MCQ PAPER- Metabolic/Laboratory 1. Which of the following statements is false? a.

in acute respiratory acidosis the only effective buffers are the intracellular proteins b. therapy of acute respiratory acidosis is directed toward correcting minute ventilation c. myasthenia gravis only causes an acute respiratory acidosis d. in chronic respiratory acidosis, plasma HCO3 concentration increases approximately 3-5 mEq/L for every 10mmHg increase in the paCO2 e. oxygen must be given with caution to patients with chronic respiratory acidosis

2. Regarding diagnostic strategies in adrenal insufficiency which of the following statements is false: a. in some patients the condition is suggested by a history of chronic adrenal failure or glucocorticoid therapy b. severe anorexia or weakness with weight loss may lead to consideration of the diagnosis c. the diagnosis is based on a failure of the adrenals to respond to exogenous ACTH with cortisol production, the ACTH stimulation test d. normal adrenals respond with an increase in cortisol to at least ten times the baseline level e. a 48-hour ACTH stimulation test can confirm the diagnosis of adrenal insufficiency and differentiate primary from secondary causes

3. Primary hypothyroidism is associated with all of the following factors except: a. b. c. d. e. previous thyroid operation dry and coarse skin sella turcica may be increased in size serum TSH increased plasma cortisol normal

4. Which of the following is not a recognised laboratory finding in myxoedema coma? a. b. c. d. e. anaemia hypercholesterolaemia hyponatraemia decreased pCO2 elevated LDH

5. All of the following statements regarding hypokalaemia are true except: a. it is defined as a serum potassium less than 3.0 mmol/L b. the most frequent causes are intracellular shifts and increased losses c. a rise in pH of 0.1 due to a metabolic cause generally decreases the serum potassium by 0.5 +/- 0.2 mmol/L d. respiratory alkalosis/acidosis have minimal effects on potassium shift e. hypokalaemia associated with vomiting has very little to do with the actual potassium lost in the vomitus

6. Which of the following is not an aetiology of hypothyroidism? a. b. c. d. e. Hashimotos disease iodine deficiency pituitary adenoma lymphoma tuberculosis

7. Causes of an increased anion gap metabolic acidosis include all of the following except: a. b. c. d. e. iron intoxication carbonic anhydrase inhibitors toluene exposure alcohol intoxication paraldehyde ingestion

8. The most common signs in alcoholic ketoacidosis include all the following except: a. b. c. d. e. tachycardia tachypnoea vomiting abdominal tenderness heme-positive stool

9. If an osmolar gap is encountered the following possibilities should be considered: a. b. c. d. e. the presence of ethanol hyperlipidaemia hyperproteinaemia the presence of lactate all of the above

10. In adrenal crisis: a. b. c. d. e. the primary manifestation is hypertension the adrenals respond by increasing corticosteroids the presentation may mimic that of ruptured abdominal aortic aneurysm the hypotension in adrenal crisis usually responds to catecholamines and IV fluids it is not seen in patients with known chronic adrenal insufficiency

11. Regarding alcoholic ketoacidosis: a. b. c. d. e. the age of presentation is variable but usually between 20 to 60 years it is more common in males patients rarely experience repeated episodes it is the cause of death in 5 percent of known alcoholics there are specific physical findings associated solely with this diagnosis

12. Although an exact definition of DKA is variable most experts agree on all the following except: a. b. c. d. e. a bicarbonate level less than 10 mmol/L a blood glucose greater than 14 mmol/L an arterial pH less than 7.3 moderate ketonaemia twenty to thirty percent of cases occur in new-onset diabetes

13. Treatment of thyroid storm may include all of the following except: a. b. c. d. e. propylthiouracil cholestyramine exchange transfusion guanethidine phenylbutazone

14. Which of the following statements is false: a. b. c. d. e. in thyrotoxicosis the TSH level is an excellent screening tool liver disease or renal failure may reduce serum TSH thyroid antibody titres are usually not helpful if Graves disease is suspected hyperglycaemia may be present in 30-55% of patients with hyperthyroidism hypercalcaemia may occur in up to 10% of cases of hyperthyroidism

15. All of the following statements regarding thyroid storm are false except: a. most studies have not demonstrated differences in thyroid hormone levels in patients with symptomatic, uncomplicated hyperthyroidism and thyroid storm b. enhanced parasympathetic nervous system activity explains many of the presenting clinical findings of thyroid storm c. signs of hyperthyroidism include tremor and narrowed pulse pressure d. non-specific laboratory findings may include leucopenia, increased transaminases and hypoglycaemia e. -blockers should never be used

16. The primary counter-regulatory hormone released in response to the cellular starvation seen with insulin deficiency is: a. b. c. d. e. cortisol glucagon catecholamine growth hormone somatostatin

17. Which of the following statements is true? a. the most characteristic ECG finding in hypocalcaemia is a prolonged QT interval but it is the ST segment that is really prolonged b. if a patient is asymptomatic both calcium salts and Vitamin D need to be given c. hypocalcaemia increases the sensitivity of the heart to digoxin d. phosphate overload may lead to hypercalcaemia e. hallucinations and seizures never occur with hypocalcaemia

18. All of the following are causes of hypocalcaemia except: a. b. c. d. e. Vitamin D deficiency chronic renal insufficiency hypermagnesaemia massive transfusions heparin

19. Known precipitants of acute adrenal insufficiency include all of the following except: a. b. c. d. e. surgery chlorpromazine myocardial infarction alcohol lithium

20. The lack of ketoacidosis in hyperosmolar hyperglycaemic nonketotic syndrome has been attributed to all of the following except: a. b. c. d. e. lower levels of glucagon lower levels of growth hormone higher levels of insulin in the peripheral circulation higher levels of insulin in the portal circulation increased lipolysis due to the hyperosmolar state

21. With regards to buffer therapy in acidosis, all of the following are true except: a. the role of buffer therapy in cardiac arrest and severe metabolic acidosis are uncertain b. bicarbonate therapy may worsen intracellular alkalosis c. bicarbonate therapy imposes an osmotic and sodium load d. the goal of high-dose bicarbonate and dialysis therapy in lactic acidosis may be to "bridge" the patient physiologically to definitive treatment of the etiology of the acidosis e. newer buffers appear to show promise in the treatment of metabolic acidosis

22. Regarding the emergency therapy of hyperkalaemia: a. salbutamol has an onset of action of 15-30 min and a duration of effect of 2-4 hrs b. calcium chloride has an onset of action of 1-3 min and a duration of effect of 1-2 hrs c. sodium bicarbonate has an onset of action of 5-10 min and a duration of effect of 1-2 hrs d. insulin plus glucose has an onset of action of 30 min and a duration of effect of 46 hrs e. sodium polystyrene has an onset of action of 1-2 hrs and a duration of effect of 46 hrs

23. Primary adrenal insufficiency may be caused by all of the following except: a. b. c. d. e. anticoagulant therapy sarcoidosis tuberculosis exogenous glucocorticoid therapy Waterhouse-Friderichson syndrome

24. All of the following statements are true except: a. T4 is peripherally deiodonated to T3 and is responsible for producing 60% of the circulating T3 hormone b. hyperthyroidism is ten times more common in females than males c. sinus tachycardia is the most common rhythm disturbance d. drug causes of thyrotoxicosis include lithium, iodine and amiodarone e. an elevated free T4 level and a low or undetectable TSH level are consistent with a diagnosis of hyperthyroidism

25. Regarding the management of adrenal insufficiency all of the following are true except: a. if the diagnosis of adrenal failure is unconfirmed, hydrocortisone is the corticosteroid replacement that should be used while an ACTH stimulation test is performed b. if salt and water replacement is adequate, mineralocorticoid replacement is usually not necessary c. treatment of hypoglycaemia should be immediate d. symptomatic hyperkalaemia should be treated with the same agents as hyperkalaemia with any other medical illnesses e. correction of hypovolaemia should be addressed

26. Which is true regarding thyroid replacement in hypothyroidism? a. myxoedema coma should never be treated aggressively b. T3 is preferred to T4 as it has a more gradual onset of action c. even in the presence of myxoedema ileus, excellent clinical responses to oral doses of T4 have been reported d. if signs of ischaemia or dysrhythmias are observed with thyroid replacement the dose should be stopped and never restarted e. the appropriate dose of thyroid hormone replacement has been well established

27. With regards to respiratory alkalosis: a. a PaCO2 of 31 to 35 mm Hg is considered abnormal in the antepartum period b. increased minute ventilation is the primary cause of respiratory alkalosis, characterized by increased PaCO2 and decreased pH c. patients with uncompensated acute respiratory alkalosis usually have normal plasma HCO3 concentrations d. assisted ventilation cannot cause a respiratory alkalosis e. symptoms do not vary according to the degree and chronicity of the alkalosis 28. In general increased concentration of an electrolyte: a. b. c. d. e. is a result of excess total body amount is a result of a shift between compartments causes symptoms proportional to the rate of change is a result of relative fluid loss all of the above

29. In acid-base disorders: a. the lower limit of respiratory compensation is a PaCO2 of 10mmHg in a simple metabolic acidosis of >24 hours duration b. in the presence of a simple metabolic alkalosis the PaCO2 will not increase to more than 85mmHg c. in the presence of a simple respiratory acidosis it is expected that for every 10mmHg increase in PaCO2 the HCO3 should increase by 3mmol/L within 10 minutes d. in the presence of a simple respiratory alkalosis it is expected that each 10mmHg decrease in pCO2 should decrease HCO3 by 3mmol/L within 10 minutes e. hydrochloric acid is usually required to correct the metabolic abnormality in respiratory alkalosis

30. All of the following are true regarding phosphate except: a. it shifts to the intracellular compartment during DKA b. it plays an integral role in the conversion of energy from ATP c. it plays an integral role in the delivery of oxygen at the tissue level through 2,3DPG d. in general intravenous phosphate therapy in DKA should be withheld unless the serum phosphate concentration is less than 1 mg/dL e. many important enzymes, cofactors, and biochemical intermediates depend on phosphate

31. A better understanding of the pathophysiology of DKA and an aggressive uniform approach to diagnosis and management has reduced mortality to less than: a. b. c. d. e. 2% of reported episodes 1% of reported episodes 5% of reported episodes 10% of reported episodes 3% of reported episodes

32. With regards to chronic adrenal insufficiency all of the following statements are true except: a. fatigue, anorexia, weight loss and loss of libido are common b. hyperpigmentation is seen in primary adrenal insufficiency due to elevated levels of ACTH c. in secondary adrenal insufficiency, hyponatraemia is due to the lack of aldosterone and sodium wasting d. hyperkalaemia may be associated with a mild azotemia and metabolic acidosis e. secondary adrenal insufficiency is commonly associated with neurologic signs and symptoms such as headaches 33. Causes of hypovolaemic hyponatraemia with a urinary sodium > 20mmol/L include all of the following except: a. b. c. d. e. diarrhoea Addisons disease ketonuria salt-losing nephropathy bicarbonaturia with metabolic alkalosis

34. Drugs that may predispose individuals to the development of hyperosmolar hyperglycaemic nonketotic syndrome include: a. b. c. d. e. diuretics lithium phenytoin blockers all of the above

35. Which of the following statements is false: a. toluene produces an anion gap acidosis that is further complicated by distal renal tubular damage b. the toxic effects of methanol result from the formation of its metabolite formaldehyde which is converted to formic acid c. in the patient with chronic renal failure an increased anion gap metabolic acidosis is common, whereas in cases of acute renal failure hyperchloremic non-anion gap metabolic acidosis is more common d. clinicians must be aware that ingestions of greater than 10 mg/kg of isoniazid pose a danger of not only recurrent seizures but also life-threatening metabolic acidosis e. metabolic acidosis from iron ingestion is typically appreciated in phase I of toxicity, usually within 6 hours of ingestion

36. Insensible fluid losses include: a. b. c. d. e. 400 mls/day from the respiratory tract 100 mls/day from the faeces 500 mls/day from the skin > 1500 mls/day with sweating none of the above

37. For treatment of hyperthyroidism or thyroid storm the following may be appropriate except for: a. b. c. d. e. thioamides should be given at least one hour after iodine therapy lithium carbonate should be given if iodine is contraindicated hydrocortisone 100mg IV every 8 hours the use of acetaminophen to treat fever propylthiouracil, in an initial dose of 600-1000mg PO or NG, followed by 200250mg every 4-6 hours

38. Regarding hyperosmolar hyperglycaemic nonketotic syndrome coma is a presenting feature in: a. b. c. d. e. less than 5% of cases less than 10% of cases less than 15 % of cases less than 20% of cases none of the above

39. Which of the following is false regarding rhabdomyolysis: a. acute renal failure is one of the most serious complications b. compartment syndromes may be a cause or a complication of rhabdomyolysis c. causes include metabolic myopathies, infections, hyperthermia and hypothermia, trauma, drugs and toxins d. characteristic physical signs are present in 50-70% of patients e. urine alkalinisation theoretically enhances renal myoglobin clearance by increasing myoglobin's solubility

40. Causes of a normal anion gap metabolic acidosis with a tendency to hyperkalaemia include all except: a. b. c. d. e. Addisons disease potassium sparing diuretics renal tubular acidosis type IV subsiding diabetic ketoacidosis acetazolamide

41. Regarding hypercalcaemia which of the following statements is false? a. b. c. d. signs include confusion, bone pain and anorexia ECG changes include depressed ST segments and widened T waves volume repletion with normal saline is one of the main treatments glucocorticoids should not be considered in patients with hypercalcaemia secondary to sarcoidosis or multiple myeloma e. diuretics such as frusemide may be used but they may worsen the volume depletion and hypokalaemia.

42. All of the following are true regarding Gelofusine except: a. b. c. d. e. the osmolality is 283 mOsm/kg it contains 77 mmol/L of sodium its pH is 7.4 +/- 0.3 disposal of the bag is environmentally harmless it contains 20gm of succinylated gelatin

43. Which of the following statements is true: a. in metabolic alkalosis if the urinary Cl is <10mmol/L it is considered saline responsive and is usually caused by GIT losses or diuretics b. mineralocorticoid excess is associated with metabolic acidosis c. there is no need to correct hypokalaemia in metabolic alkalosis d. intravenous HCO3 should never be used in metabolic acidosis associated with tricyclic antidepressant overdose e. children with diabetic ketoacidosis should always have HCO3

44. The most common cause of a potassium level greater than 5.5 mmol/L is: a. b. c. d. e. heavy exercise renal failure invitro haemolysis potassium-sparing diuretics acidosis

45. Which of the following is not a recognized cause of a respiratory alkalosis? a. b. c. d. e. steroids salicylate toxicity high altitude pulmonary embolism cerebrovascular accident

46. All of the following regarding magnesium deficiency are true except: a. b. c. d. magnesium deficiencies are seen in alcoholics and malnourished patients muscle weakness and tetany are not signs of magnesium deficiency ECG changes include prolonged PR and QT intervals hypokalaemia, hypocalcaemia and hypophosphataemia are often present with severe hypomagnesaemia e. causes include hyperthyroidism, diarrhea and acute pancreatitis

47. The average fluid deficit in hyperosmolar hyperglycaemic nonketotic syndrome is in the range of: a. b. c. d. e. 20-25% of TBW 15-20% of TBW 25-30% of TBW 10-15% of TBW > 30% of TBW

48. Mechanisms that contribute to ketone production in alcoholic ketoacidosis include: a. b. c. d. e. alcohol-induced mitochondrial structural changes mitochondrial phosphate depletion inhibition of the utilisation of NADH acute vomiting and starvation all of the above

49. Regarding metabolic alkalosis: a. it is often accompanied by hypochloremia and hyperkalemia b. under normal circumstances the kidneys find it difficult to excrete HCO3 c. if primary aldosteronism, renal artery stenosis or Cushing's syndrome is present, correction of the underlying cause will contribute little to reversing the alkalosis d. NaCl therapy is usually insufficient to reverse the alkalosis if ECFV contraction is present e. the presence of chronic hypertension and chronic hypokalemia in an alkalotic patient suggests either mineralocorticoid excess or that the hypertensive patient is receiving diuretics

50. Patients with chronic hyponatraemia may experience all of the following except: a. b. c. d. e. paraesthesiae ataxia focal weakness a positive Babinski sign hemiparesis

51. One litre of Hartmanns solution contains all of the following except: a. b. c. d. e. water for injection sodium chloride 6 gm sodium lactate 3.22 gm potassium chloride 300 mg calcium chloride 270 mg

52. Which of the following statements is not true regarding hypermagnesaemia: a. the clinical manifestations of hypermagnesaemia generally correlate well with the serum level b. early signs of hypermagnesaemia include nausea, vomiting, weakness, and cutaneous flushing. c. hypotension and ECG changes such as QRS widening and QT and PR prolongation may be seen at a later stage d. respiratory depression does not occur with hypermagnesaemia e. patients with severe hypermagnesaemia should receive intravenous calcium 53. In renal tubular acidosis: a. there are only 2 subtypes b. it is not associated with heavy metal toxicity c. it may result in a chronic metabolic acidosis with hypokalaemia, nephrocalcinosis or osteomalacia d. there is impaired ability to secrete H+ in the proximal convoluted tubule e. there is impaired ability to absorb HCO3 in the distal convoluted tubule

54. Drugs known to cause hyponatraemia include all of the following except: a. b. c. d. e. nicotine morphine paracetamol flecainide colchicine

55. The diagnostic features of hyperosmolar hyperglycaemic nonketotic syndrome include all of the following except: a. b. c. d. e. plasma glucose > 33 mmol/L arterial pH > 7.30 serum bicarbonate > 20 mmol/L urine ketone (nitroprusside reaction method) small effective serum osmolarity > 320 mosm/L

56. Which of the following statements is true regarding myxoedema coma? a. most patients present comatose with severe myxoedema b. precipitants include trauma, stroke, infection, lithium, amiodarone, congestive heart failure c. increased CO2 retention occurs in myxoedema coma because of decreased respiratory muscle strength and increased ventilatory drive d. hyperglycaemia and hyponatraemia are usual findings e. oedema if present is usually pitting

57. Diagnostic criteria for alcoholic ketoacidosis include: a. b. c. d. e. a glucose level less than 11 mmol/L a glucose level greater than 14 mmol/L a glucose level less than 16.5mmol/L a glucose level greater than 27.5mmol/L none of the above

58. Physiologic changes in pregnant patients that make them more prone to DKA include: a. b. c. d. e. a relative insulin deficiency an increase in free fatty acid levels increased levels of counter-regulatory hormones a decrease in buffering capacity all of the above

59. Which of the following is not associated with hypophosphataemia: a. b. c. d. e. impaired platelet function tremors circumoral and fingertip paraesthesiae impaired myocardial function hypoventilation

60. Causes of central diabetes insipidus include all of the following except: a. b. c. d. e. neoplasms pituitary surgery trauma malnutrition granulomas