2

24

Which of the following statements about upper esophageal sphincter (UES) is false ? Harrison’s 16th Ed. 1739

A.

Formed by cricopharyngeus & inferior pharyngeal constrictor muscles

B.

These muscles exhibit myogenic tone

Harrison’s 18th Ed. 300

C.

These muscles receive no inhibitory innervation

A.

D.

Opened by central inhibition of sphincter muscles

Nasal regurgitation & tracheobronchial aspiration with swallowing are hallmarks of oropharyngeal dysphagia or a tracheoesophageal fistula.

18

23

Which of the following skin diseases may involve the oesophagus ? Scleroderma

Gastroenterology 391 25

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Which of the following statements about lower esophageal sphincter (LES) is false ?

31

26

Innervated by parallel sets of parasympathetic excitatory & inhibitory pathways

B.

Opens in response to activity of inhibitory nerves

C.

Neurotransmitters of excitatory nerves are acetylcholine, substance P & nitric oxide

D.

Neurotransmitters of inhibitory nerves is VIP

32

Recumbent position

C.

Lateral position

D.

Head down position

A.

Heartburn

Harrison’s 17th Ed. 1849 Figure 286-3

B.

Regurgitation

A.

Scleroderma

C.

Water brash

B.

Achalasia

D.

Globus sensation

C.

Diffuse esophageal spasm

D.

None of the above

Pyrosis is best related to ? A.

Fever

B.

Heartburn

C.

Defervescence

D.

Pain

In scleroderma, thoracic esophagus shows reduced amplitude of contractions, which may be peristaltic or simultaneous in onset & hypotension of LES.

33

A.

Gastroesophageal reflux

B.

Diffuse esophageal spasm (DES)

C.

Achalasia

D.

Esophageal hypersensitivity syndrome

Motility pattern of esophagus showing reduced amplitude of contractions in lower esophagus, simultaneous in onset with hypertensive LES nonrelaxing on swallowing is suggestive of ? Harrison’s 17th Ed. 1849 Figure 286-3

Most frequent esophageal cause of chest pain is ? Harrison’s 18th Ed. 2427

A.

Scleroderma

B.

Achalasia

C.

Diffuse esophageal spasm

D.

None of the above

In achalasia, lower part of esophagus shows contractions that are reduced in amplitude & simultaneous in onset. In contrast to scleroderma, LES in achalasia is hypertensive and fails to relax in response to a swallow.

34

Motility pattern of esophagus showing large amplitude, prolonged and repetitive contractions in lower esophagus, simultaneous in onset is suggestive of ? Harrison’s 17th Ed. 1849 Figure 286-3

Gastroesophageal reflux is the most common cause of esophageal chest pain.

A.

Scleroderma

B.

Achalasia

Pill-induced esophagitis

C.

Diffuse esophageal spasm

B.

Nonreflux esophagitis

D.

None of the above

C.

Esophageal perforation

D.

Uncomplicated reflux esophagitis

Odynophagia is unusual in ? Harrison’s 18th Ed. 2427

A.

Odynophagia (painful swallowing) is characteristic of nonreflux esophagitis, herpes & pill-induced esophagitis. Odynophagia may occur with peptic ulcer of esophagus (Barrett’s ulcer), carcinoma with periesophageal involvement, caustic damage of esophagus, and esophageal perforation. Odynophagia is unusual in uncomplicated reflux esophagitis.

30

B.

Harrison’s 18th Ed. 2427

Heartburn, or pyrosis, is characterized by burning retrosternal discomfort.

29

Upright position

Motility pattern of esophagus showing reduced amplitude of contractions in lower esophagus, peristaltic or simultaneous in onset with hypotension of LES is suggestive of ?

Harrison’s 18th Ed. 2427

28

A.

Esophageal peristalsis is best studied in the recumbent position, because in the upright position barium passage occurs largely by gravity alone.

The most common esophageal symptom is ?

Heartburn is the most common esophageal symptom. It is characterized by a discomfort or burning sensation behind sternum arising from epigastrium and may radiate toward the neck.

27

Esophageal peristalsis is best studied in ? Harrison’s 17th Ed. 1848

Harrison’s 16th Ed. 1739

A.

391 Cardiology

In diffuse esophageal spasm, lower part of esophagus shows simultaneous-onset, large-amplitude, prolonged, repetitive contractions.

35

Harrison’s 17th Ed. 1849

Reflex salivary hypersecretion in response to acidification of the esophageal mucosa is called ? Harrison’s 18th Ed. 2427

A.

Water brash

B.

Salivary brash

C.

Esophageal brash

D.

Barret’s brash

Water brash is excessive reflex salivation resulting from a vagal reflex triggered by acidification of the esophageal mucosa. It is not regurgitation which is effortless appearance of gastric or esophageal contents in the mouth.

Esophageal motility studies are helpful in the diagnosis of all except ? A.

Achalasia

B.

Diffuse esophageal spasm

C.

Scleroderma

D.

Mechanical dysphagia

Esophageal motility studies are helpful in the diagnosis of esophageal motor disorders (achalasia, spasm, and scleroderma) but are of little value in the differential diagnosis of mechanical dysphagia.

36

Which is the most common type of hiatal hernia ? Harrison’s 18th Ed. 2428

A.

Type I

B.

Type II

392

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Type III

C.

Stomach

D.

Type IV

D.

Colon

Type I or sliding hiatal hernia comprising ~95% of hiatus hernias.

37

When colon herniate into the mediastinum, the type of hiatus hernia is ?

Gastroenterology

Schatzki ring is one of the most common causes of intermittent food impaction, also called “steakhouse syndrome” as meat is a typical instigator.

43

Which of the following is false about Plummer-Vinson syndrome ?

Harrison’s 18th Ed. 2428

Harrison’s 18th Ed. 2429

A.

Type I

A.

Young women

B.

Type II

B.

Symptomatic proximal esophageal web

C.

Type III

C.

Iron-deficiency anemia

Type IV

D.

All of the above

D.

With type IV hiatal hernias, viscera other than stomach herniate into mediastinum, most commonly the colon.

Symptomatic hypopharyngeal webs and iron-deficiency anemia in middle-aged women constitutes Plummer-Vinson syndrome.

38

44

Intersection of squamous epithelium of tubular oesophagus & columnar epithelium of stomach is termed ?

Which of the following is false about Zenker’s diverticula ? Harrison’s 18th Ed. 2429

Lancet 2009; 373:850 - 61

A.

Hypopharyngeal

A.

W line

B.

False diverticula

B.

X line

C.

Associated with distal obstruction

C.

Y line

D.

None of the above

D.

Z line

45

Which of the following is false about Zenker’s diverticulum ?

The intersection of squamous epithelium of the tubular oesophagus & columnar epithelium of stomach is termed Z line, because of jagged appearance of the interface.

Harrison’s 18th Ed. 2429

A.

Occurs below the Killian’s triangle

39

A lower esophageal mucosal ring is also called ?

B.

Causes halitosis & regurgitation of saliva & food

Harrison’s 18th Ed. 2429

C.

Nasogastric intubation may cause perforation

D.

Symptomatic pt’s treated by cricopharyngeal myotomy

A.

A ring

B.

B ring

C.

C ring

D.

D ring

Zenker’s diverticulum appears in natural zone of weakness in posterior hypopharyngeal wall (Killian’s triangle).

46

Esophageal inlet patch best relates to ?

A lower esophageal mucosal ring, also called B ring, is a thin membranous narrowing at the squamocolumnar mucosal junction.

Harrison’s 18th Ed. 2430

A.

Esophageal atresia

40

Location of ‘Schatzki ring’ is ?

B.

Benign esophageal tumor

Harrison’s 18th Ed. 2429

C.

Heterotopic gastric mucosa

D.

Zenker’s diverticula

A.

Hypopharyngeal

B.

Mid esophageal

C.

Lower esophageal

D.

Any of the above

Schatzki ring is a lower esophageal mucosal ring. It is a thin, weblike constriction located at the squamo-columnar mucosal junction at or near the border of the LES. It may result from GERD or be congenital in origin.

41

Heterotopic gastric mucosa, also known as an esophageal inlet patch, is an area of gastric type epithelium in proximal cervical esophagus. The inlet patch is due to incomplete replacement of embryonic columnar epithelium with squamous epithelium.

47

Harrison’s 18th Ed. 2430-31

Schatzki ring invariably produces dysphagia when the lumen diameter is ? Harrison’s 18th Ed. 2429

A.

< 1.3 cm

B.

< 2.3 cm

C.

< 3.3 cm

D.

< 4.3 cm

Schatzki ring invariably produces dysphagia when the lumen diameter is =4

400

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Pepsin activity is significantly diminished at a pH of 4 and irreversibly inactivated and denatured at a pH of 7.

133

All of the following about gastric ulcer are true except ? Harrison’s 18th Ed. 2441

Type III GU’s occur within 3 cm of the pylorus and are commonly accompanied by duodenal ulcers and normal or high gastric acid production.

139

N Engl J Med 2005;35:2421

B.

Depth to submucosa

A.

Marshall B & Warren R

C.

More than half of gastric ulcers occur in males

B.

Julie Parsonnet & Jennings R

Peak incidence is in the 4th decade of life

C.

Banatvala N & Mayo K

D.

Deeks JJ & Feldman RA

140

A.

Can represent malignancy

B.

Benign GUs are found distal to junction between antrum & acid secretory mucosa

C.

Benign GUs are common in gastric fundus

D.

Gastric acid output is normal or decreased in GU

Benign GUs are rare in the gastric fundus.

Gastric infection with H. pylori can lead to ? Harrison’s 18th Ed. 2442

Which of the following statements about GU is false ? Harrison’s 18th Ed. 2441

A.

Peptic ulcer disease (PUD)

B.

Gastric mucosal-associated lymphoid tissue lymphoma

C.

Gastric adenocarcinoma

D.

All of the above

H. pylori plays a role in the development of majority of PUD, gastric mucosal-associated lymphoid tissue (MALT) lymphoma and gastric adenocarcinoma.

141

Which of the following statements about H. pylori is false ? Harrison’s 18th Ed. 2442

~90% of DU’s occur within what distance from pylorus ?

A.

It is a gram-positive microaerophilic rod

Harrison’s 18th Ed. 2441

B.

Found between mucous layer & gastric epithelium

C.

Normally, it does not invade gastric epithelial cells

D.

S-shaped & contains multiple sheathed flagella

A.

3 cm

B.

5 cm

C.

7 cm

D.

9 cm

~90% of DU’s are located within 3 cm of the pylorus.

136

Helicobacter pylori was discovered by ?

A break in mucosal surface >5 mm in size

Gastric & duodenal ulcers are defined as breaks in mucosal surface >5 mm in size with depth to submucosa. Peak incidence of gastric ulcers is in the sixth decade & more than half of GUs occur in males.

135

Type IV

A.

D.

134

D.

H. pylori is a gram-negative microaerophilic rod found most commonly between the mucous layer and the gastric epithelium.

142

Which of the following statements about H. pylori is false ? Harrison’s 18th Ed. 2442

Which of the following statements about DU is false ? Harrison’s 18th Ed. 2441

A.

H. pylori should be eradicated in documented PUD

A.

Most often occur in first part of duodenum

B.

No single agent is effective in eradicating H. pylori

B.

Usually 12 weeks & a DU that does not heal >8 weeks of therapy is considered refractory.

183

Etiologies of refractory ulcers (GU / DU) include all except ? Harrison’s 18th Ed. 2452

A.

Ischemia

B.

Crohn’s disease

404

184

185

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Ulcerative colitis

D.

Amyloidosis

Etiologies of refractory ulcers (GU / DU) include all except ?

Gastrin stimulates acid secretion through gastrin receptors on parietal cells and by inducing histamine release from ECL cells. Gastrin also has a trophic action on gastric epithelial cells.

190

Harrison’s 18th Ed. 2455

A.

Sarcoidosis

A.

Cystic and common bile ducts

B.

Lymphoma

B.

Junction of II and III portions of duodenum

C.

Eosinophilic gastroenteritis

C.

Inferior surface of liver

D.

HIV

D.

Junction of neck & body of pancreas

Etiologies of refractory ulcers (GU / DU) include all except ?

Hypothetical gastrinoma triangle is formed by confluence of cystic & common bile ducts superiorly, junction of second & third portions of duodenum inferiorly, and junction of neck & body of pancreas medially.

A.

Leprosy

B.

Cytomegalovirus (CMV)

C.

Tuberculosis

Harrison’s 18th Ed. 2455

D.

Syphilis

A.

20 %

B.

40 %

C.

60 %

D.

80 %

191

Rare etiologies of refractory GU/DU’s include ischemia, Crohn’s disease, amyloidosis, sarcoidosis, lymphoma, eosinophilic gastroenteritis, cytomegalovirus (CMV), tuberculosis or syphilis.

Posterior DU can penetrate into ? Harrison’s 18th Ed. 2452

A.

Pancreas

B.

Colon

C.

Liver

D.

All of the above

192

A.

Stomach

B.

Duodenum

C.

Liver

D.

Lymph nodes

Duodenal gastrinoma tumors constitute the most common nonpancreatic lesion (50 to75%). Lesscommon extrapancreatic sites include stomach, bones, ovaries, heart, liver, and lymph nodes.

A.

Gastrin release from beta cell endocrine tumor

B.

Hypergastrinemia

C.

Erosive esophagitis

Harrison’s 18th Ed. 2455

D.

Diarrhea

A.

20 %

B.

40 %

C.

60 %

D.

80 %

193

Severe peptic ulcer secondary to gastric acid hypersecretion due to unregulated gastrin release from a autonomous non-beta cell endocrine tumor (gastrinoma) defines ZES. The increased gastric acid output leads to peptic ulcer diathesis, erosive esophagitis, and diarrhea.

188

Which of the following is the most common extrapancreatic site of gastrinoma ? Harrison’s 18th Ed. 2455

Which of the following is not a typical feature of Zollinger– Ellison Syndrome (ZES) ? Harrison’s 18th Ed. 2454-5

What proportion of gastrinoma are found within the hypothetical gastrinoma triangle ?

Over 80% of gastrinoma are found within the hypothetical gastrinoma triangle.

Posterior DU can penetrate into pancreas, colon, liver or biliary tree.

187

‘Gastrinoma triangle’ is formed by all except ?

Harrison’s 18th Ed. 2452

Harrison’s 18th Ed. 2452

186

Gastroenterology

In ZES, majority of patients are diagnosed between the ages of ?

What proportion of gastrinoma are malignant ?

More than 60% of gastrinoma tumors are considered malignant, with up to 30–50% of patients having multiple lesions or metastatic disease at presentation.

Harrison’s 18th Ed. 2455

A.

01 and 10 years

B.

10 and 30 years

C.

30 and 50 years

D.

50 and 70 years

194

Harrison’s 17th Ed. 1868

In ZES, males are more commonly affected than females, and majority of patients are diagnosed between the ages of 30 and 50 years.

189

Which of the following is the action of gastrin ? Harrison’s 18th Ed. 2455

Which of the following suggest the diagnosis of ZES ? A.

Ulcer in II part of duodenum & beyond

B.

Ulcers refractory to standard medical therapy

C.

Ulcer presenting with frank complication

D.

All of the above

Gastrinoma should be suspected when ulcers occur unusual locations like II part of duodenum & beyond, ulcers refractory to standard medical therapy, ulcer recurrence after acid-reducing surgery, ulcers presenting with frank complications (bleeding, obstruction, and perforation), or ulcers in the absence of H. pylori or NSAID ingestion.

A.

Stimulates acid secretion through gastrin receptors on parietal cells

B.

Stimulates acid secretion by inducing histamine release from ECL cells

Harrison’s 18th Ed. 2455

A.

25 %

C.

Has a trophic action on gastric epithelial cells

B.

50 %

D.

All of the above

C.

75 %

195

What proportion of ZES patients have diarrhoea ?

Gastroenterology 405 D.

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

100 %

202

A.

Rheumotoid arthritis

B.

Ankylosing arthritis

Harrison’s 18th Ed. 2455

C.

Pheochromocytoma

A.

Volume overload to the small bowel

D.

Vitiligo

B.

Pancreatic enzyme inactivation by acid

C.

Damage of the intestinal epithelial surface by acid

D.

All of the above

Etiology of the diarrhea in ZES is ?

Elevated fasting gastrin level are due to gastric hypochlorhydria or achlorhydria, renal insufficiency, massive small-bowel obstruction, rheumatoid arthritis, vitiligo, diabetes mellitus & pheochromocytoma.

203

A,

4 meq/hour

B.

8 meq/hour

Harrison’s 18th Ed. 2455

C.

12 meq/hour

A.

Parathyroid

D.

15 meq/hour

B.

Thyroid

C.

Pancreas

Harrison’s 18th Ed. 2456

D.

Pituitary

A.

< 0.3

B.

< 0.6

C.

> 0.3

D.

> 0.6

Organs involved in MEN I syndrome are all except ?

204

MEN I syndrome (autosomal dominant) involves parathyroid glands (80-90%), pancreas (40-80%), and pituitary gland (30-60%).

198

Patients with gastrinoma have a BAO level more than ? Harrison’s 16th Ed. 1759

In ZES, etiology of diarrhea is multifactorial, resulting from marked volume overload to small bowel, pancreatic enzyme inactivation by acid & damage of intestinal epithelial surface by acid.

197

Elevated fasting gastrin level are due to all except ? Harrison’s 18th Ed. 2455

Diarrhea is the next most common clinical manifestation after peptic ulcer and is found in up to 50% of patients of ZES.

196

Genetic defect in MEN I is in ? Harrison’s 18th Ed. 2455

A.

Short arm of chromosome 11

B.

Long arm of chromosome 11

C.

Short arm of chromosome 12

D.

Long arm of chromosome 12

What value of BAO / MAO is highly suggestive of ZES ?

BAO/MAO ratio >0.6 is highly suggestive of ZES, but a ratio = 1

B.

>= 1.5

The genetic defect in MEN I is in the long arm of chromosome 11 (11q11-q13).

C.

>= 2

199

D.

>= 3

Distinguishing feature between MEN I & sprodic ZES is ? Harrison’s 18th Ed. 2455

A.

Incidence of gastric carcinoid tumor

B.

Size, number & location of gastrinoma

C.

Disease free period after surgery

D.

All of the above

A basal gastric pH >=3 virtually excludes a gastrinoma.

206

Patients with gastrinoma have gastrin level more than ? Harrison’s 18th Ed. 2455

A.

25 pg/mL

B.

50 pg/mL

C.

100 pg/mL

D.

150 pg/mL

207

Harrison’s 18th Ed. 2455

Hypochlorhydria

B.

Renal insufficiency

C.

Diabetes mellitus

D.

Hypertension

Secretin stimulation test

B.

Calcium infusion study

C.

Standard meal test

D.

None of the above

Which of the following tests has maximum sensitivity in detecting primary gastrinoma ? Harrison’s 18th Ed. 2456 Table 293-8

Elevated fasting gastrin level are due to all except ? A.

A.

Most sensitive & specific gastrin provocative test for diagnosis of gastrinoma is secretin study. Increase in gastrin of >=120 pg within 15 minutes of secretin injection has a sensitivity & specificity of >90% for ZES. Calcium infusion study is less sensitive & specific with greater potential for adverse effects.

Fasting gastrin levels are 150 - 200 pg/mL.

201

Which of the following is the most sensitive & specific gastrin provocative test ? Harrison’s 18th Ed. 2456

Gastrinomas tend to be smaller, multiple, and located in the duodenal wall more often than is seen in patients with sporadic ZES. An additional distinguishing feature in ZES patients with MEN I is the higher incidence of gastric carcinoid tumor development (as compared to patients with sporadic gastrinomas). Gastrinomas tend to be smaller, multiple, and located in the duodenal wall more often than is seen in patients with sporadic ZES.

200

405 Cardiology

A.

Selective arterial secretin injection (SASI)

B.

Octreoscan imaging with

C.

Endoscopic ultrasonography (EUS)

D.

Magnetic resonance imaging

111

In-pentreotide

Sensitivity of EUS in Zollinger-Ellison Syndrome is 80 - 100%.

208

Which of the following is a favorable prognostic indicator in ZES ? Harrison’s 18th Ed. 2457

406

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR A.

Primary duodenal wall tumor

B.

Bacterial infection of stomach

B.

Isolated lymph node tumor

C.

Vascular congestion of stomach

C.

Undetectable tumor upon surgical exploration

D.

All of the above

D.

All of the above

In ZES, favorable prognostic indicators include primary duodenal wall tumors, isolated lymph node tumor, and undetectable tumor upon surgical exploration. Poor outcome indicators are shorter disease duration; higher gastrin levels (>10,000 pg/mL); large pancreatic primary tumors (>3 cm); metastatic disease to lymph nodes, liver, and bone and Cushing’s syndrome. Rapid growth of hepatic metastases is also predictive of poor outcome.

209

210

A.

Elderly individuals Alcoholics AIDS patients

A.

Vagotomy

D.

All of the above

B.

Billroth I

C.

Vagotomy in combination with antrectomy

D.

Billroth II

Elderly individuals, alcoholics, and AIDS patients may be affected by Phlegmonous gastritis.

216

Organism associated with Phlegmonous gastritis is ? Harrison’s 18th Ed. 2457

Cushing’s ulcer refers to ?

A.

Staphylococci

Harrison’s 18th Ed. 2457

B.

Escherichia coli

C.

Haemophilus

D.

All of the above

Stress ulceration after head trauma

B.

Stress ulceration after severe burns

C.

Stress ulceration after mechanical ventilation

D.

Stress ulceration after sepsis

Organisms associated with Phlegmonous gastritis include streptococci, staphylococci, Escherichia coli, Proteus, and Haemophilus species.

217

The final stage of chronic gastritis is ? Harrison’s 18th Ed. 2458

Curling’s ulcer refers to ?

A.

Superficial gastritis

Harrison’s 18th Ed. 2457

B.

Atrophic gastritis

C.

Gastric atrophy

D.

Intestinal metaplasia

A.

Stress ulceration after head trauma

B.

Stress ulceration after severe burns

C.

Stress ulceration after mechanical ventilation

D.

Stress ulceration after sepsis

To avoid stress ulceration, gastric pH should be maintained at ? A.

> 1.5

B.

> 2.0

C.

> 2.5

D.

> 3.5

Maintenance of gastric pH >3.5 with continuous infusion of H2 blockers or liquid antacids administered every 2–3 hours are viable options to avoid stress ulceration.

Treatment of choice for stress ulcer prophylaxis is ? Harrison’s 18th Ed. 2457

A.

H2 blocker

B.

PPI

C.

Sucralfate

D.

All of the above

PPIs are the treatment of choice for stress ulcer prophylaxis.

214

Harrison’s 18th Ed. 2457

C.

Harrison’s 18th Ed. 2457

213

Which of the following are affected by Phlegmonous gastritis ?

B.

Elevated gastric acid secretion may be noted in patients with stress ulceration after severe burns (Curling’s ulcer).

212

215

Harrison’s 16th Ed. 1756

Elevated gastric acid secretion may be noted in patients with stress ulceration after head trauma (Cushing’s ulcer).

211

Bacterial infection of the stomach or phlegmonous gastritis although rare is a potentially lifethreatening disorder characterized by marked & diffuse acute inflammatory infiltrates of entire gastric wall, at times accompanied by necrosis.

Procedure that provides the lowest rates of peptic ulcer recurrence but has highest complication rate is ?

A.

‘Phlegmonous gastritis’ refers to ? Harrison’s 18th Ed. 2457

A.

Viral infection of stomach

Gastroenterology

Early phase of chronic gastritis is superficial gastritis in which inflammatory changes are limited to lamina propria and intact gastric glands. Next stage is atrophic gastritis in which inflammatory infiltrate extends deeper into mucosa, with destruction of gastric glands. Final stage of chronic gastritis is gastric atrophy in which glandular structures are lost, and there is a paucity of inflammatory infiltrates. Endoscopically, mucosa is thin and underlying blood vessels can be visualized. Intestinal metaplasia refers to the conversion of gastric glands to small-bowel mucosal glands containing goblet cells. Intestinal metaplasia is an important predisposing factor for gastric cancer.

218

Antral-predominant form of chronic gastritis is called ? Harrison’s 18th Ed. 2458

A.

Type A gastritis

B.

Type B gastritis

C.

Type AB gastritis

D.

Type O gastritis

Chronic gastritis is also classified according to the predominant site of involvement. Type A refers to fundus and body predominant form , with antral sparing (autoimmune) and type B is the antralpredominant form (H. pylori–related). AB gastritis refers to a mixed antral/body picture.

219

Which of the following types of chronic gastritis is associated with pernicious anemia ? Harrison’s 18th Ed. 2458

A.

Type A gastritis

B.

Type B gastritis

C.

Type AB gastritis

D.

Type O gastritis

Type A gastritis, also called autoimmune gastritis is associated with pernicious anemia with circulating antibodies against parietal cells and IF.

Gastroenterology 407 220

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Parietal cell antibodies are directed against which of the following ?

226

221

A.

Cirrhosis

A.

Gastrin receptors

B.

Jejunal diverticulosis

B.

Acetylcholine receptors

C.

Wilson’s disease

C.

Histamine receptors

D.

Crohn’s disease

D.

H+,K+-ATPase

Only clinical malabsorption situations in which absorption is increased are hemochromatosis & Wilson’s disease, where absorption of iron and copper is increased respectively.

Varioliform gastritis best relates to ?

Steatorrhea is defined as an increase in stool fat excretion of how much of dietary fat intake ?

Harrison’s 18th Ed. 2459

Harrison’s 18th Ed. 2460

A.

Lymphocytic gastritis

A.

>2%

B.

Eosinophilic gastritis

B.

>4%

C.

Granulomatous gastritis

C.

>5%

D.

Sarcoidosis

D.

>6%

A subgroup of patients with lymphocytic gastritis have thickened folds noted on endoscopy. These folds are often capped by small nodules that contain a central depression or erosion; this form of the disease is called varioliform gastritis.

222

Which of the following is false about Ménétrier’s disease ?

227

Most malabsorption syndrome disorders are associated with an increase in stool fat excretion of >6% of dietary fat intake (steatorrhea).

228

A.

Protein-losing gastropathy

B.

Large gastric mucosal folds in body and fundus

C.

Hyperplasia of surface & glandular mucous cells

D.

None of the above

Ménétrier’s disease is not considered a form of gastritis. It is characterized by large, tortuous gastric mucosal folds.

229

Large gastric folds can be seen in ?

Primary lactase deficiency

B.

Celiac sprue

C.

Abetalipoproteinemia

D.

Intestinal lymphangiectasia

Malabsorption disorder not associated with steatorrhea is ? A.

Tropical sprue

B.

Celiac sprue Pernicious anemia Bacterial overgrowth syndrome

A.

ZES

C.

B.

Gastric malignancy

D.

C.

Sarcoidosis

D.

All of the above

Which of the following decreases protein loss in Ménétrier’s disease ?

Most, but not all, malabsorption syndromes are associated with steatorrhea. Primary lactase deficiency and pernicious anemia are not associated with steatorrhea.

230

A.

Anticholinergic agents

B.

Prednisone

C.

H2 receptor antagonists

D.

PPIs

Medical therapy with anticholinergic agents, prostaglandins, PPIs, prednisone, and H 2 receptor antagonists yields varying results. Anticholinergics decrease protein loss.

A.

> 100 - 200 gram / day

B.

> 200 - 225 gram / day

C.

> 300 - 425 gram / day

D.

> 400 - 500 gram / day

Diarrhea as a sign is a quantitative increase in stool weight of >200–225 mL gram per day, when a western-type diet is consumed.

231

294 - Disorders of Absorption

In a western-type diet, diarrhea as a sign is a quantitative increase in stool water or weight of ? Harrison’s 18th Ed. 2460

Harrison’s 18th Ed. 2459

225

A.

Harrison’s 18th Ed. 2460

Harrison’s 18th Ed. 2459

224

Malabsorption disorder not associated with steatorrhea is ? Harrison’s 18th Ed. 2460

Harrison’s 18th Ed. 2459

223

Intestinal absorption is increased in ? Harrison’s 18th Ed. 2460

Harrison’s 18th Ed. 2458

Antibodies to parietal cells are detected in >90% of patients with pernicious anemia and in up to 50% of patients with type A gastritis. The parietal cell antibody is directed against H+,K+-ATPase.

407 Cardiology

Which of the following diarrhea would undoubtedly cease during a prolonged fast ? Harrison’s 18th Ed. 2460

A.

Enterotoxin-induced traveler’s diarrhea

Intestinal absorption is increased in ?

B.

Primary lactase deficiency

Harrison’s 18th Ed. 2460

C.

VIPoma

A.

Cirrhosis

D.

All of the above

B.

Jejunal diverticulosis

C.

Hemochromatosis

D.

Crohn’s disease

Diarrhea secondary to lactose malabsorption in primary lactase deficiency ceases during a prolonged fast.

408 232

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Stool osmolality is ?

238

Harrison’s 18th Ed. 2461

A.

250 mosmol/kg H 2O

A.

Villi are present in small intestine & colon

B.

275 mosmol/kg H 2O

B.

C.

300 mosmol/kg H 2O

Nutrient digestion & absorption occurs in small intestine but not in colon

D.

325 mosmol/kg H 2O

C.

Digestive hydrolytic enzymes are present in brush border of villus epithelial cells

D.

Secretory function is present in crypts of both small & large intestine

Fecal osmotic gap is calculated as ? Gastroenterology 1999;116:1461-1463

A.

90 - 2([Na+] + [K+])

B.

190 - 2([Na+] + [K +])

C.

290 - 2([Na+] + [K +])

D.

390 - 2([Na+] + [K +])

Villi are present in small intestine but are absent in colon.

239

The lengths of the small intestine and colon are ? Harrison’s 18th Ed. 2461

Basolateral membrane

C.

Basomedial membrane

D.

All of the above

~200 cm and ~50 cm, respectively

B.

~250 cm and ~70 cm, respectively

C.

~300 cm and ~80 cm, respectively

A.

Apical membrane

D.

~400 cm and ~100 cm, respectively

B.

Basolateral membrane

C.

Basomedial membrane

D.

All of the above

240

Effective functional surface area of intestines is about how many times greater than that of a hollow tube ?

Transport protein SGLT is located on ? Harrison’s 18th Ed. 2461

A.

200 times

Active glucose (monosaccharide) absorption & glucose-stimulated Na + absorption require both apical membrane transport protein SGLT (sodium/glucose cotransporter) & basolateral Na +,K + ATPase. A competitive inhibitor of SGLT, phlorizin exerts a hypoglycemic effect in diabetics. Gene for SGLT is SLC5A.

B.

400 times

241

C.

600 times

Harrison’s 18th Ed. 2461

D.

800 times

A.

Primary bile acids are synthesized in liver from cholesterol

B.

Secondary bile acids are synthesized from primary bile acids

C.

Cholic & deoxycholic acids are primary bile acids

D.

Lithocholic acid is a secondary bile acid

Effective functional surface area is about 600-fold greater than that of a hollow tube due to the presence of folds, villi (in small intestine), and microvilli.

Intestinal mucosa synthesizes & secretes which of the following immunoglobulin ? Harrison’s 18th Ed. 2461

A.

Secretory IgA

B.

Secretory IgG

C.

Secretory IgM

D.

Secretory IgE

242

A.

3 to 4 L/day

B.

5 to 6 L/day

C.

6 to 7 L/day

D.

7 to 8 L/day

The intestine absorbs ~7 to 8 liters of fluid daily, comprising dietary fluid intake (1 to 2 L/day) and salivary, gastric, pancreatic, biliary, and intestinal fluid (6 to 7 L/day).

What quantity of bile acids are synthesized in liver every day ? Harrison’s 18th Ed. 2461

Daily salivary, gastric, pancreatic, biliary, and intestinal fluid amounts to ? Harrison’s 18th Ed. 2461

Which of the following about bile acids is false ?

Bile acids are not present in the diet but are synthesized in liver. Primary bile acids are synthesized in liver from cholesterol and secondary bile acids are synthesized from primary bile acids in intestine by colonic bacterial enzymes. Primary bile acids are cholic acid & chenodeoxycholic acid. Secondary bile acids are deoxycholic acid and lithocholic acid.

Intestinal mucosa synthesizes and secretes secretory IgA.

237

Apical membrane

B.

A.

Harrison’s 18th Ed. 2461

236

A.

Na+ pump is located on the basolateral membrane, which expels Na+ and maintains a low intracellular Na+ through Na+,K+ - ATPase.

Lengths of small intestine and colon are ~300 cm and ~80 cm respectively.

235

Na+, K+ - ATPase in the Na+ pump is located on ? Harrison’s 18th Ed. 2461

Osmotic diarrheas are characterized by osmotic gaps >125 mOsm/kg (nonelectrolytes account for most of the osmolality of stool water), whereas secretory diarrheas typically have osmotic gaps 20 grams) that does not respond to cholestyramine but responds to a low-fat diet.

255

Which of the following type of fatty acids compose dietary fats ? Harrison’s 18th Ed. 2463

A.

Long-chain fatty acids (LCFAs)

B.

Medium-chain fatty acids (MCFAs)

410

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Short-chain fatty acids (SCFAs)

B.

Duodenum

D.

All of the above

C.

Jejunum

D.

Iliem

Three types of fatty acids compose fats: long-chain fatty acids (LCFAs), medium-chain fatty acids (MCFAs), and short-chain fatty acids (SCFAs).

256

Dietary fat is in the form of ?

262

Gastroenterology

In lipolysis, hydrolysis of triglycerides by lipase leads to the formation of ?

Harrison’s 18th Ed. 2463

Harrison’s 18th Ed. 2463

A.

Long-chain triglycerides (LCTs)

A.

Free fatty acids

B.

Medium-chain fatty acids (MCFAs)

B.

Monoglycerides

C.

Short-chain fatty acids (SCFAs)

C.

Glycerol

D.

All of the above

D.

All of the above

Dietary fat is exclusively composed of long-chain triglycerides (LCTs), i.e., glycerol that is bound via ester-linkages to three LCFAs.

Lipolysis i.e. hydrolysis of Tg to free fatty acids, monoglycerides & glycerol by lipase is “initiated” in stomach by gastric lipase. ~20 - 30% of total lipolysis occurs in stomach.

257

263

Majority of dietary long chain fatty acids (LCFAs) have carbon chain lengths of ?

Harrison’s 18th Ed. 2463

Harrison’s 18th Ed. 2463, Table 294-3

A.

6-8

B.

8 - 10

C.

10 - 12

D.

> 12

3 types of fatty acids compose fats - long chain fatty acids (LCFAs), medium-chain fatty acids (MCFAs) & short-chain fatty acids (SCFAs). Majority of dietary LCFAs have carbon chain lengths of 16 or 18.

258

264

B.

8 - 12

C.

12 - 16

D.

16 - 20

Medium-chain triglycerides (MCTs) or medium-chain fatty acids, composed of fatty acids with carbon chain lengths of 8 to 10, are present in large amounts in coconut oil.

259

Pancreatic lipase

C.

Colipase

D.

All of the above

Normal lipolysis can be maintained by what percentage of maximal pancreatic lipase secretion ? A.

5%

B.

15 %

C.

25 %

D.

35 %

Normal lipolysis can be maintained by ~5% of maximal pancreatic lipase secretion.

265

Pancreatic lipase is inactivated at ? Harrison’s 18th Ed. 2464

Harrison’s 18th Ed. 2463

B.

pH < 7.5

A.

Intraluminal or digestive phase

C.

pH < 8

B.

Mucosal or absorptive phase

D.

pH < 8.5

C.

Delivery or postabsorptive phase

D.

Any of the above

A.

pH < 7

Lipolysis is completed in the duodenum and jejunum by pancreatic lipase, which is inactivated by pH 3:1

Which of the following is true in patients recovering from jaundice ? Harrison’s 18th Ed. 2527

A.

Urine bilirubin clears prior to serum bilirubin

B.

Serum bilirubin clears prior to urine bilirubin

C.

Urine and serum bilirubin clear simultaneously

D.

Any of the above

613

Which of the following play a role in detoxification of ammonia ?

A.

AST rarely > 300 U/L

B.

ALT often normal

Harrison’s 18th Ed. 2527

C.

Increase in IgA levels

A.

Spleen

D.

None of the above

B.

Pancreas

C.

Striated muscle

D.

Cartilage

AST in alcoholic liver disease is rarely >300 U/L and ALT is often normal. Increases in IgA levels occur in alcoholic liver disease.

614

Aspartate aminotransferase (AST) found in all except ? A.

Skeletal muscle

B.

Kidneys

C.

Spleen

D.

Lungs

Which of the following about aminotransferases is false ? Harrison’s 18th Ed. 2529

Harrison’s 18th Ed. 2528

609

Which of the following about alcoholic liver disease is false ? Harrison’s 18th Ed. 2529

Liver converts ammonia to urea which is excreted by kidneys. Striated muscles detoxify ammonia by combining it with glutamic acid to form glutamine.

608

> 1.5:1

An AST:ALT ratio >2:1 is suggestive while a ratio >3:1 is highly suggestive of alcoholic liver disease.

In patients recovering from jaundice, the urine bilirubin clears prior to the serum bilirubin.

607

615

A.

Aminotransferases are present in serum in low concentrations

B.

Liver cell necrosis not required for release of aminotransferases

C.

Absolute elevation of aminotransferases is of no prognostic significance in acute hepatocellular disorders

D.

None of the above

Low serum ALT in alcoholic liver disease is due to ? Harrison’s 18th Ed. 2529

A.

Deficiency of pyridoxal sulphate

Harrison’s 18th Ed. 2528

B.

Deficiency of pyridoxal phosphate

A.

Leukocytes

C.

Deficiency of pyridoxal gluconate

B.

Erythrocytes

D.

Deficiency of pyridoxal chloride

C.

Platelets

D.

All of the above

Aspartate aminotransferase (AST) not found in ?

439 Cardiology

A low level of ALT in the serum is due to an alcohol-induced deficiency of pyridoxal phosphate.

440 616

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following enzymes is elevated in cholestasis ? Harrison’s 18th Ed. 2529

A.

Alkaline phosphatase

B.

5’-nucleotidase

C.

Gamma glutamyl transpeptidase (GGT)

D.

All of the above

D.

622

A.

Alkaline phosphatase

B.

5’-nucleotidase

C.

Gamma glutamyl transpeptidase (GGT)

D.

All of the above

Elevated heat-stable fraction of serum alkaline phosphatase suggests its origin from ?

623

Liver

B.

Bone

C.

Placenta

D.

Intestine

Elevated heat-stable fraction of serum alkaline phosphatase strongly suggests its placental or tumor source. Bone alkaline phosphatase is most susceptible to inactivation by heat.

619

624

B.

B

C.

AB

D.

All of the above

625

B.

3 times

C.

4 times

D.

None of the above

Alkaline phosphatase elevations greater than four times normal occur primarily in cholestatic liver disorders, infiltrative liver diseases and Paget’s disease.

621

Conditions causing isolated elevations of serum alkaline phosphatase include all except ? Harrison’s 18th Ed. 2529

A.

Hodgkin’s disease

B.

Inflammatory bowel disease

C.

Hypothyroidism

All of the above

Serum albumin has a half-life of ? A.

18 to 20 days

B.

28 to 35 days

C.

35 to 45 days

D.

> 60 days

What proportion of albumin is degraded per day ? 2%

B.

4%

C.

6%

D.

8%

Albumin synthesis is inhibited by ? A.

Serum interleukin 1

B.

Cholecystokinin

C.

Lipase

D.

All of the above

Prolonged increases in levels of serum cytokines IL-1 &/or tumor necrosis factor inhibit albumin synthesis.

626

Which of the following serum globulins is not produced by hepatocytes ? Harrison’s 18th Ed. 2530

Harrison’s 18th Ed. 2529

2 times

D.

Harrison’s 18th Ed. 2529

In cholestatic liver disorders, alkaline phosphatase elevations are how many times greater than normal ? A.

Intestinal epithelial cells

Serum albumin has a half-life of 18 to 20 days with approximately 4% degraded per day.

Individuals with blood types O & B can have an elevation of serum alkaline phosphatase after eating a fatty meal due to influx of intestinal alkaline phosphatase into the blood.

620

Kidney

C.

A.

Harrison’s 18th Ed. 2529

A

B.

Harrison’s 18th Ed. 2529

Individuals of which of the following blood group can have an elevation of serum alkaline phosphatase after eating a fatty meal ? A.

Hepatocyte

Harrison’s 18th Ed. 2529

Harrison’s 18th Ed. 2529

A.

A.

Serum albumin is synthesized exclusively by hepatocytes.

Alkaline phosphatase and 5’-nucleotidase are found in or near the bile canalicular membrane of hepatocytes, while GGT is located in the endoplasmic reticulum and in bile duct epithelial cells. Serum 5'-nucleotidase or GGT are rarely elevated in conditions other than liver disease.

618

Serum albumin is synthesized by ? Harrison’s 18th Ed. 2529

Which of the following is located in endoplasmic reticulum of hepatocytes ? Harrison’s 18th Ed. 2529

Congestive heart failure

Isolated elevations of serum alkaline phosphatase is seen in Hodgkin’s disease, diabetes, hyperthyroidism, CHF, amyloidosis and inflammatory bowel disease.

Alkaline phosphatase, 5’-nucleotidase & GGT are usually elevated in cholestasis.

617

Gastroenterology

A.

Alpha globulin

B.

Beta globulin

C.

Gamma globulin

D.

All of the above

Gamma globulins (immunoglobulins) are produced by B lymphocytes and alpha and beta globulins are produced in hepatocytes.

627

Which of the following statements is false ? Harrison’s 18th Ed. 2530

A.

Gamma globulins are increased in chronic liver disease

B.

IgG levels increase in autoimmune hepatitis

C.

IgM levels increase in primary biliary cirrhosis

D.

None of the above

In cirrhosis, increased serum gamma globulin concentration is due to increased synthesis of antibodies, some directed against intestinal bacteria because cirrhotic liver fails to clear bacterial antigens. Diffuse polyclonal increases in IgG levels are common in autoimmune hepatitis. Increases in IgM levels are common in primary biliary cirrhosis, while increases in IgA levels occur in alcoholic liver disease.

Gastroenterology 441 628

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Which of the following blood clotting factors is not made by hepatocytes ?

441 Cardiology

303 - Hyperbilirubinemias

Harrison’s 18th Ed. 2530

A.

II

B.

V

C.

VIII

D.

X

634

Harrison’s 18th Ed. 2531

With the exception of factor VIII (produced by vascular endothelial cells), blood clotting factors are made exclusively in hepatocytes.

629

Serum half-life of factor VII is ? Harrison’s 18th Ed. 2530

A.

6 hours

B.

24 hours

C.

48 hours

D.

72 hours

635

A.

2 days

B.

3 days

C.

5 days

D.

7 days

636

Harrison’s 18th Ed. 2530

II

B.

V

C.

IX

D.

X

637

~ 70 - 90 %

D.

~ 100 %

Glutathione-S-transferase is related to which of the following steps in bilirubin metabolism ? A.

Hepatocellular uptake

B.

Intracellular binding

C.

Conjugation

D.

Biliary excretion

Bilirubin-UDP-glucuronosyltransferase is related to which of the following steps in bilirubin metabolism ? A.

Hepatocellular uptake

B.

Intracellular binding

C.

Conjugation

D.

Biliary excretion

Aqueous insolubility of bilirubin is due to which of the following ? Harrison’s 18th Ed. 2531

A.

Internal phosphate bonding

Single best acute measure of hepatic synthetic function is ?

B.

Internal hydrogen bonding

Harrison’s 18th Ed. 2530

C.

Internal sulphate bonding

D.

All of the above

A.

Serum albumin

B.

Serum globulins

C.

Clotting factors

D.

Serum bilirubin

Conjugation of bilirubin with glucuronic acid moieties disrupts internal hydrogen bonding that limits aqueous solubility of bilirubin & the resulting glucuronide conjugates are highly soluble in water.

638

Because of their rapid turnover, measurement of the clotting factors is the single best acute measure of hepatic synthetic function.

633

C.

Bilirubin is conjugated with one or two glucuronic acid moieties by a specific UDPglucuronosyltransferase to form bilirubin mono- and diglucuronide, respectively.

Serum prothrombin time collectively measures factors II, V, VII and X.

632

~ 50 - 70 %

Harrison’s 18th Ed. 2531

Serum prothrombin time does not measure which of the following factor ? A.

B.

After hepatocellular uptake, bilirubin is kept in solution by binding to glutathione-S-transferases formerly called ligandins.

Serum half life of fibrinogen is 5 days.

631

~ 30 - 50 %

Harrison’s 18th Ed. 2531

Serum half-life of fibrinogen is ? Harrison’s 18th Ed. 2530

A.

About 70 - 90% of bilirubin is derived from degradation of the hemoglobin of senescent red blood cells.

Serum half life of factor VII is 6 hours.

630

What proportion of bilirubin is derived from degradation of the hemoglobin of senescent red blood cells ?

Harrison’s 18th Ed. 2532

Biosynthesis of factors which of the following factors depends on vitamin K ? Harrison’s 18th Ed. 2530

A.

II

B.

IX

C.

X

D.

All of the above

Biosynthesis of factors II, VII, IX, and X depends on vitamin K.

UDP-glucuronosyltransferases (UGT) that conjugate bilirubin belong to which UGT family ? A.

UGT1

B.

UGT2

C.

UGT3

D.

UGT4

UDP-glucuronosyltransferases (UGT) that conjugate bilirubin belong to the UGT1 family. Exon A1 and the four common exons, collectively designated the UGT1A1 gene, encode the physiologically critical enzyme bilirubin-UDP-glucuronosyltransferase (UGT1A1).

639

Human UGT1 gene complex is on which of the following chromosomes ? Harrison’s 18th Ed. 2532, Figure 303-2

A.

2

442

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

4

C.

6

D.

8

645

Multidrug resistance - associated protein 2 (MRP2) is related to which of the following steps in bilirubin metabolism ?

Direct-reacting fraction is how much of total serum bilirubin in isolated hemolysis ? Harrison’s 18th Ed. 2532

Human UGT1 gene complex is on chromosome 2. It contains at least 13 substrate-specific first exons (A1, A2, etc.). Since four of these are pseudogenes, nine UGT1 isoforms with differing substrate specificities are expressed. Mutations in a first exon affect only a single isoform. Those in exons 2 - 5 affect all enzymes encoded by the UGT1 complex.

640

Gastroenterology

A.

105 copies/ml), and anti-HBe but no HBeAg as the mutant virus is incapable of encoding HBeAg. This is an example of single base substitution, from G to A, which occurs in the second to last codon of pre-C gene at nucleotide 1896 results in the replacement of the TGG tryptophan codon by a stop codon (TAG), which prevents the translation of HBeAg.

758

763

Harrison’s 18th Ed. 2541

Single base substitution

B.

Single base addition

C.

Single amino acid substitution

D.

Single amino acid addition

Extrahepatic site where Hepatitis B antigen and HBV DNA has been identified is ? Harrison’s 18th Ed. 2541

A.

Bone marrow

B.

Spleen

C.

Pancreas

D.

All of the above

764

Which of the following is a member of the genus Deltavirus ?

S

B.

C

C.

P

D.

X

HDV RNA requires which of the following for its replication ? Harrison’s 18th Ed. 2542

A.

Host RNA polymerase I

B.

Viral RNA polymerase I

C.

Host RNA polymerase II

D.

Viral RNA polymerase II

HDV RNA requires host RNA polymerase II for its replication via RNA-directed RNA synthesis by transcription of genomic RNA to a complementary antigenomic (plus strand) RNA. The antigenomic RNA, in turn, serves as a template for subsequent genomic RNA synthesis.

765

Which of the following is false about delta hepatitis virus ? Harrison’s 18th Ed. 2542

Although not associated with tissue injury, extrahepatic site where Hepatitis B antigens and HBV DNA have been identified include lymph nodes, bone marrow, circulating lymphocytes, spleen, and pancreas.

760

A.

HDV genome is a small, 1700-nucleotide, circular, single-strand RNA of negative polarity that is nonhomologous with HBV DNA, except for a small area of the polymerase gene.

In escape mutants of HBV there occurs a single amino acid substitution, from glycine to arginine at position 145 of the immunodominant “a” determinant common to all subtypes of HBsAg. This change in HBsAg leads to a loss of neutralizing activity by anti-HBs. This HBV/a mutant is seen in active and passive immunization, and in liver transplant recipients who underwent the procedure for hepatitis B and who were treated with a high-potency human monoclonal anti-HBs preparation.

759

The single-stranded RNA genome of HDV is homologous to an extent with which gene of HBV ? Harrison’s 18th Ed. 2542

HBV escape mutants best relate to which of the following ? A.

Gastroenterology

A.

HDV antigen is expressed in hepatocyte nuclei

B.

Intracellular replication of HDV RNA can occur without HBV

C.

Duration of HDV infection determined by duration of HBV infection

D.

In acute HDV infection, anti-HDV detected before symptoms appear

In acute HDV infection, anti-HDV is detected 30-40 days after symptoms appear.

Harrison’s 18th Ed. 2542

A.

Hepatitis D virus

B.

Marburg virus

C.

California encephalitis virus

D.

All of the above

766

Harrison’s 18th Ed. 2542

Delta hepatitis agent (HDV) is the only member of the genus Deltavirus.

761

Which of the following is false about delta hepatitis virus ? Harrison’s 18th Ed. 2542

A.

HDAg

B.

HDsAg

C.

HDeAg

D.

All of the above

HDV RNA has only one open reading frame, and delta antigen (HDAg), a product of the antigenomic strand is the only known HDV protein.

A.

Defective RNA virus

B.

35- to 37-nm in size

C.

1700-nucleotide genome

Harrison’s 18th Ed. 2542

D.

Has antigenic homology with HBV antigens

A.

Hepatitis A

B.

Hepatitis B

C.

Hepatitis C

D.

Hepatitis E

767

HDV is a defective RNA virus that coinfects with and requires the helper function of HBV for its replication & expression. It is formalin-sensitive, 35- to 37-nm virus with a hybrid structure. Its genome is a 1700-nucleotide, circular, single-strand RNA. Delta antigen bears no antigenic homology with any of the HBV antigens.

762

Which of the following is an HDV protein ?

The delta core of HDV is “encapsidated” by an outer envelope of ? Harrison’s 18th Ed. 2542

A.

HBcAg

B.

HBsAg

C.

HBeAg

D.

Any of the above

The delta core of HDV is “encapsidated” by an outer envelope of HBsAg quite like that of HBV.

Which of the following hepatitis was earlier called “non-A, nonB hepatitis” ?

Before its identification, Hepatitis C virus was labeled as “non-A, non-B hepatitis”.

768

Hepatitis C virus was first identified in which year ? A. 1986 B.

1989

C.

1992

D.

1995

Hepatitis C virus was first identified in 1989.

Gastroenterology 453 769

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Which of the following is a member of family Flaviviridae ? Harrison’s 18th Ed. 2542

HCV gains entry into the hepatocyte via the nonliver-specific CD81 receptor and the liver-specific tight junction protein claudin-1. Most sensitive indicator of HCV infection is presence of HCV RNA, that requires molecular amplification by PCR or transcription-mediated amplification (TMA).

A.

Yellow fever virus

B.

Dengue virus

C.

Hepatitis C virus

Harrison’s 18th Ed. 2543

D.

All of the above

A.

Viroid

B.

Nucleocapsid protein

C.

Lipoprotein

D.

CD81 receptor

775

Members of family Flaviviridae are Yellow fever virus, Dengue virus, St. Louis encephalitis virus, West Nile virus, Hepatitis C virus (HCV) and Hepatitis G virus. HCV however is the only member of the genus Hepacivirus in the family Flaviviridae.

770

HCV masquerades as a lipoprotein.

Harrison’s 18th Ed. 2543, Figure 304-6

776

C

Harrison’s 18th Ed. 2543

B.

E1

A.

2

C.

E2

B.

3

All of the above

C.

4

D.

6

In hepatitis C virus genome, which of the following functions as an ion channel ?

Till date HCV genotypes identified are 6 as well as >50 subtypes within genotypes.

777

Harrison’s 18th Ed. 2543, Figure 304-6

A.

C

B.

E1

C.

E2

D.

p7

Placed adjacent to the structural proteins, p7 is a membrane protein that appears to function as an ion channel.

772

Which of the following nonstructural regions of hepatitis C virus genome codes for RNA-dependent RNA polymerase ? A.

NS3

B.

NS4

C.

NS5A

D.

NS5B

At 3' end are six nonstructural (NS) regions, NS2, which codes for a cysteine protease; NS3, which codes for a serine protease and an RNA helicase; NS4 and NS4B; NS5A; and NS5B, which codes for an RNA-dependent RNA polymerase.

774

HCV genotypes differ one from another in sequence homology by ? Harrison’s 18th Ed. 2543

A.

10 %

B.

20 %

C.

30 %

D.

40 %

Genotypes differ one from another in sequence homology by 30%. Those with less differences in sequence homology are referred to as quasispecies.

778

HCV RNA is reported as ? Harrison’s 18th Ed. 2543

Harrison’s 18th Ed. 2543, Figure 304-6

773

Number of HCV genotypes identified is ?

A.

The three structural genes at the 5' end of hepatitis C virus genome are C - which codes for nucleocapsid, and E1 and E2 - which code for envelope glycoproteins.

771

HCV masquerades as which of the following ?

Which of the following is the structural gene in hepatitis C virus genome ?

D.

A.

International units (IUs) per milliliter

B.

Microgram per milliliter

C.

Copies per milliliter

D.

Virions per milliliter

HCV RNA is reported as international units (IUs) per milliliter.

779

Which of the following is the first detectable event during acute hepatitis C progressing to chronicity ?

Which of the following is false about HCV ?

Harrison’s 18th Ed. 2543, Figure 304-7

Harrison’s 18th Ed. 2542

A.

HCV RNA

A.

40 - 60 nm in diameter

B.

HCV DNA

B.

9600-nucleotide RNA virus

C.

Elevated alanine aminotrans ferase (ALT)

C.

Its half-life is 2.7 hours

D.

Elevation and appearance of anti-HCV

D.

None of the above

Which of the following is false about HCV ? Harrison’s 18th Ed. 2543

453 Cardiology

During acute hepatitis C progressing to chronicity, HCV RNA is the first detectable event, preceding alanine aminotransferase (ALT) elevation and the appearance of anti-HCV.

780

“Epidemic, non-A, non-B hepatitis” relates to which of the following ?

A.

HCV enters hepatocyte via CD81 receptor

B.

HCV infection does not induce lasting immunity against reinfection

N Engl J Med 2012;367:1237-44, Harrison’s 18th Ed. 2543

A.

Hepatitis A

C.

Most sensitive indicator of HCV infection is the presence of HCV RNA

B.

Hepatitis B

C.

Hepatitis C

D.

None of the above

D.

Hepatitis E

454

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Hepatitis E was initially identified in 1980 as “epidemic or enterically transmitted, non-A, non-B hepatitis”, an infectious, waterborne illness similar to hepatitis A.

781

In India, most common cause of acute hepatitis is ? Harrison’s 18th Ed. 2543

787

Hepatitis B

C.

Hepatitis C

A.

Swine

D.

Hepatitis E

B.

Bird

Harrison’s 18th Ed. 2543

Which of the following about HEV is false ?

C.

Fish

D.

Dog

Contributing to the perpetuation of HEV are animal reservoirs, most notably in swine.

A.

Enveloped virus

B.

Single-stranded, positive-sense RNA genome

C.

Genome is 7.6 kb in length

A.

Flaviviridae

D.

Genome contains three open reading frames (ORFs)

B.

Hepeviridae

C.

Rhabdoviridae

D.

Arenaviridae

788

Which of the following best relates to HEV ? N Engl J Med 2012;367:1237-44, Harrison’s 18th Ed. 2543

ORF1 encodes which of the following nonstructural proteins ?

HEV was the first member to be identified in the Hepeviridae family.

N Engl J Med 2012;367:1237-44

789

Which of the following about HEV is false ?

A.

Methyl transferase (MT)

B.

Cysteine protease (Pro)

A.

HEV replicates in cytoplasm

C.

Helicase (Hel)

B.

Genotypes 1 and 2 are human viruses

D.

All of the above

C.

Genotypes 3 and 4 are swine viruses

D.

None of the above

Which of the following ORF in Hepatitis E virus genome encodes the nonstructural, enzymatic activities required for viral replication ?

N Engl J Med 2012;367:1237-44

HEV replicates in cytoplasm. Four genotypes of HEV have been categorized into two major groups. Genotypes 1 and 2 are human viruses that cause epidemic hepatitis with waterborne and fecal-oral transmission. Genotypes 3 and 4 are swine viruses.

790

A.

ORF1

B.

ORF2

C.

ORF3

D.

All of the above

Largest of three ORFs, ORF1 encodes the nonstructural, enzymatic activities required for viral replication.

In HEV, which of the following genes encode the nucleocapsid protein ?

Which of the following about HEV infection is false ? N Engl J Med 2012;367:1237-44

N Engl J Med 2012;367:1237-44, Harrison’s 18th Ed. 2543

A.

HEV RNA is detectable in stool during incubation period

B.

HEV RNA is detectable in serum during incubation period

C.

IgM antibody is undetectable during recovery

D.

None of the above

Both IgM anti-HEV and IgG anti-HEV appear early during acute infection, but both fall rapidly after acute infection, reaching low levels within 9 - 12 months.

791

Incubation period of acute hepatitis E infection is ? N Engl J Med 2012;367:1237-44

A.

1 to 2 weeks

ORF1

B.

2 to 4 weeks

B.

ORF2

C.

3 to 8 weeks

C.

ORF3

D.

6 to 12 weeks

D.

All of the above

Harrison’s 18th Ed. 2543

A.

The middle-sized open reading frame 2 (ORF2) gene in HEV encodes the nucleocapsid protein. ORF1 encodes nonstructural proteins involved in virus replication. The smallest ORF3, encodes a structural protein whose function remains undetermined.

786

Which of the following acts as an animal reservoir contributing to the perpetuation of HEV ?

B.

ORF1 encodes nonstructural proteins namely methyl transferase (MT), cysteine protease (Pro), helicase (Hel), and RNA polymerase (Pol). ORF1 also encodes three regions of unknown function (Y, H, and X).

785

Hepatitis E

Hepatitis A

HEV is a small (32- to 34-nm), nonenveloped virus with a single-strand, positive-sense RNA genome (7.6 kb in length) which contains three partially overlapping open reading frames (ORFs) bracketed by short 5’ and 3’ nontranslated regions.

784

D.

A.

N Engl J Med 2012;367:1237-44, Harrison’s 18th Ed. 2543

783

Hepatitis C

HEV has three open reading frames (ORF) genes.

In India, enterically transmitted HEV is the most common cause of acute hepatitis.

782

C.

Gastroenterology

ORF gene relates to ? Harrison’s 18th Ed. 2543

A.

Hepatitis A

B.

Hepatitis B

Acute hepatitis E has an incubation period of 3 to 8 weeks.

792

Average case fatality rate in acute HEV infections is ? N Engl J Med 2012;367:1237-44

A.

0%

B.

2%

C.

3%

D.

5%

Gastroenterology 455

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Acute hepatitis E is mostly self-limited without progression to chronic hepatitis. Average case fatality rate is ~ 5 %.

793

Clinical features of autochthonous hepatitis E include all except ?

455 Cardiology

B.

Absence of acute-hepatitis illness

C.

Almost invariable establishment of chronic infection

D.

Never go into cirrhosis & hepatocellular carcinoma

Neonatally acquired HBV infection can may culminate into cirrhosis & hepatocellular carcinoma.

N Engl J Med 2012;367:1237-44

A.

Disease rates highest among older adults

B.

Hepatitis E is preventable by vaccination

C.

No neurologic complications

D.

Ribavirin, peginterferon indicated

In endemic, or autochthonous hepatitis E, the average age was more than 60 years, and men outnumbered women by at least 3 to 1. Hepatitis E is preventable by vaccination. Autochthonous HEV infection is usually subclinical and mild. Autochthonous hepatitis E has frequent serious complications, including “acute-on-chronic” liver failure, neurologic disorders (polyradiculopathy, the GBS, Bell’s palsy, peripheral neuropathy, ataxia, and mental confusion), and chronic hepatitis. Chronic hepatitis E is also susceptible to antiviral therapy (peginterferon, ribavirin, or a combination of two).

794

Chronic infection in Hepatitis E has been identified almost exclusively among ?

799

Harrison’s 18th Ed. 2544

Pre-existing liver disease

B.

Blood transfusion recepients

C.

Pork eaters

D.

Immunocompromised persons

Chronic HEV infection has been identified almost exclusively among immunocompromised persons (organtransplant recipients, patients receiving cancer chemotherapy, and HIV-infected persons). Blood transfusion is a potential but rare route of HEV transmission. Chronic hepatitis E is characterized by the persistence of HEV RNA in serum & stool, accompanied by fluctuating, mild-to-moderate elevations in serum ALT levels and low or moderate titers of IgG and IgM anti-HEV antibodies.

795

796

800

B.

Acute hepatitis-like illness

C.

Failure to recover is the exception

D.

Chronicity is common

Which of the following HLA allele has been linked with selflimited hepatitis C ? Harrison’s 18th Ed. 2544

A.

HLA-B*1501

B.

HLA-B*5701

C.

Single nucleotide polymorphism T allele at IL28B locus

D.

C/C haplotype of the IL28B gene

C/C haplotype of the IL28B gene has been linked with self-limited hepatitis C.

801

Which of the following plays a pathogenetic role in the extrahepatic manifestations of acute hepatitis B ? Harrison’s 18th Ed. 2545

A.

Cytopathic role of virus

Harrison’s 18th Ed. 2544

B.

Immune complex - mediated tissue damage

A.

Hepatitis B virus is not directly cytopathic

C.

Cryoprecipitable immune complexes

B.

HBcAg invites cytolytic T cells to destroy HBV-infected hepatocytes

D.

All of the above

C.

Inactive hepatitis B carriers can have normal liver histology

D.

None of the above

Immune complex - mediated tissue damage plays a pathogenetic role in the extrahepatic manifestations of acute hepatitis B.

802

Which of the following statements is false ?

Which of the following is an extrahepatic manifestation of hepatitis B ?

Harrison’s 18th Ed. 2544

Harrison’s 18th Ed. 2545

A.

Patients with defects in cellular immune competence are more likely to remain chronically infected with HBV

A.

Glomerulonephritis with nephrotic syndrome

B.

Polyarteritis nodosa

C.

Essential mixed cryoglobulinemia (EMC)

D.

All of the above

C.

Chronic HBV infection can occur in the absence of serum hepatitis B e antigen (HBeAg) Most characteristic histologic feature of chronic HBV infection is “ground-glass hepatocyte” due to intracellular accumulation of HBsAg

D.

None of the above

803

Which of the following is associated with a more severe outcome of HBV infection ? Harrison’s 18th Ed. 2544

798

Robust host-immune response

Which of the following statements is false ?

B.

797

A.

Chronicity is uncommon and risk of hepatocellular carcinoma is very low.

N Engl J Med 2012;367:1237-44

A.

HBV infection acquired during adolescence or early adulthood is associated with all except ?

A.

Infection with precore genetic mutants of HBV

B.

Concomitant HDV and HBV infections

C.

In liver transplantation for end-stage chronic hepatitis B

D.

All of the above

Which of the following is the pathognomonic manifestation of HCV infection ? A. Necrolytic acral erythema B.

Porphyria cutanea tarda

C.

Leucocytoclastic vasculitis

D.

Lichen planus (LP)

Necrolytic acral erythema is a rare, but pathognomonic manifestation of HCV.

804

Mixed cryoglobulinemia (MC) is associated with which of the following ? Harrison’s 18th Ed. 2545

A.

HAV

Harrison’s 18th Ed. 2544

B.

HCV

A.

C.

HDV

HBV infection in neonatal period is associated with all except ? Acquisition of immunologic tolerance to HBV

456

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

HEV

Mixed cryoglobulinemia (MC) is unequivocally associated with HCV.

805

Which type of cryoglobulinemia is associated with lymphoproliferative diseases ? A. Types I B.

Types II

C.

Types III

D.

Any of the above

Type I cryoglobulinemia is monoclonal & associated with lymphoproliferative diseases (multiple myeloma, Waldenström macroglobulinemia). Types II & III are mixed & polyclonal cryoglobulinemias and are associated with autoimmune disorders, viral infections, & chronic liver disease (Brouet classification).

806

Classic triad of cryoglobulinemic syndrome includes all except ? A. Purpura

811

Councilman bodies are best related to ? Harrison’s 18th Ed. 2545

A.

Fibrosis

B.

Liver cell regeneration

C.

Apoptosis

D.

Growth arrest

Liver cell damage leads to acidophilic degeneration of hepatocytes called Councilman or apoptotic bodies.

812

Which of the following is seen in chronic but not in acute HBV infection ? Harrison’s 18th Ed. 2545

A.

Acidophilic degeneration of hepatocytes

C.

Weakness

B.

Ballooning of hepatocytes

D.

Acrocyanosis

C.

Hepatocyte dropout

D.

Ground-glass appearance of cytoplasm

Cryoglobulins are immunoglobulins that precipitate at temperatures below ? A. 37°C B.

36°C

C.

35°C

D.

34°C

Morphologic lesions of viral hepatitis are all except ? A.

Panlobular mononuclear cells infiltration

B.

Hepatic cell necrosis

C.

Cholestasis

D.

Atrophy of Kupffer cells

Typical morphologic lesions of all types of viral hepatitis are panlobular infiltration with mononuclear cells, hepatic cell necrosis, Kupffer cells hyperplasia & variable cholestasis. Hepatic cell regeneration is present.

Large hepatocytes with a ground-glass appearance of the cytoplasm may be seen in chronic but not in acute HBV infection.

813

Panlobular mononuclear infiltration in viral hepatitis consists “primarily” of ? A.

Plasma cells

B.

Small lymphocytes

C.

Large lymphocytes

D.

Eosinophils

Panlobular mononuclear infiltration in viral hepatitis consists “primarily” of small lymphocytes. Plasma cells & eosinophils are present occasionally.

William Thomas Councilman (1854-1933) was of which nationality ? A. British B.

American

Ground-glass appearance of the cytoplasm in chronic HBV infection is due to ? Harrison’s 18th Ed. 2545

A.

HBsAg

B.

HBeAg

C.

HBcAg

D.

HBxAg

Ground-glass appearance of the cytoplasm in chronic HBV infection is due to HBsAg and can be identified histochemically with orcein or aldehyde fuchsin.

814

In hepatitis C, the most remarkable histologic feature is ? Harrison’s 18th Ed. 2545

A.

Marked increase in activation of sinusoidal lining cells

B.

Relative paucity of inflammation

C.

Lymphoid aggregates

D.

Bile duct lesions

In hepatitis C, the histologic lesion is remarkable for a relative paucity of inflammation.

815

Marked cholestasis is a feature of ? Harrison’s 18th Ed. 2545

Harrison’s 18th Ed. 2545

810

Canadian

Arthralgias

Harrison’s 18th Ed. 2545

809

D.

Councilman bodies are named after American pathologist William Thomas Councilman (1854-1933) who discovered them.

Cryoglobulins are immunoglobulins that precipitate at temperatures below 37°C and re-dissolve with warming.

808

Ireland

B.

Classic triad of cryoglobulinemic syndrome consists of purpura, arthralgias & weakness. Others are glomerulonephritis, peripheral neuropathy, generalized vasculitis, livedo reticularis, ischemic ulcers, acrocyanosis and hemorrhagic bullae.

807

C.

Gastroenterology

A.

HAV

B.

HCV

C.

HDV

D.

HEV

Marked cholestasis is a common histologic feature of hepatitis E.

816

What was earlier called bridging hepatic necrosis is also called ? Harrison’s 18th Ed. 2545

A.

Gradual hepatitis

B.

Interface hepatitis

Gastroenterology 457

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

C.

Coupled hepatitis

C.

Perinatal transmission

D.

Destruction hepatitis

D.

All of the above

In acute hepatitis, bridging hepatic necrosis, also termed subacute or confluent necrosis or interface hepatitis is observed occasionally.

817

N Engl J Med 2004;351:2832-8

A.

Can be transmitted through breast milk

Harrison’s 17th Ed. 1938

B.

Incubation period for acute infection is 45 to 160 days

C.

Risk of chronicity in infected neonates is 90 %

D.

No known animal reservoirs

A.

Gradual hepatitis

B.

Interface hepatitis

C.

Coupled hepatitis

D.

Destruction hepatitis

~10% of HBV infections are acquired in utero. Most infections occur at the time of delivery and early postpartum period & are not related to breast feeding.

824

In bridging hepatic necrosis, the bridge consists of ? A.

Condensed reticulum

B.

Inflammatory debris

C.

Degenerating liver cells

D.

All of the above

In bridging hepatic necrosis, the bridge consists of condensed reticulum, inflammatory debris, and degenerating liver cells that span adjacent portal areas, portal to central veins, or central vein to central vein. There is collapse of the reticulin framework.

825

Second trimester of pregnancy

C.

Third trimester of pregnancy

D.

Any of the above

Which of the following mothers almost invariably transmit hepatitis B infection to their offspring ? Harrison’s 18th Ed. 2547

A.

HAV antigen

A.

HBsAg-positive + HBeAg-positive

B.

HCV antigen

B.

HBsAg-negative + HBeAg-negative

C.

HDV antigen

C.

HBsAg-positive + HBeAg-negative

D.

HEV antigen

D.

HBsAg-negative + HBeAg-positive

Which of the following hepatitis can be transmitted by fecaloral route ? A.

Hepatitis B

B.

Hepatitis C

C.

Hepatitis D

D.

None of the above

Hepatitis A is transmitted almost exclusively by the fecal-oral route.

Which of the following body fluid from infected persons is most infectious ? Harrison’s 18th Ed. 2546

HBsAg positive mothers who are HBeAg-positive almost invariably (>90%) transmit hepatitis B infection to their offspring, whereas HBsAg carrier mothers with anti-HBe rarely (10 - 15%) infect their offspring.

826

A.

Semen

B.

Saliva

C.

Serum

D.

All are equally infectious

Which of the following is the mode of HBV transmission ? Harrison’s 18th Ed. 2547

Likelihood of perinatal transmission of HBV correlates with the presence of ? Harrison’s 18th Ed. 2547

A.

HBsAg

B.

HBcAg

C.

HBeAg

D.

HBxAg

Likelihood of perinatal transmission of HBV correlates with presence of HBeAg. 90% of HBeAgpositive mothers but only 10–15% of anti-HBe-positive mothers transmit HBV infection to their offspring.

827

Hepatitis B virus (HBV) chronically infects how many people worldwide ? Harrison’s 18th Ed. 2547

HBsAg is identified in almost every body fluid from infected persons. Semen & saliva are infectious though less than serum.

822

First trimester of pregnancy

B.

Harrison’s 18th Ed. 2545

Harrison’s 18th Ed. 2546, Table 304-2

821

A.

Perinatal transmission occurs primarily in infants born to HBsAg carrier mothers or mothers with acute hepatitis B during third trimester of pregnancy or during the early postpartum period.

Which of the following is localized to hepatocyte nucleus ?

HDV antigen is localized to hepatocyte nucleus, while HAV, HCV & HEV antigens are localized to the cytoplasm.

820

Perinatal transmission occurs in infants born to HBsAg carrier mothers during ? Harrison’s 18th Ed. 2547

Harrison’s 18th Ed. 2545

819

What is not true for Hepatitis B virus infections ?

What was earlier called piecemeal necrosis is now called ?

Piecemeal necrosis or limiting plate necrosis is now called "interface hepatitis".

818

823

457 Cardiology

A.

50 million

B.

100 million

C.

250 million

D.

350 million

Hepatitis B virus (HBV) chronically infects over 350 million people worldwide.

828

Prevalence of HBV sero-positivity is more in ?

A.

Percutaneous inoculation

Harrison’s 18th Ed. 2547

B.

Sexual contact

A.

Down’s syndrome

B.

Lepromatous leprosy

458

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Hodgkin’s disease

C.

Alterations in olfaction and taste

D.

All of the above

D.

None of the above

Prevalence of 5-20% is found in Down’s syndrome, lepromatous leprosy, leukemia, Hodgkin’s disease, polyarteritis nodosa, CKD patients on dialysis and IDUs.

829

835

Harrison’s 18th Ed. 2547

A.

A.

1 in 50,000

B.

Cervical adenopathy

B.

1 in 140,000

C.

Spider angiomas

C.

1 in 230,000

D.

All of the above

D.

1 in 320,000

836

Which of the following about HCV infection is false ? A.

Accounts for 40% of chronic liver disease

B.

Most frequent indication for liver transplantation

C.

Worldwide, genotype 1 is the most common

D.

Breast-feeding increases risk of HCV vertical infection

50 - 69 %

B.

69 - 79 %

C.

79 - 89 %

D.

95 - 99 %

837

Acute hepatitis-like clinical events in chronic hepatitis B may be due to ? Harrison’s 18th Ed. 2549

HDV superinfection

B.

Spontaneous HBeAg to anti-HBe seroconversion

Hepatitis virus with longest incubation period is ?

C.

Spontaneous reactivation

Harrison’s 18th Ed. 2546, Table 304-2

D.

All of the above

A.

Hepatitis A

B.

Hepatitis B

C.

Hepatitis C

D.

Hepatitis E

Apart from the above conditions, acute clinical exacerbations of chronic hepatitis B may be due to emergence of a precore mutant.

838

The diagnosis of anicteric hepatitis is based on ? Harrison’s 18th Ed. 2549

Hepatitis virus with an incubation period of ~2 weeks is ?

A.

S. Aminotransferase levels

Harrison’s 18th Ed. 2546, Table 304-2

B.

S. Bilirubin levels

A.

Hepatitis A

C.

S. Alkaline phosphatase levels

B.

Hepatitis C

D.

S. GGT levels

C.

Hepatitis E

D.

All of the above

The diagnosis of anicteric hepatitis is based on clinical features & on aminotransferase elevations.

839

In acute hepatitis, very high serum bilirubin level (20 - 30 mg/ dL) occur in ? Harrison’s 18th Ed. 2549

Viral hepatitis with an insidious onset only is ?

A.

Severe disease

Harrison’s 18th Ed. 2546, Table 304-2

B.

Glucose-6-phosphate dehydrogenase deficiency

C.

Sickle cell anemia

D.

All of the above

A.

Hepatitis A

B.

Hepatitis B

C.

Hepatitis C

D.

Hepatitis E

Onset : HAV - acute, HBV - insidious or acute, HCV - insidious, HDV - insidious or acute, HEV acute

834

A.

A.

Incubation period in days : HAV - 15-45, mean 30, HBV - 30-180, mean 60-90, HCV - 15-160, mean 50, HDV - 30-180, mean 60-90, HEV - 14-60, mean 40.

833

Acute hepatitis B is self-limited in what proportion of cases ?

Acute hepatitis B is self-limited in 95 - 99% of infections, while hepatitis C is self-limited in only 15%.

Worldwide, genotype 1 is the most common. Genotype 4 predominates in Egypt; genotype 5 is localized to South Africa, and genotype 6 to Hong Kong. Breast-feeding does not increase the risk of HCV infection between an infected mother and her infant.

832

Splenomegaly

Harrison’s 18th Ed. 2549

Harrison’s 18th Ed. 2547

831

Which of the following is a presentation of acute viral hepatitis ? Harrison’s 18th Ed. 2549

Risk of acquiring HBV infection from a blood transfusion is ?

Because of highly sensitive virologic screening of donor blood, risk of acquiring HBV infection from a blood transfusion is 1 in 230,000 while it is 1 in 2.3 million for transfusion-associated HCV infection.

830

Gastroenterology

Which of the following about presentation of acute viral hepatitis is false ? Harrison’s 18th Ed. 2549

A.

Constitutional symptoms may precede onset of jaundice by 1 - 2 weeks

B.

Dark urine & clay-colored stools occur 1 - 5 days before onset of clinical jaundice

Bilirubin levels >20 mg/dL persisting late into the course of viral hepatitis is associated with severe disease. Patients with underlying hemolytic anemia, like glucose-6-phosphate dehydrogenase deficiency and sickle cell anemia, also have high serum bilirubin levels (>30 mg/dL) due to superimposed hemolysis.

840

Which of the following occur transiently in acute viral hepatitis ? Harrison’s 18th Ed. 2549

A.

Neutropenia

B.

Lymphopenia

C.

Steatorrhea

D.

All of the above

Gastroenterology 459

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Neutropenia and lymphopenia are transient and are followed by a relative lymphocytosis. Also, mild and transient steatorrhea, microscopic hematuria and minimal proteinuria have been noted.

841

Which of the following is characteristically elevated during acute hepatitis A ? Harrison’s 18th Ed. 2550

A.

Serum IgG

B.

Serum IgM

C.

Serum IgA

D.

Serum IgE

Which of the following antibodies may be present during the acute phase of viral hepatitis ? Harrison’s 18th Ed. 2550

847

C.

Imminent HBsAg clearance

D.

None of the above

After hepatitis B vaccination, which is the only serologic marker to appear ? Harrison’s 18th Ed. 2550

A.

Anti-HBs

B.

Anti-HBe

C.

Anti-HBc

D.

All of the above

After immunization with hepatitis B vaccine, which consists of HBsAg alone, anti-HBs is the only serologic marker to appear.

A.

Rheumatoid factor

B.

Nuclear antibody

C.

Heterophil antibody

Harrison’s 18th Ed. 2551

D.

All of the above

A.

Cirrhosis

B.

Hepatic decompensation

C.

Hepatocellular carcinoma

D.

All of the above

848

During the acute phase of viral hepatitis, antibodies to smooth muscle and other cell constituents may be present, and low titers of rheumatoid factor, nuclear antibody, and heterophil antibody can also be found. In hepatitis C and D, antibodies to LKM may be found.

843

Chronicity

Anti-HBs is rarely detectable in the presence of HBsAg in patients with acute hepatitis B. When this happens, its of no recognized clinical significance.

A diffuse but mild elevation of the gamma globulin fraction is common during acute viral hepatitis. Serum IgM level is elevated more characteristically during acute hepatitis A.

842

B.

If levels of HBsAg are too low to be detected during acute HBV infection, which of the following establishes its diagnosis ?

459 Cardiology

In chronic hepatitis B, high levels of HBV DNA increase the risk of ?

In chronic hepatitis B, high levels of HBV DNA increase the risk of cirrhosis, hepatic decompensation, and hepatocellular carcinoma.

Harrison’s 18th Ed. 2550

A.

IgM anti-HBc

B.

IgG anti-HBc

C.

IgM & IgG anti-HBc

D.

HBeAg

If levels of HBsAg are too low to be detected during acute HBV infection, presence of IgM anti-HBc establishes its diagnosis. HBeAg is invariably present during early acute hepatitis B, HBeAg testing is indicated primarily during follow-up of chronic infection.

844

Which of the following is true in chronic HBV infection ? Harrison’s 18th Ed. 2550

Harrison’s 18th Ed. 2552

A.

Acute hepatitis A

B.

Acute hepatitis B

C.

Acute hepatitis C

D.

Hepatitis D superinfection

Complications of hepatitis A include relapsing hepatitis appearing weeks to months after apparent recovery from acute hepatitis, cholestatic hepatitis and rarely fulminant hepatitis.

850

Extrahepatic manifestations of HCV include ?

IgM anti-HBc-positive, IgG anti-HBc-positive

B.

IgM anti-HBc-negative, IgG anti-HBc-negative

A.

Mixed cryoglobulinemia

C.

IgM anti-HBc-negative, IgG anti-HBc-positive

B.

Porphyria cutanea tarda

D.

IgM anti-HBc-positive, IgG anti-HBc-negative

C.

Lichen planus (LP)

D.

All of the above

A false-positive test for IgM anti-HBc may be found in patients with ? Harrison’s 18th Ed. 2550

Harrison’s 18th Ed. 2552

Well-accepted extrahepatic manifestations of HCV include pruritus, mixed cryoglobulinemia & necrolytic acral erythema. Frequently associated conditions include porphyria cutanea tarda, leucocytoclastic vasculitis, lichen planus, sicca syndrome & polyarteritis nodosa.

851

Fulminant hepatitis is rare in ?

A.

Glucose-6-phosphate dehydrogenase deficiency

Harrison’s 18th Ed. 2552

B.

High-titer rheumatoid factor

A.

Hepatitis A

C.

Sickle cell anemia

B.

Hepatitis B & D

D.

All of the above

C.

Hepatitis E

D.

All of the above

A false-positive test for IgM anti-HBc may be encountered in patients with high-titer rheumatoid factor.

846

Relapsing hepatitis is a feature of ?

A.

IgM anti-HBc may be useful to distinguish between acute or recent infection (IgM anti-HBc-positive) and chronic HBV infection (IgM anti-HBc-negative, IgG anti-HBc-positive).

845

849

Presence of anti-HBs in the presence of HBsAg in patients with acute hepatitis B indicates which of the following ? Harrison’s 18th Ed. 2550

A.

Fulminant hepatitis

Fulminant hepatitis is primarily seen in hepatitis B and D, and hepatitis E. It is rare in hepatitis A.

852

Out of the following, fulminant hepatitis is most common in ? Harrison’s 18th Ed. 2552

A.

Hepatitis A

460

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Hepatitis B

B.

2 weeks

C.

Hepatitis C

C.

3 weeks

D.

Hepatitis E

D.

4 weeks

Hepatitis B accounts for >50% of fulminant cases of viral hepatitis.

853

Fulminant hepatitis is hardly ever seen in ? Harrison’s 18th Ed. 2552

Formalin-inactivated vaccines made from strains of HAV attenuated in tissue culture are safe, immunogenic, and effectively prevent hepatitis A. Hepatitis A vaccines provide adequate protection beginning 4 weeks after a primary inoculation.

859

Hepatitis A

B.

Hepatitis B

A.

Intradermal

C.

Hepatitis C

B.

Subcutenuous

D.

Hepatitis E

C.

Intramuscular

D.

Intravenous

Likelihood of remaining chronically infected after acute HBV infection is high in all except ? Harrison’s 18th Ed. 2552

Harrison’s 18th Ed. 2555

Hepatitis A vaccine is administered intramuscularly.

860

Old

B.

Down’s syndrome

A.

22-nm spherical forms of HBsAg

C.

Chronically hemodialyzed patients

B.

27-nm spherical forms of HBsAg

D.

HIV infection

C.

42-nm spherical forms of HBsAg

D.

All of the above

Progression of acute to chronic hepatitis is likely if ? Harrison’s 18th Ed. 2552

Harrison’s 18th Ed. 2555

First vaccine for active immunization (1982) was prepared from purified, noninfectious 22-nm spherical forms of HBsAg derived from plasma of healthy HBsAg carriers.

861

HBeAg persists for >3 months

B.

HBsAg persists for >6 months

C.

AST/ALT do not normalise within 6-12 months

A.

Nonglycosylated

D.

All of the above

B.

Hydrolyzed

C.

Oxidized

D.

Heat attenuated

Likelihood of remaining chronically infected after acute HCV infection is ? Harrison’s 18th Ed. 2553

Harrison’s 18th Ed. 2555

Plasma-derived Hepatitis B vaccine is prepared from purified, noninfectious 22-nm spherical forms of HBsAg derived from plasma of healthy HBsAg carriers, while genetically engineered Hepatitis B vaccine is derived from recombinant yeast and consists of HBsAg particles that are nonglycosylated but are otherwise indistinguishable from natural HBsAg;

A.

25 - 40 %

B.

40 - 60 %

Harrison’s 18th Ed. 2555

C.

65 - 75 %

A.

Intradermally

85 - 90 %

B.

Subcuteneously

C.

Intramuscularly

D.

Intravenously

D.

862

After acute HCV infection, the likelihood of remaining chronically infected approaches 85-90%.

857

Gianotti-Crosti syndrome is best related to ? Harrison’s 18th Ed. 2553

A.

Hepatitis A

B.

Hepatitis B

C.

Hepatitis C

D.

Hepatitis E

Gianotti-Crosti syndrome or papular acrodermatitis of childhood refers to hepatitis B that presents with anicteric hepatitis, nonpruritic papular rash of face, buttocks & limbs & lymphadenopathy.

858

Which of the following is the difference between plasmaderived vaccine and genetically engineered Hepatitis B vaccine ?

A.

Progression of acute hepatitis to chronic hepatitis is likely if clinical symptoms do not resolve, AST/ ALT, bilirubin and globulin levels fail to normalise within 6-12 months, HBeAg persists for >3 months and HBsAg persists for >6 months.

856

The first vaccine for hepatitis B active immunization was prepared from ?

A.

Likelihood of remaining chronically infected after acute HBV infection is high among neonates, Down’s syndrome, chronically hemodialyzed patients & immunosuppressed patients, including those with HIV infection.

855

Hepatitis A vaccine is administered by which route ?

A.

Fulminant hepatitis is hardly ever seen in hepatitis C.

854

Hepatitis A vaccines provide adequate protection how many weeks after a primary inoculation ?

863

Hepatitis B vaccine is administered ?

In adults, recommended site of Hepatitis B vaccine is ? Harrison’s 18th Ed. 2555

864

A.

Thigh muscle

B.

Triceps muscle

C.

Deltoid muscle

D.

Gluteal muscle

After the first dose of Hepatitis B vaccine, the third dose is given after ? Harrison’s 18th Ed. 2555

Harrison’s 18th Ed. 2555

A.

One month

A.

B.

Three months

1 week

Gastroenterology

Gastroenterology 461 C.

Six months

D.

Twelve months

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR 871

Engerix-B for adults contains what amount of HBsAg in 1 ml. ? Harrison’s 18th Ed. 2556

866

A.

5 µg

B.

10 µg

C.

15 µg

D.

20 µg

872

Patients on peritoneal dialysis

C.

Persons at occupational risk

D.

Clients & staff of institutions for developmentally disabled

Groups for whom Hepatitis B vaccine is recommended include all except ? A.

Recipients of clotting-factor concentrates

B.

Household members & sexual partners of HBV carriers

Harrison’s 18th Ed. 2556

C.

Adoptees from countries where HBV infection is endemic

D.

Travelers spending > 6 weeks in HBV endemic areas

A.

0.02 mL / kg

B.

0.04 mL / kg

C.

0.06 mL / kg

D.

0.08 mL / kg

873

Which of the following statements about Hepatitis B vaccination is false ? A.

Pregnancy is not a contraindication to vaccination

B.

Booster immunizations are not recommended routinely

C.

Booster recommended if anti-HBs levels are 3x ULN AST or ALT + >2x ULN TBL, no initial cholestasis (normal AP), no other prior or concomitant reason for liver function abnormality. Rezulin Rule is also a prognostic rule of DILI. Rezulin is the trade name of banned drug troglitazone.

462 877

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Phase I reaction in drug metabolism include which of the following chemical process ? N Engl J Med 2005;352:2211-21, Harrison’s 18th Ed. 2558

878

879

A.

Oxidation

B.

Reduction

C.

Hydrolysis

D.

All of the above

D.

Cytochrome P-450 enzymes (CYPs) are important in biosynthesis & degradation of endogenous compounds like steroids, lipids, and vitamins.

884

Anti LKM 1

Phase II reaction in drug metabolism include which of the following chemical process ?

B.

Anti LKM 2

C.

Anti LKM 3

N Engl J Med 2005;352:2211-21, Harrison’s 18th Ed. 2558

D.

All of the above

Glucuronidation

B.

Sulfation

C.

Acetylation

D.

All of the above

Drug hepatotoxicity may be associated with the appearance of autoantibodies, including a class of antibodies to liver-kidney microsomes, anti-LKM2, directed against a cytochrome P450 enzyme.

885

N Engl J Med 2005;352:2211-21, Harrison’s 18th Ed. 2558

A.

Steroids

A.

Sulfation

B.

Lipids

B.

Glucuronidation

C.

Vitamins

C.

Acetylation

D.

All of the above

D.

Hydrolysis

886

Which of the following is not a feature of direct toxic hepatitis ? A.

Predictable regularity

B.

Dose-dependent

C.

Latent period usually long

D.

Morphologic abnormalities reproducible for each toxin

Which of the following is not a feature of idiosyncratic drug hepatotoxicity ? Harrison’s 18th Ed. 2558

883

The P in P450 stands for ? Am Fam Phys 1998;57:107-16

A.

Particle

B.

Pigment

C.

Pattern

D.

Protein

The P in P450 stands for "pigment".

887

In direct toxic hepatitis, latent period between exposure and liver injury is usually short (often several hours), although clinical manifestations may be delayed for 24 - 48 hours.

882

Cytochrome P-450 enzymes (CYPs) are important in the biosynthesis & degradation of endogenous compounds like ? N Engl J Med 2005;352:2211-21

Phase II reactions in drug metabolism include all except ?

Harrison’s 18th Ed. 2558

881

Antibody to liver-kidney microsomes associated with drug induced hepatitis is ? Harrison’s 18th Ed. 2558

Drugs may be metabolized by sequential or competitive chemical processes involving oxidation, reduction & hydrolysis (phase I reactions) or glucuronidation, sulfation, acetylation & methylation (phase II reactions). CYP is important for phase I metabolism and are located primarily in endoplasmic reticulum, while phase 2 conjugation enzymes are cytosolic.

880

All of the above

A.

A.

“450” in Cytochrome P450 isoenzymes is related to ? A. Number of isoenzymes in liver B.

Number of chemical reactions

C.

Number of electron needed for its activity

D.

Spectrophotometric absorption peak

Name cytochrome P450 is derived from the fact that these are colored ('chrome') cellular ('cyto') proteins, with a "pigment at 450 nm", so named for the characteristic spectrophotometric absorption peak formed by absorbance of light at wavelengths near 450 nm when the heme iron is reduced and complexed to carbon monoxide.

A.

Unpredictability

B.

Not dose-dependent

C.

Extrahepatic manifestations of hypersensitivity

In CYP2E1, letter ‘2’ indicates ? A. Gene family

D.

None of the above

B.

Gene subfamily

C.

Individual gene

D.

None of the above

888

Cytochrome P450 (CYP) was first discovered in 1954 by ? A. Wilhelm Kuhnz & Hille Gieschen B.

Bernhardt

C.

Martin Klingenberg & David Garfinkel

D.

Akio Suzuki

Cytochrome P-450 enzymes (CYPs) are important in the biosynthesis and degradation of ?

Gastroenterology

"CYP" stands for cytochrome P450, followed by a numeral indicating gene family, a capital letter indicating subfamily and another numeral for the individual gene.

889

Which of the following about cytochrome P450 is false ? A. Hemoprotein B.

Monooxygenase reaction

N Engl J Med 2005;352:2211-21

C.

Pigment at 450 nm

A.

Steroids

D.

None of the above

B.

Lipids

C.

Vitamins

Cytochrome P450 belongs to a superfamily of hemoproteins. Most common reaction catalysed by cytochrome P450 is a monooxygenase reaction, i.e. insertion of one atom of oxygen into an organic substrate (RH) while the other oxygen atom is reduced to water: RH + O2 + 2H+ + 2e- = ROH + H2O

Gastroenterology 463 890

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Which of the following enzyme is responsible for metabolism of most of the drugs used ? Harrison’s 18th Ed. 41

A.

CYP3A4

B.

CYP3A5

C.

CYP2D6

D.

CYP2C19

897

In liver, the family of cytochrome P450 (CYP) isoforms is present in ? Harrison’s 15th Ed. Chapter 70

898

D.

Amiodarone

Which of the following anti-HIV agent is not a CYP3A inhibitor ? A.

Indinavir

B.

Ritonavir

C.

Saquinavir

D.

Nevirapine

Which of the following macrolide antibiotics is not a CYP3A Inhibitor ?

Cell membrane

C.

Golgi bodies

A.

Clarithromycin

Nucleus

B.

Erythromycin

C.

Troleandomycin

D.

Azithromycin

N Engl J Med 2005;352:2211-21

The catalytic activity of CYP2D6 in humans is best assessed by using which of the following drug ? 899

Which of the following anticonvulsant agent is not a CYP3A Inducer ?

A.

Debrisoquin

B.

Fluoxetine

C.

Perphenazine

A.

Carbamazepine

Dextromethorphan

B.

Phenobarbital

C.

Phenytoin

D.

Lamotrigine

N Engl J Med 2005;352:2211-21

CYP2D6 is second to CYP3A4 in the number of commonly used drugs that it metabolizes.

Which of the following cytochrome P-450 is present in enterocytes ?

900

Major hepatic isoenzyme involved in warfarin metabolism is ?

N Engl J Med 2005;352:2211-21

Harrison’s 18th Ed. 36 Table 5-1

A.

CYP1A2

A.

CYP 2C9

B.

CYP2D6

B.

CYP 2C19

C.

CYP2C9

C.

CYP 2D6

D.

CYP3A

D.

CYP 3A

CYP3A is present in the enterocytes.

901

Which of the following CYP is found mainly in the glomerulosa zone of adrenal gland ? A. CYP11B2 B.

CYP3A5

C.

CYP2D6

D.

CYP2C19

CYP11B2 is found mainly if not exclusively in the glomerulosa zone of the adrenal gland.

895

Lidocaine

B.

D.

894

Theophylline

C.

Endoplasmic reticulum

Harrison’s 15th Ed. Chapter 70

893

B.

A.

D. 892

Digoxin

N Engl J Med 2005;352:2211-21

CYP3A4 is the most abundant hepatic and intestinal CYP and is also the enzyme responsible for metabolism of the greatest number of drugs in therapeutic use.

891

A.

Major hepatic isoenzyme involved in phenytoin metabolism is ? Harrison’s 18th Ed. 36 Table 5-1

902

A.

CYP 2C9

B.

CYP 2C19

C.

CYP 2D6

D.

CYP 3A

Major hepatic isoenzyme in omeprazole metabolism is ? Harrison’s 18th Ed. 36 Table 5-1

Which of the following CYP is not expressed in neonates ? A. CYP1A2

A.

CYP 2C9

B.

CYP 2C19

B.

CYP3A5

C.

CYP 2D6

C.

CYP2D6

D.

CYP 3A

D.

CYP2C19

903

Major hepatic isoenzyme in metoprolol metabolism is ?

CYP1A2 is not expressed in neonates, making them particularly susceptible to toxicity from drugs such as caffeine.

Harrison’s 18th Ed. 36 Table 5-1

A.

CYP 2C9

896

B.

CYP 2C19

C.

CYP 2D6

D.

CYP 3A

Drugs having a narrow range between the plasma levels yielding therapeutic and adverse effects include all except ? Harrison’s 15th Ed. Chapter 70

463 Cardiology

464 904

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Major hepatic isoenzyme in tricyclic antidepressants metabolism is ?

912

905

906

907

CYP 2C9

B.

CYP 2C19

C.

CYP 2D6

D.

CYP 3A

Major hepatic isoenzyme involved in selective serotonin reuptake inhibitors metabolism is ?

913

A.

Phenobarbital

B.

Rifampin

C.

Carbamazepine

D.

All of the above

CYP enzyme activity inducers include ? Harrison’s 18th Ed. 45

Harrison’s 18th Ed. 36 Table 5-1

A.

Phenytoin

A.

CYP 2C9

B.

Smoking

B.

CYP 2C19

C.

Chronic alcohol ingestion

C.

CYP 2D6

D.

All of the above

D.

CYP 3A

Major hepatic isoenzyme involved in codeine metabolism is ?

CYP enzyme activity inducers lower plasma levels of which of the following drugs ?

Harrison’s 18th Ed. 36 Table 5-1

Harrison’s 18th Ed. 45

A.

CYP 2C9

A.

Warfarin

B.

CYP 2C19

B.

Quinidine

C.

CYP 2D6

C.

Mexiletine

D.

CYP 3A

D.

All of the above

Major hepatic isoenzyme in cyclosporine metabolism is ? Harrison’s 18th Ed. 36 Table 5-1

908

CYP enzyme activity inducers include ? Harrison’s 18th Ed. 45

Harrison’s 17th Ed. 29 Table 5-1

A.

Gastroenterology

914

915

CYP enzyme activity inducers lower plasma levels of which of the following drugs ?

A.

CYP 2C9

B.

CYP 2C19

A.

Verapamil

C.

CYP 2D6

B.

Ketoconazole

D.

CYP 3A

C.

Itraconazole

D.

All of the above

Harrison’s 18th Ed. 45

Major hepatic isoenzyme in statin metabolism is ? Harrison’s 18th Ed. 36 Table 5-1

909

A.

CYP 2C9

B.

CYP 2C19

C.

CYP 2D6

D.

CYP 3A

916

Harrison’s 18th Ed. 45

A.

Major hepatic isoenzyme in phenytoin metabolism is ? Harrison’s 18th Ed. 36 Table 5-1

910

A.

CYP 2C9

B.

CYP 2C19

C.

CYP 2D6

D.

CYP 3A

917

Harrison’s 18th Ed. 36 Table 5-1

911

CYP 2C9

B.

CYP 2C19

C.

CYP 2D6

D.

CYP 3A

Major hepatic isoenzyme in quinidine metabolism is ? Harrison’s 18th Ed. 36 Table 5-1

Cyclosporine

B.

Dexamethasone

C.

Methylprednisolone

D.

All of the above

CYP enzyme activity inducers lower plasma levels of which of the following drugs ? Harrison’s 18th Ed. 45

Major hepatic isoenzyme in lidocaine metabolism is ? A.

CYP enzyme activity inducers lower plasma levels of which of the following drugs ?

918

A.

Oral contraceptive steroids

B.

Methadone

C.

Metronidazole

D.

All of the above

Which of the following drugs is associated with moderate to severe chronic hepatitis ? Harrison’s 18th Ed. 2561

A.

Oxyphenisatin

B.

Methyldopa

A.

CYP 2C9

B.

CYP 2C19

C.

Isoniazid

C.

CYP 2D6

D.

All of the above

D.

CYP 3A

Gastroenterology 465 919

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Which of the following drugs is implicated in the development of cirrhosis ? Harrison’s 18th Ed. 2561

10 grams

C.

20 grams

D.

25 grams

A.

Oxyphenisatin

B.

Methyldopa

Fatal fulminant liver disease is usually associated with ingestion of 25 grams of acetaminophen.

C.

Isoniazid

926

D.

Halothane

What level of acetaminophen in blood is predictive of severe liver damage ? Harrison’s 18th Ed. 2561

Halothane and methotrexate have been implicated in the development of cirrhosis.

920

B.

465 Cardiology

Syndrome resembling primary biliary cirrhosis can occur following treatment with ? Harrison’s 18th Ed. 2561

A.

>100 µg/mL

B.

>150 µg/mL

C.

>200 µg/mL

D.

>300 µg/mL

A.

Chlorpromazine

B.

Methyl testosterone

Blood levels of acetaminophen of >300 µg/mL, 4 hours after ingestion are predictive severe liver damage.

C.

Tolbutamide

927

D.

All of the above

Maximal hepatic injury and hepatic failure occurs after how many days of acetaminophen ingestion ? Harrison’s 18th Ed. 2561

921

922

Portal hypertension in the absence of cirrhosis may result from the use of ?

A.

1 - 2 days

Harrison’s 18th Ed. 2561

B.

2 - 4 days

A.

Vitamin A

C.

4 - 6 days

B.

Arsenic intoxication

D.

7 - 9 days

C.

Exposure to vinyl chloride

D.

All of the above

Maximal hepatic injury & hepatic failure appear 4 - 6 days after acetaminophen ingestion.

928

Which of the following is “hepatoprotective” ?

Which of the following are associated with angiosarcoma of the liver ?

Harrison’s 18th Ed. 2561

A.

Activated charcoal

Harrison’s 18th Ed. 2561

B.

Cholestyramine

A.

Arsenic intoxication

C.

Glutathione

B.

Vinyl chloride

D.

All of the above

C.

Thorium dioxide

D.

All of the above

Arsenic intoxication, industrial exposure to vinyl chloride, or administration of thorium dioxide have been associated with angiosarcoma of the liver.

Alcohol suppresses hepatic glutathione production.

929

N-acetyl-benzoquinone-imine (NAPQI) is best related to which of the following ? Harrison’s 18th Ed. 2561

923

Peliosis hepatis refers to ?

A.

Acetaminophen

Harrison’s 18th Ed. 2561

B.

Quinidine

C.

Azathioprine

D.

Carbamazine

A.

Trauma of liver

B.

Blood cysts of liver

C.

Ectopic liver

D.

Unilobular liver

Peliosis hepatis refers to blood cysts of the liver.

Most of acetaminophen is metabolized by phase II reaction to sulfate & glucuronide metabolites. Phase I reaction by CYP2E1 metabolizes a small amount of acetaminophen to N-acetyl-benzoquinoneimine (NAPQI) which is hepatotoxic. However, “hepatoprotective” glutathione binds NAPQI to form harmless mercapturic acid. Alcohol induces cytochrome P450 CYP2E1.

924

930

Peliosis hepatis is seen in patients treated with ? Harrison’s 18th Ed. 2561

Oral activated charcoal or cholestyramine is useless how much time after ingestion ?

A.

Halothane

Harrison’s 18th Ed. 2563

B.

Anabolic steroids

A.

> 30 minutes

C.

Chlorpromazine

B.

> 60 minutes

Methotrexate

C.

> 90 minutes

D.

> 120 minutes

D.

Peliosis hepatis has been observed in some patients treated with anabolic steroids.

925

Fatal fulminant liver disease is usually associated with ingestion of what amount of acetaminophen ? Harrison’s 18th Ed. 2561

A.

5 grams

Oral activated charcoal or cholestyramine to prevent absorption of residual drug is useless if given >30 minutes after acetaminophen ingestion.

931

Which of the following have a role in the management of acetaminophen hepatotoxicity ? Harrison’s 18th Ed. 2563

466

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR A.

Cysteamine

A.

Valproate

B.

Cysteine

B.

Phenytoin

C.

N-acetylcysteine

C.

Halothane

D.

All of the above

D.

Acetaminophen

If given within 8 hours of ingestion of acetaminophen, administration of sulfhydryl compounds (cysteamine, cysteine, or N-acetylcysteine) reduces the severity of hepatic necrosis. These agents act by providing a reservoir of sulfhydryl groups to bind toxic metabolites or by stimulating synthesis and repletion of hepatic glutathione. If these fail, liver transplantation may be the only option.

932

A defect in epoxide hydrolase activity could cause hepatotoxicity due to Phenytoin.

938

Stevens-Johnson syndrome may be a presentation of toxicity due to ?

Which of the following about halothane hepatotoxicity is false ?

Harrison’s 18th Ed. 2564

Harrison’s 18th Ed. 2563

A.

Valproate

A.

Idiosyncratic reaction

B.

Phenytoin

B.

Halothane is not a direct hepatotoxin

C.

Halothane

C.

Cause severe centrilobular hepatic necrosis

D.

Acetaminophen

D.

Cross-reactions between halothane & methoxyflurane

The pathologic changes produced by halothane hepatotoxicity are indistinguishable from massive hepatic necrosis resulting from viral hepatitis. Severe centrilobular hepatic necrosis is typical of acetaminophen toxicity.

Gastroenterology

Aparet from drug induced hepatitis, fever, lymphadenopathy, rash (Stevens-Johnson syndrome or exfoliative dermatitis), leukocytosis & eosinophilia may manifest in hepatotoxicity due to Phenytoin.

939

Which of the following is a major metabolite of Amiodarone ? Harrison’s 18th Ed. 2564

933

Which of the following is false about methyldopa hepatotoxicity ? Harrison’s 18th Ed. 2563

A.

Desmethylamiodarone

B.

Desethylamiodarone Levomethylamiodarone Levoethylamiodarone

A.

Toxic reaction

C.

B.

Idiosyncratic reaction

D.

C.

Resolves with discontinuation of drug

D.

None of the above

940

Amiodarone metabolite desethylamiodarone accumulate in which of the following ? Harrison’s 18th Ed. 2564

934

Isoniazid hepatotoxicity is enhanced by ? Harrison’s 18th Ed. 2564

A.

Alcohol

B.

Rifampin

C.

Pyrazinamide

D.

All of the above

941

Isoniazid hepatotoxicity is enhanced by alcohol, rifampin & pyrazinamide.

935

A.

Hepatocyte lysosomes

B.

Hepatocyte mitochondria

C.

Bile duct epithelium

D.

All of the above

Toxicity with which of the following produces cholestatic idiosyncratic reaction ? Harrison’s 18th Ed. 2565

IV administration of carnitine may be ameliorate hepatotoxicity due to ?

A.

Acetaminophen

B.

Erythromycin

Harrison’s 18th Ed. 2564

C.

Azathioprine

D.

Carbamazine

A.

Valproate

B.

Isoniazid

C.

Halothane

D.

Acetaminophen

942

Drugs producing cholestatic reaction and portal inflammation is ? Harrison’s 18th Ed. 2565

A.

Erythromycin

Valproate hepatotoxicity may be ameliorated by IV administration of carnitine.

B.

Oral contraceptive

936

C.

Chlorpromazine

D.

17, -Alkyl-Substituted Anabolic Steroids

Which metabolite of sodium valproate may be responsible for hepatic injury ? Harrison’s 18th Ed. 2564

A.

1-pentenoic acid

B.

2-pentenoic acid

C.

3-pentenoic acid

D.

4-pentenoic acid

Sodium valproate is not directly hepatotoxic, but its metabolite 4-pentenoic acid may be responsible for hepatic injury.

937

A defect in epoxide hydrolase activity could cause hepatotoxicity due to which drug ? Harrison’s 18th Ed. 2564

943

In Trimethoprim-Sulfamethoxazole toxicity, hepatotoxicity is attributable to which component of the drug ? Harrison’s 18th Ed. 2565

A.

Sulfamethoxazole

B.

Trimethoprim

C.

Sulfamethoxazole + Trimethoprim

D.

None of the above

The hepatotoxicity with the use of Trimethoprim-Sulfamethoxazole is attributable to the sulfamethoxazole component of the drug.

Gastroenterology 467 944

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

The risk of trimethoprim-sulfamethoxazole hepatotoxicity is increased in persons with ?

467 Cardiology

Classification of chronic hepatitis is based on its cause, its histologic assessment of necroinflammatory activity, or grade and its degree of progression, or stage.

Harrison’s 18th Ed. 2565

950

HIV infection

B.

Severe anemia

C.

Chronic renal failure

A.

10

D.

Congestive heart failure

B.

14

C.

18

D.

20

Harrison’s 18th Ed. 2568, Table 306-2

Risk of trimethoprim-sulfamethoxazole hepatotoxicity is increased in persons with HIV infection.

945

Statin hepatotoxicity is increased in which of the following patients ? Harrison’s 18th Ed. 2565

A.

Chronic hepatitis C

B.

Hepatic steatosis

C.

Other underlying liver diseases

D.

None of the above

Out of a maximum of 18, individual scoring is degree of periportal necrosis (max. 4), degree of intralobular confluent necrosis (max. 6), degree of intralobular focal necrosis (max. 4) & degree of portal inflammation (max. 4).

951

In Total Parenteral Nutrition (TPN), steatosis or steatohepatitis may result due to an excess of ? Harrison’s 18th Ed. 2565

A.

Carbohydrate calories

B.

Protein calories

C.

Fat calories

D.

Deficiency of minerals

947

In chronic hepatitis, hepatic inflammation and necrosis continue for at least ?

952

3

B.

4

C.

6

D.

8

Histologic activity index (HAI) scoring for necroinflammatory activity (grade) includes all except ? Harrison’s 18th Ed. 2568, Table 306-2

A.

Degree of periportal necrosis

B.

Portal fibrosis

C.

Intralobular necrosis

D.

Degree of portal inflammation

Grade, a histologic assessment of necroinflammatory activity, is done by examination of liver biopsy. It includes assessment of degree of periportal necrosis, degree of hepatocyte degeneration and focal necrosis within lobule and degree of portal inflammation.

Harrison’s 18th Ed. 2567

953

What percentage of HBV infection acquired at birth will become chronic ?

A.

3 months

Harrison’s 18th Ed. 2568

B.

6 months

A.

10 %

C.

9 months

B.

40 %

D.

12 months

C.

75 %

D.

90 %

In chronic hepatitis, hepatic inflammation & necrosis continue for at least 6 months.

948

A.

Staging is based on the degree of fibrosis as categorized on a numerical scale from 0-6 (HAI) or 04 (METAVIR).

In Total Parenteral Nutrition (TPN), steatosis or steatohepatitis may result due to an excess of carbohydrate calories.

306 - Chronic hepatitis

Histologic activity index (HAI) scoring for fibrosis (stage) is done out of ? Harrison’s 18th Ed. 2568, Table 306-2

Statin hepatotoxicity is “not” increased in patients with chronic hepatitis C, hepatic steatosis, or other underlying liver diseases, and statins can be used safely in these patients.

946

Histologic activity index (HAI) scoring for necroinflammatory activity (grade) is done out of ?

A.

Chronic hepatitis is due to ?

HBV infection at birth is associated with clinically silent acute infection but a 90% chance of chronic infection.

Harrison’s 18th Ed. 2567

954

Virus

B.

Drug-induced

C.

Autoimmune

A.

~1%

D.

All of the above

B.

~4%

C.

~7%

D.

~9%

Harrison’s 18th Ed. 2568

Chronic viral hepatitis, drug-induced chronic hepatitis & autoimmune chronic hepatitis can cause chronicity.

949

What percentage of HBV infection acquired in immunocompetent young adulthood will become chronic ?

A.

Classification of chronic hepatitis is based on ? Harrison’s 18th Ed. 2567

A.

Cause

B.

Histologic activity, or grade

C.

Degree of progression, or stage

D.

All of the above

HBV infection in immunocompetent young adulthood carry a risk of chronicity of ~ 1%.

955

Which of the following has prognostic importance among adults with chronic hepatitis B ? Harrison’s 18th Ed. 2568

A.

HBV replication

468

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

HLA DR3 or DR4 markers

C.

AST and ALT

D.

Liver histology

961

Replicative phase of chronic HBV infection is characterized by ? Harrison’s 18th Ed. 2568

C.

Generalized vasculitis

D.

Leukocytoclastic vasculitis

B.

HBV DNA levels > 105 - 106 virions/mL

C.

Presence of HBcAg in liver

HBV DNA can be detected in serum at levels as low as ? A. 20 IU/mL

D.

All of the above

B.

40 IU/mL

C.

60 IU/mL

D.

80 IU/mL

962

Nonreplicative phase of chronic HBV infection is characterized by all except ? A.

Absence of HBeAg in serum

B.

HBV DNA levels < 103 virions/mL

C.

Presence of anti-HBe

D.

Presence of HBcAg in liver

HBV DNA can be detected in the serum at levels as low as 60 IU/mL.

963

964

~2-5%

B.

~ 5 - 10 %

C.

~ 10 - 15 %

D.

~ 20 - 30 %

~10-15% patients of HBeAg-reactive chronic hepatitis B convert spontaneously from relatively replicative to nonreplicative infection per year.

965

Harrison’s 18th Ed. 2569

Levels of HBV DNA

B.

Level of HBV replication

C.

Levels of aminotransferase activity

D.

All of the above

Month 3

B.

Month 6

C.

Year 1

D.

Year 2

Serum HBV DNA undetectable by PCR is defined as ? A.

< 100 to 200 copies per milliliter

B.

< 300 to 400 copies per milliliter

C.

< 500 to 1000 copies per milliliter

D.

< 1000 to 2000 copies per milliliter

Serum HBV DNA undetectable by PCR is defined as C>D

Long-term monotherapy with lamivudine is associated with mutation in which motif of HBV DNA polymerase ? Harrison’s 18th Ed. 2571

A.

Chemokine (C-C motif) receptor 6

B.

RNA-binding motif (RBM)

C.

YMDD

D.

All of the above

Factors that are most predictive of a response include a high ALT level, a low HBV DNA level, and mild-to-moderate histologic activity & stage. Likelihood of HBeAg loss in PEG IFN alfa-2b treated HBeAg-reactive patients is associated with HBV genotype A > B > C > D.

989

For HBeAg-reactive chronic HBV infection, antiviral therapy is indicated for patients with ? N Engl J Med 2008;359:1492

Long-term monotherapy with lamivudine is associated with methionine-to-valine (M204V) or methionineto- isoleucine (M204I) mutations, primarily at amino acid 204 in the tyrosine-methionine-aspartateaspartate (YMDD) motif of HBV DNA polymerase.

A.

ALT level more than two times upper limit of normal

B.

HBV DNA > 20,000 IU per milliliter

983

C.

Risk factors for progression

D.

All of the above

Which of the following antiviral drugs has dual antiviral activity against HBV & HIV ? Harrison’s 18th Ed. 2571, Lancet Infect Dis 2005;5:374–82

A.

Enfuvirtide

B.

Emtricitabine

C.

Adefovir

D.

Entecavir

For HBeAg-reactive chronic HBV, antiviral therapy is indicated if ALT levels are more than twice the upper limit of normal and HBV DNA >20,000 IU/mL. Risk factors for progression (older than 40 years, family history of HCC, or ALT level in high normal range (up to twice the upper limit of normal).

990

For HBeAg-negative chronic HBV infection, antiviral therapy is indicated for patients with ? N Engl J Med 2008;359:1492

984

Which of the following antiviral drugs has dual antiviral activity against HBV & HIV ? Harrison’s 18th Ed. 2571, Lancet Infect Dis 2005;5:374–82

A.

ALT level more than two times upper limit of normal

B.

HBV DNA > 20,000 IU per milliliter Moderate-to-severe necroinflammatory activity or fibrosis All of the above

A.

Tenofovir

C.

B.

Emtricitabine

D.

C.

Lamivudine

D.

All of the above

For HBeAg-negative chronic HBV, antiviral therapy is indicated if ALT levels are more than twice the upper limit of normal and HBV DNA >20,000 IU/mL. If ALT is 20,000 IU/mL, liver biopsy is indicated. Moderate-to-severe necroinflammatory activity or fibrosis favours antiviral therapy.

Besides lamivudine, tenofovir and emtricitabine have antiviral activity against HBV & HIV.

985

Which of the following is false for HBV treatment in HIV positive patient ? Lancet Infect Dis 2005;5:374–82

A.

Response to Interferon  is lower

B.

Indefinite treatment with nucleoside/nucleotide analogues

991

Conversion factor for HBV DNA between international units (IU) per milliliter and copies per milliliter is about ? N Engl J Med 2008;359:1492

A.

2.6

B.

3.6

C.

4.6

Gastroenterology 471 D.

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

5.6

471 Cardiology

Conversion factor HBV DNA between international units /mL & copies/mL is ~ 5.6 (1 IU/mL is ~ 5.6 copies/mL). Treatment thresholds in copies/mL are 5 times higher than international units/mL.

Entecavir is an oral cyclopentyl guanosine analogue polymerase inhibitor and is the most potent of the HBV antivirals. Its high barrier to resistance coupled with its high potency and an excellent safety profile renders entecavir a first-line drug for patients with chronic hepatitis B.

992

998

Nephrotoxicity of adefovir is best related to ? Therapeutic Advances in Gastroenterology 2008; 1; 61-75

Harrison’s 18th Ed. 2573

A.

Acute glomerulonephritis

A.

Entecavir

B.

Goodpasteur's syndrome

B.

Telbivudine

C.

Fanconi-like syndrome

C.

Tenofovir

D.

All of the above

D.

Adefovir Dipivoxil

Adefovir at 30mg has higher antiviral potency. It’s potential nephrotoxicity manifests as a Fanconilike syndrome with phosphaturia and proteinuria.

993

PEG stands for ?

Tenofovir disoproxil fumarate, an acyclic nucleotide analogue similar to adefovir.

999

Harrison’s 18th Ed. 2581

A.

Polyethylene glycerol

B.

Perethylene glycerol

C.

Polyethylene glycol

D.

Perethylene glycol

Pegylated interferon (PEG IFN) is a long-acting IFN bound to polyethylene glycol (PEG).

994

Pegylated IFN-a was approved by FDA for chronic hepatitis B in which year ? Therapeutic Advances in Gastroenterology 2008; 1; 61-75

A.

2000

B.

2002

C.

2003

D.

2005

The recommended regimen of peg IFNa-2a for CHB is ?

Which of the following is recommended as first-line therapy in Chronic Hepatitis B ? Harrison’s 18th Ed. 2575

A.

PEG IFN

B.

Entecavir

C.

Tenofovir

D.

All of the above

Among the drugs for hepatitis B, PEG IFN has supplanted standard IFN, entecavir has supplanted lamivudine, and tenofovir has supplanted adefovir. PEG IFN, entecavir, or tenofovir are recommended as first-line therapy.

1000

Therapy with which of the following is least likely to foster emergence of viral mutations ? Harrison’s 18th Ed. 2575

1992 - Interferon alfa (IFN-a), 1998 - Lamivudine (LAM), 2002 - Adefovir (ADV), 2005 - Entecavir (ETV), Pegylated IFN-a, 2006 - Telbivudine (LDT), 2008 - Tenofovir (TDF).

995

Tenofovir is similar to which of the following ?

A.

Lamivudine

B.

Tenofovir

C.

Telbivudine

D.

Adefovir

Lamivudine and telbivudine foster the emergence of viral mutations, adefovir somewhat less so, and entecavir (except in lamivudine-experienced patients) and tenofovir rarely at all.

Harrison’s 18th Ed. 2572

A.

180 µg subcutaneously weekly for one month

B.

180 µg subcutaneously weekly for three months

C.

180 µg subcutaneously weekly for six months

D.

180 µg subcutaneously weekly for one year

1001

Harrison’s 18th Ed. 2576

Recommended regimen for peg IFNa-2a in CHB is 180 µg subcutaneously weekly for one year.

996

Which of the following HBV genotype has the highest rate of IFN-induced HBeAg loss ? Harrison’s 18th Ed. 2572, Therapeutic Advances in Gastroenterology 2008; 1; 61-75

A.

PEG IFN

B.

Adefovir

C.

Entecavir

D.

All of the above

Except for lamivudine, other antivirals for hepatitis B should be avoided or used with extreme caution during pregnancy.

A.

Genotype A

B.

Genotype B

C.

Genotype C

Harrison’s 18th Ed. 2577

D.

Genotype D

A.

Lamivudine

B.

Adefovir

1002

Patients with HBV genotype A have the highest rate of IFN-induced HBeAg loss. Genotype A is most common in North America & Europe. HBeAg clearance associated with nucleos(t)ide analogues is independent of HBV genotype.

997

Which of the following should be avoided or used with extreme caution during pregnancy ?

The most potent of the HBV antivirals is ? Harrison’s 18th Ed. 2573

A.

Entecavir

B.

Telbivudine

C.

Tenofovir

D.

Adefovir Dipivoxil

In patients with HBV-HIV infection, which of the should never be used as monotherapy ?

C.

Entecavir

D.

Tenofovir

Lamivudine should never be used as monotherapy in HBV-HIV infection, because HIV resistance emerges rapidly to both viruses. Adefovir, entecavir, Tenofovir and tenofovir + emtricitabine can be used for treating HBV infection in HBV-HIV co-infected patients.

1003

Variables that favour the treatment of HBV/HIV co-infected patients with pegylated interferon are all except ? Lancet Infect Dis 2005;5:374–82

472

1004

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR A.

HBeAg-positive

B.

Elevated aminotransferases

C.

High CD4 counts

D.

Psychiatric disorders

1009

Harrison’s 18th Ed. 2577

Anti-LKM1

B.

Anti-LKM2

C.

Anti-LKM3

D.

Anti-LKM4

Extrahepatic complications unrelated to immune-complex injury in chronic hepatitis C are all except ? Harrison’s 18th Ed. 2579

Which of the following antibody is seen in chronic hepatitis D? A.

Gastroenterology

A.

Sjögren’s syndrome

B.

Porphyria cutanea tarda

C.

Essential mixed cryoglobulinemia

D.

Lichen planus

Essential mixed cryoglobulinemia is an immune complex–mediated extrahepatic complications of chronic hepatitis C. While those unrelated to immune-complex injury are Sjögren’s syndrome, lichen planus, porphyria cutanea tarda, type-II diabetes mellitus and metabolic syndrome (including insulin resistance & steatohepatitis).

1010

Which of the following in a laboratory feature of chronic hepatitis C ?

A distinguishing serologic feature of chronic hepatitis D is the presence in the circulation of antiLKM3 directed against uridine diphosphate glucuronosyltransferase.

Harrison’s 18th Ed. 2579

A.

Fluctuating aminotransferase levels

1005

B.

Jaundice is rare

Which of the following antibody is prevalent in patients with chronic hepatitis C virus (HCV) infection ? Harrison’s 18th Ed. 2579

A.

Smooth muscle antibodies (SMA)

B.

Antinuclear (ANA) antibodies

C.

Anti-liver kidney microsomal type 1 (LKM1) antibody

D.

All of the above

1011

Out of the following, which one is the most important as regards progression of liver disease in chronic hepatitis C ? Harrison’s 18th Ed. 2578

All of the above

Which of the following enhances the efficacy of IFN ? A.

Ribavirin

B.

Adefovir

C.

Entecavir

D.

Tenofovir

Oral guanosine nucleoside ribavirin is ineffective when used alone. But, ribavirin enhances the efficacy of IFN by reducing the likelihood of virologic relapse after the achievement of an endtreatment response (ETR).

1012

Rapid virologic response (RVR) is estimated at what time after institution of therapy in Hepatitis C ?

A.

Older age

B.

Longer duration of infection

C.

HIV infection

A.

2 weeks

D.

Obesity

B.

4 weeks

C.

8 weeks

D.

12 weeks

Progression of liver disease in chronic hepatitis C is more likely in older age, longer duration of infection, advanced histologic stage and grade, genotype 1, more complex quasispecies diversity, increased hepatic iron, concomitant other liver disorders (alcoholic liver disease, chronic hepatitis B, hemochromatosis, 1-antitrypsin deficiency, and steatohepatitis), HIV infection, and obesity. Out of these, duration of infection is the most important. No other epidemiologic or clinical features of chronic hepatitis C (severity of acute hepatitis, level of aminotransferase activity, level of HCV RNA, presence or absence of jaundice during acute hepatitis) are predictive of eventual outcome.

1007

Circulating anti-LKM1 antibodies

D.

Harrison’s 18th Ed. 2579

Non-organ specific autoantibodies (NOSA), particularly smooth muscle antibodies (SMA) and antinuclear (ANA) antibodies are highly prevalent in patients with chronic hepatitis C virus (HCV) infection. Occasionally, Anti-liver kidney microsomal type 1 (LKM1) antibody, Anti-liver cytosol type 1 (LC1) are found.

1006

C.

Harrison’s 18th Ed. 2579, Figure 306-2

RVR refers to undetectable HCV RNA at week 4.

Best prognostic indicator in chronic hepatitis C is ?

1013

Early virologic response (EVR) is estimated at what time after institution of therapy in Hepatitis C ?

Harrison’s 18th Ed. 2578

Harrison’s 18th Ed. 2579, Figure 306-2

A.

Liver histology

A.

2 weeks

B.

Severity of jaundice

B.

4 weeks

C.

Levels of aminotransferases

C.

8 weeks

D.

HIV status

D.

12 weeks

Best prognostic indicator in chronic hepatitis C is liver histology.

EVRrefers to 2 log10 HCV RNA reduction by week 12.

1008

1014

Which of the following is the most common symptom in chronic hepatitis C ? Harrison’s 18th Ed. 2579

Responder status is estimated at what time after institution of therapy in Hepatitis C ? Harrison’s 18th Ed. 2579, Figure 306-2

A.

Fatigue

A.

12 weeks

B.

Jaundice

C.

Fever

B.

24 weeks

D.

Weight loss

C.

48 weeks

D.

72 weeks

Fatigue is the most common symptom of chronic hepatitis C. Jaundice is rare.

Gastroenterology 473 1015

1016

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Sustained virologic response (SVR) is estimated at what time after institution of therapy in Hepatitis C ?

1021

Harrison’s 18th Ed. 2580

A.

12 weeks

A.

SLCO1B1

B.

24 weeks

B.

HLA-B*1501

C.

48 weeks

C.

IL15

D.

72 weeks

D.

IL28B

Harrison’s 18th Ed. 2579

A.

Cytokines

B.

Chemokines

C.

JAKSTAT signal transduction pathway

D.

All of the above

In studies of patients treated with PEG IFN and ribavirin, variants of the IL28B SNP that code for IFN-3 correlate significantly with responsiveness. Patients homozygous for the C allele at this locus have the highest frequency of achieving an SVR (80%), those homozygous for the T allele at this locus are least likely to achieve an SVR (25%), and those heterozygous at this locus (C/T) have an intermediate level of responsiveness (SVRs in 35%).

1022

The current standard treatment of chronic hepatitis C is ? Harrison’s 18th Ed. 2579

A.

PEG IFN

B.

Ribavirin

C.

PEG IFN + Ribavirin

D.

All of the above

Which of the following variable does not correlate favourably in the IFN-based treatment of chronic hepatitis C ?

1023

B.

Agranulocytosis

C.

Hemolysis

D.

All of the above

Which of the following is a side effect of ribavirin therapy ?

1024

A.

Pruritus

B.

Gout

C.

Anemia

D.

All of the above

Halflife in serum of Hepatitis C virion is ? Harrison’s 18th Ed. 2580

A.

2 - 3 hours

A.

Genotypes 2 and 3

B.

2 - 3 days

B.

Genotypes 1 and 4

C.

2 - 3 monhs

C.

Low baseline HCV RNA level

D.

2 - 3 years

D.

Histologically mild hepatitis

Patient variables that tend to correlate with sustained virologic responsiveness to IFN-based therapy include favorable genotype (genotypes 2 and 3 as opposed to genotypes 1 and 4), low baseline HCV RNA level (= 10 times upper limit of normal

B.

Serum AST >= 5 times upper limit of normal and gammaglobulin level >= twice normal

C.

Bridging necrosis or multiacinar necrosis on liver biopsy

D.

All of the above

Therapy for autoimmune hepatitis should continue for at least ? Harrison’s 18th Ed. 2587

A.

3 - 6 months

B.

6 - 12 months

C.

12 - 18 months

D.

18 - 24 months

1069

B.

Alcoholic hepatitis

C.

Cirrhosis

D.

All of the above

Major lesions in the pathology of alcoholic liver disease are fatty liver, alcoholic hepatitis & cirrhosis.

1067

Which of the following is considered to be a precursor to cirrhosis ? Harrison’s 18th Ed. 2589

A.

Fatty liver

B.

NASH

B.

~ 10 grams

C.

~ 12 grams

D.

~ 14 grams

In men, what quantity of ethanol produces fatty liver ? A.

10 - 20 gm / day

B.

20 - 40 gm / day

C.

40 - 80 gm / day

D.

80 - 120 gm / day

In men, 40–80 g/d of ethanol produces fatty liver.

1070

In men, what quantity & duration of ethanol consumption causes hepatitis or cirrhosis ? Harrison’s 18th Ed. 2589, Table 307-1

A.

80 gm / day for 5 - 10 years

B.

160 gm / day for 5 - 10 years

C.

80 gm / day for 10 - 20 years

D.

160 gm / day for 10 - 20 years

In men, 160 gm / day for 10 - 20 years of ethanol consumption causes hepatitis or cirrhosis.

1071

What proportion of alcoholics develop alcoholic liver disease ? Harrison’s 18th Ed. 2589, Table 307-1

A.

15 %

B.

30 %

C.

45 %

D.

75 %

Only 15% of alcoholics develop alcoholic liver disease.

1072

Which of the following statements about alcohol consumption is false ? Harrison’s 18th Ed. 2589, Table 307-1

Harrison’s 18th Ed. 2589

Fatty liver

~ 8 grams

Harrison’s 18th Ed. 2589, Table 307-1

Which of the following is the major lesion in the pathology of alcoholic liver disease ? A.

A.

One beer, four ounces of wine, or one ounce of 80% spirits all contain ~12 grams of alcohol.

Therapy for autoimmune hepatitis should continue for at least 12-18 months.

307 - Alcoholic liver disease

One beer (12 oz), four ounces of wine or one ounce of 80% spirits contain how many grams of alcohol ? Harrison’s 18th Ed. 2589

Mainstay of management in autoimmune hepatitis is ?

Harrison’s 18th Ed. 2587

1066

All of the above

Alcoholic hepatitis is thought to be a precursor to cirrhosis.

Mainstay of management in autoimmune hepatitis is daily glucocorticoid therapy. Azathioprine alone is not effective in achieving remission. Patients refractory to this regimen may be treated with cyclosporine, tacrolimus, or mycophenolate mofetil.

1065

D.

Mononuclear-cell infiltrate

Harrison’s 18th Ed. 2587

1064

Alcoholic hepatitis

A.

Autoimmune hepatitis is characterized by a mononuclear-cell infiltrate (plasma cells + eosinophils) invading the limiting plate (piecemeal necrosis or interface hepatitis). Biliary tree is generally spared and fibrosis is present.

1063

C.

477 Cardiology

A.

Alcohol is a direct hepatotoxin

B.

Men more susceptible to alcoholic liver injury than women

C.

Alcohol injury does not require malnutrition

D.

15% of alcoholics develop alcoholic liver disease

Women are more susceptible to alcoholic liver disease than men.

1073

Which of the following is related to the genetic risk factors for alcoholic liver disease ? Harrison’s 18th Ed. 2589, Table 307-1

A.

Cytochrome P450 3A

B.

Cytochrome P450 2C19

C.

Cytochrome P450 2D6

478

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

Cytochrome P-450 2E1

1080

Genepolymorphisms may include alcohol dehydrogenase, cytochrome P4502E1, and those associated with alcoholism (twin studies).

1074

Cytochrome P-450 2E1 converts alcohol to ? A. Acetate B.

Carbon dioxide

C.

Free fatty acids

D.

Acetaldehyde

In liver, there are two main pathways of alcohol metabolism, alcohol dehydrogenase and cytochrome P-450 2E1. They converts alcohol to acetaldehyde. Acetaldehyde subsequently is metabolized to acetate via acetaldehyde dehydrogenase.

1075

1081

Zone 3

D.

All of the above

The hallmark features of hepatocyte injury in alcoholic hepatitis are all except ? A.

Polymorphonuclear infiltrate

B.

Ballooning degeneration

C.

Mallory bodies

A.

10 grams

D.

Fibrosis in perisinusoidal space of Disse

B.

20 grams

C.

40 grams

D.

60 grams

Hallmark of alcoholic hepatitis is hepatocyte injury characterized by ballooning degeneration, spotty necrosis, polymorphonuclear infiltrate, and fibrosis in the perivenular and perisinusoidal space of Disse. Mallory bodies are often present in florid cases but are neither specific nor necessary for substantiating diagnosis.

1082

Which of the following accelerates progression of alcoholic liver disease to cirrhosis in chronic and excessive drinkers ? A.

Acute hepatitis B

B.

Acute hepatitis C

C.

Chronic hepatitis B

D.

Chronic hepatitis C

1083

Chronic alcohol ingestion lead to which of the following ? A.

Autoimmune response

B.

Fibrotic response

C.

Inflammatory response

D.

All of the above

1084

Harrison’s 18th Ed. 2589

Alcohol dehydrogenase

B.

Alcohol reductase

C.

Alcohol oxidase

D.

All of the above

In fatty liver secondary to alcohol induced liver injury, accumulation of fat within the perivenular hepatocytes coincides with the location of alcohol dehydrogenase which is the major enzyme responsible for alcohol metabolism.

B.

No lunula

C.

Frequent in severe liver disease

D.

None of the above

Skin texture of cheeks & nasolabial folds in patient with alcoholrelated liver disease is called ? A. Gooseberry skin B.

Cheese wind skin

C.

Weather heat skin

D.

Paper-money skin

In alcoholic hepatitis, which of the following can occur in the absence of cirrhosis ? Harrison’s 18th Ed. 2590

Major enzyme responsible for alcohol metabolism is ? A.

Which of the following is false about Terry's nails ? A. Ground glass appearance of fingernails

Terry's nails refers to finger/toe nails that have a "ground glass" appearance, with no lunula (white crescent-shaped area of finger). It frequently occurs in hepatic failure, cirrhosis, DM, CHF, hyperthyroidism, malnutrition.

Harrison’s 18th Ed. 2590, Figure 307-1

1079

Zone 2

C.

Harrison’s 18th Ed. 2589

Chronic infection with hepatitis C (HCV) is an important comorbidity in the progression of alcoholic liver disease to cirrhosis in chronic and excessive drinkers. Alcohol intake also decreases efficacy of interferon-based antiviral therapy in them.

1078

B.

Harrison’s 18th Ed. 2590

Harrison’s 18th Ed. 2589

1077

Histologically, the earliest changes in alcoholic hepatitis are located predominantly in ? A. Zone 1

Histologically, the earliest changes in alcoholic hepatitis are located predominantly around the central vein i.e. centrilobular (perivenular) areas (zone 3 of Rappaport).

In men, what is the threshold daily alcohol intake necessary to produce pathologic changes of alcoholic hepatitis ?

Threshold for developing alcoholic liver disease in men is an intake of >60 - 80 gm/day of alcohol for 10 years. Ingestion of 160 gm/day increases risk of developing alcoholic cirrhosis by 25-folds.

1076

Gastroenterology

A.

Portal hypertension

B.

Ascites

C.

Variceal bleeding

D.

All of the above

In alcoholic hepatitis, portal hypertension, ascites, or variceal bleeding can occur in the absence of cirrhosis. Patients with alcoholic cirrhosis often exhibit clinical features identical to other causes of cirrhosis.

1085

In alcoholic hepatitis, AST : ALT ratio is ? Harrison’s 18th Ed. 2590

A.

> 0.25

B.

> 0.50

Harrison’s 18th Ed. 2590

C.

> 0.75

A.

Giant mitochondria

D.

>1

B.

Perivenular fibrosis

C.

Macrovesicular fat

D.

All of the above

Which of the following hepatic pathologic features may be associated with progressive liver injury ?

In alcoholic hepatitis, the AST : ALT ratio is >1. AST:ALT ratio is higher in pericentral hepatocytes than other regions in liver lobule & pericentral zone is more selectively affected in acute alcoholic hepatitis.

Gastroenterology 479 1086

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

In alcoholic hepatitis, AST and ALT are rarely more than ?

C.

Glasgow alcoholic hepatitis score (GAHS)

Harrison’s 18th Ed. 2590

D.

All of the above

A.

100 IU/L

B.

200 IU/L

C.

300 IU/L

D.

400 IU/L

Besides the above ones and also the classical Child-Turcotte-Pugh (CTP) score, Asymmetric dimethylarginine (ADMA) score is the most recently proposed predictor of adverse clinical outcome in patients with severe alcoholic hepatitis.

1093

In alcoholic hepatitis, AST & ALT are usually elevated 2-7 fold. They are rarely >400 IU/L.

1087

Which of the following is a laboratory feature alcoholic fatty liver ? Harrison’s 18th Ed. 2590

A.

Increased gamma-glutamyl transpeptidase (GGTP)

B.

Hypertriglyceridemia,

C.

Hypercholesterolemia

D.

All of the above

479 Cardiology

Variables included in Glasgow alcoholic hepatitis score (GAHS) are all except ? A. Age B.

Hemoglobin

C.

Bilirubin

D.

BUN

Five variables included in GAHS are age, bilirubin, BUN, PT, and TLC. Glasgow Alcoholic Hepatitis score >= 9 requires treatment.

1094

MELD score is calculated based on all except ? N Engl J Med 2009;361:1279-90

1088

Which of the following in ultrasonography indicates serious liver injury with less potential for complete reversal ? Harrison’s 18th Ed. 2590

1089

A.

Portal vein flow reversal

B.

Ascites

C.

Intraabdominal collaterals

D.

All of the above

Discriminant function (DF) formula predicting the outcome of severe alcoholic hepatitis is named after ? Nathan

B.

Cushin

C.

Maddrey

D.

George

The discriminant function (DF) formula of Maddrey is based on PT and bilirubin.

1090

Which of the following is the correct formula of Discriminant function (DF) ?

1095

2.6 x PT prolongation + total S. bilirubin in mg/dL

B.

3.6 x PT prolongation + total S. bilirubin in mg/dL

C.

4.6 x PT prolongation + total S. bilirubin in mg/dL

D.

5.6 x PT prolongation + total S. bilirubin in mg/dL

Modified Maddrey's discriminant function predicts prognosis in alcoholic hepatitis. It is calculated as 4.6 x [prothombin time - control value (seconds)] + serum bilirubin (mg/dl). A value >32 implies poor outcome with one month mortality > 50% if only supportive treatment is given. Cut off value of 32 &/or hepatic encephalopathy has been used as a threshold to consider corticosteroid treatment.

1091

What count of polymorphonuclear cells predicts severe alcoholic hepatitis when discriminant function >32 ?

1092

> 500 / µL

B.

> 1500 / µL

C.

> 3500 / µL

D.

> 5500 / µL

Formula for assessment of prognosis of alcoholic hepatitis is ? A. Combined clinical & laboratory index of University of Toronto B.

Model for end-stage liver disease (MELD) score

Serum albumin

C.

Serum creatinine

D.

Serum bilirubin

Model for End-Stage Liver Disease (MELD) score was introduced in USA in year ? A.

1995

B.

1998

C.

2002

D.

2005

In 2002, MELD score derived from measurements of serum bilirubin, international normalized ratio of prothrombin time and serum creatinine to evaluate pretransplantation renal function was introduced as an aid to organ allocation among candidates for liver transplantation.

1096

Which of the following is advocated for severe alcoholic hepatitis ? Harrison’s 18th Ed. 2591

A.

Glucocorticoids

B.

Thiamine

C.

Proton pump inhibitors

D.

All of the above

Patients with severe alcoholic hepatitis, Women with encephalopathy in particular, should be given prednisone, 40 mg/day, or prednisolone, 32 mg/day, for 4 weeks, followed by a steroid taper.

1097

Use of which of the following improves survival in severe alcoholic hepatitis ? Harrison’s 18th Ed. 2591

Harrison’s 18th Ed. 2590, Table 307-2

A.

B.

N Engl J Med 2009;361:1279-90

Harrison’s 18th Ed. 2590

A.

Prothrombin time

MELD score is based on a patient’s prothrombin time, serum creatinine & bilirubin. Patients with severe alcoholic hepatitis are defined as a discriminant function >32 or MELD >20.

Harrison’s 17th Ed. 1971

A.

A.

A.

Pentoxifylline

B.

Propylthiouracil

C.

Infliximab

D.

Colchicine

The nonspecific TNF inhibitor, pentoxifylline improves survival in severe alcoholic hepatitis was primarily due to a decrease in the development of hepatorenal syndrome.

1098

Use of Infliximab in severe alcoholic hepatitis was stopped due to the increased risk of ?

480

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Harrison’s 18th Ed. 2591

A.

Bone marrow suppression

B.

Seizure

C.

Infection

D.

Jaundice

The central event leading to hepatic fibrosis is activation of the hepatic stellate cell resulting in the formation of increased amounts of collagen and other components of the extracellular matrix.

1104

In cirrhosis liver, activated hepatic stellate cells transform into ? Harrison’s 16th Ed. 1858

Use of Infliximab in severe alcoholic hepatitis was stopped due to the increased risk of increased deaths secondary to infection and renal failure.

1099

Gastroenterology

Most liver transplantation centers require alcoholics to have documented abstinence of at least ? A. 3 months

1105

A.

Elastic tissue

B.

Lymphoid tissue

C.

Myofibroblasts

D.

Hepatocytes

In cirrhosis liver, the stellate cell produces ?

B.

6 months

C.

9 months

A.

Fibril-forming type I collagen

D.

12 months

B.

Fibril-forming type II collagen

C.

Fibril-forming type III collagen

D.

Fibril-forming type IV collagen

Harrison’s 16th Ed. 1858

Most transplantation centers currently require patients with a history of alcohol abuse to have documented abstinence of at least 6 months before undergoing transplantation (“6-month abstinence rule”).

308 - Cirrhosis

1106

In cirrhosis liver, which of the following leads hepatic stellate cells to produce collagen ? Harrison’s 16th Ed. 1858

1100

Reversal of fibrosis in cirrhosis liver can be achieved with treatment in which of the following diseases ?

A.

TNF 

B.

Insulin

Harrison’s 18th Ed. 2592

C.

Transforming growth factor  (TGF-)

D.

Erythropoietin

A.

Chronic hepatitis C

B.

Hemochromatosis

C.

Alcoholic liver disease

D.

All of the above

Upon successful treatment of chronic hepatitis C, hemochromatosis and alcoholic liver disease liver fibrosis can be reversed.

1101

Alcohol induced liver injury refers to ? Harrison’s 18th Ed. 2592

A.

Cirrhosis liver

Harrison’s 18th Ed. 2592

B.

Alcoholic fatty liver

A.

Irreversible chronic injury of hepatic parenchyma

C.

Alcoholic hepatitis

B.

Extensive fibrosis

D.

All of the above

C.

Formation of regenerative nodules

D.

All of the above

Alcohol-induced liver injury includes consequences resulting from chronic alcohol ingestion like alcoholic fatty liver, alcoholic hepatitis and alcoholic cirrhosis.

1108

Hepatic fibrosis secondary to chronic alcohol use is ? Harrison’s 18th Ed. 2592

A.

Centrilobular

Harrison’s 18th Ed. 2592

B.

Pericellular

A.

Hepatocyte necrosis

C.

Periportal

B.

Destruction of the supporting reticulin network

D.

Any of the above

C.

Distortion of the vascular bed

D.

All of the above

The pathologic features of cirrhosis liver result from ?

The pathologic features result from hepatocyte necrosis, collapse of the supporting reticulin network with subsequent connective tissue deposition, distortion of the vascular bed, and nodular regeneration of remaining liver parenchyma.

1103

1107

The cardinal pathologic features of cirrhosis liver are ?

The cardinal pathologic features reflect irreversible chronic injury of the hepatic parenchyma and include extensive fibrosis in association with the formation of regenerative nodules.

1102

Upon activation by factors released by hepatocytes and Kupffer cells, the stellate cell assumes a myofibroblast-like conformation and, under the influence of cytokines like transforming growth factor  (TGF-), produces fibril-forming type I collagen.

Chronic alcohol use can produce fibrosis in the absence of accompanying inflammation and/or necrosis. Fibrosis can be centrilobular, pericellular, or periportal.

1109

The diameter of nodules in alcoholic cirrhosis is ? Harrison’s 18th Ed. 2592

A.

< 0.5 mm

Central event leading to hepatic fibrosis in cirrhosis liver is ?

B.

< 1 mm

Harrison’s 18th Ed. 2592

C.

< 2 mm

D.

< 3 mm

A.

Activation of the hepatic stellate cell

B.

Activation of the CD 8+ cells

C.

Activation of Kupffer cells

D.

All of the above

In alcoholic cirrhosis, nodules are usually 300 units

Micronodular cirrhosis may result following jejunoileal bypass & thus alcoholic cirrhosis & micronodular cirrhosis are not synonymous. Alcoholic cirrhosis may progress to macronodular cirrhosis with time.

1124

In cirrhosis liver, cell loss generally ? Harrison’s 17th Ed. 1972

A.

Lags replacement

B.

Exceeds replacement

C.

Equals replacement

D.

Any of the above

With continued alcohol intake and destruction of hepatocytes, fibroblasts, activated hepatic stellate cells and myofibroblasts appear at the site of injury and deposit collagen forming septa in periportal and pericentral zones surrounding remaining liver cells, which regenerate and form nodules. The cell loss generally exceeds replacement.

1125

In alcoholics, which concomitant hepatitis infection accelerates development of alcoholic cirrhosis ?

Hemolytic anemia due to effects of hypercholesterolemia or erythrocyte membranes resulting in unusual spurlike projections (acanthocytosis) may occur. Hyperbilirubinemia is found in association with elevated serum alkaline phosphatase levels. Levels of serum AST are frequently elevated, but levels > 300 units are unusual.

1130

A.

Acute hepatitis A

B.

Acute hepatitis B

C.

Chronic hepatitis B

D.

Chronic hepatitis C

A.

< 300 units

B.

< 400 units

C.

< 500 units

D.

< 600 units

In alcoholic cirrhosis, levels of serum AST are frequently elevated but levels > 300 units are unusual and should prompt one to look for other coincident or complicating factors.

1131

In alcoholic liver disease, AST / ALT ratio is ? Harrison’s 18th Ed. 2593

1132

A.

> 0.5

B.

> 1.0

C.

> 1.5

D.

> 2.0

In alcoholic liver disease, AST levels > ALT are due to ? Harrison’s 18th Ed. 2593

Concomitant chronic hepatitis C virus (HCV) infection significantly accelerates development of alcoholic cirrhosis.

A.

Greater inhibition of ALT synthesis by ethanol

B.

Greater production of AST by ethanol

Harrison’s 17th Ed. 1972

C.

Greater clearance of ALT by ethanol

A.

Enlarged

D.

Lesser clearance of AST by ethanol

B.

Normal

C.

Decreased

D.

All of the above

In alcoholic cirrhosis, liver size may be ?

In alcoholic cirrhosis, liver may be either enlarged, normal, or decreased in size. With continuing hepatocyte destruction and collagen deposition, the liver shrinks in size, acquires a nodular appearance, and becomes hard as ‘end-stage’ cirrhosis develops.

1127

Levels of serum AST in alcoholic cirrhosis are ? Harrison’s 18th Ed. 2593

Harrison’s 18th Ed. 2593

1126

Laboratory finding unusual in alcoholic cirrhosis is ?

Harrison’s 17th Ed. 1972

In alcoholic liver disease & in contrast to viral hepatitis, serum AST is usually disproportio-nately elevated relative to ALT (AST/ALT ratio >2) due to proportionally greater inhibition of ALT synthesis by ethanol which may be partially reversed by pyridoxal phosphate.

1133

Altered albumin/globulin ratio in alcoholic cirrhosis is due to ? Harrison’s 18th Ed. 2593

A.

Hypoalbuminemia due to impaired hepatic protein synthesis

B.

Hyperglobulinemia due to stimulation of RE system

Acute/chronic GI blood loss

C.

A+B

B.

Coexistent folic acid & vitamin B 12 deficiency

D.

None of the above

C.

Hypersplenism

D.

All of the above

Anemia in alcoholic cirrhosis may be due to ? Harrison’s 18th Ed. 2593

A.

The serum albumin level is usually depressed, while serum globulins are increased. Hypoalbuminemia reflects impairment in hepatic protein synthesis, while hyperglobulinemia result from nonspecific stimulation of reticuloendothelial system.

Gastroenterology 483 1134

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Metabolic disturbances seen in alcoholic cirrhosis are all except ? Harrison’s 18th Ed. 2593

1135

A.

Glucose intolerance

B.

Respiratory alkalosis

C.

Metabolic alkalosis

D.

Prerenal azotemia

1140

B.

Hyperphosphatemia

C.

Dilutional hyponatremia

D.

Hypokalemia

In cirrhosis, glucose intolerance due to endogenous insulin resistance may be present, however clinical diabetes is uncommon. Central hyperventilation leads to respiratory alkalosis. Dietary deficiency and increased urinary losses lead to hypomagnesemia and hypophosphatemia. In patients with ascites and dilutional hyponatremia, hypokalemia may occur from increased urinary potassium losses due in part to hyperaldosteronism. Prerenal azotemia is also observed in such patients.

1136

1141

Which of the following terms are synonymous with posthepatitic cirrhosis ? A.

Coarsely nodular cirrhosis

B.

Multilobular cirrhosis

C.

Cryptogenic cirrhosis

D.

All of the above

Viral infections that can lead to chronic liver disease include all except ? Harrison’s 16th Ed. 1860t

A.

Cytomegalovirus

A.

5 to 10 %

B.

Epstein-Barr virus

B.

10 to 15 %

C.

Hepatitis C

C.

20 to 25 %

D.

Hepatitis E

D.

30 to 35 %

Viral infections that lead to chronic liver disease include hepatitis B, C, D, cytomegalovirus, EBV.

1142

Which of the following is a cause of chronic cholestatic syndrome ? Harrison’s 17th Ed. 1974

Complicating conditions that can deteriorate clinical status of an otherwise stable cirrhotic patient include ?

A.

Primary biliary cirrhosis (PBC)

Harrison’s 17th Ed. 1972

B.

Autoimmune cholangitis

A.

Infection

C.

Primary sclerosing cholangitis (PSC)

B.

Portal vein thrombosis

D.

All of the above

C.

Hepatocellular carcinoma

D.

All of the above

Causes of chronic cholestatic syndromes are primary biliary cirrhosis (PBC), autoimmune cholangitis, primary sclerosing cholangitis (PSC) and idiopathic adulthood ductopenia.

1143

Which of the following about alcoholic cirrhosis is true ? A.

Glucocorticoids are helpful in severe alcoholic hepatitis & encephalopathy

B.

Survival benefit has been reported for S-adenosyl methionine in alcoholic cirrhosis

C.

Diuretics, sedatives, aspirin, acetaminophen should be used with caution

D.

All of the above

Glucocorticoids in moderately large doses for 4 weeks is helpful in patients with severe alcoholic hepatitis and encephalopathy but have no role in the treatment of established alcoholic cirrhosis. Sadenosyl methionine decreases proinflammatory cytokines and has survival benefit in alcoholic cirrhosis. Diuretics, sedatives, aspirin, acetaminophen should be used with caution.

Which of the following medications is approved for treating alcoholism by reducing craving ? A. Naltrexone

Histopathologic features of chronic cholestasis are all except ? Harrison’s 17th Ed. 1974

Harrison’s 17th Ed. 1973

1139

All of the above

Harrison’s 18th Ed. 2593

When clinical status of an otherwise stable cirrhotic patient deteriorates without an obvious explanation, complicating conditions like infection, portal vein thrombosis & hepatocellular carcinoma, should be looked for.

1138

Tiapride

D.

Coarsely nodular cirrhosis and multilobular cirrhosis are terms synonymous with posthepatitic cirrhosis. The term cryptogenic cirrhosis has been used interchangeably with posthepatitic cirrhosis, but this designation should be reserved for those cases in which the etiology of cirrhosis is unknown (~10% of all patients with cirrhosis).

What percentage of individuals with excessive alcohol intake develop cirrhosis ?

Alcoholic cirrhosis should be strongly suspected in patients with a history of prolonged or excessive alcohol intake and physical signs of chronic liver disease. Only 10 to 15% of individuals with excessive alcohol intake develop cirrhosis, therefore other causes & types of liver disease should be considered.

1137

C.

Harrison’s 17th Ed. 1973

Harrison’s 18th Ed. 2593

Hypomagnesemia

Acamprosate

Tiapride is a dopamine antagonist. Acamprosate helps restore balance of excitatory & inhibitory neurotransmission in nucleus accumbens by blocking GABA receptors and Glutamate receptors and activating GABA-A receptors. Naltrexone is an opioid antagonist.

Metabolic disturbances seen in alcoholic cirrhosis are all except ? A.

B.

483 Cardiology

A.

Copper deposition

B.

Xanthomatous transformation of hepatocytes

C.

Iron deposition

D.

Biliary fibrosis

Histopathologic features of chronic cholestasis are cholate stasis, copper deposition, xanthomatous transformation of hepatocytes, and biliary fibrosis. There may also be chronic portal inflammation, interface activity and chronic lobular inflammation. Ductopenia is a result of this progressive disease as patients develop cirrhosis.

1144

Steatosis is often present in patients with which HCV genotype ? Harrison’s 18th Ed. 2594

A.

1

B.

2

C.

3

D.

4

In patients with HCV genotype 3, steatosis is often present.

484 1145

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Nonalcoholic steatohepatitis (NASH) is nowadays diagnosed as what was earlier diagnosed as ?

1151

Autoimmune cholangiopathy

B.

Cardiac cirrhosis

C.

Cryptogenic cirrhosis

D.

Autoimmune hepatitis

Many patients who were thought to have cryptogenic cirrhosis in fact have nonalcoholic steatohepatitis.

1146

Antimitochondrial antibodies are detectable years before clinical signs appear

C.

Autoantibodies recognize three to five inner mitochondrial membrane proteins

D.

All of the above

Which of the following about primary biliary cirrhosis is true ? A.

Fatigue & pruritus are the commonest presenting symptoms

A.

Fibrous obliteration of intrahepatic bile ductules

B.

Pruritus precedes onset of jaundice by months to years

B.

Fibrous obliteration of larger extrahepatic ducts

C.

C.

Fibrous obliteration of intrahepatic bile ductules and larger extrahepatic ducts both

Pruritus is usually worse at night and is exacerbated by contact with wool, other fabrics, or heat

D.

All of the above

D.

None of the above

In PBC, the earliest symptom is pruritus, which may be either generalized or limited initially to palms and soles. Fatigue is a prominent early symptom.

In PBC, pruritus is most bothersome in ?

Associated findings in primary biliary cirrhosis include all except ?

Harrison’s 18th Ed. 2595

Harrison’s 16th Ed. 1861

A.

Morning

A.

Hyperlipidemia

B.

Afternoon

B.

Autoimmune thyroid disease

C.

Evening

C.

Osteomalacia

D.

Night

D.

Fibroadenoma breast

Features unique to PBC include all except ?

1153

Protracted elevation of serum lipids, especially cholesterol, leads to subcutaneous lipid deposition around the eyes (xanthelasmas) and over joints and tendons (xanthomas). Clinical evidence of sicca syndrome is found in about 75%, and serologic evidence of autoimmune thyroid disease in 25% of patients. Osteomalacia occurs due to diminished vitamin D absorption. Accelerated osteoporosis is common.

A.

Hypopigmentation

B.

Xanthelasma

C.

Xanthomata

A.

Type I diabetes mellitus

D.

Bone pain

B.

Scleroderma

C.

Pernicious anemia

D.

All of the above

1154

In PBC, hyperpigmentation is evident on ? Harrison’s 18th Ed. 2595

A.

Trunk

B.

Face

C.

Areas of exfoliation and lichenification

D.

All of the above

In PBC, hyperpigmentation is evident on trunk and arms and in areas of exfoliation and lichenification.

Which of the following about primary biliary cirrhosis is false ? N Engl J Med 2005;353:1261-73

Coexisting autoimmune disease in primary biliary cirrhosis is ? Harrison’s 16th Ed. 1861

Features unique to PBC include hyperpigmentation, xanthelasma, xanthomata & bone pain. The first three are related to the altered cholesterol metabolism seen in PBC.

1150

B.

Harrison’s 17th Ed. 1974

Harrison’s 18th Ed. 2595

1149

Antimitochondrial antibodies are present in ~90%

N Engl J Med 2005;353:1261-73

In PBC, pruritus is most bothersome in the evening.

1148

1152

A.

Primary biliary cirrhosis (PBC) is characterized by ?

PBC is characterized by portal inflammation & necrosis of cholangiocytes in small and mediumsized bile ducts.

1147

Which of the following about primary biliary cirrhosis is true ? N Engl J Med 2005;353:1261-73

Harrison’s 18th Ed. 2594

A.

Gastroenterology

1155

Coexisting autoimmune disease in primary biliary cirrhosis is ? Harrison’s 16th Ed. 1861

A.

1156

Rheumatoid arthritis

B.

CREST syndrome

C.

Renal tubular acidosis

D.

All of the above

Coexisting autoimmune disease in primary biliary cirrhosis is ? Harrison’s 16th Ed. 1861

A.

Keratoconjunctivitis sicca IgA deficiency

A.

Most prevalent in northern Europe

B.

B.

Slowly progressive autoimmune disease of liver

C.

CREST syndrome

C.

Primarily affects men

D.

All of the above

D.

Peak incidence is in fifth decade of life

Among patients with symptomatic disease, 90% are women between age 35 to 60 years.

PBC is frequently associated with a variety of autoimmune disorders, such as syndrome of calcinosis, Raynaud’s phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia (CREST); keratoconjunctivitis sicca syndrome (dry eyes and dry mouth); autoimmune thyroiditis; type 1 diabetes mellitus; IgA deficiency; rheumatoid arthritis, scleroderma, pernicious anemia, and renal tubular acidosis.

Gastroenterology 485 1157

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Which of the following is true for “autoimmune cholangitis” ? Harrison’s 16th Ed. 1861

A.

Histological features similar to PBC

B.

Negative AMA

C.

Antinuclear or smooth-muscle antibodies present

D.

All of the above

D.

All of the above

Most patients with PBC are asymptomatic, and the disease is initially detected by elevated serum alkaline phosphatase levels during routine screening.

1163

Which of the following is false about ursodiol therapy in PBC ? Harrison’s 16th Ed. 1861

A.

Dose is 13 to 15 mg/kg per day

In autoimmune cholangitis, histological features are similar to PBC. The AMA titre is negative. Antinuclear or smooth-muscle antibodies are present.

B.

Should be given with food

C.

As a single dose daily

1158

D.

None of the above

Antimitochondrial antibody (AMA) found in primary biliary cirrhosis is of which type of immunoglobulin ? Harrison’s 16th Ed. 1860

A.

IgG

B.

IgM

C.

IgA

D.

IgE

Ursodiol is given in doses of 13 to 15 mg/kg per day, with food and as a single dose daily.

1164

Which of the following is an autoreactive mitochondrial antigen in primary biliary cirrhosis ? Harrison’s 16th Ed. 1860

A.

Pyruvate dehydrogenase complex (PDC)

B.

2-oxoglutarate dehydrogenase complex (OGDC)

C.

Branched-chain 2-oxoacid dehydrogenase complex

D.

All of the above

T cells infiltrating the liver in primary biliary cirrhosis are specific for ? N Engl J Med 2005;353:1261-73

A.

Pyruvate dehydrogenase E2 complex (PDC-E2)

B.

E3-binding protein (E3-BP)

C.

Ketoglutaric acid dehydrogenase E2 complex (OGDC-E2)

D.

Branched-chain 2-oxo-acid dehydrogenase E2 complex (BCKDE2)

The major autoantigen in PBC (90%) is 74-kDa E2 component of PDC, dihydrolipoamide acetyltransferase. Antibodies are directed to a region essential for binding of a lipoic acid cofactor and inhibit the overall enzymatic activity of the PDC. Other AMA autoantibodies in PBC patients are directed to similar constituents of BCOADC and OGDC and also inhibit their enzymatic function.

1161

Hyperlipidemia seen in primary biliary cirrhosis shows a characteristic rise in ?

1165

Serum unesterified cholesterol

B.

Serum triglycerides

C.

Serum LDLc

D.

Serum VLDLc

Asymptomatic patients of PBC are initially detected by ? Harrison’s 16th Ed. 1860

A.

Elevated serum alkaline phosphatase levels

B.

Elevated AST levels

C.

Elevated ALT levels

B.

Ondansetron

C.

Rifampin

D.

Tetracycline

Which of the following drugs is not used in the treatment of primary biliary cirrhosis ? A.

Ursodeoxycholic acid

B.

Colchicine

C.

Methotrexate

D.

Imatinib mesylate

Glucocorticoids, colchicine, methotrexate, azathioprine, cyclosporine & tacrolimus are effective.

1166

The only established “cure” in the treatment of primary biliary cirrhosis is ? Harrison’s 16th Ed. 1861

A.

Liver transplantation

B.

Long term Cyclosporine therapy

C.

Long term Tacrolimus therapy

D.

All of the above

Ursodiol therapy may not prevent ultimate progression of PBC and the only established ‘cure’ is liver transplantation.

1167

In PBC, when night blindness is refractory to vitamin A therapy, which element should be supplemented ? Harrison’s 16th Ed. 1861

In PBC, hyperlipidemia is common with a striking increase of serum unesterified cholesterol.

1162

Cholestyramine

Harrison’s 16th Ed. 1861

Harrison’s 16th Ed. 1861

A.

A.

Rifampin, opiate antagonists (naloxone or naltrexone), ondansetron, plasmapheresis, and ultraviolet light have been tried for control of pruritus with varying results. Cholestyramine, an oral bile salt sequestering resin, may be helpful in doses of 12 to 16 gm/day to decrease both pruritus and hypercholesterolemia.

In PBC, circulating IgG antimitochondrial autoantibodies (AMA) recognize inner mitochondrial membrane proteins identified as enzymes of the pyruvate dehydrogenase complex (PDC), branched chain 2oxoacid dehydrogenase complex (BCOADC), and 2-oxoglutarate dehydrogenase complex (OGDC).

1160

Drugs used to treat pruritus in primary biliary cirrhosis include all except ? Harrison’s 16th Ed. 1861

A circulating IgG antimitochondrial antibody (AMA) is detected in ~90% of patients with PBC and only rarely in other forms of liver disease.

1159

485 Cardiology

A.

Copper

B.

Zinc

C.

Cobalt

D.

Selenium

In PBC, fat-soluble vitamins A, D, E, and K should be given at regular intervals. Zinc supplementation may be necessary if night blindness is refractory to vitamin A therapy.

1168

Which of the following represent the pathological Stage I of PBC ? Harrison’s 16th Ed. 1861

A.

Chronic nonsuppurative destructive cholangitis

486

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Reduction in number of bile ducts and proliferation of smaller bile ductules

C.

Decrease in interlobular ducts, loss of liver cells, and expansion of periportal fibrosis into a network of connective tissue scars

D.

Micronodular or macronodular cirrhosis

D.

Secondary biliary cirrhosis (SBC) is characterized by ? Harrison’s 16th Ed. 1860

A.

Fibrous obliteration of intrahepatic bile ductules

B.

Fibrous obliteration of larger extrahepatic ducts

C.

Fibrous obliteration of intrahepatic bile ductules and larger extrahepatic ducts both

D.

None of the above

Biliary cirrhosis results from injury to or prolonged obstruction of either the intrahepatic or extrahepatic biliary system. It is associated with impaired biliary excretion, destruction of hepatic parenchyma, and progressive fibrosis. Primary biliary cirrhosis (PBC) is characterized by chronic inflammation and fibrous obliteration of intrahepatic bile ductules. Secondary biliary cirrhosis (SBC) is the result of longstanding obstruction of the larger extrahepatic ducts.

1170

1174

B.

Elevated liver copper levels

C.

Hypoprothrombinemia

D.

Serum aminotransferase > 300

An abnormal serum lipoprotein (lipoprotein X) and elevated liver copper levels may be present in PBC, though not specific. Deficiency of bile salts in intestine leads to moderate steatorrhea and impaired absorption of fat soluble vitamins and hypoprothrombinemia. Serum aminotransferase values rarely exceed 150 to 200 units.

1171

What duration of biliary obstruction is required to result in secondary biliary cirrhosis (SBC) ?

1175

At least 1 to 3 months

B.

At least 3 to 12 months

C.

At least 12 to 18 months

D.

At least 18 to 36 months

At least 3 to 12 months is required for biliary obstruction to result in finely nodular secondary biliary cirrhosis.

1172

In children, which of the following is a common cause of SBC ?

1176

1173

Primary sclerosing cholangitis

B.

Gallstones

C.

Cystic fibrosis

D.

Chronic pancreatitis

Which of the following rarely causes SBC ? Harrison’s 16th Ed. 1861

A.

Primary sclerosing cholangitis

B.

Malignant tumors of common bile duct or pancreas

C.

Chronic pancreatitis

Toxoplasmosis

C.

Echinococcosis

D.

Leptospirosis

Inherited & metabolic disorders that can lead to chronic liver disease include all except ? A.

1-antitrypsin deficiency

B.

Fanconi’s syndrome

C.

Wilson’s disease

D.

Lyme’s disease

Inherited & metabolic disorders that can lead to chronic liver disease include all except ? Harrison’s 16th Ed. 1860t

A.

Galactosemia

B.

Gaucher’s disease

C.

Hemochromatosis

D.

Renal tubular acidosis

Inherited and metabolic disorders that can lead to chronic liver disease include  1-Antitrypsin deficiency, Alagille’s syndrome, Biliary atresia, Familial intrahepatic cholestasis (FIC) types 1-3, Fanconi’s syndrome, Galactosemia, Gaucher’s disease, Glycogen storage disease, Hemochromatosis, Hereditary fructose intolerance, Hereditary tyrosinemia, Wilson’s disease.

1177

Drugs & toxins that can lead to chronic liver disease include all except ? Harrison’s 16th Ed. 1860t

A.

Oral contraceptives

B.

Amioradone

C.

Testosterone

D.

Arsenicals

Drugs & toxins that can lead to CLD include alcohol, amioradone, arsenicals, oral contraceptives (Budd-Chiari), pyrrolidizine alkaloids & antineoplastic agents.

1178

Harrison’s 16th Ed. 1861

A.

Brucellosis

B.

Harrison’s 16th Ed. 1860t

Harrison’s 16th Ed. 1861

A.

A.

Infections that can lead to chronic liver disease include Brucellosis, Capillariasis, Echinococcosis, Schistosomiasis, Toxoplasmosis.

Prolonged cholestasis can lead to all of the following except ? Presence of Lipoprotein X

Infections that can lead to chronic liver disease include all except ? Harrison’s 16th Ed. 1860t

Harrison’s 16th Ed. 1861

A.

Postoperative CBD strictures

In children, congenital biliary atresia & cystic fibrosis are common causes of SBC. In adults, biliary tract obstruction is mostly caused by postoperative strictures, gallstones, chronic pancreatitis or primary sclerosing cholangitis. Patients with malignant tumors of CBD or pancreas rarely survive long enough to develop SBC.

PBC is divided morphologically into 4 stages. Stage I is termed chronic nonsuppurative destructive cholangitis. It is a necrotizing inflammatory process of portal triads characterized by destruction of medium & small bile ducts, a dense infiltrate of acute & chronic inflammatory cells, mild fibrosis & occasionally, bile stasis. In stage II, inflammatory infiltrate becomes less prominent, number of bile ducts are reduced & smaller bile ductules proliferate. Over months to years there is a decrease in interlobular ducts, loss of liver cells & expansion of periportal fibrosis into a network of connective tissue scars marking stage III. Stage IV represents cirrhosis - micronodular or macronodular.

1169

Gastroenterology

Disorders that can lead to chronic liver disease include all except ? Harrison’s 16th Ed. 1860t

1179

A.

Biliary obstruction (chronic)

B.

Cystic fibrosis

C.

Wegener’s granulomatosis

D.

Graft-versus-host disease

Disorders that can lead to chronic liver disease include all except ? Harrison’s 16th Ed. 1860t

A.

Jejunoileal bypass

Gastroenterology 487 B.

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Sarcoidosis

B.

Multifocal fibrosclerosis syndromes

C.

Primary biliary cirrhosis

C.

Riedel’s struma

D.

Porphyria

D.

All of the above

487 Cardiology

Disorders that can lead to chronic liver disease include Biliary obstruction (chronic), Cystic fibrosis, Graft-versus-host disease, Jejunoileal bypass, Nonalcoholic fatty liver disease, Primary biliary cirrhosis, Primary sclerosing cholangitis, Sarcoidosis.

Primary or idiopathic sclerosing cholangitis may be associated with autoimmune pancreatitis; multifocal fibrosclerosis syndromes (retroperitoneal, mediastinal, and/or periureteral fibrosis), Riedel’s struma or pseudotumor of the orbit.

1180

1186

1181

Which of the following about Primary Sclerosing Cholangitis (PSC) is false ? Harrison’s 18th Ed. 2596

Harrison’s 18th Ed. 2627

A.

Chronic cholestatic syndrome

A.

Immunoglobulin G1 - associated cholangitis

B.

Obliteration of intrahepatic biliary tree

B.

Immunoglobulin G2 - associated cholangitis

C.

Obliteration of extrahepatic biliary tree

C.

Immunoglobulin G3 - associated cholangitis

D.

None of the above

D.

Immunoglobulin G4 - associated cholangitis

Which of the following is seen frequently in Primary Sclerosing Cholangitis (PSC) ? Harrison’s 18th Ed. 2596

A.

Hodgekin’s lymphoma

B.

Ulcerative colitis (UC)

C.

Azoospermia

D.

Amenorrhoea

Immunoglobulin G4–associated cholangitis is a recently described biliary disease of unknown etiology that presents with biochemical and cholangiographic features indistinguishable from PSC. Often associated with autoimmune pancreatitis & other fibrosing conditions but not inflammatory bowel disease, it is characterized by elevated serum IgG4 and infiltration of IgG4-positive plasma cells in bile ducts and liver tissue. Glucocorticoids and/or azathioprine are helpful.

1187

Pathologic change occurs in PSC is ? Harrison’s 18th Ed. 2596

A.

Bile duct proliferation

B.

Ductopenia

C.

Fibrous cholangitis (pericholangitis)

D.

All of the above

1188

A.

Anti-DNA antibody

B.

Cryoglobulins

C.

Perinuclear antineutrophil cytoplasmic antibody (p-ANCA)

D.

Antiphospholipid antibody

Serum bilirubin concentration

C.

Liver histologic changes

D.

All of the above

Which of the following has cholangiographic appearance similar to that of PSC ? A.

AIDS cholangiopathy

B.

Traumatic biliary injury

C.

Chronic pancreatitis

D.

All of the above

1189

Which of the following is efficacious in PSC ? Harrison’s 18th Ed. 2627

A.

Glucocorticoids

B.

Methotrexate

Harrison’s 18th Ed. 2596

C.

Cyclosporine

A.

D.

UDCA

Typical cholangiographic findings in PSC is ? Multiple calculi in biliary tree

B.

Multifocal stricturing & beading of biliary tree

C.

Diffuse fibrotic narrowing of biliary tree

D.

All of the above

Typical cholangiographic findings in PSC are multifocal stricturing and beading with intervening segments of normal or dilated ducts involving both the intrahepatic and extrahepatic biliary tree.

1185

B.

AIDS cholangiopathy is a condition, usually due to infection of the bile duct epithelium with CMV or cryptosporidia, which has a cholangiographic appearance similar to that of PSC. These patients usually present with greatly elevated serum alkaline phosphatase levels (mean, 800 IU/L), but the bilirubin is often near normal. These patients do not typically present with jaundice.

Perinuclear antineutrophil cytoplasmic antibody (p-ANCA), is positive in ~65% of patients of PSC.

1184

Age

Harrison’s 18th Ed. 329, 2627

Which of the following antibody is seen frequently in Primary Sclerosing Cholangitis (PSC) ? Harrison’s 18th Ed. 2596

A.

Independent predictors of a bad prognosis in PSC are age, serum bilirubin concentration, liver histologic changes and splenomegaly. Cholangiocarcinoma is a dreaded consequence.

Pathologic changes that can occur in PSC show bile duct proliferation as well as ductopenia and fibrous cholangitis (pericholangitis).

1183

Independent predictor of a bad prognosis in PSC is ? Harrison’s 18th Ed. 2627

Over 50% of patients with PSC also have ulcerative colitis (UC). Therefore, once a diagnosis of PSC is established, colonoscopy should be performed to look for evidence of UC.

1182

Which of the following has biochemical & cholangiographic features indistinguishable from PSC ?

Glucocorticoids, methotrexate, and cyclosporine have not been shown to be efficacious in PSC. UDCA in high dosage (20 mg/kg) improves serum liver tests, but an effect on survival has not been documented.

1190

“Nutmeg liver” is the term used to describe liver in ? Harrison’s 18th Ed. 2596

A.

Cardiac cirrhosis

B.

Primary Biliary Cirrhosis

Harrison’s 18th Ed. 2627

C.

Secondary Biliary Cirrhosis

A.

D.

None of the above

Primary or idiopathic sclerosing cholangitis may be associated with ? Autoimmune pancreatitis

488

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

In right heart failure, hepatic sinusoids become dilated & engorged with blood, along with hepatic ischemia from poor perfusion leading to necrosis of centrilobular hepatocytes with fibrosis in central areas. Centrilobular fibrosis extends outward in a characteristic stellate pattern from central vein.

1191

In “nutmeg liver”, gross examination of liver shows which of the following ? Harrison’s 16th Ed. 1862

A.

Nodules on the surface of liver

B.

Alternating red and pale areas

C.

Pyramid like elevations on surface of liver

D.

Brownish black discolouration of liver

1197

Toxicity of which of the following vitamins can cause venoocclusive disease of liver ?

1198

A.

A

B.

D

C.

E

D.

K

Acute Budd-Chiari syndrome has all the features except ?

B.

Firm

A.

Abdominal pain

C.

Tender

B.

Jaundice

D.

None of the above

C.

Ascites

D.

Caudate lobe hypertrophy

Levels of which of the following is characteristically elevated in cardiac cirrhosis ?

Sherlock

1199

Initial investigation of choice in suspected Budd-Chiari syndrome is ?

Harrison’s 18th Ed. 2596

Sherlock

A.

S. Bilirubin

A.

USG abdomen

B.

SGOT

B.

Doppler studies

C.

SGPT

C.

CT abdomen

D.

S. Alkaline phosphatase

D.

MR angiography

1200

Portal hypertension is defined as elevation of hepatic venous pressure gradient to ? Harrison’s 18th Ed. 2597

Which of the following could lead to cardiac cirrhosis ? Harrison’s 16th Ed. 1862

A.

> 2 mm Hg

A.

Valvular heart disease

B.

> 3 mm Hg

B.

Constrictive pericarditis

C.

> 4 mm Hg

C.

Cor pulmonale of long duration (>10 years)

D.

> 5 mm Hg

D.

All of the above

The presence of a firm, enlarged liver with signs of chronic liver disease in a patient with valvular heart disease, constrictive pericarditis, or cor pulmonale of long duration (>10 years) should suggest cardiac cirrhosis.

1195

Centrilobular congestion & sinusoidal dilatation on liver biopsy

Enlarged

ALP levels are characteristically elevated in cardiac cirrhosis, Aminotransferases may be normal or slightly increased with AST usually higher than ALT.

1194

Right-sided heart failure

D.

A.

With prolonged right heart failure, liver becomes enlarged, firm, & is usually nontender.

1193

C.

Sherlock

Which of the following is false in hepatomegaly due to prolonged right-sided heart failure ? Harrison’s 18th Ed. 2596

Intractable ascites

In Budd-Chiari syndrome, liver is grossly enlarged, tender & severe intractable ascites is present. Signs & symptoms of heart failure are notably absent. Hepatic venography or liver biopsy showing centrilobular congestion & sinusoidal dilatation in absence of right heart failure characterize BuddChiari syndrome.

In nutmeg liver, gross examination shows alternating red (congested) & pale (fibrotic) areas.

1192

Inherited metabolic liver disease that can progress to cirrhosis is ?

Portal hypertension is defined as elevation of hepatic venous pressure gradient (HVPG) to >5 mmHg. Varices may develop but do not bleed if HVPG is 10 mm Hg) mostly results from increased resistance to portal blood flow. When hepatic cirrhosis is complicated by portal hypertension, increased resistance is usually sinusoidal.

1210

Esophageal varices are present in what percentage of compensated and decompensated cirrhosis ? A. 10 & 40 % B.

20 & 50 %

C.

30 & 60 %

D.

40 & 70 %

Esophageal varices are present in 30% of patients with compensated cirrhosis and in up to 60% of those with decompensated cirrhosis (with evidence of ascites or encephalopathy).

1205

1206

1207

A.

Brucellosis

B.

Toxoplasmosis

C.

Echinococcosis

D.

Schistosomiasis

Intrahepatic presinusoidal causes of portal hypertension include congenital hepatic fibrosis and schistosomiasis. Schistosomiasis alone results in pure fibrotic lesions in liver. Cirrhosis occurs when other nutritional or infectious agents (hepatitis B or C virus) are involved. It is characteristically periportal (Symmers’ clay pipe–stem fibrosis).

1211

Portal vein obstruction may occur in association with ?

Which of the following is a posthepatic cause of portal hypertension ?

Harrison’s 18th Ed. 2598

A.

Cirrhosis

Harrison’s 18th Ed. 2598

B.

Abdominal trauma

A.

Portal vein thrombosis

C.

Pancreatitis

B.

Budd-Chiari syndrome (BCS)

D.

All of the above

C.

Splenic vein thrombosis

D.

Venoocclusive disease

Which of the following is a posthepatic cause of portal hypertension ?

Portal vein obstruction may be idiopathic or occur in association with cirrhosis, infection, pancreatitis, or abdominal trauma.

1212

Portal vein thrombosis may develop in ? Harrison’s 18th Ed. 2598

Harrison’s 18th Ed. 2598

A.

Polycythemia vera

A.

Budd-Chiari syndrome (BCS)

B.

Deficiencies of protein C, protein S, or antithrombin III

B.

Venoocclusive disease

C.

Resistance to activated protein C (factor V Leiden)

C.

Chronic right-sided cardiac congestion

D.

All of the above

D.

All of the above

Which of the following accounts for most cases of portal hypertension ? Harrison’s 18th Ed. 2598

A.

Prehepatic

B.

Intrahepatic

C.

Posthepatic

D.

Any of the above

Intrahepatic causes of portal hypertension account for over 95% of cases of portal hypertension and are represented by the major forms of cirrhosis.

1208

‘Symmers’ clay-pipe stem fibrosis in liver is due to ? Harrison’s 18th Ed. 1755

Normal pressure in portal vein is 5 to 10 mm Hg because of low vascular resistance in hepatic sinusoids.

1204

489 Cardiology

Budd-Chiari syndrome is an example of ? Harrison’s 18th Ed. 2598

Idiopathic portal vein thrombosis may develop in hypercoagulable states like polycythemia vera, essential thrombocythemia, deficiencies of protein C / protein S / antithrombin III, resistance to activated protein C (factor V Leiden) & mutation of prothrombin gene (G20210A).

1213

Primary complication of portal hypertension is ? Harrison’s 18th Ed. 2598

A.

Gastroesophageal varices with hemorrhage

B.

Ascites

C.

Hypersplenism

D.

All of the above

Three primary complications of portal hypertension are gastroesophageal varices with hemorrhage, ascites, and hypersplenism.

1214

On screening of histologically confirmed cirrhosis cases, what proportion of patients have esophageal varices ?

A.

Pre sinusoidal obstruction

B.

Sinusoidal obstruction

A.

One - fourth

C.

Post sinusoidal obstruction

B.

One - third

D.

Any of the above

C.

One - half

D.

Three - fourth

Postsinusoidal obstruction may also occur outside the liver at the level of the hepatic veins (BuddChiari syndrome), the inferior vena cava so that the liver parenchyma is exposed to elevated venous pressures.

Harrison’s 18th Ed. 2598

On screening of histologically confirmed cirrhosis cases, one - third of patients have esophageal varices.

490 1215

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR In cirrhosis, factor predict the risk of esophageal variceal bleeding is ? Harrison’s 18th Ed. 2598

A.

Severity of cirrhosis

B.

Wedged-hepatic vein pressure

C.

Tense ascites

D.

All of the above

In cirrhosis, factors that predict risk of esophageal variceal bleeding include severity of cirrhosis (Child’s class, MELD score), height of wedged-hepatic vein pressure, size of varix, location of varix, endoscopic stigmatas (red wale signs, hematocystic spots, diffuse erythema, bluish color, cherry red spots, or white-nipple spots0 and tense ascites.

1216

1217

1221

Wedged hepatic vein pressure is elevated in sinusoidal portal hypertension

C.

Wedged hepatic vein pressure is elevated in postsinusoidal portal hypertension

D.

None of the above

What level of portal hypertension threatens bleeding from gastroesophageal varices ? A.

> 6 mm Hg

A.

Progressive decrease in platelet count

B.

> 8 mm Hg

B.

Progressive increase in platelet count

C.

> 10 mm Hg

C.

Progressive decrease in lymphocyte count

D.

> 12 mm Hg

D.

Progressive increase in lymphocyte count

Wedged and free hepatic vein pressures allow calculation of a wedged-to-free gradient, which is equivalent to the portal pressure. Average normal wedged-to-free gradient is 5 mmHg, and patients with a gradient >12 mmHg are at risk for variceal hemorrhage.

1222

Marker of the presence of cirrhosis in a patient being followed for chronic liver disease is ?

Apart from propranolol, which other  -adrenergic blocker is used to reduce portal pressure ? Harrison’s 18th Ed. 2598

Harrison’s 18th Ed. 2598

A.

Atenolol

A.

Appearance of an enlarged spleen

B.

Nadolol

B.

Development of ascites

C.

Sotalol

C.

Hepatic encephalopathy

D.

Carvedilol

D.

All of the above

The risk of variceal hemorrhage is related to ? A.

Size of varices

B.

Appearance of varices

C.

Severity of liver dysfunction

D.

All of the above

Risk of variceal hemorrhage is related to size of varices (varices 5 mm have a 30% risk of bleeding within 2 years), appearance of the varices (red wale sign i.e. red streaks of mucosa overlying varix) have an increased risk of hemorrhage & severity of liver dysfunction (high Child-Pugh score - B or C represents decompensated cirrhosis & is associated with an increased risk of bleeding).

 -adrenergic blockade with nonselective agents (propranolol or nadolol) reduces portal pressure through vasoconstrictive effects on both splanchnic arterial bed & portal venous system in combination with reduced cardiac output. Such therapy is effective in preventing both a first variceal bleed & subsequent episodes.

1223

Doses of propranolol to treat portal hypertension should aim to reduce the resting pulse rate by ? Harrison’s 16th Ed. 1863

A.

5%

B.

10 %

C.

25 %

D.

33 %

In treatment of portal hypertension, especially variceal bleeding, reduction of resting pulse through -adrenergic blockade with nonselective agents such as propranolol by 25% is reasonable.

1224

In liver disease, development of portal hypertension is revealed by the appearance of which of the following ?

The goal of treatment in patients of portal hypertension is to reduce hepatic venous pressure gradient (HVPG) to ? Harrison’s 16th Ed. 1864

Harrison’s 18th Ed. 2598

A.

25 mmol/day)

B.

Normal renal function

C.

Ascites is of recent onset

D.

All of the above

A.

Splanchnic vasodilation

B.

Arteriovenous shunting

C.

Profound renal vasoconstriction

D.

None of the above

In HRS, kidneys are structurally normal but fail due to splanchnic vasodilation & arteriovenous shunting, resulting in profound renal vasoconstriction resulting from extreme underfilling of arterial circulation.

1260

Renal failure in cirrhosis is defined as serum creatinine above ? N Engl J Med 2009;361:1279-90

A.

1.2 mg /dL

B.

1.3 mg /dL

Harrison’s 18th Ed. 2600

C.

1.4 mg /dL

A.

Develops without obvious primary source of infection

D.

1.5 mg /dL

B.

Ascitic fluid has high concentrations of albumin

C.

In ascitic fluid, >250 PMN/µL is diagnostic

D.

Monomicrobial nonneutrocytic bacterascites is a variant of SBP

Which of the following statements about spontaneous bacterial peritonitis (SBP) is false ?

SBP is characterized by spontaneous infection of ascitic fluid in absence of intraabdominal source of infection. Bacterial translocation is the presumed mechanism for development of SBP, with gut flora traversing the intestine into mesenteric lymph nodes, leading to bacteremia and seeding of the ascitic fluid.

1256

Which of the following about hepatorenal syndrome is false ? Harrison’s 18th Ed. 2601

In cirrhosis liver with ascites, response to salt restriction alone is more likely to occur if ? Harrison’s 16th Ed. 1866

1255

1259

Which of the following statements about spontaneous bacterial peritonitis (SBP) is false ? Harrison’s 18th Ed. 2601, N Engl J Med 2004;350:1646-54

A.

Escherichia coli are most commonly isolated

Most studies & consensus conferences have defined renal failure in cirrhosis as a serum creatinine concentration above 1.5 mg /dL.

1261

Which of the following about hepatorenal syndrome is false ? Harrison’s 18th Ed. 2601

A.

Type I HRS is the more aggressive form

B.

Type I HRS carries a mortality rate of >90%

C.

HRS is seen in patients with refractory ascites

D.

None of the above

HRS is a unique form of prerenal ARF that complicates advanced cirrhosis and acute liver failure and is seen in in patients with refractory ascites. Type I HRS is the more aggressive form of the disease & carries a mortality rate of >90%.

494 1262

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Type 1 HRS is characterized by doubling of serum creatinine level to > 2.5 mg/dl in ?

N Engl J Med 2009;361:1279-90

A.

< 2 weeks

A.

Norfloxacin

B.

< 4 weeks

B.

Eplerenone

C.

< 6 weeks

C.

Toresamide

D.

< 8 weeks

D.

Vitamin E

Which of the following is true for type 1 hepatorenal syndrome ?

Long-term oral norfloxacin reduces risk of hepatorenal syndrome & improves survival.

1269

N Engl J Med 2004;350:1646-54

Harrison’s 16th Ed. 1867

Progressive oliguria

A.

Worsening azotemia

B.

Rapid rise of serum creatinine

B.

Avid sodium retention

C.

Common precipitating event is SBP

C.

Oliguria without identifiable causes of renal dysfunction

D.

All of the above

D.

Kidneys are structurally smaller

1270

Harrison’s 16th Ed. 1867

N Engl J Med 2004;350:1646-54

A.

Urinalysis normal

A.

Most have refractory ascites

B.

Renal biopsy is normal

B.

Increase in serum creatinine is moderate

C.

Kidneys can be used for renal transplantation

C.

No tendency of serum creatinine to progress over time

D.

Hypernatremia

D.

All of the above

1271

Type 2 HRS is mainly characterized by ?

A.

Treatment is usually unsuccessful

N Engl J Med 2009;361:1279-90

B.

Vasodilator therapy with intravenous infusions of low dose dopamine is effective

A.

Hepatic encephalopathy

B.

Refractory ascites

C.

TIPS can improve renal function

C.

Hypotension

D.

Treatment of choice is liver transplantation

D.

All of the above

1272

Which of the following treatments have a role in hepatorenal syndrome ? A.

Midodrine

B.

Octreotide

C.

Intravenous albumin

D.

All of the above

1273

N Engl J Med 2009;361:1279-90

A.

Terlipressin

B.

Norepinephrine

C.

Midodrine

D.

All of the above

Best approach in management of HRS is administration of vasoconstrictor drugs. Treatment with renal vasodilators like dopamine or prostaglandins is ineffective.

A.

More common in chronic liver disease

B.

Essential for diagnosis of fulminant hepatic failure

C.

Diagnosis of hepatic encephalopathy is clinical

D.

None of the above

Which of the following charactetistics about hepatic encephalopathy is false ? Harrison’s 16th Ed. 1867

Currently, patients of HRS are treated with midodrine, an -agonist, along with octreotide & IV albumin. The best therapy for HRS is liver transplantation.

Which of the following is a vasoconstrictor drug ?

Which of the following is false about hepatic encephalopathy ? Harrison’s 18th Ed. 2601

Harrison’s 18th Ed. 2601

1267

Which of the following statements about hepatorenal syndrome (HRS) is false ? Harrison’s 16th Ed. 1867

Type 1 hepatorenal syndrome has severe multiorgan dysfunction, which affects not only the kidneys but also the heart, systemic circulation, brain, adrenal glands, and liver, whereas the clinical course of patients with type 2 hepatorenal syndrome is mainly characterized by refractory ascites.

1266

Which of the following statements about hepatorenal syndrome (HRS) is false ?

Which of the following is true for type 2 hepatorenal syndrome ?

In type 2 hepatorenal syndrome, most patients have refractory ascites, increase in serum creatinine is moderate and has no tendency to progress over time.

1265

Which of the following statements about hepatorenal syndrome (HRS) is false ?

A.

type 1 hepatorenal syndrome is characterized by progressive oliguria and a rapid rise of the serum creatinine. A common precipitating event is spontaneous bacterial peritonitis (SBP).

1264

Long-term administration of which of the following reduces the risk of hepatorenal syndrome & improves survival ?

N Engl J Med 2009;361:1279-90

Type 1 HRS is characterized by a doubling of serum creatinine level to > 2.5 mg/dl in < 2 weeks. Type 2 is characterized by a stable or less rapidly progressive course than in type 1.

1263

1268

Gastroenterology

1274

A.

Disturbances in consciousness

B.

Behavior & personality changes

C.

Fluctuating neurologic signs

D.

No electroencephalographic changes

Which of the following statements about hepatic encephalopathy is false ? Harrison’s 18th Ed. 2601

A.

Blood-brain barrier is intact

B.

Ammonia is incriminated in its pathogenesis

C.

Many patients have elevated blood ammonia levels

D.

Mercaptans, short-chain fatty acids, & phenol are incriminated in its pathogenesis

Gastroenterology 495 1275

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Which of the following statements about hepatic encephalopathy is false ?

1282

1276

Reduced levels of consciousness is due to excessive concentrations of GABA in the CNS

B.

Endogenous benzodiazepines act through the GABA receptor

C.

1,4-benzodiazepines is isolated from brain tissue of patients with fulminant hepatic failure

D.

Excessive magnesium deposition in basal ganglia contribute its pathogenesis

1283

Harrison’s 16th Ed. 1868

1277

Gastrointestinal bleeding

B.

Increased dietary protein

C.

Electrolyte disturbances

D.

Injudicious use of CNS-depressing drugs

1284

Harrison’s 16th Ed. 1868

1278

1279

1280

1281

Gastrointestinal bleeding

B.

Surgery

C.

Superimposed acute viral hepatitis

D.

Alcoholic hepatitis

Threonine

B.

Methionine

C.

Leucine

D.

Isoleucine

For diagnosis of hepatic encephalopathy, which of the following tests has most relevance ? A.

Elevated serum ammonia level

B.

Examination of the cerebrospinal fluid

C.

Computed tomography of brain

D.

MRI of brain

Disorders that can mimic the clinical features of hepatic encephalopathy are all except ? Harrison’s 16th Ed. 1868

Which of the following is the most common predisposing factor for hepatic encephalopathy ? A.

A.

Harrison’s 16th Ed. 1868

Which of the following is the most common predisposing factor for hepatic encephalopathy ? A.

Mercaptans are derived from intestinal metabolism of ? Harrison’s 16th Ed. 1867

Harrison’s 16th Ed. 1867

A.

1285

A.

Acute alcohol intoxication

B.

Sedative overdose

C.

Delirium tremens

D.

Encephalitis

Disorders that can mimic the clinical features of hepatic encephalopathy are all except ? Harrison’s 16th Ed. 1868

A.

Wernicke’s encephalopathy

Which of the following is the most common predisposing factor for hepatic encephalopathy ?

B.

Korsakoff’s psychosis

C.

Subdural hematoma

Harrison’s 16th Ed. 1868

D.

Schizophrenia

A.

Gastrointestinal bleeding

B.

Extrahepatic bile duct obstruction

C.

Constipation

D.

Surgery

1286

Disorders that can mimic the clinical features of hepatic encephalopathy are all except ? Harrison’s 16th Ed. 1868

A.

Meningitis

Neurologic signs in hepatic encephalopathy includes all except ?

B.

Hypoglycemia

C.

Hypocalcemia

Harrison’s 16th Ed. 1868

D.

Wilson’s disease

A.

Rigidity

B.

Decreased DTR

C.

Extensor plantar signs

D.

Seizures

1287

Which of the following about lactulose is false ? Harrison’s 18th Ed. 2602

A.

Nonabsorbable

B.

Disaccharide

Earliest sign of hepatic encephalopathy is ?

C.

Leads to colonic acidification

Harrison’s 16th Ed. 1868

D.

None of the above

A.

EEG changes

B.

Asterixis

C.

Reversal of sleep / wake cycle

D.

Deterioration in handwriting

495 Cardiology

The mainstay of treatment for encephalopathy is lactulose. It is a nonabsorbable disaccharide, which results in colonic acidification. Consequent catharsis eliminates nitrogenous products in gut that are responsible for the development of encephalopathy.

1288

Goal of lactulose therapy is to promote how many soft stools per day ?

Typical smell in fetor hepaticus is due to ?

Harrison’s 18th Ed. 2602

Harrison’s 16th Ed. 1868

A.

2-3

A.

Mercaptans

B.

4-6

B.

Ammonia

C.

6-8

C.

Bilirubin

D.

8 - 10

D.

All of the above

The goal of lactulose therapy is to promote 2 - 3 soft stools per day.

496 1289

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following has a role in the treatment of hepatic encephalopathy ? Harrison’s 18th Ed. 2602

A.

Azithromycin

B.

Ritonavir

C.

Rifaximin

D.

Lumefantrine

Rifaximin (550 mg twice daily) is very effective in treating encephalopathy without the known side effects of neomycin (renal insufficiency and ototoxicity) or metronidazole (peripheral neuropathy). Rifaximin is a poorly absorbed rifampin derivative & is highly effective against noninvasive bacterial pathogens (toxigenic & enteroaggregative E. coli).

1290

1296

B.

Zinc

C.

Calcium

D.

Magnesium

Zinc supplementation is at times helpful in patients with hepatic encephalopathy.

B.

Hypoxemia

C.

Hypercarbia

D.

Pulmonary arteriovenous shunting

Hepatopulmonary syndrome is manifested by ? Harrison’s 18th Ed. 2524, N Engl J Med 2008;358:2378-87

Harrison’s 18th Ed. 2602

Copper

Liver disease

Patients with long-standing cirrhosis and portal hypertension are prone to develop the hepatopulmonary syndrome, defined by the triad of liver disease, hypoxemia, and pulmonary arteriovenous shunting. The defect in oxygenation is due to a ventilation.perfusion mismatch.

Supplementation of which of the following is recommended in patients with hepatic encephalopathy ? A.

A.

Gastroenterology

A.

Hypoxemia

B.

Platypnea

C.

Orthodeoxia

D.

All of the above

Hepatopulmonary syndrome is characterized by platypnea and orthodeoxia, representing shortness of breath and oxygen desaturation that occur paradoxically upon assuming an upright position. If the partial pressure of oxygen in arterial blood decreases by 5% or more or by 4 mm Hg (0.5 kPa) or more when the patient moves from a supine to an upright position (called orthodeoxia), he or she may describe worsening dyspnea (platypnea) related to further ventilation perfusion mismatch.

1297

Platypnea is a clinical presentation of ? Harrison’s 18th Ed. 279

1291

First clotting factor to be depleted in cirrhosis liver is ? Harrison’s 16th Ed. 1869

1292

A.

Factor V

B.

Factor VII

C.

Factor VIII

D.

Factor IX

In hepatic cirrhosis, which clotting factor is not reduced ? Harrison’s 16th Ed. 1869

1293

B.

Budd-Chiari Syndrome

C.

Left atrial myxoma

D.

HOCM

Platypnea (dyspnea in upright position with relief in supine position) is also a feature of left atrial myxoma.

1298

Which of the following is not a part of hepatopulmonary syndrome ?

Factor II

B.

Factor V

A.

Liver disease

C.

Factor VII

B.

Pulmonary vascular dilatation

D.

Factor XI

C.

Pulmonary vascular constriction

D.

Defect in oxygenation

Reduction in levels of which clotting factor is not worsened by the coincident malabsorption of vitamin K ? A.

Factor II

B.

Factor V

C.

Factor VII

D.

Factor XI

N Engl J Med 2008;358:2378-87

Hepatopulmonary syndrome has three components - liver disease, pulmonary vascular dilatation, and a defect in oxygenation.

1299

Coagulopathy in liver disease results due to ? Harrison’s 18th Ed. 2602

A.

Decreased synthesis of clotting factors

B.

Impaired clearance of anticoagulants

C.

Thrombocytopenia due to hypersplenism

D.

All of the above

Coagulopathy is almost universal in patients with cirrhosis. There is decreased synthesis of clotting factors and impaired clearance of anticoagulants. Patients may have thrombocytopenia from hypersplenism due to portal hypertension.

The triad of hepatopulmonary syndrome includes all except ? Harrison’s 18th Ed. 2524

The unique striking pathological feature of hepatopulmonary syndrome is ? N Engl J Med 2008;358:2378-87

Vitamin K–dependent clotting factors are Factors II, VII, IX, and X. Because of a decrease in hepatic mass, administration of parenteral vitamin K does not improve clotting factors or prothrombin time.

1295

Constrictive pericarditis

A.

Harrison’s 18th Ed. 2602

1294

A.

A.

Gross dilatation of pulmonary pre- & capillary vessels

B.

Absolute increase in number of dilated vessels

C.

Pleural & pulmonary arteriovenous shunts

D.

All of the above

The unique striking pathological feature of hepatopulmonary syndrome is gross dilatation of pulmonary precapillary & capillary vessels (15 to 100 µm diameter), coupled with an absolute increase in number of dilated vessels. Also, pleural and pulmonary arteriovenous shunts and portopulmonary venous anastomoses can be seen. in a healthy person , diameter of capillary ranges between 8 and 15 µm.

1300

Which of the following has clinical similarities to hepatopulmonary syndrome ? N Engl J Med 2008;358:2378-87

A.

Blue rubber bleb syndrome

B.

Chiari malformation

C.

Dandy-Walker malformations

Gastroenterology 497 D.

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Type 1 Abernethy malformation

Rare congenital cardiac disorders without liver injury in which either hepatic venous blood flow does not reach the lung or portal venous blood reaches the inferior vena cava without passing through the liver (Type 1 Abernethy malformation) have clinical similarities to hepatopulmonary syndrome. This provides support for the hypothesis that blood from the gut must cross liver to prevent pulmonary vascular dilatation.

1306

B.

Tannic acid

C.

Safrole

D.

All of the above

497 Cardiology

A typical interval between HCV-associated transfusion and subsequent HCC is approximately ? Harrison’s 18th Ed. 778

Hepatocellular Carcinoma 1301

A.

10 years

B.

20 years

Which of the following statements is false ?

C.

30 years

N Engl J Med 2011;365:1118-27

D.

40 years

A.

Liver cancer is the fifth most common cancer in men and the seventh in women

B.

Highest incidence rates of liver cancer is in regions where infection with hepatitis B virus (HBV) is endemic

C.

Hepatocellular carcinoma rarely occurs before 40 years of age

D.

Hepatocellular carcinoma incidence reaches a peak at approximately 50 years of age

A typical interval between HCV-associated transfusion and subsequent HCC is approximately 30 years. HCV-associated HCC patients tend to have more frequent and advanced cirrhosis, but in HBV-associated HCC, only half the patients have cirrhosis; the remainder having chronic active hepatitis.

1307

N Engl J Med 2011;365:1118-27

Hepatocellular carcinoma incidence reaches a peak at approximately 70 years of age. Rates of liver cancer among men are two to four times as high as the rates among women.

1302

Which of the following is associated with a reduced risk of hepatocellular carcinoma ? N Engl J Med 2011;365:1118-27

A.

Coffee drinking

B.

Tea drinking

C.

Alcohol drinking

D.

Tobacco chewing

Major risk factors for hepatocellular carcinoma (HCC) include infection with all except ? N Engl J Med 2011;365:1118-27

B.

~ 50 %

C.

~ 75 %

D.

~ 100 %

1308

What percentage of patients with HBV-related hepatocellular carcinoma have cirrhosis ? N Engl J Med 2011;365:1118-27

A.

~ 25 %

B.

~ 50 %

C.

~ 75 %

D.

~ 100 %

HBV can cause hepatocellular carcinoma in the absence of cirrhosis. However, majority (70 to 80%) of patients with HBV-related hepatocellular carcinoma have cirrhosis.

1309

Factor associated with an increased risk of developing HCC is ?

HBV

B.

HCV

A.

Hepatitis B or C chronic infection

C.

HIV

B.

Cirrhosis from any cause

D.

Alcoholic liver disease

C.

Nonalcoholic steatohepatitis (NASH)

D.

All of the above

Aflatoxin B1 is related to which of the following pathogen ? Harrison’s 18th Ed. 777

A.

Aspergillus

B.

Nocardia

C.

Candida

D.

Cryptococcus

Aflatoxin B1 is a product of the Aspergillus fungus. It is a most potent ubiquitous natural chemical carcinogen producing signature mutations in p53 (mutation of arginine to serine at codon 249) and leads to hepatocellular carcinoma.

1305

~ 25 %

A.

Major risk factors for HCC include infection with HBV or HCV, alcoholic liver disease & nonalcoholic fatty liver disease. Less common causes include hereditary hemochromatosis, alpha1-antitrypsin deficiency, autoimmune hepatitis, some porphyrias, and Wilson’s disease.

1304

A.

Worldwide, chronic HBV infection accounts for ~50% of all cases of hepatocellular carcinoma and virtually all childhood cases.

Studies conducted in Japan and southern Europe found that coffee drinking is associated with a reduced risk of hepatocellular carcinoma. Coffee drinking has also been associated with reduced insulin levels and a reduced risk of type 2 diabetes.

1303

Worldwide, chronic HBV infection accounts for what percentage of all cases of hepatocellular carcinoma ?

Which of the following is a carcinogen ? Harrison’s 18th Ed. 777

A.

Pyrrolizidine alkaloids

Harrison’s 18th Ed. 777

Factor associated with an increased risk of developing HCC include hepatitis, alcohol, autoimmune chronic active hepatitis, cryptogenic cirrhosis and NASH/NAFL. Less common association is with primary biliary cirrhosis and several metabolic diseases including hemochromatosis, Wilson disease, alpha1-antitrypsin deficiency, tyrosinemia, porphyria cutanea tarda, glycogenesis types 1 and 3, citrullinemia. and orotic aciduria.

1310

Which of the following is a paraneoplastic syndrome in HCC ? Harrison’s 18th Ed. 779

A.

Erythrocytosis

B.

Hypercalcemia

C.

Hypercholesterolemia

D.

All of the above

Most paraneoplastic syndromes in HCC are biochemical abnormalities without associated clinical consequences. They include hypoglycemia, erythrocytosis, hypercalcemia, hypercholesterolemia, dysfibrinogenemia, carcinoid syndrome, increased thyroxin-binding globulin, changes in secondary sex characteristics (gynecomastia, testicular atrophy & precocious puberty) & porphyria cutanea tarda.

498 1311

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following estimations are useful in the surveillance for hepatocellular carcinoma ? Harrison’s 18th Ed. 779, N Engl J Med 2011;365:1118-27

6

The Child-Pugh scoring system uses five clinical measures of liver disease.

B.

Des-gamma-carboxyprothrombin (DCP)

1317

C.

Lens culinaris agglutinin-reactive fraction of AFP (AFP-L3)

D.

All of the above

Which of the following is a protein induced by vitamin K absence ? A.

PIVKA-1

B.

PIVKA-2

C.

PIVKA-3

D.

PIVKA-4

Which of the following imaging modality is most recommended for hepatocellular carcinoma surveillance ? Harrison’s 18th Ed. 780, N Engl J Med 2011;365:1118-27

A.

Ultrasonographic imaging

B.

Computed tomography (CT)

C.

Magnetic resonance imaging (MRI)

D.

All of the above

CT and MRI are not generally recommended for hepatocellular carcinoma surveillance. Their sensitivity, specificity, and positive and negative predictive values for this purpose are unknown, and their use is associated with high cost as well as possible harm.

1318

B.

Areas of early arterial enhancement

C.

Areas of delayed washout

D.

All of the above

5 or 6 points

B.

7 to 9 points

C.

10 to 15

D.

16 to 20 points

TACE stands for ? N Engl J Med 2011;365:1118-27

A.

Transarterial catheter embolization

B.

Transarterial cryo embolization

C.

Transarterial chemo embolization

D.

Transarterial cavity embolization

Transarterial chemoembolization (TACE) is useful in intermediate-stage hepatocellular carcinoma. TACE improves survival among patients with preserved liver function, particularly those with ChildPugh class A cirrhosis who do not have extrahepatic metastases, vascular invasion, or prominent cancer-related symptoms.

Chapter 310. Liver Transplantation 1319

Who pioneered liver transplantation ? Harrison’s 18th Ed. 2606

A.

N Engl J Med 2011;365:1118-27

Focal hepatic mass >2 cm in diameter in cirrhotics

A.

A sum of 5 or 6 points Child-Pugh scoring system indicate class A disease, 7 to 9 points class B, and 10 to 15 points class C, or the most severe disease.

Which of the following imaging feature is diagnostic of hepatocellular carcinoma ? A.

How many points in Child-Pugh scoring system denote class A disease ? N Engl J Med 2011;365:1118-27

PIVKA-2 is a protein induced by vitamin K absence. This protein is increased in as many as 80% of HCC patients but may also be elevated in patients with vitamin K deficiency. It is always elevated after Coumadin use. It may predict for portal vein invasion.

1314

D.

Serum alpha-fetoprotein (AFP)

Harrison’s 18th Ed. 779

1313

5

A.

Combined measurement of alpha-fetoprotein, with des-gamma-carboxyprothrombin or lectin-bound alpha-fetoprotein, provide limited additional benefit as compared with the measurement of alphafetoprotein alone.

1312

C.

Gastroenterology

PW Angus

B.

Thomas Starzl

C.

JA Fishman

D.

KF Murray

Pioneered in 1960s by Thomas Starzl at the University of Colorado and, later, at the University of Pittsburgh and by Roy Calne in Cambridge, England, liver transplantation is now performed routinely worldwide. Success measured as 1-year survival has improved from 30% in the 1970s to 90% today.

1320

In patients with cirrhosis and a focal hepatic mass larger than 2 cm in diameter, areas of early arterial enhancement and delayed washout in venous or delayed phase of four-phase multidetector CT or in dynamic contrast-enhanced MRI have high predictive value for HCC.

Arteriohepatic dysplasia, with paucity of bile ducts, and congenital malformations, including pulmonary stenosis is called ? Harrison’s 18th Ed. 2607, Table 310-1

1315

Which of the following is of no use in the diagnosis of HCC ?

A.

Alagille’s syndrome

Harrison’s 18th Ed. 780

B.

Byler’s disease

C.

Caroli’s disease

D.

Budd-Chiari syndrome

A.

Triphasic CT

B.

Gadolinium-enhanced MRI

C.

Ultrasound

D.

PET imaging

PET imaging was unsuccessful for the purpose.

1316

1321

Intrahepatic cholestasis, progressive liver failure, mental and growth retardation is called ? Harrison’s 18th Ed. 2607, Table 310-1

A.

Alagille’s syndrome

B.

Byler’s disease

N Engl J Med 2011;365:1118-27

C.

Caroli’s disease

A.

3

D.

Budd-Chiari syndrome

B.

4

Child-Pugh scoring system uses how many clinical measures of liver disease ?

Gastroenterology 499 1322

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Multiple cystic dilatations of the intrahepatic biliary tree is called ?

1328

A.

United Network for Organ Selection

A.

Alagille’s syndrome

B.

United Network for Organ Sharing

B.

Byler’s disease

C.

United Network for Organ Surgery

C.

Caroli’s disease

D.

United Network for Organ Substitution

D.

Budd-Chiari syndrome

The most common indication for transplantation in children is ?

UNOS stands for United Network for Organ Sharing. It was adopted in 2002.

1329

Harrison’s 18th Ed. 2607

A.

Congenital hepatic fibrosis

B.

Biliary atresia

C.

Crigler-Najjar disease type I

D.

Neonatal hepatitis

The most common indication for transplantation in children is biliary atresia.

1324

Currently, which of the following is the most common indications for liver transplantation in adults ? Harrison’s 18th Ed. 2607

A.

Fulminant hepatitis

B.

Primary sclerosing cholangitis

C.

Chronic hepatitis C

D.

Primary biliary cirrhosis

Which of the following is not an absolute contraindication for liver transplantation ?

Liver recipients with what MELD scores experienced higher posttransplantation mortality rates ? Harrison’s 18th Ed. 2609

A.

< 15

B.

< 20

C.

< 25

D.

< 30

Liver recipients with MELD scores 70 years)

B.

Calcineurin inhibitor (CNI)

B.

Metastatic malignancy

C.

Nonnucleoside purine metabolism inhibitor

C.

Active drug abuse

D.

Monoclonal antibodies to T cells

D.

Active alcohol abuse

Absolute contraindications for transplantation include life-threatening systemic diseases, uncontrolled extrahepatic bacterial or fungal infections, preexisting advanced cardiovascular or pulmonary disease, multiple uncorrectable life-threatening congenital anomalies, metastatic malignancy, and active drug or alcohol abuse. Advanced age (>70 years) should be considered a relative contraindication.

Cyclosporine is a calcineurin inhibitor (CNI). It blocks early activation of T cells & is specific for T cell functions that result from the interaction of T cell with its receptor and that involve the calciumdependent signal transduction pathway. Activity of cyclosporine leads to inhibition of lymphokine gene activation, blocking interleukins 2, 3, and 4, tumor necrosis factor , and other lymphokines. Cyclosporine also inhibits B cell functions. This process occurs without affecting rapidly dividing cells in the bone marrow, thus reducing frequency of posttransplantation systemic infections.

1326

1332

Cadaver donor livers for liver transplantation are procured primarily from victims of ?

Harrison’s 18th Ed. 2610

Harrison’s 18th Ed. 2608

A.

Head trauma

B.

Jail deaths

C.

Suicide deaths

D.

Voluntary donors

Which of the following is a macrolide lactone antibiotic ? A.

Cyclosporine

B.

Tacrolimus

C.

Mycophenolic acid

D.

Rapamycin

Cadaver donor livers for transplantation are procured primarily from victims of head trauma.

Tacrolimus is a macrolide lactone antibiotic isolated from a Japanese soil fungus, Streptomyces tsukubaensis.

1327

1333

Which of the following about cadaver donor livers for liver transplantation is false ?

Which of the following side effects are not present with use of Tacrolimus, but present with use of Cyclosporine ?

Harrison’s 18th Ed. 2608

Harrison’s 18th Ed. 2610

A.

Compatibility in ABO blood group is essential

A.

Nephrotoxicity

B.

Human leukocyte antigen (HLA) matching is not required

B.

Hypertension

C.

University of Wisconsin (UW) solution used for preservation

C.

Hirsutism

D.

None of the above

D.

Diabetes mellitus

Tacrolimus does not cause hirsutism or gingival hyperplasia.

500 1334

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following is a nonnucleoside purine metabolism inhibitor ?

so for 3 - 7 days. Levels usually return to normal within 7 days unless there is pancreatic ductal disruption, ductal obstruction, or pseudocyst formation.

Harrison’s 18th Ed. 2610

1340

Cyclosporine

B.

Tacrolimus

A.

Acute Pancreatitis

C.

Mycophenolic acid

B.

Diabetic ketoacidosis

D.

Rapamycin

C.

Perforated peptic ulcer

D.

All of the above

Harrison’s 18th Ed. 2632, Table 312-2

Hemolytic uremic syndrome can be associated with ?

1341

A.

Cyclosporine

B.

Tacrolimus

C.

OKT3

D.

All of the above

Hemolytic uremic syndrome can be associated with cyclosporine, tacrolimus, or OKT3.

How much of pancreas must be damaged before maldigestion of fat and protein is manifested ?

C.

Breast carcinoma

D.

All of the above

Hyperamylasemia is found in which of the following ?

1343

A.

Pregnancy

B.

Aortic aneurysm

C.

Morphine

D.

All of the above

The newer lipase assays relate best to which of the following ?

~ 25 %

B.

~ 50 %

A.

Trypsin

C.

~ 75 %

B.

Chymotrypsin

D.

~ 90 %

C.

Colipase

D.

Phospholipase A2

Harrison’s 18th Ed. 2632

Patients with proven pancreatitis have spuriously low levels of amylase in ?

Lipase is the single best enzyme to measure for diagnosis of acute pancreatitis. The newer lipase assays have colipase as a cofactor and are fully automated.

Harrison’s 18th Ed. 2631

1344

A.

Incomplete ductal obstruction

B.

Pseudocyst formation

C.

Hypertriglyceridemia

D.

All of the above

In acute pancreatitis, serum amylase rises within ? Harrison’s 18th Ed. 2631

A.

24 hours

B.

36 hours

C.

48 hours

D.

72 hours

In acute pancreatitis, serum amylase remains elevated for ? Harrison’s 18th Ed. 2631

A.

1 - 3 days

B.

3 - 7 days

C.

7 - 9 days

D.

9 - 14 days

In acute pancreatitis, the serum amylase is usually elevated within 24 hours of onset and remains

Which of the following blood test is reliable for diagnosis of acute pancreatitis in patients with renal failure ? Harrison’s 18th Ed. 2632

Serum amylase level may be normal if hypertriglyceridemia is present.

1339

Carcinoma of esophagus

A.

> 90% of pancreas must be damaged before maldigestion of fat & protein is manifested.

1338

Carcinoma of lung

B.

Harrison’s 18th Ed. 2632, Table 312-2

Chapter 312. Approach to the Patient with Pancreatic Disease

1337

A.

“Tumor” hyperamylasemia is seen in Carcinoma of lung, Carcinoma of esophagus, Breast carcinoma and ovarian carcinoma.

1342

Harrison’s 18th Ed. 2629

Hyperamylasemia is found in which of the following ? Harrison’s 18th Ed. 2632, Table 312-2

Harrison’s 18th Ed. 2611

1336

Hyperamylasemia is found in ?

A.

Mycophenolic acid, a nonnucleoside purine metabolism inhibitor derived as a fermentation product from several Penicillium species.

1335

Gastroenterology

A.

Serum amylase

B.

Serum lipase

C.

Serum trypsinogen

D.

None of the above

No single blood test is reliable for the diagnosis of acute pancreatitis in patients with renal failure. Trypsinogen, amylase & lipase are excreted by kidney therefore are elevated in renal failure.

1345

Serum amylase levels are elevated when creatinine clearance is less than ? Harrison’s 18th Ed. 2632

A.

< 100 mL / minute

B.

< 85 mL / minute

C.

< 75 mL / minute

D.

< 50 mL / minute

Serum amylase levels are elevated in patients with renal dysfunction when creatinine clearance is < 50 mL/minute.

Gastroenterology 501 1346

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

In acute pancreatitis, serum amylase values are highly specific if they are more than ?

Harrison’s 17th Ed. 2002

A.

I

Harrison’s 18th Ed. 2632

B.

II

C.

III

D.

IV

A.

Two times normal

B.

Three times normal

C.

Four times normal

D.

Five times normal

501 Cardiology

In chronic pancreatitis, radiographic pancreatic calcification is superimposed on 2nd lumbar vertebra.

In acute pancreatitis, serum amylase values > 3 times normal are highly specific.

1347

How much exocrine function of pancreas must be lost before secretin stimulation test is abnormal ? Harrison’s 17th Ed. 2002

313 - Acute and Chronic Pancreatitis 1353

~ 15 %

B.

~ 20 %

A.

1000 - 1500 ml

C.

~ 40 %

B.

1500 - 3000 ml

D.

~ 60 %

C.

3000 - 4500 ml

D.

About 5000 ml

Harrison’s 18th Ed. 2634

Secretin stimulation test for assessing pancreatic exocrine function is abnormal when >60% of exocrine function has been lost.

1348

Enzyme trypsinogen is present in which of the following ?

1354

A.

Gall bladder

B.

Pancreas

C.

Intestine

D.

All of the above

Pancreas is the only organ that contains trypsinogen.

10 enzymes and zymogens

B.

20 enzymes and zymogens

C.

30 enzymes and zymogens

D.

40 enzymes and zymogens

The pancreatic secretion is ? Harrison’s 18th Ed. 2634

A.

Isosmotic alkaline

Harrison’s 17th Ed. 2005

B.

Isosmotic acidic

C.

Hyposmotic alkaline

D.

Hyposmotic acidic

A.

18 - 28 ng/mL

B.

28 - 58 ng/mL

C.

60 - 98 ng/mL

D.

100 - 158 ng/mL

Pancreas secretes 1500 - 3000 mL of isosmotic alkaline (pH > 8.0) fluid / day containing ~20 enzymes & zymogens.

1356

Which of the following about secretin is false ? Harrison’s 18th Ed. 2634

“Sentinel loop” refers to a localized ileus of which part of intestine in acute pancreatitis ?

A.

Gastric acid is a stimulus for release of secretin

Harrison’s 17th Ed. 2002

B.

Secretin is a peptide with 27 amino acids

A.

Duodenum

C.

B.

Jejunum

pH threshold for release of secretin from duodenum & jejunum is 6.5

C.

Ileum

D.

D.

Colon

Secretin stimulates secretion of pancreatic juice rich in water & electrolytes

“Sentinel loop” refers to a localized ileus of jejunum in acute pancreatitis.

1351

1355

A.

Normal serum trypsinogen level is ?

The normal values of serum trypsinogen are 28 - 58 ng/mL.

1350

The pancreatic secretion contain about ? Harrison’s 18th Ed. 2634

Harrison’s 17th Ed. 2002

1349

The quantity of pancreatic secretion per day is ?

A.

1357

Which of the following about cholecystokinin (CCK) is false ? Harrison’s 18th Ed. 2634

“Colon cutoff sign” refers to isolated distention of which part of intestine in acute pancreatitis ?

A.

CCK evokes an enzyme-rich secretion from pancreas

Harrison’s 17th Ed. 2002

B.

Release of CCK is triggered by short-chain fatty acids

A.

Ascending colon

C.

Release of CCK is triggered by essential amino acids

B.

Transverse colon

D.

Release of CCK is triggered by gastric acid

C.

Descending colon

D.

Sigmoid colon

“Colon cutoff sign” refers to isolated distention of transverse colon in acute pancreatitis.

Release of CCK from duodenum & jejunum is triggered by long-chain fatty acids, essential amino acids (tryptophan, phenylalanine, valine, methionine), and gastric acid itself.

1358

Which of the following statements is false ? Harrison’s 18th Ed. 2634

1352

In chronic pancreatitis, pancreatic calcification on radiological examination is superimposed on which lumbar vertebra ?

A.

Bile salts stimulate pancreatic secretion

502

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Parasympathetic nervous system exerts significant control over pancreatic secretion

C.

Vasoactive intestinal peptide (VIP) is a CCK agonist

D.

H2O and HCO3- secretion by pancreas is dependent secretin and CCK

C.

Proteolytic

D.

All of the above

Gastroenterology

The pancreas secretes amylolytic, lipolytic, and proteolytic enzymes.

1365

The lipolytic enzymes secreted by pancreas are ? Harrison’s 18th Ed. 2634

Vagal stimulation leads to release of VIP which is a secretin agonist.

A.

Lipase

1359

B.

Phospholipase A

C.

Cholesterol esterase

D.

All of the above

The quantity of bicarbonate from pancreas needed to neutralize gastric acid is ? Harrison’s 16th Ed. 1895

1360

A.

20 to 30 mmol/day

B.

50 to 100 mmol/day

Lipolytic enzymes secreted by pancreas include lipase, phospholipase A & cholesterol esterase.

C.

120 to 300 mmol/day

1366

D.

About 500 mmol/day

Harrison’s 18th Ed. 2634

A.

In acini and in ducts, which hormone causes the cells to add water and bicarbonate to pancreatic fluid ?

Colipase binds to lipase & prevents inhibition by bile salts

Harrison’s 18th Ed. 2634

C.

Activate phospholipase A and cholesterol esterase

A.

Insulin

D.

None of the above

B.

Secretin

C.

Somatostatin

D.

Gastrin

Bile salts inhibit lipase in isolation, but colipase of pancreatic secretion, binds to lipase and prevents this inhibition. Bile salts activate phospholipase A and cholesterol esterase.

1367

1363

Pancreatic exocrine secretion is influenced by ?

A.

Bile salts inhibit lipase

B.

Colipase binds to lipase

Harrison’s 18th Ed. 2634

C.

Bile salts activate phospholipase A & cholesterol esterase

A.

Somatostatin

D.

None of the above

B.

Neuropeptide Y

C.

Calcitonin gene - related peptides

D.

All of the above

Bile salts inhibit lipase. Colipase in pancreatic secretion binds to lipase and prevents this inhibition. Bile salts activate phospholipase A and cholesterol esterase.

1368

Proteolytic enzymes secreted as inactive precursors are called ? Harrison’s 18th Ed. 2634

A.

Zymogens

Which of the following correlates best between stimulation with secretin and the pancreatic mass ?

B.

Proteogens

C.

Amylogens

Harrison’s 18th Ed. 2634

D.

Chymogens

A.

Maximal sodium output

B.

Maximal chloride output

C.

Maximal acid output

D.

Maximal bicarbonate output

Proteolytic enzymes are secreted as inactive precursors called zymogens.

1369

Enzyme that cleaves lysine-isoleucine bond of trypsinogen to form trypsin is ? Harrison’s 18th Ed. 2634

Bicarbonate in pancreatic secretion is related to ?

A.

Duodenokinase

Harrison’s 18th Ed. 2634

B.

Enterokinase

C.

Gastrokinase

D.

Trypsokinase

A.

Insulin

B.

Glucagon

C.

Cystic fibrosis transmembrane conductance regulator

D.

All of the above

In pancreatic ductal cells, cystic fibrosis transmembrane conductance regulator (CFTR) controls chloride and bicarbonate fluxes.

1364

Which of the following statements is false ? Harrison’s 18th Ed. 2634

Pancreatic exocrine secretion is influenced by inhibitory neuropeptides like somatostatin, pancreatic polypeptide, peptide YY, neuropeptide Y, enkephalin, pancreastatin, calcitonin gene–related peptides, glucagon, and galanin.

1362

Inhibit lipase in isolation

B.

Gastric acid is the stimulus for release of secretin which stimulates secretion of pancreatic juice rich in water and electrolytes. CCK evokes an enzyme-rich secretion from the pancreas.

1361

Which of the following about bile salts is false ?

Pancreas secretes which of the following enzymes ? Harrison’s 18th Ed. 2634

A.

Amylolytic

B.

Lipolytic

1370

Bond that is cleaved to form trypsin from trypsinogen is ? Harrison’s 18th Ed. 2634

A.

Lysine-isoleucine bond

B.

Arginine-Threonine bond

C.

Arginine-Lysine bond

D.

Threonine-Lysine bond

Gastroenterology 503 1371

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Enzyme enterokinase is found in ?

1377

503 Cardiology

Which of the following is the most common PRSS1 mutation ?

Harrison’s 18th Ed. 2634

Gastroenterology 2007;132:1557-1573

A.

Gastric mucosa

A.

R122A

B.

Duodenal mucosa

B.

R122C

C.

Jejunal mucosa

C.

R122H

D.

Ileal mucosa

D.

R122K

Enterokinase is an enzyme found in duodenal mucosa. It cleaves lysine-isoleucine bond of trypsinogen to form trypsin.

R122H is the most common PRSS1 mutation observed worldwide. Mutations in PRSS1 gene are seen in most patients with hereditary pancreatitis.

1372

1378

Which of the following can lyse and inactivate trypsin ? Harrison’s 18th Ed. 2634

CFTR and SPINK1 genetic mutations causing acute pancreatitis are frequent in ?

A.

Mesotrypsin

Lancet 2008;371:143-52

B.

Chymotrypsin c

A.

Thalassemia patients

C.

Enzyme y

B.

HIV-positive patients

All of the above

C.

COPD patients

D.

Leukemia patients

D.

Mesotrypsin, chymotrypsin c, and enzyme y can also lyse and inactivate trypsin.

1373

Protease inhibitors are found in ? Harrison’s 18th Ed. 2634

A.

Pancreatic acinar cells

B.

Pancreatic secretions

C.

Alpha1- and alpha2-globulin fractions of plasma

D.

All of the above

Genetic mutations such as those in CFTR and SPINK1 genes are frequent in HIV-positive patients with acute pancreatitis.

1379

Harrison’s 18th Ed. 2635

Protease inhibitors, that prevent autodigestion of pancreas, are found in the acinar cells, the pancreatic secretions, and the alpha1- and alpha2-globulin fractions of plasma.

1374

Kazal type 1 (SPINK1) is best related to ? Harrison’s 17th Ed. 2006

A.

Pancreatic hyperstimulation

B.

Alcohol abuse

C.

Anti-inflammatory cytokine

D.

Serine protease inhibitor

Autodigestion of the pancreas is prevented by the packaging of proteases in precursor form and by the synthesis of protease inhibitors, i.e., pancreatic secretory trypsin inhibitor (PSTI) and serine protease inhibitor, kazal type 1 (SPINK1) that prevents conversion of trypsinogen to trypsin.

1375

SPINK1 is synthesised in ? Lancet 2008;371:143-52

A.

Stomach

B.

Duodenum

C.

Jejunum

D.

All of the above

Duodenum contains a peptide CCK-releasing factor that is involved in stimulating CCK release.

1380

Which of the following is the most common cause of acute pancreatitis ? Harrison’s 18th Ed. 2635

A.

Gallstones

B.

Alcohol

C.

Drugs

D.

ERCP

Cause of acute pancreatitis include gallstones (30-60%), alcohol (15-30%), hypertriglyceridemia (1.3-3.8%), ERCP (5-20%) and drug-related (2-5%).

1381

Risk factors for post-ERCP pancreatitis include ?

A.

Gall bladder

B.

Duodenum

A.

Sphincter of Oddi dysfunction

C.

Stomach

B.

Age < 60 years

D.

Pancreas

C.

> 2 contrast injections into pancreatic duct

D.

All of the above

Pancreas synthesises SPINK1, a specific trypsin inhibitor, the function of which can be lost by mutation. In pancreatic ductal cells, CFTR controls chloride and bicarbonate fluxes. SPINK1 and CFTR mutations together may cause pancreatitis.

1376

CCK-releasing factor (CCK-RF) is present in ?

Which of the following is not a type of trypsinogen in human pancreatic juice ? Gastroenterology 2007;132:1557-1573

A.

Telotrypsinogen

B.

Cationic trypsinogen

C.

Anionic trypsinogen

D.

Mesotrypsinogen

Three different trypsinogens in human pancreatic juice have been designated according to their electrophoretic mobility, as cationic trypsinogen (PRSS1), anionic trypsinogen (PRSS2) & mesotrypsinogen (PRSS3). Compared with the anionic isoenzyme, cationic trypsinogen autoactivates more easily and is more resistant to autolysis.

Harrison’s 18th Ed. 2635

Risk factors for post-ERCP pancreatitis include minor papilla sphincterotomy, sphincter of Oddi dysfunction, prior history of post-ERCP pancreatitis, age 2 contrast injections into the pancreatic duct, and endoscopic trainee involvement.

1382

What level of hypertriglyceridemia causes acute pancreatitis ? Harrison’s 18th Ed. 2635

A.

> 250 mg / dL

B.

> 500 mg / dL

C.

> 750 mg / dL

D.

> 1000 mg / dL

Hypertriglyceridemia can cause acute pancreatitis in 1.3 - 3.8% of cases when serum triglyceride levels are usually > 1000 mg/dL. The goal is to reduce fasting plasma triglycerides to below 500 mg/ dL to prevent the risk of acute pancreatitis.

504 1383

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following statements is false ? Harrison’s 17th Ed. 2009

A.

Hypertriglyceridemia can precede & cause pancreatitis

B.

>80% patients of acute pancreatitis do not have hypertriglyceridemia

C.

Patients with pancreatitis & hypertriglyceridemia have preexisting abnormalities in lipoprotein metabolism

D.

Fasting Tg levels of < 500 mg/dL pose no risk of pancreatitis

Pancreatitis evolves in three phases. Initial phase is characterized by intrapancreatic digestive enzyme activation & acinar cell injury. Second phase involves activation, chemoattraction & sequestration of neutrophils in pancreas resulting in intrapancreatic inflammatory reaction. Third phase is due to effects of activated proteolytic enzymes & cytokines released by inflamed pancreas on distant organs.

1389

Drugs that can elevate serum triglycerides include all except ? Harrison’s 18th Ed. 2641

A.

Progesterone

B.

Vitamin A

C.

Thiazide diuretics

D.

Beta-blockers

1390

A.

ApoA-I

B.

ApoB-100

C.

ApoC-I

D.

ApoC-II

Both LPL & apoC-II deficiency usually present in childhood with recurrent episodes of severe abdominal pain due to acute pancreatitis. Apolipoprotein CII activates lipoprotein lipase. Triglycerides of chylomicrons are hydrolyzed by LPL, and free fatty acids are released. ApoC-II, which is transferred to circulating chylomicrons from HDL, acts as a required cofactor for LPL in this reaction.

1386

Deficiency of which of the following poses an increased incidence of pancreatitis ?

1391

Apolipoprotein CII

B.

Apolipoprotein A-I

C.

Apolipoprotein A-II

D.

All of the above

Patients with deficiency of apolipoprotein CII have an increased incidence of pancreatitis. Apolipoprotein CII activates lipoprotein lipase, which is important in clearing chylomicrons from bloodstream.

1387

What percentage of acute pancreatitis are drug-related ? Harrison’s 18th Ed. 2635

C.

Zymogen activation

D.

Chemoattraction of neutrophils

In pancreatitis, cellular injury results in liberation of ? A.

Bradykinin peptides

B.

Vasoactive substances

C.

Histamine

D.

All of the above

Which of the following is an accurate predictor of severity & death when measured early in the course of acute pancreatitis ? A.

Bradykinin peptides

B.

Vasoactive substances

C.

Histamine

D.

MCP-1 levels

Monocyte chemotactic protein (MCP-1) levels measured early in the course of acute pancreatitis are an accurate predictor of severity and death.

1392

Which of the following susceptibility gene is a determinant of severity of inflammatory response in pancreatitis ? Harrison’s 18th Ed. 2636

A.

PRSS1

B.

CFTR

C.

SPINK1

D.

MCP-1

Four susceptibility genes have been identified that can increase the susceptibility and/or modify the severity of pancreatic injury in acute pancreatitis. These are cationic trypsinogen mutations (PRSS1m, R122Hm, and N291), pancreatic secretory trypsin inhibitor (SPINK1), CFTR and monocyte chemotactic protein (MCP-1). MCP-1 may be an important inflammatory mediator in the early pathologic process of acute pancreatitis, a determinant of the severity of the inflammatory response, and a promoter of organ failure.

A.

2 to 5%

B.

6 to 12%

C.

15 to 20%

Harrison’s 17th Ed. 2007

D.

About 25%

A.

MCP-1 2516 G allele

B.

MCP-1 2517 G allele

C.

MCP-1 2518 G allele

D.

MCP-1 2519 G allele

1393

~ 2 - 5 % of acute pancreatitis are drug-related.

1388

Activation of elastase & phospholipase

Harrison’s 18th Ed. 2636

Harrison’s 18th Ed. 2635

A.

Fat necrosis

B.

Harrison’s 18th Ed. 2636

Deficiency of which of the following have an increased incidence of pancreatitis ? Harrison’s 18th Ed. 2635

A.

Zymogen activation is mediated by lysosomal hydrolases (cathepsin B) which become co-localized with digestive enzymes in intracellular organelles leading to pancreatic acinar cell injury.

Drugs that can elevate serum Tg are estrogens, vitamin A, thiazides and propanolol.

1385

Cathepsin B is best related to ? Harrison’s 18th Ed. 2636

Fasting Tg levels of < 300 mg/dL pose no risk of pancreatitis.

1384

Activation, chemoattraction & sequestration of neutrophils in pancreas occur in which phase of pancreatitis ? Harrison’s 18th Ed. 2636

A.

Phase 1

B.

Phase 2

C.

Phase 3

D.

Phase 4

Gastroenterology

Which of the following is a risk factor for severe acute pancreatitis ?

MCP-1 2518 G allele polymorphism is a gain-of-function promoter that increases MCP-1 expression. MCP-1 2518 G allele is a risk factor for severe acute pancreatitis.

1394

Which of the following is false about abdominal pain of acute pancreatitis ? Harrison’s 18th Ed. 2636

A.

Colicky

Gastroenterology 505

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

B.

Radiates to back

C.

More intense in supine position

D.

Located in periumbilical region

Cullen’s sign in severe necrotizing pancreatitis refers to a faint blue discoloration around umbilicus as the result of hemoperitoneum.

1401

Turner’s sign of severe necrotizing pancreatitis is due to ? Harrison’s 18th Ed. 2636

Abdominal pain of acute pancreatitis is steady & boring in character.

1395

505 Cardiology

A.

Tissue catabolism of hemoglobin

B.

Pyoperitoneum

Harrison’s 18th Ed. 111, Table 13-2

C.

Intestinal ischemia

A.

Right Upper Quadrant

D.

DIC

B.

Epigastric

C.

Left Upper Quadrant

D.

Any of the above

Abdominal pain due to pancreatitis may have which of the following location ?

Turner’s sign of severe necrotizing pancreatitis refers to a blue-red-purple or green-brown discoloration of flanks and reflects tissue catabolism of hemoglobin.

1402

Pearson syndrome is characterized by ? Harrison’s 18th Ed. Chapter e18

1396

Exudation of blood & plasma proteins into retroperitoneal space due to activated proteolytic enzymes in acute pancreatitis is termed as ?

A.

Diabetes mellitus from pancreatic insufficiency

B.

Pancytopenia

Harrison’s 18th Ed. 2636

C.

Lactic acidosis

A.

Retroperitoneal abscess

D.

All of the above

B.

Retroperitoneal tan

C.

Retroperitoneal quinsy

D.

Retroperitoneal burn

Pearson syndrome is characterized by diabetes mellitus from pancreatic insufficiency with pancytopenia & lactic acidosis, caused by sporadic deletion of several mtDNA genes.

1403

1397

Which of the following about pancreatitis is false ? Harrison’s 18th Ed. 2636

Exudation of blood & plasma proteins into retroperitoneal space due to activated proteolytic enzymes in acute pancreatitis is termed as retroperitoneal burn.

A.

Risk of acute pancreatitis is greater with gallstone 8 mm remain in gallbladder.

1404

Which of the following about acute pancreatitis is false ? Harrison’s 18th Ed. 2636

1398

Erythematous skin nodules in acute pancreatitis is due to ?

A.

Pancreatic isoamylase & lipase remain elevated for 7-14 days

Harrison’s 18th Ed. 2636

B.

Serum amylase is higher in gallstone pancreatitis

C.

Serum lipase higher in alcohol-associated pancreatitis

D.

None of the above

A.

Vasculitis

B.

Subcutaneous fat necrosis

C.

Thromboembolism

D.

All of the above

1405

Hyperglycemia in acute pancreatitis is due to ? Harrison’s 18th Ed. 2636

Erythematous skin nodules in acute pancreatitis is due to subcutaneous fat necrosis.

A.

Decreased insulin release

1399

Fat necrosis associated with pancreatic disease is seen in ?

B.

Increased glucagon release

Harrison’s 18th Ed. 420

C.

Increased output of adrenal glucocorticoids & catecholamines

D.

All of the above

A.

Pancreatic carcinoma

B.

Acute pancreatitis

C.

Chronic pancreatitis

D.

All of the above

Hyperglycemia in acute pancreatitis is due to decreased insulin release, increased glucagon release and increased output of adrenal glucocorticoids and catecholamines.

1406

Hypocalcemia may occur in which of the following conditions ?

Fat necrosis associated with pancreatic disease is secondary to circulating lipases and is seen in pancreatic carcinoma and acute & chronic pancreatitis.

Harrison’s 18th Ed. 362

A.

Burns

1400

Cullen’s sign of severe necrotizing pancreatitis is due to ?

B.

Tumor lysis

Harrison’s 18th Ed. 2636

C.

Pancreatitis

D.

All of the above

A.

Pancreatic pseudocyst

B.

DIC

C.

Intestinal ischemia

D.

Hemoperitoneum

Hypocalcemia may occur with severe tissue injury like burns, rhabdomyolysis, tumor lysis, or pancreatitis. Cause of hypocalcemia includes a combination of low albumin, hyperphosphatemia, tissue deposition of calcium, and impaired PTH secretion.

506 1407

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Markers of poor prognosis in severe pancreatitis is ? Harrison’s 18th Ed. 2637

A.

Elevated serum LDH levels (> 500 U/dL)

B.

Azotemia

C.

Hypoxemia (arterial PO 2 500 mL/day)

A.

Age > 60 years

B.

B.

Obesity (BMI > 30)

PO2 2.0 mg/dL

D.

All of the above

Which of the following is not included in the bedside index of severity (BISAP) in acute pancreatitis ?

Acute pancreatitis leading to respiratory failure i.e. PO2 < 60 mmHg determines outcome in majority of difficult to manage cases.

1416

Harrison’s 18th Ed. 2637, Table 313-2

A.

Pao2 < 60 mmHg

B.

Blood urea nitrogen (BUN) > 22 mg %

C.

Age > 60 years

D.

Impaired mental status

Indicators of a severe attack of pancreatitis are all except ?

Abdominal CT of acute pancreatitis patient showed one peripancreatic fluid collection and necrosis of one-third of pancreas - what is the CT severity index ? Harrison’s 18th Ed. 2637, Table 313-3

BISAP or bedside index of severity in acute pancreatitis includes (B) Blood urea nitrogen (BUN) >22 mg%, (I) Impaired mental status, (S) SIRS: 2/4 present, (A) Age >60 years, (P) Pleural effusion

1411

Which investigation is most helpful in differentiating acute cholecystitis from acute pancreatitis ? Harrison’s 17th Ed. 2008

Laboratory studies in acute pancreatitis may show ? A.

All of the above

Diabetic ketoacidosis is accompanied by abdominal pain & elevated total serum amylase levels. Serum lipase level is not elevated in DKA.

Azotemia is a significant risk factor for mortality.

1408

Gastroenterology

1417

A.

4

B.

5

C.

6

D.

7

Multiple factor scoring system for acute pancreatitis is ?

Harrison’s 17th Ed. 2008

Harrison’s 17th Ed. 2008

A.

Age > 70 years

A.

Ranson

B.

Body mass index (BMI) < 25

B.

Imrie

C.

Hematocrit > 44%

C.

APACHE II

D.

Admission C-reactive protein > 150 mg/L

D.

All of the above

Indicators of a severe attack of pancreatitis are age > 70 years, BMI > 30, Hct > 44% & admission C-reactive protein > 150 mg/L.

Ranson, Imrie & Apache II are multiple factor scoring systems for predicting outcome of acute pancreatitis.

1412

1418

Differential diagnosis of acute pancreatitis include ? Harrison’s 18th Ed. 2637

A.

Perforated viscus

B.

Dissecting aortic aneurysm

C.

Connective tissue disorders with vasculitis

D.

All of the above

Differential diagnosis of acute pancreatitis includes perforated viscus, acute cholecystitis, acute intestinal obstruction, mesenteric vascular occlusion, renal colic, myocardial infarction, dissecting aortic aneurysm, connective tissue disorders with vasculitis, pneumonia & diabetic ketoacidosis.

1413

Which of the following is true in diabetic ketoacidosis ? Harrison’s 18th Ed. 2639

A.

Elevated total serum amylase levels

B.

Pancreatic isoamylase levels not elevated

C.

Serum lipase not elevated

Bedside Index of Severity in Acute Pancreatitis (BISAP) incorporates how many clinical and laboratory parameters ? Harrison’s 18th Ed. 2639

A.

3

B.

5

C.

7

D.

9

Bedside Index of Severity in Acute Pancreatitis (BISAP), incorporates five clinical and laboratory parameters obtained within the first 24 hours of hospitalization. Presence of three or more of these factors is associated with substantially increased risk for in-hospital mortality in acute pancreatitis.

1419

Noninfectious etiology of systemic inflammatory response syndrome (SIRS) include which of the following ? Harrison’s 18th Ed. 2228

A.

Pancreatitis

Gastroenterology 507

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

B.

Adrenal insufficiency

B.

MRI abdomen

C.

Pulmonary embolism

C.

Transabdominal ultrasound

D.

All of the above

D.

All of the above

Noninfectious etiologies of SIRS include pancreatitis, burns, trauma, adrenal insufficiency, pulmonary embolism, dissecting or ruptured aortic aneurysm, myocardial infarction, occult hemorrhage, cardiac tamponade, postcardiopulmonary bypass syndrome, anaphylaxis, tumor-associated lactic acidosis, and drug overdose.

1420

1421

1422

1423

1424

1425

1426

1427

Biliary sludge is made up of ? Lancet 2008; 371: 143-52

A.

Cholesterol crystals

SOFA score stands for ?

B.

Calcium bilirubinate granules

Lancet 2008; 371: 143-52

C.

Gall bladder mucus

A.

Septic organ failure assessment

D.

All of the above

B.

Surgical organ failure assessment

C.

Symptomatic organ failure assessment

D.

Sequential organ failure assessment

Biliary sludge refers to a viscous bile suspension that contains cholesterol crystals and calcium bilirubinate granules embedded in strands of gall bladder mucus.

1428

Test that is more specific for acute pancreatitis than serum amylase and lipase is ?

Which test is more sensitive for identifying gallstones and sludge and for detecting bile-duct dilatation ? N Engl J Med 2006;354:2142-50

N Engl J Med 2006;354:2142-50

A.

Transabdominal ultrasonography

A.

Urine Trypsinogen activation peptide (TAP)

B.

CT abdomen

B.

Trypsinogen-2

C.

MRI abdomen

C.

Abdominal CT & MRI

D.

ERCP

D.

All of the above

1429

Transabdominal ultrasonography is insensitive for detecting ?

Which of the following tests is more specific for the diagnosis of acute pancreatitis ?

N Engl J Med 2006;354:2142-50

A.

Gallstones and sludge

N Engl J Med 2006;354:2142-50

B.

Bile-duct dilatation

A.

Serum amylase

C.

Stones in the distal bile duct

B.

Serum lipase

D.

Stones in the proximal bile duct

C.

Trypsinogen activation peptide

D.

Trypsinogen-4

1430

Which of the following genes may predict severity of acute pancreatitis ?

At 24 hours after admission, the most sensitive & specific predictor of severe acute pancreatitis is ?

N Engl J Med 2006;354:2142-50

A.

RET

N Engl J Med 2006;354:2142-50

B.

MCP-1

A.

APACHE II score >=8

C.

MEN-1

B.

C-reactive protein level >150 mg/dl

D.

VHL

C.

PMN elastase >300 µg/liter

D.

Urinary TAP >35 nmol/liter

1431

Recognized markers of risk of severe acute pancreatitis include all except ? N Engl J Med 2006;354:2142-50

Pancreatic-duct disruption is suspected when ? N Engl J Med 2006;354:2142-50

A.

Elevated C-reactive protein

A.

Fluid collections with very high levels of pancreatic enzymes

B.

Ranson’s & APACHE II scores

B.

Pseudocysts

C.

Obesity

C.

Ascites or pleural effusions

D.

High reticulocyte index

D.

All of the above

1432

Biliary sludge is associated with which of the following ?

Recurrent pancreatitis in the absence of biliary disease, alcoholism, and toxic or metabolic causes suggests ?

Lancet 2008; 371: 143-52

A.

Total parenteral feeding

N Engl J Med 2006;354:2142-50

B.

Long-lasting fast

A.

Pancreas divisum

C.

Distal bile duct obstruction

B.

Duct-obstructing masses

D.

All of the above

C.

Genetic susceptibility

D.

Any of the above

1433

Risk factors for post-ERCP pancreatitis include all except ? Lancet 2008; 371: 143-52

Test that identifies early pancreatic duct disruption is ?

A.

Old age

N Engl J Med 2006;354:2142-50

B.

Female sex

A.

C.

Number of cannulation attempts of papilla

CT abdomen

507 Cardiology

508

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

Poor emptying of pancreatic duct after opacification

C.

~ 75 %

D.

~ 90 %

Gastroenterology

Risk of acute pancreatitis is higher when ERCP is done to treat Oddi sphincter dysfunction than to remove bile duct stones. Other risk factors for post-ERCP pancreatitis include young age, female sex, number of cannulation attempts of papilla before success & poor emptying of pancreatic duct after opacification.

In most patients (85 - 90%) with acute pancreatitis, the disease is self-limited and subsides spontaneously, usually within three to seven days after treatment is instituted.

1434

1440

The median prevalence of organ failure in necrotizing pancreatitis is ? Harrison’s 18th Ed. 2639

Harrison’s 18th Ed. 2641

A.

~ 25 %

A.

Resolution of abdominal pain

B.

~ 50 %

B.

Patient is hungry

C.

~ 75 %

C.

Organ dysfunction

D.

~ 95 %

D.

Elevated levels of serum amylase/lipase

The median prevalence of organ failure is 54% in necrotizing pancreatitis.

1435

The mortality in acute pancreatitis with single organ system failure is ?

Inflammatory changes on CT scan or persistent elevations in serum amylase/lipase may not resolve for weeks to months & should not discourage feeding a hungry asymptomatic patient of pancreatitis.

1441

Harrison’s 18th Ed. 2639

1436

A.

~5%

B.

~ 10 %

C.

~ 25 %

D.

~ 50 %

The mortality in acute pancreatitis with multisystem organ system failure is ? Harrison’s 18th Ed. 2639

A.

~5%

B.

~ 10 %

C.

~ 25 %

D.

~ 50 %

What proportion of patients with acute pancreatitis have necrotizing pancreatitis ? Harrison’s 18th Ed. 2639

A.

~5%

B.

~ 10 %

C.

~ 25 %

D.

~ 50 %

Which of the following antibiotic is recommended in necrotizing acute pancreatitis ? Harrison’s 17th Ed. 2010

A.

Ciprofloxacin

B.

Metronidazole

C.

Imipenem cilastin

D.

Aztreonam

Current recommendation in necrotizing acute pancreatitis is imipenem cilastin, 500 mg thrice daily for 7 days.

1442

Lexipafant is best related to ? Harrison’s 18th Ed. 2640

With single organ system failure, the mortality is 3–10% but increases to 47% with multisystem organ failure.

1437

In pancreatitis, oral intake is started by considering all of the following factors except ?

A.

Protease inhibitor

B.

Platelet-activating factor inhibitor

C.

Antibiotic

D.

Fungicide

Platelet activating factor (PAF) enhances polymorphonuclear leukocyte (PMN) superoxide production, CD11b expression & elastase release, all essential components in the pathophysiology of multipleorgan failure. Lexipafant (BB-882) is a potent & specific PAF antagonist. It fits in PAF receptors on the surface of cells & blocks activation of these receptors by PAF itself.

1443

Which of the following is used in the management of pancreatitis ? Harrison’s 18th Ed. 357

A.

Nafamostat

B.

Pentamidine

Necrotizing pancreatitis occurs in ~10% of all patients with acute pancreatitis.

C.

Tacrolimus

1438

D.

Aliskiren

Necrosis is present in what percentage of patients with acute pancreatitis ? Harrison’s 17th Ed. 2010

A.

5 - 10 %

B.

12 - 20 %

C.

25 - 45 %

D.

50 - 70 %

Necrosis is present in 12 - 20% of patients with acute pancreatitis.

1439

In what proportion of acute pancreatitis, the disease is selflimited and subsides spontaneously ? Harrison’s 18th Ed. 2640

A.

~ 25 %

B.

~ 50 %

Nafamostat, a protease inhibitor is utilized in the management of pancreatitis, disseminated intravascular coagulation, and extracorporeal circulation (ECC), such as during hemodialysis therapy (HD), plasmapheresis, and cardiopulmonary bypass. It inhibits aldosterone-induced proteases that activate ENaC by proteolytic cleavage. It may cause hyperkalemia.

1444

Besides its use in acute pancreatitis, Lexipafant is also used in ? Harrison’s 17th Ed. 2010

A.

Asthma

B.

Glaucoma

C.

Alopecia

D.

Peripheral arterial disease

Inflammatory agent PAF is implicated in the causation of pancreatitis and asthma.

Gastroenterology 509 1445

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

Aprotinin is best related to which of the following drugs ? Harrison’s 18th Ed. 2640

“Walled-off Necrosis” occurs how many weeks after necrotizing pancreatitis ?

A.

Lexipafant

Harrison’s 18th Ed. 2641

B.

Calcitonin

A.

1 to 3 weeks

C.

Gabexate mesilate

B.

3 to 6 weeks

D.

Octreotide

C.

6 to 12 weeks

D.

12 to 24 weeks

Aprotinin & gabexate mesilate are broad spectrum antiprotease drugs that reduce pancreatic damage but have no effect on mortality rate in pancreatitis.

1446

Preferred method of nutritional support in patients of necrotizing pancreatitis is ? Harrison’s 18th Ed. 2641

Necrotizing pancreatitis is always associated with peripancreatic necrosis involving the fat around the pancreas. After 3 to 6 weeks, the pancreatic necrosis and peripancreatic fat necrosis fuse together encapsulated by fibrous tissue, adjacent to pancreas. “Walled-off necrosis” refers to this conjoint structure.

1452

Total parenteral nutrition (TPN)

B.

Feeding with a nasogastric tube

A.

Extrapancreatic

C.

Enteral-feeding with a nasojejunal tube

B.

Collections of pancreatic fluid with pancreatic enzymes

D.

PEG

C.

Do not have an epithelial lining

D.

None of the above

What proportion of patients of acute pancreatitis have a recurrence ? Harrison’s 18th Ed. 2641

Harrison’s 18th Ed. 2641

Pseudocysts of the pancreas are extrapancreatic collections of pancreatic fluid containing pancreatic enzymes and a small amount of debris. In contrast to true cysts, pseudocysts do not have an epithelial lining. The walls consist of necrotic tissue, granulation tissue, and fibrous tissue.

1453

~ 25 %

B.

~ 50 %

A.

Necrotic tissue

C.

~ 75 %

B.

Granulation tissue

D.

~ 90 %

C.

Fibrous tissue

D.

All of the above

Which of the following occult biliary tract diseases can lead to acute pancreatitis ? Harrison’s 18th Ed. 2641

A.

Microlithiasis

B.

Pancreatic cancer

C.

Pancreas divisum

D.

All of the above

If a cause could not be found in patients with recurrent pancreatitis, occult biliary tract disease should be looked at. These include microlithiasis, hypertriglyceridemia, drugs, pancreatic cancer, sphincter of Oddi dysfunction, pancreas divisum, cystic fibrosis, hereditary pancreatitis, choledochocele; ampullary tumors, pancreatic duct stones, stricture, and tumor.

1449

Harrison’s 18th Ed. 2641

Pseudocysts of pancreas do not have an epithelial lining. Their walls consist of necrotic tissue, granulation tissue, and fibrous tissue.

1454

Gram-positive bacteria of alimentary origin

B.

Gram-negative bacteria of alimentary origin

C.

Gram-positive bacteria of hematogenous origin

D.

Gram-negative bacteria of hematogenous origin

Necrotic pancreas becomes secondarily infected in 20-35% of patients, 7–10 days after the onset of acute pancreatitis, most frequently with gram-negative bacteria of alimentary origin.

Pancreatic abscess following acute pancreatitis develops after ? Harrison’s 17th Ed. 2008

A.

1 weeks

B.

2 weeks

C.

3 weeks

D.

6 weeks

Pancreatic abscess following acute pancreatitis develops usually after 6 weeks.

A.

Squamous epithelium

B.

Cuboidal epithelium

C.

Granulation tissue

D.

Any of the above

Lining of a pancreatic pseudocyst is granulation tissue from pancreatic duct leakage.

1455

Necrotic pancreas becomes secondarily infected with ? A.

The lining of a pancreatic pseudocyst is ? Harrison’s 18th Ed. 2641

After acute pancreatitis, pseudocysts of pancreas develop over a period of ? Harrison’s 17th Ed. 2011

Harrison’s 18th Ed. 2641

1450

Walls of pseudocysts consist of ?

A.

~25% of patients who have had an attack of acute pancreatitis have a recurrence.

1448

Which of the following is false about pancreatic pseudocysts ?

A.

Enteral-feeding with a nasojejunal tube has fewer infectious complications than with total parenteral nutrition (TPN) and is the preferred method of nutritional support. Also, enteral feeding helps to maintain integrity of the intestinal tract during severe acute pancreatitis.

1447

1451

509 Cardiology

A.

1 - 2 weeks

B.

2 - 3 weeks

C.

3 - 4 weeks

D.

4 - 6 weeks

Pseudocysts of pancreas are collections of tissue, fluid, debris, pancreatic enzymes & blood that develop over 4-6 weeks after acute pancreatitis.

1456

Which of the following about pseudocysts of pancreas is false ? Harrison’s 18th Ed. 2642

A.

Preceded by pancreatitis in 90% of cases

B.

Mostly located in body or tail of pancreas

C.

Abdominal pain is the usual presenting complaint

D.

Serum amylase level is mostly normal

Serum amylase level is elevated in 75% of pseudocysts of pancreas at some point during their illness and may fluctuate markedly.

510 1457

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Significant number of pancreatic pseudocysts resolve spontaneously how many weeks after their formation ?

Harrison’s 18th Ed. 2643

A.

> 1 week

A.

Peritoneum

B.

> 2 weeks

B.

Pleural space

C.

> 4 weeks

C.

Retroperitoneum

D.

> 6 weeks

D.

Any of the above

Complication of a pancreatic pseudocyst is ? Harrison’s 18th Ed. 2642

If the pancreatic duct disruption is posterior, an internal fistula may develop between the pancreatic duct and the pleural space, producing a pleural effusion (pancreaticopleural fistula) that is usually left-sided and often massive.

1464

Cardinal complications of chronic pancreatitis is ?

A.

Rupture

B.

Hemorrhage

A.

Abdominal pain

C.

Abscess

B.

Steatorrhea

D.

All of the above

C.

Diabetes mellitus

D.

All of the above

Harrison’s 18th Ed. 2643

Complications of pancreatic pseudocyst are pain, pressure on other viscera, rupture, hemorrhage & abscess.

1459

When main pancreatic duct is disrupted posteriorly, internal fistula may develop between pancreatic duct and ?

Harrison’s 18th Ed. 2642

Significant number of pancreatic pseudocysts resolve spontaneously >6 weeks after their formation.

1458

1463

Which artery most frequently forms ‘Pseudoaneurysm’ in acute pancreatitis ? Harrison’s 18th Ed. 2642

A.

Splenic artery

B.

Inferior pancreatic duodenal artery

C.

Superior pancreatic duodenal artery

D.

Hepatic artery

Gastroenterology

Complications of chronic pancreatitis are abdominal pain, steatorrhea, weight loss & diabetes mellitus.

1465

Which of the following is best related to chronic pancreatitis ? Harrison’s 18th Ed. 2643

A.

Fluctuating symptomatology

B.

Risk of malignancy

C.

Irreversible damage to pancreas

D.

All of the above

Splenic artery is most often involved, but gastroduodenal, inferior pancreatico-duodenal and superior pancreatico-duodenal arteries can be affected.

Chronic pancreatitis is characterized by irreversible damage to pancreas.

1460

1466

Which of the following statements is false for Purtscher’s retinopathy ? Harrison’s 18th Ed. 2642

Harrison’s 18th Ed. 2643

A.

Due to occlusion of anterior retinal artery

A.

Smoking

B.

Sudden and severe loss of vision

B.

Intravenous drug use

C.

Cotton wool spots & hemorrhages in optical fundus

C.

Prolonged fasting

It is a complication of acute pancreatitis

D.

Obesity

D.

Purtscher’s retinopathy in acute pancreatitis is due to occlusion of posterior retinal artery with aggregated granulocytes. Optical fundus shows cotton-wool spots & hemorrhages confined to an area limited by optic disk & macula.

1461

The fluid in true pancreatic ascites usually has an amylase concentration of ?

There is a strong independent, dose-dependent association of smoking and chronic and recurrent acute pancreatitis. Cigarette smoke leads to an increased susceptibility to pancreatic self-digestion and predisposes to dysregulation of duct cell CFTR function. It increases severity in alcohol-induced chronic pancreatitis.

1467

Harrison’s 17th Ed. 2012

1462

There is a strong association of which of the following and chronic pancreatitis ?

A.

>5000 U/L

B.

>10000 U/L

C.

>15000 U/L

D.

>20000 U/L

Differential diagnosis of pancreatic ascites is ? Harrison’s 18th Ed. 2643

Which of the following plays a key role in the development of chronic pancreatitis ? Harrison’s 18th Ed. 2643

A.

Islet cells of Langerhans

B.

Pancreatic stellate cells (PSC)

C.

Acinar epithelial cells

D.

All of the above

Pancreatic stellate cells (PSC) play a role in maintaining normal pancreatic architecture that can shift toward fibrogenesis in the case of chronic pancreatitis.

A.

Tuberculous peritonitis

B.

Constrictive pericarditis

C.

Budd-Chiari syndrome

Harrison’s 18th Ed. 2643

D.

All of the above

A.

Sentinel acute pancreatitis event

B.

Sentinel chronic pancreatitis event

C.

Sequential acute pancreatitis event

D.

Sequential chronic pancreatitis event

Differential diagnosis of pancreatic ascites includes intraperitoneal carcinomatosis, tuberculous peritonitis, constrictive pericarditis, and Budd-Chiari syndrome.

1468

Which of the following hypothesis describes events in the pathogenesis of chronic pancreatitis ?

Gastroenterology 511

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

The sentinel acute pancreatitis event (SAPE) hypothesis uniformly describes the events in the pathogenesis of chronic pancreatitis.

1469

1474

A.

Acute

B.

Chronic

Harrison’s 18th Ed. 2643

C.

Recurrent

A.

Proinflammatory cytokines

D.

All of the above

B.

Oxidants

C.

Growth factors

Harrison’s 17th Ed. 2013

D.

All of the above

A.

Sclerosing pancreatitis

B.

Tumefactive pancreatitis

C.

Nonalcoholic destructive pancreatitis

D.

All of the above

Which of the following induces pancreatic stellate cells (PSC) activity with subsequent new collagen synthesis ?

Which of the following plays a role in the self-activating autocrine pathways lead to progression in chronic pancreatitis ? Harrison’s 18th Ed. 2643

A.

Tumor necrosis factor (TNF-)

B.

Interleukin 1 (IL-1)

C.

Interleukin 6 (IL-6)

D.

Transforming growth factor (TGF-)

PSCs also possess transforming growth factor (TGF-)–mediated self-activating autocrine pathways that may explain disease progression in chronic pancreatitis even after removal of noxious stimuli.

1471

Autoimmune Pancreatitis (AIP) is which form of pancreatitis ? N Engl J Med 2006;355:2670-6

1475

Proinflammatory cytokines, tumor necrosis factor (TNF-), interleukin 1 (IL-1), and interleukin 6 (IL6) as well as oxidant complexes & growth factors are able to induce PSC activity with subsequent new collagen synthesis.

1470

Which of the following is the most frequent cause of clinically apparent chronic pancreatitis in children ? Harrison’s 18th Ed. 2644

A.

Cystic fibrosis

B.

Hereditary pancreatitis

C.

Isolated autoimmune chronic pancreatitis

D.

Pancreas divisum

511 Cardiology

Autoimmune Pancreatitis (AIP) is also called ?

AIP is also referred to as sclerosing pancreatitis, tumefactive pancreatitis and nonalcoholic destructive pancreatitis.

1476

Autoimmune pancreatitis is frequently associated with ? Harrison’s 18th Ed. 2644, N Engl J Med 2006;355:2670-6

A.

Rheumatoid arthritis

B.

Sjögren’s syndrome

C.

Inflammatory bowel disease

D.

All of the above

AIP is associated with primary sclerosing cholangitis, primary biliary sclerosis, rheumatoid arthritis, Sjögren’s syndrome, ulcerative colitis, mediastinal adenopathy, autoimmune thyroiditis, tubulointerstitial nephritis, and retroperitoneal fibrosis.

1477

Majority of patients with AIP present with ? Harrison’s 18th Ed. 2644

A.

Obstructive jaundice

B.

Acute pancreatitis

C.

Recurrent pancreatitis

D.

Malabsorption syndrome

In United States, alcoholism is the most common cause of clinically apparent chronic pancreatitis in adults, while cystic fibrosis is the most frequent cause in children.

In the United States, 50–75% of patients with AIP present with obstructive jaundice.

1472

1478

In hereditary chronic pancreatitis, defect in gene encoding for which of the following is found ?

Immunologic abnormalities in autoimmune pancreatitis include ?

Harrison’s 18th Ed. 2644

N Engl J Med 2006;355:2670-6

A.

Pepsin

A.

Hypergammaglobulinemia

B.

Chymotrypsin

B.

Autoantibodies against carbonic anhydrase

C.

Trypsinogen

C.

Autoantibodies against lactoferrin

D.

All of the above

D.

All of the above

In hereditary chronic pancreatitis, a genetic defect that affects the gene encoding for trypsinogen was identified. The defect prevents the destruction of trypsinogen and allows it to be resistant to the effect of trypsin inhibitor, become spontaneously activated, and to remain activated leading to continual activation of digestive enzymes within the gland causing acute injury and eventually chronic pancreatitis.

Autoimmune pancreatitis is characterized by the presence of increased serum gammaglobulin levels (IgG4), presence of autoantibodies (antinuclear antibodies, antilactoferrin antibodies, anticarbonic anhydrase antibodies & rheumatoid factor), pancreatic fibrosis with lymphocytic infiltration & an absence of pancreatic calcification, an association with other autoimmune diseases and response to steroid therapy.

1473

1479

Which of the following mutation increases the risk of chronic pancreatitis ?

Serum levels of which of the following immunoglobulin is elevated in AIP ?

Harrison’s 18th Ed. 2644

Harrison’s 18th Ed. 2644, 2673

A.

N32S SPINK1

A.

Immunoglobulin G1

B.

N33S SPINK1

B.

Immunoglobulin G2

C.

N34S SPINK1

C.

Immunoglobulin G3

D.

N35S SPINK1

D.

Immunoglobulin G4

Presence of an N34S SPINK1 mutation increased the risk of chronic pancreatitis by twentyfold. A combination of two CFTR mutations and an N34S SPINK1 mutation increased the risk of chronic pancreatitis 900-fold.

IgG constitutes ~75–85% of total serum immunoglobulin. The four IgG subclasses are numbered in order of their level in serum, IgG1 being found in greatest amounts and IgG4 the least. Serum IgG4 normally accounts for only 5–6% of the total IgG in healthy patients but is elevated at least twofold higher than 135 mg/dL in those with AIP.

512 1480

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following syndrome is related to IgG4 ?

1486

Gastroenterology

Harrison’s 18th Ed. 2369

Which of the following tests is useful in identifying severe pancreatic exocrine insufficiency ?

A.

IgG4-related immunologic disease

Harrison’s 18th Ed. 2645

B.

IgG4-related systemic disease

A.

D-xylose excretion test

C.

IgG4-related pulmonary disease

B.

Fecal elastase

D.

IgG4-related neuronal disease

C.

Serum amylase

D.

Serum lipase

IgG4-related systemic disease is a variety of acute tubulointerstitial disorder and a form of Acute Interstitial Nephritis (AIN). It is characterized by a dense inflammatory infiltrate containing IgG4expressing plasma cells. Glucocorticoids lead to response.

Fecal elastase levels of < 100 µg per gram of stool strongly suggests severe pancreatic exocrine insufficiency.

1481

1487

Which of the following syndrome is related to IgG4 ? Harrison’s 18th Ed. 2627

A.

Immunoglobulin G4–associated carditis

B.

Immunoglobulin G4–associated neuritis

A.

< 20 mg/mL

C.

Immunoglobulin G4–associated pneumonitis

B.

< 40 mg/mL

D.

Immunoglobulin G4–associated cholangitis

C.

< 60 mg/mL

D.

< 80 mg/mL

Immunoglobulin G4–associated cholangitis is a biliary disease of unknown etiology with biochemical & cholangiographic features indistinguishable from PSC. It is associated with autoimmune pancreatitis and is characterized by elevated serum IgG4 and infiltration of IgG4-positive plasma cells in bile ducts and liver tissue. In contrast to PSC, it is not associated with inflammatory bowel disease.

1482

Severe pancreatic exocrine insufficiency is obvious when serum trypsinogen levels are ?

Which of the following is characteristic imaging finding in AIP ?

Harrison’s 17th Ed. 2014

Decrease of serum trypsinogen level to < 20 mg/mL strongly suggests severe pancreatic exocrine insufficiency.

1488

Harrison’s 18th Ed. 2644, Table 313-6, Gastroenterology 2007;132:1557-1573

Harrison’s 18th Ed. 2644

A.

Enlargement at the head of pancreas

B.

Strictures in bile duct

C.

Narrowing of pancreatic bile duct

D.

All of the above

Absence of pancreatic calcification is a feature of ?

1489

A.

Idiopathic chronic pancreatitis

B.

Islet cell tumors

C.

Autoimmune Pancreatitis

D.

Severe protein-calorie malnutrition

Most common cause of pancreatic calcification is ? Harrison’s 18th Ed. 2645

1483

Which of the following drug is useful in AIP ? Harrison’s 18th Ed. 2644

1484

A.

Glucocorticoids

B.

Azathioprine

C.

6-mercaptopurine

D.

All of the above

Which of the following is false about chronic pancreatitis ? Harrison’s 18th Ed. 2645

A.

Deficiencies of fat-soluble vitamins are uncommon

B.

Serum amylase & lipase levels are raised

C.

Best diagnostic test is secretin stimulation test

D.

Vitamin B 12 malabsorption is corrected by oral pancreatic enzymes

A.

Idiopathic chronic pancreatitis

B.

Hypercalcemic pancreatitis

C.

Alcohol

D.

Severe protein-calorie malnutrition

Alcohol is the most common cause of pancreatic calcification. Diffuse pancreatic calcifications on FP abdomen indicates ~80% damage to pancreas. Pancreatic calcification is also seen in severe protein-calorie malnutrition, hereditary pancreatitis, posttraumatic pancreatitis, hypercalcemic pancreatitis, islet cell tumors, idiopathic chronic pancreatitis and tropical pancreatitis.

1490

Tropical pancreatitis is characterized by all except ? Gastroenterology 2007;132:1557-1573

A.

Early onset

B.

Slow progression

C.

Severe pancreatic damage

D.

No history of alcohol abuse or biliary disease

Serum amylase & lipase levels are normal.

1485

In chronic pancreatitis, secretin stimulation test is abnormal when how much of pancreatic exocrine function is lost ? Harrison’s 18th Ed. 2645

A.

20 %

B.

40 %

C.

60 %

D.

80 %

In chronic pancreatitis, secretin stimulation test becomes abnormal when 60% of the pancreatic exocrine function has been lost. This correlates well with the onset of chronic abdominal pain.

Tropical pancreatitis is characterized by early onset, rapid progression & severe pancreatic damage in the absence of a history of alcohol abuse or biliary disease. Both exocrine & endocrine insufficiency is evident at very early stages, often at the time of presentation in majority (70%) of patients.

1491

Which of the following is an uncommon complication of chronic pancreatitis ? Harrison’s 18th Ed. 2646

A.

Diabetic ketoacidosis

B.

Pancreatic cancer

C.

Gastrointestinal bleeding

D.

Biliary cirrhosis

In chronic pancreatitis, most patients have impaired glucose tolerance, diabetic ketoacidosis and coma are uncommon.

Gastroenterology 513 1492

MCQ’s FORPROFESSIONALS MEDICAL PROFESSIONALS MCQ’s FOR MEDICAL BY PROF. AJAY MATHUR

According to the American Diabetes Association, which of the following diabetes in found in chronic pancreatitis ?

1497

A.

Enteric-coated lipase & free proteases

A.

Type I

B.

Enteric-coated lipase & enteric-coated proteases

B.

Type II

C.

Free lipase & enteric-coated proteases

C.

Type IIIc

D.

Free lipase & free proteases

D.

Any of the above

Diabetes of chronic pancreatitis is classified as type IIIc according to ADA & is characterized by destruction of both insulin & glucagon-producing cells.

Increased incidence of pancreatic carcinoma is seen in which of the following ?

Ideal pancreatic enzyme preparation is enteric-coated lipase & free proteases. Free proteases enter duodenum & evoke a positive feedback control mechanism & enteric-coated lipase open beyond duodenum & enhance fat absorption. Recent data suggests that dosages up to 80,000–100,000 units of lipase per meal may be necessary to normalize nutritional parameters in malnourished chronic pancreatitis patients.

1498

Gastroenterology 2007;132:1557-1573

A.

Idiopathic chronic pancreatitis

A.

Cardiovascular disease

B.

Hypercalcemic pancreatitis

B.

Severe infection

C.

Hereditary pancreatitis

C.

Malignancy

D.

Severe protein-calorie malnutrition

D.

All of the above

Source of pancreatic enzymes in treatment of chronic pancreatitis is ?

Major causes of death in alcoholic CP are cardiovascular disease, infection & malignancy.

1499

A.

Cow

B.

Pig

C.

Human

D.

Horse

Pancreatic enzymes from porcine sources is the cornerstone of pancreatic therapy.

Which of the following significantly relieves pain in severe refractory large-duct chronic pancreatitis ?

A.

Annular pancreas

B.

Pancreas divisum

C.

Sphincter of Oddi disorders

D.

Pancreatic duct scars

Pancreas divisum is the most common congenital anatomic variant of the human pancreas.

1500

Which of the following does not predispose to the development of pancreatitis ? Harrison’s 187th Ed. 2648

Harrison’s 17th Ed. 2014, Harrison’s 18th Ed. 2646

UDCA

A.

Hereditary Pancreatitis

B.

Cholestyramine

B.

Annular Pancreas

C.

Domperidone

C.

Pancreas Divisum

Octreotide

D.

All of the above

A.

D.

Octreotide significantly relieves pain in patients with severe chronic pancreatitis refractory to other forms of therapy, including surgery. In patients with large-duct disease usually from alcohol-induced chronic pancreatitis, ductal decompression has been the therapy of choice.

1496

The most common congenital anatomic variant of human pancreas is ? Harrison’s 187th Ed. 2648

Harrison’s 17th Ed. 2014

1495

The major cause of death in alcoholic CP is ?

Harrison’s 18th Ed. 2646, 2647

Patients with hereditary pancreatitis develop pancreatic calcification, diabetes mellitus & steatorrhea. They have a tenfold higher risk of pancreatic carcinoma (40% by 70 years).

1494

The ideal pancreatic enzyme preparation is ? Harrison’s 17th Ed. 2014, Harrison’s 18th Ed. 2646

Gastroenterology 2007;132:1557-1573

1493

513 Cardiology

Small-duct chronic pancreatitis patients who respond best to serine proteases are those with ? Harrison’s 17th Ed. 2014

A.

Abnormal hormone stimulation test

B.

Minimal changes on ERCP

C.

Normal fat absorption

D.

All of the above

Pancreas divisum does not predispose to the development of pancreatitis in the great majority of patients who harbor it.

1501

Macroamylasaemia is characterised by formation of large molecular complexes between amylase and ? A. Urea B.

Haem

C.

Clotting factors

D.

Abnormal immunoglobulins

Macroamylasaemia is a syndrome characterised by formation of large molecular complexes between amylase & abnormal immunoglobulins.

Notes :

Answer

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

515

ANSWERS GASTROENTEROLOGY 1 .................. D

33 ................ B

65 ................ D

97 ................ D

129 .............. D

161 .............. C

2 .................. B

34 ................ C

66 ................ D

98 ................ D

130 .............. D

162 .............. D

3 .................. C

35 ................ D

67 ................ C

99 ................ C

131 .............. D

163 .............. A

4 .................. C

36 ................ A

68 ................ B

100 .............. C

132 .............. D

164 .............. A

5 .................. C

37 ................ D

69 ................ D

101 .............. D

133 .............. D

165 .............. C

6 .................. C

38 ................ D

70 ................ D

102 .............. B

134 .............. C

166 .............. B

7 .................. B

39 ................ B

71 ................ D

103 .............. A

135 .............. A

167 .............. D

8 .................. C

40 ................ C

72 ................ C

104 .............. A

136 .............. D

168 .............. B

9 .................. D

41 ................ A

73 ................ C

105 .............. C

137 .............. A

169 .............. D

10 ................ D

42 ................ B

74 ................ D

106 .............. D

138 .............. C

170 .............. D

11 ................ A

43 ................ A

75 ................ B

107 .............. B

139 .............. A

171 .............. A

12 ................ D

44 ................ D

76 ................ D

108 .............. D

140 .............. D

172 .............. B

13 ................ A

45 ................ A

77 ................ B

109 .............. C

141 .............. A

173 .............. C

14 ................ D

46 ................ C

78 ................ D

110 .............. D

142 .............. D

174 .............. D

15 ................ D

47 ................ B

79 ................ C

111 .............. D

143 .............. A

175 .............. C

16 ................ A

48 ................ B

80 ................ C

112 .............. D

144 .............. D

176 .............. B

17 ................ C

49 ................ B

81 ................ C

113 .............. D

145 .............. D

177 .............. B

18 ................ D

50 ................ D

82 ................ B

114 .............. B

146 .............. C

178 .............. D

19 ................ C

51 ................ A

83 ................ C

115 .............. C

147 .............. D

179 .............. B

20 ................ C

52 ................ C

84 ................ D

116 .............. D

148 .............. A

180 .............. C

21 ................ D

53 ................ A

85 ................ A

117 .............. D

149 .............. D

181 .............. C

22 ................ D

54 ................ A

86 ................ B

118 .............. D

150 .............. D

182 .............. B

23 ................ C

55 ................ A

87 ................ D

119 .............. C

151 .............. C

183 .............. C

24 ................ B

56 ................ A

88 ................ D

120 .............. C

152 .............. D

184 .............. D

25 ................ C

57 ................ D

89 ................ D

121 .............. C

153 .............. D

185 .............. A

26 ................ A

58 ................ B

90 ................ A

122 .............. C

154 .............. C

186 .............. D

27 ................ B

59 ................ D

91 ................ C

123 .............. D

155 .............. A

187 .............. A

28 ................ A

60 ................ A

92 ................ A

124 .............. C

156 .............. B

188 .............. C

29 ................ D

61 ................ D

93 ................ C

125 .............. D

157 .............. C

189 .............. D

30 ................ A

62 ................ B

94 ................ A

126 .............. C

158 .............. C

190 .............. C

31 ................ B

63 ................ B

95 ................ D

127 .............. D

159 .............. D

191 .............. D

32 ................ A

64 ................ B

96 ................ A

128 .............. B

160 .............. D

192 .............. B

516

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Answer

ANSWERS GASTROENTEROLOGY 193 .............. C

225 .............. C

257 .............. D

289 .............. D

321 .............. A

353 .............. A

194 .............. D

226 .............. C

258 .............. B

290 .............. A

322 .............. D

354 .............. A

195 .............. B

227 .............. D

259 .............. D

291 .............. D

323 .............. B

355 .............. C

196 .............. D

228 .............. A

260 .............. A

292 .............. C

324 .............. C

356 .............. C

197 .............. B

229 .............. C

261 .............. A

293 .............. D

325 .............. D

357 .............. D

198 .............. B

230 .............. B

262 .............. D

294 .............. A

326 .............. B

358 .............. A

199 .............. D

231 .............. B

263 .............. C

295 .............. C

327 .............. B

359 .............. D

200 .............. D

232 .............. C

264 .............. A

296 .............. A

328 .............. A

360 .............. B

201 .............. D

233 .............. C

265 .............. A

297 .............. A

329 .............. D

361 .............. B

202 .............. B

234 .............. C

266 .............. B

298 .............. A

330 .............. D

362 .............. A

203 .............. D

235 .............. C

267 .............. B

299 .............. D

331 .............. B

363 .............. A

204 .............. D

236 .............. A

268 .............. B

300 .............. A

332 .............. C

364 .............. A

205 .............. D

237 .............. C

269 .............. B

301 .............. A

333 .............. A

365 .............. A

206 .............. A

238 .............. A

270 .............. D

302 .............. D

334 .............. B

366 .............. A

207 .............. C

239 .............. B

271 .............. A

303 .............. D

335 .............. D

367 .............. C

208 .............. D

240 .............. A

272 .............. D

304 .............. D

336 .............. B

368 .............. A

209 .............. C

241 .............. C

273 .............. B

305 .............. C

337 .............. D

369 .............. B

210 .............. A

242 .............. D

274 .............. D

306 .............. A

338 .............. D

370 .............. C

211 .............. B

243 .............. D

275 .............. D

307 .............. C

339 .............. D

371 .............. A

212 .............. D

244 .............. C

276 .............. C

308 .............. D

340 .............. D

372 .............. D

213 .............. B

245 .............. D

277 .............. A

309 .............. D

341 .............. D

373 .............. D

214 .............. B

246 .............. A

278 .............. D

310 .............. A

342 .............. D

374 .............. D

215 .............. D

247 .............. A

279 .............. D

311 .............. D

343 .............. D

375 .............. C

216 .............. D

248 .............. C

280 .............. C

312 .............. C

344 .............. D

376 .............. B

217 .............. C

249 .............. C

281 .............. B

313 .............. D

345 .............. D

377 .............. C

218 .............. B

250 .............. A

282 .............. A

314 .............. B

346 .............. D

378 .............. A

219 .............. A

251 .............. B

283 .............. C

315 .............. C

347 .............. B

379 .............. D

220 .............. D

252 .............. D

284 .............. C

316 .............. A

348 .............. A

380 .............. D

221 .............. A

253 .............. D

285 .............. A

317 .............. D

349 .............. D

381 .............. D

222 .............. D

254 .............. C

286 .............. A

318 .............. C

350 .............. A

382 .............. D

223 .............. D

255 .............. D

287 .............. A

319 .............. C

351 .............. D

383 .............. D

224 .............. A

256 .............. A

288 .............. A

320 .............. A

352 .............. B

384 .............. D

Answer

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

517

ANSWERS GASTROENTEROLOGY 385 .............. C

417 .............. D

449 .............. D

481 .............. B

513 .............. A

545 .............. D

386 .............. D

418 .............. C

450 .............. D

482 .............. B

514 .............. D

546 .............. C

387 .............. D

419 .............. D

451 .............. D

483 .............. C

515 .............. D

547 .............. B

388 .............. A

420 .............. B

452 .............. B

484 .............. A

516 .............. D

548 .............. C

389 .............. A

421 .............. D

453 .............. D

485 .............. D

517 .............. C

549 .............. D

390 .............. A

422 .............. D

454 .............. B

486 .............. C

518 .............. C

550 .............. C

391 .............. B

423 .............. D

455 .............. D

487 .............. B

519 .............. A

551 .............. D

392 .............. C

424 .............. D

456 .............. B

488 .............. C

520 .............. A

552 .............. C

393 .............. B

425 .............. D

457 .............. C

489 .............. A

521 .............. D

553 .............. B

394 .............. D

426 .............. D

458 .............. D

490 .............. A

522 .............. A

554 .............. A

395 .............. B

427 .............. D

459 .............. C

491 .............. A

523 .............. B

555 .............. A

396 .............. C

428 .............. D

460 .............. D

492 .............. B

524 .............. B

556 .............. B

397 .............. D

429 .............. D

461 .............. B

493 .............. D

525 .............. C

557 .............. C

398 .............. C

430 .............. C

462 .............. C

494 .............. B

526 .............. D

558 .............. D

399 .............. B

431 .............. D

463 .............. D

495 .............. A

527 .............. B

559 .............. B

400 .............. D

432 .............. A

464 .............. C

496 .............. D

528 .............. B

560 .............. A

401 .............. D

433 .............. C

465 .............. D

497 .............. A

529 .............. A

561 .............. D

402 .............. C

434 .............. B

466 .............. A

498 .............. C

530 .............. B

562 .............. A

403 .............. B

435 .............. D

467 .............. D

499 .............. D

531 .............. D

563 .............. D

404 .............. C

436 .............. C

468 .............. A

500 .............. D

532 .............. D

564 .............. A

405 .............. B

437 .............. A

469 .............. B

501 .............. D

533 .............. A

565 .............. D

406 .............. C

438 .............. A

470 .............. A

502 .............. B

534 .............. D

566 .............. B

407 .............. B

439 .............. D

471 .............. B

503 .............. C

535 .............. C

567 .............. C

408 .............. C

440 .............. A

472 .............. D

504 .............. C

536 .............. D

568 .............. C

409 .............. B

441 .............. A

473 .............. D

505 .............. B

537 .............. D

569 .............. B

410 .............. B

442 .............. B

474 .............. C

506 .............. B

538 .............. D

570 .............. D

411 .............. A

443 .............. D

475 .............. A

507 .............. C

539 .............. B

571 .............. D

412 .............. D

444 .............. D

476 .............. B

508 .............. D

540 .............. B

572 .............. D

413 .............. C

445 .............. D

477 .............. C

509 .............. C

541 .............. A

573 .............. D

414 .............. A

446 .............. C

478 .............. C

510 .............. C

542 .............. C

574 .............. B

415 .............. D

447 .............. D

479 .............. C

511 .............. B

543 .............. C

575 .............. C

416 .............. D

448 .............. B

480 .............. C

512 .............. A

544 .............. A

576 .............. D

518

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Answer

ANSWERS GASTROENTEROLOGY 577 .............. A

609 .............. C

641 .............. A

673 .............. A

705 .............. C

737 .............. D

578 .............. D

610 .............. B

642 .............. C

674 .............. D

706 .............. D

738 .............. A

579 .............. D

611 .............. D

643 .............. D

675 .............. A

707 .............. A

739 .............. D

580 .............. C

612 .............. D

644 .............. B

676 .............. D

708 .............. A

740 .............. D

581 .............. C

613 .............. D

645 .............. C

677 .............. B

709 .............. B

741 .............. A

582 .............. D

614 .............. D

646 .............. C

678 .............. D

710 .............. D

742 .............. C

583 .............. C

615 .............. B

647 .............. D

679 .............. B

711 .............. A

743 .............. D

584 .............. B

616 .............. D

648 .............. C

680 .............. A

712 .............. D

744 .............. D

585 .............. C

617 .............. C

649 .............. B

681 .............. C

713 .............. A

745 .............. D

586 .............. B

618 .............. C

650 .............. B

682 .............. D

714 .............. B

746 .............. B

587 .............. A

619 .............. B

651 .............. B

683 .............. B

715 .............. C

747 .............. D

588 .............. B

620 .............. C

652 .............. D

684 .............. B

716 .............. A

748 .............. C

589 .............. D

621 .............. C

653 .............. D

685 .............. B

717 .............. A

749 .............. A

590 .............. B

622 .............. A

654 .............. C

686 .............. A

718 .............. A

750 .............. A

591 .............. D

623 .............. A

655 .............. B

687 .............. C

719 .............. B

751 .............. D

592 .............. D

624 .............. B

656 .............. D

688 .............. D

720 .............. B

752 .............. D

593 .............. D

625 .............. A

657 .............. D

689 .............. B

721 .............. C

753 .............. D

594 .............. C

626 .............. C

658 .............. D

690 .............. A

722 .............. B

754 .............. D

595 .............. C

627 .............. D

659 .............. B

691 .............. D

723 .............. D

755 .............. B

596 .............. B

628 .............. C

660 .............. D

692 .............. D

724 .............. C

756 .............. C

597 .............. D

629 .............. A

661 .............. D

693 .............. C

725 .............. D

757 .............. D

598 .............. D

630 .............. C

662 .............. A

694 .............. A

726 .............. D

758 .............. C

599 .............. D

631 .............. C

663 .............. B

695 .............. C

727 .............. D

759 .............. D

600 .............. A

632 .............. C

664 .............. D

696 .............. B

728 .............. D

760 .............. A

601 .............. C

633 .............. D

665 .............. B

697 .............. A

729 .............. D

761 .............. D

602 .............. D

634 .............. C

666 .............. D

698 .............. A

730 .............. A

762 .............. B

603 .............. D

635 .............. B

667 .............. B

699 .............. D

731 .............. C

763 .............. C

604 .............. B

636 .............. C

668 .............. D

700 .............. B

732 .............. A

764 .............. C

605 .............. B

637 .............. B

669 .............. A

701 .............. D

733 .............. A

765 .............. D

606 .............. A

638 .............. A

670 .............. D

702 .............. D

734 .............. B

766 .............. A

607 .............. C

639 .............. A

671 .............. B

703 .............. D

735 .............. D

767 .............. C

608 .............. C

640 .............. D

672 .............. C

704 .............. D

736 .............. C

768 .............. B

Answer

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

519

ANSWERS GASTROENTEROLOGY 769 .............. D

801 .............. B

833 .............. C

865 .............. D

897 .............. D

929 .............. A

770 .............. D

802 .............. D

834 .............. D

866 .............. C

898 .............. D

930 .............. A

771 .............. D

803 .............. A

835 .............. D

867 .............. D

899 .............. D

931 .............. D

772 .............. D

804 .............. B

836 .............. D

868 .............. A

900 .............. A

932 .............. C

773 .............. D

805 .............. A

837 .............. D

869 .............. A

901 .............. A

933 .............. D

774 .............. D

806 .............. D

838 .............. A

870 .............. D

902 .............. B

934 .............. D

775 .............. C

807 .............. A

839 .............. D

871 .............. B

903 .............. C

935 .............. A

776 .............. D

808 .............. D

840 .............. D

872 .............. D

904 .............. C

936 .............. D

777 .............. C

809 .............. B

841 .............. B

873 .............. B

905 .............. C

937 .............. B

778 .............. A

810 .............. B

842 .............. D

874 .............. C

906 .............. C

938 .............. B

779 .............. A

811 .............. C

843 .............. A

875 .............. D

907 .............. D

939 .............. B

780 .............. D

812 .............. D

844 .............. C

876 .............. C

908 .............. D

940 .............. D

781 .............. D

813 .............. A

845 .............. B

877 .............. D

909 .............. A

941 .............. B

782 .............. A

814 .............. B

846 .............. D

878 .............. D

910 .............. D

942 .............. C

783 .............. D

815 .............. D

847 .............. A

879 .............. D

911 .............. D

943 .............. A

784 .............. A

816 .............. B

848 .............. D

880 .............. C

912 .............. D

944 .............. A

785 .............. B

817 .............. B

849 .............. A

881 .............. D

913 .............. D

945 .............. D

786 .............. D

818 .............. D

850 .............. D

882 .............. C

914 .............. D

946 .............. A

787 .............. A

819 .............. C

851 .............. A

883 .............. D

915 .............. D

947 .............. B

788 .............. B

820 .............. D

852 .............. B

884 .............. B

916 .............. D

948 .............. D

789 .............. D

821 .............. C

853 .............. C

885 .............. D

917 .............. D

949 .............. D

790 .............. D

822 .............. D

854 .............. A

886 .............. B

918 .............. D

950 .............. C

791 .............. C

823 .............. A

855 .............. D

887 .............. D

919 .............. D

951 .............. C

792 .............. D

824 .............. C

856 .............. D

888 .............. A

920 .............. D

952 .............. B

793 .............. C

825 .............. A

857 .............. B

889 .............. D

921 .............. D

953 .............. D

794 .............. D

826 .............. C

858 .............. D

890 .............. A

922 .............. D

954 .............. A

795 .............. D

827 .............. D

859 .............. C

891 .............. A

923 .............. B

955 .............. D

796 .............. D

828 .............. D

860 .............. A

892 .............. A

924 .............. B

956 .............. D

797 .............. D

829 .............. C

861 .............. A

893 .............. D

925 .............. D

957 .............. D

798 .............. D

830 .............. D

862 .............. C

894 .............. A

926 .............. D

958 .............. C

799 .............. D

831 .............. B

863 .............. C

895 .............. A

927 .............. C

959 .............. B

800 .............. D

832 .............. D

864 .............. C

896 .............. D

928 .............. C

960 .............. B

520

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Answer

ANSWERS GASTROENTEROLOGY 961 .............. A

993 .............. C

1025 ............ C

1057 ............ C

1089 ............ C

1121 ............ D

962 .............. C

994 .............. D

1026 ............ D

1058 ............ A

1090 ............ C

1122 ............ A

963 .............. C

995 .............. D

1027 ............ D

1059 ............ B

1091 ............ D

1123 ............ B

964 .............. B

996 .............. A

1028 ............ D

1060 ............ B

1092 ............ D

1124 ............ B

965 .............. D

997 .............. A

1029 ............ C

1061 ............ C

1093 ............ B

1125 ............ D

966 .............. B

998 .............. D

1030 ............ B

1062 ............ D

1094 ............ B

1126 ............ D

967 .............. A

999 .............. D

1031 ............ B

1063 ............ B

1095 ............ C

1127 ............ D

968 .............. D

1000 ............ B

1032 ............ B

1064 ............ D

1096 ............ A

1128 ............ B

969 .............. D

1001 ............ D

1033 ............ D

1065 ............ C

1097 ............ A

1129 ............ D

970 .............. A

1002 ............ A

1034 ............ D

1066 ............ D

1098 ............ C

1130 ............ A

971 .............. C

1003 ............ D

1035 ............ D

1067 ............ C

1099 ............ B

1131 ............ D

972 .............. A

1004 ............ C

1036 ............ B

1068 ............ C

1100 ............ D

1132 ............ A

973 .............. A

1005 ............ D

1037 ............ C

1069 ............ C

1101 ............ D

1133 ............ C

974 .............. A

1006 ............ B

1038 ............ C

1070 ............ D

1102 ............ D

1134 ............ C

975 .............. D

1007 ............ A

1039 ............ C

1071 ............ A

1103 ............ A

1135 ............ B

976 .............. A

1008 ............ A

1040 ............ D

1072 ............ B

1104 ............ C

1136 ............ B

977 .............. D

1009 ............ C

1041 ............ C

1073 ............ D

1105 ............ A

1137 ............ D

978 .............. A

1010 ............ D

1042 ............ D

1074 ............ D

1106 ............ C

1138 ............ D

979 .............. A

1011 ............ A

1043 ............ D

1075 ............ D

1107 ............ D

1139 ............ D

980 .............. B

1012 ............ B

1044 ............ D

1076 ............ D

1108 ............ D

1140 ............ D

981 .............. C

1013 ............ D

1045 ............ D

1077 ............ D

1109 ............ D

1141 ............ D

982 .............. C

1014 ............ B

1046 ............ B

1078 ............ A

1110 ............ B

1142 ............ D

983 .............. B

1015 ............ D

1047 ............ D

1079 ............ D

1111 ............ D

1143 ............ C

984 .............. D

1016 ............ C

1048 ............ D

1080 ............ C

1112 ............ D

1144 ............ C

985 .............. C

1017 ............ C

1049 ............ C

1081 ............ C

1113 ............ A

1145 ............ C

986 .............. A

1018 ............ B

1050 ............ C

1082 ............ D

1114 ............ B

1146 ............ A

987 .............. D

1019 ............ C

1051 ............ A

1083 ............ D

1115 ............ D

1147 ............ C

988 .............. A

1020 ............ B

1052 ............ D

1084 ............ D

1116 ............ D

1148 ............ A

989 .............. D

1021 ............ D

1053 ............ D

1085 ............ D

1117 ............ D

1149 ............ D

990 .............. D

1022 ............ C

1054 ............ D

1086 ............ D

1118 ............ C

1150 ............ C

991 .............. D

1023 ............ D

1055 ............ B

1087 ............ D

1119 ............ A

1151 ............ D

992 .............. C

1024 ............ A

1056 ............ C

1088 ............ D

1120 ............ D

1152 ............ D

Answer

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

521

ANSWERS GASTROENTEROLOGY 1153 ............ D

1185 ............ D

1217 ............ D

1249 ............ A

1281 ............ A

1313 ............ A

1154 ............ D

1186 ............ D

1218 ............ D

1250 ............ B

1282 ............ B

1314 ............ D

1155 ............ D

1187 ............ D

1219 ............ D

1251 ............ D

1283 ............ A

1315 ............ D

1156 ............ D

1188 ............ A

1220 ............ D

1252 ............ C

1284 ............ D

1316 ............ C

1157 ............ D

1189 ............ D

1221 ............ D

1253 ............ D

1285 ............ D

1317 ............ A

1158 ............ A

1190 ............ A

1222 ............ B

1254 ............ D

1286 ............ C

1318 ............ C

1159 ............ D

1191 ............ B

1223 ............ C

1255 ............ B

1287 ............ D

1319 ............ B

1160 ............ A

1192 ............ C

1224 ............ C

1256 ............ D

1288 ............ A

1320 ............ A

1161 ............ A

1193 ............ D

1225 ............ D

1257 ............ D

1289 ............ C

1321 ............ B

1162 ............ A

1194 ............ D

1226 ............ C

1258 ............ B

1290 ............ B

1322 ............ C

1163 ............ D

1195 ............ D

1227 ............ B

1259 ............ D

1291 ............ B

1323 ............ B

1164 ............ D

1196 ............ C

1228 ............ C

1260 ............ D

1292 ............ D

1324 ............ C

1165 ............ D

1197 ............ A

1229 ............ D

1261 ............ D

1293 ............ B

1325 ............ A

1166 ............ A

1198 ............ D

1230 ............ C

1262 ............ A

1294 ............ D

1326 ............ A

1167 ............ B

1199 ............ B

1231 ............ B

1263 ............ D

1295 ............ C

1327 ............ D

1168 ............ A

1200 ............ D

1232 ............ D

1264 ............ D

1296 ............ D

1328 ............ B

1169 ............ B

1201 ............ B

1233 ............ C

1265 ............ B

1297 ............ C

1329 ............ A

1170 ............ D

1202 ............ A

1234 ............ D

1266 ............ D

1298 ............ C

1330 ............ D

1171 ............ B

1203 ............ B

1235 ............ C

1267 ............ D

1299 ............ D

1331 ............ B

1172 ............ C

1204 ............ C

1236 ............ B

1268 ............ A

1300 ............ D

1332 ............ B

1173 ............ B

1205 ............ D

1237 ............ A

1269 ............ D

1301 ............ D

1333 ............ C

1174 ............ D

1206 ............ D

1238 ............ B

1270 ............ D

1302 ............ A

1334 ............ C

1175 ............ D

1207 ............ B

1239 ............ D

1271 ............ B

1303 ............ C

1335 ............ D

1176 ............ D

1208 ............ C

1240 ............ C

1272 ............ D

1304 ............ A

1336 ............ D

1177 ............ C

1209 ............ B

1241 ............ D

1273 ............ D

1305 ............ D

1337 ............ C

1178 ............ C

1210 ............ D

1242 ............ A

1274 ............ A

1306 ............ C

1338 ............ A

1179 ............ D

1211 ............ D

1243 ............ D

1275 ............ D

1307 ............ B

1339 ............ B

1180 ............ D

1212 ............ D

1244 ............ D

1276 ............ A

1308 ............ C

1340 ............ D

1181 ............ B

1213 ............ D

1245 ............ A

1277 ............ A

1309 ............ D

1341 ............ D

1182 ............ D

1214 ............ B

1246 ............ A

1278 ............ A

1310 ............ D

1342 ............ D

1183 ............ C

1215 ............ D

1247 ............ C

1279 ............ B

1311 ............ D

1343 ............ C

1184 ............ B

1216 ............ A

1248 ............ D

1280 ............ C

1312 ............ B

1344 ............ D

522

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

ANSWERS GASTROENTEROLOGY 1345 ............ D

1377 ............ C

1409 ............ D

1441 ............ C

1473 ............ C

1346 ............ B

1378 ............ B

1410 ............ A

1442 ............ B

1474 ............ B

1347 ............ D

1379 ............ B

1411 ............ B

1443 ............ A

1475 ............ D

1348 ............ B

1380 ............ A

1412 ............ D

1444 ............ A

1476 ............ D

1349 ............ B

1381 ............ D

1413 ............ D

1445 ............ C

1477 ............ A

1350 ............ B

1382 ............ D

1414 ............ C

1446 ............ C

1478 ............ D

1351 ............ B

1383 ............ D

1415 ............ B

1447 ............ A

1479 ............ D

1352 ............ B

1384 ............ A

1416 ............ B

1448 ............ D

1480 ............ B

1353 ............ B

1385 ............ D

1417 ............ D

1449 ............ B

1481 ............ D

1354 ............ B

1386 ............ A

1418 ............ B

1450 ............ D

1482 ............ D

1355 ............ A

1387 ............ A

1419 ............ D

1451 ............ B

1483 ............ D

1356 ............ C

1388 ............ B

1420 ............ D

1452 ............ D

1484 ............ B

1357 ............ B

1389 ............ C

1421 ............ D

1453 ............ D

1485 ............ C

1358 ............ C

1390 ............ D

1422 ............ C

1454 ............ C

1486 ............ B

1359 ............ C

1391 ............ D

1423 ............ C

1455 ............ D

1487 ............ A

1360 ............ B

1392 ............ D

1424 ............ A

1456 ............ D

1488 ............ C

1361 ............ D

1393 ............ C

1425 ............ D

1457 ............ D

1489 ............ C

1362 ............ D

1394 ............ A

1426 ............ B

1458 ............ D

1490 ............ B

1363 ............ C

1395 ............ D

1427 ............ D

1459 ............ A

1491 ............ A

1364 ............ D

1396 ............ D

1428 ............ A

1460 ............ A

1492 ............ C

1365 ............ D

1397 ............ A

1429 ............ C

1461 ............ D

1493 ............ C

1366 ............ D

1398 ............ B

1430 ............ B

1462 ............ D

1494 ............ B

1367 ............ D

1399 ............ D

1431 ............ D

1463 ............ B

1495 ............ D

1368 ............ A

1400 ............ D

1432 ............ D

1464 ............ D

1496 ............ D

1369 ............ B

1401 ............ A

1433 ............ A

1465 ............ C

1497 ............ A

1370 ............ A

1402 ............ D

1434 ............ B

1466 ............ A

1498 ............ D

1371 ............ B

1403 ............ D

1435 ............ A

1467 ............ B

1499 ............ B

1372 ............ D

1404 ............ D

1436 ............ D

1468 ............ A

1500 ............ C

1373 ............ D

1405 ............ D

1437 ............ B

1469 ............ D

1501 ............ D

1374 ............ D

1406 ............ D

1438 ............ B

1470 ............ D

1375 ............ D

1407 ............ D

1439 ............ D

1471 ............ A

1376 ............ A

1408 ............ D

1440 ............ D

1472 ............ C

Answer

Endocrinology 523

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Chapter 338. Principles of Endocrinology 1

The term hormone, derived from a Greek phrase meaning ? Harrison’s 18th Ed. 2866

MR

C.

AR

D.

TR

Which of the following is not type 2 of nuclear receptor family ?

A.

“To synchronise”

Harrison’s 18th Ed. 2867

B.

“To set in motion”

A.

PR

C.

“To rewind”

B.

PPAR

“To speak”

C.

RAR

D.

VDR

D.

Starling differentiated between endocrine & exocrine secretions. Word “Hormone” is derived from a Greek phrase meaning “to set in motion”.

2

8

Which of the following is not an amino acid derivative ?

523 Cardiology

According to their specificities for DNA binding sites, nuclear receptor family is classified into type 1 receptors (GR, MR, AR, ER, PR) that bind steroids & type 2 receptors (TR, VDR, RAR, PPAR) that bind thyroid hormone, vitamin D, retinoic acid.

Harrison’s 18th Ed. 2866

3

A.

Dopamine

B.

Catecholamines

C.

Somatostatin

D.

Thyroid hormone

Which of the following is not a ‘small neuropeptide’ class of hormone? Harrison’s 18th Ed. 2866

4

5

6

A.

Gonadotropin-releasing hormone (GnRH)

B.

Thyrotropin-releasing hormone (TRH)

C.

Somatostatin

D.

Luteinizing hormone (LH)

Which of the following about hormone receptors is false ? Harrison’s 18th Ed. 2867

A.

ACTH receptors are located exclusively in adrenal cortex

B.

FSH receptors are found only in gonads

C.

Insulin receptors are widely distributed

D.

Thyroid hormone receptors are found only in thyroid gland

Hormone receptors are either membrane or nuclear. Membrane receptors bind peptide hormones & catecholamines. Nuclear receptors bind small molecules that can diffuse across cell membrane like thyroid hormone, steroids & vitamin D. ACTH receptors are located almost exclusively in adrenal cortex, & FSH receptors are found only in gonads. Insulin & thyroid hormone receptors are widely distributed.

10

Hormones that are stored in secretory granules before release are all except ? Harrison’s 18th Ed. 2868

Which of the following is not a ‘large protein’ class of hormone?

A.

GnRH

Harrison’s 18th Ed. 2866

B.

Insulin

A.

Vasopressin

C.

Steroid hormones

B.

Insulin

D.

GH

C.

Luteinizing hormone (LH)

D.

PTH

Which of the following hormone is “lipid-soluble” ?

Peptide hormones (GnRH, insulin, GH) are stored in secretory granules before a releasing factor or a neural signal stimulates their release. Steroid hormones diffuse into circulation as they are synthesized.

11

“StAR” refers to ?

Harrison’s 18th Ed. 2866

Harrison’s 18th Ed. 2868

A.

Steroids

A.

Steroidogenic active regulatory protein

B.

Thyroid hormones

B.

Steroidogenic acute regulatory protein

C.

Vitamin D

C.

Steroidogenic action regulatory protein

D.

All of the above

D.

Steroidogenic augmenting regulatory protein

The glycoprotein hormone family consists of ? Harrison’s 18th Ed. 2866

A.

Thyroid-stimulating hormone (TSH)

B.

Follicle-stimulating hormone (FSH) & LH

C.

Human chorionic gonadotropin (hCG)

D.

All of the above

Hormones are divided into 5 major classes - amino acid derivatives (dopamine, catecholamines & thyroid hormone), small neuropeptides (GnRH, TRH, somatostatin & vasopressin), large proteins (insulin, LH & PTH), steroid hormones (cortisol & estrogen) & vitamin derivatives (vitamin A & D). Amino acid derived & peptide hormones interact with cell-surface membrane receptors. Steroids, thyroid hormones, vitamin D & retinoids are lipid-soluble & interact with intracellular nuclear receptors. Glycoprotein hormones are thyroid-stimulating hormone (TSH), FSH, LH & human chorionic gonadotropin (hCG).

7

9

Which of the following is not type 1 of nuclear receptor family ?

StAR (steroidogenic acute regulatory protein) transports cholesterol into mitochondrion upon stimulation by ACTH and LH in the steroidogenic pathway.

12

T4 & T3 bind to ? Harrison’s 18th Ed. 2868

A.

Thyroxine-binding globulin (TBG)

B.

Albumin

C.

Thyroxine-binding prealbumin (TBPA)

D.

All of the above

T4 & T 3 bind to thyroxine-binding globulin (TBG), albumin & thyroxine-binding prealbumin (TBPA).

13

Which of the following is a membrane receptor for hormones ? Harrison’s 18th Ed. 2869

Harrison’s 18th Ed. 2867

A.

GPCR

A.

B.

Tyrosine kinase receptors

GR

524

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Serine kinase receptors

D.

All of the above

19

G proteins are so named because ? Harrison’s 18th Ed. 2869

A.

By alphabetical order

B.

Growth phase of cell division

C.

They bind guanine nucleotides (GTP, GDP)

D.

None of the above

20

Harrison’s 18th Ed. 2869

GTP

B.

GDP

C.

G

D.

G

21

Harrison’s 18th Ed. 2869

G s

B.

G i

C.

Gq

D.

All of the above

C.

Calcium

D.

Activin

Intracellular Janus kinases (JAKs) is related to which of the following receptors ? A.

GPCR

B.

Tyrosine kinase receptors

C.

Serine kinase receptors

D.

Cytokine receptors

Serine kinase receptors mediate the action of ? Harrison’s 18th Ed. 2870

 subunit ? Which of the following is an isoforms of G A.

TRH

Janus kinases (JAKs) phosphorylate members of signal transduction & activators of transcription (STAT) family and other signaling pathways (Ras, PI3-K, MAPK). Activated STAT proteins translocate to the nucleus & stimulate expression of target genes.

Hormone binding to the receptor induces GDP dissociation, allowing G  to bind GTP & dissociate from the complex. Then, the G  subunit is activated and mediates signal transduction through adenylate cyclase or phospholipase C. GTP hydrolysis to GDP allows reassociation with the  subunits and restores the inactive state.

16

LH

B.

Harrison’s 18th Ed. 2869

Which of the following mediates signal transduction through adenylate cyclase or phospholipase C ? A.

A.

The seven transmembrane GPCR family binds large proteins (LH, PTH), small peptides (TRH, somatostatin), catecholamines (epinephrine, dopamine), and minerals (calcium).

G proteins are a large family that form a heterotrimeric complex composed of various  and subunits. The  subunit contains the guanine nucleotide - binding site & hydrolyzes GTP to GDP. The subunits modulate the activity of the  subunit besides mediating their own effector signaling pathways.

15

The seven transmembrane GPCR family binds all of the following except ? Harrison’s 18th Ed. 2869

Membrane receptors for hormones are 7 transmembrane GPCRs, tyrosine kinase receptors, cytokine receptors & serine kinase receptors. Membrane receptors bind peptide hormones & catecholamines.

14

A.

Activins

B.

Transforming growth factor

C.

Müllerian-inhibiting substance

D.

All of the above

Serine kinase receptors mediate the actions of activins, transforming growth factor , müllerianinhibiting substance (MIS or anti-müllerian hormone - AMH), and bone morphogenic proteins (BMPs).

22

Smads is related to which of the following membrane receptor for hormones ? Harrison’s 18th Ed. 2870

There are more than a dozen isoforms of G  subunit. G s stimulates, whereas G i  inhibits adenylate cyclase that generates second messenger cyclic AMP leading to activation of protein kinase A. G q subunits couple to phospholipase C generating diacylglycerol & inositol triphosphate leading to activation of protein kinase C & release of intracellular calcium.

A.

GPCR

B.

Tyrosine kinase receptors

C.

Serine kinase receptors

17

D.

Cytokine receptors

Insulin acts via which of the following membrane receptor for hormones ? Harrison’s 18th Ed. 2869

18

Serine kinase receptors (type I & II subunits) signal through proteins called smads (fusion of Caenorhabditis elegans sma + mammalian mad).

A.

GPCR

B.

Tyrosine kinase receptors

C.

Serine kinase receptors

A.

Growth & differentiation

D.

Cytokine receptors

B.

Maintenance of homeostasis

C.

Reproduction

D.

All of the above

Tyrosine kinase receptors transduce signals for insulin & growth factors like IGF-I, epidermal growth factor (EGF), nerve growth factor, platelet-derived growth factor & fibroblast growth factor. Tyrosine kinase receptors play a prominent role in cell growth, differentiation & in intermediary metabolism.

Growth hormone (GH) acts via which of the following membrane receptor for hormones ? Harrison’s 18th Ed. 2869

23

Physiologic function of hormones is ? Harrison’s 18th Ed. 2870

Physiologic functions of hormones are growth & differentiation, maintenance of homeostasis & reproduction.

24

Short stature may be due to ? Harrison’s 18th Ed. 2870

A.

GPCR

A.

GH deficiency

B.

Tyrosine kinase receptors

B.

Hypothyroidism

C.

Serine kinase receptors

C.

Cushing’s syndrome

Cytokine receptor-linked kinase

D.

All of the above

D.

GH & PRL receptors belong to the cytokine receptor family.

Endocrinology

GH deficiency, hypothyroidism, Cushing’s syndrome, precocious puberty, malnutrition, chronic illness or genetic abnormalities affecting epiphyseal growth plates (FGFR3 or SHOX mutations) cause short stature.

Endocrinology 525 25

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following does not stimulate growth ?

C.

6

Harrison’s 18th Ed. 2871

D.

7

A.

GH

B.

IGF-I

C.

Thyroid hormone

D.

Sex steroids

Six major hormones produced by anterior pituitary gland are Prolactin (PRL), Growth hormone (GH), Adrenocorticotropin hormone (ACTH), Luteinizing hormone (LH), Follicle-stimulating hormone (FSH)& Thyroid-stimulating hormone (TSH).

31

Feedback regulation for which of the following does not involve pituitary gland ? Harrison’s 18th Ed. 2871

27

A.

Leptin

B.

IGF-I

C.

Thyroid hormones

D.

Cortisol

32

B.

Estrogen-mediated stimulation of mid-cycle LH surge

C.

Cortisol on CRH-ACTH axis

D.

Gonadal steroids on GnRH-LH/FSH axis

Following are the negative feedback regulatory systems - thyroid hormones on TRH-TSH axis, cortisol on CRH-ACTH axis, gonadal steroids on GnRH-LH/FSH axis and IGF-I on GHRH-GH axis, calcium feedback on PTH, glucose inhibition of insulin secretion, and leptin feedback on hypothalamus. Positive feedback control is estrogen-mediated stimulation of mid-cycle LH surge.

28

C.

600 mg

D.

800 mg

Which of the following about pituitary gland is false ? A.

Pituitary hormones are secreted in pulsatile manner

B.

Posterior pituitary is supplied by superior hypophyseal arteries

C.

Posterior lobe is innervated by hypothalamic neurons

D.

None of the above

33

“Median eminence” is best described as ? Guyton’s Textbook of Medical Physiology 11th Ed. 921

A.

Lowermost portion of hypothalamus

Harrison’s 18th Ed. 2872

B.

Uppermost portion of pituitary

A.

C.

Lowermost portion of pituitary

D.

Anteriormost portion of pituitary

Paracrine regulation means factors released by one cell that act on an adjacent cell in the same tissue

B.

Autocrine regulation means action of a factor on the same cell from which it is produced

C.

Levels of paracrine & autocrine control factors cannot be readily measured

34

IGF-I acts ? A.

Chondrocytes

B.

Breast epithelium

C.

Gonadal cells

D.

All of the above

IGF-I acts on many cells that produce it like chondrocytes, breast epithelium & gonadal cells (autocrine regulation).

Chapter 339. Disorders of the Anterior Pituitary and Hypothalamus The number of major hormones produced by anterior pituitary gland is ? Harrison’s 18th Ed. 2876

A.

4

B.

5

“Tuber cinereum” is best described as ? Guyton’s Textbook of Medical Physiology 11th Ed. 921

None of the above

Harrison’s 18th Ed. 2872

30

300 mg

Major blood supply for anterior pituitary is hypothalamic-pituitary portal plexus which allows effective transmission of hypothalamic peptide pulses to it without significant systemic dilution. Posterior pituitary is supplied by inferior hypophyseal arteries.

Which of the following is false ?

D. 29

100 mg

B.

Harrison’s 18th Ed. 2876

Harrison’s 18th Ed. 2872

Thyroid hormones on TRH-TSH axis

A.

Pituitary gland weighs ~600 mg. Located within sella turcica ventral to the diaphragma sella, it comprises anatomically & functionally distinct anterior & posterior lobes.

Which of the following is not a negative hormonal feedback regulatory system ? A.

The pituitary gland weighs about ? Harrison’s 18th Ed. 2876

GH, IGF-I & TH stimulate growth, whereas sex steroids lead to epiphyseal closure.

26

525 Cardiology

A.

Extension of pituitary tissue into pituitary stalk

B.

Extension of hypothalamic tissue into pituitary stalk

C.

Extension of anterior pituitary tissue into pars intermedia

D.

Extension of posterior pituitary tissue into pars intermedia

Pituitary gland is also called hypophysis (anterior pituitary - adenohypophysis, posterior pituitary neurohypophysis). It is connected to hypothalamus by pituitary (or hypophysial) stalk. Between these two portions of pituitary is a small, relatively avascular zone called pars intermedia. Lowermost portion of hypothalamus is called median eminence, which connects inferiorly with pituitary stalk. Tuber cinereum is an extension of hypothalamic tissue into pituitary stalk. Embryologically, anterior pituitary originates from Rathke’s pouch, which is an embryonic invagination of the pharyngeal epithelium, while posterior pituitary originates from a neural tissue outgrowth from hypothalamus.

35

Pit-1, Prop-1, SF-1, and DAX-1 are related to ? Harrison’s 18th Ed. 2877

A.

Hypothalamus development

B.

Pituitary development

C.

Pancreatic development

D.

All of the above

Anterior pituitary gland develops from nasopharyngeal Rathke’s pouch. Pit-1, Prop-1, SF-1, and DAX-1 are lineage-specific transcription factors in pluripotential stem cells during embryonic differentiation. Pit-1 determines cell-specific expression of GH (somatotropes), PRL (lactotropes) & TSH (thyrotropes). Prop-1 induces the pituitary development of Pit-1-specific lineages, as well as gonadotropes. Gonadotrope cell development is further defined by the cell-specific expression of nuclear receptors, steroidogenic factor (SF-1) & DAX-1. Corticotropin upstream transcription element (CUTE) & PTX-1 transcription factor play a role in development of corticotrope cells.

526 36

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Pit-1 mutations can cause deficiency of ? Harrison’s 18th Ed. 2877

A.

GH

B.

Prolactin

C.

TSH

D.

All of the above

defects of fingers, retinal degeneration & central diabetes insipidus. Patients of Frohlich Syndrome have hyperphagia, obesity & central hypogonadism. Patients of Prader-Willi Syndrome have mental retardation, adult-onset diabetes mellitus, hyperphagia, obesity & hypogonadotropic hypogonadism.

42

What median dose of cranial irradiation can lead to development of hypopituitarism ? Harrison’s 18th Ed. 2879

A.

2000 rad

Autosomal dominant or recessive Pit-1 mutations cause combined GH, PRL & TSH deficiencies resulting in growth failure & hypothyroidism.

B.

3000 rad

C.

4000 rad

37

D.

5000 rad

PROP-1 mutations result in deficiency of all except ? Harrison’s 18th Ed. 2877

A.

GH

B.

Prolactin

C.

ACTH

D.

Gonadotropin

Up to two-thirds of patients ultimately develop hormone insufficiency after a cranial irradiation median dose of 50 Gy (5000 rad) directed at skull base. Hypopituitarism occurs over 5 - 15 years & reflects hypothalamic damage rather than primary destruction of pituitary cells.

43

Kallmann syndrome is due congenital synthesis defect of ? Harrison’s 18th Ed. 2878

A.

LH

B.

FSH

C.

Testosterone

D.

GnRH

44

Harrison’s 18th Ed. 2878

Hyposmia

B.

Color blindness

C.

Nerve deafness

D.

Precocious puberty

Gonadotropin

C.

ACTH

D.

ADH

Lymphocytic hypophysitis occurs mainly in ? A.

Unmarried female

B.

Pregnant female

C.

Short statured female

D.

Infertile female

45

Pituitary apoplexy is associated with ? Harrison’s 18th Ed. 2879

A.

Diabetes

B.

Hypertension

Hormone profile of Kallmann syndrome includes ?

C.

Sickle cell anemia

Harrison’s 18th Ed. 2878

D.

All of the above

A.

Low LH

B.

Low FSH

C.

Low levels of sex steroids (testosterone or estradiol)

A.

Antenatal period

D.

All of the above

B.

Intra-partum period

C.

Postpartum period

D.

All of the above

GnRH deficiency prevents progression through puberty. Males present with delayed puberty & hypogonadism. Females present with primary amenorrhea & failure of secondary sexual development. Repetitive GnRH administration restores normal pituitary gonadotropin responses. Fertility may be restored in men with long-term treatment with human chorionic gonadotropin (hCG) or testosterone. Women are treated with cyclic estrogen & progestin.

41

B.

Lymphocytic hypophysitis occurs mainly in pregnant or post-partum women & presents with hyperprolactinemia & a pituitary mass on MRI, with mildly elevated PRL levels. Resolves after prolonged glucocorticoid treatment.

Features of Kallmann syndrome include anosmia or hyposmia, color blindness, optic atrophy, nerve deafness, cleft palate, renal abnormalities, cryptorchidism & neurologic abnormalities (mirror movements).

40

GH

Harrison’s 18th Ed. 2879

Which of the following is not a feature of Kallmann syndrome ? A.

A.

After cranial irradiation, GH deficiency is most common, followed by gonadotropin & ACTH deficiency.

Kallmann syndrome is due to defective hypothalamic gonadotropin-releasing hormone (GnRH) synthesis. KAL gene defect on chromosome Xp22.3 is the culprit. Embryonic migration of GnRH neurons from hypothalamic olfactory placode to hypothalamus is prevented due to this genetic defect.

39

Which hormone deficiency is most common after cranial irradiation ? Harrison’s 18th Ed. 2879

During development, Prop-1 is essential for Pit-1 function. PROP1 mutations result in combined GH, PRL, TSH & gonadotropin deficiency with preservation of ACTH.

38

GnRH deficiency is found in which of the following ? Harrison’s 18th Ed. 2879

A.

Prader-Willi Syndrome

B.

Laurence-Moon-Bardet-Biedl Syndrome

C.

Frohlich Syndrome

D.

All of the above

Laurence-Moon-Bardet-Biedl Syndrome, Frohlich Syndrome & Prader-Willi Syndrome have GnRH deficiency with obesity. Patients of Laurence-Moon-Bardet-Biedl Syndrome have mental retardation,

Endocrinology

46

Sheehan’s syndrome refers to pituitary apoplexy during ? Harrison’s 18th Ed. 2879

Pituitary Apoplexy (acute intrapituitary hemorrhage) may occur spontaneously in a preexisting adenoma, postpartum (Sheehan’s syndrome), diabetes, hypertension, sickle cell anemia or acute shock. It presents as severe headache with signs of meningeal irritation, bilateral visual changes, ophthalmoplegia, hypoglycemia, hypotension, CNS hemorrhage & death. Hypopituitarism is very common after apoplexy. Pituitary CT / MRI is diagnostic.

47

Indication for urgent surgical decompression after pituitary apoplexy is ? Harrison’s 18th Ed. 2879

A.

Hypotension

B.

Visual loss

C.

Seizure

Endocrinology 527 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

All of the above

Patients of pituitary apoplexy with significant or progressive visual loss, severe ophthalmoplegia or loss of consciousness require urgent surgical decompression. Rest can be managed with highdose glucocorticoids.

48

In ‘Empty Sella syndrome’, pituitary functions are usually ? Harrison’s 18th Ed. 2879

54

Decreased

A.

Basic fibroblast growth factor (bFGF)

C.

Increased

B.

Loss of negative-feedback inhibition

D.

Any of the above

C.

Estrogen-mediated or paracrine angiogenesis

D.

All of the above

ACTH reserve is most reliably assessed by ? A.

CRH test

B.

Metyrapone test

C.

Insulin-induced hypoglycemia

D.

Standard ACTH stimulation test

Harrison’s 18th Ed. 2881

Basic fibroblast growth factor (bFGF) stimulate pituitary cell mitogenesis. Other factors involved in initiation & promotion of pituitary tumors include loss of negative-feedback inhibition & estrogenmediated or paracrine angiogenesis.

55

A.

Insulin-induced hypoglycemia

B.

Arginine

C.

L-dopa

D.

All of the above

Which of the following is a genetic syndrome associated with pituitary tumors ? Harrison’s 18th Ed. 2882

Which of the following can be used to assess GH reserve ?

GH responses to insulin-induced hypoglycemia, arginine, L-dopa, growth hormone releasing hormone (GHRH) or growth hormone releasing peptides (GHRPs) can be used to assess GH reserve.

A.

Multiple endocrine neoplasia (MEN) 1

B.

Carney syndrome

C.

McCune-Albright syndrome

D.

All of the above

Genetic predisposition to parathyroid, pancreatic islet & pituitary adenomas occurs in autosomal dominant Multiple endocrine neoplasia (MEN) 1 because “MENIN”, the tumor-suppressor gene on chromosome 11q13, is inactivated by mutation. Loss of heterozygosity (LOH)of the remaining normal MENIN allele, leads to tumorigenesis. Carney syndrome is due to mutations in R1  regulatory subunit of protein kinase A (PRKAR1A). Testicular, adrenal & pituitary adenomas along with spotty skin pigmentation & myxomas are the characteristic features. McCune-Albright syndrome refers to polyostotic fibrous dysplasia, pigmented skin patches, and GH-secreting pituitary tumors, adrenal and ovarian tumours. Hormonal hypersecretion is secondary to to cyclic AMP overproduction caused by postzygotic inactivation of GTPase activity of Gs .

56

Pituitary adenomas account for what percentage of all intracranial neoplasms ?

Which of the following is not a feature of Hand-Schuller-Christian disease ? Harrison’s 18th Ed. 2883

Harrison’s 18th Ed. 2880

A.

Diabetes mellitus

A.

~2%

B.

Exophthalmos

B.

~5%

C.

Punched-out lytic bone lesions

C.

~ 15 %

D.

Axillary skin rash

D.

~ 20 %

Pituitary adenomas account for ~15% of all intracranial neoplasms. At autopsy, 25% of all pituitary glands have microadenoma (200 µg/L. Hypothalamus stimulates production of all anterior pituitary hormones except prolactin, where it has an inhibitory effect. Prolactin inhibitory hormone resembles catecholamine dopamine, secreted by arcuate nuclei of hypothalamus and decreases prolactin secretion. Thus, damage to hypothalamus or blockage of hypothalamic-hypophysial portal system increases prolactin secretion.

Loss of red perception is an early sign of optic tract pressure. Bitemporal hemianopia or superior bitemporal defects are seen due to pressure of the expanding pituitary tumour because these tracts are located within inferior & posterior part of chiasm. Homonymous field defects are postchiasmal & monocular field cuts are prechiasmal.

76

None of the above

Harrison’s 18th Ed. 2887

High phospholipid content of posterior pituitary results in a “pituitary bright spot” on MRI.

74

Predominant central control mechanism is inhibitory

D.

Harrison’s 18th Ed. 2887

Harrison’s 18th Ed. 2884

Tryptophan

C.

Chronic renal failure elevates prolactin by decreasing peripheral prolactin clearance. Primary hypothyroidism causes hyperprolactinemia because of enhanced TRH secretion.

On MRI, “pituitary bright spot” is due to high content in the posterior pituitary of ? A.

Circulating half-life of PRL is 50 minutes

Harrison’s 18th Ed. 2887 Table 339-9

On MRI, “pituitary bright spot” is due to ? Harrison’s 18th Ed. 2884

B.

Normal adult serum PRL levels are ~10 to 25 µg/L in women & 10 to 20 µg/L in men. PRL secretion is pulsatile, with the highest secretory peaks occurring during rapid eye movement sleep. Peak serum PRL levels occur between 4 & 6 AM. Circulating half-life of PRL is ~50 minutes. Central control mechanism of PRL is inhibitory.

When larger pituitary masses (>1 cm) are encountered, they must be distinguished from nonadenomatous lesions like meningioma, craniopharyngiomas & gliomas.

72

A.

Estrogens

B.

Antiandrogens

C.

TRH

D.

All of the above

A.

Normal adult serum PRL levels is 10-25 µg/L in women

B.

Normal adult serum PRL levels is 10-20 µg/L in men

C.

PRL secretion is pulsatile

A.

Sleep

D.

PRL secretory peaks occur during NREM sleep

B.

Sexual orgasm

C.

Chest stimulation

D.

All of the above

Which of the following is false about prolactin (PRL) ? Harrison’s 18th Ed. 2887

A.

Peak serum PRL levels occur between 4 - 6 AM

529 Cardiology

83

Which of the following causes increase in prolactin level ? Harrison’s 18th Ed. 2887

530 84

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following produce “drug-induced hyperprolactinemia” by blocking dopamine receptors ?

B.

Harrison’s 18th Ed. 2887 Table 339-9

85

A.

Chlorpromazine

B.

Haloperidol

C.

Metoclopramide

D.

All of the above

Which of the following produce “drug-induced hyperprolactinemia” by inhibiting dopamine synthesis ?

86

Alpha-Methyldopa

B.

Metoclopramide

C.

Chlorpromazine

D.

Haloperidol

Which of the following produce “drug-induced hyperprolactinemia” by depleting catecholamine ?

91

87

Alpha-Methyldopa

B.

Metoclopramide

C.

Chlorpromazine

D.

Reserpine

Which of the following produce “drug-induced hyperprolactinemia” by blocking dopamine release ?

C.

< 15 µg/L

D.

< 20 µg/L

Breast milk secretion is considered abnormal if it persists for ? Harrison’s 18th Ed. 2888

A.

> 3 months after childbirth or discontinuation of breastfeeding

B.

> 6 months after childbirth or discontinuation of breastfeeding

C.

> 9 months after childbirth or discontinuation of breastfeeding

D.

> 12 months after childbirth or discontinuation of breastfeeding

Galactorrhea, the inappropriate discharge of milk-containing fluid from the breast, is considered abnormal if it persists for > 6 months after childbirth or discontinuation of breastfeeding.

92

The female : male ratio for microprolactinomas is ? Harrison’s 18th Ed. 2888

Harrison’s 18th Ed. 2887 Table 339-9

A.

< 10 µg/L

Basal, fasting morning PRL levels are normally 3 µg/L > 5 µg/L

A.

~ 10 %

B.

B.

~ 20 %

C.

> 7 µg/L

C.

~ 30 %

D.

> 9 µg/L

D.

~ 40 %

Growth-promoting process requires caloric energy, amino acids, vitamins & trace metals & consumes ~10% of normal energy production. Malnutrition impairs chondrocyte activity & reduces circulating IGF-I & IGFBP3 levels.

125

Any of the above

B.

Linear bone growth rates are very high in infancy & are pituitary dependent. Mean growth velocity is ~6 cm/year in later childhood. Peak growth rates occur during midpuberty when bone age is 12 (girls) or 13 (boys). Secondary sexual development is associated with elevated sex steroids that cause progressive epiphyseal growth plate closure.

124

D.

A.

Harrison’s 18th Ed. 2891

123

Hoarse

Isolated GH deficiency is characterized by short stature, micropenis, increased fat, high-pitched voice & a tendancy for hypoglycemia.

Skeletal maturation & somatic growth is promoted by hormonal stimuli like GH, IGF-I, sex steroids, thyroid hormones, paracrine growth factors & cytokines.

122

C.

As GH secretion is released in pulses, GH deficiency is best assessed by examining the response to exercise, insulin-induced hypoglycemia wherein GH levels normally increase to >7 µg/L in children.

130

Final height of children can be predicted by ? Harrison’s 18th Ed. 2892

Normal bone age in a child with short stature is suggestive of ?

A.

Bayley-Pinneau scale

Harrison’s 18th Ed. 2891

B.

Tanner-Whitehouse scale

A.

Hormonal disorder

C.

Midparental height

B.

Systemic disorder

D.

All of the above

C.

Genetic cartilage dysplasia or growth plate disorder

D.

All of the above

Delayed bone age in a child with short stature is suggestive of ?

Final height can be predicted using standardized scales (Bayley-Pinneau or Tanner-Whitehouse) or estimated by adding 6.5 cm (boys) or subtracting 6.5 cm (girls) from the midparental height.

131

Harrison’s 18th Ed. 2891

A.

Hormonal disorder or systemic disorder

B.

Genetic cartilage dysplasia

C.

Growth plate disorder

D.

All of the above

533 Cardiology

Treatment with IGF-I is recommended for which of the following ? Harrison’s 18th Ed. 2892

A.

Turner syndrome

B.

Chronic renal failure

C.

Growth retardation due to mutations of GH receptor

D.

All of the above

Bone age is delayed in patients with all forms of true GH deficiency or GH receptor defects that result in attenuated GH action. Bone age is delayed by thyroid hormone deficiency. Elevated pubertal sex steroid levels (estrogen) induce GHRH-GH-IGF-I axis & directly stimulate epiphyseal growth. High doses of estrogen lead to epiphyseal closure. Glucocorticoid excess inhibits growth.

In patients with GH insensitivity & growth retardation due to mutations of GH receptor, treatment with IGF-I bypasses the dysfunctional GH receptor. GH treatment is moderately effective for accelerating growth rates in children with Turner syndrome & chronic renal failure.

126

132

Characteristic voice in isolated GH deficiency is ? Harrison’s 18th Ed. 2891

Which is the “last” hormone to be lost in acquired pituitary hormone deficiency ?

A.

High-pitched

Harrison’s 18th Ed. 2892

B.

Low-pitched

A.

TSH

534

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

GH

C.

Poorly controlled diabetes mellitus

C.

ACTH

D.

All of the above

D.

FSH/LH

139

A.

MEN type 1

B.

McCune-Albright syndrome

Harrison’s 18th Ed. 2893

C.

Carney’s syndrome

A.

0.1 µg/liter

B.

> 0.2 µg/liter

C.

> 0.3 µg/liter

D.

> 0.4 µg/liter

In GH-secreting microadenomas, which of the following is the preferred primary treatment for most patients ? Harrison’s 18th Ed. 2895

Octreotide acetate

D.

Pegvisomant

What proportion of pituitary cell population are ACTH-secreting corticotrope cells ? A.

~ 10 %

B.

~ 20 %

C.

~ 30 %

D.

~ 40 %

153

Besides ACTH, POMC precursor protein also produces which of the following peptides ? Harrison’s 18th Ed. 2896

154

A.

-lipotropin

B.

-endorphin

C.

Met-enkephalin

D.

All of the above

Besides ACTH, POMC precursor protein also produces which of the following peptides ?

Surgical resection

B.

Somatostatin analogues

A.

 melanocyte-stimulating hormone (MSH)

C.

Dopamine agonists

B.

-endorphin

D.

Irradiation

C.

Corticotropin-like intermediate lobe protein (CLIP)

D.

All of the above

Which of the following is false about Octreotide ? Harrison’s 18th Ed. 2895

150

C.

A.

Surgery is the preferred primary treatment for GH secreting microadenomas. The high frequency of GH hypersecretion after macroadenoma resection usually necessitates adjuvant or primary medical therapy for these larger tumors. Patients unable to receive or respond to medical treatment can be offered radiation.

149

Lanreotide

ACTH-secreting corticotrope cells constitute ~20% of pituitary cell population.

Diagnosis of acromegaly is confirmed by demonstrating failure of GH suppression to 10 µg/dL in iodine-sufficient populations.

267

T3 & T4 hormones circulate bound to which plasma protein ?

Thyroglobulin releases T4 & T3 in which structure of thyroid cell ?

T4 & T 3 are bound to plasma proteins which include thyroxine-binding globulin (TBG), transthyretin (TTR, formerly known as thyroxine-binding prealbumin, or TBPA) and albumin.

273

Function of serum-binding proteins is ?

Harrison’s 18th Ed. 2914

Harrison’s 18th Ed. 2914

A.

Mitochondria

A.

To increase pool of circulating hormone

B.

Golgi apparatus

B.

To delay hormone clearance

C.

Lysosome

C.

To modulate hormone delivery

D.

All of the above

D.

All of the above

After coupling, Tg is taken back into thyroid cell, where it is processed in “lysosomes” to release T4 & T 3.

Plasma-binding proteins increase the pool of circulating hormone, delay hormone clearance, and may modulate hormone delivery to selected tissue sites.

268

274

Which of the following is false about thyroglobulin (Tg) ? Harrison’s 18th Ed. 2914

A.

660 kDa size

B.

Dimeric protein

C.

Consists of 2769 amino acids

D.

None of the above

thyroglobulin (Tg) is a large (660 kDa) dimeric protein that consists of 2769 amino acids.

269

Congenital hypothyroidism is mostly due to mutations in ? Harrison’s 18th Ed. 2914

A.

TPO

Which of the following receptors mediate thyroglobulin (Tg) endocytosis by thyroid cells ? Harrison’s 17th Ed. 2227

A.

Cubilin

B.

Clathrin

C.

Megalin

D.

Adaptin

Megalin is a transmembrane glycoprotein that mediates endocytosis of Tg by thyroid cells resulting in its transcytosis, thereby avoiding the lysosomal pathway, where proteolytic cleavage of Tg results in hormone release. Transcytosis of Tg endocytosed from the colloid is thought to be one of the mechanisms that account for the presence of intact Tg in the circulation, where the levels have been shown to be increased under conditions with heightened TSH stimulation.

546 275

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Megalin is also known as ? A. gp280 B.

gp310

C.

gp330

D.

gp360

D.

Megalin belongs to which of the following ? A. LDL-receptor family B.

Toll-like receptor family

C.

EGF receptor family

D.

Secretin receptor family

281

A.

Unbound T3 and T4

B.

Protein bound T3 and T4

C.

TSH

D.

TRH

282

A.

Hypothyroid

B.

Hyperthyroid

C.

Euthyroid

D.

Any of the above

283

Which of the following statements about familial dysalbuminemic hyperthyroxinemia (FDH) is false ? Harrison’s 18th Ed. 2915

A.

Due to mutations in albumin

B.

Autosomal dominant transmission

C.

Increased total T4 &/or T3, but free hormone levels are normal

D.

Type I deiodinase has a relatively low affinity for T4

D.

None of the above

Which of the following about deiodinases is false ? A.

Type II deiodinase is found in pituitary, brown fat, brain & thyroid

B.

Type II deiodinase has higher affinity for T4

C.

Type III deiodinase inactivates T4 & T3

D.

None of the above

Type I deiodinase is located in all except ? A.

Thyroid

B.

Liver

C.

Prostate

D.

Kidney

Type I deiodinase is located primarily in thyroid, liver, and kidney.

284

Which of the following deiodinases is the most important source of reverse T3 (rT3) ? Harrison’s 18th Ed. 2915

A.

Type I deiodinase

B.

Type II deiodinase

C.

Type III deiodinase

D.

All of the above

Type III deiodinase inactivates T 4 and T3 and is the most important source of reverse T3 (rT3). Massive hemangiomas that express type III deiodinase are a rare cause of hypothyroidism in infants.

285

T4 to T3 conversion may be impaired by ? Harrison’s 18th Ed. 2915

TSH levels are decreased

Mutations in TBG, TTR, and albumin may increase the binding affinity for T 4 and/or T3 and cause disorders known as euthyroid hyperthyroxinemia or familial dysalbuminemic hyperthyroxinemia (FDH). Total T4 and/or T3 are increased but unbound hormone levels are normal. Familial nature with normal TSH levels suggest this diagnosis. Unbound hormone levels (ideally measured by dialysis) are normal in FDH.

Type I deiodinase is located in thyroid, liver & kidney

C.

Harrison’s 18th Ed. 2915

X-linked TBG deficiency is associated with very low levels of total T 4 and T 3. However, because unbound hormone levels are normal, patients are euthyroid and TSH levels are normal. Efforts to normalize total T4 levels should be avoided, as it may lead to thyrotoxicosis.

279

B.

Type II deiodinase has a higher affinity for T 4 and is found primarily in the pituitary gland, brain, brown fat, and thyroid gland. Expression of type II deiodinase allows it to regulate T 3 concentrations locally. Type III deiodinase inactivates T 4 and T 3 .

In X-linked Thyroxine-binding globulin (TBG) deficiency, patients are ? Harrison’s 18th Ed. 2915

T4 is converted to T3 by deiodinase enzymes

Harrison’s 18th Ed. 2915

Homeostatic mechanisms that regulate the thyroid axis are directed toward maintenance of normal concentrations of unbound hormones.

278

A.

T 4 is converted to T 3 by deiodinase enzymes. Type I deiodinase, which is located primarily in thyroid, liver, and kidney, has a relatively low affinity for T 4.

Homeostatic mechanisms regulating thyroid axis are directed toward maintenance of normal concentrations of ? Harrison’s 18th Ed. 2914

Which of the following about deiodinases is false ? Harrison’s 18th Ed. 2915

Megalin belongs to the LDL-receptor family, sharing common features with LDL receptor, LDLreceptor-related protein (LRP), very-low-density lipoprotein (VLDL) receptor, and the apolipoprotein E (apo E) receptor-2.

277

Hepatitis

Acquired TBG excess is seen with estrogen, pregnancy, cirrhosis & hepatitis.

Megalin was originally identified as the antigen in Heymann nephritis of rats. It was purified from rat kidney brush border & named gp330 on the basis of molecular weight as estimated by its mobility during gel electrophoresis.

276

Endocrinology

286

A.

Fasting

B.

Systemic illness

C.

Acute trauma

D.

All of the above

T4 to T3 conversion may be impaired by ? Harrison’s 18th Ed. 2915

280

Acquired TBG excess occurs due to all except ?

A.

Oral contrast agents

Harrison’s 18th Ed. 2915 Table 341-3

B.

Amiodarone

C.

Glucocorticoids

D.

All of the above

A.

Pregnancy

B.

CHF

C.

Cirrhosis

T 4 to T 3 conversion is impaired by fasting, systemic illness or acute trauma, oral contrast agents, and medications like propylthiouracil, propranolol, amiodarone, glucocorticoids.

Endocrinology 547 287

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following is a thyroid hormone (TH) transporter ?

Harrison’s 18th Ed. 2916

A. MCT2 B . MCT4 C . MCT6 D. MCT8

A.

TR1

B.

TR1

C.

TR2

D.

TR2

TR - 2 isoform contains a unique carboxy terminus that precludes thyroid hormone binding.

294

Which of the following X-Linked Syndromes is related to mutation in MCT8 gene ?

Harrison’s 18th Ed. 2916

A.

Thyroid hormone reccruiting elements

A.

Gustavsson syndrome

B.

Thyroid hormone receptor elements

B.

Brooks-Wisniewski-Brown syndrome

C.

Thyroid hormone response elements

C.

Allan-Herndon-Dudley syndrome

D.

Thyroid hormone reacting elements

D.

Schimke syndrome

In nucleus, thyroid hormone receptor (TR) & retinoid X receptor (RXR) form heterodimers that bind specifically to thyroid hormone response elements (TRE) in promoter regions of target genes.

295

Thyroid hormones act through ?

A.

1 day

Harrison’s 18th Ed. 2915

B.

3 days

A.

Cell membrane hormone receptors

C.

7 days

B.

Nuclear hormone receptors

D.

10 days

C.

Mitochondrial hormone receptors

D.

All of the above

296

  Thyroid hormone receptor  (TR is more abundant than TR in which of the following organs ? A.

Brain

B.

Kidney

C.

Gonads

D.

Pituitary

297

A.

1 day

B.

3 days

C.

7 days

D.

10 days

What fraction of circulating T3 comes directly from thyroid gland ? Harrison’s 18th Ed. 2914 Table 341-2

A.

10 %

  Thyroid hormone receptor  (TR is more abundant than TR in which of the following organs ?

B.

20 %

C.

30 %

Harrison’s 18th Ed. 2915

D.

40 %

A.

Muscle

B.

Kidney

C.

Liver

D.

Heart

298

Which of the following plays a role in feedback control of the thyroid axis in hypothalamus and pituitary ? Harrison’s 18th Ed. 2915

What fraction of circulating T4 comes directly from thyroid gland ? Harrison’s 18th Ed. 2914 Table 341-2

Thyroid hormones bind with high affinity to nuclear thyroid hormone receptors (TR) alpha & beta - expressed in most tissues. TR-alpha is particularly abundant in brain, kidney, gonads, muscle, and heart, whereas TR - beta expression is relatively high in the pituitary and liver.

292

Serum T3 has a plasma half-life of about ? Harrison’s 18th Ed. 2914 Table 341-2

Harrison’s 18th Ed. 2915

291

Serum T4 has a plasma half-life of ? Harrison’s 18th Ed. 2914 Table 341-2

Thyroxine (T4) and triiodothyronine (T3) act through nuclear receptors.

290

Thyroid hormone receptor (TR) binds to which of the following in the promoter region of target genes ?

Harrison’s 18th Ed. 2915

Allan-Herndon-Dudley syndrome is an X-linked mental retardation condition caused by mutations in the monocarboxylate transporter 8 (MCT8) gene. Its features include moderate-severe mental retardation, impaired speech, hypotonia, muscle weakness, and contractures. Mutations in this gene, located at Xq13.2, impair transport of T3 into neurons (elevated free T3 & decreased free T4 in blood).

289

Which of the following prevents thyroid hormone binding ?

Harrison’s 18th Ed. 2915

Circulating thyroid hormones enter cells by passive diffusion and via the monocarboxylate 8 (MCT8) transporter. Mutations in MCT8 cause neurologic deficits & thyroid function abnormalities (low T4, high T3, and high TSH).

288

293

299

A.

25 %

B.

50 %

C.

75 %

D.

100 %

Normally, secretion ratio from thyroid gland of T3 & T4 is ? Harrison’s 17th Ed. 2229

A.

TR1

A.

1 : 10

B.

TR1

C.

TR2

B.

1 : 20

D.

TR2

C.

1 : 30

D.

1 : 40

The TR-beta2 isoform, which has a unique amino terminus, is selectively expressed in the hypothalamus and pituitary, where it plays a role in feedback control of the thyroid axis.

547 Cardiology

548 300

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following statements about resistance to thyroid hormone (RTH) is false ?

306

301

A.

Autosomal dominant disorder

B.

Thyroid hormone resistance

B.

Due to mutation in TR receptor gene

C.

First trimester of pregnancy

C.

Elevated free thyroid hormone levels

D.

TSH-secreting pituitary tumor

D.

Presents as hypothyroidism

307

Which of the following statements about resistance to thyroid hormone (RTH) is false ? A.

Goiter

B.

Tachycardia

C.

Impaired metabolic responses to thyroid hormone

D.

Treated with thyroid replacement drugs

TSH levels are suppressed in ? Harrison’s 18th Ed. 2917

A.

Thyrotoxicosis

B.

First trimester of pregnancy

C.

Insulin

D.

Dopamine

Elevated TSH levels occur in hypothyroidism most commonly, and also in TSH-secreting pituitary tumor, thyroid hormone resistance & assay artifact. Suppressed TSH level (3 mm.

310

Harrison’s 18th Ed. 2918

TBG is increased due to all except ? Harrison’s 18th Ed. 2917

A.

Pregnancy

B.

Hormone replacement therapy

C.

Nephrotic syndrome

D.

Tamoxifen

Neonatal hypothyroidism is due to thyroid gland dysgenesis in 80 - 85%, to inborn errors of thyroid hormone synthesis in 10 - 15% & is TSH-R antibody-mediated in 5% of affected newborns.

311

Which of the following is the most common symptom of hypothyroidism ? Harrison’s 18th Ed. 2918 Table 341-5

Total thyroid hormone levels are elevated when TBG is increased due to estrogens (pregnancy, oral contraceptives, hormone therapy, tamoxifen). TBG is reduced by androgens & in nephrotic syndrome.

305

Neonatal hypothyroidism is most frequently due to ?

In pregnancy, circulating free T4, free T3 and TSH are ? Harrison’s 16th Ed. 35

A.

Dry skin

B.

Hair loss

C.

Constipation

D.

Weight gain with poor appetite

A.

Normal

B.

Increased

C.

Decreased

Harrison’s 18th Ed. 2918 Table 341-5

D.

Any of the above

A.

312

Which of the following is the most common sign of hypothyroidism ? Bradycardia

Endocrinology 549

313

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

Diffuse alopecia

A.

7 days

C.

Dry coarse skin

B.

15 days

D.

Peripheral oedema

C.

1 month

D.

2 months

Symptoms of hypothyroidism become more readily apparent at TSH levels of ? Harrison’s 18th Ed. 2918

TSH responses to levothyroxine therapy are gradual & should be measured ~ 2 months after instituting treatment.

A.

> 7 mU/L

B.

> 8 mU/L

C.

> 9 mU/L

A.

6.25 - 12.5 µg increments

> 10 mU/L

B.

12.5 - 25 µg increments

C.

25 - 75 µg increments

D.

75 - 100 µg increments

D.

319

Which of the following is false about Hashimoto’s thyroiditis ? Harrison’s 18th Ed. 2918

A.

Lymphocytic infiltration

B.

Atrophy of thyroid follicles

C.

No fibrosis

D.

May progress to atrophic thyroiditis

Adjustment of levothyroxine dosage is made in 12.5 or 25 µg increments if the TSH is high.

320

B.

2 to 3 months

C.

3 to 6 months

D.

6 months to 1 year

Harrison’s 18th Ed. 2919

321

A.

Activated CD4+ T cells

B.

Activated CD8+ T cells

C.

B cells

D.

All of the above

Which of the following is false about Hashimoto’s encephalopathy ?

Which of the following treatments is least recommended in hypothyroidism ? Harrison’s 18th Ed. 2921

A.

T4 alone

B.

T3 alone

C.

T3 & T4 combined

D.

T3 & T4 alternately

There is no place for liothyronine alone as long-term replacement due to its short half-life which necessitates multiple dosage per day and is associated with fluctuating T 3 levels.

322

In patients taking Levothyroxine (> 200 µg/day) with elevated TSH level suggests the possibility of ?

A.

Grand Mal seizure

B.

Slow-wave activity on EEG

A.

Poor compliance

C.

Steroid-responsive

B.

Inappropriate TSH secretion

D.

May occur in autoimmune thyroiditis without hypothyroidism

C.

Malabsorption

D.

Any of the above

Harrison’s 18th Ed. 2921

Hashimoto’s encephalopathy is a steroid-responsive syndrome associated with TPO antibodies, myoclonus & slow-wave activity on EEG.

Daily replacement dose of levothyroxine is usually ?

323

A.

1.6 µg/kg body weight

B.

1.8 µg/kg body weight

C.

2.0 µg/kg body weight

D.

2.2 µg/kg body weight

If there is no residual thyroid function, daily replacement dose of levothyroxine is usually 1.6 µg/ kg body weight (typically 100 - 150 µg).

TSH responses should be measured after what time upon levothyroxine treatment ? Harrison’s 18th Ed. 2921

Drugs that interfere with T4 absorption / clearance are all except ? Harrison’s 18th Ed. 2921

Harrison’s 18th Ed. 2921

318

15 days to 2 months

Patients experience full relief from symptoms 3 - 6 months after normal TSH levels are restored.

Harrison’s 18th Ed. 2919

317

A.

Lymphocytic infiltrate in autoimmune hypothyroidism is composed of ?

Thyroid lymphocytic infiltrate in autoimmune hypothyroidism is composed of activated CD4+, CD8+ T cells and B cells. Thyroid cell destruction is primarily mediated by CD8+ cytotoxic T cells.

316

Upon normalization of TSH levels, patients experience full relief from symptoms after ? Harrison’s 18th Ed. 2921

In Hashimoto’s thyroiditis, there is a marked lymphocytic infiltration of thyroid with germinal center formation, atrophy of thyroid follicles accompanied by oxyphil metaplasia, absence of colloid & mild to moderate fibrosis.

315

If TSH is high, levothyroxine dosage should be increased by ? Harrison’s 18th Ed. 2921

Symptoms of hypothyroidism become more readily apparent at when TSH is >10 mU/L.

314

549 Cardiology

324

A.

Cholestyramine

B.

Ferrous sulfate

C.

Calcium supplements

D.

Isoniazid

Drugs that interfere with T4 absorption / clearance are all except ? Harrison’s 18th Ed. 2921

A.

Lovastatin

B.

Aluminum hydroxide

C.

Cimetidine

D.

Rifampicin

550 325

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Drugs that interfere with T 4 absorption / clearance are all except ?

Initial dose of levothyroxine in myxedema coma given by nasogastric tube is ?

Harrison’s 18th Ed. 2921

Harrison’s 18th Ed. 2922

A.

Lidocaine

A.

200 µg

B.

Amiodarone

B.

300 µg

C.

Carbamazepine

C.

400 µg

D.

Phenytoin

D.

500 µg

Causes of increased levothyroxine requirements are malabsorption (celiac disease, small-bowel surgery), estrogen therapy & drugs that interfere with T 4 absorption or clearance like cholestyramine, ferrous sulfate, calcium supplements, lovastatin, aluminum hydroxide, rifampicin, amiodarone, carbamazepine & phenytoin.

326

331

In myxedema coma, 500 µg of Levothyroxine can be given either as intravenous bolus or by nasogastric tube.

332

During pregnancy, dose of levothyroxine may need to be ? Increased

B.

Decreased

C.

Stopped

D.

All of the above

Which of the following is not indicated while treating myxedema coma ? Harrison’s 18th Ed. 2922

Harrison’s 18th Ed. 2922

A.

Endocrinology

A.

External warming

B.

Parenteral hydrocortisone

C.

Broad-spectrum antibiotics

D.

Hypotonic intravenous fluids

The dose of levothyroxine may need to be increased by >=50% during pregnancy and returned to previous levels after delivery.

In myxedema coma, hypotonic intravenous fluids should be avoided as they may exacerbate water retention secondary to reduced renal perfusion & inappropriate vasopressin secretion. Metabolism of most medications is impaired so reduced doses are recommended.

327

333

Thyroxine doses in elderly patients should be less than younger patients by ?

Harrison’s 18th Ed. 2923

Harrison’s 18th Ed. 2922

328

A.

10 %

B.

20 %

C.

30 %

D.

50 %

In elderly patients with CAD, the starting dose of levothyroxine is ? Harrison’s 18th Ed. 2922

330

A.

Thyroid gland

B.

Spleen

C.

Bone marrow

D.

Lymph nodes

Hyperthyroidism of Graves’ disease is caused by thyroid-stimulating immunoglobulins (TSI) that are synthesized in the thyroid gland as well as in bone marrow & lymph nodes.

334

Which of the following is the most common symptom of hyperthyroidism ?

A.

12.5 to 25 µg/day

B.

25 to 37.5 µg/day

A.

Palpitation

C.

37.5 to 50 µg/day

B.

Heat intolerance and sweating

D.

50 to 62.5 µg/day

C.

Weight loss and increased appetite

D.

Diarrhoea

Elderly patients may require up to 20% less thyroxine than younger patients. In elderly with coronary artery disease, starting dose of levothyroxine is 12.5 - 25 µg/day with similar increments every 2 - 3 months until TSH is normalized.

329

TSI are synthesized in all except ?

Harrison’s 18th Ed. 2923 Table 341-7

335

Which of the following is the most common sign of hyperthyroidism ? Harrison’s 18th Ed. 2923 Table 341-7

Myxedema coma almost always occurs in ? Harrison’s 18th Ed. 2922

A.

Tremor

A.

Neonates

B.

Warm, moist skin

B.

Adolescents

C.

Tachycardia

C.

Adults

D.

Lid retraction or lag

D.

Elderly

Myxedema coma is precipitated by ?

In hyperthyroidism, von Graefe’s sign refers to ? A. Lagging of upper eye lid on looking downward

Harrison’s 18th Ed. 2922

B.

Retracted lids causing wide palpebral opening

A.

Sedatives

C.

Diminished frequency of blinking

B.

Anesthetics

D.

Inability to maintain convergence for close vision

C.

Antidepressants

D.

All of the above

Myxedema coma almost always occurs in the elderly & is usually precipitated by factors that impair respiration, such as drugs (sedatives, anesthetics, antidepressants), pneumonia, CHF, MI, GI bleeding, Sepsis or CVAs. Exposure to cold, hypoventilation, hypoglycemia & dilutional hyponatremia also contribute to the development of myxedema coma.

336

337

In hyperthyroidism, Stellwag’s sign refers to ? A. Lagging of upper eye lid on looking downward B.

Retracted lids causing wide palpebral opening

C.

Diminished frequency of blinking

D.

Inability to maintain convergence for close vision

Endocrinology 551 338

339

340

341

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

In hyperthyroidism, Dalrymple’s sign refers to ? A. Lagging of upper eye lid on looking downward B.

Retracted lids causing wide palpebral opening

C.

Diminished frequency of blinking

D.

Inability to maintain convergence for close vision

In atrial fibrillation due to thyrotoxicosis, increased doses of digoxin are needed.

346

A.

7 days

B.

14 days

B.

Retracted lids causing wide palpebral opening

C.

21 days

C.

Diminished frequency of blinking

D.

1 month

D.

Inability to maintain convergence for close vision

In hyperthyroidism, Abadie’s sign refers to ? A. Involuntary twitching or spasm of LPS muscle

Risk of thyrotoxic crisis after radioiodine therapy can be minimized by pretreatment with antithyroid drugs for at least a month before treatment.

347

Retracted lids causing wide palpebral opening

C.

Diminished frequency of blinking

A.

At least 1 day

D.

Inability to maintain convergence for close vision

B.

At least 2 days

C.

At least 3 days

D.

At least 7 days

Harrison’s 18th Ed. 2926

Which of the following is not a cause of “thyrotoxicosis without hyperthyroidism” ? A.

Subacute thyroiditis

B.

Silent thyroiditis

C.

Toxic adenoma

D.

Thyrotoxicosis factitia

Carbimazole or methimazole must be stopped at least 2 days before radioiodine administration to achieve optimum iodine uptake. Propylthiouracil has a prolonged radioprotective effect & is stopped several weeks before radioiodine is given, or a larger dose of radioiodine will be necessary.

348

A.

Toxic multinodular goiter

B.

Toxic adenoma

C.

Subacute thyroiditis

D.

Functioning thyroid carcinoma metastases

131

Unbound T3 levels

B.

Unbound T4 levels

C.

TSH

D.

Any of the above

349

B.

Dose related

C.

Duration related

D.

All of the above

When using antithyroid drugs, it is not useful to monitor blood counts prospectively, as the onset of agranulocytosis is idiosyncratic and abrupt.

15 mCi - 25 mCi

C.

25 mCi - 35 mCi

D.

35 mCi - 45 mCi

Hyperthyroidism can persist for how long before radioiodine takes full effect ? A.

1 to 2 months

B.

2 to 3 months

C.

3 to 4 months

D.

4 to 5 months

Hyperthyroidism can persist for 2 - 3 months before radioiodine takes full effect.

350

Usually, second dose of radioiodine can be given after what duration in persistent hyperthyroidism ? Harrison’s 18th Ed. 2926

Harrison’s 18th Ed. 2926

Idiosyncratic

5 mCi - 15 mCi

B.

Harrison’s 18th Ed. 2926

Agranulocytosis due to anti-thyroid drugs is ? A.

A.

I dosage generally ranges between 185 MBq (5 mCi) to 555 MBq (15 mCi).

Titration of doses of anti-thyroid drugs is best based on ? A.

Radioactive 131 I dose used for thyrotoxicosis is ? Harrison’s 18th Ed. 2926

Which of the following is not a cause of primary hyperthyroidism ?

In hyperthyroidism, thyroid function tests & clinical manifestations are reviewed 3 - 4 weeks after starting treatment & the dose is titrated based on unbound T 4 levels.

345

Antithyroid drugs must be stopped how many days before administration of radioiodine ?

B.

Harrison’s 18th Ed. 2925

344

To avoid thyrotoxic crisis after radioiodine therapy, pretreatment with antithyroid drugs should be done for at least ? Harrison’s 18th Ed. 2926

Harrison’s 17th Ed. 2233 Table 335-6

343

Any of the above

In hyperthyroidism, Moebius’ sign refers to ? A. Lagging of upper eye lid on looking downward

Harrison’s 17th Ed. 2233 Table 335-6

342

D.

551 Cardiology

A.

1 month

B.

3 months

C.

6 months

D.

9 months

Persistent hyperthyroidism is treated with a 2nd dose of radioiodine, ~6 months after first dose.

In atrial fibrillation due to thyrotoxicosis, dose of digoxin is ?

351

Women can conceive safely how many months after radioiodine treatment ?

Harrison’s 18th Ed. 2926

Harrison’s 18th Ed. 2926

A.

More

A.

1 month

B.

Less

B.

3 months

C.

Same

552

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

6 months

D.

9 months

358

Which anti-thyroid drug is preferred in pregnancy with Graves’ disease ? Harrison’s 18th Ed. 2926

A.

Propylthiouracil

B.

Carbimazole

C.

Methimazole

D.

Any of the above

Hyperthyroidism is most difficult to control in which trimester of pregnancy ? Harrison’s 16th Ed. 35

354

359

C.

6 to 9 months

D.

Any of the above

Which of the following is false about silent thyroiditis ? A.

High ESR

B.

Low radioiodine uptake

C.

No thyroid tenderness

D.

Presence of TPO antibodies

Silent thyroiditis features a painless goiter, normal ESR and presence of TPO antibodies.

360

Which of the following can cause thyroiditis ?

First

B.

Second

A.

IFN-

C.

Third

B.

IL-2

D.

All of the above

C.

Amiodarone

D.

All of the above

Harrison’s 18th Ed. 2929

Which of the following is not a cause of chronic thyroiditis ? A.

Riedel’s thyroiditis

B.

Hashimoto’s thyroiditis

C.

Radiation thyroiditis after 131I treatment

D.

Parasitic thyroiditis (Echinococcosis)

Patients receiving IFN-  , IL-2 or amiodarone may develop painless thyroiditis.

361

A.

131

I treatment

B.

Amiodarone

C.

Mycobacterial infection

D.

Riedel’s thyroiditis

Which of the following is false about Riedel’s thyroiditis ? Harrison’s 18th Ed. 2929

Which of the following can cause acute, subacute or chronic thyroiditis ?

A.

Painless goiter

B.

Dense fibrosis of thyroid

C.

Thyroid dysfunction common

D.

Tamoxifen therapy beneficial

Riedel’s thyroiditis is seen in middle-aged women. Presents insidiously as painless goiter with local symptoms due to compression of esophagus, trachea, neck veins or recurrent laryngeal nerves. Dense fibrosis disrupts normal gland architecture that can extend outside thyroid capsule. Despite extensive histologic changes, thyroid dysfunction is uncommon. Tamoxifen may be beneficial.

362

Riedel’s thyroiditis is associated with fibrosis of ? Harrison’s 18th Ed. 2929

de Quervain’s thyroiditis is a type of ? Harrison’s 18th Ed. 2928

A.

Retroperitoneum

A.

Acute thyroiditis

B.

Mediastinum

B.

Subacute thyroiditis

C.

Lung

C.

Chronic thyroiditis

D.

All of the above

D.

Any of the above

Subacute Thyroiditis is also termed de Quervain’s thyroiditis, granulomatous thyroiditis, or viral thyroiditis.

357

3 to 6 months

Harrison’s 18th Ed. 2929

Harrison’s 18th Ed. 2928 Table 341-8

356

1 to 3 months

B.

A.

Harrison’s 18th Ed. 2928 Table 341-8

355

A.

Postpartum thyroiditis occurs 3 - 6 months after pregnancy.

Propylthiouracil is titrated to lowest effective dose to manage Graves’ disease in pregnancy because of relatively low transplacental transfer and its ability to block T 4 to T 3 conversion. Carbimazole & methimazole rarely cause fetal aplasia cutis and choanal atresia.

353

Postpartum thyroiditis occurs how many months after pregnancy ? Harrison’s 18th Ed. 2929

While pregnancy & breast feeding are absolute contraindications to radioiodine treatment, patients can conceive safely 6 months after treatment.

352

Which of the following is false about subacute thyroiditis ? Harrison’s 18th Ed. 2928

A.

High ESR

B.

Low radioiodine uptake

C.

Raised serum IL-6 levels

D.

Thyroid antibodies present

In subacute thyroiditis, diagnosis is confirmed by a high ESR, low radioiodine uptake and thyroid antibodies are negative.

Endocrinology

Riedel’s thyroiditis is associated with idiopathic fibrosis in retroperitoneum, mediastinum, biliary tree, lung, and orbit.

363

Which of the following is false about sick euthyroid syndrome ? Harrison’s 18th Ed. 2929

A.

Decreased total & unbound T3 levels

B.

Normal T4 levels

C.

Normal TSH levels

D.

None of the above

In sick euthyroid syndrome (SES), there is a decrease in total & unbound T3 levels (low T3 syndrome) with normal levels of T4 and TSH.

Endocrinology 553 364

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following is increased in sick euthyroid syndrome ? Harrison’s 18th Ed. 2929

A.

Total T3 levels

B.

Unbound T3 levels

C.

Reverse T3 levels

D.

TSH levels

D.

All of the above

Corticosteroid hormones produced by adrenal cortex are glucocorticoids, mineralocorticoids & adrenal androgens.

371

Which of the following is produced by adrenal cortex ? Harrison’s 18th Ed. 2940

A.

Dehydroepiandrosterone

B.

Aldosterone

T4 conversion to T3 via peripheral deiodination is impaired, leading to increased reverse T 3 (rT 3).

C.

Cortisol

365

D.

All of the above

Amiodarone contains which of the following elements ? Harrison’s 18th Ed. 2930

372

Zinc

B.

Iodine

A.

2 - 6 gram

C.

Calcium

B.

6 - 11 gram

D.

Iron

C.

11 - 18 gram

D.

18 - 31 gram

During pregnancy, thyroid hormone requirements are ? Harrison’s 18th Ed. 2930

367

Harrison’s 18th Ed. 2941

369

373

Which of the following is located outermost in adrenal gland ?

Increased

B.

Decreased

A.

Zona glomerulosa

C.

Same

B.

Zona fasciculata

D.

Any of the above

C.

Zona reticularis

D.

Adrenal medulla

Harrison’s 18th Ed. 2941

During pregnancy, urinary iodide excretion is ? A.

Increased

B.

Decreased

C.

Same

D.

Any of the above

Adrenal glands are located above the kidneys and have their own blood supply. Arterial blood supply is from outside to inside. Initially to subcapsular region, then to outer cortical zona glomerulosa, then to intermediate zona fasciculata, then to inner zona reticularis and eventually to adrenal medulla.

374

Which of the following about adrenal glands is false ? Harrison’s 18th Ed. 2941

A.

Adrenals originate from urogenital ridge

Harrison’s 18th Ed. 2931

B.

Sexual differentiation occurs at 7th - 9th week of gestation

A.

Cassava root

C.

Left suprarenal vein drains into vena cava

B.

Cabbage

D.

SF1 and DAX1 are nuclear receptors

C.

Cauliflower

D.

All of the above

Which of the following is an environmental goitrogen ?

Right suprarenal vein drains directly into vena cava while left drains into left renal vein.

375

Size of polypeptide pro opiomelanocortin (POMC) is ?

Chemodectomas are derived from ?

Harrison’s 18th Ed. 2941

Harrison’s 16th Ed. 2148

A.

141 amino acid

A.

Adrenal medulla

B.

241 amino acid

B.

Carotid body

C.

341 amino acid

C.

Postganglionic sympathetic neurons

D.

441 amino acid

D.

All of the above

Chapter 342. Disorders of the Adrenal Cortex 370

Each normal adrenal gland weighs 6 - 11 gram.

A.

Harrison’s 18th Ed. 2930

368

Each normal adrenal gland weighs ?

A.

Amiodarone is structurally related to thyroid hormone & contains 39% iodine by weight.

366

553 Cardiology

Corticotropin-releasing hormone (CRH) stimulates cleavage of 241-amino acid polypeptide pro opiomelanocortin (POMC) by pituitary-specific prohormone convertase to produce adrenocorticotropic hormone (ACTH).

376

Size of ACTH peptide is ? Harrison’s 18th Ed. 2941

A.

21 amino acid

Corticosteroid hormone produced by adrenal cortex is ?

B.

39 amino acid

Harrison’s 18th Ed. 2940

C.

76 amino acid

D.

98 amino acid

A.

Glucocorticoids

B.

Mineralocorticoids

C.

Adrenal androgens

ACTH peptide contains 39 amino acids but first 24 are sufficient to elicit a physiologic response.

554 377

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR A normal response in standard ACTH stimulation test is defined as a cortisol level of ? Harrison’s 18th Ed. 2941

A.

> 5 µg / dL

B.

> 10 µg / dL

C.

> 15 µg / dL

D.

> 20 µg / dL

383

Endocrinology

A.

17-hydroxylase/17,20-lyase (CYP17A1)

B.

21-hydroxylase (CYP21A2)

C.

11-hydroxylase (CYP11B1)

D.

3-HSD2

Which of the following enzyme converts progesterone to 17hydroxyprogesterone ? Harrison’s 18th Ed. 2940 Figure 342-1

The standard ACTH stimulation test involves administration of cosyntropin (ACTH 1-24), 0.25 mg IM or IV, and collection of blood samples at 0, 30, and 60 minutes for cortisol. A normal response is defined as a cortisol level > 20 µg/dL or an increment of >10 µg/dL over baseline.

A.

17-hydroxylase/17,20-lyase (CYP17A1)

B.

21-hydroxylase (CYP21A2)

378

C.

11-hydroxylase (CYP11B1)

D.

3-HSD2

MC2R (melanocortin 2 receptor) interacts with which of the following to bind ACTH ? Harrison’s 18th Ed. 2942

384

MRAP

B.

MRBP

C.

MRCP

A.

17-hydroxylase/17,20-lyase (CYP17A1)

D.

MRDP

B.

21-hydroxylase (CYP21A2)

Harrison’s 18th Ed. 2940 Figure 342-1

ACTH stimulation is required for initiation of steroidogenesis. ACTH receptor MC2R (melanocortin 2 receptor) interacts with MC2R-accessory protein (MRAP) and this complex at adrenocortical cell membrane binds to ACTH.

379

PKA activation affects steroidogenesis through ?

385

Harrison’s 18th Ed. 2942

A.

Increase in import of cholesterol esters

B.

Breaks cholesterol esters to cholesterol

C.

Increases availability & phosphorylation of CREB

D.

All of the above

ACTH stimulation generates cyclic AMP (cAMP) which then upregulates protein kinase A (PKA) signaling pathway. PKA activation increases import of cholesterol esters, increases activity of hormone-sensitive lipase, which cleaves cholesterol esters to cholesterol for import into mitochondrion and increases availability & phosphorylation of CREB (cAMP response element binding), a transcription factor that enhances transcription of CYP11A1 and other enzymes required for glucocorticoid synthesis.

380

386

11-hydroxylase (CYP11B1)

D.

3-HSD2

Which of the following enzyme converts 17-hydroxyprogesterone to androstenedione ? A.

17-hydroxylase/17,20-lyase (CYP17A1)

B.

21-hydroxylase (CYP21A2)

C.

11-hydroxylase (CYP11B1)

D.

3-HSD2

Which of the following enzyme converts 11-deoxycortisol to cortisol ? Harrison’s 18th Ed. 2940 Figure 342-1

Which of the following statements is false ?

A.

17-hydroxylase/17,20-lyase (CYP17A1)

B.

21-hydroxylase (CYP21A2)

C.

11-hydroxylase (CYP11B1)

D.

3-HSD2

A.

Mineralocorticoid synthesis occurs in zona glomerulosa

B.

Glucocorticoid synthesis occurs in zona fasciculata

C.

Adrenal androgen synthesis occurs in zona reticularis

Harrison’s 18th Ed. 2940

D.

None of the above

A.

387

Adrenal steroidogenesis occurs in a zone-specific manner. Mineralocorticoid synthesis occurs in outer zona glomerulosa, glucocorticoid synthesis in zona fasciculata, and adrenal androgen synthesis in inner zona reticularis.

Cholesterol import into mitochondrion is initiated by the action of ? Harrison’s 18th Ed. 2942

A.

Phosphorylation of CREB

B.

Steroidogenic acute regulatory (StAR) protein

Action of mineralocorticoids include all except ? Immune responses

B.

Blood pressure

C.

Vascular volume

D.

Electrolytes

Glucocorticoids modulate intermediary metabolism & immune responses. Mineralocorticoids maintain blood pressure, vascular volume & electrolytes and androgens address secondary sexual characteristics (in females).

C.

CYP11A1

Basic structure of steroids is built upon a nucleus with how many rings ? A. Three-rings

D.

All of the above

B.

Four-rings

C.

Five-rings

D.

Six-rings

All steroidogenic pathways require cholesterol import into the mitochondrion, a process initiated by the action of steroidogenic acute regulatory (StAR) protein, which moves cholesterol from outer to inner mitochondrial membrane. CREB acts in the nucleus and makes available CYP11A1 which traverses to the mitochondria.

382

C.

Harrison’s 18th Ed. 2940 Figure 342-1

Harrison’s 18th Ed. 2942

381

Which of the following enzyme converts 17-hydroxyprogesterone to 11-deoxycortisol ?

A.

Which of the following enzyme converts pregnenolone to progesterone ? Harrison’s 18th Ed. 2940 Figure 342-1

388

Basic structure of steroids is built upon a five-ring nucleus.

389

Number of carbon atoms in 17-hydroxycorticosteroids is ? Harrison’s 17th Ed. 2248

Endocrinology 555 A.

17

B.

18

C.

19

D.

21

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Adrenal steroids contain either 19 or 21 carbon atoms. C21 steroids with a hydroxyl group at position 17 are termed 17-hydroxycorticosteroids.

390

D.

All of the above

Phenomenon of zonation exists in adrenal cortex in which selective genes express enzymes that form specific hormones. Aldosterone synthase is expressed only in outer (glomerulosa) cell layer. 21- & 17-hydroxylase are expressed in (inner) fasciculata-reticularis cell layers, which form cortisol & androgen biosynthesis, respectively.

396

Cortisol circulates in the plasma as ? Harrison’s 18th Ed. 2943

A.

Free cortisol

Harrison’s 17th Ed. 2248

B.

Protein-bound cortisol

A.

17

C.

Cortisol metabolites

B.

18

D.

All of the above

C.

19

D.

20

Number of carbon atoms in 17-ketosteroids is ?

397

Physiologically active form of cortisol is ? Harrison’s 18th Ed. 2943

C19 steroids have methyl groups at C-18 & C-19. C19 steroids with a ketone group at C-17 are termed 17-ketosteroids.

A.

Free cortisol

B.

Protein-bound cortisol

391

C19 steroids have predominantly ?

C.

Cortisol metabolites

Harrison’s 17th Ed. 2248

D.

All of the above

A.

Androgenic properties

B.

Glucocorticoid properties

C.

Mineralcorticoid properties

D.

All of the above

Cortisol circulates in the plasma as free cortisol, protein-bound cortisol, and cortisol metabolites. Only the unbound cortisol and its metabolites are filterable at the glomerulus.

398

393

A.

< 5 percent

B.

< 20 percent

Harrison’s 15th Ed. Chapter 331

C.

< 30 percent

A.

Steroids

D.

< 40 percent

B.

Insulin

Cyclopentenoperhydrophenanthrane nucleus is a constituent of ?

C.

Pepsin

D.

Growth hormone

Free cortisol is a physiologically active hormone that is not protein-bound. Normally, 25 µg/dL, part of excess binds to albumin.

403

-hydroxysteroid dehydrogenase 2 is ? Function of 11 Harrison’s 18th Ed. 2943

A.

Converting cortisone to cortisol

Harrison’s 17th Ed. 2248

B.

Converting cortisol to cortisone

A.

Pregnancy

C.

Promote binding of free cortisol to transcortin

B.

Oral contraceptive administration

D.

Inhibit binding of free cortisol to transcortin

C.

Both of the above

D.

None of the above

The cortisol-binding globulin (CBG) level is increased in ?

11 -HSD 2 isoform converts cortisol to the inactive metabolite, cortisone.

410

CBG is increased in high-estrogen states (pregnancy, oral contraceptive).

404

Which of the following statements about cortisol metabolites is false ? A.

Biologically inactive

B.

Bind weakly to circulating plasma proteins

C.

Low levels in urine are typical of children with 3-HSD2 deficiency

D.

Average daily secretion of aldosterone ranges between ? Harrison’s 17th Ed. 2248

Harrison’s 17th Ed. 2248

A.

5 and 10 µg

B.

10 and 15 µg

C.

50 and 250 µg

D.

300 and 600 µg

With normal salt intake, average daily secretion of aldosterone is between 50 & 250 µg.

411

None of the above

What percentage of circulating aldosterone is normally inactivated during a single passage through liver ? Harrison’s 17th Ed. 2248

Cortisol metabolites are biologically inactive & bind weakly to circulating plasma proteins.

A.

> 10 %

405

The daily secretion of cortisol ranges between ?

B.

> 25 %

Harrison’s 17th Ed. 2248

C.

> 50 %

A.

5 and 10 mg

D.

> 75 %

B.

10 and 15 mg

C.

15 and 30 mg

D.

30 and 60 mg

During a single passage through liver, >75% of circulating aldosterone is normally inactivated by conjugation with glucuronic acid.

412

A.

Steroid inactivation occurs in ? Harrison’s 17th Ed. 2248

A.

Liver

B.

Lung

C.

Kidney

D.

All of the above

Steroid inactivation occurs mainly in liver.

407

Dehydroepiandrosterone (DHEA)

B.

Androstenedione

C.

11-hydroxyandrostenedione

D.

Testosterone

Major androgen secreted by adrenal is dehydroepiandrosterone (DHEA) & its sulfuric acid ester (DHEAS). Smaller amounts of androstenedione, 11-hydroxyandrostenedione & testosterone are secreted.

413

The average daily secretion of androgens by adrenal gland ranges between ?

-hydroxysteroid dehydrogenase 1 (11 11 -HSD 1) is primarily expressed in ?

Harrison’s 17th Ed. 2248

A.

5 to 10 mg

Harrison’s 18th Ed. 2943

B.

10 to 15 mg

A.

Liver

C.

15 to 30 mg

B.

Lung

D.

50 to 100 mg

C.

Kidney

D.

All of the above

Enzyme that regulates cortisol metabolism is 11-hydroxysteroid dehydrogenase (11  -HSD). Isoform 11 -HSD 1 is primarily expressed in liver.

408

The major androgen secreted by adrenal gland is ? Harrison’s 17th Ed. 2248

Daily secretion of cortisol ranges between 15 & 30 mg (8 - 10 mg/m2), with a pronounced circadian cycle.

406

Endocrinology

-hydroxysteroid dehydrogenase 1 is ? Function of 11 Harrison’s 18th Ed. 2943

A.

Converting inactive cortisone to active cortisol

B.

Converting cortisol to inactive cortisone

~15 - 30 mg of androgens are secreted daily.

414

In females, almost all urine 17-ketosteroids are derived from ? Harrison’s 17th Ed. 2248

A.

Ovaries

B.

Adrenal

C.

Endometrium

D.

All of the above

Endocrinology 557

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

DHEA is the major precursor of urinary 17-ketosteroids. 2/3 of urine 17-ketosteroids in male are derived from adrenal metabolites, remaining 1/3 comes from testicular androgens. In female, almost all urine 17-ketosteroids are derived from the adrenal.

415

Steroids pass through the cell membrane by ? Harrison’s 17th Ed. 2248

A.

Passive diffusion

B.

Active transport

C.

Catalytic transport

D.

All of the above

422

B.

Glucocorticoids

C.

Arginine vasopressin

D.

IL-6

557 Cardiology

ACTH is synthesized and stored in ? Harrison’s 17th Ed. 2249

Steroids diffuse passively through the cell membrane and bind to intracellular receptors.

A.

Acidophilic cells of anterior pituitary

B.

Basophilic cells of anterior pituitary

C.

Acidophilic cells of posterior pituitary

D.

Basophilic cells of posterior pituitary

ACTH, a 39-amino-acid peptide, is synthesized & stored in basophilic cells of anterior pituitary.

416

Which of the following bind to both glucocorticoid & mineralocorticoid receptors ? A.

Glucocorticoids

A.

Corticotropin-releasing hormone

B.

Mineralocorticoids

B.

Free plasma cortisol concentration

C.

Androgens

C.

Sleep-wake cycle

All of the above

D.

All of the above

Glucocorticoids & mineralocorticoids bind with nearly equal affinity to the mineralocorticoid receptor (MR). Only glucocorticoids bind to the glucocorticoid receptor (GR).

Pro-opiomelanocortin (POMC) is a precursor molecule for ? Harrison’s 17th Ed. 2249

A.

ACTH

B.

Endorphin

C.

Melanocyte-stimulating hormone

D.

All of the above

ACTH, lipotropins, endorphins & melanocyte-stimulating hormones are processed from a larger precursor molecule proopiomelanocortin (POMC).

418

POMC is made in ? Harrison’s 17th Ed. 2249

419

Major factors controlling ACTH release include ? Harrison’s 17th Ed. 2249

D.

417

423

Harrison’s 17th Ed. 2248

Release of ACTH from anterior pituitary gland is stimulated by corticotropin-releasing hormone (CRH) produced in median eminence of hypothalamus. Free plasma cortisol concentration, stress & sleep-wake cycle also control ACTH release.

424

Neuropeptide ‘Urocortin’ is related to ? Harrison’s 17th Ed. 2249

A.

ACTH

B.

CRH

C.

Leptin

D.

FSH

Urocortin, a neuropeptide related to CRH, mimics many of the central effects of CRH (appetite suppression, anxiety).

425

Which of the following is released in equimolar concentrations with ACTH ?

A.

Brain

B.

Anterior pituitary

A.

-Lipotropin

C.

Posterior pituitary

B.

-endorphin

D.

All of the above

C.

Corticotropin-like intermediate lobe protein (CLIP)

D.

All of the above

Harrison’s 17th Ed. 2249

POMC (Pro-opiomelanocortin) is made in ? Harrison’s 17th Ed. 2249

A.

Anterior pituitary

B.

Posterior pituitary

C.

Lymphocytes

D.

All of the above

-lipotropin ( -LPT) is released in equimolar concentrations with ACTH, suggesting that they are cleaved enzymatically from the parent POMC before or during secretory process.  -endorphin levels may or may not correlate with circulating levels of ACTH, depending on the nature of stimulus.

426

The plasma level of ACTH peak ? Harrison’s 17th Ed. 2249

A.

Just prior to waking up

POMC is made in brain, anterior & posterior pituitary and lymphocytes.

B.

Just after waking up

420

Pro-opiomelanocortin (POMC) is a precursor molecule for ?

C.

Before sleeping

Harrison’s 17th Ed. 2249

D.

After meals

421

A.

-Lipotropin

B.

Metenkephalin

C.

Corticotropin-like intermediate lobe protein (CLIP)

D.

All of the above

427

The plasma level of ACTH are lowest at ? Harrison’s 17th Ed. 2249

A.

Just prior to waking up

B.

Just after waking up

The POMC gene is induced by all except ?

C.

Before sleeping

Harrison’s 17th Ed. 2249

D.

After meals

A.

CRH

Plasma ACTH peak just prior to waking and a nadir before sleeping.

558 428

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Normal pulsatile, circadian pattern of ACTH release is regulated by ? Harrison’s 17th Ed. 2249

A.

Corticotropin-releasing hormone

B.

Free plasma cortisol concentration

C.

Sleep-wake cycle

D.

All of the above

435

C.

Megestrol acetate

D.

All of the above

What level of cortisol level best identifies persons with clinical features of corticosteroid insufficiency ? N Engl J Med 2003;348:727-34

A.

18 µg/dL above baseline

D.

PRA depends on dietary sodium intake patient’s ambulatory status. PRA has a diurnal rhythm with peak values in morning & a nadir in afternoon. PRA & active renin correlate very well on low-sodium diets but less well on high-sodium diets.

Criterion for a normal rapid ACTH stimulation test response is a stimulated cortisol level of >500 nmol/L (>18 µg/dL), and the minimal stimulated normal increment of cortisol is >200 nmol/L (>7 g/ dL) above baseline.

470

476

The plasma level of aldosterone is increased by ? Harrison’s 17th Ed. 2253

471

A.

Dietary potassium loading

B.

Sodium restriction

C.

Upright posture

D.

All of the above

The plasma level of cortisol is increased by ? Harrison’s 17th Ed. 2253

A.

Dietary potassium loading

B.

Sodium restriction

C.

Upright posture

D.

None of the above

Harrison’s 17th Ed. 2253

477

< 5 µg/dL

B.

< 10 µg/dL

C.

< 15 µg/dL

D.

< 20 µg/dL

Cushing’s disease refers to ? Harrison’s 18th Ed. 2945

Which compound of DHEA is a useful index of adrenal androgen secretion ? Harrison’s 17th Ed. 2253

A.

The best screening procedure to test pituitary-adrenal suppressibility is the overnight dexamethasone suppression test. Measurement of plasma cortisol levels at 8 AM following oral administration of 1 mg dexamethasone the previous midnight is done. 8 AM value for plasma cortisol in normal individuals should be 50 µg/day

B.

Plasma cortisol > 5 µg/dL after standard low-dose dexamethasone suppression test

C.

Absence of normal fall of plasma cortisol at midnight

D.

All of the above

Most common cause of Cushing’s syndrome is ? Harrison’s 18th Ed. 2946

A.

Iatrogenic administration of steroids

B.

Adrenal macronodular hyperplasia

C.

Adrenal micronodular dysplasia

D.

Adrenal neoplasia

The most common cause of Cushing’s syndrome is iatrogenic administration of steroids.

489

Decreased bone mineralization due to use of steroids is particularly pronounced in ? Harrison’s 17th Ed. 2255

Primary pigmented nodular adrenal disease (PPNAD) is best related to which of the following ?

A.

Children

Harrison’s 18th Ed. 2945

B.

Adults

A.

Crow-Fukase Syndrome

C.

Elderly

B.

Hirschsprung disease

D.

All of the above

C.

Carney’s complex

D.

Von Hippel–Lindau syndrome

Mutations in a regulatory subunit of PKA (PRKAR1A) are found in primary pigmented nodular adrenal disease (PPNAD) as part of Carney’s complex.

484

Which of the following is suggestive of Cushing’s syndrome ? Harrison’s 16th Ed. 2135

Harrison’s 18th Ed. 2945

A.

Which of the following is a feature of Carney’s complex ? Harrison’s 18th Ed. 2945

Endocrinology

Decreased bone mineralization is particularly pronounced in children.

490

Which of the following is typical of Cushing’s syndrome ? Harrison’s 17th Ed. 2255

A.

Moon facies

B.

Buffalo hump

Endocrinology 563

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

C.

Truncal obesity

B.

D.

All of the above

C.

Tumor inhomogeneity

D.

Low unenhanced CT values (4 - 6 cm), irregular margins & tumor inhomogeneity, soft tissue calcifications visible on CT & high unenhanced CT attenuation values (>10 HU).

497

Harrison’s 17th Ed. 2255

A.

Principal drug for the treatment of adrenocortical carcinoma (ACC) is ? Harrison’s 18th Ed. 2949

A.

Mitotane

B.

Ketoconazole

C.

Mifepristone

D.

Metyrapone

Signs & symptoms of hypercortisolism (obesity, hypertension, osteoporosis & diabetes) are nonspecific. Easy bruising, typical striae, myopathy & virilizing signs are more suggestive of Cushing’s syndrome.

Principal drug for treatment of ACC is mitotane (o,p’-DDD), isomer of DDT.

492

498

What value of a 24-hour urine free cortisol is suggestive of Cushing’s syndrome ?

493

Harrison’s 18th Ed. 2949

A.

Ketoconazole

A.

> 5 µg/day

B.

Mitotane

B.

> 25 µg/day

C.

Metyrapone

C.

> 50 µg/day

D.

All of the above

D.

> 150 µg/day

In Cushing’s syndrome, after a standard low-dose dexamethasone suppression test, urinary cortisol to fall to ?

Chemical adrenalectomy can be done with ketoconazole or mitotane or aminoglutethimide or metyrapone or Mifepristone. These are not curative but effective as long as chronically administered in selected patients.

499

A.

< 10 µg/day

B.

< 20 µg/day

C.

< 30 µg/day

D.

< 40 µg/day

In Cushing’s syndrome, after a standard low-dose dexamethasone suppression test, plasma cortisol to fall to ? Harrison’s 17th Ed. 2256

A.

< 5 µg/dL

B.

< 8 µg/dL

C.

< 10 µg/dL

D.

< 16 µg/dL

Normal plasma ACTH level is ? Harrison’s 17th Ed. 2256

A.

< 60 pg/mL

B.

< 80 pg/mL

C.

< 100 pg/mL

D.

< 120 pg/mL

A.

Diastolic hypertension without edema

B.

Hyposecretion of renin (low PRA levels) that do not increase during volume depletion

C.

Hypersecretion of aldosterone that does not suppress in response to volume expansion

D.

All of the above

Criteria for the diagnosis of primary aldosteronism are diastolic hypertension without edema, hyposecretion of renin (low PRA levels) that fails to increase appropriately during volume depletion (upright posture, sodium depletion), and hypersecretion of aldosterone that does not suppress appropriately in response to volume expansion.

500

Which of the following is false about primary aldosteronism ? Harrison’s 17th Ed. 2260

In Cushing’s syndrome, definitive diagnosis is established by failure of urinary cortisol to fall to 15

C.

> 20

D.

> 30

Ratio of serum aldosterone to plasma renin activity if high (>30) strongly suggests autonomy of aldosterone secretion in all normokalemic/hypokalemic and difficult-to-control hypertensive patients.

503

504

509

> 50 %

C.

> 75 %

D.

> 90 %

Adrenals is a frequent site for which of the following chronic granulomatous diseases ? A.

Tuberculosis

Harrison’s 17th Ed. 2262

B.

Histoplasmosis

A.

Spironolactone

C.

Coccidioidomycosis

B.

Eplerenone

D.

All of the above

C.

Triamterene

D.

All of the above

Increased production of aldosterone occurs in secondary aldosteronism in response to ?

The adrenal is a frequent site for chronic granulomatous diseases, mainly tuberculosis but also histoplasmosis, coccidioidomycosis& cryptococcosis.

510

A.

Activation of sympathetic system

B.

Activation of parasympathetic system

C.

Activation of renin-angiotensin system

D.

All of the above

Specific adrenal antigens to which autoantibodies may be directed include ? Harrison’s 17th Ed. 2263

A.

SOX9

B.

21-hydroxylase (CYP21A2)

C.

RSPO1

D.

CYP19

Specific adrenal antigens to which autoantibodies may be directed include 21-hydroxylase (CYP21A2).

511

Secondary aldosteronism occurs in association with ?

In Addison’s disease, which of the following also occur with increased frequency ? Harrison’s 17th Ed. 2263

Harrison’s 17th Ed. 2262

A.

Accelerated phase of hypertension

A.

Chronic lymphocytic thyroiditis

B.

Underlying edema disorder

B.

Premature ovarian failure

C.

Bartter & Gitelman syndromes

C.

Type 1 diabetes mellitus

D.

All of the above

D.

All of the above

Secondary aldosteronism occurs with accelerated phase of hypertension or an underlying edema disorder. Secondary hyperaldosteronism occurs without edema or hypertension in Bartter & Gitelman syndromes.

512

In Addison’s disease, which of the following also occur with increased frequency ? Harrison’s 17th Ed. 2263

Secondary aldosteronism is a feature of ?

A.

Hypo- or hyperthyroidism

Harrison’s 17th Ed. 2262

B.

Pernicious anemia

A.

Cirrhosis

C.

Myasthenia gravis

B.

Nephrotic syndrome

D.

All of the above

C.

Congestive heart failure

D.

All of the above

Secondary aldosteronism is present edematous states like cirrhosis, nephrotic syndrome and congestive heart failure. Stimulus for aldosterone release is arterial hypovolemia and/or hypotension.

507

> 25 %

B.

Harrison’s 17th Ed. 2263

Drug that is of use in primary aldosteronism is ?

In secondary aldosteronism, an appropriately increased production of aldosterone in response to activation of renin-angiotensin system occurs.

506

A.

Addison’s disease results from progressive destruction of adrenals, which must involve >90% of the glands before adrenal insufficiency appears.

Harrison’s 17th Ed. 2262

505

What percentage of adrenal glands are destroyed before adrenal insufficiency appears ? Harrison’s 17th Ed. 2263

What ratio of serum aldosterone to PRA suggests autonomy of aldosterone secretion ? A.

Endocrinology

In Addison’s disease, there is an increased incidence of chronic lymphocytic thyroiditis, premature ovarian failure, type 1 diabetes mellitus, hypo- or hyperthyroidism, pernicious anemia, vitiligo, alopecia, nontropical sprue & myasthenia gravis.

513

Mutant gene in Type I polyglandular syndrome is on ? Harrison’s 17th Ed. 2263

As compared to essential hypertension, patients with primary aldosteronism have a higher incidence of ?

A.

Chromosome 12

Harrison’s 17th Ed. 2262

B.

Chromosome 16

A.

Left ventricular hypertrophy (LVH)

C.

Chromosome 18

B.

Albuminuria

D.

Chromosome 21

C.

Stroke

D.

All of the above

514

“C” in APECED gene stands for ? Harrison’s 17th Ed. 2263

Endocrinology 565

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

A.

Carcinoma

A.

Normocytic anemia

B.

Candidiasis

B.

Relative lymphocytosis

C.

Calcinosis

C.

Moderate eosinophilia

D.

Caif-au-lait

D.

All of the above

Type I polyglandular syndrome is caused by mutations in the autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED) gene located on chromosome 21q22.3.

515

521

In rapid ACTH stimulation test, dose of cosyntropin is ? Harrison’s 17th Ed. 2264

Mutant gene in Type II polyglandular syndrome is on ?

A.

50 µg

Harrison’s 17th Ed. 2263

B.

150 µg

A.

Chromosome 4

B.

Chromosome 6

C.

Chromosome 8

D.

Chromosome 10

Type II polyglandular syndrome is associated with a mutant gene on chromosome 6 as well as with HLA alleles B8 and DR3.

565 Cardiology

C.

250 µg

D.

500 µg

In rapid ACTH stimulation test, 250 µg of cosyntropin is given IM or IV.

522

In rapid ACTH stimulation test, cortisol level at 60 minutes after cosyntropin should be ? Harrison’s 17th Ed. 2264

516

Type I polyglandular autoimmune syndrome consists of all except ? Harrison’s 17th Ed. 2263

519

B.

> 12 µg/dL > 18 µg/dL > 24 µg/dL

A.

Parathyroid insufficiency

B.

Adrenal insufficiency

D.

C.

Chronic mucocutaneous candidiasis

D.

Myasthenia gravis

In adrenal insufficiency, upon ACTH stimulation testing, cortisol level at 60 minutes after cosyntropin should be > 18 µg/dL.

523

Primary & secondary adrenal insufficiency can be distinguished by measuring ? Harrison’s 17th Ed. 2264

Which of the following may cause or potentiate adrenal insufficiency ?

A.

Renin

B.

Aldosterone

Harrison’s 17th Ed. 2263

C.

Angiotensin I

A.

Rifampin

D.

Angiotensin II

B.

Phenytoin

C.

Ketoconazole

D.

All of the above

Medications like rifampin, phenytoin, ketoconazole, megestrol & opiates may cause or potentiate adrenal insufficiency.

518

> 6 µg/dL

C.

Combination of parathyroid & adrenal insufficiency & chronic mucocutaneous candidiasis constitutes type I polyglandular autoimmune syndrome. Pernicious anemia, chronic active hepatitis, alopecia, primary hypothyroidism, and premature gonadal failure may also be associated.

517

A.

If rapid ACTH stimulation test is abnormal, then primary and secondary adrenal insufficiency can be distinguished by measuring aldosterone levels from the same blood samples. In secondary adrenal insufficiency, the aldosterone increment will be normal (> 5 ng/dL). In primary adrenal insufficiency, plasma ACTH and associated peptides (  -LPT) are elevated.

524

Which of the following is given in the treatment of adrenal insufficiency ?

Which of the following is the most frequent presentation in adrenal insufficiency ?

Harrison’s 17th Ed. 2264

A.

Hydrocortisone

Harrison’s 17th Ed. 2263 Table 336-7

B.

Fludrocortisone

C.

DHEA

D.

All of the above

A.

Weakness

B.

Pigmentation of mucous membranes

C.

Salt craving

D.

Diarrhea

Which of the following is an early sign of hyperpigmentation in Addison’s disease ? Harrison’s 17th Ed. 2263

A.

Darkening of areolae of nipples

B.

Bluish-black patches on mucous membranes

C.

Persistent tanning following sun exposure

D.

Dark freckles

Replacement therapy in adrenal insufficiency aims to correct both glucocorticoid & mineralocorticoid deficiencies by hydrocortisone and fludrocortisone respectively. In females with adrenal insufficiency and low androgen levels, DHEA may improve quality of life & bone mineral density.

525

What proportion of total glucocorticoid dose should be given in morning ? Harrison’s 17th Ed. 2264

A.

One third

B.

One half

C.

Two third

D.

Three fourth

Persistent tanning following sun exposure is an early sign in Addison’s disease.

520

Hematologic abnormalities seen in adrenal insufficiency is ? Harrison’s 17th Ed. 2264

Dose of hydrocortisone for most adults is 20 - 30 mg/day. To simulate normal diurnal adrenal rhythm, two-thirds of the dose is taken in morning & remaining one-third is taken in late afternoon.

566 526

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR In adrenal insufficiency, during fever, the dose of hydrocortisone should be ?

532

Endocrinology

During stress, plasma cortisol levels should be constantly maintained at ?

Harrison’s 17th Ed. 2264

Harrison’s 17th Ed. 2265

A.

Kept the same

A.

10 µg/dL

B.

Doubled

B.

20 µg/dL

C.

Tripled

C.

30 µg/dL

D.

Quadrupled

D.

40 µg/dL

During periods of intercurrent illness (fever), dose of hydrocortisone should be doubled.

Continuous hydrocortisone infusion maintains plasma cortisol constantly at stress levels of 30 µg/dL.

527

533

In Addison’s disease, mineralocorticoid administration is unnecessary at hydrocortisone doses of ?

Harrison’s 17th Ed. 2266

Harrison’s 17th Ed. 2265

A.

Cortisol levels rise four- to sixfold

A.

> 10 mg/day

B.

Diurnal variation is abolished

B.

> 40 mg/day

C.

Unbound fractions of cortisol rises

C.

> 80 mg/day

D.

None of the above

D.

> 100 mg/day

In Addison’s disease, mineralocorticoid administration is unnecessary at hydrocortisone doses of >100 mg/day because of the mineralocorticoid effects of hydrocortisone at such dosages.

528

During critical illnesses cortisol levels rise 4 - 6 fold, diurnal variation is abolished & unbound fractions of cortisol rise in circulation & target tissues.

534

Which of the following favors a diagnosis of primary adrenocortical insufficiency ? A.

Dehydration

B.

Hyponatremia

C.

Hyperkalemia

D.

All of the above

Severe dehydration, hyponatremia, and hyperkalemia are characteristic of severe mineralocorticoid insufficiency and favor a diagnosis of primary adrenocortical insufficiency.

535

Which of the following is false about secondary adrenocortical insufficiency ?

Adrenal insufficiency on withdrawal of long term steroids

B.

Subnormal cortisol production during acute severe illness

C.

Failure to take replacement therapy in adrenal insufficiency

D.

Ineffective replacement therapy in adrenal insufficiency

Following cosystropin, increment of less than what between peak & baseline cortisol levels defines relative adrenal insufficiency ? Harrison’s 17th Ed. 2266

A.

< 3 µg/dL

A.

No hyperpigmentation

B.

< 6 µg/dL

B.

Low ACTH level

C.

< 9 µg/dL

C.

Near-normal aldosterone secretion

D.

< 12 µg/dL

D.

None of the above

Patients with secondary adrenocortical hypofunction are not hyperpigmented, have low ACTH levels, evidence of multiple hormone deficiencies, have near-normal level of aldosterone secretion.

531

A.

Subnormal cortisol production during acute severe illness has been termed “functional” or “relative” adrenal insufficiency.

Harrison’s 17th Ed. 2265

530

Functional or relative adrenal insufficiency is ? Harrison’s 17th Ed. 2266

Harrison’s 17th Ed. 2265

529

Which of the following is false in acutely ill patients ?

Relative adrenal insufficiency is defined as a 15 nmol/L > 25 nmol/L > 35 nmol/L > 45 nmol/L

Isolated aldosterone deficiency with normal cortisol production occurs in hyporeninism, as an inherited biosynthetic defect, following removal of aldosterone-secreting adenomas, during protracted heparin therapy, in pretectal disease of CNS, and in severe postural hypotension.

A corticotropin stimulated concentration of 17-hydroxyprogesterone higher than 45 nmol/L is diagnostic of 21-hydroxylase deficiency.

539

545

The most common form of CAH is due to impairment of ? Harrison’s 17th Ed. 2267

A.

17-hydroxylase/17,20-lyase (CYP17)

B.

21-hydroxylase (CYP21A2)

C.

11-hydroxylase (CYP11B1)

D.

3-HSD2

The most common form of CAH (95% of cases) is a result of impairment of CYP21A2.

540

CAH caused by deficiency of 21-hydroxylase is characterised by ?

“Hypertensive” variant of Congenital adrenal hyperplasia (CAH) is due to deficiency of ? Harrison’s 17th Ed. 2267

A. B. C. D.

21-hydroxylase (CYP21A2) 17-hydroxylase/17,20-lyase (CYP17) 11-hydroxylase (CYP11B1) 3-HSD2

CYP11B1 deficiency causes a “hypertensive” variant of CAH. Hypertension & hypokalemia occur because of impaired conversion of 11-deoxycorticosterone to corticosterone, resulting in the accumulation of 11-deoxycorticosterone, a potent mineralocorticoid.

Lancet 2005; 365: 2125–36

A.

Cortisol deficiency

B.

With or without aldosterone deficiency

C.

Androgen excess

D.

All of the above

546

Harrison’s 17th Ed. 2267

A. B. C. D.

CAH caused by deficiency of 21-hydroxylase is characterised by cortisol deficiency, with or without aldosterone deficiency, and androgen excess.

541

The highest rates of classic CAH occur in ? Lancet 2005; 365: 2125–36

A.

Alaska

B.

Brazil

C.

Philippines

D.

USA

The highest rates of classic CAH occur in two geographically isolated populations - Yupic Eskimos of Alaska (one in 280) & French island of La Réunion (one in 2100). High rates have also been reported in Brazil (one in 7500) and the Philippines (one in 7000).

542

The 21-hydroxylase gene is located on chromosome ? Lancet 2005; 365: 2125–36

Hypogonadism Hypokalemia Hypertension All of the above

CYP17 deficiency is characterized by hypogonadism, hypokalemia, and hypertension. It causes decreased production of cortisol & shunting of precursors into the mineralocorticoid pathway with hypokalemic alkalosis, hypertension, and suppressed plasma renin activity.

547

In CAH, prednisone is the drug of choice in all except ? Harrison’s 17th Ed. 2267

A. B. C. D.

Infants Children Adolescents Adults

Therapy in CAH is daily administration of glucocorticoids to suppress pituitary ACTH secretion. Prednisone is the drug of choice except in infants, in whom hydrocortisone is usually used.

548

Which of the following has the longest half-life ?

A.

6

Harrison’s 17th Ed. 2269 Table 336-11

B.

8

C.

10

D.

12

A. B. C. D.

21-hydroxylase gene is located on chromosome 6p21·3 within HLA histocompatibility complex. There are two highly homologous 21-hydroxylase genes resulting from ancestral duplication : an active gene, CYP21A2 (CYP21B) & an inactive pseudogene CYP21A1P (CYP21A, CYP21P).

543

CYP17 deficiency is characterized by ?

A very high concentration of which of the following is diagnostic of classic 21-hydroxylase deficiency ? Lancet 2005; 365: 2125–36

A.

Androstenedione

B.

11-deoxycortisol

C.

17-hydroxyprogesterone

D.

Pregnenolone

A very high concentration of 17-hydroxyprogesterone (>242 nmol/L; normal < 3 nmol/L at 3 days in full-term infant) in a randomly timed blood sample is diagnostic of classic 21-hydroxylase deficiency.

Prednisone Prednisolone Methylprednisolone Triamcinolone

Chapter 343. Pheochromocytoma 549

In pheochromocytoma, mean age at diagnosis is about ? Harrison’s 18th Ed. 2962

A.

20 years

B.

30 years

C.

40 years

D.

50 years

In pheochromocytoma, mean age at diagnosis is about 40 years, although the tumors can occur from early childhood until late in life.

568 550

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR The “rule of tens” for pheochromocytomas states ? Harrison’s 18th Ed. 2962

In pheochromocytoma, which of the following is the most common symptom ?

A.

~ 10 % are bilateral

Lancet 2005;366:665-675

B.

~ 10 % are extraadrenal

A.

Sustained hypertension

C.

~ 10 % are malignant

B.

Paroxysmal hypertension

D.

All of the above

C.

Orthostatic hypotension

D.

Flushing

The “rule of tens” for pheochromocytomas states that ~10% are bilateral, 10% are extraadrenal & 10% are malignant. These percentages are higher in the inherited syndromes.

551

557

Which of the following about paraganglioma is false ?

Lancet 2005;366:665-675

A.

Catecholamine-producing tumors in head & neck

A.

Palpitations

B.

Tumors arising from parasympathetic nervous system

B.

Sweating

C.

Unknown etiology

C.

Headache

None of the above

D.

Anxiety

Paraganglioma refers to catecholamine-producing tumors in head & neck, as well as tumors that arise from parasympathetic nervous system, which may secrete little or no catecholamines. Etiology of most sporadic pheochromocytomas & paragangliomas is unknown.

558

Germ-line mutations in which of the following can cause inherited pheochromocytoma ? A.

RET

B.

VHL

C.

NF1

D.

All of the above

A.

< 1 hour

B.

< 3 hour

C.

< 6 hour

D.

< 12 hour

Paroxysmal attacks in pheochromocytoma generally last less than an hour.

559

Paroxysmal attack in pheochromocytoma is precipitated by ? Harrison’s 18th Ed. 2962

A.

Positional changes

B.

Exercise

The VHL protein is a component of ?

C.

Pregnancy

Harrison’s 18th Ed. 2962

D.

All of the above

~25% of patients of pheochromocytoma are inherited due to germ-line mutations in the RET, VHL, NF1, SDHB, SDHC, or SDHD genes.

A.

Ubiquitin E3 ligase

B.

Mitochondrial kinase

C.

Cytosolic kinase

D.

All of the above

Paroxysmal attacks in pheochromocytoma are precipitated by surgery, positional changes, exercise, pregnancy, urination (bladder pheochromocytomas) & medications (tricyclic antidepressants, opiates, metoclopramide).

560

The VHL protein is a component of a ubiquitin E3 ligase.

554

Paroxysmal attacks in pheochromocytoma generally last for ? Harrison’s 18th Ed. 2962

Harrison’s 18th Ed. 2962

553

In pheochromocytoma, which of the following is the least common symptom ?

Harrison’s 18th Ed. 2962

D.

552

556

Endocrinology

Harrison’s 18th Ed. 2963

Which of the following diseases is related to E3 ubiquitin protein ligase ? Harrison’s 18th Ed. 3320

A.

Hallervorden-Spatz disease

B.

Wilson’s disease

C.

Parkinson’s Disease

D.

Frontotemporal dementia

Drugs that can induce paroxysmal attacks in pheochromocytoma include ?

561

A.

Opiates

B.

Histamine

C.

Adrenocorticotropin

D.

All of the above

Drugs that can induce paroxysmal attacks in pheochromocytoma include ? Harrison’s 18th Ed. 2963

PARK2 encodes parkin, an E3 ubiquitin protein ligase. Mutations in parkin appear to be the major cause of autosomal recessive Parkinson’s disease.

A.

Glucagon

B.

IV Methyldopa

555

Classic triad of pheochromocytoma consists of all except ?

C.

Tricyclic antidepressants

Harrison’s 18th Ed. 2962

D.

All of the above

A.

Palpitation

B.

Hypertension

C.

Headache

D.

Profuse sweating

Classic triad of pheochromocytoma consists of episodes of palpitations, headaches & profuse sweating. Association with episodic or sustained hypertension, makes pheochromocytoma a likely diagnosis.

562

Which of the following is secreted most by pheochromocytoma ? Harrison’s 18th Ed. 2963

A.

Norepinephrine

B.

Epinephrine

C.

Dopamine

Endocrinology 569 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Homovanillic acid (HVA)

Pheochromocytomas & paragangliomas synthesize & store catecholamines (norepinephrine, epinephrine & dopamine). Epinephrine is virtually never increased in extraadrenal pheochromocytomas.

563

Plasma and urinary metanephrine measure which metabolite of catecholamines ?

570

Harrison’s 18th Ed. 2963

564

A.

E-methylated metabolites

B.

S-methylated metabolites

C.

L-methylated metabolites

D.

O-methylated metabolites

Medication that increase catecholamines is ? Harrison’s 18th Ed. 2963

571

C.

7 mg

D.

9 mg

Upper limit of normal of total metanephrine excretion per day is ? A.

0.3 mg

B.

1.3 mg

C.

2.3 mg

D.

3.3 mg

Which out of the following has maximum sensitivity in the diagnosis of pheochromocytoma ?

A.

Levodopa

B.

Labetalol

A.

Plasma-free metanephrines

C.

Sympathomimetics

B.

Plasma catecholamines

D.

All of the above

C.

Urinary-fractionated metanephrines

D.

VMA

Lancet 2005;366:665-675

Plasma test for pheochromocytoma is estimation of ?

572

Harrison’s 17th Ed. 2271

A.

Catecholamines

B.

Metanephrines

C.

Chromagranin A

D.

All of the above

Plasma tests for pheochromocytoma include estimation of catecholamines, metanephrines & chromagranin A, a secretory product of endocrine cells.

566

5 mg

Harrison’s 16th Ed. 2150

Medications that increase catecholamines are levodopa, labetalol & sympathomimetics.

565

B.

569 Cardiology

Which out of the following has maximum specificity in the diagnosis of pheochromocytoma ? Lancet 2005;366:665-675

573

A.

Plasma-free metanephrines

B.

Plasma catecholamines

C.

Urinary-fractionated metanephrines

D.

VMA

Radioactive tracer used to localize phaeochromocytomas is ? Harrison’s 18th Ed. 2963

Urinary test for pheochromocytoma is estimation of ? Harrison’s 18th Ed. 2963 Table 343-2

A.

131

A.

Urinary VMA

B.

111

I- or 123I-metaiodobenzylguanidine (MIBG)

B.

Metanephrines

C.

18

C.

Catecholamines

D.

All of the above

D.

All of the above

In-somatostatin analogues

F-dopa (or dopamine)

Urinary tests for VMA, metanephrines & catecholamines are commonly used for initial testing. Fractionated metanephrines & catecholamines are the most sensitive of these.

phaeochromocytoma tumor can be localized by radioactive tracers like 131 I- or 123 Imetaiodobenzylguanidine (MIBG), 111In-somatostatin analogues, or 18F-dopa (or dopamine) positronemission tomography (PET). 131I-MIBG is also used in treatment of malignant phaeochromocytoma using 200-mCi doses at monthly intervals, over three to six cycles.

567

574

Upper limit of normal for total urinary catecholamines is ? Harrison’s 16th Ed. 2150

Which of the following provides better diagnostic sensitivity in the diagnosis of phaeochromocytomas ?

A.

10 and 50 µg/day

Lancet 2005;366:665-675

B.

50 and 100 µg/day

A.

C.

100 and 150 µg/day

B.

MRI

150 and 250 µg/day

C.

18

D.

131

D. 568

569

False-positive increases in catecholamine excretion result from ?

575

CT F-fluorodopamine PET I-MIBG

Which of the following is an -adrenoceptor blocker ?

Harrison’s 16th Ed. 2150

Lancet 2005;366:665-675

A.

Methyldopa

A.

Prazosin

B.

Levodopa

B.

Doxazosin

C.

Labetalol

C.

Urapidil

D.

All of the above

D.

All of the above

Upper limit of normal of VMA excretion per day is ? Harrison’s 16th Ed. 2150

A.

2 mg

-adrenoceptor blockers are phenoxybenzamine, prazosin, doxazosin & urapidil.

576

In pheochromocytoma, phenoxybenzamine should be administered for at least how many days prior to surgery ?

570

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Harrison’s 17th Ed. 2271

12

A.

2 to 5 days

C.

17

B.

5 to 10 days

D.

18

C.

10 to 14 days

D.

14 to 21 days

Adequate alpha adrenergic blockade with phenoxybenzamine generally requires 10 - 14 days, with a typical final dose of 20 - 30 mg three times per day.

577

B.

NF1 gene on chromosome 17 causes von Recklinghausen’s disease. NF1 gene is a tumor-suppressor gene & encodes a neurofibromin which modulates signal transduction through the ras GTPase pathway.

583

Sipple’s syndrome is also called ? Harrison’s 16th Ed. 2149

Malignant phaeochromocytoma can metastasize to ?

A.

MEN type 1A

Lancet 2005;366:665-675, Harrison’s 18th Ed. 2964

B.

MEN type 1B

A.

Bones

C.

MEN type 2A

B.

Lungs

D.

MEN type 2B

C.

Liver

D.

All of the above

584

Multiple endocrine neoplasia type 2A is characterized by ? Harrison’s 18th Ed. 2964

Term malignant pheochromocytoma is restricted to tumors with distant metastases, most commonly to lungs, bone or liver, suggesting a vascular pathway of spread.

A.

Medullary thyroid carcinoma (MTC)

B.

Pheochromocytoma

578

C.

Hyperparathyroidism

D.

All of the above

Which of the following features of phaeochromocytoma have a higher risk for malignant disease ? Lancet 2005;366:665-675

579

A.

Large size (5 cm)

B.

Paragangliomas with SDHB mutations

C.

Increased plasma/urinary dopamine and dopa

D.

All of the above

MEN 2A is characterized by MTC, pheochromocytoma & hyperparathyroidism.

585

Harrison’s 18th Ed. 2964

Dacarbazine

B.

Methotrexate

C.

Cyclophosphamide

D.

Vincristine

586

Harrison’s 18th Ed. 2964

Café au lait spots

B.

Axillary freckling of skin

C.

Lisch nodules of iris

D.

All of the above

Classic features of Neurofibromatosis type 1 (NF 1) or Von Recklinghausen’s Disease include multiple benign Schwann cell neurofibromas, pigmented café au lait macules (CALM), freckling of non-sun-exposed skin of axilla, Lisch nodules of iris and pseudoarthrosis of the tibia.

581

587

B.

Hamartoma

C.

Prolapse

D.

Dysplasia

Pheochromocytoma

C.

Multiple mucosal neuromas

D.

All of the above

Which of the following is not a feature of pheochromocytomas in MEN 2 ? A.

Benign

B.

Located in adrenals

C.

MTC may be symptomatic before pheochromocytoma

D.

Bilateral

Which of the following is not a feature of Von Hippel-Lindau syndrome ? Harrison’s 18th Ed. 2965, Lancet 2005;366:665-675

Harrison’s 18th Ed. 2964

Pigmentation

B.

Pheochromocytomas in MEN 2 are benign, located in the adrenals, and bilateral. Pheochromocytoma may be symptomatic before MTC.

Lisch nodules of iris best relates to which of the following ? A.

Medullary thyroid carcinoma (MTC)

Harrison’s 18th Ed. 2964

Classic features of neurofibromatosis include ? A.

A.

MEN 2B includes MTC, pheochromocytoma & multiple mucosal neuromas. It typically lacks hyperparathyroidism. Both types of MEN 2 are caused by mutations in RET (rearranged in transfection) that encodes a tyrosine kinase.

Averbuch’s chemotherapy protocol includes dacarbazine, cyclophosphamide, and vincristine, repeated every 21 days for three to six cycles.

580

Multiple endocrine neoplasia type 2B is characterized by ? Harrison’s 18th Ed. 2964

Averbuch’s chemotherapy protocol for treatment of malignant pheochromocytoma consists of all except ? A.

Endocrinology

A.

Renal clear-cell carcinoma

B.

Retinal hemiangioblastoma

C.

Testicular tumour

D.

Pancreatic islet cell tumour

VHL is an autosomal dominant disorder that predisposes to retinal & cerebellar hemangioblastomas, which also occur in the brain stem & spinal cord. Other features of VHL are clear cell renal carcinomas, pancreatic islet cell tumors, endolymphatic sac tumors (ELSTs) of the inner ear, cystadenomas of the epididymis & broad ligament, and multiple pancreatic or renal cysts.

Lisch nodules refers to hamartomas of the iris.

582

NF1 gene that causes von Recklinghausen’s disease is on which chromosome ? Harrison’s 17th Ed. 2272

A.

6

588

VHL gene encodes an E3 ubiquitin ligase that regulates expression of ? Harrison’s 18th Ed. 2965

A.

Insulin-like growth factor (IGF) I

Endocrinology 571

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

Basic fibroblast growth factor (bFGF)

C.

Tissue-specific transcription factor

D.

Hypoxia-inducible factor-1 (HIF-1)

594

Type of mutation in VHL gene in pheochromocytoma is ? Harrison’s 18th Ed. 2965

A.

Point

B.

Missense

C.

Transition

D.

Frameshift

Patients with pheochromocytoma predominantly have missense mutations in VHL gene. Mutations involving single nucleotides are referred to as point mutations. Substitutions are called transitions if a purine or pyrimidine is replaced by another purine or pyrimidine base. Changes from a purine to a pyrimidine, or vice versa, are called transversions. If the DNA sequence change occurs in a coding region and alters an amino acid, it is called a missense mutation. Polymorphisms are sequence variations that have a frequency of at least 1%. Small nucleotide deletions or insertions cause a shift of the codon reading frame (frameshift). Most commonly, reading frame alterations result in an abnormal protein segment of variable length before termination of translation occurs at a stop codon (nonsense mutation).

590

Mutations of which of the following gene causes paraganglioma syndrome 1 (PGL1) ?

595

596

B.

Von Hippel-Lindau syndrome

C.

Neurofibromatosis type 1

D.

All of the above

Which of the following is false about pheochromocytoma ? A.

Solitary lesions are right sided

B.

Highly vascular

C.

Tumors are not innervated

D.

None of the above

Features that suggest familial pheochromocytoma include ? Harrison’s 16th Ed. 2149

597

A.

Bilaterality

B.

Multicentricity

C.

Age of onset < 30 years

D.

All of the above

Which of the following is a hypotensive peptide ? Harrison’s 16th Ed. 2149

A.

SDHA

A.

Endothelin

B.

SDHB

B.

Adrenomedullin

C.

SDHC

C.

Erythropoietin

D.

SDHD

D.

Neuropeptide Y

598

Mutations of which of the following do not predispose to paraganglioma tumors ? A.

SDHA

B.

SDHB

C.

SDHC

D.

SDHD

599

PGL1 PGL2

C.

PGL3

D.

PGL4

600

Harrison’s 16th Ed. 2148

A.

Celiac ganglia

B.

Superior mesenteric ganglia

C.

Inferior mesenteric ganglia

D.

All of the above

Associated pancreatitis

C.

Sialolithiasis

D.

All of the above

To assess adequacy of collected urine sample, which of the following should also be determined ? Urea Creatinine Sodium Potassium

Which of the following may cause hypertension & increased excretion of catecholamines/catecholamine metabolites ? Harrison’s 16th Ed. 2151

A. B. C. D.

PGL1 is most frequent, followed by PGL4. PGL3 is rare. Adrenal, extraadrenal abdominal & thoracic pheochromocytomas are components of PGL1 & PGL4, but not of PGL3.

Abdominal extraadrenal pheochromocytoma are located in association with ?

Damaged pulmonary endothelium

B.

A. B. C. D.

Harrison’s 18th Ed. 2965

B.

A.

Harrison’s 16th Ed. 2150

Which is most frequent paraganglioma syndrome ? A.

In pheochromocytoma, elevated level of amylase is due to ? Harrison’s 16th Ed. 2150

Mutations of SDHA do not predispose to paraganglioma tumors but cause Leigh disease, a form of encephalopathy.

593

MEN type 2

Harrison’s 16th Ed. 2148

Harrison’s 18th Ed. 2965

592

A.

Harrison’s 18th Ed. 2965

Succinate dehydrogenase (SDH) is formed by four subunits (A - D). Mutations of SDHB (PGL4), SDHC (PGL3), and SDHD (PGL1) predispose to three of the paraganglioma syndromes.

591

Hereditary phaeochromocytomas occur in ? Harrison’s 16th Ed. 2148

VHL gene encodes an E3 ubiquitin ligase that regulates expression of hypoxia-inducible factor1 (HIF-1). Loss of VHL is associated with increased expression of vascular endothelial growth factor (VEGF), which induces angiogenesis.

589

571 Cardiology

601

Posterior fossa tumors Subarachnoid hemorrhage Diencephalic or autonomic epilepsy All of the above

Which of the following statements is false ? Harrison’s 16th Ed. 2069

A. B. C. D.

ACTH receptors are located exclusively in adrenal cortex FSH receptors are found only in gonads Insulin & thyroid hormone receptors are widely distributed None of the above

572 602

603

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following drugs block catecholamine synthesis ?

610

Harrison’s 16th Ed. 2229

A.

Doxazosin

A.

Pancreatic endocrine tumour

B.

Methyl-paratyrosine (metirosine)

B.

Lung tumour

C.

Phenoxybenzamine

C.

Small intestinal carcinoids

D.

All of the above

D.

All of the above

611

605

606

607

608

A.

Also called Wermer’s syndrome

A.

PTH

B.

Autosomal recessive

B.

Glucagon

C.

Neoplasia of parathyroid, pituitary & pancreatic islet

C.

Insulin

D.

Hyperparathyroidism is most common manifestation

D.

All of the above

612

Which of the following is false about MEN1 ?

In WDHA syndrome, ‘W’ stands for ?

Harrison’s 16th Ed. 2231

Harrison’s 16th Ed. 2228

A.

Increased urine calcium excretion

A.

Weight loss

B.

Serum calcium rarely elevated at birth

B.

Wasting

C.

Parathyroid hyperplasia

C.

Watery

D.

None of the above

D.

Weakness

613

Tumor-suppressor protein encoded by MEN1 gene is ?

Which of the following is a part of WDHA syndrome ?

Harrison’s 16th Ed. 2232

Harrison’s 16th Ed. 2228

A.

Henin

A.

Weight loss

B.

Menin

B.

Dementia

C.

Tenin

C.

Hypokalemia

D.

Senin

D.

Alkalosis

614

‘Pancreatic cholera’ is due to overproduction of ?

Which of the following is not caused by ‘VIP’ hormone ?

Harrison’s 16th Ed. 2232

Harrison’s 16th Ed. 2228

A.

VIP

A.

Small-intestinal chloride secretion

B.

Gastrin

B.

Inhibition of acid secretion

C.

Ghrelin

C.

Skeletal muscle excitability

D.

Glucagon

D.

Vasodilatory effects

Which of the following regarding VIPoma’s is false ?

615

Which of the following hormones is most commonly produced by pituitary tumors in MEN1 ?

Harrison’s 16th Ed. 2228

Harrison’s 16th Ed. 2233

A. B. C. D.

A.

GH

B.

Prolactin

C.

ACTH

D.

TSH

Also called Verner-Morrison syndrome Stool volume of < 700 mL/day rules out VIPoma Hyperglycemia & hypercalcemia frequent None of the above

Diseases that cause secretory large-volume diarrhea include all except ?

616

A. B. C. D.

Gastrinomas GRFomas Carcinoid syndrome Systemic mastocytosis

Nonfunctional pancreatic endocrine tumours secrete all except ?

Mutations of which of the following genes occurs in MEN2 ? Harrison’s 16th Ed. 2234

Harrison’s 16th Ed. 2229

609

Which of the following is false about MEN1 ? Harrison’s 16th Ed. 2231

Harrison’s 16th Ed. 2068

604

GRFomas are found as ?

Lancet 2005;366:665-675

Which of the following hormones is proteolytically derived from larger precursor polypeptides ?

Endocrinology

617

A.

TERC

B.

SPINK5

C.

TRIM37

D.

RET

Which of the following is not a feature of MEN type 2A ?

Harrison’s 16th Ed. 2229

Harrison’s 16th Ed. 2233

A. B. C. D.

A.

Medullary thyroid carcinoma (MTC)

B.

Pheochromocytoma

C.

Mucosal neuromas

D.

Hyperparathyroidism

Chromogranin A Chromogranin B -human chorionic gonadotropin VIP

Endocrinology 573 618

619

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following is not a feature of MEN type 2B ?

Harrison’s 18th Ed. 2969 Table 344-1

A.

Medullary thyroid carcinoma (MTC)

A.

Congenital Rubella

B.

Pheochromocytoma

B.

CMV

C.

Mucosal neuromas

C.

EBV

D.

Hyperparathyroidism

D.

Coxsackie

Subvariant of MEN2A include ? A.

Familial medullary thyroid carcinoma (FMTC)

B.

Cutaneous lichen amyloidosis

C.

Hirschsprung disease

D.

All of the above

Chapter 344. Diabetes Mellitus

Viral infections like congenital rubella, cytomegalovirus and coxsackie have been implicated in pancreatic islet destruction.

625

626

Pathogenic process leading to hyperglycemia

B.

Age of onset

C.

Type of therapy

D.

All of the above

627

Type of diabetes mellitus resulting from autoimmune beta cell destruction is ? Harrison’s 18th Ed. 2969 Table 344-1

B.

Pyrantel pamoate

C.

Pentamidine

D.

Phenytoin

Drugs that can cause DM include ? A.

Nicotinic acid

B.

Thyroid hormone

C.

Beta-adrenergic agonists

D.

All of the above

Drugs that can cause DM include ? A.

Thiazides

B.

Phenytoin

C.

Beta blockers

D.

All of the above

A.

Type IA

B.

Type IB

C.

Type II

A.

Alpha-interferon

D.

All of the above

B.

Protease inhibitors

C.

Clozapine

D.

All of the above

628

Type 2 diabetes mellitus is characterized by all except ? Harrison’s 18th Ed. 2968

Drugs that can cause DM include ? Harrison’s 18th Ed. 2969 Table 344-1

Type 1A DM results from autoimmune beta cell destruction causing insulin deficiency. Individuals with type 1B DM lack immunologic markers indicative of an autoimmune destructive process of beta cells. They develop insulin deficiency by unknown mechanisms & are ketosis prone.

Drugs that can cause DM include pentamidine, nicotinic acid, glucocorticoids, thyroid hormone, diazoxide, -adrenergic agonists, thiazides, phenytoin, -interferon, protease inhibitors, clozapine & vacor.

A.

Insulin resistance

B.

Impaired insulin secretion

C.

Increased glucose production

A.

Down syndrome

D.

Anti-insulin receptor antibodies

B.

Klinefelter syndrome

C.

Turner syndrome

D.

Cri-du-chat syndrome

629

Maturity onset diabetes of the young (MODY) is characterized by all except ? Harrison’s 18th Ed. 2968

A.

Autosomal dominant inheritance

B.

Autosomal recessive inheritance

C.

Early onset hyperglycemia

D.

Impairment of insulin secretion

Maturity onset diabetes of the young (MODY) is characterized by autosomal dominant inheritance, early onset of hyperglycemia, and impairment in insulin secretion.

Syndromes associated with DM are all except ? Harrison’s 18th Ed. 2969 Table 344-1

Type 2 DM is a heterogeneous group of disorders characterized by variable degrees of insulin resistance, impaired insulin secretion, and increased glucose production.

623

Diazoxide

Harrison’s 18th Ed. 2969 Table 344-1

“Pathogenic process leading to hyperglycemia” is the basis of classification of DM, as opposed to earlier criteria such as age of onset or type of therapy.

622

A.

Harrison’s 18th Ed. 2969 Table 344-1

Most recent classification of diabetes mellitus is based on ? A.

All of the following drugs can cause DM except ? Harrison’s 18th Ed. 2969 Table 344-1

Harrison’s 18th Ed. 2968

621

All of the following viruses can cause DM except ?

Harrison’s 16th Ed. 2233

Harrison’s 16th Ed. 2233

620

624

573 Cardiology

Genetic syndromes associated with diabetes are Wolfram’s syndrome, Down’s syndrome, Klinefelter’s syndrome, Turner’s syndrome, Friedreich’s ataxia, Huntington’s chorea, LaurenceMoon-Biedl syndrome, myotonic dystrophy, porphyria, Prader-Willi syndrome.

630

Out of the following countries, which one has the highest incidence of type 1 DM ? Harrison’s 18th Ed. 2969

A.

Japan

B.

China

C.

Scandinavia

574

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

United States of America

Scandinavia has the highest incidence of type 1 DM. US, Japan and China have a lower rate.

631

In the ADA criteria for diagnosis of DM, what is meant by “fasting state” ? Harrison’s 18th Ed. 2970 Table 344-2

637

Harrison’s 18th Ed. 2971

A.

C-peptide

No oral intake for last 12 hours

B.

Preinsulin

C.

No caloric intake for last 8 hours

C.

Proinsulin

D.

No caloric intake for last 12 hours

D.

Preproinsulin

After 2 hours of 75-gram oral glucose load, impaired glucose tolerance is defined when plasma glucose levels are between ?

Insulin is initially synthesized as a single-chain 86-amino-acid precursor polypeptide, preproinsulin.

638

Proteolytic processing of “preproinsulin” results in the formation of ? Harrison’s 18th Ed. 2971

A.

100 & 180 mg/dL

A.

C peptide

B.

126 & 180 mg/dL

B.

Proinsulin

C.

140 & 199 mg/dL

C.

Insulin

D.

160 & 200 mg/dL

D.

All of the above

After 2 hours of 75-gram oral glucose load, impaired fasting glucose is defined when fasting plasma glucose level are between ?

Proteolytic processing of “preproinsulin” removes aminoterminal signal peptide, giving rise to proinsulin.

639

Which of the following is structurally related to insulin-like growth factors I and II ? Harrison’s 18th Ed. 2971

Harrison’s 18th Ed. 2970

A.

Preproinsulin

A.

80 & 125 mg/dL

B.

Proinsulin

B.

100 & 125 mg/dL

C.

Insulin

C.

125 & 180 mg/dL

D.

Glucagon

D.

125 & 200 mg/dL

Proinsulin is structurally related to insulin-like growth factors I and II.

640

Cleavage of proinsulin generates which of the following ? Harrison’s 18th Ed. 2971

Individuals with impaired fasting glucose are at increased risk of developing which of the following condition ? Harrison’s 18th Ed. 2970

A.

C peptide

B.

A chain of insulin

C.

B chain of insulin

D.

All of the above

A.

Neuropathy

B.

Arthropathy

C.

Cardiovascular diseases

Proinsulin cleavage generates C peptide and A and B chains of insulin.

D.

Renal failure

641

Individuals with impaired fasting glucose (IFG) are at increased risk of developing ?

The A and B chains of insulin contain how many amino acids respectively ? Harrison’s 18th Ed. 2971

Harrison’s 18th Ed. 2970

A.

21 & 30 amino acids 30 & 21 amino acids

A.

Type 1 DM

B.

B.

Type 2 DM

C.

21 & 29 amino acids

C.

Pancreatitis

D.

29 & 21 amino acids

D.

Hypothyroidism

Individuals with IFG or IGT are at substantial risk for developing type 2 DM & cardiovascular disease.

636

86-amino-acid precursor polypeptide of insulin is called ?

B.

Impaired fasting glucose (IFG) is defined when fasting plasma glucose level are between 100 to 125 mg/dL.

635

>50 yrs - every year

No oral intake since last 8 hours

Impaired glucose tolerance (IGT) is defined as plasma glucose levels between 140 and 199 mg/ dL, 2 hours after a 75-gram oral glucose load.

634

D.

American Diabetes Association (ADA) recommends screening all individuals >45 years every 3 years.

Harrison’s 18th Ed. 2970

633

>45 yrs - every three years

A.

Fasting state is defined as no “caloric” intake for at least 8 hours.

632

C.

Endocrinology

American Diabetes Association (ADA) recommends screening for DM in which of the following ?

642

The A and B chains of insulin are connected by which of the following bond ? Harrison’s 18th Ed. 2971

A.

Hydrogen

B.

Amino acid

Harrison’s 18th Ed. 2971

C.

Disulfide

A.

>35 yrs - every three years

D.

Calcium

B.

>40 yrs - every three years

A & B chains of insulin contain 21 & 30 amino acids respectively. They are connected by disulfide bonds.

Endocrinology 575 643

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Insulin synthesis is stimulated by glucose levels above ?

C.

50 %

Harrison’s 18th Ed. 2971

D.

75 %

A.

30 mg%

B.

40 mg%

C.

50 mg%

D.

70 mg%

Once insulin is secreted into the portal venous system, ~50% is degraded by the liver.

650

Word insulin is derived from a Latin word “insula” meaning ? Clinical Chemistry 2002;48:2270-2288

645

646

A.

Protected

B.

Projected

C.

Island

D.

High land

651

B.

GLUT 2

C.

GLUT 3

D.

GLUT 4

“SUR” stands for ? Harrison’s 18th Ed. 2971 Figure 344-4

A.

Sugar receptor

Clinical Chemistry 2002;48:2270-2288

B.

Sulfonylurea receptor

C.

Sucrose receptor

D.

Sulphar receptor

A.

Physiologist

B.

Biochemist

C.

Orthopedic surgeon

D.

Physician

Glucose is transported into the pancreatic  cells via ?

SUR stands for sulfonylurea receptor & is the binding site for drugs that act as insulin secretagogues.

652

A.

GLUT 1

B.

GLUT 2

C.

GLUT 3

D.

GLUT 4

Which of the following acts as a rate-limiting step that controls glucose-regulated insulin secretion ?

Major portion of postprandial glucose is utilized by ? Harrison’s 18th Ed. 2972

A.

Skeletal muscle

B.

Liver

C.

Adipose tissue

D.

Brain

Major portion of postprandial glucose is utilized by skeletal muscle through insulin-stimulation.

653

Which of the following is false about insulin secretion ? Harrison’s 18th Ed. 2971

A.

Secreted in a pulsatile pattern

Pyruvate

B.

Meals induce large bursts of insulin secretion

B.

Glucose-6-phosphate

C.

About 50% of secreted insulin is degraded by liver

C.

Glucokinase

D.

None of the above

D.

All of the above

Harrison’s 18th Ed. 2971

A.

654

Glucose phosphorylation by “glucokinase” is the rate-limiting step that controls glucose-regulated insulin secretion.

All of the following are involved in insulin signal transduction in skeletal muscles except ? Harrison’s 18th Ed. 2972 Figure 344-5

Beta cell membrane depolarization that stimulates insulin secretion by opening calcium channels is done by ?

A.

IRS proteins

B.

Shc proteins

Harrison’s 18th Ed. 2971

C.

PI-3-kinase

A.

Stimulation of ATP-sensitive K+ channel

D.

PAX-3

B.

Inhibition of ATP-sensitive K+ channel

C.

Stimulation of ATP-sensitive Ca++ channel

D.

Inhibition of ATP-sensitive Ca++ channel

Metabolism of glucose-6-phosphate leads to inhibition of K+ channel inducing beta cell membrane depolarization which opens voltage-dependent calcium channels and causes insulin secretion.

649

GLUT 1

Frederick G. Banting, who discovered insulin was a ?

Glucose is transported into the beta cell by the GLUT2 glucose transporter.

648

A.

Glucose transporter - GLUT4 is translocated to cell surface following activation of PI-3-kinase pathway which is stimulated by insulin. GLUT4 is crucial for glucose uptake by skeletal muscle & fat.

Harrison’s 18th Ed. 2971

647

Which of the following glucose transporters is crucial for glucose uptake by skeletal muscle and fat ? Harrison’s 18th Ed. 2972

Glucose levels > 70 mg/dL stimulate insulin synthesis by enhancing protein translation & processing.

644

575 Cardiology

What proportion of insulin in portal system is degraded by the liver ? Harrison’s 18th Ed. 2971

A.

10 %

B.

25 %

Insulin receptor has intrinsic tyrosine kinase activity & interacts with insulin receptor substrates (IRS & Shc) proteins. A number of “docking” proteins bind to these cellular proteins & initiate metabolic actions of insulin [GrB-2, SOS, SHP-2, p65, p110 & phosphatidylinositol-3’-kinase (PI-3-kinase)]. Insulin increases glucose transport through PI-3-kinase & Cbl pathway, which promotes translocation of intracellular vesicles containing GLUT4 glucose transporter to the plasma membrane.

655

Destruction of pancreatic beta cells in Type 1A DM develops as a result of which of the following ? Harrison’s 18th Ed. 2972

A.

Genetic factors

B.

Environmental factors

C.

Immunologic factors

576

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

All of the above

Type 1A DM develops as a result of the synergistic effects of genetic, environmental, and immunologic factors that ultimately destroy the pancreatic beta cells.

656

What percentage of beta cell mass is destroyed when type 1 diabetes results ? Harrison’s 18th Ed. 2972 Figure 344-6

A.

40 %

B.

60 %

C.

80 %

D.

100 %

663

Harrison’s 18th Ed. 2972

Increased insulin requirement after marriage

B.

Glycemic control achieved by OHA

C.

Insulin requirement is nil or modest

D.

Weight gain after insulin treatment

B.

Delta cells

C.

PP cells

D.

All of the above

In type 1A DM, after all beta cells are destroyed, which of the following statements is false ? Harrison’s 18th Ed. 2973

In relation to type 1A DM, honeymoon period is ? A.

Alpha cells

Islet cell type alpha produces glucagon, delta produces somatostatin and PP produces pancreatic polypeptide. All these three though functionally and embryologically similar to beta cells and express most of the same proteins as beta cells, are spared from the autoimmune process.

Progressive impairment in insulin release due to gradual decline in beta cell mass results in type 1 diabetes when ~80% of the beta cell mass is destroyed.

657

A.

Endocrinology

A.

Inflammatory process abates

B.

Islets become atrophic

C.

Immunologic markers disappear

D.

None of the above

After all beta cells are destroyed in type 1A DM, the inflammatory process abates, the islets become atrophic, and immunologic markers disappear.

664

In pathogenesis of type 1 DM, all of the following are true except ? Harrison’s 18th Ed. 2973

After the initial clinical presentation of type 1A DM, a “honeymoon” phase may ensue during which time glycemic control is achieved with modest doses of insulin or, rarely, insulin is not needed.

A.

Pancreatic islets are infiltrated by lymphocytes

B.

All islet cell types are involved

658

C.

Release of TNF & IL-1 play a role

D.

Direct CD8+ mediated cytotoxicity

Major susceptibility gene for type 1 DM is on chromosome ? Harrison’s 18th Ed. 2973

A.

1

B.

5

C.

6

D.

12

In type 1 DM, insulitis occurs (lymphocytic infiltration of pancreatic islets). Beta cell death could be due to toxic effects of TNF- , interferon-  and IL-1. Formation of nitric oxide metabolites, apoptosis & direct CD8+ T cell cytotoxicity may also contribute.

665

659

Concordance of type 1A DM in identical twins ranges between ? Harrison’s 18th Ed. 2973

A.

10 and 40%

B.

20 and 50%

C.

40 and 60%

D.

50 and 90%

The concordance of type 1A DM in identical twins ranges between 30 and 70%.

660

661

A.

T lymphocytes

B.

B lymphocytes

C.

Eosinophils

D.

Neutrophils

In pathogenesis of type 1 DM, islet destruction is mediated by T lymphocytes rather than islet autoantibodies.

666

Pancreatic islet molecules targeted in autoimmune process in type 1A DM are all except ? Harrison’s 18th Ed. 2973

Glucagon is produced by ? Harrison’s 18th Ed. 2973

A.

Insulin

A.

Alpha cells

B.

Glutamic acid decarboxylase (GAD)

B.

Beta cells

C.

Integrin

C.

Delta cells

D.

ZnT-8

D.

PP cells

Somatostatin is produced by ? Harrison’s 18th Ed. 2973

662

In pathogenesis of type 1 DM, islet destruction is mediated by ? Harrison’s 18th Ed. 2973

The major susceptibility gene for type 1A DM is located in the HLA region on chromosome 6.

A.

Alpha cells

B.

Beta cells

C.

Delta cells

D.

PP cells

Which of the following islet cell type is spared from the autoimmune process ? Harrison’s 18th Ed. 2973

Pancreatic islet molecules targeted by autoimmune process include insulin, glutamic acid decarboxylase (GAD), ICA-512/IA-2, and phogrin (insulin secretory granule protein). Pancreatic islet molecules targeted by the autoimmune process include insulin, glutamic acid decarboxylase (GAD), ICA-512/IA-2 (homology with tyrosine phosphatases), and a beta cell–specific zinc transporter (ZnT-8).

667

Which of the following autoantigens is not found is type I DM ? Harrison’s 18th Ed. 2973

A.

GAD-65

B.

GLUR

C.

IA-2 / ICA-512

D.

Insulin

Endocrinology 577

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

577 Cardiology

Islet cell autoantibodies (ICAs) are directed at pancreatic islet molecules such as GAD, insulin, IA-2/ICA-512. ICAs serve as a marker of autoimmune process of type 1A DM.

Molecular mimicry between microbial proteins & host tissues is reported in rheumatic fever, type 1 diabetes mellitus, rheumatoid arthritis & multiple sclerosis.

668

674

Haplotypes most strongly associated with type 1 DM include all except ?

Harrison’s 18th Ed. 2974

Harrison’s 18th Ed. 2973

A.

Insulin resistance precedes insulin secretory defects

A.

DQA1*0301

B.

Insulin secretory defects precede insulin resistance

B.

DQA1*0102

C.

C.

DQB1*0302

Insulin resistance occur simultaneously with insulin secretory defects

D.

DQB1*0201

D.

Any of the above

Haplotypes DQA1*0301, DQB1*0302 & DQB1*0201 are most strongly associated with type 1 DM.

669

In type 2 DM, which of the following is true ?

The strongest single association with type 1 DM is with which haplotype ?

In type 2 DM, insulin resistance precedes insulin secretory defects and diabetes develops only if insulin secretion becomes inadequate.

675

Concordance of type 2 DM in identical twins is between ?

Harrison’s 18th Ed. 2973

Harrison’s 18th Ed. 2974

A.

DQB1*0202

A.

10 - 30 %

B.

DQB1*0302

B.

30 - 50 %

C.

DQB1*0402

C.

50 - 70 %

D.

DQB1*0602

D.

70 - 90 %

Haplotypes that carry a DQB1*0302 gene are strongly associated with type 1 diabetes.

The concordance of type 2 DM in identical twins is between 70 and 90%.

670

676

Presence of which haplotype in one individual confers the highest known genetic risk for type 1 diabetes mellitus ?

If both parents have type 2 DM, risk of developing diabetes is ? Harrison’s 18th Ed. 2974

Harrison’s 18th Ed. 2973

A.

~ 10 %

A.

DR3

B.

~ 20 %

B.

DR4

C.

~ 30 %

C.

Both DR3 & DR4

D.

~ 40 %

D.

None of the above

Most individuals with type 1A DM have the HLA DR3 and/or DR4 haplotype. Presence of both DR3 & DR4 haplotypes in one individual confers a 20-fold increased risk for type 1 diabetes

Individuals with both parents having type 2 DM, the risk approaches 40%.

677

Adipocytes secrete which of the following ? Harrison’s 18th Ed. 2974

671

DQB1*0302 gene is associated with which haplotype ? Harrison’s 18th Ed. 2973

672

A.

DR3

B.

DR4

C.

Both DR3 & DR4

D.

None of the above

Which of the following gene is considered “protective” for type 1A diabetes mellitus ? DQB1*0302

B.

DQB1*0402

C.

DQB1*0502

D.

DQB1*0602

Haplotype DQA1*0102, DQB1*0602 is extremely rare in individuals with type 1 DM & provide protection from type 1 DM. DQB1*0602 is considered “protective” for type 1 diabetes.

673

Molecular mimicry between microbial proteins & host tissues has been reported in ? Harrison’s 17th Ed. 2071

A.

Type 1 diabetes mellitus

B.

Rheumatoid arthritis

C.

Multiple sclerosis

D.

All of the above

Leptin

B.

Resistin

C.

Adiponectin

D.

All of the above

Adipocytes secrete nonesterified free fatty acids, retinol-binding protein 4, leptin, TNF- , resistin, and adiponectin).

678

Harrison’s 18th Ed. 2973

A.

A.

In type 2 DM, increased fasting plasma glucose is predominantly due to ? Harrison’s 18th Ed. 2974

679

A.

Increased hepatic glucose output

B.

Decreased peripheral utilization of glucose

C.

Both of the above

D.

None of the above

In type 2 DM, increased postprandial plasma glucose is predominantly due to ? Harrison’s 18th Ed. 2974

A.

Increased hepatic glucose output

B.

Decreased peripheral utilization of glucose

C.

Both of the above

D.

None of the above

Increased hepatic glucose output predominantly accounts for increased FPG levels, whereas decreased peripheral glucose usage results in postprandial hyperglycemia.

578 680

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following play predominant role in insulin resistance ?

Harrison’s 18th Ed. 2975

A.

Prereceptor defects

A.

Affects premenopausal women

B.

Receptor defects

B.

Chronic anovulation

C.` Postreceptor defects

C.

Hyperandrogenism

D.

D.

All of the above

All of the above

Elevated levels of free fatty acids can cause which of the following ?

PCOS affects premenopausal women & is characterized by chronic anovulation, hyperandrogenism with insulin resistance that increases the risk for type 2 DM, independent of the effects of obesity.

687

A.

Impair glucose utilization in skeletal muscle

B.

Promote glucose production by liver

C.

Impair beta cell function

D.

All of the above

688

Other than insulin,  cells also secrete ?

B.

Metformin

C.

Ramipril

D.

Atorvastatin

All are proved to delay or prevent DM except ? A.

Acarbose

B.

Metformin

C.

NSAIDs

A.

Ptyalin

D.

Pravastatin

B.

Amylin

C.

Amylase

D.

Lipase

Diabetes Prevention Program (DPP) demonstrated that metformin prevented or delayed diabetes by 31% compared to placebo. Studies in Finnish and Chinese populations noted that acarbose, metformin, thiazolidinediones, and orlistat prevent or delay type 2 DM, but are not approved for this purpose. Ramipril and pravastatin reduced the number of new cases of diabetes.

689

“Glucose toxicity” refers to ? A.

Acute hyperglycemia impairing islet function

B.

Chronic hyperglycemia impairing islet function

C.

Seizures in hyperglycemia

D.

All of the above

690

All can cause islet cell dysfunction except ? Harrison’s 16th Ed. 2158

Hyperglycemia

B.

Hypoglycemia

C.

Hyperlipidemia

D.

Islet cell autoantibodies

A.

Hypertension

B.

Acanthosis nigricans

C.

PCOD

D.

Ataxia telangiectasia

All of the following are true about MODY except ? Harrison’s 18th Ed. 2976

Chronic hyperglycemia paradoxically impairs islet function (glucose toxicity) and leads to a worsening of hyperglycemia.

A.

All are risk factors for type 2 DM except ? Harrison’s 18th Ed. 2975

Harrison’s 18th Ed. 2975

685

Life style modification

Harrison’s 18th Ed. 2975

Pancreatic beta cells cosecrete islet amyloid polypeptide (IAPP) or amylin along with insulin. It is a major component of amyloid fibrils found in islets of patients with type 2 diabetes. Its analogue is being used in treating both type 1 and type 2 DM.

684

A.

Harrison’s 16th Ed. 2158, Harrison’s 17th Ed. 2282

Elevated levels of free fatty acids can impair glucose utilization in skeletal muscle, promote glucose production by liver and impair beta cell function.

683

All are proved to delay or prevent DM except ? Harrison’s 16th Ed. 2158, Harrison’s 17th Ed. 2282

Harrison’s 18th Ed. 2974

682

Which of the following is a feature of Polycystic ovary syndrome (PCOS) ?

Harrison’s 18th Ed. 2974

Postreceptor defects play the predominant role in insulin resistance. Although insulin receptor levels and tyrosine kinase activity in skeletal muscle are reduced in T2DM, these are not a primary defect.

681

686

A.

Monogenic

B.

Autosomal dominant

C.

MODY 4 is due to mutation in IPF-1

D.

MODY 1 is due to mutation in glucokinase gene

MODY 2 is due to mutations in the glucokinase gene. MODY 4 is a rare variant caused by mutations in insulin promoter factor (IPF) 1. Six different variants of MODY have been identified so far, and all are transmitted as autosomal dominant disorders.

691

Hepatocyte nuclear transcription factor (HNF) is expressed in ? Harrison’s 18th Ed. 2976

A.

Liver

Harrison’s 18th Ed. 2975

B.

Pancreatic islets

A.

Chronic hyperglycemia

C.

Kidney

B.

Elevation of free fatty acid levels

D.

All of the above

C.

Dietary fat

D.

All of the above

Which of the following can worsen islet function ?

Chronic hyperglycemia impairs islet function (“glucose toxicity”) so does elevation of free fatty acid levels (“lipotoxicity”) and dietary fat.

Endocrinology

HNF are expressed in liver, pancreatic islets and kidney. Therefore, patients may also have renal absorption abnormalities and renal cysts.

692

MODY 1 is caused by mutations in ? Harrison’s 18th Ed. 2976

Endocrinology 579

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

A.

HNF-4 alpha

C.

Hyperglycemia

B.

HNF-1 alpha

D.

Blood Urea

C.

HNF-1 beta

D.

All of the above

Interference from acetoacetate may falsely elevate the serum creatinine measurement in DKA.

699

MODY 1, MODY 3, and MODY 5 are caused by mutations in the hepatocyte nuclear transcription factors (HNF) 4alpha, HNF-1alpha, and HNF-1beta, respectively.

693

694

1.0 meq/L

Harrison’s 18th Ed. 2976

B.

1.2 meq/L

A.

Children

C.

1.4 meq/L

B.

Adults

D.

1.6 meq/L

C.

Elderly

D.

All of the above

For every 100 mg/dL rise in serum glucose, serum sodium is reduced by 1.6 mmol/L (1.6 meq).

700

Harrison’s 18th Ed. 2977

A.

[2 x (S. Na+ + K+) + P. glucose (mg/dL)/18 + BUN/2.8]

Harrison’s 18th Ed. 2977

B.

[3 x (S. Na+ + K+) + P. glucose (mg/dL)/18 + BUN/2.8]

A.

Gluconeogenesis

C.

[4 x (S. Na+ + K+) + P. glucose (mg/dL)/18 + BUN/2.8]

B.

Glycogenolysis

D.

[4 x (S. Na+ + K+) + P. glucose (mg/dL)/18 + BUN/2.8]

C.

Ketone body formation

D.

All of the above

Serum osmolality is calculated by [2 x (serum sodium + serum potassium) + plasma glucose (mg/ dL)/18 + BUN/2.8]

701

Enzyme mediating increased ketone body formation in DKA is ?

A.

Cerebral infarction

Harrison’s 18th Ed. 2977

B.

Cocaine

A.

HMG CoA reductase

C.

Pregnancy

B.

CPT - I

D.

Hypothyroidism

C.

CPT - II

D.

Acyl CoA transferase

Precipitating events in DKA are inadequate insulin administration, infection, infarction (cerebral, coronary, mesenteric, peripheral), cocaine & pregnancy.

702

A.

Salivary

B.

Gastric

C.

Pancreatic

D.

All of the above

703

B.

Acidemia

C.

Infection

D.

All of the above

In DKA, interference from which of the following may falsely elevate serum creatinine measurement? Harrison’s 18th Ed. 2977

A.

Acetoacetate

B.

Hypertriglyceridemia

Acetoacetate

B.

Acetone

C.

Beta-hydroxybutyrate

D.

All of the above

Which of the following drug may cause false-positive reactions in the nitroprusside test used to detect urine ketones ? Harrison’s 17th Ed. 2283

Harrison’s 16th Ed. 1897

Acute pancreatitis

A.

Acetoacetate is preferentially detected by the commonly used nitroprusside ketosis detection reagent. Nitroprusside reaction only detects acetoacetate and acetone and not betahydroxybutyrate.

In DKA, elevation in serum amylase is due to ? A.

Nitroprusside reaction does not detect which of the following ? Harrison’s 17th Ed. 2284

In DKA, the elevated amylase is usually of which origin ?

in DKA the amylase is usually of salivary origin and thus is not diagnostic of pancreatitis.

698

Which of the following is not a precipitating event in DKA ? Harrison’s 18th Ed. 2976 Table 344-5

Harrison’s 18th Ed. 2977

697

Serum osmolality is calculated by which of the following formula ?

In liver, decreased ratio of insulin to glucagon promotes which of the following ?

In DKA, hyperglucagonemia alters hepatic metabolism to favor ketone body formation, through activation of enzyme carnitine palmitoyltransferase I. This enzyme is crucial for regulating fatty acid transport into the mitochondria, where beta oxidation and conversion to ketone bodies occur.

696

Harrison’s 18th Ed. 2977

A.

The decreased ratio of insulin to glucagon promotes gluconeogenesis, glycogenolysis, and ketone body formation in liver.

695

For every 100 mg/dL rise in serum glucose, serum sodium is reduced by ?

Cerebral edema in DKA is seen most frequently in ?

Cerebral edema, an extremely serious complication of DKA, is seen most frequently in children.

579 Cardiology

704

A.

Captopril

B.

Atorvastatin

C.

Aspirin

D.

All of the above

Which of the following drug may cause false-positive reactions in the nitroprusside test used to detect urine ketones ? Harrison’s 17th Ed. 2283

A.

Penicillamine

B.

Azithromycin

580

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Cephalosporin

B.

> 3.1 meq/L

D.

All of the above

C.

> 3.2 meq/L

D.

> 3.3 meq/L

Captopril or penicillamine may cause false-positive nitroprusside test used to detect urine ketones.

705

Which of the following intravenous solution is preferred for initial use in DKA to reduce hyperchloremia ? Harrison’s 18th Ed. 2978

In DKA, insulin should not be administered until potassium level is >3.3 meq/L.

711

During treatment of DKA, very large changes occur in the serum levels of all except ?

A.

0.45% saline

B.

Normal saline

A.

Sodium

C.

Lactated Ringer’s IV solution

B.

Potassium

D.

Any of the above

C.

Chloride

D.

Magnesium

Harrison’s 18th Ed. 2976 Table 344-4

Initial use of lactated Ringer’s IV solution reduces hyperchloremia that occurs with normal saline.

706

In DKA, with insulin therapy, hyperglycemia improves due to ?

712

Harrison’s 18th Ed. 2978

A.

Insulin-mediated glucose disposal

B.

Reduced hepatic glucose release

C.

Rehydration

D.

All of the above

Endocrinology

Total-body stores which of the following elements is not reduced in DKA ? Harrison’s 18th Ed. 2976 Table 344-4

A.

Sodium

B.

Chloride

C.

Calcium

D.

Magnesium

Hyperglycemia usually improves at a rate of 75 to 100 mg/dL per hour as a result of insulinmediated glucose disposal, reduced hepatic glucose release, and rehydration.

Total-body stores of sodium, potassium, chloride, phosphorous & magnesium are reduced in DKA.

707

713

In DKA, following insulin therapy, the decline in plasma glucose within the first 1 to 2 hours is mostly related to ?

In treatment of DKA, glucose should be added to 0.45% saline infusion when plasma glucose level is around ?

Harrison’s 18th Ed. 2978

Harrison’s 18th Ed. 2978

A.

Insulin-mediated glucose disposal

A.

100 mg/dL

B.

Reduced hepatic glucose release

B.

150 mg/dL

C.

Rehydration

C.

200 mg/dL

D.

All of the above

D.

250 mg/dL

The decline in the plasma glucose within the first 1 to 2 hours may be more rapid and is mostly related to volume expansion.

When plasma glucose reaches 250 mg/dL, glucose should be added to 0.45% saline infusion to maintain plasma glucose in 200 to 250 mg/dL range & insulin infusion should be continued.

708

714

With insulin therapy in DKA, which of the following resolves first ? Harrison’s 18th Ed. 2978

Harrison’s 17th Ed. 2300

A.

Acidosis

A.

Pioglitazone

B.

Ketosis

B.

Metformin

C.

Hyperglycemia

C.

Acarbose

D.

All of the above

D.

Glipizide

In DKA, following insulin therapy, acidosis and ketosis resolve more slowly than hyperglycemia.

709

Which of the following drugs should be withheld well before intravenous contrast administration ?

715

In DKA, which salt of potassium should be avoided for replacement ?

In hyperglycemic hyperosmolar state (HHS), the blood glucose level is usually above ? Harrison’s 18th Ed. 2976 Table 344-4

Harrison’s 18th Ed. 2978

A.

300 mg%

A.

Chloride

B.

400 mg%

B.

Phosphate

C.

500 mg%

C.

Acetate

D.

600 mg%

D.

Any of the above

716

In HHS, moderate ketonuria, if present, is secondary to ?

To reduce the amount of chloride administered, potassium phosphate or acetate can be substituted for the chloride salt.

Harrison’s 18th Ed. 2979

A.

Starvation

710

In DKA, insulin should not be administered until potassium level is ?

B.

Infection

C.

Oliguria

Harrison’s 18th Ed. 2978 Table 344-6

D.

All of the above

A.

> 3.0 meq/L

In HHS, moderate ketonuria, if present, is secondary to starvation.

Endocrinology 581 717

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

All are features of hyperglycemic hyperosmolar state except ?

B.

Phosphofructokinase

Harrison’s 18th Ed. 2976 Table 344-4

C.

Fructose-1,6-bisphosphatase

D.

Phosphoenolpyruvate carboxykinase

A.

Normal Na+, K+, Cl-

B.

Glucose between 600-1200 mg %

C.

Normal PCO2

D.

pH < 7.3

Intracellular glucose is predominantly metabolized by phosphorylation and subsequent glycolysis, but when increased, some glucose is converted to sorbitol by the enzyme aldose reductase.

724

In contrast to DKA, acidosis and ketonemia are absent or mild.

718

Which of the following symptom is absent in HHS ? Nausea, vomiting

B.

Abdominal pain

C.

Kussmaul respiration

D.

All of the above

In HHS, nausea, vomiting, abdominal pain & Kussmaul respirations characteristic of DKA are notably absent.

719

Which of the following statements is false ?

725

C.

Clinical nephropathy

D.

Neuropathy

Which of the following trial was not for the study of chronic complications of diabetes mellitus ? Harrison’s 18th Ed. 2981

A.

Diabetes Control and Complications Trial (DCCT)

B.

HHS patient is usually young

B.

Tuskegee Study

C.

Mortality higher in HHS than DKA

C.

Kumamoto study

D.

None of the above

D.

United Kingdom Prospective Diabetes Study (UKPDS)

Which of the following is not a nonvascular chronic complication of DM ? A.

Macular edema

B.

Glaucoma

C.

Cataracts

D.

Periodontal disease

Macular edema is a microvascular chronic complication of diabetes mellitus.

Tuskegee Study (1932–1972) was a prospective study of 431 African-American men with seropositive latent syphilis of >3 years’ duration.

726

The redox potential is zero for ? A. Oxygen

Individuals with DM are how much more likely to become legally blind than individuals without DM ? Harrison’s 18th Ed. 2981

A.

5 times

B.

10 times

C.

15 times

D.

25 times

Individuals with DM are 25 times more likely to become legally blind than individuals without DM.

727

Which of the following is the hallmark of “proliferative” diabetic retinopathy ? Harrison’s 18th Ed. 2982

B.

Hydrogen

A.

Retinal vascular microaneurysms

C.

Nitrogen

B.

Blot hemorrhages

D.

Helium

C.

Neovascularization

D.

Cotton wool spots

The redox potential is a measure (in volts) of the affinity of a substance for electrons, its electronegativity compared with hydrogen (which is set at 0).

“AGE” stands for ? Harrison’s 18th Ed. 2980

The appearance of neovascularization in response to retinal hypoxia is the hallmark of proliferative diabetic retinopathy.

728

Individuals who have had DM for >20 years, what is the probability of detecting nonproliferative retinopathy ?

A.

Activated glycosylation end products

B.

Anti glycosylation end products

C.

Advanced glycosylation end products

A.

25 %

D.

Associated glycosylation end products

B.

50 %

C.

75 %

D.

100 %

Increased intracellular glucose leads to the formation of advanced glycosylation end products (AGEs) via the nonenzymatic glycosylaton of intra- and extracellular proteins.

723

Microalbuminuria

Dehydration in HHS > DKA

Harrison’s 18th Ed. 2980 Table 344-7

722

Retinopathy

B.

A.

Typical patient of HHS is an elderly type 2 DM individual, with a several week history of polyuria, weight loss & diminished oral intake that culminates in mental confusion, lethargy, or coma. In HHS, fluid losses & dehydration are more pronounced than in DKA. HHS has a substantially higher mortality than DKA.

721

A.

DCCT demonstrated that improvement of glycemic control reduced nonproliferative & proliferative retinopathy (47%), microalbuminuria (39%), clinical nephropathy (54%) & neuropathy (60%).

Harrison’s 18th Ed. 2979

720

In the Diabetes Control and Complications Trial (DCCT), which of the following complication showed maximum reduction with improved glycemic control ? Harrison’s 18th Ed. 2981

Harrison’s 18th Ed. 2979

A.

581 Cardiology

Intracellular glucose is converted to sorbitol by which enzyme ? Harrison’s 18th Ed. 2980

A.

Aldose reductase

Harrison’s 18th Ed. 2982

Nonproliferative retinopathy is found in almost all individuals who have had DM for >20 years.

582 729

730

731

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR The earliest clinical signs of diabetic retinopathy is ?

B.

Administration of ACE inhibitors or ARBs

N Engl J Med 2004;350:48-58

C.

Administration of beta blockers

D.

Treatment of dyslipidemia

A.

Dot intraretinal hemorrhages

B.

Cotton-wool spots

C.

Neovascular glaucoma

D.

Diabetic macular edema

Lesion that occurs early in histopathology of diabetic retinopathy is ?

Interventions effective in slowing progression from microalbuminuria to overt nephropathy include near normalization of glycemia, strict blood pressure control, administration of ACE inhibitors or ARBs and treatment of dyslipidemia.

736

In type 2 DM, preferred drug for blood pressure control is ? Harrison’s 18th Ed. 2983

N Engl J Med 2004;350:48-58

A.

ACE inhibitors

A.

Selective loss of pericytes from retinal capillaries

B.

ARBs

B.

Loss of capillary endothelial cells

C.

Beta blockers

C.

Proliferation of capillary endothelial cells

D.

Calcium channel blockers

D.

None of the above

737

In type 2 DM, preferred drug for blood pressure control is ?

Screening for gestational diabetes mellitus is recommended for pregnant women between ?

Harrison’s 18th Ed. 2983

A.

Diuretics

Harrison’s 16th Ed. 2179

B.

ARBs

A.

12 & 14 weeks of gestation

C.

Beta blockers

B.

16 & 20 weeks of gestation

D.

Calcium channel blockers

C.

24 & 28 weeks of gestation

D.

32 & 36 weeks of gestation

Current recommendations advise screening for glucose intolerance between weeks 24 and 28 of pregnancy in women with high risk for GDM.

732

Endocrinology

Drug-specific benefit in diabetic nephropathy, independent of blood pressure control, has been shown for ACE inhibitors in type 1 DM and ARBs in type 2 DM. ACE inhibitors (in types 1 and 2 DM) and ARBs (in type 2 DM) slow the progression of diabetic renal disease.

738

Leading cause of death in diabetic individuals on dialysis is ? Harrison’s 18th Ed. 2984

During the first 6 to 12 months of improved glycemic control, established diabetic retinopathy ?

A.

Atherosclerosis

Harrison’s 18th Ed. 2982

B.

Infection

A.

Improves

C.

Dyselectrolytemia

B.

Remains the same

D.

Suicide

C.

Worsens

D.

Any of the above

Atherosclerosis is the leading cause of death in diabetic individuals on dialysis

739

The most common form of diabetic neuropathy is ?

During the first 6 to 12 months of improved glycemic control, established diabetic retinopathy may transiently worsen.

Harrison’s 18th Ed. 2984

A.

Distal symmetric polyneuropathy

733

B.

Diabetic polyradiculopathy

In a 24 hour collected urine sample, microalbuminuria is defined as ? Harrison’s 18th Ed. 2982

C.

Mononeuropathy

D.

Mononeuropathy multiplex

A.

10 to 100 mg/day

B.

20 to 200 mg/day

The most common form of diabetic neuropathy is distal symmetric polyneuropathy.

C.

30 to 300 mg/day

740

D.

40 to 400 mg/day

Involvement of which of the following cranial nerves is most common in DM ? Harrison’s 18th Ed. 2984

734

In a spot urine collection, microalbuminuria is defined as ? Harrison’s 18th Ed. 2982

A.

10 to 100 µg/mg creatinine

B.

20 to 200 µg/mg creatinine

C.

30 to 299 µg/mg creatinine

D.

40 to 400 µg/mg creatinine

Microalbuminuria is defined as 30 to 299 mg/day in a 24-hour collection or 30 to 299 µg/mg creatinine in a spot collection.

735

Interventions effective in slowing progression from microalbuminuria to overt nephropathy include all except ?

A.

II

B.

III

C.

VI

D.

VII

Involvement of the third cranial nerve is most common in DM and manifests as diplopia.

741

Which of the following antiarrhythmic drug is useful in the treatment of chronic, painful diabetic neuropathy ? Harrison’s 16th Ed. 2166

A.

Procainamide

Harrison’s 18th Ed. 2983

B.

Mexilitine

A.

C.

Adenosine

Strict blood pressure control

Endocrinology 583 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Ibutilide

Chronic, painful diabetic neuropathy may respond to tricyclic antidepressants, gabapentin, NSAIDS, mexilitine, phenytoin, carbamazepine and capsaicin cream.

742

Which of the following antiepileptic drug is useful in the treatment of chronic, painful diabetic neuropathy ? Harrison’s 18th Ed. 2984

A.

Gabapentin

B.

Phenytoin

C.

Carbamazepine

D.

All of the above

Which of the following drug is useful in orthostatic hypotension due to diabetic autonomic neuropathy ? Harrison’s 18th Ed. 2985

748

D.

Increased Tg and reduced HDLc

Which of the following should receive first priority in treating hyperlipidemia in DM ? A.

Lower LDLc

B.

Raise HDLc

C.

Lower triglycerides

D.

Lower VLDLc

Order of priorities in treatment of hyperlipidemia in DM is to lower LDLc, raise HDLc & lower triglycerides.

749

Combination therapy of HMG CoA reductase inhibitor and fibric acid derivative increases the chances of ?

B.

Clonidine

Harrison’s 18th Ed. 2986

C.

Octreotide

A.

Gall stones

All of the above

B.

Myositis

C.

Dementia

D.

Skin rash

Earliest sign of diabetic neuropathy is ? A.

Erectile dysfunction

B.

Gastroparesis

C.

Anhidrosis of the lower extremities

D.

Distal sensory loss

Combination therapy with an HMG CoA reductase inhibitor and fibric acid derivative increases the possibility of myositis.

750

Drugs that improve symptoms of gastroparesis in DM include all except ? Harrison’s 18th Ed. 2985

A.

Domperidone

B.

Loperamide

C.

Metoclopramide

D.

Erythromycin

Drugs that promote gastric emptying include dopamine agonists (metoclopramide, domperidone), bethanechol. Erythromycin interacts with motilin receptor and may promote gastric emptying. Diabetic diarrhea is treated symptomatically with loperamide and may respond to octreotide.

Which of the following statements is correct for cardiovascular death rate among men and women in type 2 DM ? Harrison’s 18th Ed. 2985

A.

More in men than women

B.

More in women than men

C.

Equal in men and women

D.

Any of the above

After controlling for all known cardiovascular risk factors, type 2 DM increases the cardiovascular death rate twofold in men and fourfold in women.

Most common pattern of dyslipidemia in DM is ? Harrison’s 18th Ed. 2985

In the treatment of hypertriglyceridemia, which of the following should not be used ? Harrison’s 18th Ed. 2986

Erectile dysfunction and retrograde ejaculation are very common in DM and may be one of the earliest signs of diabetic neuropathy.

747

Increased Tg

Midodrine

Harrison’s 18th Ed. 2985

746

Reduced HDLc

C.

Harrison’s 18th Ed. 2986

Orthostatic hypotension due to diabetic autonomic neuropathy may respond to fludrocortisone, midodrine, clonidine, octreotide and yohimbine.

745

B.

A.

D.

744

Increased LDLc

Most common pattern of dyslipidemia is hypertriglyceridemia & reduced HDL cholesterol levels.

Chronic, painful diabetic neuropathy may respond to gabapentin, phenytoin & carbamazepine. Chronic, painful diabetic neuropathy may respond to amitriptyline, desipramine, nortriptyline, imipramine or selective serotonin norepinephrine reuptake inhibitors, gabapentin, pregabalin, carbamazepine, lamotrigine.

743

A.

583 Cardiology

A.

HMG CoA reductase inhibitors

B.

Bile acid binding resins

C.

Fibric acid derivative

D.

All of the above

Bile acid binding resins should not be used if hypertriglyceridemia is present.

751

All of the following drugs are glucose-neutral except ? Harrison’s 18th Ed. 2986

A.

ACE inhibitors

B.

Beta blockers

C.

Calcium channel blockers

D.

Central adrenergic antagonists

ACE inhibitors, calcium channel blockers, -adrenergic blockers, central adrenergic antagonists & vasodilators are glucose- and lipid-neutral.  -blockers & thiazide diuretics increase insulin resistance.

752

Which of the following infections occur almost exclusively in diabetics ? Harrison’s 18th Ed. 2988

A.

Rhinocerebral mucormycosis

B.

Emphysematous infections of gall bladder & urinary tract

C.

“Malignant” or invasive otitis externa

D.

All of the above

Rare infections like rhinocerebral mucormycosis, emphysematous infections of gall bladder & urinary tract, and “malignant” or invasive otitis externa are seen almost exclusively in diabetics.

584 753

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR A 1% rise in HbA1C translates into how much increase in mean glucose level ?

Mixing of intermediate and short-acting insulin formulations alters the insulin absorption profile of ?

Harrison’s 17th Ed. 2296

Harrison’s 18th Ed. 2993

A.

15 mg/dL

A.

Short-acting insulin

B.

25 mg/dL

B.

Intermediate acting insulin

C.

35 mg/dL

C.

Both of the above

D.

45 mg/dL

D.

None of the above

A 1% rise in the A1C translates into a 35 mg/dL increase in the mean glucose level.

754

759

In standardized assays, HbA1C of 6% approximates what level of mean plasma glucose value ?

Endocrinology

Mixing of intermediate and short-acting insulin formulations may alter the insulin absorption profile especially of the short-acting insulins.

760

Basal insulin is provided by which of the following insulins ?

Harrison’s 17th Ed. 2296

Harrison’s 18th Ed. 2993

A.

105 mg/dL

A.

Glargine insulin

B.

115 mg/dL

B.

Aspart

C.

125 mg/dL

C.

Lispro

D.

135 mg/dL

D.

Glulisine

In standardized assays, HbA1C approximates the following mean plasma glucose values: 6% = 135 mg/dL, 7% = 170 mg/dL, 8% = 205 mg/dL.

Intermediate- or long-acting insulins (NPH, lente, ultralente, glargine) supply basal insulin, whereas regular, aspart, or lispro provides prandial insulin.

755

761

In patients who have achieved glycemic goal, ADA recommends measurement of the HbA1C how frequently ?

Which of the following insulin regimen reproduces the precise insulin secretory pattern of the pancreatic islet ?

Harrison’s 18th Ed. 2992

Harrison’s 18th Ed. 2993

A.

Once per year

A.

Short + Intermediate

B.

Twice per year

B.

Short + long

C.

Thrice per year

C.

Intermediate + long

D.

Four times per year

D.

None of the above

In patients who have achieved glycemic goal, ADA recommends HbA1C estimation twice a year.

No insulin regimen reproduces the precise insulin secretory pattern of the pancreatic islet.

756

762

Which disease may interfere with the HbA1C result ?

Harrison’s 18th Ed. 2994

A.

Hemoglobinopathies

A.

Prior evening long-acting insulin

B.

Hemolytic anemia

B.

Morning short acting insulin

C.

Uremia

C.

Morning long-acting insulin

D.

All of the above

D.

Pre-supper short-acting insulin

Depending on the assay methodology, hemoglobinopathies, hemolytic anemias, and uremia may interfere with the HbA1C result.

757

Fasting glucose is primarily determined by ?

Harrison’s 18th Ed. 2992

Which other glycated compound can be measured for determining glycemic control ?

Fasting glucose is primarily determined by the prior evening long-acting insulin, pre-lunch glucose is a function of morning short-acting insulin, pre-supper glucose is a function of morning longacting insulin and bedtime glucose is a function of the pre-supper, short-acting insulin.

763

Harrison’s 18th Ed. 2992

A.

Albumin

B.

Globulin

C.

Ketone

D.

All of the above

Which of the following insulins is used in continuous subcutaneous insulin infusion (CSII) ? Harrison’s 18th Ed. 2994

A.

NPH

B.

Ultralente

C.

Glargine

D.

Lispro

Fructosamine assay (measuring glycated albumin) reflects glycemic status over prior 2 weeks but there are no studies to indicate whether such assays accurately predict the complications of DM.

Most physicians use lispro, glulisine, or insulin aspart in CSII.

758

764

Plasma glucose values are higher than whole blood values by ?

Oral glucose lowering agents that is effective in type 1 DM is ?

Harrison’s 16th Ed. 2172 Table 323-9

Harrison’s 18th Ed. 2995

A.

2-5%

A.

Sulfonylureas

B.

5 - 10 %

B.

Biguanides

C.

10 - 15 %

C.

Thiazolidinediones

15 - 20 %

D.

Alpha glucosidase inhibitors

D.

Plasma glucose values are 10-15% higher than whole blood values.

Oral glucose lowering agents with the exception of alpha-glucosidase inhibitors and an amylin analogue are ineffective in type 1 DM.

Endocrinology 585 765

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Weight gain does not occur with which of the following drugs for type 2 DM ?

771

766

A.

Adipose tissue

A.

Insulin

B.

Pancreatic beta cells

B.

Insulin secretagogues

C.

Skeletal muscle

C.

Thiazolidinediones

D.

Macrophages

D.

Metformin

Which of the following is true for “incretin” hormones ? A. Decrease insulin secretion

A.

Adipocytes

B.

Increase insulin secretion

B.

Liver

C.

Prevents insulin degradation

C.

Skeletal muscles

D.

Augments insulin degradation

D.

Pancreas

“PPAR” stands for ? N Engl J Med 2004;351:1106-18

A.

Peroxisome-protein-activated receptor

B.

Peroxisome-proliferator-activated receptor

C.

Peroxisome-producer-activated receptor

D.

Peroxisome-promoter-activated receptor

Peroxisome-proliferator-activated receptors (PPARs) are a subfamily of 48-member nuclearreceptor superfamily & regulate gene expression in response to ligand binding. Peroxisomeproliferator-activated receptor  (PPAR  ) is a transcription factor activated by thiazolidinediones (TZDs).

768

PPAR  is expressed most abundantly in adipose tissue but is also found in pancreatic beta cells, vascular endothelium, and macrophages. Its expression is low in tissues that express predominantly PPAR  such as the liver, the heart, and skeletal muscle.

Harrison’s 18th Ed. 2995

PPAR- is found at highest levels in ?

PPAR  is a transcription factor that is activated by certain fatty acids, prostanoids & thiazolidinediones. Whereas the isoform PPAR 1 is expressed in most tissues, PPAR  2 is specific for adipose tissue, where it has a key role in regulation of normal adipocyte differentiation & proliferation as well as fatty acid uptake & storage.

767

PPAR  is expressed in all except ?

772

The incretins are hormones that work to augment glucose-stimulated insulin secretion. There are two main incretin hormones in humans, GIP (glucose-dependent insulinotropic peptide; also known as gastric inhibitory peptide) and GLP-1 (glucagon-like peptide-1). GLP-1 inhibits glucagon secretion and delays stomach emptying. Both hormones are secreted by endocrine L cells located in the epithelium of small intestine. Glucose in small intestine stimulates incretin release. Incretins are carried through the circulation to their target tissue like pancreatic beta cells. Incretin stimulation of beta cells causes them to secrete more insulin in response to the same amount of blood glucose.

773

A.

Adipose tissue

B.

Liver

C.

Heart

D.

Muscle

PPAR  is expressed in the liver, heart, and muscle, as well as in the vascular wall.

774

775

 agonist ? Which of the following is a PPAR N Engl J Med 2004;351:1106-18

A.

Fenofibrate

B.

Bezafibrate

C.

Gemfibrozil

D.

All of the above

Fibrates like fenofibrate, bezafibrate, ciprofibrate & gemfibrozil act as full or partial PPAR agonists.

770

PPAR  is expressed in which of the following tissues ? N Engl J Med 2004;351:1106-18

A.

Skin

B.

Brain

C.

Adipose tissue

D.

All of the above

Highest expression of PPAR  is in the skin, brain, and adipose tissue.

Exenatide was originally isolated from ? A. Snake venom B.

Lizard venom

C.

Spider venom

D.

Scorpion venom

Exenatide is a peptide GLP-1 receptor agonist that was originally isolated from lizard venom. It is resistant to degradation by DPP-4, the major protease that breaks down GIP and GLP-1.

N Engl J Med 2004;351:1106-18

769

Expression of PPAR is lowest in which of the following tissues ? N Engl J Med 2004;351:1106-18

Harrison’s 18th Ed. 2995

Metformin reduces fasting plasma glucose and insulin levels, improves the lipid profile, and promotes modest weight loss.

585 Cardiology

‘Incretin effect’ refers to ? A. Plasma insulin response to glucose taken orally is more than when administered intravenously B.

Plasma insulin response to glucose administered intravenously is more than when taken orally

C.

Over response to insulin

D.

Under response to insulin

The major protease that breaks down GIP and GLP-1 is ? A. Dipeptidyl peptidase (DPP) 1 B.

Dipeptidyl peptidase (DPP) 2

C.

Dipeptidyl peptidase (DPP) 3

D.

Dipeptidyl peptidase (DPP) 4

Dipeptidyl peptidase 4 is the enzyme responsible for the degradation of GLP-1 and GIP. DPP 4 is a cell-surface and circulating-peptidase enzyme and is also known as CD26 (a T-cell activating antigen). This has widespread expression throughout GI tract, pancreas, kidneys, thymus gland. Preventing degradation of incretin hormones by blocking action of DPP 4 has led to the creation of a new class of drugs known as ‘gliptins’. Sitagliptin (Januvia) is the first on the market in UK and was licensed in April 2007. It is a once-daily oral dose for combination with metformin or glitazones and not yet indicated for monotherapy. It is mostly excreted unchanged by kidneys. It involves active tubular secretion via OAT-3 and so renal function should be monitored.

776

Which of the following is a ‘long acting’ insulin analogue ? N Engl J Med 2005;352:174-83

A.

Insulin detemir

B.

Insulin glulisine

C.

Insulin lispro

D.

Insulin aspart

586 777

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following drugs does not directly cause hypoglycemia ?

Harrison’s 16th Ed. 35

A.

Biguanides

A.

Iron

B.

 glucosidase inhibitors

B.

Calcium

C.

Thiazolidinediones

C.

Folate

D.

All of the above

D.

Vitamin B12

Which of the following drugs is used as monotherapy for type 2 DM ?

Folate supplementation reduces the incidence of fetal neural tube defects, which occur with greater frequency in fetuses of diabetic mothers.

784

Harrison’s 18th Ed. 2995

A.

Metformin

B.

Alpha glucosidase inhibitors

C.

Thiazolidinediones

D.

All of the above

Insulin secretagogues, biguanides, alpha-glucosidase inhibitors, thiazolidinediones, exenatide & insulin are approved for monotherapy of type 2 DM.

779

Which of the following elements potentiates action of insulin ? Harrison’s 17th Ed. 449

A.

Zinc

B.

Copper

C.

Chromium

D.

Selenium

Chromium potentiates action of insulin in those with impaired glucose tolerance by increasing insulin receptor mediated signaling. Rich food sources of chromium include yeast, meat & grain products.

780

Supplementation of which of the following in pregnancy with diabetes mellitus reduces risk of fetal neural tube defects ?

Harrison’s 18th Ed. 2995

Biguanides, alpha-glucosidase inhibitors & thiazolidinediones do not directly cause hypoglycemia.

778

783

Which of the following statements is false ?

Endocrinology

In women with high risk for GDM, screening for glucose intolerance should be done between which weeks of pregnancy ? Harrison’s 18th Ed. 3002

A.

3 & 12

B.

12 & 24

C.

24 & 28

D.

28 & 36

Current recommendations advise screening for glucose intolerance between weeks 24 and 28 of pregnancy in women with high risk for GDM.

785

Leprechaunism is related to ? Harrison’s 18th Ed. 3002

A.

General anesthesia

B.

Lipodystrophy

C.

Bulimia

D.

All of the above

Lipodystrophy, or the loss of subcutaneous fat tissue, may be generalized in the genetic condition leprechaunism. Generalized lipodystrophy is associated with severe insulin resistance and is accompanied by acanthosis nigricans and dyslipidemia.

Harrison’s 18th Ed. 3002

A.

Pregnancy is associated with insulin resistance

B.

High glucose levels are teratogenic to fetus

C.

Insulin crosses placenta

D.

Macrosomia is due to anabolic effects of insulin

Chapter 345. Hypoglycemia 786

Harrison’s 18th Ed. 3003

Pregnancy is associated with marked insulin resistance. Glucose at high levels is a teratogen to developing fetus, readily crosses placenta. Insulin does not cross placenta. Anabolic & growth effects of insulin results in macrosomia.

781

Most crucial period of glycemic control during pregnancy is ? Harrison’s 18th Ed. 3002

A.

Soon after fertilization

B.

Around 3 months

C.

Around 7 months

D.

Intrapartum

For diagnosis of hypoglycemia, Whipple’s triad consists of all except ? A.

History of diabetes mellitus

B.

Hypoglycemic symptoms

C.

Low plasma glucose level

D.

Relief of symptoms after plasma glucose level is raised

Whipple’s triad for diagnosis of hypoglycemia includes symptoms consistent with hypoglycemia, low plasma glucose concentration and relief of symptoms after plasma glucose level is raised.

787

Hepatic glycogen stores are sufficient to maintain plasma glucose levels for ?

Most crucial period of glycemic control is soon after fertilization. The risk of fetal malformations is increased 4 to 10 times in individuals with uncontrolled DM at the time of conception.

Harrison’s 18th Ed. 3003

A.

4 to 6 hours

782

Gestational diabetes is best treated with ?

B.

8 to 12 hours

Harrison’s 16th Ed. 35

C.

24 to 48 hours

D.

72 to 96 hours

A.

Insulin

B.

Metformin

C.

Sulfonylurea

D.

Any of the above

Therapy for GDM involves MNT & insulin, if hyperglycemia persists. Oral glucose-lowering agents have not been approved for use during pregnancy. More data on safety & efficacy of glyburide for management of gestational diabetes are needed before it supplants insulin as treatment agent of choice.

Hepatic glycogen stores are sufficient to maintain plasma glucose levels for 8 to 12 hours.

788

Precursors required for gluconeogenesis include ? Harrison’s 18th Ed. 3003

A.

Lactate

B.

Pyruvate

Endocrinology 587

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

C.

Acetyl CoA

D.

All of the above

Muscle provides lactate, pyruvate, alanine. Triglycerides in adipose tissue are broken down into glycerol. Free fatty acids generate acetyl CoA for gluconeogenesis.

789

790

D.

GLUT-5 is distributed in small intestine, sperm, kidney, brain, adipose cells and muscle. It is characteristically a fructose transporter and has a very low affinity for glucose.

795

A.

GLUT-1

Harrison’s 18th Ed. 3004 Table 345-2

B.

GLUT-2

A.

Decreased Insulin

C.

GLUT-3

B.

Increased Glucagon

D.

GLUT-4

C.

Increased Epinephrine

D.

Increased Cortisol

A.

Fatigue

B.

Hunger

C.

Seizure

D.

Loss of consciousness

Neuroglycopenic symptoms are a direct result of CNS neuronal glucose deprivation that include behavioral changes, confusion, fatigue, seizure, loss of consciousness. Hypoglycemia-induced autonomic responses include adrenergic symptoms like palpitations, tremor, and anxiety while cholinergic symptoms are sweating, hunger, and paresthesia.

GLUT-3 is distributed in neurons and placenta. It is a high-affinity glucose transporter.

796

797

GLUT-1

B.

GLUT-2

C.

GLUT-3

D.

GLUT-4

Fanconi - Bickel syndrome is caused by mutations in which of the following glucose transporters ? N Engl J Med 1999;341:248

Harrison’s 18th Ed. 3005

A.

GLUT-1

A.

Insulin sensitivity is increased

B.

GLUT-2

B.

Influx of exogenous glucose is reduced

C.

GLUT-3

C.

Endogenous glucose production is reduced

D.

GLUT-4

D.

Insulin clearance is reduced

GLUT-2 mutations cause the rare, autosomal recessive Fanconi - Bickel syndrome characterized by hepatic & renal glycogen accumulation, nephropathy & impaired utilization of glucose & galactose.

798

Falling arterial glucose concentrations are sensed by ? N Engl J Med 2004;350:2272-9

GLUT is best described as a ? N Engl J Med 1999;341:248

A.

Brain

A.

Transmembrane protein

B.

Hepatic portal vein

B.

Nuclear protein

C.

Carotid body

C.

Cytoplasmic protein

D.

All of the above

D.

Mitochondrial protein

799

A. B. C. D.

Which of the following GLUT is an insulin-responsive glucose transporter ? A.

GLUT-1

B.

GLUT-2

C.

GLUT-3

D.

GLUT-4

GLUT-4 is the main insulin-responsive glucose transporter, located primarily in muscle cells & adipocytes.

Which of the following GLUT is a fructose transporter ? N Engl J Med 1999;341:248

A.

GLUT-2

B.

GLUT-3

C.

GLUT-4

Which of the following is true about syndrome of hypoglycemia unawareness ? N Engl J Med 2004;350:2272-9

N Engl J Med 1999;341:248

794

A.

Mutations in GLUT-1 are associated with intractable seizures resulting from a reduction in glucose transport across the blood–brain barrier.

Group of glucose transporters (GLUT) consists of five homologous trans-membrane proteins, GLUT-1, 2, 3, 4, and 5 that are encoded by distinct genes.

793

Blood-to-brain glucose transport is facilitated by ? N Engl J Med 2004;350:2272-9

Hypoglycemia following alcohol ingestion is due to ?

Endogenous glucose production is reduced following alcohol ingestion. Ethanol blocks gluconeogenesis but not glycogenolysis.

792

Which of the following GLUT is found in placenta ? N Engl J Med 1999;341:248

Harrison’s 18th Ed. 3005

791

GLUT-5

In hypoglycemia, which of the following is the first physiologic response to falling plasma glucose levels ?

Neuroglycopenic symptoms of hypoglycemia include all except ?

587 Cardiology

Attenuated sympathetic neural response Attenuated adrenomedullary response Loss of neurogenic warning symptoms All of the above

Periods of relative or absolute therapeutic insulin excess leading to falling glucose concentrations, with absent counterregulatory glucagon responses, reduced autonomic responses, reduced epinephrine responses cause hypoglycemia unawareness.

800

Syndrome of hypoglycemia unawareness can be reversed by ? Harrison’s 18th Ed. 3006

A. B. C. D.

>1 week of scrupulous avoidance of hypoglycemia >1 week of scrupulous avoidance of hyperglycemia >2 weeks of scrupulous avoidance of hypoglycemia >2 weeks of scrupulous avoidance of hyperglycemia

Syndrome of hypoglycemia unawareness can be reversed by >2 weeks of scrupulous avoidance of hypoglycemia.

588 801

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following statements about postprandial (reactive) hypoglycemia is false ?

807

802

A.

Fasting plasma insulin >= 6 µU/mL

A.

Occurs only after meals

B.

Fasting plasma C-peptide >= 0.6 ng/mL

B.

Self-limited

C.

Fasting plasma glucose 100 million sperm per day.

868

“Prader orchidometer” is used to measure ?

A.

D.

867

Eunuchoid proportions are defined as an arm span >2 cm greater than height & suggest that androgen deficiency occurred before epiphyseal fusion.

873

Harrison’s 18th Ed. 3012

593 Cardiology

A.

IV administration of 100 µg of GnRH

B.

Measure LH & FSH at baseline

Which of the following is an androgen-dependent event ?

C.

Measure LH & FSH at 30 & 60 min

Harrison’s 18th Ed. 3013

D.

Acceptable response is a twofold increase in LH & FSH

A.

Early morning erections

B.

Frequency & intensity of sexual thoughts

C.

Frequency of masturbation or intercourse

D.

All of the above

In eunuchoid proportions, which of the following is true ? Harrison’s 18th Ed. 3013

A.

Arm span is less than height

The GnRH test is performed by measuring LH and FSH concentrations at baseline and at 30 & 60 minutes after IV administration of 100 g of GnRH. A minimally acceptable response is a twofold LH increase and a 50% FSH increase.

878

Range of testosterone in healthy young men is ? Harrison’s 18th Ed. 3013

A.

50 to 180 ng/dL

B.

180 to 225 ng/dL

594

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

225 to 300 ng/dL

C.

11 years

D.

300 to 1000 ng/dL

D.

12 years

Endocrinology

Testosterone concentration in healthy young men ranges from 300 to 1000 ng/dL. Alterations in SHBG levels can affect total testosterone levels.

Puberty in boys before age 9 years is considered precocious. Precocity can be isosexual or heterosexual. Isosexual precocity can be gonadotropin-dependent or gonadotropin-independent.

879

885

Bioavailable testosterone refers to ? Harrison’s 18th Ed. 3013

Which of the following is false about central precocious puberty (CPP) ?

A.

Total testosterone

Harrison’s 18th Ed. 3014

B.

Unbound testosterone + testosterone bound to albumin

A.

Gonadotropin-Dependent

C.

Unbound testosterone

B.

Less common in boys than in girls

D.

Testosterone bound to albumin

C.

Elevated gonadotropin levels

D.

None of the above

Bioavailable testosterone refers to unbound testosterone + testosterone loosely bound to albumin.

880

What proportion of circulating testosterone is unbound or free ? Harrison’s 18th Ed. 3013

A.

0.05 to 0.3 %

B.

0.3 to 0.8 %

C.

0.5 to 3 %

D.

2.5 to 8 %

CPP is caused by premature activation of GnRH pulse generator and is characterized by gonadotropin levels that are inappropriately elevated for age. Because pituitary priming has occurred, GnRH elicits LH & FSH responses typical of those seen in puberty or in adults.

886

Harrison’s 18th Ed. 3014 Table 346-1

Most circulating testosterone is bound to SHBG & to albumin. Only 0.5 - 3% of circulating testosterone is unbound or “free”.

881

Which of the following about hCG stimulation test is false ? Harrison’s 18th Ed. 3014

A.

Administer 150 to 400 IU of hCG intramuscularly

B.

Measure testosterone levels at 0,24, 48, 72 & 120 hours

C.

In adult men, acceptable response is a doubling of testosterone concentration

D.

In prepubertal boys, an increase in testosterone to >150 ng/dL indicates the presence of testicular tissue

Which of the following is measured to detect presence of testes in prepubertal boys with cryptorchidism ? Harrison’s 18th Ed. 3014

A.

Inhibin B

B.

Müllerian inhibiting substance (MIS)

C.

Testosterone

D.

All of the above

887

A.

1 to 3 mL

B.

2 to 6 mL

C.

5 to 8 mL

D.

8 to 10 mL

The normal ejaculate volume is 2 - 6 mL & contains sperm counts of >20 million/mL, with a motility of >50% and >15% normal morphology.

884

Puberty in boys before what age is considered precocious ? Harrison’s 18th Ed. 3014

A.

9 years

B.

10 years

Hyperthyroidism

C.

Congenital adrenal hyperplasia

D.

McCune-Albright syndrome

Which of the following disorders is also called testotoxicosis ? A.

McCune-Albright syndrome

B.

Familial male-limited precocious puberty

C.

Congenital adrenal hyperplasia

D.

None of the above

Familial male-limited precocious puberty is also called testotoxicosis. It is an autosomal dominant disorder due to activating mutations in LH receptor leading to increased testosterone production. Testosterone levels are elevated and LH is suppressed.

888

Treatment options for familial male-limited precocious puberty include ? Harrison’s 18th Ed. 3015

Normal semen ejaculate volume is ? Harrison’s 18th Ed. 3014

hCG-secreting tumors

B.

Harrison’s 18th Ed. 3015

Measurement of MIS, a Sertoli cell product, is estimated to detect the presence of testes in prepubertal boys with cryptorchidism.

883

A.

Gonadotropin-independent causes of precocious puberty in boys are congenital adrenal hyperplasia, hCG -secreting tumor, McCune-Albright syndrome, hypothyroidism, activating LH receptor mutation & exogenous androgens. Androgens from the testis or the adrenal are high.

Administer 1500 to 4000 IU of hCG intramuscularly.

882

Which of the following is not a cause of gonadotropin-independent precocious puberty in boys ?

A.

Ketoconazole

B.

Flutamide

C.

Anastrazole

D.

All of the above

Treatment options for familial male-limited precocious puberty include inhibitors of testosterone synthesis (ketoconazole), androgen receptor antagonists (flutamide) & aromatase inhibitors (anastrazole).

889

Which of the following skin lesion is characteristic of McCuneAlbright syndrome ? Harrison’s 18th Ed. 3015

A.

Erythroderma

B.

Café au lait spots

C.

Telangiectasia

D.

Scarring alopecia

Cafe-au-lait spots are characteristic skin lesions and reflect the onset of somatic mutations in melanocytes during embryonic development.

Endocrinology 595 890

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

In McCune-Albright syndrome, mutation occurs in which of the following ? Harrison’s 18th Ed. 3015

A.

Gsalpha subunit

B.

Gsbeta subunit

C.

Gsgamma subunit

D.

Gsdelta subunit

896

Harrison’s 18th Ed. 3015

Chronic ACTH stimulation

B.

Low LH

C.

Small testes

D.

None of the above

897

Boys with CAH if untreated with adequate glucocorticoid suppression of ACTH can develop premature virilization because of excessive androgen production by adrenal gland. LH is low & testes are small.

892

Hypergonadotropic hypogonadism secondary to primary gonadal failure

Which of the following is the most common cause of delayed puberty ? A.

Constitutional delay

B.

Functional hypogonadotropic hypogonadism due to systemic illness or malnutrition

C.

Hypogonadotropic hypogonadism due to genetic or acquired defects in hypothalamic-pituitary region

D.

Hypergonadotropic hypogonadism secondary to primary gonadal failure

Constitutional delay in puberty should be suspected when there is ? A.

Positive family history

Harrison’s 18th Ed. 3015

B.

Delayed bone age

A.

Familial aromatase excess

C.

Short stature

B.

Marijuana smoking

D.

All of the above

C.

Sertoli cell tumors in the testis

D.

All of the above

Constitutional delay should be suspected when there is a family history, evidence of delayed bone age & short stature.

898

In children with gonadotropin-independent precocious puberty, which of the following is not useful ? A.

Ketoconazole

B.

Long-acting GnRH analogues

C.

Spironolactone

D.

Testolactone

899

Harrison’s 18th Ed. 3016

B.

15

C.

16

D.

18

X-linked

B.

Autosomal recessive

C.

Autosomal dominant

D.

Autosomal codominant

What testicular length generally indicates that the child has entered puberty ? Harrison’s 18th Ed. 3016

Puberty is considered delayed in boys if it has not happend by the age of ? 14

A.

Testotoxicosis or familial male-limited precocious puberty is an autosomal dominant disorder.

Long-acting GnRH analogues can be used to suppress gonadotropins in gonadotropin-dependent precocious puberty. Ketoconazole inhibits steroidogenesis, spironolactone is a weak androgen antagonist and testolactone and letrozole are aromatase inhibitor.

A.

Familial hypogonadotropic hypogonadism is transmitted most commonly as ? Harrison’s 18th Ed. 3015

Harrison’s 18th Ed. 3015

894

D.

Harrison’s 18th Ed. 3016

Breast enlargement in prepubertal boys can result from ?

Breast enlargement in prepubertal boys can result from familial aromatase excess, estrogenproducing tumors in adrenal gland, Sertoli cell tumors in testis, marijuana smoking, or exogenous estrogens or androgens and germ cell tumors that secrete hCG.

893

Hypogonadotropic hypogonadism caused by genetic or acquired defects in the hypothalamic-pituitary region

Harrison’s 18th Ed. 3016

Which of the following is false about congenital adrenal hyperplasia (CAH) ? A.

C.

Delayed puberty is more common in boys than in girls. But, functional hypogonadotropic hypogonadism is more common in girls than in boys.

McCune-Albright syndrome is caused by somatic activating mutations in G s subunit that links G protein-coupled receptors to intracellular signaling pathways. Mutations impair GTP activity of the Gs protein, leading to constitutive activation of adenylyl cyclase and stimulates testosterone production leading to gonadotropin-independent precocious puberty.

891

595 Cardiology

A.

> 1.5 cm

B.

> 2.0 cm

C.

> 2.5 cm

D.

> 3.5 cm

Testicular size >2.5 cm generally indicates that the child has entered puberty.

900

Kallmann syndrome is transmitted as ? Harrison’s 18th Ed. 3017

A.

X-linked

Puberty is delayed in boys if it has not ensued by age 14 years.

B.

Autosomal recessive

895

C.

Autosomal dominant

D.

Autosomal codominant

Which of the following categories of delayed puberty is more common in girls than in boys ? Harrison’s 18th Ed. 3016

A.

Constitutional delay of growth and puberty

B.

Functional hypogonadotropic hypogonadism caused by systemic illness or malnutrition

901

Kallmann syndrome is due to mutation in which gene ? Harrison’s 18th Ed. 3017

A.

KAL1

596

902

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

KAL2

C.

GPR54

D.

DAX1

908

Harrison’s 18th Ed. 3017

Kalmin

B.

Anosmin

C.

Migrin

D.

Neurokinin

909

904

A.

Obesity

B.

Hypotonic musculature

C.

Tall stature

D.

Mental retardation

910

Cytokine and/or glucocorticoid effects

D.

All of the above

Which of the following is false in obesity ? A.

Decrease in SHBG levels

B.

Normal free testosterone levels

C.

Higher estradiol levels

D.

None of the above

Which of the following is a cause of hypogonadism ? Harrison’s 18th Ed. 3018

Pituitary adenoma

Prader-Willi syndrome is characterized by all except ?

B.

Craniopharyngioma

Harrison’s 18th Ed. 3017

C.

Hemochromatosis

A.

Hypogonadism

D.

All of the above

B.

Lean and thin constitution

C.

Short stature

D.

Small hands and feet

Pituitary adenomas can cause hypogonadism by extension into suprasellar region & impairing GnRH secretion & mildly increasing PRL secretion. Craniopharyngioma should be suspected when sellar mass, diabetes insipidus, hypogonadism coexist. In hemochromatosis, pituitary is affected more than testis by excessive iron deposition leading to hypogonadism.

911

Hypogonadism can be caused by ? Harrison’s 18th Ed. 3018

Laurence-Moon syndrome is transmitted as ?

A.

Anorchia syndrome

B.

Myotonic dystrophy Klinefelter syndrome All of the above

A.

X-linked

C.

B.

Autosomal recessive

D.

C.

Autosomal dominant

D.

Autosomal codominant

Laurence-Moon syndrome is characterized by all except ?

Neurologic diseases associated with altered testicular function are myotonic dystrophy, spinobulbar muscular atrophy, and paraplegia.

912

A.

Obesity

B.

Hypogonadism

C.

Short stature

D.

Mental retardation

Laurence-Moon syndrome is characterized by all except ? Harrison’s 18th Ed. 3017

The occurrence of Klinefelter syndrome is ? Harrison’s 18th Ed. 3018

Harrison’s 18th Ed. 3017

907

Decreased GnRH secretion

C.

In obesity, SHBG levels decrease due to inhibitory effect of increased circulating insulin resulting in lower total testosterone levels but not free testosterone levels. Estradiol levels are elevated due to aromatization of testosterone to estradiol in adipose tissue.

Harrison’s 18th Ed. 3017

906

B.

A.

Prader-Willi syndrome is characterized by obesity, hypotonic musculature, mental retardation, hypogonadism, short stature & small hands & feet. Prader-Willi syndrome is a genomic imprinting disorder.

905

Androgen deficiency

Harrison’s 18th Ed. 3018

Prader-Willi syndrome is characterized by all except ? Harrison’s 18th Ed. 3017

A.

Mechanism of marijuana-induced hypogonadism is decreased GnRH secretion. Gynecomastia in marijuana users is caused by plant estrogens in crude preparations.

Kallmann syndrome is an X-linked disorder due to mutations in KAL1 gene, which encodes anosmin, a protein that mediates migration of neural progenitors of the olfactory bulb & GnRH-producing neurons. These individuals have GnRH deficiency and variable combinations of anosmia or hyposmia, renal defects, and neurologic abnormalities including mirror movements.

903

Mechanism of marijuana-induced hypogonadism is ? Harrison’s 18th Ed. 3017

KAL1 gene encodes which of the following ? A.

A.

1 in 1000 live-born males

B.

1 in 10000 live-born males

C.

1 in 100000 live-born males

D.

1 in 1000000 live-born males

Klinefelter syndrome is the most common chromosomal disorder associated with testicular dysfunction & male infertility. It occurs in ~ 1 in 1000 live-born males.

913

Which of the following is a feature of Klinefelter syndrome ?

A.

Polydactyly

B.

Retinitis pigmentosa

A.

Gynecomastia

C.

Mental retardation

B.

Decreased Testosterone

D.

Small hands and feet

C.

Increased estradiol

D.

All of the above

Laurence-Moon syndrome is an autosomal recessive disorder characterized by obesity, hypogonadism, mental retardation, polydactyly & retinitis pigmentosa. Recessive mutations of leptin, or its receptor, cause severe obesity & pubertal arrest because of hypothalamic GnRH deficiency.

Endocrinology

Harrison’s 18th Ed. 3018

Azoospermia is the rule in men with Klinefelter syndrome (47,XXY). Testicular histology shows absence of spermatogenesis. Number of Leydig cells is increased. Testosterone is decreased & estradiol is increased, leading to undervirilization & gynecomastia.

Endocrinology 597 914

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Men with Klinefelter syndrome are at a reduced risk of ?

B.

SF1

Harrison’s 18th Ed. 3018

C.

SOX9

D.

All of the above

A.

Breast cancer

B.

Non-Hodgkin’s lymphoma

C.

Lung cancer

D.

Prostate cancer

922

Gonadal dysgenesis & primary adrenal failure occurs due to mutations in which of the following genes ? Harrison’s 16th Ed. 2218

Men with Klinefelter syndrome are at increased risk of breast cancer, non-Hodgkin’s lymphoma & lung cancer but reduced risk of prostate cancer.

A.

WT1

B.

SOX9

915

Genotype in classic form of Klinefelter syndrome is ?

C.

SF1

Harrison’s 18th Ed. 3018

D.

All of the above

916

917

918

919

A.

47,XXY

B.

46,XY

C.

47, XXY

D.

48,XXYY

923

Harrison’s 16th Ed. 2218

WT1

Hormone profile in Klinefelter syndrome includes all except ?

B.

SOX9

Harrison’s 18th Ed. 3018

C.

SF1

A.

Increased FSH

D.

All of the above

B.

Increased LH

C.

Decreased estradiol

D.

Decreased testosterone

924

A.

Mumps virus

Clinical features of Klinefelter syndrome includes all except ?

B.

Echovirus

Harrison’s 18th Ed. 3018

C.

Lymphocytic choriomeningitis virus

A.

Gynecomastia

D.

All of the above

B.

Normal sized testes

C.

Infertility

D.

Eunuchoid features

Viral orchitis may be caused by mumps virus, echovirus, lymphocytic choriomeningitis virus & group B arboviruses.

925

Orchitis occurs in what percentage of adult men with mumps ?

Which of the following is the most frequent karyotype in Turner syndrome (TS) ?

Harrison’s 18th Ed. 3018

A.

10 %

Harrison’s 16th Ed. 2215

B.

25 %

A.

45,X

C.

50 %

B.

46,XX

D.

75 %

C.

45,X

D.

X fragments

A.

Phenotypic females

B.

Short stature

C.

Primary amenorrhea

D.

Gynecomastia

In an adult female with Turner syndrome, which of the following is not found ? Harrison’s 16th Ed. 2216

921

Viral orchitis may be caused by ? Harrison’s 18th Ed. 3018

Orchitis occurs in as many as one-fourth of adult men with mumps.

926

A.

Hypertension

B.

Osteoporosis

C.

Chronic pancreatitis

D.

Inflammatory bowel disease

Gonadal dysgenesis & renal dysfunction occurs due to mutations in which of the following genes ? Harrison’s 16th Ed. 2218

A.

WT1

At what dose of radiation, oligospermia or azoospermia develops ? Harrison’s 18th Ed. 3019

Harrison’s 16th Ed. 2215

920

Gonadal dysgenesis & campomelic dysplasia occurs due to mutations in which of the following genes ? A.

Turner syndrome is characterized by all except ?

597 Cardiology

A.

20 rad

B.

40 rad

C.

60 rad

D.

80 rad

Radiation dose of 20 rad damages spermatogonia resulting in increased FSH & LH levels. Higher dose (80 rad) causes azoospermia. After therapeutic radiation, permanent androgen deficiency is uncommon.

927

Which of the following inhibits testosterone synthesis ? Harrison’s 18th Ed. 3019

928

A.

Spironolactone

B.

Ketoconazole

C.

Marijuana

D.

All of the above

Which of the following blocks androgen action ? Harrison’s 18th Ed. 3019

A.

Spironolactone

598

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Ketoconazole

B.

> 2 cm

C.

Marijuana

C.

> 3 cm

D.

All of the above

D.

> 4 cm

Ketoconazole inhibits testosterone synthesis, spironolactone blocks androgen action, marijuana increases estrogen and chemotherapy directly inhibits spermatogenesis.

929

Pituitary tumors in Carney complex secrete which of the following hormones ?

930

935

Gynecomastia occurs as a normal physiologic phenomenon in ? Harrison’s 18th Ed. 3019

A.

GH

A.

Newborn

B.

Prolactin

B.

During puberty

C.

ACTH

C.

With aging

D.

Vasopressin

D.

All of the above

Which of the following tumors occur in Carney complex ? Harrison’s 18th Ed. 3019

Glandular breast tissue is firmer, contains fibrous-like cords & is often tender. Prevalence of gynecomastia increases with age & BMI because of increased aromatase activity in adipose tissue that converts adrenal and gonadal androgens and its precursors to estrogen.

936

Drugs that can cause gynecomastia include all except ?

A.

Testicular

Harrison’s 18th Ed. 3019

B.

Adrenal

A.

Digitalis

C.

Pituitary

B.

Quinidine

D.

All of the above

C.

Ketoconazole

D.

Spironolactone

Carney complex is characterized by spotty skin pigmentation, myxomas, and testicular, adrenal, and pituitary tumors.

931

Gynecomastia means enlargement of male breast glandular tissue & not excess adipose tissue. Ratio of estrogen/androgen is increased. True gynecomastia is associated with glandular breast tissue that is >4 cm in diameter & often tender.

Harrison’s 18th Ed. 3019

Acromegaly occurs in about 20% of patients of Carney complex.

In Carney syndrome, mutation occurs in which of the following gene ?

Digitalis acts directly as estrogenic substance, ketoconazole inhibits androgen synthesis, and spironolactone inhibits androgen action.

937

Which of the following conditions do not cause galactorrhea ?

Harrison’s 16th Ed. 2081

Harrison’s 15th Ed. Chapter 337

A.

PRKA1A

A.

Bronchogenic carcinoma

B.

PRKA1B

B.

Hypernephroma

C.

PRKA1C

C.

Choriocarcinoma

D.

PRKA1D

D.

Pancreatic carcinoma

Carney syndrome patients have mutations in the R1  regulatory subunit of protein kinase A (PRKAR1A) on chromosome 17q.

Endocrinology

938

Which of the following drugs do not cause galactorrhoea ? Harrison’s 15th Ed. Chapter 337

932

Which of the following is a feature of Carney syndrome ?

A.

Metoclopramide

Harrison’s 18th Ed. 3019

B.

Sertraline

C.

Atenolol

D.

Verapamil

A.

Myxoma

B.

Colour blindness

C.

Flat foot

D.

Hypothyroidism

939

Which of the following drugs do not cause galactorrhoea ? Harrison’s 15th Ed. Chapter 337

Carney syndrome is characterized by myxomas of heart, skin, and breast.

A.

Reserpine

933

Which of the following is not a feature of Peutz-Jeghers syndrome ?

B.

Paroxetine

Harrison’s 16th Ed. 302, 553

C.

Methyldopa

D.

Metformin

A.

Mucocutaneous pigmentation

B.

Intestinal polyps

C.

Leydig cell tumors in men

D.

Ovarian sex cord stromal tumors

Sertoli cell tumor in men is a feature of the autosomal dominant Peutz-Jeghers syndrome. Lentigines in these patients are located around nose & mouth, hands and feet, and oral cavity. Gastrointestinal polyps may become malignant.

934

What should be the diameter of glandular breast tissue in true gynecomastia ? Harrison’s 18th Ed. 3019

A.

> 1 cm

940

Which of the following endocrine conditions can cause galactorrhoea ? Harrison’s 15th Ed. Chapter 337

A.

Cushing’s disease

B.

Hyperthyroidism

C.

Hypothyroidism

D.

All of the above

Endocrinology 599 941

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Gynecomastia of digitalis ingestion occurs most commonly in men with ?

B.

Harrison’s 15th Ed. Chapter 337

942

A.

Abnormal liver function

B.

Abnormal kidney function

C.

Abnormal cardiac function

D.

All of the above

949

Harrison’s 15th Ed. Chapter 337

943

Clomiphene

B.

Ketoconazole

C.

Spironolactone

D.

Rifampin

950

Harrison’s 15th Ed. Chapter 337

944

Cimetidine

B.

Omeprazole

C.

Ranitidine

D.

Metoclopramide

951

Harrison’s 15th Ed. Chapter 337

945

Methyldopa

B.

Calcium channel blocking agents

C.

Angiotensin-converting enzyme inhibitors

D.

Beta blockers

952

Harrison’s 15th Ed. Chapter 337

946

Tricyclic antidepressants

B.

Sibutramine

C.

Antiretroviral agents

D.

Penicillamine

953

Harrison’s 16th Ed. 2192

947

Sertoli cell

B.

Peutz-Jegher syndrome

C.

Carney complex

D.

All of the above

954

A.

Domperidone

B.

Methyldopa

C.

Tricyclic antidepressants

D.

Clomiphene

Gynecomastia is not caused by ? A.

Calcium channel antagonists

B.

Digitalis

C.

Testosterone

D.

Metoclopramide

Hyperglycemia is not caused by ? A.

Chlorthalidone

B.

HIV-protease inhibitors

C.

Phenytoin

D.

ACE inhibitors

Hyperkalemia is not caused by ? A.

ACE inhibitors

B.

Heparin

C.

Lithium

D.

Theophylline

Which of the following is an aromatase inhibitor ? A.

Anastrazole

B.

Fadrozole

C.

Fromestane

D.

All of the above

Fetuses with which of the following chromosomal pattern are not viable ? Harrison’s 16th Ed. 2214

Drug that causes gynecomastia by acting directly as estrogenic substance is ? Harrison’s 16th Ed. 2192

948

Galactorrhea is not caused by ?

Harrison’s 16th Ed. 2193

Excess estrogen production may be caused by tumors in association with ? A.

Streptomycin

Harrison’s 15th Ed. Table 71-2

Drug-induced gynecomastia is due to all except ? A.

Insulin

D.

Harrison’s 15th Ed. Table 71-2

Drug-induced gynecomastia is due to all except ? A.

C.

Harrison’s 15th Ed. Table 71-2

Drug-induced gynecomastia is due to all except ? A.

Intravenous immune globulin

Harrison’s 15th Ed. Table 71-2

Drug-induced gynecomastia is due to all except ? A.

A.

47,XXY

B.

48,XXXY

C.

45,X

D.

45,Y

A.

Oral contraceptive

B.

Phytoestrogen

Harrison’s 16th Ed. 2214

C.

Digitalis

A.

Leydig cells

D.

All of the above

B.

Sertoli cells

C.

Ovarian follicles

D.

All of the above

955

Which of the following drugs is known to cause anaphylaxis and angioedema ? Harrison’s 15th Ed. Table 71-2

A.

ACE inhibitors

599 Cardiology

956

Anti-mullerian hormone (AMH) is secreted by ?

Wolffian structures include all except ? Harrison’s 16th Ed. 2215

600

957

958

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR A.

Epididymides

B.

> 150 ng/dL

B.

Vasa deferentia

C.

> 250 ng/dL

C.

Seminal vesicles

D.

> 350 ng/dL

D.

Prostate

Harrison’s 16th Ed. 2215

A.

Early-morning

A.

Fallopian tubes

B.

Noon

B.

Uterus

C.

Evening

C.

Upper vagina

D.

Midnight

D.

Lower vagina

Prostate develops from ?

Suspicion of androgen deficiency prompts measurement of total testosterone, preferably in morning. Total testosterone level 350 ng/dL makes diagnosis of androgen deficiency unlikely.

965

Genital tubercle

B.

Urogenital sinus

A.

Klinefelter syndrome

C.

Urogenital swelling

B.

HIV infection

D.

All of the above

C.

Hemochromatosis

D.

Prior infectious orchitis

Harrison’s 18th Ed. 3021

Aromatase inhibitors include all except ? 966

Tamoxifen

B.

Anastrazole

C.

Testolactone

A.

Klinefelter syndrome

D.

Fromestane

B.

Cancer chemotherapeutic agents

Which of the following statements about age related hormone status is false ? Harrison’s 18th Ed. 3020

Harrison’s 18th Ed. 3021

A.

Testosterone levels decrease with age

B.

SHBG levels are higher in older men

C.

Gradual rise of LH levels with age

D.

None of the above

967

Achondroplasia

B.

Polyposis coli

C.

Marfan syndrome

D.

All of the above

968

Harrison’s 18th Ed. 3021

963

A.

< 300 ng/dL

B.

< 400 ng/dL

C.

< 600 ng/dL

D.

< 800 ng/dL

Hyperprolactinemia

Which of the following is not a cause of acquired hypogonadotropic hypogonadism ? A.

Space-occupying lesions of sella

B.

Hyperprolactinemia

C.

Hemochromatosis

D.

Prior infectious orchitis

Which of the following is not a cause of acquired hypogonadotropic hypogonadism ? Harrison’s 18th Ed. 3021

Incidence of autosomal dominant diseases like achondroplasia, polyposis coli, Marfan syndrome & Apert’s syndrome increases in offspring of men who are advanced in age (sporadic missense mutations).

In a patient with symptoms or signs of androgen deficiency, what level of total testosterone denotes testosterone deficiency ?

Prior infectious orchitis

D.

Harrison’s 18th Ed. 3021

Which of the following diseases increase in occurrence in offspring of men who are advanced in age ? A.

C.

Common causes of primary testicular dysfunction include Klinefelter syndrome, uncorrected cryptorchidism, cancer chemotherapy, radiation to testes, trauma, torsion, infectious orchitis, HIV infection, anorchia syndrome & myotonic dystrophy.

Harrison’s 18th Ed. 3021

962

Which of the following is not a cause of primary testicular failure ?

A.

Tamoxifen is an antiestrogen. Testolactone is a relatively weak aromatase inhibitor.

961

Which of the following is not a cause of primary testicular failure ?

A.

Harrison’s 16th Ed. 2193

960

Samples for testosterone estimation are obtained in ? Harrison’s 18th Ed. 3021

Mullerian ducts forms all except ?

Harrison’s 16th Ed. 2215

959

964

A.

Chronic illness

B.

Excessive exercise

C.

Substance abuse

D.

Uncorrected cryptorchidism

Common causes of acquired secondary hypogonadism include space-occupying lesions of the sella, hyperprolactinemia, chronic illness, hemochromatosis, excessive exercise, and substance abuse.

969

Human menopausal gonadotropin (hMG) contains ? Harrison’s 18th Ed. 3022

A.

FSH

B.

LH

What level of total testosterone excludes testosterone deficiency ?

C.

FSH & LH

Harrison’s 18th Ed. 3021

D.

None of the above

A.

> 50 ng/dL

Endocrinology

Endocrinology 601 970

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Human menopausal gonadotropin (hMG) is derived from which of the following of postmenopausal women ?

976

971

972

Test for assessing the adequacy of testosterone replacement is ? Harrison’s 18th Ed. 3024

Harrison’s 18th Ed. 3022

A.

Measurements of testosterone levels

A.

Urine

B.

Measurements of LH

B.

Blood

C.

Measurements of FSH

C.

Saliva

D.

All of the above

D.

Any of the above

Human menopausal gonadotropin (hMG) is purified from urine of postmenopausal women and contains FSH & LH.

601 Cardiology

LH & FSH estimation are not useful in assessing adequacy of testosterone replacement. Testosterone should be measured 3 months after initiating therapy to assess adequacy of therapy.

Which of the following is useful in restoring spermatogenesis ?

Most frequent adverse event reported in testosterone trials in middle-aged and older men is ?

Harrison’s 18th Ed. 3022

Harrison’s 18th Ed. 3025

A.

FSH

A.

Rise in PSA levels

B.

LH

B.

Erythrocytosis

C.

hCG

C.

Cholestasis

D.

All of the above

D.

Pruritis

When drugs are used to restore spermatogenesis, testosterone levels should be raised to ?

977

Erythrocytosis is the most frequent adverse event reported in testosterone trials in middleaged and older men and is also the most frequent cause of treatment discontinuation in these trials.

Harrison’s 18th Ed. 3022

A.

Low-normal range

B.

Mid-normal range

C.

High-normal range

D.

Any of the above

978

Harrison’s 18th Ed. 3026

Drugs used to restore spermatogenesis should bring testosterone levels into the mid-normal range.

973

After 6 months of hCG alone therapy, if testosterone levels are in mid-normal range and sperm concentrations are low, which of the following should be done ? Harrison’s 18th Ed. 3022

A.

Increase dose of hCG

B.

Add LH

C.

Add FSH

D.

Any of the above

Androgenic steroids used by athletes is ? A.

Nandrolone

B.

Stanozolol

C.

Methandienone

D.

All of the above

Commonly used androgenic steroids by athletes include testosterone esters, nandrolone, stanozolol, methandienone & methenolol.

979

In athletes, stacking refers to ? Harrison’s 18th Ed. 3026

A.

Withdrawal symptoms of androgenic steroids

B.

Increasing doses of single androgenic steroid

C.

Increasing doses of multiple androgenic steroids

D.

Rage reactions with of androgenic steroids

FSH is available as hMG, highly purified urinary hFSH, or recombinant hFSH. Athletes use increasing doses of multiple steroids in a practice known as stacking.

974

Which of the following is a mandatory requirement of GnRH therapy ?

Muscle-building or performance-enhancing agents include ? Harrison’s 18th Ed. 3026

A.

Documented GnRH deficiency

A.

IGF-1

B.

Normal pituitary function

B.

Insulin

C.

Normal testicular function

C.

Thyroxine

All of the above

D.

All of the above

D.

In documented GnRH deficiency, both pubertal development & spermatogenesis can be successfully induced by pulsatile administration of low doses of GnRH. This response requires normal pituitary & testicular function.

975

980

Harrison’s 18th Ed. 3022

Drugs perceived to be muscle-building or performance-enhancing include growth hormone, IGF1, insulin, amphetamine, clenbuterol, ephedrine and thyroxine.

981

Method for detecting androgen abuse is ?

Androgen therapy can be given in all except ?

Harrison’s 18th Ed. 3027

Harrison’s 18th Ed. 3024

A.

Gas chromatography-mass spectrometry

A.

Bone marrow failure

B.

Liquid chromatography-mass spectrometry

B.

Hereditary angioedema

C.

High-resolution mass spectrometry

C.

Endometriosis

D.

All of the above

D.

Sleep apnea

Testosterone should not be given in prostate cancer, benign prostatic hypertrophy, to men with baseline hematocrit >=50% and sleep apnea syndrome.

Gas chromatography-mass spectrometry, liquid chromatography-mass spectrometry, highresolution mass spectrometry and tandem mass spectrometry are of use in detecting androgen abuse.

602 982

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Illicit testosterone use is detected by measurement of ? Harrison’s 18th Ed. 3027

A.

Urinary testosterone

B.

Urinary epitestosterone

C.

Urinary testosterone to epitestosterone ratio

D.

Urinary testosterone to serum testosterone ratio

D.

Illicit testosterone use is confirmed by measurement of ?

989

B.

Number of neonatal deaths per 1000 live births

C.

Number of neonatal deaths per 10000 live births

D.

Number of neonatal deaths per 100000 live births

Urinary 13C : 12C ratio in testosterone

Perinatal mortality rate refers to ? A. Number of neonatal deaths per 1000 total births

B.

Urinary 11C : 12C ratio in testosterone

B.

Number of stillbirths + neonatal deaths per 1000 total births

C.

Urinary C : C ratio in testosterone

C.

Number of neonatal deaths per 10000 total births

D.

Urinary C : C ratio in testosterone

D.

Number of stillbirths + neonatal deaths per 10000 total births

10 9

990

Neonatal mortality rate refers to ? A. Number of neonatal deaths per 100 live births

A.

Harrison’s 18th Ed. 3027

11

10

Exogenous testosterone use is confirmed by estimating 13C : 12C ratio in testosterone by isotope ratio combustion mass spectrometry. Synthetic testosterone has a lower 13C : 12 C ratio than endogenously produced testosterone.

Perinatal mortality rate is number of stillbirths + neonatal deaths per 1000 total births.

991

Chapter 347. The Female Reproductive System, Infertility, and Contraception 984

Death after 7 days but before 42 days

Early neonatal death refers to death of a liveborn neonate during the first 7 days after birth. Late neonatal death refers to death after 7 days but before 29 days.

Exogenous testosterone administration increases urinary testosterone glucuronide excretion & consequently testosterone to epitestosterone ratio. Ratios > 6 suggest exogenous testosterone use.

983

Endocrinology

Fetuses weighing less than what are termed abortuses ? A. 500 grams

Infant death refers to all deaths of liveborn infants from birth to ? A. 3 months of age B.

6 months of age

C.

9 months of age

D.

12 months of age

Infant death refers to all deaths of liveborn infants from birth to 12 months of age.

992

Infant mortality rate is the number of infant deaths per A. 100 live births

B.

600 grams

C.

750 grams

B.

1000 live births

D.

1000 grams

C.

10000 live births

D.

100000 live births

Fetuses weighing < 500 grams are not considered as births, but are termed abortuses for purposes of vital statistics.

Infant mortality rate is the number of infant deaths per 1000 live births.

985

986

Birth rate is expressed as ? A. Number of live births per 1000 population B.

Number of live births per 10000 population

C.

Number of live births per 100000 population

D.

Number of live births per 1000000 population

993

988

B.

1000 grams

C.

1500 grams

D.

2500 grams

Fertility rate of females is calculated between what age range ? A. 15 to 40 years

Low-birthweight is a newborn whose weight is less than 2500 grams.

B.

15 to 44 years

994

C.

15 to 46 years

Very low-birthweight is a newborn whose weight is less than ? A. 500 grams

D.

15 to 48 years

B.

1000 grams

C.

1500 grams

D.

2500 grams

Fertility rate of females is the number of live births per 1000 females aged 15 through 44 years.

987

Low-birthweight is a newborn whose weight is less than ? A. 500 grams

Early neonatal death refers to ? A. During the first day after birth

Very low-birthweight is a newborn whose weight is less than 1500 grams.

B.

During the first 3 days after birth

995

C.

During the first 7 days after birth

D.

During the first 10 days after birth

Late neonatal death refers to ? A. Death after 7 days but before 14 days B.

Death after 7 days but before 21 days

C.

Death after 7 days but before 29 days

Extremely low-birthweight is a newborn whose weight is less than ? A. 500 grams B.

1000 grams

C.

1500 grams

D.

2500 grams

Extremely low-birthweight is a newborn whose weight is less than 1000 grams.

Endocrinology 603 996

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Term neonate is a neonate born after how many days of pregnancy ? A. 245 to 284 days

C.

Women require lower doses of neuroleptics to control schizophrenia

B.

252 to 290 days

D.

Women have lower frequency of adverse drug reactions than men

C.

260 to 294 days

D.

268 to 298 days

1003

Preterm neonate is a neonate born before how many days of pregnancy ? A. 248 days B.

252 days

C.

259 days

D.

261 days

1004

Post-term neonate is a neonate born on or after how many days of pregnancy ? A. 294 days B.

295 days

C.

296 days

D.

297 days

1005

18 weeks of gestation

C.

20 weeks of gestation

D.

22 weeks of gestation

1006

Maternal mortality ratio is the number of maternal deaths that result from reproductive process per ? A. 1000 live births B.

10000 live births

C.

100000 live births

D.

1000000 live births

Maternal mortality ratio is the number of maternal deaths that result from the reproductive process per 100,000 live births.

1001

1002

10 %

C.

25 %

D.

40 %

In pregnancy, cardiac output increases by ? A.

10 %

B.

20 %

C.

30 %

D.

40 %

During pregnancy, what value of blood pressure is considered as abnormally elevated and is associated with a marked increase in perinatal morbidity and mortality ? A.

130 / 80 mmHg

B.

130 / 90 mmHg

C.

140 / 80 mmHg

D.

140 / 90 mmHg

In all pregnant women, measurement of BP should be performed in which position ? Harrison’s 17th Ed. 44

Abortus is a fetus or embryo removed or expelled from uterus during the first half of gestation i.e. 20 weeks or less and weighing less than 500 grams.

1000

B.

Harrison’s 17th Ed. 44

Abortus is fetus or embryo removed or expelled from uterus maximally before ? A. 16 weeks of gestation B.

5 %

Increase in CO is is due to increase in stroke volume. Heart rate increases by about 10 beats per minute during the third trimester.

Postterm neonate is a neonate born anytime after completion of 42nd week, beginning with day 295.

999

A.

Harrison’s 17th Ed. 44

Preterm neonate is a neonate born before 37 completed weeks (259th day).

998

What percentage of women suffer from depression during pregnancy and postpartum period ? Harrison’s 16th Ed. 31

Term neonate is a neonate born anytime after 37 completed weeks of gestation and up until 42 completed weeks of gestation (260 to 294 days).

997

603 Cardiology

A.

Supine

B.

Sitting

C.

Standing

D.

Any of the above

During pregnancy, a BP of 140/90 mmHg is considered as abnormally elevated & is associated with increase in perinatal morbidity & mortality. In all pregnant women, measurement of BP should be performed in the sitting position, because for many the lateral recumbent position is associated with a blood pressure lower than that recorded in sitting position. Diagnosis of hypertension requires measurement of two elevated BP, at least 6 hours apart. Hypertension during pregnancy is usually caused by preeclampsia, chronic hypertension, gestational hypertension, or renal disease.

1007

What percentage of pregnant women suffer from preeclampsia ?

Which of the following statements is false ?

Harrison’s 17th Ed. 44

Harrison’s 16th Ed. 31

A.

2 to 3 %

A.

Adaptive immune responses are more robust in women than in men

B.

5 to 7 %

B.

Estrogens have stimulatory actions on cellular immunity

C.

12 to 15 %

C.

Androgens have inhibitory actions on cellular immunity

D.

15 to 18 %

D.

None of the above

Which of the following statements is false ?

~5 - 7% of all pregnant women develop preeclampsia, the new onset of hypertension (BP >140/90 mmHg) and proteinuria (>300 mg/day) after 20 weeks of gestation.

Harrison’s 16th Ed. 31

1008

Which of the following contributes to endothelial dysfunction, hypertension, and proteinuria in preeclampsia ?

A.

Women have lower total body water than men

Harrison’s 17th Ed. 44

B.

Women awaken from anesthesia faster than men given the same doses of anesthetics

A.

fms-like tyrosine kinase 1

B.

fms-like tyrosine kinase 2

604

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

fms-like tyrosine kinase 3

D.

fms-like tyrosine kinase 4

1015

Stroke in preeclampsia may occur at ? Harrison’s 17th Ed. 44

A.

Sub-normal blood pressures

B.

Near-normal blood pressures

C.

Hypertension range blood pressures

D.

Any of the above

1016

Harrison’s 17th Ed. 44

1011

Multiparity

B.

Diabetes mellitus

C.

History of renal disease

D.

Chronic hypertension

1017

1012

B.

Extremes of maternal age (>35 years or 160/110 mmHg in severe preeclampsia reduces the risk of cerebrovascular accidents. IV labetalol or hydralazine and calcium channel blockers are drugs most commonly used. Raised BP should be reduced slowly to avoid hypotension & a decrease in blood flow to fetus. Angiotensin-converting enzyme (ACE) inhibitors as well as angiotensinreceptor blockers should be avoided in the second and third trimesters of pregnancy because of their adverse effects on fetal development.

Risk factors for the development of preeclampsia include nulliparity, diabetes mellitus, a history of renal disease or chronic hypertension, prior history of preeclampsia, extremes of maternal age (>35 years or 160/110 mmHg), severe proteinuria (>5 g/day), oliguria or renal failure, pulmonary edema, hepatocellular injury (ALT > 2 x the upper limits of normal), thrombocytopenia (platelet count < 100,000/L), or disseminated intravascular coagulation.

A.

GABA receptors

B.

Glutamate receptors

C.

N-methyl-D-aspartate (NMDA) receptors

D.

Dopamine receptors

Magnesium prevents seizures by interacting with N-methyl-D-aspartate (NMDA) receptors in CNS.

1020

Pregnant women with chronic hypertension are at increased risk for all except ? Harrison’s 17th Ed. 45

A.

Intrauterine growth restriction

Endocrinology 605

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

Superimposed preeclampsia

B.

Prothrombin G20210A mutation (hetero- & homozygotes)

C.

Abruptio placenta

C.

D.

Post partum hemorrhage

Methylenetetrahydrofolate reductase C677T mutation (homozygotes)

D.

All of the above

Pregnancy complicated by chronic essential hypertension is associated with intrauterine growth restriction, increased perinatal mortality, superimposed preeclampsia & abruptio placenta.

1021

Which of the following drugs is most commonly used for treatment of chronic hypertension in pregnancy ? Harrison’s 17th Ed. 45

A.

Hydralazine

B.

Labetalol

C.

Beta blocker

D.

Diuretic

Activated protein C resistance caused by factor V Leiden mutation increases risk of DVT, pulmonary embolism & severe preeclampsia during pregnancy. Prothrombin G20210A mutation (heterozygotes & homozygotes) & methylenetetrahydrofolate reductase C677T mutation (homozygotes) also increases risk of DVT.

1027

What percentage of all aortic dissections in women under 40 years of age occur during pregnancy ?

1028

Harrison’s 16th Ed. 78

1023

A.

About 25 %

B.

About 33 %

C.

About 50 %

D.

About 75 %

In “Gestational Hypertension”, the blood pressure is elevated during which trimester of pregnancy ? Harrison’s 17th Ed. 45

Prophylaxis against thrombosis with low-molecular-weight heparin (LMWH) is not recommended

C.

Prophylaxis with unfractionated heparin is recommended

D.

None of the above

Warfarin therapy during the first trimester of pregnancy is associated with ? A.

Fetal chondrodysplasia punctata

B.

Fetal optic atrophy

C.

Mental retardation

D.

All of the above

Warfarin therapy is contraindicated in the 1st trimester due to its association with fetal chondrodysplasia punctata. In 2nd & 3rd trimesters, warfarin may cause fetal optic atrophy and mental retardation.

First

B.

Second

C.

Third

A.

LMWH or unfractionated heparin can be used for anticoagulation

D.

Any time during pregnancy

B.

Warfarin therapy is contraindicated

C.

Warfarin is contraindicated in breast-feeding women

D.

DVT can occur in postpartum period

1029

Valvular disease most likely to cause death during pregnancy is ?

Which of the following about DVT in pregnancy is false ? Harrison’s 17th Ed. 46

Warfarin is not contraindicated in breast-feeding women. During pregnancy, warfarin is teratogenic & should be avoided.

A.

Mitral stenosis

B.

Mitral regurgitation

C.

Aortic stenosis

Harrison’s 17th Ed. 46

D.

Aortic regurgitation

A.

1 - 3 months

B.

3 - 6 months

C.

6 - 9 months

D.

9 - 12 months

1030

Mitral stenosis is the valvular disease most likely to cause death during pregnancy. Mitral regurgitation, aortic regurgitation & stenosis are well tolerated during pregnancy.

In pregnant women, DVT occurs much more commonly in ? Harrison’s 17th Ed. 46

When DVT occurs in the postpartum period, warfarin is given for ?

When DVT occurs in the postpartum period, LMWH therapy for 7 - 10 days may be followed by warfarin therapy for 3 - 6 months.

A.

Left leg

B.

Right leg

C.

Left arm

Harrison’s 17th Ed. 46

D.

Right arm

A.

Fasting plasma glucose is lower by 15 - 20 mg/dL

B.

Fasting plasma hydroxybutyrate higher

C.

Fasting plasma acetoacetate higher

D.

None of the above

In pregnant women, DVT occurs more commonly in left leg than in right leg, due to compression of left iliac vein by iliac artery and the uterus.

1026

Warfarin be stopped & heparin initiated prior to conception

B.

A.

Harrison’s 17th Ed. 45

1025

A.

Harrison’s 17th Ed. 46

This is the development of elevated blood pressure during pregnancy or in the first 24 hours post partum in the absence of preexisting chronic hypertension and other signs of preeclampsia.

1024

Which of the following is false for women with artificial valves contemplating pregnancy ? Harrison’s 16th Ed. 34

Alpha methyldopa, labetalol & nifedipine are the most commonly used medications for the treatment of chronic hypertension in pregnancy.

1022

605 Cardiology

Genetic mutations associated with DVT during pregnancy include ? Harrison’s 17th Ed. 46

A.

Factor V Leiden mutation

1031

Which of the following is false in pregnancy ?

Pregnancy is a state of accelerated starvation & ketosis. In pregnancy, fasting plasma glucose is lower by 15 - 20 mg/dL than in nonpregnant state due to use of glucose by fetus. Plasma hydroxybutyrate & acetoacetate levels may rise to 2 - 4 times the normal after a fast.

606 1032

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR During pregnancy, maternal insulin resistance is due to ? Harrison’s 17th Ed. 46

A.

Placental production of steroids

B.

Placental production of a growth hormone variant

C.

Placental production of placental lactogen

D.

All of the above

After a 100-gram oral glucose challenge in a pregnant woman, normally fasting, 1,2 and 3 hour plasma glucose concentrations are 180 mg/dL

Which of the following is a common feature of pregnancy ? A.

Respiratory acidosis

B.

Respiratory alkalosis

C.

Metabolic alkalosis

D.

Metabolic acidosis

Circulating levels of which of the following remains unaltered by pregnancy ? Harrison’s 17th Ed. 47

Harrison’s 17th Ed. 46

6% respectively

C.

Obesity

D.

> 48 million/mL, > 36%, > 12% respectively

D.

Chronic debilitating disease

Condition that leads to early menarche is ?

Male subfertility is associated with sperm count, motility and normal sperm morphology percentage of ?

Harrison’s 16th Ed. 2198

Harrison’s 16th Ed. 280

A.

Active participation in sports

A.

< 13 million/mL, < 32%, < 9% respectively

B.

Malnutrition

B.

< 18 million/mL, < 32%, < 9% respectively

C.

Obesity

C.

< 23 million/mL, < 32%, < 9% respectively

Chronic debilitating disease

D.

< 33 million/mL, < 32%, < 9% respectively

D.

Obese girls have earlier menarche than girls with normal body weight. Active participation in sports, malnutrition & chronic debilitating disease delay menarche.

1073

B.

A.

Average time between beginning of breast development & onset of menses (menarche) is 2 years.

1071

> 0.5 ng/mL

C.

At age 10 to 11, first secondary sexual characteristics appear in girls. They are development of the breast buds (thelarche), followed by development of pubic hair (pubarche) & later by development of axillary hair (adrenarche).

1070

A.

Which of the following determine age of menarche ? Harrison’s 16th Ed. 2198

1078

Normal male fertility is associated with sperm counts of > 48 million/mL, with a motility of > 63%, with > 12% showing normal morphology. Subfertility is seen with sperm counts of < 13 million/mL, motility of < 32%, and < 9% normal morphology.

1079

Which of the following is true in males with “primary gonadal deficiency” ?

A.

Total body weight

B.

Percent body fat

A.

Low testosterone level

C.

Nutrition

B.

Elevated levels of LH

D.

All of the above

C.

Elevated levels of FSH

D.

All of the above

A critical combination of total body weight & percent body fat is associated with development of hypothalamic insensitivity to feedback by steroids that leads to increased secretion of gonadotropins & to menarche.

Harrison’s 16th Ed. 280

Low testosterone level with raised levels of LH & FSH indicate primary gonadal deficiency.

610 1080

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following is false in males with “secondary hypogonadism” ?

1086

1081

A.

Ovarian cancer

A.

Low testosterone level

B.

Endometrial cancer

B.

Low LH level

C.

Cervical cancer

C.

Low FSH level

D.

Breast cancer

D.

Low prolactin level

In addition to prevention of pregnancy, tubal ligation reduces the risk of ovarian cancer, possibly by limiting the upward migration of potential carcinogens.

Congenital absence of the vas deferens can be diagnosed by ?

After vasectomy, development of azoospermia may be delayed for ?

Harrison’s 16th Ed. 280

Harrison’s 16th Ed. 282

A.

Deficiency of glucose in ejaculate

A.

15 days to 3 months

B.

Deficiency of fructose in ejaculate

B.

1 to 4 months

C.

Deficiency of sucrose in ejaculate

C.

2 to 6 months

D.

Deficiency of galactose in ejaculate

D.

6 to 9 months

Congenital absence of vas deferens is diagnosed by deficiency of fructose in the ejaculate. It is often associated with an abnormality of cystic fibrosis transmembrane regulator (CFTR) gene.

1082

Tubal ligation reduces the risk of ? Harrison’s 16th Ed. 281

Harrison’s 16th Ed. 280

Decreased spermatogenesis due to hypothalamic or pituitary disease show low testosterone & decreased spermatogenesis with low LH & FSH levels.

Endocrinology

Inspissated secretions precluding normal sperm transport is seen in ?

1087

After vasectomy, development of azoospermia may be delayed for 2 to 6 months.

1088

Harrison’s 16th Ed. 282

Harrison’s 16th Ed. 280

A.

Bowen syndrome

B.

Hess syndrome

C.

Young’s syndrome

D.

Bloom syndrome

Copper IUDs inhibit pregnancy primarily through ? A.

Alteration in endometrial lining

B.

Spermicidal effect

C.

Inhibition of implantation

D.

All of the above

Young’s syndrome, characterized by inspissated secretions, can preclude normal sperm transport.

Intrauterine devices (IUDs) inhibit pregnancy primarily through a spermicidal effect caused by a sterile inflammatory reaction produced by the presence of a foreign body in the uterine cavity (copper IUDs) or by release of progestins (Progestasert).

1083

1089

Which of the following about “Clomiphene citrate” is false ?

IUD should not be used in women at high risk for ?

Harrison’s 16th Ed. 280

Harrison’s 16th Ed. 282

A.

Nonsteroidal estrogen antagonist

A.

Urinary tract infections

B.

Increases FSH levels

B.

Bacterial endocarditis

C.

Increases LH levels

C.

Pneumonia

D.

None of the above

D.

All of the above

Clomiphene citrate is a nonsteroidal estrogen antagonist that increases FSH & LH levels by blocking estrogen negative feedback in hypothalamus.

IUD should not be used in women at high risk for development of STDs or in women at high risk for bacterial endocarditis.

1084

1090

Which of the following drugs has no risk of ovarian hyperstimulation ?

Oral contraceptive pills act by ? Harrison’s 16th Ed. 282

Harrison’s 16th Ed. 280

A.

Suppressing ovulation

A.

Gonadotropins

B.

Changing cervical mucus

B.

Pulsatile GnRH

C.

Altering endometrium

C.

Clomiphene

D.

All of the above

D.

All of the above

Pulsatile GnRH restores ovulation in hypothalamic amenorrhea and carries virtually no risk of ovarian hyperstimulation.

Oral contraceptive pills act by suppressing ovulation, changing cervical mucus & altering endometrium.

1091

Which of the following progestins is most androgenic ? Harrison’s 16th Ed. 282

1085

“ICSI” stands for ? Harrison’s 16th Ed. 281

A.

Intracavitary sperm injection

B.

Intracytoplasmic sperm injection

C.

Intracorporeal sperm injection

D.

None of the above

1092

A.

Norgestimate

B.

Norethindrone

C.

Levonorgestrel

D.

Desogestrel

Which of the following progestins is least androgenic ? Harrison’s 16th Ed. 282

ICSI stands for intracytoplasmic sperm injection.

A.

Norgestimate

Endocrinology 611

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

Norethindrone

B.

Phasic estrogen progestin combination

C.

Levonorgestrel

C.

Microdose Progestin

D.

Gestodene

D.

Injectable progestin-based contraceptives

611 Cardiology

Synthetic progestins like norethindrone, norgestimate, desogestrel, gestodene and drospirenone have a less androgenic profile. Levonorgestrel is most androgenic of the progestins & should be avoided in hyperandrogenic states.

Major advantage of injectable progestin-based contraceptives is lack of increased arterial & venous thromboembolic events. But increased gallbladder disease & decreased bone density may occur.

1093

1099

Oral contraceptive formulations include all except ? Harrison’s 16th Ed. 282

Contraception by injectable Norplant is effective for what duration ?

A.

Fixed-dose estrogen-progestin combination

Harrison’s 16th Ed. 282

B.

Phasic estrogen progestin combination

A.

1 year

C.

Progestin only

B.

3 years

D.

Estrogens only

C.

5 years

D.

7 years

Major oral contraceptives are fixed-dose estrogen-progestin combination, phasic estrogenprogestin combination & progestin only.

Long-term progestin Norplant requires surgical insertion & is effective for up to 5 years afer insertion.

1094

1100

Combination oral contraceptive is administered daily for ? Harrison’s 16th Ed. 282

1095

A.

1 week

B.

2 weeks

A.

2 %

C.

3 weeks

B.

8 %

D.

4 weeks

C.

16 %

D.

25 %

Which of the following oral contraceptive formulation is administered continuously ? Harrison’s 16th Ed. 282

Harrison’s 16th Ed. 282

1101

Emergency contraceptives should be used within how many hours after unprotected intercourse ?

A.

Fixed-dose estrogen-progestin combination

B.

Phasic estrogen progestin combination

A.

12 hours

C.

Progestin only

B.

24 hours

D.

All of the above

C.

36 hours

D.

72 hours

Combination formulations are given daily for 3 weeks followed by a week of no medication during which menstrual bleeding generally occurs. Progestin-only pills are administered continuously.

1096

Unprotected intercourse without regard to time of month carries what incidence of pregnancy ?

Which of the following oral contraceptive formulation is appropriate for women with cardiovascular disease ? Harrison’s 16th Ed. 282

Harrison’s 16th Ed. 282

Unprotected intercourse without regard to time of month carries 8% incidence of pregnancy which can be reduced to 2% by the use of emergency contraceptives within 72 hours of unprotected intercourse.

1102

Which of the following is used as emergency contraceptive ? Harrison’s 16th Ed. 282

A.

Fixed-dose estrogen-progestin combination

A.

Ethinyl estradiol and Levonorgestrel

B.

Phasic estrogen progestin combination

B.

Levonorgestrel

C.

Microdose Progestin only

C.

Mifepristone

D.

Any of the above

D.

All of the above

Microdose progestin-only minipill is appropriate for women with cardiovascular disease or for women who cannot tolerate synthetic estrogens.

Ethinyl estradiol + levonorgestrel, levonorgestrel and mifepristone are approved for postcoital contraception.

1097

1103

After discontinuation of Depo-Provera, fertility usually returns after ? Harrison’s 16th Ed. 282

Which of the following is part of a reversible male contraceptive ? Harrison’s 16th Ed. 282

A.

2 to 6 months

A.

Long-acting testosterone

B.

6 to 12 months

B.

GnRH antagonist

C.

12 to 18 months

C.

Progestin

D.

18 to 24 months

D.

All of the above

Intramuscular Depo-Provera is effective for 3 months. Return of fertility after discontinuation may be delayed for up to 12 to 18 months.

Combination of a long-acting testosterone preparation with GnRH antagonist or a progestin (norgestral, desonorgestrel, norethisterone) is part of an effective male contraceptive or male pill.

1098

1104

Increased incidence of gallbladder disease is seen after use of which of the following contraceptive formulation ? Harrison’s 16th Ed. 282

A.

Fixed-dose estrogen-progestin combination

In which week of developing foetus, primitive ovary can be distinguished from the testis ? Harrison’s 16th Ed. 2198

A.

Fifth week

612

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

Sixth week

C.

Seventh week

D.

Eighth week

Gonads exist in an undifferentiated state until the seventh week of fetal life, at which time the primitive ovary can be distinguished from the testis.

1105

1111

Harrison’s 16th Ed. 2198

A.

From end of one menstrual bleeding episode to onset of next

A.

5th to 6th month of gestation

B.

From end of one menstrual bleeding episode to end of next

B.

Birth

C.

From onset of one menstrual bleeding episode to onset of next

C.

Menarche

D.

From onset of one menstrual bleeding episode to end of next

D.

Pregnancy

Length of the menstrual cycle is defined as the time from the onset of one menstrual bleeding episode to onset of the next.

1112

In an adult female, menstrual cycle averages ? Harrison’s 16th Ed. 2200

How many germ cells are present in ovary at birth ? Harrison’s 17th Ed. 2325

A.

28 ± 2 days

A.

~ 1 million

B.

28 ± 3 days

B.

~ 2 million

C.

28 ± 4 days

C.

~ 3 million

D.

28 ± 5 days

D.

~ 4 million

1113

In an adult female, mean duration of menstrual flow averages ? Harrison’s 16th Ed. 2200

How many germ cells are present in ovary at menarche ? Harrison’s 16th Ed. 2198

A.

4 ± 2 days

B.

4 ± 3 days

C.

4 ± 4 days

D.

4 ± 5 days

A.

~ 200,000

B.

~ 400,000

C.

~ 600,000

In women of reproductive age, cycle averages 28 ± 3 days & mean duration of flow is 4 ± 2 days.

D.

~ 800,000

1114

Germ cells decrease in number through atresia so that approximately 1 million remain at birth, 400,000 at menarche& only a few remain at menopause.

1108

Length of menstrual cycle is defined as ? Harrison’s 16th Ed. 2200

At birth, oogonia are no longer present in the ovary, and only 1 - 2 million germ cells remain.

1107

LH secretion is suppressed maximally by sustained high levels of estrogen

LH secretion is suppressed maximally by sustained low levels of estrogen and is enhanced by a rising level of estradiol denoting a positive feedback.

Maximum number of germ cells are present in ovary at ?

Ovary contains a finite number of germ cells, the number peaking at about 7 million oogonia by 5th to 6th month of gestation.

1106

D.

Endocrinology

Menstrual cycles at menarche and near the onset of menopause are ? Harrison’s 16th Ed. 2200

A.

Shorter

Harrison’s 16th Ed. 2199

B.

Longer

A.

Proliferative phase

C.

Normal duration

B.

Luteal phase

D.

Any of the above

C.

Secretory phase

D.

None of the above

Follicular phase of menstrual cycle is also called ?

Proliferative or follicular phase of menstrual cycle is estrogen driven intital phase.

Longer menstrual cycles (usually anovulatory) occur at menarche and near the onset of menopause.

1115

Preceding menopause, interval between menses becomes ? Harrison’s 16th Ed. 2200

1109

Luteal phase of menstrual cycle is also called ?

A.

Shorter

Harrison’s 16th Ed. 2199

B.

Longer

C.

Normal duration

D.

Any of the above

A.

Proliferative phase

B.

Follicular phase

C.

Secretory phase

D.

None of the above

Secretory or luteal phase of menstrual cycle is progesterone driven later phase.

1110

Which of the following statements about FSH is false ?

Preceding menopause, pattern of menstrual cycles is variable, but the interval between menses usually becomes shorter, as follicular recruitment is hastened by increases in FSH.

1116

Which of the following is true at the end of a menstrual cycle ? Harrison’s 16th Ed. 2200

Harrison’s 16th Ed. 2200

A.

Plasma levels of estrogen fall

A.

Inhibin selectively suppresses FSH

B.

Plasma levels of progesterone fall

B.

Feedback of estrogen involves hypothalamus & pituitary

C.

Circulating levels of FSH increase

C.

FSH secretion is inhibited progressively as estrogen levels increase

D.

All of the above

Endocrinology 613 1117

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Plasma estradiol levels begin to rise about how many days before the “midcycle LH surge” ?

Harrison’s 16th Ed. 2200

A.

Plasma FSH begins to rise

Harrison’s 16th Ed. 2200

B.

Plasma estrogen decreases

C.

Plasma progesterone decreases

D.

None of the above

A.

5 to 7 days

B.

8 to 10 days

C.

11 to 13 days

D.

13 to 15 days

1124

Following one menstrual cycle, development of the next follicle is usually in the ?

~ 8 to 10 days prior to midcycle LH surge, plasma estradiol levels begin to rise as the result of estradiol formation by the granulosa cells of the dominant follicle.

Harrison’s 16th Ed. 2200

A.

Same ovary

1118

Estradiol secretion reaches a peak at ?

B.

Contralateral ovary

Harrison’s 16th Ed. 2200

C.

Both ovaries

D.

Any of the ovaries

A.

Just before ovulation

B.

At the time of ovulation

C.

Just after ovulation

D.

Any of the above

Near the end of luteal phase, progesterone & estrogen levels fall & FSH levels begin to rise to initiate development of the next follicle (usually in the contralateral ovary) & the next menstrual cycle.

1125

Just before ovulation, estradiol secretion reaches a peak and then falls.

1119

A.

Inhibin A levels are low in the follicular phase

B.

Inhibin A levels reach a peak in the luteal phase

Harrison’s 16th Ed. 2200

C.

Inhibin B levels are increased in the follicular phase

A.

10 to 12 hours

D.

Inhibin B levels reach a peak in the luteal phase

B.

12 to 14 hours

C.

16 to 23 hours

D.

24 to 38 hours

Ovulation from the dominant follicle occurs how many hours after the LH peak ?

Inhibin A levels are low in the follicular phase but reach a peak in the luteal phase. Inhibin B levels are increased in the follicular phase & low in the luteal phase.

1126

1123

A.

Intense vasospasm occurs in the spiral arterioles

B.

Intense vasospasm occurs in the spiral venules

Harrison’s 16th Ed. 2200

C.

Intense vasospasm occurs in endometrial capillaries

A.

10 to 12 hours

D.

All of the above

B.

12 to 14 hours

C.

16 to 23 hours

D.

24 to 38 hours

Intense vasospasm caused by locally synthesized prostaglandins occurs in spiral arterioles supplying blood to endometrium causing ischemic necrosis, endometrial desquamation and menstrual bleeding.

1127

Secretory phase of menstrual cycle is characterized by all except ? Harrison’s 16th Ed. 2200

Plasma progesterone level begins to rise at what time ?

A.

Tortuosity of the glands

Harrison’s 16th Ed. 2200

B.

Curling of the spiral arterioles

C.

Glandular growth of the endometrium

D.

Glandular secretion

A.

Just prior to midcycle

B.

At midcycle

C.

After midcycle

D.

Any of the above

Plasma progesterone level begins to rise just prior to midcycle & facilitates the positive feedback action of estradiol on LH secretion.

1122

Menstrual bleeding is due to ? Harrison’s 16th Ed. 2200

Ovulation from the dominant follicle occurs how many hours after the onset of the LH surge ?

Ovulation from the dominant follicle occurs 16 to 23 hours after the LH peak and 24 to 38 hours after the onset of the LH surge when the follicular wall ruptures in the area of the stigma.

1121

Which of the following statements about “Inhibin” is false ? Harrison’s 16th Ed. 2200

Follicular rupture & ovulation occurs 16 to 23 hours after the LH peak.

1120

613 Cardiology

Glandular growth of the endometrium is is mediated by estrogen during the proliferative phase.

1128

Which of the following about menopause is false ? Harrison’s 17th Ed. 2334

A.

Permanent cessation of menstruation

B.

Diagnosed retrospectively >12 months of amenorrhea

Harrison’s 16th Ed. 2200

C.

Smoking accelerates menopausal transition by 2 years

A.

Plasma FSH decreases

D.

None of the above

B.

Plasma LH decreases

C.

Plasma progesterone increases

D.

None of the above

Which of the following is false about hormone status at the onset of luteal phase ?

Which of the following is false about hormone status near the end of the luteal phase?

Menopause is the permanent cessation of menstruation due to loss of ovarian follicular function.

1129

Menopause is the consequence of ? Harrison’s 17th Ed. 2334

A.

Resistance of ovaries to gonadotropins

B.

Exhaustion of ovarian follicles

614

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Resistance of pituitary to estradiol

D.

All of the above

D.

Endocrinology

Hypoestrogenic, hyperprogestagenic environment

Process of exhaustion of ovarian follicles begins in intrauterine life & terminates at menopause.

In perimenopause, anovulatory cycles produce a hyperestrogenic, hypoprogestagenic environment that leads to an increased incidence of endometrial hyperplasia or carcinoma, uterine polyps, and leiomyoma observed among women of perimenopausal age.

1130

1136

Menopause is diagnosed retrospectively after how many months of amenorrhea ?

Harrison’s 17th Ed. 2334

Harrison’s 17th Ed. 2334

A.

3

B.

6

C.

9

D.

12

Menopause is diagnosed retrospectively >12 months of amenorrhea. Smoking accelerates the menopausal transition by 2 years.

1131

Preceding menopause, interval between menses is usually ? Harrison’s 17th Ed. 2334

1132

B.

Estrone

C.

Estriol

D.

None of the above

1137

Which of the following statements about hormone levels is false as regards menopause ?

Shorter

B.

Longer

A.

Estradiol levels fall more than estrone levels

C.

Same

B.

FSH levels increase more than LH levels

D.

Any of the above

C.

Reduced inhibin secretion

D.

None of the above

In perimenopause, intermenstrual intervals shorten significantly due to ? A.

Acceleration in follicular phase

B.

Acceleration in luteal phase

C.

Acceleration in follicular & luteal phase

D.

None of the above

Harrison’s 17th Ed. 2334

In menopause, estradiol levels fall markedly, whereas estrone levels are relatively preserved, reflecting peripheral aromatization of adrenal & ovarian androgens. FSH levels increase more than LH because of the loss of inhibin, as well as estrogen feedback.

1138

A.

12

B.

24

C.

36

D.

48

1139

3

B.

6

C.

9

D.

12

Perimenopause refers to the time period preceding menopause, when fertility wanes and menstrual cycle irregularity increases, until the first year after cessation of menses.

Perimenopause is characterized by which of the following ? Harrison’s 17th Ed. 2334

A.

Hypoestrogenic, hypoprogestagenic environment

B.

Hyperestrogenic, hyperprogestagenic environment

C.

Hyperestrogenic, hypoprogestagenic environment

< 20 mIU/mL

B.

20 to < 30 mIU/mL

C.

30 to < 40 mIU/mL

D.

>= 40 mIU/mL

Which of the following treatments is useful in perimenopausal women ? Harrison’s 17th Ed. 2334

“Perimenopause” time period extends up till what time after final menses ? A.

A.

FSH measurement aid in assessing fertility. Levels of 10 IU/L

B.

> 20 IU/L

C.

> 30 IU/L

D.

> 40 IU/L

1147

1149

Which of the following is a selective estrogen receptor modulator ? Harrison’s 16th Ed. 2211

Raloxifene is a selective estrogen receptor modulator (SERM).

1150

Postmenopausal Estrogen/Progestin Interventions trial found ? Harrison’s 16th Ed. 2212

A.

Increased risk of breast cancer

What value of LH suggests hypogonadotropic hypogonadism ?

B.

Increased risk of endometrial cancer

Harrison’s 16th Ed. 2201

C.

Increased risk of fracture

D.

All of the above

A.

< 0.8 IU/L

B.

< 1.8 IU/L

C.

< 2.8 IU/L

D.

< 3.8 IU/L

Postmenopausal Estrogen/Progestin Interventions (PEPI) trial found 24% of women assigned to unopposed estrogen for 3 years developed atypical endometrial hyperplasia, a premalignant lesion, compared to only 1% of women assigned to placebo. Use of a progestin eliminates these risks.

1151

In the Heart and Estrogen/progestin Replacement Study (HERS), risk of which of the following cancers was increased ? Harrison’s 16th Ed. 2212

Which of the following is not useful in controlling vasomotor and genitourinary symptoms of menopause ?

A.

Breast cancer

Harrison’s 16th Ed. 2210

B.

Endometrial cancer

A.

Estrogen therapy

C.

Colorectal cancer

B.

Clonidine

D.

Urinary bladder cancer

C.

Vitamin E

D.

Vitamin D

Estrogens, venlafaxine, clonidine, vitamin E are effective for controlling vasomotor and genitourinary symptoms in menopause.

1146

Increased physical activity, adequate calcium (1000 to 1500 mg/day) & vitamin D (400 to 800 IU/ day) intakes reduces the risk of osteoporosis-related fractures.

A.

FSH levels that are persistently > 40 IU/L are diagnostic of ovarian failure, and an LH value < 0.8 IU/L suggests hypogonadotropic hypogonadism.

1145

Dose of oral calcium given to reduce the risk of osteoporosisrelated fractures is ?

A.

In the Heart & Estrogen/progestin Replacement Study (HERS), 4 years of combination therapy was associated with a 27% increase in breast cancer risk.

1152

Exogenous estrogen administration in postmenopausal women produces all except ? Harrison’s 16th Ed. 2212

Which of the following reduces the risk of osteoporosis-related fractures ?

A.

Lowers LDL cholesterol

Harrison’s 16th Ed. 2211

B.

Raises HDL cholesterol

A.

Estrogen

C.

Lowers lipoprotein(a)

B.

Calcium

D.

Lowers triglycerides

C.

Vitamin D

D.

All of the above

Dose of vitamin D given to reduce the risk of osteoporosis-related fractures is ? Harrison’s 16th Ed. 2211

A.

100 to 300 IU/day

B.

200 to 500 IU/day

C.

400 to 800 IU/day

Exogenous estrogen lowers plasma LDL cholesterol & Lp(a), raises HDL cholesterol levels and triglyceride levels.

1153

Which of the following is a “primary” prevention trial for assessing efficacy of hormone therapy in postmenopausal women ? Harrison’s 16th Ed. 2212

A.

Heart and Estrogen/progestin Replacement Study (HERS)

B.

Women’s Health Initiative trial (WHI)

C.

Estrogen Replacement and Atherosclerosis (ERA) trial

616

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

Estrogen in the Prevention of Reinfarction Trial (ESPRIT)

In WHI, women assigned to receive combination hormones for an average of 5.6 years were 24% more likely to develop breast cancer than women assigned to placebo, but 7.1 years of estrogen-only therapy did not increase risk. Indeed, the WHI showed a trend toward a reduction in breast cancer risk with estrogen alone, although it is unclear whether this finding would pertain to formulations of estrogen other than conjugated equine estrogens or to treatment durations longer than 7 years.

1154

1161

Harrison’s 16th Ed. 2212

Colorectal cancer

B.

Breast cancer

C.

Gallbladder disease

D.

Coronary heart disease

1162

In hot flush, a characteristic manifestation of menopause, sudden feeling of heat in felt over ? Lancet 2005; 366: 409–21

1156

1157

A.

Face

B.

Neck

C.

Chest

D.

All of the above

1163

Human chorionic gonadotropin (hCG) is secreted by ? A.

Trophoblastic cells of the placenta

B.

Uterine myocardium

C.

Cervical mucus

D.

All of the above

By plasma or urine hCG assays, pregnancy can be detected how many days after ovulation ? A.

1 to 3 days

B.

3 to 5 days

C.

5 to 7 days

D.

8 to 10 days

Which of the following is not a feature of cervical mucus that indicates adequate estrogen production ? Harrison’s 16th Ed. 2201

The average hot flush lasts about ? Lancet 2005; 366: 409–21

A.

Thick

A.

1 minutes

B.

Copious

B.

2 minutes

C.

Exhibiting arborization or ferning

C.

3 minutes

D.

Clear

D.

4 minutes

1164

Oral oestrogen preparation used in HRT include ? A.

Oestrone sulphate

B.

Oestriol

C.

Estradiol valerate

D.

All of the above

Vaginal oestrogen does not improve which of the following ? Lancet 2005; 366: 409–21

1159



hCG is secreted by trophoblastic cells of placenta into maternal plasma & excreted in urine. Plasma or urine assays of hCG CAN detect pregnancies 8 to 10 days after ovulation, before the first missed menstrual period.

A.

Vaginal dryness

B.

Vaginal atrophy

C.

Urinary incontinence

D.

All of the above

A. B. C. D.

1165

Oestrogenic Progestagenic

C.

Androgenic

D.

All of the above

What plasma progesterone level suggests successful ovulation and adequate corpus luteum function ? Harrison’s 16th Ed. 2202

A. B. C. D.

Lancet 2005; 366: 409–21

B.

Mature vaginal epithelial cells Abundant cornified squamous epithelial cells Predominantly intermediate cells Pyknotic nuclei

Presence of viscous cervical mucus that does not stretch or fern and of predominantly intermediate cells on vaginal cytology or demonstration of a secretory epithelium in an endometrial biopsy during the luteal phase is typical of progesterone secretion.

Tibolone has which of the following actions ? A.

Vaginal cytology findings that confirm the presence of adequate estrogen levels include all except ? Harrison’s 16th Ed. 2201

Lancet 2005; 366: 409–21

1158

D.

Harrison’s 16th Ed. 2202

In WHI, estrogen-progestin was associated with a significant 44% reduction in colorectal cancer over a 5.6-year period, although no benefit was seen with 7 years of estrogen-only therapy.

1155



Harrison’s 16th Ed. 2202

Estrogen-progestin therapy reduces risk of ? A.

C.

Endocrinology

> 0.8 ng/mL > 1.6 ng/mL > 2.3 ng/mL > 3.0 ng/mL

Plasma progesterone level > 10 µmol/L (> 3 ng/mL) suggests successful ovulation and adequate corpus luteum function.

1166

Under normal conditions, the ovary secretes which of the following androgen ? Harrison’s 16th Ed. 2202

1160

Phyto-oestrogens have oestrogen-like effects because of preferential binding to which oestrogen receptor ? Lancet 2005; 366: 409–21

A.



B.



A. B. C. D.

Androstenedione Testosterone Dehydroepiandrosterone All of the above

Under normal conditions, ovary secretes androstenedione, testosterone & dehydroepiandrosterone.

Endocrinology 617 1167

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Puberty is considered precocious if breast budding begins before the age of ? Harrison’s 16th Ed. 2202

1168

A.

8 years

B.

9 years

C.

10 years

D.

11 years

Puberty is considered precocious if menarche occurs before the age of ? 8 years

B.

9 years

C.

10 years

D.

11 years

Head injury

C.

Neurofibromatosis

D.

All of the above

Constitutional or idiopathic precocious puberty accounts for 90% cases of true precocious puberty, 10% causes are due to organic brain diseases like brain tumors (hypothalamic gliomas, astrocytomas, ependymomas, germinomas & hamartomas), encephalitis, meningitis, hydrocephalus, head injury, tuberous sclerosis & neurofibromatosis.

1174

Most common form of congenital adrenal hyperplasia (CAH) is due to impairment of ? Harrison’s 16th Ed. 2145

Harrison’s 16th Ed. 2202

A.

B.

617 Cardiology

A.

CYP21A2 (21-Hydroxylase)

B.

17-hydroxylase (CYP17)

C.

11-hydroxylase (CYP11B1)

D.

3-HSD2

Most common form of CAH (95%) is a result of impairment of CYP21A2. Puberty is precocious if breast budding begins before 8 years of or if menarche occurs before age 9.

1169

Heterosexual precocity is defined as ?

1175

Harrison’s 16th Ed. 2202

Harrison’s 16th Ed. 2202

1170

A.

Virilization in girls

B.

Feminization in boys

C.

Both of the above

D.

None of the above

Which of the following is a type of “isosexual precocious puberty in girls” ? Harrison’s 16th Ed. 2202

A.

True precocious puberty

B.

Precocious pseudopuberty

C.

Incomplete isosexual precocity

D.

All of the above

Which of the following is false about precocious pseudopuberty ? A.

Gonadotropin-independent

B.

Enhanced estrogen formation

C.

Anovulatory cycles

D.

Regular cyclic menses

Gonadotropin-independent precocious pseudopuberty occurs when girls undergo feminization as a consequence of enhanced estrogen formation but do not ovulate or develop cyclic menses.

1176

Most frequent cause of precocious pseudopuberty is ? Harrison’s 16th Ed. 2202

A.

Dysgerminomas

B.

Ovarian teratomas

C.

Granulosa-theca cell tumors

D.

Cystadenomas

Feminization in girls or virilization in boys are termed isosexual precocity. Heterosexual precocity occurs when sexual characteristics are not according to genetic sex i.e. virilization in girls or feminization in boys.

Ovarian cysts or tumors that secrete estrogen (granulosa-theca cell tumors) are the most frequent cause of precocious pseudopuberty.

1171

1177

Which of the following is false about true precocious puberty ? Harrison’s 16th Ed. 2202

Harrison’s 16th Ed. 2202 Table 326-1

A.

Gonadotropin-dependent

A.

McCune-Albright syndrome

B.

Ovulatory menstrual cycles

B.

Primary Hypothyroidism

C.

Early normal pubertal development

C.

Russell-Silver syndrome

D.

None of the above

D.

All of the above

Gonadotropin-dependent true precocious puberty is characterized by an early but otherwise normal sequence of pubertal development, including increased secretion of gonadotropins & ovulatory menstrual cycles.

1172

Precocious pseudopuberty can be caused by ?

Which of the following is of use in treatment of true precocious puberty ?

Precocious pseudopuberty can be caused by ovarian tumors, adrenal tumors, McCune-Albright syndrome, hypothyroidism, Russell-Silver syndrome, and estrogen-containing medications.

1178

Harrison’s 16th Ed. 2202

Harrison’s 16th Ed. 2202

A.

GnRH analogues

B.

Gonadotropins

C.

Estrogen

D.

Progesterone

Hormone responsible for development of precocious pseudopuberty in primary hypothyroidism is ? A.

FSH

B.

LH

C.

GnRH

D.

All of the above

GnRH analogues suppress gonadotropins & inhibit estrogen synthesis thus blocking precocious puberty.

Primary hypothyroidism is sometimes associated with increased secretion of FSH, inducing ovarian estrogen secretion. High levels of TSH caused by hypothyroidism may also stimulate FSH receptor.

1173

1179

Which of the following can cause true precocious puberty ? Harrison’s 16th Ed. 2202

A.

Encephalitis

Which of the following can be a feature of incomplete isosexual precocity ? Harrison’s 16th Ed. 2202

618

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Harrison’s 16th Ed. 2203

A.

Premature thelarche

B.

Premature adrenarche

A.

Spontaneous

C.

Premature pubarche

B.

Regular, cyclic

Any of the above

C.

Predictable

D.

Painless

D.

In incomplete isosexual precocity, premature development of a single pubertal event occurs.

1180

Which of the following is not a feature of incomplete isosexual precocity ? Harrison’s 16th Ed. 2202

A.

Premature thelarche

B.

Premature adrenarche

C.

Premature pubarche

D.

Clitoromegaly

Clitoromegaly is a feature of syndromes of virilization.

1181

Which of the following is recommended treatment of incomplete isosexual precocity ? Harrison’s 16th Ed. 2203

A.

Treatment with glucocorticoids

B.

Treatment with estrogens

C.

Treatment with ACTH

D.

No treatment

Normal menstrual bleeding with ovulatory cycles is spontaneous, regular, cyclic, & predictable. It is frequently associated with discomfort (dysmenorrhea).

1186

1187

Cyclic

B.

Unpredictable menstruation

C.

Spotting or light bleeding

D.

None of the above

Polymenorrhea is defined when regular menstruation occurs by how many days apart ? Harrison’s 16th Ed. 2203

A.

21

B.

23

C.

25

D.

27

Virilization in a prepubertal female can be due to ?

Polymenorrhea refers to occurrence of regular menstruation more frequently than 21 days.

Harrison’s 16th Ed. 2203

1188

Which of the following about dysfunctional uterine bleeding is false ?

A.

Congenital adrenal hyperplasia

B.

Androgen secretion by ovarian tumor

A.

Unpredictable in amount

C.

Androgen secretion by adrenal tumor

B.

Unpredictable in onset

D.

Any of the above

C.

Unpredictablein duration

D.

Painful

Harrison’s 16th Ed. 2203

Abnormal uterine bleeding refers to a bleeding pattern that differs in which of the following from a normal menstrual cycle ?

1189

A.

Frequency

B.

Duration

C.

Amount

D.

Any of the above

Abnormal uterine bleeding is defined as any bleeding pattern that differs in frequency, duration or amount from the pattern observed during a normal menstrual cycle.

Average blood loss during a menstrual cycle is ?

Which of the following is the cause of dysfunctional uterine bleeding ? Harrison’s 16th Ed. 2203

Harrison’s 16th Ed. 2203

1184

A.

Regular, cyclic, predictable menstruation characterized by spotting or light bleeding is termed hypomenorrhea and is due to obstruction of the outflow tract as from intrauterine synechiae or scarring of the cervix.

Virilization in a prepubertal female is usually due to congenital adrenal hyperplasia or to androgen secretion by an ovarian or adrenal tumor.

1183

Which of the following is false about hypomenorrhea ? Harrison’s 16th Ed. 2203

Usually, incomplete isosexual precocity is self-limited & resolves spontaneously. It requires no treatment & patients enter puberty around the average time.

1182

Endocrinology

A.

Abnormalities of the uterus

B.

Interruption of normal sequence of follicular & luteal phases

C.

Permanent disruption of synchronous hypothalamic-pituitaryovarian patterns

D.

All of the above

Dysfunctional uterine bleeding occurs in women who have a transient disruption of synchronous hypothalamic-pituitary-ovarian patterns required for ovulatory cycles.

1190

Harrison’s 16th Ed. 2203

Most common type of primary dysfunctional uterine bleeding is due to ? Harrison’s 16th Ed. 2203

A.

35 to 80 mL

A.

Estrogen withdrawal bleeding

B.

80 to 135 mL

B.

Estrogen breakthrough bleeding

C.

150 to 185 mL

C.

Progesterone breakthrough bleeding

D.

200 to 230 mL

D.

None of the above

Average blood loss during a normal menstrual cycle is 35 to 80 mL.

Most common type of DUB is estrogen breakthrough bleeding

1185

1191

Normal menstrual bleeding with ovulatory cycles is characterized by all except ?

Primary amenorrhea is failure of menarche by age of ? Harrison’s 16th Ed. 2203

A.

13

Endocrinology 619

1192

B.

14

C.

15

D.

16

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Secondary amenorrhea is failure of menses for ?

D.

3 months

B.

6 months

C.

9 months

D.

12 months

Amenorrhea is failure of menarche by age 15, irrespective of presence or absence of secondary sexual characteristics, or absence of menstruation for 6 months in a woman with previous periodic menses.

1193

1198

Harrison’s 16th Ed. 2237

1199

B.

Primary hypogonadism

C.

Type 1 diabetes mellitus

D.

Panhypopituitarism

Wolfram’s syndrome consists of which of the following ? Harrison’s 16th Ed. 2237

A.

Hyperthyroidism

A.

45,XX

B.

Panhypopituitarism

B.

46,XX

C.

Congenital diabetes insipidus

C.

47,XX

D.

Vitiligo

D.

48,XX

Wolfram’s syndrome consists of congenital diabetes insipidus & diabetes mellitus.

1200

IPEX syndrome consists of which of the following ? Harrison’s 16th Ed. 2237

Which of the following is false about Mayer-Rokitansky-KusterHauser syndrome ?

A.

Polyendocrinopathy

Harrison’s 16th Ed. 2204

B.

Enteropathy

A.

Phenotypically normal females

C.

Immunodysregulation

B.

46,XX karyotype

D.

All of the above

C.

Developed secondary sex characteristics

D.

Abnormal ovarian function

IPEX syndrome consists of immunodysregulation, polyendocrinopathy, enteropathy and is X-linked.

1201

The tissue affected in Asherman’s syndrome is ? A.

Ovary

B.

Endometrium

C.

Cervix uteri

D.

Vagina

1202

B.

Primary amenorrhea

C.

Sexual infantilism

D.

Hypertension

17  -Hydroxylase deficiency is an autosomal recessive disorder characterized by primary amenorrhea, sexual infantilism, and hypertension.

Features of Kearns-Sayre syndrome include all except ? Harrison’s 16th Ed. 2237

A.

Hypoparathyroidism

B.

Primary hypogonadism

C.

Type 2 diabetes mellitus

Vitiligo

B.

Blindness

C.

Hypothyroidism

D.

Panhypopituitarism

In the original observations of Stein and Leventhal in 1935, which of the following was not noted ? N Engl J Med 2005;352:1223-36

Harrison’s 16th Ed. 2204

Autosomal dominant

A.

Congenital rubella syndrome consists of type 1 diabetes mellitus & hypothyroidism.

Which of the following is not a feature of 17  -hydroxylase deficiency ? A.

Congenital rubella syndrome consists of ? Harrison’s 16th Ed. 2237

Destruction of endometrium due to vigorous curettage is called Asherman’s syndrome.

1197

Hypoparathyroidism

Harrison’s 16th Ed. 2204

Harrison’s 16th Ed. 2204

1196

A.

DiGeorge syndrome is hypoparathyroidism due to glandular agenesis & mucocutaneous candidiasis.

Mayer-Rokitansky-Kuster-Hauser syndrome (46,XX) subjects are women with mullerian agenesis i.e. absence or hypoplasia of the vagina. Female secondary sex characteristics with normal ovarian function, including cyclic ovulation are present.

1195

DiGeorge syndrome consists of which of the following ?

Karyotype in Mayer-Rokitansky-Kuster-Hauser syndrome is ?

Karyotype in women with Mayer-Rokitansky-Kuster-Hauser syndrome is 46,XX. Müllerian agenesis or Mayer-Rokitansky-Kuster-Hauser syndrome is associated with mutations in WNT4 gene.

1194

Panhypopituitarism

Kearns-Sayre syndrome consists of hypoparathyroidism, primary hypogonadism, type 1 diabetes mellitus & panhypopituitarism.

Harrison’s 16th Ed. 2203

A.

619 Cardiology

A.

Amenorrhea

B.

Galactorrhoea

C.

Hirsutism

D.

Obesity

Published in 1935 in Am J Obstet Gynecol, observations in seven women with amenorrhea, hirsutism, obesity, and a characteristic polycystic appearance to their ovaries was mentioned.

1203

In woman with polycystic ovary syndrome, which of the following systems is affected ? N Engl J Med 2005;352:1223-36

A.

Reproductive system

B.

Metabolic health

C.

Cardiovascular health

D.

All of the above

“Syndrome XX” is the term proposed for PCOD since it involves the metabolic millieu of the body through its effects on insulin resistance & plasma lipids leading to increased possibility of cardiovascular disease.

620 1204

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following is not a feature of PCOS ?

C.

First child birth

N Engl J Med 2005;352:1223-36

D.

Following oral contraceptive pill intake

A.

Oligoovulation or anovulation

B.

Hyperandrogenemia

C.

Hyperandrogenism

D.

Reduced level of luteinizing hormone

PCOD symptoms begin around menarche which comes at the expected time. Oligomenorrhoea may occur after variable time thereafter.

1211

In most women with PCOS, menarche occurs ? Harrison’s 16th Ed. 2205

Characteristically, LH levels are increased in PCOD due to increased pulse frequency of GnRH and stimulation by excess extraglandular estrogen.

A.

Early

B.

At the expected time

1205

Oligomenorrhea refers to ?

C.

Late

N Engl J Med 2005;352:1223-36

D.

Any of the above

1206

A.

Fewer than four menses per year

B.

Fewer than six menses per year

C.

Fewer than nine menses per year

D.

Fewer than ten menses per year

1212

Harrison’s 16th Ed. 2205

Obesity

B.

Elevated adrenal androgens

C.

Increased formation of extraglandular estrogen

D.

All of the above

A.

Increased frequency of LH pulses

B.

Synergistic action of insulin with LH

C.

Reduced hepatic synthesis of sex hormone - binding globulin (SHBG)

D.

All of the above

SHBG is synthesized by liver under the influence of androgens & insulin. Due to decreased levels of SHBG, excess of free, unbound testosterone is available in plasma leading to hyperandrogenemia & hyperandrogenism.

1213

Which of the following is false in PCOS ? N Engl J Med 2005;352:1223-36

Obesity along with elevated adrenal androgens lead to increased formation of extraglandular estrogen which stimulates LH secretion and depresses FSH secreation by pituitary.

1207

Enhanced androgen production in PCOS is due to ? N Engl J Med 2005;352:1223-36

For the initiation and perpetuation of chronic anovulation in PCOD, which of the following play a role ? A.

Endocrinology

A.

Increased pulse frequency of hypothalamic GnRH

B.

Increased LH pulse frequency

Harrison’s 16th Ed. 2204-5

C.

Increased FSH pulse frequency

A.

Sclerotic ovary

D.

Hyperinsulinemia

B.

Multiple follicular cysts

C.

Hyperplastic theca and stroma

D.

Presence of corpora albicans

Which of the following is not a feature of ovary in PCOD ?

FSH levels are characteristically reduced in plasma of PCOS patients due to negative feedback of estrogens on pituitary.

Corpora albicans is the degenerating corpus luteum which is not formed in PCOD due to anovulation

In PCOS, LH to FSH ratio in plasma is characteristically greater than ?

1208

Anovulatory cycles in PCOD may cause ?

A.

0.75

N Engl J Med 2005;352:1223-36

B.

1.25

C.

1.75

D.

2.00

A.

Oligomenorrhea or amenorrhea

B.

Dysfunctional uterine bleeding

C.

Decreased fertility

D.

All of the above

1214

Harrison’s 16th Ed. 2205

1215

Due to anovulation, copus luteum is not formed thus causing estrogen - progesterone imbalance.

1209

Chronic anovulation with estrogen present is found in all except ? Harrison’s 16th Ed. 2205

A.

Brenner tumors

B.

Isolated hypogonadotropic hypogonadism

N Engl J Med 2005;352:1223-36

C.

Hypothyroidism

A.

Hirsutism

D.

Krukenberg tumors

B.

Acne

C.

Acanthosis nigricans

D.

Androgenic alopecia

Cutaneous manifestations of hyperandrogenemia in polycystic ovary syndrome include all except ?

Acanthosis nigricans is the manifestation of hyperinsulinemia.

Isolated hypogonadotropic hypogonadism is a condition of chronic anovulation with estrogen absent.

1216

Chronic anovulation with estrogen present is found in all except ? Harrison’s 16th Ed. 2205

1210

Symptoms of polycystic ovary syndrome usually begin around ? N Engl J Med 2005;352:1223-36

A.

Menarche

B.

First sexual contact

A.

Kallmann syndrome

B.

Adult-onset adrenal hyperplasia due to partial 21-hydroxylase deficiency

Endocrinology 621

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

C.

Mucous cystadenomas

D.

Cystic teratomas

D.

621 Cardiology

All of the above

Kallmann syndrome is Isolated hypogonadotropic hypogonadism associated with defects of smell due to a single gene defect in the X-linked KAL gene.

Cyproterone acetate is antiandrogenic by inhibiting androgens from binding to androgen receptors. Estrogen suppresses LH and thus ovarian androgen production. Estrogen also enhances hepatic production of SHBG thereby reducing free and unbound plasma testosterone. Drospirenone is an analogue of spironolactone with antimineralocorticoid and antiandrogenic activities.

1217

1223

If pregnancy is desired by a woman suffering from PCOS, which of the following drugs is useful ?

N Engl J Med 2005;352:1223-36

Harrison’s 16th Ed. 2205

A.

Metformin

B.

Thiazolidinediones

C.

Clomiphene

D.

All of the above

Insulin-sensitizing drugs improve fertility in women with PCOS. Clomiphene promotes ovulation.

1218

If pregnancy is desired by a woman suffering from PCOS, ovulation can be induced with which of the following drugs ? Human menopausal gonadotropin (hMG)

B.

Purified FSH (Urofollitropin)

C.

Gonadorelin

D.

All of the above

All the three drugs induce ovulation.

1219

1224

Endometrial carcinoma

B.

Cervical carcinoma

C.

Vaginal carcinoma

D.

All of the above

Teratogenic effect of which of the following drugs produces “Neural-tube defects” ? N Engl J Med 1998;338:1129

1225

If a woman having PCOS is not hirsute and does not desire pregnancy, treatment of choice is ?

A.

Warfarin

B.

Thalidomide

C.

Carbamazepine

D.

Tetracycline

Teratogenic effect of which of the following drugs produces “Neural-tube defects” ? N Engl J Med 1998;338:1129

Harrison’s 16th Ed. 2205

A.

Warfarin

A.

Medroxyprogesterone acetate

B.

Thalidomide

B.

Combined estrogen-progestogen therapy

C.

Valproic acid

C.

Cyproterone acetate

D.

Tetracycline

D.

Drospirenone

Medroxyprogesterone acetate treatment prevents development of endometrial hyperplasia and carcinoma by bringing about withdrawal menses.

1220

A.

In PCOS, there is increased prevalence of endometrial hyperplasia and carcinoma due to the persistent stimulation of endometrial tissue by estrogen without progesterone-induced inhibition of proliferation and differentiation to secretory endometrium.

Harrison’s 16th Ed. 2205

A.

Chronic anovulation is associated with an increased risk of ?

1226

N Engl J Med 1998;338:1129

If a woman having PCOS is hirsute and does not desire pregnancy, treatment of choice is ? Harrison’s 16th Ed. 2205

A.

Medroxyprogesterone acetate

B.

Combined estrogen-progestogen therapy

C.

Clomiphene

D.

Human menopausal gonadotropin (hMG)

Teratogenic effect of which of the following drugs produces “Ebstein’s anomaly” ?

1227

A.

Angiotensin-converting–enzyme inhibitors

B.

Lithium

C.

Carbamazepine

D.

Misoprostol

Teratogenic effect of which of the following drugs produces “Moebius sequence” ? N Engl J Med 1998;338:1129

Estrogen is anti-androgenic.

A.

Angiotensin-converting–enzyme inhibitors

1221

FSH secretion in PCOS can be enhanced by ?

B.

Lithium

Harrison’s 16th Ed. 2205

C.

Carbamazepine

A.

Clomiphene

D.

Misoprostol

B.

Human menopausal gonadotropin (hMG)

C.

GnRH (gonadorelin)

D.

All of the above

1228

N Engl J Med 1998;338:1129

Clomiphene citrate is antiestrogenic and induces rise in FSH and LH.

1222

Which of the following drugs has antiandrogen effects ? N Engl J Med 2005;352:1223-36

A.

Cyproterone acetate

B.

Estrogen

C.

Drospirenone

Teratogenic effect of which of the following drugs produces “Dandy–Walker syndrome” ?

1229

A.

Angiotensin-converting–enzyme inhibitors

B.

Lithium

C.

Carbamazepine

D.

Warfarin

Teratogenic effect of which of the following drugs produces “aplasia cutis” ?

622

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR N Engl J Med 1998;338:1129

1230

A.

Agenesis of corpus callosum

A.

Angiotensin-converting–enzyme inhibitors

B.

Dandy–Walker malformations

B.

Methimazole

C.

Webbed neck

C.

Carbamazepine

D.

Hearing loss

D.

Warfarin

1237

Teratogenic effect of which of the following drugs produces “necrotizing enterocolitis” ?

Fetal Minamata disease is caused by the teratogenic effect of which of the following drug ? N Engl J Med 1998;338:1129

N Engl J Med 1998;338:1129

1231

Endocrinology

A.

Warfarin

A.

Nonsteroidal antiinflammatory drugs

B.

Methyl mercury

B.

Methimazole

C.

Hydantoin

C.

Carbamazepine

D.

Thalidomide

D.

Valproic acid

Teratogenic effect of which of the following drugs produces “decreased skull ossification” ?

Vitamin D

N Engl J Med 1998;338:1129

1232

A.

Nonsteroidal antiinflammatory drugs

B.

Angiotensin-converting enzyme inhibitors

C.

Carbamazepine

D.

Valproic acid

Teratogenic effect of which of the following drugs produces “Masculinization of female fetuses” ? N Engl J Med 1998;338:1129

1233

A.

Nonsteroidal antiinflammatory drugs

B.

Danazol

C.

Diethylstilbestrol

D.

Misoprostol

1238

Harrison’s 17th Ed. 2373

1239

1234

B.

Angiotensin-converting–enzyme inhibitors

C.

Diethylstilbestrol

D.

Misoprostol

1240

1235

1236

B.

Hypoplasia of nails

C.

Thymic defects

D.

Spontaneous abortion

C.

Enzyme

D.

All of the above

UV radiation of skin leads to synthesis of Vitamin D from ? A.

5-dehydrocholesterol

B.

6-dehydrocholesterol

C.

7-dehydrocholesterol

D.

8-dehydrocholesterol

Which of the following statements about Vitamin D is false ? Harrison’s 17th Ed. 2373

N Engl J Med 1998;338:1129

Optic-nerve blindness

Hormone

In response to ultraviolet radiation of skin, a photochemical cleavage results in formation of vitamin D from 7-dehydrocholesterol.

Retinoid embryopathy caused by teratogenic effect of “Isotretinoin” includes all except ? A.

Vitamin

B.

Harrison’s 17th Ed. 2373

N Engl J Med 1998;338:1129

Nonsteroidal antiinflammatory drugs

A.

Vitamin D & its metabolites are hormones & hormone precursors rather than vitamins, since they can be synthesized endogenously.

Teratogenic effect of which of the following drugs produces “renal tubular dysgenesis” ? A.

Vitamin D is better related to which of the following ?

A.

Vitamin D from plant sources is vitamin D2

B.

Vitamin D from animal sources is vitamin D3

C.

D2 has more biologic activity than D3

D.

25(OH)D is major circulating &storage form of vitamin D

Vitamin D from plant sources is vitamin D 2 whereas that from animal sources is vitamin D 3. Both have equivalent biologic activity & are activated equally by vitamin D hydroxylases. 25hydroxyvitamin D [25(OH)D] is the major circulating & storage form of vitamin D.

1241

The half-life of 25(OH)D is approximately ?

Fetal hydantoin syndrome caused by teratogenic effect of “Phenytoin” includes all except ?

Harrison’s 17th Ed. 2374

A.

1 - 12 hours

N Engl J Med 1998;338:1129

B.

1 - 2 weeks

A.

Short nose with broad nasal bridge

C.

2 - 3 weeks

B.

Epicanthus

D.

4 - 6 weeks

C.

Webbed neck

D.

Micrognathia

Fetal warfarin syndrome caused by teratogenic effect of “Warfarin” includes all except ? N Engl J Med 1998;338:1129

The half-life of 25(OH)D is ~ 2 - 3 weeks.

1242

The formation of the mature Vitamin D hormone occurs in ? Harrison’s 17th Ed. 2374

A.

Liver

Endocrinology 623

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

Kidney

C.

Skin

D.

All of the above

1250

Drugs associated with increased risk of generalized osteoporosis in adults include all except ? Harrison’s 16th Ed. 2271

1244

A.

Aluminum

B.

Gonadotropin-releasing hormone agonists

C.

Protamine

D.

Lithium

Biochemical markers of bone formation include all except ? Harrison’s 16th Ed. 2273

1245

A.

Serum bone-specific alkaline phosphatase

B.

Serum bone sialoprotein

C.

Serum osteocalcin

D.

Serum propeptide of type I procollagen

1251

1247

1248

1249

A.

Calbindin 9K

B.

ECaC

C.

ICaC

D.

All of the above

1,25(OH)2 D has an antiproliferative effect on ? Harrison’s 16th Ed. 2247

1252

A.

Keratinocytes

B.

Breast cancer cells

C.

Prostate cancer cells

D.

All of the above

Accelerated loss of vitamin D due to increased metabolism is due to all except ? Harrison’s 16th Ed. 2247

Biochemical markers of bone resorption include all except ? Harrison’s 16th Ed. 2273

1246

Active transport of calcium across enterocytes is a function of ? Harrison’s 16th Ed. 2247

The formation of the mature Vitamin D hormone occurs in the kidney after second hydroxylation.

1243

1253

A.

Barbiturates

B.

Phenytoin

C.

Rifampin

D.

Isoniazid

Impaired 1  hydroxylation leading to improper activation of vitamin D is due to all except ?

A.

Serum tartrate-resistant acid phosphatase

B.

Serum bone sialoprotein

C.

Serum osteocalcin

A.

Hypoparathyroidism

D.

Urine hydroxyproline

B.

Renal failure

Harrison’s 16th Ed. 2247

25(OH)D-1  hydroxylase is expressed in ?

C.

Liver disease

Harrison’s 16th Ed. 2246

D.

Ketoconazole

A.

Proximal convoluted tubule cells

B.

Cells of loop of Henle

C.

Distal convoluted tubule cells

D.

All of the above

1254

Which of the following drugs causes impaired 25-hydroxylation of Vitamin D3 ? Harrison’s 16th Ed. 2247

A.

Phenytoin

B.

Rifampin

Harrison’s 16th Ed. 2246

C.

Isoniazid

A.

Sarcoidosis

D.

Ketoconazole

B.

Tuberculosis

C.

Berylliosis

D.

All of the above

1  hydroxylase is produced in the granulomas of ?

1255

Radiologic feature of osteomalacia ‘Looser’s zones’ is related to ? Harrison’s 16th Ed. 2248

A.

Nerves

B.

Arteries

Harrison’s 16th Ed. 2246

C.

Veins

A.

Cell membrane

D.

Lymph nodes

B.

Nuclear

C.

Mitochondrial

D.

Endoplasmic reticulum

Vitamin D receptor (VDR) is what kind of a receptor ?

1256

Harrison’s 16th Ed. 2247

25(OH)D2

B.

25(OH)D3

C.

1,25(OH)2 D

D.

All of the above

In patients whose 1  hydroxylation is impaired, which of the following vitamin D analogues is given ? Harrison’s 16th Ed. 2248

Normally, Vitamin D receptor (VDR) has maximum affinity for ? A.

623 Cardiology

1257

A.

Dihydrotachysterol (DHT)

B.

1,25(OH)2 D3

C.

1  hydroxyvitamin D2

D.

Any of the above

What level of urinary calcium excretion predisposes to nephrolithiasis ? Harrison’s 16th Ed. 2249

A.

> 50 mg/day

624

1258

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR B.

> 100 mg/day

C.

> 175 mg/day

D.

> 250 mg/day

Burnett’s syndrome is related to ?

TNFRSF11B gene encodes osteoprotegrin with an autosomal dominant pattern of inheritance with variable penetrance. Its homozygous deletion causes juvenile Paget disease which is characterized by uncontrolled osteoclastic differentiation & resorption.

1264

Aluminum Intoxication

B.

Milk-Alkali Syndrome

C.

Vitamin A Intoxication

D.

Thiazides diuretics

Chapter 355. Paget’s Disease and Other Dysplasias of Bone 1259

1265

Number of nuclei in the normal osteoclast is ?

C.

Osteoblast progenitors

D.

Osteoclast progenitors

Gene which encodes osteoprotegrin is ? A.

TNFRSF11A

B.

TNFRSF11B

C.

TNFRSF11C

D.

TNFRSF11D

1-3

B.

3-5

C.

5-8

TNFRSF11B gene encodes osteoprotegrin.

D.

8 - 12

1266

A.

Increased number of osteoclasts

B.

Increased activity of osteoclasts

C.

Increased size of osteoclasts

D.

All of the above

Pain

B.

Paresthesias

C.

Diplopia

D.

Warmth over underlying pagetic lesion

Pain is the most common presenting symptom.

A.

Serum ALP

B.

Serum AST

C.

Urinary hydroxyproline

D.

All of the above

Serum ALP and urinary hydroxyproline levels are markers of bone formation & resorption respectively.

1267

In Paget disease of bone, which of the following is the most common presenting symptom ? A.

Which of the following is a marker of bone formation ? Harrison’s 18th Ed. 3137

Principal abnormality in Paget disease is ?

Which of the following is a product of type I collagen degradation ? Harrison’s 18th Ed. 3138

Harrison’s 18th Ed. 3137

A.

Serum deoxypyridinoline

B.

Serum N-telopeptide

C.

Serum C-telopeptide

D.

All of the above

Urinary and serum deoxypyridinoline, N-telopeptide, and C-telopeptide levels are products of type I collagen degradation.

Which of the following is a marker of bone resorption ?

Which of the following is not a urine or serum bone resorption marker ?

N Engl J Med 2006;355:593-600

Harrison’s 18th Ed. 3137

A.

Urinary Oxypyridinoline

A.

Deoxypyridinoline

B.

Urinary pyridinoline

B.

Osteocalcin

C.

Urinary deoxypyridinoline

C.

N-telopeptide

D.

All of the above

D.

C-telopeptide

Markers of bone resorption are urinary deoxypyridinoline & cross-linked N-telopeptide of type I collagen.

1263

Osteoclast-mediated resorption of bone

A.

Principal abnormality in Paget disease is the increased number and activity of osteoclasts. Pagetic osteoclasts are large.

1262

Osteoclast development

B.

Harrison’s 18th Ed. 3136

Harrison’s 18th Ed. 3137

1261

A.

Osteoclast-mediated resorption of bone takes place in scalloped spaces called Howship’s lacunae where the osteoclasts are attached through a specific integrin to components of the bone matrix such as osteopontin.

Harrison’s 18th Ed. 3137

1260

Howship’s lacunae is related to which of the following ? Harrison’s 17th Ed. 2408

Harrison’s 16th Ed. 2259

A.

Endocrinology

Inheritance of Juvenile Paget’s disease is ? Harrison’s 18th Ed. 3136

A.

Autosomal recessive

B.

Autosomal dominant

C.

X linked

D.

Any of the above

1268

Urine or serum bone resorption markers include pyridinoline, deoxypyridinoline, N-telopeptide and C-telopeptide), while serum markers of bone formation are ALP and osteocalcin.

1269

Which of the following is an intravenous bisphosphonate ? N Engl J Med 2006;355:593-600

A.

Zoledronic acid

B.

Olpadronate

C.

Pamidronate

Endocrinology 625 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

All of the above

Intravenous bisphosphonates are pamidronate, zoledronic acid & olpadronate.

1270

Which of the following is an intravenous bisphosphonate ?

C.

Hypogonadotropic hypogonadism

D.

All of the above

625 Cardiology

Major clinical manifestation of hemochromatosis are cirrhosis of liver, diabetes mellitus, arthritis, cardiomyopathy, and hypogonadotropic hypogonadism.

N Engl J Med 2006;355:593-600

1271

A.

Etidronate disodium

B.

Tiludronate disodium

C.

Risedronate sodium

D.

None of the above

1276

N Engl J Med 2012;366:348-59

Potencies of various bisphosphonates are expressed relative to that of ? Harrison’s 17th Ed. 2409

A.

Alendronate

B.

Risedronate

C.

Pamidronate

D.

Etidronate

1277

Harrison’s 18th Ed. 3139

Tiludronate

B.

Alendronate

C.

Risedronate

D.

Etidronate

Second-generation oral bisphosphonates include tiludronate, alendronate, and risedronate.

1273

1274

B.

Erythroid precursors

C.

Reticuloendothelial macrophages

D.

All of the above

Which of the following is the first step in iron metabolism ? A.

Reduction

B.

Absorption

C.

Storage

D.

Transfer

Dietary iron is absorbed primarily by duodenal enterocytes. After the iron is reduced at the apical membrane, it is taken into the cell through the divalent metal transporter 1 (DMT1). Export of iron from enterocytes to plasma occurs through the basolateral transporter ferroportin. Iron is stored as ferritin and is lost on sloughing of senescent enterocyte.

1278

Which of the following regulates iron metabolism ? N Engl J Med 2012;366:348-59

Radiographic finding of Paget disease include ?

A.

Oxygen tension in enterocytes

Harrison’s 18th Ed. 3137

B.

Intracellular iron levels

C.

Systemic iron needs

D.

All of above

A.

Osteoporosis circumscripta

B.

Picture frame vertebra

C.

Ivory vertebra

D.

All of the above

Brim sign refers to ? Harrison’s 18th Ed. 3137

A.

Thickening of diploic skull areas

B.

Thickened & sclerotic ileopectinal line

C.

Vertebral cortical thickening

D.

Diffuse radiodense enlargement of a vertebra

In Pagets disease od bone, skull radiographs show regions of “cotton wool” or osteoporosis circumscripta, thickening of diploic areas, enlargement & sclerosis of a portion or all of one or more skull bones. Vertebral cortical thickening of the superior & inferior end plates creates a “picture frame” vertebra. Diffuse radiodense enlargement of a vertebra is referred to as “ivory vertebra.” Pelvic radiographs show disruption or fusion of sacroiliac joints, porotic & radiodense lesions of ilium with whorls of coarse trabeculation, thickened & sclerotic ileopectinal line (Brim sign), and softening with protrusio acetabuli, with axial migration of hips & functional flexion contracture.

Chapter 357. Hemochromatosis 1275

Duodenal enterocytes

N Engl J Med 2012;366:348-59

Which of the following is a 1st generation oral bisphosphonate ? A.

A.

Four major cell types determine body iron content & distribution. They are duodenal enterocytes (dietary iron absorption), erythroid precursors (iron utilization), reticuloendothelial macrophages (iron storage & recycling), and hepatocytes (iron storage & endocrine regulation).

Potencies of various bisphosphonates are expressed relative to that of etidronate.

1272

Which of the following cell types determine body iron content & distribution ?

Which of the following is the major clinical manifestation of hemochromatosis ? Harrison’s 18th Ed. 3162

A.

Diabetes mellitus

B.

Cardiomyopathy

Regulation of each step of iron metabolism (reduction, absorption, storage, and transfer) is mediated by signals reflecting oxygen tension in enterocytes, intracellular iron levels, and systemic iron needs.

1279

Enterocyte tension regulates iron absorption through ? N Engl J Med 2012;366:348-59

A.

Hypoxia-inducible factor 2 (HIF-2)

B.

Hypoxia-inducible factor 2 (HIF-2)

C.

Hypoxia-inducible factor 2 (HIF-2)

D.

Hypoxia-inducible factor 2 (HIF-2)

Enterocyte tension regulates iron absorption through its effects on transcription factor hypoxiainducible factor 2 (HIF-2 ) & subsequent changes in transcription of DMT1 & ferroportin.

1280

Enterocyte iron content regulates iron absorption through ? N Engl J Med 2012;366:348-59

A.

Iron absorption protein

B.

Iron metabolism protein

C.

Iron regulatory protein

D.

Iron synthesis protein

Enterocyte iron content regulates iron absorption through its effects on iron regulatory protein (IRP) types 1 & 2 and their subsequent effects on messenger RNAs (mRNAs) encoding DMT1, ferroportin, ferritin, and HIF-2 . The IRPs bind to sequences (iron-responsive elements [IREs]) that influence mRNA translation (with respect to ferroportin, ferritin, and HIF-2 ) or stability (with respect to DMT1). The IRE-IRP system increases ferritin mRNA translation in response to cellular iron.

626 1281

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Systemic regulation of iron absorption is mediated by ?

C.

Circulating transferrin iron

N Engl J Med 2012;366:348-59

D.

Non-transferrin bound iron (NTBI)

A.

Hepcidin

B.

Ferroportin

C.

Ferritin

D.

DMT1

Reticuloendothelial cells obtain most of their iron from phagocytosis of senescent erythrocytes.

1287

Plasma iron transport protein is ? N Engl J Med 2012;366:348-59

A.

Hepcidin

B.

Ferroportin

C.

Transferrin

D.

Ferritin

1288

N Engl J Med 2012;366:348-59

Acetate

B.

Butyrate

C.

Citrate

D.

Sulphate

Transferrin receptor 1 (TfR1) is best related to ? N Engl J Med 2012;366:348-59

A.

Non-transferrin bound iron (NTBI)

B.

Entry of iron-bound transferrin into cells

C.

Labile plasma iron

D.

Recycling endosomes

1289

Which of the following represents the most dynamic iron compartment ? N Engl J Med 2012;366:348-59

18

D.

24

Hepatocytes are an important site of iron storage in the form of ? A.

Ferritin

B.

Hemosidrin

C.

Transferrin

D.

Ferroportin

Which of the following is called as “hypoferremia hormone” ? A.

Ferroportin

B.

Hepcidin

C.

Transferrin

D.

Hemosidrin

Hepatocytes serve a central role in iron homeostasis as the site of regulated production of hormone hepcidin. Hepcidin functions as the “hypoferremia hormone” by down-regulating ferroportin-mediated release of iron into circulation. The consequent iron retention in duodenal enterocytes decreases dietary iron absorption. Iron retention in RE macrophages decreases iron turnover.

1290

Hepatocellular hepcidin production is regulated by ? N Engl J Med 2012;366:348-59

A.

Inflammation

B.

Iron status

C.

Erythropoietic activity

D.

All of the above

Hepatocellular hepcidin production is regulated by signals reflecting inflammation, iron status, erythropoietic activity, and oxygen tension.

A.

Liver

B.

Intestinal cells

C.

Reticuloendothelial macrophages

A.

Type I

D.

Bone marrow

B.

Type II

C.

Type III

D.

Type IV

1291

Reticuloendothelial cells obtain most of their iron from ? N Engl J Med 2012;366:348-59

A.

Phagocytosis of senescent erythrocytes

B.

Labile plasma iron

Hepcidin is which type of acute-phase protein ? N Engl J Med 2012;366:348-59

Reticuloendothelial cells serve as the major hepcidin-regulated iron storehouse. At equilibrium, RE cells release ~25 mg of iron per day. As the pool of circulating transferrin iron is 95% of symptomatic patients. The association of hepatomegaly, skin pigmentation, diabetes mellitus, heart disease, arthritis, and hypogonadism should suggest hemochromatosis.

1307

Which of the following is most common in hemochromatosis ? Harrison’s 18th Ed. 3165

Harrison’s 18th Ed. 3163

1306

Which of the following is usually the first joint involved in hemochromatosis ? Harrison’s 18th Ed. 3164

Hepcidin binds to which of the following ?

Iron moves from enterocyte to the circulation via a process requiring basolateral iron exporter ferroportin (FPN) and iron oxidase hephaestin (Heph). In the circulation, iron binds to plasma transferring. Hepcidin is a liver-derived peptide that represses basolateral iron transport in intestine & iron release from macrophages and other cells by binding to ferroportin. Hepcidin, in turn, responds to signals in liver mediated by HFE, TfR2, and hemojuvelin. Mutations in genes encoding HFE, TfR2, hemojuvelin and hepcidin lead to decreased hepcidin release and increased iron absorption, resulting in hemochromatosis.

1305

Endocrinology

Bronzing or characteristic metallic or slate-gray skin pigmentation in hemochromatosis is due to ? Harrison’s 18th Ed. 3164

1 mL blood contains approximately how much iron ?

1 mL blood contains approximately 0.5 mg iron.

1313

An increase of 1 mg/L in serum ferritin level reflects an increase of about how much iron in body stores ?

A.

Increased iron in the epidermis

B.

Decreased iron in the epidermis

Harrison’s 18th Ed. 3165

C.

Increased iron in the dermis

A.

2 mg

D.

Decreased iron in the dermis

B.

3 mg

C.

4 mg

D.

5 mg

In hemochromatosis, characteristic metallic or slate-gray skin pigmentation referred to as bronzing results from increased melanin and iron in the dermis. Pigmentation is diffuse but more pronounced on face, neck, extensor aspects of lower forearms, dorsa of the hands, lower legs, and genital regions, as well as in scars.

An increase of 1 mg/L in serum ferritin level reflects an increase of about 5 mg iron in body stores.

1308

1314

Which of the following is the least common in hemochromatosis ? Harrison’s 18th Ed. 3164

Which of the following is the strongest predictor of hemochromatosis expression in individuals homozygous for C282Y mutation ?

A.

Arthropathy

Harrison’s 18th Ed. 3165

B.

Hepatomegaly

A.

Plasma iron

C.

Cardiac involvement

B.

Total iron-binding capacity

Diabetes mellitus

C.

Serum ferritin

D.

Endocrinology 629 D.

FOR MEDICAL PROFESSIONALS MCQ’s FOR MCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

C-reactive protein

Serum ferritin level >1000 mg/L is the strongest predictor of disease expression among individuals homozygous for the C282Y mutation.

1315

Which of the following indicates risk of severe fibrosis in a C282Y homozygous subject ? Harrison’s 18th Ed. 3165

A.

Serum ferritin level 2. In homozygotes with early, asymptomatic hemochromatosis it si between 1 and 2.

1318

C.

A.

D.

1317

Acute intermittent porphyria (AIP)

Porphyrias are either hepatic or erythropoietic, depending on the primary site of overproduction and accumulation of their respective porphyrin precursors. PCT is the most common porphyria. It is hepatic and presents with blistering cutaneous photosensitivity, which is usually a manifestation of the erythropoietic porphyrias.

There is virtually no risk of severe fibrosis in a C282Y homozygous hemochromatosis subject with serum ferritin level 1015 synapses.

Spasticity refers to an increase in tone associated with disease of upper motor neurons. Spasticity is velocity-dependent, has a sudden release after reaching a maximum and predominantly affects the antigravity muscles (upper-limb flexors and lower-limb extensors).

4

11

Which of the following is a monogenic disorder ?

Which of the following about ‘Rigidity’ is false ?

Harrison’s 18th Ed. 3224

Harrison’s 18th Ed. 182

A.

Familial Alzheimer’s disease

A.

Present throughout range of motion

B.

Frontotemporal dementia

B.

Affects flexors & extensors equally

C.

Parkinson’s disease

C.

Occurs with extrapyramidal disorders

D.

All of the above

D.

None of the above

Mutations of amyloid precursor protein in familial Alzheimer’s disease, microtubule-associated protein tau (MAPT) in frontotemporal dementia & alpha-synuclein in Parkinson’s disease represent monogenic causes of common phenotypes.

Rigidity is increased tone that is present throughout the range of motion and affects flexors and extensors equally. Rigidity occurs with certain extrapyramidal disorders such as Parkinson’s disease.

5

12

6

Nissl bodies are composed of ? A. Mitochondria

Harrison’s 18th Ed. 182

B.

Endoplasmic reticulum

A.

Also called gegenhalten

C.

Golgi complex

B.

Increased tone varies irregularly

D.

Lysosomes

C.

Present throughout range of motion

D.

None of the above

Synaptic glomeruli are found in ? Harrison’s 16th Ed. 176

7

Which of the following about ‘Paratonia’ is false ?

13

Which of the following about ‘Paratonia’ is false ?

A.

Cerebellum

Harrison’s 18th Ed. 182

B.

Olfactory bulb

A.

Increased muscle tone

C.

Lateral geniculate body

B.

Affects flexors & extensors equally

D.

All of the above

C.

Results from disease of frontal lobes

D.

None of the above

What fraction of genes encoded in human genome is expressed in the nervous system ? Harrison’s 16th Ed. 2339

Paratonia (gegenhalten) is increased tone that varies irregularly related to the degree of relaxation. It is present throughout the range of motion and affects flexors & extensors equally. Results from disease of frontal lobes.

644 14

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Which of the following about ‘flaccidity’ is false ?

Harrison’s 18th Ed. 183 Figure 22-1

A.

Weakness

A.

Tectospinal pathway

B.

Decreased tone

B.

Vestibulospinal pathway

C.

Disorder of motor unit

C.

Reticulospinal pathway

D.

None of the above

D.

All of the above

Which of the following is false about fasciculation ? Harrison’s 18th Ed. 182

A.

Visible twitch

B.

Palpable twitch

C.

Spontaneous discharge of a motor unit

D.

None of the above

Descending ventromedial bulbospinal pathways include tectospinal, vestibulospinal, and reticulospinal pathways. These pathways influence axial & proximal muscles and are involved in the maintenance of posture and integrated movements of the limbs and trunk.

21

Which of the following is false about upper motor neuron weakness ? Harrison’s 18th Ed. 182

All of the following are part of descending ventromedial bulbospinal pathways except ? Harrison’s 18th Ed. 183 Figure 22-1

Fasciculations are visible or palpable twitch within a muscle due to spontaneous discharge of a motor unit.

16

Descending ventromedial bulbospinal pathways include ?

Harrison’s 18th Ed. 182

Weakness with decreased tone is called flaccidity. It occurs with disorders of motor units which consists of a single lower motor neuron and all of the muscle fibers that are innervated by it.

15

20

A.

Tectospinal pathway

B.

Vestibulospinal pathway

C.

Reticulospinal pathway

D.

Rubrospinal pathway

Descending ventrolateral bulbospinal pathways, which originate predominantly in red nucleus (rubrospinal pathway), facilitate distal limb muscles. Bulbospinal system is also called extrapyramidal upper motor neuron system.

22

Which of the following is false about lower motor neuron weakness ?

A.

Proximal muscle groups affected more than distal

B.

Axial movements spared

A.

Due to loss of  neurons

C.

Affects ability to perform rapid repetitive movements

B.

Due to loss of  motor neurons

D.

Normal movement rhythmicity is maintained

C.

Absent tendon stretch reflex suggests involvement of spindle afferent fibers

D.

Fasciculations signify anterior horn cell disease

Harrison’s 18th Ed. 182

In UMN lesions, distal muscle groups are affected more severely than proximal ones.

17

Upper motor neurons have their cell bodies in which layer of primary motor cortex ? Harrison’s 18th Ed. 183 Figure 22-1

Loss of -motor neurons does not cause weakness but decreases muscle tone and attenuates the stretch reflexes elicited on examination.

A.

Layer III

B.

Layer IV

C.

Layer V

A.

motor neurons innervate extrafusal muscle fibers

D.

Layer VI

B.

motor neurons innervate intrafusal muscle fibers

C.

 motor neuron receives direct excitatory input from corticomotoneurons & primary muscle spindle afferents

D.

 motor neurons receive direct excitation from Renshaw cell interneurons

23

What proportion of pyramidal axons do not decussate and remain ipsilateral ? Harrison’s 18th Ed. 183 Figure 22-1

-motor neurons receive direct inhibition from Renshaw cell interneurons.

A.

2 to 10 %

B.

5 to 15 %

C.

10 to 30 %

A.

Due to disorders of muscle fibers

D.

20 to 35 %

B.

Due to defect in neuromuscular junctions

C.

In EMG, size of each motor unit action potential is reduced

D.

Distribution of weakness is distal

24

Pyramidal axons innervate most densely which of the following lower motor neurons ? Harrison’s 18th Ed. 183 Figure 22-1

Which of the following is false about myopathic weakness ? Harrison’s 18th Ed. 182, Table 22-1

At cervicomedullary junction, most pyramidal axons decussate into contralateral cortico-spinal tract of lateral spinal cord, but 10 - 30% remain ipsilateral in anterior spinal cord.

19

Which of the following is false about motor neurons ? Harrison’s 18th Ed. 183 Figure 22-2

Cell bodies of UMN’s is in layer V of primary motor cortex (precentral gyrus, or Brodmann’s area 4) and in premotor & supplemental motor cortex (area 6).

18

Neurology

Distribution of myopathic weakness is typically proximal. Lower motor neuron weakness is most profound distally.

25

“Pure motor” hemiparesis of the face, arm, or leg is due to a lesion in ?

A.

Of hand muscles

B.

Of foot muscles

C.

Of axial muscles

A.

Posterior limb of internal capsule

D.

Of face muscles

B.

Cerebral peduncle

C.

Upper pons

Pyramidal neurons innervate most densely the LMN’s of hand muscles.

Harrison’s 18th Ed. 184

Neurology 645 D.

FOR MEDICAL PROFESSIONALS MCQ’s FORMCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Any of the above

“Pure motor” hemiparesis of face, arm, or leg is due to lesion in posterior limb of the internal capsule, cerebral peduncle or upper pons.

26

Paraparesis can arise due to ? Harrison’s 18th Ed. 184

27

A.

Anterior horn cell disorders

B.

Cauda equina syndrome

C.

Peripheral neuropathies

D.

Any of the above

33

28

B.

Cortical venous thrombosis

C.

Acute hydrocephalus

D.

Any of the above

34

29

B.

10 billion

C.

20 billion

D.

50 billion

Cerebral cortex of human brain has an area of ? 0.5 m2

B.

1.5 m2

C.

2.5 m2

D.

3.5 m2

Anomic aphasia is the single most common language disturbance seen in ? A.

Head trauma

B.

Metabolic encephalopathy

C.

Alzheimer’s disease

D.

All of the above

Inability to read aloud or comprehend single words and simple sentences is called ? A.

Alexia

B.

Agraphia

C.

Anomia

D.

Paraphasia

Alexia describes an inability to either read aloud or comprehend single words and simple sentences; agraphia (or dysgraphia) is used to describe an acquired deficit in the spelling or grammar of written language.

35

Which of the following is impaired in Wernicke’s aphasia ? Harrison’s 18th Ed. 203 Table 26-1

Harrison’s 18th Ed. 202

A.

Any of the above

Harrison’s 18th Ed. 203

Harrison’s 18th Ed. 202

5 billion

Naming a different object

D.

Anomic aphasia is the single most common language disturbance seen in head trauma, metabolic encephalopathy, and Alzheimer’s disease.

Cerebral cortex of human brain contains approximately how many neurons ? A.

C.

Harrison’s 18th Ed. 203

Harrison’s 18th Ed. 184

Superior sagittal sinus thrombosis

Deficit of naming

Deficit of naming or anomia is the single most common finding in aphasic patients. Naming with the wrong word is called paraphasia.

Acute paraparesis can be due to which of the following diseases of cerebral hemispheres ? A.

B.

645 Cardiology

A.

Comprehension

B.

Repetition of spoken language

C.

Naming

D.

All of the above

Human cerebral cortex contains ~20 billion neurons spread over an area of 2.5 m 2.

Comprehension, repetition of spoken language and naming are impaired in Wernicke’s aphasia. Fluency is preserved or increased.

30

36

Primary sensory & motor areas constitute what percentage of cerebral cortex ?

Harrison’s 18th Ed. 203 Table 26-1

Harrison’s 18th Ed. 202

A.

Comprehension

A.

10 %

B.

Repetition of spoken language

B.

15 %

C.

Naming

C.

20 %

D.

Fluency

D.

25 %

Primary sensory & motor areas constitute 10% of the cerebral cortex.

31

Which of the following is preserved in Broca’s aphasia ?

37

Harrison’s 18th Ed. 205

A language disturbance occurring after a right hemisphere lesion in a right hander is called ? Harrison’s 18th Ed. 203

A.

Ipsilateral aphasia

B.

Sequence aphasia

C.

Crossed aphasia

D.

Retro aphasia

Fluency is severely impaired in ? A.

Aphemia

B.

Alexia

C.

Anomia

D.

Wernicke’s aphasia

Aphemia is an acute onset of severely impaired fluency.

38

Apraxia refers to ? Harrison’s 18th Ed. 205

Language disturbance occurring after a right hemisphere lesion in a right hander is called crossed aphasia.

A.

Repetition of spoken language

32

Anomia refers to ?

B.

Disorder of initiating skilled / learned movement

Harrison’s 18th Ed. 203

C.

Impaired comprehension

D.

No purposeful speech

A.

Naming with the wrong word

646 39

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR In apraxia, complex motor deficit is attributed to ?

A.

Hypoglycemia

Harrison’s 18th Ed. 205

B.

Sagittal sinus thrombosis

C.

Atypical forms of Alzheimer’s disease

D.

All of the above

A.

Pyramidal dysfunction

B.

Extrapyramidal dysfunction

C.

Cerebellar dysfunction

D.

None of the above

46

Face recognition deficit is termed as ? Harrison’s 18th Ed. 209

Apraxia refers to a complex motor deficit that cannot be attributed to pyramidal, extrapyramidal, cerebellar, or sensory dysfunction. It is a disorder of planning & initiating a skilled or learned movement unrelated to a significant motor or sensory deficit.

A.

Primary progressive aphasia (PPA)

B.

Visual object agnosia

40

Gerstmann’s Syndrome includes all except ?

C.

Aprosodia

Harrison’s 18th Ed. 206

D.

Prosopagnosia

A.

Acalculia

B.

Aphasia

C.

Right-left confusion

D.

Finger anomia

Face & object recognition deficits are known as prosopagnosia & visual object agnosia. Lesions in prosopagnosia & visual object agnosia consist of bilateral infarctions in the territory of posterior cerebral arteries.

47

In isolated Gerstmann’s syndrome, the damage is in ? Harrison’s 18th Ed. 206

A.

Superior parietal lobule in dominant hemisphere

B.

Inferior parietal lobule in dominant hemisphere

C.

Superior parietal lobule in non-dominant hemisphere

D.

Inferior parietal lobule in non-dominant hemisphere

48

Paratonic rigidity or gegenhalten results from disease of ? Harrison’s 17th Ed. 147

A.

Frontal lobes

B.

Temporal lobes

C.

Parietal lobes

D.

Occipital lobes

Statements uttered in a monotone are termed ? Harrison’s 18th Ed. 206

44

A.

Primary progressive aphasia (PPA)

B.

Anomic aphasia

C.

Aprosodia

D.

Prosopagnosia

Migraine

B.

Temporal lobe seizures

C.

TIA in the posterior cerebral territory

D.

All of the above

What proportion of all human cerebral cortex is located in the frontal lobes ? A.

One - fourth

B.

One - third

C.

One - half

D.

Three - fourth

~ One-third of all human cerebral cortex is located in the frontal lobes.

49

Characteristics of dystonia include all except ? Harrison’s 18th Ed. 193

Paratonia (or gegenhalten) is increased tone that varies irregularly in a manner that may seem related to the degree of relaxation, is present throughout the range of motion, and affects flexors and extensors equally; it usually results from disease of the frontal lobes.

43

A.

Harrison’s 18th Ed. 210

Isolated Gerstmann’s syndrome results from damage to inferior parietal lobule (angular gyrus) in the left hemisphere.

42

Cause of transient global amnesia is ? Harrison’s 18th Ed. 210

Gerstmann tetrad comprises of acalculia, alexia, finger anomia and right-left confusion. Pure Gerstmann syndrome is without aphasia.

41

A.

Ill sustained muscle contractions

B.

Repetitive twisting movements

C.

Abnormal posture

D.

Often has a genetic basis

Dystonia is a disorder characterized by sustained muscle contractions, resulting in repetitive twisting movements and abnormal posture. It often has a genetic basis.

50

Freezing gait is a feature of ? Harrison’s 18th Ed. 193

A.

Progressive supranuclear palsy

B.

Multiple system atrophy

Which symptom can occur in Bálint’s syndrome ?

C.

Corticobasal degeneration

Harrison’s 17th Ed. 168

D.

All of the above

A.

Optic ataxia

B.

Oculomotor apaxia

C.

Simultagnosia

D.

All of the above

Freezing gait is a feature of Parkinson’s disease, progressive supranuclear palsy, multiple system atrophy, corticobasal degeneration, and primary pallidal degeneration.

51

Pill-rolling tremor is a characteristic feature of ? Harrison’s 18th Ed. 193

Bálint’s syndrome is a state of severe spatial disorientation involving deficits in orderly visuomotor scanning of the environment (oculomotor apraxia) and in accurate manual reaching toward visual targets (optic ataxia) and simultanagnosia and reflects an inability to integrate visual information in the center of gaze with more peripheral information.

A.

Progressive supranuclear palsy

B.

Multiple system atrophy

C.

Corticobasal degeneration

45

D.

Parkinson’s disease

Bálint’s syndrome may result from ? Harrison’s 17th Ed. 168

Neurology

Neurology 647 52

FOR MEDICAL PROFESSIONALS MCQ’s FORMCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Term “gait apraxia” refers to ?

B.

256 Hz

Harrison’s 18th Ed. 193

C.

512 Hz

D.

Any of the above

A.

Cautious gait

B.

Cerebellar gait ataxia

C.

Frontal gait disorder

D.

Sensory ataxia

647 Cardiology

Sense of vibration is tested with a tuning fork that vibrates at 128 Hz.

59

Cortical sensation are tested by ? Harrison’s 18th Ed. 188

53

“Astasia-abasia” best relates to ? Harrison’s 18th Ed. 194

A.

Cautious gait

B.

Cerebellar gait ataxia

C.

Psychogenic gait disorder

D.

Sensory ataxia

Hysterical gait disorders with odd gyrations of posture & wastage of muscular energy (astasiaabasia), extreme slow motion & dramatic fluctuations over time are seen in somatoform disorders & conversion reaction.

54

60

Graphesthesia

D.

All of the above

Normal individuals can distinguish separation of points by what minimum distance in 2-PD test ? A.

1 mm 3 mm

Tingling

B.

B.

Numbness

C.

5 mm

C.

Burning

D.

7 mm

D.

Pricking

Normal individuals can distinguish separation of points by 3 mm distance in two-point discrimination test.

61

Which of the following is false about small-fiber polyneuropathy ? Harrison’s 18th Ed. 191

Hyperesthesia means pain or increased sensitivity in response to?

A.

Burning, painful dysesthesias

Harrison’s 18th Ed. 186

B.

Sparing of proprioception

A.

Touch

C.

Sparing of motor function

B.

Pain

D.

Absent tendon reflexes

C.

Warm or cold stimuli

D.

All of the above

62

Which of the following is false about large-fiber polyneuropathy ? Harrison’s 18th Ed. 191

A.

Vibration & position sense deficits

B.

Imbalance

Harrison’s 18th Ed. 186

C.

Absent tendon reflexes

A.

Pain on imagination

D.

None of the above

B.

Fear of pain

C.

Painful response to nonpainful stimulus

D.

Nonpainful response to painful stimulus

Allodynia refers to ?

Painful response to nonpainful stimulus is termed allodynia. Like, elicitation of a painful sensation by application of a vibrating tuning fork.

Small-fiber polyneuropathies are characterized by burning, painful dysesthesias with reduced pinprick & thermal sensation but sparing of proprioception, motor function & deep tendon reflexes. Large-fiber polyneuropathies are characterized by vibration & position sense deficits, imbalance, absent tendon reflexes & variable motor dysfunction but preservation of most cutaneous sensation.

63

Which of the following is false about Brown-Séquard syndrome ? Harrison’s 18th Ed. 191

Hyperpathia includes which of the following ?

A.

Hemisection of the spinal cord

Harrison’s 18th Ed. 186

B.

Absent pain & temperature sensation contralaterally

A.

Hyperesthesia

C.

Loss of proprioceptive sensation & power ipsilaterally

B.

Allodynia

D.

None of the above

C.

Hyperalgesia

D.

All of the above

Hyperpathia, a broad term, encompasses all the phenomena described by hyperesthesia, allodynia, and hyperalgesia. With hyperpathia, the threshold for a sensory stimulus is increased and perception is delayed, but once felt, is unduly painful.

58

Bilateral simultaneous stimulation

C.

A.

Hyperesthesia means pain or increased sensitivity in response to touch.

57

B.

Harrison’s 18th Ed. 188

Which of the following is not a positive sensory symptom ?

Loss of sensory function (diminished or absent feeling) is termed negative phenomena experienced as numbness and abnormal finding on sensory examination.

56

Two-point discrimination

Commonly used tests of cortical function are two-point discrimination, touch localization, bilateral simultaneous stimulation & tests for graphesthesia and stereognosis.

Harrison’s 18th Ed. 186

55

A.

Hemisection of spinal cord produces Brown-Séquard syndrome, with absent pain & temperature sensation contralaterally & loss of proprioceptive sensation & power ipsilaterally below the lesion.

64

Which of the following sensory loss occurs in syringomyelia ? Harrison’s 18th Ed. 191

A.

Pinprick & temperature

Harrison’s 18th Ed. 187

B.

Light touch

A.

C.

Position sense

Sense of vibration is tested with a tuning fork that vibrates at ? 128 Hz

648

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR D.

Vibration

In syringomyelia there is a dissociated sensory loss with impairment of pinprick & temperature appreciation. Light touch, position sense and vibration appreciation are preserved.

65

Which of the following is related to Lhermitte’s sign ? Harrison’s 18th Ed. 191

69

Normal CSF pH is ? A.

7.31 - 7.34

Electric shock like sensation

B.

7.34 - 7.37

C.

Radiation down the back & into the legs

C.

7.37 - 7.40

D.

All of the above

D.

7.40 - 7.44

73

Which receptor for PGE2 in brain is essential for fever ? Harrison’s 18th Ed. 145

A.

EP-1

Pansensory loss contralaterally is produced by a lesion in ?

B.

EP-2

Harrison’s 18th Ed. 191

C.

EP-3

D.

EP-4

A.

Cervical spinal cord

B.

Thalamus

C.

Tegmentum of pons & midbrain

D.

Lateral medulla

Elevation of PGE2 in brain starts the process of raising hypothalamic set point for core temperature. Out of the 4 receptors for PGE 2, EP-3 is essential for fever.

74

Which of the following statements is false about Type I muscle fibers ? Harrison’s 16th Ed. 134

A.

Rich in mitochondria

Harrison’s 18th Ed. 191

B.

Poor in oxidative enzymes

A.

Cervical spinal cord

C.

Have low energy demands

B.

Thalamus

D.

Produce relatively low force

C.

Tegmentum of pons & midbrain

D.

Lateral medulla

The site of lesion in Déjerine-Roussy syndrome is in ?

75

Which of the following statements is false about Type II muscle fibers ? Harrison’s 16th Ed. 134

A.

Rich in glycolytic enzymes

B.

Produce relatively high force

Harrison’s 17th Ed. 70

C.

Have high energy demands

A.

Pain

D.

None of the above

B.

Skin hue

C.

Cooperation of patient

D.

Colour of nails

Which of the following is labeled as the “Fifth vital sign” ?

In adults, normal CSF volume is ? A.

~ 100 ml

B.

~ 150 ml

C.

~ 200 ml

D.

~ 250 ml

Normal CSF pressure is ? Harrison’s 17th Ed. A 11

71

298 - 302 mOsm/L

B.

Headache 76

A.

20 - 70 mm H 2O

B.

80 - 120 mm H2O

C.

50 - 180 mm H2O

D.

120 - 280 mm H2O

Normal CSF osmolarity is ? Harrison’s 17th Ed. A 11

A.

280 - 285 mOsm/L

Which cranial structure is pain-insensitive ? Harrison’s 18th Ed. 112

Harrison’s 17th Ed. A 11

70

292 - 297 mOsm/L

D.

Harrison’s 17th Ed. A 11

Lesion affecting VPL nucleus of thalamus produces a syndrome of thalamic pain called DéjerineRoussy syndrome.

68

C.

Flexion of the neck

A lesion in tegmentum of pons & midbrain, where lemniscal & spinothalamic tracts merge, causes pansensory loss contralaterally.

67

285 - 292 mOsm/L

A.

In Lhermitte’s sign, flexion of neck leads to an electric shock like sensation that radiates down the back and into the legs. It is seen in patients with a cervical lesion affecting posterior columns like multiple sclerosis, cervical spondylosis or recent irradiation to the cervical region. Vitamin B 12 deficiency syndrome & Cisplatin toxicity can also cause it.

66

72

B.

Neurology

77

A.

Scalp

B.

Choroid plexus

C.

Dural sinuses

D.

Falx cerebri

Which cranial structure is pain-sensitive ? Harrison’s 18th Ed. 112

A.

Ventricular ependyma

B.

Choroid plexus

C.

Pial veins

D.

Falx cerebri

Pain-producing cranial structures include scalp, middle meningeal artery, dural sinuses, falx cerebri and proximal segments of large pial arteries. Ventricular ependyma, choroid plexus, pial veins, and much of the brain parenchyma are not pain-producing.

Neurology 649 78

79

FOR MEDICAL PROFESSIONALS MCQ’s FORMCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Which of the following is a type of primary headache ?

84

Migraine activators include all except ?

Harrison’s 18th Ed. 112 Table 14-1

Harrison’s 17th Ed. 96

A.

Migraine

A.

Red wine

B.

Tension-type

B.

Menstruation

C.

Cluster

C.

Pregnancy

D.

All of the above

D.

Lack of sleep

Which of the following is not a type of primary headache ?

85

649 Cardiology

Migraine deactivators include all except ?

Harrison’s 18th Ed. 112 Table 14-1

Harrison’s 17th Ed. 96

A.

Idiopathic stabbing

A.

Sleep

B.

Exertional

B.

Pregnancy

C.

Systemic infection

C.

Exhiliration

D.

Tension-type

D.

Hunger

Primary headaches are those in which headache and its associated features are the disorder in itself, whereas secondary headaches are those caused by exogenous disorders. Examples of primary headache are migraine, tension-type, cluster, idiopathic stabbing & exertional. Examples of secondary headache are systemic infection, head injury, vascular disorders, subarachnoid hemorrhage & brain tumor.

Activators of migraine are referred to as triggers. These include glare, bright lights, sounds, or other afferent stimulation; hunger, excess stress, physical exertion, stormy weather or barometric pressure changes, hormonal fluctuations during menses, lack of or excess sleep & alcohol or other chemical stimulation.

80

86

Of the following cause of primary headache, which one is the most common ?

Harrison’s 18th Ed. 115

Harrison’s 18th Ed. 112 Table 14-1

A.

A.

Migraine

5-HT1A receptor

B.

B.

Tension-type

5-HT1B receptor

C.

C.

Cluster

5-HT1D receptor

D.

D.

Exertional

5-HT1F receptor

Relative frequency of various types of primary headache is migraine 16%, tension-type 69%, cluster 0.1%, idiopathic stabbing 2% and exertional 1%.

81

Triptans are potent agonists of 5-HT1B, 5-HT 1D, and 5-HT1F receptors and are less potent at the 5HT 1A receptor.

87

Of the following cause of secondary headache, which one is the most common ?

A.

A.

Systemic infection

5-HT1A receptors

B.

B.

Vascular disorders

5-HT1B receptors

C.

C.

Subarachnoid hemorrhage

5-HT1C receptors

D.

D.

Brain tumor

5-HT1E receptors

Relative frequency of various types of secondary headache is systemic infection 63%, head injury 4%, vascular disorders 1%, subarachnoid hemorrhage 6 months. Risk of fibrosis is about 1:1500 and is likely to reverse after drug is stopped.

120

Lower-half headache or facial migraine called ? Harrison’s 16th Ed. 90

121

122

Chapter 274. Coma 127

Basilar migraine

B.

Carotidynia

A.

Lethargy

C.

Raeder’s syndrome

B.

Drowsiness

D.

Opthalmoplegic migraine

C.

Semicoma

D.

Obtundation

Harrison’s 18th Ed. 2247

Common precipitant of carotidynia attacks is ? A.

Cervical spondylosis

B.

Dental trauma

C.

Hypertension

D.

All of the above

At bedside, stupor, drowsiness and coma are precise narrative descriptions of the level of arousal and of the type of responses evoked by various stimuli and are preferable to ambiguous terms such as lethargy, semicoma, or obtundation.

128

Out of the following, which is the commonest symptom accompanying severe migraine ? A.

Photophobia

B.

Scalp tenderness

C.

Vomiting

D.

Vertigo

129

124

B.

At least three attacks per week

C.

At least three attacks per month

D.

At least three attacks per year

Drugs used for prophylactic treatment of migraine include all except ? Harrison’s 18th Ed. 120

Ventral pons

B.

Medial thalamic nuclei

C.

Temporal lobe

D.

Any of the above

Abulia describes a milder form of ? Harrison’s 18th Ed. 2247

Harrison’s 16th Ed. 93

At least three attacks per day

A.

Akinetic mutism results from damage in regions of medial thalamic nuclei or frontal lobes (particularly orbitofrontal surfaces) or from extreme hydrocephalus.

For instituting prophylactic treatment of migraine, what should be the frequency of attacks ? A.

Akinetic mutism results from damage in ? Harrison’s 18th Ed. 2247

Harrison’s 16th Ed. 90

123

At bedside, which of the following terms is not ambiguous and is preferred ?

A.

Harrison’s 16th Ed. 91

Neurology

A.

Parkinsonism

B.

Akinetic mutism

C.

Catatonia

D.

Locked-in state

Abulia is a milder form of akinetic mutism characterized by mental & physical slowness with diminished ability to initiate activity. It is usually the result of damage to frontal lobes and its connections.

130

Which of the following occurs as part of a major psychosis ? Harrison’s 18th Ed. 2247

A.

Akinetic mutism

Neurology 653 B.

Abulia

C.

Catatonia

D.

Locked-in state

FOR MEDICAL PROFESSIONALS MCQ’s FORMCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Catatonia occurs as part of a major psychosis (schizophrenia or major depression).

131

D.

137

B.

Babinski signs

C.

Blinking

D.

Mobility

Catatonia is differentiated from akinetic mutism by clinical evidence of cerebral damage such as Babinski signs and hypertonicity of the limbs present in akinetic mutism.

132

“Waxy flexibility” is a feature of which of the following ? Harrison’s 18th Ed. 2247

A.

Abulia

B.

Akinetic mutism

C.

Catatonia

D.

Locked-in state

In catatonia, the patient retains the posture in which they have been placed by the examiner (“waxy flexibility,” or catalepsy).

133

“Locked-in state” results from damage in ? Harrison’s 18th Ed. 2247

Pupillary enlargement

B.

Loss of light reaction

C.

Loss of vertical & adduction movements of eyes

D.

All of the above

138

The term ‘coma dépassé’ means ? N Engl J Med 2001;344:1215

A.

Hysteria

B.

Irreversible coma

C.

Coma during pregnancy

D.

Coma in children

In 1959, Mollaret & Goulon introduced the term coma dépassé (irreversible coma) in 23 comatose patients who lost consciousness, brainstem reflexes & respiration & whose EEGs were flat.

139

As brain death occurs, which is the last part of brain to cease to function ?

A.

Ventral pons

B.

Medial thalamic nuclei

A.

Cerebral cortex

C.

Temporal lobe

B.

Midbrain

D.

Any of the above

C.

Pons

D.

Medulla oblongata

“Locked-in state” like condition may be seen in ? Harrison’s 18th Ed. 2247

135

A.

Pupillary enlargement with loss of light reaction and loss of vertical and adduction movements of the eyes suggests that the lesion is in the upper brainstem. On the other hand, if pupillary light reaction and eye movements are intact, the lesion is more widespread or the cause of coma is metabolic suppression of the cerebral hemispheres.

N Engl J Med 2001;344:1216

“Locked-in state” results from an infarction or hemorrhage of ventral pons that transects all descending motor (corticospinal and corticobulbar) pathways.

134

Which of the following finding suggests that the lesion is in the upper brainstem ? Harrison’s 18th Ed. 2247

Harrison’s 18th Ed. 2247

Level of awakening

All of the above

Metabolic derangements that can lead to suppression of reticulocerebral function are hypoglycemia, anoxia, uremia, and hepatic failure.

Catatonia is differentiated from akinetic mutism by ? A.

As brain death occurs, patients lose their reflexes in a rostral-to-caudal direction, and medulla oblongata is the last part of brain to cease to function.

140

Misdiagnosis of brain death is possible in ?

A.

Guillain-Barré syndrome

B.

Critical illness neuropathy

A.

Locked-in syndrome

C.

Pharmacologic neuromuscular blockade

B.

Hypothermia

D.

Any of the above

C.

Drug intoxication

D.

All of the above

Coma results due to damage in reticular activating system (RAS) at the level of ?

653 Cardiology

N Engl J Med 2001;344:1215

Misdiagnosis of brain death is possible in locked-in syndrome, hypothermia or drug intoxication.

Harrison’s 18th Ed. 2247

A.

Medulla oblongata

B.

Pons

C.

Lower midbrain

D.

Upper midbrain

141

N Engl J Med 2001;344:1215

Coma results due to damage in reticular activating system (RAS) at the level of upper midbrain or its projections.

136

Metabolic derangement that can lead to suppression of reticulocerebral function is ?

In the tests to confirm brain death, “hollow-skull sign” is a finding in which of the following ? A.

EEG

B.

Dynamic radionuclide brain scan

C.

Cerebral angiography

D.

Transcranial Doppler measurements

When brain death has occurred, a dynamic radionuclide brain scan shows no intracranial filling the so called hollow-skull sign.

Harrison’s 18th Ed. 2247

A.

Hypoglycemia

B.

Uremia

C.

Hepatic failure

142

Which part of brain is damaged in “locked-in syndrome” ? N Engl J Med 2001;344:1215

A.

Medulla oblongata

B.

Pons

654

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR C.

Midbrain

D.

Thalamus

Harrison’s 18th Ed. 2248

The locked-in syndrome (pseudocoma) is a consequence of destruction of base of pons mostly caused by acute embolus to basilar artery. Patient cannot move limbs, grimace, or swallow (damaged corticospinal & corticobulbar tracts), but upper rostral mesencephalic structures involved in voluntary blinking and vertical eye movements remain intact. Consciousness persists because tegmentum, with the reticular formation, is not affected.

143

The principal cause of coma is ? Harrison’s 16th Ed. 1625

144

Temporal transtentorial herniation

B.

Central transtentorial herniation

C.

Transfalcial herniation

D.

Foraminal herniation

In foraminal herniation, cerebellar tonsils move downward into foramen magnum, causing compression of medulla that may result in respiratory arrest and death.

149

Drowsiness occurs when horizontal displacement of the pineal calcification occurs by ?

Lesions that damage substantial portion of RAS

B.

Destruction of large portions of both cerebral hemispheres

Harrison’s 18th Ed. 2248

C.

Suppression of thalamocerebral function by drugs, toxins, hypoglycemia, anoxia, azotemia, or hepatic failure

A.

1 to 3 mm

B.

3 to 5 mm

D.

All of the above

C.

6 to 8 mm

D.

> 9 mm

150

Stupor occurs when horizontal displacement of the pineal calcification occurs by ? Harrison’s 18th Ed. 2248

Kernohan-Woltman sign best relates to ? Harrison’s 18th Ed. 2248

A.

1 to 3 mm

A.

Hypoglycemia

B.

3 to 5 mm

B.

Central fever

C.

6 to 8 mm

C.

Transtentorial herniation

D.

> 9 mm

D.

Epileptic Coma

151

Transtentorial herniation refers to part of brain being displaced from supratentorial to infratentorial compartment through the tentorial opening. Consequent lateral displacement of midbrain may compress the opposite cerebral peduncle thus eliciting Kernohan-Woltman sign.

145

A.

A.

Principal causes of coma are lesions that damage the reticular activating system (RAS) or its projections, destruction of large portions of both cerebral hemispheres and suppression of reticulocerebral function by drugs, toxins, or metabolic derangements such as hypoglycemia, anoxia, azotemia, or hepatic failure.

Coma occurs when horizontal displacement of the pineal calcification occurs by ? Harrison’s 18th Ed. 2248

A.

1 to 3 mm

Kernohan-Woltman sign refers to ?

B.

3 to 5 mm

Harrison’s 18th Ed. 2248

C.

6 to 8 mm

D.

> 9 mm

A.

Contraleteral pupillary dilatation in brain mass lesion

B.

Waxing and waning levels of consciousness

C.

Hemiparesis contralateral to original hemiparesis

D.

Bilateral nystagmus

On CT/MRI, horizontal displacement of pineal calcification of 3 to 5 mm is associated with drowsiness, 6 to 8 mm with stupor, and >9 mm with coma, in acutely appearing masses.

152

Cerebral blood flow is principally influenced by all except ?

Kernohan-Woltman sign refers to a Babinski response and hemiparesis contralateral to the original hemiparesis due to compression of the opposite cerebral peduncle.

Harrison’s 16th Ed. 1632

A.

Systemic blood pressure

146

Brain herniation can be ?

B.

pH

Harrison’s 18th Ed. 2248

C.

PCO 2

D.

PO 2

A.

Transfalcial

B.

Transtentorial

C.

Foraminal

D.

All of the above

CBF is strongly influenced by systemic blood pressure, pH and PCO 2 . CBF increases with hypercapnia and acidosis and decreases with hypocapnia and alkalosis.

153

Various forms of brain herniations are transtentorial (temporal & central), transfalcial, foraminal.

147

148

Volume of CSF within ventricles and surrounding the brain and spinal cord is about ? Harrison’s 16th Ed. 1632

Cingulate gyrus is likely to be involved in which of the following brain herniations ?

A.

50 mL

Harrison’s 18th Ed. 2248

B.

100 mL

A.

Temporal transtentorial herniation

C.

150 mL

B.

Central transtentorial herniation

D.

200 mL

C.

Transfalcial herniation

D.

Foraminal herniation

In transfalcial herniation, the cingulate gyrus is displaced under the falx and across the midline.

Cerebellar tonsils are likely to be involved in which of the following brain herniations ?

Neurology

154

Cerebral blood volume is about ? Harrison’s 16th Ed. 1632

A.

50 mL

B.

100 mL

C.

150 mL

Neurology 655

FOR MEDICAL PROFESSIONALS MCQ’s FORMCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

655 Cardiology

About 150 mL of CSF is present within the ventricles and surrounding the brain and spinal cord. Cerebral blood volume is also ~150 mL.

100 gram/minute in white matter (mean of 55 mL per 100 gram/minute). Oxygen consumption is 3.5 mL per 100 gram/minute, and glucose utilization is 5 mg per 100 gram/minute. Brain stores of glucose provide energy for ~2 minutes after blood flow is interrupted, and oxygen stores last 8 to 10 seconds after cessation of blood flow.

155

162

D.

200 mL

Cerebral blood flow (CBF) in gray matter is about ? Harrison’s 18th Ed. 2248

156

A.

25 mL per 100 g/min

B.

50 mL per 100 g/min

C.

75 mL per 100 g/min

D.

100 mL per 100 g/min

Cerebral blood flow (CBF) in white matter is about ? Harrison’s 18th Ed. 2248

157

158

159

A.

10 mL per 100 g/min

B.

20 mL per 100 g/min

C.

30 mL per 100 g/min

D.

40 mL per 100 g/min

A.

125 mmol/L

B.

120 mmol/L

C.

118 mmol/L

D.

115 mmol/L

Sodium levels 300 mosmol/L

Harrison’s 18th Ed. 2248

C.

>320 mosmol/L

A.

25 mL per 100 g/min

D.

>350 mosmol/L

B.

35 mL per 100 g/min

C.

45 mL per 100 g/min

D.

55 mL per 100 g/min

Mean cerebral blood flow (CBF) is about ?

In hyperosmolar coma, the serum osmolarity is generally >350 mosmol/L.

164

Disorder that occlude small blood vessels throughout the brain causing bihemispheral damage is ? Harrison’s 18th Ed. 2249

Oxygen consumption of brain tissue is ? Harrison’s 18th Ed. 2248

A.

Cerebral malaria

A.

1.5 mL per 100 g/min

B.

Thrombotic thrombocytopenic purpura

B.

2.5 mL per 100 g/min

C.

Hyperviscosity

C.

3.5 mL per 100 g/min

D.

All of the above

D.

4.5 mL per 100 g/min

Glucose utilization of brain tissue is ? A.

1 mg per 100 g/min

B.

3 mg per 100 g/min

C.

5 mg per 100 g/min

D.

7 mg per 100 g/min

After the cessation of blood flow, brain stores of glucose provide energy for approximately ? Harrison’s 18th Ed. 2249

161

Harrison’s 18th Ed. 2249

A.

Harrison’s 18th Ed. 2248

160

Sodium levels below how much is associated with coma and convulsions ?

Disorders that occlude small blood vessels throughout the brain causing bihemispheral damage are cerebral malaria, thrombotic thrombocytopenic purpura, and hyperviscosity.

165

Hypothermia itself causes coma only when the temperature is ? Harrison’s 18th Ed. 2249

A.

< 34°C

B.

< 33°C

C.

< 32°C

D.

< 31°C

Hypothermia itself causes coma only when the temperature is 65 mmol/L (0.3 g/dL) is associated with stupor.

202

Most cases of coma (and confusion) are due to ?

Agonal gasps are the result of damage to ?

Harrison’s 18th Ed. 2251

Harrison’s 18th Ed. 2251

A.

Hemorrhage

A.

Cortex

B.

Tumor

B.

Midbrain

C.

Metabolic or toxic origin

C.

Pons

D.

Hydrocephalus

D.

Medulla

Agonal gasps are the result of lower brainstem (medullary) damage and are recognized as the terminal respiratory pattern of severe brain damage.

197

Kussmaul breathing

Harrison’s 18th Ed. 2251

Harrison’s 18th Ed. 2251

196

Cheyne-Stokes respiration

C.

Fifth and same sided seventh cranial nerve

Corneal reflex depends on the integrity of pontine pathways between fifth (afferent) & both seventh (efferent) cranial nerves.

195

B.

A.

D.

194

Shallow, slow, regular

Kussmaul or rapid, deep breathing is usually seen in metabolic acidosis but may also occur with pontomesencephalic lesions.

Presence of corrective nystagmus indicates that the frontal lobes are functioning and connected to the brainstem; thus functional or hysterical coma is likely.

193

A.

Which of the following respiratory pattern is seen in pontomesencephalic lesions ? Harrison’s 18th Ed. 2251

Neurology

Most cases of coma (and confusion) are metabolic or toxic in origin.

203

In a case of coma, which of the following may not be detected by CT scan ? Harrison’s 18th Ed. 2251

A.

Acute brainstem infarction

Neurology 659

FOR MEDICAL PROFESSIONALS MCQ’s FORMCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

B.

Sagittal sinus thrombosis

C.

Encephalitis

D.

All of the above

Bilateral hemisphere infarction, acute brainstem infarction, encephalitis, meningitis, mechanical shearing of axons (closed head trauma), sagittal sinus thrombosis, and subdural hematoma isodense to adjacent brain may not be detected.

204

D.

Conditions that cause sudden coma include drug ingestion, cerebral hemorrhage, trauma, cardiac arrest, epilepsy, or basilar artery embolism.

210

Gaze paresis is a feature of which cerebrovascular disease ? Harrison’s 18th Ed. 2252

A.

Thalamic hemorrhage

B.

Pontine hemorrhage

Harrison’s 18th Ed. 2251

C.

Cerebellar hemorrhage

D.

Subarachnoid hemorrhage

Clinically unrecognized seizure

B.

Herpesvirus encephalitis

C.

Prion (Creutzfeldt-Jakob) disease

D.

All of the above

Occipital headache, vomiting, gaze paresis, and inability to stand are features of cerebellar hemorrhage.

211

The EEG is useful in metabolic or drug-induced states and is diagnostic when coma is due to clinically unrecognized seizure, to herpesvirus encephalitis, or to prion (Creutzfeldt-Jakob) disease.

205

Encephalitis

In coma, EEG is useful in which of the following conditions ? A.

Asymmetric limb paresis is a feature of which cerebrovascular disease ? Harrison’s 18th Ed. 2252

Which of the following is typical of metabolic coma ?

A.

Basilar artery thrombosis

Harrison’s 18th Ed. 2251

B.

Infarction in middle cerebral artery territory

A.

Delta or triphasic waves in the frontal regions

C.

Acute hydrocephalus

B.

Widespread fast beta activity

D.

Subarachnoid hemorrhage

C.

Widespread variable 8- to 12-Hz activity

D.

Normal alpha activity

212

Neurologic prodrome or warning spells are a feature of which of the following ?

Predominant high-voltage slowing (delta or triphasic waves) in the frontal regions is typical of metabolic coma.

Harrison’s 18th Ed. 2252

A.

Basilar artery thrombosis

206

B.

Infarction in middle cerebral artery territory

C.

Acute hydrocephalus

D.

Subarachnoid hemorrhage

Which of the following is typical of coma due to sedative drugs (diazepines, barbiturates) ? Harrison’s 18th Ed. 2251

A.

Delta or triphasic waves in the frontal regions

B.

Widespread fast beta activity

C.

Widespread variable 8- to 12-Hz activity

D.

Normal alpha activity

Neurologic prodrome or warning spells, diplopia, dysarthria, vomiting, eye movement and corneal response abnormalities, and asymmetric limb paresis are features of basilar artery thrombosis.

213

Hyperventilation and excessive sweating are a feature of which cerebrovascular disease ?

Widespread fast beta activity implies sedative drugs (diazepines, barbiturates) as a cause of coma.

Harrison’s 18th Ed. 2252

A.

Thalamic hemorrhage

207

Alpha coma results from ?

B.

Pontine hemorrhage

Harrison’s 18th Ed. 2252

C.

Cerebellar hemorrhage

D.

Subarachnoid hemorrhage

A.

Hyperventilation

B.

Hypoglycemia

C.

Pontine damage

D.

Subdural hematoma

Sudden onset, pinpoint pupils, loss of reflex eye movements and corneal responses, ocular bobbing, posturing, hyperventilation, and excessive sweating are features of pontine hemorrhage.

214

Which of the following is typical of locked-in syndrome ? Harrison’s 18th Ed. 2252

A.

Thalamic hemorrhage

B.

Cerebellar hemorrhage Subarachnoid hemorrhage All of the above

A.

Delta or triphasic waves in the frontal regions

C.

B.

Widespread fast beta activity

D.

C.

Widespread variable 8- to 12-Hz activity

D.

Normal alpha activity

Normal alpha activity on EEG is found in locked-in syndrome, hysteria or catatonia.

209

Vomiting is a feature of which of the following ? Harrison’s 18th Ed. 2252

Alpha coma results from pontine or diffuse cortical damage and is associated with a poor prognosis.

208

215

Precipitous coma after headache and vomiting is a feature of which of the following ? Harrison’s 18th Ed. 2252

A.

Thalamic hemorrhage

Which of the following condition causes sudden coma ?

B.

Pontine hemorrhage

Harrison’s 18th Ed. 2252

C.

Cerebellar hemorrhage

D.

Subarachnoid hemorrhage

A.

Acute hydrocephalus

B.

Basilar artery embolism

C.

Cerebral infarction

659 Cardiology

Precipitous coma after headache and vomiting is a feature of subarachnoid hemorrhage.

660 216

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Acute hydrocephalus accompanies particularly which of the following ? Harrison’s 18th Ed. 2252

A. B. C. D.

Thalamic hemorrhage Pontine hemorrhage Cerebellar hemorrhage Subarachnoid hemorrhage

223

Which of the following diseases cause meningeal irritation ? Harrison’s 18th Ed. 2252, Table 274-1

A. B. C. D.

Fat embolism Cholesterol embolism Carcinomatous meningitis All of the above

224

Which of the following diseases cause focal brainstem or lateralizing cerebral signs ? Harrison’s 18th Ed. 2252, Table 274-1

219

220

221

A.

Herpes simplex encephalitis

B.

Thrombotic thrombocytopenic purpura

C.

Pituitary apoplexy

D.

All of the above

CT contrast

C.

MRI

D.

MRI with contrast

Which of the following investigation is recommended in myelopathy ? A.

CT (noncontrast)

B.

CT contrast

C.

MRI

D.

MRI with contrast

MRI + contrast is the investigation of choice for all of the following except ?

225

A.

Neoplasm (primary or metastatic)

B.

White matter disorders

C.

Infection/abscess

D.

Immunosuppressed with focal findings

Which of the following is the most sensitive technique for detecting acute ischemic stroke of brain ? Harrison’s 18th Ed. 3240

A.

CT angiography (CTA)

B.

Perfusion CT (pCT)

Cellular content of the CSF is not normal in which of the following ?

C.

MR angiography (MRA)

Harrison’s 18th Ed. 2252, Table 274-1

D.

Diffusion MR

A.

Malaria

B.

Fat embolism

C.

Typhoid fever

D.

Eclampsia

Diffusion MR is the most sensitive technique for detecting acute ischemic stroke of brain or spinal cord, encephalitis, abscesses and prion diseases.

226

In normal CNS, which of the following structure lacks bloodbrain barrier (BBB) ? Harrison’s 18th Ed. 3241

Which of the following is a feature of brain death ? Harrison’s 18th Ed. 2252

A.

Pituitary gland

A.

Heart rate unresponsive to atropine

B.

Choroid plexus

B.

Diabetes insipidus

C.

Dura

C.

Absent Babinski signs

D.

All of the above

D.

All of the above

In a valid apnea testing, Pco2 should be at least ? Harrison’s 18th Ed. 2253

A.

30 - 40 mmHg

B.

40 - 50 mmHg

C.

50 - 60 mmHg

D.

60 - 70 mmHg

To confirm brain death, apnea is confirmed if no respiratory effort is observed in the presence of a sufficiently elevated Pco 2 i.e. 50 - 60 mmHg.

In normal CNS, the pituitary gland, choroid plexus, and dura lack blood-brain barrier (BBB) and enhance after contrast administration.

227

Which of the following investigation is recommended in meningeal disease ? Harrison’s 18th Ed. 3240, Table 368-1

In a routine brain CT study, radiation dose is normally about ? Harrison’s 18th Ed. 3241

A.

0.2 to 1 mSv

B.

2 to 5 mSv

C.

6 to 12 mSv

D.

22 to 50 mSv

In a routine brain CT study, radiation dose is normally between 2 and 5 mSv (millisievert).

228

Chapter 3 68. Neuroimaging in Neurologic Disorders 222

B.

Harrison’s 18th Ed. 3240, Table 368-1

Fat embolism, cholesterol embolism, carcinomatous and lymphomatous meningitis cause meningeal irritation with or without fever, and with an excess of WBCs or RBCs in CSF, usually without focal or lateralizing cerebral or brainstem signs. CT or MRI shows no mass lesion.

218

CT (noncontrast)

Harrison’s 18th Ed. 3240, Table 368-1

The syndrome of acute hydrocephalus accompanies particularly subarachnoid hemorrhage.

217

A.

Neurology

Rise in serum creatinine of at least 1 mg/dL within how many hours of contrast administration defines contrast nephropathy ? Harrison’s 18th Ed. 3241

A.

6 hours

B.

12 hours

C.

24 hours

D.

48 hours

Neurology 661 229

FOR MEDICAL PROFESSIONALS MCQ’s FORMCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Risk factors for contrast nephropathy include all except ?

C.

Demyelination

Harrison’s 18th Ed. 3241

D.

Infarction

A.

Solitary kidney

B.

Diabetes mellitus

C.

Hypertension

D.

Advanced age (>80 years)

T2-weighted (T2W) images are more sensitive than T1-weighted (T1W) images to edema, demyelination, infarction, and chronic hemorrhage, while T1W imaging is more sensitive to subacute hemorrhage and fat-containing structures.

235

What is the eGFR threshold below which iodinated contrast should not be given ? Harrison’s 18th Ed. 3243

A.

90 mL/min/1.732

B.

75 mL/min/1.732

C.

60 mL/min/1.732

D.

45 mL/min/1.732

236

C.

Chelated to DTPA

D.

Approximate dose 2 mL/kg IV

Gadolinium is produced both from which of the following minerals ? A. Ilmenite B.

Zircon

C.

Monazite

D.

Sillimanite

Harrison’s 18th Ed. 3243

237

A.

Acetylcysteine

B.

Oxygen inhalation

Which of the following countries has deposits of monazite sands ? A. India

C.

Osmolar diuretics

B.

Brazil

D.

Loop diuretics

C.

South Africa

D.

All of the above

Severe allergic reactions occur in what proportion of patients receiving nonionic media ?

238

Symbol of Gadolinium is ? A. Ga B.

Gd

0.04 %

C.

Gl

B.

0.12 %

D.

Gm

C.

0.18 %

D.

0.24 %

A.

Symbol of Gadolinium is Gd with atomic number 64 and atomic weight of 157.25.

239

Severe allergic reactions occur in 0.04% of patients receiving nonionic media, sixfold lower than with ionic media.

Which of the following is best related to gadolinium contrast agents ? Harrison’s 18th Ed. 3244

A.

Nephrogenic diabetes insipidus (NDI)

B.

Nephrogenic Syndrome of Inappropriate Antidiuresis

Harrison’s 18th Ed. 3243

C.

Nephrogenic systemic fibrosis (NSF)

A.

Hydrogen protons in biologic tissues

D.

Nephrotic syndrome

B.

Dynamic magnetic field

C.

Static magnetic field

D.

Radiofrequency (Rf) waves

Which of the following is not related to magnetic resonance imaging (MRI) ?

MRI is a complex interaction between hydrogen protons in biologic tissues, a static magnetic field (the magnet), and energy (echo) in the form of radiofrequency (Rf) waves of a specific frequency.

234

Paramagnetic substance

Gadolinium is produced both from monazite and bastnäsite.

Harrison’s 18th Ed. 3243

233

Heavy-metal element

B.

Use of which of the following may reduce the incidence of contrast nephropathy ?

Apart from hydration and reduction in dose of contrast media, use of bicarbonate & acetylcysteine may reduce the incidence of contrast nephropathy.

232

A.

Approximate dose of gadolinium is 0.2 mL/kg body weight administered intravenously. Gadolinium has the greatest ability to capture thermal neutrons.

The American College of Radiology suggests using an estimated glomerular filtration rate (eGFR) of 45 mL/min/1.73 2 as a threshold below which iodinated contrast should not be given without serious consideration of the potential for contrast nephropathy.

231

Which of the following statements about gadolinium is false ? Harrison’s 18th Ed. 3244

Risk factors for contrast nephropathy include advanced age (>80 years), preexisting renal disease (serum creatinine exceeding 2 mg/dL), solitary kidney, diabetes mellitus, dehydration, paraproteinemia, concurrent use of nephrotoxic medication or chemotherapeutic agents, and high contrast dose.

230

661 Cardiology

T2W images are more sensitive than T1W images to all of the following except ?

Patients with renal insufficiency exposed to gadolinium contrast agents may develop a rare complication - nephrogenic systemic fibrosis (NSF) between 5 and 75 days following exposure.

240

Nephrogenic systemic fibrosis (NSF) involves which of the following parts of the body most ? Cleveland Clinic Journal of Medicine 2008;75(2):95-111

A.

Upper extremities

B.

Between ankles and thighs

Harrison’s 18th Ed. 3244

C.

Trunk

A.

Edema

D.

Face

B.

Fat-containing structures

662 241

MCQ’s FOR MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR Nephrogenic systemic fibrosis (NSF) involves which of the following parts of the body least ?

B.

Cleveland Clinic Journal of Medicine 2008;75(2):95-111

Seizure is derived from Latin word “sacire” meaning “to take possession of”.

C.

Trunk

247

D.

Face

What percentage of population will have at least one seizure in lifetime ? Harrison’s 18th Ed. 3251

A.

~1 - 3 %

B.

~3 - 5 %

Which of the following is a laboratory biomarker for NSF ?

C.

~5 - 10 %

Cleveland Clinic Journal of Medicine 2008;75(2):95-111

D.

~10 - 15 %

A.

Anti nuclear antibodies

B.

Rheumatoid factor

C.

Anti-SCL70 antibodies

D.

None of the above

248

Highest incidence of seizure is in which of the following age groups ? Harrison’s 18th Ed. 3251

Which of the following is characteristic and pathognomonic of NSF ?

A.

Infancy

B.

Early childhood & late adulthood

C.

Middle age

D.

Old age

~5–10% percentage of population will have at least one seizure in lifetime and the highest incidence is in early childhood and late adulthood.

A.

Proliferation of dermal spindle cells

B.

Thick collagen bundles with surrounding clefts

C.

Immunohistochemically CD34 reactivity in fibroblast-like cells

Harrison’s 18th Ed. 3251

D.

Absence of mucin and elastic fibers

A.

Single seizure

B.

Acute

Disorder that causes thickening & hardening of skin of extremities & trunk is ? Cleveland Clinic Journal of Medicine 2008;75(2):95-111

249

Which of the following is false about epilepsy ?

C.

Correctable or avoidable circumstance

D.

All of the above

Epilepsy is a clinical phenomenon & is said to be present when a person has recurrent seizures due to a chronic, underlying process. A person with a single seizure or recurrent seizures due to correctable or avoidable circumstances, does not have epilepsy. By definition, epilepsy is two or more UNPROVOKED seizures.

A.

Systemic sclerosis

B.

Scleromyxedema

C.

Eosinophilic fasciitis

Harrison’s 17th Ed. 2498

D.

All of the above

A.

1965

B.

1978

250

Besides NSF, other disorders that can cause thickening & hardening of skin of extremities & trunk include systemic sclerosis or scleroderma, scleromyxedema, and eosinophilic fasciitis.

Most frequently used radionuclide moiety in Positron Emission Tomography (PET) is ? Harrison’s 18th Ed. 3248

A.

2-[16F]fluoro-2-deoxy-d-glucose

B.

2-[17F]fluoro-2-deoxy-d-glucose

C.

2-[ F]fluoro-2-deoxy-d-glucose

D.

2-[ F]fluoro-2-deoxy-d-glucose

18 19

In Positron Emission Tomography (PET), the most frequently used moiety is 2-[ 18F]fluoro-2-deoxyd-glucose (FDG), an analogue of glucose. It is taken up by cells competitively with 2-deoxyglucose.

369 - Seizures and Epilepsy 246

“to take possession of”

Upper extremities

A characteristic and almost pathognomonic staining profile is the immunohistochemical identification of CD34 reactivity in the fibroblast-like cells. Cells expressing CD34 are normally found in the umbilical cord, the bone marrow (as pluripotential hematopoietic stem cells), and in the vascular endothelium.

245

“to silence”

D.

Between ankles and thighs

Cleveland Clinic Journal of Medicine 2008;75(2):95-111

244

C.

B.

There is no laboratory biomarker for NSF.

243

“to destroy”

A.

NSF typically presents between ankles and the thighs (symmetric, progresses to involve the entire lower extremities). Upper extremity involvement occurs frequently, but usually with lower extremity disease. Trunk is involved less commonly than legs and arms. The face is typically spared.

242

Seizure is derived from a Latin word “sacire” that means ? Harrison’s 18th Ed. 3251

A.

“to invade”

Neurology

In which year did the International League Against Epilepsy (ILAE) classify seizure disorders ?

C.

1981

D.

1995

In 1981, the International League against Epilepsy (ILAE) classification is based on clinical features of seizures and associated EEG findings. Etiology or cellular substrate are not considered.

251

Focal seizures are associated with ? Harrison’s 18th Ed. 3251

A.

Structural abnormalities of brain

B.

Cellular abnormalities

C.

Biochemical abnormalities

D.

All of the above

Focal seizures are associated with structural abnormalities of brain, there are exception though. In the new classification system (International League against Epilepsy (ILAE) Commission on Classification and Terminology, 2005–2009), term partial seizures is no longer used and subcategories of “simple focal seizures” and “complex focal seizures” have been eliminated.

Neurology 663 252

FOR MEDICAL PROFESSIONALS MCQ’s FORMCQ’s MEDICAL PROFESSIONALS BY PROF. AJAY MATHUR

Generalized seizures are associated with ? Harrison’s 18th Ed. 3251

A.

Cellular abnormality

B.

Biochemical abnormality

C.

Structural abnormality

D.

Any of the above

The EEG hallmark of typical absence seizures is a generalized, symmetric, 3-Hz spike-and-wave discharge that begins and ends suddenly, superimposed on a “normal” EEG background. Hyperventilation provokes these EEG discharges.

258

Generalized seizures may result from cellular, biochemical, or structural abnormalities.

253

Main difference between simple partial and complex partial seizure is ? Harrison’s 17th Ed. 2498

A.

Unilateral or bilateral

B.

Focal or generalised

C.

Consciousness or unconsciousness

D.

Absence or presence of aura

259

Breath holding

D.

Lack of sleep

What percentage of patients of typical absence seizures will have a spontaneous remission during adolescence ? A.

~ 10 - 20 %

B.

~ 30 - 40 %

C.

~ 50 - 60 %

D.

~ 60 - 70 %

~ 60-70% patients of absence seizures have a spontaneous remission during adolescence.

B.

Todd’s paralysis

C.

Epilepsia partialis continua

Harrison’s 18th Ed. 3252

D.

All of the above

A.