Anatomy MCQ'S: Answer: S Is True and R Is False

ANATOMY MCQ’S
This is a collection of the bank questions that were on the RACS website in December 2005. They 20625 – S. Cerebrospinal fluid is produced in the lateral ventricles of the
are arranged in an attempt to make studying regions easier, remembering that there is significant brain BECAUSE R. the choroid plexus is situated only in the lateral
overlap, especially in pathology and physiology.
ventricles
I found it useful to have a paper copy that could be annotated and an electronic copy that could be
searched easily. Do the bank questions in it’s entirety a few times as there is a significant proportion Answer: S is true and R is false
of questions that are repeated in the exam. In Feb 2006, 20-30% of questions were familiar. There is
also a book “Multiple Choice Questions in Basic Surgical Sciences” by Buzzard that has additional Last 8th ed. PAGE: 618
questions that pop up on the exam.
14586 – The third ventricle is
Bear in mind that errors errors exist on the college website and in this document, and that the college 1: anterior to the pineal gland
website, bank questions and answers are updated (occasionally). In in doubt of an answer 2: marked antero-inferiorly by the optic chiasma
crossreference with the website and texts. 3: superior to the mamillary bodies
4: subdivided by commissural fibres between the two thalami
If anyone wants an editable copy of this to edit/rearrange/add questions or has any questions send an
email, eugelim@bigpond.net.au Answers: TTTF
Good luck! Refer to Last, 10th Ed, page 463
21568 – The decussation of the pyramids

HEAD 1: is found at the level of the fourth ventricle
2: involves 25% of corticospinal fibres
3: represents the crossing of the main sensory tract
23339 – The central sulcus 4: occurs rostral to the 'sensory' decussation
1: lies in front of the major sensory cortex
2: is the only long sulcus to pass over onto the medial surface of the hemisphere Answers: FFFF
3: separates the frontal and temporal lobes
4: lies behind the major motor cortex Last PAGE: 527
Answers: TTFT 7814 – A bitemporal hemianopia would be consistent with a localised lesion
Last (6) PAGE: 495-6 of
1: visual cortex
2: an optic tract
15403 – The motor area of the cerebral cortex 3: geniculo-calcarine tracts
1: lies wholly on the lateral surface of the cerebral hemisphere
4: optic chiasma
2: lies in the parietal lobe of the cerebrum
3: is partly supplied by the anterior cerebral artery
Answers: FFFT
4: lies in the precentral gyrus and anterior wall of the central sulcus
Last 10th ed, Ch 7
Answer: FFTT
Refer to Last, 10th Ed, Ch 7, page 457-458 22859 – The inferior petrosal sinus
1: drains the transverse sinus
2: terminates in the internal jugular vein outside the skull
22564 – The cerebral aqueduct of Sylvius 3: receives the superior petrosal sinus
1: lies medial to the mesencephalic nucleus of the trigeminal nerve
4: communicates with the basilar venous plexus
2: is surrounded by grey matter
3: lies dorsal to the nucleus of the trochlear nerve
Answers: FTFT
4: connects the fourth ventricle and the subarachnoid space
Last 9th Edition PAGE: 564; 567
Answers: TTTF
Last 8th ed. PAGE: 583, 596 20367 – S. Extradural haemorrhage arising from rupture of the ascending
part of the frontal branch of the middle meningeal artery may be associated
ANATOMY Page 1 of 215
with twitching of muscles on the opposite side of the body BECAUSE R. Answers: FFFT
the sensorimotor cortex lies deep to the frontal branch of the middle
Last PAGE: 489. Pending review. Jan 2003
meningeal artery
14860 – All of the following are branches of the maxillary artery EXCEPT
Answer: S is true, R is true and a valid explanation of S
the
Last 8th ed. PAGE: 565 A. ascending pharyngeal artery
B. middle meningeal artery
C. infraorbital artery
20247 – S. Occlusion of the posterior cerebral artery may give rise to visual
D. inferior alveolar artery
disturbance BECAUSE R. the visual cortex receives its principal blood E. deep auricular artery
supply from the posterior cerebral artery
Answer: A
Refer to Last, 10th Ed, page 354-355
Last 8th ed. PAGE: 603
21548 – The anterior cerebral artery supplies blood to the
21403 – The anterior inferior cerebellar artery 1: orbital surface of the frontal lobe
1: commonly gives rise to the labyrinthine artery 2: auditory and speech areas of the cerebral cortex
2: usually arises from the posterior inferior cerebellar artery 3: medial surface of the hemisphere anterior to the parieto-occipital sulcus
3: is distributed to the superior surface of the cerebellum 4: motor and sensory areas for the opposite leg and perineum
4: supplies the medulla oblongata
Answers: TFTT
Answer: TFFF
Last PAGE: 534
24084 – The lingual artery
20115 – S. Thrombosis of the posterior inferior cerebellar artery causes 1: is a branch of the internal carotid artery
palatal and pharyngeal paralysis BECAUSE R. the posterior inferior 2: passes forward along the upper border of the greater horn of the hyoid bone
3: accompanies the lingual nerve
cerebellar artery supplies the nucleus ambiguous
4: lies deep to the hyoglossus muscle
Answers: FTFT
Last PAGE: 534
Last 8th Edition PAGE: 437
22879 – The vertebral artery supplies 15012 – The facial artery is closely related to
1: posterior spinal arteries posterior to the denticulate ligament
1: submandibular salivary gland
2: a posterior inferior cerebellar artery which insinuates between the rootlets of cranial nerves XII, XI
2: genio-hyoid muscle
and X
3: superior constrictor of the pharynx
3: meningeal branches before penetrating the dura
4: digastric muscle
4: the posterior cerebral arteries directly
Answers: TFTT
Answer: TTTF
Last, 10th Ed, page 334
Last PAGE: 380,472,496
22028 – The internal carotid artery 20145 – S. A severed labial branch of the facial artery bleeds freely from
1: passes lateral to the anterior clinoid process both ends BECAUSE R. there is an arterial anastomosis across the midline
2: is distributed to the visual cortex
3: gives off the posterior cerebral artery Answer: S is true, R is true and a valid explanation of S
4: is distributed to the auditory cortex

1: XII nerve attached lateral to the olive
23154 – With regard to the venous drainage of the cerebellum 2: X nerve attached lateral to the olive
1: venous drainage is from the surface of the cerebellum into the venous sinuses 3: IX nerve attached medial to the olive
2: the superior and posterior surfaces drain mostly into the superior sagittal sinus 4: V nerve arising from the anterior surface
3: the inferior surface drains mostly into the great cerebral vein
4: a single vein is formed to drain each hemisphere Answers: FTFF
Answer: TFFF Last 8th ed. PAGE: 614
Last PAGE: 534 20631 – S. Destruction of a major portion of the brain stem causes
death BECAUSE R. the caudate nucleus is contained within the brain stem
21563 – The midbrain
1: receives blood from the superior cerebellar artery Answer: S is true and R is false
2: has a decussation of the trochlear fibres dorsal to the aqueduct
3: has a third nerve nucleus dorsal to the aqueduct Last PAGE: 512
4: contains motor nuclei of the seventh cranial nerve
8570 – The oculomotor nerve
Answers: TTFF 1: emerges from the midbrain medial to the cerebral peduncle
2: supplies the levator palpebrae superioris muscle
Last PAGE: 525. This question is currently under review by the Anatomy Sub Committee. 23 August, 3: supplies the ciliary muscle
2001. Question updated 14 March 2002. 4: contains postganglionic parasympathetic nerve fibres
23344 – The pons Answers: TTTF

1: obtains its blood supply from the branches of the basilar artery
2: lies against the upper part of the clivus Last 10th ed, Ch 6
3: has the 5th nerve emerging from its surface
4: has the cerebellum concealing its dorsal surface 12440, 19318 – The trochlear nerve emerges from
A. anterior surface of midbrain
Answer: TTTT B. lateral surface of midbrain
C. posterior surface of midbrain
Last 8th ed. Page: 611 D. lower border of pons
E. posterior surface of pons
21953 – The pons
1: lies dorsal to the labryinthine artery Answer: C
2: has the sixth cranial nerve on its ventral surface
3: has nuclei of VI and VII nerves within it Last PAGE: 544. The trochlear nerve fibres decussate completely dorsal to the aqueduct and
4: grooves the basi-occiput above the jugular tubercle emerge from the midbrain below the inferior colliculi on the dorsal surface (C true)
Answers: TTTT 8580 – The trochlear nerve differs from all other cranial nerves in that it
1: is a purely motor nerve
Last 10th Ed, Ch 7, page 471-473 2: decussates completely with its fellow of the opposite side
3: emerges from the dorsal side of the brain
21553 – The medulla oblongata 4: supplies the superior obliquus oculi muscle
1: extends partly through the foramen magnum
2: has the olives lying on its superodorsal aspect Answers: FTTT
3: gives rise to the middle cerebral peduncle
4: has the superior cerebellar artery as an anterior relation Last 10th ed, Ch 7
Answers: TFFF 21573 – The trochlear nerve

1: has decussating fibres dorsal to the aqueduct
Last PAGE: 530 2: emerges below the inferior colliculus
3: courses between the posterior cerebral and superior cerebellar arteries
21558 – The medulla oblongata has the rootlets of the 4: lies below the oculomotor nerve in the anterior part of the lateral wall of the cavernous sinus
Answers: TTTF
Answer: TTTF
24229 – The roots of the fifth cranial nerve contain
18916 – All EXCEPT one of the following statements about the lingual nerve 1: sensory fibres supplying the lobe of the ear
are true 2: secretory fibres to the lacrimal gland
A. it passes between the lateral pterygoid muscle and the mandible 3: motor fibres to the levator palati muscle
B. it lies on the buccal surface of the mylohoid muscle 4: motor fibres to the masticatory muscles
C. it crosses medial to the maxillary artery
D. it lies close to the medial aspect of the root of the third molar tooth Answers: FFFT
E. all its trigeminal fibres are sensory
Answer: A
23074 – Paralysis of the sympathetic supply to the eye causes
Last 8th Edition PAGE: 416 1: inability to accommodate
2: reduced sweating of the forehead
804 – The maxillary nerve transmits sensation from 3: constriction of the pupil
1: the third upper molar tooth 4: ptosis
2: the dura of the middle cranial fossa
3: the skin over the zygoma Answers: FTTT
4: the skin of the lower eyelid
Last 9th Edition PAGE: 519. Reviewed and Updated Nov 2003
Answers: TTTT
21098 – The ophthalmic division of the trigeminal nerve
Last, 10th ed, Ch 6 1: provides the motor root to the ciliary ganglion
2: carries corneal sensation
20889 – S. A lesion of the buccal branch of the mandibular nerve may 3: subserves sensation to the lower palpebral conjunctiva
4: subserves sensation to the tip of the nose
disrupt chewing BECAUSE R. paralysis of the buccinator allows food to
lodge in the vestibule between cheek and gum Answers: FTFT
Answer: S is false and R is true Last 9th Edition PAGE: 451. Question reviewed and updated Nov 03.
Last 8th Edition PAGE: 448 20289 – S. Damage to the greater petrosal nerve results in a dry
20673 – S. Corneal ulceration may accompany herpes zoster lesions on the eye BECAUSE R. the lacrimal gland indirectly derives its secretomotor
tip of the nose BECAUSE R. afferent fibres from both the cornea and the tip innervation from the pterygo-palatine ganglion
of the nose run in the maxillary nerve Answer: S is true, R is true and a valid explanation of S
Answer: S is true and R is false Last 7th Edition PAGE: 437

24249 – The lingual nerve
1: appears in the infratemporal fossa on the lateral aspect of the lateral pterygoid muscle
22083 – The mandibular division of the trigeminal nerve gives motor fibres 2: is a branch of the anterior division of the mandibular nerve
to the 3: runs on the hyoglossus muscle inferior to the hypoglossal nerve
1: medial pterygoid muscle 4: enters the mouth by passing between the superior and middle constrictor muscles
2: anterior belly of the digastric muscle
3: tensor palati muscle Answers: FFFT
4: buccinator muscle
Last 10th ed. PAGE: 356; 376

24089 – The facial nerve Refer to Last, 10th Ed, page 407. Question to be reviewed at July 2004 meeting. Trainee states all
1: supplies the muscles of the lower lip through its cervical branch answer options should be TRUE.
2: emerges from the skull through the stylomastoid foramen
3: divides into upper and lower branches just before or within the substance of the parotid gland 21083 – The auriculotemporal nerve
4: emerges from the parotid gland in five main divisions 1: takes origin from the posterior division of the mandibular nerve
2: supplies the temporalis muscle
Answers: FTTT 3: supplies the skin of the tragus
4: supplies the skin of the forehead
Answers: TFTF
12698 – The hypoglossal nerve
1: emerges from the medulla oblongata medial to the olive Last 7th Edition PAGE: 394
2: emerges from the hindbrain lateral to the pyramid
3: leaves the skull through a canal in the occipital bone 13974 – The occipital belly of the occipitofrontalis muscle is supplied by
4: supplies intrinsic but not extrinsic muscles of the tongue A. the great auricular nerve
B. the greater occipital nerve
Answers: TTTF C. the auriculotemporal nerve
D. the facial nerve
The hypoglossal nerve emerges from the medulla between the pyramid and the olive (A and B true) E. the third occipital nerve
and leaves the skull through the anterior condylar canal in the occipital bone (C true). It supplies all
intrinsic and extrinsic muscles of the tongue except the palatoglossus (D false). Answer: D
24299 – The hypoglossal nerve Refer to Last, 10th Ed, page 347
1: emerges from the medulla oblongata medial to the olive
2: has its central connections in the hind brain 23719 – The greater occipital nerve
3: leaves the skull through a canal in the occipital bone 1: supplies the scalp as far forward as the vertex
4: supplies intrinsic but not extrinsic muscles of the tongue 2: contains fibres from the third cervical spinal segment
3: is derived from a posterior primary ramus
Answers: TTTF 4: supplies motor fibres to the occipitalis muscle
Last 10th Ed, Ch 7 PAGE: 495, 498 Answers: TFTF
21093 – The following muscles are supplied by the cranial part of the Last 8th ed. Page: 454
accessory nerve
1: the tensor palati
2: the palatoglossus 19084 – The main sensory nerve to the back of the head is the
3: the levator palati A. greater auricular
4: the palatopharyngeus B. greater occipital
C. posterior auricular
Answers: FTTT D. lesser occipital
E. third occipital
Answer: B
15017 – The epithelia lining the tympanic membrane on meatal and
Last 7th Edition PAGE: Plate 33
mucosal surfaces are supplied by the
1: auriculo-temporal nerve
24169 – The muscles arising from the styloid process are supplied by
2: facial nerve
1: the facial nerve
3: vagus nerve
2: the hypoglossal nerve
4: glossopharyngeal nerve
3: the glossopharyngeal nerve
4: the lingual nerve
Answers: TFTT

Answers: TTTF 1: the base of the tonsil is covered with a layer of fibrous tissue which is an extension of the
pharyngo-basilar fascia
Last 9th ed. Page: 465 2: it lies on the superior constrictor muscle and is embraced by the palatopharyngeus muscle
3: its arterial blood supply is by way of the ascending palatine branch of the lingual artery
772 – S. Parasympathetic innervation is probably most important for 4: its lymphatic drainage is directly into the jugulo-digastric node
salivary secretion because R. atropine abolishes normal reflex salivary
Answers: TTFT
secretion.
22164 – The palatine tonsil
Salivary secretion, amounting to around 1500 ml of saliva per day, is under neural control.
1: lies between the palatoglossus muscle in front and the palatopharyngeus muscle behind
Parasympathetic innervation stimulation causes profuse secretion of watery saliva with a low content
2: is related laterally to the superior constrictor muscle
of organic material associated with vasodilatation due to the local release of VIP which co-transmits
3: drains lymph to the jugulo-digastric node
with acetyl choline. Atropine and other cholinergic blocking agents reduce salivary secretion, blocking
4: is supplied by the maxillary artery
the normal reflex secretion of saliva (thus both S & R are correct and R validly explains S).
Sympathetic nerve stimulation of the salivary glands causes vasoconstriction; and secretion of small
Answers: TTTF
amounts of saliva with a high organic content.
Last's 9th ed, p490. Question reviewed and updated 14 March 2002. Updated Nov 03
19180 – In the submandibular region
A. the deep cervical fascia splits to enclose the submandibular salivary gland
20895 – S. Scalping causes necrosis of the bones of the cranial
B. submandibular lymph nodes lie superficial to the deep fascia
C. the lingual artery lies on the middle constrictor muscle deep to the hyoglossus muscle vault BECAUSE R. the bones of the cranial vault are supplied by branches
D. the hypoglossal nerve lies superficial to the stylohyoid muscle and emerges from between the of the external carotid artery
internal and external carotid arteries
E. the glossopharyngeal nerve runs superficial to the hyoglossus muscle to reach the tongue Answer: S is false and R is true
Answers: C Last 8th Edition PAGE: 453
Last 7th Edition PAGE: 415 Plate 36 8565 – Bleeding into the subaponeurotic space of the scalp may track
1: across the midline
15398 – The lateral pterygoid muscle 2: deep to the temporal fascia
1: is attached to the medial surface of the lateral pterygoid plate 3: into the eyelid
2: protracts the mandible 4: to the inferior nuchal line
3: lies deep to the sphenomandibular ligament
4: is attached to the infratemporal surface of the skull Answers: TFTF
Answers: FTFT Last 10th ed, Ch 6
Refer to Last, 10th Ed, Ch 6, page 353 19923 – The foramen ovale is situated in
A. the frontal bone
21488 – The buccinator muscle B. the temporal bone
1: receives its motor innervation from the mandibular nerve C. the ethmoid bone
2: interdigitates with fibres of the superior constrictor muscle of the pharynx D. the maxillary bone
3: is pierced by the parotid duct E. none of the above
4: arises partly from the pterygomandibular raphe
Answer: E
Answers: FTTT
Last PAGE: 563
18898 – The metopic suture is the point of articulation between
21088 – With respect to the palatine tonsil A. the two halves of the frontal bone
B. the two parietal bones

C. the occipical and parietal bones 3: transmits cranial nerves IX, X, XI
D. the parietal and temporal bones 4: may be subdivided by ossified septa
E. none of the above
Answers: TTTT
Answer: A
Last PAGE: 553
23374 – The jugular foramen transmits the
22844 – A fracture of the inferior border of the bony orbit may give rise to 1: internal jugular vein
anaesthesia of the 2: glossopharyngeal nerve
1: upper lip 3: vagus nerve
2: inferior conjunctival fornix 4: hypoglossal nerve
3: ala of the nose
4: labial gum of upper incisors and canine Answers: FTTF
Answers: TTTT Last 8th ed. PAGE: 575
Last 8th Edition PAGE: 451, 639 19641 – For the normal adult Caucasian the total number of permanent
teeth is
23379 – Bones lining the orbital margin include the A. 24
1: lacrimal bone B. 26
2: zygoma C. 28
3: frontal bone D. 32
4: maxilla E. None of the above
Answers: TTTT Answer: D
Last PAGE: 430. This question is currently under review by the Anatomy Sub Committtee. 23 Last PAGE: 408
August, 2001.
19833 – Forward dislocation of the head of the mandible is opposed by all
23389 – The internal auditory meatus transmits the of the following EXCEPT
1: vestibulocochlear nerve A. tension in the temporo-mandibular ligament
2: nervus intermedius B. the slope of the articular eminence of the temporal bone
3: facial nerve C. the posterior fibres of the temporalis muscle
4: labyrinthine artery D. the medial pterygoid muscle
E. the lateral pterygoid muscle
Answers: TTTT
Answer: E
Last PAGE: 491
23364 – The jugular foramen
1: lies between the sphenoid and temporal bones 23384 – Nerves coming into close contact (within 1/2 centimeter) with the
2: is a foramen entirely within the occipital bone
periosteum of the mandible include the
3: is lateral to the hypoglossal canal (anterior condylar foramen)
1: lingual nerve
4: transmits the vagus nerve
2: nerve to mylohyoid
3: hypoglossal nerve
Answers: FFTT
4: mental nerve
Last (8) PAGE: 575, 664. Question reviewed and updated July 03.
Answers: TTFT
23394 – The jugular foramen Last 8th ed. PAGE: 670
1: is grooved medially by the inferior petrosal sinus
2: is occupied partly by the termination of the sigmoid sinus
19935 – One of the following nerves is NOT in contact with the mandible A. splits to enclose the trapezius muscle
A. the mandibular branch of the facial nerve B. splits to include the parotid gland
B. the lingual nerve C. is attached to the hyoid bone
C. the auriculotemporal nerve D. is attached to the superior nuchal line
D. the mylohoid nerve E. splits to enclose the sterno-hyoid muscle
E. the buccal nerve
Answer: E
Answer: E
Last 9th. ed. PAGE: 421
Last 8th Edition PAGE: 450, 460
15272 – S:Pus from an abscess in a cervical vertebra tracks down into the
14092 – S:An incision 0.5 cm inferior and posterior to the angle of the posterior mediastinum because R:the prevertebral fascia is attached
mandible may cause deformity of the mouth when showing the teeth inferiorly to the body of the sixth thoracic vertebra
because R:the cervical branch of the facial nerve supplies the muscles of
the lower lip Answer: both S and R are false
Refer to Last, 10th Ed, Ch 6, page 323

Answer: S is true and R is false
Refer to Last, 10th ed, page 345 22033 – The prevertebral layer of cervical fascia contributes to
1: the carotid sheath
2: the clavipectoral fascia
14896 – S:An artificial denture may compress the mental nerve
3: the suprapleural membrane
because R:absorption of alveolar bone from the edentulous mandible may 4: the axillary sheath
expose the mental nerve
Answers: FFFT
23459 – Structures lying deep to the prevertebral fascia include
7700 – S:An apical abscess in a third lower molar tooth points in the 1: the cervical sympathetic trunk
neck BECAUSE R:the apex of the third lower molar tooth lies above the 2: the trunks of the brachial plexus
3: the third part of the subclavian artery
mylohyoid line of the mandible
4: the scalenus anterior muscle
Answers: FTTT
Last 10th ed, Ch 6
NECK 23844 – The thyroid gland

1: is related medially to the cricopharyngeus muscle
2: has a sheath derived from the pretracheal fascia
20967 – S. The investing layer of deep fascia is a relatively insensitive 3: is related medially to the cricothyroid muscle
4: is covered by the thyrohyoid muscle
tissue BECAUSE R. the sensory supply of deep fascia is the same as that
of the underlying muscle Answers: TTTF
Answer: E: both S and R and false Last 8th Edition PAGE: 430
Last PAGE: 4 10472, 19815 – During thyroidectomy

A. anterior jugular veins are seen deep to the invesying layer of deep cervical fascia
19809 – All EXCEPT one of the following statements about the investing B. the investing layer of the deep cervical fascia splits to enclose the infrahyoid muscles
layer of the deep cervical fascia are true. It
C. the pretracheal fascia is divided as it envelops the gland and is firmly bound to the capsule of the
gland 654 – The oesophagus
D. the internal laryngeal nerve may be damaged during ligation of the superior thyroid pedicle 1: receives its motor innervation via the vagus nerves.
E. the recurrent laryngeal nerve may be seen disappearing under the inferior border of the crico- 2: has a well defined anatomical sphincter at its lower end just below the diaphragm.
pharyngeus muscle 3: is drained by systemic veins only.
4: is constricted to some extent by the right main bronchus.
Answer: E
Answers: TFFF
Last 8th ed. PAGE: 422; 428; 435; 464. The anterior jugular veins are superficial to the deep fascia
at the level of the thyroid incision (A incorrect), and pierce the deep fascia at the suprasternal notch. The motor innervation to the oesophagus is via the vagus nerves (1 true). The left vagus supplies the
The investing layer of deep fascia splits to enclose the sternomastoid and trapezius muscles (B anterior surface, the right the posterior surface. The upper striated muscle receives its nerve supply
incorrect). The pretracheal fascia is not firmly bound to the capsule of the thyroid gland (C incorrect). from the nucleus ambiguus within the medulla and runs via the cranial root of the accessory to the
The external laryngeal nerve may be damaged during ligation of the superior thyroid pedicle (D vagus. The smooth muscle in the lower part receives its supply via parasympathetic nerves from the
incorrect). The recurrent laryngeal nerve enters the larynx by passing deep to the inferior border of dorsal motor vagal nucleus through the vagal plexus with relays in the oesophageal wall. A dense
cricopharyngeus anterior to the inferior cornu of the thyroid cartilage (E correct). myenteric nerve plexus with abundant ganglia coordinates muscular activity. The cricopharyngeus, a
striated muscle 3 to 5cm wide, closes the upper end of the oesophagus at rest, preventing inspired air
22894 – Concerning the development of the thyroid gland entering the gut. The lower oesophageal sphincter has no defined anatomical features (2 false) but is
1: thyroid cells are all derived from the floor of the pharynx represented by a zone of high resting pressure (10-15mm of mercury) in the lowest (intra-abdominal)
2: the foramen caecum marks the site of origin of the thyroid downgrowth segment below the diaphragm. Venous return from the upper oesophagus is to the brachiocephalic
3: thyroglossal cysts may be posterior to the body of the hyoid bone veins and from the midoesophagus via the azygos veins to vena cava. The lower oesophagus is
4: the pyramidal lobe of the thyroid is the distal remnant of the thyroglossal duct drained by tributaries leading to the left gastric vein, emptying into the portal vein (3 false). This region
of the lower oesophagus is the most important surgically relevant site of collaterals developing in
Answer: FTTT portal hypertension. These submucosal varicosities can give rise to serious or fatal haemorrhage. The
oesophagus crosses behind the left main bronchus at 27cm (11inches) from the incisor teeth where
Last PAGE: 42, 362 there is a slight constriction of oesophageal lumen (4 false).
20607 – S. The inferior parathyroid is derived from a more rostral 21958 – With respect to the cervical oesophagus
pharyngeal pouch (i.e. the third pouch) than the superior parathyroid (i.e. 1: the muscle is supplied by the recurrent laryngeal nerve
the fourth pouch) BECAUSE R. the third pharyngeal pouch contributes to 2: there is no submucosa
3: it inclines slightly to the left of midline but enters the thoracic inlet in the midline
the development of the thyroid gland 4: external to its muscle layer is a layer of connective tissue which is firmly adherent to the
prevertebral fascia
Answers: TFTF
Last PAGE: 42,369
Last's 9th Ed., p277. This question has been reviewed and remains unchanged. Dec 03
20043 – S. The thyroid gland moves with the larynx and trachea during
swallowing BECAUSE R. the thyroid gland is bound to the larynx and 643 – The oesophagus is closely related to the vertebral bodies from the
trachea by the pretracheal fascia A. cricoid cartilage to the median arcuate ligament.
B. cricoid cartilage to the oesophageal hiatus in the diaphragm.
Answer: S is true, R is true and a valid explanation of S C. cricoid cartilage to the lower limit of the superior mediastinum.
D. thoracic inlet to the oesophageal hiatus of the diaphragm.
Last 8th Edition PAGE: 422, 430 E. thoracic inlet to the limit of the superior mediastinum.
22899 – The oesophagus Answer: C

1: passes between the crura of the diaphragm
The oesophagus extends from the cricoid cartilage at the level of the sixth cervical vertebra to the
2: has a coat containing non-striated muscle fibres in its lower two-thirds
cardiac orifice of the stomach at the level of the tenth thoracic vertebra (left seventh costal cartilage).
3: is not in contact with the right mediastinal pleura in the posterior mediastinum
In the adult it is approximately 25cm (10 inches) long and is normally collapsed and empty with
4: pierces the diaphragm at the level of the tenth thoracic vertebra
functional sphincters at its upper and lower ends. On endoscopy the oesophagus starts below the
cricopharyngeal sphincter at 15cm (6 inches) from the incisor teeth and extends to the cardiac orifice
Answers: FTFT
40cm (16 inches) from the incisor teeth. It lies predominantly in the midline but inclines to the left as it
Last (8) PAGE: 250, 262, 433, 278 descends from its cervical origin through the thorax and into the abdomen. The oesophagus is directly

in front of the vertebral bodies at its origin at C6 vertebral level, and stays in contact with the vertebral Answers: TTTT
bodies throughout the superior mediastinum, which extends to the lower border of T4 (level of manubrio-
sternal joint and tracheal bifurcation) (C true). After passing behind the left main bronchus the Last 8th Edition PAGES: 434; 440
oesophagus inclines forward away from the vertebral bodies to reach the oesophageal opening in the
diaphragm at the level of T10 just to the left of the midline. 23464 – Nerves commonly at risk during exposure of the bifurcation of the
common artery are
21073 – The cervical oesophagus 1: hypoglossal nerve
1: is related posteriorly to longus capitis muscle 2: superior laryngeal nerve
2: is supplied by oesophageal branches of the inferior thyroid artery 3: lingual nerve
3: enters the mediastinum to the right of the midline 4: accessory nerve
4: has venous drainage to the brachiocephalic veins
Answers: TTFF
Answers: FTFT
Last 9th ed. Page: 463. Pending review. Jan 2003
22854 – Structures which pass between the external and the internal
20775 – S. The dehiscence of Killian is a common site for pharyngeal carotid arteries include
diverticula BECAUSE R. the dehiscence is a weak area of the pharyngeal 1: the hypoglossal nerve
wall below the cricopharyngeus 2: the glossopharyngeal nerve
3: a portion of the parotid gland
Answer: S is true and R is false 4: the stylopharyngeus muscle
Last 9th Edition PAGE: 488 Answers: FTTT
22139 – An incision along the anterior border of sternomastoid to expose Last 8th Edition PAGE: 462
the common carotid artery bifurcation will commonly divide the
1: supraclavicular nerves 22169 – Nerves which pass between the internal and external carotid
2: a sternomastoid branch of the occipital artery arteries include
3: transverse cervical nerve 1: hypoglossal nerve
4: common facial vein 2: glossopharyngeal nerve
3: superior laryngeal branch of vagus
Answers: FTTT 4: pharyngeal branch of vagus
Last 8th Edition PAGE: Plate 31 Answers: FTFT
23724 – The carotid sheath Last 8th Edition PAGE: 462

1: is attached to the aortic arch
2: invests the vagus nerve 23979 – The external carotid artery lies
3: is attached to the pretracheal fascia 1: on the middle constrictor muscle
4: is attached to the carotid foramen 2: deep to the stylohyoid muscle
3: superficial to the stylopharyngeus muscle
Answers: TTTT 4: superficial to the pharyngeal branch of the vagus nerve
Last 9th Edition PAGE: 423; 464 Last 9th Edition PAGE: 423; 464 Answers: TTTT
22174 – The common carotid artery lies anterior to Last 8th Edition PAGE: 437
1: the cervical sympathetic chain
2: the prevertebral fascia 21638 – The thoracic part of the left common carotid artery
3: the cervical transverse processes 1: lies medial to the left pleura and lung
4: the inferior thyroid artery 2: lies anterior to the thoracic duct
3: has the left recurrent laryngeal nerve on its lateral side
4: has no branches

Answers: TTFT 20457 – S. The left brachio-cephalic vein is at risk during tracheostomy in a
young child BECAUSE R. the left brachio-cephalic vein lies above the
Last 10th ed. PAGE: 186. This question is currently under review by the Anatomy Sub Committee. 23
August, 2001. Question updated 14 March 2002. jugular notch in a young child
23794 – The vertebral artery Answer: S is true, R is true and a valid explanation of S
1: enters a foramen in the transverse process of the seventh cervical vertebra
Last PAGE: 50
2: terminates in the foramen magnum by joining the artery of the opposite side
3: terminates as the posterior cerebral artery
4: turns medially at the level of the lateral mass of the atlas 20409 – S. The subclavian vein is free to dilate when venous return
increases BECAUSE R. the subclavian vein lies anterior to the prevertebral
Answers: FFFT fascia
Last 9th Edition PAGE: 547, 573 Answer: S is true, R is true and a valid explanation of S
12703 – The vertebral artery gives rise to Last 8th Edition PAGE: 422
1: a meningeal branch before penetrating the dura
2: posterior spinal arteries which pass along the spinal cord close to the posterior nerve rootlets 14854 – The inferior thyroid veins usually drain into
posterior to the dentate ligament A. the brachiocephalic veins
3: a posterior inferior cerebellar artery which insinuates among the rootlets of cranial nerves XII, XI B. the internal jugular veins
and X C. the subclavian veins
4: the posterior cerebral artery directly D. the vertebral veins
E. the external jugular veins
Answers: TTTF
Answer: A
The vertebral artery after piercing the posterior atlanto-occipital membrane gives a meningeal branch
which lies between the endosteal and fibrous layers of the dura of the posterior fossa (A true). It also Refer to Last, 10th Ed, page 331
gives rise to the posterior spinal arteries, which pass along the spinal cord as described (B true). The
anterior spinal and posterior inferior cerebellar arteries arise before the vertebral arteries join to form
19174 – The accessory nerve
the basilar artery. The posterior inferior cerebellar artery coils in a sinuous manner between the
A. lies on the scalenus medius muscle in the posterior triangle
rootlets of cranial nerves XII, XI and X (C true). The posterior cerebral arteries arise from the basilar
B. supplies the levator scapulae muscle
artery (D false).
C. passes through the substance of the sternomastoid muscle
D. crosses anterior to the styloid process
22559 – The posterior relations of the internal jugular vein include E. crosses anterior to the external carotid artery
1: the thoracic duct
2: the subclavian artery Answer: C
3: the scalenus anterior muscle
4: the omo-hyoid muscle Last 8th Edition PAGE: 464
Answer: TTTF
20793 – S. Paralysis of the sterno-mastoid muscle may occur after
Last 8th Edition PAGE: 438, 443 operations on the posterior triangle of the neck BECAUSE R. the accessory
nerve is at risk in operations on the posterior triangle of the neck
8485 – The external jugular vein
1: receives blood from the posterior branch of the retromandibular vein Answer: S is false and R is true
2: lies superficial to the investing layer of deep fascia in the neck
3: usually drains into the subclavian vein Last 9th Edition PAGE: 425
4: has valves about 4cm above the clavicle
24059 – The phrenic nerve
Answers: TTTT 1: carries efferent fibres to the diaphragm
2: carries afferent fibres from the diaphragmatic pleura
Last 10th ed, Ch 6 3: carries afferent fibres from the parietal pericardium

4: may pass anterior to the subclavian vein under the lower border of the inferior constrictor muscle supplies before entering the larynx (B
incorrect). It supplies the intrinsic laryngeal muscles except cricothyroid, which is supplied by the
Answers: TTTT external laryngeal nerve on its outer surface (C incorrect). It supplies sensation to the laryngeal
mucosa below the level of the cords, sensation above the cords being supplied by the internal
Last 10th ed. PAGE: 189 laryngeal nerve (D incorrect). The motor fibres of the recurrent laryngeal nerve are derived from the
cranial root of the accessory from the nucleus ambiguus (E incorrect). Question reviewed and
21003 – S. In the neck, the thoracic duct lies posterior to the phrenic updated July 03. Question to be reviewed at March 04 meeting re: option B.(23/02/04).
nerve BECAUSE R. the phrenic nerve lies superficial to the prevertebral
fascia 7658, 19671 – The glossopharyngeal nerve supplies
A. the constrictor muscles of the pharynx
B. the palatopharyngeus muscle
Answer: both S and R and false
C. the salpingopharyngeus muscle
D. the stylopharyngeus muscle
Last 8th Edition PAGE: 442 Fig.6.8
E. the palatoglossus muscle
21078 – The cervical sympathetic trunk Answer: D
1: lies medial to the highest intercostal vein on the neck of the first rib
2: is crossed anteriorly by the inferior thyroid artery Last 10th Ed, Ch 6 PAGE: 358
3: is connected with every cervical nerve by grey rami communicantes
4: innervates the sphincter pupillae 22839 – The sternomastoid muscle
1: rotates the head to the opposite side
Answers: TFTF
2: tilts the head to the same side
3: flexes the cervical spine
Last 9th Edition PAGE: 440 Fig. 6.6 518
4: protracts the head
20781 – S. Division of the external laryngeal nerve results in flaccidity of Answers: TTTT
the vocal fold BECAUSE R. the external laryngeal nerve supplies the ary-
epiglottic muscle Last 9th Edition PAGE: 424
Answer: S is true and R is false 19659 – The scalenus anterior and scalenus medius muscles are separated
by
Last 8th Edition PAGE: 464 A. the dorsal scapular nerve
B. the phrenic nerve
20211 – S. The glossopharyngeal nerve supplies the carotid C. the subclavian vein
sinus BECAUSE R. the glossopharyngeal nerve is the nerve of the third D. the roots of the brachial plexus
E. all of the above
pharyngeal arch
Answer: D
Last PAGE: 41
10466 – The left recurrent laryngeal nerve 19821 – The scalenus anterior muscle
A. lies anterior to the thoracic duct on the left side
1: hooks around the arch of the aorta anterior to the attachment of the ligamentum arteriosum
B. is separated from the phrenic nerve by the prevertebral fascia
2: supplies a branch to the left inferior constrictor muscle before entering the larynx
C. is crossed anteriorly by the subclavian artery
3: supplies the left cricothyroid muscle
D. overlies the trunks of the brachial plexus
4: supplies sensation to the whole of the laryngeal mucosa on the left side
E. is crossed anteriorly by the transverse cervical artery
5: contains motor fibres derived from the spinal root of the left accessory nerve
Answer: E
Answers: FFFFF
The left recurrent laryngeal nerve hooks round the aortic arch posterior and to the left of the
attachment of the ligamentum arteriosum (A incorrect). It then runs up alongside the trachea to pass
19827 – Fibres of the superior constrictor muscle are attached to
A. the sphenomandibular ligament B. posterior crico-arytenoid muscles
B. the lateral pterygoid plate C. vocalis muscles
C. the stylohyoid ligament D. thyro-aryepiglottic muscles
D. the greater cornu of the hyoid bone E. lateral crico-arytenoid and transverse arytenoid muscles
E. the mandible
Answer: B
Answer: E
These tiny muscles are the sole abductors of the vocal cords - the others are all constrictive. Voice
Last 8th Edition PAGE: 485 was a late evolutionary development of the larynx - thus most muscles subserve the primitive
sphincteric laryngeal function of protecting the airway during swallowing.
18982 – The inferior constrictor muscle
A. arises from the stylohyoid ligament and the hyoid bone 8988 – Abduction of the vocal cords results from contraction of the
B. includes the cricopharyngeus muscle A. cricothyroid muscles
C. is supplied by the internal laryngeal nerve B. posterior cricoarytenoid muscles
D. is supplied by the glossopharyngeal nerve C. inter arytenoid muscle
E. has none of the above properties D. aryepiglottic muscle
E. lateral cricoarytenoid and transverse arytenoid muscles
Answer: B
Answer: B
22144 – The trachea
1: is lined by pseudostratifid ciliated columnar epithelium 7809 – The atlas
2: is supported by 'C' shaped hyaline cartilaginous 'rings' 1: is the widest of the cervical vertebrae
3: derives part of its blood supply from the superior thyroid artery 2: has the vertebral artery lying on its anterior arch
4: diminishes in diameter as the carina is approached 3: has a transverse process which is palpable through the skin
4: can rotate laterally on the occipital bone
Answers: TTFF
Answers: TFTF
Last 10th ed, Ch 6
23064 – The vocal cord is lengthened by
1: the thyroarytenoid muscle 10312 – A patient presents with a midline swelling in the neck just above
2: the lateral cricoarytenoid muscle the suprasternal notch. The swelling moves upwards on swallowing. It is
3: the posterior cricoarytenoid muscle
most likely to be a
4: the cricothyroid muscle
A. thyroglossal cyst
B. dermoid cyst
Answers: FFFT
C. branchial cyst
D. thyroid nodule
E. parathyroid adenoma
19498 – The vocal cord is shortened by Answer: D
A. the lateral cricoarytenoid muscle
B. the posterior cricoarytenoid muscle The correct response to this question has mostly been discussed in the resource unit and texts.
C. the circothyroid muscle
D. the thyroarytenoid muscle
THORAX
Answer: D
Last 7th Edition PAGE: 428 19462 – In the superior mediastinum

A. the left superior intercostal vein passes forward across the arch of the aorta deep to the vagus
7084 – Abduction of the vocal cords results from contraction of the nerve
A. crico-thyroid muscles
B. the left superior intercostal vein passes forward across the arch of the aorta superficial to the 21015 – S . The inferior vena cava in the thorax has no serous pericardial
phrenic nerve covering BECAUSE R. the right atrium is directly attached to a part of the
C. the aortic bodies subserve respiratory reflexes via vagal fibres
D. the left subclavian artery gives its internal thoracic branch fibrous pericardium
E. the ligamentum arteriosum passes from the right pulmonary artery to the aortic arch
Answer: E: both S and R and false
Answer: C
Last 10th ed. Page: 177; 183
18940 – The right atrium
19108 – The superior mediastinum contains the A. lies anterior to the left atrium
A. left phrenic nerve passing medial to the left vagus nerve, just above the arch of the aorta B. receives blood from all the venae cordis minimae
B. left superior intercostal vein C. has its left wall formed by the interventricular septum
C. whole of the superior vena cava D. has the coronary sinus opening to the right of the fossa ovalis
D. oesophagus held to the left of the midline by the aorta E. has a valve for the superior vena cava
E. origin of the right recurrent laryngeal nerve
Answer: A
Answer: B
19114 – The right atrium
23584 – The serous pericardium A. has the atrioventricular node in the upper part of the crista terminalis
1: has the phrenic nerve supplying sensation to its pareital layer B. continues above as the auricular appendage
2: encloses the aorta and pulmonary trunk in separate sheaths of its visceral layer C. has the coronary sinus opening in the fossa ovalis
3: has an oblique sinus behind the left atrium D. has the inter-atrial septum forming the left wall of the atrium
4: has a transverse sinus directly behind both atria E. recovers blood from all the vena cordis minimae
Answers: TFTF Answer: B
Last 10th. ed. PAGE: 190 Last 10th ed. PAGE: 193; 198
19354 – The fibrous pericardium 22539 – Within the right atrium

A. has visceral and parietal layers 1: the crista terminalis separates the true auricular appendage from the part of the atrium derived
B. has no attachments to the sternum from the sinus venosus
C. encloses a part only of the superior vena cava 2: the opening of the coronary sinus lies to the left of the valve of the inferior vena cava
D. is inferiorly related to the diaphragmatic pleura 3: the fossa ovalis lies in the inferior part of the interatrial septum
E. has none of the above properties 4: the AV node is in the interatrial septum above and to the left of the opening of the coronary sinus
Answers: C Answers: TTTT
Last 10th ed. Page: 190. Question to be reviewed at March 04 meeting re: option C to be re worded Last 10th ed. Page: 193
(23/02/04)
14977 – The atrioventricular node
23079 – The fibrous pericardium 1: lies subendocardially within the interatrial septum
1: is attached to the sternum 2: lies above the opening of the coronary sinus
2: is separated from the central tendon of diaphragm 3: is supplied with blood from the left coronary artery in 60% of individuals
3: is derived from the septum transversum 4: lies above the anterior cusp of the tricuspid valve
4: fuses with the root of the IVC
Answers: TTFF
Answers: TFTF
Refer to Last, 10th Ed, page 196, 197
19995 – The AV node receives blood from the
A. conus arteriosus 21613 – The fibrous skeleton of the heart
B. interventricular branch of the left coronary artery 1: is traversed by muscle bundles
C. right marginal artery 2: is traversed by specialized conducting tissue
D. left marginal artery 3: lies in the coronal plane
E. by a terminal branch of the right coronary artery 4: gives attachment to the membranous part of the interventricular septum
Answer: E Answers: FTFT
Last 10th ed. PAGE: 197 Last 10th ed. PAGE: 190
19360 – In valves of the heart 20241 – S. The posterior wall of the right atrium is smooth
A. the mitral valve has 3 cusps internally BECAUSE R. the posterior wall of the right atrium develops from
B. the aortic sound is best heard at the apex
C. the interatrial and interventricular septa lie at about 45 degrees to the saggital plane the right horn of the sinus venosus
D. the tricuspid valve has 2 large papillary muscles
E. the right coronary artery arises from the right posterior aortic sinus Answer: S is true, R is true and a valid explanation of S
Answer: C Last 10th ed. PAGE: 199, 193, 29
Last 10th ed. PAGE: 195. This question has been reviewed and updated. Sep 2002 23824 – The diaphragmatic surface of the heart consists of parts of
1: (R) atrium
21618 – Heart valves are characterized by 2: atrioventricular groove
1: many elastic fibres in fibrous tissue covered with vascular endothelium 3: (R) ventricle
2: the aortic valve having left, right and anterior cusps 4: (L) ventricle
3: the aortic and pulmonary valves having thick cusps with a central fibrous nodule in the free edge
4: the pulmonary valve having a posterior papillary muscle and chordae tendineae Answers: TTTT
Answers: TFTF Last 10th ed. PAGE: 191. Question reviewed and updated Nov 03.
Last 10th ed. PAGE: 195 14153 – In the surface projection of the normal heart
1: the tricuspid valve lies beneath the fourth right costal cartilage
22814 – The aortic valve 2: the upper border of the heart lies below and behind the manubriosternal joint
1: has 2 cusps, whereas the pulmonary valve has 3 cusps 3: the 'apex beat' lies just medial to the midclavicular line
2: has an anterior cusp adjacent to which the left coronary artery arises 4: the pulmonary valve lies on the left border of the sternum opposite the third left costal cartilage
3: has a surface marking at the medial end of the left 3rd costal cartilage behind the sternal border
4: is best auscultated in the second right interspace Answers: FTTT
Answers: FFTT Last's 9th Ed., p266. Question reviewed and unchanged. Dec 03
Last 10th ed. PAGE: 194. Updated Nov 2003 13439 – S:The size of hypertrophied cardiac muscle fibres cannot exceed a
certain maximum because R:increase in the size of cardiac muscle cells is
22008 – The left atrio-ventricular valve (mitral valve) not accompanied by an increase in the number of capillaries supplying
1: has an anterior (septal) cusp with a larger atrioventricular ring attachment than the posterior cusp each muscle fibre and is limited by mitochondrial oxidative capacity
2: can be a tricuspid valve
3: has a small posterior cusp
4: has thicker cusps than the right atrioventricular valve
It is believed that each heart muscle fibre is supplied by only one capillary. When the heart muscle
Answer: FTFT
fibre undergoes hypertrophy there is no increase in the vascular supply of the fibre (R true). The
extent to which the muscle fibre can enlarge is thus limited by the blood supply (S true and R is a
valid explanation S).
This question is currently under review by the Anatomy Sub Committee. 23 August, 2001
Question updated 14 March 2002.
23314 – The right coronary artery
1: arises from the right posterior aortic sinus 1: is crossed anteriorly and to the left by the left supreme intercostal vein
2: does not have a corresponding draining vein 2: has the left brachiocephalic vein above it
3: supplies the sino-atrial node in less than 10% of cases 3: usually causes an impression on the left side of the oesophagus
4: gives off an anterior interventricular branch 4: is crossed anteriorly and to the left by the left phrenic nerve
Answers: FTFF Answers: FTTT
Last 10th ed. PAGE: 197; 198. Updated May 2004 Last 10th ed. PAGE: 186. This question is under review by the Anatomy Sub Committee. August 23,
2001
22819 – The right coronary artery
1: arises from the right aortic sinus 21633 – The ascending aorta
2: usually supplies the sino-atrial node 1: gives origin to the right coronary artery from its anterior sinus
3: gives off a posterior interventricular branch 2: is a posterior relation of the left auricle
4: provides the main blood supply of the conus arteriosus(infundibulum) 3: is encased in a common pericardial sheath with the pulmonary trunk
4: is an anterior relation of the right atrium
Answers: TTTT
Answers: TFTF
Last 10th ed. PAGE:190, 197
19989 – Which of the following statements about the right coronary artery
is NOT true? It supplies 27150 – Type A dissection of the aorta
A. most of the right ventricle A. arises proximal to the left subclavian artery
B. part of the diaphragmatic surface of the left ventricle B. may produce neurological signs
C. about half of the interventricular septum C. causes pain which differs from typical myocardial ischaemic pain
D. the lower part of the interatrial septum D. has a very high mortality when untreated
E. the atrioventricular node in a minority of cases E. all of the above responses concerning Type A dissection are correct
Answer: E Answer: E
Last 10th ed. PAGE: 197 Type A dissection arises just distal to the aortic valve, and is most frequent in patients with
hypertension or a pre-existing aneurysm. Compression of the vessels arising from the arch of the
19366 – The left coronary artery aorta may cause cerebral ischaemic symptoms and signs. Pain often radiates to the back, which is
uncommon in myocardial ischaemia. The mortality of untreated type A dissection approaches 90% at
A. arises from the posterior aortic sinus
four weeks. Thus, all options are correct, answer E.
B. supplies the sinuatrial node in only 10% of cases
C. gives off the anterior interventricular artery
D. usually gives off the posterior interventricular artery 22224 – The thoracic part of the left subclavian artery
E. supplies no part of the right ventricle 1: arises from the aortic arch at the level of the disc between the 3rd and 4th thoracic vertebrae
2: is separated by the left vagus nerve, the cardiac nerves and the phrenic nerves from the left
Answer: C brachio-cephalic vein
3: lies posteriorly on the oesophagus, thoracic duct and longus colli muscles
Last 10th ed. PAGE: 197 4: is related medially to the trachea and the left recurrent laryngeal nerve
Answers: TTTT
21943 – The left pulmonary artery
1: is connected to the arch of the aorta by a fibrous ligament
Last 10th ed. Page: 191. Review July 2004 re: option 3.
2: is shorter than the right pulmonary artery
3: passes in front of the left main bronchus
4: lies above the left recurrent laryngeal nerve 7769 – The pulmonary trunk
1: arises at a slightly higher level than the aortic orifice
Answers: TTTF 2: is at first anterior, then to the left of the ascending aorta
3: is bounded on either side by the appropriate auricle and coronary artery
Last 10th ed. PAGE: 207 4: is enclosed with the aorta in a common tube of serous pericardium
22484 – The arch of the aorta

Answers: TTTT Last 10th ed. PAGE: 187
Last 10th ed, Ch 4 21643 – The superior vena cava

1: fuses with the fibrous pericardium
24054 – The right pulmonary artery 2: is formed by union of the brachio-cephalic veins
1: is shorter and smaller than the left pulmonary artery 3: receives the azygos vein opposite the second right costal cartilage
2: is an anterior relation of the azygos vein 4: represents the persistence of part of the right anterior cardinal vein
3: divides at the root of the right lung into two branches
4: is a posterior relation of the thoracic duct Answers: TTTT
Answers: FFTF Last 10th ed. PAGE: 187
Last 10th, pgs 185 (Fig 4.11) & 265. The azygos is in superior relation. Question has been reviewed 22914 – The inferior vena cava
and updated July 03. 1: enters the right atrium to the right of the fossa ovalis
2: enters a deep groove on the bare area of the liver, to the right of the caudate lobe
21598 – The internal thoracic artery 3: commences at level of L4
1: supplies the anterior body wall from clavicle to umbilicus 4: is posterior to the medial part of the right suprarenal gland
2: at its origin is closely related to the phrenic nerve
3: supplies the pleura and fibrous pericardium Answers: TTFF
4: passes into the rectus sheath between rectus abdominis and the anterior sheath
Last (8) PAGE: 363. This question will be submitted at the March meeting, regarding option 1
Answers: TTTF (09/03/2004)
Last 10th ed. PAGE: 177 19120 – The left brachio-cephalic vein
A. lies posterior to the lower half of the manubrium when the neck is extended
21628 – Coronary venous blood returns directly to the right atrium via B. receives the left superior intercostal vein
1: the coronary sinus C. crosses in front of the aortic arch
2: the venae cordis minimae D. joins the right brachio-cephalic vein below the second costal cartilage
3: the anterior cardiac veins E. represents the left anterior cardinal vein
4: the oblique vein (of Marshall)
Answers: B
Answers: TTTF
Last's 9th Ed., p45. The left anterior cardinal vein disappears. The cross channel between L + R AC
Last 10th ed. PAGE: 198. Question reviewed and updated Nov 03. vein persists.
24179 – The coronary sinus 20001 – The right brachio-cephalic vein

1: receives almost all myocardial blood flow A. lies anterior to the thymus gland
2: lies below the openings of the inferior pulmonary veins B. projects above the jugular notch in infants
3: receives the anterior cardiac veins C. receives the superior intercostal vein
4: opens into the posterior wall of right atrium D. crosses the right vagus nerve sub-pleurally
E. occasionally receives the right supreme intercostal vein
Answers: TTFT
Answer: E
Last 10th ed. PAGE: 187, 185v
24269 – The superior vena cava
1: has the right phrenic nerve on its lateral side 19330 – The azygos vein
2: receives the azygos vein A. joins the right brachiocephalic vein
3: lies anterior to the right pulmonary artery B. passes in front of the right lung root
4: lies to the left of the transverse sinus of the pericardium C. is joined by the right superior intercostal vein
D. is crossed anteriorly by right posterior intercostal arteries
Answers: TTTF E. commences by the union of the lower posterior inter-costal veins

Answer: C Answers: TTTT
Last 10th ed. PAGE: 204 Last 10th ed. PAGE: 188
19977 – Tributaries of the vena azygos include 14581 – The phrenic nerve
A. the right superior intercostal vein 1: descends on the anterior surface of scalenus anterior muscle from medial to lateral
B. some oesophageal veins from the middle third of the oesophagus 2: may contain C5 fibres which pass anterior to the subclavian vein
C. the right fifth to eleventh posterior intercostal veins 3: lies anterior to the prevertebral fascia
D. the right ascending lumbar vein 4: lies lateral to the ascending cervical artery
E. all of the above
Answers: FTFT
Answer: E
Refer to Last, 10th Ed, page 188-189. This question was referred to the Anatomy Sub Committee for
Last 10th ed. PAGE: 204 review on 1 Feb 2002. Question updated 14 March 2002.
21653 – The left vagus in the thorax 22804 – The anterior primary rami of the spinal nerves in the thorax
1: is held off the trachea by the great arteries 1: give a collateral branch near the angle of the ribs
2: is crossed by the left phrenic nerve just above the arch of the aorta 2: have some fibres of the first three thoracic nerves going to the upper limb
3: is crossed by the left superior intercostal vein on the arch of the aorta 3: are at first anterior to the internal intercostal muscles
4: runs posterior to the root of the left lung 4: end as the intercostal nerves, lying above the artery and vein in the intercostal space
Answer: TTTT Answer: TTTF
Last 10th ed. PAGE: 189 Last's 10th Ed., p176. Updated Nov 03
18934 – In relation to the vagus nerves in the thorax 19468 – The cardiac plexus
A. pre-ganglionic contributions are made to the oesophageal plexus A. is formed by postganglionic fibres from the vagi
B. the left vagus nerve passes medial to the aortic arch B. is formed by preganglionic sympathetic fibres from T1-4 ganglia
C. the right vagus nerve passes anterior to the right lung root C. lies anterior to the left bronchus at the bifurcation of the pulmonary trunk
D. entry into the abdomen is achieved by piercing the crura of the diaphragm D. has a component from the left phrenic nerve
E. recurrent laryngeal nerves are given off by both vagi in the superior mediastinum E. innervates the pleura over the pericardium
Answer: A Answer: C
Last 10th ed. PAGE: 204; 189 Last 10th ed. PAGE: 187
18994 – The left recurrent laryngeal nerve 27156 – Innervation of the lung includes
A. hooks round the arch of the aorta anterior to the attachment of the ligamentum arteriosum A. sensory supply to the tracheobronchial tree
B. may supply a branch to the inferior constrictor muscle before entering the larynx B. parasympathetic innervation inhibiting secretion of mucus
C. supplies the left cricothyroid muscle C. sympathetic innervation mediating vasoconstriction
D. supplies sensation to the whole of the laryngeal mucosa D. sympathetic innervation constricting bronchial smooth muscle
E. contains motor fibres derived from the spinal root of the accessory nerve E. sensory supply to the visceral pleura
Answer: B Answer: A
Last 8th Edition PAGE: 404, 488 Mechanical stimulation or chemical irritation of the epithelium of the airways evokes the cough reflex
(Option A is correct). There is a modest parasympathetic innervation, which is secretomotor, through
22239 – The right phrenic nerve muscarinic receptors, blocked by atropine and related drugs - hence the use of ipratropium in asthma.
1: runs subpleurally, lateral to the right brachio-cephalic vein The sympathetic supply to the lung - only modest in density - releases noradrenaline, which acts on
2: runs anterior to the root of the right lung beta-2-receptors to dilate bronchioles. There is virtually no effect on the vasculature, which in the lung
3: runs over the fibrous pericardium covering the right atrium has little autonomic regulation. Its major vasoconstrictor stimulus is hypoxia, which helps match
4: penetrates the diaphragm through or just lateral to the opening for the inferior vena cava perfusion to ventilation. The pulmonary beta-receptors respond mainly to circulating adrenaline (and
asthma drugs). The lung parenchyma and visceral pleura have no sensation; hence the observation

that a localised inflammatory process produces no symptoms until it impinges on the parietal pleura 7688 – S:The lingula of the left lung corresponds to the middle lobe of the
giving pleuritic pain. right lung because R:the lingula of the left lung is separated from the lower
19402 – The sympathetic trunk in the thorax has lobe by the oblique fissure
1: a stellate ganglion lying medial to the first posterior intercostal vein
Answer: S is true, R is true but not a valid explanation of S
2: a distribution to the heart via the first 4 thoracic ganglia
3: motor fibres to the eye, causing dilation of the pupil
Last 10th ed, Ch 4
4: a distribution to the upper limb via the subscapular vessels
5: a distribution to the abdomen, via the splanchnic nerves, under the medial arcuate ligaments
15408 – The diaphragm
Answers: FTTFF 1: develops, in part, from the septum transversum
2: has part of the right crus that lies to the left of the oesophagus supplied by the right phrenic nerve
Last 10th ed. Page: 204. Question reviewed and updated March 02. Question re-submitted - 3: has a caval opening lying behind the right 8th costal cartilage
reviewed and updated July 03. Review July 2004 re: option 1. 4: has the right phrenic nerve supplying the muscle from its superior surface
Answers: TFFF
21858 – The thoracic trachea
1: is directly related to the right lung and pleura
Refer to Last, 10th Ed, Ch 4, page 178-181
2: lies immediately posterior to the brachio-cephalic artery
3: does not contact the left lung and pleura directly
4: has the bifurcation of the pulmonary trunk directly anterior 19983 – The diaphragm
A. has motor innervation from the phrenic nerve, to all its parts except the crura
Answers: TTTF B. has sensory innervation from the vagus nerves
C. has a blood supply mostly from the pericardiacophrenic arteries
Last 10th ed. PAGE: 187 D. has lymph nodes that drain into the tracheobronchial group
E. moves in respiration under central control of cell groups in the region of the nucleus of the tractus
solitarius
23089 – In the left lung
1: the main bronchus is longer than on the right
Answer: E
2: the lingular bronchopulmonary segment is equivalent to the apical bronchopulmonary segment of
the lower lobe on the right
Last 9th ed. PAGE: 251, 279, 253
3: the left pulmonary artery is longer than the right
4: the pleural reflection crosses the midaxillary line at the eighth rib
21828 – In the diaphragm
Answers: TFFF 1: the sympathetic trunk passes behind the medial arcuate ligament
2: the subcostal nerve and vessels pass behind the lateral arcuate ligament
Last 10th ed. Page: 206-207 3: the greater and lesser splanchnic nerves pierce each crus
4: the neurovascular bundles of the seventh to eleventh inter-costal spaces pass between the
digitations of the diaphragm and transversus abdominis into the neurovascular plane of abdominal
7774 – The left lung root
wall
1: contains the pulmonary ligament, whose layers separate on inspiration
2: contains the pulmonary ligament, that maintains lung compliance
Answers: TTTT
3: has the pulmonary artery above and anterior to the bronchus
4: has the upper lobe bronchus leave the main bronchus outside the lung
Answers: TFTF
13469, 21608 – The central tendon of the diaphragm
Last 10th ed, Ch 4 1: gives passage to the right phrenic nerve
2: is fused with the fibrous pericardium
3: is attached to the falciform ligament
20163 – S. The pulmonary ligament and femoral canal serve a similar
4: is attached to the phreno-oesophageal ligament
function BECAUSE R. each provides space for increased venous distenion
Answers: TTTF
Last 10th ed. PAGE: 178; 318. The central tendon of the diaphragm is trefoil and is inseparable from
Last 10th ed. PAGE: 206 the fibrous pericardium with which it is embryologically identical (B true). Near the junction of central

and right leaves it is pierced by an opening for the inferior vena cava. The wall of the inferior vena
cava is attached to the foramen, which is at the level of T8, just behind the right sixth costal cartilage. 18922 – Structure(s) closely related to the neck of the first rib are
The right phrenic nerve pierces the central tendon alongside the inferior vena cava (A true). The A. the sympathetic trunk and the stellate ganglion
falciform ligament of the liver is attached to the liver's upper surface somewhat to the right of the B. the superior intercostal vein
midline, and its diaphragmatic attachment is to the central tendon near the base of the fibrous C. internal thoracic artery
pericardium and runs forwards and to the left to reach the xiphisternum and thence down along the D. the intercosto-brachial nerve
linea alba to the umbilicus (C true). The phreno-oesophageal ligaments are thickenings of the E. the sympathetic outflow to the upper limb
infradiaphragmatic fascia around the oesophageal opening, which is in the right crus at the level of
T10 to the left of the midline (D false). This question will be resubmitted for review in its entirety at the Answer: A
March 04 meeting (20/02/04).
638 – In relation to the diaphragm
1: the vagus nerves pass through its oesophageal opening. 19695 – The arterial supply of the posterior part of the first intercostal
2: the sympathetic trunks pass behind the medial arcuate ligaments.
space arises from
3: the major motor nerve supply comes from C4.
A. the arch of the aorta
4: the right phrenic nerve passes through the central tendon.
B. the descending aorta
C. the suprascapular artery
Answers: TTTT
D. the costocervical trunk
E. the transverse cervical artery
The major openings in the diaphragm are at T8 in the dome, where the central tendon is pierced by
inferior vena cava and right phrenic nerve (which supplies the diaphragm from its lower surface) (4
Answer: D
true); the oesophageal opening at T10 vertebral level transmitting the oesophagus and its associated left
(anterior) and right (posterior) vagal nerves (1 true); and the opening for the aorta between the right and Last 10th ed. PAGE: 177
left crura opposite T12 vertebra, transmitting aorta and azygos vein and thoracic duct. The left phrenic
nerve pierces the muscle of the left diaphragmatic dome. The splanchnic nerves pierce each crus,
and the sympathetic trunks run on psoas behind the medial arcuate ligaments (2 true). Each half of the
24309 – At the level of the 2nd costal cartilage
diaphragm is supplied by its own phrenic nerve, originating from C3, 4 & 5 but predominantly from C4 1: the superior vena cava receives the azygos vein
2: the oesophagus is a midline structure
(3 true). The motor supply is solely from the phrenic. Sensation is supplied by both the phrenic nerve
3: the left main bronchus arises
centrally and the lower intercostal nerves peripherally. The oesophageal opening is within the left crus
4: the right recurrent laryngeal nerve hooks around the arch of the aorta
but fibres from the right crus encircle it and contribute to oesophago-gastric competence. Those
muscle fibres to the right of the oesophageal opening are supplied by the right phrenic nerve and
Answers: TTTF
fibres to the left of the opening are supplied by the left phrenic nerve.
Last 10th Ed PAGE: 186. This question will be submitted for review at the March 04 meeting
23649 – In relation to the diaphragm (16/03/2004)
1: the vagus nerves pass through its oesophageal opening
2: the splanchnic nerves pass behind the medial arcuate ligament
3: the major nerve supply comes from C4
22013 – The 12th rib is characterised by
1: a complete articular facet on the head
4: the right phrenic nerve passes through the central tendon
2: many muscular attachments
3: a relationship to pleura, medially
Answers: TFTT
4: the absence of a subcostal groove
Last PAGE: 217
Answers: TTTT
19348 – Structures penetrating the diaphragm include Last 10th ed. PAGE: 212
A. the oesophagus at the level of T8
B. the aorta at the level of T10
C. the splanchnic nerves, through the crura
21493 – The lower five intercostal nerves
1: cross anterior to the costal margin
D. the right phrenic nerve through the muscle of the right dome
2: run deep to the internal intercostal muscles
E. the left phrenic nerve through the central tendon
3: supply parietal and visceral peritoneum
4: supply the rectus abdominis muscle
Answer: C
Answers: FTFT
Last 8th ed. PAGE: 249-251

Last (8) PAGE: 247
19480 – The anterior intercostal membrane
21648 – The anterior primary ramus of the 12th thoracic spinal nerve A. is derived from the same layer as the internal oblique muscle
1: emerges beneath the lateral arcuate ligament of the diaphragm B. commences lateral to the costochondral junction
2: lies behind the kidney C. is a continuation of the external intercostal muscle
3: has a lateral branch which crosses the iliac crest to reach the buttock D. extends laterally to the angle of the rib
4: supplies the pyramidalis muscle E. none of the above properties
Answers: TTTT Answer: C
Last 10th. ed. PAGE: 272 Last 10th ed. PAGE: 175
19971 – The intercostal spaces have the 19959 – The transverse processes of the thoracic vertebrae
A. collateral branches located superior to the main nerve in the neurovascular plane A. articulate with the tubercles of the ribs
B. neurovascular bundles between the external and internal intercostal muscles B. articulate with the ribs of the same number
C. internal intercostal muscle as the main muscle of respiration C. articulate with the upper ten ribs via synovial joints
D. levator costae muscles innervated by the anterior primary rami of the spinal nerves D. are attached to the ribs via costo-transverse ligaments
E. intercostal nerves related inferior to the vein and arteries E. have all of the above features
Answers: E Answer: E
Last 10th ed. PAGE: 176-77 Last 10th ed. PAGE: 425
19689 – The arterial supply to the intercostal spaces are 7824 – The sterno-clavicular joint
A. anteriorly, directly from the subclavian artery 1: is a synovial joint
B. anteriorly, from the superior epigastric artery 2: is attached to the first costal cartilage by the costo-clavicular (rhomboid) ligament
C. posteriorly, from the vertebral artery 3: allows some 40 degrees of rotation of the clavicle
D. posteriorly, from the superior intercostal branch of the costocervical trunk, to spaces 1 and 2 4: gains its stability mainly from the bony configuration of the joint
E. posteriorly, from the inferior phrenic arteries
Answers: TTTF
Answer: D
Last 10th ed, page 41
19144 – At the level of the manubriosternal angle (angle of Louis)
20871 – S. The internal intercostal muscles are purely inspiratory A. the left common carotid artery commences
muscles BECAUSE R. the fibres of the internal intercostal muscles run B. the second costal cartilage articulates
downwards and backwards from one rib to the next below C. the brachio-cephalic veins join
D. the right recurrent laryngeal nerve recurves
E. the phrenic nerve has the vagus nerve related anteriorly
Answer: S is false and R is true
Answer: B
Last 10th Ed PAGE: 175; 176; 181
18952 – The serratus posterior superior muscle is characterized by
A. glistening tendinous fibres 19102 – At the level of the manubrio-sternal angle (angle of Louis)
B. lying immediately adjacent the serratus posterior inferior muscle
A. the brachiocephalic veins join to form the superior vena cava
C. being a muscle of expiration
B. the trachea divides into right and left main bronchi
D. being superficial to the dorsal scapular nerve and descending scapular vessels
C. the arch of the aorta reaches its upper limit
E. being inserted into the posterior angle of the upper four ribs
D. the left common carotid artery commences
E. the thoracic duct crosses from right to left anterior to the oesophagus
Answer: A
Answer: B

Last 10th ed. PAGE: 183 D. the accessory hemi-azygos vein crossing from left to right behind the oesophagus and aorta at the
level of T4
20733 – S. Movement can occur at the manubriosternal joint BECAUSE R. E. posteriorly the spinal canal containing extra-dural fat and the internal vertebral venous plexus
the manubriosternal joint is a synovial joint
Answer: E
Last 10th ed. PAGE: 425, 203-204. Question reviewed and updated Nov 03.
Last 10th ed. Page: 181;175
23614 – The lines of pleural reflection
20319 – S. The sternocostal joint at the manubriosternal angle has two 1: lie posterior to the kidneys
2: are adjacent from the angle of Louis to the level of the 4th costal cartilage
synovial joints BECAUSE R. the manubrium and body do not usually fuse 3: cross the mid-clavicular line at the tenth costal cartilage
as the other sternebrae do 4: project above the neck of the first rib
Answer: S is true, R is true and a valid explanation of S Answers: TTFF
Last 10th ed. Page: 175 Last 10th ed. PAGE: 205. This question is currently under review by the Anatomy Sub Committee. 23
August, 2001. Question updated 14 March 2002.
20259 – S. Two separate synovial joints persist at the costal articulation
with the manubrio-sternal junction BECAUSE R. fusion does not normally 7096, 19372 – Which of the following statements about the surface marking
occur between the body of the sternum and the manubrium of the line of pleural reflection on the left is NOT true?
A. it lies behind the sternoclavicular joint
Answer: S is true, R is true and a valid explanation of S B. it lies in the midline behind the angle of Louis
C. it lies at the level of the sixth rib in the midclavicular line
Last 10th ed. PAGE: 174; 175 D. it crosses the midaxillary line at the level of the tenth rib
E. it crosses the twelfth rib at the lateral border of sacrospinalis muscle
19803 – The body of the sternum
Answer: C
A. gives attachment to the external intercostal muscles laterally
B. has the internal thoracic artery on its posterior surface
Last 10th. ed. PAGE: 205. The level of pleural reflection on the left lies at the level of the eighth rib
C. gives attachment to the pectoralis major and minor anteriorly
(not the sixth rib) in the midclavicular line. The response is the only false one and C is thus the correct
D. has a manubrium and body connected by a secondary cartilaginous joint
answer.
E. is related directly to the trachea
Answer: D 8530 – The left pleural reflection

1: is in contact anteriorly with the right pleura from the sternal angle to the level of the 4th costal
Last 10th ed PAGE: 211, 175 cartilage
2: crosses the 10th rib in the midclavicular line
15345 – The lower part of the body of the sternum 3: runs lateral to the body of the sternum from the 4th to the 6th costal cartilages on the left
4: is related to the spleen and left kidney posteriorly
1: forms a secondary cartilaginous joint with the xiphoid process
2: articulates via synovial joints, with the 5th, 6th and 7th costal cartilages
Answer: TFTF
3: is attached to the xiphoid process at the level of the 8th thoracic vertebra
4: has the superior epigastric vessels related posteromedially
Last 10th ed, Ch 4. This question was referred to the Anatomy Sub Committee for review on 1 Feb
2002. Question updated 14 March 2002. Question to be reviewed at March 04 meeting re: option D
Answer: TTTF
being false. (23/02/04).
Refer to Last, 10th Ed, Ch 4, page 174 and following
23839 – The apex of the pleura (dome) on either side
19965 – Relations of thoracic vertebrae body include 1: is related to the subclavian artery
2: is a posterior relation of the lateral third of the clavicle
A. anteriorly, the descending aorta supplying a segmental intercostal artery to all intercostal spaces
3: is covered by a layer of fascia attached to the seventh cervical transverse process
B. antero-laterally the sympathetic trunk lying against the vertebral bodies
4: medially reaches 2.5 cm above the neck of the first rib
C. the thoracic duct ascending behind the right intercostal arteries to cross the midline behind the
oesophagus at the T4 level

Answers: TFTF thoracic vertebra. The lower margin of the pleura thus overlies posteriorly the upper pole of the
kidney. The lower margins of the lungs lie usually about two rib levels above the line of the pleura and
Last 10th ed. PAGE: 205 its costo-diaphragmatic recess; so that stab wounds can traverse the pleura while missing the lower
border of the lung, especially in full expiration.
21623 – The pleura is innervated by the The dome of the diaphragm reaches as high as the level of the eighth thoracic vertebra, which is
1: intercostal nerves approximately at the nipple line level. Stab wounds between the nipple line and the costal margin can
2: sympathetics thus potentially injure first pleura and lung; and after penetration of the diaphragm, a variety of intra-
3: recurrent laryngeal nerves abdominal organs.
4: phrenic nerves The spleen in its surface anatomy lies above the costal margin posterolaterally, with its long axis
centred along the line of the tenth rib and extending over an area about as large as a closed fist
Answers: TTFT immediately under the diaphragm, and extending as far forward as the mid axillary line. A stab wound
passing horizontally from the left intercostal space in the mid axillary line and running in the coronal
Last 10th ed. PAGE: 205 plane can therefore pierce the parietal and diaphragmatic pleura, the diaphragm, and the underlining
spleen (1 and 3 true). It will be too far forward and too high for kidney, and too low to injure lung (2
and 4 false).
23924 – The classical posterolateral thoracotomy in the 5th interspace
1: will divide levator scapulae
2: follows roughly the oblique fissure on both sides 15230 – The thoracic duct
3: encounters the horizontal fissure on the left side at the midaxillary line A. enters the thorax anterior to the aorta between the crura of the diaphragm
4: causes skin pain mediated in part by the T\b5 posterior ramus B. crosses anterior to the oesophagus from right to left as it ascends
C. at its termination arches laterally and lies posterior to the vagus nerve
Answers: FTFT D. crosses the dome of pleura inferior to the subclavian artery
E. contains a valve at its termination
Last 10th ed. Page: 210
Answer: C
22809 – The classical posterolateral thoracotomy incision in the fifth
Refer to Last, 10th Ed, Ch 4, page 203; Ch 6, page 403. Review July 2004 re: option should be false.
interspace, individual muscles divided include
1: transversus thoracis
2: latissimus dorsi 22149 – The thoracic duct
3: external intercostal
1: reaches the left side of the oesophagus in the superior mediastinum
4: serratus anterior
2: drains the right posterior intercostal nodes
3: has numerous valves similar to that of the venous system
Answers: FTTT
4: lies anterior to the intercostal branches of the aorta
Answers: TFTT
623 – In full expiration, a stab wound passing horizontally through the left Last 10th ed. Page: 203
9th intercostal space in the mid-axillary line and in the coronal plane, is
likely to penetrate the 19390 – The thoracic duct
1: spleen. A. enters the chest anterior to the aorta, between the crura of the diaphragm
2: lung. B. crosses the oesophagus anteriorly from right to left
3: pleura. C. arches forward lateral to the vagus nerve but medial to the phrenic nerve in the neck
4: kidney. D. crosses the dome of the pleura deep to the subclavian artery
E. contains effective valves at its termination
Answers: TFTF
Answer: C
The lowest part of the pleural cavity is the costo-diaphragmatic recess. The line of its reflection from
diaphragm to parietal pleura lining the ribs runs from the lateral sternal edge on the right, at the level Last 10th ed. PAGE: 203
of the sixth costal cartilage (on the left the reflection arches out between fourth and sixth costal
cartilages about half way to the apex of the heart). The reflection then runs just above the costal 13197, 19396 – The thoracic duct contains lymph from all of the following
margin anteriorly, crossing the eighth rib at the midclavicular line, and the tenth rib at the mid axillary EXCEPT
line. From this point it runs horizontally around the back, crossing the obliquely running twelfth rib at
A. the large intestine
the lateral border of the erector spinae. It continues horizontally to the lower border of the twelfth
B. the adrenal glands
C. the right arm
D. the left arm 649 – The oesophagus
E. the left side of the head and neck 1: Is encircled by fibres of the left crus as it passes through the diaphragm.
2: has a coat containing non-striated muscle fibres in its lower two-thirds.
Answer: C 3: is in contact with the right mediastinal pleura in the posterior mediastinum.
4: pierces the diaphragm at the level of the tenth thoracic vertebra
Last 10th ed. PAGE: 203. The thoracic duct in the neck contains all lymph draining the lower half of
the body (A and B false), the left half of the thorax, and, through the left jugular and subclavian lymph Answers: FTTT
trunks, the lymph from the left arm (D false) and head and neck (E false). Lymph from the right arm
enters the right lymph trunk which drains into the great veins on the right side of the neck (C true). The oesophagus as it passes through the diaphragm at T10 level, is encircled by the fibres of the
right crus (1 false, 4 true). The muscle wall of the oesophagus has an inner circular and outer
23084 – In the trunk longitudinal layer. This muscle is striated skeletal muscle in approximately the upper third and smooth
1: the surface area of the anterior chest and abdomen is 18%of total body surface area non-striated visceral muscle in the lower two-thirds (2 true). There is no sharp line of demarcation
2: relaxed skin tension lines are at right angles to the underlying ribs between the two areas and there is some overlap of the two muscle types. The surface epithelium is
3: posterior rami have cutaneous distribution almost to the posterior axillary lines stratified squamous epithelium throughout in the normal oesophagus. The relations of the
4: nerves are predominantly above the accompanying arteries and veins oesophagus in the posterior mediastinum below the bifurcation of the trachea include the mediastinal
pleura on both sides (especially the right) (3 true). Spontaneous rupture of the oesophagus, provoked
Answers: TFTF by vomiting against a closed upper sphincter, occurs in its unsupported lower third, and can cause
accumulation of fluid in either the left or right pleural spaces.
Last 10th ed. Page: 2, 3
20169 – S. Swallowed material may be held up at the level of the fifth
24379 – In the trunk thoracic vertebra BECAUSE R. the oesophagus may be indented by the left
1: the surface area of the anterior and posterior chest and abdomen is 36% of total body surface area
2: posterior rami have no cutaneous distribution
main bronchus
3: relaxed skin tension lines generally follow the direction of ribs
4: the platysma muscle is histologically equivalent to the subareolar muscle of the nipple and dartos Answer: S is true, R is true and a valid explanation of S
muscle
Answers: TFTF
22519 – The mammary gland
Last 10th ed. Page: 3; 11 1: contains myoepithelial cells between glandular epithelium and basal lamina
2: has lactiferous sinuses beneath the areola
19240, 19378 – The oesophagus is closely related to the vertebral bodies 3: has large branched apocrine glands
4: has lymphatics which drain to the lateral group of axillary lymph nodes
from the
A. cricoid cartilage to the median arcuate ligament Answers: TTTF
B. cricoid cartilage to the oesophageal hiatus in the diaphragm
C. cricoid cartilage to the lower limit of the superior mediastinum Wheater & Last PAGE: Wheater (pp.75, 305) Last (p.67)
D. thoracic inlet to the oesophageal hiatus of the diaphragm
E. thoracic inlet to the lower limit of the superior mediastinum
20349 – S. Lymphatic spread of carcinoma of the breast can pass intra-
Answer: C abdominally BECAUSE R. lymph may pass from the breast through the
diaphragm or rectus sheath
Last (8) PAGE: 238, 290, 369 277, 434. Last 10th ed. PAGE: 201
22179 – The oesophagus is closely related to the
1: pericardium Last 10th. ed. Page: 54
2: left phrenic nerve
3: left main bronchus 23144 – The blood supply of the breast is derived from
4: right sympathetic trunk 1: the lateral thoracic artery
2: the internal thoracic artery
Answers: TFTF 3: the thoraco-acromial artery
4: the superior thoracic artery
Last (8) PAGE: 277
Answers: TTTF Last (6) PAGE: 297
Last 10th Edition, page 54 721 – The liver

1: is partly supplied by the phrenic nerves.
2: has a fissure for the ligamentum teres which extends to the porta hepatis.
ABDOMEN 3: is separated from the subdiaphragmatic part of the inferior vena cava by the peritoneum.
4: develops from a foregut diverticulum in the septum transversum.
558 – From a functional perspective, the liver is divided into eight Answers: FTFT
segments. Which of the following responses is MOST correct?
A. The falciform ligament represents the division into right and left sides of the liver. The liver develops from a foregut diverticulum within the septum transversum (26.4 true). The ventral
B. The division between the right and left sides of the liver is through the gallbladder bed. mesentery of the septum transversum persists as the lesser omentum running from stomach to liver,
C. There are six segments on the right side and two on the left side. splitting to enclose the liver, and continuing as the falciform ligament to the anterior abdominal wall
D. The quadrate lobe is identical with segment 1. and diaphragm. Bilateral reduplications of the peritoneum are drawn out into the small left triangular
E. The right side of the liver is fed by the portal vein and the left side by the hepatic artery. ligament and the much larger coronary ligament and right triangular ligament. The two enclose a large
area of the liver posteriorly bare of peritoneum, where the liver sits flush against the diaphragm with
Answer: B the inferior vena cava embedded in its posterior surface. This bare area of the liver is in direct contact
with the inferior vena cava (25C true, 26.3 false), right suprarenal gland and posterior cupola of
The morphological lobes of the liver do not correspond to the right and left sides of the liver. The diaphragm. The lower free margin of the ventral mesentery contains the ligamentum teres. This runs
falciform ligament was previously used to separate right and left lobes, but it is the portal trinity which back from umbilicus to a fissure in the lower surface of the liver which extends to the porta hepatis (26.2
divides the liver into right and left sides. true). The phrenic nerves are motor to the right and left halves of the diaphragm (26.1 false). The liver
B Correct. The division between right and left sides of the liver, supplied respectively by the right and receives an autonomic supply of sympathetic and vagal fibres. The sympathetic supply enters via the
left halves of the portal trinity (hepatic artery, portal vein and bile duct) runs through the gall bladder coeliac ganglion into the portal hepatis; one or more hepatic vagal branches run within the upper part
bed inferiorly. The right side of the liver consists of four segments (segments 5 and 8 anteriorly, 6 and of the lesser omentum from the left vagus.
7 posteriorly). The left side contains three segments (segments 3 and 4 anteriorly, and 2 posteriorly).
Segment 1 (caudate lobe) receives branches from both sides. 13494 – The liver
1: is not separated by peritoneum from the oesophagus
20697 – S. The anatomical right lobe of the liver is much larger than the 2: is separated from the subdiaphragmatic part of the inferior vena cava by peritoneum
left BECAUSE R. the right hepatic artery supplies the caudate and quadrate 3: has a fissure for the ligamentum teres which extends to the right end of the porta hepatis
lobes 4: has a bare area separated by renal fascia from the right adrenal gland
Answers: FFFT
The peritoneal attachments of the liver form the subphrenic spaces. The liver is entirely separated by
Last (6) PAGE: 299
peritoneum from the oesophagus (A false). The ventral mesentery by which the liver is suspended
from the diaphragm forms the left and right triangular ligaments with a bare area bordered by their
22189 – The quadrate lobe of the liver attachment to the liver. The subdiaphragmatic part of the inferior vena cava occupies the bare area
1: forms the anterior wall of the upper recess of the lesser sac below the central tendon. The vena cava is thus an immediate posterior relation of the liver, contained
2: is bounded by the fissure for the ligamentum venosum in a groove on its posterior surface (B false). The ligamentum teres is a rounded fibrous cord in the
3: is bounded by the fissure for the ligamentum teres free lower edge of the falciform ligament. It is the remnant of the obliterated left umbilical vein of the
4: is in close contact with the right kidney foetus and it runs in the free edge of the falciform ligament from the umbilicus to the anterior surface
of the liver. It lies in a deep groove, the fissure for the ligamentum teres, on the under surface of the
Answers: FFTF liver as far as the left end of the porta hepatis (C false). The lower reflection of the right triangular
ligament runs horizontally across the diaphragm near the level of the upper pole of the right kidney;
Last (8) PAGE: 344 the right adrenal gland lies in the bare area along with the inferior vena cava. The renal fascia
surrounds the kidney and sends an extension over the right adrenal (D true).
23644 – The falciform ligament of the liver
1: has the ligamentum teres in its free border 715, 19288 – The bare area of the liver is in direct contact with parts of
2: passes from the anterior abdominal wall to the liver A. the head of the pancreas
3: prevents ptosis of the liver B. the right sympathetic chain
4: ascends from the umbilicus to the left of the median plane C. the inferior vena cava
D. the left supra renal gland
Answers: TTFF E. the pelvis of the right ureter

Answer: C Answer: S is true, R is true and a valid explanation of S
Last (6) PAGE: 298. The bare area of the liver is in direct contact with the inferior vena cava which is Last 9th ed. Page: 347
embedded in its posterior surface.
22919 – The common hepatic artery usually
732 – Concerning the blood supply of the liver 1: gives off the gastro-duodenal artery
1: the hepatic artery inflow and hepatic venous drainage do not communicate across left and right 2: is entirely retroperitoneal
halves of the liver. 3: gives off the cystic artery
2: the portal vein has a Y-shaped division into left and right portal vein branches in the porta hepatis. 4: divides into right and left branches in the porta hepatis
3: the hepatic ducts in the porta hepatis lie in front of the branches of the hepatic artery & portal vein.
4: the quadrate and caudate lobes receive their major blood supply from the right hepatic artery and Answers: TTFF
right portal vein.
Last (8) PAGE: 326
Answers: FFTF
726 – The right hepatic artery may arise anomalously from the
The right and left hepatic arteries do not communicate. Each of the individual right and left arterial A. superior mesenteric artery.
branches is functionally an end artery, as are their segmental branches which run together with the B. left gastric artery.
accompanying portal vein branches and hepatic duct tributaries in the ensheathing ‘portal canals’ of C. splenic artery.
histological sections. D. superior pancreatic-duodenal artery.
E. short gastric arteries.
Arterial and portal venous blood mix in the sinusoids and drain to hepatic vein tributaries in the centre
of each ‘lobule’, which unite to form the hepatic veins. The hepatic venous drainage, as distinct from Answer: A
the unmixed vascular inflow, allows mixing of the drainage coming from right and left liver halves (1
false) The arterial blood supply of the liver is via the hepatic artery. This arises from the coeliac axis, and
runs in the lesser omentum to the porta hepatis where it normally divides into right and left branches.
The left and right hepatic veins have a very short extrahepatic course; and drain segments 2 & 3, and The right hepatic artery normally passes behind the common hepatic duct and then has intrahepatic
5 & 8 respectively. A long middle hepatic vein marks the junction between left and right liver halves divisions into anterior and posterior segmental branches the right hepatic artery suppling liver
posteriorly; and receives part of the drainage of both right (segments 6 & 7) and left (segment 4) segments 5 & 8 anteriorly and 6 & 7 posteriorly.
halves of the liver. The middle hepatic vein runs vertically and drains into the vena cava or may join
the left hepatic vein. A number of accessory hepatic veins below the main veins drain separately into Variations in the common hepatic artery and in its left and right hepatic branches are common and
the vena cava along its length, including one from the caudate lobe. important; particularly in liver transplantation and in resectional liver and biliary surgery. The
Ligation of the main hepatic artery may be possible without liver infarction because of the double commonest and most important abnormality is that either the common hepatic artery or its right and
vascular inflow; and has been used to inhibit growth of hepatic metastases. The operation is now less left hepatic branches may arise from the superior mesenteric artery rather than from the coeliac trunk
commonly performed; chemotherapy delivered via percutaneous hepatic arterial infusion is less (A true).
hazardous and less invasive.
Portal venous diversion by portacaval or reversed (Warren) lienorenal shunting can reduce bleeding 18886 – The right hepatic artery may arise from
risks from varices in portal hypertension. The division of the hepatic artery into right and left hepatic
A. the superior mesenteric artery
artery branches in the porta hepatis is Y-shaped, and differs from the portal vein bifurcation, which is
B. the left gastric artery
at a higher level via a T-junction into right and left portal veins (2 false). The hepatic ducts in the porta
C. the splenic artery
hepatis accompany the corresponding arteries. They lie anteriorly to the arterial and venous
D. the superior pancreatic-duodenal artery
branches, rendering the ducts more easily accessible to surgical exploration (3 true).
E. the short gastric arteries
KEY ISSUE
Although quadrate and caudate lobes are described by older nomenclature as part of the right liver
Answer: A
lobe (ie the portion lying to the right of the falciform ligament), it is essential surgically to appreciate
that functionally the caudate lobe (segment 1) and most of the quadrate lobe (segment 4) belong to
Last (8) PAGE: 346
the left half of the liver they receive blood supply from the left hepatic arterial and left portal vein
branches and drain bile to the left hepatic duct (4 false).
Question to be reviewed at the March 04 meeting re: option 4 (20/02/04). 13499 – The portal vein
1: runs upwards behind the epiploic foramen (aditus to the lesser sac)
20475 – S. Needle biopsy of the liver should be performed through the right 2: is usually formed by the union of the splenic and superior mesenteric veins
3: has no tributaries other than the veins forming it
eighth or ninth intercostal space in the mid axillary line BECAUSE R. this 4: lies posterior to the (common) hepatic artery
level is below the level of the lung
Answers: FTFT After birth the umbilicus becomes the watershed between cephalic and caudal direction of venous
return from the subcutaneous tissues. Anastomosing networks of veins radiate upwards via the lateral
The portal vein is usually formed by the union of the superior mesenteric and splenic veins (B true), thoracic vein to axillary vein; and downwards to the great saphenous vein and femoral vein. Within
and runs upward in the free edge of the lesser omentum anterior to the epiploic foramen (A false). It the peritoneal cavity, veins within the ligamentum teres continue to drain into the portal system. In
has a number of important tributaries (C false). In the free margin of the lesser omentum it is posterior portal hypertension shunting of blood occurs from the portal to the systemic venous circulation via the
to the hepatic artery and the bile duct (D true). Under review June 2003 ligamentum teres and umbilicus to the subcutaneous veins. These dilate and run centrifugally from
the umbilicus - upwards and downwards to either the axillary or femoral veins, forming a Caput
801, 19893 – The portal vein Medusae (S true). These anastomotic channels are an aid to diagnosis of portal hypertension. Both S
A. commences at the level of the third lumbar vertebra and R are thus correct and R validly explains S.
B. is formed by the union of the splenic and inferior mesenteric veins Dilated subcutaneous abdominal wall collateral venous channels are also seen following thrombosis
C. lies anterior to the bile duct of the inferior vena cava. In this instance the venous flow is entirely upwards.
D. has a valve at its commencement The other main site of collateral venous channels linking portal and systemic circulations in portal
E. receives the left gastric vein hypertension is across the mucosa of stomach and oesophagus as oesophageal submucosal varices.
Answer: E 20361 – S. The liver is supported by the hepatic veins BECAUSE R. the
hepatic veins attach the liver firmly to the adjacent inferior vena cava
Last (6) PAGE: 302
807, 14163 – The portal vein
1: runs upwards between the layers of the lesser omentum Last (6) PAGE: 345
2: is usually formed by the union of the splenic and superior mesenteric veins
3: has gastric and oesophageal tributaries 20997 – S. In the porta hepatis the hepatic ducts are
4: lies posterior to the (common) hepatic artery inaccessible BECAUSE R. the hepatic ducts lie behind the hepatic artery
Answers: TTTT and portal vein
Refer to Last, 10th Ed, page 260. The portal vein is formed by the junction of splenic and superior Answer: both S and R and false
mesenteric veins (40.2 true) at the level of the first lumbar vertebra behind the neck of the pancreas.
The portal vein and its tributaries are valveless, and measurements of the portal venous pressure can Last (8) PAGE: 344
therefore be made readily from any of the tributaries of the vein or from the soft tissue pulp of the
spleen. The portal vein in its first part runs vertically upwards behind pancreas and first part of 743, 24289 – The common bile duct
duodenum and in front of the vena cava. It then loses contact with the vena cava and enters between 1: is formed by the junction of the right and left hepatic ducts
the two layers of the lesser omentum where it lies behind the bile duct and hepatic artery to run to the porta 2: lies in the free edge of the lesser omentum
hepatis (40.1 & 4 true). Here it divides in a T-shape into right and left branches which supply the 3: lies behind the neck of the pancreas
respective liver halves. It receives its major tributaries from pancreaticoduodenal veins, right and left 4: opens at the ampulla, 10 cm. from the pylorus
gastric veins including oesophageal venous drainage (40.3 true), cystic veins, periumbilical veins and
the remains of the embryonic umbilical veins (39E true and A, B, C, and D false). Questions reviewed Answers: FTFT
and updated July 03.
Last 10th Ed, Ch 5, page 259. The bile duct is formed by the junction of cystic duct with common
606 – S:Caput medusae is a feature of portal hypertension because R:the hepatic duct (1 false), which in turn is formed by the junction of right and left hepatic ducts. The bile
duct is most surgically accessible in its upper third where it lies in the free edge of the lesser omentum
left umbilical vein joins the left branch of the portal vein. supraduodenally to the right of the hepatic artery and in front of the portal vein (2 true). The bile duct
in its second third passes behind the duodenum inclining to the right away from the portal vein, which
Answer: S is true, R is true and a valid explanation of S runs more vertically. The lowest third then runs behind the pancreas in a groove between the head of
the pancreas and the C of the duodenum, now some distance to the right of the portal vein which lies
The umbilicus is an area of potential communication between the portal and systemic venous
behind the neck of the pancreas (3 false). The bile duct opens into the duodenum at the ampulla
circulation.
approximately 10cm from the pylorus (4 true).
In the fetus, fetal blood is oxygenated in the placenta, not in the lungs, and returns from the placenta
KEY ISSUE
via the left umbilical vein to the portal venous system by running into the left portal vein in the porta The most surgically important variations of the biliary ducts are cystic duct anomalies - these range from
hepatis (R true). This oxygenated blood then short circuits the liver by running directly into the an absence of cystic duct with the gall bladder opening directly into the common hepatic duct, to a long
systemic circulation to the inferior vena cava via the ductus venosus. The two vessels (left umbilical cystic duct entering the main duct system so low down in the third part of the main channel that there is
vein and ductus venosus) run in a cleft in the liver from front to rear along its inferior surface. After effectively no (common) bile duct, just a long common hepatic duct and adjacent cystic duct - often united
birth the left umbilical vein and ductus venosus become fibrous cords - the ligamentum teres and by a fascial ensheathment. The cystic duct may also drain into the right hepatic duct or into an aberrant or
ligamentum venosum - which lie imbedded in their respective fissures. accessory right hepatic duct.
4: it is lined by simple columnar epithelium
23859 – The common bile duct
1: crosses anterior to the right renal vein Answers: FFFT
2: has a middle part lying between the first part of the duodenum and the inferior vena cava
3: lies in the substance of the neck of the pancreas Last 8th ed. PAGE: 349. This question is currently under review by the Anatomy Sub Committee. 23
4: is formed by the junction of right and left hepatic ducts in the porta hepatis August, 2001. Question updated 14 March 2002.
Answers: TTFF 18880 – The gall bladder

A. is lined by simple columnar epithelium
Last (7) PAGE: 303 B. is in contact extraperitoneally with the duodenum
C. is directed downwards, backwards, and laterally from the fundus to duct
15218 – The (common) bile duct D. has considerable smooth muscle in its wall
A. lies over the inferior vena cava in the middle 1/3 of its course E. has a submucosa with mucous glands
B. is about 12 cm long in the adult
C. lies to the left of the hepatic artery Answer: A
D. opens into the duodenum at the vertebral level of L3
E. receives the right and left hepatic ducts Last (8) PAGE: 350
Answer: A 13215 – The gall bladder

A. bed forms one border of the caudate lobe of the liver
Refer to Last, 10th Ed, Ch 5, page 259 B. bed lies entirely within the functional right lobe of the liver
C. contains mucus-secreting glands in the mucosa of its body
13504 – The (common) bile duct D. neck is an anterior relation of the right kidney
1: is lined by tall columnar epithelium which is mucus-secreting E. has a submucosa in its wall
2: is related posteriorly, in succession from above downwards, to the portal vein, inferior vena cava
and right renal vein Answer: E
3: lies in a deep groove on the posterior surface of the head of the pancreas
4: lies to the left of the hepatic artery The gall bladder bed forms one border of the quadrate, not the caudate, lobe (A false). The gall
bladder bed lies on the division between the left and right lobes of the liver (B false). There are no
Answers: TTTF mucous glands in the body of the gall bladder (C false), although few mucous glands are found in its
neck. The neck of the gall bladder is superior and medial to the anterior surface of the right kidney (D
The extrahepatic bile ducts are all lined by tall columnar epithelium which is mucus-secreting (A true). false). There is a submucosa in the gall bladder (E true).
The accessible upper third of the bile duct lies in the free edge of the lesser omentum in front of the
portal vein and to the right of the hepatic artery. The middle third lies behind the first part of the 13379 – S:Truncal vagotomy causes hypotonia of the gallbladder
duodenum and on the inferior vena cava below the aditus to the lesser sac. The lower third runs to because R:in truncal vagotomy fibres destined for the hepatic branch of
the right behind the head of the pancreas in a deep groove in front of the right renal vein (B and C the vagus are spared
true). The bile duct lies to the right of the hepatic artery (D false).
19294 – The bile duct
A. is lined by tall columnar, non-mucus secreting epithelium Truncal vagotomy eliminates all the branches of the vagus below the diaphragm including the hepatic
B. is formed by the right and left hepatic ducts branch. Transection of the hepatic branch of the vagus results in a dilated and hypotonic gall bladder
C. passes anterior to the right renal vein with increased risk of gall stone formation (S true). In truncal vagotomy the vagus is transected
D. lies to the left of the hepatic artery proximal to the hepatic branch whereas in selective or highly selective vagotomy the vagus is
E. is about 14 cm in length transected distal to the hepatic branch (R false).
Answers: C 737, 19629 – The cystic artery usually arises from

A. the superior mesenteric artery
Last (8) PAGE: 350
B. the hepatic artery directly before its bifurcation
C. the right gastric artery
24279 – With respect to the gall bladd D. the right branch of the hepatic artery
1: its bed forms one border of the caudate lobe E. the gastroduodenal artery
2: the mucosa in the body of the gall bladder contains mucus-secreting glands
3: it contains considerable smooth muscle in its wall
Answer: D 2 is true. The neck of the pancreas is anterior to the origin of the portal vein from the superior
mesenteric and splenic vein junctions.
Last 8th ed. PAGE: 350. The cystic artery normally arises from the right hepatic artery (D true) 3 is true. The splenic artery runs to the left just above the upper border of the pancreas.
behind the biliary passages to run to the neck of the gall bladder in a triangle formed by the liver, 4 is true. The pancreas is almost entirely retro-peritoneal and forms an important posterior
common hepatic duct and cystic duct (Calot’s triangle). Variations in its origins are very common and relationship of the stomach in the stomach bed behind the lesser sac.
are important in gall bladder surgery. The right hepatic artery may run in front of the common hepatic
duct, and the cystic artery may come from such an aberrant right hepatic artery or from the main 14158 – The pancreas
hepatic artery itself. In any of these instances the cystic artery may pass in front of the biliary 1: mostly lies in the supracolic compartment
passages to reach the gall bladder, instead of passing behind these structures as is the normal 2: is supplied by the splenic artery
pattern. An aberrant hepatic artery may be divided, if its course takes it unusually close to the gall 3: lies at the level of the first lumbar vertebra
bladder, in a mistaken belief that it is the cystic artery. 4: lies anterior to the common hepatic duct
KEY ISSUE Answers: TTTF

The morphological lobes of the liver do not correspond to the right and left sides of the liver. The
portal trinity divides the liver into right and left sides. The surgical importance of such a division is Refer to Last, 10th Ed, page 260-264. To be reviewed at March 04 meeting - regarding option 3.
manifest; the right side of the liver consists of a right lateral (posterior) sector and a rig 800 ht medial (10/02/2004)
(anterior) sector. The left side of the liver consists of left medial (anterior) and left lateral (posterior)
sectors. The right medial (anterior) sector comprises segments 5 & 8, the right lateral (posterior)
767 – The tail of the pancreas
sector comprises segments 6 & 7; the left medial (anterior) sector comprises segments 3 & 4, and the
1: lies in the gastro-splenic ligament.
left lateral (posterior) sector comprises segment 2. Segment 1 is the caudate lobe receiving branches
2: lies in the lieno-renal ligament.
from both sides and draining independently into vena cava.
3: is anterior to the left renal hilum.
4: touches the hilum of the spleen.
21963 – The lesser sac
1: extends behind the first 2.5cm of duodenum Answers: FTTT
2: lies behind the transverse mesocolon
3: extends down in front of the stomach 1 is false. The tail of the pancreas does not lie within the gastro-splenic ligament. The gastro-splenic
4: has the common hepatic artery in its posterior wall ligament contains the short gastric branches of the splenic artery.
2 is true. The tail of the pancreas lies within the two layers of the lieno-renal ligament.
Answers: TFFT 3 is true. The tail of the pancreas lies anterior to the hilum of the left kidney.
4 is true. The tail of the pancreas abuts the hilum of the spleen accompanied by the splenic vessels
Last (6) PAGE: 274. To be submitted for review at the July 2004 meeting. Query answer option 1 - and associated lymph nodes. In this site it is at potential risk during the operation of splenectomy.
should say 2cm NOT 2.5cm. (18/04/04).
778 – The pancreas usually receives arterial branches from the
23094 – In pancreatic tissue 1: splenic artery.
1: islets of Langerhans are scattered irregularly among the numerous glandular acini 2: left gastric artery.
2: the islets are paler staining than the acini in haematoxylin and eosin preparations 3: superior mesenteric artery.
3: acinar cells have abundant rough endoplasmic reticulum 4: right gastro epiploic artery.
4: the alcohol-soluble B granules contain glucagon, and the A granules contain insulin
Answers: TFTF
Answers: TTTF
The pancreas is almost entirely retroperitoneal, forming an important posterior relationship of the
Leeson & Leeson PAGE: 377, 380 stomach in the stomach bed behind the lesser sac. It consists of head, neck, body and tail. The neck
covers the origin of the portal vein from superior mesenteric and splenic vein junctions; the splenic
762 – The pancreas vein lies behind much of the body of the pancreas, while the splenic artery runs to the left just above
1: has the splenic vein as a posterior relation. its upper border (33.1, 2, 3, 4 true). The body and tail cover the hilum of the left kidney; and the tail
2: has a neck which is anterior to the origin of the portal vein. lies within the two layers of the lienorenal ligament, and thus abuts on the hilum of the spleen
3: has the splenic artery running above its upper border. accompanied by the splenic vessels and associated lymph nodes (34 F1, T 2, 3, 4). The main
4: is related to the lesser sac. pancreatic duct running from the tail to the head drains into the duodenal papilla about halfway down
the second part of the duodenum. All the pancreas except for the uncinate process and lower part of
Answers: TTTT the head are drained by the main pancreatic duct. The accessory pancreatic duct draining the
remaining structures opens more proximally into the second part of the duodenum. Communication
1 is true. The splenic vein lies behind much of the body of the pancreas as a direct posterior relation. between the two duct systems is common (32.1 & 3 true, 2 & 4 false).

The blood supply of the pancreas straddles the junction of the coeliac and superior mesenteric arterial
territories. The main supply is by the splenic artery from the coeliac axis which gives the artery 19941 – The spleen
pancreatica magna running the length of the organ. Much of the head is supplied by A. extends forward to the left costal margin
pancreaticoduodenal arteries arising both from coeliac and superior mesenteric arteries (35.1 & 3 B. receives its main blood supply via the gastrolienal ligament
true, 2 & 4 false). Venous return is by numerous small veins running to the splenic vein along the tail C. develops in the ventral mesogastrium
and body and into superior mesenteric and portal veins from the head. The development of the D. lies within the lesser sac
pancreas as a dorsal and ventral bud into both dorsal and ventral mesogastria (the latter in common E. develops in the dorsal mesogastrium
with the bile duct) leads to close adherence of the pancreas within the concavity of the duodenal C
and to multiple vascular connections via pancreaticoduodenal vessels across this junction. Pancreatic Answer: E
resections thus usually require removal of the adjacent duodenal second part. In pancreatico-
duodenectomy careful separation of the pancreas from its portal venous connections is the key Last (6) PAGE: 304
feature of the operation. In pancreatic transplantation it is necessary to use both the superior
mesenteric artery and the splenic artery inflow (either as separate anastomoses or using a Carrel
752 – The spleen
patch from the aorta containing the origin of both vessels), to use the portal vein as the venous
1: receives its main blood supply via the gastrolienal ligament.
effluent, and to transplant the pancreas and second part of duodenum as a composite block, draining
2: develops in the dorsal mesogastrium.
exocrine pancreatic secretions into gut or bladder. The pancreas can be transplanted either into the
3: projects into the greater sac.
portal venous circulation or into the systemic venous circulation without apparent variation in results.
4: is in contact with the tail of the pancreas at its hilum.
757, 22319 – The main pancreatic duct Answers: FTTT
1: drains all but the lower part of the head of the pancreas.
2: opens into the first part of the duodenum. The spleen develops in the dorsal mesogastrium (2 true), lying to the left of the lesser sac. It projects
3: usually communicates with the accessory duct when this is present. into the greater sac (3 true) covered by peritoneum of the original left leaf of the dorsal mesogastrium.
4: opens into the duodenum proximal to the accessory duct. The spleen is attached to the posterior abdominal wall by the lienorenal ligament, which contains the
main splenic artery and vein (1 false) and the tail of the pancreas (which is in contact with the hilum of
Answers: TFTF the spleen) (4 true). Damage to the tail of the pancreas is a potential complication of splenectomy. The
dorsal mesogastrium continues from the spleen to stomach as the gastrolienal ligament containing
Last (8) PAGE: 351. Question reviewed and updated Nov 03 the short gastric vessels. Splenectomy involves division of both peritoneal ligaments, taking care to
1 is true. The main pancreatic duct drains all of the pancreas except for the uncinate process and avoid potential damage to pancreas and splenic flexure of colon posteriorly, and to stomach
lower part of the head. anteriorly.
2 is false. The main pancreatic duct opens into the second part of the duodenum about half way down
its length.
3 is true. Communication between the two duct systems of the pancreas is common.
21398 – The spleen
4 is false. The main pancreatic duct opens into the duodenum distal to the accessory duct; the latter 1: contains lymphatic nodules which collectively form the white pulp
opens more proximally into the second part of the duodenum. 2: contains red pulp in which are found the splenic cords (of Billroth), venous sinuses and arterioles
3: has trabeculae of connective tissue which extend inward from the capsule
4: possesses lymphatic nodules with germinal centres containing Hassall's corpuscles
20451 – S. Splenectomy may be complicated by a pancreatic
fistula BECAUSE R. the pancreatic tail touches the hilum of the spleen Answers: TTTF
Answer: S is true, R is true and a valid explanation of S Leeson & Leeson PAGE: 297
13233, 19581 – The spleen 13239 – The splenic vein

A. has a convex surface related to the diaphragm and quadratus lumborum muscles A. is valveless
B. has a long axis which lies along the line of the seventh rib B. empties into the inferior vena cava
C. projects into the lesser sac C. joins the superior mesenteric vein behind the body of pancreas
D. is in the supra colic compartment D. receives the left testicular vein
E. develops from the ventral mesogastrium E. has none of the above properties
Answers: D Answer: A
The convex surface of the spleen is related entirely to the diaphragm (A false). The long axis lies The splenic vein is valveless (A true). The vein or splenic pulp can be used to measure the pressure
along the line of the tenth rib, not the seventh (B false). The spleen projects into the greater sac, not in the portal vein, of which the splenic vein is a tributary (B false). The splenic vein joins the superior
the lesser sac (C false), and lies in the supra-colic compartment (D true). It develops from the dorsal mesenteric vein behind the neck of the pancreas (C false). The left testicular vein drains into the left
mesogastrium (E false). renal vein (D false).
1: the body of the pancreas separates the posterior wall of the stomach from the left renal vein
19384 – The oesophagus 2: anterior relations include diaphragm, anterior abdominal wall and left lobe of liver
A. commences about 25 cm from the incisor teeth in the average adult 3: the posterior wall is in direct contact with the spleen
B. is constricted to some extent by the right main bronchus 4: the posterior wall is directly related to the splenic vein on the posterior wall of the lesser sac
C. is anterior to the thoracic aorta above the diaphragm
D. usually passes between the two crura of the diaphragm Answers: TTFF
E. has a thickening of circular muscle at its lower end just below the diaphragm
Last (8) PAGE: 334
Answer: C
659, 19066 – The stomach
Last 10th ed. Page: 201 et seq A. has a posterior surface related, in part, to the inferior vena cava
B. has its junction with the duodenum indicated by the prepyloric vein
20283 – S. Air does not enter the oesophagus on inspiration BECAUSE R. C. sends lymphatics from the lesser curvature to the pancreatico-lienal lymph nodes
D. has its cardiac orifice at the level of the 9th thoracic vertebra
tonic contraction of the crico-pharyngeus muscle is maintained through its
E. is separated from the spleen by the lesser sac of peritoneum
innervation by external and/or recurrent laryngeal nerves
Answer: B
Last (6) PAGE: 290. The gastroduodenal junction is often indicated by a pre-pyloric vein.
664 – The stomach
564 – A surgeon is planning to mobilise the stomach into the chest to form 1: has an anterior surface innervated by the left vagal nerve.
a conduit after an oesophagectomy for cancer. Which blood vessel will she 2: is completely invested by peritoneum.
preserve to maintain its vascularity? 3: may lie with the greater curvature in the pelvis.
A. The left gastric artery. 4: is supplied by coeliac axis vessels only.
B. The gastro-omental arcade.
C. The short gastric vessels. Answers: TTTT
D. The posterior gastric artery.
E. The splenic artery. The stomach is a large mobile muscular bag relatively fixed at both ends; the ends are relatively close
together on either side of the midline. The cardiac orifice under the diaphragm lies just to the left of
Answers: B the midline at the level of the 10th thoracic vertebra (19D false); and the pyloric opening is to the right
of the midline at the level of the L1 vertebra. The stomach is completely invested by peritoneum (20:2
The gastro-omental arcade containing right gastro-epiploic and left gastroepiploic vessels needs to be true) with the lesser omentum attached to its lesser curvature and the greater omentum to greater
preserved along the greater curvature of the stomach as this is mobilised. This arcade will maintain curvature. The fundus is in contact with the left diaphragmatic dome. The greater curvature may
the vascularity of the stomach up to the fundus after division of the other vessels. extend as far distally as the pelvis (20.3 true) in the upright position. The stomach’s anterior surface is
related to the left lobe of the liver and abdominal wall. The posterior surface is related to the lesser
13489 – With respect to the stomach sac, behind which is the stomach bed covered by peritoneum of the posterior abdominal wall. Behind
the lesser sac and stomach are the aorta and its upper branches (not the inferior vena cava), the
1: anterior relations include diaphragm, anterior abdominal wall and left lobe of liver
diaphragm, pancreas, left suprarenal and left kidney (19A false). The spleen also lies behind the
2: the posterior wall is in direct contact with the spleen
stomach, but stomach and spleen are separated by the greater peritoneal sac (19E false). The
3: the body of the pancreas separates the posterior wall of the stomach from the left renal vein
gastroduodenal junction is often indicated by a prepyloric vein (19B true) draining into the portal
4: the posterior wall is related to the splenic vein on the posterior wall of the lesser sac
system. The blood supply of the stomach comes from the coeliac axis (20.4 true) via left and right
gastric and gastroepiploic, gastroduodenal and short gastric vessels. The anastomosis across the
Answers: TFTF
junction of coeliac axis and superior mesenteric artery blood supply is via pancreaticoduodenal
vessels. The lymphatic drainage of the lesser curvature is predominantly to gastric nodes adjacent to
The upper part of the stomach and lesser curvature are overlapped by the left lobe of the liver;
the left and right gastric arteries (19C false). The lower part of the stomach’s anterior and posterior
elsewhere the anterior surface is in contact with the anterior abdominal wall and diaphragm (A true).
surfaces drain to splenic and pancreatic nodes. The left vagus supplies the anterior surface (20.1 true).
The posterior wall of the stomach is separated from the spleen by two layers of peritoneum (B false).
The hilum of the spleen lies in the angle between the stomach and the left kidney. The body of the
pancreas separates the posterior wall of the stomach from the left renal vein (C true). At a slightly 23489 – The trans-pyloric plane is
more cephalic level the splenic vein also is covered by the pancreas. The tortuous splenic artery lies 1: at the lower limit of the spinal cord
above the upper border of the pancreas (D false). 2: just above the level of the fundus of the gall-bladder
3: the level of origin of the coeliac artery
23129 – With respect to the stomach 4: where the linea semilunaris meets the 8th costal cartilage

4 is correct. The first part of the duodenum forms the lowermost boundary of the opening into the
Answers: TTFF lesser sac.
This question will be submittedt at the March 04 meeting (16/03/2004)
Last (8) PAGE: 311. Pending review. Mar 03
699 – The first part of the duodenum
22184 – The first part of the duodenum 1: has no villi.
1: has no villi 2: is touched by the gall bladder.
2: is touched by the gall bladder 3: is anterior to the bile duct.
3: is anterior to the bile duct 4: is approximately 5cm in length.
4: forms the lower boundary of the epiploic foramen
Answers: FTTT
Answers: FTTT
1 is wrong. Like all the rest of the small bowel the duodenum's absorbing mucosal surface is
Last (9) PAGE: 335-336. This question is currently under review by the Anatomy Sub Committee. 23 enhanced by microscopic villi.
August, 2001. Question updated 14 March 2002. 2 is correct. An important anterior relation of the first part of the duodenum is the neck of the gall
bladder and Hartman's pouch. This is the site at which cholecystoduodenal fistulae can occur as a
13221 – The first part of the duodenum complication of cholelithiasis.
A. runs backwards and downwards from the pylorus 3 is correct. At the junction of its free and fixed halves, the first part of the duodenum crosses the bile
B. lies opposite the eleventh thoracic vertebra in the recumbent position duct anteriorly.
C. is completely invested by peritoneum 4 is correct. The first part of the duodenum is approximately 5 cm (2 inches) in length. The first half of
D. lies anterior to the hilum of the right kidney this is free and mobile; the second half is fixed and retro-peritoneal.
E. in part of its course is in contact with the anterior surface of the inferior vena cava
23999 – The 3rd part of the duodenum
Answer: E 1: is anterior to the inferior mesenteric vein
2: is anterior to the right ureter
The first part of the duodenum runs to the right, backwards and somewhat upwards from the pylorus 3: is crossed by the root of the mesentery
towards the posterior abdominal wall and inferior vena cava (A false), and extends from the level of 4: is posterior to the superior mesenteric vessels
L1 to T12 (B false). The first part is about 5 cm (2") long. The first half is called the free or mobile part
of the duodenum (the duodenal cap by radiologists) and lies between the peritoneal folds of the Answers: FTTT
greater and lesser omenta. It is mobile because it is not attached to the posterior abdominal wall. The
next 3 cm of the first part passes backwards and upwards on the right crus of the diaphragm and right Last 8th ed./Leeson and Leeson PAGE: 292 / 338. Pending review. Jan 2003
psoas muscle to reach the medial border of the right kidney. Its posterior surface is bare of
peritoneum (C false). The first part of the duodenum is above the hilum of the right kidney; the second 13227 – The third part of the duodenum
part lies anterior to the hilum as it curves downwards (D false). The first part of the duodenum forms A. is anterior to the superior mesenteric vessels
the lowermost boundary of the epiploic foramen (opening into the less sac) and lies upon the bile B. is anterior to the bile duct
duct, gastroduodenal artery and portal vein. Behind the epiploic foramen lies the inferior vena cava C. is anterior to the right ureter
and the first part of the duodenum near its termination has the anterior surface of the inferior vena D. is anterior to the inferior mesenteric vein
cava (E true). Question reviewed and updated Nov 03. E. has no circular folds
694 – The first part of the duodenum Answer: C

1: runs upwards and posteriorly from the pylorus.
2: is partly invested in peritoneum. The superior mesenteric vessels and the root of the mesentery run across the anterior aspect of the
3: in part of its course, is closely applied to the anterior surface of the inferior vena cava. third part of the duodenum (A false). The bile duct terminates in the second part of the duodenum and
4: forms the lowermost boundary of the opening into the lesser sac. never becomes a relation of third part of the duodenum lis anterior to the right ureter (C true), psoas
muscle, right gonadal (testicular or ovarian) vessels, the inferior vena cava and the abdominal aorta.
Answers: TTTT The inferior mesenteric vein is a posterior relation of the fourth part of the duodenum, not the third
part (D false). Circular folds are not found at the commencement of the duodenum but begin to
1is correct.The first part of the duodenum runs upwards, posteriorly and to the right from the pylorus. appear 2.5-5 cm distal to the pylorus. Distal to the sphincter of Oddi they are large and close to each
2 is correct.The first part of the duodenum is partly invested in peritoneum. Only the first 1 inch of the other (E false). In the upper half of the jejunum they are large and numerous, but beyond this point
first part is mobile and is invested by the peritoneal folds of the greater and of the lesser omenta. The they diminish considerably in size, being almost absent in the distal part of the ileum.
fixed second 1 inch is retro-peritoneal.
3 is correct. The fixed second half of the first part of the duodenum is retro-peritoneal and crosses the 23654 – The fourth part of the duodenum
anterior surface of the vena cava. 1: lies on the left lumbar sympathetic trunk and the left psoas muscle

2: is associated with the duodenal recesses Answer: A
3: is suspended from the right crus of the diaphragm by a suspensory ligament
4: has a mesentry Last (8) PAGE: 338 Fig. 5.29
Answers; TTTF 13349 – S:During mobilization of the right colon, the duodenum may be
damaged at the junction of its second and third parts because R:the
Last (8) PAGE: 337-338
junction of the second and third parts of the duodenum is directly related
704 – The fourth part of the duodenum to the colon
A. is anterior to the left lumbar sympathetic trunk.
B. is crossed anteriorly by the inferior mesenteric vein. Answer: S is true, R is true and a valid explanation of S
C. is crossed anteriorly by the inferior mesenteric artery.
D. lies anterior to the left ureter. During mobilisation of the right colon, the colon and its mesentery are lifted away from the second
E. is crossed by the attachment of the transverse colon. and third parts of the duodenum (S true) which they overlie (R true and is a valid explanation). This
question was referred to the Anatomy Sub Committee for review on 1 Feb 2002. Question updated
Answer: A 14 March 2002.
The duodenal ‘C’ defines 1st, 2nd, 3rd and 4th parts, which are respectively 2, 3, 4 and 1 inches long. 25716 – Concerning a loop ileostomy
The first part of duodenum runs upwards, posteriorly and to the right from the pylorus (21.1 true). Its A. the opening is flush on the skin
initial 1" only is mobile and invested in the peritoneal folds of greater and of lesser omenta (21.2 true); B. the effluent fluid is nonirritant to the skin
this "duodenal cap" of radiologists is without macroscopic folds, unlike the reminder of the duodenum. C. is used as a routine to defunctional anterior resection anastomosis
This first 1" of the duodenum forms the lowermost boundary of the opening into the lesser sac D. is often temporary
(epiploic foramen, foramen of Winslow) (21.4 true). The fixed second 1" is retroperitoneal and crosses E. is easy to manage
the anterior surface of the inferior vena cava (21.3 true), where it lies immediately to the right of the
aditus to the lesser sac. At the junction of its free and fixed halves the first part of duodenum also Answer: D
crosses the bile duct anteriorly (22.3 true). An important anterior relation of the first part is the neck of
the gall bladder and Hartmann’s pouch (22.2 true). Acute cholecystitis can be associated with 20427 – S. Significant tears in the jejunal mesentery can lead to bowel
impaction of a stone which erodes and fistulates between gall bladder and duodenum to cause gall necrosis BECAUSE R. the straight vessels from the arterial arcades in the
stone ileus by subsequent impaction, usually in lower small bowel. Like all the rest of the small
bowel, the duodenum’s absorbing mucosal surface is enhanced by microscopic villi (22.1 false); and jejunal mesentery are end arteries
(except for the first 1" of the first part) also by macroscopic folds, the circular plicae or valvulae
conniventes. The first part totals 5cm in length (22.4 true). The duodenum’s second, third and fourth Answer: S is true, R is true and a valid explanation of S
parts complete a retroperitoneal C. The duodenum makes its loop around the head of the pancreas in
its first 3 parts, crossing aorta and IVC twice. The short 4th part to the left of the aorta ascends to the Last 8th ed. PAGE: 327
duodenojejunal flexure at the level of L2, below the body of pancreas. It lies on the left psoas muscle
and left lumbar sympathetic trunk (23A true). The 4th part is bound to the psoas fascia. The 25981 – The jejunum differs from the ileum in that the former has
duodenojejunal flexure is also supported by a suspensory ligament with some muscular fibres 1: taller villi
(ligament of Treitz) running from the right crus in front of the aorta but behind the body of the 2: a thicker wall
pancreas. The transverse mesocolon attachment runs along the anterior border of the pancreas and 3: Peyer's patches on the antimesenteric border
lies above the fourth part and its duodenojejunal flexure (23E false). The mesentery of the small 4: a wider lumen
bowel runs downwards to the right from the duodenojejunal flexure, crossing the 3rd part of
duodenum which is also crossed by the superior mesenteric artery and vein the vein lying to the right Answers: TTFT
of the artery. The inferior mesenteric artery originates at the level of L4, below the 3rd and 4th parts
of duodenum (23C false), and the inferior mesenteric vein ascends to the left of the 4th part to drain Last (6) Page:293, 289
into the splenic vein (23B false). The 2nd part of duodenum lies over the pelviureteric junction of right
kidney, but the fourth part is medial to the kidney and left ureter throughout (23D false). 710 – Characteristics of the small intestine are
1: the jejunum is wider, thicker and redder than the ileum and has taller villi.
18874 – The fourth part of the duodenum 2: the wall of the jejunum is thicker and feels double layered, the wall of the ileum is thinner and feels
A. is anterior to the left lumbar sympathetic trunk single layered.
B. is attached to the left crus by a suspensory muscle 3: the lower part of the ileum has Peyer’s patches on the antimesenteric border.
C. is crossed anteriorly by the inferior mesenteric artery 4: Meckel’s diverticulum is present in approximately 2% of people, 60cm (2ft) from the caecum.
D. lies anterior to the left ureter
E. is crossed by the attachment of the transverse colon Answers: TTTT

The small intestine from duodenojejunal flexure to ileocaecal valve comprises upper jejunum (l. Answers: TTTT
empty) and lower ileum (l. twisted), the ileum contributing a little more than half the total. The length is
variable and depends upon circumstances of measurement. The length is shorter during life than in Last (8) PAGE: 314
cadavers, the endoscopic distance from pylorus to ileocaecal valve in living humans is about 300cm
(120 inches). The more important aspect is the minimal length required after resection before short 20469 – S. Superior mesenteric arterial embolism usually results in midgut
bowel syndrome becomes severely manifest (around 50-100cm, depending upon whether the colon
gangrene BECAUSE R. the superior mesenteric artery is functionally an
and ileocaecal valve remain intact).
Differences between jejunum and ileum are the wider lumen and thicker wall of the jejunum which end artery
feels of double thickness and is juicier and redder, in contrast to the thinner single-walled ileum; and
the presence of lymphoid Peyer’s patches in the lower ileum on the antimesenteric border. The Answer: S is true, R is true and a valid explanation of S
jejunum’s mucous membrane is also thicker with taller villi (1, 2, 3 true).
Meckel’s diverticulum, a remnant of the vitellointestinal duct, has characteristics as stated (4 true). 783 – The termination of the superior mesenteric artery is at
The arcades of mesenteric vessels in the jejunum are long and narrow like Gothic cathedral windows; A. the ileocaecal junction.
those of ileum are shorter and stubbier and less transparent because obscured by fat more like earlier B. the appendix.
Romanesque or Norman church windows. C. the caecum.
D. the terminal ileum.
KEY ISSUE E. none of the above sites.
Notwithstanding the above, the only way to establish indubitably which part of small bowel is which is
to find the duodenojejunal flexure and work down, or the ileocaecal junction and work up. Failure to Answer: D
observe this simple but vital rule has led to inadvertent gastroileal instead of gastro-jejunal
anastomoses after partial gastrectomy, or to embarrassingly reversed Roux-Y loops. Make sure it The termination of the superior mesenteric artery is in the terminal ileum at the apex of the loop of the
doesn’t happen again with you or your patients. See also the Nutrition/Metabolism resource unit midgut which is the site of attachment of the vitello-intestinal duct. This is about 60 cm proximal to the
regarding rapid access to the duodenojejunal flexure. caecum; the rotation of the midgut loop occurs around the superior mesenteric artery and its axis.
20265 – S. The jejunum has a greater absorptive area than the 24244 – The superior mesenteric artery supplies the
ileum BECAUSE R. the jejunum has more circular folds and longer villi than 1: ileo-colic artery
2: inferior pancreatico-duodenal artery
the ileum
3: superior pancreatico-duodenal artery
4: gastroduodenal artery
Answers: TTFF
Last Page: 339 Leeson & Leeson Page: 362
Last 10th Ed, Ch 5, page 238
7079 – The jejunum differs from the ileum in that the jejunum has
A. shorter vasa recta 818 – Posterior relations of the root of the small bowel mesentery include
B. a greater number of mucosal circular folds
1: inferior vena cava.
C. aggregated lymphatic nodules in the submucosa
2: right ureter.
D. a lesser vascularity
3: right gonadal vessels.
E. a thinner wall
4: third part of the duodenum
Answer: B
Answers: TTTT
The jejunum has a greater number of mucosal circular folds than does the ileum. This accounts for
The origin of the dorsal mesentery of fore, mid and hind gut from the posterior abdominal wall is
the differences in appearance of dilated upper and lower small bowel loops. The jejunum has
modified from its simple vertical midline origin because of the rotational development of the gut and
numerous transverse folds running across the lumen - the valvulae conniventes; the lower ileum looks
subsequent peritoneal fusions (zygosis). The mesentery of the small intestine extends from the level
more like a blown up featureless balloon without internal folds.
of the duodenojejunal flexure to the left of the midline, across the spinal column into the right iliac
fossa to the caecum. The root of the mesentery crosses successively the 3rd part of duodenum, IVC,
21888 – Posterior relations of the root of the mesentery include the right gonadal vessels and ureter (42 1, 2, 3 & 4 true). The midgut mesentery contains duodenal and
1: inferior vena cava jejuno-ileal branches from the superior mesenteric midgut artery. The transverse mesocolon is attached
2: right ureter transversely to the anterior border of the pancreas (41C true).
3: right gonadal vessels
4: third part of the duodenum
812 – The mesentery of the

A. small intestine is attached obliquely along a line extending from the descending part of the D. has a continuous coat of longitudinal muscle
duodenum to the left sacroiliac joint. E. has none of the above properties
B. small intestine contains branches of the inferior mesenteric artery.
C. transverse colon is attached transversely to the anterior border of the pancreas. Answer: E
D. sigmoid colon lies over the promontory of the sacrum.
E. sigmoid colon does not attach below the pelvic brim. Last 10th, Ch 5 PAGE:249
Answer: C 23834 – The vermiform appendix

1: arises from the posteromedial aspect of the caecum
19234 – The mesentery of the 2: has numerous lymphoid follicles
A. small intestine is attached obliquely along a line extending from the descending part of the 3: usually has a complete longitudinal muscle coat
duodenum to the left sacroiliac joint 4: is attached by a mesoappendix to the left leaf of the mesentery of the terminal ileum
B. small intestine contains branches of the inferior mesenteric artery
C. transverse colon is attached transversely to the anterior border of the pancreas Answers: TTTT
D. sigmoid colon lies over the promontory of the sacrum
E. sigmoid colon does not attach below the pelvic brim Last (9) PAGE: 345
Answers: C 795, 19593 – The appendicular artery arises from

A. the anterior caecal artery
Last (6) PAGE: 271 et. seq. Review July 2004 re: wording of option 3. B. a branch of the terminal ileal artery
C. the marginal artery
823, 23119 – The large bowel is characterised by D. the posterior caecal artery
1: taeniae coli, converging on the appendix and the terminal sigmoid. E. none of the above
2: a mucosa with large crypts and villi.
3: a sigmoid colon mesentery with its apex over the bifurcation of the common iliac artery. Answer: D
4: a transverse colon freely suspended by a mesocolon.
Last 10th Ed, Ch 5 PAGE: 249, 250. The appendicular artery normally arises from the posterior caecal
Answers: TFTT artery (D true) which in its turn arises from the descending terminal branch of the ileocolic artery. The
appendicular artery is contained in the free margin of the meso-appendix, lying behind the terminal
Last (8) PAGE: 339. The large bowel is characterised by taeniae coli, which are three separate bands ileum and its mesentery. The artery finally runs directly on the wall of the appendix to terminate. This
of longitudinal smooth muscle converging on the appendix base at the caecum and again at the question is currently under review by the Anatomy Sub Committee. August 23, 2001
termination of sigmoid colon (1 true), where they become a continuous covering. Their relatively short
length compared to the bowel gives the colon its characteristic sacculations. The ascending and 19623 – The sigmoid colon
descending colons are retroperitoneal, the transverse colon is freely suspended by its mesentery (4 A. receives parasympathetic innervation from the vagus
true). The sigmoid colon has a mesentery attached in the shape of an upside down V. The upper limb B. sends venous drainage into the inferior vena cava
runs along the pelvic brim, with the apex over the bifurcation of the common iliac artery (3 true) and C. is retroperitoneal
close to where the left ureter crosses the external iliac artery at its origin. The lower limb descends D. is supplied by the pelvic splanchnic nerve (the nervi erigentes)
into the pelvis to the 3rd piece of the sacrum. The mucosa of the large bowel contains numerous E. has a mesocolon with a 5cm base over the common iliac vessels
goblet cells and large crypts, but no villi (2 false).
Answer: D
23639 – The left colic flexure
1: lies lower than the right colic flexure Last (8) PAGE: 342
2: receives parasympathetic vagal fibres
3: lies directly anterior to the left adrenal gland 789 – The middle colic artery is a branch of the
4: is attached to the diaphragm by the phrenico-colic ligament A. superior mesenteric artery
Answer: FFFT B. inferior mesenteric artery.
C. coeliac trunk.
Last (6) PAGE: 272, 295 D. common hepatic artery.
E. left gastric artery.
19917 – The caecum
A. is retroperitoneal Answer: A
B. bears more appendices epiploicae than the sigmoid colon
C. is supplied by the right colic vessels

The superior mesenteric artery is the artery of the mid gut, supplying the territory from the middle of
the second part of the duodenum to the region of the transverse colon near the splenic flexure. Its Answers: TTTT
main branches are the ileocolic, right colic and middle colic arteries (37A true), as well as jejunal, ileal,
and pancreatico duodenal arteries. It terminates in the lower ileum at the site of the embryological apex Last (8) PAGE: 316
of the midgut loop (36D true), and at the site at which Meckel's diverticulum develops. The rotation of
the midgut loop is based around the axis of the artery. 14086 – S:Surgical removal of the right suprarenal gland is especially
hazardous because R:the right suprarenal gland is drained by a short vein
8398 – The peritoneum has directly into the inferior vena cava
1: a firm attachment to the pancreas
2: an opening into the omental bursa, lying behind the pyloric antrum Answer: S is true, R is true and a valid explanation of S
3: a diaphragmatic part innervated completely by the phrenic nerve
4: its visceral part innervated by the intercostals Refer to Last, 10th ed, page 281
Answers: TFFF
21898 – The right suprarenal gland
Last 10th ed, Ch 5 1: lacks a peritoneal covering over the inferior half of its anterior surface
2: is drained by a short vein directly into the inferior vena cava
3: is crescentic in shape
22494 – The lesser omentum is attached to 4: lies between the right crus of the diaphragm and the inferior vena cava
1: the greater curvature of the stomach
2: the margin of the caudate lobe of the liver Answer: FTFT
3: the quadrate lobe
4: porta hepatis Last 9th ed. Page: 373. Question reviewed and updated Nov 03.
Answers: FTFT
22549 – The left suprarenal gland
Last (9) PAGE: 315 1: is pyramidal in shape
2: is separated from the kidney by the renal fascia
3: is separated by peritoneum from the pancreas
19420 – The lesser omentum 4: produces mineralocorticoids mainly in the zona glomerulosa
A. contains the splenic artery
B. contains the right gastro-epiploic artery Answers: FTFT
C. contains the left gastric artery
D. is attached to the fissure for the ligamentum teres Last (8) Page: 373 Wheater Page: 268
E. has none of the above properties
Answer: C 24004 – The left suprarenal gland

1: surmounts the upper pole of the left kidney
Last 8th ed. Page: 317 2: is partially covered by peritoneum of the lesser sac
3: lies lateral to the left crus of the diaphragm
4: is crossed by the splenic artery
22043 – The lesser omentum
1: contains the hepatic branches of the anterior vagal trunk Answers: FTFT
2: has a L shaped attachment to the lower surface of the liver
3: has an anterior layer which is continuous with the posterior layer of the left triangular ligament Last 10th Ed., Ch 5, p281. Question reviewed and will remain unchanged. Nov 03
4: develops from the ventral mesogastrium
Answers: TTTT 20433 – S. The adrenal medulla contains cells equivalent to post-ganglionic
neurones BECAUSE R. the adrenal medulla is of neuroectodermal origin
Last (8) PAGE: 317. Question reviewed and updated Nov 03.
21893 – The greater omentum is attached to
1: oesophagus Wheater et al Chapter: 17 Page: 271
2: stomach
3: left kidney 24239 – The right kidney
4: colon 1: has a long axis sloping downwards and laterally
2: in the erect position, lies opposite the first three lumbar vertebrae
3: has the suprarenal gland in direct contact with its true capsule 21533 – Structures marking the normal course of the ureter in an
4: is separated from the duodenum by peritoneum
intravenous pyelogram include
1: tips of lumbar transverse processes
Answers: TTFF
2: sacro-iliac joints
3: ischial spines
Last (7) PAGE: 316,318. Question reviewed and updated Nov 03.
4: pubic tubercles
22038 – The muscles lying posterior to the kidney include the Answers: TTTT
1: quadratus lumborum
2: diaphragm Last (6) PAGE: 320
3: psoas major
4: transversus abdominis 23854 – The ureter
1: crosses the genito femoral nerve
Answers: TTTT
2: is 35 cm long
3: is lined by cubical epithelium
4: has a sole arterial supply from the renal artery
19599 – Which structure makes contact with the surface of the left kidney Answers: TFFF
A. left suprarenal gland
B. the 4th part of the duodenum Last (6) PAGE: 320, 331
C. the left lumbar sympathetic trunk
D. the pancreas 21838 – The right renal artery
E. the duodenojejunal flexure
1: arises at the level of the 1st lumbar vertebra
2: crosses the right crus and psoas muscles
Answer: D
3: runs posterior to the inferior vena cava
4: is longer than the left renal artery
Last (6) PAGE: 315 et seq
Answers: FTTT
20301 – S. Pneumothorax may occur during operations on the
kidney BECAUSE R. the pleura is a posterior relation of the kidney Last 8th ed. Page: 363
Answer: S is true, R is true and a valid explanation of S 14173 – The right renal vein
1: joins the inferior vena cava at the level of the second lumbar vertebra
8540 – The left ureter in the female 2: receives the right suprarenal vein
1: crosses the genitofemoral nerve 3: lies anterior to the right renal artery
2: is crossed superficially by the uterine artery 4: sometimes receives the right gonadal vein
3: crosses the anterior to the inferior mesenteric vessels
4: is lateral to the obturator nerve in the pelvis Answers: TFTT
Answer: TTFF Refer to Last, 10th Ed, page 271
Last 10th ed, Ch 5 14982 – The renal artery

1: is posterior to the pancreas
22929 – The right ureter 2: lies posterior to the renal vein
1: crosses posterior to the right colic artery 3: has no branches except to the kidney
2: crosses anterior to the right common iliac artery 4: is the only paired branch of the aorta
3: crosses anterior to the right gonadal vessels
4: runs along the lateral margin of the right psoas major muscle Answers: TTFF
Answers: TTFF Refer to Last, 10th Ed, page 268
Last (8) PAGE: 372 et seq

833 – The structure labelled 'D' in the abdominal CT scan (refer to desirable than the right. The other structures illustrated in the CT scan are the superior mesenteric
illustration 3) artery (C) and vein (B) passing in front of the uncinate process of the pancreas (A) with the head of
the pancreas to the right of this. The lower part of the liver is also seen, together with some loops of
1: is three times as long as its right sided equivalent.
large and small bowel containing contrast, and the beginnings of psoas and quadratus lumborum
2: receives the left adrenal vein.
posteriorly.
3: connects with the azygos and vertebral venous systems.
4: receives the left gonadal vein.
8525 – The arch of the aorta is crossed on the left side by
1: the left superior intercostal vein
2: branches from the cervical ganglia of the sympathetic trunk
3: the left vagus
4: the left phrenic nerve
Answers: TTTT
Last 10th ed, Ch 4. Updated Dec 2003
829 – The structure outlined by "B" in the aortogram (refer to illustration 2)

1: lies anterior to the 3rd part of the duodenum.
2: lies posterior to the left renal vein.
3: lies anterior to a part of the pancreas.
4: gives branches to the duodenum.
Answers: TTTT
The CT scan illustrated is through one of the lumbar vertebrae, and shows the kidneys on either side
of the midline. The structure labelled D running from the left kidney towards the midline is a large
structure which must be either the left renal vein or left renal artery. The size of the structure and
subsequent questions make it clear that it is indeed the left renal vein; although its insertion into the
vena cava after crossing in front of the aorta is not seen; and it looks rather confusingly as if it is
originating from the aorta. This is due to its oblique course so that only the part originating from the
kidney coming to the midline is seen. We are clearly at an upper vertebral level, probably L1. The left
renal vein is about three times as long as its right sided counter part (1 true). The right renal vein
incidentally can be seen entering the vena cava from the right kidney, and is a short stubby vein
usually receiving no tributaries. The left renal vein, which crosses the aorta to reach the inferior vena
cava, receives a number of tributaries. The left adrenal vein enters it from above, and it may also
receive from above the left inferior phrenic vein. It receives the left gonadal vein inferiorly. This junction
may or may not contain a valve, which is probably relevant to the development of varicocele in males.
The left renal vein connects the azygos and vertebral venous systems (2, 3 & 4 true). The other major
tributaries of the left renal vein of importance are one or more lumbar veins. These various tributaries
and their control are of particular importance in the operation of left nephrectomy. In living donor
nephrectomy, the increased length of the left renal vein makes the use of the left kidney more

Answers: TFTT
The superior mesenteric artery comes off at L1 level behind the body of the pancreas and is labeled B. Its
jejunal and other branches are not yet visible. It runs from its origin steeply downwards behind the
splenic vein and the neck of the pancreas with the superior mesenteric vein on its right side. It then
crosses in front of successively the left renal vein (2 false), the uncinate process of the pancreas, and the
anterior surface of the third part of the duodenum, and then leaves the posterior abdominal wall to enter
the upper end of the small gut mesentery. Its first branch is the inferior pancreaticoduodenal artery
supplying the duodenum below the entrance of the bile duct, and running in the curve between the
duodenum and the head of the pancreas (true 1, 3 and 4).
The remaining arteries illustrated are the right renal artery C, the right inferior phrenic artery E giving
branches to the suprarenal, and what appears to be an aberrant renal artery supplying the lower pole
of the left kidney. When investigating live donors for renal transplantation, careful study of the first
phases of aortography is important in identifying any anomalous renal arterial branches, which can be
difficult to separate from lumbar arteries and jejunal arteries in later phases of the aortogram.
23109 – At the level of the 12th thoracic vertebra the aorta

1: lies to the right of the median plane
2: lies to the right of the thoracic duct
3: passes through the left crus
4: gives off the coeliac trunk
Answers: FFFT
Last (8) PAGE: 325
23499 – The lumbar arteries on the right side

1: are separated by psoas major from the lumbar vertebrae
2: are five in number
3: pass behind the inferior vena cava
4: usually pass posterior to the lumbar sympathetic trunks
Answers: FFTT
Last (6) PAGE: 307
22504 – The inferior vena cava

1: receives blood from the five paired lumbar veins
2: is formed behind the right common iliac artery
3: receives both gonadal veins directly
4: is anterior to the right lumbar sympathetic trunk
Answers: FTFT
13509 – The inferior vena cava

1: commences at the level of the fourth lumbar vertebra
2: enters a deep groove on the bare area of the liver to the left of the caudate lobe
3: is posterior to the medial part of the right suprarenal gland
4: enters the right atrium to the right of the fossa ovalis
Answers: FFFT 21338 – The coeliac ganglion
1: gives postganglionic fibres to the foregut
The inferior vena cava is formed by the junction of the right and left common iliac veins at a slightly 2: supplies postganglionic fibres to the hindgut
lower level than the bifurcation of the aorta, behind the commencement of the right common iliac 3: contains the ganglion cells of visceral afferent neurons
artery. The aorta bifurcates on the body of the fourth lumbar vertebra and the inferior vena cava forms 4: is mainly concerned with the parasympathetic innervation of the gut
on the body of the fifth lumbar vertebra (A false). The inferior vena cava runs in a deep groove on the
bare area of the liver to the right of the caudate lobe (B false). The medial part of the right supra-renal Answers: TTFF
gland insinuates itself behind the vena cava (C false). The inferior vena cava ends by entering the
right atrium. The fossa ovalis is in the inter-atrial septum above the site of entry of the vena cava and Last (8) PAGE: 33, 366
the atrium is thus to its right (D true).
15913 – The coeliac plexus
13968 – The sympathetic trunk enters the abdomen 1: bradykinin
A. through the aortic opening 2: complement activation by-product (C5a)
B. behind the medial arcuate ligament 3: prostacyclin ( PGI2)
C. together with the greater splanchnic nerve 4: fibronectin
D. behind the lateral arcuate ligament
E. through the crura Answers: TFTF
Answer: B Last (9) PAGE: 314; 365. Question to be reviewed at March 04 meeting re: option B. (23/02/04)
Refer to Last, 10th Ed, page 180 19258 – The greater splanchnic nerve contains mainly
A. somatic afferent fibres
24049 – The sympathetic trunk B. somatic efferent fibres
1: is usually crossed anteriorly by lumbar vessels C. preganglionic sympathetic fibres
2: enters the abdomen by passing behind the medial arcuate ligament D. postganglionic sympathetic fibres
3: passes anterior to the common iliac arteries E. para-sympathetic fibres from the vagus
4: ends in front of the coccyx as the ganglion impar
Answer: C
Answers: FTFT
Last (6) PAGE: 241, 315
Last (7) PAGE: 314, 344
3484 – With respect to the distribution of the vagal nerve trunks
13479 – The abdominal sympathetic trunk 1: the posterior vagus gives rise to hepatic branches which enter the liver via the lesser omentum and
1: is crossed anteriorly by lumbar vessels the porta hepatis
2: leaves the abdomen by passing through the aortic opening 2: the main terminal branch of the anterior vagus nerve crosses the stomach distal to the incisura
3: passes anterior to the common iliac arteries angularis about 5-6 cm from the pylorus
4: ends in front of the coccyx as the ganglion impar 3: vagal branches to the stomach run parallel with the branches of the left and right arteries
4: some vagal fibres travelling to the parietal cell mass may sink into the muscular wall at the
Answers: FFFT oesophagus some distance above the cardia
The sympathetic trunk lies in front of the segmental vessels (A false). It leaves the chest by passing Answers: FTFT
behind the medial arcuate ligament (B false). The common iliac vessels lie in front of the sympathetic
trunks at the pelvic brim (C false). The trunks converge at the front of the coccyx and unite at a small The anterior vagus gives rise to hepatic branches in the upper part of the lesser omentum (A false),
swelling, the ganglion impar (D true). and the main terminal branch of the anterior vagus (nerve of Latarget) runs down the lesser curvature
and crosses onto the anterior wall of the stomach about 5-6 cm from the pylorus, and is preserved in
20313 – S. Injury to the superior hypogastric plexus may reduce male highly selective vagotomy (B true). Vagal nerve fibres to the stomach do not accompany blood
fertility BECAUSE R. loss of contraction of the internal urethral muscle may vessels but run obliquely downwards whereas the vessels tend to run transversely (C false). To
result in retrograde ejaculation denervate the upper stomach, it is necessary to clear the lowermost 5 cm or so of the oesophagus of
all vessels and nerves, suggesting that some vagal fibres travelling to the parietal cell mass may sink
into the muscle wall of the oesophagus well above the cardia (D true). This question was referred to
the Anatomy Sub Committee for review on 1 Feb 2002. Question updated 14 March 2002.
Last 10th Ed, Ch 5, page 291, 313
618 – In the photograph of the abdominal wall (refer to illustration No.1)
1: ‘A’ lies over the linea alba.
2: ‘B’ lies over the fundus of the gall bladder.
3: ‘C’ lies at the level of the transpyloric plane.
4: ‘D’ lies at the level of the aortic bifurcation.

Last (8) PAGE: 296. When performing appendicectomy through a McBurney or Lanz incision, the
Answers: TTTF external oblique is aponeurotic in most of its extent but fleshy fibres are encountered laterally (2
false). The internal oblique muscle is split almost entirely in its fleshy portion, becoming aponeurotic just
In the photograph of the abdominal wall A lies over the linea alba (1 true). The aponeuroses of all the lateral to the rectus abdominis muscle (4 true). The ilio-inguinal nerve runs in the plane between the
abdominal flat muscles are fused between the recti to form the linea alba in the midline. This runs internal oblique and transversus abdominis muscles to enter the inguinal canal, and may occasionally
vertically from the xiphoid to the pubis. Below the umbilicus it is thinner and weaker than above the be injured (1 false). The transversus abdominis has an aponeurosis extending more laterally than that
umbilicus where the distance between the recti is greater (as shown in the picture). The fused of the internal oblique, and is split where it is usually half aponeurotic and half fleshy (3 false).
aponeuroses form a thick felted fibrous band, the fibres criss-cross like a radial ply tyre.
B lies at the junction of the lateral rectus edge with the costal margin at the site of the tip of the ninth
costal cartilage; which corresponds to the surface anatomy of the fundus of the gall bladder (2 true). 20691 – S. Accidental damage to the ilio-inguinal nerve can occur during
The transpyloric plane at level C runs transversely at the mid point between the sternal notch above
and pubic symphysis below. It crosses the costal margin at the tip of the ninth costal cartilage at the
appendicectomy BECAUSE R. the ilio-inguinal nerve runs obliquely over
lateral rectus edge (3 true); it marks the approximate surface anatomy of the pylorus and the lower the iliacus muscle in the right iliac fossa
border of lumbar vertebra 1. Its anterior surface manifestation, as well as often corresponding with an
abdominal skin crease, as shown in the photograph, can be used to mark the transition from the Answer: S is true and R is false
epigastrium above to the umbilical region below; although many find a more convenient junction at
the sub-costal plane, which is at a lower level (approximately at the plane indicated by A) which also Last PAGE: 131. This question is currently under review Jun 2002.
often has a transverse skin crease and marks a functional boundary between upper and lower
abdominal integument. 7343 – S Accidental damage to the ilio-inguinal nerve can occur during
D, which overlies the umbilicus (4 false) lies approximately at the level of disc between third and open appendicectomy Because R the ilio-inguinal nerve runs obliquely
fourth lumbar vertebrae (quartering the abdomen around the umbilicus is another common descriptive
device). The transpyloric plane also lies approximately halfway between the lower end of the sternum
superior the iliacus on the posterior abdominal wall in the right iliac fossa
and the umbilicus. The bifurcation of the aorta is below and to the left of the umbilicus, at
approximately the level of the disc between the fourth and fifth lumbar vertebrae. The pulsation of the
aorta can be felt in slim patients and for the most part is above the umbilicus. Similarly an aortic
The ilio-inguinal nerve can be damaged by the incision through the anterior abdominal wall during
aneurysm gives a predominantly epigastric swelling.
open appendectomy. The course of the nerve across the posterior abdominal wall on iliacus is
correctly described, but this is not the site of iatrogenic damage to the nerve. Question reviewed and
612, 13209 – The right-sided intercostal nerve that is invariably cut in a updated Nov 03.
Kocher's subcostal incision is the
A. seventh 922, 19222 – Blind incision of the lacunar ligament in operative treatment of
B. eighth
C. ninth
strangulated femoral hernia via a low approach may be dangerous,
D. tenth because of the presence of an abnormal obturator artery arising from the
E. eleventh A. femoral artery
B. external iliac artery
Answer: C C. inferior epigastric artery
D. cremasteric artery
Kocher's oblique subcostal incision divides the rectus abdominis muscle and extends laterally for a E. medial circumflex femoral artery
variable distance, depending on the patient's build. The seventh and eighth intercostal nerves run
upwards and transversely close to the costal margin within the sheath and are often spared (A and B Answer: C
false). The ninth intercostal nerve runs obliquely across the incision at the lateral edge of the rectus
sheath and is invariably cut (C true). The tenth, and rarely the eleventh, nerves may be divided only if Last (9) PAGE: 305. The obturator artery normally arises from the internal iliac artery, giving a pubic
the incision is extended laterally (D and E false). Under review January 2004 branch which anastomoses with the pubic branch of the inferior epigastric artery. An anomalous
obturator artery occurs when the normal obturator artery is replaced by an aberrant origin from the
633, 13519, 23484 – At the site of a McBurney’s incision for inferior epigastric artery, which runs along the edge of the lacunar ligament to reach the obturator
foramen. In this position it is at risk from blind incision of the lacunar ligament in operations for
appendicectomy strangulated femoral hernia done by the low approach (C true).
1: the ilio-inguinal nerve may be seen running superficial to the internal oblique muscle.
2: the external oblique muscle is entirely aponeurotic.
3: the transversus abdominis muscle is almost entirely fleshy.
20103 – S. Division of the lacunar ligament during repair of a femoral hernia
4: the internal oblique muscle is almost entirely fleshy. may result in haemorrhage BECAUSE R. an abnormal obturator artery may
run medial to the femoral canal
Answers: FFFT

Answer: S is true, R is true and a valid explanation of S Answer: C
Last 8th ed. PAGE: 397 Last 8th ed. Page: 304
20511 – S. Lateral to the rectus sheath a transverse abdominal incision will 21528 – The rectus abdominis muscle
minimise postoperative pain BECAUSE R. the direction of pull and maximal 1: is completely enclosed within the internal oblique aponeurosis
tension of the lateral abdominal muscles is generally transverse 2: forms part of the anterior wall of the inguinal canal
3: is supplied by T7-T12 ventral rami
4: extends above the costal margin
Answers: FFTT
C.S.S. 2nd ed. PAGE: 308 STEM Module: Gastrointestinal
7718, 13343 – S:During lumbar sympathectomy, the peritoneum is less
likely to be injured if the transversus abdominis muscle is split in the line of 24079 – The rectus abdominis muscle
its fibres starting from the most medial aspect of the wound and extending 1: is attached below to the ilio-pectineal line
laterally because R:the peritoneum is closely adherent to the lateral part of 2: is attached by tendinous intersections to the posterior wall of the rectus sheath
3: has a sheath formed entirely from the aponeuroses of external and internal oblique muscles
the transversus abdominis muscle
4: is attached above to the 4th costal cartilage
Answers: FFFF
Last 10th ed, Ch 5 MCQs in Basic Surgical Science, Buzzard & Bandaranayake. During the
Last (8) PAGE: 298. This question is currently under review by the Anatomy Sub Committee. 23
operation of lumbar sympathectomy the transversus abdominis muscle is split in the line of its fibres
starting preferably at the extreme lateral aspect of the wound where the fibres are muscular (S false),
rather than medially where the fibres are aponeurotic and closely adherent to the underlying
peritoneum (R false). 628, 13514 – The rectus abdominis muscle fibres
1: may atrophy in part following a paramedian muscle-splitting incision.
2: must be carefully sutured after division, to prevent incisional hernia
594 – The medial umbilical fold contains the
3: are divided in a Kocher’s sub-costal incision.
A. urachus.
4: are attached superiorly to the seventh, eighth and ninth costal cartilages.
B. inferior epigastric artery.
C. obliterated umbilical artery.
Answers: TFTF
D. umbilical vein.
E. falciform ligament.
The medial portion of the rectus abdominis muscle may atrophy after a paramedian muscle-splitting
incision (1 true). Division of the muscle as in a Kocher or transverse incision causes a new tendinous
Answer: C
intersection to develop; the muscle need not be sutured (2 false, 3 true). The attachment of rectus abdominis
superiorly is to the fifth, sixth and seventh costal cartilages (4 false).
In the lower abdomen peritoneal folds are raised on the posterior abdominal wall by the obliterated
urachus running in the vertical midline from bladder apex to umbilicus as the median umbilical fold (A
false), by the obliterated umbilical arteries on either side of the midline as the medial umbilical folds 20823 – S. The rectus abdominis muscle is made more powerful by the
(C true), and by the inferior epigastric arteries before they pass in front of the posterior rectus sheath presence of transverse intersections attached to both the anterior and
at the arcuate line as the lateral umbilical folds (B false). posterior walls of its sheath BECAUSE R. the power of a muscle is
In the upper abdomen the falciform (sickle-shape) ligament connects the posterior rectus sheath and dependent on the number of muscle fibres it contains, and not on their
diaphragm with the anterior surface of the liver. The free lower edge of the falciform ligament contains
a fibrous cord, the obliterated left umbilical vein, comprising the round ligament of the liver (D & E length
false).
19474 – The medial umbilical fold contains
Last (6) PAGE: 6, 257
A. the urachus
B. the inferior epigastric artery
C. the obliterated umbilical artery 25983 – The semicircular fold of Douglas of the rectus sheath is
D. the umbilical vein 1: anterior to the rectus abdominis muscle
E. the falciform ligament 2: at the level of the umbilicus

3: the line below which the transversus aponeurosis, which include transversus, passes anterior to 1: lies nearer to the xiphoid than to the pubis
the rectus abdominis muscle 2: is supplied with cutaneous innervation by the 11th thoracic nerve
4: lateral to the rectus abdominis muscle 3: transmits, during development, the umbilical cord containing two arteries and two veins
4: usually lies at about the level of the disc between the third and fourth lumbar vertebrae
Answers: FFTT
Answers: FFFT
Last's 8th Ed., p299. Under Review January 2004
Last (6). The umbilicus lies approximately midway between xiphoid and pubis (A false), derives its
588, 13203, 18928 – The surface landmark which is a guide to the position cutaneous innervation from the tenth thoracic nerve (B false), transmits, during development, the
umbilical cord, containing two arteries and one vein (C false) and lies at about the level of the disc
of the gastro-oesophageal orifice is the
between the third and fourth lumbar vertebrae (D true).
A. seventh left costal cartilage
B. left linea semilunaris
C. tip of the ninth left costal cartilage 14992 – In relation to the diaphragm
D. eighth thoracic vertebra 1: the inferior vena cava passes through in the midline
E. left nipple 2: the thoracic duct passes through the aortic opening
3: the right crus has more extensive attachments than the left
Answer: A 4: the sympathetic trunk passes posterior to the median arcuate ligament
Last 10th ed. PAGE: 201. The oesophagus extends from the cricoid cartilage at the level of the sixth Answers: FTTF
cervical vertebra, to the cardiac orifice of the stomach at the level of the lower part of the tenth thoracic
vertebra over the left seventh costal cartilage, a thumb breadth from the side of the sternum (A true). Refer to Last, 10th Ed, page 179-180
The left linea semilunaris marks the lateral rectus edge which crosses the costal margin at the tip of the left
ninth costal cartilage, or approximately the level of L1 (B and C false). The eighth thoracic vertebral level 18850 – The internal oblique muscle
marks the inferior vena caval orifice at the dome of the diaphragm to the right of the midline (D false); and A. is attached to the lateral 2/3 of the inguinal ligament
the left nipple is commonly in the fourth left intercostal space (E false). B. becomes aponeurotic in the lumbar region
The Oesophagus extends from the cricoid cartilage at the level of the sixth cervical vertebra in the C. forms the posterior rectus sheath immediately above the inguinal ligament
midline, to the cardiac orifice of the stomach at the level of the lower part of the tenth thoracic D. has a free upper muscular border
vertebra and the left seventh costal cartilage a thumb's breadth from the side of the sternum (A true). E. is innervated by the 7 - 12 intercostal nerves exclusively
The left linea semilunaris marks the lateral rectus edge and crosses the costal margin at the tip of the
left ninth costal cartilage, or approximately the level of L1 (B and C false). The eighth thoracic Answers: A
vertebral level marks the inferior vena caval orifice at the dome of the diaphragm to the right of the
midline (D false); and the left nipple is commonly in the fourth left intercostal space (E false). Last 10th Ed, page 217
20907 – S. Lymph drainage from the anterior abdominal wall between the 21498 – The internal oblique muscle of the abdomen
umbilicus and costal margin is to the inguinal region BECAUSE R. 1: has partial origin from the inguinal ligament
2: innervated from 7th to 12th intercostal nerves exclusively
lymphatic channels may follow subcutaneous veins
3: has a free upper muscular border
4: corresponds to the internal intercostal muscle layer in the thorax
Answers: TFFT
Last 10th ed, pgs 173 & 178. Question reviewed and updated July 03.
Last (6) PAGE: 256
21968 – The inferior epigastric artery
1: runs between the transversus and internal oblique muscles 19216 – The external oblique muscle of the abdomen
2: runs anterior to the rectus abdominis muscle
A. arises from the costal cartilages of the lowest eight ribs
3: gives rise to the artery of the ductus deferens
B. attaches to the lumbar fascia posteriorly
4: lies medial to the deep inguinal ring
C. interdigitates with the serratus anterior muscle
D. has an aponeurotic attachment to the iliac crest
Answers: FFFT
E. is innervated by the ilio-inguinal nerve
Last (9) PAGE: 300
Answer: C
13474, 21508 – The umbilicus Last 8th ed. PAGE: 295

Answers: C
PELVIS Last PAGE: 16
22204 – The pelvic inlet or brim 22639 – Structures passing through the lesser sciatic foramen include
o
1: lies in an oblique plane at 30 to the horizontal 1: the pudendal nerve
2: is bounded laterally by the iliac crest 2: the inferior gluteal vessels
3: is proportionately larger in the female than in the male 3: the tendon of obturator internus muscle
4: is bounded posteriorly by the sacral promontory 4: the posterior cutaneous nerve of thigh
Answers: FFTT Answers: TFTF
Last 10th ed. PAGE:282 Last 10th ed. PAGE: 161
22904 – The pubic crest gives attachment to 22634 – Structures crossing the back of the ischial spine are
1: part of the rectus abdominis 1: the nerve to obturator internus
2: the interfoveolar ligament 2: the pudendal nerve
3: external oblique aponeurosis 3: the inferior gluteal nerve
4: the lacunar ligament 4: the nerve to quadratus femoris
Answers: TFTF Answers: TFFF
Last (8) PAGE: 217, 297 et. Seq. Last 10th ed. PAGE: 161. Reviewed and Updated Nov 2003
8470 – The ilium 18970 – The ischial spine

1: gives attachment to the rectus femoris muscle A. gives rise to coccygeus
2: gives attachment to the quadratus lumborum B. gives rise to piriformis
3: gives attachment to the latissimus dorsi muscle C. is crossed by the pudendal nerve
4: forms two-thirds of the acetabulum D. gives rise to gemellus inferior
E. gives rise to the falciform ligament
Answers: TTTF
Answer: A
Last 10th ed, Ch 3
Last 10th ed. PAGE: 284; 282; 308; 122; 228; 374; 405; 313
23629 – The greater sciatic foramen transmits
1: the piriformis muscle 19563 – The inguinal canal
2: the inferior gluteal vessels A. has the internal oblique muscle in the lateral part of its posterior wal
3: the superior gluteal vessels B. is situated inferior to the inguinal ligament
4: the posterior cutaneous nerve of the thigh C. has the transversus abdominis in the medial part of its anterior wall
D. has the internal oblique muscle in the lateral part of its anterior wall
Answers: TTTT E. has an external ring directly lateral to the pubic tubercle
Last PAGE: 147 Answer: D
19246 – A structure leaving the pelvis through the greater sciatic notch Last (6) PAGE: 259 et. seq.
above the piriformis muscle is
A. the inferior gluteal nerve 21503 – The inguinal canal
B. the nerve to the quadratus femoris muscle 1: has an internal ring lying 1.5 cm lateral to the midpoint of the inguinal ligament
C. the superior gluteal artery 2: has the fascia transversalis as a posterior relation
D. the posterior femoral cutaneous nerve 3: is about 1.5cm long in the adult
E. the pudendal nerve 4: has the lacunar ligament in the medial part of its floor

Answer: FTFT Inguinal hernia is more common in males than females (1 true). Looking at the records of your last
100 patients with inguinal hernia, a considerable majority will be males. The region of the male
Last (6) PAGE: 259 inguinal canal is more likely to have a congenital sac and also more prone under stress to herniate
than the female inguinal canal, which only transmits the round ligament of the uterus in contrast to the
24234 – Structures forming the posterior wall of the inguinal canal include male spermatic cord leading to the testis.
1: the internal spermatic fascia Inguinal hernias are also more common than femoral hernias overall in both sexes (2 true). Looking at
2: the fascia iliaca the records of the last 100 female patients with groin hernia inguinal hernias will predominate; but the
3: the conjoint tendon majority will not be so great as in the first example. Thus in both males and females the inguinal canal
4: the fascia transversalis region is more likely to give rise to hernia than is the femoral canal area.
When an inguinal hernia is found to be inguinoscrotal it is virtually certain to be indirect (3 true).
Answers: FFTT Indirect hernias as they enlarge descend with the spermatic cord into the scrotum. Direct hernias do
not; they remain in the groin above the scrotal neck.
Last 10th Ed, Ch 5, page 220-221 A Richter hernia describes a strangulated hernia with entrapment of portion of the circumference of
the bowel within a hernial sac with a small opening from the peritoneal cavity. This classically occurs
with femoral (not inguinal) hernias (4 false).
22304 – The lacunar ligament
Overall recurrence after hernia repair is low; but inguinal hernias have in general a higher recurrence
1: in the erect position, has the spermatic cord on its superoanterior surface
rate than do femoral hernias (5 true). A standard repair of an inguinal hernia defect in males must still
2: forms part of the posterior wall of the inguinal canal
leave a passageway for the spermatic cord through the inguinal canal. Repair of femoral hernias can
3: is attached to the pectineal line
obliterate or plug the femoral ring and femoral canal completely.
4: is attached to the pubic bone in continuity with the adductor longus
Answers: TFTF 940 – In direct inguinal hernia, the hernia sac

1: passes through the internal inguinal ring.
Last (8) PAGE: 297 2: passes through the posterior wall of the inguinal canal.
3: passes through the external inguinal ring.
22264 – The superficial inguinal nodes 4: lies within the internal spermatic fascia.
5: may contain urinary bladder.
1: consist of medial, lateral and vertical groups
2: receive lymph from subcutaneous tissues of the back below the waist
Answers: FTTFT
3: receive lymph from the gluteal region
4: receive lymph from the anal canal
Both indirect and direct hernias pass through the superficial (external) ring (3 true). However a direct
inguinal hernia (the sac of which is always acquired, and which thus occurs in an older age group)
Answers: TTTT
does not pass through the internal inguinal ring (1 false). A direct inguinal hernia passes through a defect
Last 8th ed. PAGE: 148 in the posterior wall of the inguinal canal (2 true), usually through the fascia transversalis within the
triangle of Hesselbach (bounded by the inferior epigastric vessels laterally, the lateral edge of rectus
medially and the inguinal ligament below). A direct hernia as it emerges from the external inguinal
23479 – The conjoint tendon (falx inguinalis) ring, lies not within the internal spermatic fascia of the spermatic cord as does an indirect hernia (4
1: has a free inferolateral border false), but behind the cord which it displaces forward. A portion of the urinary bladder, at the medial end
2: attaches to the superior pubic ramus of the inguinal canal, may occasionally protrude into the sac of a direct hernia. This needs to be
3: attaches along the pectineal line recognised at operation to avoid bladder injury (5 true).
4: is formed partly from aponeurotic fibres of the transversus muscle
Answers: TTTT 916 – In indirect inguinal hernia, all of the following statements concerning
the hernial sac are true EXCEPT
Last (8) PAGE: 302 A. Passes through the internal inguinal ring.
B. Passes through the external inguinal ring.
928 – Inguinal hernia is C. Runs within the spermatic cord
1: More common in male than in female patients. D. Requires total excision to prevent recurrence
2: More common than femoral hernia in female patients. E. Commences lateral to the inferior epigastric vessels
3: Likely to be indirect if the swelling is inguinoscrotal.
4: Classically associated with Richter type hernia (strangulation of part of bowel wall). Answers: D
5: More prone to recurrence after surgery than is femoral hernia.
An indirect inguinal hernia sac may be congenital or acquired. Inguinal hernias in childhood occur
Answers: TTTFT mostly into preformed sacs due to incomplete closure of the processus vaginalis.

Hamilton Russell, a prominent Australian surgeon, was a strong proponent of the congenital basis of E. supplies skin over the root of the penis
indirect inguinal hernias. In adult hernias the sac can be preformed but acquired sacs originating from
the internal inguinal ring are also common. Whether of congenital or acquired origin, the sac of an Answer: E
indirect inguinal hernia originates lateral to the inferior epigastric vessels and passes along the
inguinal canal within the spermatic cord, passing successively through the internal (deep) and Last (9) PAGE: 145; 304; 362
external (superficial) inguinal rings before giving a palpable groin swelling. (responses A, B, C, E all
true). Herniotomy (exploration followed by excision of the sac) is usual in open repair of an indirect 19887 – The ilio-inguinal nerve
inguinal hernia. Total sac excision (provided a sound repair of the orificial defect is performed) is not A. supplies the rectus abdominis
obligatory; and is contradicted in at least two clinical circumstances (D is false and thus is the correct B. enters the deep inguinal ring
answer). C. supplies the cremaster muscle
D. supplies the urethra
KEY ISSUE E. does none of the above
Left sided indirect inguinal hernias containing sigmoid colon are quite common in elderly patients and
are associated with a large indirect inguinal hernial sac. The serosa of sigmoid colon in this instance Answer: E
progressively descends as part of the wall of the sac. The bowel does not lie within the sac lumen, but
forms part of its posterior wall. These are known as sliding hernias ("hernia en glissade"). They Last 10th Ed, Ch 3, page 107
usually present clinically as large reducible inguinoscrotal hernias containing bowel. When diagnosed
the sac is simply closed and the defect of the inguinal ring repaired by any of the appropriate
23504 – The lumbosacral trunk
techniques.
1: contributes to the sacral plexus
2: first appears medial to the psoas major muscle
Occasionally the patent processus vaginalis forming a congenital sac remains in its embryonic form.
3: gives off the presacral nerve
This leads to a large inguinoscrotal hernia, and on exploration the lower part of the sac is found to be
4: does not contribute fibres to any cutaneous nerves
continuous with the coverings of the testis. The sac must be transected and its lower portion left in
situ on the testis and cord.
Answers: TTFF
21273 – Branches of the lumbar plexus which appear at the medial border Last 8th ed. PAGE: 310, 362, 398
of the psoas major are
1: obturator nerve 15002 – With regard to the obturator internus
2: ilio-hypogastric 1: the pudendal nerve lies adjacent to it
3: lumbo-sacral trunk 2: the internal pudendal artery lies adjacent to it
4: femoral nerve 3: the levator ani arises adjacent to its medial aspect
4: it forms a wall of the ischiorectal fossa
Answers: TFTF
Answers: TTTT
Last (8) PAGE: 356. Pending review. Jan 2003
19587 – The branch of the lumbar plexus which appears at the medial
border of the psoas major muscle is 22789 – The obturator internus muscle forms
A. iliohypogastric nerve 1: part of the lateral pelvic wall
B. sciatic nerve 2: a wall of the ischioanal fossa
C. femoral nerve 3: a boundary of the lesser sciatic foramen
D. obturator nerve 4: part of the pelvic floor
E. genitofemoral nerve
Answers: TTFF
Answer: D
Last (8) PAGE: 416
19785 – The obturator nerve often
20037 – The ilioinguinal nerve A. supplies the skin of the labium majus
A. supplies the rectus abdominus muscle B. divides into an anterior division which innervates pectineus
B. enters the deep inguinal ring C. may leave the pelvis through the greater sciatic foramen
C. supplies the cremaster muscle D. arises from anterior divisions of anterior rami of L2, L3 and L4
D. supplies the urethra E. emerges onto the sacrum to lie medial to the lumbosacral trunk
Answer: D 22934 – The nervi erigentes carry
1: motor fibres to the descending colon
Last 8th ed. PAGE: 398 2: sensory fibres from the trigone of the bladder
3: postganglionic parasympathetic fibres
7839 – The obturator nerve 4: branches of the sympathetic trunks
1: arises from the anterior divisions of the posterior rami of L2, L3 and L4
2: lies above the obturator vessels on the lateral wall of the pelvis Answers: TTFF
3: supplies the gracilis muscle
4: has no sensory branches Last (8) PAGE: 398
Answer: FTTF 14576 – The urogenital diaphragm

1: contains the external urethral sphincter
Last 10th ed, Ch 3 and Ch 5 2: lies above the perineal membrane
3: contains the deep transverse perineal muscle
23494 – The obturator nerve 4: is contained by the deep perineal pouch
1: has an anterior branch which is anterior to the adductor longus muscle
2: is lateral to the ureter in the pelvis Answer: TTTT
3: has a posterior branch which supplies the obturator externus muscle
4: supplies both the knee and hip joints Refer to Last, 10th Ed, page 285
Answers: FTTT 22649 – The urinary bladder

1: is related to the cervix uteri and anterior wall of the vagina
Last (6) PAGE: 341, 357, 144 2: has pain sensation through the superior hypogastric plexus only
3: contains mucus glands in the submucosa
8465 – The obturator nerve 4: has a base which is covered by peritoneum
1: pierces the medial border of the psoas muscle
2: supplies the obturator internus muscle Answers: TFFF
3: arises from anterior divisions of ventral rami of L2, L3, L4
4: passes lateral to the sacroiliac joint Last (8) PAGE: 384; 365
Answers: TFTF 7652 – The urinary bladder has

A. a base posteriorly which is completely covered by peritoneum
Last 10th ed, Ch 5 B. an internal urethral sphincter in both sexes
C. a parasympathetic nerve supply from the vagus nerve
20505 – S. Pain associated with an obstructed obturator hernia is referred D. a sensory nerve supply via the parasympathetic pathway
along the medial thigh BECAUSE R. the obturator nerve straddles adductor E. mucous glands in the submucosa
brevis and supplies medial thigh sensation
Answer: D
Last 10th ed, Ch 5
Last 10th Ed, Ch 3, page 118-119
8555 – The trigone of the bladder is
1: smoother than the rest of the lining of the bladder
15375 – The levator ani receives its motor nerve supply from
2: immediately adjacent to the apex of the prostate
1: the inferior hypogastric plexus on its pelvic surface
3: the least mobile part of the bladder
2: the pudendal nerve on its perineal surface
4: attached to the side wall of the pelvis by way of the lateral ligament of the bladder
3: the coccygeal plexus
4: the perineal branches of S3 and S4 on its pelvic surface
Answers: TFTF
Answers: FTFT
Last 10th ed, Ch 5
Refer to Last, 10th Ed, Ch 5, page 283-284. Question reviewed and updated July 03.

27663 – During radical prostatectomy the common sources of major 22554 – The ductus deferens
bleeding include 1: is ampullated posterior to the prostate
1: dorsal vein complex of the penis 2: lies lateral to the epididymis at its commencement
2: bladder neck vessels 3: lies medial to the seminal vesicles at its termination
3: external iliac vessels 4: is lined by stereo-ciliated columnar epithelium
4: neurovascular bundles to the penis, containing cavernosal arteries and veins
5: internal iliac vessels Answers: FFTT
Answers: TFFTF Last 8th ed. PAGE: 386
The common sites of bleeding during a radical prostatectomy include the dorsal vein complex of the 15224 – The terminal part of the ductus deferens
penis, a large venous complex anterior to the urethra (1 True). This dorsal vein complex needs to be A. lies lateral to the seminal vesicles
controlled and divided in order to expose the apex of the prostate during the dissection. The B. is a storehouse for spermatozoa
neurovascular bundles to the penis to assist in erectile ability run posterior to the lateral prostatic C. is lined by transitional epithelium
fascia immediately in the groove between the prostate and the lateral surface of the rectum. As the D. is crossed superiorly by the ureter
prostate is being dissected off the rectal surface, disruption of these neurovascular bundles are E. opens onto the urethral crest of the prostate, separate from the ejaculatory duct
common leading not only to intra-operative bleeding but also to post-operative potency difficulties (4
True). Although minor bleeding can be identified at the bladder neck from vessels originating from the Answer: B
inferior vesical pedicles, this is usually negligible; and both iliac vessels should be well outside the
field of dissection and would be uninjured during a routine radical prostatectomy (2, 3 & 5 False). Refer to Last, 10th Ed, Ch 5, page 292
19264 – The seminal vesicles 22514 – The ejaculatory ducts

A. lie medial to the termination of each ductus deferens 1: are formed by the union of the prostatic ducts and the ducts of the seminal vesicles
B. are posterior relations of the prostate gland 2: lie on the posterior surface of the bladder
C. are posterior relations of the bladder 3: open into the membranous urethra
D. empty directly into the prostatic urethra 4: open on the sides of the urethral crest
E. can normally be felt through the posterior wall of the rectum
Answers: FFFT
Answers: C
23729 – The mesonephric (Wolffian) ducts
22654 – The seminal vesicles 1: form the prostatic utricle
1: are partly invested by the peritoneum of the rectovesical pouch 2: form part of the epoophoron
2: are lined by ciliated simple columnar epithelium 3: form part of the paroophoron
3: terminate in ejaculatory ducts which enter the apex of the prostate 4: form part of the bladder wall
4: separate the terminal parts of the ureters from the bladder wall
Answers: FTFT
Answers: TFFF
Last (8) PAGE: 387
8480 – In the male
15355 – The ductus deferens 1: the deep dorsal vein of the penis remains closed during erection of the penis
1: lies lateral to the external iliac artery 2: the corpus spongiosum is continuous distally with the glans penis
2: crosses the ureter 3: the openings of the ejaculatory ducts lie lateral to the prostatic utricle
3: is crossed anteriorly by the obturator nerve 4: the prostatic utricle is the homologue of the uterus
4: passes lateral to the inferior epigastric artery
Answers: FTTT
Answers: FTFT
Last 10th ed, Ch 5
Refer to Last, 10th Ed, Ch 5, page 225-226. Question to be reviewed at the March 04 meeting re: all
answer options and the "definition" of lateral (20/02/04). 2674 – The corpus cavernosum
1: is firmly anchored posteriorly to the perineal membrane
2: is enclosed in the tunica albuginea Symptomatic varicocele is usually treated with a high ligation of the gonadal vein above the
3: has venous drainage into the prostatic venous plexus pampiniform plexus (2 False). Ligation may be at the level of inguinal canal or in the retroperitoneum.
4: is supplied by the deep artery to the penis Division of the gonadal vein during other abdominal surgery has no apparent effect. Ligation
presumably relieves the pressure effect of the column of blood exerted down the gonadal vein in the
Answers: TTTT standing position. Venous infarction does not occur as alternative venous return channels develop
and open up. The pampiniform plexus drains into the gonadal vein which drains into the left renal
Last 8th ed. Page: 408 & 409 vein (or IVC on right) (3 True). Primary varicocele is usually unilateral and is most frequently found
on the left side (4 False).
19881 – The testis
A. has lymph drainage to common iliac nodes 27712 – Concerning varicocele
B. receives an arterial supply from the deep exyernal pudendal artery 1: a renal ultrasound should be obtained at the time of diagnosis of varicocele
C. receives parasympathetic innervation via the nervi erigentes 2: if unilateral, varicoceles are commoner on the right side
D. has venous drainage on both sides to the renal veins 3: injection of sclerosants is the preferred method of treatment
E. descends to the deep inguinal ring by the seventh month in the male foetus 4: varicoceles are more easily diagnosed with the patient recumbent
Answer: E Answers: TFFF
Last (9) PAGE: 305, 308 Varicocele is usually primary but may result from obstruction of the renal vein, particularly the left, by
renal cell carcinoma (1 True).
19569 – The testis Primary varicoceles in young males are more frequent on the left (2 False) - perhaps related to the
A. has a venous drainage ending on both sides in the renal veins differing anatomy of the left-sided gonadal vein compared to the right, or to the fact that males more
B. has the sinus epididymis on its posteromedial aspect commonly 'dress on the left'! More importantly, any recently appearing varicocele on either side in
C. has a lymph drainage to the superficial inguinal nodes older males should raise the suspicion of a renal tumour, so check clinically and by imaging.
D. is continuous with the lobules of the epididymis via the efferent ductules The preferred treatment is high gonadal vein ligation (3 False). Sclerosant injection and local surgery
E. has a sensory innervation from the pelvic parasympathetics are each hazardous and ineffective. Varicoceles are best diagnosed with the patient standing, and
give the characteristic 'bag of worms' sign. They collapse on recumbency (4 False).
Answer: D
27701 – Concerning vasectomy
Last (6) PAGE: 263 1: the operation is best performed through an inguinal approach to minimise damage to the
pampiniform plexus
23099 – The testis 2: there is a 1:5000 risk of spontaneous recanalisation of the vas
1: has a rete testis composed of straight tubules 3: the patient must wait 2 weeks before having intercourse without contraception
2: has Sertoli cells adjacent to the basal lamina of the seminiferous tubules 4: vasectomy can be performed adequately under either local or general anaesthesia
3: has primary spermatocytes adjacent to the basal lamina of the seminiferous tubules 5: there appears to be a strong relationship between vasectomy and prostate cancer
4: drains lymph to the para-aortic nodes
Answers: FTFTF
Answers: FTFT
Response 1 is False - I hope you did not fall for that one!!
Last (6) , Leeson & Leeson PAGE: 263 (Last), 510 et. seq. (L & L) Response 2 is True - Patients must be warned of this pre-operatively.
Patients require 25 ejaculations or 10 weeks before a semen analysis is made (3 False). Only when
27707 – Concerning varicocele this semen analysis is clear can other forms of contraception be withdrawn.
Either general or local anaesthesia may be used (4 True).
1: the most common presentation of varicocele is infertility
Several years ago a large study suggested a relationship between vasectomy and prostate cancer
2: accidental ligation of the gonadal vein at laparotomy results in varicocele
but this has been since refuted (5 False). On this happier note we conclude this commentary.
3: a varicocele is a dilatation of the pampiniform plexus of testicular veins (above the testes)
associated with venous failure/incompetence in the gonadal vein
4: varicocele is usually bilateral 19228 – The nerve supply of the testis is
A. ilio-inguinal nerve
Answer: FFTF B. genital branch of genito-femoral nerve
C. sympathetic nerves
Varicocele is fairly common and is seen in approximately 15% of young men. The majority of such D. parasympathetic nerves
men are asymptomatic. Patients may present with dragging discomfort, particularly following E. all of the above
prolonged standing or lifting. Varicocele may occasionally be associated with infertility and testicular
atrophy, but this is not the most common presentation (1 False).

Answer: C 21523 – The cutaneous nerves of the scrotum include
1: scrotal branches of the perineal nerve
Last 8th ed. PAGE: 306 2: twigs from the anterior branch of the obturator nerve
3: anterior scrotal branches of the ilio-hypogastric nerve
20109 – S. Ligation of the testicular artery carries a risk of atrophy of the 4: the ilio-inguinal nerve
testis BECAUSE R. the artery of the vas, which anastomoses with the
testicular artery, is small Answers: TFFT
Last (6) PAGE: 351

Last 8th ed. PAGE: 308 7102 – The most constricted part of the male urethra is
A. at the external meatus
B. where it pierces the perineal membrane (inferior fascia of the pelvic diaphragm)
24099 – The internal spermatic fascia is derived from
C. at the apex of the prostate
1: transversalis fascia
D. at the level of the urethral crest
2: tansversus abdominis muscle
E. at the internal meatus
3: internal oblique muscle
4: external oblique muscle
Answer: A
Answers: TFFF
The external meatus is the narrowest portion of the male urethra; the constriction focusses and
spirals the urinary stream.
Last (6) PAGE: 263
22309 – The contents of the spermatic cord in the inguinal canal include 7694 – S:Continence of urinary function is ensured by the integrity of the
1: the ductus deferens sphincter urethrae externus because R:the sphincter urethrae externus can
2: the cremaster muscle maintain urinary continence even if the internal sphincter is weak or
3: the obliterated processus vaginalis incompetent
4: the ilio-hypogastric nerve
Answers: TFTF
Last 10th ed, Ch 5
Last 8th ed. PAGE: 304-305. Question has been reviewed and updated July 03.
22219 – The perineal membrane
19575 – A structure never included amongst the components of the 1: is attached to the ischio-pubic rami
spermatic cord is 2: in the male is pierced by the deep dorsal vein of the penis
A. the genital branch of the genitofemoral nerve 3: in the male is pierced by the ducts of the bulbo-urethral glands
B. the processus vaginalis 4: lies above the dorsal nerve of the penis
C. the testicular artery
D. the ilioinguinal nerve Answers: TFTF
E. sympathetic fibres from T10
Answer: D
15007 – The superficial perineal pouch
Last (8) PAGE: 304 1: contains the ischio-cavernosus muscle
2: is enclosed by the superficial perineal fascia of Colles
20355 – S. The scrotum is not anaesthetized by a low spinal 3: contains the vestibular glands
anaesthetic BECAUSE R. the skin of the anterior third of the scrotum is 4: extends in front of the symphysis pubis
innervated by the first lumbar segment of the spinal cord
Answers: TTTT
Answers: S is true, R is true and a valid explanation of S
Refer to Last, 10th Ed, page 310
22669 – The superficial perineal pouch
1: is traversed by only the urethra in the male
2: has a membranous covering which provides a fascial sheath around the penis
3: contains the testes
4: is limited inferiorly by the perineal membrane
Answers: TTTF
Last (8) PAGE: 408
20751 – S. Urine extravasated from a ruptured bulbous urethra can pass

into the scrotum BECAUSE R. the membranous layer of the superficial
fascia of the abdominal wall attaches to the external oblique aponeurosis
15388 – The contents of the deep perineal pouch in the male include the
1: bulbo-urethral glands
2: internal pudendal artery
3: membranous urethra
4: sphincter urethrae muscle
Answers: TTTT
27502 – The broad ligament

1: has the ovarian artery in its lower attached border
2: has the ureter passing forward in its lower attached border
3: is the main support of the uterus
4: has the uterine artery cross anterior to the ureter within its lower attached border
Answers: FTFT
The broad ligament is a loose double fold of peritoneum rather than a ligament; as a result it offers
little support to the uterus (3 False). The uterus is supported by the transverse cervical ligaments
which extend laterally to the side wall of the pelvis from the cervix and vaginal fornix on the pelvic
floor, within the lower attached border of broad ligament; by the uterosacral ligaments which extend
backwards from the cervix to the front of the sacrum, running lateral to the recto-uterine pouch; and
by (most importantly) the levator ani muscle.
The ureter, uterine artery and inferior hypogastric plexus all traverse the connective tissue of the
transverse cervical ligament which is at the base of the broad ligament (2 True). The ovarian vessels
(artery, vein and lymphatics) are contained in the upper lateral part of the broad ligament (1 False).
The relationship of the ureter and uterine artery, which cross each other within the transverse cervical
ligament (4 True), is critical in hysterectomy as both the ligament and the uterine artery (but not the
ureter!) need to be divided. The relationship of these structures is seen in Fig 5.59 of Sinnatamby CS,
Last's Anatomy, Churchill Livingstone, 1999, 10th Edition and in Figure 2.
Key Issue The uterine artery, along with other anteriorly-running branches of the internal iliac artery,
runs initially on the side wall of the pelvis and as it runs forwards is crossed on its medial aspect by
the ureter running down the lateral pelvic wall. The uterine artery then curves inwards to enter the

transverse cervical ligament and runs to the cervix and uterus. As it runs medially it lies anterior to the Answers: FTTT
ureter and again crosses the ureter as the latter inclines forwards to the bladder.
As can be seen in Fig. 5.61 (Sinnatamby CS, Last's Anatomy, Churchill Livingstone, 1999, 10th
20943 – S. The broad ligament forms the most important ligamentous Edition) there is a direct extra-peritoneal relationship of the uterus, via its cervical part, to the bladder
support of the uterus BECAUSE R. the broad ligament attaches the whole anteriorly; but not to the rectum posteriorly (1 False, 2 True). The word "direct" is used as "indirect" is
redundant - The distinction is direct OR otherwise. In addition observe the angulation of the uterus and
body of the uterus to the lateral wall of the pelvis vagina of 90 degrees or more (3 True). The pubovaginalis part of the levator ani, and the perineal body,
support the vagina and cervix of the uterus (4 True). Uterine prolapse or retroversion may follow damage
Answer: S is false and R is true to these structures during childbirth. Question has been reviewed and will remain unchanged. Dec 03
Last 10th ed. PAGE: 293; 294
27508 – The uterus
1: derives its entire blood supply from the uterine arteries
27523 – The right ovary 2: has no sympathetic autonomic nerve supply
1 : is covered by peritoneum in the adult 3: is posteriorly covered by peritoneum to a greater extent than anteriorly
2: has its lymphatic drainage to internal iliac nodes 4: has in the wall of its body as much fibrous tissue as muscular tissue
3: has a mesovarium attached equatorially around the ovary
4: is attached to the anterior (inferior) layer of the broad ligament Answers: FFTF
Answers: FFTF The blood supply of the uterus is derived primarily from the uterine artery with significant
anastomoses with the vaginal arteries below and ovarian arteries above (1 False).
The ovary is covered with cubical cells rather than the flattened mesothelium of the peritoneum (1 The uterus receives branches from the inferior hypogastric plexus with the sympathetic elements
False). The junction is usually marked by a fine white line around the anterior (mesovarian) border of being vasoconstrictor (2 False). Parasympathetics convey pain from the cervix but not from the body
the ovary. The mesovarian border runs equatorially along the anterior border of the ovary attaching to of the uterus. Abolition of uterine sensation requires division of all nerves, or transection of the cord,
the posterior (superior) leaf of the broad ligament (3 True, 4 False). above T10 level.
The lymph drainage follows the ovarian artery to its origin at the L2 level of the aorta, thus involving
The peritoneal covering can be seen to be more extensive posteriorly (3 True, Fig 5.60 Sinnatamby CS,
para-aortic nodes at this level (2 False).
Last's Anatomy, Churchill Livingstone, 1999, 10th Edition), coming to a level below the cervix. This
gives potential access to the peritoneal cavity through the posterior fornix of the vagina.
20151 – S. Pain from the ovary may be referred to the skin on the medial The uterus is composed of three ill-defined layers of smooth muscle. It is only in the vaginal portion of
side of the thigh BECAUSE R. the obturator nerve supplies the parietal the cervix that the muscle is almost completely replaced by elastic and fibrous tissue (4 False).
peritoneum adjacent to the ovary
7799 – The cervix of the uterus
Answer: S is true, R is true and a valid explanation of S 1: is related laterally to the ureters and uterine arteries
2: is attached to the base of the bladder anteriorly
Last 9th ed. PAGE: 214 3: is separated from the rectum by the recto-uterine pouch
4: is the most freely moveable part of the uterus
A. has a supravaginal cervix separated from the bladder by peritoneum Answers: TTTF
B. sometimes sends lymph vessels to the superficial inguinal lymph nodes
C. depends for its support mainly on the round ligaments Last 10th ed, Ch 5. This question will be submitted for review at the March 2004 meeting, regarding
D. is in extraperitoneal contact with the rectum the re-wording of option (27/02/2004)
E. has a cervix lined throughout with stratified squamous epithelium
8560 – The uterine artery
Answer: B 1: arises from the anterior division of the internal iliac artery
2: supplies the vaginal vault
Last 8th ed. PAGE: 389 3: supplies the medial part of the uterine tube
4: crosses above the ureter in the broad ligament
1: has a direct extra-peritoneal relation to the rectum in its cervical portion Answer: TTTT
2: has a direct extra-peritoneal relation to the bladder in its cervical portion
o
3: forms an angle of 90 or more with the vagina Last 10th ed, Ch 5
4: is supported by levator ani muscle
27497 – The uterine (Fallopian) tube
1: is lined by non-ciliated columnar epithelium
2: undergoes cyclical change during the menstrual cycle Answers: FTTT
3: is developed from the paramesonephric duct
4: is narrower at its lateral than its medial end Last's 9th Ed., p378. Updated Nov 2003.
Answers: FTTF 22209 – With respect to the rectum

1: there is an incomplete outer layer of longitudinal muscle
The uterine tube is lined by a mixture of ciliated and non-ciliated columnar cells (1 False). The cilia 2: the fascia of Denonvilliers separates the anterior wall of the rectum from the prostate and seminal
are most abundant at the fimbriated end of the tube and beat towards the uterus. The tube is vesicles
composed of two layers of muscle (inner circular and outer longitudinal). The tube widens laterally at 3: the lateral ligament of the rectum contains the middle rectal artery
the ampulla and infundibulum (4 False). 4: the fascia of Waldeyer suspends the rectum in the hollow of the sacrum
The uterine tube is influenced by both ovarian hormones (2 True). Oestrogens cause the glandular
tissues to proliferate, as well as an increase in both the number and activity of ciliated cells. Answers: FTTT
Progesterone promotes secretory changes to enhance nourishment of the fertilised, dividing ovum as
it traverses the tube. Last (8) PAGE:
The paramesonephric (Mullerian) ducts begin to develop in the sixth week as a groove-like
invagination of the coelomic epithelium on the lateral aspect of the mesonephric ridge. The upper
15380 – The following structures separate the distended rectum from the
(cranial) vertical part forms the uterine tube whilst the lower (caudal) parts of right and left
paramesonephric ducts ultimately fuse to form the uterus (3 True). sacrum and coccyx
1: the ganglion impar
2: the sacral part of the sympathetic trunk
27518 – The following open into the vestibule of the vagina
3: the piriformis muscle
1: urethra
4: the inferior hypogastric plexuses
2: para-urethral glands
3: greater vestibular glands (Bartholin's glands)
Answers: TTTF
4: bulbo-urethral glands (Cowper's glands)
Answers: TTTF
The vestibule of the vagina is the cleft between the labia minora. In it are the orifices of both the 3361, 20641 – S:Abdomino-perineal resection in the male can result in
vagina and external urethra. In addition there are the mucous glands (para-urethral glands) which failure of erection because R:damage to the sympathetic fibres may occur
open just inside the external meatus whilst the ducts of the greater vestibular (Bartholin's) glands during the operation of abdomino-perineal resection
open on each side just below the hymen in the postero-lateral wall (1, 2 and 3 True). Cowper's
glands (bulbo-urethral) are found in the male lying above the bulb of the penis with a 3 cm excretory Answer: S is true, R is true but not a valid explanation of S
duct entering the spongy portion of the urethra 2.5 cm below the inferior fascia of the urogenital
diaphragm (4 False). Last 8th ed. PAGE: 386. The mechanism of erection, though incompletely understood, involves
vasodilatation of arteries of the erectile tissue of the corpora. This vasodilatation is mediated by pelvic
22509 – The rectum has peritoneum parasympathetic nerves. These may be injured during excision of the rectum (S true). Sympathetic
1: on its lateral surface for its upper 2/3 fibres derived from T11 and T12 mediate ejaculation by stimulating contraction of smooth muscle in
2: on its anterior surface for the upper 2/3 the epididymis, ductus deferens, seminal vesicle, ejaculatory duct and prostate. These may be
3: surrounding its upper 2/3 damaged during abdomino-perineal resection (R true). Injury to the sympathetic fibres controlling the
4: on its lateral surface for its upper 1/3 internal urethral opening of the bladder neck may allow retrograde ejaculation into the bladder. Failure
of erection is not due to injury to sympathetic fibres.
Answers: FTFT
13355 – S:The anterior surface of the ampulla of the rectum can be
Last (9) PAGE: 378 separated from the posterior surface of the prostate at operation without
22794 – The rectum bleeding because R:peritoneum descends to the apex of the prostate
1: is covered laterally by peritoneum in its upper two-thirds between it and the rectum
2: has no taeniae coli
3: has an ampulla which is concave to the left Answer: S is true and R is false
4: has permanent folds running transversely, consisting of mucous membrane and circular smooth
muscle Sharp dissection is necessary to separate the ampulla of the rectum from the posterior surface of the
prostate at operation. The rectovesical pouch does not extend behind the prostate in the adult (R
false). In the fetus the rectovesical pouch extends down to the pelvic floor to the apex of the prostate
between prostate and rectum. Fusion of anterior and posterior layers of the pouch makes it more
shallow, and the fused layers persist in the adult as a membrane between the rectovesical pouch and 21813 – Pectoralis major
the pelvic floor. The membrane covers the seminal vesicles and posterior surface of the prostate and 1: arises from the upper eight ribs
is called the rectovesical fascia (of Denovilliers). The anterior wall of the rectum is freely mobile over 2: is inserted into the medial lip of the bicipital groove
the fascia and once the space is entered between the two layers by incising the peritoneum in the 3: is a powerful flexor of the gleno-humeral joint
floor of the rectovesical pouch an avascular plane is found between rectum and prostate right down to 4: is supplied by all five segments of the brachial plexus
the apex of the prostate (S true).
Answers: FFFT
22684 – The superior rectal artery
1: crosses the bifurcation of the left common iliac artery Last 10th Edition Page 36
2: freely anastomoses with the inferior rectal artery in the submucosa
3: is a direct continuation of the inferior mesenteric artery 22299 – Pectoralis minor muscle
4: crosses the ureter at the level of the sacroiliac joint 1: is supplied by fibres from C5 root
2: arises from the second, third and fourth costal cartilages
Answers: TTTF 3: is an adductor of the shoulder joint
4: inserts into the medial border and upper surface of the coracoid process of the scapula
Last 8th ed. PAGE: 329; 381; 403
Answers: FFFT
22214 – The anal valves
1: are felt on rectal examination Last 10th Edition, page 36
2: lie above a smooth surfaced area of the anal canal
3: lie inferior to the pectinate line 24064 – The clavi-pectoral fascia is pierced by
4: are at the lower end of the anal columns 1: the cephalic vein
2: the medial pectoral nerve
Answers: FTFT 3: lymphatics passing from the infraclavicular nodes to the apical nodes of the axilla
4: the superior thoracic artery
Answers: TFTF
19324 – The internal sphincter of the anal canal Last PAGE: 55

A. is a striated muscle
B. is supplied by the perineal nerve 22834 – The axillary artery
C. is without bony attachments 1: terminates at the inferior border of the ters major
D. is a continuation of the longitudinal muscle coat of the rectum 2: lies posterior to the medial pectoral nerve
E. surrounds the lower 2/3 of the anal canal 3: has its corresponding vein on its medial side
4: begins at the medial border of the pectoralis minor
Answer: C
Answers: TFTF
Last (8) PAGE: 403
Last 10th Edition, page 48. Trainee disagrees with answer option B. Review November 2004.
20439 – S. The ischio-rectal fossa extends anteriorly above the urogenital
diaphragm BECAUSE R. the ischio-rectal fossa extends forwards below the 12743 – In the axilla
levator ani muscles which are attached to the body of the pubic bone above 1: the long thoracic nerve runs on the medial wall deep to the fascia over serratus anterior muscle
2: the axillary (circumflex) nerve leaves the axilla by passing through a space bounded by humerus,
the level of the urogenital diaphragm long head of triceps, subscapularis and teres major
3: the thoraco-dorsal nerve runs on the posterior wall accompanied by a vascular pedicle
4: the musculocutaneous nerve pierces the coraco-brachialis muscle
Answers: TTTT
The long thoracic nerve (nerve to serratus anterior) arises from the posterior aspects of the nerve
UPPER LIMB roots C5, 6 and 7. The nerve emerges on the surface of scalenus medius, crosses the first rib to lie
on serratus anterior in the medial wall of the axilla, deep to its fascia (A true) and runs vertically
downwards behind the mid-axillary line to supply the muscle segmentally. The axillary (circumflex)
nerve, from the posterior cord of the brachial plexus, gives no branches in the axilla, and leaves it Answers: FTFF
immediately through the quadrangular space (B true) to run around the neck of the humerus. The
thoraco-dorsal nerve (nerve to latissimus dorsi), from the posterior cord, descends through the axilla Last 10th Edition, page 50
to the posterior wall, to enter and supply latissimus dorsi. It is accompanied by the subscapular
vessels, which are initially anterior to the nerves, but reverse their position in the lower axilla (C true). 20067 – S. In a lesion of the upper trunk of the brachial plexus function of
The musculocutaneous nerve (C7), from the lateral cord, pierces the coracobrachialis muscle after
levator scapulae and rhomboids may be preserved BECAUSE R. the dorsal
supplying it (D true). After supplying biceps and brachialis muscles it becomes the lateral cutaneous
nerve of the forearm. scapular nerve arises from the root of C5
7108 – In performing an axillary dissection, you should remember that Answer: S is true, R is true and a valid explanation of S
A. the long thoracic nerve runs on the medial wall of the axilla anterior to the midaxillary line
Last 10th Edition, pages 50, 51, 89
B. the thoracodorsal nerve runs on the lateral wall of the axilla
C. the medial pectoral nerve pierces the clavipectoral fascia to supply pectoralis major muscle on its
deep surface 20637 – S. Division of the upper trunk of the brachial plexus will produce
D. the intercostobrachial nerve crosses the axilla within the axillary fat weakness of shoulder abduction BECAUSE R. the suprascapular,
E. the axillary sheath, an extension of the prevertebral fascia, invests both axillary artery and vein subscapular, and axillary nerves arise from the posterior cord
Answer: D Answer: S is true and R is false
The intercostobrachial nerve (T2) is purely sensory and supplies a variable amount of skin on the Last 10th Edition, page 50
inner aspect of axilla and upper arm. It crosses the axilla after emerging from the second intercostal
space in the midaxillary line. It runs within axillary fat to the upper arm, surrounded by lymph nodes of 20799 – S. A lesion involving the C5 and C6 nerve roots does not result in
the axilla. It can be preserved during axillary clearance; but this usually involves compromising the
dissection somewhat, and the nerve is usually excised with the specimen in a complete therapeutic loss of abduction at the shoulder BECAUSE R. the C5 and C6 nerve roots
axillary clearance. Patients should be warned to expect an area of anaesthesia, which diminishes are distributed to the muscles which produce flexion at the elbow
gradually with time.
21603 – The first thoracic spinal nerve
1: supplies fibres to the musculocutaneous nerve Last 10th Edition, pages 50, 51
2: supplies the parietal pleura of the first intercostal space
3: carries postganglionic sympathetic fibres to the upper limb 22294 – Branches from the medial cord of the brachial plexus include
4: is the largest of the thoracic nerves 1: the upper subscapular nerve
2: the medial pectoral nerve
Answers: FTTT 3: the medial cutaneous nerve of the forearm
4: the musculo-cutaneous nerve
Last 10th ed. PAGE: 50; 176; 205
Answers: FTTF
21413 – Fibres from the first thoracic segment of the spinal cord supply
1: the intrinsic muscles of the hand Last 10th Edition, page 51
2: the dilator pupillae muscle of the iris
3: sweat glands on the face 20757 – S. Division of the lateral cord of the brachial plexus at its origin will
4: part of the levator palpebrae superioris muscle produce some weakness of adduction of the arm Because R. division of the
lateral cord of the brachial plexus at its origin results in loss of function in
Answers: TTTT
the medial pectoral nerve
Last PAGE: 063
21113 – The upper trunk of the brachial plexus
Last 10th Edition, pages 50, 51
1: forms behind the scalenus medius muscle
2: is covered anteriorly by the prevertebral fascia
3: gives off the dorsal scapular nerve 7748 – S:In tetraplegia sparing the C6 root but complete below that, the
4: lies anterior to the cervical sympathetic trunk power of elbow extension is preserved because R:triceps is supplied by
the C5 and C6 roots
Answer: E
Last 10th Edition, pages 46, 47
Last 10th ed, Ch 1 and Ch 2
21108 – The serratus anterior
14884 – S:The axillary vein lies external to the axillary sheath 1: is supplied by the thoraco-dorsal nerve
because R:the subclavian vein passes anterior to the prevertebral fascia, 2: is a retractor of the scapula
3: helps in elevating the arm above shoulder level
from which the axillary sheath is derived
4: is a medial rotator of the scapula
Answers: FFTF
Last 10th Edition, page 40
1948 – Scapular muscles contributing to the rotator cuff 24034 – The deltoid muscle
1: are supplied by nerves arising from upper trunk and posterior cord
1: consists of short multipennate fibres in its central part
2: are attached to the capsule of the shoulder joint
2: has an origin which includes the upper surface of the lateral third of the clavicle
3: are the principal muscles involved in lateral rotation at the shoulder
3: has the cephalic vein lying medial to its anterior edge
4: act to brace the head of the humerus against the glenoid fossa
4: is supplied by nerve fibres from the C6 root only
Answers: TTTT
Answers: TTTF
Last 10th Edition, pages 42-46. Question reviewed and updated Nov 03.
21138 – Lateral rotation of the arm at the glenohumeral joint is 21133 – The deltoid muscle (or part of it) assists in
1: an associated movement in abduction of the upper arm at the glenohumeral joint
1: flexion of the arm at the glenohumeral joint
2: produced by the contraction of muscles supplied by the fifth cervical spinal nerve
2: abduction of the arm at the glenohumeral joint
3: produced by the contraction of the infraspinatus muscle
3: extension of the arm at the glenohumeral joint
4: produced by the contraction of the subscapularis muscle
4: steadying the arm in the abducted position
Answers: TTTF
Answers: TTTT
Last 10th Edition, pages 42-44
21118 – The infraspinatus muscle 22524 – The scapula
1: is covered, along with teres major, by a dense fascial membrane
1: is raised upwards on the chest wall by the trapezius muscle
2: is inserted anterior to the supraspinatus tendon
2: ossifies in membrane
3: is a medial rotator of the humerus
3: has rhomboid major muscle attached from the inferior angle to the base of the scapular spine
4: is supplied by the subscapular nerve
4: has the glenoid fossa facing directly lateral
Answers: FFFF
Answers: TFTF
19845 – The muscle pair which most often assists in elevating the arm 21158 – The scapula
above the head is the 1: has the latissimus dorsi muscle attached to its inferior angle
A. trapezius and pectoralis minor 2: is moved forwards on the chest wall by the serratus anterior muscle
B. levator scapulae and serratus anterior 3: has a glenoid angle developed from two centres of ossification
C. rhomboid major and serratus anterior 4: is rotated by the trapezius muscle so that the glenoid faces upwards
D. rhomboid major and levator scapulae
E. trapezius and serratus anterior Answers: TTTT

22274 – The acromio-clavicular joint
1: lies anterior to the origin of the coraco-acromial ligament 22829 – The quadrilateral space
2: is a synovial joint with a fibro cartilaginous disc 1: lies in the posterior wall of the axilla
3: has a strong capsule 2: is bounded by subscapularis and teres major
4: relies upon the conoid and trapezoid ligaments for stability 3: is bounded by the humerus laterally and the long head of triceps medially
4: transmits the axillary nerve and anterior circumflex humeral artery
Answers: FTFT
Answers: TTTF
Last 10th Edition, page 41. This question is currently under review by the sub committee. 4 June
2002. Last PAGE: 62
19857 – Which of the following structures is not attached to the coracoid 23149 – In the arm
process of the scapula 1: brachialis may be partly innervated by the radial nerve
A. short head of biceps brachii muscle 2: the radial nerve pierces the lateral intermuscular septum below the origin of brachio-radialis
B. trapezoid ligament 3: the ulnar nerve pierces the medial intermuscular septum below the insertion of coraco-brachialis
C. pectoralis minor muscle 4: the lateral cutaneous nerve of the forearm is given off by the radial nerve in the spiral groove
D. a major anterior stabilizer of the glenohumeral joint
E. subclavius muscle Answers: TFTF
Answer: E Last 10th Edition, pages 55-60
Last PAGE: 113 19521 – Which of the following muscles is NOT a medial rotator of the
humerus at the shoulder joint?
19000 – The transverse scapular ligament (transverse ligament of the A. pectoralis major
scapular notch) B. latissimus dorsi
A. often lies above the suprascapular artery C. teres major
B. usually gives partial origin to the omohyoid muscle D. teres minor
C. is a thickened portion of the axillary fascia E. subscapularis
D. can be attached to the spine of the scapula
E. often lies below the suprascapular nerve Answer: D
Answer: B Last 10th Edition, pages 43, 44
Last 10th Edition, page 44 21168 – The lesser tuberosity of the humerus
1: gives attachment to the coracohumeral ligament
8505 – The long thoracic nerve 2: is ossified from the diaphysis
1: lies on the serratus anterior muscle 3: gives attachment to the infraspinatus muscle
2: is accompanied by the subscapular artery 4: gives attachment to the transverse ligament covering the long tendon of the biceps
3: runs behind the first part of the axillary artery
4: contains fibres from spinal segment C8 Answers: FFFT
Answers: TFTF Last 10th Edition, page 98
Last 10th ed, Ch 2 21183 – With respect to the arm

1: the musculo-cutaneous nerve passes between the two heads of the biceps muscle
20571 – S. Dissection of lymph nodes near the subscapular artery may 2: the median and ulnar nerves have no branches in the arm
3: the radial nerve supplies the brachialis, coraco-brachialis and brachio-radialis muscles in the arm
result in paralysis of the latissimus dorsi muscle BECAUSE R. the lower
4: the median nerve crosses the brachial artery from lateral to medial
subscapular nerve supplies the latissimus dorsi muscle
Answers: FTFT

Last 10th Edition, pages 56-58. This question is currently under review by the sub committee. 4 June E. may be pierced by the median nerve
2002.
Answer: C
21163 – The humerus
1: has a lesser tuberosity continuous with the medial lip of the bicipital groove Last 10th Edition, page 55
2: has a greater tuberosity which projects lateral to the acromion process
3: has a medial epicondyle whose ossific centre appears around the age of 5 years 0583 – S. Injury to structures running in the spiral groove of the humerus
4: has a capitulum whose ossific centre appears around the age of 2 years may produce sensory change on the extensor surface of the forearm
proximal to the wrist BECAUSE R. this area of skin is supplied by the
Answer: TTTT
superficial division of the radial nerve
12470, 19869 – The humerus has
A. a greater tuberosity located medial to the lesser tuberosity
B. the capsule of the shoulder joint attached along its entire anatomical neck
C. a capitulum which articulates with the olecranon process 19863 – Which one of the following nerves is NOT directly related to the
D. a covering of synovial membrane over its head humerus?
E. a greater tuberosity which projects further laterally than the acromion process of the scapula A. the radial nerve
B. the ulnar nerve
Answer: E C. the nerve to the lateral head of the triceps muscle
D. the axillary nerve
Last 10th Edition, pages 98, 99. The greater tuberosity lies lateral to the lesser, separated from it by E. the median nerve
the bicipital groove (A false). The capsule is not attached to the anatomical neck of the humerus
inferiorly (B false). The capitulum articulates with the radial head (C false). The synovial membrane is Answer: E
reflected at the articular margins, and does not cover the head (D false). The greater tuberosity
projects further laterally (E true) than the acromion, and can be so palpated in the living subject. Last 10th Edition, page 57
7754 – The upper end of the humerus 21153 – Division of the radial nerve in the spiral groove of the humerus will
1: has the subscapularis muscle attached to the greater tuberosity produce
2: has three epiphyses each of which fuses separately with the shaft 1: inability to extend the wrist
3: grows for a longer period than the lower end 2: loss of sensation on the dorsum of the radial three and a half digits and the web of the thumb
4: has the capsular ligament of the glenohumeral joint attached to the whole of the anatomical neck 3: inability to extend the interphalangeal joint of the thumb
4: inability to extend the interphalangeal joints of the fingers
Answers: FFTF
Answers: TFTF
Last 10th ed, Ch 2, pages 98-100
Last 9th Ed., p126. Updated Dec 03
21173 – The lower end of the humerus
1: develops four secondary centres of ossification 24274 – Division of the musculocutaneous nerve may result in
2: is cartilaginous at birth 1: weakness of supination
3: has part of the pronator teres muscle attached to it 2: anaesthesia of the lateral side of the forearm extending to the interphalangeal joint of the thumb
4: gives origin to the common extensor muscles from the posterior surface of the lateral epicondyle 3: weakness of elbow flexion
4: weakness of adduction at the shoulder
Answers: TTTF
Answers: TFTT
Last 10th Ed, Ch 2 PAGE: 51, 57. This question was referred to the Anatomy Sub Committee for
19486 – The medial intermuscular septum of the arm review on 1 Feb 2002. Question updated 14 March 2002. Review July 2004 re: entire question.
A. is often pierced by the basilic vein
B. often gives part origin to the long head of triceps 12763 – The brachial artery
C. may be pierced by the ulnar collateral artery 1: lies medial to the biceps tendon in the cubital fossa
D. may be pierced by the radial nerve 2: is crossed in the mid-upper arm from medial to lateral side by the median nerve
3: divides at the level of the radial tuberosity into its terminal branches
4: has the basilic vein lateral to it
Answers: TFTF
The brachial artery is palpable in the cubital fossa medial to the tendon of biceps (A true). In the mid-
upper arm the median nerve crosses the artery from the lateral to medial side (B false). The artery
usually divides at the level of the radial tuberosity (C true). The basilic vein is medial to the artery and
pierces the deep fascia to run with the artery from mid-arm level (D false).
28901 – The cephalic vein

1: the structure labelled 19 is supplied by the axillary nerve
2: the structure labelled 8 is supplied by the lateral pectoral nerve
3: the structure labelled 16 is supplied by the nerve to latissimus dorsi
4: the structure labelled 13 can be felt in the posterior axillary fold to contract on coughing
Answers: FFFT
Last 10th Edition, page 68. Review July 2004 re: typo?
21818 – The cephalic vein

1: in the distal arm, lies medial to the muscle belly of biceps
2: in the forearm, runs in the superficial fascia along the pre-axial border of the limb
3: in the proximal arm, lies under the deep fascia in the delto-pectoral groove

4: ends by joining the subclavian vein
Answer: E
Answers: FTTF
Last 10th Edition, page 61. Review July 2004 re: option B
Last 10th Edition, page 68. Pending review. Dec 2002
7829 – The extensor carpi radialis longus
22289 – Muscles arising from the radial collateral ligament of the elbow 1: is supplied by the posterior interosseous nerve
joint include 2: is inserted into the base of the third metacarpal bone
1: the flexor digitorum superficialis 3: lies superficial to the tendon of abductor pollicis longus
2: the brachio-radialis 4: arises from the lateral epicondyle of the humerus
3: the anconeus
4: the supinator Answers: FFFF
Answer: FFFT Last 10th ed, Ch 2, page 71
Last 10th Edition, pages 70, 72 2768 – Extensor carpi ulnaris

1: originates partly from the subcutaneous border of the ulna
21027 – S. Division of the median nerve in the cubital fossa will produce 2: is inserted into the fifth metacarpal bone
3: is supplied by the posterior interosseous nerve
weakness of supination of the forearm BECAUSE R. supinator is supplied
4: is inserted partly into the triquetrum
by the anterior interosseous division of the median nerve
Answers: TTTF
Extensor carpi ulnaris is supplied by the posterior interosseous nerve (C true). It has a humeral and
Last 10th Edition, page 94 an ulnar origin via an aponeurosis from the posterior subcutaneous border of the ulna (A true). It is
inserted into the base of the fifth metacarpal bone (B true). It is not inserted into the triquetrum (D
18838 – Concerning the ulna false).
A. the majority of growth takes place at the distal epiphyseal plate
B. ossification of the distal epiphyseal centre occurs in foetal life 20277 – S. The extensor digitorum is a comparatively weak extensor of the
C. the deep head of pronator teres arises from the medial border of the olecranon
inter-phalangeal joints of the fingers when the interossei are
D. the inferior articular facet articulates directly with the triquetrum
E. the annular ligament is attached to the ulnar shaft just below the radial notch paralysed BECAUSE R. most of the pull of the extensor digitorum is
expended in hyperextension of the metacarpophalangeal joints when the
Answer: A interossei are paralysed
Last's 9th Ed., p139. Question has been reviewed and remains unchanged. Dec 03. Answer: S is true, R is true and a valid explanation of S
25973 – The brachioradialis Last 8th ed. PAGE: 120

1: arises from the lateral epicondyle of the humerus
2: is a weak pronator of the supinated forearm 19851 – The posterior interosseous nerve
3: is supplied by the posterior interosseous nerve A. does not contain afferent fibres
4: is inserted into the base of the styloid process of the radius B. winds around the medial side of the radial neck
C. does not supply extensor carpi ulnaris
Answers: FTFT D. usually supplies brachioradialis
E. supplies the supinator
Answer: E
20013 – The flexor carpi radialis muscle
A. often arises from the lateral epicondyle of the humerus Last 10th Edition, page 74
B. may be inserted into the scaphoid
C. often has a tendon which lies lateral to the radial artery
D. can be supplied by the anterior interosseous nerve
E. may have a tendon that lies in its own tunnel in the flexor retinaculum

20577 – S. Division of the posterior interosseous nerve at its origin causes Answers: TFTF
weakness of extension of the wrist BECAUSE R. the posterior interosseous
The ulnar nerve arises from the medial cord of the brachial plexus (C8, T1) and in 90% of cases
nerve supplies the extensor carpi radialis longus muscle receives a branch in the axilla from the lateral cord (C6, 7) which supplies the motor branch to flexor
carpi ulnaris (A true). The nerve enters the forearm by passing between the two heads of the flexor
Answer: S is true and R is false carpi ulnaris muscle (B false). It gives no branches in the arm; in the forearm it supplies flexor carpi
ulnaris and part of flexor digitorum profundus. The ulnar artery inclines medially to join the nerve and
Last 10th Edition, page 74 runs parallel to it an on its lateral side on flexor digitorum profundus (C true). The terminal superficial
branch supplies palmaris brevis as well (D false).
20643 – S. Grip deteriorates after division of the posterior interosseous
nerve BECAUSE R. no extension of the wrist is possible after division of 22073 – During the surgical exposure of the ulnar nerve in Guyon's canal
the posterior interosseous nerve (at the wrist)
1: a slender band of fascia over the flexor retinaculum must be divided
Answer: S is true and R is false 2: division of the nerve does not affect sensation in the little finger
3: the ulnar artery lies on the radial aspect
Last 10th Edition, page 74 4: the nerve lies on the ulnar border of the pisiform
12758 – The radial nerve Answers: TFTF

1: supplies extensor carpi radialis longus and brevis above the elbow joint
2: gives off the posterior cutaneous nerve of the forearm in the axilla Last 10th Edition, page 93
3: gives off the posterior interosseous nerve which is entirely muscular
4: passes deep to the tendon of brachio-radialis and superficial to the tendons of the anatomical snuff 22284 – Division of the ulnar nerve at the level of the pisiform will produce
box 1: weakness of adduction of the fingers
2: loss of sensation on the dorsal skin of little and half ring fingers, over the proximal phalanx
Answers: FFFT 3: loss of sensation on the volar skin of little and half ring fingers, over the proximal phalanx
4: weakness of abduction of the thumb
The extensor carpi radialis brevis is supplied by the posterior interosseous nerve (A false). The
posterior cutaneous nerve of the forearm is given off in the spiral groove (B false). The posterior Answers: TFTF
interosseous nerve is sensory to the interosseous membrane, periosteum of radius and ulna and the
wrist and carpal joints on their extensor surfaces (C false). The radial nerve lies to the radial side of Last 10th Edition, page 69
the radial artery under cover of brachioradialis, and passes backwards under the tendon 5 cm above
the radial styloid. Its terminal branches run superficial to the tendons of the anatomica snuff box and 20061 – S. When the ulnar nerve is divided at the level of the pisiform bone,
can be rolled over the taut tendon of extensor pollicis longus (D true). sensation on the dorsum of the hand is unaffected BECAUSE R. the dorsal
19527 – Division of the median nerve above the elbow often causes total branch of the ulnar nerve passes on to the dorsal aspect proximal to the
loss of active head of the ulna
A. flexion of the wrist
B. flexion of all proximal interphalangeal joints
C. abduction of the index finger
Last PAGE: 109
D. flexion of the interphalangeal joint of the thumb
E. extension of the thumb
21178 – In relation to the carpus
Answer: D 1: the carpal bones are all ossified at birth
2: the flexor retinaculum is attached medially to the pisiform and hamate
Last 10th Edition, page 94 3: the range of extension at the radiocarpal joint is greater than the range of flexion
4: the tubercle of the scaphoid lies medial to the tendon of the flexor carpi radialis
12753 – The ulnar nerve
Answers: FTTF
1: often picks up fibres of the seventh cervical spinal nerve from the lateral cord of the brachial plexus
in the axilla
2: enters the forearm by passing between the two heads of the extensor carpi ulnaris muscle
3: runs parallel and medial to the ulnar artery in the forearm
4: has a terminal superficial branch which is entirely sensory 20223 – S. A fracture across the waist of the scaphoid bone may result in
avascular necrosis of the proximal fragment BECAUSE R. the blood
vessels to the scaphoid bone from its dorsal surface are more numerous flexors on the radial side - the flexor pollicis longus flexing the end joint of the thumb, and the flexor
distally than proximally digitorum profundus to index and middle fingers flexing the terminal interphalangeal joints of these
fingers. The ulnar nerve has already supplied the deep flexors of ring and little fingers. Responses 1,
2, and 3 dealing with function of the forearm - innervated flexor tendons to the fingers and wrist are
thus irrelevant to injuries of the median and ulnar nerves at the wrist, which will not affect the
branches previously given off by both nerves to these muscles. Response 4 is also incorrect - there is
deformity of the index and middle fingers, but it is not due to a nerve injury. Any or all of the flexor
tendons of wrist, thumb and fingers may have been divided, and the deformity assumed by the hand
27402 – A 27-year-old man presents to the Emergency Department with a and fingers helps us to diagnose these. Characteristic deformities occur with acute divisions of
wound of the flexor aspect of the left wrist due to a slash from a knife in a tendons. The normal position of rest of the hand (when no muscles are actively contracting, but with
brawl, and the appearance is as illustrated. normal elastic tensions involving all intact muscles) is with the fingers all flexed towards the palm, and
1: Inability to flex the terminal joint of the index finger will confirm that the median nerve has been the thumb at right angles to the fingers and lying against the curled index and middle fingers. The
divided. fingers are progressively more curled into the palm as we move from index, to middle, ring, and little
2: Inability to flex the terminal joint of the little finger will confirm that the ulnar nerve has been divided. finger. In this patient the ring and little fingers look normally flexed, but the index and middle fingers
3: Transection of the median nerve would render it impossible to demonstrate on clinical examination are extended and straight, and the thumb also looks abnormally straight. He has almost certainly
whether flexor carpi radialis tendon has been divided. divided the flexor digitorum superficialis and also the flexor digitorum profundus tendons to the index
4: The deformities of index and middle fingers are due to division of the median nerve. and middle fingers. He probably has also divided the flexor pollicis longus tendon. With these
5: Absence of sweating over the radial three digits on their volar surfaces would suggest median injuries, he is almost certain to have divided additionally the more superficial flexor carpi radialis
nerve injury. tendon and palmaris longus, if this is present. Confirmation of each of these tendon injuries, and
checking for any others, should be meticulously sought. The cooperative patient is asked to flex
against resistance, firstly the terminal joints of thumb and all fingers. This should confirm the loss of
flexion in thumb, index and middle fingers, and will establish if the deep flexors of ring and little fingers
are intact. In the circumstances of pain and anxiety following an injury, an isolated division of the
more superficial flexor digitorum sublimis tendon will be difficult to diagnose, as the intact deep flexor
can also flex the proximal interphalangeal joint. Flexor digitorum profundus needs to be incapacitated
before the isolated action of flexor digitorum sublimis on the proximal interphalangeal joint can be
tested. In this instance, however, having confirmed that the profundus tendons to index and middle
fingers are not acting, one can then proceed to test flexion of the proximal interphalangeal joints of
those fingers, which can confirm that in these fingers at least, FDS has been severed. The wrist
flexors are also tested, by palpating and observing the prominent tendons of flexor carpi radialis and
flexor carpi ulnaris while the patient is asked to flex the wrist. Given the injuries to the deeper flexor
tendons to the fingers, flexor carpi radialis will almost certainly be found to be severed also. We need
separately to test for injury to the median and ulnar nerves. Again, given the injury to the tendons, the
median nerve at least is very likely to have been divided, but all our testing to date has been for
tendon injuries, not nerve injury. If the patient is conscious and cooperative, testing for nerve function
will be easy by assessing sensation and motor function below the site of the cut. Loss of sensation to
light touch over the volar aspects of thumb, index and middle fingers, including the pulps, and half of
the ring finger will be found in a median nerve injury. Loss of sensation to the corresponding areas of
little finger and half of the ring finger will be found in an ulnar nerve injury. It is essential to confirm
this diagnosis by checking that the expected loss of motor activity in the short hand muscles is also
present. There are many deformities and tests relevant to later manifestations of nerve palsies -
Answers: FFFFT however in the acute situation wasting and late deformities will not be present. The best test for
median nerve function is to check by palpation and observation whether abductor pollicis brevis is
Knife wounds commonly involve the front of the wrist as illustrated. Accurate identification of tendon, acting. Can the patient abduct the thumb (held at right angles to the other fingers) away from the palm
nerve and vessel injuries is essential to facilitate management. The median nerve just above the and at right angles to it, and can you see and feel the muscle contract while the action occurs. For
wrist lies near to or in the midline. It is found just to the radial side of the tendon of flexor digitorum the ulnar nerve, can the patient abduct the little finger away from the others in the plane of the palm,
superficialis to the midline finger. The radial artery lies superficially on the far radial side of the wrist, and can you see and feel the contraction of abductor digiti minimi as this occurs. Adult patients may
lateral to the prominent tendon of flexor carpi radialis. The ulnar nerve accompanies the ulnar artery, be uncooperative from the influence of alcohol, drugs or anxiety. Children pose special difficulties. In
the nerve lying on the ulnar side of the artery. Artery and nerve lie close together on the surface of the both these instances checking the third component of the peripheral nerve - namely inspection of
flexor digitorum profundus muscle beneath its investing fascia. Both median and ulnar nerves have hand sweating for autonomic paralysis - can be very helpful. Absence of sweating in median or ulnar
given off their motor branches to the forearm flexor muscles by the time they reach the wrist. The nerve distribution suggests injury to the appropriate nerve (5 is correct).
median nerve has supplied the radial flexor of the wrist - flexor carpi radialis - and if present, also
palmaris longus. It has also supplied all of flexor digitorum superficialis which flexes the proximal
interphalangeal joints of the fingers; and by its anterior interosseous branch it has supplied the deep
20517 – S. A penetrating wound of the wrist at the level of the distal wrist 14952 – To demonstrate the surface marking of the flexor retinaculum it
crease just to the radial side of the median nerve, and entering the would be relevant to seek the position of the
scaphoid bone may result in weakness of pinch grip BECAUSE R. adductor 1: proximal flexion crease of wrist
2: styloid process of ulna
pollicis is supplied by the deep branch of the ulnar nerve
3: styloid process of radius
4: pisiform bone
Answers: FFFT
21738 – Flexor pollicis longus
1: derives its nerve supply directly from the median nerve 20973 – S. Compression of structures within carpal tunnel results in the
2: has some fibres of origin from the coronoid process of the ulna
3: passes through the carpal tunnel superficial to the median nerve weakness of the adductor pollicis muscle BECAUSE R. the oblique head of
4: has some origin from the interosseous membrane the adductor pollicis muscle is supplied by the median nerve
Answer: FTFT Answer: both S and R and false
Last's 10th Ed., p91. This question has been reviewed and will remain unchanged. Dec 03 Last PAGE: 96
14122 – The abductor pollicis longus 23139 – Structures passing deep to the flexor retinaculum include
1: arises partly from the ulna 1: the ulnar artery
2: is inserted into the base of the first metacarpal 2: the palmar branch of the median nerve
3: may send a slip to the abductor pollicis brevis at its insertion 3: the tendon of flexor carpi radialis
4: is supplied by the posterior interosseous nerve 4: the dorsal branch of the ulnar nerve
Answers: TTTT Answers: FFTF
Refer to Last, 10th Ed, page 73 Last 10th Edition, page 78
12578, 21021 – S:The head of the ulna articulates with bones of the 12773, 24284 – The digitations of the palmar aponeurosis are attached to
proximal row of the carpus because R:the cavity of the wrist joint is the
usually continuous with the cavity of the inferior radio-ulnar joint 1: deep transverse ligaments of the palm
2: fibrous flexor sheaths of the fingers
Answer: both S and R and false 3: bases of the proximal phalanges of the fingers
4: common flexor synovial sheath
Last 10th Edition, page 75. The head of the ulna articulates with the proximal surface of the triangular
fibrocartilage, or articular disc, which is normally a complete, intact structure although it may become Answers: TTTF
perforated in the elderly. The inferior radio-ulnar joint is thus normally quite separate from the wrist
joint. Last 10th Edition, page 77. Each digitation of the palmar aponeurosis divides into two bands over the
proximal end of the fibrous flexor sheath. They are inserted into the deep transverse ligaments of the
palm, into the fibrous flexor sheath of the fingers, and into the sides of the proximal phalanges of the
7640 – The surface marking of the radio carpal joint is often
fingers (A,B,C true). The synovial sheath is not attached to the palmar aponeurosis (D false).
A. at the distal skin crease of the wrist
B. at the proximal skin crease of the wrist
C. 1cm proximal to the proximal skin crease of the wrist 21143 – The palmar aponeurosis
D. 1cm distal to the distal skin crease of the wrist 1: is continuous with the palmaris longus
E. midway between the proximal skin crease of the wrist and the hook of the hamate 2: overlies the adductor pollicis brevis
3: sends a slip to each of the four fingers
Answer: B 4: is crossed by the ulnar artery
Last 10th ed, Ch 2 Answers: TFTF
Last 10th Edition, pgs 77 & 81. Question reviewed and updated Nov 03.
12464 – The sharp borders of the middle phalanx of the index finger give
21148 – The midpalmar space attachment to
1: is covered superficially by fascia lying deep to common synovial sheath and flexor tendons A. the tendon of flexor digitorum profundus muscle
2: has sides formed by septa dipping in from the margins of the palmar aponeurosis B. the oblique retinacular ligaments
3: connects distally with the ulnar three lumbrical canals C. the fibrous flexor sheath
4: is floored by the interossei and metacarpals of the third and fourth spaces D. the long vinculum of the flexor digitorum profundus tendon
E. the short vinculum of the flexor digitorum profundus tendon
Answers: TTTT
Answer: C
Last 10th Edition, page 86. This question was referred to the Anatomy Sub Committee for review on
1 Feb 2002. Question updated 14 March 2002. Question updated 3 Dec 2002. The tendon of flexor digitorum profundus muscle, which is inserted into the base of the distal phalanx
on its flexor aspect, has no attachment to the middle phalanx (A false). The oblique retinacular
15212 – Which of the following is NOT a property of the first dorsal ligaments pass from the palmar aspect of the fibrous flexor sheath to join the lateral band of the
interosseous muscle in the hand? extensor expansion (B false). The sheath itself takes part of its origin from the sharp borders of the
A. it is usually supplied by the ulnar nerve middle phalanx (C true). The vinculum longum of the flexor digitorum profundus tendon is attached to
B. it extends the proximal interphalangeal joint of the index finger the palmar surface of the proximal phalanx just proximal to the proximal interphalangeal joint, and the
C. it passes in front of the deep transverse metacarpal ligament vinculum breve to the capsule of the distal interphalangeal joint (D and E false).
D. it abducts the index finger
E. it is dorsal to the transverse head of the adductor pollicis muscle
LOWER LIMB
Answer: C
Refer to Last, 10th Ed, Ch 2, page 83-84 12713 – At the hip joint
1: the obturator internus produces lateral rotation
7349 – S Hyperextension of the metacarpophalangeal joint of the little 2: the gluteus medius produces abduction
3: the gluteus minimus produces medial rotation
finger occurs in ulnar nerve lesions at the wrist Because R the 4: the obturator externus produces medial rotation
interosseous and lumbrical muscles which go to the little finger are
supplied by the ulnar nerve Answers: TTTF
Answer: S is true, R is true and a valid explanation of S Any muscle passing obliquely or transversely across the back of the hip joint and behind the vertical
axis around which the femoral head rotates must act as a lateral rotator of the extended thigh.
Last 10th Edition, pages 82 & 94. The ‘ulnar claw hand’ is a deformity developing some time after an Gluteus maximus is the most powerful lateral rotator. The others are more active as stabilisers of the
ulnar nerve lesion at the wrist (or at a higher level); and involves clawing of the little and ring finger hip joint but obturator internus together with the gluteus medius, piriformis, gemelli and quadratus
with hyper-extension at the metacarpophalangeal joints. All the interossei muscles, including those to femoris and lateral rotators (A true). Any muscle whose line of pull passes across the front of the hip
the little finger, together with the lumbrical muscles to the little and ring fingers, are supplied by the joint and thus anterior to the vertical axis around which the femoral head rotates must act as a medial
ulnar nerve. The weakness of flexion of the metacarpophalangeal joint due to paralysis of the fourth rotator of the extended thigh. The anterior portions of both gluteus minimus (C true) and gluteus
lumbrical and of the interossei to the little finger causes hyperextension of the metacarpophalangeal medius can thus act as medial rotators as do the psoas major and illiacus. The obturator externus
joint due to unopposed action of the extensor digitorum communis and extensor digiti minimi. passes behind the hip joint, and although mainly a stabiliser of the hip joint, is therefore also a lateral
rotator of the extended thigh (D false). Abduction is produced by the gluteus medius and gluteus
15302 – With regard to movements of the fingers minimus (B true). Pending review. Jan 2003
1: flexion at the distal interphalangeal joints of all the digits is lost if the ulnar nerve is cut at the elbow
2: movement of the index finger in a radial direction is produced by the first dorsal interosseous 22018 – The gluteus maximus muscle
muscle 1: is attached to the intertrochanteric line of the femur
3: extension at the metacarpophalangeal joints is effected by the dorsal interosseous muscles 2: is attached to the iliotibial tract
4: flexion at the metacarpophalangeal joints, while there is extension at the interphalangeal joints, is 3: is supplied by fibres from L4, L5 and S1
produced by the interossei muscles 4: is an extensor of the trunk on the lower limb
Answers: FTFT Answers: FTFT
Last's 9th Ed., p120. STEM Module: Locomotor System/Bones/Joints/Muscles. Updated Dec 03. Last PAGE: 145, 146
19198 – The superior gluteal nerve

A. has a cutaneous distribution to the skin of the buttock 1: inguinal ligament
B. gives off deep and superficial branches 2: femoral vein
C. supplies the tensor fascia lata 3: lacunar ligament
D. supplies the gluteus maximus 4: pectineal ligament
E. contains fibres from the second sacral spinal segment
Answers: TTTT
Answer: C
Last PAGE: 138
Last 8th ed. PAGE: 164, 399
946 – In femoral hernia, the hernial sac
19312 – The ossification centre of the femoral head appears 1: passes behind the inguinal ligament.
A. at the eighth week of foetal life 2: Passes medial to the femoral vein.
B. by the sixth post-natal week 3: Passes anterior to the superior pubic ramus.
C. in the first year of life 4: Is covered by the fascias of the femoral septum and the cribriform fascia.
D. at 2 years of age 5: Contains a large quantity of fat.
E. at 3 years of age
Answers: TTTTT
Answer: C
The sac of a femoral hernia passes behind the inguinal ligament (1 true) into the femoral canal, which
Last 8th ed. PAGE: 224 lies medial to the femoral vein and anterior to the superior pubic ramus. (2 & 3 true). The sac enters the
femoral canal through its upper opening -the femoral ring. This is normally closed by the femoral septum, a
23474 – The femoral canal fusion of iliopectineal fascia behind and transversalis fascia anteriorly. The sac, covered by extraperitoneal
1: at its proximal end is medial to the femoral vein fat and femoral septum fascia, leaves the femoral canal to enter the subcutaneous tissues of thigh and groin,
2: contains the femoral branch of the genitofemoral nerve by passing anteriorly through the fossa ovalis and its overlying cribriform fascia. (4 true). The sac of a
3: at its proximal end is posterior to the inguinal ligament femoral hernia thus contains several fascial layers separated from each other by fat. A large portion of the
4: is the lateral compartment of the femoral sheath sac is fatty (5 true) which can make the cough impulse of a femoral hernia less obvious.
Answer: TFTF 21033 – S. A femoral hernia can present deep to the membranous layer of
superficial fascia of the abdominal wall (scarpa's fascia) BECAUSE R.
Last PAGE: 138 Scarpa's fascia inserts into the deep surface of the inguinal ligament
21193 – The femoral triangle Answer: both S and R and false
1: has a floor formed by the iliacus muscle, the psoas major tendon, the pectineus muscle and the
adductor longus muscle Last Page: 133
2: is bounded below and medially by the adductor brevis muscle
3: is roofed over by the fascia lata of the thigh 934 – Femoral hernia is
4: contains the obturator nerve
1: More common in female than in male patients.
2: More common than inguinal hernia in female patients.
Answers: TFTF
3: Able to be controlled by the wearing of a hernia truss.
4: Classically associated with strangulation bowl obstruction of Richter type.
Last 8th ed. PAGE: 152-4. Under Review January 2004
5: More prone to recurrence after surgery than is inguinal hernia.
7834 – The femoral vein in the femoral triangle Answers: TFFTF
1: is medial to the femoral artery
2: is lateral to the femoral canal Femoral hernia is more common in females than in males (1 true). You would need to go back further to
3: directly receives the great (long) saphenous vein find the records of 100 femoral hernia repairs, because femoral hernias are much less common than
4: directly receives the profunda femoris vein are inguinal hernias. But there would be a majority of females in your group. The femoral ring and
canal are wider in females than males, in keeping with the wider female pelvis.
Answers: TTTT Inguinal hernias outnumber femoral in women as well as in men (2 false). Thus if you identify a groin
hernia and you cannot be sure of the clinical diagnosis in a male, the odds on it being inguinal are
Last 10th ed, Ch 3 quite high. In a woman under the same circumstances the hernia is also more likely to be inguinal, but
the odds will not be so great. For most hernias, a truss is not a reliable method of control. The hernia
22529 – Boundaries of the femoral ring include must be reducible and the truss needs to control the defect and prevent the hernia escaping. If the
hernia does protrude while a truss is worn, the effectiveness of the truss is lost and the risk of
strangulation increased. A truss might be occasionally helpful in an infirm patient when the mouth of Answers: TTTT
the hernial sac is wide, the hernia is easily reducible and the risk of strangulation considered low.
Femoral hernias have a small neck and a tortuous sac pathway and are particularly unsuited to truss Last (8) PAGE: 362
use (3 false). Response 4 is true and 5 false (see X1).
13956 – The femoral nerve is most likely to
7759 – Division of the lumbo-sacral trunk would cause A. arise from the anterior divisions of the ventral rami of L2, L3, L4
1: loss of skin sensibility in the great toe B. supply the gracilis muscle
2: weakness of peroneus longus C. lie medial to the femoral artery under the inguinal ligament
3: weakness of extensor hallucis longus D. supply sensation to skin on the medial malleolus
4: weakness of abductor hallucis E. supply sensation to the skin over the central border of the foot via the sural nerve
Answers: TTTF Answers: D
Last 10th ed, Ch 1 and Ch 5. This question is currently under review by the Anatomy Sub Refer to Last, 10th Ed, page 157
Committee. 23 August, 2001. Question updated 14 March 2002.
12718 – The femoral nerve supplies the
19617 – The ventral primary ramus of S1 1: pectineus
A. contributes to the pudendal nerve 2: tensor fasciae latae
B. is distributed to skin on the back of the thigh 3: psoas major
C. is distributed to flexors of the hip 4: gracilis
D. is distributed to evertors of the foot
E. contributes to the lumbo-sacral trunk Answer: TFFF
Answer: D he femoral nerve in the thigh branches into superficial and deep branches and supplies pectineus (A
true), sartorius, rectus femoris and the vasti. The gracilis is supplied by the obturator nerve as are the
Last PAGE: 29 adductors (D false). Psoas is supplied segmentally from the lumbar plexus (C false). Tensor fasciae
latae is supplied by the superior gluteal nerve which ends in it (B false).
21883 – The sacral plexus
1: supplies obturator externus muscle 20199 – S. The femoral nerve remains outside the femoral
2: is formed by ventral rami of L4, L5, S1, S2,S3 and S4 spinal nerves sheath BECAUSE R. the femoral nerve lies behind the fascia iliaca
3: receives the lumbosacral trunk
4: lies in front of the piriformis muscle Answer: S is true, R is true and a valid explanation of S
Answers: FTTT Last PAGE: 138
Last (8) PAGE: 160, 416

20307 – S. The femoral nerve supplies muscles in the extensor
23134 – The femoral nerve compartment of the thigh BECAUSE R. the femoral nerve is derived from
1: supplies skin on the medial side of the leg posterior divisions of anterior primary rami
2: enters the thigh anterior to the iliopsoas fascia
3: supplies the psoas major muscle Answer: S is true, R is true and a valid explanation of S
4: supplies the pectineus muscle
Answers: TFFT
24109 – The sciatic nerve
Last PAGE: 139, 165 1: gives a branch to adductor magnus
2: supplies extensors of the hip
2324 – The femoral nerve 3: supplies flexors of the knee
1: is formed in the substance of psoas major 4: supplies skin on the posterior aspect of the thigh
2: emerges on the lateral side of the psoas muscle
3: lies on the iliacus muscle beneath the inguinal ligament Answers: TTTF
4: is formed from the posterior divisions of the ventral rami of L 2, 3, 4
Last PAGE: 153, 154
Answer: C
21333 – The sciatic nerve
1: supplies all three hamstrings and ischial fibres of adductor magnus Last PAGE: 143, 152
2: is a direct posterior relation of the hip capsule
3: supplies quadratus femoris and obturator internus 20337 – S. Fracture of the femoral neck proximal to the capsular attachment
4: is supplied with blood by a branch of the inferior gluteal artery may cause aseptic necrosis BECAUSE R. the head and neck of the femur
receive their blood supply mainly through the subcapsular retinacular
Answers: TFFT
arteries
19683 – Division of the sciatic nerve would result in loss of sensation
A. on all of the thigh, leg and foot
B. on the back of the thigh and calf, and on the sole of the foot
C. on all of the leg and foot 14957 – The deep fascia of the thigh
D. on the lateral side of the calf and most of the foot 1: receives the insertion of the whole of the tensor fasciae latae muscle
E. over most of the sole of the foot alone 2: splits to enclose the gluteus maximus muscle
3: is attached to the inguinal ligament
Answers: D 4: receives the insertion of the whole of the gluteus maximus muscle
Last PAGE: 154 Answers: TTTF
19018 – As it passes down the thigh, the sciatic nerve is crossed Refer to Last, 10th Ed, page 111-112
superficially from medial to lateral by 21188 – The femoral artery
A. adductor magnus
1: is deep to the adductor brevis muscle
B. long head of biceps femoris
2: lies anterior to the tendon of psoas major
C. semimembranosus
3: gives only a profunda branch in the femoral triangle
D. quadratus femoris
4: is posterior to the femoral vein in the upper part of the adductor (subsartorial) canal
E. short head of biceps femoris
Answers: FTFF
Answer: B
Last PAGE: 154
14132 – With respect to the nerve supply of the lower limb 22864 – The cruciate anastomosis is formed from
1: the transverse branch of the medial circumflex artery
1: all interosseous muscles of the foot are supplied by the medial plantar nerve
2: the descending branch of the inferior gluteal artery
2: the weight bearing area of the heel is supplied by the medial calcaneal nerve
3: the ascending branch of the first perforating artery
3: extension of the knee is associated with spinal segments L4/5
4: the ascending branch of the lateral circumflex artery
4: sensation in the groin is associated with spinal segment L1
Answers: TTTF
Answers: FTFT
Refer to Last, 10th Ed, page 13-17, 148-149
19252 – Which of the following muscles does not arise from the ischial 19192 – The pectineus muscle
A. is covered on its deep surface by the fascia lata
tuberosity? B. is inserted along the spiral line of the femur
A. semimembranosus C. lies anterior to the anterior division of the obturator nerve
B. adductor magnus D. is attached to the pubic tubercle
C. obturator externus E. is supplied by the posterior division of the femoral nerve
D. long head of biceps femoris
E. semitendinosus

Answer: C Lying deep to them, adductor brevis arises from the inferior pubic ramus (A false). The obturator
nerve splits to lie in front of and behind adductor brevis, and is its sole supply (B false). The adductor
Last 8th ed. PAGE: 154 muscle with a double nerve supply is adductor magnus. The femoral nerve, which supplies pectineus
alone of the adductor group, lies lateral to the femoral sheath, and this is well separated from
22259 – At the distal end of the femur adductor brevis (C false).
1: the popliteus muscle is attached to the anterior end of a groove on the lateral condyle of the femur
2: the lateral condyle projects further forwards than the medial condyle 22624 – The adductor brevis
3: the anterior cruciate ligament is attached to the lateral condyle 1: arises from the superior pubic ramus deep to pectineus
4: growth stops before the cessation of growth at the proximal end 2: is supplied both by the femoral and obturator nerves
3: has the femoral nerve as a direct anterior relation
Answers: TTTF 4: lies in front of the posterior division of the obturator nerve
Last (Page 157,200) Green Book (K2, K3) Answers: FFFT
20703 – S. The short head of biceps femoris is supplied from segments L5 Last's 10th Ed., p160. Updated Nov 03
and S1 BECAUSE R. the short head of biceps femoris is supplied by the
tibial division of the sciatic nerve 19024 – The semimembranosus muscle
A. produces lateral rotation of tibia upon femur
B. helps to limit flexion at the hip when the knee is extended
C. has two heads of origin
D. is supplied by the common peroneal division of the sciatic nerve
E. crosses superficial to the sciatic nerve in the upper part of the thigh
7664 – The adductor muscles of the thigh are arranged anteroposteriorly in Answer: B
the order
A. longus, magnus, brevis Last PAGE: 152-154
B. brevis, longus, magnus
C. longus, brevis, magnus 24104 – Important abductors of the hip joint include
D. brevis, magnus, longus 1: gluteus maximus
E. none of the above 2: gluteus medius
3: piriformis
Answer: C 4: gluteus minimus
Last 10th ed, Ch 3 Answers: FTFT
20805 – S. The adductor magnus is partly supplied by the peroneal Last PAGE: 151
component of the sciatic nerve BECAUSE R. the adductor magnus is a
composite of adductor and hamstring muscles 22269 – With regard to the quadriceps femoris muscle
1: the rectus femoris has one attachment to the pelvis
Answer: S is false and R is true 2: the vastus lateralis has fleshy fibres extending more distally than those of the vastus medialis
3: its nerve supply comes from the lumbar and sacral spinal nerves
Last 8th ed. PAGE: 159-60 4: the lowermost fibres of the vastus medialis are nearly vertical
12728 – The adductor brevis Answers: FFFF

1: arises from the superior pubic ramus
Last PAGE: 140
2: is supplied by both the femoral and obturator nerves
3: has the femoral nerve directly in front of it
4: lies deep to the pectineus 21203 – Muscles which may be innervated by more than one nerve include
1: obturator externus
Answers: FFFT 2: pectineus
3: semimembranosus
Adductor brevis constitutes the middle layer of the adductor group, deep to pectineus (D true) and 4: adductor magnus
adductor longus, which arise from the superior pubic ramus and body of the pubis below the crest.
Answers: FTFT 3: the cruciate ligaments prevent backward and forward gliding of the femur on the tibia
4: the semimembranosus muscle can rotate the leg medially on the thigh
Answers: TTTT
12572, 20985 – S:The hamstring muscles are used only in strong extension
Refer to Last, 10th Ed, Ch 3, page 130 and following
of the thigh at the hip, but not as extensors in normal walking
because R:the gluteus maximus muscle is used for extension of the hip 21363 – The synovial membrane of the knee
joint in normal walking 1: may communicate with a bursa under the medial head of gastrocnemius
2: is reflected over the front of the anterior cruciate ligament
Answer: both S and R and false 3: is reflected as a bursa beneath the tendon of popliteus
4: connects with a prepatellar bursa
Last PAGE: 146, 154. The hamstring muscles cross two joints and are the main extensors of the
thigh at the hip, and flexors of the leg at the knee, especially during walking (S false). Gluteus Answers: TTTF
maximus is not used for extension of the hip joint in normal walking, remaining lax in this activity (R
false). Gluteus maximus is important at the extremes of hip extension; eg in climbing stairs, running. Last 8th ed. PAGE: 182
22474 – The adductor (subsartorial) canal 8515 – The patella

1: contains the nerve to the vastus medialis muscle 1: is not ossified at birth
2: contains the saphenous nerve 2: is prevented from lateral displacement by the greater prominence of the lateral femoral condyle
3: is bounded laterally by the vastus lateralis muscle 3: gives attachment to fibres of the vastus medialis
4: contains the profunda femoris vessels 4: has a larger medial articular surface as compared with its lateral articular surface
Answers: TTFF Answers: TTTF
Last PAGE: 157-8 Last 10th ed, Ch 3
22023 – The boundaries of the adductor canal include the 18868 – Which of the following bursae normally communicates with the
1: sartorius and the subsartorial fascia knee joint
2: adductor magnus
A. the popliteus bursa
3: vastus medialis
B. the bursa under lateral head of gastrocnemius
4: adductor longus
C. the prepatellar bursa
D. the superficial infrapatellar bursa
Answers: TTTT
E. the bursa anserine
Answer: A
14127 – At the knee joint Last's 9th Ed., p182. Question reviewed and will remain unchanged. Dec 03.
1: lateral rotation of the femur at the beginning of flexion of the leg on the thigh is produced by
popliteus
23819 – The anterior cruciate ligament of the knee
2: active rotation of the leg on the thigh is possible when the leg is flexed to ninety degrees
1: limits extension of the lateral condyle of the femur
3: the suprapatellar bursa communicates with the cavity of the joint
2: is the primary restraint of posterior displacement of tibia upon femur
4: the medial meniscus is attached along its peripheral border to the deep portion of the tibial
3: is extrasynovial
collateral ligament
4: arises from the anterior tibial spine
Answers: TTTT
Answers: TFTF
Manual PAGE: P.K4
15307 – At the knee joint 18946 – The anterior cruciate ligament
1: the lateral and medial collateral ligaments contribute to the limitation of rotatory movements of the
A. passes upwards, backwards and laterally from the tibial eminence
thigh on the leg
B. lies anteromedial to the posterior cruciate ligament
2: quadriceps power is increased by hip extension
C. limits external rotation by winding around the posterior cruciate ligament
D. prevents the femur from slipping forward off the tibial plateau 22479 – The popliteal artery
E. lies within the synovial cavity 1: is anterior to the popliteal vein
2: is anterior to the tibial (medial popliteal) nerve
Answer: A 3: is anterior to the popliteus muscle
4: divides into the anterior and posterior tibial arteries
Answers: TTFT
23739, 25447 – The semilunar cartilages of the knee
1: function in load absorption Last PAGE: 156
2: contribute to stability of the joint
3: move passively during flexion and extension of the knee 21543 – With respect to the venous drainage of the lower limb
4: are vascular close to their peripheral attachments 1: the saphenous nerve is closely associated with the long saphenous vein in the leg
2: the long saphenous vein does not provide the principal drainage of the medial side of the leg
Answers: TTTT between the tibia and tendo calcaneus
3: the femoral vein is posterior to the femoral artery at the lower angle of the femoral triangle
Last PAGE: 184. Question to be reviewed at March 04 meeting - Regarding option C being 4: the soleus muscle contains a rich plexus of veins
True(25/02/04)
Answers: TTTT
20613 – S. The knee joint is locked in full extension BECAUSE R. the
ligaments of the knee are tightened by medial rotation of the tibia on the Last PAGE: 132, 139, 165, 172
femur
7764 – With regard to the tibia
Answer: S is true and R is false 1: the flexor hallucis longus muscle is attached to its posterior surface
2: growth occurs principally at its upper end
Last PAGE: 183 3: the superior and inferior tibio-fibular joints are both synovial
4: there may be a separate epiphysis for the tuberosity
12452, 19168 – The lateral meniscus of the knee
Answers: FTFT
A. is attached to the fibular collateral ligament
B. gives part origin to the popliteus muscle
Last 10th ed, p168. This question is currently under review by the Anatomy Sub Committee. 23
C. is attached to the anterior cruciate ligament by an extension of the attachment of the anterior hor
D. is larger than the medial meniscus
E. is totally devoid of vascular supply
19282 – Flexor digitorum longus
Answer: B A. crosses deep to tibialis posterior in the calf
B. crosses deep to flexor hallucis longus in the sole
Green Book PAGE: K5, 6. The fibular collateral ligament is extracapsular, running from lateral C. is a bipennate muscle that arises from both bones of the leg
condyle of femur to fibular head (A false). The lateral meniscus has an attachment to the tendon of D. is the bulkiest and most powerful of the three deep muscles of the calf
popliteus (B true), but not to the anterior cruciate ligament (C false). The medial meniscus is rather E. is superficial to the neurovascular bundle
larger than the lateral (D false): both menisci are vascularised at their outer margins (E false).
Question to be reviewed at March 04 meeting re: option B being false. (23/02/04). Answer: C
Last's 9th Ed., p195-6. Question reviewed and reference updated. Dec 03
19605 – The popliteus
A. arises by tendon from the soleal line
B. is supplied by the deep peroneal nerve 15340 – The gastrocnemius muscle
C. is an extensor of the knee joint 1: originates partly from the popliteal surface of the femur just above the medial condyle
D. rotates the femur laterally on the tibia 2: is innervated by the tibial nerve
E. has a bursa lying superficial to its tendon 3: is attached through the tendo calcaneus to the middle third of the posterior surface of the
calcaneus
Answer: D 4: has its dominant blood supply from the inferior genicular arteries
Last PAGE: 151, 158 Answers: TTTF

Refer to Last, 10th Ed, Ch 3, page 141-142. This question was referred to the Anatomy Sub and then divides into superficial and deep peroneal nerves just below the neck of the fibula. The
Committee for review on 1 Feb 2002. Question updated 14 March 2002. superficial peroneal nerve supplies the evertors of the foot (D true) and ends by dividing into medial
and lateral cutaneous branches on the dorsum of the foot. A division of the lateral branch supplies the
7712 – S:The strength of plantar flexion by gastrocnemius is increased by cleft between third and fourth toes (A true).
simultaneous extension of the knee because R:the foot acts as a lever
during plantar flexion 19911 – The deep peroneal nerve supplies
A. popliteus
B. plantaris
C. skin on the lateral side of the dorsum of the foot
D. peroneus longus
Last 10th ed, Ch 3
E. peroneus tertius
21378 – The soleus muscle Answer: E
1: arises from the tibia and fibula
2: is active while walking downstairs Last 8th ed. PAGE: 188
3: is a plantar flexor of the foot at the ankle joint
4: has a tendon which begins at a higher level than that of the gastrocnemius muscle 19186 – The motorneurones responsible for the knee-jerk are located
Answers: TTTF mainly in spinal cord segments
A. L1, L2
Last PAGE: 173 B. L2, L3
C. L3, L4
D. L4, L5
21358 – The tibial nerve
E. L5, S1
1: is superficial to the popliteal vessels in the popliteal fossa
2: gives branches to the muscles which dorsiflex the foot
Answer: C
3: gives branches to the knee and ankle joints
4: gives off the sural nerve to the medial side of the leg and foot
Last PAGE: 28
Answers: TFTF
21051 – S. Division of the superficial peroneal nerve results in foot
Last PAGE: 155 drop BECAUSE R. the superficial peroneal nerve supplies the tibialis
anterior muscle
14848 – The tibial nerve
A. is derived from the ventral rami of L4, L5, S1, S2 and S3 Answer: both S and R and false
B. lies medial to the popliteal vessels in the upper part of the popliteal fossa
C. gives off the lateral sural nerve Last PAGE: 171
D. supplies the short head of the biceps femoris
E. has none of the above properties 19042 – A patient has foot drop and anaesthesia over the dorsum of the
foot except on the lateral side. The lesion is likely to involve the
Answer: A
A. tibial and peroneal nerves
B. common peroneal nerve
Refer to Last, 10th Ed, page 148, 149, 158, 320
C. lumbosacral trunk
D. ventral rami of S1 and S2
12733 – The common peroneal nerve is distributed to E. tibial nerve
1: the skin between the third and fourth toes
2: the knee joint Answer: B
3: the skin of the lateral side of the calf
4: all the muscles producing eversion of the foot Last PAGE: 165
Answers: TTTT
23744 – Fibres of the fourth lumbar spinal nerve
1: supply skin between the first and second toes
The common peroneal nerve passes the knee joint and supplies it in accordance with Hilton's law (B
2: are found in the femoral nerve
true). On the lateral head of gastrocnemius it gives off the lateral cutaneous nerve of the calf (C true),
3: are found in the tibial nerve
4: are found in the common peroneal nerve B. the navicular
C. the posterior tibiofibular ligament
Answers: FTTT D. the inferior calcaneonavicular ligament
E. the long plantar ligament
Last PAGE: 27, 311, 358
Answer: E
21823 – The ventral primary ramus of L4 is distributed to
1: the skin of the medial side of the leg Last PAGE: 181, 182, 184
2: muscles which dorsiflex the ankle joint
3: muscles which invert the foot 12723 – The sustentaculum tali
4: muscles which flex the knee joint 1: gives partial attachment to the spring ligament
2: is a projection from the calcaneus
Answers: TTTF 3: supports the head of the talus
4: gives partial attachment to the deltoid ligament
Last 8th ed. PAGE: 186-187, 195
Answers: TTTT
19048 – The cutaneous innervation over the medial malleolus at the ankle is
derived from which of the following spine segments? The sustentaculum tali is a shelf projecting from the upper part of the medial surface of the calcaneus
supporting the head of the talus (B and C true). The rounded medial border of the sustentaculum tali
A. L3
gives attachment over its whole thickness to the spring ligament in front and the superficial lamina of
B. L4
the deltoid ligament behind (A and D true).
C. L5
D. S1
E. S2 24224 – The deltoid ligament is attached to the
1: medial malleolus
Answer: B 2: sustentaculum tali in continuity with the inferior transverse ligament
3: inferior calcaneo-navicular (spring) ligament
Last 8th ed. PAGE: 25 4: tuberosity of the navicular
14962 – The great (long) saphenous vein Answers: TFTT

1: has more valves above the knee than below
Last 8th ed. PAGE: 203.
2: is intimately related to the saphenous nerve in the leg
3: is connected to the deep veins by perforating vessels whose valves contain muscular sphincters
derived form the tunica media 12738 – The deltoid ligament is attached to the
4: is anterior to the medial malleolus 1: medial malleolus
2: sustentaculum tali
Answers: FTFT 3: inferior calcaneo-navicular (spring) ligament
4: tuberosity of the navicular
Refer to Last, 10th Ed, page 147, 185; Wheater, page 127
Answers: TTTT
22254 – In the region of the ankle joint
The deltoid (medial) ligament of the ankle is an extremely strong ligament arising from the lower
1: the posterior tibial artery can be palpated behind the medial malleolus
border of the medial malleolus (A true) and having a long distal attachment extending from the body
2: the anterior tibial artery can be palpated between the tendons of the extensor hallucis longus and
of the talus posteriorly, along the sustentaculum tali, talar neck and the medial edge of the spring
extensor digitorum longus
ligament to the tuberosity of the navicular (B,C,D true).
3: the flexor retinaculum is attached to the medial malleolus above and the calcaneus below
4: the dorsalis pedis artery terminates at the distal end of the first intermetatarsal space
19905 – On the anterior aspect of the ankle joint the tendon of the extensor
Answers: TTTF hallucis longus
A. is medial to the tibialis anterior
Last 10th Ed, Ch 3 PAGE: 141-145. This question is currently under review by the Anatomy Sub B. is lateral to the deep peroneal nerve
Committee Aug 2002. C. is lateral to the extensor digitorum longus
D. possesses no synovial sheath
19947 – The talus articulates with all EXCEPT which of the following? E. is medial to the anterior tibial artery
A. the tibia
Answer: E 4: grooves the posterior aspect of the talus
Last PAGE: 169 Answers: FFFT
22869 – The lateral plantar artery Last 8th ed. PAGE: 195
1: anastomoses with the medial plantar artery to complete the plantar arch
2: crosses the sole obliquely on the lateral side of the lateral plantar nerve 19276 – Extensor digitorum longus
3: lies deep to the flexor accessorius muscle A. crosses the ankle joint medial to tibialis anterior
4: anastomoses with dorsalis pedis and arcuate arteries B. crosses the ankle joint medial to extensor hallucis longus
C. crosses the ankle joint lateral to the deep peroneal nerve
Answers: FTFT D. supplies tendons to the medial four toes
E. does none of the above
Answer: C
21538 – The muscles which are commonly supplied by the medial plantar
nerve include Last PAGE: 170
1: the adductor hallucis
2: the flexor hallucis brevis 20343 – S. Mobility of the first metatarso-phalangeal joint is important in
3: the flexor accessorius (quadratus plantae) normal walking BECAUSE R. flexor hallucis longus is a powerful
4: the first lumbrical muscle contributor to the propulsive force of the foot
Answers: FTFT Answer: S is true, R is true and a valid explanation of S
Last 8th ed. PAGE: 196-200 Last PAGE: 188
19533 – Flexion of both hip and knee joints is produced by

A. rectus femoris BACK
B. semitendinosus
C. biceps femoris 23619 – The vertebral canal
D. sartorius 1: encloses the spinal cord, ending at L1, enclosed in a much longer dural sac
E. tensor fasciae latae 2: is small and circular in the thoracic region
3: contains the dorsal root ganglia of the thoracic spinal nerves
Answer: D 4: contains an extensive internal vertebral venous plexus in the epidural space
Last PAGE: 136 Answers: TTFT
19438 – Which of the following lies in the second muscular layer of the Last 10th ed. PAGE: 425
sole?
A. peroneus longus tendon 22199 – The sacral canal
B. abductor digiti minimi 1: contains the conus medullaris of the spinal cord
C. flexor accessorius 2: opens into four intervertebral foramina on each side
D. flexor digitorum brevis 3: is circular in section
E. flexor digiti minimi brevis 4: contains dura mater down to the the 2nd sacral segment
Answer: C Answers: FTFT
Last 8th ed. Page: 197-201 Last 10th ed. PAGE: 429; 430
21383 – The flexor hallucis longus 15022 – The fourth lumbar vertebra
1: arises from the inferior two-thirds of the posterior surface of the shaft of the tibia 1: develops from sclerotomal mesoderm
2: grooves the posterior surface of the medial malleolus 2: is formed by fusion of caudal and cranial halves of adjacent somites
3: crosses superficial to the tendon of the flexor digitorum longus in the sole of the foot 3: develops secondary centres of ossification at the tips of the spinous and transverse processes after
puberty
4: ossifies from membrane 15370 – The 4th lumbar nerve
1: contributes to the genito-femoral nerve
Answers: TTTF 2: receives a white ramus communicans
3: gives a branch to the psoas major muscle
Refer to Last, 10th Ed, page 415-416 4: contributes fibres to the femoral and obturator nerves
15278 – S:Rupture of the transverse band of the cruciform ligament of the Answers: FFFT
atlas may be fatal because R:anterior dislocation of the dens causes
pressure on the medulla oblongata Refer to Last, 10th Ed, Ch 5, page 272 Response from Anatomy Sub Committee to trainee's inquiry
on Question 15370 5.1 L4 does not contribute to the genitofemoral nerve. So, 1: false. 5.2 L4 does
not receive a white ramus. So, 2: false. 5.3 L4 can supply the psoas, but various sources disagree on
the actually segmental supply of the psoas. In different locations Gray says L1, 2(3) and L2, 3(4).
Hollinshead allows L (1), 2, 3, 4 (5). However, the fact that Last says L1, 2, 3 means that 3: false.
[This is too fine a point to include in a question.] 5.4 L4 does contribute to the femoral and obturator
nerves. So, 4: true. Question reviewed and updated July 03. Entire question to be reviewed at the
20229 – R. Rotation between adjacent lumbar vertebrae is March 04 meeting (20/02/04).
minimal BECAUSE R. the lumbar articular facets lie in an antero-posterior
plane 24294 – The 4th lumbar nerve
1: has no cutaneous fibres
Answer: S is true, R is true and a valid explanation of S 2: receives a white ramus communicans
3: joins the 5th lumbar nerve in the psoas muscle
Last 8th ed. PAGE: 543 4: contributes fibres to the femoral and obturator nerves and common peroneal part of the sciatic
nerve
23919 – The body of a lumbar vertebra
1: contains haemopoietic tissue only in childhood Answers: FFFT
2: has an arterial supply direct from the abdominal aorta
3: is wholly ossified from the ossification centre of the centrum Last 10th Ed, Ch 5 PAGE: 317-318
4: is separated from adjacent intervertebral discs by hyaline cartilage in the adult
19342 – The dorsal (posterior) primary rami of spinal nerves
Answers: FTFT A. all have lateral branches innervating the skin
B. have no cutaneous branches from C1, C2
Last (10) PAGE: 431, 432. Pending review. Jan 2003 C. innervate the levator costae muscles
D. innervate the serratus posterior muscles
15365 – Lumbar vertebrae show E. give off recurrent meningeal branches
1: a large rounded vertebral foramen
2: a mammillary process projecting from the superior articular process Answer: C
3: a body which is heart shaped
4: an accessory tubercle at the root of the transverse process Last 8th ed. PAGE: 18,246
Answers: FTFT 14168 – The lumbar fascia

1: is continuous with the thoracolumbar fascia and surrounds the quadratus lumborum muscle
Refer to Last, 10th Ed, Ch 6, page 426-427 2: forms a boundary of the lumbar triangle of Petit
3: gives origin to the external oblique muscle of the abdomen
14987 – The lumbar triangle of Petit 4: is attached medially to the bodies of the lumbar vertebrae
1: is floored by the internal oblique muscle
2: is a common site of hernia formation Answers: TFFF
3: lies between external oblique and latissimus dorsi muscles
4: lies between external oblique and internal oblique muscles Refer to Last, 10th Ed, page 267-268
Answers: TFTF 21513 – The lumbar fascia

1: consists of three lamellae
Refer to Last, 10th Ed, page 216 2: contains quadratus lumborum and erector spinae
3: is made up of tough fibrous tissue
4: has a posterior layer which is continuous with the thoraco-lumbar fascia 12566, 20121 – S. Injury to the anterior spinal artery in the cervical segment
causes greatest ischaemia at C8 BECAUSE R. the nerve root arteries at T1
Answers: TTTT
do not provide blood to the cervical part of the anterior spinal artery
Last (8) PAGE: 357
22689 – The ligamentum denticulatum
Last PAGE: 536. The principal blood supply to the spinal cord is derived from anterior and posterior
1: is attached to the spinal cord by a continuous line
spinal arteries. The larger anterior spinal is formed by the union of a branch from each vertebral
2: is attached laterally to the spinal dura
artery. Blood flow in the anterior spinal artery is supplemented by spinal branches of the first and
3: stabilizes the spinal cord within the spinal dura mater
eleventh intercostal arteries which anastomose with the anterior spinal artery (S true). Blood flow in
4: has its lowest denticulation at the root of the first lumbar segment
the spinal branch of the first thoracic intercostal artery is directed distally rather than to the cervical
part of the cord (R true and valid explanation of S).
Answers: TTTT
Last (8) PAGE: 625; 578 21045 – S. Damage to the arteria radicularis magna (Adamkiewicz) is
unlikely to cause spinal cord infarction BECAUSE R. the anterior spinal
22874 – The spinal pia mater artery provides an adequate blood supply to the spinal cord
1: terminates at the level of the first lumbar vertebra
2: forms the denticulate ligaments Answer: both S and R and false
3: forms a posterior median septum in the subarachnoid space
4: blends with the epineurium of the spinal nerves Last PAGE: 536
Answers: FTFT 15236 – Arterial blood is supplied to the spinal cord mostly from
A. the intercostal vessels
Last (8) PAGE: 562 B. vessels entering the cervical intervertebral foramina
C. branches of the lumbar vessels
12708 – The spinal dura mater D. the vertebral arteries
1: is firmly attached to the posterior longitudinal ligament on the body of the axis E. the costo-cervical trunks
2: is separated from the spinal canal by a layer of fat
3: is pierced segmentally by both anterior and posterior spinal nerves Answer: D
4: forms a lateral projection entering each intervertebral foramen
Answers: TTTT
23359 – The internal vertebral venous plexus
The spinal dura mater lies free of bony or ligamentous attachments except where it is attached to the 1: has numerous venous valves
membrana tectoria and the posterior longitudinal ligament on the body of the second cervical vertebra 2: drains into posterior intecostal veins
(A true). A layer of extra-dural fat contains the internal vertebral plexus (B true). The spinal nerve 3: acts as a venous collateral in obstructon of the inferor vena cava
roots are covered by prolongations of the dura mater and pierce the dura mater within the 4: receives the basivertebral veins
intervertebral foramen (C and D true). Question to be reviewed at the March 04 meeting re: option 3
(20/02/04). Answers: FTTT
23354 – The dura mater of the spinal cord Last (8) PAGE: 577
1: forms a covering for the spinal nerve roots as they form the spinal nerves
2: is separated from the walls of the vertebral canal by a space containing the internal vertebral 7090, 19336 – Which of the following pairs of spinal nerves supply adjacent
venous . plexus
dermatomes on the trunk?
3: extends downwards in the vertebral canal no further than the first sacral vertebra
A. C3 and T1
4: is attached to the edge of the foramen magnum
B. C4 and T1
C. C4 and T2
Answers: TTFT
D. C4 and T3
E. None of the above
Last 8th ed. PAGE: 577. Question to be submitted for review at the July 2004 meeting. Query answer
option 1 - should be FALSE. (18/04/04).
Answer: C

Last 8th ed. PAGE: 24. C4 supplies neck skin around the clavicle and upper chest extending from Last 10th ed. PAGE: 316; 428; 429
the trunk as a cowl over the shoulder tip. T2 is the next dermatome below C4 on the trunk. The
dermatomes of C5 to T1 have been drawn out onto the arm skin and do not extend to the trunk. 15260 – S:The upper posterior chest wall, below the postaxial line, is
supplied by medial branches of the posterior rami because R:all the
20769 – S. In the Brown-Sequard syndrome (hemisection of the spinal cord) posterior rami from C5-8 inclusive are drawn into the upper limb during
there is paralysis and loss of touch and kinaesthetic sense, below the level development
of the lesion BECAUSE R. the hemisection of the spinal cord lesion
interrupts the lateral corticospinal tract and posterior column on the Answer: S is true and R is false
opposite side
Last 8th ed. Page: 632 EMBRYOLOGY & HISTOPATHOLOGY

21518 – The approximate vertebral level of 20445 – S. The spinal cord possesses two fusiform
1: the trans-tubercular plane is the 3rd lumbar vertebra enlargements BECAUSE R. at the limb plexuses there is a greatly increased
2: the sternal angle is the 4th thoracic vertebra mass of motor cells in the spinal cord
3: the transpyloric plane is the 1st lumbar vertebra
4: the suprasternal notch is the 3rd thoracic vertebra (upper border) Answer: S is true, R is true and a valid explanation of S
Answers: FTTT Last PAGE: 536
Last (6) PAGE: 267, 250 & 191 23804 – The endoderm of the first pharyngeal pouch gives rise to the
1: superior parathyroid gland
22194 – The lateral cortico-spinal tract 2: epithelium of the external acoustic meatus
1: contains fibres derived mainly from cells of the frontal lobe 3: thymus
2: contains fibres which mainly terminate in synaptic contact with neurons of the posterior grey . horn 4: epithelium of the auditory (Eustachian) tube
3: contains mainly unmyelinated nerve fibres
4: is composed of crossed fibres Answers: FFFT
Answers: FFFT Last PAGE: 41
Last PAGE: 537. Pending review. Jan 2003 21298 – Derivatives of the first branchial arch (Meckel's) cartilage include
the
22629 – The sacro-iliac joint 1: body of the mandible
1: is a fibrous joint in young people 2: spheno-mandibular ligament
2: owes its stability to the neighbouring muscles 3: stapes
3: lies behind the bifurcation of the common iliac vessels and the ureter 4: incus
4: allows only slight rotation and gliding movements
Answers: FTFT
Answers: FFTT
Last PAGE: 39, 40, 460. Question to be reviewed at March 04 meeting re: option A being true
Last 10th ed. PAGE: 315 (23/02/04)
22784 – The sacrum 819 – The first pharyngeal pouch gives rise to
1: articulates with the coccyx by a symphyseal joint 1: the auditory (pharyngo-tympanic) tube
2: usually has four pairs of foramina on its pelvic surface 2: part of the tympanic membrane
3: is completely covered by peritoneum, on its pelvic surface 3: the middle ear
4: contains the filum terminale which extends to the coccyx 4: the mastoid antrum
Answers: TTFT Answer: TTTT

Last 10th ed, Ch 1 2: the arch of the aorta
3: the right pulmonary artery
15350 – In the branchial arches 4: the right subclavian artery
1: the second arch artery remains as the stapedial artery
2: the fourth on the right is the pulmonary artery Answers: TFTF
3: the fifth arch artery disappears completely
4: the fifth arch may persist as the ligamentum arteriosum Last PAGE: 42, 43
Answers: TFTF 22889 – Derivatives of the third pharyngeal arch include the
1: crico-thyroid muscle
Refer to Last, 10th Ed, Ch 1, page 25-26. This question is under review by the Anatomy Sub 2: superior laryngeal nerve
Committee. 23 August, 2001 3: carotid sinus
4: thyroid gland
23809 – Derivatives of the first branchial arch include the
1: mucous membrane of the anterior two-thirds of the tongue Answers: FFFF
2: maxillary artery
3: temporalis muscle Last (6). Updated Dec 03
4: intrinsic muscles of the tongue
7706 – S:The right recurrent laryngeal nerve 'loops' under the subclavian
Answers: TTTF artery because R:on the right side the fifth and the dorsal part of the sixth
branchial arch arteries degenerate
Last PAGE: 40
22884 – The second branchial arch gives rise to the
1: stylo-mandibular ligament Last 10th ed, Ch 1
2: stylo-hyoid muscle
3: stapedial artery 13529 – Derivatives of the left sixth pharyngeal arch include the
4: anterior belly of the digastric muscle
1: ductus arteriosus
2: left recurrent laryngeal nerve
Answers: FTTF
3: left pulmonary artery
4: left superior laryngeal nerve
Last PAGE: 41
Answers: TTTF
21303 – The third branchial arch gives rise to the
1: greater cornu of the hyoid bone The dorsal part of the sixth arch artery persists on the left side as the ductus arteriosus (A true), while
2: stylo-pharyngeus muscle the ventral part which is connected to the pulmonary trunk becomes the pulmonary artery (C true).
3: glossopharyngeal nerve The recurrent laryngeal nerve is the nerve of the sixth arch (B true), while the superior laryngeal nerve
4: platysma muscle is the nerve of the fourth arch (D false).
Answers: TTTF 20205 – S. Pain sensation in the heart is subserved by the sympathetic
Last PAGE: 41 system BECAUSE R. the heart is a modified blood vessel
20949 – S. The thymus usually has a single lobe BECAUSE R. the thymus is
derived from the central diverticulum of the third pharyngeal pouch Last 10th ed. PAGE: 187

21593 – The septum transversum
1: has a cranial part which forms the pericardial membranes and part of the diaphragm
2: is invaded by cervical myotomes
3: picks up its innervation, the phrenic nerve - as it migrates past the 4th cervical segment
24149 – Derivatives of the sixth branchial arch artery include 4: forms the ventral mesogastrium around the developing liver
1: the ductus arteriosus

Answers: TTFT 13524, 23469 – In the newborn
1: the spinal cord ends at the level of the first lumbar vertebra
Last 10th ed. PAGE: 24; 181. Question reviewed and updated Nov 03. 2: the internal ear is rudimentary
3: the suprarenal glands are poorly developed
21308 – The ductus arteriosus 4: the appendix arises from the apex of a conical caecum
1: contracts at birth on account of its sensitivity to reduced oxygen tension
2: is part of the fifth branchial arch arterial system Answers: FFFT
3: remains patent in the tetralogy of Fallot
4: has thick walls of smooth muscle Last PAGE: 47, 50. The spinal cord extends to the third lumbar vertebra at birth but ends
Answers: FFFT 13534 – In the newborn

1: the fundus of the bladder lies above the symphysis pubis
13367, 20235 – S:The ductus arteriosus closes at birth by muscular 2: skull vault, cancellous bone is not develop
contraction because R:oxygen tension in the blood perfusing the ductus 3: the thymus lies in the superior and anterior mediastina
4: the left brachiocephalic vein crosses the trachea above the jugular notch
arteriosus rises when the pulmonary circulation opens up
Answer: TTTT
The pelvic cavity is very small at birth and the fundus of the bladder lies above the symphysis pubis
Last’s Page 46. At birth the ductus arteriosus is occluded by contraction of its muscular walls (S
(A true). In the skull vault only compact bone is developed at birth; subsequently the interior of the
true). The ductus is caused to contract into closure by the stimulus, acting locally, of a raised oxygen
bones becomes excavated into cancellous bone (the diplo?) (B true). The large thymus extends from
tension (R true and is a valid explanation).
the lower part of the neck through the superior into the anterior mediastinum (C true). In the newborn
the left brachiocephalic vein crosses the trachea so high in the superior mediastinum that it lies above
8500 – The ventral mesogastrium the jugular notch into the neck (D true), a hazard for tracheostomy in a young child.
1: has a free border containing the left umbilical vein
2: has a free border containing the common bile duct
22244 – In the newborn
3: forms the gastrosplenic ligament
1: the left brachio-cephalic (innominate) vein may cross the trachea in the neck
4: forms the lesser omentum
2: the thorax is nearly circular in cross-section
3: the normal liver is palpable below the costal margin
Answers: TTFT
4: the foot is everted
Last 10th ed, Ch 5. Review July 2004 re: entire question.
Answers: TTTF
7789 – The diaphragm is derived from Last PAGE: 50
1: the transverse septum
2: the pleuroperitoneal membrane
23734 – In the newborn
3: body wall tissue
1: the fundus of the bladder lies above the symphysis pubis
4: 3rd, 4th and 5th cervical myotomes
2: the suprarenal gland is nearly as large as the kidney
3: the thymus lies in the superior and anterior mediastina
Answers: TTTT
4: the spinal cord ends at the level of the third lumbar vertebra
Last 10th ed, Ch 4. Question reviewed and unchanged. Dec 03
Answers: TTTT
14591 – In its development, the diaphragm receives contributions from Last PAGE: 50
1: the transverse septum
2: fourth cervical myotomes
600, 19072 – The ductus venosus
3: pleuro-peritoneal membranes
A. joins the umbilical vein to the right branch of the portal vein
4: transversus layer of body wall musculature
B. connects the left branch of the portal vein to inferior vena cava
C. runs in the falciform ligament
Answers: TTTT
D. is discontinuous with the ligamentum teres
E. persists in most adults
Last's 9th Ed., p251. Question reviewed and unchanged. Dec 03

Answer: B A. at the eighth week of foetal life
B. by the sixth post-natal week
Last (6) PAGE: 46. The right umbilical vein fails to develop in the fetus (A false). Blood is returned C. at about one year of age
from the placenta to the fetus via the (left) umbilical vein, which then runs in the ligamentum teres of D. at about two years of age
the falciform ligament (C false) to the left portal vein. The ductus venosus, which is continuous with the E. at about three years of age
ligamentum teres (D false), connects the left branch of the portal vein to the inferior vena cava (B true). It
thus acts in the developing fetus as a short circuit for oxygenated blood from the placenta to the vena Answer: C
cava and clots after birth (E false), as does the umbilical vein.
In normal development, the secondary ossification centre in the femoral head appears around one
21313 – The ductus venosus year of age.
1: carries blood from the left umbilical vein to the inferior vena cava
2: persists in the adult as the ligamentum teres 15284 – S:Aberrant parathyroid glands may be found in the thorax
3: short-circuits the developing hepatic vasculature because R:the inferior para-thyroid glands develop in close relation to the
4: runs between quadrate and caudate lobes of the liver developing thyroid gland
Answers: TFTF
Last PAGE: 46. Question to submitted for review at the July 2004 meeting. Query answer options 1 &
Refer to Last, 10th Ed, Ch 1, page 26; Ch 6, page 332
2. (26/04/04)
7627, 13245 – The paramesonephric (Mullerian) ducts
19509 – Secondary cartilaginous joints A. degenerate
A. consist of two plates of fibrocartilage separated by a layer of hyaline cartilage
B. are incorporated in the bladder
B. are immovable
C. form the uterine tubes and uterus
C. are confined to the vertebral column D. form the paroophoron
D. are found only in or near the median plane
E. form the epoophoron
E. occur between the epiphyses and diaphyses of long bones
Answer: C
Answer: D
Last 10th ed, Ch 5. The cranial parts of the paramesonephric (Mullerian) ducts in the female persist
Last 8th ed. PAGE: 11-12 as the uterine tubes, while their caudal parts fuse to form the uterus (C true), and upper part of the
vagina. They degenerate in the male, not in the female (A false), except at the two ends, the upper
23984 – Fibrocartilage is found in the end forming the appendix testis and lower contributing to the utriculus masculinus. The epophoron
1: intervertebral discs and paraophoron are remnants of the mesonephric tubules and duct in the female (D and E false).
2: medial end of the juvenile clavicle
3: symphysis pubis 13251 – The best evidence for the neuroectodermal origin of the adrenal
4: cricoid cartilage
medulla is that
Answers: TTTF A. it has a direct arterial supply from the abdominal aorta
B. its venous drainage is into a persisting part of the sub-cardinal vein
Wheater, P.R. PAGE: 144, (Wheater) Last PAGE: 12, 112 (Last) C. it lies near the sympathetic trunk
D. its secretory cells are innervated by preganglionic nerve fibres
E. its cells show a well developed granular endoplasmic reticulum
19953 – Centres of ossification present before birth include
A. the greater trochanter of the femur
Answer: D
B. the patella
C. the navicular bone The secretory cells of the adrenal medulla are functionally equivalent to postganglionic neurons of the
D. the femoral head
sympathetic nervous system in that they are innervated by preganglionic nerve fibres. The reason for
E. the calcaneus
this is that the adrenal medullary cells share a common origin from neural crest ectoderm with the cell
bodies of sympathetic ganglia (D true). Although the adrenal gland obtains a direct arterial supply
Answer: E
from the aorta, this does not indicate its embryological origin from neurectoderm (A false).
Embryological symmetry of the two glands is evident in their venous drainage into the inferior vena
Last PAGE: 200, 210 cava (on the right side) and the left renal vein (on the left side), both persisting segments of the
embryonic subcardinal veins. However, this does not indicate its neurectodermal origin (B false), the
12458 – The ossification centre of the femoral head usually appears same symmetry being evident in the venous drainage of the gonads. Neither proximity to the
sympathetic trunk, nor the presence of granular endoplasmic reticulum (characteristic of nerve and Wheater PAGE: 115
secretory cells) is proof of the embryological origin of the adrenal medulla (C and E false).
19060 – In the neurohypophysis, secretory granules accumulate in
16860 – Laminin in basement membranes has binding sites for A. pituicytes
1: macrophage Fc receptors B. nerve endings
2: epithelial cell membrane receptors C. intercellular spaces
3: proteoglycan D. capillary endothelium
4: collagen type IV E. the lumen of sinusoids
Answers: FTTT Answer: B
Explanation as for the previous two questions. Laminin is not a ligand for Fc receptors. Wheater PAGE: 259
22249 – The cell nucleus is surrounded by a nuclear envelope which 21323 – Features of the development of the pancreas include
1: comprises two membranes separated by a space 1: fusion of dorsal and ventral outgrowths from the gut
2: is usually continuous with the endoplasmic reticulum 2: assymetrical growth of the duodenal wall bringing the openings of its two ducts in line with each
3: is interrupted by pores other
4: is present throughout the cell cycle 3: drainage of part of the head of the pancreas by an accessory pancreatic duct
4: an interchange of drainage areas between the two ducts through anastamotic channels
Answers: TTTF
Answers: TTTT
Wheater PAGE: 11, 30
Last PAGE: 354
20961 – S. The Golgi apparatus is known to be a major site of protein
synthesis BECAUSE R. the membranes of the apparatus are studded with 19515 – The chief source of antibody is the
A. Kuppfer cell
ribosomes on their surfaces
B. macrophage
C. mast cell
D. plasma cell
E. eosinophil
Wheater PAGE: 14
Answer: D
19503 – Cytoplasmic basophilia in cells actively producing protein is
mainly due to a high concentration of Wheater PAGE: 163
A. hyaluronic acid
B. mitochondria 20055 – S. The secretory granules of many glandular cells are surrounded
C. Golgi cisternae
by smooth cytomembranes BECAUSE R. the secretory granules have
D. RNA particles
E. DNA particles originated from the Golgi apparatus
Answer: D Answer: S is true, R is true and a valid explanation of S
Wheater PAGE: 23 Wheater PAGE: 14
19054 – Meissner's corpuscles are 3849 – Mucus-secreting cells normally occur in the epithelium of
A. pressor receptors 1: gastric pits
B. tactile receptors 2: crypts of Lieberkuhn
C. pain receptors 3: pyloric glands
D. thermal receptors 4: intra-pulmonary bronchi
E. none of the above
Answers: TTTT
Answer: B
Wheater, P.R. PAGE: 184, 208, 209, 218

2: there are usually no non-myelinated fibres
24039 – Stratified squamous epithelium lines the 3: Schwann cell nuclei are found outside the myelin sheath
1: oesophagus 4: the fibres associated with the sensation of pain are large
2: vocal cords
3: vagina Answers: TFTF
4: membranous urethra
Leeson & Leeson Clinical Science for Surgeons PAGE: 233, 227
Answers: TTTF
20565 – S. Schwann cells are not responsible for myelination within the
Wheater PAGE: 68, 178 central nervous system BECAUSE R. myelin sheaths are not encountered
around nerve fibres in the brain and spinal cord
19839 – A feature that typifies the cell nucleus is
A. a single nuclear membrane Answer: S is true and R is false
B. the absence of RNA
C. centrioles Wheater et al PAGE: 99
D. pigment inclusions
E. a membrane in continuity with endoplasmic reticulum
Answer: E
Wheater PAGE: 10, 11
20559 – S. The smallest contractile unit of striated muscle is the

sarcomere BECAUSE R. each sarcomere carries a motor end plate
Wheater, P.R. PAGE: 84
24174 – Endoplasmic reticulum

1: can be rough or smooth
2: is continuous with the plasma membrane of the cell
3: is continuous with the nuclear envelope
4: carries ribosomes on its luminal aspect
Answer: TFTF
Wheater, P.R. PAGE: 11, 12
21103 – Tight junctions (zonulae occludentes) between epithelial cells of

the intestine
1: restrict molecular movement across the epithelium
2: facilitate cell-to-cell adhesion
3: are found just below the luminal surface
4: facilitate cell-to-cell communication
Answers: TTTF
Wheater PAGE: 74
21393 – In a peripheral nerve

1: the largest fibres are associated with proprioception

PHYSIOLOGY MCQ’S
Answers: FFFT
CELLULAR PHYSIOLOGY
Ganong 13th Ed. Ch. 3 P. 54 Ch. 17 P. 243
18958 – Gap junctions of cells
A. are spanned by corresponding connexons 21683 – Concerning biological oxidations
B. characteristically surround apical margins of epithelial cells 1: phosphorylcreatine synthesis takes place during anaerobic glycolysis
C. endow tissues with stability and strength 2: oxidative deamination takes place in the liver
D. maintain cell polarity 3: the liver is the major site of urea formation
E. are made up of ridges from adjacent cells 4: free fatty acids are oxidized in muscle and heart
Answer: A Answers: FTTT
Ganong 19th ed. Ch 1 Page: 16 Ganong 20th Edition, Ch 3, pages 70, 71. This question is currently under review by the Physiology
Sub Committee. 28 June 2002. This question has been updated. 9 Dec 2002
22349 – The equilibrium potential across a membrane for any particular ion
+
exists when 23179 – If extracellular K concentration is reduced to 3.0 mmol/1
+
1: the concentration of that ion is the same on both sides of the membrane 1: K will diffuse out of the cell
2: the membrane is completely impermeable to the ion 2: the cell membrane will become less negative on the inside
+
3: the potential difference across the membrane is zero 3: H will diffuse into the cell
+
4: there is no net passive movement of the ion across the membrane 4: K will be actively transported out of the cell
Answers: FFFT Answers: TFTF
Guyton 7th Ed. Chapter: 10 Page: 101-104 Ganong 13th Ed. Chapter: 1 Page: 22-26 Guyton 7th ed. CHAPTER: 35 PAGE: 421
21343 – The sodium pump in the cell membrane is inhibited by 22949 – Intercellular communciation via chemical messengers that bind to
1: decreased ATP production receptors are typical of
2: a low intracellular potassium 1: neural communication
3: cardiac glycosides 2: endocrine communication
4: aldosterone 3: paracrine communication
4: keratine communication
Answers: TFTF
Answers: TTTF
Guyton 7th ed/Ganong 11th ed. CHAPTER: 9, 26/1, 20 PAGE: 97-98, 309/19-20/308
Ganong 11th ed. CHAPTER: 1 PAGE: 25-26
22109 – With regard to energy metabolism
1: ATP is the most important source of energy for cellular metabolism 20553 – S. Bicarbonate is the most important buffer in the extra-cellular
2: more ATP is formed when glycogen is metabolized to pyruvate than when glucose is metabolized fluid BECAUSE R. buffers work most effectively near their pK
to pyruvate
3: phosphocreatine is used to resynthesize ATP during exercise
4: phosphocreatine is the most abundant source of high energy phosphate bands
Guyton 9th ed. Page: 389
Answers: TTTT
Guyton 8th ed. Page: 790 20421 – S. Scurvy is associated with blood vessel fragility BECAUSE R.
ascorbic acid is an essential cofactor for the synthesis of collagen
1698 – High-energy phosphate compounds include
1: cyclic adenosine monophosphate Answer: S is true, R is true and a valid explanation of S
2: glucose 6 phosphate
3: dihydronicotinamide adenosine dinucleotide (NADH2) Guyton 8th ed. Page: 785
4: phosphocreatine
PHYSIOLOGY Page 83 of 215

12530 – The most important buffer base in the extracellular fluid is 4: a decrease in resting membrane potential (depolarization)would result from a decrease in ECF
A. plasma protein sodium concentration
B. phosphate
C. bicarbonate Answers: TTTF
D. haemoglobin
E. lactate Ganong 13th ed. CHAPTER: 1, 19 PAGE: 22-26, 286
Answer: C 21288 – Osmosis may be described as the diffusion across a

semipermeable membrane of
here are three important buffer systems within the body. The phosphate buffer system has a pK of 1: ionic solutes
6.8: ie near to plasma pH and therefore is an ideal buffer. However, phosphate concentration is quite 2: water
low compared to bicarbonate concentration (B false). Proteins are effective buffers because many of 3: solutes
the constituent amino acids have pKs close to physiological pH. However, most of the protein 4: solvent
buffering capacity is intracellular (A false). The bicarbonate system has a pK of 6.1 which is far from
ideal for buffering at pH 7.4. However, the two components of the buffer system can be individually Answers: FTFT
regulated: CO2 by respiration and HCO - by the kidney. This dual regulation makes the bicarbonate
system the most important for the extracellular fluid (C true). Ganong 13th Ed. Ch. 1 P. 6
12919 – Filtration of a substance through the capillary basement membrane 19306 – Which of the following statements about Na+ - K+ activated
depends on adenosine triphosphatase is correct?
1: the molecular size of the substance A. this enzyme exchanges 2 Na+ ions for 3 K+ ions
2: the protein-bound plasma concentration of the substance B. the activity of this enzyme leads to depolarization of the cell
3: the electrical charge on the surface of the substance C. the activity of this enzyme increases when the intra-cellular Na+ concentration rises
4: the positive charge of the endothelium and basement membrane of the capillary D. the enzyme is made up of one alpha and two beta subunits
E. the drug ouabain binds to the enzyme at an intracellular site
Answers: TFTF
Answer: C
The glomerular membrane has two important features which determine whether a substance will be
filtered through it: (i) pores of approximately 8 nm in diameter; and (ii) glycosylated proteins with a Ganong 13th Ed. Chapter: 1 Page: 23
strong negative charge lining the pores. Thus an absolute size limit of 8 nm exists for substances to
be filtered (A true). In addition substances slightly smaller than this but bearing a negative charge will
0397 – S. Intracellular oedema may occur in areas where local blood flow is
be prevented from passing through by electrostatic repulsion (C true). An example of the latter is
albumin, which has a molecular diameter of approximately 6 nm but is filtered to a very small degree depressed BECAUSE R. inadequate oxygenation depresses cell membrane
because of its negative charge. Protein is not filtered because of its size and charge (B and D false). ionic pumps and allows sodium to leak into cells
The basement membrane is negatively charged. This question is currently under review by the sub
committee. 4 June 2002. This question has been reviewed and has not been altered. 9 Dec 2002. Answer: S is true, R is true and a valid explanation of S
Comments: This question is asking about factors influencing filtration, not the amount of a substance
that is filtered. Guyton 8th ed. Page: 281
24189 – Nitric oxide 14918 – S:Vasodilatation, hypovolaemia and oedema are prominent
1: is synthesised from arginine features of anaphylaxis because R:the antigen antibody reaction in
2: activates adenyl cyclase by binding to the heme group
anaphylaxis releases 5-hydroxytryptamine which causes increased
3: crosses cell membranes readily
4: is also known as EDRF capillary permeability and widespread vasodilatation
Answers: TFTT Answer: S is true and R is false
Ganong 18th ed. Chapter: 4 Page: 105 Refer to Ganong, 19th Ed, Ch 33, page 610
22339 – In the cell membrane 23534 – Which of the following hormones stimulate(s) adenylate cyclase?
1: of nerve and muscle the resting membrane potential is -70 to -90mV 1: Glucagon
2: potassium permeability is greater than sodium permeability 2: Cortisol
3: insulin causes an increase in resting membrane potential (hyperpolarization) 3: Vasopressin

4: Calmodulin 20655 – S. Down regulation occurs when a hormone is present in excess of
the number of available receptor sites BECAUSE R. the presence of a
Answers: TFTF
receptor-hormone complex gradually induces an increase in the number of
Ganong CHAPTER: 11 PAGE: 26 active receptors
15513 – Basophils contain Answer: S is true and R is false

1: histamine
2: thromboxanes Ganong 19th Ed. CHAPTER: 1 PAGE: 35
3: heparin
4: lymphokine 21918 – With regards to capillary membranes
1: different tissues may have greatly differing permeabilities
Answers: TFTF 2: water is the molecule which most readily crosses capillary membranes
3: liver capillaries are readily permeable to plasma proteins
Refer to Ganong, 19th Ed, Ch 27, page 494 4: pores in the membranes are the sole means by which molecules can pass into interstitial fluid
22334 – Fundamental properties of the plasma membrane include Answers: TFTF

1: semipermeable nature
2: preferential permeability to lipid-soluble substances Guyton 7th ed. Chapter: 30 Page: 350-351
3: low surface tension
4: high electrical resistance 20679 – S. Anaerobic metabolism produces less ATP per molecule of
glucose than aerobic metabolism BECAUSE R. glycolysis of glucose to
Answers: TTTT pyruvate does produce not ATP
23799 – A striated muscle fibre Answer: S is true and R is false
1: develops from a single myoblast
2: contains numerous nuclei which are usually peripherally located Ganong 14th ed. PAGE: 24
3: contains intercalated discs
4: has only one motor end plate
20685 – S. Energy derived from fat supplies most of the needs for the
Answers: FTFT peripheral tissues BECAUSE R. fat is readily converted to carbohydrate
involving the reaction of acetyl CoA to pyruvate
Wheater, E.R. PAGE: 82, 105
12813 – Concerning biological oxidations
1: loss of electrons may occur from a substance which is oxidized Burnett - C. S. S. CHAPTER: 14.6
2: the energy content of acetyl CoA is greater than that of acetic acid 2+
3: one end product of the flavoprotein cytochrome system is water 20979 – S. Intracellular Ca is not necessary for muscle
2+
4: conversion of NADH 2 to NAD is associated with oxidative phosphorylation contraction BECAUSE R. Ca is released from ATP during formation of the
actin myosin complex
Answers: TTTT
Oxidation is a chemical reaction resulting either in the combination of a substance with oxygen or in
the loss of hydrogen or of electrons (A true). Oxidative phosphorylation is the production of ATP Ganong 13th ed. CHAPTER: 3 PAGE: 50-53
coupled to an oxidation reaction. Therefore, the conversion of NADH2 to NAD, which is an oxidative
reaction, if coupled with the conversion of ADP to ATP, is an oxidative phosphorylation (D true). Co- 15147 – Cell membranes are practically impermeable to
2+
enzyme A (CoA) is a high energy thioester. Reduced CoA (HS-CoA) can oxidise acetic acid to acetyl 1: Ca
CoA, giving acetyl CoA a much higher energy content than acetic acid (B true). The flavoprotein 2: Urea
cytochrome system (respiratory chain) of oxidative phosphorylation, is coupled with the oxidation of
NADH and generates 3 moles of ATP and in the final step with oxidation of cytochrome a2 is coupled 3: H 2O
with the conversion of O2 to H2O (C true). 4: organic anions

Answers: FFFT Ganong CHAPTER: 3 PAGE: 58
Refer to Ganong, 19th Ed, Ch 1, page 26 and following 27065 – S:Muscular arteries adapt to changing requirements for blood flow
+ + in the distal tissues because R:muscular arteries sense and adapt to the
13319 – Na -K activated adenosine triphosphatase flow and pressure in their lumen.
+ +
A. exchanges two Na ions for three K ions
B. activity leads to depolarisation of the cell
+
C. activity increases when the intracellular Na concentration rises The formation of a collateral circulation around occlusions of the femoropopliteal and iliac systems is
D. is made up of one alpha and two beta subunits well known. Sudden occlusions cause dramatic symptoms and signs because the collaterals cannot
E. is bound to the drug ouabain at an intracellular site adapt instantaneously: however, slowly developing occlusions may be tolerated because of the
development of a rich collateral supply. The mechanisms by which arteries (and indeed veins)
Answer: C respond to such demands are not fully understood; however, it is clear that they respond to flow
velocity. The shear stress in the flowing blood is sensed by endothelial cells, which release
+
Sodium, potassium activated adenosine triphosphatase transports three Na out of the cell for each vasodilators including nitric oxide. Thus, a high flow demand will in the longer term, cause vessel
+
two K it transports in (A false). Cellular depolarization is dependent on factors other than the dilatation. The role of transmural pressure is less clear, but it has been long known that muscular
sodium/potassium pump (B false), and the structure is made up of single alpha and single beta arteries and arterioles constrict in response to increased pressure and dilate in response to
subunits (D false). Ouabain binding site is extracellular (E false). It is an electrogenic pump, ie it diminished pressure. This mechanism, known as myogenic pressure autoregulation, might contribute
+
produces net movement of positive charge out of the cell. The amount of Na provided to the pump is to dilatation in a collateral vessel when the pressure in its distal segment decreases as the main
+
a rate limiting factor; the amount of Na extruded is regulated in feedback fashion by the amount of vessel occludes. Thus, the assertion is true, and the reason given is a justifiable causal explanation
+
Na in the cell (C true). (A is the correct answer).
20841 – S. If the capillary blood pressure in a muscle falls to 10 mm Hg 22574 – With respect to the metabolism of cardiac muscle
negligible glucose transfer will occur BECAUSE R. glucose transfer across 1: normally less than 1% of its total energy liberated is provided by anaerobic metabolism
2: 60% of the energy is provided by carbohydrates
the capillary wall occurs mainly by passive diffusion 3: less than 5% of the energy is provided by amino acids
4: approximately 35% of the energy is provided by fat
Answers: TFTF
Ganong 13th ed. Chapter 1 Page: 8
21863 – Events in contraction of skeletal muscle include
NEUROMUSCULAR / CNS 1: release of acetylcholine at motor end plate
2: binding of acetylcholine to muscarinic receptors
2+
19767 – In skeletal muscle 3: binding of Ca to troponin C thus uncovering myosin binding sites on actin
A. phosphocreatine is the initial energy source for contraction 4: inward spread of depolarization along sarcoplasmic reticulum
B. Ca\p2\p+ initiates contraction by binding to tropomyosin
C. transverse tubules (T tubules) release Ca\p2\p+ in the vicinity of the myofibrils in contraction Answers: TFTF
D. the Z lines move closer together in contraction
E. Ca\p2\p+ passively diffuses back into the sarcoplasmic reticulum in relaxation Ganong 15th ed. Chapter: 3 Page: 62
Answer: D 10099 – During muscle contraction

1: the immediate source of energy is NADP
Guyton CHAPTER: 11 PAGE: 122 & 129 2: the width of the A bands remains constant
3: the electrical and mechanical responses in a single maximal stimulus occur simultaneously
23669 – In smooth muscle 4: Ca++ initiates contraction by binding to troponin C
1: calmodulin is the regulatory calcium binding protein
2: the T tubules transmit the action potentials Answers: FTFT
3: the calcium pump is slow-acting in comparison with the calcium pump in skeletal muscle
4: both sarcoplasmic reticulum and the T tubules release Ca\p2+ to initiate contraction Ganong, 19th ed, Ch 3
Answers: TFTF 23914 – During vigorous exercise

1: the efficiency of conversion of nutrient energy into muscle work is of the order of 20% - 25%

2: the efficiency of conversion of nutrient energy into heat is of the order of 20% - 25%
3: oxygen consumption may increase 20-fold in the trained athlete Answers: FTFT
o
4: heatstroke is likely to develop when the body temperature passes 41 C
Ganong 13th Ed. CHAPTER: 7 PAGE: 110-111
Answers: TFTT
21478 – Nerve growth factor
Guyton 9th ed. Page: 1068 1: is a polysaccharide with separate subunits and a total molecular weight of approximately 30,000
2: is transported from the neurone cell body to the growing process
20085 – S . All the energy of an isometric muscle contraction is dissipated 3: stimulates the growth of myelinated motor neurons
as heat BECAUSE R. no external work is done in an isometric contraction 4: beta subunit has all the nerve growth promoting activity
Answer: S is true, R is true and a valid explanation of S Answer: FFFT
Ganong 13th ed. CHAPTER: 3 PAGE: 55-56 Ganong 11th ed. CHAPTER: 2 PAGE: 44
21263 – Steps in the sequence of events involved in contraction but not 19078 – Which of the following is NOT a known or suspected neuro-
relaxation of skeletal muscle include transmitter or neural hormone in mammals
1: movement of Ca++ toward the lateral sacs of the sarcoplasmic reticulum A. gastrin-releasing peptide
2: formation of cross-linkages between actin and the tails of myosin B. phlorhizin
3: release of Ca++ from troponin C. serotonin
4: lateral movement of tropomyosin D. cholecystokinin octapeptide
E. substance P
Answers: FFFT
Answer: B
Ganong 13th Edition CHAPTER: 1 PAGE: 50 - 52 Table 3-2
Ganong 13th Ed. CHAPTER: 4/38 PAGE: 74/591
21468 – The firing of motoneurons
1: can be inhibited by nerve terminals which release glycine 20193 – S. In skin where complete nerve degeneration has occured the
2: can be inhibited by nerve terminals which release gamma-aminobutyric acid triple response to stroking is absent BECAUSE R. the flare of the triple
3: is subject to supraspinal control response is mediated by an axon reflex
4: is subject to negative feed-back control by means of Renshaw cells
Answers: TTTT
Ganong 13th Ed. Chapter: 32 Page: 518-519
Ganong 13th ed./Guyton 7th ed. CHAPTER: 4/51 PAGE: 74,82-83/ 607
20931 – S. During accommodation the curvature of the eye lens
19539 – During the relatively refractory period following the action spike in decreases BECAUSE R. when viewing a near object the lens ligaments are
a single squid axon, the intensity of stimulus required to elicit another relaxed by contraction of the ciliary muscle
spike is
A. unchanged Answer: S is false and R is true
B. reduced
C. unchanged, but produces a smaller spike Ganong 13th ed. Chapter: 8 Page: 122
D. increased
E. unchanged, but produces a larger spike
20661 – S. Stimulation of sympathetic fibres to human sweat glands causes
Answer: D secretion of sweat BECAUSE R. all sweat glands are activated by
noradrenergic nerve fibres
21473 – The sensation of painful stimuli
1: is perceived by specific receptors dedicated to its detection Answer: S is true and R is false
2: is transmitted by two different nerve fibre systems
3: travel via descending pathways in the dorsal column of the spinal cord Guyton 7th Ed. CHAPTER: 72 PAGE: 852
4: is associated with significant levels of substance P in the substantia gelatinosa
20601 – S. Sympathetic postganglionic terminals release mainly
noradrenaline rather than adrenaline BECAUSE R. prior to release, Answers: TTFF
phenylethanolamine-N-methyl-transferase converts adrenaline to Refer to Ganong, 19th Ed, Ch 13, page 216 and following
noradrenaline
21458 – Which of the following statements are correct?
Answer: S is true and R is false 1: the axons of postganglionic parasympathetic neurones are typically short
2: transmission at parasympathetic ganglia differs pharmacologically from that at sympathetic ganglia
Ganong 13th Ed. Ch. 4 P. 77 3: the adrenal medulla is functionally a sympathetic ganglion
4: the effectors which receive postganglionic sympathetic nerve supply always contain alpha-
24364 – Features of Parkinsonism include adrenoceptors
1: akinesia
2: rigidity Answers; TFTF
3: hypersalivation
4: athetosis Ganong 13th Ed. CHAPTER: 13 PAGE: 183-185
Answers: TTFF 24124 – Sympathetic vasodilator fibres are characterized by the fact that
the
Guyton 9th Ed. Ch: 56 page 728-729 Robbins 6th Ed Ch:30 page 1333. This question is currently
1: liberate noradrenaline at postganglionic endings
under review by the sub committee. 4 June 2002. This question has been updated. 9 Dec 2002.
2: liberate acetylcholine at preganglionic endings
3: relay through the medullary vasomotor centre
20403 – S. atropine abolishes normal reflex salivary secretion BECAUSE R. 4: cannot sustain vasodilatation for more than 30 seconds
Parasympathetic innervation is probably most important for salivary
secretion Answers: FTFT
Answer: S is true, R is true and a valid explanation of S Ganong 13th ed. Chapter: 14 & 31 Pages: 192-193 495-497
Ganong, 19th Ed Ch 26, Pages: 467-469. Question updated 2 Dec 2002. 22964 – Alpha-adrenergic receptors at sympathetic postganglionic nerve
endings
8627 – S:Destruction of the conus medullaris may almost completely 1: are blocked by phenoxybenzamine (dibenzyline)
paralyse defaecation because R:spinal cord mediated defaecation reflex is 2: are present in the presynaptic location on the nerve endings
3: are blocked by phentolamine (regitine)
integrated in the conus medullaris
4: mediate their effect by activation of adenylate cyclase
Answers: TTTF
Guyton, 9th ed, Ch 66
Ganong 13th ed. CHAPTER: 4:13 PAGE: 80:188
22954 – Spontaneous electrical activity is seen in 15518 – In relation to the Weber and Rinne tests of hearing using a tuning
1: cardiac muscle
2: multi-unit type smooth muscle fork
3: visceral type smooth muscle 1: in the Rinne test normal hearing is diagnosed when the sound from the fork is heard equally in both
4: skeletal muscle ears
2: in the Rinne test, conduction deafness is diagnosed when the patient cannot hear the vibrations via
Answers: TFTF bone conduction after the sensations have dissipated from air conduction
3: in the Weber test, conduction deafness is diagnosed when the vibration is heard in air after
Guyton CHAPTER: 12 PAGE: 141 vibrations heard via bone conduction have ceased
4: in the Weber test, nerve conduction deafness is diagnosed in the 'affected' ear when the sound is
heard louder in the 'normal' ear
14691 – The vagus nerve supplies
1: sensation to skin of part of the external auditory canal
Answers: FFFT
2: preganglionic cholinergic axons to the cardiac ganglia
3: parasympathetic outflow to the distal two thirds of the colon
Refer to Ganong, 19th Ed, Ch 9, page 174, Table 9-1
4: cholinergic motor fibres to sweat glands
Answer: A
14686 – An experimental drug which proves to be a selective beta-2
Ganong 11th Edition CHAPTER: 14 PAGE: 166, 172
adrenergic receptor antagonist would be predicted to cause
1: bronchodilation
2: coronary vasodilation 24119 – Anterolateral cordotomy
3: peripheral vasodilation 1: produces contralateral analgesia
4: tachycardia 2: leaves discriminative touch sensation intact
3: produces contralateral thermal anaesthesia
Answers: FFFF 4: leaves proprioceptive sensation intact
Refer to Ganong, 19th Ed, Ch 4, page 89 and following Answers: TTTT
15468 – Micturition is a function of 21463 – With respect to autonomic nerve distribution

1: a nervous reflex triggered by intravesical pressure 1: most blood vessels have a parasympathetic nerve supply
2: voluntary neurological control of the internal sphincter 2: salivary glands receive both sympathetic and parasympathetic supply
3: post-ganglionic parasympathetic nerve fibre stimulation 3: sweat glands are supplied by sympathetic neurones releasing noradrenaline
4: sympathetic nerve stimulation of the body of the bladder 4: most blood vessels have a sympathetic nerve supply
Answers: TFTF Answers: FTFT
Refer to Guyton, 9th Ed, Ch 31, page 407; Ganong, 19th Ed, Ch 38, page 693 and following Ganong 11th ed. CHAPTER: 13 PAGE: 176
21848 – In the brain 13415 – S:Dopamine and L-dopa cross the blood-brain barrier and are
1: little glycogen is stored in neurons therefore useful in the management of Parkinson's disease
2: the main energy supply is glucose because R:dopamine is the transmitter in elements of the nigrostriatal
3: metabolic rate is much higher than the body average system damaged in Parkinson's disease
4: neuronal uptake of glucose is insulin-independent
Answers: TTTT
Like other catecholamines, dopamine does not cross the blood-brain barrier. However, the dopamine
Guyton Page: 684
precursor, L-dopa, does, where it is metabolised to dopamine in cases of Parkinson's disease (S
false). It is known that dopamine is one of the key transmitters released from the relevant negro-
22344 – In the mammalian brain striatal pathways for co-ordinated extrapyramidal function (R true).
1: a lesion of the post-central gyrus abolishes the perception of sensation
2: representation of lower limb sensation is expected in the midline
27979 – S:Parasympathetic innervation is probably most important for
3: cortical sensory representation of the trunk occupies a large part of the post-central gyrus
4: projections of afferents on the post-central gyrus are not innate and immutable but may be salivary secretion because R:atropine abolishes normal reflex salivary
changed by experience secretion.
Ganong 13th Ed. CHAPTER: 7 PAGE: 108 Salivary secretion, amounting to around 1500 ml of saliva per day, is under neural control.
Parasympathetic innervation stimulation causes profuse secretion of watery saliva with a low content
18910 – Disorders of the cerebellum are associated with all of the following of organic material associated with vasodilatation due to the local release of VIP which co-transmits
EXCEPT with acetyl choline. Atropine and other cholinergic blocking agents reduce salivary secretion, blocking
the normal reflex secretion of saliva (thus both S & R are correct and R validly explains S).
A. ballism
Sympathetic nerve stimulation of the salivary glands causes vasoconstriction; and secretion of small
B. dysmetria
amounts of saliva with a high organic content.
C. dysdiadochokinesia
D. intention tremor
E. hypotonia 25861 – The following are true of acute confusional states
1: treatment should not commence until a cause for the confusion has been found
2: they may form part of the systemic inflammatory response syndrome
3: the side-effects of drugs used to treat confusion are minor
4: reasoning with the patient is of considerable benefit
5: sedative drugs should form the first line of treatment
GASTROINTESTINAL
22944 – Which of the following occur(s) in the liver?
Answers: FTFFF 1: conversion of free fatty acids to ketones
2: conversion of ammonia to urea
Answer to come. Question to be reviewed at March 04 meeting re: option D being true (23/02/04) 3: synthesis of very low density lipoproteins
4: synthesis of somatomedin-C (IGF-I)
21908 – Below a hemisection of the spinal cord
1: paralysis is ipsilateral Answers: TTTT
2: loss of proprioception and vibration sense is ipsilateral
3: analgesia is contralateral Ganong 13th Ed. Chapter: 17 Page: 243, 248, 251 Ch. 22 P. 337
4: thermal anaesthesia is ipsilateral
23519 – Metabolic functions of the liver include
Answers: TTTF 1: storage of glucose as glycogen
2: processing of chylomicron remnants from the blood
9745 – Likely sequelae within the first week of complete transection of the 3: gluconeogenesis to maintain blood glucose concentration
lower cervical spinal cord include 4: chemical modification and excretion of thyroxine
1: bradycardia
2: a negative nitrogen balance Answer: TTTT
3: hypothermia
4: flexor spasms of the leg Guyton Page: 837
Answers: TTTF 23549 – The abnormally high blood ammonia levels commonly found in
hepatic coma are due to
Ganong, 19th ed, Ch 12 1: porto-systemic shunting of blood
2: reduced capacity for urea synthesis in the liver
13655, 21723 – Spinal shock following transection of the cord in man 3: bacterial production of ammonia in the gut
1: profoundly depresses spinal tendon reflexes 4: decreased hydrogen ion excretion by the kidney
2: renders the patient poikilothermic
3: usually lasts longer than 1-2 weeks Answers: TTTF
4: is associated with the disappearance of arterial baroreceptor responses
Guyton 7th Edition CHAPTER: 70 PAGE: 837
Answer: TTTT
21973 – Ammonia
Ganong 13th Ed. Ch. 12 P. 171 Guyton 7th Ed. Chapter: 51 Page: 617, 618. Immediately following 1: may be formed from glutamine in the kidney
cord transection the resting membrane potential of distal nerves is up 6mV greater than the normal, 2: is taken up by glutamic acid in the brain
resulting in depression of spinal reflex responses (A true). The depression lasts at least one week, 3: is converted to urea in the liver
and usually beyond two weeks, at which time distal neuronal excitability slowly returns (C true). The 4: is a substrate for urea production in the kidney
lack of functioning autonomic efferent pathways regulating skin blood flow blunts thermoregulation
and the patient’s body temperature tends to follow ambient temperature swings (B true). While resting Answers: TTTF
blood pressure may be almost normal. Because autonomic function is, lost, compensation for evoked
changes in arterial presssure through the arterial baroreceptor reflexes is not evident (D true). Ganong 13th Ed. Ch. 32 P. 514 Ch. 38 P. 599
15290 – S:Reflex evacuation of the rectum rarely occurs following chronic 10094 – With respect to bile pigments
transection of the spinal cord because R:the sympathetic division of the 1: about 85% of bilirubin is formed from haemoglobin released by destruction of mature red blood
autonomic nervous supply to the internal anal sphincter is excitatory cells which normally have a life-span of 74 days
2: unconjugated bilirubin in plasma is filtered into the proximal convoluted tubules
Answer: S is false and R is true 3: about 20% of bilirubin in the small intestine recirculates to the liver in the enterohepatic circulation
4: unconjugated bilirubin rises in the plasma when there is excessive destruction of red blood cells
Refer to Ganong, 19th Ed, Ch 12, page 201
Answer: FFFT

Ganong, 19th ed, Ch 26 E. bile pigments
22409 – With respect to bile salts Answer: A

1: they are absorbed largely from the ileum
2: the primary bile salts are cholate and chenodeoxycholate and are conjugated with glycine or Hepatic bile is made up of bile salts (0.7%), bile pigments (0.2%), cholesterol (0.06%), and other
taurine in the liver substances (fatty acids 0.15%, fat 0.1%) dissolved in an alkaline electrolyte solution resembling
3: they are synthesised from cholesterol and are concentrated in the gall bladder pancreatic juice (A true).
4: about 90% of cholate and chenodeoxycholate which enter the small intestine are absorbed from
the jejunum and recirculate to the liver 14651 – Concerning bile production and secretion
1: reabsorption of bile salts from the intestine leads to further secretion of bile
Answers: TTTF 2: active transport of NaCl out of the gall bladder is the mechanism by which the bile is concentrated
3: a certain concentration of bile salt is required for the formation of micelles
Ganong CHAPTER: 26 PAGE: 403 4: bile salts are derived from waste products of haemoglobin breakdown
12929 – Bilirubin is Answers: TTTF

1: normally transported in the blood bound to albumin
2: normally converted to urobilinogen in the small intestine Refer to Ganong, 19th Ed, Ch 26, page 479-482. This question is currently under review by the
3: conjugated in the liver with glucuronic acid Physiology Sub Committee. 28 June 2002. This question has been updated. 9 Dec 2002.
4: formed in the reticuloendothelial system and bone marrow
853, 13397, 20649 – S. If there is complete obstruction of the common bile
Answers: TTTT duct, retained bile salts may cause skin itch because R. the liver forms
cholic acid from which 10-20gm of bile salts are formed daily.
Haemoglobin is broken down in the reticuloendothelial system and bone marrow (D true). The 'haem'
portion is subsequently transported to the liver bound to albumin (A true) where it is conjugated with
glucuronic acid (C true). After secretion in the bile, it is converted in the small intestine to urobilinogen
(B true) of which 10-20% is reabsorbed.
Ganong 13th Edition CHAPTER: 26 PAGE: 418. The liver secretes about 500ml of bile daily,
containing 0.7% bile salts. These are sodium and potassium salts of conjugated bile acids
0835 – S. The bile pigment in greatest quantity recycling in the synthesised from cholesterol. The two principal bile acids formed in the liver are cholic acid and
enterohepatic circulation is bilirubin BECAUSE R. bilirubin glucuronide is chenodeoxycholic acids. The normal rate of bile salt synthesis is only 0.2 to 0.4 gram daily (R false).
deconjugated by bacteria in the intestine. The total bile salt pool of approximately 3.5 gram recycles repeatedly via the enterohepatic circulation
with minimal faecal loss. Obstructive jaundice associated with complete obstruction of the bile duct can
Answer: S is false and R is true cause intense skin itching mainly contributed to by bile salt retention (S true). Five hundred ml of bile are
secreted daily. Bile salts are secreted into the bowel lumen. Ninety to ninety-five per cent of these are
Guyton 7th Ed./Ganong 13th Ed./Walter & Israel 6th Ed. CHAPTER: 70/26/47 PAGE: 838-839/419/5 absorbed in the terminal ileum, and returned to the liver via the enterohepatic circulation, and then re-
excreted. In complete obstruction of the common bile duct bile salts accumulate in the serum and
21453 – Cholesterol solubility in bile depends on the relative itching occurs (S true). Cholic acid is formed in the liver. This represents 50% of total bile salt
production which amounts to 0.2-0.4 gm/day (R false). This is recycled, so effectively that 3.5 gm are
concentrations of recycled daily as the bile salt pool
1: lecithin
2: calcium
3: bile salts
25970 – The bile acids are converted in the colon to
1: chenodeoxycholic acid
4: bilirubin
2: deoxycholic acid
3: cholic acid
Answers: TFTF
4: taurocholic acid
Ganong 13th Edition CHAPTER: 26 PAGE: 420 (Fig.26-23)
Answers: FTFF
13313 – If bile is analysed chemically, which of the following would be Ganong 15th ed Chapter:26 Page:466
found in highest concentration?
A. bile salts 14110 – S. About 90-95% of the cholate and chenodeoxycholate which
B. cholesterol
C. fatty acids
enters the small intestine recycles in the enterohepatic because R. cholate
D. fat
and cheno-deoxycholate are passively reabsorbed in the jejunum (C true) amylase and gelatinase. These are of little quantitative significance in digestion. The stomach
12
circulation secretes intrinsic factor which is essential for vitamin B absorption (D true).
Answer: C: S is true and R is false 7355 – S Removal of the part of the stomach nearst the pylorus would be
expected to reduce gastric acid secretion Because R the part of the
Refer to Gangong, 19th Ed, Ch 26, page 480-481 stomach nearest the pylorus secretes most of the hydrochloric acid
20091 – S. The patient who has obstructive jaundice due to gallstones may Answer: S is true and R is false
have an increased tendency to bleed because R. in obstructive jaundice
Removal of the part of the stomach nearest the pylorus would be expected to reduce gastric acid
decreased absorption of vitamin K occurs in the gut
secretion; this operation would remove the antrum, and with it the hormonal stimulus to acid
secretion. The response is incorrect. The antrum does not secrete most of the hydrochloric acid the
body and fundus do this.
Kyle CHAPTER: 18 PAGE: 408
20589 – S. The secretion of acid from the stomach is reduced when chyme
19929 – The oesophagus is normally enters the duodenum BECAUSE R. pancreatic polypeptide in the
A. relaxed, and open at both ends duodenum causes pancreatic exocrine secretion
B. closed at the stomach end only
C. closed at the oral end only Answer: S is true and R is false
D. contracted throughout its length
E. closed at both ends Ganong 11th Edition CHAPTER: 19 PAGE: 284
Answers: E 838 – With respect to gastric secretion

1: vagal stimulation increases the secretion of acid and pepsin.
Ganong 13th Edition CHAPTER: 26 PAGE: 408 2: resection of large segments of small intestine is associated with hypersecretion of acid.
3: vagotomy abolishes acid production.
15107 – Concerning the lower oesophageal sphincter 4: vagotomy abolishes gastric motility.
1: it has a resting pressure of 5mm of Hg above gastric pressure
2: exhibits tonic muscular activity unlike the body of the oesophagus Answers: TTFF
3: in achalasia absence of ganglion cells results in failure of adequate contraction in this region
4: reflex relaxation of the sphincter is integrated in the tractus solitarius and the nucleus ambiguous The cells of the gastric glands secrete 2.5 litres of gastric juice daily. Regulation is by neural and
humoral mechanisms. Vagal stimulation increases gastrin secretion by release of gastrin-releasing-
Answers: FTFF peptide and acetylcholine. It is convenient to break up the physiological regulation of gastric secretion
into cephalic, gastric and intestinal influences. Cephalic influences are vagally-mediated responses
Refer to Ganong, 19th Ed, Ch 26, page 469. Review July 2004 re: option should be true. induced by activity in the CNS. The gastric influences are primarily local reflex responses and
responses to gastrin. The intestinal influences are the reflex and hormonal feedback effects on gastric
13605, 22584 – Physiological properties of the stomach include secretion initiated from the small intestine. Resection of large segments of small intestine is
1: receptive relaxation associated with hypersecretion of acid (2 true). Vagal stimulation increases the secretion of acid and
2: control of the rate of access of food to the small intestine pepsin (1 true). Vagotomy affects only the cephalic phase of secretion, and diminishes (but does not
3: secretion of a lipase abolish) acid secretion. Gastrin is produced by G cells in the gastric antral mucosa and stimulates
4: secretion of a factor contributing to erythrocyte formation gastric acid and pepsin secretion. Acid in the antrum inhibits gastric secretion by a feedback
mechanism involving somatostatin. Gastric motility is also reduced (but not abolished) after vagotomy
Answers: TTTT (3 & 4 false). Gastric drainage procedures are required if total truncal vagotomy is performed, but not
with highly selective vagotomy. All these operations are now relatively rare for peptic ulcer disease
Guyton 7th Edition Chapter: 63 & 64 Page: 761, 774-775. Receptive relaxation of the stomach takes due to the effectiveness of H2 receptor blockers and proton pump inhibitors; and by control of
place as oesophageal peristaltic waves pass towards the stomach, transmitted by myenteric inhibitory infection from the bacterium Helicobacter pylori which disrupts the mucus barrier (as does aspirin and
nerves (A true). The gastro-oesophageal sphincter relaxes ahead of time ready to receive food being other NSAIDs).
propelled down the oesophagus during the act of swallowing. Stomach emptying is regulated by signs
from both the stomach and duodenum. Signals from the stomach are twofold: (i) nervous signals, 23409 – With respect to gastric secretion
caused by distention by food; (ii) gastrin released by antral mucosa in response to certain types of 1: vagal stimulation increases the secretion of acid and pepsin but not mucus
food within the stomach (B true). The stomach secretes a number of minor enzymes, such as lipase 2: after the operation of high gastro-jejunostomy (gastric bypass) for obesity the level of plasma
gastrin may rise following a meal

3: vagotomy abolishes acid production 1: metabolic alkalosis
4: vagotomy abolishes gastric motility 2: low pH of the urine
3: high serum sodium
Answers: FTFF 4: low serum potassium
Ganong 13th Edition CHAPTER: 26 PAGE: 409-413, 403-404 Answers: TTFT
22544 – With respect to the vagal distribution to the stomach 22078 – Following prolonged vomiting associated with complete pyloric
1: the posterior vagus gives rise to hepatic branches which enter the liver via the lesser omentum and obstruction, a patient would be likely to develop
the porta hepatis 1: an increase in alveolar ventilation
2: the main terminal branch of the anterior vagus nerve crosses the stomach distal to the incisura 2: a rise in plasma Cl-concentration
angularis about 5-6 cm from the pylorus 3: an increase in CSF pressure
3: most of the fibres of the posterior vagus nerve terminate in the stomach 4: a rise in plasma HCO-3 concentration
4: some vagal fibres travelling to the parietal cell mass may sink into the muscular wall at the
oesophagus some distance above the cardia Answers: FFFT
Answers: FTFT Ganong 13th Edition Chapter: 39 Page: 608-611
Last (8) PAGE: 336 848 – Which of the following may be associated with prolonged vomiting
21258 – A decrease in gastric antral pH to 2.0 from severe pyloric stenosis due to a duodenal ulcer?
1: Low serum potassium.
1: inhibits the release of gastrin
2: Low pH of the blood.
2: occurs due to the synergistic action of histamine, gastrin and acetyl choline
3: Low pH of the urine.
3: reflexly inhibits gastric secretion
4: Extracellular metabolic acidosis.
4: promotes activity in inhibitory afferent fibres of the vagus
Answers: TFTF
Answers: TTTF
"Pyloric" stenosis occurs when the gastric outlet is obstructed by a benign duodenal or prepyloric
ulcer or by a stomach cancer. Loss of gastric acid from prolonged vomiting can cause extracellular
metabolic alkalosis (4 false), particularly when the cause of the obstruction is a peptic ulcer
20385 – S.The respiratory quotient of the stomach during secretion of associated with hypersecretion of acid. Serum bicarbonate rises and serum chloride falls, with a rise
gastric juice is less than one BECAUSE R. the stomach takes up more CO2 in blood pH (2 false). The renal response of urinary bicarbonate excretion is initially associated with
from the arterial blood than it puts into the venous blood an alkaline urine containing sodium, potassium and bicarbonate. Subsequently the urine can become
acid ("paradoxical aciduria") (3 true) after prolonged vomiting with continuing combined
Answer: S is true, R is true and a valid explanation of S gastrointestinal and urinary losses of water and electrolytes, associated with gross deficiencies in
water, sodium, chloride and potassium with low serum potassium (1 true). The late aciduria is
Ganong 11th Edition CHAPTER: 26 PAGE: 397-398 associated with hydrogen ion excretion by renal tubular cells in the face of severe depletion of the
cations sodium and potassium.
22404 – A patient with pyloric stenosis due to an active duodenal ulcer has
KEY ISSUE
been vomiting most of his meals during the past week. He is hypokalaemic. Correction requires intravenous administration of isotonic saline with added potassium, which almost
The mechanisms causing this hypokalaemia include always suffices to restore acid-base balance provided that continuing losses are avoided by
1: intracellular protein breakdown correcting the obstruction.,
2: loss of potassium into gastric juice
3: decreased insulin production 13307 – Which of the following results in an increase in the pH of duodenal
4: increased renal loss of potassium contents?
A. gastrin-releasing peptide
Answers: FTFT
B. secretin
C. intrinsic factor
Guyton 7th Edition CHAPTER: 64, 77 PAGE: 774-775, 911
D. cholecystokinin
E. gastrin
13625 – Prolonged vomiting from severe pyloric stenosis may be
associated with
Answer: B 24014 – Substances maximally absorbed in the upper part of the small
intestine include
Secretin is released from the duodenum in response to duodenal acidification. It significantly
1: vitamin B12
increases pancreatic water and bicarbonate secretion and inhibits gastric acid output. Thus it leads to
2: iron
increased pH of duodenal contents (B true). Gastrin and gastrin-releasing peptide increase gastric
3: bile salts
acid output which would lower duodenal pH (A and E false). Cholecystokinin stimulates pancreatic
4: calcium
enzyme secretion and contraction of the gallbladder (D false). Intrinsic factor is released from the
oxyntic cells along with the secretion of acid and is essential for Vitamin B12 absorption in the ileum.
Answers: FTFT
It has no effect on duodenal pH (C false).
Ganong 13th Edition CHAPTER: 25 PAGE: 399-400
22414 – In the small intestine
1: the most significant single factor that increases the luminal surface area is the presence of villi 20079 – S. Patients who undergo massive resection of the proximal small
2: mucosal cells are formed from undifferentiated cells in the crypts of Lieberkuhn
3: peristalsis is the only type of movement demonstrated bowel are likely to develop peptic ulcer BECAUSE R. in such patients there
4: the frequency of slow waves decreases from the jejunum to the ileum is decreased secretion of secretin and gastric inhibitory polypeptide (G.I.P.)
Ganong 20th Ed, Chapter 26, p490. It is the microvilli that make the greater contribution to increase Ganong 13th Edition CHAPTER: 26 PAGE: 402-405
in surface area. Reviewed March 2003.
13385 – S:Patients who undergo massive resection of the proximal small
870 – With regard to the intestine bowel are likely to develop peptic ulcer disease because R:patients who
1: about 8-9 litres of water are absorbed by the small and large intestine daily. undergo massive resection of the proximal small bowel have hyper-
2: potassium is absorbed by the small intestine and secreted by the large intestine.
3: the absorptive surface of the small intestine is increased 600 fold by the valvulae conniventes, villi secretion of gastric acid
and microvilli.
4: diarrhoea can cause hypokalaemia. Answer: S is true, R is true and a valid explanation of S
Answers: TTTT Gastrin secreted by the stomach is inactivated primarily in the kidney and in the small intestine. Thus
if this inhibitory effect is removed in part, more gastrin is present to stimulate gastric acid production
The endogenous secretions (salivary glands 1500ml, stomach 2500ml, bile 500ml, pancreas 1500ml (R true and is a valid explanation) and peptic ulcer may develop (S true).
and small intestine 1000ml) total around 7 litres; to which is added 2 litres of ingested water in food
and fluid. Of this total intestinal input of 9 litres almost all is absorbed (1 true), leaving 100 to 200ml as 19557 – After massive resection of the small bowel all of the following are
output in the stool. Of the reabsorption, approximately 8 litres occurs in the small intestine (6 litres in common, EXCEPT
the jejunum and 2 litres in the ileum); and one litre in the colon. The absorptive surface of the small A. intractable diarrhoea
intestine is increased about 600 fold by the valvulae conniventes and villi (3 true). Potassium is B. increased likelihood of renal stone
absorbed from the small intestine and can be actively secreted into the large intestine (2 true). There C. hypergastrinaemia
is normally a nett secretion of potassium and bicarbonate into the colon. Active absorption of sodium D. increased serum calcium
from the colon is accompanied by water absorption. Diarrhoea can cause significant loss of E. lowered serum protein
electrolytes, including potassium (4 true). Reviewed Dec 2002.
Answer: D
13599, 23539 – The intestinal mucosa below the duodenum produces
1: mucus 10179 – Resection of the ileum markedly reduces the absorption of
2: secretin 1: bile salts
3: cholecystokinin 2: vitamin B12
4: isotonic intestinal secretion 3: fat-soluble vitamins
4: ferrous iron
Answers: TTTT
Answers: TTTF
Ganong 11th Edition CHAPTER: 26 PAGE: 390, 408. The intestinal glands of the jejunum produce
secretin, cholecystokinin and mucus (A, B and C true) in an isotonic secretion (D true) as do glands in Ganong, 19th ed, Ch 26
the duodenum.

20817 – S. Resection of the last metre of small bowel leaving the ileo-caecal Answers: TTTT
valve intact might result in a macrocytic anaemia developing within three
Burnett - C. S. S. CHAPTER: 18.22.4 PAGE: 347
months BECAUSE R. the last metre of ileum is the major site of vitamin B12
absorption 15478 – Features of colonic function include
1: constancy of faecal content despite variation in diet
Answer: S is false and R is true +
2: active transport of Na out of the colonic mucosa
3: sterile contents at birth
Guyton 7th Edition, Ganong 13th Edition CHAPTER: 66 & 26 PAGE: 799 & 414 + -
4: secretion of K and HCO 3 into lumen
20745 – S. Intestinal bacteria are largely responsible for the odour of the Answers: TTTT
faeces BECAUSE R. the odour of the faeces is largely due to the presence
of methane formed by bacterial action on ingested food Refer to Ganong, 19th Ed, Ch 26, page 486 and following
Answer: C: S is true and R is false 13403 – S: A narrowed segment of the distal third of the colon is more likely
to produce symptoms than a narrowed segment of the proximal third of the
Ganong 13th Ed. CHAPTER: 26 PAGE: 425 colon because R: faeces are more fluid in the proximal third of colon than
they are in the distal third
20787 – S. In the blind loop syndrome steatorrhea occurs BECAUSE R. the
proliferation of bacteria in a blind loop results in excessive oxidation of Answer: S is true, R is true and a valid explanation of S
conjugated bile salts
Approximately 1000-2000 ml of isotonic chyme enter the colon each day from the ileum. As it passes
Answer: S is true and R is false through the colon, 90% of the water is absorbed by the colon until 200-250 ml of semi-solid faeces
are found at the distal colon. Semi-solid or fluid faeces passes more easily through a constriction than
Ganong 13th Edition CHAPTER: 26 PAGE: 425-426 solid faeces. Thus a proximal tumour will not stop fluid and semi-solid colonic contents and will be
quiescent.
23244 – In the blind loop syndrome
1: the harmful effects are caused by bacterial invasion of the small intestine 23419 – Of the gastrointestinal hormones
2: steatorrhoea is a clinical feature 1: gastrin stimulates gastric mucosal growth
3: bacterial overgrowth may contribute to the development of macrocytic anaemia 2: cholecystokinin secretion by cells of the upper small intestine is enhanced by amino acids and fatty
4: jaundice is a clinical feature acids
3: secretin augments the action of cholecystokinin in producing pancreatic secretion of digestive
Answer: TTTF enzymes
4: gastric inhibitory peptide (GIP) increases the sensitivity of insulin response to raised blood glucose
This question will be submitted at the March 2004 meeting regarding option 1(15/03/2004) Answers: TTTT
Ganong 16th Edition CHAPTER: 26 PAGE: 452-54 Guyton CHAPTER: 78 PAGE: 977-78
20187 – S. Steatorrhoea may follow resection of the terminal
ileum BECAUSE R. 95% of the bile salts are absorbed in the terminal ileum 23434 – Common features of the gastrointestinal hormones VIP, GIP,
and recycled by the enterohepatic circulation secretin and glucagon include
1: lipolytic activity
2: present in the nerves of the gastrointestinal tract
3: release by vagal stimulation
Ganong 13th ed. Chapter: 26 Page: 418
4: portions of similar amino acid sequence
22384 – Diarrhoea during enteral tube feeding may be due to Answers: FFFT
1: excess volume of feed
2: hyperosmolarity of feed Ganong 13th Edition CHAPTER: 26 PAGE: 442-44
3: malabsorption
4: short bowel syndrome 9820 – The following are all gastrointestinal hormones EXCEPT
A. glucagon
B. GIP
C. enterokinase 23414 – Somatostatin inhibits acid secretion because it
D. gastrin - releasing peptide 1: stimulates luminal gastrin release
E. cholecystokinin 2: stimulates gastric inhibitory peptide release
3: inhibits gastrin release into the blood stream
Answer: C 4: inhibits parietal cell function
Ganong 19th ed, Ch 26 Answers: FFTT
13620, 23399 – Secretin Ganong 11th Edition CHAPTER: 26 PAGE: 391

1: is a powerful stimulant of pancreatic enzyme
2: inhibits gastric motility 25975 – Cholecystokinin
3: is produced in the upper small intestine 1: secretion is increased by fatty acids in the duodenum
4: inhibits gastric acid secretion 2: has a more marked effect on the ducts than on the acini of the pancreas
3: exerts a trophic effect on the pancreas
Answer: FTTT 4: inhibits the action of secretin in producing secretion of an alkaline pancreatic juice
Secretin is produced by cells in the mucosal glands of the duodenum and jejunum (C true). Its main Answers: TFTF
action is to stimulate the pancreas to secrete watery, alkaline pancreatic juice augmenting CCK (A
false). Secretin decreases gastric acid secretion (D true) by a feedback loop via gastrin by increasing Ganong 16th Ed. Chapter 26 Page:442-443
the pH of the duodenum. Secretin has a mild inhibitory effect on the motility of most of the gastro-
intestinal tract (B true). Ganong 13th Edition & Guyton 7th Edition CHAPTER: 26/63 & 64 (Guyton) 23249 – Serum gastrin
PAGE: 405/764 -778 (Guyton)
1: is decreased by products of protein digestion in the stomach
2: is increased by hypercalcaemia
9998 – Secretin is 3: is low in pernicious anaemia
1: released by acid in the duodenum 4: is increased after massive small bowel resection
2: released by vagal stimulation
3: a stimulant of secretion from biliary and pancreatic duct cells Answers: FTFT
4: responsible for a high chloride ion concentration in external pancreatic secretion
Ganong 14th ed. Chapter: 26 Page: 411
Answers: TFTF
13295 – Gastrin
Ganong, 19th ed, Ch 26
A. is produced in the gastric antrum, stimulates HC1 secretion and is inhibited by secretin
B. is produced in the gastric body, stimulates secretin production and is inhibited by HC1 secretion
21733 – Secretin C. is produced in the gastric fundus, stimulates HC1 production and stimulates secretin production
1: is secreted by cells in the mucosa of the duodenum D. stimulates secretin production
-
2: increases HCO 3 secretion from the exocrine pancreas E. is produced in the gastric antrum, suppresses HC1 secretion and stimulates secretin production
3: decreases gastric acid secretion
4: augments the action of CCK on the pancreas Answer: A
Answers: TTTT Gastrin is formed in the G cells principally in the gastric antrum (B and C false), and is present in the
duodenum in one-tenth the concentration released into the blood stream. It has two principal actions -
Ganong 13th ed. Chapter: 26 Page: 405 one of increased HC1 secretion (E false) by the parietal cells of the fundus, the other a trophic effect
on gastric an intestinal mucosa. An acid pH in the antrum is the powerful shut-off mechanism for acid,
14646 – Secretin acting mainly through inhibition of gastric release. This is complete at pH 1.2. Gastrin and
1: is secreted when protein breakdown products arrive in the upper small intestine cholecystokinin (CCK) are partial agonists, but gastrin and secretin are antagonists. Secretin inhibits
2: increases the secretion of bicarbonate from the biliary tract gastrin release after a meal. Acidification of the duodenum is the principal stimulus for secretin
3: is released in conjunction with Substance P release (D false). Thus gastrin is formed principally in the gastric antrum, stimulates HC1 secretion
4: is structurally similar to glucagon and is inhibited by secretin (A true).
Answers: TTFT 843, 13635 – Gastrin

1: is functionally and structurally related to cholecystokinin
Refer to Ganong, 19th Ed, Ch 26, page 465-466 2: is secreted by the antral mucosa
3: is liberated by distension of the antrum
4: stimulates the secretion of both acid and pepsin 576 – Cholecystokinin causes all the following EXCEPT
A. Stimulation of an enzyme-rich pancreatic juice.
Answers: TTTT B. Relaxation of the sphincter of Oddi.
C. Stimulation of hepatic flow of bile.
Gastrin, which is secreted by the antral mucosa under stimulus of antral distension is functionally and D. Contraction of the gallbladder.
structurally related to cholecystokinin; and stimulates secretion of both acid and pepsin (1, 2, 3 and 4 E. Stimulation of pancreatic juice rich in bicarbonate
true). The C-terminal pentapeptide of gastrin is identical to that of cholecystokinin (A true). Both
peptides are released by a protein meal and both stimulate glucagon secretion. Gastrin is produced Answer: E
by G cells in the antral mucosa (B true). Receptors in the wall of the stomach and in the gastric
mucosa respond to stretch (C true). Gastrin stimulates both the oxyntic and peptic cells to secrete Secretin, not cholecystokinin, stimulates a pancreatic juice rich in bicarbonate. The response is false
acid and pepsin (D true). and E is accordingly the correct answer.
23424 – Circulating gastrin levels are high in 570 – In the control of gastric acid secretion, the MAIN action of
1: Zollinger-Ellison syndrome somatostatin is to
2: pernicious anaemia A. suppress the release of gastrin.
3: secretory tumours of the pancreatic delta cells B. bind with the gastrin molecule to prevent its action.
4: most patients with duodenal ulcer C. stimulate the secretion of bicarbonate.
D. stimulate the parietal cell.
Answers: TTFF E. stimulate the release of gastrin.
Ganong 13th Edition CHAPTER: 26 PAGE: 403-404, 413 Answer: C
14661 – Gastrin secretion is increased by 22068 – With respect to fat absorption

1: glucagon 1: it is greatest in the upper small intestine
2: calcium 2: it occurs through active absorption of micelles
3: secretin 3: 95% of dietary fat is normally absorbed in adults
4: tryptophan 4: only 75% of dietary fat is absorbed in infants
Answers: FTFT Answers: TFTF
Refer to Ganong, 19th Ed, Ch 26, page 462 and following Ganong 20th Edition, p459. Active absorption does not occur. Ganong refers to some "carrier"
transport which is not neccessarily "active" and does not refer to evidence for "active" transport.
15092 – Gastrin is present in the following tissues Reviewed March 2003.
1: gastric antrum
2: gastric fundus 15097 – With respect to fat absorption
3: first part of duodenum 1: small amounts of medium and larger chain fatty acids are absorbed directly into the portal blood
4: renal parenchyma
2: chylomicra are small droplets of fat combined with apoproteins which aid diffusion through
enterocyte membrane
Answers: TFTF 3: without bile acids, less than 15% of fat is normally absorbed
4: between 80 - 90% of all fat absorbed from the gut is transported to the blood via the thoracic duct
Refer to Ganong, 19th Ed, Ch 26, page 470 and following. To be reviewed at March 04 meeting re:
as chylomicrons
option 2 "gastric fundus". (16/02/04).
Answers: FFFT
23664 – VIP (Vasoactive intestinal peptide)
1: potentiates action of acetylcholine in salivary glands Refer to Guyton, 9th Ed, Ch 65, page 842-843; Ganong, 19th Ed, Ch 25, page 452 and following
2: is formed from prepro-VIP
3: inhibits gastric acid secretion 24339 – During fat digestion/absorption
4: causes vasoconstriction of peripheral blood vessels
1: bile salts combine with fatty acids and monoglycerides to form micelles
2: in the absence of bile salts fatty acids are not absorbed
Answers: TTTF
3: fatty acids containing more than 10-12 carbon atoms are re-esterified to triglycerides in the
mucosal cells
Guyton 13th Edition CHAPTER: 26 PAGE: 405 4: pancreatic lipase produces fatty acids and monoglycerides from dietary triglycerides
phospholipid to form chylomicrons which leave the mucosal cells and pass into the lymphatics as
Answers: TFTT emulsified particles, accounting for most of the fat transport (B true). Only fatty acids containing less
than 10 to 12 carbon atoms pass from mucosal cells directly into the portal blood. Absorption of long
Ganong 19 Edition CHAPTER: 25 PAGE: 452-453 (also fig. 25.4) chain fatty acid begins in the duodenum and is greatest in the upper parts of the small intestine,
although appreciable amounts are also absorbed from the ileum. Short chain fatty acids are produced
82, 10404 – With regard to the parenteral administration of fat: by bacterial action on undigested complex carbohydrates from fruits and vegetables in the colon, and
A. Can constitute up to 70% of the total energy administered per day. are probably trophic to colonic mucosa.
B. There is a specific requirement for short-chain fatty acids in order to generate ketone bodies for
metabolism by colonocytes. 14104 – S:Fat in the duodenum delays stomach emptying because R:fat in
C. Omega-6 polyunsaturated fatty acid triglycerides should be provided in doses adequate to prevent the duodenum releases CCK, secretin and gastric inhibitory peptide (GIP)
essential fatty acid deficiency.
D. There is a specific requirement for medium-chain triglycerides to maintain the fluidity of Answer: S is true, R is true and a valid explanation of S
membranes.
E. Omega-3 polyunsaturated fatty acids may modulate the immune response by inhibiting the Refer to Ganong, 19th Ed, Ch 26, page 474-475
induction of free-radical lipid peroxides.
22704 – Plasma cholesterol levels are decreased by
Answer: C
1: thyroxine
2: androgens
Between 15% to 30% of the total calories administered per day can be provided as fat. There is no
3: oestrogens
specific requirement for short-chain fatty acids. Medium-chain triglycerides can be used as a source
4: growth hormone
of calories. Omega-6 polyunsaturated fatty acid triglycerides should be provided in doses adequate to
prevent essential fatty acid deficiency ie. at least 7.0% of total calories. Omega-3 polyunsaturated
Answers: TFTF
fatty acids are sometimes referred to as 'Fish Oils'. Whilst they have no established requirement in
critically ill patients, they are under clinical investigation as immune - modulating and anti-
Ganong 16th ed. CHAPTER: 17 PAGE: 279. This question is currently under review by the sub
inflammatory agents. They may regulate the immune response in at least three ways: (1) by
committee. 4 June 2002. This question has been reviewed and has not been altered. 9 Dec 2002
increasing membrane fluidity, (2) inducing free-radical lipid peroxides, and (3) by providing precursors
for eicosanoid metabolism.
21213 – Endogenously-derived triglyceride circulating in the plasma is
18856 – Which of the following (after fat) is the largest energy store? 1: transported primarily as very low density lipoprotein
2: increased by carbohydrate excess in the diet
A. muscle protein
3: removed from the circulation by both muscle and adipose tissue
B. visceral protein
4: increased when plasma cholesterol levels rise
C. extracellular protein
D. liver glycogen
Answers: TTTF
E. muscle glycogen
Ganong 13th ed. Chapter 17 Page: 251-254
Answer: A
BURNETT. C.S.S. CHAPTER: 14.2.2 PAGE: 208 19647 – With respect to lipoproteins, which of the following statements is
FALSE?
864, 3980 – After a fatty meal, most of the fat will be transported away from A. low density lipoproteins (LDL) contain more cholesterol than high density lipoproteins (HDL)
the intestine B. low density lipoproteins (LDL) contain more triglyceride than high density lipoproteins (HDL)
C. individuals with elevated LDL have a higher than normal incidence of atherosclerosis
A. as free fatty acids in the portal vein blood.
D. individuals with elevated HDL have a higher than normal incidence of atherosclerosis
B. as emulsified particles in the lymph.
E. the primary function of HDL is in cholesterol exchange and esterification
C. as monoglycerides in the portal vein blood.
D. as triglyceride in the portal vein blood.
Answer: D
E. attached to plasma albumin carrier molecules.
Answer: B
Refer to Ganong, 19th Ed, Ch 25, page 453-454, Figure 25.5. Fats are emulsified in the small 15102 – Iron absorption is
intestine by the detergent action of bile salts, lecithin, and mono-glycerides. After a fatty meal 95% or 1: facilitated by pancreatic juice
more of the ingested fat is absorbed. Fatty acids containing more than 10 to 12 carbon atoms are re- 2: inhibited by cereal products
esterified to triglycerides in the mucosal cells; and are coated with protein, cholesterol and 3: increased by adding ascorbic acid to the diet

4: predominantly in the duodenum This man has lost 900 mg of iron which, under normal conditions, would have been his reserve iron
store. As he has a past history of duodenal ulcer with probable iron loss and a history of active
Answers: FTTT rheumatoid arthritis which will affect iron absorption and mobilisation, he is most likely to have iron
deficiency anaemia (A true). Consequent to this iron deficiency, his plasma iron binding capacity may
Refer to Ganong, 19th Ed, Ch 25, page 456 and following be increased (C false) although chronic inflammation may reduce the expected rise (B true). His iron
absorption will thus tend to increase. Melaena will not be seen on macroscopic examination until
14681 – Iron absorption more than 100 ml of blood are lost daily into the large intestine (D true).
1: is increased by low pH of gastric secretions
2: is increased in states of iron overload 13409 – S:Iron deficiency anaemia may occur in patients who have had
3: requires the presence of transferrin radical gastrectomy because R:following radical gastrectomy, iron in the
4: occurs in terminal ileum 3+
ferric (Fe ) state is the main form present for absorption in the small
Answers: TFTF intestine
Refer to Ganong, 19th Ed, Ch 25, page 456-458 Answer: S is true, R is true and a valid explanation of S
12934 – Iron absorption is inhibited by ron is readily absorbed as ferrous (Fe++) iron. Most dietary iron, however is in the Fe+++ form.
Gastric secretions are necessary to convert Fe+++ to Fe++ forms. Absorption takes place mainly in
1: pH of pancreatic juice
the duodenum and upper jejunum. Following radical gastrectomy iron deficiency anaemia is a
2: phytic acid
relatively frequent complication (S true, R true and is a valid explanation of S).
3: ascorbic acid
4: phosphates
9892 – S:Iron deficiency anaemia is a recognised complication of partial
Answers: TTFT gastrectomy because R:acid is required for iron absorption within the
stomach
The absorption of non-haem iron is inhibited by its binding to dietary phytates in cereals (B true) and
phosphates (D true). Alkaline conditions reduce iron absorption (A true). Ascorbic acid forms a highly Answer: S is true and R is false
soluble iron chelate which facilitates intestinal mucosal attachment. Ascorbate also acts as a reducing
agent to maintain iron in the ferrous form which is more soluble than ferric iron in alkaline conditions Ganong, 19th ed, Ch 35
and thereby more readily absorbed (C false).
20529 – S. Following total removal of the stomach, microcytic anaemia is
23164 – Concerning iron likely to develop BECAUSE R. a secretion from the stomach is essential for
1: absorption is mainly in the ferrous form
2: adult males require absorption of 0.5-1.0 mg. per day normal erythropoiesis
3: absorption occurs mainly in the upper small intestine
4: haemosiderin is the principal storage form of iron in the tissues Answer: S is true, R is true but not a valid explanation of S
Answers: TTTF Ganong 15th Edition CHAPTER: 25, 26 PAGE: 446-47; 461-62. July 2004 review re: trainee
suggests question should be true/false format.
20139 – S. Anaemia may be a consequence of peptic ulcer
12939 – A 50-year-old man has a past history of a duodenal ulcer and has surgery BECAUSE R. there are less gastric secretions to convert dietary
3+ 2+
been taking aspirin 4-hourly for painful rheumatoid arthritis for a period of Fe to its more easily absorbable form Fe after peptic ulcer surgery
two months. This has caused a loss of 30 ml of blood daily in his stools. It
is likely that
1: his blood will show an iron deficiency anaemia
Ganong CHAPTER:25 PAGE: 399
2: his absorption of iron from a full normal diet will be affected by arthritis
3: his plasma iron binding capacity will be decreased
4: there will be no suspicion of melaena on macroscopic examination of his stools 662 – Which of the following statements, concerning iron metabolism,
is/are true?
Answers: TTFT 1: gastric acidity is required for absorption of haem-iron
2: achlorhydria leads to a significant reduction in absorption of non-haem-iron
3: iron absorption does not increase after haemolysis

-
4: iron absorption is increased after haemorrhage are HCO3 and chloride. The concentration of bicarbonate is about 80 mmol/l rising to 150 mmol/l on
stimulation by secretin. The concentration of chloride, by contrast, is about 55 mmol/l and falls when
Answers: FTFT the pancreas is stimulated by secretin (C false). Question to be reviewed at March 04 meeting re:
option a being true - proenzymes. (16/02/04). Question to be reviewed at March 04 meeting re:
Ganong, 19th ed, Ch 26; Guyton, 9th ed, Ch 32; Robbins, 6th ed, Ch 14. This question is currently option D. (23/02/04)
under review by the sub committee. 4 June 2002. This question has been reviewed and has not been
altered. 9 Dec 2002. Comments: Gastric acidity and secretions enhance iron absorption and patients
10174 – The external secretion of the pancreas contains
without a stomach can become iron deficient but may still absorb some iron. (Hence can be treated
1: phospholipase A
with iron tablets.) Thus gastric acidity is not required.
2: chloride at about 130 mmol/l concentration
3: ribonuclease and deoxyribonuclease which split nucleotides from nucleic acids
20955 – S. In patients suffering from pernicious anaemia the serum gastrin 4: a bile salt activated lipase capable of hydrolysing cholesterol esters
levels are normal BECAUSE R. there is no increase in gastric intra-luminal
acid in pernicious anaemia Answers: TFTT
Answer: S is false and R is true Ganong, 20th ed, Ch 26 Pages 483, 458. Question updated 2 Dec 2002.
-
Ganong 11th Edition & W & I 5th Edition CHAPTER: 26 PAGE: 390 609 23429 – HCO3 rich pancreatic juice is secreted by the pancreas in response
to
13072 – Pernicious anaemia is typically associated with 1: secretin
1: a reduced packed cell volume 2: vagal stimulation
2: megaloblastic marrow 3: CCK
3: gastric atrophy 4: gastrin
4: thrombocytopenia
Answers: TFFF
Answers: TTTT
Ganong 13th Edition CHAPTER: 26 PAGE: 452-454. This question was referred to the Physiology
Anaemia is typically associated with a reduced packed cell volume (A true). Even though the red cells Sub Committee for review on 1 Feb 2002.
are larger than normal in pernicious anaemia, their numbers are considerably reduced, and the PCV
is, therefore, low. Gastric atrophy is the most important cause of pernicious anaemia and results from 859, 13610, 233404 – Enzyme-rich pancreatic juice is secreted when
an auto-immune reaction (C true). The megaloblastic marrow reflects a deficiency of Vitamin B12 and 1: secretin acts on the pancreas.
folate (B true). Pernicious anaemia is typically associated with a thrombocytopenia (D true). 2: cholecystokinin (CCK) acts on the pancreas.
3: the vagus stimulates the pancreas.
10089 – The pancreas secretes 4: the sympathetic nerves stimulate the pancreas.
1: insulin, in increased quantity following a-adrenergic stimulation
2: proelastase Answers: FTTF
3: glucagon, in decreased quantity following administration of somatostatin
4: inactive precursors of trypsin and lipase Ganong 13th Edition Chapter: 26 Page: 415-416. The pancreatic juice of the exocrine pancreas
contains enzymes of major importance in digestion. Their secretion is controlled by the
Answers: FTTT gastrointestinal hormones secretin and CCK, and by reflex mechanisms. The active enzymes
secreted include pancreatic amylase, trypsin and chymotrypsins, pancreatic lipase and
Ganong, 19th ed, Ch 19 and 26 carboxypeptidases. The juice is alkaline with a high bicarbonate content. About 1500ml is secreted
daily. Secretion is primarily under hormonal control. Secretin acts on the pancreatic ducts to cause a
5977, 13630 – The exocrine secretion of the pancreas contains copious secretion of a very alkaline pancreatic juice which is rich in bicarbonate and poor in enzymes
1: phospholipase A (1 false). CCK acts on the acinar cells to cause production of pancreatic juice rich in enzymes (2
2: ribonuclease and deoxyribonuclease which split nucleotides from nucleic acids true). Stimulation of the vagi with release of acetylcholine causes discharge of zymogen granules and
3: chloride at about 130 mmol/l concentration secretion of a small amount of juice rich in enzymes (3 true). A vagally-mediated conditioned reflex
4: prolipase from nucleic acids secretion of pancreatic juice occurs in response the sight or smell of food. The sympathetic nerve
supply of the pancreas is vasoconstrictive, and has minimal effect on exocrine secretion (4 false).
Answers: TTFT
Secretin stimulates pancreatic secretion, but this is poor in enzymes. Stimulation of the vagus causes
Pancreatic juice is alkaline and about 2 litres are secreted daily. Pancreatic juice contains secretion of a small amount of pancreatic juice rich in enzymes. This effect is blocked by atropine and
phospholipase A, ribonuclease and deoxyribonuclease and prolipase (A,B,D true). The main anions by denervation of the pancreas, whereas the effects of cholecystokinin-pancreozymin are not. There
is evidence for a vagally mediated conditioned reflex secretion of pancreatic juice. Sympathetic
stimulation in the gastro-intestinal tract can inhibit peristalsis and increase the tone of the sphincters E. carbohydrates must be broken down to disaccharides or monosaccharides before they can be
but does not affect pancreatic secretion. Cholecystokinin-pancreozymin causes contraction of the gall absorbed in any quantity
bladder and stimulates the pancreas to secrete pancreatic juice rich in enzymes. Furthermore, CCK
augments the action of secretin in producing an alkaline-rich pancreatic juice. Answer: E
23254 – The serum amylase may be elevated during Guyton 7th Edition Chapter: 65 PAGE: 787-788. Transport of most monosaccharides is an active
1: acute renal insufficiency process. This is demonstrated by the following: (i) Transport of most monosaccharides can be
2: administration of morphine blocked by metabolic inhibitors such as iodoacetic acid, cyanides and phlorizin (A false). (ii) Transport
3: acute perforation of a duodenal ulcer is selective for the different monosaccharides (D false). (iii) There is a maximum rate of transport for
4: mumps each monosaccharide the most rapid being for galactose (C false). (iv) There is competition between
certain sugars for respective carrier systems (B false). This question has been reviewed by the sub
Answers: TTTT committee and remains unchanged.
Canadian Exam 976, 10398 – With regard to the parenteral administration of carbohydrates:
A. Patients require 15 kcal/kg/day.
9838 – In the absence of pancreatic enzymes the faeces contain more fat B. Patients require 25 kcal/kg/day.
C. Patients require 35 - 40 kcal/kg/day.
MAINLY because
D. Patients require 50 kcal/kg/day and the blood glucose levels should be maintained less than 225
A. there is little enteric lipase in the epithelial cells of the small intestine
mg/dL (12.5 mmol/L).
B. pancreatic enzymes are necessary for adequate emulsification of fat
E. Patients require 50 kcal/kg/day and the blood glucose level should be maintained more than 225
C. lack of pancreatic bicarbonate reduces the efficiency of succus entericus enzymes
mg/dL (12.5 mmol/L).
D. proteolytic enzymes in pancreatic secretion are essential for the release of fat from the forms in
which it is ingested
Answer: B
E. pancreatic secretion is necessary to stimulate bile production
Administering 25 kcal/kg usual body weight/day appears to be adequate for most patients. From 30%
Answer: A
to 70% of the total calories administered per day can be given as glucose. The dose should be
adjusted to maintain a blood glucose level <225 mg/dL - it may be desirable to administer insulin in
Ganong 19th ed, Ch 26
patients with higher levels of glucose in the blood. The calorie-to-nitrogen ratio should be 150 kcal per
gm of nitrogen (about 6.25 gm of protein contains 1 gm of nitrogen). In trying to adapt nutritional
20865 – S. If a carcinoma of the head of the pancreas obstructs the supply to needs, most dieticians and nutritionists will estimate energy expenditure from standard
common bile duct, there a high level of urobilinogen in the formulas like those of Harris and Benedict, which are derived from sex, weight, height, and age.
urine BECAUSE R. urobilinogen entering the circulation is excreted in the
urine 1012, 10434 – With regard to the inclusion of fibre in solutions of enteral
nutrients:
Answer: S is false and R is true A. Butyrate, an endogenous product of fibre fermentation, is an important fuel for colonocytes.
B. It is desirable to consume > 250 gm of fibre each day.
Ganong 13th. ed. Chapter: 26 Page: 419 C. A deficient fibre intake can lead to secretory diarrhoea.
D. The long-term consumption of a diet that is low in fibre increases the risk of bacterial translocation
20331 – S. Although protein has a theoretically higher caloric content than across the wall of the proximal colon.
E. An inadequate fibre intake can impair the entero-hepatic circulation of bile salts and thereby lead to
carbohydrate, in the body similar values are obtained from protein and
the diminished absorption of fat soluble vitamins.
carbohydrate BECAUSE R. the oxidation of protein is incomplete
Answer: A
Endogenous products of fibre fermentation are important for colonocyte integrity and function.
Ganong 15th ed. Page: 262 However, the provision of fibre has not been clearly demonstrated to be of any clinical advantage.
Bacterial translocation, as well as other aspects of the gut barrier, will be covered later on in this
13301, 19875 – Which of the following could NOT be considered evidence module.
that intestinal absorption of carbohydrate is an active process?
A. absorption is inhibited by metabolic poisons 13391, 20073 – S:Ingestion of protein foods such as eggs can sometimes
B. glucose in the lumen strongly reduces fructose absorption from the lumen provoke antibody formation in infants because R:in infants there is
C. there is a maximum rate of absorption for glucose from the intestinal lumen
absorption of whole protein from the alimentary canal
D. absorption rate can be different for sugars of similar molecular weight

Answer: S is true, R is true and a valid explanation of S 18904 – Regarding the digestion and absorption of amino acids from the
intestine
Ganong 13th Edition CHAPTER: 25 PAGE: 395. In infants, moderate amounts of undigested protein
A. less than 5% of the protein in the small intestine escapes digestion and absorption
are absorbed (R true and is a valid explanation of S). Maternal protein from colostrum is absorbed,
B. absorption of amino acids is rapid throughout the whole of the small intestine
affording passive immunity against infection. Absorption is via the small intestine by endocytosis and
C. over 90% of the digested protein is dietary
subsequent exocytosis. Foreign proteins entering the circulation, provoke the formation of antibodies
D. the protein in the stools is largely undigested dietary protein
(S true) leading to possible allergic symptoms.
E. amino acids are actively transported from the mucosal cells into the blood stream
10410 – With regard to the parenteral administration of protein: Answer: A
A. Glycine should constitute at least 50% of the amino acids.
B. Dosing should ensure that the blood urea nitrogen level remains > 200 mg/dL. Ganong 13th Ed. CHAPTER: 25/26 PAGE: 394-395/424-425. Quesiton to be reviewed at the March
C. Hepatic encephalopathy is not influenced by the amount of protein that is administered 04 meeting re: options A & E (20/02/04).
parenterally.
D. Solutions should contain > 0.25 g/kg/day of nucleotides to maintain the proliferative ability of bone
10416 – With regard to the parenteral administration of branched chain
marrow.
E. The protein requirement is about 1.2 to 1.5 g/kg/day. amino acids (BCAA):
A. BCAA administration to catabolic surgical patients enhances the quality and number of
Answer: E polyribosomes in skeletal muscle.
B. BCAA administration improves patient outcome after major hepatic surgery.
The protein requirement is about 1.2 to 1.5 g/kg/day. Considerations for a decrease in dosing include C. BCAA are mainly metabolised in the liver.
a rising blood urea nitrogen level that exceeds 100 mg/dL or a rising blood ammonia level that is D. There is no role for parenteral BCAA therapy in patients with hepatic encephalopathy.
associated with clinical encephalopathy. A nutritional requirement for nucleic acids has not been E. When used clinically, BCAA should be administered at a dose of 0.1 to 0.3 g/kg/d.
established, but they are being investigated as beneficial nutrients for proliferation of intestinal crypt
cells, lymphocyte proliferation, and cellular DNA and RNA synthesis. Glycine is the simplest of the Answer: A
amino acids as it is based only one carbon molecule. Its administration has no defined biological or
clinical advantages, but it is often included in commercial solutions as a 'stuffer' amino acid ie. a The BCAA - leucine, isoleucine, and valine - are essential amino acids required for protein synthetic
convenient source of nitrogen. Incidentally, as opposed to chronic renal failure, there is no need to functions. BCAA are primarily metabolised by skeletal muscle, rather than the liver. When given in a
alter the amount of protein administered to patients with acute renal insufficiency. There is also no balanced amino acid formulation at a dose of 0.5 to 1.2 g/kg/d BCAA can improve nitrogen retention
demonstrable advantage to be gained by administering just essential amino acids. Haemodialysis and and increase protein synthetic functions relative to standard amino acids formulations e.g. the number
haemofiltration remove amino acids in the range of 3 to 5 g/h. These losses need consideration when and quality of polyribosomes in skeletal muscle. As illustrated, BCAA can be consumed in muscle to
adjusting the amount of protein to be administered. generate glutamine. Nevertheless, their exact role in promoting improved patient outcomes in surgical
patients remains to be defined. But it is clear that, in patients who are protein-intolerant because of
24194 – With regard to trace elements chronic or latent hepatic encephalopathy, BCAA-enriched parenteral nutrition permit greater protein
intake without inducing encephalopathy than do standard protein formulas.
1: iron deficiency may cause anaemia
2: cobalt deficiency may cause megaloblastic anaemia
3: iodine deficiency may cause goitre formation 21728 – The amino acid glycine
4: chromium deficiency may cause insulin resistance 1: is probably the mediator responsible for direct inhibition in the spinal cord
2: when directly applied to the membranes of neurones causes hyperpolarization
Answers: TTTT 3: with arginine and methionine is responsible for the synthesis of creatine in muscle
4: has an inhibitory function in the cord antagonized by atropine
Ganong 18th ed. Page: 293
Answers: TTTF
19270 – Which of the following is NOT an essential trace element
Ganong 7th Ed. Ch. 4 P. 74 126 243. Pending review. May 2003
A. zinc
B. copper
C. beryllium 1000, 10422 – With regard to arginine:
D. molybdenum A. When administered in pharmacological doses arginine may act as a neuotransmitter.
E. selenium B. Alanine is the main precursor of arginine.
C. Critically ill patients require 30 g/day of arginine.
Answer: C D. Arginine is a unique substrate for the production of nitric oxide.
E. Arginine is the preferred nutrient for immunocytes.
BURNETT. C.S.S. CHAPTER: 14.7 PAGE: 213
Answer: D

Arginine is now considered to be a conditionally essential amino acid. Arginine is synthesised Answers: TFTF
endogenously in the kidney from gut-derived citrulline (the small intestine converts dietary amino
acids, including glutamine, to citrulline). Arginine participates in a variety of metabolic functions, Refer to Burnett, 2nd Ed, Ch 6, page 104; STEM Module: Metabolism/Nutrition
including urea synthesis, lymphocyte proliferation, and wound healing. In addition, arginine is a
unique substrate for the production of the biologic effector molecule, nitric oxide. This important 23439 – Transport of glucose across intestinal cell membranes is thought
pathway has been shown to be present in many tissues and cells including endothelium and
to require
inflammatory cells. The role of arginine in critically ill patients remain to be defined but doses of up to +
1: Na transport across enterocyte membrane
30 g/day have been used in evaluative studies. Combinations of nutrients with immune function
2: glucagon
activity - arginine, fish oil, and nucleic acids - are being evaluated as enteral nutrients in critically ill
3: carrier molecules
patients: although they are sometimes referred to as 'immunonutrients', their clinical efficacy has yet
4: brush border disaccharidases
to be confirmed by independent clinical trials.
Answers: TFTF
1006, 10428 – With regard to glutamine:
A. Glutamine is the only amino acid that contains three nitrogen molecules. Ganong 16th Edition CHAPTER: 25 PAGE: 430
B. Glutamine constitutes about 25% of the amino acid content of standard solutions of parenteral
nutrients. 8651 – If conscious, pain would be experienced in response to which of the
C. Critically ill patients require 20 g/day of glutamine.
D. Glutamine is the principal fuel used by rapidly proliferating cells. following stimuli applied to bowel?
E. The kidney consumes glutamine during periods of metabolic alkalosis. 1: visceral distension
2: surgical diathermy
Answer: D 3: visceral ischaemia
4: cutting with a sharp instrument
We discussed the metabolism of glutamine in Topic 1. It is the main fuel consumed by rapidly dividing
cells such as the gut mucosa, immunocytes, and some tumours. Glutamine is not included in Answer: TFTF
standard solutions of parenteral nutrients because it is unstable in solution and breaks down to form
toxic amounts of pyroglutamate and ammonia. It remains to be determined whether administering Guyton, 9th ed, Ch 48; Ganong, 19th ed, Ch 17
glutamine to catabolic patients results in an improved outcome. As mentioned in Topic 1, the kidney
consumes glutamine during periods of metabolic acidosis. 23169 – Uric acid
1: is formed from breakdown of purines
23544 – Absorption of vitamin B12 requires 2: reabsorption in renal tubules can be inhibited by probenecid (Benemid)
1: intrinsic factor binding with vitamin B12 in the small intestine 3: level in plasma is normally 0.2 - 0.4 mmol/l
2: pepsin 4: urinary excretion is increased by allopurinol
3: trypsin which facilitates efficient absorption
4: a high oral intake of vitamin B12 Answer: TTTF
Answers: TFTF Ganong 13th ed. Chapter 17 Page: 246
Ganong 13th ed. PAGE: 414 964 – With regard to albumin:

A. Serum concentrations < 30 g/L strongly correlate with a poor clinical outcome.
20097 – S. Arctic explorers developed headache, diarrhoea and dizziness B. It is a useful marker of nutritional status because it has a relatively short half-life.
eating polar bear liver BECAUSE R. liver is a rich source of vitamin A C. Synthesis is markedly inhibited during the early stages of undernutrition.
D. It has a low exchange rate between the intra- and extra-vascular compartments.
E. Serum concentrations are increased during sepsis.
Answer: A
Ganong 13th Ed. CHAPTER: 17 PAGE: 259
Hepatic secretory proteins such as albumin, transferrin, retinol binding protein, and prealbumin are
15433 – Sources of carbohydrates which may be used in parenteral markers of visceral protein stores and are used as indicators of nutritional status. Numerous studies
nutrition solutions include have demonstrated that a low serum albumin concentration ( < 30 g/L) strongly correlates with a high
1: glycerol incidence of mortality and morbidity. However, albumin has a half-life of about 28 days and acute
2: maltodextrins changes in serum albumin concentration cannot be ascribed to poor nutrition. For example, serum
3: sorbitol albumin concentrations are usually not affected by nutritional intake during starvation until starvation
4: starch has reached an advanced stage and there is a marked reduction in body weight accompanied by
overt muscle wasting. On the other hand, the low serum albumin concentrations that are observed in
stressed patients persist until the parts start to recover and there is an absence of inflammatory foci. C. group B blood and group AB blood
The exchange rate between intravascular and extravascular albumin is large and even small D. group AB blood, group B blood and group O blood
variations in the percentage of exchange can cause significant changes in serum albumin E. group B blood and group O blood
concentration. Levels of regulatory hormones, acute-phase reactants, and the measurement of the
circulating levels of a number of cytokines have also been proposed as 'nutritional markers'. For Answer: C
example, C-reactive protein has the attraction of being present in very low concentrations in the
serum of normal subjects, but rising exponentially within four hours of the onset of infection. However, See commentary in STEM Module: Peri-operative Care and Complications (Q18). Plasma from
such measurements reflect metabolic stress rather than nutritional status. group A blood contains anti-B antibodies and will thus agglutinate both group B blood and group AB
blood (C).
HAEMATOLOGY 20547 – S. Haemoglobin has a greater buffering capacity than plasma

proteins at physiological pH BECAUSE R. according to the Henderson-
14676 – Erythropoiesis is
1: subject to feedback control Hasselbach equation, the buffering capacity of a system is greatest when
2: a feature of acclimatisation to altitude pH=pK
3: inhibited by a rise in the circulating red cell level to supernormal values
4: controlled by erythropoietin produced by erythrocytes Answer: S is true, R is true but not a valid explanation of S
Answers: TTTF Ganong 13th Ed. Ch. 35 P. 554
Refer to Ganong, 19th Ed, Ch 27, page 508 and following 12524 – Of the following, the safest combination for packed red cell
transfusion in an emergency would be
10104 – Fetal haemoglobin (haemoglobin F) A. donor type A recipient type O
1: has less affinity for O2 than adult haemoglobin (HbA) B. donor type AB recipient type B
2: binds 2-3 DPG less effectively than HbA C. donor type B recipient type O
3: at birth is 20% of the circulating Hb D. donor type B recipient type AB
4: at four months is 10% of the circulating Hb E. donor type AB recipient type O
Answers: FTFT Answer: D
Ganong, 19th ed, Ch 27, 32 and 35 People with Type AB red cells have no iso-agglutinins. It is therefore safe to transfuse B cells (in the
absence of atypical anti-red blood cell antibodies in the recipient). If whole blood were transfused
15296 – S:Complications commonly arise when an Rh negative mother (Group B), the donor alpha-agglutinin may haemolyse recipient AB cells dependent on the donor
carries an Rh positive baby during her first pregnancy because R:small agglutinin titre.
amounts of foetal blood leak into the materal circulation
13090 – Thrombocytopenia sometimes complicates the repeated
Answer: S is false and R is true transfusion of large quantities of blood because
1: the patient's platelets are diluted by the transfusion
Refer to Ganong, 19th Ed, Ch 27, page 515 2: anti-platelet antibodies may be produced by the recipient
3: the platelets in stored blood are non-viable
8657 – A child who is group O Rh negative can have a parent who is 4: the transfused plasma sometimes contains anti-platelet antibodies
1: group B Rh positive
2: group O Rh positive Answers: TTTT
3: group A Rh positive
4: group AB Rh positive After a massive haemorrhage (which will have preceded the repeated transfusion of large quantities
of blood) the patient will have lost functional platelets, only to have them replaced by non-viable
Answers: TTTF platelets in the transfused blood (A and C true). The transfusion of serum or blood always carries the
risk of transferring unwanted antibodies (D true). The production of anti-platelet antibodies is a well
Ganong, 19th ed, Ch 27 recognised phenomenon which can occur in a variety of circumstances (B true).
7114, 18316 – Plasma for group A blood will agglutinate 9953 – The delivery of O2 from blood to tissues would be increased by an
A. only group AB blood increase in the tissue capillaries of
B. only group B blood 1: the 2,3-DPG (diphosphoglycerate) content of the red blood cells
2: blood pCO2 12644 – S:5000 Units of Heparin given subcutaneously twice daily
3: blood temperature perioperatively reduces the incidence of post-operative deep vein
4: blood pH
thrombosis because R:Heparin, in sub-therapeutic dosage, potentiates
Answers: TTTF anti-thrombin activity
Ganong, 19th ed, Ch 35 Answer: S is true, R is true and a valid explanation of S
27240 – S:Heparin and warfarin have significant similarities in mechanism The high incidence of postoperative venous thrombosis has been shown in many studies to be
significantly reduced by the administration of heparin subcutaneously in a low dosage of 5000 units
of action but the action of aspirin is different because R:platelets have no
bd (S true). In the vast majority of people this is a sub-therapeutic dose of anticoagulant which does
influence on the clotting cascade. not change parameters such as activated partial thromboplastin time and which produces minimal
bleeding. The subtherapeutic prophylactic dose of heparin exerts its effect by potentiating the action
Answer: S is true and R is false of the naturally occurring inhibitor of activated Factor X, known as antithrombin III (R true and is a
valid explanation of S). This question was referred to the Physiology Sub Committee for review on 1
Heparin acts to potentiate antithrombin III, which inhibits several serine proteases in the intrinsic Feb 2002.
clotting cascade (but not actually thrombin; the name is misleading). Warfarin, the vitamin K
antagonist, blocks the conversion of six clotting factors, including prothrombin, to their active form by
15137 – Following injury to a small artery, the formation of a temporary
inhibiting a process essential to their activation: namely, conversion of glutamate residues to gamma-
carboxyglutamate. Thus heparin and warfarin, despite their differences in route of administration, time platelet plug is
course of activation, and clinical uses, do have a final common pathway of action: they block the 1: unaffected by therapeutic doses of heparin
clotting cascade. Aspirin acts to inhibit cyclo-oxygenase in platelets, and thus inhibit platelet 2: unaffected by therapeutic doses of dicoumarol
aggregation. Platelets have multiple inputs to their aggregation cascade, including contact with 3: associated with local vasoconstriction
collagen and mediators such as ADP released from other platelets. The assertion in the question is a 4: followed by the conversion of insoluble plasma fibrinogen to insoluble fibrin
true statement. The proposed reason identifies platelets as the target of action of aspirin, but the
proposition that platelets have no influence on the clotting cascade is incorrect. In fact, platelet Answers: TTTF
phospholipids are essential cofactors in several steps of the clotting cascade, which occur on the
surface of the platelet. Clotting can occur without red cells or leucocytes, but not without platelets. Refer to Ganong, 19th Ed, Ch 27, page 516 and following
Thus, the reason given is a false statement.
13584 – Erythropoietin
8645 – S:The formation of the platelet plug after vessel injury is inhibited by 1: is closely linked to the renin-angiotensin system
2: increases differentiation of stem cells to proerythroblasts
anticoagulation with Heparin because R:Heparin inhibits platelet
3: is a glycoprotein
aggregation because of its strong antithrombin effect 4: cannot be formed in humans in the absence of the kidney
Answer: both S and R and false Answers: FTTF
Ganong, 19th ed, Ch 27 Erythropoietin is a circulating glycoprotein with a molecular weight of about 23,000 (C true). Much of it
comes from the kidneys although some comes from other organs (D false). In the foetus,
12662 – S:Aspirin inhibits platelet aggregation by inhibiting cyclo- erythropoietin causes certain stem cells in the bone marrow to be converted to proerythroblasts (B
oxygenase activity because R:cyclo-oxygenase converts arachidonic acid true). The erythropoietin system is quite separate from the renin-angiotensin system. Angiotensin II
has no erythropoietic effect and erythropoietin has no effect on blood pressure of aldosterone
to endoperoxides PGG2 and PGH 2 secretion (A false).
Answer: S is true, R is true and a valid explanation of S 12924 – In the lymphoid and reticuloendothelial systems
1: congenital agammaglobulinaemia is thought to be due to the absence or gross dysfunction of the B
Cyclo-oxygenase converts arachidonic acid to endoperoxides PGG 2 and PGH 2 some of which is
series of lymphocytes
converted by thromboxane synthetase to thromboxane A2 in the platelets (R true and valid
2: total thoracic duct lymph flow in a normal adult is about 2 litres in 24 hours
explanation of S). This promotes both vasoconstriction and platelet aggregation. Nonsteroidal anti-
3: the protein content of the lymphatic outflow from the limbs is about 7g/litre
inflammatory drugs such as Aspirin inhibit cyclo-oxygenase activity and thus the amount of
4: the liver and spleen can be shown by gamma scintigraphy after the injection of intravenous 99m-Tc
endoperoxides PGG2, PGH2 and thromboxane A2 which are produced. Thus they decrease platelet
sulphur colloid
aggregability (S true).
Answers: TTFT

Reticuloendothelial cells in liver and spleen take up sulphur colloid (D true). Gamma-globulin is 1: is used to calculate intracellular fluid volume
produced by B lymphocytes (A true). The protein content of lymph from the lower limbs is about 2: is a greater percentage of body weight in men than women
20g/litre (C false), while the total thoracic duct lymph flow in a normal adult is about 2 litres per day (B 3: is calculated using Deuterium oxide dilution
true). Reviewed March 2003. 4: increases with age
9015 – Indicate whether the following statements about the Answers: TTTF
reticuloendothelial system are true or false.
Ganong 13th Ed. Chapter: 1 Page: 2-3 Guyton 7th Ed. Chapter: 33 Page: 382-386
1: congenital agammaglobulinaemia is thought to be due to the absence or gross dysfunction of the B
series of lymphocytes
2: the lymphatic outflow from the limbs has a protein content of about 7g/litre 23174 – The total body water expressed as a percentage of body weight is
3: total thoracic duct lymph flow in a normal adult is about 2 litres in 24 hours 1: unaffected by obesity
4: the liver and spleen can be shown by gamma scintigraphy after the injection of intravenous 99m-Tc 2: greater in women than in men
sulphur colloid 3: approximately 45% in a 70 kilogram man of normal build
4: decreased in Cushing's disease
Answers: TFTT
Answers: FFFT
Guyton & Hall, Ch 16; Ch 33. Question updated 2 Dec 2002.
Manual of Resource Material Ganong, 19th Ed, Ch 1, p1-3
21483 – Lysosomes
1: are found in granulocytic white blood cells 7367 – Which of the following is/are true with regard to body composition?
2: may be involved in gouty arthritis 1: The total amount of the exchangeable sodium in the body is approximately 3000 mmol, this being
3: merge with intracellular membrane lined vacuoles containing exogenous substances forming a 70% of the total body sodium.
phagocytic vacuole 2: The total body potassium is approximately 3000 mmol and of this, 90% is exchangeable.
4: are released extracellularly in normal host response to infection to cause bacteriolysis 3: Serum osmolality is approximately 300 milliosmoles / kg.
4: The pH of the extracellular fluid is approximately 7.36 to 7.44.
Answers: TTTF
Answers: TTTT
Ganong 12th Edition CHAPTER: 1 PAGE: 4
21433 – Which of the following is/are true with respect to percentage water
o composition of the body?
12656 – S:When freshly taken blood is cooled rapidly to 0 C coagulation
1: it is lower in females
will be slowed because R:low temperature reduces the activity of enzymes 2: it can be estimated from measurement of plasma volume
necessary for coagulation 3: it decreases with age
4: it is independent of body fat composition
Answers: TFTF
The activity of coagulation enzymes is temperature dependent with maximal measurable in vitro
o
activity at 37 C. Ganong 13th ed CHAPTER: 1 PAGE: 3
22434 – Hyperplasia of bone marrow is characteristic of anaemia due to 12793, 21218 – Concerning body water compartments
1: iron deficiency 1: the extracellular fluid is isosmotic with the intracellular fluid at equilibrium
2: severe rheumatoid disease 2: the extracellular volume of a 70 kg man is 18-20 litres
3: pernicious (vitamin B12 deficiency) anaemia 3: transcellular water is that component of extracellular water that has been processed through cells
4: chronic renal failure into special compartments
4: an individual's total water is directly proportional to his fat content
Answers: TFTF
Answers: TFTF
Robbins 6th ed. Ch 14 Pages: 604-633
Ganong 13th Ed. Chapter: 1 Page: 1-3 Guyton 7th Ed. Chapter: 33 Page: 382-386. Transcellular
water is, by definition, that component of extra-cellular fluid (ECF) that has been processed through
FLUID & ELECTROLYTES cells into special compartments (C true); examples include aqueous humour, CSF and synovial fluid.
ECF comprises 20% of total body water (TBW) and in a 70kg man is approximately 14 l (B false).
21713 – Total body water Water content of fat is lower than that of muscle and other tissues so that TBW is inversely
proportional to the amount of fat (D false). Women have relatively less TBW than men. ECF is iso- Answer: D
osmotic with intracellular fluid (ICF) at osmotic equilibrium; any changes in osmolarity of either ECF or
ICF are accompanied by movement of water across the cell membrane to restore osmotic equilibrium Guyton 7th Edition CHAPTER: 37 PAGE: 449
with resultant change in volume of either compartment (A true).
22569 – In intracellular fluid
21428 – Concerning plasma 1: the potassium concentration is about 160 mmol/l
1: it has a higher sodium concentration than interstitial fluid 2: potassium, magnesium and sodium are the main cations present
2: it has a higher magnesium concentration than interstitial fluid 3: organic phosphates are present in high concentration
3: it has a higher protein concentration than interstitial fluid 4: the hydrogen ion concentration exceeds that in extracellular fluid
4: it has a higher chloride content than interstitial fluid
Answers: TTTT
Answers: TTTF
Ganong 11th Edition CHAPTER: 1 PAGE: 17. Question to be reviewed at March 04 meeting re:
Ganong 13th Ed. Ch. 1 P. 5 Guyton 7th Ed. Ch. 33 P. 389 Ch. 30 P. 356 option 1 [Page 7 table 1-2 Ganong 20th edition states K+concentration inside the cell is 150mmol/L -
10mmol diff]. (17/02/04).
7291 – The following are true or false for plasma components
1: the half-life of factor VIII infusion is 12 - 16 hours 21293 – Interstitial fluid production is increased in patients who have
2: Prothrombin complex concentrates contain factors II, IX and X, and are useful in vitamin K 1: extensive thermal burns
deficiency, warfarin overdose and patients with haemophilia B 2: irreversible shock
3: Cryoprecipitate contains factor VIII, IX and von Willebrand factor and fibrinogen 3: major deep vein thrombosis
4: the main use of intravenous albumin is for nutritional purposes, rather than as a volume expander 4: acute hypoalbuminaemia
5: fresh frozen plasma contains normal levels of all coagulation factors
Answers: TTTT
Answers: TTFFT
19300 – Under basal conditions, the route of greatest water loss is via the
20133 – S. The electrolyte concentration of the plasma is greater than the A. skin
electrolyte concentration of the interstitial fluid BECAUSE R. plasma B. lung
C. kidney
proteins are negatively charged
D. gastrointestinal tract
E. salivary glands
Answer: C
Guyton Ch. 30 P. 356-7 Ganong 13th Ed. Ch. 1 P. 5
Guyton 7th Ed. Ch. 33 P. 383
23194 – Regarding the buffer systems of the body
1: bicarbonate is the most important buffer in the body
18964 – To correct metabolic alkalosis due to vomiting, the best initial
2: bicarbonate is not a good buffer at body fluid pH
3: phosphate is a good physiological buffer because of its pKa replacement solution is
4: bicarbonate is the most plentiful buffer in body fluid A. sodium chloride
B. calcium chloride
Answers: TTTF C. potassium chloride
D. sodium lactate
Guyton 7th ed. Chapter: 37 Page: 441 E. ammonium lactate
Answer: A
19653 – Derangements of body fluid and electrolytes characteristic of
gastric outlet obstruction are 18280 – Concerning daily fluid and electrolyte balance in adults, which one
A. HCO3 18 mmol/l, K 4.5 mmol/l Cl 101 mmol/l Na 135 mmol/l of the following statements is most correct?
B. HCO3 10 mmol/l, K 2.5 mmol/l Cl 112 mmol/l Na 140 mmol/l
A. The minimal obligatory urinary loss is 1000 ml
C. HCO3 35 mmol/l, K 3.0 mmol/l Cl 152 mmol/l Na 120 mmol/l
B. Insensible losses normally total about 200 ml
D. HCO3 37 mmol/l, K 2.8 mmol/l Cl 71 mmol/l Na 135 mmol/l
C. About 500 ml is normally lost in the stool
E. HCO3 27 mmol/l, K 3.0 mmol/l Cl 164 mmol/l Na 140 mmol/l
D. Average fluid intake varies between 2000 and 3000 ml
E. Urinary losses of potassium exceed those of sodium

Answer: D Answers: TTTF
Total daily fluid intake (as ingested liquid and as water of food) averages between 2-3 litres in adults 12828, 23899 – A plasma osmolality of 230 mOsm/Kg induced by rapid
(D). The other responses are all incorrect. water infusion would be associated with
1: an increase in interstitial fluid volume
21693 – Potassium depletion may be associated with 2: marked haemolysis in vivo of red blood cells
1: flaccid paralysis 3: altered consciousness
2: T wave inversion and U waves in the ECG 4: a marked rise in the blood urea concentration
3: paralytic ileus
4: polyuria Answers: TFTF
Answers: TTTT Guyton 7th Ed. Ch. 33 P. 390 Ch. 36 P. 431 Ganong 13th Ed. Ch. 27 P. 438. A rapid water infusion
into the intravascular space with a reduced plasma osmolarity is an example of acute water
Ganong 13th Ed. Chapter: 20 Page: 316-317 Ch. 28 P. 465 Ch. 33 P. 533 Ch. 26 P. 423
intoxication. There is an immediate expansion of ECF including the interstitial fluid volume (B true). To
maintain osmotic equilibrium water will pass into the cells. As the cerebral neurones are the most
19006 – Serum hyperosmolality is LEAST likely to occur as a possible sensitive an altered state of consciousness will result (D true). Spontaneous haemolysis will only
complication early in the course of occur when the osmolarity is less than 200 mOsm/kg (A false). Urea is a freely diffusible compound
A. a severe body burn and rapidly obtains equilibrium with ECF without any significant changes in its concentration in
B. acute oliguric renal failure plasma (C false).
C. hyperpyrexia
D. total parenteral nutrition 19408 – The most important buffer base in the extracellular fluid is
E. hyperglycaemia A. plasma protein
B. phosphate
Answer: B C. bicarbonate
D. haemoglobin
Burnett - C. S. S. CHAPTER: 13.5 E. lactate
25704 – Hyponatraemia Answer: C

A. may appear to be present if the blood sample is taken from a patient with frank lipaemia
B. is associated with sodium depletion rather than water overload Guyton 7th Ed. Chapter: 37 Page: 441-442
C. is best treated by sodium chloride infusion if the patient has normal renal function
D. in association with a high urine sodium is likely in nephrotic syndrome 4009 – Hypokalaemia may be associated with
E. when associated with systemic inflammatory response syndrome (SIRS) results in decreased ECF 1: paralytic ileus
volume 2: muscle weakness
3: increased sensitivity to digitalis
Answer: A 4: peaked T waves and ST elevations on an electrocardiogram
25840 – Regarding electrolyte balance Answers: TTTF

1: the principal intra-cellular cation is potassium
2: a patient with a serum sodium level of 125 mmol/L could be sodium replete Clinical Science for Surgeons CHAPTER: 13.6.5 PAGE: 203
3: hypernatraemia is preferably corrected by oral administration of water
4: hypomagnesaemia can occur from long term loop diuretic therapy 15047 – A 65-year-old man of 70 kg body weight is vomiting from a small
bowel obstruction. He has lost approximately 5 litres of fluid. It is likely that
Answers: TTTT
1: he will pass urine with a high osmolarity
2: his urine output will be decreased
21268 – Regarding potassium requirements in a post-operative patient, it is 3: his plasma protein concentration will be increased
true that +
4: his plasma Na concentration will be increased
1: during the first 24 hours normally no parenteral potassium is necessary
2: kidney function must be adequate before any parenteral potassium is administered Answers: TTTF
3: 60 to 80 mmol/day are adequate in a normal adult
4: daily estimations of urinary potassium are necessary before any potassium salts are administered Refer to Ganong, 19th Ed, Ch 39, page 702; MCQ Book

Answer: E
12596 – S:Cl- levels in the interstitial fluid are higher than in the blood
The nonapeptide bradykinin is one of the vasodilator peptides formed in the plasma. The octapeptide
plasma because R:capillary membranes are not freely permeable to protein
angiotensin II is the most potent vasoconstrictor known and acts directly on the adrenal cortex, on
anions peripheral noradrenergic neurons, and on water metabolism as well. The nonapeptide vasopressin
(ADH) is one of the two posterior pituitary gland hormones. Its main physiologic effect is the retention
Answer: S is true, R is true and a valid explanation of S of water by the kidney. Gastrin is a polypeptide hormone produced by the G cells of the gastric antral
mucosa. Its principal action is stimulation of gastric acid and pepsin secretion. The above mentioned
The Donnan effect is that, in the presence of non-diffusible ions, the diffusible ions will distribute four physiologically active peptides (or polypeptides) have no enzymatic activity (A, B, C and D false).
themselves in equilibrium across a semipermeable membrane. In plasma the protein anions are in a Renin is a proteolytic enzyme secreted by the kidney into the bloodstream, with a molecular weight of
greater concentration than in the interstitial fluid but are non-diffusible (not freely permeable) and, 40 000 in humans. It splits the end off one of the plasma proteins called renin substrate, to release a
therefore, exert a Donnan effect; thus chloride anion concentration is slightly greater in interstitial fluid decapeptide, angiotensin I (E true).
than in the plasma. Therefore S and R are true and R is a valid explanation of S.
23189 – Atrial natriuretic peptide production
9886, 20739 – S. Tetany results from plasma proteins binding more calcium 1: is increased when ECF volume increases
during hyperventilation BECAUSE R. plasma proteins are less ionized at 2: increases sodium excretion by increasing glomerular filtration rate
higher pH 3: lowers the blood pressure
4: stimulates the secretion of renin and angiotensin
Answers: TTTF
Ganong, 19th ed, Ch 25, Ganong 19th ed. Chapter: 21 Page: 365
Ganong CHAPTER: 24 PAGE: 386
22989 – Osmoreceptor cells
1: are located in the supraventricular and paraventricular nuclei 13645 – With regard to sympathomimetic amines
2: control the rate of discharge of oxytocin containing neurons in the posterior pituitary 1: dopamine acts on alpha, beta 1 and beta 2 and specific ‘dopaminergic’ receptors
3: respond to changes in extracellular fluid volume 2: isopreterenol acts predominantly on beta 1 and beta 2 adrenergic receptors
4: are sensitive to small changes in plasma osmolarity 3: noradrenaline has little or no effect on alpha adrenergic receptors
4: adrenaline acts on alpha, beta 1 and beta 2 adrenergic receptors
Answers: FFFT
Answers: TTFT
The catecholamines vary in the degree to which they engage the receptors specific to catechol
effects. This fact is revealed within the spectrum of agonist drugs used clinically. Dopamine acts on its
CARDIOVASCULAR own receptor and on alpha, beta 1 and beta 2 receptors (A true). Noradrenaline and adrenaline can
engage alpha, beta 1 and beta 2 receptors (D true, C false) but isoproterenol is the most selective in
10018 – Vasodilator metabolites which relax arterioles and precapillary being agonist to only beta 1 and beta 2 receptors (B true).
sphincters include
1: endothelium 1 13579 – In the carcinoid syndrome vasoactive substances which may be
2: thromboxane A2 released include
3: lactate 1: serotonin
4: circulating Na+ - K+ AT Pase inhibitor 2: bradykinin
3: prostaglandin
Answers: FFTF 4: histamine
Ganong, 19th ed, Ch 31 Answers: TTTT
13289 – Which of the following is an enzyme? Apart from serotonin (5-hydroxy-tryptamine), which is the best known vasoactive substance produced
A. bradykinin by carcinoid tumours, several other vasoactive agents are secreted by these tumours. All the
B. angiotensin 11 compounds enumerated in this question can be present in the carcinoid syndrome.
C. vasopressin
D. gastrin 12833, 23254 – Prostacyclin (PGI2)
E. rennin 1: causes vasoconstriction
2: stimulates renin secretion
3: inhibits blood clotting
4: mimics the effects of oestrogen Answers: FFFT
Answers: FTTF Ganong, 19th ed, Ch 28
Prostacyclin (PGl2) is derived from arachidonic acid which is closely related to, but has slightly 10109 – In regard to the overall synchronisation of the heart beat
different actions from, the prostaglandins and thromboxanes. It is produced by endothelial and 1: right atrial systole precedes left atrial systole
smooth muscle cells in blood vessels and generally promotes blood flow. It inhibits platelet 2: right ventricular contraction precedes left ventricular contraction
aggregation (C true) and is a vasodilator (A false). It stimulates renin secretion by a direct action on 3: right ventricular ejection precedes left ventricular ejection
the juxtaglomerular cells and indirectly by reducing blood pressure (B true). There is no evidence that 4: pulmonary valve closure precedes aortic valve closure
its actions mimic those of oestrogen (D false). Review July 2004 re: option 2.
Answers: TFTF
10008 – The factors influencing the total cerebral blood flow include
1: cerebral metabolic rate Ganong, 19th ed, Ch 29
2: the arterial pressure at brain level
3: mainly noradrenergic and cholinergic nerve fibres 10003 – In atrial flutter
4: the venous pressure at brain level 1: the atrial rate is 150-220/min
2: there is accelerated AV conduction
Answers: FTFT 3: the heart rate is irregular
4: the ventricular rate can be slowed by carotid sinus pressure
Ganong, 19th ed, Ch 32. Please note that cerebial metabolic rate remains remarkably constant
irrespective of brain activity, in contrast to many other tissues. 22 August, 2001 Answers: FFFT
20481 – S. Increased intracranial pressure causes hyper-tension and Ganong, 19th ed, Ch 28
bradycardia BECAUSE R. with increased intracranial pressure there is
stimulation of the vasomotor centre due to local accumulation of carbon 9933 – In accelerated atrio-ventricular conduction (Wolff-Parkinson-White-
dioxide Syndrome) the electrocardiograph may show
1: an abnormal P wave
2: paroxysmal atrial tachycardia
3: a short PJ interval
4: normal QRS complex
Guyton 7th ed. Page: 250-251
Answers: FTFF
27168 – Coronary blood flow has all the following characteristics except
A. high oxygen extraction fraction of about 70% at rest Ganong, 19th ed, Ch 28
B. nearly 100% oxygen extraction during exercise
C. a large increase in flow, up to five or six times, during maximal exercise
14626 – In accelerated atrio-ventricular conduction (Wolff-Parkinson-White
D. limitation of increased flow in exercise in the presence of proximal stenoses
E. flow peaking during systole when the driving pressure is greatest syndrome)
1: there is a prolonged PR interval and prolonged QRS complex slurred on the upstroke
Answers: E 2: circus movement tachycardia is usually initiated by an atrial premature beat
3: the arrhythmia commonly progresses to complete heart block
The heart is extremely aerobic, burning fatty acids, ketones and some glucose continuously. The 4: atrial fibrillation is a life threatening arrhythmia
extraction fraction is large at rest, and can therefore be increased only moderately, so that increased
oxygen delivery during exercise depends on increased flow. For the left ventricle, pressure within the Answers: FTFT
myocardium limits flow during systole. Maximal flow occurs during diastole, so E, being incorrect, is
the required answer. Refer to Ganong, 19th Ed, Ch 28, page 534
9922 – Concerning the conducting system of the heart 15448 – The QT interval of the electrocardiogram
1: stimulation of cholinergic vagal fibres to nodal tissue decreases potassium ion conductance 1: varies inversely with heart rate
2: depolarization of the ventricular muscle starts on the right side of the interventricular system 2: has a normal duration of 0.6 seconds
3: the last part of the heart depolarized is the epicardial surface of the left ventricular apex 3: corresponds to electrical systole
4: stimulation of sympathetic cardiac nerves results in increased intracellular cyclic AMP 4: is prolonged in hypokalaemia

E. systolic shortening of myocardial fibre length
Answers: TFTF
Answer: B
Refer to Ganong, 19th Ed, Ch 28, page 526 and following
The biochemical changes in a failing ventricle lead to a shift of the Starling curve (stroke volume
25686 – In a post-operative surgical patient with a tachycardia of 120 bpm versus filling pressure) to the right. Changes in expression of myosin isoforms results in slower
A. acute atrial fibrillation is the most likely cause contraction with reduced dP/dt, which is an important index of ventricular function derived during
B. biochemical disorders associated with tachycardia include hypokalaemia and hypermagnesaemia catheter studies. Stroke volume is reduced at each value of filling pressure, so that systolic fibre
C. supraventricular tachycardia is associated with narrow QRS complexes whereas a broad complex length shortening is reduced, ejection fraction falls, and end systolic volume increases. Thus B, being
is more likely in ventricular tachycardia incorrect, is the required answer.
D. multifocal ectopics in a 12 lead ECG imply myocardial infarction or an electrolyte disorder
E. amiodarone is a useful medication for atrial flutter and supraventricular tachycardia 27210 – Isometric contraction of the left ventricle
A. occurs during the first third of systole
Answer: C B. involves the most rapid change in pressure per unit time in the cardiac cycle
C. occurs after closure of the aortic valve
9856 – S:Injections of noradrenaline cause coronary vasodilation because D. is terminated at the T wave of the ECG
E. is responsible for ejection of a majority of the stroke volume
R:injections of noradrenaline produce vasodilator metabolites as a result of
increased myocardial activity Answer: B
Answer: S is true, R is true and a valid explanation of S During the cardiac cycle, the time sequence is: diastolic filling (with atrial systole in late diastole
increasing filling); the QRS complex; ventricular contraction commencing at the peak of the R wave;
Ganong, 19th ed, Ch 32 A-V valve closure; isometric ventricular contraction (isometric means equal size: the volume does not
change) with rapidly rising ventricular pressure; opening of the aortic and pulmonary valves as the
15057 – Alpha adrenergic blocking agents can be used in refractory shock ventricular pressure exceeds arterial diastolic pressure; rapid ejection in the first third of systole; slow
to ejection; the T wave; ventricular relaxation with falling ventricular pressure; aortic and pulmonary
1: increase blood pressure valve closure and the dicrotic notch in the arterial pressure waveform; isometric relaxation; opening of
2: increase renal blood flow the A-V valves; rapid phase of diastolic filling. Isometric contraction occurs at the commencement of
3: increase venoconstriction systole, does not involve any ejection of blood, and is the steepest part of the pressure-time graph.
4: prevent the imbalance between precapillary and venular tone Answer B is the only one correct.
Answers: FTFT 27246 – S:Patients with severe aortic stenosis causing left ventricular
failure have poor outcomes from valvular surgery because R:impaired left
Refer to Ganong, 19th Ed, Ch 33, page 609 and following. Question to be reviewed at the July 2004
ventricular function may persist after correction of the stenosis.
meeting. Query use of reference to alpha blockers / refractory shock. Reference listed also out of
date. Review July 2004 re: reference incorrect, alpha blockers not indicated in reference text for
refratory shock.
The long-term changes in ventricular function occurring in failure due to pressure overload, including
25830 – Concerning inotropes pathological hypertrophy, fibrosis, vascular insufficiency and changes in myosin isoform expression,
1: they ideally should reduce afterload and preload as well as increasing cardiac output and ejection may persist postoperatively. However, the patient's cardiac status is improved (often dramatically) by
fraction operation, because the large pressure gradient across the aortic valve is relieved and cardiac
2: adrenaline is an ideal all-around inotrope workload is greatly reduced. Thus, the assertion is false, and the reason given is a correct statement,
3: higher doses are used to compensate for hypovolaemia but not a reason for the assertion. This question has been reviewed and updated. 6 Dec 2002
4: their safe use requires a full range of monitoring being available
27222 – In a patient with mixed aortic stenosis and insufficiency due to
Answers: TFFT
rheumatic heart disease, deteriorating cardiac function could be
27192 – In a failing left ventricle all of the following parameters are reduced exacerbated by all except
A. increased pressure gradient across the aortic valve
except
B. increased reflux through the aortic valve
A. ejection fraction
C. increased aortic diastolic pressure
B. end-systolic volume
D. increased aortic systolic pressure
C. rate of rise of pressure (dP/dt) at the commencement of systole
E. rapid heart rate
D. stroke-volume at a given filling pressure
diamond-shaped systolic murmur of aortic stenosis. All the options are plausible associations, except
Answer: C C, which is therefore the required answer.
Cardiac workload is increased by both volume and pressure overload in valve disease. Systemic 27216 – Volume overload in a left ventricle with valve pathology will occur
hypertension will add to the pressure workload and is a well-known, correctable factor in cardiac with
failure. The diastolic pressure has other implications, however. Because of the intramural pressure
A. aortic stenosis
increase during systole, most of the left ventricular coronary blood flow occurs during diastole:
B. aortic insufficiency
therefore, diastolic pressure and time are important. The reduced aortic diastolic pressure seen with
C. mitral stenosis
aortic incompetence will seriously compromise coronary flow. Thus, C is the only factor that improves
D. mitral insufficiency
rather than worsens the patient's cardiac function, and is therefore the required answer.
E. combined aortic and mitral insufficiency
27204 – Essential differences between cardiac failure with diastolic Answer: E
dysfunction and failure with systolic dysfunction include all of the
following except Cardiac output is actually regulated by factors external to the heart, so that the heart meets demands,
A. diastolic filling pressure unless the patient is in cardiogenic shock leading to circulatory failure. Cardiac output must be kept
B. ejection fraction normal, despite changes in valve function. In aortic insufficiency, the stroke volume increases so that
C. myocardial wall thickness the output is kept normal despite part of the stroke volume being lost back into the ventricle during
D. end-diastolic volume diastole. Likewise, in mitral insufficiency, the volume refluxing back into the atria must be pumped
E. end-systolic volume again at the next cycle. Aortic stenosis increases pressure workload, but does not increase volume
load; while in mitral stenosis, the left ventricle is protected and the increased pressure is in the left
Answer: A atrium. The answer is option E, with both aortic and mitral insufficiency.
Systolic dysfunction is the commoner pattern of failure, and is caused by ischaemic heart disease, 27144 – A loud pericardial rub is consistent with
myopathy, or severe volume or pressure overload from valve pathology: it results in a dilated ventricle A. a small effusion
(increased end diastolic volume) with reduced ejection fraction (giving increased end systolic volume). B. negligible risk of tamponade
Diastolic dysfunction is reduced ventricular compliance, as seen with extreme myocardial hypertrophy C. an infective or systemic inflammatory process
in, for example, hypertrophic subaortic stenosis, or longstanding severe hypertension. The D. widespread Q waves
hypertrophied, stiffer ventricle requires increased diastolic filling pressure. In this respect, it is similar E. none of the above features
to systolic dysfunction, though the mechanism is different (A correct). With systolic dysfunction, the
failing ventricle needs increased filling pressure to achieve increased end-diastolic volume and move Answer: C
it further up the Starling curve. With diastolic dysfunction, the increased stiffness requires increased
filling pressure to approach a normal end-diastolic volume. The hypertrophied muscle has increased Pericardial effusions are commonly due to infectious pericarditis (Coxsackie virus, influenza,
performance, so that the ejection fraction is increased. echoviruses, HIV) or occasionally due to collagen diseases such as SLE (C correct). Because the
fluid is often rich in fibrin, it may produce a loud rub, despite having a large volume that prevents
27234 – A congenital ventricular septal defect would be associated with all contact between the myocardium and the pericardium. Thus, loud rubs are by no means inconsistent
except with large or even life-threatening effusions. The ECG changes reflect myocardial inflammation and
are typically ST depressions and T wave changes, not the Q waves which are seen in full-thickness
A. a pansystolic murmur
myocardial infarction.
B. increased pulmonary blood flow
C. cyanosis from birth
D. possible late right ventricular failure 27108 – A majority of patients with significant pulmonary
E. possible late pulmonary hypertension thromboembolism show
A. haemoptysis
Answer: C B. friction rubs
C. clinical signs of deep vein thrombosis
Flow through septal defects follows the pressure gradients: therefore, both atrial and ventricular D. cyanosis
septal defects usually have left-to-right flow unless the pressures are highly abnormal. Cyanosis E. tachycardia and dyspnoea
requires the delivery of deoxygenated blood to the left heart and so to the systemic circulation: ie
right-to-left shunts. Left-to-right shunts do not result in cyanosis, though they increase pulmonary Answer: E
blood flow. A late sequel to the increased volume load on the right ventricle and pulmonary circulation
may be attenuation of the pulmonary vasculature, pulmonary hypertension and right ventricular Pulmonary thromboembolism was recently the third most frequent cause of death in the USA. Clinical
failure. The murmur of a VSD is pansystolic since it reflects only the pressure profile of the ventricle diagnosis is made difficult by the inconstancy of clinical signs: only a minority of patients present the
and not the acceleration of the long, massive, blood column in the aorta, which determines the textbook picture of haemoptysis, friction rub, gallop rhythm, cyanosis, wide fixed split of the second

sound and signs of the source of the embolism from deep vein thrombosis in the legs. The majority of Refer to Ganong, 19th Ed, Ch 30, page 560
patients, however, do have tachycardia and dyspnoea, at least transiently (E True).
9928 – Mean venous pressure in the
25692 – Pulmonary artery flotation catheters 1: dural sinuses is constantly negative
A. directly measure central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), and 2: foot is higher when standing still than when walking
cardiac index (CI) 3: foot, when standing still, is 50 mmHg
B. show decreased readings of 1 mmHg for every 5 cm of PEEP applied 4: subclavian vein, as it crosses the first rib, is positive above atmospheric pressure, when lying down
C. are likely to be correctly placed if wedged PaO2 < mixed venous PaO2
D. may migrate into the pulmonary veins with prolonged wedging leading to distal infarction Answers: FTFT
E. are essential for the management of high risk surgical patients with recent myocardial infarction
Answer: A
25746 – A high CVP reading may be caused by all of the following EXCEPT
Answer to come. Pending review. Jun 2003 A. a rapid fluid bolus
B. pulmonary embolism
15508 – The haemorrhage associated with streptokinase infusion is due to C. tension pneumothorax
1: Hypofibrinogenaemia alone D. supraventricular tachycardia
2: high levels of fibrin degradation products alone E. cor pulmonale
3: high levels of plasminogen
4: high levels of fibrin degradation products and hypofibrinogenaemia Answer: D
Answers: FFFT 10013 – On assuming the upright position

1: the arterial pressure at head level and the jugular venous pressure fall 20 - 30 mm Hg
Ganong Chapter 27, p525-6. Reference updated July 03. 2: cerebral vascular resistance is reduced
3: brain tissue pO2 is maintained by autoregulation
15052 – In the foetal circulation 4: cerebral O2 consumption is about the same as in the supine position
1: superior vena caval blood enters the left atrium via the patent foramen ovale
2: haemoglobin in the umbilical vein blood is 80% saturated with oxygen Answers: FTFT
3: inferior vena caval blood is directed via the ductus arteriosus to the head vessels
4: the inferior vena cava receives blood directly from the ductus venosus Ganong, 19th ed, Ch 33
Answers: FTFT 23184 – Acclimatization to altitude is associated with

1: enhancement of erythropoietin secretion and the circulating red cell mass
Refer to Ganong, 19th Ed, Ch 32, page 597 and following 2: lactic acidosis in the brain causing a fall in CSF pH to enhance the ventilatory response to hypoxia
3: an increase in tissue content of cytochrome oxidase
10129 – With respect to the fetus 4: an increase in red blood cell 2, 3 DPG which decreases O\b2 affinity of haemoglobin
1: umbilical venous haemoglobin saturation is 97%
2: haemoglobin F in fetal blood has a lower P50 than haemoglobin A in maternal blood Answers: TTTT
3: placental blood flow is about 20% of fetal cardiac output
4: superior vena cava blood is preferentially directed into the pulmonary circulation Ganong 13th Edition Chapter: 37 Page: 572-574. Review July 2004 re: option 4.
Answers: FTFT 19156 – Extracellular edema may be caused by all of the following except
A. high venous pressure
Ganong, 19th ed, Ch 32 B. increased arteriolar resistance
C. low plasma protein content
15443 – From Bernoulli's principle of blood flow it can be derived that D. increased capillary permeability
1: the sum of the kinetic energy of flow and the pressure energy is constant E. lymphatic obstruction
2: the energy lost in overcoming resistance is irreversible
3: the pressure drop due to conversion of potential to kinetic energy is reversible Answer: B
4: in a narrowed segment of a vessel the velocity flow and lateral wall pressure are reduced
Answers: TTTF
15062 – Negative gravitational forces acting on the body produce
1: increased cardiac output
2: increase in cerebral arterial pressure
RESPIRATORY
3: ecchymoses around the eyes 9938 – Sudden elevation of the arterial pCO2 level is associated with
4: mental confusion 1: raised intracranial pressure
2: respiratory acidosis
Answers: TTTT 3: skin vasodilatation
4: an increased plasma bicarbonate level
Answer: TTTT
27126 – The procedure and interpretation of the Brodie-Trendelenburg test
include all the following except Ganong, 19th ed, Ch 32, 37 and 39.
A. the patient reclines with the leg elevated to empty the veins
B. the superficial veins are compressed in the thigh 14616 – Alveolar ventilation
C. the patient then stands while the veins are observed 1: is the volume of fresh gas entering alveoli per minute
D. rapid filling on standing of the superficial veins below the knee during the phase of compression 2: is about 350 ml per breath
indicates incompetent leg and ankle perforators
E. rapid filling of the long saphenous vein from above on release of the tourniquet indicates deep 3: determines the alveolar PCO 2 by means of an inverse relationship
venous occlusion extending up to the saphenofemoral junction 4: is measured with a spirometer
Answer: E Answers: TTTF
he Brodie-Trendelenburg procedure is described correctly except for item E, which is therefore the Refer to West, Chapter 2, p14 Reviewed March 2003.
required answer. Rapid filling from above of the long saphenous vein after removal of pressure from
the saphenofemoral junction indicates incompetence of the saphenofemoral junction, rather than of 12494 – The following acid-base data pH 7.21 PaCO2 20 mmHg HCO3 8
the valves in the lower deep venous system. The Brodie-Trendelenburg test can sometimes be mmol/1 BE -19mmol/1 would be most consistent with
additionally useful in detecting incompetent lower leg and ankle perforators, which indicate severe A. lobar atelectasis of the lung
dysfunction of the venomuscular pump. Duplex-Doppler venous flow studies are now increasingly B. starvation
used to pinpoint incompetent perforators. C. septicaemic shock
D. anxiety
27083 – Venous pressure in the veins of the foot exhibits all the following E. duodenal ulcer with pyloric obstruction
properties except
A. in all subjects, increases on standing Answer: C
B. in normal subjects, diminishes on exercise
C. in subjects with varicose veins but competent perforators, fails to diminish on exercise The data pattern suggests a partially compensated metabolic acidosis because the hypocapnia is
D. in subjects with incompetence of the perforators and valves of the deep veins, remains elevated accompanied by a low pH and low bicarbonate together with a large negative base excess. This is not
during exercise due to atelectasis of the lung, because the low PaCO2 would not be accompanied by the extreme
E. in all subjects, diminishes on elevation of the legs hypoxaemia needed to produce such a severe metabolic acidosis (A false), nor is it due to anxiety as
the pH would be raised in the presence of the hypocapnia (D false). It is not pyloric obstruction (with
Answer: C vomiting) where one would expect acid loss resulting in metabolic alkalosis (E false). Both starvation
and septic shock would result in metabolic acidosis, but the former would be mild and compensated
The key to understanding the pathology of the venous system of the lower limb is the operation of the with a higher pH and plasma bicarbonate (B false). Therefore this severe acid-base disturbance
veno-muscular pump. Simple physics dictates that the pressures in the veins of the dependent limb would be most consistent with the anaerobic metabolism of septic shock (C true).
will tend to increase in the standing posture by up to the equivalent of a column of blood from ankle to
heart - a little over a metre of water, about 100 millimetres of mercury. Pumping the blood up the limb 23199 – Respiratory acidosis is associated with
on exercise depends on the competence of the valves in the ankle perforators and the deep veins. 1: elevated arterial PCO2
Cyclic compression of the deep veins pushes blood up the deep veins during their positive pressure 2: decreased plasma bicarbonate level
excursions. Competent perforators allow blood from the saphenous system to enter the deep veins 3: inadequate ventilation
during their negative pressure excursions, without allowing that blood back into the superficial veins at 4: increased arterio-venous oxygen difference
the next contraction of leg muscles. Even patients with incompetence of the valves in the saphenous
system, but competent perforators, experience a fall in venous pressure on walking - though it is not Answers: TFTF
as marked as the fall with competent valves at all levels. Option C describes the behaviour incorrectly,
and is therefore the required answer. Question to be reviewed at March 04 meeting re: option D being true. (23/02/04)

10119 – The total amount of carbon dioxide in arterial blood exists as
follows 9898 – S:The uptake of CO2 by blood in the tissue capillaries assists the
1: 60% as bicarbonate in plasma release of oxygen from haemoglobin because R:with the Bohr effect a rise
2: 5% as dissolved carbon dioxide in blood pCO2 shifts the haemoglobin oxygen dissociation curve to the left
3: 30% as carbamino haemoglobin
4: 5% as carbonic acid Answer: S is true and R is false
Answers: FTFF Ganong, 19th ed, Ch 34
West, 6th ed, Ch 6, Ganong, 19th ed, Ch 35

10043 – With respect to carbon dioxide uptake by blood in tissue capillaries
1: H+ generated is buffered by deoxyhaemoglobin
9862 – S:During exercise there is an increase in alveolar 2: about 60% of CO2 is carried in carbamino combination with haemoglobin
pCO2 because R:during exercise venous blood pCO2 increases 3: there is a chloride and water shift into red blood cells
4: plasma carbonic anhydrase is required
Answers: TFTF
24354 – With regard to acid-base status, if the arterial blood pH, pCO2 and
bicarbonate are all above their respective reference ranges 10033 – Factors determining the alveolar pO2 include the
1: a primary respiratory alkalosis exists 1: inspired oxygen concentration
2: the pattern is consistent with pyloric obstruction 2: alveolar ventilation
3: a primary respiratory acidosis exists 3: oxygen consumption of the body
4: the pattern is consistent with primary hyperaldosteronism 4: haemoglobin level in the blood
Answers: FTFT Answers: TTTF
Guyton 9th ed. p400 Ganong, 19th Ed, Ch 39 p697-704 Ganong, 19th ed, Ch 34
10134 – Peripheral chemoreceptors regulating respiration 14601 – Which of the following contribute(s) significantly to the oxygen
1: are located in the carotid bodies tension difference between alveolar gas and systemic arterial blood (A-a
2: represent the only chemoreceptors in man able to produce a hypoxic ventilatory response
PO2 diff.) in healthy subjects?
3: are not stimulated by anaemia
4: do not produce a significant ventilatory response until the PaO2 is reduced to 50 - 60 mmHg 1: rate of diffusion of oxygen across the alveolar-capillary membrane
2: anatomical R to L shunts
3: reaction rate of oxygen combining with haemoglobin
Answers: TTTT
4: low ventilation/perfusion ratio regions of lung
Answers: FTFT
12602 – S:The measured respiratory quotient (RQ) may rise during severe Refer to West, 2nd Ed, Ch 5, page 61-68
exercise because R:hyperventilation will result from lactic acidosis
10114 – Arterial hypoxia causes
Answer: S is true, R is true and a valid explanation of S 1: an increased respiratory rate
2: dilatation of coronary arterioles
The respiratory quotient (RQ) is the ration of CO2 production to O2 consumption and can be 3: respiratory alkalosis
measured for a tissue, an organ or the body. This question relates to the body RQ. During severe 4: dilatation of renal arterioles
exercise, because of hyperventilation from lactic acidosis and a relative O2 debt, RQ may rise to 2.0.
Therefore S and R are true and R is a valid explanation of S. This question was referred to the Answers: TTTF
Physiology Sub Committee for review on 1 Feb 2002. A trainee has questioned whether respiratory
exchange ratio rather than respiratory quotien should have been used in this question. This was Ganong, 19th ed, Ch 36
refered to the Sub Committee who responded as follows. RQ is measured at steady state, but as
question does not record if subject is at steady state or not, "R" is acceptable, as RQ.
10023 – Accumulation of water in pulmonary alveoli is chiefly prevented by 4: old T6 spinal cord injury
1: elimination of excess water in the expired air
2: surfactant, which maintains a low surface tension in alveoli Answers: TTTT
3: capillary permeability to water being negligible in alveolar capillaries
4: a low hydrostatic pressure in alveolar capillaries Refer to West, Ch 10
Answers: FTFT 15027 – With regard to respiratory dead space

1: physiological dead space is equal to the sum of anatomical and alveolar dead space
Ganong, 19th ed, Ch 34 2: alveolar dead space is negligible in health
3: physiological dead space may be estimated by use of the Bohr equation
9904 – S:The functional residual capacity of the lung cannot be measured 4: physiological dead space to tidal volume ratio (V D/VT) is normally about 0.3
by spirometry because R:the functional residual capacity of the lung
Answer: TTTT
includes the residual volume which cannot be expelled by respiratory effort
Refer to West, 2nd Ed, Ch 2, page 18-20; Ch 10, page 148-152; Ganong, Ch 34, page 627-628
14596 – Oxygen uptake by haemoglobin in lung capillaries
1: varies directly with the blood pH
2: varies inversely with PaCO 2
10028 – The functional residual capacity of the lung is decreased 3: is characterised in the fetus by a shift of the dissociation curve to the left compared with that after
1: in the supine position birth
2: with chronic obstructive airways disease 4: varies inversely with the concentration of 2,3 diphosphoglycerate (2,3-DPG) in the red cell
3: with term pregnancy
4: with positive end-expiratory pressure Answers: TTTT
Answers: TFTF Refer to Ganong 19th Ed, Ch 35, page 636-637. This questions is under review Jan 2004
Ganong, 19th ed, Ch 34 12608 – S: Metabolic acidosis has a greater respiratory stimulating effect
9868 – S:The arterial Po2 is reduced in carbon monoxide poisoning than would be suggested by the measured change in blood pH
because R:in carbon monoxide poisoning carboxy-haemoglobin because R:during metabolic acidosis pCO2 also increases and stimulates
(COHb)shifts the haemo-globin-oxygen dissociation curve of the remaining respiration
haemoglobin to the left Answer: both S and R and false
Answer: S is false and R is true The stimulatory effect on the respiratory centre that results from acidosis is mediated via the CSF.
CO2 is more soluble in CSF than H+ and in the CSF is rapidly converted to H2CO3. Therefore, larger
Ganong, 19th ed, Ch 37 rises in blood pH are required to increase the CSF H+ sufficiently to stimulate the respiratory centre
(S false). As a consequence of respiratory centre stimulation with resultant hyperventilation, pCO2
10124 – The closing volume of the lung levels fall in metabolic acidosis (R false).
1: is the lung volume when small airway closure begins to occur
2: is usually between the residual volume and functional residual capacity 15037 – Breathing 60% oxygen by face mask would be expected to correct
3: increases with age
arterial hypoxaemia due to
4: is increased by small airways disease
1: an increase in physiological dead space
2: hypoventilation
Answers: TTTT
3: a small physiological shunt (venous admixture less than 10%)
4: a large physiological shunt (venous admixture more than 10%)
Answers: TTTF
14611 – A restrictive defect in ventilatory function occurs with
1: fractured ribs Refer to Ganong, 19th Ed, Ch 37, page 562-655
2: upper abdominal surgery
3: lobar pneumonia

14606 – An increase in ventilation results from an increase in the rate of Answers: FTFT
firing of the arterial chemoreceptors in response to
West, Ch 4
1: an increase in arterial PCO 2
2: a reduction in arterial PO2 to 70 mm Hg (9.3 kPa)
10038 – In the upright lung
1: intrapleural pressure is more negative at the apex than at the base
3: a reduction in arterial pH
2: the ventilation/perfusion ratio is greater at the base than at the apex
4: chronic anaemia (less than 9.0 gm haemoglobin/dl blood)
3: alveolar pO2 is higher at the apex than at the base
4: the apex is more compliant than the base
Answers: TFTF
Answers: TFTF
15042 – A healthy young individual hyperventilates leading to a doubling of
alveolar ventilation. Immediate effects before the onset of any renal 15032 – Emphysema would be associated with
compensatory changes would include 1: a reduced FEV1/VC ratio
1: a PaCO2 of about 20 mmHg (2.7 kPa) 2: an impaired expiratory flow-volume curve
2: a decrease in plasma bicarbonate level 3: a reduced peak expiratory flow rate
3: a decrease in intracranial pressure 4: a reduced functional residual capacity
4: a PaO2 of about 120 mmHg (16 kPa)
Answers: TTTF
Answers: TTTT
Refer to West, Ch 10; Ganong, 19th Ed, Ch 37, page 658
Refer to Ganong, 19th Ed, Ch 37, page 661; Ch 39, page 700
9948 – With normal quiet breathing
15423 – During the carriage of CO2 from the tissues to the lungs 1: respiratory work is done mainly to overcome airways resistance
1: there is an increase in the chloride content of the red blood cells 2: expiratory work is accomplished by energy stored in stretched elastic structures
2: venous plasma bicarbonate increases by 6 mmol/l 3: elastic work is done only to stretch the elastic fibres in the lung
3: carbamino compounds are formed both in the plasma and the red blood cell 4: the work of breathing represents less than 5% of the total resting oxygen consumption
4: venous blood pH decreases to less than 7.30
Answers: FTFT
Answers: TFTF
West, 7th Ed, Chapter 7. Ganong 20th Ed, Chapter 34, p635. Elastic work is performed by the resp
Refer to Ganong, 19th Ed, Ch 36, page 640 and following muscles in stretching the elastic tissues of the chest wall and lungs. Reviewed March 2003.
15428 – Factors involved in ventilatory control during aerobic exercise 15418 – With respect to forced expiratory flow volume curves
1: expiratory flow declines with decreasing lung volume
include 2: maximum expiratory flow rate is independent of effort at mid to low lung volumes
1: a rise in arterial PCO 2 3: features of the curve are due to dynamic airway collapse
2: afferent feedback from limb movement 4: effective driving pressure for expiration is alveolar minus intrapleural pressure
3: lactic acidosis
4: an increase in body temperature Answers: TTTT
Answers: FTFT Refer to West, Ch 7, page 107-110
Refer to West, Ch 8, page 126-127 15413 – Forces which are acting on the lung at the end of normal expiration
include
9943 – Pulmonary vascular resistance is 1: elastic tendency of the thoracic cage to sustain expansion
1: increased with a rise in pulmonary arterial pressure 2: surface tension effects at the alveolus tending to produce collapse
2: approximately 10% of the systemic vascular resistance 3: elastic tendency of the lung to collapse
3: decreased with an increase in lung volume 4: a negative intrapleural pressure
4: locally controlled by the oxygen tension in adjacent alveoli

Answers: TTTT 4: showing a PaO 2 of 120 mmHg (16.0 kPa) indicates good oxygenating ability in a patient breathing
80% oxygen
7126 – Which of the following would NOT be expected in a 70kg adult
Answers: TFTF
human male at rest?
A. inspiratory reserve volume 3500 ml
B. expiratory reserve volume 1000 ml 18331 – The so-called ‘acute brain syndrome’ as seen in surgical patients
C. tidal volume 2000 ml after operation is
D. residual volume 1200 ml A. a common component of grieving
E. physiological dead space 150 ml B. usually a manifestation of a patient’s inability to cope
C. most importantly due to deprivation of rapid eye movement (REM) sleep
Answer: C D. commonly a result of the unmasking of a pre-existing depressive illness
E. commonly associated with hypoxia
The tidal volume is the amount of air moving into the lungs with each normal inspiration (or out of the
lungs with each normal expiration). A normal value of the tidal volume would be 500 ml, not 2000 ml. Answer: E
The response is false and would not be the expected volume in a 70 kg man; C is thus the correct
answer. 'Acute brain syndrome' is a synonym for acute delirium with a confusional state. In the post-operative
period this is commonly associated with hypoxia (E); and blood gas measurements are often required
25855 – The pulse oximeter to confirm this diagnosis. The other respones are false.
1: is unaffected by the level of carboxyhaemoglobin
2: is a useful indicator of PaO 2 25788 – Patients can be weaned from the ventilator
3: may be inaccurate in hypovolaemia
1: when an FIO 2 of 40% maintains normal PaO2
4: may be used to measure pulse rate
5: measures oxygen saturation, which is independent of arterial pH or hypercapnia 2: once the original cause of respiratory failure has been treated successfully
3: more easily while still heavily sedated
Answers: FFTTT 4: with a modern ventilator irrespective of nutritional status
5: when CO 2 elimination is no longer a problem
25794 – Patients for whom mask oxygen therapy is inadequate
1: are often tachypnoeic Answers: TTFFT
2: show distress, dyspnoea, exhaustion, sweating and confusion
3: may not show low oxygen saturation or low pulse oximetry until at a late stage 25740 – Pulse oximetry
4: include those with vital capacity less than 15 ml/kg A. utilises both plethysmography and light spectroscopy in producing its output
5: include those with FEV1 less than 10 mI/kg B. is useful in determining the presence of acidosis
C. is fooled by carboxyhaemoglobin into giving an erroneous low reading
Answers: TTTTT D. when giving a reading of SaO2 of 90% equates to a PaO2 of 50mmHg (6.5kPa)
E. is not affected by ambient light
25782 – An acute fall in lung functional residual capacity (FRC)
1: occurs during post-operative atelectasis Answer: A
2: is caused by chronic bronchitis with sputum retention
3: occurs following pulmonary embolism Answer to come. Question to go to Sub Committee: trainees suggested that further referencing (eg.
graph of PaO2 / SaO2) would be useful (20/02/04).
4: results in respiratory failure when PaO 2 = 8.3 kPa and PaCO2 = 6.2 kPa
5: should be treated initially by high flow mask oxygen
18322 – In a patient receiving post-operative assisted ventilation with
Answers: TTFFT positive end-expiratory pressure (PEEP), the sudden occurrence of
hypotension is most likely caused by
Answer to come. Question to be reviewed at March 04 meeting re: option 2(20/02/04). A. hypovolaemia
B. acute congestive cardiac failure
25805 – Arterial blood gases and acid base status C. haemothorax
1: give some assessment of respiratory, renal and cardiovascular function D. massive atelectasis
2: assessment by once daily arterial puncture causes greater morbidity than an indwelling arterial line E. tension pneumothorax
3: readings consistent with metabolic acidosis could be characterised by pH = 7.15 and HCO3 = 18
mmol/L and negative base excess of 10 Answer: E

Assisted ventilation with positive end-expiratory pressure (PEEP) is liable to precipitate tension rate is governed by the hydrostatic pressure in the afferent arteriole, which affects the juxtaglomerular
pneumothorax because of the persistently positive intra-pulmonary pressures generated; such a apparatus. However, the glomerular filtration rate does not control renin secretion (D false).
complication would be the first to exclude or verify in the clinical circumstances listed (E).
15498 – Renin secretion is increased by
25800 – Concerning routine respiratory management in surgical wards 1: cirrhosis
1: management is better guided by regular radiography than by auscultation 2: diuretics
2: chest physiotherapy and nebulized saline therapy should be employed in a highly selective manner 3: upright posture
3: management depends on adequate analgesia 4: sodium loading
4: pulse oximetry assesses all key aspects of ventilatory function
Answers: TTTF
Answers: FFTF
RENAL 13569 – Aldosterone increases the reabsorption of sodium from the

1: collecting duct
12904, 22489 – Renin secretion is controlled by 2: saliva
1: intrarenal baroreceptors 3: sweat
2: substance P 4: small intestine
3: sodium content of the proximal and distal tubular fluid
4: glomerular filtration rate Answer: TTTT
Answer: TFTF The major action of adlosterone is on the collecting duct (A true) where it promotes the reabsorption
of sodium in exchange for potassium and hydrogen ions. It also has an effect in promoting sodium
Renin is produced in the juxtaglomerular apparatus by stimuli that decrease extracellular fluid volume reabsorption in salivary and sweat glands as well as in the small bowel (B,C,D true).
and blood pressure or increase sympathetic output. The control of renin secretion is achieved by an Review July 2004 re: option 4 should be false.
intrarenal baroreceptor mechanism which causes renin secretion to increase when the intra-arterial
pressure at the juxtaglomerular cells is decreased (A true). The macula densa cells of the distal 22048 – Aldosterone increases the reabsorption of sodium from the
+ -
convoluted tubule form the part of the juxtaglomerular apparatus which is sensitive to the NA and CI 1: distal renal tubule
concentration of the fluid delivered to it, renin secretion being partly controlled by the rate of transport 2: saliva
- +
of CI and NA across the macula densa cells (C true). Substance P is a neural transmitter that is 3: sweat
liberated in the primary afferent neurons in the brain, the retina and gastrointestinal tract (B false). 4: intestine
The glomerular filtrate is governed by the hydrostatic pressure in the afferent arteriole which, of
course, affects the juxtaglomerular apparatus. However, the glomerular filtration rate does not control Answers: TTTT
renin secretion (D false).
Question to be reviewed at March 04 meeting(23/02/04) Guyton 8th ed. CHAPTER: 77 PAGE: 844-845
13594 – Renin secretion is controlled by 13574 – Aldosterone secretion is increased by

1: intrarenal baroreceptors 1: high potassium intake
2: prostaglandins 2: low sodium intake
3: sodium content of the proximal and distal tubular fluid 3: standing
4: glomerular filtration rate 4: constriction of the inferior vena cava in the thorax
Answers: TTTF Answers: TTTT

+
Renin is produced in the juxtaglomerular apparatus by stimuli that decrease ECF volume and blood Plasma K need only increase 1 mmol/l or less to stimulate aldosterone and such changes may occur
+
pressure or increase sympathetic output. The control of renin secretion is achieved by an intrarenal after ingestion of a meal rich in K (A true). Dietary sodium restriction increases aldosterone secretion
+
baroreceptor mechanism which causes renin secretion to increase when the intra-arterial pressure at via the renin-angiotensin system. A fall in plasma Na also has a direct effect on the adrenal cortex (B
the juxtaglomerular cells is decreased (A true). The macula densa cells of the distal convoluted tubule true). In the normal individual there is an increase in plasma aldosterone concentration during that
+ -
form the part of the juxtaglomerular apparatus which is sensitive to the Na and Cl concentration of part of the day when the individual is standing. This is due to a decrease in the rate of removal of
- +
the fluid delivered to it, renin secretion being partly controlled by the rate of transport of Cl and Na aldosterone by the liver and an increase in production due to a postural increase in renin secretion (C
across the macula densa cells (C true). Prostaglandins stimulate renin secretion, and mediate the true). Haemorrhage and constriction of the inferior vena cava in the thorax produce a decrease in the
effects of the renal baroreceptor cells and cells of the macula densa (B true). The glomerular filtration intra-arterial vascular volume, increasing renin secretion, the angiotensin II formed by the action of
the renin increases the rate of secretion of aldosterone (D true).

12884 – In the kidney
20715 – S. The administration during operation of 2 litres of saline solution 1: protein concentration of blood in efferent arterioles is the same as that in afferent arterioles
to a patient having an uncomplicated vagotomy for chronic duodenal ulcer 2: potassium is secreted by the distal tubules
results in increased sodium excretion in the urine BECAUSE R. the 3: glucose is removed from the glomerular filtrate by active transport
4: potassium is largely reabsorbed in the proximal tubules
increase in aldosterone secretion which follows operation is completely
abolished by the administration of saline solution during the procedure Answers: FTTT
Answer: S is true and R is false Approximately 65% of filtered potassium and all the filtered glucose are actively reabsorbed in the
proximal tubule (D and C true). Potassium is secreted by the distal tubules (B true) and collecting
Clinical Science for Surgeons CHAPTER: 13.5.8 PAGE: 201 ducts, in response to the negative charge resulting from sodium resorption in these segments.
Filtration of water, but very little protein, in the glomerulus results in an appreciable increase in protein
21748 – Angiotensin II concentration in the efferent arterioles compared to the afferent arterioles (A false).
1: facilitates release of noradrenaline from sympathetic neurons
2: has less aldosterone - stimulating activity than angiotensin III 12878 – With respect to the kidney
3: acts in the central nervous system to stimulate release of vasopressin 1: in the presence of hyponatraemia and hypokalaemia the renal response is to lower further the
+
4: crosses the blood-brain barrier plasma K level
2: mean hydrostatic pressure in the peritubular capillaries is lower than that in glomerular capillaries
Answers: TFTF 3: in the proximal tubule, water moves passively out of the tubule along an osmotic gradient
+
4: in the presence of hypokalaemia and metabolic alkalosis the renal response is to retain K in
+
Ganong 20th Edition, page 441. This question is currently under review by the sub committee. 4 preference to H
June 2002. This question has been reviewed and has not been altered.
Answers: FTTT
22374 – Angiotensin II produces
1: arteriolar constriction The proximal tubule is highly permeable to water which diffuses passively from the tubule (C true) and
2: a rise in diastolic blood pressure solute concentration is nearly the same on both sides of the tubular membrane. Low plasma sodium
3: increased water intake concentration leads to reduced vascular fluid volume and this stimulates aldosterone secretion,
4: inhibition of adrenocorticotrophin hormone (ACTH) secretion resulting in sodium resorption and potassium secretion in the collecting ducts. Thus hyponatraemia
results in a lowering of plasma potassium concentration (A true). The peritubular capillaries are more
Answers: TTTF distal in the vascular tree and hence at lower hydrostatic pressure (B true).
Ganong 19th ed. Chapter: 24 Page: 433-436 10154 – Diuretics

1: inhibit water and solute reabsorption of tubular fluid
23709 – Angiotensin II increases water intake by acting on the 2: inhibit Na-K-Cl co-transport in the luminal membrane of the loop of Henle
1: area postrema 3: inhibit H+ secretion and HCO3 reabsorption in the tubules
2: posterior pituitary 4: inhibit the action of aldosterone in the glomerulus
3: pineal body
4: subfornical organ Answers: TTTF
Answers: FFFT Guyton 9th ed, Ch 31, Ganong, 19th ed, Ch 38
Ganong 13th ed. Chapter: 24 PAGE: 382 14631 – Renal blood flow falls in
1: hypovolaemia
10144 – In the kidney 2: stimulation of !1 adrenergic receptors
1: potassium is largely reabsorbed in the proximal tubules 3: stimulation of the vasomotor area in the medulla oblongata
2: urea is actively reabsorbed from the tubules 4: exercise
3: glucose is removed from the glomerular filtrate by active transport
4: protein concentration of blood in efferent arterioles is the same as that in afferent arterioles Answers: TTTT
Answers: TFTF Refer to Ganong, 19th Ed, Ch 38, page 672
Guyton, 9th ed, Ch 26, Ch 27, Ganong, 19th ed, Ch 39

12638 – S:A rise in the rate of renal blood flow results in increased Answers: TTTT
glomerular filtration of fluid from the plasma because R:the rise in colloid
osmotic pressure within the plasma of the more distal glomerular
capillaries becomes less with increased plasma flow 12512 – Which of the following normally has the highest renal clearance?
A. inulin
Answer: S is true, R is true and a valid explanation of S B. glucose
C. para-amino hippurate
Glomerular filtration causes a rise in protein concentration and hence colloid osmotic pressure, in the D. urea
distal glomerular capillaries. This increased colloid osmotic pressure opposes filtration. Renal blood E. water
flow does increase glomerular filtration because of the increase in glomerular pressure (S true).
Because a small percentage of plasma is filtered, the rise in distal capillary osmotic pressure is Answer: C
lessened and glomerular filtration increases overall (R true and is a valid explanation of S).
Urea is filtered at the glomerulus and partially reabsorbed in its passage along the nephron (D false).
12626 – S:An increase in renal blood flow causes an increase in oxygen Inulin is not secreted or reabsorbed in the renal tubules and is excreted as it is filtered (A false) but
consumption per gram of renal tissue because R:an increase in renal para-amino hippurate is secreted in the proximal tubules so that it is nearly totally cleared from the
plasma by the time the blood leaves the kidney (C true). Glucose is rapidly reabsorbed in the proximal
blood flow increases the volume of filtrate to be reabsorbed
tubule (B false and water is reabsorbed throughout the tubules, collecting tubules and ducts (E false).
12518 – The ascending limb of the loop of Henle
An increase in renal blood flow results in an increase in glomerular filtration rate which in turn results A. is impermeable to sodium ions
in increased filtration and reabsorption of sodium. Oxygen consumption in the kidney is proportional B. actively transports the majority of potassium ions
to Na+ transport (reabsorption in the tubules) and hence to renal blood flow and the volume of filtrate C. actively transports most of the filtered water into the tubule lumen
reabsorbed (S and R are true and R is a valid explanation of S). D. actively transports chloride ions out of the tubule lumen
E. actively transports sodium ions into the tubule lumen
15077 – The operation of the loop of Henle as a countercurrent multiplier
Answer: D
depends
+ - The loop of Henle is active in the final event for increasing the osmolar concentration of urine. Sodium
1: on the active transport of Na and Cl out of the thick ascending limb
2: the high water permeability of its thin descending limb and chloride ions are transported into the inner medullary interstitium (A and E false; D true). Similarly
3: the relative water impermeability of the thin ascending limb only 27% of filtered potassium is actively reabsorbed in the loop of Henle, 65% having previously
4: the concentration of urea in the interstitial spaces been actively transported in the proximal tubule. D is more appropriate than B in the context of the
question. Reviewed March 2003.
Answers: TTTT
12853 – In osmotic diuresis
Refer to Ganong, 19th Ed, Ch 38, page 681-685 1: decreased water reabsorption in the proximal tubule accounts for approximately one-quarter of the
diuresis
9973 – The protein concentration in the glomerular capillaries 2: significant sodium loss may occur
1: is 20% higher at the efferent end of the glomerular capillary 3: the urine becomes more acid than normal
2: will alter the filtration fraction 4: the increased urine output is caused by substances which are not reabsorbed in the renal tubule
3: results in an average colloid osmotic pressure of over 30 mm Hg in the glomerular capillary system
4: is lower than the protein concentration in muscle capillaries
Answers: FTFT
Answers: TTTF
In osmotic (solute) diuresis, the increased flow is due to substances such as mannitol, which are
Ganong, 19th ed, Ch 38 filtered but not reabsorbed, or to substances such as glucose or urea present in amounts exceeding
tubular reabsorptive capacity (D true). Decreased water reabsorption in the proximal tubules is the
main cause of the diuresis (A false). As very large amounts of urine can be produced, significant
15458 – The glomerular filtration rate varies losses of electrolytes, such as sodium, carried in the urine can occur (B true). No specific change in
1: with efferent arteriolar constriction the reaction of urine occurs (C false).
2: agents affecting the mesangial cells
3: with the permeability of the glomerular capillaries
4: with changes in extracellular volume

12632 – S: The phosphate buffer system plays a major role in H+ buffering The ingestion of 1000 ml of water, which is rapidly absorbed into the blood, will obviously increase the
in the tubules because R:the phosphate buffer system has a pK suited to circulating blood volume (A true). There will be a reduction in the osmolarity of blood plasma which
will cause the osmoreceptors in the hypothalamus to reduce posterior pituitary stimulation leading to a
the pH of tubular fluid reduction in ADH secretion (D true). The rise in circulating blood volume will increase the hydrostatic
pressure in the glomerular capillaries resulting in a rise in the glomerular filtration rate (GFR) (B true).
Answers: S is true, R is true and a valid explanation of S There are no volume receptors in the hypothalamus, these being located peripherally (C false).
The phosphate buffers are composed of a mixture of HPO and H2PO and are poorly reabsorbed from
21228 – Factors concerned with the onset of a diuresis in a healthy young
the tubules where they become concentrated in association with water reabsorption. This makes
them an important buffer source (S true). Their pK of 6.8 also makes these active buffers as the urine man who drinks a litre of water in 5 minutes include
becomes concentrated through the tubules and the pH falls to about 6.0. That is the phosphate 1: rise in glomerular filtration rate
buffers function in their most effective range near their pK value (R is true and is a valid explanation of 2: rise in circulating blood volume
S). 3: suppression of ADH secretion
4: stimulation of volume receptors in the hypothalamus
9910 – S:The initial decline in sodium ion excretion after haemorrhage is
Answers: TTTF
due to increased circulatory levels of aldosterone because R:in
haemorrhagic shock secretion of renin results in an increased aldosterone Guyton 7th Ed. Ch. 22 P. 262 Ch. 36 P. 430-431
secretion
12614 – S:During acidosis the pH of the glomerular filtrate can fall below
Answer: S is false and R is true 4.5 in the proximal tubule because R:the proximal tubule is the major site
for removal of HCO from the filtrate
14934 – S:Even though the diameter of albumin is 7 nm, minimal amounts
are found in the urine because R:albumin is a plasma protein that is Although the bulk of H+ secretion occurs in the proximal tubule via the Na+ H+ counter-transporter,
negatively charge the maximum concentration gradient which can be achieved is only approximately three-fold, resulting
in a proximal tubular fluid pH which is not lower than approximately 6.9 (S false). The secreted H+
Answer: S is true, R is true and a valid explanation of S combines with filtered bicarbonate to form carbonic acid which is immediately converted to H2O and
CO2 by carbonic anhydrase. The CO2 diffuses back across the tubular membrane for either
Refer to Ganong, 19th Ed, Ch 38, page 674-675 resynthesis of bicarbonate, or transport to the lungs for excretion.
23749 – Extra-renal losses of potassium are usually small but may be 10149 – The ability of the kidneys to conserve urinary chloride depends on
markedly increased with the
1: small bowel fistulae 1: efficiency of Na+ reabsorption in the distal tubules
2: villous tumours of the rectum 2: active Cl- reabsorption in the ascending limb of the loop of Henle
3: profuse sweating 3: efficiency of Na+ reabsorption in the proximal tubules
4: fulminating ulcerative colitis 4: varying permeability to chloride of the distal convoluted tubules and collecting ducts
Answers: TTFT Answers: TTTF
This question is currently under review by the Physiology Sub Committee. 28 June 2002. This Ganong, 19th ed, Ch 38
question has been updated. 9 Dec 2002
14098 – S:Hydrogen ion that reacts with bicarbonate contributes to urinary
12798 – Factors concerned with the onset of a diuresis in a healthy young titratable acidity because R:the titratable acidity is the amount of alkali that
man who drinks a litre of water in 5 minutes include is added to urine to return the pH to 7.4, the pH of the glomerular filtrate
1: rise in circulating blood volume
2: rise in glomerular filtration rate Answer: S is false and R is true
3: stimulation of volume receptors in the hypothalamus
4: suppression of ADH secretion Ganong, 19th Ed, Ch 38, page 687
Answers: TTFT 24344 – Beer in moderate quantity causes diuresis because the
1: water in beer significantly increases the glomerular filtration rate 3: buffered by HCO 3 in the proximal tubule
2: alcohol in beer inhibits anti-diuretic hormone release 4: exchanged for K+ in the distal tubule
3: alcohol in beer inhibits tubular sodium reabsorption
4: water in beer inhibits anti-diuretic hormone release Answers: TTTF
Answers: FTFT Refer to Guyton, 9th Ed, Ch 27, page 337; Ganong, 19th Ed, Ch 38, page 676 and following. Review
July 2004 re: option 4.
Guyton 7th ed. CHAPTER: 75 PAGE: 893-894 Ganong, 19th Ed, Ch 38, p691
+
12894 – H ions are
15072 – The production of urine with a high osmolarity is associated with 1: exchanged for potassium in the early distal tubule
1: a decrease in membrane permeability of the distal tubule and collecting duct to water 2: secreted into the distal tubule in increased amounts in the presence of aldosterone
2: a decrease in medullary blood flow -
3: buffered by HCO 3 in the proximal tubule
3: an increase in secretion of aldosterone 4: secreted into the proximal tubule
4: an increase in secretion of antidiuretic hormone
Answers: FTTT
Answers: FTFT
Hydrogen ions are actively secreted in the proximal (D true) and distal tubules and the collecting
Refer to Guyton, 9th Ed, Ch 28, page 356; Ganong, 19th Ed, Ch 38, page 681 and following ducts. Although aldosterone mainly causes potassium to be secreted into the tubules in exchange for
Question to be reviewed at March 04 meeting re: option C being true (23/02/04) sodium it also causes tubular secretion of hydrogen ions in exchange for sodium (B true). The
secreted hydrogen ions are buffered by bicarbonate (C true), varying with the extracellular
19210 – Elevated serum bicarbonate is commonly associated with each of concentration of carbon dioxide. Hydrogen ions are exchanged for sodium but not for potassium ions
the following EXCEPT (A false).
A. chronic emphysema
B. duodenal ulcer with obstruction 22399 – Blood urea concentration may be influenced by
C. total parenteral nutrition 1: glomerular filtration rate
D. milk-alkali syndrome 2: dietary protein intake
E. hyperaldosteronism 3: hepatic function
4: body hydration state
Answer: C
Answers: TTTT
Burkett - C. S. S. CHAPTER: 13.8.1 Ganong, 19th Ed, Ch 39, p703-704, 359
14912 – S:The bicarbonate buffer system is the most important in the body
because R:its pK is close to the pH of the extra-cellular fluid 21678 – Urinary potassium excretion rate usually
1: increases in pyloric stenosis
Answer: S is true and R is false 2: decreases in the first 24 hours after injury
3: is not influenced by ADH (vasopressin)
Refer to Ganong, 19th Ed, Ch 39, page 698-699 4: remains the same during osmotic diuresis
21978 – Hydrogen ions Answers: TFTF

1: directly stimulate the respiratory centre
2: are excreted in the urine predominantly by combining with urinary buffers Guyton 7th ed. Ch.35 P.421-423. Ganong 13th ed.Ch.77 P.911,916 26 P.409. Reviewed March
2003.
3: can be secreted against a concentration gradient until a urine pH of approximately 4.5 is reached
4: can be secreted against a large concentration gradient in the collecting ducts +
14636 – In the renal nephron, Na is actively absorbed from
Answers: TTTT 1: proximal tubule
2: distal tubule and collecting duct
Guyton 3: ascending portion of the loop of Henle
4: descending portion of loop of Henle
+
15453 – H ions are
1: secreted into the proximal tubule Answers: TTTF
2: secreted into the distal tubule in increased amounts in the presence of aldosterone

Refer to Ganong, 19th Ed, Ch 38, page 677 concentration in proximal tubular fluid and as a result there is increased diffusion of filtered urea into
the interstitium (B and D true). Urea is not actively reabsorbed (A false).
23594 – With regard to the renal tubular lumen
1: hydrogen ions are secreted into the lumen in exchange for sodium 12620 – S:Urea clearance is increased at high rates of urine flow
2: carbon dioxide diffuses from the lumen into the tubular cells because R:reabsorption of urea across the tubular system of the nephron
3: secreted hydrogen is excreted predominantly as free hydrogen ions is largely a passive phenomenon
4: filtered bicarbonate is directly resorbed into the tubular cells
Answers: TTFF
Urea of the glomerular filtrate leaves the tubules by simple diffusion (R true) according to the counter-
Guyton 9th ed.Page: 394 Ganong, 19th Ed, Ch 38 page 686-689
current exchange of the vasa recta and, as water is reabsorbed in the tubules, so too is urea. At high
glomerular filtration with consequent high urine flow the excretion of urea rises (S true R is a valid
10058 – The renal changes associated with severe haemorrhage include explanation of S).
1: afferent and efferent arteriole constriction
2: increased filtration fraction
20667 – S. After a meal the urine maybe alkaline (postprandial alkaline
3: enhanced sodium retention by the renal tubules
4: potassium retention in association with sodium by the renal tubules tide) BECAUSE R. the stomach venous blood has a higher PCO2 than
stomach arterial blood after a meal
Answers: TTTF
Answer: S is true and Ris false
Ganong 13th ed. CHAPTER: 26 PAGE: 410
13640 – Blood urea may rise with
1: hypovolaemic shock 12803 – Creatinuria occurs in
2: severe infection 1: normal children
3: steroid therapy 2: pregnant women
4: liver failure 3: thyrotoxicosis
4: starvation
Answers: TTTF
Answers: TTTT
Urea is synthesised in the liver, from ammonia formed by the deamination of amino acids. Thus, in
liver failure, urea levels in blood will be low (D false). Urea is excreted by filtration through the renal Creatine is synthesised in the liver from methionine, glycine and arginine and is phosphorylated in
glomerular membrane. In conditions of reduced blood flow, as in hypovolaemia, much water is muscle to phosphocreatine which is an immediate energy source of ATP. Creatinine found in urine is
reabsorbed in the proximal tubules, causing urea to become highly concentrated within the tubule. derived from phosphocreatine not creatine, and its daily rate of excretion is relatively constant.
The diffusion of urea back into the renal interstitium is thereby facilitated (A true). Both infection and Creatinuria occurs normally in children and in women during and after pregnancy (A and B true).
steroid therapy produce a catabolic state, with increased turnover of protein and a resultant increased There is very little creatine in the urine of men. Creatinuria is exacerbated in any condition associated
synthesis of urea (B and C true). This question is currently under review by the sub committee. 4 with muscle breakdown, particularly starvation and thyrotoxicosis (C and D true).
June 2002. This questions has been reviewed and will remain unchanged. Question is asking what
happens to urea when the LIVER fails only. 6 Dec 2002. 12914 – Changes after four hours of complete ureteric obstruction include
1: a rise in renal blood flow
10053, 12889 – Rise in blood urea in a previously normal man deprived of 2: a fall in glomerular filtration rate
water is the consequence of 3: a rise in renal tissue fluid volume
1: active reabsorption of urea in the distal tubule 4: a fall in glomerular blood flow
2: increased diffusion of filtered urea from tubular lumen to medullary interstitium
3: increased production rate Answers: FTFT
4: reduced tubular flow rate of urine
The ureters have a rich innervation by autonomic nerve fibres. When a ureter becomes obstructed a
Answers: FTFT ureterorenal reflex produces constriction of renal arterioles, with a resultant fall in renal blood flow (A
false), glomerular blood flow (D true) and glomerular filtration rate (B true), but no change in renal
Ganong, 19th ed, Ch 17 and 38. Production rate of urea is primarily dependent upon diet and liver tissue fluid volume (C false).
function and is independent of hydration state (C false). During dehydration, there is reduced
glomerular filtration and most water is resorbed proximally. This causes an increased urea 12506 – A patient suffers from a metabolic acidosis due to excessive
production of keto-acids. In this state all of the following exist EXCEPT
A. increased urinary NH excretion
B. decreased PCO2 of the arterial blood Answers: TTTT
C. increased renal excretion of titratable acid
D. decreased intracellular H+ concentration Refer to Ganong, 19th Ed, Ch 38, page 677, 690
E. an increased rate of production of bicarbonate
12823 – Extra-renal losses of potassium are usually small but may be
Answer: D
markedly increased with
1: villous tumours of the rectum
Little free hydrogen can be excreted in the urine; so in acidosis excess quantities of urinary hydrogen
2: fulminating ulcerative colitis
ion secreted are buffered with ammonia and phosphate buffers (A and C false). Free hydrogen ion is
3: profuse sweating
buffered by bicarbonate derived from CO2 and H2O to form carbonic anhydrase with dissociation to
4: small bowel fistulae
HCO and H+. The latter is excreted in the tubules in exchange for Na. This process is driven by
increased H+ ions (D true) which cause increased rate and depth of respiration to blow off CO2 and
Answers: TTFT
decrease the blood pCO2 (E and B false).
Extra-renal losses of potassium are markedly increased in conditions involving excessive loss of
12899 – Regarding the acidification of urine mucus, which has a high protein content, from the large bowel. Potassium losses are excessive with
+
1: H is secreted into the urine by the cells lining the distal tubules villous tumours of the rectum and in fulminating ulcerative colitis, because of large amounts of
+
2: K is normally reabsorbed from the tubular fluid as part of the acidification process of urine diarrhoea (A and B true). The K+ loss in diarrhoea is appreciable because the potential difference
+
3: when there is a large load of H to be excreted, most of it appears in the urine in the form of across the mucosa is greater in the colon than in the ileum and the steady state K+ concentration of
ammonium salts colonic contents is relatively high. Even though there will be some loss of K+ in small bowel fistulae, it
4: H 2CO3 is present in the urine in very high concentration compared with plasma will be less than in colonic conditions (D true). The content of K+ in sweat is low (C false). This
question is currently under review by the Physiology Sub Committee. 28 June 2002. This question
Answers: TFTF has been updated. 9 Dec 2002
Hydrogen ions are secreted by tubular epithelial cells throughout the tubular system (A true). Carbon 22389 – The major consequences of untreated renal failure include
dioxide which diffuses into cells with water is rapidly converted by carbonic anhydrase into carbonic
+ - 1: anaemia due to decreased production of erythropoietin
acid which in turn rapidly dissociates into H and HCO3 (D false). Potassium is reabsorbed in the 2: toxicity due predominantly to very high concentration of urea
proximal tubule but is predominantly secreted at other sites (B false). In the distal tubule potassium or 3: coma due to the development of a profound acidosis
hydrogen ions are secreted in exchange for sodium in an aldosterone dependent process. Hydrogen 4: hypocalcaemia due to decreased secretion of parathyroid hormone
ions can only be secreted into urine until urine pH reaches approximately 4.5. To excrete the required
acid load, secreted hydrogen ions combine with buffers, thereby enabling a great increase in capacity Answers: TFTF
+ +
for H excretion. Ammonia produced by the tubular epithelial cells combines readily with H to form
ammonium. Ammonium secretion may rise 10-fold to 15-fold in chronic acidosis and under these Guyton Page: 347. Question updated 2 Dec 2002
conditions is the major urinary buffer (C true). Trainee queried whether option 2 should have been
maked false since type A intercalated cells int the distal nephron have a K+/H+ exchanger. This was 15463 – The osmolarity of the medullary interstitial fluid would become less
refered to the Sub Committee who replied that the question and explanation is still valid : K+ is hypertonic and eventually approach the osmolarity of plasma when
"normally" secreted in the Tubular fluid.
1: aldosterone secretion is reduced sufficiently
2: the fluid flow through the Loop of Henle increases sufficiently
This question was referred to the Physiology Sub Committee for review on 1 Feb 2002. The Sub
3: an osmotic diuresis is pronounced
Committee provided the following comment:
4: the blood flow through the vasa recta increases sufficiently
The net flux of potassium in the distal tubule is secretion rather than absorption. Most of the secretion
is via K channels and is encouraged by the electrical potential difference across the cells, which in
Answers: FTTT
turn results from the aldosterone sensitive uptake of sodium through amiloride sensitive channels.
This electrical coupling produces the well know effects of changing the sodium load in the distal
Refer to Guyton, 7th Ed, Ch 35, page 416-422
tubule on potassium loss and acid base balance. However, this is all getting very subtle for a Ganong
level of renal physiology, where the focus is on the major flux of the ions.
23964 – Urine pH less than 5.0
1: is within normal limits
15082 – Regarding potassium excretion and the kidney -
2: contains HCO3 in greater than normal concentration
1: approximately 600 mmol of potassium are filtered each day in a normal person - -
3: contains more H2PO4 than HPO4
2: secretion of potassium occurs in the distal tubule and the collecting duct +
4: contains less than normal NH 4
3: approximately 90% of filtered potassium is resorbed in the proximal tubule and loop of Henle
+
4: the rate of K secretion is proportionate to the rate of flow of the tubular fluid Answers: TFTF

Burnett - C. S. S. CHAPTER: 13 PAGE: 204 2: increases amino-acid transport across muscle cell membranes
3: stimulates lipoprotein lipase in vicinity of fat cells
13433 – S:Bilateral nephrectomy in a patient suffering from renal failure is 4: decreases somatomedin synthesis
followed by osteomalacia because R:renal tissue is essential for the
Answers: TFTF
formation of 1,25 dihydroxycholecalciferol
Ganong 13th Ed. CHAPTER: 19, 17 PAGE 285, 253
23214 – Which of the following increase the secretion of insulin
1,25 dihydroxycholecalciferol is the main metabolite of Vitamin D, and is responsible for most of the
1: raised plasma glucose concentration
actions of the vitamin. It is produced in the renal cortical cells (R true and is a valid explanation).
2: glucagon
Chronic renal disease is often associated with osteomalacia (S true) and rickets late in the disease.
3: gastrin
4: vagal stimulation of beta cells
METABOLISM Answers: TTTT
21248 – Insulin Ganong 16th ed. CHAPTER: 19 PAGE: 314 (Table 19-8)
1: augments the activity of hormone-sensitive lipase in fat cells
2: secretion is controlled by a pituitary hormone
3: inhibits lipoprotein lipase in fat cells 23579 – Changes resulting from insulin deficiency include
4: secretion is increased by vagal stimulation 1: diminished growth
2: reduced lipogenesis
Answers: FFFT 3: decreased glucose transport into muscle
4: decreased intestinal absorption of glucose
Ganong 13th Ed. Ch. 19 P. 288 Guyton 7th Ed. Chapter: 78 Page: 926-928
Answers: TTTF
13273 – The primary physiological action of insulin is to increase Guyton 7th ed. CHAPTER:78 PAGE: 923-929
A. glycogen synthesis by the liver
B. lipid synthesis by the liver and fat depots
C. glucose uptake by the brain 23939 – Which of the following comments regarding Glucagon are true
D. glucose uptake by the muscles 1: it increases ketone body formation
E. protein synthesis 2: it is calorigenic via increased hepatic clearance of amino acids
3: in large doses, it is a positive ionotrope
Answer: D 4: it causes glycogenolysis in muscles
The principal action of insulin in muscle, adipose tissue and connective tissue is the facilitation of Answers: TTTF
entry of glucose into the cells by an action on the cell membrane (D true). Insulin has additional
effects on the liver facilitating glycogen synthesis and decreased glucose output. Insulin also Ganong 20th Edition, page 337. This question is currently under review by the Physiology Sub
increases lipid synthesis in the liver and adipose tissue inhibiting hormone sensitive lipase, facilitating Committee. 28 June 2002. This question has been updated. 9 Dec 2002.
amino acid storage and protein synthesis in ribosomes. Glucose uptake by the brain is not insulin
dependent. 23224 – Glucagon
1: increases glycogenolysis in muscle
15483 – Insulin facilitates the glucose uptake in 2: increases gluconeogenesis
1: 'A' cells of the pancreatic islets 3: decreases lipolysis
2: intestinal mucosa 4: increases ketone body formation in liver
3: adipocytes
4: kidney tubules Answers: FTFT
Answers: TFTF Ganong PAGE: 271, 283
Refer to Ganong, 19th Ed, Ch 19, page 319 and following 23229 – Glucagon secretion is stimulated by
1: amino acids
21253 – Insulin differs from growth hormone in that it 2: raised glucose level in plasma
1: inhibits hormone-sensitive lipase in fat cells 3: gastrin
4: somatostatin Answer: D
Answers: TFTF Guyton, 7th ed, Ch 37
Ganong 13th Edition CHAPTER: 19 PAGE: 291 12808 – In adipose tissue intracellular lipase
1: is liberated into the circulation by glycogen
15117 – Glucagon secretion is increased by 2: activity is increased during starvation
1: beta-adrenergic stimulants 3: is activated by the sympathetic nervous system
2: amino-acids 4: activity is increased following insulin administration
3: gastrin
4: somatostatin Answer: FTTF
Answers: TTTF Intracellular lipase is the hormone-sensitive lipase which is confined to adipose tissue and catalyses
the breakdown of stored triglyceride to glycerol and fatty acids, the latter being released into the
Refer to Ganong, 19th Ed, Ch 19, page 332 and following circulation. The enzyme is different from lipoprotein lipase, which is located in the endothelium of the
capillaries, catalyses the breakdown of circulating triglyceride, is not hormone-sensitive and requires
22579 – Glucagon secretion is increased by heparin as a co-factor. The hormone-sensitive lipase does not enter the circulation (A false) but is
1: hypoglycaemia activated by catecholamines released by sympathetic nerve stimulation, growth hormones, cortisol,
2: raised plasma level of some amino acids thyroxine, and, therefore, stress and starvation (B and C true). This lipase is, however, inhibited by
3: cholecystokinin-pancreozymin feeding and insulin (D false).
4: somatostatin
22714 – In starvation there is
Answers: TTTF 1: increased hepatic gluconeogenesis
2: adaptive utilization of ketone bodies by the brain
Ganong 15th ed. CHAPTER: 19 PAGE: 327 3: increased activity of hormone-sensitive lipase
4: increased glucose synthesis from fatty acids
13421, 20595 – S:Glucagon elevates blood glucose level
Answers: TTTF
because R:glucagon enhances glycogenolysis in muscle
Ganong 19th Edition CHAPTER: 17 PAGE: 285
Ganong 11th Edition CHAPTER: 19 PAGE: 290. Glucagon elevates blood glucose (S true) by 25770 – Metabolic responses to fasting include all of the following EXCEPT
stimulating phosphorylation of glycogen in the liver via adenylate cyclase. It also increases A. hepatic gluconeogenesis
gluconeogenesis from amino acids in the liver. Glucagon does not cause glycogenolysis in muscle (R B. hepatic glycogenolysis
false). C. muscle and visceral protein catabolism
D. falling glucagon levels
E. ketogenesis
20127 – S. Ketosis not uncommonly occurs in starvation BECAUSE R.
carbohydrate is anti-ketogenic Answer: D
Answer: S is true, R is true and a valid explanation of S 25728 – Concerning the metabolic effects of starvation in the postoperative
Ganong 13th Ed. Chapter: 17 Page: 246-247 period
A. glycogen storage in the liver provides a source of glucose for several days
B. fatty acids provide the main metabolic fuel
9850 – A patient suffers from a metabolic acidosis due to excessive
C. thyroxine conversion plays little role
production of keto-acids. In this state all of the following are true EXCEPT D. visceral protein is preserved
A. urinary NH4 excretion is increased E. glycogen levels fall and insulin levels rise
B. there is decreased PCO2 of the arterial blood
C. the renal excretion of titratable acid is increased Answer: B
D. there is a decrease in the intracellular H+ concentration
E. there is an increase in the rate of production of bicarbonate
12843 – When food has not been taken for several days, there is usually
1: an increase in plasma ketone
2: an increase in urinary urea output
3: a decrease in respiratory quotient C. Body mass index (BMI: weight divided by the square of height).
4: an increase in acidity of the urine D. A history of unintentional weight loss greater than 10% over the preceeding 6 months.
E. Body composition measurement using neutron activation.
Answers: TFTT
Answer: D
During starvation energy is derived initially from glycogen stores but these are rapidly depleted. In
seven days fat is the major energy source, resulting in an increase in the production of plasma Body weight can be compared with an "ideal" or "desirable" weight, or assessment of body mass
ketones (A true) and a fall in the respiratory quotient towards 0.7 (C true). Despite increased protein index can be used to determine both undernutrition and overnutrition. However, measurement of body
catabolism with amino acid breakdown urea production and excretion in the urine is decreased (B weight in sick patients is confounded by changes in body water because of dehydration, oedema, and
false). There is an associated increase in the excretion of titratable acid, especially phosphate and ascites. Furthermore, a person who starts at the upper end of the normal range may be classified as
sulphate, making the urine more acid (D true). "normal" despite considerable changes in the measured value. Dietary recall histories lack reliability
and are associated with poor compliance from those who are seriously ill. Unintentional weight loss
21913 – During glucose metabolism greater than 10% over the previous six months is a good prognosticator of clinical outcome. However,
1: the steps from G-6-P to pyruvate by the Embden-Meyerhof pathway occur in the cytoplasm it can be difficult to determine true weight loss because of errors in recall. It has been estimated that
2: conversion of glucose to G-6-P is irreversible in non-gluconeogenic tissue e.g. muscle one-third of patients with weight loss would be missed and one-quarter of weight-stable patients
3: pyruvate is oxidised in mitochondria would be diagnosed as having lost weight when weight loss is based on patient recall. So, although it
4: fructose catabolism via the Embden-Meyerhof pathway is dependent on the presence of glucagons is the most clinically useful of the measurements that have been listed, it is a far from perfect
measure of nutritional status. Formal measures of body composition, such as neutron activation,
Answers: TTTF provide accurate and precise information, but a detailed understanding of the body's muscle, fat, and
water content is more relevant to clinical research than it is to clinical practice.
Ganong 19th Ed. Chapter: 17 Page: 274-280
958 – Which of the following statements about anthropometric
13279 – Which of the following increases blood glucose, mobilises fat from measurements, such as triceps skinfold thickness and midarm
depots and has no effect on protein synthesis? circumference, best describes their clinical role:
A. insulin A. Simple measurements that are highly reliable.
B. glucagon B. Values below the 5th percentile are associated with a poor clinical outcome.
C. adrenaline C. Simple measurements that lack reliability, but are very precise.
D. cortisol D. Such measures cannot be used to estimate muscle mass.
E. growth hormone E. Useful ward-based tests that should be employed by nutrition support teams.
Answer: C Answer: B
Adrenaline increases blood glucose by increasing hepatic glycogenolysis and increases circulating Anthropometry uses simple measurements of body thicknesses to estimate fat and lean tissue mass.
free fatty acids (C true). Glucagon has similar effects but also increases gluconeogenesis from Triceps and subscapular skinfold thicknesses provide an index of body fat; and midarm muscle
available amino acids (B false). Cortisol increases protein catabolism and tends to increase blood circumference provides a measure of muscle mass. Interpretation of the data may be limited by
glucose levels (D false). Growth hormone stimulates protein synthesis, increases hepatic glucose interobserver variability, age, and hydration status. Nevertheless, markedly abnormal values, below
production and elevates free fatty levels in plasma (E false). Insulin, on the other hand, lowers blood the 5th percentile, are often associated with poor clinical outcome. However, such patients usually
glucose levels, increases protein synthesis and increases triglyceride deposition in adipose tissue (A look thin and wasted from the foot of the bed. Anthropometry is most appropriate when evaluating
false). groups rather than individuals and starved young populations rather than sick and elderly patients.
Hence, they offer a low technology approach to the measurement of body composition that is most
20853 – S. A high intake of glucose is dealt with in the body by its storage applicable to epidemiological surveys of starving third-world populations. It might be more appropriate
predominantly as glycogen BECAUSE R. with a high intake of glucose, to measure muscle function rather than muscle bulk. Muscle function testing represents a new
approach for evaluating the adequacy of nutrient intake and entifying patients who are at increased
insulin is secreted and glycogen formation is increased risk for complications. Muscle function tests include measuring grip strength, respiratory muscle
strength, and the response of specific muscles to electrical stimulation. Some initial studies have
Answer: S is false and R is true suggested that they are more accurate than other measures of nutritional status. It is unknown
whether restoring muscle function with nutritional therapy improves clinical outcome.
Ganong 20th Edition, Ch 17, pages 278-284. Pending review. Nov 2002
952 – The most clinically useful form of nutritional assessment related to THYROID
body weight is:
A. Absolute weight measured on an accurate set of scales. 21243 – In the thyroid
B. A 72-hour dietary recall history. 1: iodide enters cells against a concentration gradient

2: thiocyanate (or perchlorate) competitively inhibits iodide uptake Answers: FFTF
3: LATS (long acting thyroid stimulator) resembles TSH in its actions
4: daily synthesis of triiodothyronine is greater than that of tetraiodothyronine (thyroxine) MCQ BOOK QUESTION 4TH EDITION (2.066)
Monoiodotyrosine and diiodotyrosine are formed in the thyroid cell by enzymatic binding of iodine to
Answers: TTTF the tyrosine molecules attached to the thyroglobulin molecule. Diiodotyrosine forms about one-third of
the iodinated compounds in the thyroglobulin complex (B false). Two diiodotyrosine molecules
Guyton 7th ed. CHAPTER: 76 PAGE: 898-905 undergo oxidative condensation to form thyroxine, still linked to thyroglobulin. After proteolysis of
thyroglobulin the diiodotyrosine and monoiodotyrosine liberated into the cytoplasm are deiodinated
10451, 13554, 21743 – In the thyroid and the iodine liberated is reutilised. Thus diiodotyrosine is not secreted to the blood (C true, D false)
1: iodide enters cells against a concentration gradient and has essentially no biological action as thyroid hormone (A false).
2: daily synthesis of triiodothyronine is greater than that of thyroxine
3: thyroid-stimulating immunoglobulin (TSI) resembles thyroid stimulating hormone (TSH) in its 23589 – Tetraiodothyronine (thyroxine) and triiodothyronine
actions 1: circulate in plasma predominantly bound to proteins
4: thiocyanate (or perchlorate) competitively inhibits iodide uptake 2: levels increase in plasma during pregnancy and mild hyperthyroidism normally occurs
3: increase glucose absorption from small intestine
Answers: TFTT 4: have no effect on erythropoiesis
MCQ BOOK QUESTION 4TH EDITION (2.065). Iodine is actively concentrated in thyroid cells up to Answers: TFTF
approximately 40 times the level in serum (A true). Thiocyanate (or perchlorate) competitively inhibits
iodide uptake (D true). The thyroid normally secretes about 80 ?g of thyroxine and about 4 ?g of Guyton 7th ed. CHAPTER: 76 PAGE: 897-903
triiodothyronine per day (B false). Thyroid stimulating immunoglobulin is similar in its actions to
pituitary TSH (C true). Iodide is actively concentrated in thyroid cells up to approximately 40 times the 10446 – The release of thyroid-stimulating hormone (TSH) by the anterior
level in serum (A true). Thiocyanate (or perchlorate) competitively inhibits iodide uptake (D true). The
pituitary is increased by
thyroid normally secretes about 80?g of thyroxine and about 4?g of triiodothyronine per day (B false).
1: nerve impulses in nerve tracts from the hypothalamus
Thyroid stimulating immunoglobulin is similar in its actions to pituitary TSH (C true). Reviewed March
2: reduced blood levels of thyroxine
2003.
3: a hypothalamic releasing factor
4: a hot environment raising the temperature of blood passing through the hypothalamus
22359 – Thyroid hormones
1: increase gluconeogenesis in liver Answers: FTTF
2: increase glycogen content in muscle
3: lower plasma cholesterol Anterior pituitary thyrotrophin cells are under the stimulatory control of thyrotropin releasing hormone
4: increase the duration of tendon reflexes from the hypothalamus via the hypothalamo-hypophyseal portal system, and are inhibited by
circulating thyroxine and triiodothyronine (B and C true). Unlike the posterior pituitary there are no
Answers: TFTF neural connections to the anterior pituitary (A false). The response to cold stress involves thyroid
activation to assist in calorigenesis by raising metabolic rate, but this would be counter-adaptive in
Ganong 13th Edition CHAPTER: 1 PAGE: 269-270 heat stress and, of course, does not occur (D false).
23879 – Thyroid hormone excess causes 9880 – S:There is very little free thyroxine in the plasma
1: creatinuria because R:thyroxine is bound to thyroxine-binding prealbumin in the
2: increased glucose absorption from small intestine
3: increased uric acid excretion in urine plasma
4: decreased pulse pressure
Answers: TTTF
15132 – Thyroid stimulating hormone (TSH)
10456, 13559, 23444 – Diiodotyrosine is 1: requires glycosylation for full biological activity
1: physiologically active 2: is primarily degraded in the liver
2: not stored in the thyroid as part of the thyroglobulin molecule 3: acts by combining with a G protein linked receptor
3: not found in the blood 4: causes exocytosis of colloid in the thyroid
4: loosely bound to plasma proteins

Answers: TFTF 13564 – Calcitonin
1: deficiency has profound clinical effects
Refer to Ganong, 19th Ed, Ch 18, page 312 2: is secreted mainly by parafollicular cells within the thyroid
3: is only secreted when calcium levels in the blood exceed 2.4 mmol/1 (9.5 mg/dl)
20721 – S. Patients with high levels of TBG (thyroxinebinding globulin) are 4: lowers serum calcium levels by inhibiting bone resorption
usually euthyroid BECAUSE R. high TBG levels suppress pituitary
thyrotrophin (THS) Answers: FTTT
Calcitonin is secreted by the parafollicular of C cells in the thyroid gland (B true) but only when the
plasma calcium level exceeds 2.4 mmol/1 (9.5 mg/dl) (C true). Calcitonin lowers plasma calcium and
phosphate levels by inhibiting bone resorption (D true). Parathyroid hormone promotes the synthesis
Ganong 20th Edition, page 312. This question has been reviewed and has not been altered. 9 Dec
of 1,25 dihydroxycholecalciferol in the kidney but calcitonin has no efect on this factor. (A false).
2002
Updated June 2003.
23944 – Parathyroid hormone 9983 – Calcitonin
1: is secreted by the oxyphil cells of the parathyroid gland
1: lowers serum calcium levels by inhibiting bone resorption
2: in excess causes hypophosphaemia
2: is only secreted when calcium levels in the blood exceed 2.4 mmol/l (9.5 mg/dl)
3: deficiency is a cause of calcium-containing renal calculi
3: is secreted mainly by parafollicular cells within the thyroid
4: increases distal tubular reabsorption of calcium
4: secretion is increased by gastrin
Answers: FTFT
Answers: TTTT
Ganong 13th ed. CHAPTERS: 21 PAGES: 328-329
23454 – Parathyroid hormone (PTH) secretion is 23449 – Calcitonin
2+
1: increased by a low plasma Ca level
- 1: promotes synthesis of 1,25 dihydroxycholecalciferol in the kidney
2: decreased by a low plasma PO 4 level
2: is secreted mainly by parafollicular cells within the thyroid
3: increased in chronic renal disease
3: is only secreted when calcium levels in the blood exceed 2.4 mmol/l
4: reduced by ?-adrenergic stimulation
4: lowers serum calcium levels by inhibiting bone resorption
Answers: TFTF
Answers: FTTT
Guyton 16th ed. Chapter: 21 Pages: 356-357
MCQ book question 4th edition (2.067). This question was referred to the Physiology Sub Committee
for review on 1 Feb 2002. Question updated 15 March 2002.
21443 – PTH (parathyroid hormone)
2+
1: increases mobilisation of Ca from bone
2+ 23929 – Calcitonin
2: increases reabsorption of Ca from distal tubules of kidney 2+
1: increases Ca concentration of plasma
3: increases synthesis of 1, 25-Dihydroxycholecalciferol, the 'active' metabolite of vitamin D 2+
2: increases absorption of Ca from bone
4: increases phosphate reabsorption from renal tubules 2+
3: increases absorption of Ca from small intestine
2+
4: secretion is increased by a raised Ca concentration of plasma
Answers: TTTF
Answers: FFFT
25758 – Hypercalcaemia
A. results in hypovolaemia from the kidney’s inability to retain water
15493 – The absorption of calcium from the upper small intestine is
B. can be rescued by administration of intravenous biphosphonate
C. is a common sequel of total thyroidectomy facilitated by
D. can be managed by oral vitamin D administration 1: 1, 25 - dihydroxycholecalciferol
E. is invariably associated with elevated serum parathyroid hormone levels 2: a calcium-binding protein in small intestinal epithelium
3: a low ionised calcium in plasma
Answer: B 4: phosphate in small intestine

Answers: TTTF 18844 – Which of the following is inhibited by both alpha - and beta-
adrenergic agonist substances?
Refer to Guyton, 7th Ed, Ch 79, page 937-939; Ganong, 19th Ed, Ch 25, page 456
A. intestinal smooth muscle
B. terminal bronchiolar smooth muscle
C. pulmonary arteriolar smooth muscle
ENDOCRINOLOGY D. cardiac muscle
E. cutaneous vascular smooth muscle
21673 – Adrenaline
1: stimulates glycogenolysis in liver and muscle
Answer: A
2: mobilises free fatty acids from adipocytes
3: increases the B.M.R. (Basal Metabolic Rate)
4: increases the pulse pressure 24069 – Alpha-adrenergic receptors are found in
1: intestinal smooth muscle
Answers: TTTT 2: terminal bronchial smooth muscle
3: cutaneous vascular smooth muscle
Ganong - 13th ed. Chapters: 17, 20, 31 Pages: 231,238,299-300, 495 4: cardiac muscle
Answers: TFTF
23574 – Noradrenaline causes
1: increased cardiac contractility
2: vasodilation in skeletal muscle and liver 15067 – The effects of Dopamine include
3: increased myocardial excitability 1: activation of dopaminergic receptors to decrease appetite
4: widening of the pulse pressure 2: a net negative inotropic effect
3: stimulation of prolactin secretion
Answers: TFTF 4: a net decrease in peripheral vascular resistance
Ganong 13th Edition CHAPTERS: 19 PAGES: 300 Answers: TFFF

21353 – Which of the following is/are induced by noradrenaline?
1: reduction of the cardiac output
2: constriction of skeletal muscle arterioles 9988 – Factors increasing both glucocorticoid and aldosterone secretion
3: stimulation of hydrolysis of fat to release fatty acids and glycerol include
4: stimulation of the secretion of gastric parietal cell HCl. 1: haemorrhage
2: a high potassium (K+) diet
Answers: TTTF 3: anxiety
4: assuming the erect posture content of the mucosal cells is decreased
14902 – S:When noradrenaline is infused into normal humans the pulse
Answers: TFTF
slows because R:noradrenaline has no beta-adrenergic agonist activity
Ganong, 19th ed, Ch 20. Some trainees thought that option 4 did not make sense. The question was
referred to the Physiology Sub Committee for comment. The Committee response is that it does
make sense. August 22, 2001. This question is under review. 28 May 2002. This question has been
Refer to Ganong, 19th Ed, Ch 20, page 342-344; Ch 31, page 573
reviewed and has not been changed. 9 Dec 2002. Comments: The word "assume" in option four
should be interpreted as follows: "assume the erect posture" = "to take up the erect posture.
23674 – Activation of the adrenergic nervous system may lead to the
following physiological responses 19899 – All but one of the following are associated with adrenal cortical
1: increase in circulating renin levels hyperfunction. Which is the EXCEPTION?
2: arteriolar coronary dilatation
A. osteoporosis
3: hepatic glycogenolysis
B. excessive fat deposition
4: pancreatic acinar secretion
C. peptic ulceration
D. aseptic necrosis of bone
Answers: TTTF
E. delayed closure of epiphyses

Answer: E Refer to Ganong, 19th Ed, Ch 22, page 378 and following. This question was referred to the
Physiology Sub Committee for review on 1 Feb 2002.
Ganong 16th Edition Chapter: 20 Page: 336-337; 346
20811 – S. In patients with adrenal insufficiency excessive pigmentation of
14671 – Glucocorticoids the skin indicates pituitary disease BECAUSE R. in primary adrenal
1: produce multiple effects via transcription of DNA insufficiency circulating ACTH levels are high
2: modulate sensitivity to olfactory stimuli
3: are essential for vascular smooth muscle responses to catecholamines
4: stimulate the production of interleukin-2
Guyton 7th ed. CHAPTER: 77 PAGE: 920
Answers: TTTF
Refer to Ganong, 19th Ed, Ch 20, page 350 and following 10159 – Growth hormone
1: in excessive amounts produces ketosis
2: enhances amino acid transport through cell membranes
23959 – Cortisol
3: stimulates the islets of Langerhans to secrete insulin
1: promotes gluconeogenesis in the liver
4: acts directly on bone and cartilage to promote growth
2: decreases utilization of glucose by muscle cells
3: increases utilization of free fatty acids by adipocytes
Answers: TTFF
4: increases the intensity of antigen-antibody reactions
Answer: TTTF
Guyton 7th Ed. Ch. 77 P. 915 Ganong 13th Ed. Chapter: 20 Page: 310-311 23219 – Growth hormone secretion is increased by
1: hypoglycaemia
24359 – Cortisol 2: exercise
3: fasting
1: increases gluconeogenesis by the liver
4: L-dopa
2: decreases glucose utilisation by muscle cells
3: increases free fatty acid mobilization
Answers: TTTT
4: increases ACTH secretion via a feedback control mechanism
Ganong 19th ed. CHAPTER: 22 PAGE: 387 (Table 22.3)
Answers: TTTF
Ganong, 19th Ed CHAPTER:20 PAGE: 353-358 22594 – Prolactin secretion is increased by

1: exercise
21843 – The metabolic actions of cortisol include 2: surgery
3: suckling
1: stimulated synthesis of hepatic gluconeogenic enzymes
4: dopamine
2: mobilization of extra-hepatic amino acids
3: decreased glucose utilization by cells
Answers: TTTF
4: decreased hepatic protein synthesis
Ganong 15th ed. Chapter: 23 Page: 398-399
Answers: TTTF
Guyton 8th ed. Page: 846 27556 – Concerning the effect of the anterior pituitary
1: follicle-stimulating hormone (FSH) and luteinising hormone (LH) are secreted only in females
15127 – With regard to the pituitary 2: luteinising hormone acts via receptors on theca interna cells
3: pulsatile release of gonadotropin-releasing hormone (GnRH) from the hypothalamus is vital
1: follicle stimulating hormone maintains spermatogenesis
4: prolactin causes milk secretion from the oestrogen-primed and progesterone-primed breast
2: luteinizing hormone is responsible for progesterone secretion from the corpus luteum
3: prolactin causes milk secretion from the oestrogen and progesterone primed breast
Answers: FTTT
4: growth hormone produces a fall in blood urea nitrogen
Both FSH & LH are secreted in the male as well as the female (1 False). In the male, FSH stimulates
Answers: TTTT
the Sertoli cells to control the maturation of spermatids to spermatozoa; and LH is trophic on the

interstitial Leydig cells - stimulating androgen production. Luteinising hormone in the female acts via 2: low pressure receptors in the great veins and atria
receptors on theca interna cells (2 True); to stimulate ovulation and luteinisation of the ovarian follicle. 3: nicotine
Research with gonadotrophic releasing hormones (GnRH) have clearly shown that a constant 4: spironolactone
infusion of GnRH will down-regulate the GnRH receptor of the anterior pituitary and hence LH
secretion ceases. An hourly pulse, on the other hand, will stimulate LH secretion (see Ganong) (3 Answers: TTFF
True).
Prolactin is another of the hormones secreted by the anterior pituitary. Its action is to stimulate milk Guyton 7th ed. PAGE: 894
secretion from a breast that is 'primed' by oestrogen and progesterone (4 True). Prolactin also inhibits
the action of the gonadotropins. 13589 – Vasopressin or ADH
1: increases permeability to water of the proximal tubules
22088 – The increase in antidiuretic hormone secretion which follows 2: increase permeability to water of the collecting ducts of the kidney
operation is due to 3: decreases blood flow in the renal medulla
1: pain 4: increases permeability of the collecting ducts of the inner medulla of the kidney to urea
2: administration of morphine
3: loss of extracellular fluid Answers: FTTT
4: hypoxia
Vasopressin or ADH is produced in the posterior part of the pituitary. It has its effect on the collecting
Answers: TTTF ducts of the kidney, not on the proximal tubules (A false). In the collecting ducts it increases
permeability to water (B true), urea (D true) and some other solutes. It also decreases the blood flow
Ganong 14th ed. Page: 202 in the renal medulla (C true).
21348 – ADH (antidiuretic hormone) 22053 – Thirst is

1: is synthesized in neurones different from those which synthesize oxytocin 1: controlled by a hypothalamic mechanism
2: can constrict the vasa recta vessels in the renal medulla 2: caused by intracellular dehydration
3: facilitates urine concentration in the collecting ducts 3: stimulated by haemorrhage or low cardiac output
4: release is decreased when the central venous pressure falls below normal 4: stimulated by angiotensin II
Answers: TTTF Answers: TTTT
Guyton 7th Ed. Ch. 75 P. 893 Ganong 13th Ed. Chapter: 14-38 Page: 196-200, 594 Guyton 7th ed. Chapter: 36 Page: 431
22589 – Stimuli that increase vasopressin secretion include 22984 – Thirst is stimulated by
1: increased extracellular fluid volume 1: increased osmolality of plasma due to increased sodium concentration
2: nicotine 2: angiotensin
3: alcohol 3: decrease in ECF volume
4: chlorpropamide 4: increased oncotic pressure of plasma
Answers: FTFT Answers: TTTF
Ganong 16th Ed. CHAPTER: 14 PAGE: 219 Ganong 16th Ed. Chapter: 14 Page: 215-216. This question will be submitted at the March 2004
meeting regarding: option 2(27/02/2004)
21718 – Increased ADH secretion is induced by
1: mild hyperosmolality of the ECF 23889 – Which of the following conditions is/are important cause(s) of
2: severe hypovolaemia thirst?
3: mild hypovolaemia plus mild hyperosmolality of the ECF 1: extracellular dehydration
4: severe hypovolaemia plus severe hypo-osmolality of the ECF 2: intracellular dehydration
3: elevated angiotensin levels after haemorrhage
Answers: TTTT 4: extracellular hypertonicity
Guyton 7th ed. Chapter: 75 Page: 893-895 Ganong 19th Ed. Ch. 14 p230 Answers: TTTT
23954 – Vasopressin (ADH) secretion is affected by Guyton 7th Ed. Chapter: 36 Page: 431-432 Ganong 19th Ed. Chapter: 14 Page: 229-230
1: osmoreceptors in the hypothalamus
20463 – S. Thirst can occur without a change in plasma 2: in the blood is largely confined to the red blood cells
osmolality BECAUSE R. haemorrhage stimulates thirst by a different 3: increases salivation
4: has 5 hydroxy-indoleacetic acid as a urinary metabolite
mechanism to that evoked by osmo-receptors
Answers: TFFT
Serotonin is found typically in blood platelets, in the retina, in enterochromaffin cells, in the myenteric
Ganong 18th ed. Chapter: 14 Page: 225 plexus and in brain neurons, but not in red blood cells (B false). It is formed in the body by
hydroxylation and decarboxylation of tryptophan. However, the hydroxylase is not saturated so that
20379 – S. With haemorrhage, thirst can occur without any change in an increase in dietary tryptophan can increase brain serotonin content. After release from
plasma osmolality BECAUSE R. with haemorrhage, increased amounts of serotonergic neurons, much of the released serotonin is returned by an active re-uptake mechanism
and inactivated by monamine oxidase to form 5-hydroxyindoleacetic acid which is excreted in the
angiotensin are liberated which stimulate the hypothalamic thirst area
urine (D true). It will constrict, or dilate, blood vessels (A true), but does not enhance salivation (C
false).
Ganong 13th Ed. Ch. 14 P. 196 12909, 15473 – Serotonin (5-hydroxytryptamine) causes
1: constriction of some vessels
14928 – S:In the syndrome of inappropriate ADH secretion (SIADH) the 2: contraction of the ileum
3: stimulation of salivary secretion
urine volume/day may be normal because R:with inappropriate ADH 4: stimulation of cardiac muscle
secretion the glomerular filtration rate may be increased
Answers: TTFF
Refer to Guyton, 7th Ed, Ch 18, page 242; Ch 20, page 338; Ganong, 19th Ed, Ch 4, page 98-99; Ch
Refer to Guyton, Ch 36, page 431 15, page 250-251. Serotonin is present in highest concentrations in blood platelets and in the
gastrointestinal tract where it is found in enterochromaffin cells and in the myenteric plexus. When
13267 – Administration of growth hormone does NOT result in increased blood vessel walls are injured platelets collect at the site and stick to the injured vessel liberating
A. mitosis serotonin to cause local vasoconstriction (A true). Serotonin contracts small intestinal muscle (B true)
B. protein synthesis but has little direct effect on salivary secretion (C false) or cardiac function (D false).
C. fat metabolism
D. carbohydrate utilisation 22979 – With respect to the ovary
E. release of insulin from the pancreas 1: luteinising hormone is the main hormone responsible for ovulation
2: during the first trimester of pregnancy, bilateral oophorectomy may be followed by abortion
Answer: D 3: plasma progesterone level peaks about day 21 of a 28-day menstrual cycle
4: plasma oestrogen level peaks about day 8 of a 28-day menstrual cycle
Growth hormone is a protein-anabolic hormone which stimulates protein synthesis (B false) and cell
proliferation via somatomedin (A false), and which increases fat metabolism by mobilising free fatty Answers: TTTF
acids from adipose tissue (C false). Growth hormone does not stimulate pancreatic B cells directly,
but increases the ability of the pancreas to respond to insulinogenic stimuli (E false). Growth hormone Guyton 7th ed. CHAPTER: 81, 82 PAGE: 969-970, 988
decreases glucose utilisation, and the glucose uptake into some tissues (D true).
27543 – Concerning the ovary
22709 – The human pineal gland 1: luteinising hormone stimulates the secretion of oestrogen from the theca interna
1: contains serotonin 2: follicle-stimulating hormone regulates the theca interna
2: is outside the blood brain barrier 3: plasma oestrogen level peaks about day 8 of a 28-day menstrual cycle
3: contains melatonin 4: during the first trimester of pregnancy, bilateral oophorectomy may be followed by abortion
4: influences K\p+ metabolism
Answers: TTTF
Ganong 16th Ed. Chapter: 24 Page: 422
13650 – Serotonin
1: constricts blood vessels

Answers: TFFT
Guyton A, Hall J, Textbook of Medical Physiology, WB Saunders, 1996, 9th Edition; Ch 81.
Both follicle-stimulating hormone (FSH) and luteinising hormone (LH) are secreted by the anterior
pituitary in response to stimulation of the pituitary by gonadotropin-releasing hormone (GnRH)
secreted by the hypothalamus.
Ovarian function is entirely dependent on stimulation by FSH/LH. FSH, in particular, stimulates the
accelerated growth of 6-12 primary follicles with rapid proliferation of granulosa cells as well as a
second class of cells that form theca interna and externa. As its name suggests the development of
the primary follicle to vesicular follicle is due to FSH.
Both granulosa cells and theca interna cells secrete oestrogens. Granulosa cells initially have FSH
receptors but later develop LH receptors. Theca interna cells have LH receptors, not FSH (2 False);
and also secrete oestrogens under the stimulus of LH (1 True).
LH is needed for the final development of the follicle, as well as ovulation. There is a rapid rise of both
LH & FSH in the hours before ovulation. LH then seems to convert the granulosa and theca interna
cells into a more progesterone-secreting type of cell.
The rise and fall of the various hormones are seen subsequently in Figures 4 and 5. Plasma
oestrogen levels peak near ovulation in midcycle (3 False).
The progesterone secreted by ovarian corpus luteum in the second half of the menstrual cycle
prepares a receptive endometrium for the fertilised ovum (Figures 4 and 5). After implantation,
ongoing nutrition of this conceptus is dependent on corpus luteum secretion of progesterone,
oestrogen and relaxin. After about six weeks the placenta is able to produce enough oestrogen and
progesterone to maintain pregnancy. Oophorectomy before the sixth week will thus lead to abortion (4
True).
27612 – Concerning menstruation

1: heavy periods are an unusual cause of anaemia
2: polymenorrhoea usually reflects a clotting disorder
3: stress can upset the menstrual cycle
4: intermenstrual bleeding is common and of no concern
Answers: FFTF
Excessive menstrual loss is actually the commonest cause of anaemia in Western society (1 False).
Investigations of iron deficiency anaemia must include consideration of this possibility - it can be
easily overlooked by all parties.
When considering abnormal menstrual loss it is best to remember that: 1 'menorrhagia' is excessive
bleeding in regular cycles and tends to have a local cause in uterine fibroids, or faulty clotting. 2
'polymenorrhea' are periods that are too frequent, due usually to a disturbance of the hormones of the
pituitary/ovarian axis (2 False). 3 'polymenorrhagia' is the condition of periods that are both too heavy
and too frequent, usually due to a combination of the above causes.
Alterations to the menstrual cycle can be due to emotional and traumatic factors acting on neuro-
endocrine effector pathways (3 True) emanating from the hypothalamus (Chapter 14 Ganong).
Intermenstrual bleeding is a serious symptom that may be due to uterine/cervical cancer (4 False)
and so must be thoroughly investigated.
27548 – Concerning the menstrual cycle

1: new ova are formed during the proliferative phase
2: involution of the corpus luteum removes feedback inhibition on the anterior pituitary
3: follicle-stimulating hormone is essential to allow the follicle to progress to ovulation
4: thecal cells mainly form androgens

Answers: FTFT
27571 – In human pregnancy

1: there is a decrease in maternal antibody production
2: maternal blood volume is lower at the 30th week compared to the 12th week
3: placental cells secrete relaxin
4: the anterior pituitary gland enlarges at least 50 per cent
Answers: TFTT
See Ganong WF, Review of Medical Physiology, Appleton & Lange, 1999. 19th Edition and Guyton A,
Hall J, Textbook of Medical Physiology, WB Saunders, 1996, 9th Edition.
A number of changes occurs to the mother during pregnancy (Table 3).
The enlarging uterus can also move abdominal contents around. In particular, a mobile caecum can
lead to the appendix riding up out of the right iliac fossa.
Table 3 - Changes During Pregnancy

Organ/System Changes During Pregnancy
50% increase in size (4 True) with increased secretion corticotropin,
Pituitary
thyrotropin and prolactin.
Increase glucocorticoid secretion.
Adrenal
2 x aldosterone secretion.
50% increase in size and in production thyroxine as a result of stimulation
Thyroid by human chorionic gonadotropin and placental human chorionic
thyrotropin.
Gland enlargement and increased parathyroid hormone.
Parathyroid
More marked increase during lactation.
Ovaries and Placenta Produces oestrogens, progesterone and relaxin (3 True).
Uterus increases 22 fold.
Breasts double in size.
Mother's body
Vagina and introitus enlarge.
General weight gain in excess of fetus and amniotic fluid.
15% increase basal metabolic rate in latter half pregnancy.
Metabolism Increased absorption and storage of protein, calcium, phosphates and iron
Answers: FTFT through pregnancy.
Cardiac output 30-40% above normal by 27th week but near normal in final
The formation of ova occurs during fetal development (1 False). Some 300,000 - 400,000 are present 8 weeks.
Circulation
at puberty but only some 400 of these follicles will develop enough to expel their ova. The feedback Blood volume increases during second half pregnancy (2 False) by about
regulation of ovarian function is seen well in Figure 3 below. As can be seen, involution of the corpus 30% (1-2 litres).
luteum means loss of inhibin and oestrogen which removes feedback inhibition of the anterior pituitary Minute ventilation increases 50% and a fall in arterial pCO2.
and allows for the next cycle to commence (2 True). The mid-cycle burst of LH is responsible for Respiration Respiratory rate increases as diaphragm less effective with enlarged
ovulation. There is a similar, but smaller, pulse of FSH which is of uncertain significance - however it uterus.
is not necessary for ovulation (3 False). Androgens are produced from thecal cells (4 True). Slight increase in urine production.
Urinary Near balance of increased glomerular filtration rate and increased re-
10084 – During the follicular phase of the menstrual cycle absorption of sodium, chloride and water.
1: basal body temperature progressively increases Immune system Decrease in maternal antibody production (1 True).
2: progesterone levels are depressed
3: oestradiol secretion is inhibited 15112 – In human pregnancy
4: vaginal mucus is thin and alkaline 1: plasma oestriol levels decrease during the second trimester
2: oestriol is synthesised by the combined effect of foetal and placental tissue (ie by the foeto-
placental unit)
3: removal of the ovaries after three months leads to abortion • Human chorionic somatomammotropin (hCS) (4 True) which is lactogenic, growth
4: human chorionic somatomammotropin (HCS) has some of the actions of growth hormone stimulating and causes reduced insulin sensitivity and decreased glucose utilisation in
mother.
Answers: FTFT • Oestrogens.
• Progesterone.
10461 – In the breast
23204 – During pregnancy the 1: prolactin is the most important hormone for milk 'letdown'
1: plasma level of oestriol is higher at the 36th week than at the 20th week 2: milk production is facilitated after parturition because circulating oestrogen levels are maintained
2: secretion of FSH and LH into the maternal blood is increased 3: prolactin is the most important hormone for the release of milk into the alveoli
3: maternal blood volume is higher at the 30th week than it is at the 6th week 4: progesterone is the most important hormone for duct development
4: plasma level of free thyroxine is increased and maternal hyperthyroidism is present
Answers: FFTF
Answer: TFTF
Oestrogens are primarily responsible for duct development and progesterone for lobular development
Guyton 8th Ed. Chapter: 82 Page: 919-922 Ganong 15th Ed. Ch. 23 P. 422 in the breast (D false). During pregnancy, prolactin levels steadily increase until term, reaching a peak
at the time of parturition. Prolactin is responsible for the formation of milk and its secretion into the
27581 – During pregnancy ducts (C true). The hormone responsible for milk 'let down' is oxytocin released in response to
1: increased aldosterone production, combined with marked oestrogen secretion is the cause of fluid touching the nipples and areolae (A false). After parturition, there is an abrupt decline in circulating
retention in pregnancy oestrogens and progesterone. The drop in oestrogens initiates lactation. Oestrogen antagonises the
2: maternal cardiac output is 30-40 per cent above normal at term milk-producing effect on prolactin in the breast and may be given to stop lactation (B false).
3: maternal thyroxine production increases by some 50 per cent
4: the position of the mother's appendix can be pushed into the right upper quadrant 23884 – With respect to breast development and lactation
1: prolactin initiates milk secretion
Answers: TFTT 2: oxytocin induces milk ejection ('let-down')
3: oestrogen stimulates duct growth
See Guyton A, Hall J, Textbook of Medical Physiology, WB Saunders, 1996, 9th Edition. 4: growth hormone alone stimulates lobule-alveolar growth
Pregnant women have a two-fold increase in secretion of aldosterone, which, together with the
increased oestrogen secretion, causes fluid retention (1 True). Cardiac output increases to a level 30- Answers: TTTF
40% above normal by the 27th week, but thereafter falls to near normal by the end of the pregnancy (2
False). The thyroid gland enlarges during pregnancy by upwards of 50%, with corresponding increase in Guyton 7th Ed. Chapter: 82 Page: 994-995 Ganong 13th Ed. Chapter: 23 Page:378-379
thyroxine production (3 True). The enlarging uterus can displace other abdominal viscera, so that the
position of the appendix can be in the right upper abdominal quadrant (4 True). 22364 – Breast development in females requires
1: progesterone for lobule-alveolar growth
27576 – Concerning placental function 2: oxytocin and oestrogen for lobule-alveolar growth
1: the placental trophoblast prevents rejection of the 'foreign tissue fetus' by the mother 3: oestrogen for duct growth
2: secretion of human chorionic gonadotropin is vital to prevent expulsion of an implanted ovum 4: prolactin and no other hormones for duct growth
3: hCG-b cannot be detected in the blood until 18 days after conception
4: secretes human chorionic somatomammotropin Answers: TFTF
Answers: TTFT Ganong 13th Ed. CHAPTER: 23 PAGE: 378
See Ganong WF, Review of Medical Physiology, Appleton & Lange, 1999. 19th Edition (1 and 3) and 22369 – With respect to the ovarian hormones
Guyton A, Hall J, Textbook of Medical Physiology, WB Saunders, 1996, 9th Edition (2 and 4). 1: during the luteal phase of the menstrual cycle urinary pregnanediol excretion normally exceeds
The placenta develops from the trophoblast cells, as well as adjacent cells of the blastocyst and 2mg/24 hours
endometrium. This placental trophoblast does not express a polymorphic class of gene - instead the 2: plasma oestrogen level peaks about 24-48 hours preceding ovulation
placental trophoblast expresses a non-polymorphic gene which does not induce maternal antibodies 3: progesterone decreases the response of the uterus to oxytocin
against the fetus (1 True). 4: progesterone induces secretion of thick, tenacious and cellular cervical mucus
The placenta secretes a number of hormones:
• Human chorionic gonadotropin (hCG) - hCG can be detected in the blood as early as six Answers: TTTT
days after conception (3 False) and possibly in the urine at 14 days. The hCG prevents
normal involution of the corpus luteum, thus promoting increased ovarian secretion of Ganong 13th ed. Chapter: 23 Page: 367-369 Guyton 7th ed. Chapter: 81 Page: 969; 975
oestrogen and progesterone which prevents shedding of endometrium (2 True).

27561 – Oestrogens Answer: S is true, R is true and a valid explanation of S
1: increase the amount of uterine muscle and content of contractile proteins
2: are largely responsible for breast enlargement in puberty After fertilisation the corpus luteum in the ovary fails to regress. Instead it enlarges in response to the
3: cause increased secretion of thyroid-binding globulin secretion of placental human chorionic gonadotropin (HCG), and secretes oestrogens and
4: are the primary cause of growth of pubic and axillary hair progesterone. After six to eight weeks HCG secretion subsides and the corpus luteum starts to
regress. Ongoing oestrogen and progesterone production is then taken over by the placenta (S and R
Answers: TTTF are both true and R is a valid explanation of S).
See Ganong WF, Review of Medical Physiology, Appleton & Lange, 1999. 19th Edition and the 27617 – Concerning post-menopausal vaginal bleeding
Effects of Oestrogen Table . Oestrogens are secreted by the granulosa cells of the ovarian follicles, 1: exogenous oestrogens are a possible cause
corpus luteum and the placenta. Their essential action is to stimulate growth and cell proliferation of 2: uterine cancer needs to be ruled out
the sex organs. 3: urethral caruncle is very rarely a factor
4: post-menopausal vaginal bleeding can be caused by colon cancer
15503 – Oestrogens
1: increase secretion of angiotensinogen Answers: TTFT
2: reach peak levels during the mid-follicular phase of the menstrual cycle
3: sensitise the myometrium to oxytocin Exogenous oestrogens influence the endometrial lining causing proliferation of the endometrial
4: inhibit contractile proteins in uterine muscle stroma and glandular proliferation with shedding of this thickened layer is likely with any drop in the
level of oestrogen. Such 'post-menopausal' bleeding is a common effect of female 'hormone replacement
Answers: TFTF therapy' (HRT) (1 True).
Uterine cancer is a very important diagnosis and a common cause of post-menopausal bleeding (2 True).
Refer to Ganong, 19th Ed, Ch 23, page 419 and following About 25% of post-menopausal bleeding is due to a genital malignancy.
A urethral caruncle is an inflammatory lesion that occurs (quite commonly) at the external urethral
27566 – Progesterone meatus, usually in elderly women. It is a highly vascular lesion with young connective tissue and a
1: is secreted by both placenta and corpus luteum variably present epithelial covering of transitional or squamous cells. It is equally important to
2: stimulates development of breast lobules and alveoli examine the external genitalia thoroughly as cancer or infection externally can be interpreted as blood
3: induces secretion of thick, viscous and cellular cervical mucus of vaginal origin. Caruncle is an important and relatively frequent cause of vaginal bleeding (3 False).
4: decreases excitability of myometrial cells Due to the relatively thin 'window' of the posterior vaginal fornix it is possible, although unusual, for an
abdominal cancer to grow through into the vagina to cause bleeding (4 True). Due to its thick muscular
Answers: TTTT wall, full thickness infiltration of the uterus is exceedingly uncommon
Progesterone is secreted by the corpus luteum and placenta (1 True), and to a minor degree the 10079 – With regard to the testis
follicle. 1: normal spermatogenesis takes place under the effect of F.S.H. (Follicle Stimulating Hormone)
alone
Table - Effects of Progesterone 2: Sertoli cells secrete inhibin which has a negative feedback effect on the anterior pituitary
Organ Effects of Progesterone 3: testosterone from Leydig cells inhibits the release of F.S.H. from the anterior pituitary
Promotes secretory epithelium in endometrium. 4: testosterone inhibits luteinising hormone secretion at the level of the hypothalamus
Uterus Decreases frequency and intensity of uterine contractions through decreased
excitability of myometrial cells (4 True). Answers: FTFT
Uterine cervix Thickens mucus and makes it more tenacious and cellular.
Fallopian Tube Promotes secretory changes of mucosa. Ganong, 19th ed, Ch 23. Please note that testosterone has no effect on FSH except in large doses.
See Ganong, 19th ed, pages 412-413. This question was referred to the Physiology Sub Committee
Breasts Promotes development of lobules and alveoli to become secretory (2 True).
for review on 1 Feb 2002. The following comment was provided by the Sub Committee: The major
Vagina Epithelial proliferation and thick viscous mucus production (3 True). control of FSH at the pituitary level is feedback by the hormone inhibin from the Setoli cells of the
Endocrine Inhibits LH secretin. seminiferous tubules. Large doses of testosterone do indeed inhibit GnRH release at hypothalamic
organs Potentiates inhibitory effect of oestrogens. level, thereby reducing the drive on secretion of both LH and FSH. However in terms of the "big
Other effects Thermogenic, probable cause of basal body temp rise at time of ovulation. picture" on control of gonadotrophin secretion, LH is mainly under negative feedback control by
testosterone, thus stabilising testosterone levels, while FSH is mainly under control of inhibin, thereby
13373 – S:Production of progesterone by the corpus luteum is not stabilising spermatogenesis. The answer is thus somewhat of a judgement call. This type of question,
necessary during the last half of pregnancy because R:during the last half where there is merit on both sides, tends to get trickier the longer you look at it.
of pregnancy the placenta secretes sufficient amounts of progesterone to
22354 – Testosterone
maintain pregnancy 1: is the most androgenic sex steroid

2: circulates in the plasma mainly bound to protein Answers: TTTT
3: has no effect on spermatogenesis
4: is synthesized from cholesterol in the Leydig cells Guyton Page: 800
o
Answers: FTFT 20391 – S. A man will get colder in water at 25 C than in air at the same
temperature BECAUSE R. the thermal conductivity of water is greater than
Ganong 19th Edition CHAPTER: 23 PAGE: 409. Review July 2004 re: option 1.
that of air
23949 – Testosterone is
1: elaborated in the male embryo especially during 7th - 12th weeks
2: almost absent in the male up to the age of about 10 years
Guyton 7th Ed. Chapter 72 Page: 850-851
3: an inhibitor of LH production working through the hypothalamus
4: necessary for normal spermatogenesis
9963, 12838 – A patient suffering from a feverish illness
Answers: TTTT 1: tends to feel coldest while his central body temperature is rising
2: shows marked body temperature swings with swings in environmental temperature
Guyton 7th ed. CHAPTER: 80 PAGE: 960-964 3: has a raised basal metabolic rate
4: sweats only when his central body temperature is rising
22379 – Steady state compensation of a poorly clad individual during
Answers: TFTF
exposure to a cold environment is achieved by
1: reduced heat loss by radiation Ganong, 19th ed, Ch 14. When fever occurs in man the thermoregulatory mechanism behaves as if
2: mobilization of free fatty acid the body temperature has been set a higher level. The temperature receptors then signal the actual
3: increased metabolic activity in muscles temperature below the set point. Thus the patient will feel coldest when the central body temperature
4: increased catecholamine secretion (A true) is rising and will have a raised metabolic rate (C true). Because the core temperature is set at
a higher level, marked swings do not occur with changes in environmental temperature (B false).
Answers: TTTT Sweating will occur whenever the temperature is elevated, not only when it is rising (D false).
20181 – S. By keeping a patient with a severe burn in a room temperature in 12500 – Of the types of cellular lipid, the chief one that produces heat and
oC
the range 27 – 30 , the excessive metabolic rate is reduced BECAUSE R. aids in thermoregulation is
heat losses are minimized by raising the room temperature A. lipoprotein
B. brown fat
Answer: S is true, R is true and a valid explanation of S C. saturated fat
D. neutral fat
Ganong 13th Ed. Chapter: 17 Page: 230-232 Chapter: 14 Page: 206-207 E. depot fat
20919 – S. Temperature regulation in a dry environmental temperature of Answer: B

o
38 C is obtained primarily by skin vasodilatation BECAUSE R. dilatation of
Brown fat is a special type of fat formed between the scapulae of human infants, and some animals,
skin vessels allows skin temperature to approach core temperature but is not present in adult humans. This fat has a high rate of metabolism and therefore aids in
thermoregulation in the infant (B true). Lipoprotein is a structural fat and, although saturated, neutral
Answer: S is false and R is true and depot fats are rich sources of energy but do not contribute directly to thermoregulation (A, C, D
and E false).
Guyton 7th ed. CHAPTER: 72 PAGE: 854
21853 – With regard to sweating TRAUMA / CLINICAL

1:when sweating is minimally stimulated, sweat urea is usually very concentrated
2: maximal sweat production in a heat-acclimatized person is approximately 2L/hr 25845 – In an adult patient with haemorrhagic shock
3: heat-acclimatised persons secrete less sodium in their sweat by an aldosterone-dependent 1: systolic blood pressure of 60 mm suggests more than 1.5 litres blood loss
mechanism 2: an isolated closed femoral fracture is unlikely to be the cause of a fall in systolic blood pressure
4: potassium concentration in sweat is greater than in plasma 3: urine output is a useful sign of tissue perfusion
4: an acute 1 litre blood loss requires 3-4 litres of crystalloid for resuscitation

Answers: TFTT • Renal artery stenosis/thrombosis.
• A-V fistula (4 True).
12818, 21283 – The usual urinary nitrogen loss following trauma is further Approach should be from a midline vertical laparotomy incision to obtain best exposure and vascular
control when dealing with renal trauma (5 False).
increased when
Penetrating renal trauma (bullets and stab injury) will commonly be associated with injuries to other
1: the patient has adrenal insufficiency
intra-abdominal and thoracic viscera. Surgical exploration will almost invariably be necessary to repair
2: parenteral sources of nitrogen are provided
other structures and to perform drainage. High powered shotgun injuries will be associated with more
3: the patient is chronically ill and debilitated before trauma
widespread tissue destruction and necrosis requiring, at times, extensive debridement and drainage
4: the patient has a fever
(6 True).
Answers: FTFT
25825 – A 63-year-old man becomes hypotensive six hours after a
The urinary loss of nitrogen in trauma is the result of the stress-induced protein catabolism and procedure to realign a fractured pelvis. An epidural is in place and running.
muscle breakdown of amino acids. As cortisol is a catabolic hormone, in adrenal insufficiency Blood pressure is 80 mmHg and peripheries are cool. Management should
catabolism nitrogen loss in the urine is reduced (A false). Moreover, when protein stores and muscle include
bulk are depleted in chronic illness, further catabolism associated with trauma is minimal (C false).
1: administering oxygen and checking airway and breathing
However, when extraparenteral sources of nitrogen are provided, amino acid in excess is secreted in
2: administration of 500 ml colloid over two hours
the urine, increasing the urinary nitrogen content (B true). Urinary nitrogen loss is increased in the
3: checking the drains for bleeding
febrile patient due to raised catabolism (D true).
4: checking if the pulse is over 60 per minute as this will exclude the epidural as a cause of
hypotension
25710 – A 15-year-old back seat passenger restrained by a lap-only seat
belt in a car involved in a road traffic crash Answers: TTTF
A. is likely to suffer a lumbar spine compression fracture
B. would have hypotension as a likely early consequence of intra-abdominal bowel injury Answer to come. Review July 2004 re: option 2.
C. should have a diagnostic peritoneal lavage if pancreatic injury is suspected
D. with an elevated plasma or peritoneal lavage amylase almost certainly has a pancreatic injury 25698 – In a trauma patient with a crush pelvic fracture, a large
E. should have a lumbar spine x-ray looking for a Chance hyper-flexion fracture retroperitoneal haematoma and shock
A. complete anuria would imply lower urinary tract obstruction until proved otherwise
Answer: E
B. low urine output precludes the use of contrast for radiological studies
C. renal dose dopamine, diuretics and mannitol are useful first line of treatment agents to prevent the
27844 – Concerning renal trauma development of renal failure
1: general resuscitation measures are the first priority in any multi-trauma case D. myoglobinuria secondary to rhabdomyolysis is unlikely to occur in the first 12 hours after injury
2: CT scan is the imaging modality of choice in the acute phase E. hyperkalaemia > 6 mMoI/I with ECG signs of toxicity would be an indication for immediate
3: surgical exploration is required for all cases of renal trauma requiring blood transfusion treatment with ion exchange resins (eg resonium)
4: hypertension can occur in the long term after conservative management of renal trauma
5: the flank approach is ideal for isolated renal injuries Answer: A
6: penetrating renal injuries almost invariably require exploration
18237 – A previously fit 55 year old man has undergone an emergency right
Answers: TTFTFT
hemicolectomy for a perforated caecal carcinoma. On review 24 hours after
True. Remember your A B Cs (as per EMST). the operation you note the following on his fluid balance sheet -
CT scanning allows assessment of renal perfusion; the presence and function of the contralateral intravenous input 2L, nasogastric aspirate 2L, drain losses 700 ml, urine
kidney; the extent, if any, of perirenal haematoma; and the presence or absence of urinary output 500 ml. Biochemistry shows Na+ 135 mmol/L, K+ 3.0 mmol/L, Cl- 100
extravasation (2 True). If CT scans are not available intravenous pyelography may be used but this
study is inadequate in 20% of cases. In the presence of continued or severe haemorrhage, mmol/L, HC03- 27 mmol/L. Which of the fluid balance regimens below
arteriography may be helpful to elucidate the site of arterial bleeding and the presence or absence of would you order for the next 24 hr period?
arteriovenous malformation. A. 2L N. saline + 3L dextrose 5% + 50 mmol KCl
Surgical exploration and repair or nephrectomy may be necessary in the presence of continued B. 2L N. saline + 1L dextrose 5% + 50 mmol KCl
severe haemorrhage. Patients who respond to blood transfusion and remain stable do not necessarily C. 1L N. saline + 3L dextrose 5% + 100 mmol KCl
require exploration. Surgery will more often be required for assessment and treatment of other intra- D. 3L N. saline + 2L dextrose 5% + 100 mmol KCl
abdominal injuries include damage to spleen, duodenum and bowel (3 False). E. 1L N. saline + 1L dextrose 5% + 100 mmol KCl
Causes of hypertension include:
• The 'Page' kidney with increased pressure due to a chronic subcapsular haematoma Answer: D
causing release of renin.
He has a total of 3200 ml sensible loss in the previous 24 hours, compared to a 2000 ml intake; and
his urine output has only been 500 ml in that 24 hours. He is hypokalaemic. He is likely to be ‘saline’ Answers: FTTTT
depleted; and should have 5000 ml of fluid ordered in the next 24 hours to allow for this, with
additional saline for ECF losses and both basal and additional potassium intake. D is thus the best 25810 – A 75-year-old patient becomes shocked on the surgical ward the
combination. night after left nephrectomy. A subclavian CVP line is inserted and the
18292 – A 58-year-old man is admitted for elective surgery for a carcinoma reading is 18 cm H 20. This may be
of the gastric antrum. On admission, it is found that he has been taking 1: due to fluid overload or congestive cardiac failure (CCF)
2: a result of pulmonary embolism
aspirin 100 mg daily for the past five years. What should be done? 3: a temporary elevation following a rapid fluid bolus
A. Proceed to surgery forthwith 4: artefactual due to the line passing upward into the neck
B. Give vitamin k 10 gm intravenously with the premedication
C. Give protamine sulphate with the premedication Answers: TTTT
D. Stop aspirin and delay surgery for one week
E. Halve dose of aspirin and delay surgery for one week
7297 – In the pre-operative assessment it is important to do which of the
Answer: D following?
1: Perform a routine INR, APTT and /or platelet count on all patients
The excess bleeding risk from prolonged aspirin medication will take upwards of a week to reverse; 2: Obtain a personal and family history of bleeding and bruising, particularly with dental extractions
so D is the correct response in this patient preparing for major excisional surgery. and operative procedures; if positive perform platelet count, INR and APTT and complete blood
examination
25850 – You are presented with an obese 50-year-old man due on the 3: Referral to a haematologist for special tests of haemostasis may be indicated even if the INR and
APTT are normal
afternoon list for repair of a right inguinal hernia. He complains of central 4: If the patient has been taking aspirin, perform INR, APTT and platelet count
chest pain which has lasted for one hour and is not subsiding. He has a 5: If the APTT is 43 seconds (normal range 23-35 seconds) surgery should be postponed until the
history of indigestion. He has smoked 20 cigarettes daily for over ten years. cause of the prolonged clotting time is determined
1: you delay the surgery, inform the anaesthetist and request an ECG
2: a normal ECG in this case definitely excludes a myocardial infarction Answers: FTTFT
3: there is a high risk of reinfarction and death if this patient has an acute myocardial infarct, and
surgery proceeds 25815 – Patients at highest cardiac risk during non-cardiac surgery include
4: this risk is eliminated if surgery is performed under local anaesthesia those with
1: myocardial infarction less than six months ago
Answers: TFTF 2: unstable angina
3: severe aortic stenosis
25820 – Concerning commonly prescribed cardiovascular drugs 4: decompensated heart failure
1: antihypertensives should be omitted on the morning of the surgery
2: diuretics can cause hypokalaemia Answers: TTTT
3: diuretics can cause hyperkalaemia
4: Beta-blockers may cause impaired responses to hypovolaemia 18343 – A 37-year-old patient is noted to be difficult to rouse one hour after
Answers: TTFT
a subcutaneous injection of 12.5 mg morphine. Her respiratory rate is 16
breaths/min. Which one of the following statements is most correct?
This question is currently under review by the sub committee. 4 June 2002. This question has been A. No immediate action is required but the amount of morphine she is given next time should be
reviewed and closed. reduced
B. She does not have respiratory depression
7309 – Prior to elective surgery a patient with myeloproliferative disorder is C. She may have respiratory depression and should be given supplemental oxygen and 1000 ?g
naloxone iv prn
found to have a platelet count of 65,000 per cubic millimetre D. She may have respiratory depression and should be given supplemental oxygen and 100 ?g
1: surgery should proceed under cover of platelet concentrates naloxone iv prn
2: surgery should not proceed because the patient may have antibodies to blood platelets E. She should be given supplemental oxygen and nalorphine
3: a bleeding time estimation may be helpful to assess the degree of platelet dysfunction
4: platelet increments assessed by platelet count at say 10 minutes and 24 hours after infusion of Answer: D
blood platelets may be helpful to determine management
5: if platelet increments are known to be satisfactory, platelet concentrates need be given only if
bleeding during surgery is excessive
Respiratory depression from opiate is the most likely diagnosis in this patient with a Sedation Score of 4: deep venous thrombosis
3. She requires supplemental oxygen to treat potential hypoxia; and naloxone intravenously as the
specific morphine antagonist, in a starting dose of 100 micrograms intravenously to observe the initial Answers: TFTT
effect (D).
Answer to come. Pending review. Jan 2003
18337 – A 45-year-patient has been receiving 10 mg morphine
subcutaneously every 2 to 3 hours for pain relief following open reduction 19204 – A 26 year old housewife underwent subtotal adrenalectomy for
and internal fixation of a fractured ankle. He appears to be a little drowsy Cushing's disease 6 years previously and now complains of headache,
and, although he wakes easily when you talk to him, he keeps falling asleep excessively deepening pigmentation, but no loss of weight or appetite. You
during the conversation. His respiratory rate is 14 breaths/min. Which one might reasonably expect
A. normal diurnal variation of plasma cortisol
of the following statements is most correct?
B. normally suppressible plasma ACTH activity
A. He does not have respiratory depression
C. bitemporal hemianopia and erosion of the posterior clinoids
B. The same dose of morphine can be repeated if needed
D. an adenoma developing in the remaining adrenal tissue
C. The next dose of morphine should be decreased and effect on pain relief noted
E. hypotension, hyperkalemia, and low plasma cortisol
D. If he is still complaining of severe pain subsequent doses of morphine can be increased
E. He will not require further morphine for at least 24 hours
Answer: C
Answer: C
Guyton 7th Ed. Chapter: 77Page: 920-921 Ganong 13th Ed. Ch. 20 P. 310
His opioid requirements during this first 24 hours have been relatively high. The patient appears likely
to have respiratory depression from his opiate analgesia; causing drowsiness (Sedation Score of 2) 25835 – A 52-year-old diabetic women develops recurrent septic shock four
without major effect on respiratory rate. Dosage of morphine should be decreased and results of this days following resection of infarcted small intestine. She is transferred to
regimen observed (C). Question to be reviewed at the March 04 meeting re: explanatory text for ITU where she develops acute renal failure which ultimately requires three
answer options (20/02/04).
weeks of haemofiltration. The following therapies might have prevented
25734 – Each of the following is an important component of the daily post- renal failure
1: earlier fluid loading with isotonic (normal) saline
operative plan that should be formulated for surgical patients who are 2: high dose frusemide given as first line treatment of septic shock
progressing satisfactorily, EXCEPT 3: dopamine given as first line treatment of septic shock
A. inspecting drains and considering time of their removal 4: mannitol given as first line treatment of septic shock
B. monitoring nutritional requirements
C. determining the appropriate level of care Answers: TFFF
D. considering likely discharge timing
E. commencing DVT prophylaxis
Answer: E
18243 – In the management of acute postoperative pain, which one of the

following is incorrect?
A. morphine is generally a better analgesic than pethidine
B. the best dosing is on a mg per kg basis
C. subcutaneous administration is less reliable than intramuscular
D. people over the age of 70 years often require a lower dose to achieve comfort
E. intramuscular narcotic should not be given more frequently than every four hours
Answer: E
25867 – The possible side-effects of treating confusion with sedatives

include
1: an increase in the sedation score
2: respiratory alkalosis
3: further confusion
PATHOLOGY MCQ’S
15616 – Apoptosis
CELLULAR PATHOLOGY 1: mediates development of endothelial injury in Gram-negative sepsis
2: results from plasma membrane ‘ionic pump’ failure
22114 – Regarding normal cell division 3: mediates the vascular injury causing ‘fibrinoid’ necrosis
1: activation of a growth factor receptor may stimulate a quiescent cell to divide 4: is a major mechanism of cell injury in graft-versus-host reactions
2: tumour necrosis factor may act as an inhibitor of cell division
3: growth factor receptors are almost always located in the cell nucleus Answers: FFFT
4: cells in the G\bo phase of the cell cycle are not able to undergo further cell division
Graft-versus-host reactions are Tc-lymphocyte-mediated and, as with transplant allograft cellular
Answers: TTFF rejection and some viral infections, cell death is mediated by activation of host endonuclease in target
cells. Ionic pump failure is commonly induced by hypoxia and leads to ionic imbalance and cell
Robbins 5th ed. PAGES: 36-40 swelling. Fibrinoid necrosis is usually an expression of the Arthus reaction. Endothelial injury in Gram-
negative sepsis is possibly IL-1 / TNF-mediated and has (as far as is known) no connection to
15631 – Apoptosis apoptosis!
1: is the major mechanism of cell death in viral hepatitis
2: stimulates an acute inflammatory reaction 15626 – Apoptosis
3: is seen in pancreatic acinar cells due to duct obstruction 1: is a determinant of growth rate of many cancers
4: is mediated through calcium-dependent endonuclease 2: is a major cause of shock in Gram-negative bacteraemia
3: will result from carbon tetrachloride (CCI4) cell poisoning
Answers: TFTT 4: is a form of programmed cell destruction in normal body processes
15621 – Apoptosis Answers: TFFT

1: causes cell death by enzyme-induced membrane injury
2: occurs in prostatic epithelial cells following castration Certain genes involved in growth and genesis of cancer (oncogenes & suppressor genes) have a
3: is the common mechanism of cancer cell death following chemotherapy regulatory role in apoptosis: eg bcl-2 gene (inhibits hormone- and cytokine-induced apoptosis), or
4: results in a predominantly eosinophil leukocyte inflammatory reaction mutation of p53 (normally stimulates apoptosis in radiation-damaged cells). Activation of bcl-2 or loss
of activity of p53 product allows cell survival following radiation which would ordinarily induce
Answers: FTTF apoptotic death in that cell. Apoptosis plays a major role in regulation of normal cell populations.
Mediation of shock in Gram-negative bacteraemia is complicated, multi-factorial and involves many
Apoptotic cell death is mediated through calcium-sensitive endonuclease; the mechanism of mediators involved in acute inflammation; apoptosis appears to have no role. CCl4 cell poisoning is
activation of this reaction differs according to the inducing stimulus. Withdrawal of the appropriate membrane-damaging and when severe enough to cause cell death, induces necrosis.
hormone induces apoptosis in the dependent tissue. Chemotherapy (appropriate to the cancer, of
course) and radiotherapy induce apoptosis in the susceptible tumour. There is usually no 15763 – Apoptosis is cell death which
inflammation induced by apoptotic cell death, unless extensive (eg in massive chemical-induced 1: is caused by activation of endogenous endonuclease
tumour lysis). 2: results in ‘haematoxylin body’ formation in systemic lupus erythematosus (SLE)
3: may result from virus-induced Tc cytotoxic effect
15606 – Apoptosis 4: induces a brisk acute inflammatory reaction
1: has important regulatory influence on normal cell population
2: is the mechanism causing menopausal ovarian follicle atresia Answers: TFTF
3: commonly causes polymorphonuclear leukocyte reaction
4: induces cell death through lysosomal enzyme activation Apoptosis is ‘death by endonuclease’ - activated in quite a variety of ways, including such things as
activation of p53 gene and also the attentions of Tc cells interacting with virion-MHC I complex on the
Answers: TTFF surface of virus-infected cells. The haematoxylin body is produced from coating of a naked (usually
lymphocyte) nucleus by anti-DNA antibody and then its phagocytosis. Inflammation does not follow
Responses 1 and 2 deal with some normal ‘uses’ of apoptotic cell death in normal body economy - apoptosis - it is ‘death without fuss’.
physiological functions, if you like. Apoptosis induces cell death through causing activation of
endogenous endonuclease which causes denaturation of DNA as the lethal action. Endonucleases 21873 – Apoptosis is cell death that
are activated by a number of different mechanisms, depending on the stimulus causing the apoptosis. 1: is commonly seen during hormone-dependent involution
The only reaction which is stimulated by apoptotic cell death is phagocytosis by adjacent cells (any 2: results in haematoxylin body production in systemic lupus (SLE)
cells - epithelial, mesenchymal, macrophages etc) activated by the expression of ‘phagocytosis 3: may result from virus-induced cytotoxic T lymphocyte effect
ligands’ (perhaps opsonins) on the cell membrane component of the cell fragments or ‘apoptotic 4: induces a brisk acute inflammatory response
bodies’.
PATHOLOGY Page 143 of 215
Answer: TFTF Answers: FTFF
Robbins 5th ed. Chapter: 1 Pages: 17-21 The early response to lethal cell damage is acceleration of glycolysis (because of ATP decrease) with
cytoplasmic acidosis. Alkalosis may or may not occur as a late development when cell derangement
15611 – Apoptosis is the major mechanism causing is far advanced. Haemorrhagic infarction is almost the rule with rapid reperfusion (spontaneous eg in
1: hepatocyte death in acute viral hepatitis the brain following embolic lysis, or induced by tPA or streptolysin-induced coronary thrombolysis).
2: cell death due to chemical poisons Many Tc responses result in apoptosis, but brisk TH2 reactions to antigen frequently result in necrosis
3: renal tubule cell death in cell-mediated transplant rejection (eg Mantoux reaction) and TH1 ‘help’ results in maximised immunoglobulin production, facilitating
4: cancer cell death induced by radiotherapy complement activation, chemotaxis, etc. Necrosis always elicits an acute inflammatory reaction, large
or small, in all tissues. Pending review. Jan 2003
Answers: TFTT
15696 – Necrosis
Cell death in many viral infections is due to apoptosis. In the liver, this results in the Councilman body 1: always induces an acute inflammatory reaction
- surrounded by lymphocytes which have induced the cell death. Lymphocyte (Tc)-induced cell death 2: on occasion serves an essentially physiological function
of similar pathogenesis is also the mechanism of cell death in ‘acute’ or cell-mediated transplant 3: usually results in rapid depletion of cytoplasmic glycogen
rejection. Apoptosis is induced by radiation cell injury in normal and cancer cells (also by 4: has its usual common pathway of causation through membrane damage
chemotherapy) providing these injuries are not too vigorous. Although cytotoxic (anticancer) drugs in
therapeutic dosage induce apoptosis, severe chemical injury causes cell necrosis with all the Answers: TFTT
consequent trappings of acute inflammation.
Response 1 is true; there is always acute inflammation - mild or marked - after necrosis of one or
15641 – Apoptosis is the mechanism of cell attrition seen in many cells. Necrosis is always pathological. Interference with cell oxygen supply usually results in
1: menopausal ovarian follicle atrophy rapid glycolysis (with attendant lactate accumulation and acidosis). Whatever cause, evidence
2: salivary gland atrophy caused by duct obstruction strongly favours the current hypothesis that the final pathway leading to cell demise in necrosis-
3: prostatic epithelial cells following castration inducing damage is cell membrane injury - specifically either plasma membrane or mitochondrial
4: lactating breast epithelium during weaning membrane. Breach of lysosomal membranes and acidic activation of enzymes then leads on to what
is essentially autolysis.
Answers: TTTT
15691 – Necrosis
Responses 1, 3 and 4 illustrate apoptosis induced by hormone withdrawal. Pressure atrophy of 1: commonly induces a moderate lymphocytic infiltration
epithelial cells (2) is also apoptosis-induced. Inflammation will not ensue - this is ‘death without 2: is not caused by any of the ‘reactive’ body processes (immune, inflammatory, etc)
drama’. 3: if solid and structureless (‘caseous’), is diagnostic of tuberculosis
4: may form a nidus for deposition of calcium salts
15636 – Important mechanisms which mediate cell death by apoptosis
include Answers: FFFT
1: lysosomal enzyme release and activation
2: denaturation of cell and cytoplasmic organelles Necrosis always induces an acute inflammatory reaction as the first response; the response is never
2+
3: Ca -dependent, endonuclease-induced DNA denaturation lymphocytic (although the cause may be, if Tc-lymphocyte mediated). Immune and acute
4: endogenous activation of oxidising free radicals inflammatory reactions can (and commonly do) result in tissue necrosis. Caseous necrosis is a
species of 'carcass degeneration' found due to many infective diseases (and some non-infective: eg
Answers: FFTF Wegener's granulomatosis). Calcium deposition in necrotic tissues is common (eg comedo
carcinoma, tuberculous foci etc).
Apoptosis and necrosis have major differences, both in pathogenesis and in consequences.
Apoptosis involves a primary attack on the cell DNA, usually by enzyme induction leading to increase 15701 – Necrosis
++
in intracellular Ca and endonuclease activation. Responses 1 and 2 obviously refer to primary 1: can be confidently diagnosed if one observes nuclear pyknosis
membrane injury (necrosis) as does endogenous oxygen free radical induction (cell oxidase 2: usually rapidly causes cytoplasmic acidosis
systems). 3: is pathogenetically different in neurones and myocardial cells
4: is most commonly induced by nuclear DNA damage
15706 – Necrosis
1: causes rapid development of intracellular alkalosis Answers: TTFF
2: is often haemorrhagic if blood flow is rapidly restored following lethal ischaemia (‘reperfusion’)
3: never occurs as a result of T-lymphocyte-mediated reactions Nuclear signs (pyknosis [condensation shrinkage], karyolysis [DNA dissolution] and karyorrhexis
4: in brain tissue does not elicit an acute inflammatory response [nuclear fragmentation]) are the ‘hard’ signs of cell death. Acidosis is induced by failure of aerobic
metabolism, plus activation of glycolytic enzyme systems (particularly with hypoxic cell death).

‘Necrosis is necrosis is necrosis’ (response 3 is FALSE ). DNA damage can cause necrosis, but this
is the common pathogenesis of the onset of apoptosis. Review July 2004 re: option 1. 15646 – Induction of free radicals, with resultant cell injury, occurs as a
result of
23269 – 'Fibrinoid necrosis' is seen in 1: Tc-lymphocyte immune reactions
1: rheumatic fever 2: cyanide poisoning
2: malignant hypertension 3: acute inflammation
3: the Arthus phenomenon 4: carbon tetrachloride (CCI4) poisoning
4: x-ray damage of the skin
Answers: FFTT
Answers: TTTT
Tc lymphocytes induce cell death in (for example) virus-infected cells by inducing apoptosis. Cyanide
Robbins 5th ed. CHAPTER: 3; 4; 2; 1 PAGES: 187; 405; 489; 547-550 denatures the protein enzyme cytochrome oxidase, thus inhibiting the completion of electron transfer
and inhibiting aerobic metabolism. Toxic oxygen radicals are manufactured in phagocytic cells
15162 – Morphological changes which indicate irreversible cell injury following phagocytosis or with 'reverse phagocytosis' when the phagocytosis-inducing signals are
(necrosis) include present, but phagocytosis cannot take place. CCl4 supplies the first 'free radical' and then
1: cytoplasmic fatty change autocatalytically induces ‘secondary’ free radicals.
2: hydropic change
3: nuclear pyknosis 15728 – S:It is accepted that cell membrane damage is a central factor in
4: karyolysis the pathogenesis of irreversible cell injury from many causes
because R:loss of (membrane-based) regulation of cell volume and ionic
Answers: FFTT
gradients, plus cell membrane ultrastructural defects, are found in the
Refer to Robbins, 6th Ed, Ch 1, page 16-17 earliest stages of irreversible injury.
15734 – S:The eventual zone of tissue necrosis caused by arterial Answer: S is true, R is true and a valid explanation of S
occlusion is larger if ischaemic tissue is quickly reperfused
While the precise biochemical explanation (if such there be!) of the cross-over from reversible to
because R:oxygen free radicals, which can cause cell injury, are generated irreversible injury is uncertain, two mechanisms are accepted; loss of cytoplasmic ATP and membrane
locally in ischaemic tissues following rapid reperfusion. damage. However, there is also strong evidence that the major contribution of ATP depletion to the
critical change from reversible to lethal injury is its role in cell membrane damage. At least one major
++
Answer: S is false and R is true effect of the membrane damage is influx of calcium ions (Ca ) into the cell, which activates
phospholipases (further membrane injury), proteases, ATPases and endonucleases.
Ischaemic damage will be maximal following arterial occlusion if the occlusion is not relieved and the
infarct ‘completes’.With reperfusion, tissue injury caused by local production of reactive oxygen 15711, 15722 – Cytoplasmic pH falls in cells lethally injured due to hypoxia
metabolites (in the reperfused tissue) does occur, due to several mechanisms:
• production by polymorphs which infiltrate the site during reperfusion; because activation of lysosomal enzymes during cell necrosis causes the
• incomplete mitochondrial reduction of oxygen; early pH fall in lethal hypoxic cell injury.
• superoxide ion produced by endothelial cells (xanthine oxidase) in the reperfused zone.
So, despite (undoubted) reperfusion damage, the eventual volume of necrosis is significantly reduced
by early reperfusion; this is the rationale for streptokinase/tPA use early in the evolution of myocardial In ischaemic cell damage, the early fall in pH is due to loss of ATP and accumulation of AMP, both of
infarction. which stimulate phosphofructo-kinase and phosphorylase enzyme activity. This results in increased
rate of anaerobic glycolysis causing lactate accumulation which, of course cannot enter the Krebs'
15543 – Reperfusion injury which occurs following restoration of cycle/electron exchange pathway due to oxygen depletion. ATP is generated from creatine phosphate
anaerobically, leading to accumulation of acidic inorganic phosphate. The assertion is correct; the
interrupted blood flow is reason is incorrect and does not explain the well-known early fall in pH caused by ischaemia.
1: intensified by pretreatment with antioxidants Lysosomal enzyme action may contribute to pH alterations (these usually result in pH rise) in the later
2: probably dependent on influx of polymorphonuclear leukocytes to the site and extremely complex stages of cell necrosis.
3: probably brought about by exocytosis of lysosomal enzymes
4: associated with development of large dense granules in mitochondria
15752 – Morphological features indicating cell death include each of the
Answers: FTFT following except
A. nuclear shrinkage and chromatin condensation
Refer to Robbins, 6th Ed, Ch 1, page 8, 11 B. mitochondrial calcium deposition
C. lysosomal membrane disruption 2: alveolar walls of the lung
D. rupture of cell plasma membrane 3: ovarian papillary carcinomas
E. swelling of mitochondria 4: aortic valve
Answer: E Answers: TTFF
Mitochondrial swelling (‘high amplitude swelling’) is a good indicator of very significant cell injury, but The renal tubules and alveolar walls are ‘acid producing’ tissues and are therefore the prime
not of cell death. Calcification of mitochondria is a death knell for the cell and indicates that the candidates for calcium phosphate deposition in states of hypercalcaemia. Other sites are gastric
organelle is non-functional and more significantly, that cell membrane rupture has occurred allowing a mucosa (same explanation) and arterial walls (not only in atheromatous zones - explanation
sufficient change in the electrolyte gradient for mitochondrial calcification to occur. unknown). Calcification in papillary ovarian carcinoma (psammoma bodies) and in (aging and/or
diseased) aortic valves are examples of dystrophic (ie occurring in abnormal tissues) calcification.
21933 – Sublethal hypoxic injury to the cell causes intracellular
1: accumulation of ATP 15676 – Examples of dystrophic calcification include
2: accumulation of lactate 1: renal calcification complicating disseminated breast cancer
3: accumulation of potassium 2: alveolar wall calcification complicating acute leukaemia
4: depletion of glycogen 3: psammoma bodies in papillary thyroid carcinoma
4: calcified comedo breast cancer
Answers: FTFT
Answers: FFTT
Robbins 6th ed. Chapter: 1 Page: 7, 8
Both disseminated breast cancer and acute leukaemia are common causes of rapid bone resorption
13325 – Of the following cellular changes which are possible sequelae of and therefore of hypercalcaemia, thus resulting in metastatic calcification. The psammoma bodies in
thyroid papillary carcinoma are due to calcification in abnormal papillary connective tissue and the
hypoxia, the one which occurs last is
calcification of comedo carcinoma occurs in necrotic cancer - both examples of 'dystrophic' (ie
A. karyolysis
occurring in pathological tissue) calcification. The calcium deposition referred to in responses 1 & 2 is
B. impaired respiration and ATP formation
occurring in normal tissue (acid-producing).
C. imbibition of water
D. impaired synthesis of protein in membrane
E. change from aerobic to anaerobic glycolysis 21938 – Dystrophic calcification occurs in
1: asbestosis
Answer: A 2: Addison's disease
3: papillary carcinoma of thyroid
This question lists a series of degenerative changes in the cell. Options B to E represent a sequence 4: multiple myeloma
of progressively more severe cytoplasmic damage, in which the earliest change is described in Option
B and the most severe abnormality in Option E. If these changes are to occur the cell must be alive. Answer: TFTF
Karyolysis (Option A) is nuclear dissolution and thus characterises cell death. Clearly the cytoplasmic
changes listed in B to E could not occur if the cell were dead. Of the changes listed karyolysis is the Robbins 5th ed. PAGE: 17, 30
last to occur (A true).
15773 – Dystrophic calcification is commonly seen in
22774 – Examples of metastatic calcification include which of the 1: ovarian carcinoma
2: thyroid carcinoma
following?
3: breast carcinoma
1: calcification of uterine fibroids
4: prostate carcinoma
2: nephrocalcinosis
3: calcification of atheromatous plaques
Answers: TTTF
4: calcium encrustation of internal elastic lamina of arteries
Prostatic carcinoma commonly stimulates osteoblastic metastases in bone, but the primary cancer
Answers: FTFT
does not commonly calcify. In all of the remainder, dystrophic calcification is extremely common.
Robbins 5th ed. CHAPTER: 1 PAGE: 31
22779 – Which of the following frequently become/s calcified?
15681 – Examples of what are generally assumed to be purely ‘metastatic’ 1: psammoma bodies
2: Ghon lesion
calcifications classically occur in 3: Mallory hyaline
1: renal tubule cells 4: haematoxylin bodies

9061 – Lipoxygenase
Answers: TTFF 1: is enhanced by the presence of glucocorticoids
2: is active in platelets (thrombocytes)
Robbins 6th ed. Chapters: 2; 9; 19 Pages: 45; 46; 351; 869-871 3: is found in restricted types of body cells
4: catalyses production of prostaglandins (eg. PGI2, TxA2)
15157, 15778 – Calcification within arterial walls may complicate
1: sarcoidosis Answers: FFTF
2: chronic renal failure
3: cancer Robbins, 6th ed, Ch 3. Question to be submitted for review at November committee meetings re:
4: atherosclerosis option 2.
Answers: TTTT 25993 – Potassium is lost from cells into the plasma and thence into the
urine
Refer to Robbins, 6th Ed, Ch 1, page 43. The mechanisms differ, but metastatic calcification occurs
1: in Addison's disease
with all of 1, 2 and 3. Sarcoidosis secretes a vitamin D-like substance. Chronic renal failure leads to
2: following administration of glucose and insulin
major calcium and phosphate imbalance which exceeds solubility levels (often not easily rationalised).
3: when cell protein is broken down (e.g. in trauma, starvation)
Many cancers cause hypercalcaemia (often thought to be mediated by cytokine production or
4: in alkalosis
stimulation by the cancer).
Answer: FFTT
25344 – The acute phase proteins
1: include substances such as C-reactive protein and fibrinogen Robbins 6th ed. Page: 1158 Pending review. Jan 2003
2: tend to rise late in acute infection
3: include amyloid AL component
4: tend to inhibit activation of complement INFLAMMATION
Answers: TFFF 21778 – Prostacyclin (PGI\b2)
1: is synthesised by mast cells
Essential Immunology 9th ed. Pages: 16-18 2: mediates vascular spasm
3: is an antagonist of platelet aggregation
22459 – Pus invariably contains an abundance of 4: production is inhibited by aspirin
1: micro-organisms
2: nucleic acids Answers: FFTT
3: haemosiderin
4: dead neutrophils Robbins 6th ed. Page: 70-71
Answers: FTFT 23699 – Ferritin

1: is located in lysosomes
Robbins 5th ed. PAGE: 53 2: is visible by light microscopy in routine paraffin sections
3: is stored in mononuclear phagocytic cells
15972 – S:Growth induction in normal cells most commonly begins 4: levels in serum reflect iron stores except in inflammation
following cytokine interaction with a specific surface receptor on a target
cell because R:cytokine ‘growth factor’ actions are highly cell type- Answers: TFTT
specific. Robbins 5th ed. PAGE: 28-29; 610
14798 – Cytokines
1: act locally on immediately adjacent cells
According to current knowledge, most cell growth is induced by a cytokine ‘growth factor’ reacting
2: have individual actions in modulating cell function which are specific for each cytokine
with a cell plasma membrane receptor triggering a ‘cascade’ effect which eventuates in DNA
3: bind to non-specific receptors on target cells
synthesis. Cytokines are highly ‘receptor-specific’, but most act on a number of different cell types
4: are involved in stimulating cell growth but not cell differentiation
and most appear to influence a number of different target cell functions such as growth, chemotaxis,
differentiation. Accordingly, they are receptor-specific, but not (usually) cell or function specific.
Answers: TFFF

Refer to Robbins, 6th Ed, Ch 7, page 191-192 15928 – S:Complement activation through the ‘bypass’ mechanism is of
critical importance in early defence against infection by virulent pyogenic
15841 – Actions of the cytokines interleukin-1 (IL-1) and tumour necrosis bacteria not previously encountered because R:some subgroups of
factors (TNF alpha and beta) in defence reactions in the body, include immunoglobulin G (IgG) do not activate complement by the ‘classical’
1: when released systemically, protecting against shock
2: enhancing leukocyte-endothelial adhesion in acute inflammation pathway following reaction with specific (bacterial) antigen.
3: activating fibroblast migration and collagen synthesis
4: influence on the hypothalamus resulting in fever Answer: S is true, R is true but not a valid explanation of S
Answers: FTTT Complement activation is critical to a successful acute inflammatory reaction and to opsonisation of
bacteria in the early phases of acute inflammation in immunologically ‘unprimed’ individuals. This
IL-1/TNF is all pro-inflammation, pro-healing (including healing by fibroplasia). Hence, responses 2, 3 must protect the person until infection is controlled by innate mechanisms or until an immune
and 4 are all True (fibroplasia and collagen synthesis are stimulated). However, the vasoactive and response is generated. Subgroup 4 of IgG does not (after reacting with specific Ag) activate C?; IgG2
prothrombocoagulant effects can be devastating when there is avid systemic release/activation of IL- is a poor C? activator. However, the phenomenon under discussion has nothing to do with subgroup
1/TNF systemically (as, for example in severe bacteraemia [septicaemia in non-Robbins terms]), IgG activation of C? - this important ‘bypass activation’ of C? takes place far earlier than the
when widespread vasodilatation and increased vascular permeability contribute to the syndrome of immunologic production of Ig capable of dealing with this ‘new’ bacterium and is the ‘stopgap’
irreversible shock (and to DIC also). protection, pending Ig release.
23779 – Interleukin-1 (IL-1), secreted by cells of the mononuclear- 25324 – Effects of complement activation may include
1: opsonisation
phagocyte system (MPS), has been demonstrated to have an important 2: lysis of bacteria
direct role in 3: chemotaxis of neutrophils
1: inhibiting proliferation of T helper cells 4: haemolysis
2: endothelial cell activation
3: hypothalamus-mediated fever induction Answers: TTTT
4: enhancement of monocyte/macrophage bactericidal capacity
Roitt 9th Edition PAGE: 12-16 Robbins 5th ed. PAGE: 182-183
Answers: FTTF
25978 – Activators which induce platelet aggregation include
Robbins 5th ed. Chapter: 3 Pages: 71, 174
1: thromboxane A2 (TxA2)
2: nitric oxide
15528 – Complement 3: thrombin
1: may be activated in the absence of immune complexes 4: adenosine triphosphate ATP
2: is important in the formation of granulomas
3: binds to the mast cell membrane and inhibits degranulation Answers: TFTF
4: kills target cells by triggering apoptosis
Robbins 6th Edition Page: 120-122
Answers: TFFF
15923 – The following mediators are synthesised ‘on the spot’ and
Refer to Roitt, 9th Ed, page 11-14
immediately released by injured/ stimulated cells
1: tissue thromboplastin
8621 – Complement may play an important part in each of the following
2: leukotriene B4 (LTB4)
activities EXCEPT 3: Interleukin- 2 (IL-2)
A. increasing vascular permeability 4: C3b opsinic factor
B. phagocytosis of bacteria
C. release of histamine from mast cells Answers: TTTF
D. activation of fibrinolysis
E. destruction (killing) of bacteria Platelets (activated) and endothelial cells (injured), in particular, manufacture tissue thromboplastin.
LTB4 is a product of the lipoxygenase pathway metabolism of arachidonic acid (from cell membrane
Answer: D phospholipid). IL-2 production is particularly the province of CD4+, TH2 cells in B cell ‘help’.
Complement is, of course, a plasma protein system.
Robbins, 6th ed, Ch 3 and 5

15918 – Chemicals activated during/following tissue injury which normally
circulate as inactive plasma precursors include Answers: TTTF
1: platelet activating factor
Robbins 5th Edition Page: 55&68 vs 180, 184&(677)
2: major basic protein
3: C3b opsinic factor
4: plasmin 15881 – Arteriolar dilatation occurring in the early stages of acute
inflammation, is mediated by
Answers: FFTT 1: prostacyclin (PGI2)
2: nitric oxide (NO)
Platelet activating factor is stored in granules within some cells and manufactured ‘on the spot, on 3: leukotriene B4 (LTB4)
demand’ by others. Major basic protein is a product of eosinophil leukocytes - very effective in 4: neutrophil lysosomal enzymes
destroying multicellular parasites (and also bystander host cells). Complement components are, of
course, plasma components (though some components are present in some cells also). Plasmin is Answers: TTFF
another ‘cascade’ enzyme systems - contact activated.
Prostacyclin and nitric oxide are both powerful vasodilating agents, both produced by intact
15994 – Fibroblasts proliferate and migrate during the healing process in endothelium. Leukotriene B4 is produced from arachidonic acid through the lipoxygenase pathway; it
response to the direct action of has powerful chemotactic effects, but does not directly influence either vascular flow or permeability.
Neutrophil lysosomal enzymes appear to have no effect on vasodilatation and, in any case, are not
1: cytokines
active in the zone until acute inflammation is well established.
2: expression of adhesion molecules on endothelial cells
3: leukotrienes
4: platelet activating factor (PAF) 15966 – S:Lysozyme (n-acetyl muramidase) is an effective antibacterial
because R:lysozyme enzymatically destroys specific components of
Answers: TFFF bacterial cell walls.
Fibroblast proliferation and differentiation appears to be largely under the control of growth-promoting Answer: S is true, R is true and a valid explanation of S
and growth-controlling cytokines. The influence of other factors such as extracellular matrix products
(particularly fibronectin, laminin, etc and fibrino-peptides), although persuasive, is still equivocal. The Muramic acid-N acetyl glucosamine bond is found in the cell wall of all bacteria. Lysozyme specifically
endothelial adhesion molecules include members of the immunoglobulin family of proteins - they have hydrolyses the bond, thus damaging the bacterial cell wall.
no known influence on fibroblast ( or other ECM cell ) activity and the same goes for the two cell
membrane phospholipid derivatives LT and PAF.
23274 – The monocyte/macrophage system of cells subserves
1: processing and presentation of antigens
15886 – Chemical mediators which increase permeability of venules during 2: control of fibroblast proliferation
the acute inflammatory reaction include 3: induction of neutrophil adhesion molecules on endothelial cells
1: platelet activating factor (PAF) 4: secretion of endogenous pyrogen, IL-1
2: gamma interferon
3: bradykinin Answers: TTTT
4: histamine
Robbins 5th ed. CHAPTER: 2 PAGES: 701; 76
Answers: TFTT
23974 – The mononuclear cells in an acute inflammatory exudate
Platelet activating factor is derived from cell membrane phospholipid by phospholipase (PLA2) action, 1: morphologically resemble lymphocytes
but not via pathways of prostaglandin or HETE/leukotriene metabolism. In low concentrations, it is an 2: are derived from stem cells in the germinal centres of lymph nodes
extremely potent inducer of vasodilator and permeability, as well as other aspects of the inflammatory 3: undergo chemotaxis in response to IgE antibody
process. Bradykinin and histamine are also both 'classic' permeability factors. Gamma-interferon has 4: are mainly transformed blood monocytes
no effect on endothelial cells (other cytokines may act indirectly through endothelium-activation in
pavementing, thus aiding ‘leukocyte-mediated’ permeability - but not directly). Answers: FFFT
25980 – Increase in vascular permeability may account for the oedema in Robbins 5th ed. Chapter: 5 Pages: 59; 74; 76
1: acute anaphylaxis
2: adult respiratory distress syndrome 15856 – Monocyte (macrophage) chemotaxis into inflammatory foci is
3: serum sickness stimulated by
4: lymphoedema
1: histamine
2: cytokines oxygen-derived free radicals only influence vascular actions through direct endothelial cell damage).
3: activated complement products C5a, on the other hand, is strongly chemotactic.
4: activated T helper lymphocyte (TH1) secretions
15871 – Chemicals which have a direct chemotactic effect on neutrophil
Answers: FTTT leukocytes include
1: leukotriene (LTB4)
The amines which are important in acute inflammation are vasoactive, but not chemotactic. Cytokines 2: bradykinin
(IL-8 family) and complement products (C5a) are chemotactic for PMN and monocytes. TH 1 3: prostacyclin (PGI2)
secretions include the ‘lymphokines’ of which MCF is a prominent member! 4: nitric oxide (NO)
15795 – Intact endothelium secretes Answers: TFFF

1: thrombomodulin
2: adenosine diphosphate (ADP) Leukotriene is the most potent chemotactic agent known. Others include C5a, bacterial products and
3: an inhibitor of plasminogen activation (tPA inhibitor) cytokines ( IL-8 ‘family’). Products of the cyclo-oxygenase arm of arachidonic acid metabolism have
no chemotactic action. Bradykinin causes increased vascular permeability, while NO mediates
4: prostacyclin (PGI2) vasodilatation and tissue damage.
Answers: TFFT 23279 – Mechanisms of adhesions between leucocytes and endothelium

include
It is useful to assume that all of the actions of the intact endothelium are anticoagulant and antiplatelet
1: increased binding activity of integrins
(the endothelium also secretes a plasminogen activator (tPA), inducing fibrinolysis, nitric oxide, a
2: P-selectin/ICAM-1 (intercellular adhesion molecule-1)interaction in low-flow conditions
powerful vasodilator, as well as heparin-like glycosaminoglycans etc) Materials secreted by the
3: induction of endothelial adhesion molecules
injured endothelium are procoagulant (eg vWF secretion) and proplatelet (eg ‘switch-off’ of PGI2 and 4: redistribution of P-selectin by histamine stimulation
tPA secretion), as well as ‘thromboplastic’ material. Review July 2004 re: entire question.
Answers: TFTT
15897 – The most potent chemotactic agent for granulocytes is
A. complement activation product (C5a) Robbins 6th ed. Chapter: 3 Page: 57-59
B. thromboxane A2 (Tx-A2)
C. high molecular weight kininogen (HMWK) 15876 – Leukocyte pavementing in acute inflammation is the result of the
D. leukotriene (LTB4)
E. fibronectin direct action of
1: bradykinin
Answer: D 2: ligand action of thromboxane-A2 (Tx-A2)
3: adhesion molecules expressed on endothelial cells
4: adhesion molecules expressed on leukocytes
The two chemoattractants for granulocytes shown are C5a and LTB4. Of the two, LTB4 is generally
stated to be the most powerful naturally occurring in inflammation. HMWK is an intermediate Answers: FFTT
metabolite for the various ‘cascade’ enzyme systems active in inflammation and coagulation systems.
Fibronectin is certainly chemotactic for fibroblasts (and perhaps also endothelial cells) in healing and Direct causes of the phenomena of leukocyte adhesion to endothelium in zones of acute inflammation
possibly also has a role in chemotaxis for some cancers during the invasive process. Question being are the interactive adhesion molecules expressed on the surfaces of leukocytes and endothelial cells.
reviewed at March 04 meeting for further referencing (20/02/04). These include redistribution of P-selectin and increased activity of integrins in leukocytes, together
with cytokine-induced induction of endothelial adhesion molecules (these are of the immunoglobulin
15851 – Neutrophil chemotaxis is induced by family). Expression of these interactive adhesion molecules is stimulated variously by histamine,
1: prostacyclin (PGI2) thrombin, IL-1 and chemotactic agents. Bradykinin and Tx-A>Sub>2 have no influence, either direct
or indirect.
2: bradykinin
This question is currently under review by the Pathology Sub Committee. 28 June 2002.
3: activated complement products
Pathology Sub Committee comments: This question relates to molecules having a direct influence on
4: oxygen-derived free radicals
leukocyte pavementing. 1. It is resonable to assess mediators directly causing pavementing (ie.
leukocyte - endothelial adhesion) as the interactive adhesion molecules (selectins, integrins, ICAM-1,
Answers: FFTF
VCAM-1) on endothelial cells and leukocytes; 2. Mediators indirectly influencing pavementing are
those which induce expression of those adhesion molecules on the surfaces of endothelial cells (IL-1,
Prostacyclin and other cyclo-oxygenase pathway arachidonic acid derivatives are vasoactive, but not
TNF) and of leukocytes (C5a at least); 3. Anything even more remote from direct indluence (including
chemotactic. The same goes for bradykinin and the free radicals (NO as a vasodilator - probably the
bradykinin) is surely highly speculative as having any effect. Bradykinin certainly has no direct effect

(ie. as an adhesion molecule per se) or even at the next level (ie influencing the expression of those E. does not necessarily ensure death of the bacteria
adhesion molecules).
This question has been reviewed. Answer: A
15908 – Leukocyte pavementing in acute inflammation occurs because of Robbins 5th ed. CHAPTER: 6 PAGES: 62-64
the direct effect of
15846 – Free radical derivatives, produced by phagocytes during acute
1: ligand action of LTB4 inflammation, kill bacteria and damage host tissues. They include
2: complement activation by-product (C5a) 1: n-acetyl muramidase (lysozyme)
3: adhesion molecules on endothelial cells 2: hypochlorite ion
4: adhesion molecules of neutrophil leukocytes 3: hydrogen peroxide
4: major basic protein
Answers: FFTT
Answers: FTTF
A number of chemical mediators of the acute inflammatory reaction influence the expression of
adhesion molecules on both endothelial cells (these adhesion molecules are generally members of Oxygen-derived free radicals and their metabolic derivatives may be released extracellularly from
the immunoglobulin superfamily) and granulocytes (these are generally integrins). However they may leukocytes by a number of stimuli. Their action is dependent on the activation of the NADPH oxidative
be influenced to be expressed, it is the adhesion molecules themselves which are responsible for the system and the generation of superoxide (?). This, in turn, is converted to H 2O 2, OH-, NO derivatives
adhesion (and therefore, for the pavementing). -
and, through the myeloperoxidase-halide system, to OHCl . Lysozyme and major basic protein are
Pending Review Jan 2004 lysosomal enzymes and not free radicals.
8697 – The agents involved in bacterial destruction by neutrophils include 21768 – Cellular metabolic actions which prevent or lessen damage caused
1: lysozyme
2: defensins
by activated oxygen species (e.g. superoxide, hydroxyl) include
3: lactoferrin 1: catalase reaction
4: bacterial permeability increasing protein 2: interaction with iron
3: interaction with glutathione peroxidase
Answers: TTTT 4: oxidase (e.g. xanthine oxidase) reactions
Robbins, 6th ed, Ch 3 Answers: TFTF
Robbins 6th ed. Chapter: 1 Page: 12-14

15891 – The most powerful action of granulocytes in killing pyogenic
bacteria is 15651 – Induction of free radicals, with resultant cell injury, occurs as a
A. n-acetyl muramindase (lysozyme)
B. peroxide-myeloperoxidase-halide system
result of
C. lactoferrin 1: cysteine and methionine-containing ‘remedies’
D. superoxide hydroxyl radical system 2: paracetamol (acetaminophen) poisoning
E. major basic protein 3: prolonged positive pressure ventilation at FIO2 of 1.0
4: immune complex-induced PMN chemotaxis in acute glomerulonephritis
Answer: B
Answers: FTTT
The production of hypochlorite (OHCl) by this enzyme system results in the most powerful bactericidal
effect against pygenic bacteria. MPO-deficient leukocytes are capable of killing bacteria (albeit more Cysteine and methionine are antioxidant amino acids and are therefore protective. Paracetamol is
slowly), by virtue of the other oxygen-dependent enzyme systems. Individuals who cannot generate metabolised to form a toxic ‘free radical’ product by the liver. This is usually detoxified by reduced
the superoxide radical suffer a major disorder of bacterial killing, chronic granulomatous disease glutathione (GSH), but the system may be overwhelmed with paracetamol overdose. Normal oxygen
(usually an X-linked disorder). partial pressure intracellularly result in formation of reactive oxygen species - rapidly detoxified; this
formation is intensified (mass action) by raising the FIO 2 which can cause tissue damage (to lung
pneumocytes and endothelial cells in particular - ARDS). PMN are direct pathogenetic suppliers of the
18826 – All of the following statements regarding phagocytosis of bacteria damage (via exocytosis - toxic oxygen radicals and enzymes) in acute glomerulonephritis.
by granulocytes are true EXCEPT that it
A. requires prior opsonisation of the organism 15656 – Protection from free radical-induced cell injury is afforded by
B. results in a phagocytic vacuole which will fuse with lysosome(s) 1: cytochrome enzyme system
C. results in degranulation of the granulocyte 2: superoxide dismutase enzyme system
D. frequently requires production of hydrogen peroxide to cause bacterial destruction
3: catalase enzyme system 24219 – Opsonins which directly enhance phagocytic engulfment of
4: glycolytic (Embden-Meyerhof) pathway enzymes bacteria include
1: immunoglobulin G subtypes
Answers: FTTF
2: collectins
3: a derivative of complement component C3
Glycolytic and cytochrome enzyme systems are concerned with glycolysis (E-M with anaerobic
4: intercellular adhesion molecule (ICAM)
glycolysis and cytochrome system with electron transfer) - they have no protective effect from or
detoxification action of reactive oxygen (or other ‘free radical’) species. Superoxide dismutase
Answers: TTTF
‘dismutes’ superoxide (?)!; catalase metabolises H2O 2 to water and oxygen - both are detoxicants and
are therefore protective.
Robbins 6th ed. Chapter: 3 Page: 59; 62
15866 – Phagocytic activity of neutrophil leukocytes is stimulated when the 15558 – During healing of acute inflammation by resolution, the exudate is
bacteria are opsonised by 1: removed via lymphatics
1: alpha-interferon 2: replaced by reticulin
2: IL-8 3: phagocytosed by macrophages
3: immunoglobulin 4: replaced by granulation tissue
4: C3b and fibronectin
Answers: TFTF
Answers: FFTT
Refer to Robbins, 6th Ed, Ch 3, page 78
The two major opsonins are the Fc fragment of immunoglobulin G and C3b, the so-called ‘opsonic
fragment of C3’. The corresponding phagocyte receptors are FcgR which recognises the Fc fragment
15836 – Resolution of inflammation, with regeneration, leads to restoration
of IgG, and complement receptors CR 1, 2 and 3, which interact with C3b and C3bi. CR 3 also binds
laminin and fibronectin; it is responsible for non-opsonic binding of some bacteria. The cytokines have of normal structure and function following
no opsonic activity, although some may 'activate' phagocytes. IL-8 (‘family’) is chemotactic 1: pneumococcal pneumonia
2: uncomplicated healing of a sutured surgical incision
3: pulmonary infarct
25339 – Mechanisms commonly used by phagocytic cells (neutrophils and
4: paracetamol-induced hepatic necrosis
macrophages) to kill micro-organisms include
1: formation of nitric oxide Answers: TFFT
2: production of superoxide radicals
3: production of the complement C1q In both pneumococcal pneumonia and paracetamol poisoning, although there may be cell injury and
4: production of hydroxyl radicals necrosis (of pneumocytes and hepatocytes respectively), the basement membrane is not damaged
and remains as a framework along which regenerating cells can migrate. Despite careful suturing of a
Answers: TTFT skin incision, there is always some scarring and dermal appendages do not regenerate. Basement
membrane does not survive pulmonary infarction - scarring results (although, interestingly, elastic
Essential Immunology 9th ed. Pages: 8-10 tissue survives).
15903 – Opsonin-induced phagocytosis of bacteria is stimulated by 16010 – Resolution of inflammation and regeneration lead to complete
1: simultaneous binding of C3b and fibronectin to leukocyte receptor restoration of normal structure and function following healing of
2: interleukin (IL-6) receptor binding
1: renal papillary necrosis
3: gamma-interferon
2: acute viral hepatitis
4: receptor binding to IgFc
3: hypovolaemic acute renal tubular necrosis
4: liver abscess
Answers: TFFT
Answers: FTTF
C3b requires simultaneous binding with fibronectin for effective opsonin action. Fc receptors are
present on granulocytes and macrophages - this ligand action of the Fc fragment of Ig is, of course,
Renal papillary necrosis and liver abscess both result in total destruction of the ‘framework’ of the
activated by the binding of the Fab fragment with antigen. Phagocytosis is most avid when both C3b
tissue involved - healing by scarring is the best possible outcome here. In acute viral hepatitis
and Fc ligands bind simultaneously to their respective receptors on the phagocyte; clearing of
(apoptotic cell death, not necrosis), cells regenerate along the intact basement membrane framework
bacteria is enormously enhanced by the presence of both.
as they also do following acute renal tubular necrosis. Although oliguric renal failure caused by
hypovolaemic shock is a hazardous disorder, when recovery occurs without complications (eg
infection etc), eventual complete restoration of ‘pre-injury’ renal structure and function occurs.

2: contain contractile cytoplasmic filaments
15983 – Granulomatous inflammation may be composed of 3: secrete collagen
1: a compact mass of immature granulation tissue 4: develop from fibroblast progenitor cells
2: a compact mass of lymphocytes and plasma cells
3: a mass of macrophages and giant cells Answers: TTTT
4: a mass of epithelioid cells and giant cells
Myofibroblasts are important cells in wound healing and variants of this (chronic inflammation, tumour
Answer: FFTT fibroplasia etc). In all of these , ‘wound contraction’ leads to a scar which, in uncomplicated healing, is
smaller than the original tissue it replaces; in other circumstances, this leads to such problems as
The clear distinction between epithelioid cells and macrophages and the clear implications of their bowel obstruction in cancer, Crohn disease etc. All of the suggested functions and the cell origin are
different morphologies and functions is poorly dealt with in Robbins. Nevertheless, at least the book true. ‘Wound contraction’ is common and important - that message does not come through clearly in
makes it clear that there are both innate (non-immune - characterised by macrophages, ie. Robbins, but the gist of the phenomenon and its importance is clear - where there is granulation
phagocytic) and immune (characterised by epithelioid cells - which are not phagocytic, but are tissue, there is wound contraction, occurring early in connective tissue healing.
synthetic and secretory and probably also fulfil a ‘barrier’ function before fibrosis). Granulomas are not
composed of granulation tissue, not primarily made up of immunocytes (lymphocytes and plasma 23049 – Keloid formation
cells), though both may be present. 1: contains abundant amounts of dense collagen
2: is commoner in males than in females
9066 – Focal granulomatous lesions resembling those of sarcoidosis are 3: is commoner in Negroes than in white races
characteristic of 4: usually shows premalignant changes
1: primary syphilis
Answers: TFTF
2: berylliosis
3: Echinococcus granulosus infestation
Robbins 5th ed. Page: 90
4: the reaction to yersiniae
Answer: FTFF
INFECTION
Robbins, 6th ed, Ch 3; Ch 9 and Ch 16
25595 – In relation to the toxins of Staphylococcus aureus
15167 – Granuloma formation is characteristic of 1: the enterotoxins are superantigens
1: Crohn's disease 2: most are cell wall associated
2: primary biliary cirrhosis 3: the systemic effects of toxic shock syndrome toxin are mediated by the release of cytokines
3: sarcoidosis 4: none have haemolytic activity
4: cat scratch lymphadenitis
Answers: TFTF
Answers: TTTT
Refer to Robbins, 6th Ed, page 83, 878, 817
13992 – Virulence factors found associated with Staphylococcus aureus
21783 – Classical immune (epitheloid) granulomas are characteristically
include all of the following except
seen in A. the enzyme coagulase
1: lepromatous leprosy B. surface receptors that enable them to bind to host cells
2: mycobacterial infections in AIDS patients C. enterotoxins
3: Cryptococcus neoformans infections D. a variety of lytic enzymes (lysins)
4: sarcoidosis E. lipid A endotoxin
Answers: FFFT Answer: E
Robbins 6th ed. Chapter: 3; 7; 9 Page: 83-84; 248; 351; 386. Question to be reviewed at March 04 Refer to Textbook of Surgery, Robbins, 6th Ed, Ch 9, page 365
meeting re: option C (23/02/04)
22124 – Pneumonia caused by Streptococcus pneumonia
15999 – Myofibroblasts in granulation tissue 1: commonly causes residual fibrosis in the affected area of lung
1: cause wound contraction 2: is uniformly responsive to penicillin therapy

3: results in blood shunting through affected lung 21788 – Gram negative bacterial lipopolysaccharide complexes, when
4: is usually a community acquired infection injected intravenously
1: produce arteriolar dilatation
Answer: FFTT
2: activate complement through the alternate pathway
3: injure endothelial cell membranes
Robbins 5th ed. Chapter: 15 Pages: 694-696
4: inhibit intrinsic pathways of coagulation
15949 – S:Pneumococcal pneumonia causes inflammation without Answers: TTTF
significant lung necrosis because R:pneumococci induce chemotaxis, but
elaborate no major toxins. Robbins 6th ed. Page: 134-136
Answer: S is true, R is true and a valid explanation of S 12991 – In patients with Gram-negative septicaemia, shock is commonly
caused by
There is some necrosis of pneumocytes - probably more from the attentions of leukocyte enzymes 1: bacterial endotoxins
and oxidising free radicals than from the pneumococci. However, there is no tissue necrosis as we 2: bacterial exotoxins
mean the term (eg staphylococcal abscess; infarct), with destruction of alveolar wall lattice-work. 3: bacterial lipopolysaccharide
Therefore, regeneration of pneumocytes and resolution of inflammation leads to restoration of 4: products of complement activation
normality. Pneumococci produce a-haemolysis ie there is some tissue damage possible, but this is
negligible - hence ??elaborate no major toxins?. Answers: TFTT
8707 – The bacterium Enterococcus faecalis Endotoxins are a feature of Gram negative bacteria, and are associated with the lipopolysaccharide
1: is an increasingly important nosocomial pathogen portion, in particular the lipid A (glycolipid), of the outer membrane of the cell wall. Liberation of these
2: is susceptible to cephalosporins endotoxins from dying bacteria is responsible for the classical 'shock' seen in Gram negative
3: reveals increasing resistance to vancomycin septicaemia (A and C true); exotoxins are only rarely of significance in Gram negative bacteria (eg
4: should be considered in intra-abdominal sepsis originating from the upper gastrointestinal tract exotoxin A of Pseudomonas aeruginosa) and have more specific actions (B false). Pathophysiological
features associated with the liberation of endotoxin include complement activation (D true), fever, and
Answer: TFTT irreversible collapse of the microvascular circulation.
Smith & Payne, Aust NZJ, Surgery 1994; Smith & Payne, Integrated Basic Surgical Sciences, Ch 14813 – The bowel commensal Escherichia coli is a major causative agent
37.2 of
1: haemorrhagic colitis
11672, 25984 – Cell walls of Gram-negative bacteria 2: bacteraemic episodes in the early stages of peritonitis
1: have proteinaceous pores (porins) in the outer membrane 3: vaginitis
2: are a useful taxonomic aid 4: osteomyelitis in IV drug abusers
3: contain endotoxin in the form of lipopolysaccharide
4: may act as a barrier to the entry of antimicrobials Answers: TTFT
Answers: TTTT Refer to Robbins, 6th Ed, Ch 18, 24, page 807-809, 1039, 793, 1230. Review July 2004 re: option 4.
J.M.B. Smith. Although thinner than the cell wall of Gram-positive bacteria, the cell wall of Gram-
25579 – Pseudomonas aeruginosa is
negatives is more complex and is responsible for many of the intrinsic properties of Gram-negatives.
1: one of the few Gram negatives to elaborate a significant exotoxin
This applies especially to the so-called outer membrane (OM) - a lipid bilayer external to the
2: widely distributed in the hospital environment
peptidoglycan structural backbone. Most antibiotics are not lipid soluble and have difficulty diffusing
3: readily contained by normal host defences
passively through this membrane; in order to penetrate they must disrupt the layer (eg cationic
4: an important pathogen in burns units
compounds such as gentamicin), be carried actively through the membrane, or pass through it via the
water filled porin channels that bisect the membrane (eg water soluble antibiotics of sufficiently small
Answers: TTTT
molecular size). Extruding from the surface of the OM is the polysaccharide 'tail' of the
lipopolysaccharide (LPS). The lipid A component of LPS is the classical endotoxin of Gram-negatives
Robbins 5th ed. Pages: 352-353
(although endotoxin and LPS are often used synonymously), while the polysaccharide portion is used
in the taxonomy of many Gram-negatives (O or somatic antigen).
25584 – Anaerobic Gram negative bacteria
1: are important pathogens following faecal leakage during colonic surgery
2: are important pathogens in lung abscesses following aspiration

3: are frequently associated with more oxygen tolerant microbes in lesions 11682, 25479 – Exotoxins are produced by
4: include Clostridium perfringens 1: Corynebacterium diphtheria
2: Clostridium difficile
Answers: TTTF 3: Staphylococcus aureus
4: Pseudomonas aeruginosa
Answers: TTTT
25564 – The obligate anaerobe Bacteroides fragilis
1: is seldom resistant to clindamycin Robbins 5th ed. Pages: 318; 319; 335-340 Microbiology Update: PMP8. Bacteria classically
2: has a capsule which is significant in abscess formation elaborate two types of toxins - exotoxins which are proteinaceous high molecular weight, antigenic
3: is the most common anaerobe associated with intra-abdominal sepsis compounds actively secreted by growing bacterial cells and which can have a variety of functions (eg
4: is the only gut anaerobe associated with intra-abdominal abscesses tetanus toxin, staphylococcal enterotoxins), and endotoxins which are the lipid A portion of the outer
membrane lipopolysaccharide component of the Gram-negative cell wall. Endotoxins are highly
Answers: FTTF inflammatory compounds and initiate a series of events (starting with activation of excessive amounts
of cytokines such as tumour necrosis factor with subsequent vascular endothelial damage) leading to
Robbins 5th ed. Page: 339-340 Aust. NZ Journal Surgery the classic endotoxic or septic shock syndrome (NB a similar series of events can be induced by
some toxins from Gram-positive bacteria). As Gram-positives do not posses an outer membrane in
8717 – With intra-abdominal abscesses involving Bacteroides fragilis the cell wall structure, endotoxins are limited to Gram-negative bacteria (eg E. coli, pseudomonads).
1: surgical intervention is required wherever possible In comparison, few Gram-negatives elaborate exotoxins which are a feature of Gram-positive bacteria
2: the presence of the microbes polysaccharide capsule is an important virulence factor (eg staphylococci, clostridia). Pseudomonas aeruginosa is one of the few Gram-negatives to excrete
3: metronidazole alone is satisfactory cover during any attempted needle aspiration process a significant exotoxin.
4: other microbes are unlikely to be involved
22063 – Lesions in which negligible polymorph infiltration accompanies
Answers: TTFF extensive tissue injury include
1: streptococcal myositis
Smith & Payne, Aust, NZ Journal 1994; Smith & Payne, Integrated Basic Surgical Sciences, Ch 37.2 2: clostridial myositis
3: Cryptococcus neoformans meningitis
12986 – Bacterial exotoxins 4: tuberculosis lymphadenitis
1: sometimes produce severe local and distant effects
2: are generally more toxic than endotoxins Answers: FTTT
3: often stimulate the production of antibodies which provide a good measure of immunity
4: are characteristically complex lipopolysaccharide molecules Robbins 6th ed. CHAPTER: 9 Pages: 367; 369; 379
Answers: TTTF 10383, 15177 – Necrotising fasciitis

1: commonly involves the deep underlying muscle
Exotoxins may produce severe local effects, as in gas gangrene, and serious effects at sites distant 2: can be monomicrobial in aetiology
from the portal of entry, as in tetanus (A true). Bacterial exotoxins are classically proteinaceous in 3: has diabetes mellitus as one of the common predisposing factors
nature (D false), as compared to endotoxins which are lipopolysaccharide. They are highly 4: always involves obligate anaerobes
immunogenic (C true). They are secreted during the growth of many Gram positive bacteria (eg
staphylococci, streptococci, corynebacteria, clostridia), unlike endotoxins which are liberated from the Answers: FTTF
cell wall of Gram negative bacteria following lysis. As a general rule, exotoxins are more potent than
endotoxins (B true) and tend to have a more specific site of action. Refer to Smith & Payne, ANZ Journal of Surgery 1994. Necrotising fasciitis involves the areolar
tissue layers under the skin [really the fibrous tissue overlying muscles (superficial) and structures
25484 – Bacterial exotoxins differ from endotoxins in being such as nerves and blood vessels (deep fascia)]. Where muscle is involved, the term myositis is
1: lipopolysaccharide in nature applicable; in contrast to fasciitis, the primary location of infection is skeletal muscle. Although group
2: convertible into toxoids A streptococcal (Streptococcus pyogenes) necrotising fasciitis has received recent publicity world
3: predominantly heat stable wide (‘the flesh eating bug’), this bacterium is not the dominant cause of necrotising fasciitis. The
4: cell wall associated microbial aetiology is usually polymicrobial, involving at least one obligate anaerobe (eg
peptostreptococci) in combination with one or more facultative anaerobes (eg Gram-negative enteric
Answers: FTFT bacilli, Staphylococcus aureus, St. pyogenes) or aerobic (eg Pseudomonas aeruginosa) species.
S.aureus and St. pyogenes appear more commonly when infections involve the extremities or head
Update Mp PAGE: 8 IBSS, Ch 37.2, p782-793. Resolved Nov 2003 and neck region. Monomicrobial infections (eg with S. aureus) occurs in only about 10% of cases.
Predisposing associations include diabetes and peripheral vascular disease, trauma, alcoholism,

surgery and the use of anti-inflammatory agents (eg NSAIDs). Treatment strategies include excision Synergistic gangrene occurs in debilitated patients and has a significant mortality of around 10% (C).
(with a margin) of involved tissues, and appropriate antimicrobial therapy. In light of the known causal Crepitus is not usually an early sign and if present, does not confirm clostridial infection. Hyperbaric
agents, empiric therapy with the likes of cefuroxime (anti-staphylococcal and streptococcal) plus oxygen therapy is adjunctive to surgery, and Clostridium perfringens is not the common organism.
ciprofloxacin (anti-Gram negative bacilli) plus clindamycin or metronidazole (for anaerobes) makes
sense. On a pharmacokinetic bases, penicillin and flucloxacillin would appear inferior to the likes of 12674 – S:Synergistic gangrene responds dramatically to high doses of
cefuroxime for staphylococci and streptococci. Following microbiological investigations, more specific
penicillin because R:Synergistic gangrene is typically due to clostridial
therapy can be initiated.
infection
25589 – Which one of the following statements does NOT apply to gas
Answer: both S and R are false
gangrene (clostridial myonecrosis)
A. disease is exacerbated by the presence of foreign bodies Synergistic bacterial gangrene is caused by anaerobic streptococci in association with other bacteria,
B. is associated with marked oedema and necrosis of involved muscle eg Proteus, pseudomonads, Staphylococcus aureus, beta-haemolytic streptococci, anaerobes (R
C. lesions reveal marked infiltration by neutrophils false). The condition presents with swelling and pain followed by necrosis of local skin and
D. blood may appear completely haemolysed in the terminal stages subcutaneous tissues. Wide excision and drainage are mandatory; antibiotic therapy is only
E. gas bubbles appear early in the gangrenous tissues complementary (S false).
Answer: C 12969 – Principles to be followed in the treatment of tetanus include

1: surgical excision of the wound which is left open
2: administration of penicillin intravenously
3: administration of human hyperimmune globulin intramuscularly
25605 – Clostridial myonecrosis 4: sedation of the patient and respiratory support
1: is most commonly caused by Clostridium septicum
2: commonly involves tissues with an impaired blood supply Answers: TTTT
3: has a mortality rate less than 5%
4: apart from debridement, requires the use of high dose gentamicin therapy Tetanus is attributed to the anaerobic spore former, Clostridium tetani. Spores in the environment
enter cutaneous wounds, and if conditions for germination and growth of the microbe occur - eg
Answers: FTFF necrotic devitalised tissue, anaerobic conditions - the tetanus exotoxin is produced and liberated. This
is a neurotoxin which has been referred to as tetanospasmin. Prevention of such infections, which
Aust. N.Z.J. Surgery Paper Textbook Surgery - Clunie 97 may follow apparently minor skin trauma, therefore, relies on preventing conditions suitable for the
growth of the anaerobe. Dead tissue should be excised from wounds which should be left open, ie
25509 – Clostridium perfringens aerobic (A true). Treatment consists of high doses of penicillin (B true) and the use of hyperimmune
1: is an obligate aerobe globulin (C true) in an attempt to convey some degree of passive immunity to the toxin. The main
2: relies on the presence of a capsule for its virulence effect of the toxin is muscle hyperirritability. The toxin blocks inhibitory neurones in the CNS so that
3: is susceptible to metronidazole stimulatory signals remain unopposed and muscles, including those in the jaw and respiratory
4: is an important microbe to be considered when formulating antibiotic prophylaxis for lower limb system, are constantly stimulated (D true). NB. IV for clinical (active) desease, but in
amputation prophylaxis/prevention give IM (C true). This question has been reviewed and all answers are
corrected as stated. 28 August 2002
Answers: FFTT
15960 – In viral hepatitis A, the main clinical effects are due to damage to
Robbins 5th ed. Antibiotic Supplement
hepatocytes, caused by
A. competitive cell receptor blockade by viral capsid
18304 – Which one of the following statements applies most correctly to B. subversion of cell metabolism to virus production
synergistic gangrene (chronic progressive bacterial gangrene)? C. inactivation of cyclic-AMP by lymphokines
A. Crepitus is an early physical sign D. lymphocyte-mediated cytolysis
B. The presence of crepitus confirms clostridial infection E. gamma-interferon production by lymphocytes
C. The overall mortality rate is about 10%
D. Hyperbaric oxygen is the treatment of choice Answer: D
E. Clostridium perfringens is usually involved in the process
The clinical manifestations of hepatitis (A, B, C, etc) are insignificant during the prodromal phase
Answers: C while an immune response is being mounted. Following the immune reaction, the main event is the
Tc-mediated destruction of infected hepatocytes (virus-MHC-I/Tc interaction). There may also be
some effects of immune complex deposition with the usual common manifestations in skin, joints etc.

as the free virus gets ‘mopped up’ by the immunoglobulin which is manufactured by plasma cells, 12981 – Hydatid disease in Australasia
synchronous with T cell production. 1: is a zoonosis
2: follows ingestion of ova
11763 – In relation to hepatitis B virus (HBV) infection 3: is acquired from dogs
1: the presence of antibody to the HBV surface antigen, HBsAg, is considered to represent an 4: cannot be effectively treated chemotherapeutically
immune state
2: antibody to HBsAg (anti-HBs) is formed following successful vaccination with Hepatitis B vaccine Answers: TTTT
3: a positive test for HBs Ag indicates potential infectivity
4: the Hepatitis B vaccine utilises a live attenuated virus Hydatid disease has a primary sheep/dog cycle in Australasia, ie. It is a zoonosis (A true). Human
disease results from ingestion or inhalation of ova of the tapeworm (Echinococcus granulosus) which
Answer: TTTF resides in the dog intestine. Tape worm segments (proglottids) containing eggs (ova) are in the dog's
faeces (C true). Dogs, but not humans, become infected by eating sheep offal (eg. Liver, lungs)
Hepatitis B virus (HBV) infection is one of the most important blood borne diseases of relevance to containing hydatid cysts (B false). The only really effective treatment of hydatid disease in humans, is
surgeons. Health care workers may be immune to this disease: ie they possess antibody to hepatitis surgical removal of cysts. Chemotherapy (eg. Mebendazole type drugs) is generally ineffective (D
B surface antigen (anti-HBs), due to prior immunisation or infection. Those who suspect or know they true). This question was referred to the Pathology Sub Committee for review on 1 Feb 2002.
have had significant contact and/or exposure (eg needle stick injury) with a HBV carrier (ie a person Question updated 14 March 2002. Question updated 28 May 2002.
who is positive for the hepatitis B surface antigen, HBsAg) should be directed to an appropriate
clinician for testing of their immunological status to HBV. At present, there are three hepatitis B 9780 – In relation to hydatid disease in humans
vaccines available - all are non-infectious sub-unit vaccines derived from genetically engineered yeast 1: infection occurs following ingestion of infected sheep meat
cells. Seroconversion (immunity) occurs in most subjects after two vaccine doses but should never be 2: albendazole is a chemotherapeutic consideration in some cases
assumed without serological proof. Three doses are normally given. Booster doses are presently 3: the parasite involved is Taenia solium
recommended, at 5-year intervals for health care workers. Protective immunity is recognised by an 4: less than 10% of cysts are found in the liver
anti-HBs response (ie development of antibody to HBsAg). This test becomes positive in most people
after recovery from acute infection with HBV, and also in persons successfully vaccinated. A positive Answers: FTFF
test for HBs Ag indicates active infection and potential infectivity. A low percentage of acutely infected
individuals develop chronic infection and remain HBsAg positive. Such 'carrier' rates may reach Robbins, 6th ed, Ch 9. Question updated 2 Dec 2002.
around 1:1000 or greater in some populations.
The other HBV antigen of importance is the 'e' or early antigen (HBeAg). Persons with circulating 'e'
12974 – Lobar pneumonia
1: is classically due to the organism Streptococcus pneumoniae
antigen (HBeAg positive) pose a greater risk of infection to contacts than those who are HBsAg
2: on resolution, leaves few functional abnormalities
positive but HBeAg negative. While HBeAg has been recommended as identifying infectious
3: is a disease, especially, of otherwise healthy young adults
individuals, it does not reliably identify all infectious people. HBV contains double stranded DNA and
4: is usually not accompanied by a bacteraemia
detection of HBV DNA provides a measure of how much HBV is present in a sample, and is therefore
a direct marker of infectivity.
Answers: TTTF
Rules for recipients to follow after exposure to possible HBV-containing (donor) blood:
Lobar pneumonia is classically due to the bacterium Streptococcus pneumoniae (the pneumococcus) a
• If recipient HBsAg positive - already infected, no prophylaxis.
microbe which owes its virulence to the presence of a capsule (A true). No bacterial toxins are
• If recipient anti-HBs positive (> 10iu|L) - immune, no prophylaxis.
• If recipient anti-HBs negative or <10iu|L (and HBsAg negative) - possibly susceptible, give involved. This capsule allows the bacteria to escape the process of phagocytosis by inhibiting
attachment; hence bacteraemia and blood borne spread are features of major pneumococcal
hepatitis B vaccine regardless of donor (source) status. If donor (source) blood available
infections such as lobar pneumonia (D false). The pathogenesis centres around survival and growth
and is infectious (ie HBsAg positive), give as well hepatitis B immunoglobulin (as soon as
possible but within 7 days). If donor blood unavailable, the use of immunoglobulin is of the microbe in the lung parenchyma, the resulting host inflammatory response to this foreign
material being responsible for lung consolidation. The exudate is absorbed once the bacteria are
controversial, and depends on the perceived risk of the exposure.
removed leaving few, if any, functional abnormalities (B true). The disease appears to occur
predominantly in otherwise healthy adolescents and young adults (C true), in contrast to most other
15573 – Herpes viruses pneumonias which tend to have a predilection for the extremes of age and for those with underlying
1: are important pathogens following organ transplantation lung pathology (eg virus disease, CORD).
2: have been associated with nasopharyngeal carcinoma
3: have a tendency to become latent following primary infection
4: do not induce a characteristic cytopathic change in infected cells
15944 – Pneumocystis carinii infection
1: is due to a microbe which results in intracellular colonisation of host cells (Type 2 pneumocytes)
2: causes disease only in immunocompromised hosts
Answers: TTTF
3: commonly causes respiratory failure
4: induces granulomatous inflammation
Refer to Robbins, 6th, Ch 8, page 313; Ch 9, page 359-361

Answers: FTTF
Answers: TFTF
The organism (classified currently as fungal) exists within the lung of an infected patients in an
extracellular environment, virtually exclusively confined to the alveolar spaces, causing death from Aust. N.Z.J. Surgery paper Textbook Surgery - Clunie '97
progressive respiratory failure. It causes disease only in immunocompromised patients (AIDS; anti-
cancer chemotherapy; patients receiving organ transplants; steroid therapy; severe malnutrition). In 13057 – 'Slow viruses' (prions) are
the clinical situations outlined, there is generally no recognisable inflammatory response of any sort. 1: characterised by a long incubation period
2: responsible for Creutzfeldt-Jakob encephalopathy
23284 – Pneumocystis carinii infection 3: resistant to normal autoclaving procedures ie.15psi (121 degrees C) for 15 minutes
1: usually produces a protective immune reaction in childhood 4: so called because the resultant diseases are chronic
2: characteristically produces around 20 micron cysts
3: is usually cleared by treatment with folic acid Answers: TTTF
4: induces granulomatous inflammation
'Slow viruses' are so named because of their long incubation period; the disease appears gradually
Answers: TFFF and progresses to death months or years after the agent enters the body (A true). In slow virus
infections, the replicative cycle of the agent is not necessarily slow; rather, manifestation of the signs
Robbins 6th ed. Chapter: 7; 9 Pages: 247; 381-382 and symptoms of disease is slow (D false).The best studied slow virus infections of man involve CNS
degeneration and include kuru, Creutzfeldt-Jakob disease (CJD) (B true) and subacute sclerosing
25574 – Regarding tuberculosis panencephalitis (SSPE). The agents in the first two are regarded as unconventional 'viruses', having
1: most primary cases are self-terminating never been visualised or cultured, while those of the latter are regarded as convention viruses (eg
2: tuberculin anergy may be seen with overwhelming disseminated disease measles virus). The agent responsible may be highly resistant to normal sterilising procedures (C
3: Mycobacterium tuberculosis has no known exotoxins true): eg CJD agent requires autoclaving for one hour, rather than 15-20 minutes, and is not
4: disease in AIDS patients is often widely disseminated and atypical susceptible to ethylene oxide gas.
This question is currently under review by the Pathology Sub Committee. 28 June 2002.
Answers: TTTT NB. (Accumulating evidence that even at higher temps/pressure for larger intervals - eg 138 degrees
C for 30 minutes - that prions may "survive". There is really no satisfactory sterilizing procedure.)
Robbins 5th ed. Pages: 324-327 This question has been updated. 28 August 2002.
25529 – Candida albicans 14808 – The protozoan parasite, Toxoplasma gondii

1: is an important microbe to consider with intra-abdominal infections arising following gastric surgery 1: is an important cause of brain infection in patients with AIDS
2: cannot induce septic shock and multiorgan failure 2: is an obligate human parasite
3: reveals increasing resistance to fluconazole 3: cannot be transmitted congenitally
4: is an important catheter-related pathogen 4: is capable of infecting all types of cells
Answers: TFTT Answers: TFFT
ANZ Journal of Surgery Smith & Payne Refer to Robbins, 6th Ed, page 382-383
25610 – Infection by the yeast Candida albicans 25349 – Intracellular parasites such as mycobacteria may survive by
1: is frequently associated with long-term intravascular catheterization A. preventing activation of proto-oncogenes
2: may be spread via hands in hospitals B. preventing the formation of phagolysosomes
3: invariably results in positive blood cultures C. scavenging activated complement components
4: can be treated with metronidazole D. inhibiting the activation of T lymphocytes
E. neutralising specific antibodies
Answers: TTFF
Answer: B
Smith & Payne A.N.Z. Journal '94
Roitt 9th ed. Page: 267-268
25534 – Invasive Candida infection
1: is often associated with colonized intravascular lines 10388 – Significant microbe/disease causative associations include
2: is invariably caused by Candida krusei 1: Bacteroides fragilis/pelvic abscess
3: can be treated with fluconazole in most surgical patients 2: Enterococcus faecalis/early onset bacteraemia following rupture of the appendix
4: results in positive blood cultures in over 80% of patients 3: Staphylococcus aureus/osteomyelitis

4: Streptococcus pyogenes/necrotisingfasciitis 4: anaerobes found in the mouth are usually susceptible to coamoxyclav
Answers: TFTT Answers: TTFT

14
Intra-abdominal abscesses involving the pelvic region are invariably polymicrobial with obligate By far the majority of the body's normal flora exists in the large intestine where numbers exceed 10 .
10 12
anaerobes such as Bacteroides fragilis being major causative agents. Other more important The skin is home to over 10 microbes and the oral cavity to more than 10 microbes. Over 99.9% of
participating microbes include Gram-negative bacilli such as E.coli, and to a lesser degree, microbes in the gastrointestinal tract, oral cavity, and areas of skin with hair (eg scalp) are obligate
streptococci (eg Streptococcus anginosus). Early onset bacteraemia following rupture of the appendix anaerobes and these clearly dominate the mucocutaneous normal flora. Compared to the large
usually involves Gram negative enteric bacilli (eg E. coli) or less often the Gram-negative bacillus bowel, only small numbers of microbes inhabit the small intestine of which coliforms such as E. coli,
Pseudomonas aeruginosa (a gut transient). However, the role of Gram-negative anaerobes such as enterococci (eg Enterococcus faecalis) and yeasts (eg Candida albicans) dominate. Commensals
Bacteroides fragilis, and other obligate anaerobes (eg clostridia) cannot be ignored, especially if the found on the skin consist predominantly of staphylococci - eg S. epidermidis, coryneforms (both
appendix is gangrenous. Enterococci are insignificant in early onset problems, especially where the aerobic, eg Brevibacterium and Corynebacterium species, and anaerobic, eg Propionibacterium
stomach or upper small intestine is not involved. By far the major microbe associated with all forms of forms), and lipophilic yeasts (eg Malassezia furfur). Under normal conditions Candida albicans is not
osteomyelitis is Staphylococcus aureus, followed by coagulase - negative species (eg found, ie it is not part of the normal skin flora, although excessive hydration may allow this yeast to
Staphylococcus epidermidis). Streptococcus pyogenes is a significant causal agent of necrotising transiently colonise skin (eg nappy rash). The predominant oral anaerobes are members of the
fasciitis, although its importance is often over-dramatised (eg the ‘flesh eating bug’). Empiric Porphyromonas, Prevotella and Peptostreptococcus genera (historically often listed as pigmented
antimicrobial cover in necrotising fasciitis should always include activity against streptococci. 'Bacteroides' species) which are invariably susceptible to amoxycillin/clavulanic acid (coamoxyclav)
combinations. This antibiotic is a good choice for cutaneous lesions arising following bite wounds.
25764 – In managing a patient with severe intra-abdominal sepsis after Many of the oral anaerobes, however, now elaborate !-lactamases, and are not susceptible to
breakdown of a colonic anastomosis penicillin G (or amoxycillin). Also present in the oral cavity are more aerotolerant streptococci,
staphylococci, Neisseria species, Moraxella catarrhalis and Haemophilus influenzae. Pending review.
A. IVN should be delayed until all sepsis has resolved
Jan 2003
B. definitive abdominal closure is essential to protect the bowel from risk of fistula formation
C. limited exploration with drainage is the most important aspect of reoperative surgery
D. feeding jejuonostomy is contraindicated because of the risk of leakage 11698 – Surgical-site infection rates are increased
E. second look laparotomy is essential if viability of the gut was in doubt at the time of operation 1: in the presence of obesity
2: when the skin is left unshaved
Answers: E 3: in non-vascular tissue
4: in patients with advanced malignancy
15578 – Intra-abdominal abscesses
Answers: TFTT
1: wherever possible require drainage in addition to antimicrobial therapy
2: are predominantly polymicrobial in origin
t is accepted (and proven) that surgical-site infection rates undoubtedly increase with the degree of
3: contain clostridia as the dominant obligate anaerobe
contamination (eg contaminated versus clean surgery), the duration of the operation over 2 hours,
4: most commonly occur under the diaphragm and in the pelvis of recumbent patients
and the 'physiological' status of the patient (eg presence of other diseases such as diabetes and
cancer, malnutrition). Other accepted, but less significant factors include increasing age and obesity,
Answers: TTFT
while skin shaving clearly results in increased local microbial growth (attributable in traumatic
injury/increased fluid) and the potential for subsequent wound infection. Hairs should be clipped
Refer to Textbook of Surgery, 1997; Aust NZJ Surgery, 1994; STEM Module: Surgical Infections and
(rather than shaved at any time) with this being carried out immediately prior to incision. Blood with its
Antimicrobials
associated cells, fluid and oxygen, is a primary host defence 'barrier' against infection, which more
readily becomes established in non vascularised/necrotic tissue. Most (eg over 70%) of wound
9790 – The microbial flora of the body infections only become apparent after the patient has left hospital.
1: is an important reservoir of post-surgical sepsis
2: is found predominantly in the large bowel
11703 – Important infection control measures shown to reduce the
3: may be influenced in composition by hospitalization
4: is composed predominantly of anaerobes incidence of operation-related patient infections include
1: restriction in the numbers and movement of theatre staff
Answers: TTTT 2: wearing of face masks
3: 12-hour rather than 24-hour preoperative skin shaving
Toouli et al, Integrated Basic Surgical Sciences, Ch 37.2 4: cleansing of the skin in the operation field by antiseptics
Answers: TFFT
11692 – Regarding the body's normal flora
1: obligate anaerobes predominate
A few operating room 'rituals' have been shown to have no significant effect on post-operative patient
2: Enterococcus faecalis is found in the upper intestinal tract
sepsis, ie surgical site infection. These include the wearing of face masks and gowns. On the other
3: Candida albicans is a common skin commensal
hand, preoperative skin shaving of the incisional area does significantly increase the likelihood of
subsequent wound sepsis, as does increased staff numbers and movement in the operating theatre Answer: C
(perhaps related to movement of air). Hair clipping immediately prior to incision is less likely to result
in subsequent wound sepsis, than any form of razor shaving. A reduction in the numbers of microbes Significant hypo-albuminaemia, significant hyperbilirubinaemia, significant renal insufficiency and
colonising the incisional area by the use of topical antiseptics does reduce subsequent wound long-term steroid therapy all impede wound healing significantly. Hypoxaemia of mild degree (pO 2 80
infection rates, which are invariably endogenous and which may take several weeks to become mm) would have the least effect (C).
apparent.
881, 18310 – Which of the following is MOST often found to be a
18255 – Which one of the following statements about wound infection in a contributing factor in patients with postoperative abdominal wound
clean, uncontaminated wound, is most correct? disruption?
A. It is usually associated with deep wound dehiscence A. Advanced age.
B. Pyrexia typically occurs on the second post-operative day B. Increased intra-abdominal pressure.
C. The incidence of sepsis is in proportion to the number of sutures inserted C. Sepsis.
D. Infection is commonly due to skin commensals D. Anaemia.
E. The infecting organism is most commonly Escherichia coli E. Hypoproteinaemia.
Answer: D Answer: B
In clean uncontaminated wounds the incidence of infection should be low. When infection occurs it is Local factors are more commonly a cause of postoperative wound disruption than general factors,
most commonly due to skin commensals (eg staphylococcus epidermidis) (D). although these latter can be important. Hypoproteinaemia and anaemia, if severe, may contribute,
and advanced age is usually associated with other factors such as malnutrition or carcinoma. Local
9091 – Control measures proven to reduce risk of endogenous infection sepsis or a digestive fistula can contribute to wound necrosis. Adequate techniques of wound closure
following intraabdominal surgery include using strong nonabsorbable sutures can minimise the risk of disruption. Increased intra-abdominal
1: pre-operative cleansing of the skin pressure (coughing, sneezing, ileus, distension) is the most common contributor of those listed (B
2: the administration of prophylactic antibiotics prior to skin incision correct). Although all of the responses can contribute to wound dehiscence, increased intra-
3: extensive skin shaving 24 hours prior to surgery abdominal pressure (from coughing and straining, or from abdominal distension due to ileus), is the
4: a pulse of antibiotics 12 hours after wound closure most common contributing factor of those listed (B).
Answers: TTFF 25615 – Wound infection rates are increased

1: in the presence of obesity
Toouli et al, Integrated Basic Surgical Sciences; Smith, Payne, Berne, The Surgeon's Guide to 2: when the skin is left unshaved
Antimicrobial Chemotherapy; STEM Module: Surgical Infections/Antimicrobials; Smith & Payne, 3: in nonvascular tissue
Integrated Basic Surgical Sciences, Ch 37.2 4: in those with advanced malignancy
582 – Which of the following circumstances would have LEAST effect on Answers: TFTT
impeding wound healing?
C.S.S. 2nd Ed. PAGE: 151-153
A. A 56 year old alcoholic with a serum albumin of 20 gm/L.
B. A 35 year old asthmatic on prednisolone 10 mg daily.
C. A 72 year old smoker with a arterial pO2 of 80 mm Hg. 23604 – Wound contraction is delayed by
D. A 65 year old man with a serum bilirubin of 80 umol/L. 1: corticosteroid administration
E. A 42 year old man with a serum creatinine of 0.31mmol/L 2: the changes occuring in a burn
3: skin grafting
Answer: C 4: X-radiation
18286 – In all the following circumstances wound healing may be impaired. Answers: TTTT
Which would cause the least impediment to healing? 21063 – Factors known to inhibit wound contraction include
A. A 56 year old alcoholic with a serum albumin of 26 gm/L
1: X-irradiation
B. A 35 year old asthmatic on long term prednisolone, 10 mg daily
2: hyperbaric oxygen
C. A 72 year old smoker with an arterial pO 2 of 80 mm Hg 3: glucocorticoid therapy
D. A 65 year old man with a serum bilirubin of 80 micromol/L 4: anabolic steroid therapy
E. A 42 year old man with a serum creatinine of 0.21mmol/L

Answers: TFTF viable after such exposure. Thus where suspect Creutzfeldt-Jacob Disease (CJD) contaminated
o
material is involved, it is recommended that autoclaving be at 134 C (29 psi or 205 Kpa) for at least
Robbins 5th ed. 18 minutes (sterile supply departments frequently have such high pre-vacuum sterilisers). Most
autoclaves have a final vacuum drying cycle which can be applied when surgical gowns are being
24139 – Reduction in size of large traumatic skin defects (wound sterilised (come out dry). Where dry heat (eg hot air oven) is used for sterilising, a temperature of
o
160 C for at least 2 hours is required. Clearly boiling for 10 minutes or so while killing many
contraction) occurring during the first two weeks following injury probably
vegetative bacteria, is unsuitable for killing some microbial forms eg sporing bacilli. Ethylene oxide
results from o
gas is suitable for items which cannot withstand heating above 60 C, eg instruments with electrical,
1: surface dehydration fibre optic or electronic components, and non-disposable heat sensitive plastics. The gas is only
2: epithelial ingrowth into the wound effective if it can penetrate the packaging and reach all surfaces of the article. The process is carried
3: actions of ingrowing myofibroblasts o o
out at 54 -60 in 60-75% humidity for at least 12 hours, which includes time for aeration to rid the
4: enzyme-induced contraction of type IV collagen article of residual toxic ethylene oxide gas. With most plastics, the aeration time has to be extended
for several hours. While most bacteria are readily removed by filtration through a 0.45mm membrane,
Answers: FFTF mycoplasmas and viruses will pass through. Reducing the pore diameter to 0.2m will result in removal
of all bacteria, including mycoplasmas. However filtration as a means of removing viruses, which may
Robbins 5th ed. Chapter: 3 Page: 86 be as small as 0.02mm (20 nm) in size (eg poliovirus is 28 nm in diameter), is not really a feasible
method of sterilisation as filters block very readily with pore diameters in the 0.02mm range. Certainly
9071 – In healing wounds viruses and mycoplasmas will pass through a 0.45mm grid membrane - the filtrate from such filtration
1: newly formed collagen has a high content of soluble collagen cannot be taken as sterile.
2: in the first three months the tensile strength corresponds directly to the amount of collagen present
3: fibronectin plays an important role in healing 13135 – Sterilisation of materials for operation can be achieved by
4: cross-linkage and reorganisation of collagen is achieved by oxidation of proline 1: pressurised steam
2: subatmospheric steam and formaldehyde
Answers: TFTF 3: ethylene oxide gas
4: dry heat
Robbins, 6th ed, Ch 4
Answers: TTTT
8702 – In epithelial cells involved in the healing of a sutured skin wound
1: migration begins 48-60 hours after injury Sterilisation implies the complete removal or destruction of all living material, including viruses and
2: mitoses are evident in migrating cells spores (0.45 micrometres pore size membranes remove most bacteria but not viruses and the like).
3: cells migrate over the surface of the clot The important methods of sterilisation are steam under pressure (15 lbs/sq inch) as with the
4: the major stimulus to cell division is transforming growth factor-beta (TGF-b) autoclave (A true); dry heat, which takes longer than steam under pressure (D true); certain
chemicals such as ethylene oxide gas, which is slow and highly combustible (C true); and
Answers: FFFF formaldehyde or glutaraldehyde vapour (B true). Resolved Nov 2003.
Robbins, 6th ed, Ch 4 25559 – The clinical signs associated with septic shock can be attributed to
1: peripheral vasodilation
11758, 25985 – Which of the following is/are adequate for sterilisation? 2: diffuse endothelial damage
o
1: Steam at 121 C for 15 minutes (autoclaving) 3: release of interleukin 1 (IL1)
2: Filtration through an 0.45µm pore size membrane 4: stimulation of tumour necrosis factor (TNF)
3: Ethylene oxide gas for 24 hours
4: Boiling for 10 minutes Answers: TTTT
Answers: TFTF C.S.S. 2nd ed. Page: 151 Roitt 7th ed. Page: 142 Robbins 5th ed. Page: 70-71; 117-120
Update (size of viruses) Chapter: MP.31 Page:MP.20. Sterilisation implies the removal of all 25872 – Diagnosis of SIRS (systemic inflammatory response syndrome)
microbes, or at least removing the viability of all microbes. The most accepted method is the use of requires the presence of which two of the following?
steam under pressure, ie moist heat. The presence of water allows heat to penetrate much better 1: lactate > 1.2mmol/l
than under dry conditions. For instance, you will all be aware of the difference in picking up a hot
2: tachycardia >90 bpm in the absence of a beta-blocker
object with a dry or wet cloth. Heat travels in waves and needs a ' vehicle to carry it '- eg poor / nil 9
3: white cell count >20 or <1 (x10 /L)
penetration through a vacuum. Autoclaving is the usual form of sterilisation where the product is to be o
4: pyrexia >38 C or hypothermia <36 C
o
discarded or is heat stable. Steam under pressure of 15lbs per square inch (103 Kpa) reaches a 5: urine output <240 ml over 4 hours
o
temperature of 121 C. Exposure of microbes to these conditions for 15 minutes will result in a loss of
viability, ie death, although some concern has been expressed concerning whether prions can remain
Answers: FTFTF by vitamin K supplementation. MRSA are resistant to all !-lactams (including flucloxacillin,
coamoxyclav, piperacillin/tazobactam, imipenem) because resistance is associated with a new target
site (penicillin binding protein 2a) to which all !-lactams have low affinity, and not to penicillinase (!-
ANTIBIOTICS / PHARMACOLOGY lactamase) production. However, all of the penicillins listed above are penicillinase-stable and
effective against 'normal' (methicillin-susceptible) strains of Staphylococcus aureus.
11687 – The skin is an unsatisfactory environment for many microbes This question is currently under review by the Pathology Sub Committee. 23 August, 2001.
because of its
1: resident microbial flora 23784 – In relation to antibiotics
2: alkaline pH 1: vancomycin is active only against Gram positive bacteria
3: dryness 2: alcohol intolerance is an adverse reaction seen with metronidazole
4: mucus secretions 3: tetracyclines should not be used in young children
4: gentamicin is not active against obligate anaerobes
Answers: TFTF
Answers: TTTT
The skin is normally dry (ie unsuitable for microbial growth) with an acid pH (around 5.5 in places
such as the forehead), and in most areas contains a resident microflora of bacteria (eg staphylococci, Update (antibiotics) pM12-M22
coryneforms, anaerobes such as Propionibacterium and lipophilic yeasts (eg Malassezia furfur). Most
normal flora microbes occur in areas high in humidity and secretions (eg scalp, foot, axilla). None of 23059 – In relation to antibiotics
the secretions (eg sweat, sebaceous) contains mucus; with the presence of fatty acids, lactate, salt 1: fusidic acid is a useful consideration for infections by Staphylococcus aureus
(NaCl), and products of keratinisation in secretions contributing to the 'acid mantle' that covers most 2: rifampicin is well absorbed from the alimentary tract
skin areas. The skin of the feet while moist (sweat) is not covered in oily secretions; hence its ability 3: chloramphenicol penetrates better than most other antibiotics into the CSF
to harbour Gram-negative bacilli such as Acinetobacter and pseudomonads. All of these properties 4: vancomycin is well absorbed after oral administration
(dryness of some areas, acidity, resident flora occupying available niches) renders the skin unsuitable
as an environment for many microbes. Those that occur as part of the normal flora are adapted in Answers: TTTF
some way to these conditions.
Update (antibiotics) pM18-M21
25994 – In relation to antibiotics
1: quinolones are well absorbed after oral administration 9795 – Examples of cell wall active antibacterials include
2: aminoglycosides include vancomycin 1: vancomycin
3: cephalosporins may induce bleeding problems following some prolonged administration 2: imipenem
4: cephalosporins are generally less resistant than the penicillins to staphylococcal beta-lactamases 3: piperacillin
4: gentamicin
Answers: TFTF
Answers: TTTF
C.S.S. 2nd ed. P.155/156 Update (antibiotics) M14-M20
Toouli et al, Integrated Basic Surgical Sciences, Ch 37.2
11728 – In relation to antibiotics
1: quinolones are well absorbed after oral administration 10378, 23299 – Antibiotics which can be used effectively in the empiric
2: aminoglycosides include vancomycin therapy of intra-abdominal sepsis originating from the pancreas include
3: some cephalosporins may induce bleeding problems following prolonged administration
1: imipenem alone
4: piperacillin/tazobactam is effective therapeutically against MRSA
2: gentamicin alone
3: a combination of piperacillin and tazobactam (Tazocin)
Answers: TFTF
4: cefotaxime alone
A feature of the quinolone group of antimicrobials is their good bioavailability and excellent body
Answers: TFTF
distribution after oral administration. Newer quinolones also have long half-lifes permitting once daily
oral dosing in most cases. The aminoglycosides now commonly used are gentamicin, tobramycin,
Smith & Payne Aust. NZJ Surgery '94. The same general facts apply to Q2 as for Q1 above.
netilmicin, and amikacin; vancomycin is a cell wall active glycopeptide unrelated to the ribosomal-
However, in this case upper gastrointestinal surgery raises the distinct possibility of the participation
active aminoglycosides. One of the major problems of prolonged cephalosporin use is a reduction in
of enterococci, and possibly yeasts. Although it is generally agreed that empiric cover against yeasts
the body's vitamin K levels (vitamin K is synthesised by gut microbes) with consequent platelet
is not at present warranted, certainly the potential for yeasts to be involved should be considered, and
dysfunction and bleeding (hypoprothrombinaemia). This is particularly a feature of cephalosporins
requested in specimen cultures. Imipenem-type drugs, and piperacillin/tazobactam have proved to be
possessing a methyl-thiotetrazole side chain (eg cefamandole, cefotetan), and although uncommon,
superior to most antimicrobials in this situation apparently covering all important aerobic (eg Gram-
has been seen in the elderly and/or malnourished surgical patient. It can be treated and/or prevented
negative bacilli, enterococci, staphylococci, streptococci) and obligate anearobes (eg Bacteriodes
fragilis, clostridia). Where patients fail to respond as anticipated to one of these drugs, the coamoxyclav are still acceptable second line alternatives to metronidazole or the glycopeptides (eg
participation of yeasts such as Candida albicans should be seriously considered. Aminoglycosides imipenem). Over 80% of Staphylococcus aureus strains now elaborate penicillinases, which destroy
such as gentamicin, or third generation cephalosporins like cefotaxine fail to cover obligate anaerobes the activity of most penicillins (eg penicillin G, amoxycillin, piperacillin, ticarcillin) other than the so-
and bacteria such as Enterococcus faecalis. called penicillinase-stable group eg flucloxacillin, dicloxacillin. Addition of a - lactamase inhibitor (eg
clavulanic acid, tazobactam, sulbactam) restores the activity of penicillinase-labile penicillins (eg
22609 – Antibiotics/combinations which are adequate prophylaxis for amoxycillin, piperacillin) against S. aureus (eg amoxycillin plus clavulanic acid or coamoxyclav).
Enterococci reveal inherent decreased susceptibility or resistance to aminoglycosides and penicillin
biliary surgery include
G. However, combinations of gentamicin plus penicillin reveal synergy against enterococci and this
1: Augmentin (co-amoxyclav)
combination is a useful therapeutic consideration. Ampicillin (or amoxycillin) is more active naturally
2: penicillin
than penicillin G against enterococci this also reveals increased activity when combined with
3: amoxycillin plus gentamicin
gentamicin. The usual therapy for enterococcal infections is ampicillin plus gentamicin. Piperacillin is
4: flucloxacillin plus metronidazole
somewhat similar to ampicillin. In addition some of the newer quinolones, eg clinafloxacin, show
useful activity against enterococci. Mycoplasmas do not posses a cell wall, and are unaffected by cell
Answers: TFTF
wall active antimicrobials such as -lactams and vancomycin. Imipenem is a -lactam. The usual
therapeutic option for infections involving mycoplasmas is a macrolide (eg erythromycin,
Antibiotic Update: Page: AM27. Pending review. Jan 2003
clarithromycin).
23309 – The following are therapeutically useful microbe/antimicrobial 23909 – Aminoglycosides
agent combinations in the surgical patient 1: are well absorbed after oral administration
1: candida albicans/fluconazole 2: are synergistic with penicillins
2: bacteroides fragilis/amoxycillin 3: have a high therapeutic index
3: staphylococcus aureus/benzyl penicillin 4: are ineffective against Staphylococcus auerus
4: enterococcus faecalis/metronidazole
Answers: FTFF
Answers: TFFF
C.S.S. PAGE: 155, 159 Update pM16
Smith & Payne Aust. NZJ Surgery '94
11718 – Aminoglycosides
15568 – The following are therapeutically useful microbe/drug 1: have activity against Gram-negative bacilli
combinations 2: reveal synergy with penicillins
1: methicillin-resistant Staphylococcus aureus/imipenem 3: tend to accumulate in renal tissues
2: Bacteroides fragilis/benzyl penicillin 4: are well absorbed after oral administration
3: Clostridium difficile/metronidazole
4: Escherichia coli/gentamicin Answers: TTTF
Answer: FFTT Aminoglycosides are generally safe drugs with known adverse effects, which can be administered by
intravenous or intramuscular push or infusion over 15-20 minutes, and which show excellent activity
Refer to Aust NZJ Surgery, 1994; STEM Module: Surgical Infections and Antimicrobials. This against many Gram-negative bacilli. They also have often unappreciated anti-Staphylococcus aureus
question is currently under review by the Pathology Sub Committee. 23 August, 2001. This question activity (including some MRSA), but are devoid of therapeutic anti-anaerobe activity. Although
has been updated. 28 August 2002 ineffective by themselves against enterococci and streptococci, they reveal synergy with penicillins
against these two groups of bacteria. Older regimens of 8-12 hourly dosing, have in many cases been
10393, 23694 – Therapeutically useful microbe/antimicrobial agent replaced by 24 hourly schedules. This is because aminoglycosides display concentration-dependent
bacterial killing (unlike the !-lactams), and a pronounced post-antibiotic effect (PAE) against many
combinations include
bacteria. In addition, complete 'wash out' of the previous dose before administering the next dose
1: Bacteroides fragilis/metronidazole
results in enhanced cidal activity of the second dose (bacteria exhibit what has been termed adaptive
2: Staphylococcus aureus/piperacillin
resistance in the presence of low levels of the drug), while once a day dosing is clearly less toxic (to
3: Enterococcus faecalis/gentamicin
kidney and ear) than multiple daily doses. The most feared complications of aminoglycoside use are
4: Mycoplasma pneumoniae/imipenem
nephrotoxicity and ototoxicity. These both result from excessive local accumulation of drug in the
presence of poor or deteriorating renal function. Monitoring of trough levels is essential in all patients
Answers: TFFF
receiving more than a couple of days of aminoglycoside therapy, especially in the elderly or where
renal function is deteriorating. Renal toxicity is reversible, although ototoxicity is not. Some evidence
Smith & Payne Aust. N.Z. Journal Surgery '94. Bacteroides fragilis has remained universally
is available that susceptibility to ototoxicity is related to a defect (mutation) in a mitochondrial gene.
susceptible to metronidazole and imipenem or meropenem (and also chloramphenicol). Increasing
Aminoglycosides are not absorbed from the alimentary tract, and cannot be given orally if systemic
resistance to clindamycin and cefoxitin is common, while the likes of piperacillin/tazobactam and
distribution is required.
3: has anaerobe activity
15182 – Gentamicin 4: is not stable to penicillinase
1: reveals concentration dependant bacterial killing
2: can be used successfully once daily in many surgical situations Answers: TFTF
3: is effective against the gram-negative Bacteroides fragilis
4: cannot be administered by intramuscular injection Coamoxyclav ('Augmentin' - although the generic name is now out of patent and may change eg
'Synermox', 'Alpha-amoxyclav'), is a combination of two !-lactams, amoxycillin and clavulanic acid.
Answers: TTFF The latter is highly resistant to the activity of some !-lactamases (eg staphylococcal penicillinases)
and has high affinity for them. When administered together with the !-lactamase labile amoxycillin,
Refer to updates of Aust. NZ Journal of Surgery any !-lactamase elaborated by the bacterial pathogen is attracted (and bound) to the clavulanic acid
leaving the amoxycillin 'free' to carry out its antibacterial activity. The activity of coamoxyclav relies on
the two components (which are not physically bound) having similar body distribution and other
11713 – Cephalosporins
pharmacokinetic properties. Coamoxyclav is available as an oral (as well as parenteral) formulation,
1: are active therapeutically against enterococci
although the clavulanate portion often has unpleasant gastrointestinal activity eg nausea, diarrhoea.
2: are associated with greater allergic problems than penicillins
This cell wall active B-lactam combination is ineffective against mycoplasmas which do not possess a
3: have no action against Staphylococcus aureus
cell wall, but has excellent activity against many significant anaerobes including clostridia and
4: are generally more resistant to beta-lactamases than the penicillins
Bacteroides fragilis, and against Staphylococcus aureus - the latter two bacteria elaborate B-
lactamase susceptible to inactivation by clavulanic acid. Update - Microbiology Basic Principles
Answers: FFFT
PAGE:p M14
Cephalosporins can be divided into four generations - reflecting to some extent their date of discovery
and increasing spectrum of activity against Gram-negative bacteria (from first to third generation). 19432 – The antimicrobial of choice for sepsis involving Bacteroides
While activity against some Gram-positive cocci (eg Staphylococcus aureus) decreases slightly from fragilis is
first to third generation, the latter generations, including fourth, have excellent activity against most A. penicillin G
streptococci. Second generation compounds, such as cefuroxime, are excellent anti-S. aureus drugs. B. clindamycin
Most cephalosporins are parenteral-only drugs, although oral formulations are gradually being C. metronidazole
produced. All cephalosporins show no therapeutic activity against enterococci. Indeed, the D. cefoxitin
widespread use of cephalosporins for prophylaxis, and in some countries (eg USA) for therapy, is E. coamoxyclav (Augmentin)
thought to be one of the main reasons enterococci have emerged as increasingly significant hospital
pathogens. Apart from a few cephamycins (7-methoxycephalosporins) often referred to as second Answer: C
generation cephalosporins (eg cefoxitin, cefotetan), none of the cephalosporins has useful therapeutic
activity against obligate anaerobes. Resistance to the likes of cefoxitin (the most active agent) is also 11723, 22058 – Antibiotics effective against Bacteroides fragilis include
now increasing in important anaerobes such as Bacteroides fragilis; cefoxitin and cefotetan are really 1: penicillin G
only second-line anti-anaerobe agents, although they have found a role in large bowel prophylaxis. 2: coamoxyclav (Augmentin)
Compared to penicillins, cephalosporins have always been significantly more resistant to !-lactamase 3: metronidazole
inactivation (eg first and second generation compounds have excellent activity against 4: gentamicin
Staphylococcus aureus), and clearly are less likely to induce allergic/hypersensitive states.
Cephalosporins can be used with reasonable safety in patients with mild allergy (eg skin rash) to Answers: FTTF
penicillins, although should be avoided where anaphylaxis or similar serious event is likely. The
degree of cross reactivity of cephalosporins in patients with penicillin allergy is around 10% or less. C.S.S. 2ND ED. CHAPTER: 8 PAGE: 154-159 165. Bacteroides fragilis is an encapsulated Gram-
negative obligate anaerobe, frequently associated with intra-abdominal sepsis. It produces B-
23564 – The broad spectrum antibiotic amoxicillin lactamases capable of inactivating most penicillins (eg penicillin G, amoxycillin), but susceptible to
1: is effective in prevention of Clostridium difficile diarrhoea clavulanic acid inactivation. Clavulanic acid thus renders coamoxyclav (amoxycillin plus clavulanic
2: is resistant to staphylococcal penicillinases acid) a useful agent against B. fragilis. Aminoglycosides (eg gentamicin) have no predictable
3: is cell wall active therapeutic activity against any obligate anaerobes including B. fragilis. As with most other obligate
4: is effective in meningitis anaerobes, the most useful and potent therapeutic agent is metronidazole.
Answers: FFTF 23874 – Antibiotics effective therapeutically against Bacteroides fragilis

include
C.S.S. 2nd ed. Page: 154-155 Update (antibiotic) M12-14
1: penicillin (benzyl penicillin)
2: coamoxyclav (Augmentin)
11708, 25986 – Augmentin (coamoxyclav) 3: ceftriaxone
1: is a useful oral anti-staphylococcal agent 4: imipenem
2: is effective against mycoplasmas

Answers: FTFT 19707 – In a hospital where methicillin-resistant Staphylococcus aureus
(MRSA) is absent, the empiric therapy for septicaemia involving
Aust. NZJ Surgery
Staphylococcus aureus should be
A. Augmentin (co-amoxyclav)
23054 – Penicillins resistant to penicillinases (beta-lactamases) of
B. ciprofloxacin
Staphylococcus aureus include C. metronidadole
1: penicillin V (phenoxy methyl penicillin) D. flucloxacillin
2: amoxycillin E. vancomycin
3: piperacillin
4: flucloxacillin Answer: D
Answers: FFFT Aust. NZJ Surgery; Update
C.S.S. 2ND. ED. PAGE: 155 Update pM14 11753 – In hospitals where MRSA are absent, acceptable antibiotics for hip
14818 – Resistance in Staphylococcus aureus to "-lactam antibiotics may replacement surgery prophylaxis include
1: cephazolin alone
be mediated by 2: vancomycin alone
1: changes in the penicillin binding proteins 3: metronidazole plus amoxycillin
2: decreased permeability of the cell wall outer membrane 4: penicillin G plus flucloxacillin
3: enzymatic destruction of the drug
4: mutation in the gyrase A gene Answers: TFFF
Answers: TFTF Hip replacement surgery, like open-heart surgery, is an area of 'clean surgery' where antimicrobial
prophylaxis is clearly warranted and cost effective. The major potential pathogens to be covered are
Refer to Microbiology Update, Aust & NZ Journal Surgery 1994 staphylococci - both Staphylococcus aureus and coagulase-negative species such as Staphylococcus
epidermidis which have the ability to form biofilms and adhere to foreign materials eg screws,
11738 – Regarding the treatment of infections by methicillin-resistant prostheses. First or second generation cephalosporins have ideal antibacterial spectra for this
Staphylococcus aureus situation - cefamandole possibly has better overall antistaphylococcal activity than cephazolin,
1: vancomycin is the only reliable empiric therapy although the latter has a longer half life and better bone penetration and is favoured by many
2: coamoxyclav is useful for some strains institutions. Vancomycin should not be used unless MRSA are a major consideration, and even then it
3: imipenem is useful for some strains is apparent that the glycopeptide teicoplanin is a better alternative (easier to administer, less potential
4: an antibiotic such as fusidic acid maybe useful for some strains toxicity and adverse reactions). In general, glycopeptides such as vancomycin and teicoplanin should
be reserved for situations where no other antibiotic choice is available. Metronidazole plus amoxycillin
Answers: TFFT is devoid of staphylococcal activity (metronidazole is effective only against obligate anaerobes, and
amoxycillin against the likes of streptococci but not staphylococci which elaborate penicillinases).
Methicillin-resistant Staphylococcus aureus (MRSA) elaborate a new penicillin-binding protein (PBP), Penicillin G has minimal activity against S. aureus (less than 10% strains), and while flucloxacillin is
PBP2a, which has low affinity for all B-lactam drugs, and permits growth of cells in the presence of B- active against methicillin-susceptible S. aureus, it has poor activity against many (around 50%) strains
lactams. MRSA strains are resistant to all B-lactams (eg penicillin, flucloxacillin, coamoxyclav, of coagulase-negative staphylococci. This combination (penicillin + flucloxacillin) is not adequate
cefuroxime, and imipenem), because of this new target PBP. Since the late 1950s, most (around 80% prophylaxis for hip replacement surgery.
plus) strains of S. aureus have been resistant to many penicillins (eg benzylpenicillin, amoxycillin,
piperacillin) because of the production of penicillinases (B-lactamases) which destroy the biological 8727 – Antibiotics effective therapeutically against methicillin susceptible
activity of the drug. Penicillinase-stable penicillins (eg flucloxacillin, coamoxyclav) must be used for Staphylococcus aureus include
the empiric treatment of S. aureus infections. MRSA strains, which only became common around the 1: cephalexin
early 1990s, are resistant to these classical antistaphylococcal (ie penicillinase-stable) penicillins. The 2: coamoxyclav (Augmentin)
only antibiotic to which 100% of MRSA strains are consistently susceptible is vancomycin; although 3: flucloxacillin
MRSA strains with reduced susceptibility to vancomycin are slowly appearing world-wide. In countries 4: cefuroxime
such as New Zealand and Australia, MRSA strains are community (cMRSA) as well as hospital
based. While most hospital MRSA strains are multiresistant - ie also resistant to a variety of non B- Answer: TTTT
lactam antistaphylococcal agents - most cMRSA are not, and are susceptible to agents such as
cotrimoxazole, fusidic acid, rifampicin, gentamicin and ciprofloxacin. Treatment of cMRSA infections Smith, Payne, Berne, Surgeon's Guide to Antimicrobial Chemotherapy, Ch 1; Smith & Payne,
usually relies on a combination of two of these drugs. Integrated Basic Surgical Sciences, Ch 37.2

24329 – Features of vancomycin include 3: is a useful agent against Candida albicans
1: therapeutically active against methicillin resistant staphylococci, e.g. MRSA 4: is less nephrotoxic than amphotericin B
2: no therapeutic activity against the obligate anaerobe Clostridium perfringens
3: no therapeutic activity against gram-negative bacilli Answers: TTTT
4: inhibits cell wall synthesis in susceptible bacteria
Aust. NZJ Surgery. This question is currently under review by the sub committee. 4 June 2002. This
Answers: TFTT question has been updated. 28 August 2002
Antibiotic Update Aust. NZJ Surgery Paper IBSS, Ch 37.2, p782-793 Module: Surgical Infections 14116 – S:Amphotericin B and fluconazole are both active against the yeast
Candida albicans because R:they inhibit glucan synthesis in the yeast cell
11733 – Antifungals therapeutically useful for Candida fungaemia in the wall
post surgery patient include
1: amphotericin B Answer: S is true and R is false
2: griseofulvin
3: fluconazole Refer to MCQ Book: Buzzard & Bandanayake; The Surgeon's Guide to Antimicrobials &
4: nystatin Chemotherapy, Smith, Payne & Berne
Answers: TFTF 13457 – S:Amphotericin B, ketoconazole and 5-fluorocytosine are all

antifungal agents because R:antifungal agents prevent cell wall synthesis
Antifungals target some part of the fungal cell absent or sufficiently different to the similar structure
found in mammalian cells. As fungal and human cells are both eukaryotic in structure, finding in fungi
antifungals which are sufficiently toxic for fungi without unduly harming the human cell is not easy.
One obvious target is the fungal cell wall - a structure composed of various polysaccharides (eg Answer: S is true and R is false
chitin, cellulose, glucans) of which the glucans appear to provide the structural backbone akin to the
peptidoglycan of bacterial cell walls. A few cell wall active antifungals have been developed (eg Like mammalian cells, fungal cells are eukaryotic in nature. The most important antifungal agents
echinocandins, pneumocandins), and while appearing extremely promising in the laboratory (in vitro) currently available are amphotericin B, 5-fluorocytosine and the azoles: eg imidazoles such as
have in general failed to be acceptable in clinical trials because of toxicity problems. Other potential ketoconazole and miconazole; triazoles such as fluconazole and itraconazole (S true). Activity of
targets are the ribosomes (eg elongation factor 2 which occurs in yeasts and not human cells), these agents is directed against membrane (eg cytoplasmic) functions and DNA synthesis/function.
DNA/RNA synthesis or function, and the cell membrane. Flucytosine (5-fluorocytosine) and Similar structures occur in mammalian cells; hence the general toxicity to man of many of the
griseofulvin have as their target nucleic acids; these agents have found some clinical use (eg 5FC for antifungal agents. As yet antifungal agents with activity against the cell wall (a structure unique to
yeast infections, griseofulvin for ringworm), but because they have some effects on human nucleic fungi and not present in mammalian cells) are unavailable (R false).
acids, are unsuitable where rapid cell growth and division is found (eg pregnancy). Most of the anti-
fungals currently in clinical use are membrane-active compounds, inhibiting in some way the 11677 – Bacterial plasmids
production of the sterol ergosterol in the cell membrane. Specificity for fungal rather than mammalian 1: may be associated with virulence
cells resides in the fact that ergosterol is a major component of fungal but not human cell membranes, 2: are incapable of integration with the bacterial chromosome
(cholesterol is the major sterol found in mammalian cell membranes). The azole group of antifungals 3: are important in the transfer of drug resistance
(eg fluconazole) inhibit the cytochrome P450 activity of an enzyme in the ergosterol pathway, while 4: can only be transferred amongst strains of the same species
the polyenes (eg amphotericin B) inhibit in some way the amount of ergosterol in the membrane.
Cells lacking in sufficient ergosterol in the membrane 'leak' and die. Unfortunately amphotericin B Answers: TFTF
does have some effects on the membranes of human cells, and has a well-documented toxicity
profile. Azoles may interact with other drugs (eg cyclosporin) where the conserved cytochrome P450 Plasmids are extra chromosomal fragments of DNA, usually circular, which are readily transmissible
is also significant in some way. Fluconazole and amphotericin are suitable for treating yeast (eg between related and unrelated bacterial strains, and which often carry genes responsible for virulence
Candida) infections in surgical patients. In most cases, oral fluconazole (rather than intravenous and antibiotic resistance (eg resistance or R plasmids). While these self-replicating (unlike
amphotericin B) is the agent of choice, with amphotericin B being reserved for situation where WBC transposons) DNA elements usually remain separate in the cytoplasm of cells, whole plasmids or
numbers or function is impaired (eg neutropenia). Fluconazole is much easier to administer and far fragments from them may incorporate into the chromosomal DNA. Acquisition of antibiotic resistance
less toxic than amphotericin B. Nystatin (a polyene) is presently only available as a cream/ointment by DNA (gene) transfer between cells is often plasmid mediated.
for topical use, or as lozenges or ovules for lesions involving the mouth or vagina. It is not absorbed
from the gut following oral administration. Griseofulvin is only active against the dermatophytes 12959 – Genes for antibiotic resistance
(ringworm fungi). 1: are often found in plasmids
2: may be incorporated into cosmids
24259 – Characteristics of the anti-fungal agent, fluconazole include 3: often occur in circular DNA molecules
1: can be administered intravenously 4: are useful markers in recombinant DNA technology
2: has potential interaction with cytochrome P450 metabolised drugs

Answers: TTTT Answers: FTFT
Genes for antibiotic resistance are widely used as markers in recombinant DNA technology (D true). Toouli et al, Integrated Basic Surgical Sciences, Ch 37.1
They are usually incorporated close to the gene under investigation, and are easily identified in
culture. Genes for antibiotic resistance are often found in plasmids, whose DNA is circular (A and C 11743 – Adequate antibiotic prophylaxis for surgery involving the large
true). Cosmids are plasmids/phage hybrids used in recombinant DNA technology (B true).
bowel includes
1: amoxycillin plus metronidazole (both parenterally)
23304 – With successful antimicrobial prophylaxis for surgery involving the 2: cefotetan alone (parenterally)
colon 3: flucloxacillin plus metronidazole (both parenterally)
1: the antimicrobial used need only cover microbes released from the bowel 4: tobramycin alone (parenterally)
2: antimicrobials are effective if commenced one hour post incision
3: post operative wound sepsis may only become apparent weeks after surgery Answers: FTFF
4: wound infection rates increase with the duration of the operation
With large bowel surgery, the significant microbes which are associated with infection in patients who
Answers: FFTT do not receive prophylaxis or where prophylaxis fails, are enteric coliforms such as Escherichia coli,
the obligate anaerobe Bacteroides fragilis and of course Staphylococcus aureus (the latter is an
Smith & Payne Aust. NZJ Surgery '94 important skin wound pathogen in all invasive surgical settings). Acceptable prophylaxis for large
bowel surgery must cover these 3 microbes. The combination of amoxycillin plus metronidazole, while
10373 – Antibiotics useful for peritonitis in a 78 year old patient following adequately covering B. fragilis (metronidazole), is devoid of cover against E. coli (at least 50% of E.
large bowel surgery, who had been hospitalised for 6 weeks preoperatively coli strains are resistant to amoxycillin by B-lactamase production), or S. aureus (over 80% elaborate
penicillinases which inactivate amoxycillin). The 'second generation' cephalosporin cefotetan (in fact a
include 7-methoxy cephalosporin or cephamycin), provides adequate prophylactic cover against all 3
1: imipenem alone bacteria, although being only of doubtful use for established and ongoing intraabnormal sepsis. The
2: coamoxyclav (Augmentin) combination of flucloxacillin plus metronidazole is devoid of any cover against E. coli-like coliforms,
3: cefuroxime plus metronidazole although adequate for S. aureus (flucloxacillin) and B. fragilis (metronidazole). Tobramycin alone is
4: piperacillin/ tazobactam (Tazocin) devoid of any obligate anaerobe activity, although being excellent for E. coli and probably S. aureus.
In addition, anaesthetic agents may potentiate the neuromuscular blocking effects of
Answers: TFFT aminoglycosides. For this reason they are probably best avoided in prophylactic regimens.
Peritonitis associated with previous intestinal surgery is a biphasic process an initial local infection
14823 – Antibiotics acceptable for the empiric treatment of intra-abdominal
often leading to a bacteraemic phase, involving primarily enteric Gram-negative coliforms (eg E. coli)
or transient Gram-negative bacilli such as Pseudomonas aeruginosa; followed in those who survive sepsis following rupture of the appendix include
by a second polymicrobial abscess phase in which obligate anaerobes such as Bacteroides fragilis 1: ciprofloxacin alone
and more aerotolerant gut bacteria (eg coliforms) participate. Empiric antimicrobial regimens must 2: metronidazole plus cephalothin
take this proven sequence of events into consideration. Another important consideration, is that in a 3: metronidazole plus amoxycillin
patient following prolonged preoperative hospitalisation or following re-operation, more resistant 4: imipenem alone
microbes maybe implicated in the peritonitis, eg resistant Gram-negative bacilli, enterococci, yeasts
(eg Candida albicans). It must also be remembered that yeasts and enterococci increase in potential Answers: FFFT
significance with surgery, or leakage, involving the stomach or small intestine. In a 78-year-old
following previous hospitalisation, monotherapy with the likes of imipenem, meropenem or piperacillin/ Refer to Smith & Payne, ANZ Journal Surgery
tazobactam is adequate. This covers the important Gram-negative bacilli and obligate anaerobes.
Coamoxyclav lacks sufficient activity against Gram-negative bacilli and probably obligate anaerobes 19797 – Which one of the following antibiotic combinations is appropriate
in this situation (really only a second line anti-anaerobe drug), while cefuroxime plus metronidazole for treating peritonitis associated with a ruptured large bowel
lacks appropriate Gram-negative bacillus activity (metronidazole is fine for the obligate anaerobes). A. cefuroxime plus gentamicin
Pending review. Jan 2003 B. penicillin plus gentamicin plus ampicillin
C. metronidazole plus ampicillin
9800 – The following antibiotic regimen is considered adequate as D. metronidazole plus ciprofloxacin
prophylaxis for large bowel surgery E. cefuroxime plus gentamicin plus penicillin
1: cephazolin alone
2: cefoxitin alone Answer: D
3: flucloxacillin plus metronidazole
4: coamoxyclav (Augmentin) alone Syllabus Update - Microbiology Antibiotics in Surgery PAGE: m8 AUST. NZJ Surgery

911 – In sepsis following surgery for colon cancer eg Escherichia coli, which may adhere to any foreign material/implants. This group of microbes is
1: anaerobes are almost invariably involved in abscess formation. more significant in valve replacement rather than artery graft surgery. The antibiotic(s) to be used
2: benzyl penicillin (penicillin G) is an adequate therapeutic regimen. must therefore cover all types of staphylococci plus or minus Gram-negative coliforms. Second
3: the most common participating anaerobe is Clostridium perfringens. generation cephalosporins adequately fill this role (eg cefamandole, cefuroxime), although most
4: early onset bacteraemias commonly involve Escherichia coli. consider the first generation cephazolin (slightly less coliform activity than second generation
compounds) also acceptable in artery graft procedures. While most surgical antibiotic prophylaxis is
Answers: TFFT now given parenterally at the induction of anaesthesia (ie around 20 minutes before incision) some
institutions favour oral administration (which is clearly cheaper). However, the timing of any orally
Sepsis following surgery for colonic cancer is often associated with anastomotic leakage and can administered drug is critical, as maximum levels of drug must be present in the tissues to be involved
present early with abdominal signs or bacteraemia, or later with abscess formation. Sepsis is (ie skin, heart, and arteries) at the time of incision. Clearly parenteral regimens offer more control on
commonly due to a mixture of organisms. Early onset bacteraemias commonly involve E.coli (4 this aspect of prophylaxis, and as demonstrated in the classical studies of Burke, must be given within
correct). Anaerobes are almost always involved in later abscess formation (1 correct), together with the 2-hour period proceeding operation. Significantly elevated levels of surgical-site sepsis are seen
other enteric bacteria. The most common participating anaerobes are obligate anaerobes such as B when intravenous antibiotics are given more than two hours before incision, or after commencement
fragilis (3 false). Penicillin G, although very effective against Clostridium perfringens, is not an of the operation.
adequate therapeutic agent in treating sepsis associated with colonic cancer (2 false); it is ineffective
against the most significant anaerobe B fragilis, which elaborates a B-lactamase (penicillinase). 13463 – S:In the prophylaxis of infection in patients having above-knee
Agents with a wide spectrum covering facultative enteric bacteria (E. coli etc) as well as obligate amputations for ischaemia metronidazole is the drug of choice
anaerobes, are required. because R:the most serious infection occurring after above-knee
25620 – For surgery involving insertion of an artificial hip amputations is caused by anaerobic organisms
1: antibiotic prophylaxis is not required
2: the principal infecting microbes are staphylococci
3: enteric Gram-negative coliforms occasionally result in significant post operative infection
Infections associated with above-knee amputations commonly involve bacteria acquired from the skin
4: the incidence of infective complications is low (generally less than 1%)
in the perianal region. Important examples are Staphylococcus aureus and bowel commensals such as
the anaerobe Clostridium perfringens ; the latter becomes especially important where devitalised and
Answers: FTTT
necrotic tissue is involved (eg trauma) and is the most serious infective consequence reported (R
C.S.S. 2ND ED. PAGE: 162 true). Such operations are a proven area for prophylaxis which should be with augmentin or
flucloxacillin which will cover both the S. aureus and clostridia. While benzyl penicillin alone could be
used, it does not cover possible S. aureus contamination although it is the drug of choice for clostridia.
8722 – Common pathogens found in intravenous catheter-associated The role of the anaerobic agent metronidazole in lower limb prophylaxis is as yet unknown; however,
sepsis include it does not have effective staphylococcal activity. Better choices are available (S false). The use of
1: Streptococcus pyogenes benzyl penicillin with flucloxacillin (to cover clostridia and S. aureus respectively) is unwarranted as
2: Staphylococcus epidermidis flucloxacillin has adequate clostridial cover. Some texts may still (falsely) recommend such a
3: Bacteroides fragilis combination or even benzyl pencillin alone, which is inadequate cover against staphylococci.
4: Candida species Problems associated with infection by S. aureus should not be underestimated. Controversy still exists
over which pencillin(s) should be used.
Answers: FTFT
13451 – S:Alteration of the intestinal flora by some broad spectrum
Smith, Payne, Berne, Surgeon's Guide to Antimicrobial Chemotherapy, Ch 11; Smith & Payne,
Integrated Basic Surgical Sciences, Ch 37.2 antibiotics may increase the effect of anticoagulants because R:antibiotics
inhibit the synthesis of vitamin D absorbed from the gut
11748 – With antimicrobial prophylaxis for coronary artery graft surgery
1: parenteral antibiotics should be commenced 24 hours prior to surgery Answer: S is true & R is false
2: cefamandole is an acceptable choice
3: the antibiotic(s) used, must cover obligate anaerobes Prolonged use of some broad spectrum antibiotics can undoubtedly change and reduce the numbers
4: cover against coagulase-negative staphylococci must be included in the antibiotic(s) chosen of bacteria, eg Bacteroides fragilis found in the intestines. These anaerobes are normally responsible
for the synthesis of Vitamin K (S true), not Vitamin D which is formed exogenously (R false). Vitamin
Answers: FTFT K is used by the body in such processes as blood clotting. In some cases, additional dietary Vitamin K
as to be given to patients on long term antibiotics if bleeding problems are to be averted.
Coronary artery graft surgery is one of the recognised areas of 'clean' surgery where antibiotic
prophylaxis is warranted and proven. The most significant potential post-operative pathogens are 24129 – Features of antibiotic associated diarrhoea include that
staphylococci, both coagulase-negative (eg Staphylococcus epidermidis) and coagulase-positive (eg 1: it has been associated with almost all antibiotics
Staphylococcus aureus) species. Of more minor but still significant risk are Gram-negative coliforms, 2: it should be treated with intravenous vancomycin in severe cases
3: anticholinergic drugs should be avoided A. cis-platinum
4: it is due to overgrowth of Clostridium sporogenes B. bleomycin
C. nitrogen mustard
Answers: TFTF D. 5-fluoruracil
E. doxorubicin
C.S.S. 2nd ed. PAGE: 165,166
Answer: B
23689 – Antibiotics useful in the treatment of antibiotic associated
Refer to Robbins, 6th Ed, Ch 16, page 740. Pending review. Jan 2003
diarrhoea include
1: vancomycin
2: co-amoxyclav (augmentin) 8597 – Which of the following chemotherapeutic agents has cardiotoxicity
3: metronidazole as one of its important side effects?
4: ciprofloxacin A. doxorubicin
B. bleomycin
Answers: TFTF C. cis-platinum
D. methotrexate
C.S.S. 2nd ed. p 155/156, 166 Update pM27. This question was referred to the Pathology Sub E. 5-fluorouracil
Committee for review on 1 Feb 2002.
Answer: A
18249 – Which one of the following statements concerning overwhelming
postsplenectomy sepsis is most correct:
A. pneumococci and meningococci are the most common pathogens
B. it is seen in more than one fifth of patients who undergo splenectomy 25544 – Topical antibacterial agents for the treatment of burn wound
C. the majority of cases occur in the second year after splenectomy infections include
D. it can be prevented by leaving small parts of the spleen to regenerate 1: mupirocin (Bactroban)
E. adults are more prone to the syndrome than children 2: silver nitrate
3: mafenide (sulphamylon cream)
Answer: A 4: silver sulphadiazine
The most common pathogens are pneumococci and meningococci (A). All the other responses are Answers: TTTT
incorrect.
Update - Microbiology Basic Principles - PAGE: P M22-23
22003 – Azathioprine
1: metabolism is inhibited by allopurinol 22619 – Neostigmine is an anticholinesterase
2: can be hepato-toxic 1: used to reverse the effect of non-competitive neuromuscular blockers
3: suppresses the bone marrow 2: whose side-effects may be prevented by co-administration with atropine
4: is a folic acid antagonist 3: whose action would be antagonistic to that of suxamethonium
4: used to improve neuromuscular transmission
Answers: TTTF
Answers: FTFT
Pharmacology Textbook 4th ed. Rang, Dale & Ritter Page: 243
A.C.P. 1996. Pending review. Jan 2003
20763 – S. Cyclosporin A suppresses the activity of some T helper and
cytotoxic lymphocytes BECAUSE R. Cyclosporin A blocks the synthesis of 19414 – Suxemethonium is a neuromuscular blocker which may produce
A. hypothermia
nucleic acids by its antimetabolite actions
B. tachycardia
C. hyperkalaemia
D. respiratory alkalosis
E. CNS stimulation
Syllabus Extension & Update ACP1 - ACP39
Answer: C
14004 – Which of the following chemotherapeutic agents may result in a
fatal pulmonary reaction? Syllabus Extension & Update ACP1 - ACP39
E. Give a 10 day course of subcutaneous heparin, starting at premedication
8747 – Digoxin is more likely to cause symptoms of toxicity in the
1: patient with renal failure Answer: C
2: elderly patient
3: patient with hypokalaemia Any action taken to reduce the risk of post-operative venous thrombo-embolic problems will be
4: patient on amiloride related to the presence of any risk factors. The patient described in this scenario has a total number
of three risk factors, namely a past history of deep venous thrombosis (weighting 2) and she is about
Answers: TTTF to undergo a laparoscopic procedure (weighting 1). She is classified as low risk and use of anti-
embolism stockings or a low molecular weight heparin given subcutaneously is sufficient prophylaxis
Integrated Basic Surgical Sciences, Ch 37; STEM Module: Pharmacology (C is correct, D is incorrect). The subcutaneous heparin would only need to be continued until the
patient was mobile (E is incorrect). Intravenous heparin would be more suitable for a high risk patient,
particularly one who had been on warfarin before the operation. The dose mentioned is in any event
21798 – The following are results from a patient with worsening cardiac
therapeutic rather than prophylactic (B is incorrect).
failure serum creatinine 0.20 mmol/L (reference range 0.05-0.11) serum There would be few circumstances where warfarin would be commenced immediately after an
potassium 3.0 mmol/L (reference range 3.4 -4.5 ) serum alanine operation. If a patient had been on warfarin immediately prior to surgery, it would almost certainly
transaminase 100 U/L (reference range < 40 ) serum digoxin (12 hour 1.5 have been stopped and the anticoagulation maintained in the interim with heparin. It is easier to
?g/L (reference range 1.0 -2.0 )post dose) reverse the effects of heparin than warfarin (A is incorrect).
1: peak serum digoxin concentration would better reflect clinical status
2: the patient may have a bradyarrhythmia 22098 – The side effects of prednisolone include
3: clearance of digoxin will be enhanced 1: cataract formation
4: the patient may be clinically digoxin toxic 2: peptic ulceration
3: growth retardation
Answers: FTFT 4: skin striae
A.C.P. 1996 Answers: TTTT
ACP 1996
18213 – You are admitting a 70 year old man for an anterior resection of the
rectum for carcinoma. He is otherwise in good health. What is the MOST 19162 – The side effects of prednisolone include
appropriate DVT prophylaxis? A. osteopetrosis
A. Early mobilisation alone B. hypernatremia
B. Heparin (unfractionated UFH or low molecular weight MWH) pre-operatively and until fully mobile. C. diabetes insipidus
C. Anti-embolus stockings and heparin (UFH or LMWH) pre-operatively and until fully mobile plus D. hyperkalaemia
pneumatic compression in theatre. E. cerebral calcification
D. Aspirin 100mg bd commencing one week before operation
E. An infusion of 500ml of dextran solution (Macrodex) over the period of surgery Answer: B
Answer: C ACP 1-39
This is a high-risk patient (cancer, age 70). Early ambulation, aspirin and Macrodex infusion may be 23259 – The side effects of prednisolone include
appropriate but each is inadequate as sole prophylaxis. The combination of heparin until mobile,
1: diabetes insipidus
stockings and pneumatic compression (C) gives best protection of those listed. Pending review. Jan
2: pancreatitis
2003.
3: hypotension
4: necrosis of the head of the femur
18298 – A 32-year-old woman with gallstones is admitted for an elective
cholecystectomy. After the birth of her daughter three years ago she Answers: FTFT
suffered a deep venous thrombosis in her left calf. At operation you plan to
use pneumatic calf compression devices. What additional course of action ACP 1996
would be most appropriate? 21868 – Lignocaine is a local anaesthetic
A. Start on warfarin immediately after the operation
1: which is pharmacologically active as the cation
B. Give intravenous heparin 1000 units/hr with the premedication and continue until mobile
2: which is hydrolysed by plasma cholinesterase
C. Use anti-embolism stockings and apply from the time of premedication
3: whose duration of effect is terminated by metabolism
D. No specific measures need to be taken other than early mobilisation
4: whose efficacy is enhanced by low tissue pH recently commenced on azathioprine, in an attempt to limit her reliance on
steroids. On examination the appearances of her skin which would be
Answers: TFFF
consistent with long term glucocorticoid use include
ACP 1: thin skin
2: bruising
19779 – The following drugs are competitive inhibitors of the named 3: acne
4: hirsutism
enzyme EXCEPT
A. Warfarin: Vitamin K reductase Answers: TTTT
B. Simvastatin: HMG-CoA reductase
C. Captopril: Angiotensin converting enzyme All features are consistent with glucocorticosteroid use and they can all contribute to the major
D. Aspirin: Cyclo-oxygenase subjective dissatisfaction in some patients. Wound healing could also be delayed in this patient due to
E. Neostigmine: Acetyl cholinesterase steroid use. Other changes in physical appearance which are common with long term and/or high
dose glucocorticoid use include the ‘Cushinoid’ appearances of ‘moon facies’, redistribution of
Answer: D adipose tissue (centripetally) to give the ‘buffalo hump’ at the back of the neck, and the thinning of the
limbs.
ACP 1996
25946 – Ms SLE (30 years of age) has asceptic necrosis of the head of the
19713 – A patient who weighs 50 Kg is fitting. Given the following right femur. She has been taking prednisone (20 mg/day) for 5 years and
pharmacokinetic parameters of phenytoin, what is the correct loading dose has used various NSAIDs (currently she is taking ketoprofen). She was
for this patient, in order to give a plasma concentration of 40 micro mol/L recently commenced on azathioprine, in an attempt to limit her reliance on
(10 mg/L)? Vol of distribution = 0.65 L/Kg Therapeutic range = 40 - 80 micro steroids. Important side effects of glucocorticoids include
mol/L(10 - 20 mg/L) 1: pathological fractures
A. 32.5 mg 2: retinal detachment
B. 65 mg 3: pancreatitis
C. 190 mg 4: hypertension
D. 325 mg
E. 650 mg Answers: TFTT
Answer: D Pathological fractures are one of the manifestations of the effect of corticosteroids on protein
synthesis. Other examples would include the proximal myopathy of the limb girdles, the thinning of
A.C.P. the skin (made more apparent by loss of subcutaneous fat in the limbs), cataracts, and delay in
healing. Changes in calcium balance associated with steroid use would also contribute to the
23029 – In a patient who has been receiving gentamicin 80 mg. tds for 5 pathological fractures. The major side-effects of steroids seen in the eye are cataract formation and
days, and whose investigation yields the following results serum creatinine glaucoma. The underlying pathology of steroids causing pancreatitis is not understood. Not all
0.20 mmol/L (reference range 0.05 - 0.11) serum potassium 5.0 mmol/L patients appear to have developed the severe diabetes mellitus or hyperlipidaemia which may
predispose to its occurrence. Pending review. Feb 2002
(reference range 3.4 - 4.5)serum HCO\p-\b3 17 mmol/L (reference range 25 -
35) serum gentamicin 4.0 mg/L (reference range <2.5)(trough) . 25941 – Ms SLE (30 years of age) has asceptic necrosis of the head of the
1: a likely clinical diagnosis is acute tubular necrosis secondary to gentamicin toxicity right femur. She has been taking prednisone (20 mg/day) for 5 years and
2: a peak (30 min post dose) gentamicin concentration is necessary to confirm the diagnosis
3: gentamicin dosing of 240 mg. mane is less likely to produce these clinical results has used various NSAIDs (currently she is taking ketoprofen). She was
4: administration of intravenous HCO\p-\b3 is necessary to correct the acidosis recently commenced on azathioprine, in an attempt to limit her reliance on
steroids. Laboratory investigations consistent with prednisone use would
Answers: TFTF include
1: polycythaemia
A.C.P. 1996 Page: 1-39
2: hypernatraemia
3: hypoglycaemia
25936 – Ms SLE (30 years of age) has asceptic necrosis of the head of the 4: hyperbilirubinaemia
right femur. She has been taking prednisone (20 mg/day) for 5 years and
has used various NSAIDs (currently she is taking ketoprofen). She was Answers: TTFF

Bone marrow stem cells including those of the erythroid series are stimulated by glucocorticoids, and
in bone marrow aplasia for instance high dose steroid therapy may be initiated. Answers: TFFT
Prednisone is metabolised to prednisolone which has substantial agonist properties on the
mineralocorticoid receptors of the renal tubules. Although marked hypernatraemia is unusual in these Both suxamethonium and mivacurium are metabolised by plasma (pseudo) cholinesterase, the
patients it can occur, and one would anticipate there should be a relative hypokalaemia synthesis of which is decreased in liver disease. Atracurium usually has a short duration of action
accompanying it. Hyperglycaemia and glucose intolerance due to insulin resistance are common in because it undergoes spontaneous nonenzymatic rearrangement (Hoffman reaction) in plasma.
patients on high dose glucocorticoids. In cases when very high doses are being used, such as part of Gallamine is excreted almost entirely by the kidney.
chemotherapy regimes, it may be necessary to use insulin. Unlike the oestrogenic and androgenic
steroids, glucocorticoids per se do not cause hepatic dysfunction. 25931 – Mr CC has cryptogenic cirrhosis and is admitted with peritonitis,
for which an exploratory laparotomy is necessary. If this patient developed
23814 – A woman being assessed for hip replacement has been taking oral cardiac failure and dysrhythmias post-operatively what would be the effect
prednisone (5-10 mg/day) for 5 years as part of her management for chronic on the following drugs?
obstructive airways disease. The following clinical and laboratory findings 1: the half-life of digoxin would be increased
would be consistent with her steroid use 2: the clearance of lignocaine would be increased
1: hyperkalaemia 3: the half-life of vancomycin would be decreased
2: neutropenia 4: the clearance of metronidazole would be decreased
3: glaucoma
4: hyperglycaemia Answers: TFFF
Answers: FFTT Significant cardiac failure causes decreased perfusion of both the kidney and the liver. Plasma half-
life is a pharmacokinetic function dependent upon the rate of clearance of a compound. Whether
ACP decreased liver perfusion has an effect upon hepatic clearance depends upon whether the drug has a
high liver extraction and flow-dependent clearance (eg diltiazem, lignocaine, imiprimine, midazolam,
25926 – Mr CC has cryptogenic cirrhosis and is admitted with peritonitis, morphine, naloxone). For a drug with a high extraction ratio, changes due to enzyme induction or
for which an exploratory laparotomy is necessary. Which of the following hepatic disease should have little effect. Whilst metronidazole is metabolised in the liver, its clearance
is not flow dependent and cardiac failure will not significantly alter its half-life. Likewise changes in
drugs would have significantly altered clearance in this patient because of plasma protein binding should have little influence on a flow-dependent drug. This can be compared
his cirrhosis? with drugs which have low extraction ratios in the liver, and whose clearance will be significantly
1: Frusemide affected by changes in intrinsic clearance such as enzyme induction or inhibition, and by protein
2: Paracetamol binding (eg phenytoin, salicylic acid and warfarin).
3: Aspirin
4: Gentamicin Digoxin’s clearance is predominantly renal, both glomerular filtration and some active secretion down
the pathways for basic compounds. Its half-life is significantly increased by both decreased perfusion
Answers: FTTF of the kidney and by glomerular loss such as occurs with age. Vancomycin’s excretion entirely
depends upon glomerular filtration, and with the increase in half-life which would occur in cardiac
Aspirin (acetylsalicylic acid) is metabolised by plasma esterases to salicylic acid, which in turn is failure, the risk of toxicity is increased. Plasma level monitoring is therefore important.
metabolised and conjugated in the liver. It has a saturable metabolism, and the half-life is increased in
cirrhosis, particularly if there is significant intra-hepatic shunting. Paracetamol is usually cleared by
conjugation in the liver, but if this pathway is saturated, the excess is metabolised by the cytochrome IMMUNOLOGY
P450 system. In severe liver cirrhosis, with a decrease in liver cell mass the toxicity of paracetamol is
significantly increased at doses of paracetamol usually considered to be without significant side- 8682 – Concerning the major histocompatibility complex (MHC)
effects, and hepatic necrosis can occur at total doses of less than 10 g. 1: class I MHC molecules include complement components
Gentamicin is excreted by the kidney, and frusemide also is excreted mainly by the kidney. 2: class II MHC products are transmembrane heterodimers
3: class II MHC molecules are normally expressed on all cells in the body
25921 – Mr CC has cryptogenic cirrhosis and is admitted with peritonitis, 4: class III products include heat shock proteins
for which an exploratory laparotomy is necessary. The use of the following
Answers: FTFT
drugs during anaesthesia may lead to prolonged neuromuscular blockade
in this man Roitt Essential Immunology, 9th ed, Ch 4
1: Suxamethonium
2: Atracurium 25412 – Regarding the major histocompatibility complex
3: Gallamine 1: the genes are found within the cell cytoplasm as nucleosomes
4: Mivacurium 2: there are 3 classes of antigens (MHC I, II & III)
3: the genes show co-dominant expression 2: contains both intrachain and interchain disulphide bonds
4: beta-2 microglobulin is part of the MHC class II complex 3: consists of a number of domains with a helical secondary structure
4: consists of equal numbers of heavy and light chains
Answers: FTTF
Answers: FTFT
Roitt 9th ed. Pages: 72-77. This question is currently under review by the Pathology Sub Committee.
23 August, 2001. Question updated 14 March 2002. Refer to Roitt, 9th Ed, Part 2, page 44 and following
14716 – The genes for the human major histocompatibility complex (MHC) 25299 – Cytotoxic T lymphocytes are
1: include some genes which are invariant in structure 1: capable of killing virus infected cells
2: are usually grouped into three classes 2: characterised by the CD8 surface marker
3: are found on chromosome 7 in humans 3: less susceptible to HIV infection than T4 (CD4) positive cells
4: may be switched off by cyclosporin A 4: unable to recognise antigen associated with class II MHC
Answers: TTFF Answers: TTTT
Refer to Roitt, 9th Ed, Part 4, 6, page 71-72, 365 Roitt 9th ed. Page: 188-189 Robbins 5th ed. Page: 222
25442 – Regarding the Class II antigens of the major histocompatibility 25976 – Resting, mature human T lymphocytes express
complex 1: the CD3 molecule on their surface
1: their tissue distribution is normally more limited than that of the Class I antigens 2: MHC Class I on their surface
2: tissue typing for Class II antigens may be carried out by the polymerase chain reaction (PCR) 3: Epstein Barr virus receptors
3: the expression of Class II antigens can be increased by a variety of stimuli 4: MHC Class II on their surface
4: they are exemplified by HLA-DP, DQ and DR antigens
Answers: TTFF
Answers: TTTT
Roitt 9th Edition Pages: 151-152; 163-165
Roitt 8th ed. PAGE: 72; 77; 345
25283 – Activation of B lymphocytes by thymus-dependent antigens
15152 – Regarding the Class II antigens of the major histocompatibility requires all of the following EXCEPT
complex A. T cells expressing CD8 surface marker
1: HLA-DR antigens are normally expressed on all circulating human lymphocytes B. T cells expressing CD3 surface marker
2: Class II antigens are associated on the cell surface withbeta-2 microglobulin C. processing of antigen and presentation of antigenic peptides bound to MHC class II antigens
3: HLA-A and HLA-B are categorised as Class II antigens D. T cells expressing T cell receptors
4: the tissue distribution of Class II antigens is more limited than that of Class I antigens E. costimulation through CD40L/CD40 interactions
Answers: FFFT Answer: A
Refer to Roitt, 9th Ed, page 71-79 Roitt 9th ed. Pages: 177-178
25304 – The constant region of an antibody heavy chain 25309 – T lymphocytes are characterised by
1: determines the idiotype of the antibody 1: the ability to differentiate into plasma cells
2: determines the avidity of antigen binding 2: surface CD3 molecules
3: determines the half-life 3: surface Epstein Barr Virus receptors
4: determines the ability of the antibody to cross the placenta 4: maturation in the thymus during early development
Answers: FFTT Answers: FTFT
Roitt 8th ed. Pages: 49-51, 54 Essential Immunology 8th ed. Pages: 169; 33; 35
14706 – A typical immunoglobulin molecule 25294 – During the maturation of T lymphocytes in the thymus
1: is able to bind to only one antigen via its Fc fragment 1: rearrangement of T cell receptor genes takes place
2: some cells express the CD4 and CD8 surface markers at the same time
3: clones of cells which are self-reactive are eliminated or inactivated 1: HLA-DR antigens
4: active proliferation of immature T cells takes place 2: HLA Class III antigens
3: ABO blood group antigens
Answers: TTTT 4: rhesus blood group antigens
Roitt 9th ed. Page: 229-231 Answers: TFTF
25395 – In primary T cell immunodeficiency (Di George syndrome) Roitt 9th ed. Page: 359-363
A. affected infants have prominent lymphoid follicles in lymph nodes
B. there is commonly an association with hypothyroidism 13427 – S:Among the immunoglobulins only IgA and IgM characteristically
C. common bacterial infections are often fatal include J chains because R:J chains are found in those immunoglobulins
D. the paracortex of the lymph node is often expanded which exist in the monomeric form
E. partial Di George syndrome is more common than the complete syndrome
Answer: E
The J chain in the immunoglobulin molecule binds together two or more immunoglobulin monomers,
Roitt 8th ed. PAGE: 299-300
and is found only in those immunoglobulin molecules that exist in polymeric form (R false). These are
IgA, a dimer in external secretions and IgM, usually a pentamer (S true).
8677 – Type I (anaphylactic) hypersensitivity is associated with
1: degranulation of mast cells 8672 – Secretory component is added to IgA dimers within
2: positive "wheal and flare" reaction to intradermal antigen
1: colonic epithelium
3: complement activation
2: plasma cells
4: raised serum IgE
3: B lymphocytes
4: bronchial epithelium
Answers: TTFT
Answers: TFFT
Roitt, 9th ed, Ch 16
Roitt, 9th ed, Ch 3
25380 – The deleterious effects of immune complex-mediated
hypersensitivity can be attributed to 25334 – Genes which are important in determining the molecular structure
1: release of vasoactive amines of antibodies include
2: interaction between IgE and antigen
1: V genes
3: acute inflammation
2: D genes
4: platelet aggregation
3: C genes
4: J genes
Answers: TFTT
Answers: TTTT
Roitt 8th ed. Page: 326, 313
Roitt 8th ed. Page: 47
15248 – Hyperacute rejection of renal grafts is typically due to
A. cytotoxic T cells
8667 – In a primary immune response, B lymphocyte activation and clonal
B. immunological enhancement
C. humoral antibodies expansion is usually dependent on
D. blood borne infection 1: processing of antigen by antigen presenting cells
E. delayed type hypersensitivity 2: expression of surface Ig on the B cell membrane
3: increased expression of MHC Class II on the B cell surface
Answer: C 4: co-recognition of antigen by a T-helper cell
Refer to Roitt, 9th Ed, page 377 Answers: TTTT
Roitt Essential Immunology, 9th ed, Ch 9

25432 – In organ transplantation, antigens likely to cause a strong rejection
reaction if mismatched include 25401 – Recognised immunological reactions to drugs include
1: IgE mediated hypersensitivity 3: normally found on all nucleated cells in the body
2: immune complex disease 4: important in the presentation of antigenic peptides to T lymphocytes
3: delayed type hypersensitivity
4: auto-immune reactions Answers: FFFT
Answers: TTTT Roitt 9th ed. Pages: 71-79
Robbins 4th ed. Page: 176, 179, 182, 191 14701 – The CD3 (T3) molecule on human lymphocytes is
1: expressed by all T lymphocytes
14711 – A well-matched thymus transplant could be expected to correct the 2: common to all blood leucocytes
immunodeficiency in 3: associated with the T cell receptor for antigen
1: a severe radiation accident 4: a Class 1 antigen of the major histocompatibility complex
2: severe combined immunodeficiency (Swiss type)
3: Di George syndrome Answers: TFTF
4: dysgammaglobulinaemia
Refer to Roitt, 9th Ed, Part 4, page 152, 168
Answers: FFTF
15533 – Which of the following pairs is/are very likely (more than 95%) to
Refer to Roitt, 9th Ed, page 315-316 have one HLA haplotype in common
1: grandmother and grandson
25437 – Regarding the HLA haplotype 2: brother and sister
1: it refers to the HLA antigens on one chromosome 3: first cousins
2: a parent will characteristically have one haplotype in common with each child 4: father and son
3: the genotype comprises 2 haplotypes
4: full siblings have a 1:4 chance of being haplo-identical Answers: FFFT
Answers: TTTT Refer to Roitt, 9th Ed, page 262
Roitt 7th Edition PAGE 284-285 9040 – Human immunodeficiency virus (HIV)
1: may cause a latent infection lasting many years
25453 – Routine HLA typing utilises 2: is easily transmitted by casual personal contact
1: complement dependent cytotoxicity 3: infects cells which express CD8
2: dye uptake as an indication of cell death 4: has a genome consisting of a single strand of DNA
3: mixed lymphocyte reaction
4: polymerase chain reaction Answers: TFFF
Answers: TTTT Robbins, 6th ed, Ch 7
Roitt 8th ed. PAGE: 282-285 14803 – Human immunodeficiency virus (HIV)
1: is a DNA-containing virus
25417 – Which of the following cells carry HLA-A and HLA-B antigens? 2: consists of at least 2 strains
1: B lymphocytes 3: shows tropism for CD8-bearing cells
2: neutrophil leucocytes 4: is readily transmissible by casual non-sexual contact
3: T lymphocytes
4: macrophages Answers: FTFF
Answers: TTTT Refer to Robbins, 6th Ed, Ch 7, page 238-239
Roitt Essential Immunology 9th ed. Page: 77 8712 – Compared to human immunodeficiency virus (HIV), hepatitis B virus
is more
25464 – Class II HLA antigens are 1: resistant to environmental inactivation
1: made up of one alpha chain and one molecule of beta-2-microglobulin 2: likely to undergo genetic change
2: closely associated with the CD3 molecule on resting T lymphocytes
3: likely to cause immunosuppression where it acts as a c-oncogene (eg too near an ‘activator’ gene or too distant from a
4: easily controlled by vaccination ‘controller/suppressor’ gene).
Answers: TFFT 15955 – Defence mechanisms primarily responsible for curing a primary
viral infection include
Robbins, 6th ed, Ch 19; Smith & Payne, Integrated Basic Surgical Sciences, Ch 37.2
1: Tc lymphocyte destruction of infected host cells
2: NK lymphocyte destruction of infected host cells
25406 – Infection with human immunodeficiency virus (HIV) is 3: TH1 cell lymphokine production
characterised by 4: IgG or IgM mediated inactivation of free virus
A. an early acute viral infection
B. an early drop in CD8 positive T lymphocytes Answers: TTTT
C. a positive Mantoux test throughout the illness
D. circulating viral DNA in the peripheral blood Refer Really Essential Medical Immunology, Roitt & Rabson pp99-103, particularly summary on p103.
E. depressed serum immunoglobulin levels NK lymphocytes are the first innate cellular defence in viral infection. Activated (ie specifically APC-
cell primed by the Ag epitope-MHC-I presentation and TH help) Tc cells are the ‘rooters out’ of the
Answer: A virus within infected cells. Both kill the infected host cell. Ig (any) inactivates free virus or virions
liberated by cell lysis. (Interferon helps prevent new cell infection etc). Monocyte activation (by TH1
Roitt 8th ed. Pages: 310-311; 308 lymphocytes) is probably not primal in defence but probably carries out eventual viral/Ig complex
degradation. This question has been reviewed. The relevant reference information has been added.
25365 – The immune response leading to recovery from infection with This question has been updated. 22 Nov 2002.
Mycobacterium tuberculosis
1: is characterised by large amounts of antibody production 25469 – An increase in serum levels of a single homogeneous
2: involves activation of macrophages immunoglobulin or its fragments (paraproteinaemia) is commonly
3: characteristically involves the formation of granulation tissue associated with
4: involves production of interferon gamma by T lymphocytes 1: Hodgkin's lymphoma
2: Waldenstrom's macroglobulinaemia
Answers: FTFT 3: multiple myeloma
4: AA type amyloidosis
Roitt 9th ed. Pages: 269-271
Answers: FTTF
25385 – Immune complexes are frequently responsible for
1: acute vasculitis Robbins 5th ed. Pages: 662-663
2: renal lesions in systemic lupus erythematosus
3: farmer's lung 21793 – In viral infection, immunoglobulins
4: serum sickness 1: induce the characteristic symptoms of the disease by reacting with the virus
2: may prevent entry of virus through mucous membranes
Answers: TTTT 3: facilitate viral uncoating thus rendering them susceptible to inactivation
4: inactivate viruses circulating in the bloodstream
Robbins Pathologic Basis of Disease 5th ed. Pages: 184; 202
Answers: FTFT
16947 – RNA oncogenic viruses
1: are causally involved in the genesis of many human cancers Robbins 6th ed. Chapter: 9 Page: 340-341
2: can convert normal host cell proto-oncogenes into oncogenes (c-oncogenes)
3: form templates for DNA transcription within the host cell
4: usually splice directly into host genome before activation GENETICS
Answer: FTTF 19755 – During the replication of DNA
A. introns are spliced out of the DNA molecule
Only human T cell leukaemia virus (HTLV-1) which is, like HIV, strongly tropic for T4/TH cells, has B. mutations arising in a non-coding region are clinically unimportant
been implicated in causing human cancer, although there are heaps of animal counterparts. They act C. deletion of a whole gene will always be detectable by karyotype analysis
as oncogenic viruses by incorporating a copy DNA (ie. mirror image of virus RNA structure [response D. point mutations may result in an abnormally short protein chain
3, but not 4]) into host genome. They can (indirectly) then activate host proto- c- E. RNA polymerase is important in the replication process
oncogenes or possibly splice in a DNA copy identical to a host proto-oncogene into the wrong place
Answer: D C. Genomic imprinting
D. Deletions
Robbins 5th ed. Pages: 153; 126 Selected Topics D3-D5 E. Triplet repeat mutations
9750 – Aneuploidy Answer: C

1: may be detected by karyotyping
2: is characterised by the formation of a ring chromosome 18820 – The most usual chromosome complement in Klinefelter's
3: rarely arises during the first meiotic division syndrome is
4: in tumour cells may be detected by flow cytometry A. 44 autosomes plus XXY
B. 44 autosomes plus XY
Answers: TFFT C. 45 autosomes plus XXY
D. 44 autosomes plus XO
Robbins, 6th ed, Ch 6 E. 43 autosomes plus XXY
12949 – Aneuploidy describes the chromosomal abnormality in Answer: A

1: most patients with Down's syndrome
2: all trisomy syndrome Robbins 5th ed. Page: 159
3: Turner's syndrome
4: poly-X females 10330 – What type of underlying genetic abnormality is most commonly
seen with cystic fibrosis
Answers: TTTT
A. Point mutations
B. Gonadal mosaicism
Aneuploidy refers to a chromosome number different from the normal or euploid number. Aneuploid
C. Genomic imprinting
cells may have more or fewer chromosomes than normal. In man normal diploid cells have 46
D. Deletions
chromosomes. Most patients with Down's syndrome have trisomy of chromosome 21 (A true).
E. Triplet repeat mutations
Turner's syndrome occurs in females who have a single X chromosome (XO) instead of the normal
XX (C true). X chromosomes in excess of normal are compatible with life, and are found in poly-X
Answer: D
females (D true).
21758 – Down's syndrome due to trisomy 21 10324 – What type of underlying genetic abnormality is most commonly
1: is most commonly caused by meiotic nondysjunction seen with osteogenesis imperfecta
2: is associated with an increased incidence of childhood leukaemia A. Point mutations
3: is the commonest form of autosomal trisomy B. Gonadal mosaicism
4: in milder cases may be associated with mosaicism C. Genomic imprinting
D. Deletions
Answers: TTTT E. Triplet repeat mutations
Robbins 6th ed. Pages: 170-1 Answer: B
22444 – In Turner's syndrome 10342 – What type of underlying genetic abnormality is most commonly
1: the individual may show mosaicism with respect to the sex chromosomes seen with beta-thalassaemia
2: the condition is unlikely to be due to nondysjunction A. Point mutations
3: the condition is not likely to be due to a balanced reciprocal translocation B. Gonadal mosaicism
4: most fetuses survive to birth C. Genomic imprinting
D. Deletions
Answers: TFTF E. Triplet repeat mutations
Robbins 5th ed. Pages: 160-161; 152 Answer: A
10336 – What type of underlying genetic abnormality is most commonly Annotated answer to come. This question is currently under review by the Pathology Sub Committee.
23 August, 2001. Question updated 14 March 2002.
seen with Angelman syndrome
A. Point mutations
B. Gonadal mosaicism 23969 – In an individual with sickle cell trait (heterozygote)
1: an abnormal haemoglobin is synthesized 1: The disease occurs more frequently in the children of an affected person than among the
2: the haemoglobin precipitates at high oxygen concentrations grandchildren.
3: there is only mild likelihood of vascular occlusions 2: The incidence of the disease in the population is 3% and is 50% in the offspring of the affected
4: haemolytic crises are a prominent feature person.
3: The risk of developing the disease is greater if both parents are affected than if only one parent is
Answers: TFTF affected.
4: The disease occurs more frequently in women than in men.
Robbins 5th ed. Chapter: 13 Pages: NOT GIVE
Answers: TFTT
10356 – What type of underlying genetic abnormality is most commonly
seen with Fragile x syndrome 22439 – Diseases inherited as autosomal recessive include
A. Point mutations 1: cystic fibrosis
B. Gonadal mosaicism 2: achondroplasia
C. Genomic imprinting 3: sickle cell anaemia
D. Deletions 4: congenital agammaglobulinaemia
E. Triplet repeat mutations
Answers: TFTF
Answer: E
Robbins 6th ed. Pages: 145
9025 – The relevant gene is on the X chromosome in
1: familial polyposis coli 24024 – In disorders inherited by autosomal recessive inheritance
2: glucose 6-phosphate dehydrogenase deficiency 1: enzyme proteins are often affected
3: haemophilia B 2: heterozygotes produce insignificant amounts of normal enzyme
4: haemophilia A 3: complete penetrance is rare
4: onset is often early in life
Answers: FTTT
Answers: TFFT
23684 – Concerning familial hypercholesterolaemia
1: there is a mutation in the gene for high-density lipoprotein receptor 12964 – In diseases with an autosomal recessive inheritance, typically,
2: it is inherited as an autosomal dominant condition 1: all children of an affected parent will be carriers
3: the relevant gene is on chromosome 19 2: the parents of an affected individual usually appear normal
4: almost all cases have been shown to have the same mutation 3: the birth of an affected child is usually the first indication of the disease in a family
4: both of the parents have transmitted the disease
Answers: FTTF
Answers: TTTT
Robbins 6th ed. Pages: 145, 150-153. This question is currently under review by the Pathology Sub
Committee. 23 August, 2001. Question updated 14 March 2002 Recessive genes manifest their presence in the homozygous state, ie the relevant gene is present in
double dose. Homozygous patients will have received one copy of the gene from each of their
parents (D true), who are typically asymptomatic carriers (B true). They are usually unaware of their
23569 – In disorders with multifactorial inheritance
carrier state until they have produced an affected child (C true). All children of an affected parent will
1: mutations may be present in more than one gene
receive the relevant gene (since he/she is homozygous), and will typically be carriers (A true), though
2: the risk of recurrence in subsequent pregnancies is less than 10%
the parent's children could manifest the disease if the parent's partner also carried the relevant gene.
3: identical twins will show 100% concordance
This would not, however, be typical.
4: the severity of expression is constant for a given condition
Answers: TTFF 23294 – In a disease showing autosomal dominant inheritance

1: very few cases are due to de novo mutations
Robbins 4th ed. Pages: 154-155 2: the mutations usually involve enzyme proteins
3: the disease is not necessarily clinically apparent at birth
4: approximately half of the patient's children are likely to manifest the disease
10368 – The following characteristics suggest that the disease is inherited
as a multifactorial trait:
Answers: FFTT 13986 – S:The possession of an X chromosome in excess of the normal
complement is less harmful than the possession of an extra autosome
Robbins 6th ed. Page: 144-145
because R:only one X chromosome in a cell is functional
23759 – Single gene disorders with an autosomal dominant pattern of
inheritance
1: usually arise as new mutations Refer to Robbins, 6th Ed, Ch 6, page 173
2: almost always present in early childhood
3: commonly involve the genes for enzymes
17725 – S:Major karyotype/chromosomal abnormalities are not thought to
4: characteristically show variable expressivity
be a primary event in human neoplasms because R:in human neoplasms,
Answers: FFFT any karyotype abnormalities are uncommon and always variable within the
same tumour type.
Robbins 5th ed. Page: 128-129
16974 – S:The effects of carcinogenic initiators on DNA chemistry are
reversible because R:tumours do not eventuate if the subsequent See previous discussions.
promoter application is delayed.
17719 – S:Karyotype/chromosomal abnormalities are thought to be a
Answer: Both S and R are false primary event in development of many human neoplasms because R:in
certain types of human neoplasia, karyotype abnormality is non-random
This is central to the ‘initiator’ and ‘promoter’ model. Initiation is rapid, irreversible and has ‘memory’:
and common in that tumour type.
ie application of the promoter by appropriate method and amount is equally effective whether it
follows application of the initiator immediately, or after a delay. The action of the promoter is,
however, potentially reversible as shown by the fact that divided doses of promoter cannot be
separated by too long an interval, or the promoter effect is lost: ie some form of repair has occurred
‘Nonlethal genetic damage lies at the heart of carcinogenesis.’ Robbins 6th Ed Chapter 8, page 277.
between applications of the promoter.
‘... karyotypic alterations ... are found in many ... cancerous cells ... are gene changes present in all ‘
...With each passing year, it becomes more certain that the malignant cells of most types of human
24074 – Regarding single-gene (Mendelian) disorder cancers have chromosomal abnormalities and ... defects are consistent ‘’
1: X-linked disorders are the most common type The most common types of nonrandom structural abnormalities in tumour cells are:
2: mutations in structural genes are commonly transmitted as autosomal dominant (a) balanced translocations,
3: most X-linked disorders are codominant (b) chromosomal deletions, and
4: familial hypercholesterolaemia is caused by a mutation in the gene for a membrane receptor (c) cytogenetic manifestations of gene amplification.
Robbins 5th Edition, Chapter 7, page 258.
Answers: FTFT
19426 – In the case of a woman who is heterozygous for a recessive X-
linked disorder
15192 – Malignant conditions usually associated with chromosomal A. the abnormal allele is preferentially inactivated in her cells
B. the diagnosis can be made by chromosomal banding studies
translocation include C. the disorder may be partially expressed
1: medullary carcinoma of the thyroid D. all of her sons will be affected
2: chronic myeloid leukaemia E. Barr bodies will not be detectable
3: Burkitt's lymphoma
4: carcinoma of the breast Answer: C
Answers: FTTF Robbins 6th ed. Pages: 146
Refer to Robbins, 6th Ed, Ch 8, page 284-286 12536 – A young man is diagnosed as having red-green colour blindness.
Of his relatives, the one LEAST likely to carry (or to manifest the effects of)
the relevant gene is his
A. father

B. mother Answers: FTTF
C. maternal grandfather
D. maternal grandmother Refer to Robbins, 6th Ed, Ch 6, page 166-168
E. daughter
Answer: A NEOPLASIA
Red-green colour blindness is caused by a gene on the X chromosome. The young man in question 8742 – Paraneoplastic syndromes may
received his X chromosome from his mother (B false), and will transmit his own X chromosome to his 1: occur in the absence of a demonstrable primary neoplasm
daughters (E false), but not to his sons, who receive his Y chromosome. His mother presumably 2: mimic metastatic disease
received the gene either from her father (C false), who had the disease, or from her mother (D false), 3: include hypercalcaemia produced by skeletal metastasis
who was a carrier. The patient is male, so could not have received an X chromosome from his father 4: be due to hormones indigenous to the tissues of origin of the primary neoplasm
(A true).
Answers: TTFF
12954 – The term mutation includes
1: loss of a single nucleotide base Robbins, 6th ed, Ch 8
2: loss of a whole gene
3: addition of a single nucleotide base 16807 – In the following sequential developments in the 'metastatic,
4: substitution of one nucleotide base for another cascade' the second event to occur is
A. degradation of collagen and other matrix components
Answers: TTTT B. tumour embolisation
C. extravasation
The term mutation simply means a change in the genetic code. This can be effected by any of the D. carcinogenic cell transformation
means listed in the question. E. tumour cell interaction with platelets
21763 – The technique of Southern blot analysis Answer: A

1: involves separation of DNA sequences according to size
2: will not allow identification of heterozygote carriers of autosomal recessive disorders The ‘metastatic cascade’ concept is a useful one, in that it takes the whole process and itemises the
3: involves amplification of the target DNA sequence with DNA polymerase steps in sequence from cancer cell ‘initiation’ through the concepts of genetic instability, selection of
4: may be used to detect abnormalities due to point mutations ‘metastatic subclones’, the necessity for acquisition of new characteristics of cells to break down
extracellular matrix and so on. Detailed consideration of each of these areas is considered in
Answers: TFFT preceding or following sections of the same chapter.
Robbins 5th ed. Pages: 165-169 16033, 16819 – In the following steps in the ‘metastatic cascade’, the
second occurrence is
19126 – The polymerase chain reaction A. development of a ‘metastatic subclone’
A. involves amplification of the target DNA using an RNA primer B. extravasation
B. is a very sensitive technique for the detection of HIV C. expansion, growth and diversification
C. is an ideal quantitative test for the detection of amplified oncogenes D. passage through extracellular matrix
D. cannot detect the presence of an organism after the patient is symptomatic E. tumour cell embolus
E. can be used to detect increased transcription of a normal gene
Answer: A
Answer: B
The concept is, that before cancer cells can invade (or metastasise), there has to be: (1) initiation, (2)
Selected Topics: D13, D29-30. This question is currently under review by the Pathology Sub promotion, (3) proliferation (clonal expansion, growth) and diversification through subclone selection;
Committee. 23 August, 2001. Question updated 14 March 2002. via the inherent genetic instability of cancer cells, (4) selection of a ‘metastatic subclone’ (requires eg
laminin and fibronectin receptor elaboration, ECM protease synthesis etc, locomotion capability and
14696 – Fluorescence in situ hybridisation (FISH) perhaps chemotaxis), before any of the possible responses (D), (E) or (B) come onto the scene
1: generally requires induction of mitosis (these last three are in that order of events).
2: enhances karyotyping
3: can identify intragene deletion 16021 – In the following sequential developments in the 'metastatic,
4: requires repetitive use of individual DNA probes
cascade' the second event to occur is
A. degradation of collagen and other matrix components
B. tumour embolisation 16896, 22729 – Experimental studies have shown that human cancer cells,
C. extravasation when compared with normal tissues derived from labile cell populations
D. carcinogenic cell transformation
1: have a higher percentage of terminally maturing cells
E. tumour cell interaction with platelets
2: do not have a shorter cell cycle time
3: have a greater proportion of their cells in the replication cycle (growth fraction)
Answer: A
4: replicate at a rate in excess of most labile cell populations
The ‘metastatic cascade’ concept is a useful one, in that it takes the whole process and itemises the
Answers: FTFF
steps in sequence from cancer cell ‘initiation’ through the concepts of genetic instability, selection of
‘metastatic subclones’, the necessity for acquisition of new characteristics of cells to break down
Robbins 6th ed. Chapter: 7 Pages: 300-301. This is a difficult concept - as discussed in any treatise
extracellular matrix and so on. Detailed consideration of each of these areas is considered in
on neoplasia with which I am familiar. The points are valid - responses 1, 3 and 4 are false and 2 is
preceding or following sections of the same chapter.
correct - the explanations for continued growth are, however, not explored in depth and the bland
statement ?... there is an imbalance between cell production and cell loss ?? is meant to explain it all!
24019 – The kinetics of malignant growth include Perhaps a major factor here is that in normal epithelia (for example), mitosing cells are present only in
1: dependency between the growth fraction and the degree of inbalance between cell production and basal layers (skin or gut crypt) and the bulk of the epithelial cells are terminally maturing. In CIN, for
cell loss example, mitoses are present at all layers of dysplastic epithelium - I suspect that the cells being
2: a progressive increase in the proportion of cells actively cycling included for defining the ‘proliferative pool’ stacks the result. Perhaps more importantly, labile cells
3: tumour cell cycling time is often longer than for corresponding non-neoplastic cells such as granulocytes and gut epithelia have a very short life span - cancer cells may well be more
4: constant cell doubling time robust!
Answers: TFTF 16848 – There is a positive experimental and/or clinical correlation between
Robbins 5th ed. Page: 273 metastatic potential of cancer cells and their
1: elaboration of plasminogen activator
2: blockade of fibronectin receptors on tumour cells
13998 – A carcinoma 1 cm in diameter represents approximately how many
3: secretion of type IV collagenase
cell doublings? 4: density of laminin receptors
A. 30
B. 100 Answers: TFTT
C. 300
D. 1,000 Responses 2 and 4 (pages 303-4) relate to the important capacity of tumour cells to bind to collagen
E. 10,000 of basement membrane (type IV - laminin) and interstitium (type I - fibronectin). Blockade of receptors
will decrease metastatic potential (response 2); 1 and 3 refer to breakdown of intercellular matrix,
Answer: A which creates space for cancer cell invasion and probably also growth and chemotactic stimuli (for
stromal and perhaps also cancer cells). Experimental fibronectin receptor blockade (using an
Refer to Robbins, 6th Ed, Ch 8, page 300, Ch 7, page 273 analogue which occupies the receptor sites for laminin on tumour cells) inhibits lung metastases.
15187, 16843 – Using a standard accepted model of theoretical growth of a 16027 – Each of the following is true of carcinogenic initiation, except
cancer clone (30 doublings = 1 x 109 cells = 1 gram), this potential is never A. effects are rapid
achieved because cells are lost to the proliferative pool when they B. effects are reversible
1: enter the Go phase C. induces DNA alteration
2: are in the G1 phase D. has ‘memory’
3: enter the G2 phase E. can be active when given in divided doses
4: differentiate
Answer: B
Answers: TFFT
This deals with oncogenic initiation and promotion. It relates to chemical carcinogenesis but is
Refer to Robbins, 6th Ed, Ch 8, page 300-301. The ‘30 doublings = 109 cells = 1 gram; 10 more applicable, with modification, to radiation and viral oncogenesis. Rigid classification as 'complete'
doublings = 1012 = 1 kg = maximum possible tumour burden’ concept is alive and well! The question carcinogens (oncogens, but not oncogenes), initiators and promoters is conceptually useful, but not
asks for the reason(s) why that model is not applicable to clinical cancer. Cells in any of the G1, S, G2 always easy. The concept is that initiators damage DNA in a fashion which is not susceptible to repair
or M phases of the cell cycle are considered to be in the ‘proliferative pool’ by definition; in clinical (either widely, or in individuals with genetic defect in DNA repair capability). Promoters then
cancer, cells are lost to the proliferative pool for many reasons and cell proliferation is not apparently ‘push’ the cell the extra step(s) to uncontrolled growth. This is central to understanding
synchronous. Much of theoretical oncology deals with ‘models’ - try ‘Gompertzian growth curve’! oncogenesis.

23289 – Chemical carcinogens usually less promptly. Some are irreparable - these may lead to cell death or become the initial steps
1: are intrinsically electrophilic of oncogenesis. By implication, the same should be true for chemicals, but a direct and definitive
2: usually produce characteristic molecular fingerprints statement to this effect cannot be found in Robbins.
3: metabolism may be correlated with genetically determined enzyme levels
4: cause more cell necrosis than proliferation 22739 – DNA viral carcinogenesis
1: is usually a single step (single hit) process
Answers: TTTT 2: may act by neutralising the influence of growth-inhibiting gene(s)
3: may involve incorporation of viral oncogene into host DNA
Robbins 6th ed. Pages: 305-9 4: may activate growth-promoting gene(s)
17817 – S:Acquisition of the characteristics of ability to metastasise by Answers: FTTT

cancer cells is presumed to be dependent on multiple different mutations in
the cells because R:no single gene has thus far been discovered which
appears to code for metastasising behaviour by neoplastic cells. 17799 – S:Genes controlling apoptosis such as p53 are believed to be
important in controlling/preventing growth of potential cancer cells
because R:apoptosis genes arrest the mitotic process of cells with DNA
At present, no single ‘metastasis gene’ has been discovered. It is thought that such a ‘master gene’ damaged by mutagenic agents which allows time for DNA repair or, if repair
influencing metastatic (or, indeed, invasive) behaviour is unlikely, because each of these activities does not occur, induces cell autodestruction.
involves multiple, apparently individual, processes (eg adhesion, secretion of extracellular matrix-
digesting enzymes, locomotion etc). However, some experimental evidence does exist that some Answer: S is true, R is true and a valid explanation of S
genes act to specifically suppress one or more properties which are essential for metastasis. There is
some tantalising evidence that one such gene may operate in modulating metastasis behaviour in There is no evidence that p53 gene expression is necessary for normal cell division. Once cells are
human breast cancer. exposed to mutagenic agents such as chemicals or radiation, the p53 protein (normally with very
short half-life) is stabilised and accumulates in the nucleus, where it binds to DNA, causing cells to
16952, 22734 – Proto-oncogenes arrest in the G1 phase. This allows time for DNA repair mechanisms to work. If this does not occur,
1: are rendered incapable of transcribing growth-related proteins following chromosomal translocation the cell undergoes apoptotic death. p53 is widely active and has been dubbed ‘guardian of the
2: are, in the normal cell, inactive DNA sequences without physiological action genome’.
3: may be activated into functional oncogenes (c-onco-genes) by mutation of a specific gene site
4: may be activated by destruction of adjacent controller genes, which normally suppress their action 10362 – What is the most common genetic change underlying the
development of tumours?
Answers: FFTT
A. Somatic activation of the ras proto-oncogene
B. Activation of the c-myc gene by chromosomal rearrangement
Robbins 5th ed. Chapter: 7 Pages: 259 et seq. Response 1 is false; gene sequences may be
C. Inherited inactivation of the p53 gene
activated (removed from a ‘suppressor’ or inserted near an ‘activator’) by translocation. For response
D. Loss of the p53 gene by somatic mutation
2, proto-oncogenes are, in the normal cell, the activators and switches (‘on’ and ‘off’) for normal
E. Point mutation of the Rb gene
growth. Responses 3 and 4 outline two of the ways in which normal proto-oncogenes may be
influenced to become oncogenes (also referred to as c-oncogenes). [Cellular] oncogenes are
Answer: D
perverted proto-oncogenes (growth genes).
16795, 16968 – S:DNA damage by chemicals is not necessarily 25390 – Tumour necrosis factor
1: is synthesized by macrophages
carcinogenic because R:DNA damage can be repaired by cellular enzyme 2: is present in lower than normal amounts in HIV infected individuals
systems. 3: may induce acute phase protein synthesis in vascular endothelial cells
4: may be an important mediator in endotoxic shock
Answers: TFFT
Whether they act as complete, direct or indirect initiators, the action of carcinogenic initiators is
presumed to be because they cause permanent alteration to the DNA, by an action which is rapid and Roitt 9th ed. CHAPTER: 7 PAGE: 181 Robbins 5th ed. Page: 226
irreversible. It also has ‘memory’, in that a threshold dose is effective when given either in a single
dose or as divided doses. The written evidence for this statement and reason is, perhaps, not as 19761 – Tumour suppressor genes
direct as I would like. The evidence for repair of DNA following radiation injury is very strong. Single A. are commonly found to be mutated in the germ cells of cancer patients
strand breaks are rapidly repaired (within minutes) and double strand breaks may also be repaired, B. have no known physiologic function
C. are present in increased copy numbers in tumour cells Answer: S is true, R is true and a valid explanation of S
D. include p53 and the retinoblastoma gene
E. are each related to a specific type of tumour "Every human cancer that has been analysed reveals multiple genetic alterations involving activation
of several oncogenes and loss of two or more cancer suppressor genes. Each of these alterations
Answer: D represents a crucial step in the progression from a normal cell to a malignant tumour." - Robbins.
Robbins also quotes the evidence relating to one or more ‘master mutator genes’ which may point to
Robbins 6th ed. Pages: 291 some overall control (or, more specifically, its loss) of mutation. Note here the APC gene which
appears to regulate or influence mutations at hundreds (at least) of other loci.
23009 – Tumour angiogenesis factor
1: is uniquely tumour derived 16931 – Carcinogenesis induced by DNA viruses
2: stimulates fibroblast growth 1: is usually a single step (‘single hit’) process
3: binds to steroid receptors 2: may act by neutralising growth-inhibiting molecules
4: belongs to a family of heparin-binding growth factors 3: may involve incorporation of viral oncogene into host DNA
4: may cause stimulation of function of growth-promoting protein(s)
Answers: FTFT
Answers: FTTT
Robbins 6th ed. Chapter: 8 Pages: 301
Each of items 2, 3 and 4 is correct under different circumstances and with various viruses. However
25458 – The HLA-B27 antigen occurs with unusual frequency in patients ?? studies provide firm evidence that cancer, even when caused by highly oncogenic viruses, is a
multistep process?. This section of Robbins also deals with other important concepts of viral
with
oncogenesis eg the cell must survive the infection; early transcribed genes are essential for
A. Hodgkin's disease
oncogenic transformation, they are incorporated stably into the host cell genome (and subsequent
B. psoriasis
generations) and they interrupt the subsequent replication of the late viral genes, thus preventing
C. diabetes mellitus
assembly of the complete virus.
D. Reiter's syndrome
E. Hashimoto's thyroiditis
16962 – S:The effects of carcinogenic promoters are thought to be
Answer: D potentially reversible because R:tumours do not eventuate if the
‘promoter-effective’ dose is applied prior to the application of the
Roitt 8th ed. Page: 356
appropriate initiator.
17805 – S:Oncogenic viruses all contain oncogenes which are virtually or Answer: S is true, R is true and a valid explanation of S
actually identical with proto-oncogenes present in normal cells
because R:cancer-causing viruses are oncogenic only because of the Promoters are not electrophilic compounds and do not damage DNA. They induce clonal proliferation
of initiated cells and influence their differentiation programmes. They appear to bring about these
actions of proto-oncogene- homologous DNA.
changes by the use of existing normal growth-promoting physiologic transduction pathways, not by
inducing new ones.
Some oncogenic DNA viruses do contain DNA sequences which have close homology with normal 16855 – Extracellular matrix degradation by tumour cells, together with the
proto-oncogenes. However, there are other ways by which oncogenic viruses influence the products of such matrix breakdown, gives rise to
proliferative activity of the cell. For example, translocation may separate a proto-oncogene from its 1: angiogenesis factors
controlling suppressor gene or may relocate a proto-oncogene gene (usually normally controlled) 2: chemotaxis factors
adjacent to a promoter gene (eg EBV in causation of lymphoma). RNA viruses do not contain DNA 3: growth factors
and so cannot ‘contain’ oncogenes per se! It is true that they cause transcription of cDNA which may 4: a physical passage for tumour cell migration
function as a c-oncogene.
Answers: TTTT
17811 – S:Oncogenesis probably involves multiple sequential DNA
mutations before neoplastic behaviour develops because R:all human The discussion is the same as for the previous question: any increase in matrix/tumour cell binding;
anything which increases matrix destruction (response 2); any factor which makes space or growth
cancers which have been analysed in detail have been found to have factors or chemotactic factors, will increase the invasion/metastatic potential of a malignant neoplasm.
mutations which involve both activation of promoter genes and loss of There is excellent, and increasing, evidence that matrix breakdown products are very active in all of
cancer suppressor genes. these areas for neoplasia (and for the pathophysiological counterpart - wound healing).

17793 – S:Carcinomas develop through ‘dedifferentiation’ of normal,
differentiated, cells because R:carcinomas result from repression of 16865 – When complicated by extensive metastatic spread, the following
normal gene activity in differentiated, mature cells which revert to cancers characteristically cause hypercalcaemia
1: kidney
‘immature’ cells.
2: lung
3: breast
4: prostate
Cancers arise from mutations in the DNA of cells. Such mutations will not induce growth in terminally
Answers: TTTF
differentiated cells which are not undergoing proliferation (ie are not dividing). There is general
agreement that most, if not all, clinical cancers are the result of multiple mutations occurring
Hypercalcaemia is probably the commonest paraneoplastic syndrome. In some cancers, this is simply
sequentially in a clone of proliferating cells ie stem cells from which the resident cell population of the
a calcaemic effect of rapid osteolysis; in others the elaboration of a calcaemic tumour secretion (PTH-
particular tissue derives its adult cell population.
like; TNF-??) is either known or assumed to cause raised plasma calcium - in such discussions, the
question of why some cancers cause rapid bone destruction obviously raises the same possibilities!
12668 – S:Under abnormal circumstances cells produce substances (eg With tumours 1, 2 and 3, both mechanisms are thought to be active. Bone lysis is the exception in
hormones) which differ from their customary products because R: the DNA prostatic cancer, as is the corresponding (presumably) hypercalcaemia.
repression in a differentiated cell is reversible
14878, 16015, 16801 – The closest association between development of
Answer: S is true, R is true and a valid explanation of S malignancy and radiation is seen with
A. thyroid
All somatic nucleated cells in a given individual have the same basic content of genes. Sequential B. salivary gland
repression of selected genes takes place during normal differentiation, in a manner that is C. bone
characteristic for the tissue in question. These changes are often reversible, and under abnormal D. leukaemia
conditions (usually neoplasia) a given cell may produce an inappropriate product, eg a hormone (S E. breast
true, R true and is a valid explanation of S).
Answer: D
9815 – The presence of lymph node metastases is associated with a
significant reduction in disease-free survival in the following malignancies Refer to Robbins, 6th Ed, Ch 8, page 310-311. Thyroid papillary cancer is a major risk following
1: adenocarcinoma of the colon childhood head and neck radiation, often for trivial problems. The story of bone cancer following
2: adenocarcinoma of the breast repeated ingestion of radium in young women who painted watch dials is (in)famous (they 'pointed'
3: papillary carcinoma of the thyroid their brushes by moistening them with their tongues!). Leukaemia > thyroid > breast, lungs, salivary
4: anaplastic carcinoma of the thyroid gland > skin, bone, G-I oncogenesis is the hierarchy experience of fluoroscopy, and post-Hiroshima,
Nagasaki, Marshall Islands and Chernobyl epidemics. CML does not share the radiation risk seen
Answers: TTFF with other leukaemias.
Robbins, 6th ed, Ch 18; Ch 25 and Ch 26 15563 – Recognised sequelae of exposure to ionising radiation include
1: breast cancer
13047 – Involvement of lymph nodes is characteristically seen in 2: pericarditis
1: toxoplasmosis 3: endarteritis obliterans (subintimal fibrosis)
2: secondary syphilis 4: peritibular fibrosis and glomerular hyalinization
3: tertiary syphilis
4: pulmonary tuberculosis in childhood Answers: TTTT
Answers: TTFT Refer to Robbins, 6th Ed, page 428-429
Involvement of lymph nodes represents an attempt by the body to prevent spread of infection from 25988 – In which of the following human neoplasms has ionising radiation
some local site, and in many cases is a forerunner to and/or a manifestation of haematogenous been demonstrated as one of the known carcinogens?
spread. Microbes are usually readily visible in biopsy material. Lymph node involvement is 1: carcinoma of the lung
characteristically seen in a variety of disease, including toxoplasmosis (A true), the secondary stage 2: osteosarcoma
of syphilis (B true), primary pulmonary tuberculosis (D true), but not in tertiary syphilis, where the 3: carcinoma of thyroid
clinical manifestations are vasculitis and chronic inflammation (C false). These tertiary lesions 4: carcinoma of the breast
(gummas) are presumed to result from the host's response to treponemal antigens although they
usually contain few or no visible spirochaetes.
Answers: TTTT mediated immunity - CMI (hereditary, renal transplant immunosuppression), HPV (5, 8, 14) and
sunlight appear to interplay in formation of skin cancer.
Robbins 5th Edition Chapter:7, 27 PAGE: 285; 1236
13130 – Neoplasms in which thrombophlebitis migrans is a recognised
15553 – Examples of metaplasia include complication include carcinoma of the
1: myositis ossificans 1: stomach
2: Barretts' oesophagus 2: pancreas
3: skin warts 3: kidney
4: keratoacanthoma 4: lung
Answers: TTFF Answers: TTTT
Refer to Robbins, 6th Ed, page 33, 38, 1181 Thrombophlebitis migrans, sometimes complicates deep seated cancer, eg of the pancreas, stomach,
kidney, lung (A,B,C and D true). In these circumstances inflammation of the vessel wall is not a
15988 – S:Epithelial metaplasia in considered to be an adaptive response to feature, and the lesion may be a manifestation of low grade disseminated intravascular coagulation.
a change in the cell environment because R:epithelial metaplasia does not This question is currently under review by the Pathology Sub Committee. 23 August, 2001.
revert to normal morphology following cessation of the causal injury.
9055 – A lung hamartoma may contain
Answer: S is true and R is false 1: cartilage
2: respiratory epithelium
Metaplasia is an adaptive response to chronic cell injury. Moreover, influences predisposing to such 3: neoplastic neuroendocrine cells
metaplasia, if persistent, may induce cancerous transformation in the metaplastic epithelium. 4: glial tissue
Metaplasia is thought to be caused by the environmental change inducing, in differentiating progeny
of ‘stem cells’, expression of different genes, thus resulting in a different phenotypic expression (ie a Answers: TTFF
different adult cell). With removal of the environmental injury, metaplastic cells die off and the stem
cells regenerate under the now normal environmental situation - usually back to normal. Robbins, 6th ed, Ch 8 and Ch 16
14828 – Strong circumstantial evidence suggesting a viral aetiology is 25992 – Which of the following conditions is/are classifiable as
available for hamartomata?
1: astrocytoma 1: cystic hygroma
2: carcinoma of the nasopharynx 2: struma ovarii
3: carcinoma of the pancreas 3: small intestinal polyp (Peutz-Jehger type)
4: carcinoma of the liver 4: branchial cysts
Answers: FTFT Answers: TFTF
Refer to Robbins, 6th Ed, Ch 8, page 313-314 Robbins 6th ed. PAGES:263; 483; 533; 826; 1074
16831 – The human papilloma virus (HPV) has been causally implicated in 23024 – Sensitivity of cancers to radiotherapy is enhanced by
the genesis of 1: ability to repair DNA
2: central hypoxia
1: nasopharyngeal cancer
3: proximity to a radioresponsive tissue of origin
2: cancer of the uterine cervix
4: decreased level of specialization
3: Hodgkin's disease, nodular sclerosing type
4: skin cancer in individuals with inherited or induced (renal transplant) cell-mediated immune defects
Answers: FFFT
Answers: FTFT
Robbins 6th ed. Chapter: 9 Page: 425-430
There is close association of HPV (types 16, 18 & 31) with anogenital cancers (especially cervix).
HPV (multiple strains) causes venereally acquired condyloma acuminatum. High risk HPV strains
(16,18 & 31): (a) Often become incorporated in the host genome (b) Co-operate in cultured cells with
SKIN & BONE
the ras oncogene to form tumourigenic foci; and (c) The probable transforming sequences of HPV
are consistently/mostly found in cancer cells from clinical CIN and invasive cancer. Defective cell-
14793 – Recognised sequelae of severe burns include
1: impaired lymphocyte responsiveness
2: increased phagocytosis
3: nitrous oxide intoxication 16911 – Dysplastic melanocytic naevi
4: haemodilution 1: very seldom occur on other than sun-exposed skin
2: usually have pale edges with a uniform central 'salmon pink' papule
Answers: TFTF 3: most develop into malignant melanoma within two decades if not ablated
4: atypia and superficial dermal lymphocytic infiltrate
Refer to Robbins, 6th Ed, Ch 10, page 433-435
Answers: FFFT
21068 – Tissue reactions are associated with
1: stainless steel Unlike ordinary moles, dysplastic naevi are common on sun-protected skin. Like malignant
2: silica melanoma, they are larger than moles, irregular in both outline and colour, but lack the distinct
3: catgut nodular development seen in MM (unless they themselves develop a focus of malignant
4: asbestos degeneration), being macular (flat) or slightly raised (papular). Dysplastic naevi do show melanocytic
dysplasia, and upper dermal lymphocytosis, do have a very significant premalignant potential;
Answers: FTTT nevertheless, the majority of dysplastic naevi are stable lesions.
Robbins 5th. ed. Page: 81 16916 – Merkel cell carcinoma of the skin
1: is an indolent ‘adnexal’ tumour resembling basal cell carcinoma in behaviour
25375 – Contact dermatitis is 2: histologically resembles ‘oat cell’ bronchial carcinoma
1: mediated by a subset of T lymphocytes 3: most commonly arises in axillae, groins or midline anterior abdominal skin
2: associated with complement activation 4: shows both neuroendocrine and epithelial differentiation by cell marker studies
3: associated with an infiltration of lymphocytes and macrophages
4: associated with the combination of IgE and antigen Answers: FTFT
Answers: TFTF Robbins pays this cancer scant attention and considers it to be rare. Not in our experience - unusual
perhaps. It has a formidably aggressive biology, and morphologically resembles neuroendocrine
Robbins 5th ed. Chapter: 6 Pages: 187-188 cancers elsewhere in the body (‘oat cell’ cancer, carcinoids in various sites, islet cell tumour etc). It is
most commonly present in head and neck (and extremities).
7162 – One of the following is NOT associated with the development of
carcinoma of the skin 8692 – Hutchinson's freckle (lentigo maligna)
A. exposure to aniline dyes 1: commonly occurs on the foot
B. arsenical dermatitis 2: commonly occurs in adults
C. chronic exposure to ultra-violet light 3: commonly occurs in sun damaged skin
D. xeroderma pigmentosum 4: rarely develops into a malignant melanoma
E. renal transplantation
Answers: FTTF
Answer: A
Xeroderma pigmentosum, an inherited skin anomaly with enhanced sensitivity to effects of solar
exposure, is associated with development of skin cancers. 16906 – Malignant melanoma
1 : is usually uniformly either black or amelanotic
A Correct: Aniline dyes are implicated in tumours of urinary epithelium. They are NOT associated with 2: may arise in diverse mucosal sites
carcinoma of the skin and A is accordingly the correct answer. 3: usually has irregular ‘notched’ borders
4: prognosis is predicted most accurately by the mitotic rate
22754 – Dysplastic naevi
1: virtually always occur on sun-exposed skin Answers: FTTF
2: have pale edges and a uniform central "salmon pink" papule
3: most will develop into malignant melanoma within two decades if not ablated The points highlighted here are that malignant melanoma is characterised by irregularity of colour
4: show melanocytic atypia and superficial dermal lymphocytic infiltrate within individual lesions and usually an irregular outline. There are many factors being investigated as
to relevance in terms of prognosis; the ?? nature and extent of the vertical growth phase, however,
Answers: FFFT determines the biologic behaviour ??. Melanomas occur in a variety of sites other than skin (including
virtually every mucosa).
16921, 23019 – Kaposi's sarcoma 4: carcinoma of the thyroid
1: arises in skin and usually remains confined to skin and subcutaneous tissue
2: is less biologically aggressive when it occurs in HIV-positive individuals Answers: TFFT
3: presents as reddish, spreading and merging papules and plaques in the skin
4: is a suppressor T lymphoproliferative disorder Robbins 6th ed. Page: 266; 305; 911; 1245. This question is currently under review by the Pathology
Sub Committee. 28 June 2002. Pathology comments: The question refers to metastasis in the bone
Answers: FFTF being solitary, not bone as a single site. Ref: p1245 Robbins. This question has been updated. 28
August 2002.
Robbins 5th ed. Chapter: 11 Page: 511. This tumour is of as yet undefined histogenesis. As seen up
until about two decades ago in USA, this was an indolent tumour of ageing men of Mediterranean 15172 – Mature bone, remodelled after a simple fracture in an adult
origin. As part of the AIDS syndrome, it is an aggressive skin neoplasm which fairly rapidly contains
disseminates to the viscera. It is almost certainly an endothelial sarcoma of some sort; certainly not a 1: type 1 collagen
T lymphoma. 2: osteonectin
3: Haversian systems
9740 – In the genesis of malignant melanoma 4: woven bone
1: a lesion which is macular is predictably in the radial growth phase
2: development of a nodule probably indicates potential for metastasis Answers: TTTF
3: lentigo maligna usually has a shorter preinvasive radial growth phase than superficial spreading
melanoma Refer to Robbins, 6th Ed, page 1216-1218
4: solitary dysplastic naevus has a high likelihood of malignant transformation
Answers: TTFF HAEMATOLOGY

Robbins, 6th ed, Ch 27 15593 – Neutropenia may be associated with
1: cotrimoxazole therapy
7361 – S Carcinoma of the tongue has a propensity to metastasise to bone 2: systemic lupus erythematosus
because R malignant squamous cells require a high local concentration of 3: polyarteritis
4: Addisonian (pernicious) anaemia
calcium
Answers: TTFT
Refer to Robbins, 6th Ed, Ch 15, page 646-647
Both the statement and response are incorrect. Carcinoma of the tongue (a squamous cell
carcinoma) has no special propensity to metastasise to bone ? it may of course involve bone by direct
extension to the mandible. There is no evidence that malignant squamous cells require a high
13077 – Neutropenia may be associated with
1: thiouracil therapy
concentration of calcium. This question will be submitted at the Match 04 meeting (16/03/2004).
2: systemic lupus erythematosus
3: polyarteritis
23679 – Malignancies metastatic to bone are likely to be predominantly 4: Addisonian (pernicious) anaemia
osteoblastic when derived from primary cancers in
1: colon Answers: TTFT
2: lung
3: prostate Patients with systemic lupus erythematosus have leukocyte autoantibodies causing neutropenia (B
4: kidney true). Agranulocytoses is encountered as an idiosyncratic reaction to a number of drugs including
thouracil (A true) while the white cell share in the general reduction in cell cycling consequent on
Answers: FFTF vitamin B12 deficiency (D true). Leukocytosis characterises the reaction in polyarteritis (C false).
Robbins 6th. ed. Page: 1245 24324 – Microcytic hypochromic anaemia

1: is due to iron deficiency
24264 – Which of the following tumours is/are particularly liable to produce 2: is common in females of menstrual age
solitary metastasis in bone 3: may be associated with a lack of vitamin B6 (pyridoxine)
1: carcinoma of kidney 4: is a common complication of gastrectomy
2: cancer of the lung
3: prostatic carcinoma
Answers: TTFT 3: local arterial/arteriolar constriction
4: secretion of protease inhibitors by adjacent intact endothelium
Robbins 6th ed. Pages: 449; 623; 629 Ch 14, p627-630
Answers: TTFT
23754 – A marked increase in blood eosinophils often accompanies
1: Trichinella spiralis This is the reinstatement of homeostatic mechanisms by the intact endothelium. Without these
2: Loeffler's syndrome feedback mechanisms, any initiation of the protective or pathological thrombocoagulant state would
3: systemic vasculitis progress inexorably.
4: acute renal allograft rejection
23334 – Acute intravascular haemolysis, due to incompatible blood
Answers: TTTF transfusion causes
1: decreased plasma haptoglobin level
Robbins 6th ed. Pages: 648; 738 Roitt 9th ed. Pages: 277; 357 2: methaemalbuminaemia
3: splenomegaly
13082 – A marked increase in blood eosinophils often accompanies 4: obstructive hyperbilirubinaemia
1: hydatid disease
2: Loeffler's syndrome Answers: TTFF
3: Delayed type hypersensitivity
4: Polyarteritis nodosa Robbins 5th ed. Chapter: 13 Pages: 587-588
Answers: TTFT 21923, 13067 – Acute intravascular haemolysis is characteristically

accompanied by
Eosinophilia characteristically accompanies a number of parasitic diseases, including hydatid disease
1: reduced level of serum haptoglobin
(A true). It is a frequent concomitant of polyarteritis nodosa (D true) and Loeffler's syndrome (B true),
2: raised plasma haemoglobin
a transient condition associated with helminth infestation. It is not a feature of delayed hypersensitivity
3: haemoglobinuria
(C false).
4: methaemalbuminaemia
13120 – Conditions predisposing to thrombosis include Answers: TTTT
1: polyarteritis nodosa
2: giant cell arteritis Robbins 6th ed. CHAPTER: 14 PAGE: 606. Following acute intravascular haemolysis the binding
3: Buerger's disease power of the plasma (due to haptoglobin, haemopexin and albumin) is soon exhausted. The level of
4: Takayasu's disease serum haptoglobin is thus reduced (A true). Haemoglobinuria soon follows, along with
methaemalbuminaemia (C and D true). Following acute intravascular haemolysis the plasma
Answers: TTTT haemoglobin increases (B true).
Thrombosis is very likely in those diseases of the vessels in which the intima is inflamed. All four of 13105 – Disseminated intravascular coagulation may cause the
the conditions listed show intimal inflammation (A,B,C,D true).
development of
1: haemolytic anaemia
22764 – Antithrombin III
2: renal failure
1: potentiates the action of PGI\b2 (prostacyclin)
3: haemorrhagic diathesis
2: deficiency causes recurrent phlebothrombosis
4: circulating anticoagulant substances
3: antagonises the actions of a wide spectrum of activated serum proteases
4: deficiency may be successfully treated with low dose heparin
Answers: TTTT
Answers: FTTT
The extensive intravascular coagulation associated with disseminated intra-vascular coagulation
(DIC) consumes coagulation factors, and this is further exacerbated by the action of the fibrinolytic
system. Thus DIC is associated with a haemorrhagic diathesis (C true). The deposition of fibrin within
the microvasculature may lead to haemolytic anaemia (A true). Fibrinogen breakdown products
15800 – Factors which tend to localise and limit thrombocoagulation include anticoagulant substances (D true). The events characterising DIC result in renal ischaemia,
(pathological or in response to injury) include even to a degree of bilateral renal cortical necrosis, as can a number of the conditions which
1: clearance of activated prothrombocoagulants precipitate DIC (B true). A number of the conditions which may cause DIC, can themselves cause
2: local degradation of clotting factors renal failure of other mechanisms.

15805 – Disseminated intravascular coagulation (thrombocoagulation) may
cause Answers: TFFF
1: acute oliguric renal failure
Refer to Australian Red Cross NTBC Booklet, Jan 1994, supplement Feb 1998
2: haemorrhage
3: neutropenia
4: diffuse alveolar damage (adult respiratory distress syndrome) 7284 – In a patient undergoing massive transfusion, severe capillary-type
oozing develops
Answers: TTFT 1: blood for haemoglobin, platelet count, INR and APTT should be taken immediately
2: transfusion of platelets and fresh frozen plasma should await the assessment of the laboratory
Responses 1 and 4 relate to the likelihood of thrombo-occlusive problems occurring as a result of results
formation of platelet-fibrin masses in the blood stream with resulting emboli in renal and/or pulmonary 3: fresh frozen plasma is indicated even if INR and APTT are normal
microcirculation. The spontaneous haemorrhage relates to the ‘consumptive’ component of DIC with 4: if INR and / or APTT are prolonged, estimation of fibrinogen is important
consequent lack of platelets and coagulation proteins in the blood. WBC are not involved in the 5: fibrinogen deficiency may be corrected by administration of cryoprecipitate
‘consumption’. 6: capillary oozing, especially if accompanied by a falling blood pressure, may be a sign of a
haemolytic transfusion reaction
23329 – Severe intravascular haemolysis may be seen as a complication of
1: clostridial infections Answers: TFFTTT
2: hereditary spherocytosis
3: lead poisoning 20271 – S. The ABO blood group system is the most important in
4: disseminated intravascular coagulation (thrombocoagulation) transfusion practice BECAUSE R. Anti-A and Anti-B antibodies are
regularly found in subjects whose red cells lack the corresponding antigen
Answers: TFFT
Robbins 6th ed. PAGE: 473 Blood Transfusion Therapy P40
22093 – Intravascular haemolysis may occur as a result of
1: alpha-thalassemia
7278 – Each of the following statements may be True or False
2: Clostridium perfringens infection
1: Hepatitis G is an important source of hepatitis infection in blood transfusion practice
3: mechanical heart valves
2: febrile non-haemolytic reactions to donor white cells occur in 1% of all transfusions
4: incompatible blood transfusion
3: autologous blood transfusion eliminates the infective risks of blood transfusion
4: urticaria during blood transfusion is usually a reaction to donor white cells
Answer: FTTT
5: neutrophils have a half-life in the blood of 3-4 days
Robbins 5th ed. Chapter: 13 Pages: 586-587; 506-600
Answers: FTFFF
24184 – In Australia and New Zealand, donor blood for transfusion is 13062 – One week after a severe haemorrhage, the blood is likely to show
screen-tested for markers of the following viruses an increased number of
1: cytomegalovirus (CMV)
1: reticulocytes
2: hepatitis B and C (HBV and HCV)
2: acanthocytes
3: human immunodeficiency viruses (HIV 1/2)
3: polychromatic erythrocytes
4: Epstein-Barr virus (EBV)
4: larger than normal red cells
Answers: FTTF
Answers: TFTT
Blood Transfusion & Component Therapy ARC 1994 Page: 3. Pending review. April 03
One week after acute haemorrhage the bone marrow shows normoblastic hyperplasia, and this is
reflected in an increase in the number of reticulocytes (immature red cells) in the circulation (A true).
15207 – For transfusion purposes, stored whole blood can be considered to These are larger than normal red cells (D true) and often exhibit polychromatic staining (C true).
be a suitable clinical source of Acanthocytes are characteristic of haemolytic anaemia. They are not a feature of the blood picture
1: oxygen-transportable haemoglobin following a severe haemorrhage (B false).
2: functional platelets
3: coagulation factors V and VIII 21803 – One week after a haemorrhage of about one litre, the peripheral
4: functional granulocytes blood will usually show greatly increased numbers of
1: immature white blood cells Robbins 5th ed. Page: 231-8 1312
2: platelets
3: polychromatic erythrocytes 17748 – Likelihood of infections in advanced, untreated myeloma is
4: lymphocytes
contributed to by
1: reduced levels of normal (non-myeloma) immunoglobulins
Answers: FFTF
2: high rate of infection by low-grade ('opportunistic') pathogens
3: depression of cellular (T cell) immunity
Robbins 5th ed. Chapter: 13 Page: 587
4: progressive, unrelenting viral infections
25427 – Bone marrow grafting in humans Answers: TFFF
1: may be carried out using cord blood as a source of haemopoietic stem cells
2: has improved primary engraftment if cyclosporin A is used for immunosuppression The raised total level of plasma immunoglobulins is predominantly due to the monoclonal tumour-
3: requires matching of only HLA Class I antigens to avoid graft versus host disease manufactured Ig (which is, protectively speaking, 'nonsense Ig'). The infections which pose the threat
4: has improved survival if donor B lymphocytes are removed before grafting to life are, therefore, the 'usual' pyogenic infections for which adequate protection is lost. T-cell
immunity is well conserved and so the relentlessly progressive viral infections which are characteristic
Answers: TTFF of depressed T-cell function are not a feature of myeloma.
Roitt Essential Immunology 8th ed. Pages: 354-355 15538 – Regarding multiple myeloma
1: the antibodies produced by a given myeloma are likely to have the same heavy chains
13100 – Cells likely to be seen in the peripheral blood of a patient whose 2: IgG is often excreted in the urine
bone marrow has been extensively replaced, as in myelofibrosis, include 3: parts of antibody molecules may be produced rather than whole molecules
1: normoblasts 4: the majority of myelomas produce IgM antibodies
2: megaloblasts
3: myelocytes Answer: TFTF
4: myeloblasts
Refer to Robbins, 6th Ed, page 663-664
Answers: TFTT
20007 – Patients with multiple myeloma commonly show all the following
The patient whose bone marrow is replaced can compensate by producing bone marrow in other
EXCEPT
sites, eg in the spleen. Haemopoiesis in extramedullary sites lacks the regulatory mechanisms
A. increased susceptibility to pyogenic infections
operating in the bone marrow, and primitive cells are apt to enter the circulation. Thus normoblasts,
B. bone fracture
myelocytes and myeloblasts are seen in the peripheral blood (A,C and D true). The deficiencies which
C. renal failure
lead to megaloblastic differentiation do not usually complicate the picture in extramedullary
D. normochromic, normocytic anaemia
haemopoiesis (B false).
E. peripheral blood plasmacytosis
9770 – Amyloid associated protein (AA) is greatly elevated in serum in Answer: E
1: multiple myeloma
2: Crohn's disease Robbins 5th ed. CHAPTER: 14 PAGE: 664-665
3: patients on long term haemodialysis
4: rheumatoid arthritis 17823 – The commonest cause of death in multiple myeloma is
1: renal failure
Answers: FTFT
2: amyloid-related multiple organ failure
3: intestinal infarction due to hyperviscosity syndrome
4: infections by pyogenic bacteria
5: cardiac arrhythmia due to hypercalcaemia
23704 – Systemic amyloidosis is commonly associated with
1: bleeding Answer: FFFTF
2: proteinuria
3: neutrophil leucocytosis What’s to add? The specific immunoglobulin lack (not only the lack of ability to make ‘new’
4: parenchymal atrophy of affected organs immunoglobulins to combat infections with ‘new’ invaders, but loss of adequate levels from previous
infections) leads to particular susceptibility to infections with encapsulated bacteria (eg pneumococci).
Answers: TTFT All of the others are hazards for patients with multiple myeloma, but pyogenic infections are the
commonest killer.
24144 – A high percentage saturation of transferrin with iron is present in
14843 – Symptomatic haemophilia A (factor VIII deficiency) 1: transfusion haemosiderosis
1: commonly causes severe `spontaneous' bleeding when plasma levels fall to approximately 25% of 2: haemochromatosis
normal 3: blacks consuming food and beverages prepared in iron utensils
2: characteristically causes petechial and ecchymotic haemorrhages 4: polycythaemia vera
3: does not occur in females
4: requires assay of plasma factor VIII levels for reliable diagnosis Answers: TTTF
Answers: FFFT Robbins 5th ed. PAGE: 73; 28; 610-616; 862
Refer to Robbins, 6th Ed, Ch 14, page 638-639 25474 – Concerning malignant lymphoma
1: the majority of non-Hodgkin lymphomas are of B-cell origin
12944 – A previously normal adult suffers a ruptured spleen in an 2: they can easily be differentiated from anaplastic carcinoma by routine H & E staining
automobile accident. Removal of his spleen causes 3: in Burkitt's lymphoma the c-myc oncogene is commonly suppressed
1: transient thrombocytosis 4: it is 35 times more common in transplanted patients than in normals
2: increase in red cell survival time
3: an increased liability to infection Answers: TFFT
4: reduced iron transport in blood
Roitt Essential Immunology 9th ed. Page: 387-390
Answers: TFTF
15202 – A lymph node biopsied from a patient diagnosed as showing
In the immediate postoperative period following splenectomy, the platelet count usually rises to 600- malignant lymphoma (non-Hodgkin's type)
1000 x 109/1 in the first 7-10 days. This is usually transitory with a fall to near normal values within 1- 1: is likely to contain Reed-Sternberg cells
2 months (A true). Although a reticulocytosis often occurs, red cell survival time will not be altered (B 2: is more likely to be composed of malignant T cells than B cells
false). Overwhelming infection is an uncommon but serious complication following splenectomy (C 3: will not contain reactive lymphocytes of the same lineage (ie T or B) as the neoplastic cells
true). Changes in iron metabolism are not seen following splenectomy (D false). 4: will contain a monoclonal population of tumour cells
23004 – Tumour cells disseminated by the blood stream Answers: FFFT

1: have enhanced implantability when aggregated with platelets
2: are destroyed by cytotoxic T lymphocytes Refer to Robbins, 6th Ed, Ch 15, page 652-653
3: are distributed by affinity with endothelial cell receptors
4: have a limited chance of survival 13052, 22454 – An increased incidence of lymphoma and/or leukemia is
associated with
Answers: TFTT
1: treatment with alkylating agents
2: human immunodeficiency virus (HIV) infection
Robbins 6th ed. PAGE: 305. Pending review. Jan 2003
3: hereditary immunological deficiency syndromes
4: autoimmune haemolytic anaemia
15768 – The following haematological problems commonly occur either as
a direct effect or as a complicating result of chronic alcohol abuse Answers: TTTF
1: coagulation disorder
2: microcytic, hypochromic anaemia Robbins 6th ed. Chapters: 6; 7 Pages: 234; 247; 309. Alkylating agents are direct-acting carcinogens
3: normocytic, normochromic anaemia with particular reference to leukaemias and lymphomas (A true); HIV infection is similar as are other
4: erythrocyte macrocytosis (hereditary, but also therapeutically-induced) immune deficiency syndromes (B and C true).
Autoimmune haemolytic anaemia has no precancerous connotations (D false). This question is
Answers: TTTT currently under review by the Pathology Sub Committee. 23 August, 2001. Question updated 12
April, 2002.
Coagulation disorders of potential disaster magnitude may be asymptomatic in cirrhotic patients with
occult liver failure, as may be oesophageal varices (or alcohol-related peptic ulcer) of sufficient 21928 – Which of the following drugs may cause red blood cells deficient in
severity to cause chronic bleeding with iron deficiency (response 2) or occult more acute recent glucose-6-phosphate dehydrogenase to undergo lysis?
bleeding (response 3). Macrocytosis is a common marker of alcohol abuse with subclinical,
1: primaquine
asymptomatic folate deficiency.
2: probenecid
3: aspirin

4: sulphonamides 7303 – A patient is bleeding excessively post-operatively. INR, APTT and
platelet count are normal
Answers: TTTT
1: two units of fresh frozen plasma should be given
2: despite the normal APTT, the patient may have haemophilia A or von Willebrand disorder
3: chronic renal failure is not likely to be a contributing factor
4: a normal platelet count excludes platelet dysfunction as a possible cause
12650 – S:Haemophiliacs usually have a normal 'bleeding time' test 5: if the cause is due to reduced platelet function, an infusion of desmopressin may be helpful
because R:haemophiliacs have a normal platelet aggregatory response to
microvascular injury Answers: FTFFT
Answer: S is true, R is true and a valid explanation of S Annotated answer to come. Pending review. Jan 2003
Patients with haemophilia have normal amounts of functional von Willebrand factor (vWF). The skin
bleeding time is prolonged when vWF is reduced or dysfunctional but is normal when the only CNS
coagulation abnormality is reduction of Factor VIII. Thus the statement and response are both true
with the response being a valid explanation of the statement. 23524, 27839 – A bitemporal homonymous hemianopia may result from
1: unilateral infarction of visual cortex or radiation
12680 – S:Patients suffering from von Willebrand's disease bleed 2: craniopharyngioma
3: pineal tumour
excessively post operatively because R:in von Willebrand's disease there 4: pituitary tumour
is usually a deficiency of Factor VIII and a platelet defect
Answers: FTFT
Updated June 2003
In von Willebrand's disease there is an inherited deficiency of the named factor (vWF) which is
necessary for platelet adhesion, serving as a molecular bridge between platelets and collagen. This 21123 – Which of the following statements is true of a medium to large
bridge withstands high shear forces generated by flowing blood. VWF is the predominant moiety of a
VIII-vWF complex, serving as a carrier for factor VIII. A deficiency of vWF gives rise to a secondary
sized cerebral infarct 2 weeks old?
1: compound granular corpuscles are a prominent histological feature
decrease in factor VIII level.
2: numerous polymorphs infiltrate the brain adjacent to the infarct
3: gliosis is apparent at the periphery of the lesion
14940 – S:Patients with Factor IX deficiency are very rarely asymptomatic 4: in the gross specimen the infarct is raised above the surface of the adjacent normal brain
because R:it is inherited as an X-linked recessive disorder
Answers: TFTF
Robbins 5th ed. PAGES: 115; 1310. Pending review. Jan 2003
16957 – Familial retinoblastoma
12548, 19492 – A favourable response to splenectomy is most likely to 1: is always a congenital neoplasm
occur in 2: is activated by chromosomal translocation
A. hereditary elliptocytosis 3: inheritance pattern is autosomal recessive
B. thalassaemia major 4: develops only in a retinoblast which has the appropriate DNA defect in both of the paired
C. paroxysmal nocturnal haemoglobinuria chromosomes
D. hereditary spherocytosis
E. autoimmune haemolytic anaemia Answers: FFFT
Answer: D Familial retinoblastoma is inherited, but not necessarily congenital. The inheritance genetics is of a
single defective gene, which is protected by the paired gene in each retinoblast cell. However, all of
Walter & Israel 6th Ed. CHAPTER: 52 PAGE: 647-650. Splenectomy is of no value in the the retinoblasts are ‘primed’ by having one defective gene - mutation of the other gene in just one
haemoglobinopathies or in paroxysmal nocturnal haemoglobinuria. It has some value in acquired retinoblast, removes all of that suppressor gene activity from that cell. If that retinoblast is still in the
haemolytic anaemia and hereditary elliptocytosis. The indication par excellence for splenectomy is ‘replication pool’, retinoblastoma ensues; if that cell has matured to join the ranks of permanent cells
hereditary spherocytosis. (differentiated), presumably cancer does not ensue.
25991 – Medulloblastoma
1: characteristically occurs in the cerebrum of children 3: polio virus
2: often shows rosette formation as a histological feature 4: cytomegalovirus
3: is typically calcified
4: is often found in the vicinity of the 4th ventricle Answers: TTTT
Answers: FTFT Robbins 5th ed. Pages: 1315-1326
Robbins 5th ed. Chapter:29 PAGE:1347 13125 – An intracranial aneurysm may be

1: caused by an infective embolus
13445 – S:Microglia surrounding a cerebral infarct are DOPA positive 2: due to a congenital weakness of the wall of the vessel
because R:some cells in the brain contain melanin 3: associated with polyarteritis nodosa
4: associated with atheroma
Answers: TTTT
Microglia are the phagocytes of the central nervous system, and accumulate in the vicinity of
damaged tissues. They do not, however, manufacture melanin, and are therefore not DOPA positive Acute inflammation of the vessel wall may result from an infective embolus or from inflammatory
(S false). Some cells in the brain (eg in the substantia nigra) are able to produce melanin (R true). diseases of the vessel wall such as polyarteritis nodosa (C true). Aneurysms may occur at any site as
These cells are not, however, microglia. a result of infective emboli (A true). Berry aneurysms in the circle of Willis are due to a congenital
weakness in the vessel wall (B true). Atheroma is common in the cerebral vessels, and consequently
may give rise to intra-cranial aneurysms (D true).
27059 – Vertebrobasilar insufficiency may present with all of the following
except
A. vertigo and nystagmus BREAST
B. dysphagia
C. diplopia 10488 – A core biopsy on a breast lesion reports the following feature.
D. blurred vision
E. motor dysphasia
Answer in each case whether excisional biopsy is required to diagnose or
exclude associated invasive carcinoma.
Answers: E 1: A papillary lesion
2: Atypical ductal hyperplasia (ADH)
The vertebrobasilar system supplies the medulla, pons, cerebellum, and occipital cortex: regions of 3: Intraduct papilloma
the central nervous system concerned with balance, coordination of eye movements, and vision. 4: Radial scar
Additionally, cranial nerve nuclei driving the muscles of the mouth and pharynx may be affected, 5: Ductal carcinoma in-situ (DCIS)
causing swallowing difficulty and dysarthria. Since the major motor pathways to the limbs must pass
through this territory, transient ischaemia may result in drop attacks without loss of consciousness, Answers: TTTTT
due to weakness of the lower limbs. Motor dysphasia (not always easy to distinguish from dysarthria)
is due to lesions affecting Broca's motor speech area. The motor speech area is in the territory of the All of the above reponses are true. In each case, because the core biopsy has identified a
middle cerebral artery, and therefore is affected by carotid, but not vertebrobasilar, lesions. The exception is proliferative lesion, there may be adjacent invasive carcinoma and therefore full excision of the lesion
thus option E. is required.
20253 – S. The effects of beta-endorphin are very similar to many of the 25987 – Common sites for metastatic breast carcinoma include
effects of morphine BECAUSE R. beta-endorphin is the endogenous ligand 1: liver
2: adrenal gland
for mu receptors, for which morphine is considered the primary exogenous 3: skin
ligand 4: skeletal muscle
Answer: S is true, R is true and a valid explanation of S Answers: TTTF
A.C.P. 1996 Robbins PAGE: 1200. Pending review
25519 – Viruses capable of producing diseases of the central nervous 10478 – In the evaluation of a breast biopsy showing changes of fibrocystic
system include disease, the likelihood of subsequent development of carcinoma is
1: herpes simplex virus significantly increased by the histological appearance of
2: measles virus
1: florid fibroplasia Robbins 6th ed. Chapter: 12 Page: 498
2: florid epithelial hyperplasia without cellular atypia
3: extensive apocrine metaplasia
27186 – S:The distribution of atherosclerotic lesions along the course of
4: atypical lobular hyperplasia
the great vessels could be explained by arterial wall stress
Answers: FTFT because R:humans adopt an erect posture, increasing the pressure in the
distal arteries by gravity.
In the pathology of 'fibrocystic disease' of the breast , pathological components exhibiting any degree
of epithelial hyperplasia (B and D true) and/or epithelial atypia (D true) carry an increased risk of Answer: S is true, R is true and a valid explanation of S
subsequent development of carcinoma. Apocrine metaplasia alone (C false) and fibrosis do not carry
cancer risk above the normal (A false). The distribution of atherosclerotic lesions is quite striking: they increase progressively from the
thoracic aorta to the iliac and femoro-popliteal systems. This seems to reflect two properties of the
15583 – An increased risk for developing breast cancer is associated with blood pressure. Firstly, because of the erect posture, pressure increases from above down, being
1: positive family history for breast cancer some 30 mmHg higher at the level of the inguinal ligaments than at the heart, due to gravity. Systemic
2: early first pregnancy hypertension is a major risk factor for atherosclerosis. Secondly, the vibrational components of the
3: late menarche pressure, that is the pulse wave, increase in the more distal arteries. This is due to dispersive
4: obesity properties where different frequencies propagate at different speeds so that the arterial pulse
waveform acquires an exaggerated dicrotic notch and oscillations during diastole in the distal vessels.
Answers: TFFT Although there is much remaining to be learned about the pathogenesis of atherosclerosis, current
theories include a role for endothelial injury promoted by wall stress. Hence, the statement and
Refer to Robbins, 6th Ed, Ch 25, page 1105-1106. Pending review Oct 03. reason are arguably true and related as cause and effect.
8737 – Paget's disease of the nipple 15789 – According to current understanding, the third of the following
1: is not a form of ductal carcinoma in situ stages to occur in the development of atherosclerosis is
2: has characteristic cells which invade the lower epidermis A. synthesis and secretion of extracellular matrix
3: is associated with underlying adenocarcinoma B. platelet and monocyte synthesis and release of cytokine ‘growth factors’
4: has Paget cells which often contain mucopolysaccharide C. smooth muscle cell migration into the intima
D. atrophy and degeneration of medial muscle and elastica
Answers: FTTT E. matrix vesicles initiate dystrophic calcification
Robbins, 6th ed, Ch 25 Answer: A
First the ‘growth factors’ (after the endothelial injury and the platelet and monocyte attachment), then
CARDIOVASCULAR the migration of ‘smooth muscle cells’ (these are, in fact, ‘myofibroblasts’) recruited from uncommitted
‘reserve cells’ in the media, then the making and depositing of connective tissue component of the
23264 – Monckeberg's sclerosis is atheroma.
1: an example of dystrophic calcification
2: typically associated with a raised serum calcium level 180 – S:Symptoms of left ventricular failure may have rapid onset while
3: a common accompaniment of Buerger's disease
4: commonly seen in young adults right ventricular failure occurs gradually because R:infarction of right
ventricular myocardium is uncommon
Answers: TFFF
Robbins 6th ed. CHAPTER: 2; 13 PAGE: 43; 498; 523
Pure right ventricular lesions are indeed uncommon, however the rate of onset of symptoms in
22769 – Monckeberg's arterial sclerosis cardiac failure is related to the mobility of fluid volumes rather than the rate of onset of ischaemic
1: affects largely the muscular arteries damage to the myocardium. The capacity of the pulmonary system is only a few hundred millilitres, so
2: predisposes towards thrombosis that in the event of sudden left ventricular dysfunction, significant volume overload of the pulmonary
3: is characterised by medial calcification system occurs rapidly with blood flowing in from the systemic circuit and right ventricle. However,
4: is a frequent cause of peripheral ischaemia peripheral oedema involves many litres of fluid (often five to ten litres before gross oedema is
apparent), which can only be accumulated slowly by dietary intake and renal fluid retention. Thus, it is
Answers: TFTF impossible to suddenly develop peripheral oedema and venous overload. Therefore, the assertion is
correct, but the reason given, though it is a true statement in itself, is not a valid reason for the
assertion.
elevated twenty or more mmHg, thus effectively doubling right ventricular workload. Such great
22469 – Pressure-volume vascular overload is the major reason for the elevations in left atrial pressure are less common in aortic valve disease or ischaemia, and would only
be seen in patients with severely decompensated failure and a grossly dilated left ventricle.
oedema caused by
1: adult respiratory distress syndrome
2: serum sickness 27198 – In a patient with rapidly progressing congestive cardiac failure,
3: acute anaphylaxis myocardial biopsy shows round cell infiltrates and tissue oedema. This
4: congestive (dilated) cardiomyopathy would be consistent with
A. a healing infarct
Answers: FFFT B. alcoholic cardiomyopathy
C. acute thiamine deficiency
Robbins 4th ed. Chapter:3 Pages: 87-89, 118 5 176, 180 D. viral myocarditis
E. dilated cardiomyopathy
15826 – Pressure-volume overload is the pathogenesis of oedema
occurring in Answer: D
1: local anaphylaxis
2: adult respiratory distress syndrome Oedema with round cell infiltrates indicates an acute inflammatory process with an active
3: lymphoedema immunological challenge in progress, as seen in viral myocarditis (D correct). The necrosis of
4: acute left heart failure infarction provokes a prominent neutrophil infiltration and the debris of dead myocytes is conspicuous.
Thiamine deficiency is seen in starving alcoholics and extreme dieters: the lesion is biochemical,
Answers: FFTT since thiamine forms a cofactor for enzymes in energy metabolism of glucose, and patients develop
acute left ventricular failure which is promptly reversed by thiamine injection. Dilated cardiomyopathy,
The oedema of left heart failure is due to pressure-volume overload, as is (in a somewhat different seen as an idiopathic state, or as a late sequel of viral myocarditis, or in chronically debilitated
way), lymphoedema. Local anaphylaxis is a histamine release phenomenon. ARDS is due primarily to alcoholics, shows a biopsy picture of extensive fibrosis, rather than an active inflammatory process.
endothelial and pneumocyte injury. This question is currently under review by the Pathology Sub
Committee. 23 August, 2001. Question updated 14 March 2002. 7162 – Stenoses in coronary atherosclerosis
A. in the left coronary are typically more diffuse than lesions than in the right
15815 – The major pathogenetic mechanism causing ‘nutmeg liver’ in B. in the anterior interventricular artery (left anterior descending) are usually distal
congestive cardiac failure is C. in the circumflex artery are usually distal
D. involve a worse prognosis for two-vessel disease than for untreated left main disease
A. cardiogenic hepatomegaly
E. usually spare the right posterior descending artery
B. pressure atrophy of hepatocytes
C. reduced arterial oxygen saturation
Answer: E
D. hepatic hypoperfusion
E. intestinal vasopressor polypeptide
Patterns of coronary disease have very characteristic distributions. In the left coronary system, the
stenoses are usually short and lesions of the (left) anterior interventricular and circumflex are usually
Answer: D
proximal. Lesions on the right are more diffuse and distal, but usually spare the (right) posterior
descending artery (E correct). Prognosis of untreated lesions worsens progressively with one, two or
The pathogenesis is that the centrilobular cells get the last remnants of oxygen in the blood which has
three arteries involved, but left main coronary artery disease is comparable to three-artery disease
already supplied the gut and then the periportal cells; all of this in a pathophysiological situation of
(worse than two).
profound global hypoperfusion due to the cardiac problem.
27228 – Right ventricular failure is most likely to be a long-term sequel of 14872 – The most specific serum indicator of acute myocardial infarction is
A. troponin T
which cardiac pathology? B. the BB isoenzyme of creatinine phosphokinase
A. Aortic stenosis C. the MM isoenzyme of creatine phosphokinase
B. Aortic incompetence D. the MB isoenzyme of creatine phosphokinase
C. Mitral stenosis E. lactic dehydrogenase
D. Atrial fibrillation
E. Stenosis of the left main coronary artery Answer: Troponin T
Answers: C Refer to Robbins, 6th Ed, Ch 13, page 561
The right ventricle may fail secondary to pressure overload transmitted back from a failing left
ventricle. This mechanism is prominent in mitral stenosis, where the left atrial pressure may be

12560 – A large cardia infarct, three days old, may show all of the following D. prevented by class I antiarrhythmics
EXCEPT E. due to supraventricular tachycardia
A. coagulative necrosis
Answer: C
B. peripheral inflammatory reaction
C. thrombus formation on the endocardial surface
Although any type of interference with the electrical or mechanical functions of the heart may lead to
D. red cells among the dead muscle fibres
sudden death, in fact the overwhelmingly commonest cause is ventricular fibrillation - option C. Asystole
E. perivascular accumulation of lymphocytes
may follow interruption to the conducting system below the AV node with occlusion of the left
circumflex artery, but is less common than tachyarrhythmia. Cardiogenic shock is fortunately
Answer: E
uncommon. When due to loss of a large zone of myocardium, its poor prognosis is not improved by
early thrombolytic intervention. Antiarrhythmics are useful in treating arrhythmias, but disappointing
A large cardiac infarct three days old will show coagulative necrosis (A false). This typically excites an
when used prophylactically. Class Ic agents actually increase post-infarct mortality, emphasising the
acute inflammatory reaction at its margins (B false), and may provoke the formation of a thrombus on
arrhythmogenic potential of antiarrhythmic drugs.
the endocardial surface (C false). Cardiac infarcts typically show seepage of red cells among the
muscle fibres (D false). Perivascular accumulation of lymphocytes is not a feature of the reaction to
infarcts (E true). 14946 – S:The size of hypertrophied cardiac muscle fibres cannot exceed a
certain maximum because R:the phenotype of the myocytes is altered and
27174 – S:Non-Q wave infarction is associated with a lower risk of re- the process is limited by apotosis
infarction because R:the partial thickness lesion involves less muscle
necrosis. Answer: S is true, R is true and a valid explanation of S

Although most infarcts are predominantly subendocardial when examined pathologically, the pattern 12686 – S:If a patient with mitral stenosis has a pulmonary embolus,
with Q waves does reflect more complete transmural extension of the lesion. However, the viable infarction is especially likely to occur because R:the bronchial arterial
muscle in the territory of the affected vessel in non-Q infarction remains at risk of re-infarction, and so supply is reduced in mitral stenosis
the risk is greater, not less, with non-Q patterns. Thus, the statement is incorrect,and the reason is a
correct statement but not a valid explanation.(D correct) Answer: S is true, R is true and a valid explanation of S
27132 – With respect to myocardial ischaemia Blockage of a pulmonary artery does not usually cause infarction in healthy subjects, because the
A. acute unstable angina is usually precipitated by increased oxygen demand bronchial arterial supply provides well-aerated blood. In mitral stenosis the bronchial arterial supply is
B. angina pectoris is typically due to plaque disruption and platelet deposition reduced (R true), and blockage of a pulmonary artery is likely to lead to infarction.
C. painless myocardial ischaemic episodes precipitated by emotional stress in patients with
documented coronary occlusive lesions, are a recognised entity with similar prognostic implications to 22119 – Common predisposing causes of aortic dissection include
classical angina 1: idiopathic cystic medionecrosis
D. angina in the absence of angiographically normal coronary vessels is moderately common 2: syphilitic aortitis
E. 'syndrome X' only occurs in patients with demonstrated single vessel lesions 3: systemic hypertension
4: atherosclerosis
Answer: C
Answers: TFTF
A and B are reversed - it is the acute coronary syndromes of myocardial infarction and unstable
(crescendo) angina which are due to thrombosis, while classical angina is precipitated by increased Robbins 5th ed. Page: 499-502. This question is currently under review by the sub committee. 4
myocardial workload in the presence of fixed reductions in calibre of major vessels. Not all ischaemia June 2002. This question has been updated. 28 August 2002.
is painful - the mechanisms are poorly understood, but the prognostic implications are similar to
symptomatic ischaemia: statement C is correct. Options D and E are inverted. Angina is rare in the
16005 – New blood vessel formation (angiogenesis) is a feature of
absence of occlusive lesions: when it occurs it is known as 'syndrome X' and believed to be due to
1: chronic inflammation
lesions in the microvasculature. This question has been forwarded to the sub committee for review.
2: metastatic spread of cancer
This question has been reviewed and has not been altered. 9 Dec 2002
3: tuberculous granuloma formation
4: pulmonary silicosis
27138 – Sudden cardiac death is commonly
A. due to pump failure Answers: TTFF
B. due to asystole
C. due to a ventricular tachyarrhythmia

Chronic inflammation is a continuing attempted healing which never completes itself unless/until the Fatal pulmonary embolism is usually due to impaction of a large embolus in the main pulmonary
damaging agent is removed. Continuous granulating scar formation is characteristic of this process - artery and its branches, or in the right ventricle. An embolus of this size commonly arises in the leg
ie. angiogenesis. Likewise, metastatic cancer foci can not establish a separate existence without veins. Thrombi occur in both the pelvic and the leg veins. In fatal pulmonary embolism, the size of the
establishing a microvasculature for supply of nutrients, including oxygen. Tubercles and silicotic embolus is the point at issue.
nodules are generally described as 'avascular' - this may or may not be absolutely true but overt
granulation tissue formation with angiogenesis is not a feature of either. 27102 – Deep venous thrombosis is more common in patients with a
history of any of the following except
27077 – S:Provocation by exercise and relief by rest are characteristic of A. malignancy
limb pain due to arterial insufficiency because R:exercise requires an B. oral contraceptive usage
increased blood flow to meet the metabolic needs of working muscle. C. surgery, especially abdominal, pelvic or hip, or immobilisation
D. obesity, old age, or past history
Answer: S is true, R is true and a valid explanation of S E. anaemia
Resting skeletal muscle has very low requirements for blood flow: as little as 1% of the values seen in Answer: E
maximal exercise. Pain of arterial insufficiency is provoked by exercise, since the flow restriction of
the stenosis results in diminished flow and pressure at the working muscles. This is the critical Deep venous thrombosis can occur in any clinical setting, and pulmonary embolism is the commonest
diagnostic feature of intermittent claudication thus statement and response are true and linked (A potentially preventable cause of death after major surgery. There is an impressive list of known risk
correct). Other causes of lower limb pain, such as osteoarthritis, will not have the pattern of factors, all connected more-or-less plausibly to either hypercoagulability or venous stasis. Among
predictable onset with exercise and relief within a short period of rest. An arterial bruit at the site (and common conditions, anaemia is one of the few not conspicuously associated with DVT (E True).
distal to) the stenosis, may not always be apparent at rest, but can appear during exercise as flow is Polycythaemia, as a cause of elevated blood viscosity, is a known association with DVT.
increased due to the functional hyperaemia in working muscle, and flow velocity in the stenosis
crosses the threshold for turbulence. Rest pain in arterial insufficiency is an extremely grave 27120 – Acute superficial thrombophlebitis is commonly associated with all
symptom, and in the light of the minimal nutritional requirements of resting muscle and connective except
tissues of the lower limb, indicates a profoundly reduced ability of the vasculature to supply blood A. pain, induration, heat and tenderness along the involved vein
flow. B. oedema of the limb
C. trauma
27089 – Incompetence of the venous valve of the long saphenous trunk at D. neighbouring bacterial infection
the saphenofemoral junction, with competent leg and ankle perforators, is E. venous cannulation
most likely to be associated with Answer: B
A. oedema
B. pigmentation
Thrombophlebitis of superficial veins is often caused by trauma, cannulation, or a nearby infection. Its
C. cutaneous ulceration
clinical signs are obvious. The process tends to remain localised to a single vein system: therefore,
D. simple varicose veins
venous hypertension of the limb with oedema does not usually occur (option B).
E. none of the above features
Answer: D 27095 – Lymphoedema occurs when lymphatic vessels fail to remove from
the interstitial space
The presence of an incompetent saphenofemoral valve alone leads to varices in the long saphenous A. salt
system. Since the ankle perforating vein valves are competent, the pressure in the superficial veins B. water
will fall on walking; and these patients tend not to develop the severe signs of venous hypertension C. protein
(oedema, pigmentation, trophic changes, ulcers) seen in those suffering from incompetent valves in D. cells
the ankle perforators. Typically, they suffer simple varicose veins (option D). The degree of pathology E. none of the above components
correlates better with the measured venous pressure during exercise and standing, than with the
clinical assessment of venous valves. Answer: C
12692 – S:Thrombosis arising in the pelvic veins is the commonest cause The question does not ask what lymphatics remove, but rather, which of the things that they normally
remove is the cause of oedema when lymphatic function is absent. Interstitial fluid pressure depends
of fatal pulmonary embolism because R:thrombosis is more frequent in the on the equilibrium of Starling forces: the hydrostatic pressure in the capillary pushing fluid out, and the
pelvic veins than in calf veins osmotic pressure of plasma proteins pulling fluid back into the capillary. Capillaries are generally fully
permeable to salt, water and small molecules, but nearly completely impermeable to proteins like
Answer: both S and R and false albumin. The 'nearly' is the catch. Lymphatics remove a small amount of interstitial fluid, including the
protein that leaks slowly through capillaries. In the absence of lymphatic function, that protein
accumulates, abolishing the colloid osmotic pressure gradient from blood to interstitial fluid which
normally pulls fluid back into the capillary. The result is oedema - lymphoedema. Thus, option C is the
required answer. Answers: TTTF
Pulmonary oedema occurs in a number of circumstances. Neurogenic factors may be important, eg

RESPIRATORY following head injuries and as a complication of neurosurgery (A true). It is a recognised complication
of the rapid withdrawal of a pleural effusion (B true) and of uraemia (C true). The pathophysiological
22759 – Pulmonary emboli may cause mechanisms involved in the last two examples are not entirely clear. Pulmonary oedema is more
1: pulmonary artery atherosclerosis likely to complicate left ventricular failure than right ventricular failure (D false).
2: chronic pulmonary hypertension
3: no clinical effect 12554 – A patient with pulmonary infarction is most likely to have had
4: cardiogenic shock A. pulmonary hypertension
B. chronic obstructive airways disease
Answers: TTTT C. right ventricular failure
D. passive venous congestion of lungs
Robbins 5th ed. Chapter: 4 Page: 111 E. chronic bronchitis
27114 – Patients with significant pulmonary embolism usually show on Answer: D

investigation all except
A. ECG changes with ST depression and T inversion Any of the diseases listed may precede pulmonary infarction. However, the lung has a double blood
B. defects in pulmonary perfusion scans supply, and pulmonary vascular obstruction is normally unlikely to cause infarction. Infarction is likely
C. normal pulmonary ventilation scans only in the presence of a compromised pulmonary circulation. Thus, patients with chronic venous
D. arterial hypoxaemia with increased A-a oxygen tension difference congestion of the lungs are more likely to develop a pulmonary infarct following pulmonary obstruction
E. normal chest X-ray, at least initially than patients with the other diseases listed.
Answer: A 9810, 16880 – Carcinoma of the bronchus may cause

1: hypocalcaemic syndrome of pseudohypoparathyroidism
Investigations are also difficult in pulmonary embolism. Disparity between the ventilation and 2: Cushing's syndrome
perfusion scans in nuclear medicine techniques is highly specific and usefully sensitive for 3: hyponatraemia
haemodynamically significant emboli. The ventilation-perfusion mismatch is apparent on blood gas 4: inappropriate secretion of norepinephrine
investigations, where there is an alveolar to arterial oxygen tension difference. Chest X-ray is initially
unhelpful; the wedge-shaped radiological opacity occurring later as the lung in the territory of the Answers: FTTF
obstructed artery consolidates. ECG changes are seen in a small minority of patients - those with
severe right ventricular overload from pulmonary hypertension. Thus, option A is inconsistent with the Robbins, 6th ed, Ch 8. I am unaware of the occurrence of either syndrome 1 or 4 in neoplasia as a
majority picture, and is therefore the required answer. ‘para’ neoplastic syndrome (epinephrine secretion in phaeochromocytoma, for instance, is
predictable). Options 2 and 3 are common in lung cancer.
15810 – Extensive pulmonary fat embolism may
1: result from severe soft tissue trauma 25982 – In the causation of decompression sickness, the nitrogen
2: cause disseminated intravascular thrombocoagulation 1: may cause physical tissue damage
3: cause the adult respiratory distress syndrome 2: may cause ischaemic tissue damage
4: result from abdominal trauma in the alcoholic 3: dissolves preferentially in lipid
4: preferentially causes damage in areas of rich blood supply
Answer: TTTT
Answers: TTTF
The normal adipose tissue and the extensive amount of fat which may be present in the liver of the
alcoholic can form the reservoir from which the embolic material in fat necrosis emanates. The Robbins 5th Edition PAGE: 113, 401
previous idea that the fat in fat embolism arises from some enzymatic activation of triglyceride
formation within the plasma or ‘in situ’ in the lung, currently has no takers. 15740 – S:Separation of respiratory epithelium from basement membrane
often occurs in acute attacks of allergic asthma because R:major basic
13110 – Pulmonary oedema is a recognised complication of protein, secreted by eosinophils reacting in IgE-mediated inflammation,
1: head injury
2: aspiration of a pleural effusion causes epithelial cell injury.
3: uraemia
4: right ventricular failure

Answer: S is true, R is true and a valid explanation of S A. heparin
B. acyclovir
The prolonged effects of an acute asthmatic attack are due to the chemotactic effects of leukotrienes C. morphine
(the old SRSA) and especially the eosinophil chemotactic effect, these cells being responsible for the D. propranolol
exocytosis of major basic protein - a powerful parasitoxic agent, but in this clinical situation, bringing E. phenytoin
about tissue injury without benefit.
Answer: B
25680 – In a post-operative patient with respiratory failure and
A.C.P. 1996
compromised breathing
A. pulse oximetry is a useful tool to monitor hypercapnia
B. inadequate oxygenation in the presence of an FIO2 of 0.6 implies an unstable patient who needs 22129 – When generalised oedema complicates chronic hepatic failure,
further diagnosis and definitive treatment pathogenetic mechanisms include
C. decreased level of consciousness is most commonly due to opiate medication rather than hypoxia 1: increased renal sodium retention
or hypercarbia 2: reduced plasma colloid osmotic pressure
D. if the patient is hypoxic, delivery of high flow oxygen by mask is the first intervention required 3: increased renal renin secretion
E. if ventilation is required, minimum minute volume (tidal volume x respiratory frequency) is 10 ml/kg 4: increased microvascular permeability
Answer: B Answers: TTTF
Answer to come. Pending review. Jan 2003 Robbins 6th ed. Pages: 113-11
15661 – Fatty change in the liver (hepatic steatosis)

GASTROINTESTINAL 1: is characteristically seen with active hepatitis B infection
2: will cause dangerous derangement of the coagulation profile
8687 – The disorders of haemostasis seen in cirrhotic liver failure may 3: when due to alcohol abuse, does not regress with abstention
include 4: is seen in persons suffering from protein malnutrition
1: disseminated intravascular coagulation
2: hypoprothrombinaemia Answers: FFFT
3: secondary thrombocytopenia
4: impaired synthesis of several clotting factors Fatty change in the liver though common with active hepatitis C, is not part of hepatitis B infection.
With simple (uncomplicated) fatty liver, even when quite extensive, significant derangement of
Answers: TTTT function is exceptional. Hepatic fat in the alcoholic usually ‘melts away’ with abstention. The enlarged
liver of kwashiorkor and other protein malnutrition states is, paradoxically, due to storage, in the liver,
Robbins, 6th ed, Ch 14 and Ch 19 of the (unavailable) calorie source.
15821 – Pathogenetic mechanisms in development of generalised oedema 15666 – Hepatic steatosis (fatty liver)
in chronic liver failure include 1: is the major liver injury resulting acutely from hypovolaemic shock
1: increased microvascular permeability 2: may be due to poorly controlled diabetes mellitus
2: increased renal sodium retention 3: is potentially reversible
3: increased renal renin secretion 4: if discovered in liver biopsy (ie without ‘toxic hepatitis’), has no sinister long term implications for
4: reduced plasma colloid osmotic pressure the chronic alcoholic
Answers: FTTT Answers: FTTF
There is not enough sodium and water aboard the normal individual to produce generalised oedema Hypovolaemic shock, when severe, causes hepatic hypoperfusion, with centrilobular degeneration/
under any circumstances. When there is sudden loss of fluid from the plasma (without extra being necrosis of hepatocytes - this is an acute injury situation. Poorly controlled diabetes mellitus almost
loaded aboard first), the result is shock (anaphylactic, if the loss was due to histamine release, with always causes prominent fatty liver. If the stimulus to fatty change is reversed, resolution always will
increased permeability). While the fluid accumulation of ascites in the cirrhotic may or may not involve occur. However, there is strong evidence that alcoholic fatty liver (even without hepatocyte acute
increased vascular permeability, the generalised oedema does not. necrosis) of very long standing will stimulate fibrosis (perhaps via activation of the Ito cell) with
eventual progression to ‘fatty alcoholic cirrhosis’.
19138 – In severe liver disease, the dose of all of the following drugs
15758 – Hepatic steatosis is commonly seen in
should be reduced EXCEPT 1: chronic congestive heart failure
2: malnutrition 1: commonly causes obstructive jaundice
3: chronic hepatitis B carrier state 2: causes palpable gallbladder enlargement in most cases
4: paracetamol (acetaminophen) poisoning 3: is surgically resectable in most instances
4: has a prognostic outlook similar to that of colonic carcinoma
Answers: TTFT
Answers: TFFF
Of the viral hepatitides, only hepatitis C is said to be associated with fatty change in the liver - it is
quite a common finding on biopsy. I see no reason why someone with alcoholic (or other) steatosis Robbins 5th ed. Chapter: 18 Pages: 893
should not contract hepatitis B, but the finding of significant steatosis in active hepatitis B is quite
exceptional and off-putting to the histopathologist. It is certainly not a feature of the disease (but is of 17773 – Carcinoma of the extrahepatic bile ducts
hepatitis C). The others are ‘givens’. 1: in most cases does not cause palpable gallbladder enlargement
2: has a prognostic outlook similar to that of colonic carcinoma
23039 – Hepatic steatosis (fatty change of the liver) may be caused by 3: is curably resectable in most instances
1: chronic venous congestion 4: commonly causes obstructive jaundice
2: alcohol excess
3: protein malnutrition Answers: TFFT
4: alpha-1-antitrypsin in liver cells
Only approximately 25% of patients have palpable gallbladder, but obstructive jaundice is the rule,
Answers: TTTF often with stool decolourisation. The majority of ductal cancers are not resectable at the time of
diagnosis, despite their small size; mean survival times range from 6 to 18 months, no matter what
Robbins 5th ed. Chapter: 1 Page: 25, 27 the treatment given; this is in sharp contrast to the considerably superior survival rates for colonic
cancer.
17768 – Most carcinomas of the gallbladder
1: are squamous or adenosquamous carcinomas 15588 – Adenocarcinoma of the pancreas
2: present clinically with pain plus an enlarged gallbladder 1: usually presents at a stage of development when it is incurable
3: have invaded the liver at the time of operation 2: commonly presents with secondary diabetes attributable to carcinomatous pancreatic destruction
4: are always associated with presence of gall bladder calculi 3: can be reliably predicted in a person presenting with migratory thrombophlebitis
4: most commonly follows a prolonged history of recurrent or 'chronic' pancreatitis
Answer: FFTF
Answers: TFFF
Most cancers of the gallbladder are adenocarcinomas. Clinical presentation is typically insidious and
indistinguishable from the symptoms and signs of benign gallbladder disease - palpable enlargement Refer to Robbins, 6th Ed, Ch 19, page 910-911
of the gallbladder is distinctly unusual. According to Robbins, 60-90% of carcinoma of the gallbladder
is associated with gallstones - the point is that there is a very significant incidence of cases occurring 893 – Reduction in the mortality of acute pancreatitis is most likely to result
without gallstones and the overall incidence of gallbladder carcinoma in patients with gallstones is so from
low that prophylactic cholecystectomy for gallstones is considered unjustified. By the time these
A. administration of glucagon.
cancers are discovered, most have invaded the liver.
B. administration of aprotinin.
C. early correction of fluid and electrolyte losses.
15671 – Calcification occurring during the acute phase of haemorrhagic D. total parenteral nutrition.
pancreatic necrosis E. peritoneal lavage.
1: occurs predominantly in necrotic pancreatic acinar cells
2: commonly causes severe hypocalcaemia Answer: C
3: may eventually extensively involve peripancreatic tissues
4: commonly resolves rapidly following recovery from the acute event Acute pancreatitis exhibits a spectrum of severity. Severe acute pancreatitis is accompanied by
hypovolaemia with massive sequestration of fluid and electrolytes in the abdomen and
Answers: FTTF retroperitoneum. Early correction of such losses is of major importance in treatment, and is the most
likely of the responses to influence mortality (C correct). Aprotinin and glucagon have been widely
Calcification is due to reaction of calcium ions with fatty acids formed by lipase action on triglyceride used in treatment, but have not been demonstrated effective in influencing mortality in clinical trials (A
released from cells due to the action of phospholipases released from the necrotic pancreatic and B incorrect). Parenteral nutrition is helpful in treating the complications of acute pancreatitis such
parenchymal cells. This commonly results in severe hypocalcaemia and a more or less permanent as prolonged ileus and abscess formation, but is not so relevant to early mortality (D incorrect).
presence of calcium soaps replacing the retroperitoneal and other fat involved. Peritoneal lavage and dialysis have a role in management of acute pancreatitis (particularly when
acute pancreatitis is diagnosed at operation) and in the management of local and systemic
23554 – Carcinoma of the extrahepatic bile ducts
complications (pancreatic abscess and renal failure). There is no evidence that they reduce the early
mortality (E incorrect). Answer: D
899 – Which of the following problems does NOT accompany the use of a Robbins 5th ed. CHAPTER: 17 PAGE: 820
Sengstaken-Blakemore tube inserted for balloon tamponade of bleeding
oesophageal varices? 17763 – Most colorectal carcinomas
1: arise within pre-existing adenomas
A. Aspiration.
2: occur in the absence of pre-existing ulcerative colitis or familial adenomatous polyposis syndrome
B. Asphyxia.
3: present clinically in individuals under age 55 years
C. Oesophageal rupture.
4: arise in the distal 15 cm of colon/rectum
D. Rebleeding upon balloon deflation.
E. Vagal-induced bradycardia.
Answers: TTFF
Answer: E
Colonic adenomas are premalignant and most adenocarcinomas arise from pre-existing adenomas -
the larger the adenoma, the greater the risk that adenocarcinoma has developed in it. Less than 5%
The Sengstaken-Blakemore tube can give effective control of acute bleeding from oesophageal
of cases of colorectal cancer arise in the setting of pre-existing familial adenomatous polyposis or
varices. There are a of hazards and complications of its use. Aspiration or asphyxia during insertion,
inflammatory bowel disease - responses (1 and 2) are correct. Peak incidence for colorectal
oesophageal pressure necrosis or rupture, and rebleeding after balloon deflation are the most
carcinoma is 60-70 years ie the incidence increases with increasing age. Less than 25% are located
important. The tube should preferably be inserted, and the patient managed, in an intensive-care
in the rectosigmoid and this trend of higher incidence of proximal involvement is more prevalent in
environment. Vagal-induced bradycardia is not a complication. Stimulation of afferent vagal fibres
Australasia.
related to the oesophagus or stomach does not evoke cardio-inhibitory reflexes, whereas hypovolaemic
tachycardia is common. E is thus the correct response.
23014 – Lesions known to predispose to colonic adenocarcinoma include
1: hyperplastic polyps
16891, 22744 – Gastrointestinal carcinoid tumours 2: diverticulosis
1: show neuroendocrine differentiation
3: tubular adenomas
2: are most commonly found incidentally at surgery or autopsy
4: chronic ulcerative colitis
3: are clinically innocuous neoplasms
4: most commonly grow "within the range of the competent sigmoidoscopist"
Answers: FFTT
Answers: TTFF
Robbins 5th ed. Chapter: 17 Pages: 809 & 815
Robbins 5th ed. Chapter: 17 Pages: 819-820. Options 1 and 2 are clearly correct. However, despite
the truth of option 1, carcinoids presenting with symptoms referable to the presence of the tumour 16901 – Colonic carcinoma has an increased incidence in individuals with
(either its mass effect or due to its secretory products) present a formidable problem thereafter. 1: hyperplastic polyps
Obstructing gut carcinoids usually eventually metastasise and bronchial carcinoids are ?? often 2: Peutz-Jegher's syndrome
locally invasive or occasionally capable of metastasis?. Option 4 is wildly optimistic, even for 3: tubular adenomas
exhibitionists! 4: chronic ulcerative colitis
Answers: FFTT
25990 – Recognised accompaniments of carcinoid syndrome include
1: cramping abdominal pains
Chronic ulcerative colitis is the most significant non-neoplastic precursor of carcinoma and the debate
2: facial flushes
over whether or not adenomas (tubular or villous) are precancerous has long been settled!
3: tachycardia
Hyperplastic polyps are generally agreed to have no premalignant potential in their own makeup, but
4: pulmonary stenosis
may be admixed with adenoma whereupon the lesion takes on the premalignant mantle of the
adenoma. Peutz-Jegher's polyps are considered to be hamartomas with no innate premalignant
Answers: TTTT
potential. The syndrome is, however, associated with an increased incidence of cancers of other
sites.
Robbins 5th ed. Chapter:17 PAGE:820 (Table 17-15)
19701 – The carcinoid syndrome 17753 – Precursor lesions of colonic adenocarcinoma include
1: hyperplastic polyps
A. is seen in association with renal cancer
2: Peutz-Jegher polyps
B. often causes paroxysmal hypertension
3: adenomatous polyps
C. is associated with eosinophilia
4: juvenile polyps
D. is associated with pulmonary stenosis
E. often occurs with phaeochromocytoma
Answers: FFTF 4: epithelial cell dysplasia is present out of proportion to the degree of inflammation in that area of
mucosa
The usual small hyperplastic polyp has virtually no malignant potential. Large hyperplastic polyps
occasionally contain foci of admixed adenoma - as may any part of the colonic mucosa; the Answers: FTTF
‘hyperplastic’ component is considered to be innocuous. Adenomatous polyps are on the ‘normal
mucosa to adenoma to carcinoma’ trail and have already undergone the initial mutation(s) which will Robbins 6th ed. Chapter: 18 Pages: 816-818
occur progressively if carcinoma is to eventually develop. The other two polyps are examples of
hamartoma (responses 2 and 4) and have no known pre-malignant potential. 17758 – Colonic epithelial neoplasia is considered as not having significant
metastatic potential if adequate histological examination shows
14833 – Malignant change is likely to occur in individual examples of 1: adenoma with carcinoma in situ
colonic 2: adenoma showing severe epithelial dysplasia with focal intramucosal carcinoma
1: juvenile polyps 3: adenocarcinoma, invasive into submucosa only
2: hyperplastic polyps 4: invasive adenocarcinoma to superficial muscularis propria, without demonstrable vascular or
3: adenomatous polyp lymphatic permeation
4: Peutz-Jegher polyps
Answers: TTFF
Answers: FFTF
Carcinoma in situ is still, for pragmatic purposes, a benign lesion. It has not yet acquired the attributes
Refer to Robbins, 6th Ed, Ch 18, page 828-829 which will cause metastasis. Because lymphatic channels are largely absent from colonic mucosa,
intramucosal carcinoma is regarded as having little or no metastatic potential. Invasion into
19731 – The jejunal polyps found in the Peutz-Jeghers syndrome are submucosa indicates adenocarcinoma which has now acquired metastatic potential - real in all cases.
A. adenomatous Likewise for response (4).
B. premalignant
C. carcinomatous 7737 – S:Gardner's syndrome is a clinically more sinister variant of familial
D. hamartomatous polyposis coli(FPC) because R:aggressive neoplasms, other than colonic
E. sarcomatous
carcinoma, may determine mortality in Gardner's syndrome.
Answer: D
Because of co-existence of other ‘tumours’, Gardner’s syndrome has a deservedly sinister reputation.
The fatal problem in many of these patients becomes intra-abdominal fibromatosis which often follows
15978 – Chronic colitis is more likely to be due to Crohn disease if surgery for polyposis and may not be clinically obvious before this. Regarding the time onset of the
1: epithelial cell dysplasia is present out of proportion to the degree of inflammation in that area of malignancies, there is no difference between those with and those without extra-colonic
mucosa manifestations.
2: submucosal oedema and lymphocytic infiltrate are prominent
3: multiple biopsies show progressive distal increase in mucosal disease severity
17731 – S:Gardner's syndrome is a clinically more sinister variant of
4: colonoscopic biopsy shows focal epithelioid cell granulomas
familial polyposis coli (FPC) because R:in Gardner's syndrome, colonic
Answers: FTFT malignancies occur, on average, about one decade earlier than when FPC
occurs alone.
Non-inflammatory epithelial dysplasia is said to be the hallmark of developing carcinoma in long-
standing active ulcerative colitis - cancer incidence is probably increased in all long-standing IBD, but Answer: S is true and R is false
this is disproportionately so in UC. Mucosal inflammation is present in involved zones in both UC and
Crohn disease and there may be some superficial submucosal lymphocytic infiltration in UC, but 875 – The frequency of post-operative adhesions is lowest when parietal
prominent submucosal lymphocytic infiltration and oedema are strong hallmarks of Crohn disease.
Crohn's disease is random and discontinuous; UC involvement is progressively distally severe. peritoneal defects which are created intra-operatively are
Granulomas are regarded as a virtually pathognomonic diagnostic feature of Crohn disease. A. closed with plain catgut.
B. closed with chromic catgut.
C. closed with silk.
23319 – Crohn's disease is strongly indicated as the diagnosis in a case of
D. closed with nylon.
inflammatory disease of the colon if E. not closed.
1: mucosal biopsies show increasing disease severity more distal in the colon
2 : there is prominent oedema and lymphocytic infiltrate of the submucosa
3: focal epithelioid cell collections are present in the mucosa
Answer: E Answer: B
Adhesion formation is a response to ischaemia and irritation so that suturing peritoneal defects is more The thyroid gland is enlarged (A false) and shows increased vascularity (D false). The thyroid
likely to increase than to reduce adhesion formation, especially if the sutures are inserted under tension epithelium is taller than normal (C false), but the amount of colloid in the thyroid follicles is reduced (B
(E correct). The type of suture material is less relevant. true). TSH levels are suppressed (E false).
20535 – S. Aluminium hydroxide and magnesium trisilicate used in an 22429 – Features of secondary hyperparathyroidism may include
antacid mixture may cause diarrhoea BECAUSE R. gastric bacterial 1: hyperphosphataemia
2: adjacent areas of vertebral osteosclerosis and osteoporosis
overgrowth occurs with altered intra-luminal pH 3: aluminium deposition at the site of mineralization
4: reduced intestinal absorption of calcium
Answers: TTTT
Syllabus Extension & Update ACP1 - ACP39
Robbins 6th ed. Page: 1150; 1228. Review July 2004 re: options 3 & 4.
25722 – Concerning the gut as a potential source of sepsis
A. enteral glutamine has little protective effect 10185 – Secondary hyperparathyroidism has become much more common
B. translocation of bacteria can occur with an intact gut
C. early enteral feeding is more likely to cause ileus than be of benefit since the initiation and wide use of maintenance haemodialysis in patients
D. sucralfate is cytoprotective throughout the GI tract with renal disease. Concerning this problem
E. oral antibiotic regimens with gut decontamination have little effect on the incidence of pneumonia 1: secondary hyperparathyroidism is commonly associated with renal osteodystrophy
2: persistent and symptomatic hypercalcaemia is an indication for parathyroidectomy if a renal
Answer: B transplant is being considered
3: about 25% of patients with renal osteodystrophy have parathyroid hyperplasia
4: total parathyroidectomy combined with intramuscular autografting of some parathyroid tissue is a
THYROID valid procedure
5: secondary hyperparathyroidism may cause pain and itching
10197 – Concerning thyroid gland swellings
1: an enlarged gland may extend down into the superior mediastinum Answers: TTFTT
2: the ‘lateral aberrant thyroid’ is a solitary nodule in one lobe of the gland
3: the most frequent cause of a solitary thyroid nodule is papillary carcinoma 10191 – Concerning a solitary nodule in the thyroid gland
4: Hashimoto’s disease can present as a solitary thyroid nodule 1: a solitary thyroid nodule is more likely to be malignant than is a multinodular goitre
5: the lymphatic drainage of the thyroid is confined to the internal jugular chain of nodes 2: low-dose radiation in infancy or childhood is associated with an increased incidence of thyroid
cancer later in life
Answer: TFFTF 3: a thyroid nodule is more likely to be cancerous in women than in men
4: hot thyroid nodules rarely are malignant
10221 – Which of the following findings suggests that a thyroid mass is 5: thyroid cancer is present in approximately 50% of young patients with solitary cold nodules
malignant?
A. Size greater than 5cm Answers:TTFTF
B. Retrosternal extension
C. Recurrent laryngeal nerve palsy All thyroid conditions are 8 times commoner in women than men. However, a solitary thyroid nodule
D. Positive Pemberton’s sign in a male is more likely to be malignant than a solitary thyroid nodule in a female. Whilst hot nodules
E. Stridor are unlikely to be malignant on rare occasions they may be so. The incidence of cancer in solitary
nodules in young patients and children is greater than in adults, but not as great as 50%.
Answer: C
10306 – Concerning follicular adenoma of the thyroid gland
10440 – Primary thyroid hyperplasia does NOT result in an increase of the 1: adenomas of the thyroid may develop after irradiation of the neck
A. size of the thyroid gland 2: excision of the whole adenoma is sound practice
B. amount of colloid in the thyroid follicles 3: after excision of a follicular adenoma, permanent thyroid hormone replacement is necessary to
C. height of the epithelium of the thyroid follicles reduce the incidence of recurrence
D. vascularity of the thyroid gland 4: fine needle aspiration cytology (FNAC) is diagnostic as a method of distinguishing a follicular
E. serum TSH adenoma from a follicular carcinoma
5: ultrasound using present techniques can differentiate readily between solid adenomas, carcinomas
and non-toxic thyroid nodules
3: may secrete calcitonin, 5-hydroxytryptamine and prostaglandins
Answers: TTFFF 4: is usually associated with hypocalcaemia
Fine needle cytology cannot distinguish adenoma from carcinoma because this diagnosis rests on the Answers: TTTF
histological features of capsular and/or vascular invasion.
Robbins 5th ed. Chapter: 25 Page: 1140. Medullary carcinoma arises in C cells and produces
14838 – Papillary carcinoma of the thyroid calcitonin, but there are no outstanding changes in plasma calcium levels (D false). C cells have
1: generally has an excellent prognosis (~90% twenty year survival) properties of other APUD cells, having a high content of amines and prostaglandins (C true).
2: has metastasised to cervical lymph nodes in about 50% of cases by the time of first diagnosis Medullary carcinoma has a familial tendency (A true) and is associated with the multiple endocrine
3: prognosis is worsened by finding co-existent follicular growth pattern neoplasia II syndrome. The reason for stromal amyloid is not understood (B true). Pending review,
4: has a more sinister course when onset is in the first two decades of life April 2003.
Answers: TTFF 22699 – A 30 year old man with medullary carcinoma of the thyroid
diagnosed by drill biopsy will have
Refer to Robbins, 6th Ed, Ch 26, page 1143,1144 1: hypothyroidism
2: hypercalcaemia
10209 – Papillary carcinoma of the thyroid gland 3: a tendency to tetany
A. is a tumour usually occurring in young adults 4: high circulating calcitonin levels
B. is three times more common in males
C. usually presents as a diffuse enlargement of one lobe of the thyroid Answers: FFFT
D. is often associated with distant metastases
E. is usually associated with hyperthyroidism Ganong 16th ed. CHAPTER: 21 PAGE: 351 & 359
Answer: A 20901 – S. Medullary cancer of the thyroid is characteristically

accompanied by low serum calcium BECAUSE R. medullary cancer of the
2749, 16942 – Papillary carcinoma of the thyroid thyroid is a neoplasm of the para-follicular (C)cells of the thyroid
1: can be the result of childhood thyroid irradiation
2: may have asymptomatic metastases for many years
3: commonly presents clinically because of metastases
4: when the histology shows an admixture of papillary and follicular growth patterns, behaviour is
Robbins 5th ed. Chapter: 25 Page: 1140
predictably more aggressive
Answers: TTTF 16040, 16825, 19773 – The best survival with thyroid neoplasia is seen with
A. sporadic (non-familial) medullary carcinoma
Robbins 5th ed. Chapter: 25 Pages: 1137-1138. This question is currently under review by the B. giant cell carcinoma
Pathology Sub Committee. 28 June 2002. Pathology Sub Committee comments: Papillary carcinoma C. follicular carcinoma
of thyroid has an overall 10 year survival rate of 98%.....10% to 15% have distant metastases. In D. papillary carcinoma
gerneal the prognosis is less favourable....with distant metastases." (Robbins 6th ed p1144) These E. small cell carcinoma
figures clearly indicate metastases are compatible with long survival. However, specific mention of
lung metastases from papillary thyroid cancer is not detailed in Robbins. While this origin could be Answer: D
inferred from the quote "The lung is frequently the site of metastatic neoplasms. Both carcinomas and
carcomas arising anywhere in the body many spread to the lungs....". Papillary cancer follows Robbins 5th ed. Chapter: 25 Page: 1138. Papillary cancer of the thyroid has a very good medium
childhood radiation like bills follow credit cards. There is no reason to feel confident that this will not and even long term outlook, even in the presence of disseminated disease. Familial medullary cancer
continue. This is an indolent cancer which has been likened in behaviour to endometriosis; metastatic also has an excellent prognosis; this is not shared by the sporadic (non-familial) form of medullary
spread is extremely common, sometimes widespread (even to lungs, brain! for many years) with cancer, which also has marked differences in clinical presentation. Follicular cancer has an outlook
minimal deterioration - however, needless to say, overall these are markers for poorer prognosis. somewhere between papillary/familial medullary and the highly malignant giant and small cell
Over half of papillary carcinomas have admixtures of follicular growth. However, long-term follow-up (collectively ‘undifferentiated’) forms.
shows that ?? regardless of precise proportions, all neoplasms containing some papillary areas have
identical biologic behaviour ?". This question has been updated. 29 August 2002. 10203 – A 25-year-old woman who is 11 weeks pregnant, is diagnosed with
thyrotoxicosis. Which is the most appropriate form of initial management?
10483, 22724 – Medullary carcinoma of the thyroid A. Beta-blocker
1: shows a familial tendency B. Anti-thyroid medication (neomercazole)
2: often has a stroma rich in amyloid C. Bilateral subtotal thyroidectomy

D. Total thyroidectomy
E. Radioiodine
16875 – Neuroblastoma of the adrenal
Answer: A 1: commonly matures spontaneously to form a ganglioneuroma
2: is a cancer of childhood
20031 – Hyperplasia of the parathyroid gland occurs in chronic renal 3: commonly causes hypertension
disease because there is 4: has often metastasised by the time of diagnosis
A. excessive loss of potassium in the urine
B. excessive loss of calcium in the urine Answers: FTFT
C. excessive loss of phosphate in the urine
D. excessive loss of sodium in the urine Neuroblastoma has been documented to mature to ganglioneuroma - to find out why is currently akin
E. impaired calcium absorption from the gut to the quest for the holy grail! This type of regression/maturation is rare. More than 90% of adrenal
neuroblastomas secrete catecholamines, but hypertension is rare.
Answers: E
15861 – Individuals with long-standing and poorly-controlled diabetes
Robbins 5th ed. PAGE: 1/45, 6 Guyton Chapter: 79 Page: 877. Question to be reviewed at the March mellitus are prone to infections with pyogenic organisms because
04 meeting re: decreased abs from gut of Ca2+ (20/02/04). 1: B-cell-mediated immunity is often selectively compromised
2: neutrophil phagocytosis of bacteria is impaired
3: neutrophil reactions to chemotactic stimuli are defective
ENDOCRINE 4: the inflammatory vascular reaction is likely to be reduced
16926 – Multiple endocrine neoplasia syndromes may threaten life because Answers: FTTT
they may cause
1: hypertension Immune response in diabetes may be abrogated to some degree (as in many chronic diseases), but
2: inappropriate ADH secretion this is not predictable or measurable and is certainly not a defined immunoglobulin deficiency of any
3: relentless peptic ulcer syndrome sort. However, neutrophil reactivity of virtually all kinds is severely compromised and this, together
4: 'malignant' thyrotoxicosis (thyrotoxic storm) with the micro (and macro) vascular pathology which characterises diabetes, accounts for the
frequency and severity of pyogenic infections. Leukocyte problems are likely to respond to adequate
Answer: TFTF medium-term metabolic control and presumably the same goes for lifetime management in genesis of
vasculopathy.
Phaeochromocytoma is part of the variations on the theme of MEN II. Zollinger-Ellison syndrome is
part of MEN I. Inappropriate ADH secretion is seen with bronchial cancer (usually ‘oat cell’ or a 15831 – Inflammation and repair are often defective in persons with
variant) or with hypothalamic pathology. Life-threatening thyrotoxicosis is seen only in Graves' diabetes mellitus because of
disease, which is not part of MEN.
1: impaired neutrophil chemotaxis
2: microvascular sclerosis
15197, 16936 – Asymptomatic family members of a patient with multiple 3: diminished neutrophil phagocytosis
endocrine neoplasia syndrome MEN II (includes phaeochromocytoma and 4: impaired antigen presentation by dendritic cells
medullary carcinoma of the thyroid) require clinical follow-up. Effective
Answers: TTTF
screening tests include
1: urinary catecholamine estimation
Neutrophil defects seem to be directly related to the current (ie long term, not minute to minute)
2: plasma calcitonin levels
control of the metabolic state. All aspects of neutrophil anti-bacterial function seem to be impaired,
3: plasma calcium estimation
beginning with endothelial adhesion problems. The microvascular sclerosis (plus atheroma) impairs
4: serum ionised calcium/phosphate ratio
the microvascular response in terms of vasodilatation and probably endothelial responsiveness as
well.
Answers: TTFF
Refer to Robbins, 6th Ed, Ch 26, page 1166-1167. Despite the theoretical action of calcitonin on 15783 – S:The distribution of ischaemic organ damage in diabetics differs
plasma ionised calcium, plasma calcium and phosphate levels are normal in this syndrome, even in from that in patients with non-diabetic vascular disease because R:the
the presence of a calcitonin-secreting medullary cancer of the thyroid with metastases. Urinary pathogenesis of ischaemic damage differs significantly between patients in
catecholamine determinations, on the other hand, will often unearth an early phaeochromocytoma. these two groups.
This question will be reviewed at the March Sub Committee meeting - re: option 3 and relevance of
Ca/PO4 ratio. (12/02/04).

Answer: S is true, R is true and a valid explanation of S with ‘inappropriate hyperparathyroid’ state, it does not cause Cushing’s syndrome. Nor has breast
cancer been documented as a cause of ‘inappropriate ACTH production’.
The atherosclerosis is apparently identical in the two groups. However, in diabetics, there is also the
microvascular pathology which adds another dimension to the ischaemic problems. In diabetics and 5254 – Conn syndrome (primary hyperaldosteronism) may be controlled by
non-diabetic ‘ischaemics’, stroke is about equally prevalent; myocardial infarction about 5X and administration of
ischaemic lower limb disease about 25X.
A. frusemide
B. spironolactone
15686 – Hypercalcaemia is commonly caused by C. chlorothiazide
1: ‘primary’ osteoporosis D. amiloride
2: prolonged dialysis for chronic renal failure E. fludrocortisone
3: renal cell carcinoma
4: acute duodenal peptic ulcer Answer: B
Answers: FTTF Refer to Ganong, 19th Ed, Ch 38, page 691
Osteoporosis of ‘primary’ or postmenopausal type is not associated with hypercalcaemia. Peptic ulcer 23044 – Endogenous oestrogens are a likely cause of
may occur as a result of hyperparathyroidism. Prolonged hypocalcaemia in chronic renal failure leads
1: breast cancer in transvestites
to secondary hyperparathyroidism and the gland overactivity commonly progresses during prolonged
2: coronary artery disease in young women
dialysis for chronic renal failure. Renal carcinoma is one of the more common causes of the
3: clear-cell adenocarcinoma of the vagina
‘paraneoplastic’ syndrome of hypercalcaemia probably related to cytokine elaboration by the
4: gynaecomastia
neoplasm.
Answers: FFFT
15548 – Osteoporosis is
1: a condition of bone atrophy Robbins 5th ed. PAGE: 385-7; 1109
2: a feature of scurvy
3: common in severe thyrotoxicosis 19719 – Each of the following hormones is known to stimulate
4: associated with a normally calcified osteoid matrix
erythropoiesis EXCEPT
Answers: TTTT A. androgen
B. erythropoietin
Refer to Robbins, 6th Ed, Ch 28, page 1222-1224. Resolved Nov 2003 C. glucocorticoids
D. renin
E. thyroxine
9765 – In post-menopausal osteoporosis
1: the serum calcium is low
Answer: D
2: activity of bone matrix bound growth factors is decreased
3: parathyroid adenomata are common
Walter & Israel CHAPTER: 52 Ganong CHAPTER: 13 PAGE: 384, 385
4: osteoid matrix of the cancellous compartment of vertebral bodies is reduced
Answers: FTFT
RENAL / UROLOGY / GYNAECOLOGICAL
23559 – Clinical manifestations of renal adenocarcinoma may include
16838 – Cushing's syndrome may be caused by neoplasms originating in evidence of
1: amyloidosis
1: bronchus
2: polycythaemia
2: pituitary
3: hypercalcaemia
3: oesophagus
4: fever and cachexia
4: breast
Answers: TTTT
Answers: TTFF
Robbins 5th ed. Chapter: 20 Pages: 987
Responses 1 and 2 are straightforward (pituitary as a ‘normal’ producer; bronchus as an
‘inappropriate’ producer). While oesophageal squamous cell carcinoma occasionally is associated

24029 – A young man with osteosarcoma is given cyclical chemotherapy Answers: TTTT
including high dose intravenous methotrexate. Following the third cycle,
By the time a renal infarct is two weeks old it will show clear morphological evidence of tissue death.
there is a marked deterioration in renal function. Possible causes and The affected tissue is whitish yellow in the gross specimen (B true). The dead tissue excites an
contributing factors include inflammatory reaction, which includes macrophages. These ingest haemosiderin which is a
1: acute renal tubular necrosis breakdown product of haemoglobin from the red cells that have seeped into the area (C true). By two
2: crystalluria weeks healing will have started at the periphery of the lesion, and granulation tissue is discernible (A
3: tumour lysis syndrome true). A ghostly outline of the original architecture is perceptible in many infarcts (D true).
4: concurrent use of indomethacin
14721 – Alkaline urine predisposes to
Answers: FTTF 1: oxalate stones
2: phosphate stones
ACP 1996 3: uric acid stones
4: cystine stones
17778 – Clinical manifestations/complications of renal adenocarcinoma
may include Answers: FTFF
1: amyloidosis
2: polycythaemia Refer to Robbins, 6th Ed, Ch 21, page 989-990
3: fever and cachexia
4: hypercalcaemia 23324 – In cases of prostatic carcinoma
1: haematogenous spread occurs chiefly to bone
Answers: TTTT 2: plasma prostate-specific antigen (PSA) levels correlate well with total tumour volume
3: raised plasma prostate-specific antigen (PSA)level is a reliable marker for the disease in
Renal adenocarcinoma is a rich source of ‘paraneoplastic’ syndromes and of syndromes relating asymptomatic men
more directly to some of the legitimate endocrine functions of the kidney. Polycythaemia is a classical 4: most patients, at presentation with symptomatic disease, have carcinoma which is localised within
association with renal carcinoma (5-10% incidence) and this neoplasm is one of the group which the gland
produces hypercalcaemia (even in the absence of bone metastases at times, but particularly in
association with tumour osteolysis). It is one of the classical causes of ‘pyrexia of uncertain cause’ Answers: TTFF
and is the major cancer apart from myeloma which causes amyloidosis (but of the AA type, not AL).
13095 – Conditions contributing to renal failure which complicates multiple
myeloma include 17788 – In cases of prostatic carcinoma
1: amyloidosis 1: raised plasma prostate-specific antigen (PSA) level is a reliable marker for disease in
2: protein deposition asymptomatic men
3: pyelonephritis 2: plasma prostate-specific antigen (PSA) levels correlate well with total tumour volume
4: hypercalcaemia 3: most patients, at presentation with symptomatic disease, have carcinoma which is localised within
the gland
Answers: TTTT 4: haematogenous spread occurs chiefly to bone
The hypercalcaemia accompanying the skeletal demineralisation of multiple myeloma Answers: FTFT
characteristically leads to renal failure (D true). Renal tubules may be blocked by Bence Jones protein
(B true). Amyloidosis often complicates multiple myeloma and causes renal damage (A true). Patients PSA is of value in diagnosis and management of prostatic cancer. PSA levels correlate well with total
with multiple myeloma show increased susceptibility to infection by pyogenic organisms, and thus to tumour volume. However, PSA levels are also raised in prostatic hyperplasia and, because of overlap
pyelonephritis (C true). between levels found in hyperplasia and in early and localised cancer, PSA alone cannot be used for
the reliable detection of early cancer. More than 75% of patients have advanced prostatic cancer
when diagnosed. When haematogenous spread occurs, it is chiefly to the axial skeleton and
13115 – A two-week-old renal infarct has
produces predominantly osteoblastic metastases.
1: granulation tissue at the periphery of the lesion
2: a whitish-yellow colour macroscopically
3: macrophages containing haemosiderin at its periphery 27627 – Prostate cancer is best diagnosed by
4: an easily identifiable outline of the original renal architecture on microscopic examination, although A. digital rectal examination
devoid of nuclei B. prostate specific antigen (PSA) serum levels
C. transrectal ultrasound of the prostate and biopsy
D. a combination of the above three responses

E. cystoscopy and endoscopic biopsy of the prostate
Answer: D
When patients are first seen in the consulting rooms wishing a prostate check up, a digital rectal
examination and PSA are often done to work-up symptoms or possibly as a routine prostate check.
The definitive form of diagnosis, however, is with a transrectal ultrasound of the prostate with several
biopsies. Diagnosis is best made by a combination of the three previous responses A, B & C (D is correct).
Biopsies are taken from the base, mid, and apex of each lobe of the prostate gland and submitted for
histopathologic review. Many prostate cancers are isoechoic and hence are unable to be clearly
identified on ultrasound, but some are associated with a hypoechoic nodule and hence can be
targeted specifically if identified on ultrasound. There is very little, if any place, for a cystoscopy and
endoscopic biopsy in the diagnosis of the vast majority of prostate cancers. As mentioned earlier,
most cancers begin in the peripheral zone rather than in the periurethral zone and hence are unlikely
to be sampled endoscopically (E False).
25989 – Carcinoma of the prostate is frequently associated with

1: raised serum acid phosphatase
2: androgen dependency
3: osteoblastic (osteosclerotic) bony metastases
4: raised serum calcium
Answers: TTTF
Figure 10 - Semi-horizontal cross-section through prostate and rectum
Robbins 5th ed. Chapter:22 PAGE:1029-1031
Answer: TTFTF
27682 – Common occurrences in advanced prostate cancer include
The most common are problems in advanced hormone-refractory prostate cancer and are associated
1: spinal cord compression
with ongoing progression of bony metastatic disease as well as morbidity related to local spread.
2: haematuria
Hence ongoing bone pain is an issue and if affecting the thoracic/lumbar cord may lead to cord
3: jaundice from hepatic metastase
compression and to a rapid onset of paraparesis and paraplegia in affected individuals (1 True). This
4: renal failure from bilateral ureteric obstruction
needs prompt treatment with urgent radiotherapy, or if unsuccessful urgent decompression
5: respiratory distress and pneumonia secondary to lung metastases
laminectomy. Other strategies to assist in the management of bone pain include local radiotherapy,
chemotherapy using mitozantrone and steroids, administration of radioactive strontium or palladium,
referral to palliative care team and administration of analgesia (for example, MS Contin).
The other problems relate to local growth of tumour, which include ongoing lower urinary tract
symptoms, such as hesitancy, diminishing urinary stream, frequency, and nocturia (which may require
palliative TURP) as well as haematuria due to the fragility of the neoplastic blood vessels (which may
require cystoscopy and diathermy) (2 True). As the tumour infiltrates the base of the bladder, bilateral
ureteric obstruction is a common accompaniment of the disease requiring endoscopic manipulation in
the form of nephrostomies and ureteric stents (4 True). Hepatic and lung metastases are uncommon
in advanced prostate cancer, although they may occur; but require palliation far less frequently than
the previously mentioned problems (3 & 5 False).
Resolved Nov 2003
27645 – Concerning prostate specific antigen (PSA)

1: PSA is a glycoprotein secreted by prostate cells into the ejaculate
2: PSA serum levels are almost always raised in prostate cancer
3: PSA serum levels are unaffected by age of the patient
4: PSA serum levels may be elevated in benign prostatic hyperplasia, prostatitis or prostatic infarct
5: PSA is universally endorsed and recommended as a screening test for prostate cancer
Answers: TFFTF

Prostate specific antigen is a glycoprotein secreted by the prostate cells into the ejaculate (1 True), 27675 – Hormone manipulation for prostate cancer can be optimally
whose functions is to assist in the breaking down of gel proteins within the ejaculate - leading to administered by
liquefaction. Small quantities of prostate specific antigen leak into the peripheral circulation and hence
1: orchidectomy
can be detected on serum studies. Prostate specific antigen is not always elevated in the presence of
2: LHRH agonist
prostate cancer (2 False) and up to 20% of cancers may be missed if relying on prostate specific
3: antiandrogen therapy
antigen levels alone. Digital rectal examination must, therefore, be done in all patients who wish a
4: orchidectomy plus antiandrogen therapy
check up of their prostate. Prostate specific antigen levels can be elevated with benign prostatic
5: LHRH plus antiandrogen therapy
hyperplasia, prostatitis and prostatic infarct and hence 70-80% of men with mildly elevated levels will,
in fact, have one of these conditions rather than prostate cancer (4 True).
As one would expect, the degree of benign prostatic hyperplasia tends to increase with age - one
would also expect prostatic specific antigen levels to similarly increase with age, and age specific
levels have been designed by many laboratories to take this factor into account (3 False). The use of
prostate specific antigen as a formal screening test for prostate cancer is controversial. It is endorsed
by the American Urologic Association as well as the American Cancer Society, but it is not endorsed
in many other countries including Australia and New Zealand (5 False). This uncertainty regarding its
efficacy for screening is based on the lack of results of randomised controlled trials identifying a
mortality benefit. Nonetheless, PSA detected cancers are significant cancers based on volume of
tumor and histological grade and are more likely to be confined within the prostate and hence
amenable to cure. A reduction in mortality has been seen in the 1990's throughout the world including
Australia, which may possibly be due to PSA based screening. Obviously definitive results of the
randomised controlled trials will provide an answer, which will settle this controversy, but
unfortunately these answers may only be available in five to ten years time. Until then the
uncertainties of the benefits of screening must be discussed with the patient and informed consent
obtained.
27657 – What factors may influence choice of initial treatment for prostate
cancer?
1: age of patient
2: co-morbid illnesses
3: patient preference
4: doctor preference
5: grade of the cancer
Answers: TTTFT
Answers: TTFFF
Various factors influence the choice of therapy for localised prostate cancer.
An older man, in particular, over 70 years of age, especially within the presence of co-morbid Prostate cancer is a known hormonally sensitive cancer in 80% of cases and will respond to
illnesses is more likely to die of those co-morbid illnesses rather than from the prostate cancer. testosterone deprivation therapy. The bulk of the male androgens come from the testes and hence
Therefore, the expected ten-year life expectancy of the patient must be taken into account if active either a surgical castration in the form of a bilateral orchidectomy or a medical castration in the form
therapy is being considered. Grade of the tumor plays a major role, as a well-differentiated cancer of an LHRH agonist, for example, Zoladex (10.8mg subcutaneously three-monthly) or Lucrin depot
has excellent 10-15 year cause-specific survival regardless of therapy (1, 2 & 5 True). Moderate and (22.5mg IM three-monthly) are acceptable alternatives (1 & 2 True). There is no need to add an
poorly differentiated tumors do show a survival advantage of treatment over no treatment and hence it LHRH to an orchidectomy, as they serve the same function, and side-effects are identical (namely,
is imperative that one identifies a patient with these grades of tumors before contemplating active hot flushes, impotence, weight gain, gynaecomastia and mood disturbances).
therapy. Patient preference also plays a major role in the choice of therapy for localised prostate Oral anti-androgen therapy alone has generally not been recognised as adequate treatment (3 False)
cancer (3 True). The treatment of prostate cancer is commonly associated with impotence, in the although the steroidal anti-androgen Cyproterone Acetate (100mg three times a day) may be used as
case of surgery a low but definite risk of incontinence, and in the case of radiotherapy a low but monotherapy in selective cases. The non-steroidal anti-androgens, namely, Flutamide (250mg orally
definite risk of rectal irritation, diarrhea and rectal bleeding. No early treatment, as a preferred first TDS), Nilutamide (150-300mg daily), and Bicalutamide (50mg a day) are not as effective as
option, clearly preserves rectal function, continence and erectile ability and hence many patients may monotherapy in current dosage schedules. The anti-androgens have the theoretic advantage that
choose no initial therapy to avoid the side effects of treatment even if it may ultimately compromise they may eradicate the additional 5-10% of male androgens that are derived from the adrenal gland
long-term survival. Doctors' preference should play a relatively minor role in the choice of therapy for rather than from the testes. Hence there has been considerable debate, as to whether combined
the patient in these circumstances (4 False). androgen blockade, in the form of an orchidectomy, or LHRH agonist in conjunction with an anti-
androgen may provide superior results to an orchidectomy or LHRH agonist alone. Although some
randomised controlled trials do show a slight survival advantage in the combined androgen blockade
group, this data overall has not been conclusive with many conflicting reports showing no benefit (4 & Lymph node metastases are common and often this mode of dissemination precedes spread to the
5 False). Figure 9 shows the hormonal influences affecting the prostate cell and the site of action of bones. When haematogenous spread occurs, it is very commonly confined at first to the axial
some drugs used in treatment of prostate cancer. skeleton. Massive visceral dissemination is unusual.
LHRH analogues inhibit pituitary secretion and diminish testosterone secretion, as does
orchidectomy. Anti-androgens act peripherally to block testosterone action on androgen receptors. 27639 – What statements are true regarding prostate cancer?
Agents such as ketoconazole and aminoglutethamide inhibit circulating androgens. 1: the incidence of the disease increases with increasing age
2: younger patients have a more virulent form of prostate cancer than older patients
27651 – Once diagnosed, appropriate choices of therapy for prostatic 3: it is the most prevalent male cancer in men over 45 years of age
cancer may include 4: most men die with the disease rather than of the disease
1: no initial treatment 5: typically begins in the transition or periurethral zones of the prostate
2: external beam radiotherapy alone
3: brachytherapy alone Answers: TFTTF
4: external beam radiotherapy plus brachytherapy
5: surgery (radical prostatectomy) There is no doubt that the incidence of prostate cancer increases with increasing age, with the vast
majority of cancers being detected in men over 70 years of age (1 True). It is the most prevalent male
Answers: TTTTT cancer in men over 45 years of age (3 True). There is no evidence to suggest that younger patients
have a more vigorous course than older patients (2 False), but, rather, as prostate cancer is a
There is no doubt that all of the options ranging from no immediate treatment (viz. 'watchful-waiting' relatively slow growing disease and younger patients have less co-morbid illnesses, younger patients
with the institution of delayed hormonal therapy) may be useful treatment options; together with all the are, therefore, more likely to die of their prostate cancer than older patients. Overall most men die
radiotherapeutic options and surgery in the form of radical prostatectomy. with prostate cancer rather than of prostate cancer (4 True). However, this has been shown
repeatedly in studies not to be true in younger men (50-60 years) diagnosed with the disease.
27669 – After definitive treatment for localised prostate cancer, follow-up is Prostate cancer claims approximately 2,500 Australian lives per year and, hence, demonstrates a
similar incidence and mortality to breast cancer in women.
optimally done by Prostate cancer typically begins in the peripheral zone of the prostate in 70% of cases, which is the
1: bone scan zone immediately adjacent to the anterior surface of the rectum. It only uncommonly involves the
2: CT scan of abdomen and pelvis transitional/periurethral zones of the prostate (5 False), which explains why prostate cancer typically
3: PSA presents with symptoms late in the cause of the disease rather than early.
4: a digital rectal examination
5: transrectal biopsies of the vesico-urethral anastomosis (after surgery) or prostate (after 27717 – The following statements concern haematuria
radiotherapy) 4
1: microscopic haematuria is defined as >10 RBC/ml urine
Answers: FFTTF 2: dysmorphic RBC may be present in stale urine samples and in patients with renal cell tumour
3: asymptomatic microscopic haematuria in the absence of protein casts is rarely associated with
After definitive treatment for localised prostate cancer follow-up is usually done by prostate specific pathology in people aged less than 50 years
antigen (PSA) assay and digital rectal examination (3 & 4 True). In the case of surgery PSA should 4: painless macroscopic haematuria always requires further investigation
fall to undetectable levels (less than 0.3 nanogram per ml) and following radiotherapy one would want 5: the most common cause of abdominal pain associated with haematuria is renal cell carcinoma
to see a level below 1 nanogram per ml and preferably below 0.5 nanogram per ml. Rectal
examination is also performed to exclude a palpable local recurrence. In the absence of an elevated Answers: TFTTF
PSA, a bone scan and CT scan are usually unnecessary, as are biopsies of the vesico-urethral
anastomosis or the prostate (1, 2 & 5 False). Clearly, if there is evidence of PSA failure following 1. Microscopic haematuria is defined by the individual laboratory giving a normal range (usually less
surgery or radiotherapy then a biopsy of these regions may become necessary as may a bone scan than 104 RBC/ml urine, or less than ten blood cells per high power field). Urine is also examined for
or CT scan casts, protein, bacteria and crystals. The aetiology of microscopic haematuria includes
glomerulonephritis, renal cell tumour, inflammation, stones, urothelial bladder or renal tumour
17783 – With adenocarcinoma of the prostate (transitional cell carcinoma), prostatic causes (benign and malignant enlargement) and urinary tract
1: there is good correlation between tumour differentiation and prognosis infection (1 True).
2: early haematogenous visceral metastatic dissemination is common 2. Dysmorphic cells are always present in stale urine but if in fresh urine this may indicate a source of
3: lymph node metastases are unusual bleeding from glomerulonephritis. Renal cell tumours typically demonstrate non-glomerulated red
4: local extension commonly involves seminal vesicles cells (2 False).
3. Haematuria in the younger age group (less than 50 years) and in the absence of protein casts or
Answers: TFFT infection is rarely associated with pathology (3 True) (see Table 7).
The Gleason staging system is best known; in prostatic carcinoma there is generally fairly good Table 7 Asymptomatic Microscopic Haematuria
correlation between prognosis and degree of differentiation; grading is therefore considered to be of • Stone AGE <50 >50
considerable importance. Local extension to involve seminal vesicles and base of bladder is common. • Tumour Pathology (+) 2% 10%
• Obstruction Pathology (-) 98% 90% Answers: TFTTF
• Inflammation
Seminoma is exquisitely radiosensitive (1 True) and for stage I and early stage II tumors 95% of
4. Painless macroscopic haematuria is a critical symptom always requiring further investigation - no patients are cured with retroperitoneal low dose radiotherapy. (Delivery of 25-30 Gray to the
exceptions (4 True). retroperitoneal and ipsilateral pelvic lymph nodes).
5. Microscopic haematuria is always looked for in a patient with severe abdominal pain. Renal calculi Response 2 is false. Seminomas of high stage and with bulky retroperitoneal nodes or distant
are the most common cause of abdominal pain and haematuria. The classic triad of presentation of metastatic disease are treated with systemic chemotherapy using a regime of Bleomycin, Etoposide
renal cell carcinoma is abdominal pain, macroscopic haematuria and a palpable mass - but the and Cis-platinum. Four cycles of treatment, three weeks apart, are associated with cure rates of
incidence of haematuria with stone disease is significantly higher (5 False). >90% in this group of patients. The treatment of node negative disease is more controversial.
If abdominal pain is present with haematuria the cause is usually renal pathology. In the absence of 'Watchful-waiting' in this group has several disadvantages:
haematuria we look for other causes of severe pain, including pancreatitis, perforated ulcer and Natural History: 25% of patients can be expected to relapse, usually with retroperitoneal nodal
ruptured aortic aneurysm (Table 8). disease - in seminoma relapse occurs up to 5 years after orchidectomy.
• Haematuria present – renal colic 95% or other renal pathology Ease of surveillance: Tumour markers are generally not elevated so surveillance is with CT imaging
• Haematuria absent – pancreatitis, perforated ulcer, ruptured AAA alone - this is quite a lot of radiation with regular CT for 5 years. Patient compliance also becomes a
This question is currently under review by the Pathology Sub Committee. 28 June 2002. factor.
Low dose radiotherapy to the retroperitoneum is well tolerated and minimises the risk of recurrence to
21753 – Human bladder cancer is a recognised complication of exposure to <5%.
1: cigarette smoke Conclusion - Radiotherapy to the retroperitoneal lymph nodes for stage I disease is the preferred
2: asbestos treatment in the vast majority of centres.
3: 2-naphthylamine Stage 1 non-seminomatous germ cell tumour is treated with surveillance after orchidectomy (3 True).
4: lead Seventy-five per cent of patients with stage 1 NSGCT are cured with inguinal orchidectomy alone.
Twenty-five per cent of patients relapse, usually in the retroperitoneal lymph nodes within two years.
Answers: TFTF For this reason close follow-up with chest x-rays, CT, and tumour markers on clinical examination are
appropriate. Tumour markers are checked six-weekly on clinical examination and chest x-rays and
Robbins 5th ed. CHAPTER: 7; 21 PAGE: 282; 1001 CT scans are checked three-monthly in the first year; with gradually diminishing intensity of follow-up
over the subsequent two to three years. The majority of relapses occur within the first year and many
cases of residual disease are detected by failure of tumor markers to normalise following inguinal
17743 – Testicular seminoma orchidectomy.
1: when dissemination occurs, is usually first manifest by blood stream spread Overall in this group 25% of patients will develop recurrent disease. This risk increases to 45-50% in
2: is highly radiosensitive patients with embryonal cancer, with vascular invasion present in the inguinal orchidectomy
3: when associated with raised plasma human chorionic gonadotrophin (HCG), shows no different specimen, or with a higher T stage. In patients who develop recurrent disease the appropriate
clinical behaviour treatment in the first instance is chemotherapy, again, initially with four cycles of BEP. Greater than
4: is the least aggressive of the testicular germ cell neoplasms 90% of patients can expect to be cured.
(Response 4 is true) High stage NSGST is treated initially following orchidectomy with chemotherapy.
Answers: FTTF If residual retroperitoneal mass exists despite chemotherapy and tumour marker normalisation,
retroperitoneal lymph nodes dissection is required. Twenty per cent of these masses contain residual
Seminoma and ‘non-seminomatous germ cell tumours’ (NSGCT) are the clinically important testicular tumour, 40% mature teratoma, and 40% fibrosis. (Mature teratoma is generally benign but may cause
tumours. Seminomas remain confined to the testis longer and typically metastasise to lymph nodes, local compression to neighbouring structures and can rarely undergo malignant degeneration.)
with blood spread occurring (when it does) as a later phenomenon. NSGCT metastasise earlier and Overall, 70% of patients with high volume disease are cured with chemotherapy +/- retroperitoneal
more frequently by blood stream. Seminomas are extremely radiosensitive whereas NSGCT are lymph node dissection. Residual chest masses similarly are best excised.
radio-resistant. Significance of a positive HCG in some seminoma patients is unknown; it does not The risk of malignancy is very high in patients with a solid testicular mass (5 False). Such patients
alter the generally good prognosis for seminoma. have a testicular malignancy until proven otherwise.
27695 – The following statements are correct regarding treatment of 27622 – Concerning invasive cancer of the cervix
testicular tumours 1: screening programmes have significantly reduced the death rate from this condition
1: seminoma is highly radiosensitive 2: specific human papilloma virus (HPV) types are associated with cervical cancer and not
2: most centres adopt a management policy of intense surveillance without additional therapy after condylomata
orchidectomy for organ-confined seminoma 3: peak incidence is in post-menopausal women
3: most centres adopt a management policy of intense surveillance without additional therapy after 4: the cancer is usually an adenocarcinoma
orchidectomy for organ-confined non-seminomatous germ cell tumour
4: residual masses in the chest and retroperitoneum after chemotherapy for non-seminoma are best
managed by surgical resection
5: a solid mass arising within the testis has a 50% risk of being malignant

Answers: TTFF
Answers: FTTF
Screening programmes, using the Papanicolaou smear, have reduced the US death rate from cancer
of the cervix by two-thirds (1 True). Fifty years ago cancer of the cervix was the leading cause of Robbins 6th ed. Page: 414
cancer death in women, it has now been reduced to eighth.
The human papilloma virus is currently considered an important factor in cervical oncogenesis (2 23774 – Which of the following is/are recognised as contributing to the
True). This sexually transmitted virus is found in 85% of cervical cancers and interestingly certain
renal failure which complicates multiple myeloma
sub-types of HPV are specifically associated with these cancers; and a separate group is associated
1: amyloidosis
with condylomata. (This association between HPV and the cervix is well treated in Cotran, Kumar,
2: renal tubular protein casts
Collins, Robbins Pathologic Basis of Disease, Saunders, 6th Edition, 1999; Chapter 24.
3: pyelonephritis
The peak incidence of cervical cancer is 40-45 years (3 False) but can occur from the second decade
4: hypercalcaemia
to old age. The very great percentage of cervical cancers are of squamous type (4 False) owing to the
epithelial surface of the cervix. However the endocervix contains a glandular epithelium which may
Answers: TTTT
develop an adenocarcinoma in 10% of cases.
Robbins 5th ed. CHAPTER: 20 PAGE: 975
16870 – Choriocarcinoma of gestational origin
1: can be monitored clinically by plasma gonadotrophin (HCG) levels
27602 – Concerning vaginal bleeding
2: metastases early and widely
1: menorrhagia is a feature in 50% of women with von Willebrand's disease
3: has a generally good prognosis with chemotherapy
2: vaginal bleeding is almost never confused with rectal bleeding
4: can be monitored clinically by plasma gonadotrophin (HCG) levels
3: vaginal bleeding is seen in 70% of ruptured ectopic pregnancies
4: vaginal bleeding is excessive in Graves' disease
Answers: TTTT
Answers: TFTF
This cancer is one of the success stories of modern systemic chemotherapy. It contrasts markedly
with the still formidable mortality of non-gestational choriocarcinoma, despite the fact that both
Surgeons need to remember that clotting abnormalities do occur and that such a disorder may
neoplasms share the same morphology, cell markers, HCG elaboration etc. This question will be
manifest itself as abnormal menstrual loss - 50% of those with von Willebrand's disease (1 True) and
submitted at the March '04 meeting regarding duplicate answers.(16/03/2004)
50% with idiopathic thrombocytopenic purpura - so don't just ask about abnormal bleeding or bruising.
Elderly women, in particular, can easily confuse vaginal bleeding for a rectal source (2 False) as they
20295 – S. There is a positive association between granulosa cell tumour of do not believe a vaginal loss is possible once menstruation has ceased. Placement of a tampon can
the ovary and endometrial carcinoma BECAUSE R. granulosa cell tumour be an easy way to resolve the problem if a thorough clinical examination does not demonstrate the
produces large amounts of oestrogen source. Yes, it is reported that some 70% of ruptured ectopics will have some vaginal loss at the time of
presentation (3 True). This can be misleading as it can be interpreted as the late arrival of the
Answer: S is true, R is true and a valid explanation of S previously missed period. Remember this fact. Excessive menstrual loss is a feature of
hypothyroidism (myxoedema). Menstrual loss can become scanty or absent in Graves' disease
Robbins 5th ed. CHAPTER: 23 PAGE: 1074-1075 (hyperthyroidism); and oligomenorrhoea may be a presenting symptom (4 False).
21438 – With respect to lactation in women 27607 – When differentiating between a ruptured ectopic pregnancy and a
1: milk secretion is stimulated by oxytocin threatened abortion
2: suckling stimulates the release of antidiuretic hormone (ADH) 1: pain is not a feature of a threatened abortion
3: milk ejection is stimulated by prolactin (PRL) 2: ultrasound is very helpful
4: suckling stimulates the release of prolactin (PRL)and oxytocin 3: amenorrhoea is consistent with both diagnoses
4: the two can be differentiated from each other by a serum "-hCG
Answers: FTFT
Answers: FTTF
Ganong 13th Ed. CHAPTER: 23/14 PAGE: 378-379/197-201
Pain can certainly be a feature of both a threatened abortion as well as a ruptured ectopic pregnancy
23789 – Use of oral contraceptive agents is associated with an increased (1 False). The pain of a threatened abortion is often described as colicky and tends to be sited
incidence of the following neoplasms centrally at the pelvic brim. A ruptured ectopic may be localised to the relevant iliac fossa and may be
1: ovarian carcinoma associated with hypotension and shoulder tip pain. Pain is usually more constant and severe.
2: hepatic adenoma Amenorrhoea, obviously, will be present in both conditions as conception has taken place (3 True).
3: cervical carcinoma For this same reason a serum/urinary "-hCG will be positive, at the time of presentation, in both
4: endometrial carcinoma instances (4 False). Ultrasound of the uterus is the most useful defining investigation (2 True), as
presence of products of conception within the uterine cavity would indicate a threatened abortion. In
the case of a ruptured ectopic one would expect the uterine cavity to be empty. The ectopic itself may
be visualized in a Fallopian tube and fluid (blood) is likely to be seen in the pelvis. Answer: A
27689 – The following statements refer to tumour markers commonly used This ominous clinical picture is classical of a subcutaneous wound dehiscence.
for testicular cancer
1: cAMP and P57 are the most useful markers in testicular tumour 18268 – A 40-year-old man is confused and restless 48 hours after upper
2: tumour markers are optimally first measured within 48 hours after orchidectomy for testicular abdominal surgery with anti-reflux repair of an oesophageal hiatus hernia.
cancer The most probable cause of his condition is
3: tumour markers have a role for all the following - histological diagnosis, prognosis, response to A. pulmonary embolism
treatment, long term follow up B. narcotic overdose
4: seminoma is never associated with elevation of tumour markers C. pulmonary atelectasis
5: all patients with non-seminoma have elevated tumour markers D. electrolyte imbalance
E. starvation ketosis
Answers: FFTFF
Answer: C
Beta-HCG and alpha Feto-protein are the most useful tumour markers (1 False). LDH is a non
specific marker commonly elevated with significant metastatic disease. In cases of suspected testis The development of confusion and restlessness at 48 hours post-operatively suggests a hypoxic
tumor, tumor markers should be checked prior to inguinal orchidectomy to assess the baseline level cause. Pulmonary atelectasis (C) is the most likely of the first four responses considering its
with the primary tumour in situ (2 False, 3 True). Five to ten per cent of seminomas have elevated development on the second post-operative day. Starvation ketosis is unlikely at this stage.
Beta HCG (Syncitio-trophoblastic component) (4 False). Alpha feto-protein is elevated in 35-70% of
patients with nonseminomatous germ-cell tumors (and never in pure seminoma). Beta HCG is
887 – A 45 year old patient has an elective laparoscopic cholecystectomy
elevated in 30-60% of patients with nonseminomatous germ-cell tumour, including virtually 100% of
patients with choriocarcinoma (5 False). for proven gall stones. No problems occurred and the visualisation was
good. Operative cholangiography was performed and considered normal.
o
Twelve hours after operation the temperature is 39 C and pulse rate is 110
CLINICAL per minute. You would suspect as the MOST likely cause
A. atelectasis.
18219 – Five days after an appendicectomy a 25 year old patient develops a B. intra-peritoneal biliary leak.
o
tachycardia and a fever of 39.5 C. The most likely cause is which one of the C. cholangitis.
following? D. reaction to the contrast medium.
A. Chest infection E. wound infection.
B. Urinary infection
C. Wound infection Answer: A
D. Pelvic abscess
E. Deep venous thrombosis After an upper abdominal operation such as elective laparoscopic cholecystectomy without bile duct
exploration, the commonest complication is postoperative atelectasis, which is especially common in
Answers: C smokers or those with pre-existing chest disease. Atelectasis commonly presents within the first 12-24
hours after surgery with fever and tachycardia, often without obvious clinical findings in the chest (A
Any of the complications listed could be present, but the timing most suggests a wound infection (C) correct). It is thus the most likely of thediagnoses listed.
in this young patient after appendicectomy for acute appendicitis.
You would of course need to consider operative complications as well! Intraperitoneal bile leak is
more likely to occur when the bile duct has been explored, but can follow simple cholecystectomy as
18274 – You are asked to see a patient in the ward, seven days following a a result of leakage from the liver bed or due to the cystic duct clip(s) slipping. Clinical presentation is
left hemicolectomy. The patient has a discharging wound. The discharge often delayed until 24 hours or more after operation, and presentation may be with abdominal signs of
oozes freely between the skin sutures and is profuse, watery and blood- varying degree associated with shock.
stained. There are no signs of surrounding inflammation. The most likely
Cholangitis is rare after elective cholecystectomy without bile duct exploration. The frequency of
diagnosis is infected bile rises in operations for acute cholecystitis and with bile duct stones. Reaction to the
A. subcutaneous wound dehiscence contrast medium is les common than atelectasis; and wound infection does not usually present within
B. an anastomotic leak the first 12 hours.
C. discharge from a wound haematoma
D. discharge from a deep wound infection
E. discharge from an intraperitoneal seroma
15934 – The following are major risk factors for heroin addicts
1: hepatitis B
2: adult respiratory distress syndrome
3: infective endocarditis Answer: C
4: malignant lymphoma
The sudden onset in a young woman of severe acute abdominal pain in the right lower abdomen with
Answers: TTTT nausea and vomiting, combined with faintness or syncope, and associated with signs of lower
abdominal peritonitis, is classical of a ruptured ectopic pregnancy.
Question updated 6 May 2002.
18225 – A 65 year old overweight woman has an emergency laparotomy
10215 – A patient has a subtotal thyroidectomy. Three hours after the and colostomy for an obstructing carcinoma. On the eighth post-operative
operation she develops severe respiratory distress. The correct treatment day she develops left sided chest pain. This is associated with a low grade
is to fever, dyspnoea and a blood pressure of 110/70, pulse rate 100 per minute
A. administer an anaesthetic and explore the wound and a respiratory rate of 30 per minute. The most likely diagnosis is:
B. intubate the patient in bed
A. pelvic abscess
C. administer morphine to allay distress
B. pulmonary embolism
D. remove the skin sutures
C. myocardial infarction
E. open the wound in the ward and divide the sutures in the deep fascia
D. subphrenic abscess
E. pneumonia
Answer: E
Answer: B
18231 – You are called to see a 56-year-old man with dyspnoea and
pleuritic chest pain. Five days earlier he had a laparotomy and gastric Pulmonary embolism (B) is the most likely diagnosis of those listed in this high-risk patient.
o
resection. On examination he has a temperature of 37.5 C, a respiratory
rate of 25 per minute, a pulse rate of 90 and a blood pressure of 130/95 mm
Hg. His heart sounds are normal and there are no added sounds or
STATISTICS
murmurs. There is good air entry to both bases and the percussion note is 14866 – To monitor the incidence of cancer in patients as a result of
resonant in all areas. Which one of the following combinations of test differing degrees of severity of ulcerative colitis, the preferred method
results indicates a high probability of a pulmonary embolus in a particular would be
zone of the lung: A. prospective survey
A. Chest X-ray: NORMAL, Ventilation scan: NORMAL and Perfusion scan: REDUCED B. retrospective survey
B. Chest X-ray: NORMAL, Ventilation scan: ABNORMAL and Perfusion scan: NORMAL C. therapeutic trial
C. Chest X-ray: CONSOLIDATION, Ventilation scan: NORMAL and Perfusion scan: REDUCED D. double blind trial
D. Chest X-ray: CONSOLIDATION, Ventilation scan:ABNORMAL and Perfusion scan: NORMAL E. meta-analysis
E. Chest X-ray: NORMAL, Ventilation scan: ABNORMAL and Perfusion scan: REDUCED
Answer: A: prospective survey
Answer: A
Refer to Motulsky, page 183-191
A reduced lung perfusion scan, combined with a normal ventilation scan and normal chest x-ray is
highly suggestive of a segmental pulmonary artery embolism (A). 8603 – ‘Values for plasma sodium concentration are normally distributed in
a population of normal young adults'. From this statement it can be inferred
905, 7144 – A 25 year old woman is admitted to hospital one hour after the that
sudden onset of severe pain in the right lower abdomen with nausea, A. values in 95% of this population will lie within +1 standard error of the whole-population mean
vomiting and faintness. She is afebrile. She has a blood pressure of 100 B. the values in about two-thirds of this population will lie within +2 standard deviations of the whole-
mm Hg and a pulse rate of 120/min. On examination of the abdomen she is population mean
C. about 2.5% of this population will have values that lie above the population mean +2 standard
tender in the right lower abdomen with guarding and rigidity and rebound deviations
tenderness. The most likely diagnosis is D. the variance of values is described as the square-root of the standard deviation
A. ruptured appendicitis E. none of the above inferences can be made
B. perforated peptic ulcer
C. ruptured ectopic pregnancy Answer: C
D. salpingitis
E. torsion of ovarian cyst Motulsky, Ch 4
The incidence, however, of microscopically detected cancers at autopsy are similar throughout all
19725 – With respect to the correlation coefficient (r) for two variables, x countries; and hence prostate cancer in a western country tends to progress to a clinical stage as
opposed to Asian countries. Migration affects this incidence, as a patient moves from a country of low
and y
incidence to high incidence they adopt the incidence of their host country. Obviously, diet has been
A. a correlation coefficient of -1 implies that there is no correlation between x and y
implicated - but not proven - as a possible explanation for this differing incidence depending on
B. a negative correlation would be expressed numerically as r=0
country of origin (3 False?). Food substances that have been implicated include dietary fat, isoflavin
C. when expressed graphically, r can be derived from the tangent of a curved line
ingestion (commonly found in soy products), and lycopenes (commonly found in tomato base
D. a positive correlation between x and y does not imply that x causes y
products). Other possible explanation include exposure to ultraviolet light as those countries with
E. the correlation between x and y always lies within the range -10 to +10
minimal exposure to ultraviolet light such as the Scandinavian countries or those races that absorb
vitamin D poorly (eg African-Americans) have a significant higher incidence of prostate cancer
Answer: D
compared to their counterparts.
There is no evidence that smoking is related to prostate cancer (2 False). Family history has been
Motulsky Page: 155-159
conclusively shown to be associated with the incidence of prostate cancer with a two-fold incidence of
prostate cancer with one first degree relative affected and up to eight to nine times increased risk if
21983 – The standard error of the mean two first degree male relatives are affected (4 True). The presence of symptoms is not associated
1: is an estimate of the standard deviation of the means of a large number of samples from a with the development of prostate cancer (5 False) as most studies have identified equal number of
population men with and without symptoms who have been diagnosed with the disease, despite the fact that
2: is larger than the standard deviation symptoms was the most common reason why men sought to have their prostates checked.
3: may be used to study the significance of the difference between means of two samples
4: is not related to the number of observations in the sample
12542 – At present, the most useful method of epidemiological
Answers: TFTF investigation of staphylococcal infections is to determine
A. colony and colour variation
Motulsky Page: 44 B. M protein production
C. coagulase production
D. specific bacteriophage typing
8615 – You wish to investigate under what circumstances a surgeon should
E. specific antihaemolysin titre
advise inguinal lymph node dissection in patients with melanoma on the
leg. You should begin your investigation by Answer: D
A. requesting your hospital research committee for permission to undertake a clinical trial
B. reading the relevant literature reports and the protocols of previous studies of the question The classical method of 'typing' staphylococci (both Staphylococcus aureus and coagulase negative
C. designing a randomized, controlled clinical trial of dissection/no dissection species) in epidemiological investigations is phage typing (D true) although other molecular
D. surveying the clinical records covering your experience and that of your colleagues/hospital techniques are slowly being developed (eg plasmid analysis, chromosomal DNA analysis) as are
retrospectively antibiogram analyses for coagulase negative strains. Colony and colour variation is of little use as
E. designing a prospective survey to follow up all such patients with melanoma on the leg to relate most colonies look the same (A false), while the presence or absence of the enzyme coagulase
their outcome to whether lymph nodes were dissected or not simply serves to delineate the heterogenous species S. aureus from the remaining 20 or so species
(C false). Serological procedures have not been adopted for investigating outbreaks of staphylococcal
Answer: B sepsis (E false) except perhaps for determining the presence of a high level of antibody against cell
wall teichoic acids as an indication of chronic staphylococcal infection (eg osteomyelitis). M proteins
Motulsky, Ch 20 are antiphagocytic virulence factors in streptococci; they have been used in streptococcal typing
schemes but are not present on staphylococci (B false).
7633 – From an epidemiological viewpoint, what factors are known to be
associated with the development of prostate cancer? 7156 – A null hypothesis represents
1: country of origin A. the absence of an hypothesis
2: smoking B. an unsatisfactory hypothesis
3: diet C. an hypothesis that no relationship exists
4: family history D. the evidence that no relationship exists
5: presence of lower urinary tract symptoms E. an hypothesis that a negative relationship exists
Answers: TFFTF A null hypothesis is a fundamental statistical tool comparing two events; and represents the
hypothesis that no relationship exists between the two events. The hypothesis is then tested and
There is a significant variation in the incidence of prostate cancer depending on the country of origin either confirmed or refuted.
of the patient, with Asian countries typically having an extremely low incidence of prostate cancer and
most developed western countries having a high incidence (1 True).

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ANATOMY MCQ’S

Good luck! Refer to Last, 10th Ed, page 463

21568 – The decussation of the pyramids

ANATOMY Page 2 of 215

Answer: TFFF Last 8th ed. PAGE: 614

23344 – The pons Answers: TTTF

Answers: TFFF 21573 – The trochlear nerve

Answer: S is true and R is false Last 7th Edition PAGE: 437

Last 8th Edition PAGE: 451

ANATOMY Page 4 of 215

Last 10th Ed, Ch 7 PAGE: 495, 498 Answers: TFTF

ANATOMY Page 5 of 215

Answers: C Last 8th Edition PAGE: 453

Answers: FTFT Last 10th ed, Ch 6

ANATOMY Page 6 of 215

Answers: TTTT Last 8th ed. PAGE: 575

Answers: TTTT Answer: D

Refer to Last, 10th Ed, Ch 6, page 323

NECK 23844 – The thyroid gland

Last PAGE: 4 10472, 19815 – During thyroidectomy

22899 – The oesophagus Answer: C

ANATOMY Page 9 of 215

Last 9th Edition PAGE: 488 Answers: FTTT

Last 8th Edition PAGE: Plate 31 Answers: FTFT

23724 – The carotid sheath Last 8th Edition PAGE: 462

ANATOMY Page 10 of 215

ANATOMY Page 11 of 215

Last 7th Edition PAGE: 428 19462 – In the superior mediastinum

Answers: TFTF Answer: B

19354 – The fibrous pericardium 22539 – Within the right atrium

Answers: C Answers: TTTT

Answer: E Answers: FTFT

Answer: C Last 10th ed. PAGE: 199, 193, 29

Answers: FTFF Answers: FTTT

22484 – The arch of the aorta

Last 10th ed, Ch 4 21643 – The superior vena cava

Answers: FFTF Last 10th ed. PAGE: 187

24179 – The coronary sinus 20001 – The right brachio-cephalic vein

ANATOMY Page 17 of 215

Answer: TTTT Answer: TTTF

ANATOMY Page 18 of 215

ANATOMY Page 19 of 215

ANATOMY Page 20 of 215

Answers: TTTT Answer: C

ANATOMY Page 21 of 215

Answer: S is true, R is true and a valid explanation of S Answers: TTFF

Answer: D 8530 – The left pleural reflection

ANATOMY Page 22 of 215

Last 10th Edition, page 54 721 – The liver

ANATOMY Page 25 of 215

Answers: TTFF 18880 – The gall bladder

Answer: A 13215 – The gall bladder

Answers: C 737, 19629 – The cystic artery usually arises from

KEY ISSUE Answers: TTTF

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13233, 19581 – The spleen 13239 – The splenic vein

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694 – The first part of the duodenum Answer: C

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