RACGP Bridging Course AMC PDF

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Bridging Course MCQs

Block 1
Block 2
Block 3
Block 4
Block 5
Block 6
Block 7
Block 8
Block 9
Block 10
Block 1
Question 3
Question 1
Maud is a 70 year old who presents with acute peri-
Patients suffering from schizophrenia may experience
umbilical abdominal pain gradually increasing in
both positive and negative symptoms. All of the
intensity. She is vomiting profusely and develops watery
following are negative symptoms EXCEPT:
diarrhoea with flecks of blood after an hour of pain.
a) Anhedonia Examination of the abdomen reveals localised
periumbilical tenderness with some rigidity. Rectal
b) Hallucinations examination is normal. An irregular pulse is noted and
an ECG is recorded (shown below).
c) Lack of motivation
The MOST LIKELY diagnosis is:
d) Emotional blunting
a) Acute appendicitis
e) Alogia
b) Acute pancreatis

c) Perforated peptic ulcer


Answer: B
d) Biliary colic
Hallucinations are abnormal perceptions, e.g. hearing
voices speaking about the patient, and/or giving e) Mesenteric artery occlusion
instructions to do certain things. They represent
additional phenomena and, therefore, are classified as
positive symptoms. Delusions (false ideas) is the other
Answer: E
major group of positive symptoms. In contrast, each of
the other options represents a loss or diminution of a The clinical presentation is typical of mesenteric artery
mental function, e.g. anhedonia is a loss of capacity for occlusion. This occurs most commonly in patients with
pleasure. atrial fibrillation leading to embolism. The ECG shows
atrial fibrillation. Arteriography will show the vascular
occlusion.
Question 2

Martha was born at 35 weeks gestation. She required


Question 4
phototherapy for jaundice whilst in hospital. Martha is
being breast-fed and is beginning to gain weight. She is A 15 year old male has sudden onset of severe pain in
now two months old. Regarding routine childhood his right lower abdomen commencing 2 hours ago. He
vaccination which of the following statements is has vomited several times in the last hour. He is rolling
CORRECT? on the bed, stating that the pain is going down into his
groin. T 37.1 degrees Celcius, P 110min, BP 135/ 80.
a) Vaccinations due to be given at two months
Abdomen - soft, no rebound. Tender right testicle. Your
of age should be postponed until Martha is at
immediate management is:
least 13 weeks old to allow for her prematurity.
a) i/v fluids and antibiotics
b) Martha's past history of jaundice is not a
contraindication to oral polio vaccine. b) arrange urgent ultrasound examination
c) Vaccines for intramuscular injection should c) i/v metoclopramide (maxolon)
be given into the buttock in a premature baby.
d) refer for emergency surgery
d) Breast-feeding is a contraindication to
vaccination. e) arrange for intravenous pyelogram (IVP)

e) It is not necessary to immunise Martha


against hepatitis B.
Answer: D

The sudden onset of severe pain in the lower abdomen,


Answer: B groin or scrotum, in a young male under 25 years,
should be considered to be testicular torsion until proved
A history of jaundice after birth is not a contraindication otherwise. This is a surgical emergency, as infarction of
to any of the vaccines in the standard schedule. the testis can occur quickly, and surgical exploration
Vaccination should not be postponed because of should be undertaken urgently. This patient has no
prematurity. The fact that a child is breast-fed is not a fever,
contraindication to vaccination. Vaccines should never
be given into the buttocks. The anterolateral thigh is the nor tenderness of the epididymis to indicate epididymo-
preferred site for vaccination in infants under 12 months orchitis. Antibiotic treatment will not help. Colour
of age. The deltoid region is the preferred site in older doppler ultrasound may show increased blood flow in
children (those who have commenced walking) and in infection and the absence of flow in advanced torsion.
adults. Martha would be due to receive vaccination However, these are not reliable findings, and the
against hepatitis B at the age of two months according investigation would waste valuable time. The vomiting is
to the current standard vaccination schedule. related to the pain, and would be alleviated by
appropriate analgesia. Metoclopramide is not an
immediate priority. The clinical picture is highly c) Descent is unlikely to occur after 1 year of
suggestive of testicular torsion rather than renal colic, age.
thus IVP is not the appropriate immediate management.
d) Orchidopexy should be delayed until late
childhood.

Question 5 e) The undescended testis is at reduced risk of


malignancy.
In a 3 year old child with signs and symptoms
suggestive of bacterial meningitis, which of the following
is the BEST initial management?
Answer: C
a) Erythromycin IV
Testes which are undescended at birth may well descend
b) Gentamicin IV into the scrotum during the first two weeks of life,
however descent is unlikely to take place after the age
c) Ceftriaxone IV of one
d) Phenoxymethylpenicillin oral year. 2% of boys born at full-term, and 20% of
premature males, have undescended testes. A testis
e) Amoxycillin oral
which was palpable in the scrotum in infancy may
ascend and become impalpable due to failure of the
spermatic cord to elongate at the same rate as body
Answer: C growth. Orchidopexy is best performed by 12-18 months
of age as spermatogenesis in the undescended testis is
If bacterial meningitis is suspected clinically it is vital to impaired after the age of two years. The undescended
immediately administer an appropriate antibiotic prior to testis is at 5-10 times greater risk of developing
urgent transfer to hospital, as meningococcal meningitis malignancy (seminoma).
may be rapidly fatal. The drug of choice would be
benzylpenicillin 60mg/kg up to 3g IV or IM, or
ceftriaxone 50mg/kg up to 2g IV in patients
hypersensitive to penicillin or when further drug Question 8
treatment may be delayed.
An aspirate in an acutely painful, swollen knee shows
the following:

Question 6 • white cell count 4100/uL (< 2000/uL)

Atypical antipsychotic drugs (eg. olanzapine) have • red blood cells ++


certain advantages compared to the typical
• no crystals
antipsychotic drugs (eg. chlorpromazine) in the
treatment of schizophrenia. All of the following are • no organisms cultured
advantages of atypical drugs EXCEPT:
What is your interpretation of these results?
a) Improved therapeutic effect on positive
symptoms a) Inflammation is more likely

b) Improved therapeutic effect on negative b) Traumatic tap - cannot be interpreted


symptoms
c) Gonococcal arthritis
c) Reduced potential for acute extrapyramidal
symptoms d) Tuberculosis arthritis

d) Reduced potential for longer-term e) Viral arthritis


extrapyramidal symptoms

e) Improved therapeutic effect in some


Answer: A
treatment-resistant patients
Normal synovial fluid contains less than 2000 white
blood cells per microlitre. Inflammation causes counts of
Answer: A 3000 or higher. Inflammation can also cause red blood
cells to migrate into the joint fluid.
Both the typical and atypical antipsychotic drugs have a
beneficial effect on positive symptoms in schizophrenia.
However, they differ with regard to negative symptoms.
Question 9
Atypical antipsychotics are much better at combating
these. The other options are true for the atypical drugs. Concerning prostate cancer, which ONE of the following
is INCORRECT?

a) The majority of carcinomas arise in the


Question 7
peripheral zone of the gland
Which of the following statements regarding
b) The prostate specific antigen (PSA) is
undescended testes is CORRECT?
elevated in all prostate cancers greater than
a) The testes are undescended at birth in 40% 1.5 cm
of boys.
c) Metastatic spread to pelvic lymph nodes
b) Once the testis is palpable in the scrotum it occurs early
will remain so.
d) Radionuclide bone scan is not a reliable the metaphysis and a dense slightly flattened femoral
method of detecting bony metastases head. There is no need for testing white cell count or
CRP as these are normal. In most cases the prognosis is
e) Prostate cancers usually appear as excellent and the only requirement is to avoid prolonged
hypoechoic nodules on transrectal ultrasound walking or exercise. Progress is assessed by clinical
examination and serial radiological examinations. Where
there are severe changes containment of the femoral
Answer: B head is the treatment of choice and this usually requires
a plaster cast or orthosis. Osteotomy of the pelvis or
A normal PSA occurs in up to 20% of cancers, including femur is only rarely required.
tumours greater than 1.5 cm. Prostate cancer is the
second most common cause of cancer deaths in men in
Australia. The majority of prostate cancers- usually
Question 12
adenocarcinomas- arise in the peripheral zone of the
gland, and metastasise early to pelvic lymph nodes. Significant protein-energy malnutrition is likely to lead
Bony metastases are also common. Bone scan is to increased postoperative complications and prolonged
unreliable at detecting bony metastases when the recovery times. In assessing a patient's nutritional
prostate specific antigen (PSA) is <20ng/ml. The status, which ONE of the following findings would be of
commonest pattern for prostate cancer on transrectal MOST concern?
ultrasound is of hypoechoic nodules. This pattern may
also be seen in prostatic hypertrophy or prostatitis. a) bony shoulder girdle sharply outlined

b) weak grip strength

Question 10 c) an elevated white cell count in a patient with


multiple trauma
Which ONE of the following atypical antipsychotic drugs
is optimal as first line therapy in managing the first d) at the biceps skin fold, the dermis can be felt
episode of schizophrenia in a patient? between finger and thumb

a) Risperidone e) recent weight loss of >5kg

b) Olanzapine

c) Quetiapine Answer: B

d) Amuisulpride Assessment of physiological function is of most


importance, as weight loss without
e) Clozapine
evidence of physiological abnormality is probably of no
consequence. Physical weakness (as shown by weak
grip strength), and poor respiratory muscle function
Answer: B
increases the risk of post-operative pneumonia. When
Olanzapine is the drug of choice for treatment of first the bony shoulder girdle is sharply outlined, and tendons
episode schizophrenia, since it does not cause (eg of biceps and triceps) are readily palpable, the
extrapyramidal symptoms at therapeutic doses, and is patient is likely to have lost more than 30% of total
useful for combating affective symptoms, including protein stores. Loss of body fat is often readily apparent
depression. Its major disadvantage is weight gain. The on looking at the patient, and a biceps skinfold where
other drugs listed carry a greater risk of extrapyramidal the dermis can be felt between finger and thumb
symptoms and other side effects. indicates that the body mass has less than 10% fat.
Metabolic stress can occur from trauma, sepsis or
ongoing inflammation. The trauma patient may well
have near normal stores of protein and fat to call on in
Question 11 the short term.
Ara, 5 years old, presents with a painless limp. You
suspect Perthes' disorder. Which of the following
statements is CORRECT? Question 13

a) Hip mobility is usually reduced, particularly In Australia, all of the following are risk factors for
adduction and external rotation suicide, EXCEPT:

b) Ultrasound is required to make a definitive a) Schizophrenia


diagnosis
b) Family history of suicide
c) The white cell count and C reactive protein
(CRP) are usually raised c) Social disadvantage

d) Progress is assessed with serial radiological d) Female


examination
e) Youth
e) Osteotomy is the treatment of choice

Answer: D
Answer: D
Males, particularly young men and elderly single men,
Perthes' disorder is most common in 4-8 year olds. On are at greater risk of suicide than women who generally
examination hip mobility is reduced, particularly have better social support structures than their male
abduction in flexion. Xray confirms the diagnosis contemporaries.
showing widening of the joint space, decalcification of
Question 14 Question 16

A 15kg child with a known food allergy to peanuts All of the following groups are at higher risk than
suddenly develops anaphylaxis. The RECOMMENDED average of depression, EXCEPT:
immediate management is:
a) Women
a) 0.1ml of Adrenaline 1:1000 by deep intramuscular
injection b) Postpartum women

b) 0.1ml of Adrenaline 1:10,000 by deep subcutaneous c) Young rural males


injection
d) Urban males
c) 0.15ml of Adrenaline 1:1000 by deep intramuscular
e) Adolescents
injection

d) 0.15ml of Adrenaline 1:1000 by subcutaneous


injection Answer: D
e) 0.15ml of Adrenaline 1:10,000 by deep intramuscular Men living in urban areas are not especially at risk of
injection depression. However, young men living in rural areas
are at greater risk because of social isolation. Women,
particularly in the postpartum period, and adolescents
Answer: C are also more vulnerable to depression.

Adrenaline 1:1000. is recommended as it is readily


available, and this concentration contains 1mg of
Question 17
adrenaline per ml. The recommended dose of 1:1000
adrenaline is 0.01mg/kg body weight by deep 14 month old Mark is brought in to see you. He has had
intramuscular injection, so a 15kg patient would require high fever and a mild runny nose for three days but has
0.01 X 15 = 0.15ml i.m. still been quite active. Mark's temperature has returned
to normal today but he has now developed a red
maculopapular rash on his trunk. The MOST LIKEY
Question 15 diagnosis is:

Which ONE of the following is a mass population a) Measles


screening test which has been demonstrated to reduce
b) Chicken pox
cancer mortality significantly?
c) Erythema infectiosum
a) annual faecal occult blood testing in the over
50 age group d) Rubella
b) annual colposcopy in sexually active women e)Roseola infantum
c) annual plasma CA125 in post menopausal
women
Answer: E
d) annual colonoscopy in siblings of patients
with colon cancer Roseola infantum is a viral infection usually affecting
children between the ages of 6-18 months. The patient
e) 2 yearly mammography in women in the 35- typically develops high fever up to 40 degrees Celsius,
45 age group but is otherwise not particularly unwell. There may be
mild cervical lymphadenopathy and pharyngitis. After
three days the temperature usually returns suddenly to
Answer: A normal and the patient develops a red macular or
maculopapular non-desquamating rash which is truncal,
There have been at least 3 randomised control screening usually sparing the face and limbs. The rash abates
trials conducted which show that faecal occult blood within two days.
testing every 1-2 years in the over 50 year population
reduces the mortality from colorectal cancer by around
20%. Colposcopy is a diagnostic, not a screening test.
Question 18
The appropriate screening test for cancer of the cervix in
sexually active women is the Papanicolaou (Pap) smear. A 50 year old woman has had major abdominal surgery
Plasma CA125 levels may be raised in asymptomatic yesterday. You are called to see her urgently as she has
women with ovarian cancer but there is not, as symptoms of shock. Which ONE of the following
examination findings is of MOST concern?
yet, any evidence for its benefit as a mass screening
measure. Colonoscopy for siblings of patients with a) the patient is restless and confused
colorectal cancer may reduce their mortality, but this is
'selective' screening, by targeting a high-risk group. b) Temperature 39.2 degrees Celsius
While mammography in the 50-70 age group has been
shown to reduce mortality from breast cancer by around c) pulse 130, sinus tachycardia
30%, the benefit for women in the 40-50 age range is
d) urine output over past 4 hours of 120ml
quite small, and there is little evidence for benefit in still
younger women. e) BP 80/45 mm Hg
Answer: E Answer: A

The above signs taken together suggest a picture of The clinical picture suggests respiratory infection with
shock, probably septic shock. Hypotension (defined as Bordetella pertussis. The history of cyanosis associated
systolic BP <90mm Hg, or >40mm Hg fall from baseline with the coughing suggests the need for admission to
level) is a sinister development and requires urgent hospital but, in addition, children under 6 months of age
attention. It is often a LATE manifestation of circulatory usually require admission for pertussis because of the
failure. Thus it is the most alarming of these findings, risk of complications. Complications include respiratory
and the one most indicative of the urgency of this arrest, bacterial pneumonia and encephalitis.
situation. Salbutamol has not been shown to be helpful in a child
of this age and is of no benefit. Immunisation at a later
date should be encouraged even if the child has had
pertussis. Erythromycin is not curative but may reduce
Question 19
infectivity.
Arthur is a 74 year old man who presents reluctantly
because his wife feels 'he has not been himself since he
came home and is not sleeping properly.' His appetite is Question 21
poor and he has lost 6 kg in weight since discharge from
hospital eight weeks ago following treatment for Simon aged 4 months is diagnosed with pertussis. What
myocardial infarction. He has lost interest in his hobbies is the MOST APPROPRIATE management of Simon's
and is not taking his medications. He has been a type 2 parents to reduce their risk of infection?
diabetic for 12 years. On examination he shows signs of
mild cardiac failure. The result of an HbA1C test is a) Immediate booster immunisations for
10.5% (target <7%). Which ONE of the following is the pertussis
MOST likely cause of Arthur's condition.
b) A 10 day course of erythromycin
a) Senile dementia
c) Commence a 3 dose pertussis revaccination
b) Uncontrolled diabetes schedule

c) Depression d) Arrange nasopharyngeal swabs

d) Silent reinfarction e) Immediate immunisation with pertussis


immunoglobulin
e) Chronic fatigue syndrome

Answer: B
Answer: C
All household contacts of patients with pertussis should
Arthur is showing several typical features of depression, receive erythromycin for 10 days to prevent further
viz insomnia, loss of interest in pleasurable activities, spread of the disease. Cotrimoxazole is recommended
loss of appetite and loss of weight. Depression following for those intolerant of erythromycin. An initial or booster
myocardial infarction is well recognised and increases dose of pertussis vaccine should be considered for
the risk of complications and death. Such patients are children aged up to 8 years. This is not required for
less likely to observe instructions regarding medications, adults nor is it necessary for them to recommence a full
making their situation worse. Arthur's diabetes is poorly vaccination schedule. Babies under 2 months of age who
controlled, as shown by the elevated HbA1C level but have been exposed are best vaccinated early. Passive
this is insufficient to explain his condition. The other immunisation with pertussis immunoglobulin is not
options could contribute to the clinical picture shown by effective in the prevention of pertussis. Isolation is not
Arthur but are less likely to be the cause of his required for household contacts.
condition.

Question 22
Question 20
Which of the following conditions is the COMMONEST
Aidan, a 3 month old boy, presents with paroxysms of anxiety disorder encountered in general practice?
coughing associated with cyanosis, lethargy and poor
feeding for several days. On examination, between a) Generalised anxiety disorder
episodes of coughing, he is afebrile and examination is
b) Phobic disorder
normal. What is the NEXT step in management?
c) Obsessive compulsive disorder
a) Admission to hospital
d) Panic disorder
b) Nasopharyngeal aspirate and review in 24
hours e) Post-traumatic stress disorder
c) Immunisation at this visit with DTP and
review in 24 hours
Answer: A
d) Erythromycin syrup and review in 24 hours
Generalised anxiety disorder is the commonest anxiety
e) Trial of salbutamol by mask disorder seen in general practice. It has an insidious
onset, usually having been present 5 to 10 years before
diagnosis. It occurs more commonly in women and the
frequency increases with age.
Question 23 d) Amitriptyline

Which of the following is NOT a diagnostic feature e) Any of the above


accompanying anxiety in generalised anxiety disorder
(GAD)?

a) Restlessness Answer: E

b) Fatigue There is a well defined role for short-term use of a


hypnotic medication in a situation like sudden
c) Difficulty concentrating bereavement. None of the drugs listed stands out as the
best hypnotic with few side effects. Temazepam is the
d) Muscle tension most often prescribed hypnotic in Australia. However,
benzodiazepines have generally fallen from favour
e) Loss of appetite
because of their addictive properties if taken for more
than several weeks. Zopiclone and zolpidem share some
of the properties of benzodiazepines but have fewer
Answer: E adverse effects. Amitriptyline is a tricyclic
antidepressant which is a useful hypnotic in lower doses
Loss of appetite is not a feature of GAD. The DSM-IV than are used for depression.
criteria include 3 or more of the following in addition to
anxiety and worry: restlessness, fatigue, difficulty
concentrating, irritability, muscle tension, and sleep
disturbance. Question 26

Insomnia is defined as inability to:

Question 24 a) Fall asleep

Martin, aged 50 years, complains of insomnia for two b) Maintain sleep


weeks. He says this relates to anxiety about problems at
c) Sleep at normal times
work which surround the end of the financial year. While
he is describing his problem, he is excited and agitated. d) Obtain good quality sleep
On examination, his pulse rate is 75/min and BP 135/95
mm Hg. Which of the following behavioural therapies e) Obtain enough sleep
would be MOST helpful to Martin?

a) Cognitive therapy
Answer: D
b) Sleep restriction therapy
Insomnia is the commonest sleep disorder and is
c) Stimulus control therapy defined as poor quality sleep which often results in
daytime symptoms, including fatigue, irritability,
d) Relaxation therapy problems with concentration and memory, and feeling
unwell. The other options describe features of various
e) Interpersonal therapy
insomnia syndromes but do not define the overall
problem.

Answer: D

The successful treatment of insomnia depends on both Question 27


behavioural and pharmacological approaches. Relaxation
Miriam, aged 67 years, presents with insomnia for two
therapy would be the most useful behavioural therapy
weeks. She has tried several over-the-counter
for Martin, because he displays exaggerated arousal -
medications but has not received any benefit. Further
emotional, cognitive and physiological, shown by his
questioning reveals that she is feeling unusually worried
mental approach when describing the problem and his
about her health, is also irritable and restless and has
physiological response in terms of pulse rate and BP.
generalised muscle tension. You have known Miriam for
Progressive muscle relaxation aims to reduce somatic
5 years since you joined this practice. She has
arousal and attention focussing techniques (e.g. on
previously complained of 'arthritis' of the hips and
tranquil situations) to reduce cognitive and emotional
knees, back pain and gastro-oesophageal reflux on
arousal. (See reference for descriptions of other options,
various occasions. Which of the following drugs would be
except interpersonal therapy which is not an accepted
MOST suitable for long-term treatment Miriam.
form of behavioural therapy.)
a) Amitriptyline

b) Diazepam
Question 25
c) Venlafaxine
Doris is a 74 year old woman whose husband has died
suddenly a week ago. She seeks your help in dealing d) Oxazepam
with insomnia which has been troubling her since her
husband's death. She has tried an over-the-counter e) Fluoxetine
preparation which she obtained at the local pharmacy
but has not found it helpful. Which of the following drugs
would you offer to prescribe for Doris?
Answer: C
a) Temazepam
Miriam is suffering from generalised anxiety disorder
b) Zopiclone (GAD). Fluoxetine and paroxetine are selective serotonin
reuptake inhibitors (SSRI) which have not been shown
c) Zolpidem to be effective in the treatment of GAD. Amitriptyline is
a tricyclic antidepressant; diazepam and oxazepam are b) Inadvertently play down their anxiety
benzodiazepines. All three drugs can be used for
treating anxiety, but have major disadvantages in terms c) More often present with somatic complaints
of side affects and are unsuitable for long-term
d) Are misdiagnosed as having depression
treatment of GAD. Venlafaxine is a serotonin and
noradrenaline reuptake inhibitor (SNRI) which has been e) Tend to keep away from doctors
shown to be effective in the long-term treatment of
GAD. However, it is important that patients also receive
appropriate psychotheraphy, viz-cognitive behavioural
therapy (CBT). Answer: C

Patients with GAD are frequently not diagnosed for


years because they tend to present with associated
Question 28 somatic complaints, such as asthma, back pain,
migraine, allergies, and gastrointestinal disorders and
The prevalence of insomnia in the Australian community often consume a large amount of medical resources
is about: before the diagnosis is made. They are not deliberately
concealing things from their doctors - they simply do not
a) 10%
appreciate the significance of their feelings. Patients
b) 20% with GAD may also have clinical depression which can
further complicate the issue.
c) 30%

d) 40%
Question 31
e) 50%
All of the following are effective first line topical
treatments for severe dandruff EXCEPT:

Answer: C a) Selenium sulphide

The prevalence of insomnia in Australia is about 30%. b) Zinc pyrithione


The situation is similar in other industrialised nations.
Male sufferers outnumber females by 1.3 to 1 in the c) Betamethasone
40+ years age group. Other factors which increase the
d) Miconazole
prevalence of insomnia are old age, unemployment and
lower socio-economic status. The majority of patients e) Ketoconazole
have a co-existing disorder, such as depression or
generalised anxiety, and often present with fatigue or
daytime sleepiness rather than insomnia.
Answer: C

Dandruff, pityriasis capitis and seborrhoeic dermatitis


Question 29 are related conditions on a continuum of severity.
Pityrosporidium ovale is a fungus which has been
Which of the following is a cause of primary insomnia? implicated
a) Obstructive sleep apnoea in the development of these conditions. Eradication of
the fungus has been shown to relieve the symptoms of
b) Restless legs syndrome
the condition. Selenium sulphide, zinc pyrithione,
c) Behavioural conditioning miconazole and ketoconazole are all first line treatments
which can be used once weekly to daily depending on
d) Sleep phase disorder severity. Topical application of betamethasone lotion is
effective but only considered if there has been little
e) Bereavement response to the first line treatments.

Answer: C Question 32
In primary insomnia there is no pre-existing cause of Amy, a young girl, is worried about a rash on her face
sleep disorder as there is, for example, in obstructive which has been there for a few weeks. It is mildly itchy
sleep apnoea, restless legs syndrome, sleep phase and has slowly increased in size. On examination it is a
disorder and bereavement. With behavioural circular lesion which looks scaly around the edges with
conditioning or behaviours impairing sleep the patient the center appearing normal(see figure).
has developed a habit of doing things immediately
before bedtime which are not conducive to sleep, such The MOST LIKELY diagnosis is:
as sitting in bed watching television. With the other
options there is another established condition or a) Tinea corporis
situation which disrupts sleep. Hence insomnia is
b) Impetigo
regarded as secondary in these cases.
c) Pityriasis versicolor

d) Psoriasis
Question 30
e) Dermatitis
Patients suffering from generalised anxiety disorder
(GAD) often go undiagnosed for years because they:

a) Deliberately conceal their anxiety


Answer: A fingers and wrist. Contact dermatitis to her watch would
produce a local contact dermatitis.
In children, tinea commonly involves the hair, face and
body. Tinea corporis is recognised by its scaly,
erythematous edge with clearing centre. Dermatitis and
psoriasis can mimic tinea and where the clinical picture Question 35
is uncertain a fungal scraping may confirm tinea.
Which of the following statements about routine
Impetigo may present with blisters that leave a brown
immunisation is CORRECT?
crust, or erosions with yellow crusts but without
blistering. Pityriasis versicolor presents as well a) If more than 3 months elapses between
demarcated pale or tan-coloured macules usually on the triple antigen injections the series should be
upper trunk. restarted to obtain adequate immunisation

b) The first triple antigen injection should


always be half dose (1/2 cc) to reduce allergic
Question 33
reactions
After referral to a paediatric oncologist, Bronwyn is
c) A convulsion following acellular pertussis
diagnosed as having acute lymphoblastic leukaemia
triple antigen vaccine (DTPa) does not
(ALL). Both her parents are very distressed and visit you
contraindicate its further use
to find out more about this condition. Which of the
following statements about acute lymphoblastic d) Tetanus booster injections should be
leukaemia is INCORRECT? repeated every 3 years
a) 75% of children with ALL are cured e) Measles vaccine should be given at 6 months
of age to protect the child as soon as possible
b) An initial intense course of treatment lasting
approximately 4-6 weeks is required

c) Intrathecal therapy is required only if the Answer: C


disease has spread to the spine
A convulsion, in the presence or absence of fever,
d) Relapse rates are of the order of 30% occurring after DTPa vaccination, does not
contraindicate completion of the course with DTPa-
e) Remission rates are of the order of 95%
containing vaccine. The only adverse events which
contraindicate further doses of pertussis containing
vaccine are:
Answer: C
• encephalopathy within 7 days and
Intrathecal therapy is now given to all children with ALL.
Prior to blanket intrathecal therapy, up to 60% of • an immediate severe allergic reaction.
children had a relapse due to CNS disease. The use of
It is now recommended that, after a full primary course
blanket CNS therapy has reduced the CNS relapse rate
of childhood vaccination, a single booster of tetanus
to less than 10%.
toxoid is administered at age 50 years only (unless
required sooner for managing a tetanus-prone wound).
Measles, mumps and rubella immunisation is
Question 34 recommended at 12 months of age. Triple antigen (DPT)
immunisation is recommended at 2, 4, 6 and 18 months
Mary is an attendant at a local accommodation centre of age. The first dose should not be reduced.
and has an intensely itchy rash on her wrists and arms
that has been present for the past few days (see figure).

She has recently bought a new watch and wonders if Question 36


this is the cause of the problem. The MOST LIKELY
diagnosis is: The MOST appropriate treatment for first degree
atrioventricular (AV) heart block is:
a) Papular urticaria
a) An artificial pacemaker
b) Tinea
b) Isoprenaline hydrochloride (Isuprel)
c) Contact dermatitis
c) Atropine
d) Eczema
d) Digoxin
e) Scabies
e) Requires no treatment

Answer: E
Answer: E
Scabies is a skin infestation by the mite Sarcoptes
scabei. It is generally spread by skin to skin contact First degree AV block often does not require any
such as in crowded areas, poverty, sexual contact and treatment. Acute treatment of
casual contact. The mite can live for 2 days outside the
extreme bradycardia or second degree AV block (Mobitz
human body, so infection by contact with bed linen and
type II) may require atropine or isoprenaline, but
other infected material is possible. Intense itch is
temporary pacing is the preferred treatment. Permanent
characteristic of the condition - if it is not itchy, it is not
pacing is recommended for distal block (Mobitz type 2)
scabies. Distinct erythemato-papular itchy nodules are
because of frequent early progression to third-degree
due to an allergic reaction to the mite, its faeces and its
atrioventricular block. Most patients with third degree
larvae. 0.5-1.0cm "burrows" can often be found on the
(complete) AV block will require permanent cardiac
pacing. Drugs such as digoxin may be the cause of an Question 39
AV block and should be ceased or the dose reduced.
A 61 year old farmer with a history of hypertension
presents with an amnesic episode of sudden onset.
When assessed he is perplexed and bewildered, and
Question 37 repeatedly asks where he is and how he comes to be
there. He has short term memory loss but knows his
Melissa, a 49 year old woman, presents with loss of
identity and is fully conscious. He recovers from his
libido which has been worsening over the past 12
memory loss after 6 hours. Neurological examination is
months. She takes a combined oral contraceptive tablet,
normal. His blood pressure is 165/96 sitting. The MOST
and a selective serotonin reuptake inhibitor (SSRI) for
LIKELY diagnosis is:
depression. She is a non smoker but drinks 1-2 glasses
of wine a night. Which of the following advice would you a) Hypertensive encephalopathy
offer Melissa to help her regain her libido?
b) Richardson-Steele syndrome
a) Change to a progestagen only oral
contraceptive c) Alzheimer's disease

b) Change to an oestrogen only oral d) Transient global amnesia


contraceptive
e) Complex partial seizure
c) Reduce her alcohol intake

d) Change antidepressant medication


Answer: D
e) Undertake cognitive behavioural therapy
The most likely diagnosis is transient global amnesia.
This is a syndrome in which a previously well person
suddenly becomes confused and amnesic. The attacks
Answer: D are usually spontaneous. The patient appears
bewildered and repeatedly asks questions about present
Various medications may cause loss of libido, including
and recent events. Orientation for person and
antidepressants like the SSRIs. The remedy is to change
sometimes place is preserved but recent memory is
to a different class of antidepressant. Excess alcohol
impaired and the patient cannot recall new information
consumption can have a deleterious effect on libido,
after a few minutes delay. Attacks usually last 24 to 48
however Melissa's intake is within recommended limits
hours. Recovery is complete and recurrence occurs in
for adult females. Changing the oral contraceptive would
about 20% of patients. The cause is a mystery. Complex
be unlikely to help. Cognitive behavioural therapy would
partial seizures are brief and the individual loses
be the next step if suitable pharmacotherapy cannot be
conscious contact with the environment. Post-ictal
established.
amnesia is common if the seizure becomes generalised.
Richardson Steele Syndrome (or progressive
supranuclear palsy) resembles Parkinson's disease in
Question 38 that there is a disturbance of balance and gait, with
rigidity of the trunk and neck muscles. Alzheimer's
In assessing a patient for adult-onset asthma, which of disease is a progressive form of dementia which does
the following is FALSE? not resolve. Hypertensive encephalopathy is an acute
syndrome where severe hypertension is associated with
a) There is usually a history of past or present
headache, vomiting, convulsions, confusion, stupor and
cigarette smoking
coma.
b) There is usually a long history of atopic
disease
Question 40
c) Attacks can be triggered by chemical and
physical agents Which of the following factors would NOT be a poor
prognostic indicator for joint replacement in hip
d) The asthma tends to be more chronic than
osteoarthritis in a 65 year old man?
episodic
a) Age
e) The associated cough can be harsh,
suffusing and non-productive b) A BMI of 33

c) Associated diabetes
Answer: B d) Presence of osteoporosis
Adult onset asthma is non-atopic, although patients can e) A previous joint replacement
have attacks precipitated by aspirin, viruses, cold air
and coughing itself. A history of smoking is nearly
ubiquitous, but the connection to the development of
adult-onset asthma is not yet understood. Patients tend Answer: A
not to have long spells of being 'puffer free', but regular
Poor prognostic indicators for joint replacement include:
inhaled steroids are very effective in controlling the
age less than 50 years, diabetes, obesity, high demand,
condition. The cough can keep the patient awake all
poor bone quality, previous joint surgery and poor
night, along with the rest of the family.
general health. Since Michael is 65 years old his age
would not be a poor prognostic indicator.
Block 2

Question 1 Question 2

All of the following tests should be part of a routine Martin is 5 years old. His mother reports he has been
initial (first trimester) antenatal screen EXCEPT: waking her at night screaming in apparent fear. She is
extremely worried. Although Martin is obviously
a) Full blood examination frightened during these episodes, he does not seem fully
awake, and she is unable to comfort him or wake him
b) Blood group and antibodies fully. He is sweaty, tachypnoeic and tachycardic. Martin
does not recall these episodes in the morning. He is
c) Dating ultrasound
MOST LIKELY suffering from:
d) Syphilis serology
a) Nightmares
e) Hepatitis B surface antigen
b) Thyrotoxicosis

c) Night terrors
Answer: C
d) Panic disorder
Although there are no official national antenatal
e) Seizure disorder
screening guidelines in Australia, there are a set of
recommendations by the Royal Australian and New
Zealand College of Obstetricians and Gynaecologists.
Tests to be offered at the first trimester initial antenatal Answer: C
visit include the following:
Night terrors are a disorder of arousal from NREM sleep,
1. Blood group and antibody screen usually occurring in 3 to 8 year olds. The child wakes
only partially, cannot be fully roused or comforted, and
2. Full blood examination will have no recall of the episode. Autonomic symptoms
as described are common. With nightmares, the child
3. Rubella antibody status
wakes fully, and frequently has full recall of dreams.
4. Syphilis serology Night terrors may be precipitated by anxiety or an
experience which has frightened the child prior to sleep.
5. Midstream urine culture

6. Hepatitis B serology
Question 3
7. HIV Antibody
All of the following are associated with the timing of
8. Hepatitis C serology secondary sexual maturation EXCEPT:

9. Others to consider: a) body weight

10. Cervical cytology b) adequate sleep

11. Haemoglobinopathy screen c) phenotype

12. Varicella antibody d) optic exposure to sunlight

Where the blood group has already been performed it e) latitude of habitation
does not need to be repeated. However, the antibody
screen should be repeated at the beginning of each
pregnancy, and all Rhesus negative women and all those
Answer: E
who have had isoimmunisation of any type in the past
should be re-screened. Although a previous high rubella Girls must attain a critical body weight (irrespective of
antibody titre is generally used to justify exclusion of height) before sexual maturation will begin. A body
this investigation from first visit testing, there is some weight of 38 - 48 kilograms must be achieved before
evidence that antibody levels may decline after rubella menses begins and a proportion of body fat of 16-24%
immunisation, especially since antibody levels are rarely is required to sustain ovulatory cycles. Other critical
boosted by exposure to wild viruses in the community. elements to the timing of secondary sexual maturation
All pregnant women should be offered hepatitis C and include adequate sleep and vision. Blind girls have
HIV screening at the first antenatal visit and if necessary delayed menarche and blind boys have delayed
after exposure to risk of infection. It is imperative that spermatogenesis and ejaculation. Chromosomal
the woman is provided with appropriate counselling as abnormalities such as Turner's syndrome result in
to the limitations of the testing and the implications of premature ovarian failure and lack of secondary sexual
both positive and negative findings. Documented normal maturation. Latitude has no impact.
cervical cytology within the preceding 18 months may
be used to delay repeat screening if there is no clinical
indication for another Papanicolaou smear. Routine
vaginal ultrasound during the first trimester is not
recommended except where the viability of the
pregnancy is in question such as when the woman has
had first trimester bleeding.
Question 4 epilepsy, the incidence being about 2 - 3%. The chance
of developing epilepsy is increased if there is a family
Eve is 9 weeks pregnant. She presents with a history of history of epilepsy, the child has a pre-existing
24 hours of intermittent dark blood loss staining her neurological
underwear. On vaginal examination, the uterus is the
expected size and the cervical os is closed and non- abnormality, the child is under one year of age, the
tender. You should advise her that: seizure is prolonged (greater than 15 minutes) and/or
has complex or focal features, or if the child fits more
a) she is likely to have miscarried than once in one day.
b) approximately half of all pregnant women
suffer bleeding during the first trimester
Question 6
c) she requires admission to hospital for a D&C
Vera, aged 61 years, has noticed a swelling in the front
d) there is a higher incidence of congenital of her neck, which is enlarging quite rapidly. She is
malformations in fetuses where bleeding otherwise well, without symptoms of hypothyroidism or
occurred in the first trimester hyperthyroidism. On examination she has a multinodular
goitre, with a dominant nodule of 4 cm diameter in the
e) she should have an ultrasound examination
right upper pole of her thyroid gland. Of the following
investigations, which is the MOST important in assisting
diagnosis?
Answer: E
a) Thyroid function tests
Eve has a threatened abortion as the cervical os is
closed and there is no history of passage of products of b) Thyroid ultrasound
conception. This occurs in 25% of pregnancies and half
c) Fine needle biopsy
of these progress to spontaneous abortion. For those
who carry the pregnancy to term, there is no increased d) Thyroid isotope scan
risk of congenital malformation. An ultrasound
examination would be helpful, as it could demonstrate e) CT scan
the presence (or absence) of a foetus appropriately
sized for dates. The demonstration of a foetal heart is
very reassuring. At 9 weeks, when a foetal heartbeat is
Answer: C
present and not slow, 90% of pregnancies will continue
despite bleeding. The incidence of malignancy in a dominant thyroid
nodule is approximately 7%, and fine needle biopsy is
the appropriate investigation to exclude malignancy.
Question 5 Vera has several features consistent with a thyroid
malignancy, including a rapidly growing solitary lump,
Samantha is 18 months old. She is usually well, with no her age (over 60 years) and the fact that the dominant
significant past history, and is up to date with her nodule is >3cm in diameter. Detection or exclusion of
childhood vaccinations. Samantha has been miserable malignancy is the MOST important issue initially. Thyroid
and unwell for 24 hours with a clear runny nose, and a function tests must also be performed to assess
fever of 39 to 40 degrees Celsius. She has no cough, no glandular activity, but they
diarrhoea or vomiting, and is drinking well, even though
her appetite for solids is decreased. Suddenly Samantha do not help in determining malignancy. Ultrasound scan
has a generalised tonic-clonic seizure, lasting 3 minutes. adds little to clinical examination, but may be used to
Which of the following statements regarding febrile guide the biopsy needle. CT scan may be useful to
convulsions in children is TRUE? assess retrosternal extension of the thyroid, but
currently Vera has no symptoms of this problem.
a) most febrile convulsions are focal or partial Nuclear medicine scan is useful to determine the
seizures functional status of a nodule but carcinoma cannot be
excluded on the basis of a radionuclide scan.
b) There is a 10% chance of developing
epilepsy

c) the most common cause is CNS infection Question 7


such as meningitis
All of the following are true of ectopic pregnancy
d) 30-50% of children have recurrent episodes EXCEPT:

e) Peak incidence is 2-3 years of age a) an ectopic pregnancy is one where there is
implantation outside the uterine cavity

b) the primary risk factor for ectopic pregnancy


Answer: D is a history of salpingitis
Febrile convulsions may be recurrent in 30 - 50% of c) the prevalence of ectopic pregnancies has
cases, but this does not usually worsen long term decreased over the last 20-30 years
prognosis. Most febrile convulsions occur in children
aged 3 months to 5 years, the peak incidence being d) ectopic pregnancy is one of the leading
between 6 and 20 months of age. More than 90% of causes of maternal mortality
seizures are generalised. Acute upper respiratory tract
infections are the most common cause of febrile e) less than 50% of women who have an
convulsions. In children under the age of two years if ectopic will subsequently have a successful
the cause of the febrile convulsion is not obvious, a normal pregnancy
lumbar puncture must be performed to exclude CNS
infections. Only rarely do febrile seizures lead to
Answer: C Answer: D

The prevalence of ectopic pregnancies has increased by The rapid growth of a painful swelling in the region of
up to six-fold since 1970. The reason behind this the parotid gland, suggests a malignant process. 15-
increase may be an increase in the prevalence of 20% of parotid tumours are malignant, and in Australia
sexually transmitted diseases and tubal sterilizations, or the most common parotid malignancy is metastatic
that women are conceiving later in life with a melanoma or squamous cell carcinoma from a skin
corresponding increase in the risk of tubal problems. primary in the head and neck region. Sjorgrens
Ectopic pregnancy remains one of the leading causes of syndrome produces persistent and painful parotid
maternal mortality. Probably because of underlying tubal swelling, but growth is usually slow; associated
problems, <50% of women who have an ectopic will go symptoms include dryness of the mouth and eyes.
on to have a successful intrauterine pregnancy.
Pleomorphic adenoma is the commonest parotid
tumour; it is benign grows slowly and rarely causes
pain. Salivary duct calculi produce intermittent swelling
Question 8 of the salivary gland, often during eating; they are more
common in the submandibular gland. Acute sialadenitis
Regarding urinary tract infection (UTI) in children, which
is salivary gland inflammation presenting as rapid
of the following statements is INCORRECT?
development of erythema, pain, tenderness and swelling
a) Diagnosis is based on a colony count of 108 often due to infection, most commonly with Staph
organisms/litre from a bag urine specimen aureus.

b) Approximately 5% of children will have had


a UTI by the age of 10 years, girls more often
Question 10
than boys
A 26-year-old woman (G3P2), who has reached 30
c) Infants often present with non-specific fever
weeks gestation, telephones you to say that she has had
and failure to thrive, irritability and
an episode of bright red vaginal bleeding. It occurred
hypothermia
several hours ago and she has had no associated
d) Even one UTI in a child <4 years of age symptoms. She estimates she lost about a teaspoonful
needs a renal ultrasound and micturating of blood. What would be the MOST APPROPRIATE
cystourethrogram (MCU) IMMEDIATE management?

e) Renal scarring on an isotope scan increases a) Advise rest at home and to call back if
the risk of early onset hypertension bleeding recurs

b) Advise her to attend immediately for further


evaluation
Answer: A
c) Reassure her that spotting without other
By 10 years of age, 2% of boys and 8% of girls will have symptoms is unlikely to be significant at this
had at least one UTI. About 25% of these will have stage
vesicoureteric reflux (VUR). Escherichia coli is
responsible for more than 80% of childhood UTIs. A bag d) Send her directly for urgent ultrasound
specimen of urine is only of value excluding a UTI as the examination
sample is easily contaminated. However a clean catch or
e) Book an ambulance as this may be a
midstream sample showing >108 colony-forming units
warning of an impending massive bleed
per litre is highly suggestive of a UTI. Most children,
especially those under 4 years of age with a confirmed
UTI require further investigation. This will always involve
an ultrasound and for younger patients, an MCU which is Answer: B
necessary to define the grade of VUR. In the case of
high grade VUR or a febrile UTI, radioisotope scan will Although this bleeding may have a benign cause, it is
be done 3 months after the UTI has resolved to assess important to recognise that she may have a placenta
renal scarring. If the scan is abnormal the child is at risk praevia, or have had a placental abruption. Both of
of hypertension and should have blood pressure and these conditions require urgent attention because of the
urinalysis monitored yearly. risk of maternal and fetal morbidity and mortality. The
patient should be examined (vital signs, examination of

the uterus and foetus and a sterile speculum


Question 9 examination) to assess the nature of the bleeding and
whether or not the cervical os is closed. An ultrasound
Betty, aged 62 years, first noticed a swelling just below examination will be necessary to assist in confirmation
and in front of her left ear, a month ago. The overlying of the diagnosis. It should be done only after the patient
skin is normal and the swelling has enlarged rapidly and has been assessed and is stable.
become painful. She has some "pins and needles" in the
skin of her left cheek but is otherwise well. Which of the
following is the MOST LIKELY diagnosis?
Question 11
a) Sjogren's syndrome
Brian is 9 years old. He has been complaining of itchy
b) Pleiomorphic adenoma hands for over a week and is constantly scratching. On
inspection, you note a lumpy excoriated rash between
c) Salivary duct calculus several of his fingers on both hands. You suspect Brian
may have scabies. Which of the following statements
d) Metastatic skin cancer
regarding scabies is CORRECT?
e) Acute sialadenitis
a) History taking must include recent travel and completely ignored. While clinical examination is always
contacts with animals including pets important, detailed neurological assessment is not
appropriate initially.
b) Family and close contacts only require
treatment if they are symptomatic

c) Persistent itch 5 days after treatment Question 13


indicates treatment failure
In women of reproductive age the most common causes
d) Permethrin 5% cream may be used to treat of vaginal irritation and discharge in DESCENDING order
scabies in a child of Brian's age of occurrence are:

e) Brian should be excluded from school for a) Bacterial vaginosis, candidiasis, trichomonas
seven days, or until the itch has subsided
b) Bacterial vaginosis, candidiasis, herpes
simplex

Answer: D c) Candidiasis, bacterial vaginosis, Chlamydia

Permethrin 5% cream is a suitable treatment option in d) Candidiasis, Chlamydia, herpes simplex


children over the age of 6 months. Sarcoptes scabiei,
the mite which causes scabies, is spread by close human e) Chlamydia, bacterial vaginosis, trichomonas
contact and is not from animals. All family members and
close contacts should be treated, regardless of
symptoms. Patients and their families should be advised Answer: A
that the itch does not resolve immediately and may take
three weeks to subside. It is unnecessary to repeat Bacterial vaginosis is the most common cause of vaginal
treatment for scabies during this time based on irritation and discharge. It is often misdiagnosed by
persistence of itch. Brian needs to be kept away from women and their doctors as "thrush". Proven candidal
school only until he has begun appropriate treatment. infections are the second most common, accounting for
around 35% of infections. Trichomoniasis is a sexually
transmitted disease that causes vaginitis. Chlamydia
and gonorrhoea infect the cervix and urethra and do not
Question 12
cause "vaginitis" per se. Herpes may cause vaginal pain
Margaret, aged 46 years, is distressed and agitated. She and irritation if vesicles occur in the vagina but is not
is holding her head, and complaining of 'the worst commonly associated with discharge.
headache I have ever had'. This headache began
suddenly 2 hours ago. She has vomited twice, and is
photophobic. Her temperature is 37.8 degrees Celsius, Question 14
her pulse 110/min and her blood pressure 140/80 mm
Hg. Which of the following is the MOST appropriate All of the following may be extra-intestinal features
action? associated with Crohn's Disease EXCEPT:

a) give intravenous fluids, metoclopramide a) Episcleritis


(maxolon) then soluble aspirin
b) Ankylosing spondylitis
b) request an emergency CT scan of her head
c) Hepatic steatosis
c) perform or refer for urgent lumbar puncture
d) Erythema nodosum
d) do not leave the patient unattended in your
rooms e) Dermatitis herpetiformis

e) perform a full clinical neurological


assessment
Answer: E

Up to 35% of patients with inflammatory bowel disease


Answer: B have an extra intestinal manifestation. The more
common are erythema nodosum, pyoderma
The sudden onset of 'the worst headache' the patient gangrenosum, psoriasis, arthritis, ankylosing spondylitis,
can ever recall, accompanied by vomiting, must raise episcleritis, iritis, conjunctivitis, fatty liver (hepatic
the suspicion of subarachnoid haemorrhage.(SAH). steatosis), primary sclerosing cholangitis, cholelithiasis,
While this is rare (and only 1 patient in 8 who presents nephrolithiasis and thromboembolism. Dermatitis
with sudden extreme headache will have a SAH) it is a herpetiformis is associated with coeliac disease.
diagnosis which must not be missed. SAH occurs most
frequently in patients under 65 years of age, the
majority being in the fourth decade. Women are more
Question 15
frequently affected than men. All patients with this
clinical picture require investigation commencing with Michael, aged 12 years, sustained a blow to his left
emergency head CT scan to exclude SAH. Lumbar temple when he fell while climbing a tree. He was
puncture may be undertaken as the next investigation if dazed, but able to recount what had happened. An hour
the CT scan does not confirm SAH. Blood or later he complained of an increasingly severe headache,
xanthochromia in CSF may be detected in a smaller vomited once, and then was brought to hospital. His
SAH, and meningitis may be excluded. Migraine may be pulse is now 54 bpm, BP 130/90 mm Hg and he is
considered after exclusion of SAH and meningitis. drowsy and confused. His left pupil is larger than his
right. Which is the MOST appropriate advice to give
Suspected drug seekers should not be left alone in your
Michael's parents? Michael:
rooms. However, this is not a typical presentation from
a drug-seeker, but that possibility should not be
a) will need an urgent CT scan of his head to children a tonsillectomy would not be recommended. In
confirm the diagnosis all of the other cases, tonsillectomy is likely to be
recommended. Claire's four episodes of (proven)
b) has a severe concussion and must be tonsillitis have been accompanied by a worrying if not
observed closely overnight sinister symptom. Steven's quinsy is a clear indication
for tonsillectomy, and Olive may have a malignancy.
c) requires urgent neurosurgery to reduce the
Peter's snoring and sleep apnoea also justifies
chance of disability or death
tonsillectomy.
d) will be monitored in ICU until stabilized for
surgery in 24 hours
Question 17
e) is gravely ill and has a 50% chance of
survival Cindy is 13 months old. She presents with two days of
fever, runny nose and cough. Her cough is becoming
increasingly distressing, and she is quite tachypnoeic.
Answer: C On auscultation of her chest you hear some expiratory
wheeze and scattered crepitations. Cindy's breathing is
The history of the injury is highly suggestive of an obviously laboured and there is rib retraction. You
extradural (epidural) haematoma. Although Michael did diagnose bronchiolitis. Which of the following statements
not lose consciousness initially, his condition has is CORRECT?
deteriorated rapidly and significantly. He is now
bradycardic, hypertensive and his pupil is dilated on the a) Parenteral penicillin is the treatment of
side of the injury. His level of consciousness is also choice
deteriorating. An extradural haematoma will result in
b) Chest Xray may show hyperinflation
death if not evacuated promptly. There is approximately
75% chance he will have a fracture overlying the c) Parainfluenza virus is the most common
haematoma, but skull x ray is not indicated. There may pathogen
be 'concussive' injury to the underlying brain but the
life-threatening factor is the raised intracranial pressure d) Corticosteroids are contraindicated
from the extradural haematoma. While it would be ideal
to have a CT scan, the rapidly deteriorating condition e) Inpatient treatment is often necessary
means that emergency surgery should not be delayed.
Michael is clearly gravely ill, but the mortality from
epidural haematoma is 9% for obtunded patients and Answer: B
20% for those who are comatose prior to surgery.
Prognosis is better for young patients, but deteriorates Chest x-ray findings in bronchiolitis typically include
with other associated intracranial injuries and with delay hyperinflation with depression of the diaphragm and
between injury and surgical intervention. horizontal ribs. There may also be streaky hilar
shadows, mild interstitial infiltrates and some segmental
atelectasis. RSV (respiratory syncitial virus) is by far the
most common pathogen, although some cases may be
Question 16
due to the parainfluenza, influenza and adenoviruses.
Tonsillectomy would be recommended for each of the Antibiotics are not indicated. Corticosteroids are not
following patients EXCEPT: contraindicated, but their use has not been shown to
modify the course of the disease. While some very
a) Claire, aged 3, has had four episodes of young or very unwell children may require supportive
tonsillitis in the last 12 months, each time inpatient management, most children with bronchiolitis
associated with a febrile convulsion. can be confidently managed as outpatients.

b) Sarah aged 4 years, has had six episodes of


a sore throat in the last 12 months and now
has bilateral large tonsils and enlarged cervical Question 18
lymph nodes
Six weeks ago you excised a skin lesion from the cheek
c) Steven aged 25 years, has recently required of 65 year old Bill. The wound had healed well when you
incision and drainage of a quinsy (peritonsillar removed the sutures five days later, but the pathology
abscess) report was not available. You told Bill you would contact
him if anything further needed to be done, as he was
d) Olive aged 63 years, has noticed that her leaving on an extended holiday. In doing some
right tonsil has enlarged recently. She also has paperwork today, you discover to your horror, Bill's
an enlarged cervical lymph node on the right pathology report, which states: There is a squamous cell
carcinoma (SCC) measuring 5 mm in diameter, with a
e) Peter, aged 10 years, snores loudly, depth of 4 mm. The lesion has been completely excised
sometimes "stops breathing" at night and is but extends to within 1mm of one lateral margin, and to
sleepy at school. He has large tonsils. within 2 mm of the base of the excision. What is your
MOST appropriate course of action?

a) contact Bill urgently, apologising for the


Answer: B
delay and explain that he should have further
It is not unusual for young children to have several excision as a clearance margin of 5mm in depth
episodes of 'sore throat' each year. These could be due and laterally is required to minimise local
to a number of conditions including pharyngitis, recurrence or metastasis
laryngitis, tonsillitis (either viral or bacterial), or
b) contact Bill, apologising for your delay, and
exposure to irritants like cigarette smoke. Children such
advise it was a skin cancer (SCC) but it has
as Sarah in the preschool age group frequently have
been completely excised, and there is minimal
large tonsils, adenoids and cervical glands as part of the
risk of local recurrence or metastasis
normal growth pattern of lymphoid tissue. In these
c) do not attempt to contact Bill during his hepatitis A infection so from 1999 a programme for
holiday as the matter is not urgent. Clearance HepA vaccination was commenced from 18mths of age.
of 1mm in all directions is adequate to Otherwise, the Standard Vaccination Schedule now
minimise local recurrence
applies to all Australian children. All parents and
d) do not disturb Bill as the holiday is important guardians must be given appropriate information
to him, but ensure that you recall him when he regarding vaccination so as to be able to give informed
returns to discuss options for further surgery consent to vaccination.

e) contact Bill, saying you have just received


the report which the laboratory must have lost.
Advise him he had a skin cancer (SCC) and that Question 20
he should have further excision on his return,
Patricia, aged 25 years, has been diagnosed with
as there is a very small risk this cancer could
polycystic ovarian syndrome. In counselling this patient
spread
regarding long-term consequences the MOST
APPROPRIATE advice would be:

Answer: A a) There are no serious long-term


consequences
Squamous cell carcinomas (SCC) can recur locally, and
unlike basal cell carcinomas, they can also metastasise. b) There is an increased risk of endometrial
Local recurrence due to incomplete primary excision is hyperplasia
associated with a high rate of subsequent recurrence
c) There is an increased risk of cervical cancer
(23%) and then metastasis to regional lymph nodes
(30%). Metastatic SCC has a 33% mortality rate. d) There is an increased risk of osteoporosis
Lesions less than 2cm in diameter require a 4mm
margin for adequate excision with depth through normal e) There is an increased risk of premature
underlying fat. Larger lesions may need up to 10mm menopause
margins. Clearance for BCC excision is usually adequate
at 3mm margins. It is important to accept responsibility
for your failure to follow up as planned, and then to
Answer: B
recommend further excision. The re-excision should be
done quickly. It is not appropriate to blame the Polycystic ovarian syndrome is a metabolic condition
pathology laboratory. It is wise to contact your medical whose long term consequences include an increased risk
defence organisation. of cerebrovascular disease, non insulin dependent
diabetes and endometrial hyperplasia .The latter is due
to unopposed action of oestrogen in anovulatory cycles
Question 19 .There is no effect on the timing of the onset of
menopause and no evidence for an effect on bone
Jarrah is a 2 month old Aboriginal boy. He was born at density.
term via an uncomplicated vaginal delivery, and he has
been well. He lives with his family in Darwin. His mother
has brought him in for his immunisations. Which ONE of
Question 21
the following statements is CORRECT?
Sally, aged 14 years, has mitral valve prolapse with
a) Jarrah will need to receive the first of his
regurgitation. For which of the following procedures
hepatitis A vaccines at 18 months of age
should she be given antibiotic prophylaxis?
b) Limiting information to his mother about
a) urethral catheterisation
risks will improve the chance of completing the
schedule b) flexible bronchoscopy
c) Jarrah should have had the BCG vaccine c) dental examination
soon after delivery before leaving hospital
d) orthodontic bands placement
d) The oral polio vaccine (OPV) provides better
immunity than the inactivated type (IPV) in e) local anaesthetic injection
Aboriginal children

e) Jarrah will need his first MMR vaccine at 6


months of age due to his higher susceptibility Answer: D

In patients with mitral valve prolapse with valvular


regurgitation antibiotic prohylaxis is required for dental
Answer: C procedures which produce bleeding from the gingiva,
mucosa or bone. This includes the placement of
Indigenous Australians are at increased risk of acquiring orthodontic bands. Prophylaxis is not required for
tuberculosis. BCG is recommended for indigenous routine dental examination (except where scaling of the
neonates in 'regions of high incidence' of pulmonary TB, teeth is to be performed), nor for the other options
particularly Darwin and the Northern Territory. It is listed.
usually given to eligible infants soon after delivery.
Aboriginal children in north Australia have a suboptimal
response to OPV so there is likely to be improved
immunity to polio with the introduction of IPV as part of Question 22
the funded schedule. Although measles is very common Rodney, aged 30 years, a diesel mechanic, presents
in indigenous communities, the first dose of MMR is with a painful right eye. He was using a metal lathe at
administered as usual at 12 months of age. Indigenous work last night, and states that he was wearing his
children in Far North Queensland are at higher risk of safety goggles as required. He was aware that the eye
was a little irritable at the end of his shift, but it was not Question 24
until this morning that it became painful. On
examination, Rodney's visual acuity is 6/6 in his left eye Which of the following statements about colonisation of
and 6/7.5 in the right. No obvious foreign body is seen, pregnant women by group B Strep is CORRECT?
but the pupil is slightly distorted. You do not have a slit
a) most pregnant women are colonised
lamp. Of the following, which is the MOST appropriate
initial action? b) colonisation poses no risk to the woman or
foetus
a) Instill antibiotic drops, apply an eye pad and
check visual acuity in 24 hours c) colonisation is associated with premature
labour
b) Irrigate the eye copiously with sterile saline
until the pH is neutral d) colonised women are usually symptomatic
c) Apply loose fitting eye shields to both eyes, e) diagnosis requires serological testing
commence antibiotic and antiemetic

d) Order antero-posterior and lateral facial X-


rays Answer: C

e) Reassure Rodney that his safety goggles Group B Strep infection is the leading cause of neonatal
have prevented serious eye injury infection, and is implicated in premature labour and
other maternal morbidity. 10-30% of women may be
colonised with vaginal Group B Strep during pregnancy,
but the infection may be transient or intermittent. It
Answer: C
usually causes no symptoms. Transmission to the infant
The history of eye pain after working with metal and almost always occurs after the onset of labour, or
high-speed machinery should raise the suspicion of membrane rupture. There is little evidence that
penetrating eye injury. This may still occur despite treatment earlier in pregnancy is beneficial. However,
safety goggles being worn. Not all goggles conform to treatment of women who, test positive at 35-37 weeks
standards, and not all workers wear them correctly! gestation, with intrapartum antibiotics has been shown
Visual acuity is not always greatly reduced, but the pupil to reduce the incidence of neonatal sepsis significantly.
commonly shows a 'tear-drop' deformity. There may be Testing for Group B Strep colonisation of pregnant
hyphaema. Facial X ray and CT may be useful in locating women by vaginal swab is therefore offered by many
an intra-ocular pressure. Always check tetanus doctors in the third trimester.
immunisation status and give a booster if necessary.

Question 25
Question 23
Felicia is a 15 month old girl. She has symptoms and
Warren, aged 40 years, had a malignant melanoma signs consistent with a viral upper respiratory tract
removed from his thigh last week. Which of the infection (URTI), including a fever of 38.8 degrees
following factors is MOST important in determining his Celsius. Her weight is 11kg. Felicia's mother has decided
overall prognosis? to use paracetamol to help relieve her symptoms. Which
of the following is CORRECT regarding the dose of oral
a) The depth of invasion of the skin and paracetamol in this case? Daily dose should not exceed:
subcutaneous tissue
a) 90 mg/kg/day
b) The fact that he has multiple dysplastic
naevi b) 75 mg/kg/day

c) The diameter of the lesion removed c) 60 mg/kg/day

d) A family history of malignant melanoma d) 45 mg/kg/day

e) The site of the lesion- on his lower limb e) 30 mg/kg/day

Answer: A Answer: C

The single most important feature in determining the The recommended oral or rectal paracetamol dose is
ultimate prognosis in melanoma is the depth of invasion 15mg/kg every 4 to 6 hours. In an unsupervised
of skin and subcutaneous tissue. Melanoma classification community setting, dosage is limited to 60 mg/kg/day
systems are based on either the vertical thickness of the for up to 48 hours. Up to 90 mg/kg/day can be used
lesion in millimetres as in Breslow's classification, or the under medical supervision with review after 48 hours. It
anatomic level of invasion of the layers of skin as in was believed that doses >150mg/kg/day were
Clark's classification. The diameter of the lesion is not as necessary for hepatotoxicity but sick children <2 years
important. Family history, multiple freckles and of age having > 90mg/kg/day for more than one day
melanocytic naevi are risk factors for melanoma, not are at higher risk
indicators of prognosis. The site of the lesion is of some
prognostic importance; those on the extremities have a
better outlook than those on the trunk or face.
Question 26 Answer: E

All of the following are causes of secondary Studies indicate that maternal transmission of HIV to
amenorrhoea EXCEPT: the infant is most likely in the perinatal period. The
other options are correct. Advanced maternal disease is
a) Diabetes also a risk factor for increased transmission risk.
b) Drug abuse

c) Eating disorders Question 29


d) Asherman's syndrome Which of the following statements concerning a retained
placenta is CORRECT?
e) Autoimmune disorders
a) antibiotic cover is rarely necessary after a
manual removal of placenta
Answer: A
b) the third stage of labour takes on average
Secondary causes of amenorrhoea and oligomenorrhoea two hours to complete
include eating disorders, drug abuse, Asherman's
c) when delivering the placenta the doctor or
syndrome (intrauterine adhesions), thyroid or adrenal
midwife should pull the cord upwards
dysfunction, uterine or vaginal obstruction, familial early
menopause, chromosomal abnormalities and d) there is no association between placenta
autoimmune disorders. Diabetes is not a cause. praevia and placenta accreta

e) oxytocics and continuous cord traction


enable delivery of most placentas within 10
Question 27
minutes
Muriel, aged 80 years, fell onto her outstretched right
hand sustaining a Colles' fracture. Which of the following
is the most frequent LATE complication of this fracture Answer: E
for a patient of her age?
The third stage of labour (when the placenta is
a) delayed union of the fracture delivered) is normally completed within 30 minutes. If
not, it is unlikely to occur spontaneously. With the use
b) ischaemic necrosis of the distal fragments
of oxytocics and gentle continuous downward cord
c) neuralgic pain in the arm and hand traction, 97% of third stages are complete within 10
minutes. Antibiotic cover is necessary for manual
d) stiffness of the wrist and fingers removal of the placenta, because of passage of the hand
from a non-sterile (vagina) to a sterile (uterus)
e) ulnar nerve weakness environment. Placenta accreta (where placental villi
penetrate the uterine wall preventing separation) occurs
more commonly in cases of placenta praevia and after
Answer: D caesarean section.

Joint stiffness is common following a Colles' fracture,


especially after prolonged immobilisation. All of the
Question 30
other complications are relatively uncommon. Union is
usually not delayed but there may be a degree of mal- Hazel, aged 40 years, has a month-long history of a
union. Appropriate management of the elderly patient burning pain in the middle of her right foot. She says it's
with a Colles' fracture includes early mobilisation aimed "as though I'm standing on a sharp stone". The pain
at restoring function. radiates into the tips of her toes. Pressure applied to the
dorsum of the head of the third metatarsal reproduces
her pain, but there is no other abnormality noted. What
Question 28 is the MOST likely diagnosis?

Amanda, aged 24 years, is HIV positive. She has just a) Interdigital (Morton's) neuroma
given birth to twin sons, George and Harry, by normal
b) Plantar fasciitis
vaginal delivery. Regarding vertical transmission of HIV
from mother to baby, which ONE of the following c) Gout
statements is INCORRECT?
d) Peripheral neuropathy
a) the first born twin is more likely to be
infected than is the second born twin e) Stress fracture of the third metatarsal

b) higher rates of transmission are likely with


low maternal CD4 lymphocyte count
Answer: A
c) breast feeding is a possible route of vertical
transmission Interdigital neuroma represents a gradual and persistent
thickening of the perineurium of one, or less commonly
d) high maternal plasma HIV RNA increases two or more interdigital nerves. Hazel's history is
transmission risk typical, as is the examination finding of reproduction of
the pain by direct pressure over over the head of the
e) transmission to the foetus is most likely in metatarsal. Plantar fasciitis causes primarily heel pain.
the antenatal period
The absence of heat, redness or swelling over the B. Symptoms cause marked interference with work,
metatarsal heads makes gout and rheumatoid arthritis school, usual social activities, or relationships with
unlikely. Peripheral neuropathy is usually associated others.
with nocturnal paraesthesia, dysaesthesia and burning
pain across the sole of the foot but is unlikely to be C. The problem is not an exacerbation of the symptoms
affected by dorsal pressure on a metatarsal head. Stress of a chronic condition (e.g., major depressive disorder).
fractures of the metatarsals cause pain that is felt along
D. The above criteria must be confirmed by prospective
the shafts of the metatarsals, and is unlikely to radiate
daily ratings during at least three consecutive
to the tips of the toes.
symptomatic cycles to confirm a provisional diagnosis.

Question 31
Question 32
With regard to symptoms of the severe form of the
Classic symptoms of endometriosis include all of the
premenstrual syndrome (premenstrual dysphoric
following EXCEPT:
disorder) which of the following is CORRECT? The
symptoms: a) pelvic pain
a) are confined to the late luteal phase of the b) dysmenorrhoea
menstrual cycle
c) dyspareunia
b) may eventually extend throughout the whole
menstrual cycle d) oligomenorrhoea

c) disappear within hours of the onset of e) infertility


menstruation

d) may fluctuate and disappear altogether in


some cycles Answer: D

e) may present as an exacerbation of Endometriosis is the presence of endometrial tissue


endogenous depression outside the uterine cavity. It causes pelvic pain,
dysmenorrhoea, dyspareunia and infertility.
Oligomenorrhoea is not associated with endometriosis.

Answer: A

While premenstrual syndrome is the term commonly Question 33


used to describe the constellation of symptoms prior to
periods, Premenstrual Dysphoric Disorder is a much For a perimenopausal woman who has irregular cycles,
more specific condition listed by the American severe hot flushes and no contraindications to hormone
Psychiatric Association in the Diagnostic and Statistical replacement therapy the MOST APPROPRIATE therapy
Manual of Mental Disorders (DSM-IV). The diagnostic is:
criteria for PMDD are:
a) continuous oestrogen therapy
A. At least five of the following symptoms (one of which
b) continuous combined (oestrogen and
must be 1, 2, 3 or 4, below) must be present in the
progestogen) therapy
majority of menstrual cycles in the last year. Symptoms
should be isolated to the late luteal phase of the c) sequential oestrogen therapy
menstrual cycle and remit within days of onset of
menses. d) sequential combined (oestrogen and
progestogen) therapy
1. Markedly depressed mood, feelings of
hopelessness, self-deprecating thoughts e) continuous progestogen therapy

2. Marked anxiety, tension, feelings of being Answer: D


"keyed up" or "on edge"
Hormone replacement therapy (HRT) is indicated in
3. Marked affective lability women who are suffering from severe menopausal
symptoms, provided they have no contraindications to
4. Persistent and marked anger or irritability or its use. Sequential combined HRT is the best option for
increased interpersonal conflicts perimenopausal women who do not require
contraception and for women in the first 2 years after
5. Decreased interest in usual activities
menopause. It can alleviate symptoms and control
6. Subjective sense of difficulty concentrating irregular cycles. The use of continuous or sequential
unopposed oestrogen is associated with endometrial
7. Lethargy, easy fatigability, marked lack of hyperplasia and the development of endometrial cancer
energy and is contraindicated in women who have not had a
hysterectomy. Continuous combined HRT is
8. Marked change in appetite recommended for symptomatic women more than 2
years post menopause; 50% will have irregular bleeding
9. Marked change in sleep pattern
for the first 6 months but 90% are amenorrhoeic after
10. Subjective sense of being overwhelmed or 12 months. Progestogen alone is not always effective at
out of control treating menopausal symptoms. The issues surrounding
potential complications of HRT must always be fully
11. Physical symptoms (e.g., breast tenderness discussed before commencing therapy.
or swelling, headaches, joint or muscle pain,
sensation of bloating, weight gain)
Question 34 Question 36

Sherri, aged 56 years, complains that she loses control Cheryl, aged 28 years, (G1P0), presents at 8 weeks
of her "waterworks" when she puts her key in the front gestation complaining of constant nausea and vomiting.
door. Given this history, which form of incontinence is Which of the following statements about nausea and
she MOST LIKELY to have? vomiting in pregnancy is CORRECT?

a) stress incontinence a) Less than 30% of women suffer nausea and


vomiting in pregnancy
b) urge incontinence
b) Metoclopramide (antiemetic) is
c) overflow incontinence contraindicated in pregnancy
d) incontinence from a urinary fistula c) Women should try to have frequent small
feeds to control nausea
e) incontinence secondary to a neuropathic
bladder d) Nausea and vomiting should subside by 9
weeks gestation

e) Nausea and vomiting in the evening points


Answer: B
to a more sinister cause
Urge incontinence occurs when there is an inability to
delay micturition and may be precipitated by various
triggers including the sound of running water or placing Answer: C
a key in the door when arriving home. Stress
incontinence occurs when the intra-abdominal pressure At least two thirds of women experience nausea during
is raised as with coughing or sneezing. Overflow the first trimester, and 50% experience vomiting.
incontinence is due to obstruction and may be Symptoms can occur at any time of the day, although
secondary to uterovaginal prolapse or a hypotonic classically they predominate in the morning. These
bladder as in a neuropathic bladder. A urinary fistula is symptoms usually subside by 12-16 weeks gestation.
associated with continuous dribble of urine or leakage of The best advice for women is to take small frequent
small amounts on effort. meals but, if the symptoms persist antiemetics such as
metoclopramide can be used safely.

Question 35
Question 37
Teresa, aged 25 years, presents having experienced an
episode of postcoital bleeding two days ago. What is the Which of the following elements on an antenatal
MOST APPROPRIATE management? cardiotocograph (CTG) at term is considered
"abnormal"?
a) Reassure her and ask her to return if
bleeding recurs a) Accelerations of 15 beats per minute lasting
15 seconds
b) Undertake cauterisation of the cervix to
prevent further bleeding b) One reactive movement in a 20 minute CTG
recording
c) Treat her with metronidazole gel to eradicate
infection c) Decelerations during Braxton Hicks
contractions
d) Send her to the emergency department for
immediate assessment d) Variability in foetal heart rate beat-to-beat

e) Do a Pap smear and screen for sexually e) Baseline heart rate of 120-160 beats per
transmitted infections minute

Answer: E Answer: C

Postcoital bleeding is a serious symptom that could be Decelerations occurring after contractions are ominous,
indicative of cervical pathology. It is not an emergency particularly if they are prolonged. A healthy CTG shows
requiring assessment in hospital. Common causes of a baby that is moving and having acceleration of
postcoital bleeding include a cervical erosion, an heartbeat after movement. The beat to beat variability
infection such as chlamydia and other less common is indicative of an intact central nervous system.
pathologies, such as a cervical polyp. Medical
practitioners must however ensure that they exclude
precancerous or cancerous lesions of the cervix by
Question 38
making sure that cervical cytology (Pap smear) is
performed as well as appropriate STI (sexually Melinda has just started to menstruate (experience
transmitted infection) screening. If the bleeding is periods). She is age 16 and has Down syndrome
recurrent, or the cervix looks abnormal, colposcopy is (Trisomy 21). She wants to know all about her periods
recommended. Cauterisation of the cervix is sometimes and why she has to bleed. Which of the following
performed if a friable cervical erosion is present, statements should you NOT tell Melinda regarding
bleeding is recurrent and other cervical pathology has menstruation (periods)?
been excluded.
a) Most females start having their periods malpresentations, polyhydramnios, during breech
between the ages of 9 and 16 deliveries and with premature rupture of the membranes
It is an obstetric emergency, as the umbilical vessels
b) Other body changes may be happening when constrict, once exposed to the extrauterine
periods start. Breasts get bigger and hair starts environment. Unless the cervix is fully dilated and an
to grow under arms and around the vagina immediate operative vaginal delivery can be conducted,
an emergency caesarean section is required. During the
c) A period will occur about once a month and
transfer to theatre the woman should be positioned so
will last for several days (about 3 to 7 days)
that gravity can assist in keeping the presenting part off
d) The blood that comes out with a period is the cord, i.e the knee - chest position (kneeling with
clean and healthy and it is normal head down). The presenting part should also be pushed
digitally up and away from the cord which should be
e) Tampons must be used during periods to placed wholly within the vagina.
avoid bleeding onto underwear and clothes

Question 40
Answer: E
In counselling a woman regarding use of the mini pill
All the other statements are true and helpful when a (progestogen only contraceptive pill, POP) which of the
female with a potential learning disability starts learning following is CORRECT?
about her menstruation. Tampons can be particularly
convenient for certain activities, such as swimming, but a) The menstrual cycle will be unaffected by
they are not essential and are not recommended for the POP
women who cannot comfortably manage their own
b) The main mode of action is to thicken
menstrual self-care. If tampons are to be used it is
cervical mucous
worth checking instructions are understood before
encouraging practice. c) Active pills are taken for 21 of 28 days to
allow a withdrawal bleed

d) A delay of 12 hours in taking the POP does


Question 39
not affect efficacy
Angelina, aged 27 years (G3 P2), has a transverse lie at
e) Contraceptive efficacy of the POP is
36 weeks gestation. Should her membranes rupture,
equivalent to combined pill in all women
what would be the MOST APPROPRIATE MANAGEMENT?

a) Advise attendance at the Delivery Suite


when contractions are 5 minutes apart Answer: B
b) Attempt an external cephalic version to allow The principal mode of action of the progestogen only pill
safer vaginal delivery is thickening of cervical mucus. In about one third of
women the minipill will also inhibit ovulation but in the
c) Wait for contractions to establish as this will
majority this is not the case. As a result of the variability
probably correct the lie
of the effect of the POP on ovulation and the effects of
d) Augment the labour with intravenous progesterone on the endometrium, menstrual cycles
oxytocin to facilitate swift delivery may be regular, irregular or spotting can occur
throughout the cycle in POP users. Women take the
e) Place in the knee-chest position and organise minipill everyday without a break (28 active pills with no
emergency Caesarian section inactive pills) in the same three-hour period each day in
order to maintain maximal efficacy. In general, it is less
efficacious than combined oral contraception because it
does not uniformly inhibit ovulation. However, in older
Answer: E
women who are less fertile and who use the POP
Cord prolapse occurs when the umbilical cord lies beside correctly, the efficacy of the POP can approximate that
or in front of the presenting part. It is more common in of combined oral contraception.
Block 3

Question 1 Question 3

Tom, aged 18 years, presents with a typical first episode Sarah, a 40 year old woman whose husband has a
of schizophrenia. Which of the following antipsychotic plasma cholesterol of 6.9 mmol/l (normal <5.5mmol/l)
medications is the treatment of choice for him? wants to know which oil she should use in meal
preparation for her spouse. Which of the following would
a) chlorpromazine you advise?

b) haloperidol a) It makes little difference which cooking oil


she uses
c) thioridazine
b) She should use either canola or sunflower oil
d) olanzapine
c) Any margarine is suitable
e) clozapine
d) Choose an oil rich in saturated fat over one
rich in unsaturated fats
Answer: D e) None of the above
Olanzapine, risperidone and quetiapine are three of the
new so-called atypical antipsychotic medications. These
are now preferred (over traditional antipsychotic drugs Answer: B
like chlorpromazine, haloperidol and thioridazine) as first
line therapy in first episode schizophrenia, because of Epidemiological studies have shown reduced mortality
improved efficacy and reduced incidence of psychomotor from cardiovascular causes associated with diets
retardation, a well-known and troubling side effect of containing increased levels of mono- and
these medications. Clozapine is an atypical antipsychotic polyunsaturated fatty acids. Canola oil, like olive oil, has
drug recommended for schizophrenic patients who prove a high concentration of monounsaturated fatty acids,
resistant to other antipsychotic medications. while sunflower oil is rich in n-6 polyunsaturated fatty
acids. For lowering of plasma cholesterol levels, the
National Heart Foundation of Australia recommends that
saturated fat in the diet be replaced with a combination
Question 2 of mono- and
Pete, aged 54 years, has been a heavy smoker for most polyunsaturated fats.
of his adult life. He complains about coughing up blood
first thing in the morning. The MOST IMPORTANT
condition to exclude is:
Question 4
a) Bronchiectasis
The diagnosis of acute gonorrhoea in a male is ideally
b) Recurrent pulmonary emboli made by:

c) Leukaemia a) Gonococcal complement fixation test

d) Bronchogenic carcinoma b) VDRL reaction

e) Laryngeal cancer c) Dark ground illumination of urethral pus

d) Gram stain and culture of urethral pus

Answer: D e) Prostatic massage

Smokers are prone to develop a range of diseases


including:
Answer: D
• atherosclerotic cardiovascular disease,
The gonococcal organism is rapidly identified by gram
• various cancers (lung, larynx, oral, oesophagus, stain and culture of urethral pus. Dark ground
bladder, kidney, pancreas, stomach, cervix) illumination is a method for demonstrating the presence
of Treponema pallidum. VDRL is used for the diagnosis
• chronic obstructive pulmonary disease of syphilis. Prostatic massage is an unreliable method of
obtaining a test sample for acute gonorrhoea.
• peptic ulcer.

As bronchogenic carcinoma has a much more aggressive


course than the other options, a bronchoscopy should be
performed as soon as possible.
Question 5 Answer: D

A COMMON side effect of the atypical antipsychotic drug, Only about 10% of human breast cancers are due to a
olanzapine, is: germline mutation (of genes p53, BRCA-1, BRCA-2). The
other 90% are due to somatic mutations, often of the
a) Neutropenia same genes as are involved in the familial varieties. A
family history of one 1° family member diagnosed with
b) Hypotension
breast cancer at 60 years of age (ie. over the age of 50
c) Sexual dysfunction years) places June at average or only slightly increased
risk (1.5 times higher than population average). All the
d) Weight gain other options place June at a moderate to high risk.

e) Parkinsonism

Question 8

Answer: D A 40 year old female undergoing treatment for


schizophrenia, is admitted repeatedly for not taking her
Weight gain of between 4kg and 9kg is a common side prescribed medication. She has delusional ideas,
effect of treatment with olanzapine. Neutropaenia is a claiming she communicates with angels and, as she
rare side effect. Sexual dysfunction can occur through does not consider herself to be ill, believes that she
medication with major tranquillisers and selective should not have to take any medication. The CORRECT
serotonin reuptake inhibitors (SSRI) antidepressants. term for the latter phenomenon is:
Parkinsonism tends to occur with long-term use of major
tranquillisers, especially phenothiazines and a) Therapeutic delusions
butyrophenones.
b) Side effect of drug

c) Impaired insight
Question 6
d) Transference
A patient with a past history of rheumatic fever requires
oral amoxycillin cover for a tooth extraction. The e) Hallucinations
optimum time for commencing this is:

a) One week before the extraction


Answer: C
b) Two days before the extraction
Impaired insight is one of the cardinal signs of psychotic
c) The day before the extraction illness. It describes the situation where the patient lacks
a realistic awareness of self and the relationship of self
d) One hour before the extraction to others. Delusions are beliefs held, despite proof to the
contrary. Hallucinations are abnormal sensory
e) Immediately after the extraction perceptions and are usually auditory in schizophrenia.
Transference is a psychoanalytical term referring to
transfer by a patient of subconscious or conscious
Answer: D feelings onto the therapist.

The risk of endocarditis in patients with valvular heart


disease stems from the bacteremia introduced by the
Question 9
extraction. Antibiotics need only cover this period of
time and therefore are given orally one hour before the The MOST COMMON cause of a blood-stained discharge
extraction. from the nipple of a 45 year old woman is:

a) Gynaecomastia
Question 7 b) Duct papilloma
June, aged 38 years, has a family history of breast c) Paget's disease of the nipple
cancer and seeks advice about her risk of developing the
disease. All of the following are indicative of moderate to d) Fibroadenoma
high risk EXCEPT:
e) None of the above
a) Two 2° individuals on the one side of the
family affected with breast cancer

b) One 1° family member with ovarian cancer Answer: B


diagnosed before the age of 50 years
A blood stained discharge from the nipple is commonly
c) One 1° or 2° family member with bilateral caused by an intraductal
breast cancer
papilloma. Less common causes are an intraductal
d) One 1° family member diagnosed with carcinoma and mammary dysplasia. Gynaecomastia is
breast cancer at 60 years of age breast enlargement in the male and may be associated
with discharge, depending on the underlying cause.
e) One 1° and one 2° family member Paget's disease of the nipple usually presents with a dry,
diagnosed with ovarian cancer eczematous rash of the nipple. Fibroadenoma tends to
present with an asymptomatic discrete, mobile breast
lump.
Question 10 Answer: A

Which of the following drugs, causes stimulation of A traumatic perforation of the tympanic membrane (ear
cardiac contraction with LEAST vasoconstrictor effect? drum) that occurs in wet conditions eg. swimming or
waterskiing will generally become infected and be
a) Adrenaline associated with purulent discharge. Pseudomonas is
more likely to be the offending organism than
b) Isoprenaline
staphylococcus. A short course of topical antibiotics is
c) Pitressin indicated, as is analgesia. Most traumatic perforations
heal spontaneously, but may take up to 9 months.
d) Ephedrine Surgical repair is indicated for the rare failure to heal.

e) Noradrenaline

Question 13

Answer: B Which of the following statements about patent ductus


arteriosus is INCORRECT?
Isoprenaline works almost exclusively on beta receptors
causing increased rate and strength of cardiac a) It occurs frequently as an isolated
contractions (B1) and vasodilatation (B2). All the other phenomenon
drugs listed cause significant vasoconstriction.
b) Cyanosis is usually present

c) It causes a pansystolic 'machinery' murmur


Question 11 at the upper left sternal edge

While counselling a patient, a therapist becomes aware d) There is a wide pulse pressure
that the patient is avoiding discussion of certain topics,
and is steering away from topics he finds uncomfortable. e) Treatment is by surgical closure
Which of the following types of behaviour is the patient
exhibiting?
Answer: B
a) Resistance
Cyanosis is not usually present unless a right to left
b) Suppression
shunt develops. Patent ductus arteriosus is usually an
c) Regression isolated problem occurring most commonly in females.
There are often no symptoms until later in life, when
d) Repression heart failure or infectious endocarditis

e) Projection develops. Clinical signs include a continuous murmur


and a bounding peripheral pulse with wide pulse
pressure due to shunting of blood from the aorta to the
pulmonary artery.
Answer: B

Suppression refers to the conscious or 'semi-conscious'


decision of an emotionally mature, healthy adult to Question 14
postpone dealing with conflict. Resistance refers to the
conscious and informed decision of a patient not to Where both parents have schizophrenia, what is the
change behaviour or comply with treatment. Regression probability of their child developing schizophrenia?
refers to return to an earlier stage of developmental
function. Repression refers to the mechanism by which a) More than 90%
ideas, impulses or emotions which the person finds
b) About 70%
painful or unacceptable are forced out of consciousness
and forgotten. Projection refers to the unconscious c) About 40%
attribution to others of one's own unacknowledged
feelings, thoughts or characteristics. d) About 10%

e) Less than 1%

Question 12

A traumatic perforation of the ear that has occurred in Answer: C


wet conditions such as swimming or waterskiing will
often: Pooled data from a number of family studies show that
the risk of schizophrenia is about 40% for each child of
a) Be associated with a purulent discharge two schizophrenic parents. The incidence in the general
community is about 1%.
b) Be complicated by a staphylococcal infection

c) Require a short course of oral antibiotics

d) Not heal spontaneously

e) Require surgical repair


Question 15 Answer: E

Which of the following tympanic membrane perforations, Pre-contemplation is the first stage in a model of
if left untreated, is NOT likely to progress to significant behavioural change that helps the clinician assess the
complications? likelihood that a patient will be receptive to an
intervention. At the pre-contemplation stage the patient
a) Continuously discharging central perforation has not yet considered change as an option. The other
options all indicate that the patient is aware of the
b) Large dry central perforation
process of change.
c) Marginal perforation with discharge

d) Perforation associated with a cholesteatoma


Question 18
e) Perforation surrounded by granulation tissue
Epistaxis is UNLIKELY to arise from:

a) Injury to the turbinates


Answer: B
b) Spontaneous bleeding from Little's area
A dry central perforation will not progress to
complications, even if it does not heal. Surgical repair is c) Anticoagulation therapy
therefore elective and not mandatory. The other types d) Enlarged adenoids
of perforation are not 'safe' and require specialist
attention. A continuously discharging central perforation e) Nasal fracture
indicates granulation and a risk of osteitis and bone
destruction. Marginal perforation carries the same risk.
A cholesteatoma is not a neoplasm but a cystic lesion
containing amorphous debris (and sometimes spicules of Answer: D
cholesterol). It is formed through chronic infection and Enlarged adenoids do not usually cause epistaxis. In
perforation of the eardrum with ingrowth of squamous 90% of cases, epistaxis arises from Little's area, the
epithelium, forming a nest which becomes cystic. By lower anterior portion of the nasal septum, and
progressive enlargement a cholesteatoma can erode the responds to first aid. A fracture commonly causes
ossicles, labyrinth and adjacent bone and carries the risk epistaxis. Rarely, it can be associated with medical
of cerebral abscess formation and meningitis. conditions.

Question 16
Question 19
Which one of the following features is UNLIKELY to be
Harold, aged 24 years, presents with fatigue, shortness
due to arterial ischaemia?
of breath on exercise and orthopnoea. On examination
a) Pain along the buttock and thigh after there are signs of moderate left-sided heart failure. A
exertion grade III pansystolic murmur is heard most prominently
at the apex and radiating into the left axilla. Which of
b) Weakness of the buttock and thigh the following conditions is the MOST LIKELY diagnosis?

c) Shooting pain from buttock along the back of a) Mitral stenosis


the leg to calf
b) Mitral regurgitation
d) Weakness of the leg
c) Aortic stenosis
e) Smooth shiny skin on the leg below the
knees d) Aortic regurgitation

e) Tricuspid stenosis

Answer: C

Diffuse pain, weakness and paralysis are all signs of Answer: B


arterial ischaemia. Characteristically the pain is a
cramp-like ache due to the release of pain-inducing Mitral regurgitation presents as fatigue, exertional
metabolites in muscle. Due to the aetiology, the pain is dyspnoea and orthopnoea. It is associated with a
diffuse and cannot be localised, as can the shooting pain pansystolic murmur loudest at the apex but radiating
of nerve irritation. over the praecordium and into the axilla. It may also be
associated with a short mid-diastolic flow murmur
following a third heart sound, due to the rapid flow of
blood into the dilated left ventricle. The second heart
Question 17 sound is normal.
When someone is referred to as being in the pre-
contemplation stage with regard to a change in
behaviour, this means s/he is: Question 20

a) Resistant to change Stephen, aged 18 years, presents with spontaneous


epistaxis. What is the FIRST STEP in managing Stephen?
b) Preparing for change
a) Direct pressure to the lower nose for two
c) Receptive to change minute interval
d) Looking forward to specific advice b) Position Stephen so that he is sitting and
leaning forward
e) Has not yet considered change
c) Application of topical local anaesthetic Question 23

d) Cautery of bleeding vessel Sarah is a 28 year old diabetic patient who presents
with a recent history of fever and increased urinary
e) Nasal packing with gauze frequency. Urine culture shows E. coli sensitive to
ampicillin and gentamycin with which she is treated
intravenously. However, a week later she is still having
Answer: B fever and the same urinary symptoms. Blood culture
reveals motile E.coli. All of the following are likely to be
The initial steps are to position the patient sitting causes for her symptoms EXCEPT:
forward to prevent blood dripping down the throat; and
to compress the cartilaginous portion of nose (Little's a) In vivo resistance of the organism
area) for 5-10 minutes without interruption (constant
b) Autonomic dysregulation due to her diabetes
checking is likely to interfere with haemostasis and
restart bleeding). If this is ineffective, application of c) Papillary necrosis
local anaesthetic (traditionally cocaine for its
vasoconstrictive properties) will facilitate packing of the d) Inadequate dosage of antibiotic
nose with ribbon gauze, Foley's catheter or similar
devices. Only in extreme cases would surgery be e) Perinephric abscess
needed.

Answer: B
Question 21
Clinical failure of antimicrobial therapy may be due to
What is the cause of the GREATER life expectancy at inadequate dose, accelerated drug inactivation, poor
birth of females than males in Australia'? penetration to a site of infection, undrained abscess,
poor host defences, dead tissue, superinfection by
a) Males exercise more than females another pathogen, or development of drug resistance.

b) Genetic and biological differences

c) Females seek health care facilities more than Question 24


males
The aim of surgery in patients with perforation and
d) Males die more in accidents and violence infection of the tympanic membrane is to:
than the females
a) Restore hearing
e) Employment stress is more for males
b) Produce a dry, safe, waterproof ear

c) Improve the appearance of the drum


Answer: B
d) Prevent further perforation
Genetic and biological factors play a role together with
environmental factors in causing the greater life e) Restore Eustachian tube function
expectancy of females at birth.

Answer: B
Question 22
The aim of myringoplasty is to produce a dry, 'safe',
Which of the following is CORRECT? Epistaxis is often: waterproof ear to which a hearing aid may be fitted.
'Safe' implies free of risk of cholesteatoma.
a) A sign of underlying nasal disease Myringoplasty may not restore hearing, as this also
depends on Eustachian tube function. The appearance of
b) Influenced by environmental conditions the drum is obviously unimportant, nor will surgery
prevent recurrence of perforation.
c) Attributable to posterior nasal causes

d) Associated with congenital causes of


bleeding Question 25
e) Copious unless promptly treated Victor, a 36 year old man, has known ischaemic heart
disease. He complains of a recent increase in frequency
of chest pain and presents with a prolonged episode of
Answer: B chest pain. There are no ECG changes on your initial
assessment. Management includes all of the following
Epistaxis is very common and is not usually a sign of EXCEPT:
underlying disease. Environmental factors predisposing
to epistaxis include pollens causing allergic rhinitis, the a) Admission to hospital
irritant effects of some nasal sprays, nose picking and
b) Plasma troponin measurement
hot, dry, air dessicating the nasal mucosa and rendering
it more friable. In 90% of cases bleeding is from Little's c) Continuous ECG monitoring
area, i.e. anterior nasal septum. While systemic causes,
such as bleeding diatheses and hypertension are d) Commencement of a statin drug
important causes of severe haemorrhage, they are rare,
as is life threatening bleeding. e) Begin thrombolytic therapy
Answer: E a) An elderly debilitated patient

Clinically this patient has unstable angina pectoris b) The wound is more than 8 hours old
(UAP). Management should include continuous ECG
monitoring,-admission to hospital and plasma troponin c) The patient has alcoholic liver disease
measurement to exclude myocardial infarction. The
d) A deep wound to the hand
Heart Foundation guidelines 2000-2002 state that
immediate commencement of a statin reduces risk in e) A large superficial abrasion on the thigh of a
UAP, as does aspirin and antithrombotic agents such as 22 year old
heparin. Use of thrombolytics in UAP is not indicated
since they are ineffective and may be harmful. If there
is no improvement in 24-48 hours, cardiac
catheterisation and angioplasty are indicated. Answer: E

Wounds treated appropriately and early do not need


antibiotics. Antibiotics may be needed if the following
Question 26 risk factors are present:
Moira, a 21 year old woman, presents with an enlarged • delayed presentation
lower cervical lymph node. Biopsy shows thyroid
glandular tissue. The MOST LIKELY diagnosis is: • contamination

a) Ectopic thyroid • compromised patient, debilitated or general ill health

b) Adenoma of lateral thyroid • wounds in areas where infection may have serious
consequences, eg hands
c) Thyroglossal cyst
• patients in whom presence of bacteremia may have
d) Metastasis from thyroid carcinoma serious consequences, eg prosthetic heart valves or
orthopaedic appliances
e) Lymphadenoid goitre

Answer: D Question 29

Thyroid cancer typically presents as a nodule in the John, a 58 year old overweight plumber, complains of
gland but can present as an enlarged cervical node, as lack of energy towards the middle of the day. He has to
in this case. Surgical removal of involved nodes is get up twice at night to pass urine and wants a check for
usually curative, especially in young patients. They are prostate cancer. The MOST LIKELY cause of his
sensitive to TSH and so thyroxine can be used to symptoms is:
suppress them. The cervical nodes lie more lateral in the
neck than is usual for ectopic thyroid tissue or an a) Psychogenic polydipsia
adenoma. Similarly, thyroglossal cysts lie in the midline b) Diabetes insipidus
between the thyroid gland and the base of the tongue,
and move when the tongue is protruded. Lymphadenoid c) Diabetes mellitus
goitre is due to Hashimoto's thyroiditis.
d) Hypercalcaemia

e) Chronic renal failure


Question 27

Which of the following usually results in a left


homonymous hemianopia? Answer: C

a) Damage to the left optic nerve The classical symptoms of type 1 diabetes mellitus are
polydipsia, polyuria, polyphagia, fatigue and loss of
b) A pituitary tumour weight. In type 2 diabetes mellitus, patients have insulin
resistance related to obesity, rather than loss of weight.
c) Damage to the right optic nerve
The other options listed also cause polyuria, but are less
d) A lesion of the left optic radiation likely in the circumstances described.

e) A lesion of the right optic tract


Question 30

Answer: E Which of the following statements about post-traumatic


stress disorder, is correct?
Lesions of the optic tracts cause homonymous
hemianopic visual field defects. A lesion of the right a) It develops in every person who is affected
optic tract causes a left homonymous hemianopia, i.e. with the same severe stressful event
left half of visual field lost in both eyes. Damage to the
b) Signs and symptoms usually occur between
optic nerve results in a unilateral blindness while
1 and 6 months after the stressful event
damage to the optic radiation results in a quadrantic
field defect. A pituitary tumour causes a bitemporal c) Alcohol abuse reduces the likelihood of its
hemianopia. development

d) It seldom occurs in assaulted spouses in


domestic violence
Question 28
e) Debriefing and counselling are insufficient as
Which one of the following situations will NOT require
initial treatment
prophylactic antibiotics to manage a wound:
Answer: B Answer: D

According to DSM-IV, the person must have experienced This ECG shows ventricular tachycardia with a rate of
an event outside the range of usual human experience 150 b.p.m. There is a rapid ventricular rhythm with
that would be markedly distressing to anyone. Signs and broad, abnormal QRS complexes. Since his blood
symptoms usually occur between 1 and 6 months of the pressure is well maintained, medical treatment is
stressful event. Not every person who suffers the same indicated as first line approach. Lignocaine IV or sotalol
stressful event will develop post-traumatic stress IV or amiodarone IV can be used. DC cardioversion is
disorder, and there are some known protective factors, required if medical therapy is unsuccessful. If the
such as being part of a group involved in a traumatic cardiac output and blood pressure are very depressed,
event. Risk factors include alcohol and drug abuse, emergency DC cardioversion must be considered.
previous history of depression and previous history of Carotid sinus massage is not indicated in this setting
sexual abuse. Victims of domestic violence can develop because there is a high likelihood of carotid artery
post-traumatic stress disorder. Short term counselling disease which makes the procedure dangerous. Also the
and debriefing are effective treatments. Some sufferers arrhythmia is unlikely to be a supraventricular
will also require drug therapy. tachycardia with bundle branch block. If untreated the
ventricular tachycardia may rapidly progress to a
ventricular fibrillation.
Question 31

Malcolm, a 55 year old man, presented with worsening Question 33


symptoms of gastro-oesophageal reflux disorder (GORD)
despite following your lifestyle advice. You referred him Which of the following is INCORRECT with regard to the
for a gastroscopy which has not revealed any management of syphilis?
abnormality. He still complains of bloating and
heartburn. Which of the following is the MOST a) The diagnosis should be confirmed with
APPROPRIATE advice? treponemal tests

a) Reflux has been excluded as a cause of his b) Intramuscular injection (IMI) of penicillin is
symptoms the treatment of choice

b) He should see a dietician to review possible c) Serological and clinical review should be
food allergies done at six and 12 months

c) Endoscopy detects the presence of reflux in d) The patient should be tested for other STDs
only 60-80% of patients
e) Sexual contacts should be clinically
d) He should begin a trial of a proton pump examined for features of syphilis
inhibitor (PPI)

e) He should have a repeat endoscopy in 6


Answer: E
months
Syphilis should be confirmed on diagnosis with specific
tests such as FTA-Abs. IMI benzathine penicillin as a
Answer: D single dose followed by procaine penicillin IMI daily with
probenecid for 10 days is the first line treatment for
About 50% of patients with significant symptoms of syphilis. Follow up with serological and clinical review is
GORD have no abnormality on endoscopy. A good recommended, as is the need to test for other STD's.
response to a PPI is as good as 24 hour pH monitoring Recent sexual contacts may not have clinical features of
to confirm the diagnosis. True food allergies are syphilis but should be treated.
uncommon (1-2% of adults) and typically cause skin
reactions, nausea, vomiting, diarrhoea or anaphylaxis.
Other reactions are non-immune and are called food
Question 34
intolerance or idiosyncrasy.
Daryl is a 3 year old boy who presents with lesions at
the corner of his mouth and ulcers in the mouth (see
Question 32 image below).

Herman is a 57 year old man who is recovering from a These have developed rapidly over a few days and he is
hitherto uncomplicated myocardial infarction. On the febrile and not eating. Daryl's management should
fourth day he complains of sudden onset of include:

palpitations. Initial examination confirms a tachycardia a) Commencement of oral metronidazole


with blood pressure of 140/80. The ECG shows the
b) Commencement of oral flucloxacillin
following rhythm (see figure).
c) Commencement of famciclovir
The first line treatment for this patient is:
d) Application of topical mupirocin
a) Carotid sinus massage
e) Application of topical corticosteroid
b) Digoxin IV

c) Verapamil IV
Answer: C
d) Lignocaine IV
This is an example of herpes simplex infection (primary
e) DC cardioversion
herpetic gingivostomatitis). Regional lymphadenopathy,
fever, headache and malaise may also be present.
Where there is difficulty eating or swallowing oral Question 37
famciclovir, valaciclovir or aciclovir should be
commenced. Systemic analgesics and topical Edith is a 70 year old woman who presents with
anaesthetic agents, eg lignocaine gel can be used and palpitations. Her ECG is shown below.
chlorhexidine mouthwashes may prevent secondary
What is the diagnosis?
infection. Topical corticosteroids are contraindicated.
a) Atrial flutter

b) Atrial fibrillation
Question 35
c) Atrial premature beats
Maria brings Amy, her 6 month old daughter, who has
never been immunised, to see you. Maria states that d) Sinus arrhythmia
she is using homoeopathic drops. Which of the following
concepts is it important to ensure that Maria e) 1st degree AV block
understands?

a) Vaccine preventable diseases are still


prevalent Answer: B

b) Side effects of the disease are greater than This ECG shows atrial fibrillation. There are no p waves
side effects of the vaccine and the rhythm is irregularly irregular which causes the
patient to perceive palpitations.
c) The acellular form of the pertussis vaccine
reduces the incidence of side effects

d) Amy could still be fully immunised with Question 38


conventional vaccines
The clinical features of classical migraine include all of
e) All the above the following EXCEPT:

a) Unilateral temporofrontal distribution

Answer: E b) Retro-orbital and occipital radiation

Maria needs to appreciate all the concepts listed in the c) Intense throbbing character
options. Moreover, she needs to be made aware that-
d) Duration 4 hours to a week
homeopathic 'immunisation' has not been proven to give
protection against infectious diseases-only conventional e) Associated with nausea and vomiting
immunisation produces a measurable immune response.
The Australian Immunisation Handbook has a table
which clearly shows a comparison of the effects of
vaccines versus the much greater morbidity of the Answer: D
diseases against which they protect. Migraine attacks last 4-72 hours (average 6-8 hours),
but never as long as a week.

Question 36

Which of the following statements regarding dementia is Question 39


CORRECT? Malcolm, aged 25 years, presents complaining of feeling
a) One in nine Australians in the group aged unwell with a painful ulcer on his penis. He has tender
>85 suffers from dementia inguinal lymphadenopathy on examination. What is the
MOST LIKELY diagnosis?
b) Dementia affects one in four people aged
80-85 a) Primary genital herpes

c) Family history is a major risk factor for b) Primary syphilis


Alzheimer disease c) Secondary syphilis
d) Vascular disease is the most common cause d) Recurrent genital herpes
of dementia
e) Chancroid
e) Dementia is no more common in the
indigenous population than in the general
community
Answer: A

Primary genital herpes is the most likely cause of a


Answer: C painful ulcerative lesion on his penis. It begins as
multiple vesicles which ulcerate and can become
Age and family history are the two most common risk secondarily infected. Recurrent genital herpes episodes
factors for dementia. One in 15 Australians aged 65 and tend to become milder and less frequent over time. The
over has dementia. In people aged 80-85 years, it primary lesion of a syphilitic ulcer is painless and usually
affects 1 in 9 people. In those over 85 years, it affects 1 persists for 4-6 weeks and heals spontaneously.
in 4. Alzheimer's disease is the most common cause of Chancroid produces multiple painful exudative
dementia. In the most recent assessment of indigenous nonindurated ulcers.
Australians, 10% of those aged 65 and over were found
to have dementia and another 10% were suspected of
having it.
Question 40 Answer: C

A 24 year old married woman presents with patches of a The description is typical of Pityriasis rosea and
scaly coppery pink macular rash over the trunk. The management is usually reassurance only as this is a
rash has been present for one week. The patches are self-limiting condition and disappears in 4-10 weeks.
oval, of different sizes, and appear to be spreading. The Calamine lotion can be used if there is an associated itch
patches are arranged along the skin creases. She feels and topical steroids are only rarely used in the presence
well. There are no other abnormal findings. Which of the of moderately severe itch.
following is the MOST APPROPRIATE management?

a) Application of benzyl benzoate lotion

b) Prescription of antihistamines

c) Reassurance as it is a self limiting condition

d) Pathology test for rubella antibody titre

e) Application of topical steroids


Block 4

Question 1 breathe, heavy in the chest, clammy and her heart


races. These symptoms also occur at other times quite
Which of the following statements about Dupuytren's unexpectedly. These 'turns' last about 10 mins and then
contracture is CORRECT? she feels better, but Mary is really scared about when
they might occur next. What is the MOST LIKELY
a) It is a thickening of the tendon sheath diagnosis?
b) It usually causes flexion contracture of the a) Mary has anxiety
2nd and 3rd fingers of the hand
b) Mary has a phobia
c) It is more common in women than men
c) Mary has anxiety with panic attacks
d) The mode of inheritance is autosomal
recessive d) Mary is depressed and has a phobia for
shopping centres
e) It is more common in diabetics
e) Mary has anxiety, and ongoing angina

Answer: E
Answer: C
Dupuytren's contracture is a thickening of the palmar
fascia resulting in flexion contracture of the fingers of Mary has the classical symptoms of panic attacks with
the hand particularly the ring and fifth fingers. Its some pre-existing anxiety. With panic attacks symptoms
aetiology is unknown, but it is thought to be familial. It must peak within 10 min and usually dissipate within
is more common in men than women. It is more minutes, leaving little to observe, except the person's
common in alcoholics, diabetics and epileptics treated fear of another terrifying panic attack. A distinguishing
with phenytoin. feature of panic disorder is that some of the panic
attacks are unexpected or spontaneous.

Question 2
Question 4
Which of the following drugs is contraindicated in a child
with known glucose-6-phosphate dehydrogenase (G6PD) Clarice, 26 years, presents to you concerned because
deficiency? she has noticed that a dark mole on her thigh has
become enlarged, slightly lumpy and itchy over the last
a) Paracetamol two months. The MOST APPROPRIATE initial
management would be to:
b) Salbutamol
a) Ask Clarice to return for review in three
c) Metronidazole
months
d) Sulphamethoxazole
b) Take an incisional biopsy of the lesion for
e) Prednisolone histopathology

c) Treat the lesion using liquid nitrogen

Answer: D d) Remove the lesion using laser

Glucose-6-phosphate dehydrogenase deficiency is a e) Undertake an elliptical excision clear of the


genetically inherited enzyme deficiency which results in margin for histopathology
acute haemolysis upon exposure to an environmental
stress (viral or bacterial infections), drugs or toxins.
Particular drugs may cause haemolysis in patients Answer: E
deficient in G6PD including Sulphamethoxazole,
nitrofurantoin, primaquine, aspirin and others. Fava If a malignant melanoma is suspected then an accurate
beans may also precipitate haemolysis in a minority of pathological report is required to guide further
patients. management. For this reason it is important that the
initial

management involves complete removal of the lesion


Question 3 without destruction of the tissue. Early detection and
removal of melanomas leads to better outcomes (Clark's
It has been 18 months since Mary had her heart attack
level one and two melanomas have a five year prognosis
and stroke. She is 81 years old, slightly anxious, but
of >90%). If a melanoma is diagnosed then referral to a
very independent & mobile, even though she gets a little
plastic surgeon is necessary for a wide local excision
short of breath going up stairs. Increasingly, Mary is
involving a margin of 1-3 cm and to a depth of the deep
fearful of leaving the house, because sometimes as she
fascia.
is due to leave, she feels dizzy, unsteady, unable to
Question 5 deviation. As the apparent right ventricular hypertrophy
disappears the ECG takes on a more adult appearance,
All of the following may be features of Down syndrome and should have an adult pattern by the age of ten
(Trisomy 21) EXCEPT: years.
a) Hypotonia

b) Webbing of the neck Question 8


c) Congenital heart defects Benny has always loved to go clubbing, and often after a
few drinks at the end of a night of dancing, he ends up
d) Abnormalities of the dermal ridge pattern
having casual sex with someone he meets at the
e) Epicanthic folds nightclub.

Benny had his first hepatitis B serology testing done last


week. These are his test results:
Answer: B
• HBsAg = positive
Webbing of the neck is a feature seen in patients with
Turner syndrome. All other listed features may be • HBsAb = negative
present in a patient with Down syndrome.
• IgM HBcAb = positive

• HBeAg = positive.
Question 6
What is the MOST LIKELY cause of these results?
The clinical features associated with raised intracranial
a) Benny has been vaccinated in the past for
pressure include all of the following EXCEPT:
hepatitis B and is now immune
a) morning headache
b) Benny has had hepatitis B infection
b) vomiting sometime in the past and it has resolved,
leaving him with life-long immunity
c) presence of papilloedema
c) Benny is a hepatitis B carrier
d) decrease in conscious state
d) Benny has acute or current hepatitis B
e) falling blood pressure with a falling pulse infection

e) Benny has early liver cirrhosis

Answer: E

Rising blood pressure (not falling) in combination with a Answer: D


falling pulse rate is a classical feature of rising
intracranial pressure known as the Cushing response. Benny is HBsAg positive which occurs 1-6 months after
Headache occurs as a result of the deformation of exposure to the hepatitis B virus and indicates acute
intracranial blood vessels and dural membranes which infection. If HBsAg persists after 6 months, it defines
arises from conditions which give rise to raised carrirer status. HBsAb is not present (it would be
intracranial pressure. The headache is worst in the positive following vaccination). IgM HBcAb is present in
morning (as is vomiting) and is aggravated by coughing, acute infection only (IgG HBcAb is present in highly
sneezing or stooping. When present papilloedema infective carriers and in acute infection). HBeAg is
(swelling of the nerve fibres of the optic disc) is highly present and implies high infectivity in recent infection
suggestive of raised intracranial pressure. A decrease in and carriers. Benny needs education about hepatitis B,
conscious state commencing with confusion and safe sex & drug use.
progressing through various grades of coma is also seen
with increasing intracranial pressure.
Question 9

Which of the following is FALSE regarding neural tube


Question 7
defects and folate before and during pregnancy?
In the first year of life which of the following ECG
a) Folate intake should be increased at least
features may be considered normal?
one month before and three months after
a) Right axis deviation conception

b) Sinus bradycardia b) Most women before and during pregnancy


need 0.5mg folate daily
c) First degree heart block
c) Women on anti-epileptic medication may
d) Left bundle branch block require 5mg folate daily before and during
pregnancy
e) ST segment depression
d) Folate reduces the incidence of neural tube
defects which occur at the rate or 1:5000
pregnancies
Answer: A
e) Women with a family history of neural tube
At birth the right ventricular muscle is as thick as the
defects need more folate before and during
left. This results in an ECG pattern which would indicate
pregnancy
right ventricular hypertrophy, including right axis
Answer: D Question 12

Pregnant women are at increased risk of folate Kylie is pregnant. She has smoked 25 cigarettes per day
deficiency due to the high demand of the developing for the past 10 years and continues to smoke even now
foetus. Deficiency in the first few weeks of pregnancy she is pregnant. Early in her pregnancy you outline to
can cause neural tube defects in the newborns. Neural her, that, compared with infants born to non-smoking
tube defects occur at a rate of 1:500 pregnancies. The mothers, her infant is more likely to experience a
other options are true. number of disadvantages. These include all of the
following EXCEPT:

a) Higher perinatal mortality


Question 10
b) Small for gestational age
Pamela aged 45 years, attends having found a lump in
the upper outer quadrant of her right breast two days c) Greater likelihood of sudden infant death
ago. She is concerned about the likelihood of cancer. In syndrome
order to diagnose the nature of the lump you invoke the
use of the "triple test" or "triple assessment". The triple d) Developmental lag at least in early years
test consists of:
e) Greater likelihood of developing small teeth
a) Clinical examination, mammography, with faulty enamel
magnetic resonance imaging

b) Mammography, ultrasound, fine needle


Answer: E
biopsy
Small teeth with faulty enamel is a disorder resulting
c) Clinical examination, mammography, fine
from excess alcohol intake in pregnancy and the foetal
needle biopsy
alcohol syndrome. The other options are all
d) Clinical examination, ultrasound, magnetic disadvantages experienced by infants of women who
resonance imaging smoke.

e) Ultrasound, fine needle biopsy, magnetic


resonance imaging
Question 13

Alison, aged 18 years presents with a mobile, smooth,


Answer: C solid lump of 2 cm diameter in her left breast. The MOST
LIKELY diagnosis is:
Management of breast lumps is now based on the triple
test, which combines the results of clinical examination, a) malignancy
mammography (+/- ultrasound) and fine needle
b) fibroadenoma
aspiration biopsy. When combined, these tests give a
sensitivity of 95-99% in the diagnosis of breast lumps. c) breast cyst

d) intraductal carcinoma
Question 11 e) breast abscess
On examining Fatima (aged 18 months), whom you are
seeing for the first time, you hear a heart murmur.
Which of the following clinical findings would suggest Answer: B
that this is an innocent heart murmur?
A fibroadenoma is a benign breast condition that arises
a) The murmur is diastolic as an aberration of normal development and involution.
The diagnosis is best made using the triple test.
b) The murmur is associated with a thrill Indications for removal include patient preference or
discomfort, size > 3 cm, continued growth or lump
c) The murmur is pansystolic
presenting for the first time > 40 years. Fibroadenomas
d) The murmur disappears when the child lies may spontaneously disappear or calcify.
down

e) The murmur is associated with reduced


Question 14
exercise tolerance
Which of the following statements concerning nappy
rash is CORRECT?
Answer: D
a) Seborrhoeic dermatitis is the most common
The disappearance of the murmur when the child lies cause
down suggests it is the innocent murmur known as
b) Management should include liberal use of
'venous hum'. This is a murmur produced by blood flow
talcum powder to help keep the nappy area dry
through the great veins and is heard at the base of the
heart, often just below the clavicles. It is blowing and c) The napkin area should be washed
continuous in nature. The murmur varies with frequently with soap to avoid recurrences
respiration and the position of the head, and disappears
when the child lies down. The other features listed are d) Superinfection with Candida tends to involve
not those of an innocent murmur. the flexures

e) Topical steroids are the mainstay of


treatment
Answer: D a) The usual age of symptom onset is 2-6 years

Irritant dermatitis is the most common cause of nappy b) Genetic inheritance is usually X-linked
rash and tends to spare the flexures. Candidiasis will recessive
involve the flexures and may extend beyond the napkin
area as 'satellite lesions'. In managing nappy rash, the c) Approximately 25% of patients die by the
area should be kept dry, but powders should be avoided age of 20 years
as should soaps and excessive bathing or scrubbing.
d) A lordotic, waddling gait is a feature
Topical corticosteroids should be used with caution to
treat specific causes of nappy rash only, including atopic e) Female carriers are usually asymptomatic
dermatitis and seborrhoeic dermatitis.

Answer: C
Question 15
75% of patients with Duchenne muscular dystrophy die
The classical signs of congenital rubella (German by age 20, usually from cardiac or respiratory failure.
measles) include all of the following EXCEPT: The other options given are correct for this condition.
a) Cataract

b) Heart disease Question 18


c) Deafness Mel always loved playing girls games as a child and had
fantasies about being female. When puberty arrived he
d) Low birth weight
was distressed at the physical changes that occurred in
e) Koplik's spots his body, and as soon as he left home he adopted a
complete female appearance and female role in public
and private. He obtained a driver's license and was able
to work and live in society as a woman. Mel takes
Answer: E ethinyl estradiol 0.10 mg/day and has nearly completed
2-years of living completely as a woman. Mel has
Koplik's spots are typically associated with measles
requested sex reassignment surgery. What is Mel's
(rubeola) only and not any other infectious diseases.
diagnosis?
The other options are features of congenital rubella.
a) Transvestite

b) Cross-dressing homosexual
Question 16
c) Schizophrenia with gender issues
Which of the following statements regarding carcinoma
of the lung is CORRECT? d) Borderline personality disorder
a) Lung cancer is the most common registrable e) Male transsexual
cancer in women

b) Approximately 10% of lung cancers are


derived from squamous cells Answer: E

c) Approximately 60% of lung cancers are Male transsexualism is a gender identity disorder in
adenocarcinomas which the male believes he is the victim of a biologic
accident, cruelly imprisoned in a body incompatible with
d) The majority of lung cancers are his subjective gender identity. Transvestism occurs
asymptomatic at diagnosis when heterosexual males dress in women's clothing,
and at least initially this is associated with sexual
e) Exposure to asbestos increases risk of lung
arousal. Transvestism is a psychiatric disorder only if the
cancer
fantasies, urges, or cross-dressing behaviours are
associated with clinically significant distress or
recognizable dysfunction. Cross-dressing per se is not a
Answer: E disorder. Homosexuality is not a psychosexual disorder
but a preference of a sexual partner. Schizophrenia is
Smoking and exposure to asbestos are associated with not a gender disorder.
the development of squamous cell and adenocarcinoma
of the lung. Prostate and breast cancer are the most
common registrable cancers in men and women
respectively. Lung cancer is the most common Question 19
malignancy causing death in men and second most
Regarding Sudden Infant Death Syndrome (SIDS),
common in women after breast cancer although
which of the following statements is CORRECT?
incidence in women is rising. Of lung cancers, 32% are
adenocarcinoma, 29% are squamous cell, 9% a) Positioning a baby prone (on its front) to
undifferentiated large cell and 18% small cell type. Up sleep may reduce the risk
to 15% of people are asymptomatic of their lung cancer
at diagnosis. b) The incidence is greater in female infants

c) Maternal smoking has not been shown to be


a risk factor
Question 17
d) Breastfed infants are at greater risk
Which of the following statements regarding Duchenne
muscular dystrophy is INCORRECT? e) Infant overheating may be a risk factor
Answer: E trauma or spontaneously. The physical signs of a
pneumothorax are a hyper-resonant percussion note
Regarding modifiable risk factors for SIDS, positioning and absent breath sounds. In cases of tension
the infant supine (on its back) to sleep, breastfeeding, pneumothorax, there is mediastinal displacement away
avoidance of overheating, and maternal smoking from the side of the defect. Treatment is necessary
cessation may reduce risk. Male infants are more at risk when there is a large enough pneumothorax to inhibit
from SIDS (the male: female ratio is approximately respiratory activity and involves the insertion of an
3:2). intercostal drain in the fifth intercostal space in the
midaxillary line or alternatively in the second intercostal
space anteriorly in the midclavicular line.
Question 20

With regards to cryptorchidism (undescended testes),


Question 22
which of the following statements is CORRECT?
Beth, aged 6 months, is brought to see you by her
a) It is essential that the testes are returned to
mother who has noticed her eyes are not always lined
their normal position in the scrotum by the
up. You are concerned Beth may have a squint
time the boy is five years old
(strabismus). Which of the following statements
b) Bilateral undescended testes is a more regarding strabismus is CORRECT?
common occurrence than unilateral
a) Investigation is unnecessary in this age
undescended testis
group as strabismus improves with time
c) The lower the arrest in the line of descent of
b) By the age of 6 months Beth's eyes should
the testis the more hypoplastic it is
be constantly well aligned
d) Malignancy in the undescended testis is 20-
c) Strabismus is rarely a marker of other ocular
30 times more common than usual
disease
e) Inguinal hernia is associated with
d) Strabismus is not associated with amblyopia
undescended testes in approximately 50% of
cases e) The corneal light reflex is a reliable test to
diagnose strabismus

Answer: D
Answer: B
Complications of undescended testes include defective
spermatogenesis, torsion, trauma, and malignant A baby's eyes should be constantly well aligned by the
degeneration 20-30 times more common even after age of 5 to 6 months. Intermittent ocular deviation
surgical placement in the scrotum. Ninety five percent should be investigated if present at six months, as it
are associated with a patent processus vaginalis but may be a marker of severe underlying ocular or
only 25% develop a clinical hernia. Twenty five percent neurologic disease. It should never be assumed that the
have bilateral undescended testes. The testis/es may be strabismus will be outgrown. The corneal light reflex test
intrabdominal, inguinal or high in the scrotum. The should not be relied upon to diagnose or exclude
higher the arrest along the line of descent the more strabismus. The cover test is a more accurate diagnostic
hypoplastic the testis. In order to minimise these test. Strabismus may lead to amblyopia, which in turn
complications the testis/es should be placed in their may result in permanent loss of vision if it is not
normal position before the second year of life. corrected by 4 to 6 years of age.

Question 21 Question 23
Regarding pneumothorax, which of the following Sam and Mary have two daughters. Their second
statements is CORRECT? daughter has Cystic Fibrosis, but their elder daughter
does not. They are considering having another baby.
a) It is due to the presence of air outside the
The likelihood of Sam and Mary having another child
parietal pleura
with Cystic Fibrosis is?
b) It may occur spontaneously with or without
a) 1 in 2
underlying lung disease
b) 1 in 4
c) Clinical examination reveals a dull percussion
note and absent breath sounds c) 1 in 10
d) There may be a mediastinal shift towards d) 1 in 16
the side of the pneumothorax
e) 1 in 25
e) Treatment consists of an intercostal drain in
the second intercostal space in the mid axillary
line
Answer: B

Cystic Fibrosis is an autosomal recessive disorder. If a


Answer: B husband and wife are both carriers of the autosomal
recessive gene then each pregnancy has a 25% chance
Pneumothorax is the presence of air between the of resulting in a child who will be homozygous for and
visceral and parietal pleura. It can occur as result of thus affected by the disease.
Question 24 mother, father and older brothers, aged 2 and 4 years.
Neither of her brothers have been immunised against
Sean, aged 65 years, presents with a history of painless pertussis. Choose the BEST INITIAL MANAGEMENT
haematuria over the last week. Possible causes include option from the list below.
all of the following EXCEPT:
a) Arrange to have Kari admitted to hospital
a) Cancer within the kidney and isolated immediately
b) Use of anticoagulants c) Glomerulonephritis b) Report the family to the child protection
agency in your state for failing to immunise
d) Benign prostatic hypertrophy
their children
e) Use of cyclophosphamide
c) Vaccinate Kari immediately with DTPa-hepB
or DTPa

Answer: D d) Prescribe oral erythromycin for Kari and the


whole family
Benign prostatic hypertrophy is associated with difficulty
micturating but not haematuria. Common causes of e) Take a nasopharangeal aspirate for
painless haematuria include malignancy of the renal diagnosis, and await confirmation of diagnosis
pelvis, drugs such as anticoagulants, cyclophosphamide prior to starting any other treatment measures
and D- penicillamine, and glomerulonephritis. Rarely it
can result from a bleeding tendency due to inherited
disorders, bleeding secondary to idiopathic Answer: D
thrombocytopenic purpura or Henoch Schonlein disease,
malaria, "jogger's haematuria", schistosomiasis. Whilst it is important to obtain a laboratory diagnosis of
pertussis, this should not delay treatment, which should
be commenced after appropriate nasopharangeal
aspirate or serological samples are collected. Kari should
Question 25
be treated with erythromycin 10mg/kg/dose up to
Robyn, aged 43 years, is known to have gallstones. On 250mg orally 6 hourly for 10 days, as should all
this occasion she presents with the acute onset of household and other close contacts. This will not shorten
severe pain which was at first central in location but has the course of the illness in Kari but will reduce infectivity
now moved to the right costal margin and radiates to and eliminate carriage of the Bordatella pertussis
the back. She is pyrexic, slightly tachycardic and has organism in family members. Hospitalisation and
tenderness over the area of the gall bladder but no isolation are unnecessary unless the clinical condition of
rigidity of the abdomen. The MOST APPROPRIATE the patient warrants inpatient management or in infants
MANAGEMENT would be to: less than 6 months of age. Catch-up vaccination should
be addressed, but is not the most immediate concern
a) Observe her at home for 2 to 3 days to allow here. There is no requirement to report the family to
this attack to settle authorities if they are conscientious objectors to
immunisation.
b) Admit her to hospital for treatment with IV
fluids and antibiotics

c) Avoid opioid analgesia due to the risk of Question 27


worsening biliary spasm
Which of the following statements regarding
d) Admit her to hospital for urgent surgery nephroblastoma (Wilms tumour) is CORRECT?

e) Treat this episode with the goal of preparing a) It usually presents as an asymptomatic
for surgery in 2 to 3 months abdominal mass

b) It is frequently associated with congenital


abnormalities
Answer: B
c) Most patients will be hypertensive at
Robyn has acute cholecystitis. Initial management diagnosis
includes IV fluids and nil by mouth, pain relief with
parenteral opiate administration and a short, intensive d) Prognosis is worse for stage 1 than for stage
course of antibiotics. Although opiates may increase 4 tumours
biliary spasm this is not a contra-indication in view of
their excellent analgesic effect. The patient is monitored e) The treatment of choice involves
and immediate operation is ONLY indicated if the fever chemotherapy prior to surgery
does not settle or symptoms worsen, indicating
perforation of the gall bladder or peritonitis. Immediate
operation is not warranted, as there is no indication of Answer: A
perforation of the gall bladder or peritonitis. However,
early operation for acute cholecystitis is now Nephroblastoma is a tumour arising from the kidney and
recommended compared to delaying surgery. is a common tumour in children. Most nephroblastomas
present as an asymptomatic abdominal mass. Fever and
haematuria and hypertension are present in 20 to 25%
of patients. The majority of Wilms tumours occur
Question 26
sporadically, although rarely there may be associated
Kari is 7 months old and has not received any malformations and syndromes. Prognosis is worse for
immunisations. She presents with two weeks of stage 4 than for stage 1 tumours. Wilms tumours are
paroxysmal coughing and vomiting, but is relatively first resected, then chemotherapy or radiotherapy may
happy between paroxysms. You suspect she may have be administered depending on tumour histology and
whooping cough (pertussis). Kari lives at home with her stage.
Question 28 sequelae of this common condition. Bathing the lesions
to remove the crusts may be helpful.
Bobby presents with a fracture which is found to be
pathological in nature. Further investigation confirms
osteosarcoma. Which of the following statements
regarding osteosarcoma is CORRECT? Question 29

a) The peak occurrence of osteosarcoma is in Which of the following statements is CORRECT? Type 1
early childhood Diabetes Mellitus:

b) The tumour usually arises in the midshaft of a) Is less common than Type 2 diabetes in
the tibia adolescents

c) The X-ray appearance of osteosarcoma is b) Is due to immunological damage to


characteristic pancreatic Alpha cells

d) Osteosarcoma accounts for 10% of primary c) Occurs in 6% of siblings of an affected


malignant bone tumours of childhood person

e) Osteosarcoma rarely metastasizes to lung d) Presents with polyuria, polydipsia and weight
gain

e) Can be managed initially with oral


Answer: C hypoglycaemic agents and exercise

The x-ray appearance of osteosarcoma is quite


characteristic with destruction of the normal bony
trabecular pattern and periostial new bone formation Answer: C
with lifting of the bony cortex to create a Codman
Type 1 diabetes mellitus is the most common type of
triangle. However, a tissue sample is required for
diabetes in people under 40 years of age, including
diagnosis. Osteosarcoma accounts for 60% of primary
adolescents. Type 1A diabetes mellitus, or immune-
malignant bone tumours in childhood, and occurs mostly
mediated diabetes, results from immunologic damage to
in adolescents and young adults. More than 40% of
the insulin-producing Beta cells of the pancreatic islets.
tumours arise in the distal femur. At diagnosis a chest
About 6% of siblings of an affected person also develop
CT is essential to look for lung metastases which may be
Type 1 diabetes. The classic presentation is with
present in 20% of cases, worsening prognosis.
symptoms of polyuria, polydipsia and weight loss.
Insulin is the required treatment for Type 1 diabetes.

Question 29

Esther is 7 years old. She presents with a large yellow Question 31


crusted lesion on her left cheek and similar yellow
This pure tone audiogram is recorded from a 12 year old
crusted lesions along her left lower jawline. She has no
Maori girl complaining of deafness in her right ear. The
lesions or rash elsewhere and is otherwise well. Which is
MOST likely explanation for this problem is:
the MOST ACCURATE statement regarding this
condition? a) Debris in the external auditory meatus
a) Herpes simplex is the likely causative b) Cholesteatoma
organism
c) Middle ear effusion
b) It is important not to disturb the crusts
d) Toxin-induced nerve damage
c) Esther should be screened for immune
deficiency e) Necrosis of the ossicular chain

d) Topical mupirocin is an appropriate


treatment
Answer: D
e) Oral antibiotics should be commenced as
early as possible to prevent septicaemia The pure tone audiogram provides measurement of the
developing threshold of hearing at a variety of frequencies, by air
and bone conduction. The pattern of hearing loss shown
on this audiogram is of significant hearing deficit in the
higher frequencies, in the right ear. Air and bone
Answer: D conduction are equally affected. This is the pattern of
sensorineural deafness. The left ear shows a normal
The most likely diagnosis is impetigo, with the ruptured
pattern.
vesicles that form yellow crusts and weeping erosions
being quite typical of the lesions. Herpes simplex has a Toxin-induced nerve damage is the only option which
different clinical presentation. In childhood, primary HSV would produce sensorineural hearing loss. All of the
infection usually presents as severe acute others would give rise to a conductive deafness, where
gingivostomatitis. Impetigo is a very common, highly the loss would be in the lower frequencies during air
contagious infection, and does not suggest an conduction. The bone conduction curve would be
underlying immune deficiency. The usual pathogen is normal.
Staphylococcus aureus, or Streptococcus pyogenes. For
mild or localised impetigo, topical mupirocin 2%
ointment or cream 3 times daily for 7 days is
appropriate treatment. The lesions must be covered.
Whilst oral antibiotics may be indicated for more
widespread infection, septicaemia is not a usual
Question 32 Answer: C

One minute after birth an infant shows deep cyanosis of Heberden's nodes are due to primary osteoarthritis.
the trunk and limbs, makes no reaction to a catheter They are firm swellings composed of bone and cartilage
inserted into the nose, is limp but takes an occasional on the dorsomedial and dorsolateral aspects of the distal
gasp. What is the Apgar score? interphalangeal joints in the hand joints. Rheumatoid
arthritis is characterised by symmetrical joint
a) 0 involvement (usually proximal interphalangeal joints and
metacarpophalangeal joints), morning stiffness greater
b) 1
than an hour, synovial inflammation. Rheumatoid
c) 2 nodules can occur on extensor surfaces of joints in 20-
30% of people with rheumatoid arthritis.
d) 3

e) Insufficient data
Question 35

Herman, a 58 year old businessman, finds it difficult to


Answer: E travel by air or train. When he has no option but to
travel, he finds the journey very difficult and gets out of
The table below shows the data required to determine the aircraft or train as soon as possible. Because of this
an Apgar score. The scenario given lacks information he mostly avoids travel and this liability is interfering
about the heart rate. Other data given are compatible with his work. What is the MOST LIKELY diagnosis?
with a score of 0.
a) Social phobia

b) Agoraphobia

c) Depression

d) Generalised anxiety disorder

e) Panic disorder

Answer: B

Agoraphobia is anxiety about being placed in crowded


situations from which escape might be difficult or
embarrassing, e.g. on aircraft or trains. Generalised
Question 33 anxiety disorder, panic disorder and social phobia are
other varieties of anxiety disorders. Anxiety is frequently
In Huntington's disease the mode of inheritance is: a symptom of clinical depression.
a) X (or sex) linked

b) Recessive Question 36
c) Dominant In which of the following conditions does acute arthritis
commonly occur?
d) Isolated genetic mutation
a) Rubella
e) None of the above
b) Influenza

c) Measles
Answer: C
d) Infectious mononucleosis
Huntington's disease is an autosomal dominant condition
with full penetrance. Therefore, the child of an affected e) Varicella
parent has a 50% chance of developing the disease.
Onset is usually in middle age.

Answer: A

Question 34 Acute polyarthritis may occur in rubella, especially in


young women. The pain and swelling involve wrists,
Each of the following is characteristic of adult fingers and knees. It is most marked during the period
rheumatoid arthritis EXCEPT: of the rash, but can persist for up to 14 days after other
manifestations have disappeared. Recurrent joint
a) Morning stiffness of joints
symptoms up to a year have been recorded. Acute
b) Soft tissue swellings polyarthritis is not one of the usual manifestations or
complications of the other diseases listed.
c) Herberden's nodes

d) Subcutaneous nodules at pressure points

e) Symmetrical joint involvement


Question 37 Question 39

All of the following characteristics describe the 'ideal' Sanjay, a 45-year-old man, presents with a one-year
vaccine, EXCEPT? history of progressive ankle swelling, difficulty with
speaking due to an enlarged tongue, pain and
a) It is heat stable paraesthesiae in the forearm and hand, particularly at
night, and easy bruising. What is the MOST LIKELY
b) It provides lifelong immunity with a single
diagnosis?
dose
a) Membranous nephritis
c) It has minimal adverse reactions
b) Allergic reaction
d) It has a good antibody response in the
presence of other antigens c) Chronic leukaemia
e) It is administered orally d) Amyloidosis

e) Hypothyroidism
Answer: E

All the characteristics listed in the options are desirable Answer: D


in an 'ideal' vaccine, except (e). Each vaccine has an
appropriate route of administration which determines its Amyloidosis involves the deposition of excess amounts
efficacy and probability of side effects. For compliance of insoluble, fibrous amyloid protein in the extracellular
and ease of administration, delivery without a spaces of organs and tissues. The causes are multiple,
hypodermic syringe would be ideal but most vaccines including neoplastic disease, inflammatory disease and
are ineffective via the oral route. Other desirable advancing age. There is a rare hereditary form. All
features of the 'ideal' include: being able to combine organ systems can be involved, with cardiomyopathy,
readily with other antigens, ease of administration and macroglossia and vessel disease. The other conditions
low cost. Although characteristics of the ideal vaccine can produce oedema, bruising and abnormal hormone
are well established, developing and producing them is production, but not the complete clinical picture as
often difficult. described above. Amyloidosis is usually well advanced
by the time it is diagnosed.

Question 38
Question 40
Lulu is a three year old child who has swallowed
kerosene and is brought immediately to the hospital Amelie is a severely depressed 29-year-old woman with
casualty department. Which of the following measures suicidal thoughts who is two months pregnant. Which of
should be undertaken in the immediate management of the following approaches to treatment would be MOST
Lulu's problem? appropriate?

a) Gastric lavage a) Counselling and reassurance

b) An emetic b) Termination of pregnancy

c) Chest x-ray c) Treatment in hospital with monoamine


oxidase inhibitor (MAOI)
d) Intravenous saline
d) Treatment at home with tricyclic
e) Methicillin antidepressant

e) Electroconvulsive therapy (E.C.T) in hospital


Answer: C

Kerosene is an aliphatic, highly volatile hydrocarbon Answer: E


which is poorly absorbed from the gastrointestinal tract.
Pneumonitis through aspiration of fumes is the In severely depressed pregnant women ECT has been
predominant toxic mechanism in children and shown to be safe and effective both antenatally and post
respiratory distress can be severe and occur rapidly. partum. Tricyclic antidepressants have been used for
While a chest xray is not useful for the prediction of lung over 40 years and are a good choice in a supervised
involvement, serial chest xrays are important to monitor setting but not if the woman is suicidal because of the
progression. In children who present with lethargy, fever risk of overdose. MAOIs have not been shown to be safe
or respiratory signs in the first 4 hours 80% develop in pregnancy.
pneumonitis. Gastrointestinal irritation is common with
nausea and vomiting. There may also be a high fever
within 30 minutes of ingestion. Management should be
conservative and decontamination (emesis or gastric
lavage) should not be attempted - it merely increases
the risk of aspiration, and development of pneumonitis.
IV saline may be required if haemolysis from the
kerosene occurs and hypotension develops.
Block 5

Question 1
(50% of cases) and a fluctuating level of consciousness
Audrey is a 61 year old widow who lives alone. She has occurs in 35% of cases. Headaches, localised
become very anxious about leaving her house to go neurological symptoms and a change of personality may
shopping, or to attend appointments, like visits to the also occur.
doctor, since viewing a TV new story about the rise in
daytime home burglary. She finds that she has to check
and recheck that she has closed and locked all windows
Question 3
and doors over and over again, before she can reduce
her anxiety enough to leave her house. This usually Jane (age 28) and her husband, Mike, have been trying
takes more than an hour. Some weeks, she does not go to have a child for 18 months. Mike has one child with a
out at all, because she still feels anxious after this previous partner. Jane's menses started at age 12 and
extensive checking procedure. In such cases her they have always been infrequent, irregular and
daughter does her shopping for her. Audrey does not sometimes very heavy. Jane used the combined oral
have anxiety about other things. What is the most likely contraceptive pill (Diane 35) for 10 years but stopped all
diagnosis? contraceptives 2 years ago. Recently Jane has been
trying to lose weight. At a height of 165cms, she weighs
a) Generalised anxiety disorder
85kg. On examination Jane appears normal but she
b) Obsessive compulsive disorder relies heavily on waxing to remove embarrassing facial
and lower abdominal hair. What is the MOST LIKELY
c) Posttraumatic stress disorder diagnosis?

d) Agoraphobia a) Endometriosis

e) Panic disorder b) Post-pill infertility

c) Polycystic ovarian syndrome

Answer: B d) Pituitary prolactinoma

Audrey displays the features of obsessive compulsive e) Hypothyroidism


disorder. This is characterised by (a) obsessive thoughts
and/or compulsive behaviour that impair everyday
functioning, e.g. fears of contamination by germs,
Answer: C
repeated handwashing, checking windows and doors
etc; (b) the disruptive behaviours are undertaken to Polycystic ovarian syndrome (PCOS) is characterized by
relieve the anxiety, and (c) they take up more than one oligoamenorrhoea, hirsutism, acne, infertility, obesity
hour per day. The other conditions listed are also forms and insulin resistance. Menarche occurs at the usual
of anxiety disorders. time and androgen excess becomes apparent during
puberty with development and persistence of hirsutism
and/or acne. Diagnosis is largely based on clinical
Question 2 evaluation. Endometriosis is more associated with
dysmenorrhoea than irregular cycles. Prolactinoma and
Mavis is 82 years old and recently she fell, landing face hypothyroidism may cause oligoamenorrhoea but not
down on the floor. She was very shaken and had androgen excess. Prolonged use of the combined oral
bruising about her lower face. Two weeks later her contraceptive pill is not associated with infertility after
family started to notice that Mavis seemed very the cessation of its use.
withdrawn and was sleeping a lot more than usual.
Mavis would spend the whole day in bed and she was
not really herself. When her family visited, she was
Question 4
increasingly abrupt and moody. Mavis was usually very
gentle and quietly spoken. What is the MOST LIKELY Mr Davy has had severe intermittent pain in the right
diagnosis? side of his back, radiating into his right groin and to the
tip of his penis. It has been present for the last 6 hours.
a) Subdural haemorrhage
He feels continuously nauseous, and with every spasm
b) Extradural haemorrhage of pain, he feels he cannot lie still but must move
around. Sometimes, curling himself into a tight ball
c) Dementia helps. He has had one similar, but less severe episode of
pain one year ago that resolved spontaneously. On
d) Stroke examination he is afebrile and his urine has only a trace
of red blood cells. What is the MOST LIKELY diagnosis?
e) TIA
a) Appendicitis

b) Urinary tract infection


Answer: A
c) Pyelonephritis
Subdural haemorrhage may be insidious in onset, and
the elderly are particularly susceptible due to brain d) Ureteric calculi
shrinkage. A history of trauma may not be recalled
e) Diverticular disease
Answer: D extension is suspected it would be preferable to confirm
this by doppler ultrasound before commencing
Renal calculi (stones) may be asymptomatic. However anticoagulants. Varicose veins have many risk factors,
calculi in the ureters commonly cause pain from the loin, one of which is prolonged standing. This increases
into the groin and/or pain in the tip of the penis. There hydrostatic pressure leading to chronic venous
is usually no penile redness or discharge and few other distension and secondary valvular incompetence.
abdominal signs are present, unless urinary obstruction Women are particularly susceptible as the vein walls
is occurring with urethral calculi. Haematuria and loin become more distensible under the cyclic influence of
tenderness are common. progesterone. The condition is likely to resolve
spontaneously over a few days. Non-steroidal anti-
Question 5
inflammatory agents may be used to reduce pain and
John is a 28 year old unemployed man with multiple local inflammation, and graduated compression
complaints, including headache, low backache, upper stockings may be helpful if the condition does not
abdominal pain, pain in both feet, nausea, bloating, resolve quickly. Thrombophlebitis is not usually infective
impotence and weakness in both forearms and left leg. however antibiotics may be used in the case of
Physical examination shows no abnormal clinical signs. persistent or severe symptoms.
Previous investigations including chest X-ray, full blood
count, biochemical profile and abdominal ultrasound
show no abnormality. What is the MOST LIKELY Question 7
diagnosis?
Little Andrew, aged 18months, was 'helping' Dad in the
a) Factitious illness shed, when he began screaming and rubbing his eyes.
He had climbed onto the workshop bench, on which was
b) Munchausen's syndrome
kept a variety of potential ocular hazards. Which of the
c) Conversion disorder following substances is potentially MOST harmful to
Andrew's eyes?
d) Hypochondriasis
a) Methylated spirits
e) Somatisation disorder
b) Superglue

c) Acetic acid
Answer: E
d) Dog shampoo
In somatisation disorder the patient has multiple
physical complaints referable to different organ systems, e) Powdered cement
including at least four pain, two gastrointestinal, one
sexual and one pseudoneurological symptom(s) which
are not consistent with any specific diagnosis. There is Answer: E
significant impairment of social, occupational or other
important area of functioning. Treatment involves Cement is alkaline, and alkaline burns are more
behaviour modification and limitation of further dangerous than those from other chemicals. Alkali has
investigations. the potential to penetrate the cornea and gain access to
the anterior chamber, causing uveitis, secondary
glaucoma and cataract. Alcohols and solvents cause
severe pain initially but although the epithelium is burnt,
Question 6
it tends to regenerate quickly. Superglue, while it may
Myra, a 38 year old bank teller, presents with a painful cause distress in gluing eyelids together, is actually not
right lower leg. On examination, she has some dilated, harmful to the eye- in fact it is sometimes used in
tortuous veins mostly on the posterior and lateral treatment of corneal wounds. The weak acid, and the
aspects of her calf. There is an area of redness and heat dog shampoo, will both cause more irritation than actual
over one of these veins, and a firm cord like lump in the damage. First aid treatment for any substance splashed
vein, 3 cm long, which is tender to touch. The MOST into an eye is profuse irrigation.
correct statement is:

a) Myra requires antibiotic treatment with


Question 8
flucloxacillin
Fred is a 74 year old hypertensive man who has been
b) There is a small risk of extension into deep
found to have a 55mm fusiform abdominal aortic
veins
aneurysm, discovered when he had an abdominal
c) Myra should have subcutaneous low ultrasound for right flank pain two days ago. Of the
molecular weight heparin while awaiting a following, which is NOT a risk factor for rupture of Fred's
venous Doppler scan aneurysm?

d) This condition is unrelated to her occupation a) Persistently elevated mean arterial pressure

e) The condition is unlikely to resolve without b) The fact that he still smokes 15
specific treatment cigarettes/day

c) His chronic obstructive pulmonary disease

Answer: B d) The fact that Fred is male

Myra has superficial thrombophlebitis, a relatively e) The size of the aneurysm


common problem. In this particular site, it is likely to be
in the short saphenous vein system and the risk of
extension to the deep system via perforating veins is
small. However, it is not negligible. If deep vein
Answer: D 105/70mm Hg. There appears to be diminished
excursion of his right chest wall, and the breath sounds
Risk factors for the development of an abdominal aortic are hard to hear on the right. There is hyperresonance
aneurysm (AAA) include smoking, increasing age, to percussion on of the right chest. Your IMMEDIATE
hypertension, family history, chronic obstructive response should be?
pulmonary disease (COPD) and being male. Risk factors
for AAA rupture are an elevated mean arterial pressure, a) Arrange an urgent chest X ray
continuing to smoke, more severe COPD and having an
aneurysm that is either rapidly enlarging or is measured b) Perform rapid sequence induction and
at >50mm diameter. Although women have a lower intubate
incidence of AAAs which tend to be smaller, they have a
c) Insert a thoracostomy tube in the right fifth
much higher risk of rupture. In this scenario, the flank
intercostal space in the anterior axillary line
pain may well be an indicator of expansion of the
aneurysm. d) Insert a wide bore needle in the right second
intercostal space

e) Insert a wide bore needle in the left second


Question 9
intercostal space
Colin is 22 years old. His right arm was amputated
above the elbow when it became caught in the industrial
mulcher he was using. His mate tied his own T shirt Answer: D
firmly around the stump and brought him to hospital. On
arrival, 15 minutes later, the T shirt is soaked, and Brendon has almost certainly developed a right tension
blood is trickling out. Colin is pale, his skin is cool and pneumothorax, as indicated by his increasing dyspnoea ,
clammy, and he looks anxious. His pulse is 110 and the physical signs described above. This is a life-
beats/min and his BP 130/95 mmHg. His respiratory threatening condition which requires urgent
rate is 20 breaths/min. Capillary refill time is 5 seconds. management. Decompression with a wide-bore needle in
You are able to insert an intravenous cannula in his left the second intercostal space, in the midclavicular line of
arm. Which fluid orders are MOST appropriate in this the affected side is potentially life-saving, and allows
circumstance? time for the more complex procedure of the tube
thoracostomy to follow. Tension pneumothorax is a
a) 1 litre Normal saline as a bolus, then 1 Litre clinical
4% dextrose in 1/5N saline
diagnosis, and emergency treatment should not be
b) 2 units O negative blood delayed for X ray confirmation. Intubation and
ventilation may turn a simple pneumothorax into one
c) 500ml normal saline
under tension. It is not indicated in this situation.
d) 500ml colloid

e) 1.5 L Normal saline


Question 11

Mary, aged 65, had a laparotomy for resection of a


Answer: E bowel cancer seven days ago. She has been progressing
well, but has just noticed some pinkish fluid leaking
Colin is a young adult, apparently fit. His signs indicate from her wound. Which of the following is TRUE
that he has suffered a class 2 haemorrhage, and has regarding this situation?
lost approximately 15-30% of his total blood volume or
750-1500ml. So far his body has compensated well, but a) This complication occurs in 10% of older
this may not be sustained. He requires replacement of patients undergoing abdominal surgery
volume and the most commonly recommended fluid is
b) The wound will require urgent surgical repair
an isotonic crystalloid such as normal saline. O negative
blood is not required in this c) There is a mortality rate of 1% associated
with this complication
situation. There would normally be time to obtain cross
matched blood if bleeding could not be controlled. d) If the wound breaks down, it must heal by
Hypotonic saline/dextrose solutions are not appropriate. secondary intention
These fluids are used to maintain fluid balance in a
normovolaemic, normonatraemic patient and do not e) The appropriate management is intravenous
restore intravascular volume in the volume-depleted antibiotics
patient.500ml of normal saline is not sufficient. While
there are some theoretical advantages to using colloid
as the replacement fluid, there is little evidence of
Answer: B
improved outcome from using this instead of crystalloid.
500ml of colloid is not sufficient on its own. 1-2 litres as The serosanguinous discharge heralds dehiscence of the
the initial bolus, for an adult of average build is wound, and after undertaking any necessary
appropriate in this circumstance, then the patient's resuscitation and preparations for theatre, Mary should
response should be assessed. return to theatre as soon as possible. Early wound
dehiscence is a serious complication, usually occurring
around the 7th to 10th post-operative day. It occurs in
Question 10 fewer than 1% of laparotomy wounds but can have a
mortality of around 30%. Risk factors include poor
Brendon is a 35 year old man who has been involved in nutritional state, malignancy, obesity, prolonged
a motor vehicle accident. He was wearing his seat belt, surgery, infection or coughing. The wound cannot be left
but it did not hold and he was thrown against the to heal by secondary intention. Intravenous antibiotics
steering wheel. He is anxious and increasingly may form part of the management but will not suffice
dyspnoeic. His pulse is 126 beats/minute and his BP alone.
Question 12 Answer: A

Kevin, a 45 year old labourer, had a laparotomy five As increasing age is a risk for colorectal cancer, a
years ago when he suffered a ruptured appendix. He has patient over the age of 40 who presents with PR
recently noticed a dragging sensation in the region of his bleeding should have a digital rectal examination and be
scar, especially when lifting heavy objects at work, and investigated by colonoscopy. If this is not available a
now presents with a swelling of 1.5 cm diameter in the flexible sigmoidoscopy and double contrast barium
medial end of his scar. Concerning Kevin's problem, enema would be satisfactory. Rectal bleeding is a
which of the following is TRUE? common symptom of haemorrhoids, but a rectal
neoplasm may also cause PR bleeding. Even in the
a) Kevin's lean, muscular body type presence of obvious haemorrhoids patients at increased
predisposes him to this problem risk for colorectal cancer should be investigated. FOBT is
a screening test , not a diagnostic investigation.
b) The fact that the scar is paramedian and in
the lower abdomen predisposes to this problem

c) The problem is of nuisance value only, as Question 14


only fatty tissue protrudes into the swelling
Florence, aged 50, has decided to have a
d) Kevin should have surgical repair as soon as haemorrhoidectomy after months of unsuccessful
convenient conservative management of her haemorrhoids. In
obtaining informed consent, you discuss with her the
e) Kevin should wear an abdominal support
potential complications of haemorrhoidectomy. Which of
garment to prevent complications
the following is the LEAST likely complication?

a) Urinary retention
Answer: D
b) Post-operative bleeding
Kevin has an incisional hernia, which is a protrusion of
c) Sepsis
abdominal contents into the subcutaneous plane through
a defect at the site of a previous incision. Incisional d) Faecal incontinence
herniae should be repaired as soon as convenient
because they can increase in size over time and may e) Pain
become very difficult to repair. More particularly, as with
most herniae, they may become irreducible, with Answer: C
possible obstruction and strangulation of abdominal
Sepsis is fortunately a very rare complication of
contents including bowel. Incisional herniae are more
hemorrhoidectomy. Urinary retention occurs in
common in obese patients in whom there is fatty
approximately 5-10% of cases and may be due to spinal
infiltration of the tissues, increased intra- abdominal
anaesthesia and/or the use of IV fluids and urinary
pressure and reduced muscle tone. They are more
catheter intraoperatively. Bleeding is uncommon but
common in midline and upper abdominal scars. There is
may be severe. It can occur in the first 24 hours or 7 to
no evidence that any supportive garment will prevent
10 days later due to local infection. Pain is fairly
complications in an incisional hernia although it may
common and may be severe. It is associated with faecal
relieve discomfort.
impaction and incontinence. Later rare complications
include fissures, fistulae and anal stenosis.

Question 13

Peter is 47 years of age and presents with a single Question 15


episode of bright red bleeding per rectum (PR). which he
Brian, a 52 year old man, walks awkwardly into your
noticed after passing a bowel motion this morning. He is
rooms. He complains of severe pain, which he indicates
unaware of any significant family history of colorectal
as being quite deep in his rectum. He says the pain
problems. On examination Peter has some obvious
began earlier in the day but has become much worse in
haemorrhoids but nothing else of note on rectal or
the last hour and he it feels like 'something coming
proctoscope examinations. What is the MOST
down' in his back passage. Which of the following
appropriate advice for Peter?
statements MOST accurately describes Brian's condition?
a) In view of his age he should have a
a) Brian has a thrombosed external
colonoscopy to investigate this bleeding
haemorrhoid
b) As there is an obvious cause for his
b) Brian's deep pain is due to prolapsing
bleeding, no further investigation is needed at
internal haemorrhoids
present
c) Brian has a rectal prolapse
c) As he has no significant family history of
colorectal disease, he only needs reassurance d) Brian has grade three haemorrhoids
d) Monitoring with 6 monthly faecal occult e) Brian has strangulated internal
blood testing (FOBT) is required haemorrhoids
e) He should have a trial of increased fibre in
his diet and review the haemorrhoids in 3
months
Answer: E Answer: D

The pain from strangulated internal haemorrhoids is Unilateral renal agenesis is not uncommon and the
typically felt as a deep pain. Prolapsing internal solitary kidney compensates by hypertrophy and
haemorrhoids can cause perianal pain by causing a maintains normal renal function. It is usually
spasm of the anal sphincter complex. If the accompanied by ureteral agenesis. Potter's syndrome is
haemorrhoids become trapped by the spasm, they bilateral renal agenesis and it is fatal.
become engorged with secondary venous and later
arterial thrombosis, and become irreducible. This is
known as 'strangulation' and results in deep seated
Question 19
pain, especially if necrosis and ulceration occur. The
pain of thrombosed external haemorrhoids is felt Jane is 45 years of age and she has noticed the
perianally. Rectal prolapse is rarely painful. Brian's following changes in herself over the last 4 months. She
haemorrhoids are now irreducible, so are no longer has lost weight, her eyes feel dry, but they are
grade 3 (require manual reduction). constantly watering and she feels irritable and 'on edge'
and occasionally experiences palpitations. Her periods
have become irregular, her hair is thinning and her
Question 16 fingernails seem very brittle. Her father and older sister
experienced the same symptoms when they were 40
Jason is a 30 year old mature age medical student. He years of age. What is the MOST LIKELY diagnosis?
has been hospitalised following a haematemesis due to a
Mallory-Weiss tear. Jason asks for an explanation about a) Graves' disease
Mallory-Weiss tears. Which of the following statements
b) Toxic adenoma
is FALSE?
c) Simple diffuse goitre
a) Mallory-Weiss tears are tears in the mucosa
of the lower oesophagus d) Multi-nodular goitre
b) Haematemesis in Mallory-Weiss tears is e) Hashimoto's thyroiditis
always preceded by retching or vomiting

c) Bleeding from Mallory-Weiss tears stops


spontaneously in 80-90% of patients Answer: A

d) Alcoholic binge drinking may be associated Graves' disease is characterized by hyperthyroidism and
with Mallory-Weiss tears one or more of the following: goitre, exophthalmos, and
pretibial myxoedema. It is an auto-immune disorder
e) Haematemesis is not a universal symptom of that has a genetic component and commonly presents in
a Mallory Weiss tear women aged 40 -50 years. Toxic adenoma can occur at
any age.It usually presents as a single thyroid nodule
not a goitre, and hyperthyroidism. Simple diffuse goitre
Answer: B occurs mostly in younger women aged 15-25 years. The
thyroid gland is enlarged but the person is euthyroid.
The classical presentation of Mallory-Weiss syndrome is Multi-nodular goitre is often a simple diffuse goitre that
haematemesis from a tear in the oesophagus, brought has progressed as the person has become 'middle-aged'
on by prolonged vomiting of any cause. It is often or elderly. The goitre is 'lumpy', not diffusely enlarged
associated with alcoholic excess but this is NOT always and initially the person is euthyroid but may become
the case. Haematemesis may occur without prior hyperthyroid in the long-term. Sometimes it causes
retching or vomiting. The tear is typically a longitudinal difficulty with swallowing and breathing if large.
one in the mucosa of the lower oesophagus close to the Hashimoto's thyroiditis is a chronic inflammation of the
gastro-oesophageal junction. The bleeding settles thyroid caused by autoimmune factors. It causes
spontaneously in 80-90% of cases of Mallory-Weiss painless enlargement of the thyroid gland or fullness in
tears. Not all MW tears present with haematemesis. In a the throat and many patients have hypothyroidism when
small proportion, melaena, haematochezia, syncope or first seen. Other forms of autoimmune disease are
abdominal pain are the presenting symptoms. common.

Question 18 Question 20

Hugo did not realise until he volunteered to be a kidney Amanda, 47 years, has noticed her right eyelid is higher
donor that he had been born with only one kidney. than her left and her right eye seems more prominent.
Which ONE of the following statements is TRUE? She first noticed she can apply her mascara to her left
eyelashes easier if she tilts her head back and looks
a) Hugo's condition is known as Potter's upward. Her contact lenses still fit perfectly. Amanda is
syndrome otherwise well with no other symptoms or signs. What is
the MOST LIKELY diagnosis?
b) Unilateral renal agenesis is uncommon
a) Bell's palsy
c) Usually in unilateral renal agenesis there are
still two ureters b) Hyperthyroidism
d) In unilateral renal agenesis the solitary c) Myasthenia gravis
kidney maintains normal renal function
d) Horner's syndrome
e) Hugo needs an annual ultrasound scan of his
solitary kidney e) Optic nerve glioma
Answer: D shallow respiration, no abnormal physical findings. Of
the following, which is the MOST LIKELY diagnosis?
Ptosis is drooping of the upper eyelid associated with an
inability to elevate the lid completely. Nerves from the a) Agoraphobia
sympathetic chain innervate the superior tarsal muscle
causing unilateral partial ptosis that can be overcome by b) Posttraumatic stress disorder
looking upward. Horner's syndrome includes unilateral
c) Generalised anxiety disorder
partial ptosis, ipsilateral constricted pupil and ipsilateral
lack of sweating of the face. Myasthenia gravis usually d) Panic disorder
causes bilateral partial ptosis. Hyperthyroidism causes
protruding eyes (proptosis/ exophthalmos) which may e) Acute psychosis
be unilateral. Bell's palsy (VII nerve paralysis) prevents
the patient from forcefully closing their eyes and they
have bilateral wide palpebral fissures. Optic nerve
Answer: D
glioma causes painless progressive proptosis.
Karen's story displays the features of a panic attack
which is the cardinal manifestation of panic disorder.
Question 21 Patients with panic disorder experience repeated
unexpected attacks of intense, disabling anxiety. In
Michelle needs a transfusion after a major motor vehicle between attacks they experience at least one month of
accident. In the accident her pelvis was fractured, both worry about having further attacks and/or fear of losing
femurs have mid-shaft fractures and she sustained a control, going mad or dying. Agoraphobia is an irrational
hemothorax requiring a chest drain. Michelle was fear of being trapped in a place from which escape is
trapped for an hour before the fire rescue could cut her impossible. Patients with posttraumatic stress disorder
out of her vehicle. Michele has blood group O Rh are repeatedly distressed by re-experiencing highly
positive. Which of the following statements is TRUE? traumatic events. Generalised anxiety disorder involves
persistent excessive and/or unrealistic worry
a) Michelle has type A antigens on her red accompanied by other signs and symptoms, such as
blood cells muscle tension, restlessness and feeling on edge. Acute
psychosis is a severe mental disturbance involving
b) Naturally occurring A and B antigens are
hallucinations and/or delusions.
called isoagglutinins

c) Michelle has anti-A and anti-B antibodies


Question 23
d) Persons with Type O blood are "universal
recipients" Sue is 30 years old and concerned she will get breast
cancer because her mother had breast cancer diagnosed
e) Michelle lacks the D antigen
when she was 45 years of age. Which of the following
statements is TRUE regarding breast cancer?

Answer: C a) BRCA1 and BRCA2 mutations account for


60% of breast cancer cases
The ABO blood group system is the most important in
transfusions. Persons with Type O blood are "universal b) Sue does not have an increased risk of
donors" because their red blood cells lack A or B breast cancer because her mother had breast
antigens. Type O individuals produce their own anti-A cancer
and anti-B. However, their cells are not recognised by
c) Breast cancer is a disease of younger women
any naturally occurring anti-A or anti-B antibodies
(otherwise known as isoagglutinins), when their red d) Sue should have bilateral mastectomies to
blood cells are transfused. The Rh system is the second prevent breast cancer developing
most important blood group system in pretransfusion
testing. Rh 'positive' individuals have the D antigen of e) If Sue does develop breast cancer she is
the Rh system, while people lacking the D antigen are most likely to develop it after she is 50 years of
Rh 'negative'. age

Question 22 Answer: E

Karen is a 21 year old university student. She is Although mutations in BRCA1 and BRCA2 are associated
accompanied to your consulting rooms by two women with an increased risk of breast cancer, and the lifetime
friends who observed her collapse this morning in a risk of developing breast cancer in women who have
bathroom of their university residence. Karen tells you these mutations approaches 80%, these lesions account
that soon after she woke today she suddenly began together for less than 10% of breast cancer cases.
feeling unwell, with intense fear, palpitations, sweating, Women who have first-degree relatives who have
shortness of breath, nausea and tingling in her fingers. . developed breast cancer do have an increased risk of
She does not remember anything after entering the developing breast cancer themselves, and if their first-
bathroom. This is the third similar attack that she has degree relative with breast cancer was diagnosed before
experienced during the past two months. After the first age 50 they have a higher risk of developing breast
attack, she worried that she 'might be going crazy' but cancer than women whose first-degree relative was
postponed seeking medical advice for fear of being diagnosed after age 50. However, in all cases, breast
institutionalised, like one of her aunts who has cancer is uncommon in young women. Furthermore,
schizophrenia. She does not smoke, drink alcohol or use most women with affected first-degree relatives with
illicit drugs. The only medication she takes is breast cancer who themselves develop breast cancer do
paracetamol occasionally for headaches. On examination so after 50 years of age In the absence of mutations in
you find: PR 85/min, BP 135/95 mm Hg, moist palms, BRCA1 or BRCA2, the risk associated with a positive
family history does not seem of sufficient magnitude to c) Migraine is rare in children less than 10
justify routine bilateral mastectomy. years of age

d) The most common form of migraines has a


prodrome and an aura
Question 24
e) Migraine is accompanied by nausea in 90%,
At birth Sammy has a cleft lip but otherwise looks vomiting in 60% and diarrhoea in 15% of
normal. Sammy's parents are very distressed about this, attacks
and are concerned to know if Sammy has anything else
wrong which they cannot see yet, or that may develop
when he's older. Which of the following is TRUE?
Answer: E
a) Sammy is likely to have Pierre Robin
syndrome and a cleft lip is just part of this There are two main types of migraine: classical migraine
syndrome (migraine with aura) and common migraine (migraine
without aura), the latter accounting for the majority of
b) Sammy has a cleft lip due to his mother's migraine headaches. About 10% of the population in
use of antidepressants Australia have migraine.

c) Sammy is likely to have this isolated Migraine usually starts during the teenage years or early
abnormality and no other problems except the adult life and occurs more commonly in women than
cleft lip men (ratio 3:1). In children the incidence is 3-7%.
Migraine may be accompanied by a variety of symptoms
d) Sammy is likely to have congenital other than the typical nausea, vomiting and photophobia
dislocation of the hips as well as his cleft lip

e) Cleft lip and cleft palate are associated with


talipes (clubfoot deformities) Question 26

Dimitri is a 45 year old man who presents with


insomnia. He goes to sleep at night without difficulty,
Answer: C but wakes frequently from distressing dreams in which
he is being forced to watch people being tortured. Then
The cleft may vary from involvement of the soft palate
he has great difficulty in going back to sleep. Dimitri has
only, to a complete cleft of the soft and hard palates,
been in Australia for two years, having emigrated from
the alveolar process of the maxilla, and the lip. The
Kosovo, where he was imprisoned for a year. His wife
mildest form is a bifid uvula. These children have normal
says he had a 'bad experience' while in detention, but
intelligence and development. Cleft lip with or without
will not talk about it. Over the past six weeks, he has
cleft palate occurs in 1:700-1000 live births, more often
become irritable, prone to outbursts of anger and has
in Asian groups and less often in African Americans;
begun drinking heavily. This has led to marked tension
more often in males. Cleft palate alone occurs in 1:2000
in the home and Dimitri's workplace. Which of the
across all races with slightly more females affected.
following is the probable cause of Dimitri's distress?
There may be genetic and environmental factors
including maternal smoking and use of alcohol, retinoic a) Acute stress disorder
acid and anticonvulsants. Associated anomalies occur in
about 15 to 20% of cases of cleft lip with or without cleft b) Posttraumatic stress disorder
palate but in 50%
c) Panic disorder
of cases of cleft palate alone. Pierre Robin syndrome
typically presents with micrognathia (small mandible) d) Phobic disorder
and a cleft soft palate. Congenital dislocation of the hip
e) Generalised anxiety disorder
seems to be secondary to laxity of the ligaments around
the hip or to in utero positioning. Clubfoot (talipes)
deformities, result in the foot being plantar flexed,
inverted, and markedly adducted. Neither of these Answer: B
congenital abnormalities is associated with cleft lip or
palate. Posttraumatic stress disorder is an anxiety disorder of
more than one month's duration, consequent upon a
severe traumatic experience in the individual's past, and
which s/he now re-experiences in one or more ways
Question 25 (e.g. flashbacks or dreams). This is accompanied by
avoidance of stimuli which recall the event, numbing of
Mandy has had migraines since she was a teenager.
the individual's responsiveness, symptoms of arousal
They are the classical migraine with a prodrome when
(e.g. insomnia) and distress or social/occupational
she is clumsy, yawns a lot, is tired, has a stiff neck and
impairment.(see refs for full diagnostic criteria). In
feels irritable. Then she gets the aura, with 'sparks' in
contrast , an
her vision. Then she gets a severe headache that starts
at the back of her neck and moves to one of her temple acute stress disorder develops soon after the traumatic
areas and then her forehead. She feels sick and wants experience. A panic attack is the cardinal manifestation
to curl up in bed, in a dark room, and let the headaches of panic disorder. Patients experience intense, disabling
pass, which it usually does in about 6 hours. Which of anxiety and may fear they are losing control, going mad
the following statements is TRUE regarding migraine or dying. Generalised anxiety disorder involves
headaches? persistent excessive and/or unrealistic worry,
accompanied by other signs and symptoms, such as
a) Migraine headaches are equally common in
muscle tension, restlessness and feeling on edge.
women and men
Patients with phobic disorders display marked fear of
b) In Australia 30% of the population have objects or situations which provoke an immediate
migraine headaches anxiety reaction.
Question 27 sympathetic overactivity or cerebral compromise,
resulting from hypoglycaemia, rapidly progress to coma,
Jane is 24 years of age and 10 weeks pregnant with her if untreated. Hypoglycaemic coma commonly occurs in
first child. She has just been diagnosed with her first well-controlled diabetic patients, and is due to their
ever urinary tract infection. Which drug would you diabetic medications eg: longer acting sulphonylureas.
choose to treat Jane's urinary tract infection? However blood glucose should always be tested (dipstick
and laboratory confirmation) in an unconscious patient
a) Trimethoprim
(diabetic or not) and hypoglycaemia assumed to be the
b) Cephalexin cause of any coma, until proven otherwise.

c) Amoxycillin
Question 29
d) Norfloxacin
Mike has come to you to discuss vasectomy. He is 45
e) Erythromycin
years of age, and he has three children to his current
partner Sam. Sam has tried many different
contraceptives, but none have been satisfactory. She
Answer: B has finally told Mike he has to do something about
contraception for them now they have had all the
The important time for teratogenic effects of drugs given
children they want. Mike is very nervous about any type
in pregnancy is in the first trimester. All drugs, if
of surgery, especially if it involves his genital area. He
possible should be avoided in the first 12 weeks of
has never been near a surgeon in his life. Which of the
pregnancy. However if Jane has a urinary tract infection
following statements is CORRECT? Vasectomy:
she requires treatment. Trimethoprim and norfloxacin
(usually used to treat pyelonephritis) are category B3 a) Is not as permanent as male sterilisation
drugs in pregnancy and should be avoided. Amoxycillin
and Cephalexin are both category A in pregnancy, b) Is not effective immediately
however amoxycillin is only recommended if
susceptibility of the organism is proven. Erythromycin is c) Is totally functionally reversible
also category A but unsuitable in the management of
d) May be followed by a reduced testosterone
urinary tract infections.
level

e) May result in a reduced volume of semen


Question 28 production

May was found at home in a coma and brought into


hospital, where she is now recovering well. May is 80
Answer: B
years of age, and she has been well most of her life, but
in the last 5 years she has gained about 10kg in weight. Vasectomy is sterilisation of the male and it involves a
During the past week or two, before she was brought small incision in the scrotal skin under local anaesthetic.
into hospital, May has been tired, sleepy, 'dry as a chip', The vas deferens is separated from its blood supply and
forever running to the toilet to pass urine, and yet she approximately 1cm of it is removed between ligatures.
had been unable to drink enough to satisfy her thirst. Post-vasectomy it takes up to 3 months for the sperm to
What was the MOST LIKELY diagnosis when May was be eliminated from the ejaculate (the volume of sperm
brought into hospital? in the vas deferens between the point of excision and
the tip of the penis). Vasectomy is to be considered
a) Diabetic ketoacidotic coma
irreversible as microsurgery may repair the vas
b) Hypoglycaemic coma deferens, but sperm function may never return ( due to
the production of sperm antibodies). There is no change
c) CVA with coma to male testosterone levels, balding patterns or libido.

d) Hyperosmolar non-ketotic coma

e) Hypothyroid crisis Question 30

Pamela, an 18 year old first year music student,


complains of disabling anxiety. She says she has always
Answer: D been 'nervous in front of strangers', but her problem has
been aggravated since she started her music studies.
Hyperosmolar non-ketotic coma (HONC) occurs in
She feels well during the weekend, but is very anxious
elderly patients with Type 2 diabetes mellitus, but the
during the week, and wonders whether she should
history of diabetes is usually unknown. It has an
withdraw from the course. Her main problem is fear of
insidious onset that includes polyuria and polydipsia,
solo performances. Her tutor requires all students to
severe dehydration, and an impaired level of
perform solo each week without prior warning for of a
consciousness, which correlates with plasma osmolality.
group of staff members . Pamela finds this very
Coma is usually associated with an osmolality
unnerving. She cannot think or play properly under
>440mmol/l. Respiration is usually normal. Patients
these conditions, and has 'frozen' and burst into tears
may rarely present with a CVA, seizures or an MI, but
on more than one occasion. Which of the following is the
the underlying disorder is primarily diabetes. Blood
most likely diagnosis?
glucose is usually >40mmol/l, there is severe
hypernatraemia and dehydration, with a relatively a) Generalised anxiety disorder
normal arterial pH, unless there is coexisting lactic
acidosis. Rehydration and insulin are the mainstays of b) Panic disorder
treatment and causes of infection should be sought as
well as ECG changes consistent with infarct or c) Phobic disorder
ischaemia. Diabetic ketoacidotic coma only occurs in
d) Obsessive compulsive disorder
Type 1 diabetes. Hypoglycaemic coma has more rapid
onset than HONC. The preceding symptoms of e) Posttraumatic stress disorder
Answer: C b) Mandy will develop renal failure within 12
hours
The features of phobic disorder are (a) a marked
persistent fear of objects or situations, exposure to c) Mandy should be given oral methionine
which provokes an immediate anxiety reaction that may
take the form of a panic attack; (b) avoidance behaviour d) Other commonly prescribed medication
to avoid the phobic stimulus; and (c) anxiety is taken at the time of a paracetamol overdose
provoked only in specific situations. Pamela has a social will not alter subsequent liver damage
phobia, characterised by fear of social or performance
e) FFP (fresh frozen plasma) is the treatment of
situations, where she is exposed to unfamiliar
choice when the prothrombin time is abnormal
individuals, or to possible evaluation by others.
following paracetamol overdose
Medication with selective serotonin reuptake inhibitors
(SSRIs) may be helpful, but the mainstay of
management is behaviourally focussed psychotherapy.
Generalised anxiety disorder, panic disorder, obsessive Answer: A
compulsive disorder and posttraumatic stress disorder
are other anxiety disorders each with its characteristic N-acetyl cysteine (iv) is given to all severe paracetamol
presentation. overdoses (>10grams) presenting with symptoms or
abnormal investigations (liver function tests (LFTs),
prothrombin time (PT)). All patients with paracetamol
plasma levels on or above the "Normal" treatment line
Question 31 (when plasma paracetamol levels are plotted against
time in hours), presenting up to 24hours following
Alison has been taking the tricyclic antidepressant drug
ingestion, should also be given N-acetyl cysteine. Only
(TCAD) amitriptyline for 6 years. She started taking it
patients presenting within 10-12 hours, who are allergic
when her husband John passed away with cancer. Alison
to N-acetyl cysteine, should be given oral methionine.
is "much better" now, as she has adapted to life without
Oliguria and renal failure generally occur late (day 3
John. She is sleeping well, her appetite has returned,
following ingestion) following paracetamol overdose.
and even though she still desperately misses John, she
However 10% of patients develop acute renal failure
no longer avoids neighbours and friends, and she feels
from acute tubular necrosis. Vitamin K, 10mg, given
less like crying every minute of the day. Alison stopped
intravenously (iv) is preferable in paracetamol overdose
her amitriptyline suddenly last week without
and FFP (fresh frozen plasma) should be avoided, unless
consultation with her doctor. Which of the following is
there is active bleeding. FFP may make future
NOT common after abrupt cessation of TCADs?
management, including liver transplant more difficult.
a) Cholinergic activation - abdominal cramps, Patients on enzyme-inducing drugs (e.g. phenytoin,
diarrhoea and vomiting carbamazepine, rifampicin, phenobarbitone) or those
who are malnourished (e.g. anorexia, alcoholism)
b) Sleep disturbance - insomnia and vivid develop paracetamol toxicity and require intervention at
dreams lower plasma paracetamol levels than previously healthy
patients on no enzyme-inducing medications.
c) Somatic distress - flu-like symptoms and
headache

d) Cardiovascular symptoms - palpitations and Question 33


arrhythmias
Shamila is a 16 year old schoolgirl who consults you
e) Psychiatric symptoms - anxiety and agitation because she is very unhappy at home and says she is
considering suicide. You assess her as being clinically
depressed. Which ONE of the following strategies would
you adopt NEXT to deal with the threat of suicide in this
Answer: D
case?
All the other options are withdrawal syndromes
a) Refer Shamila to a psychiatrist
associated with withdrawal from tricyclic antidepressant
drugs. TCADs can cause adverse effects such as b) Referral to a local mental health crisis team
orthostatic hypotension, conduction defects and
arrhythmias while they are being used. However upon c) Admit Shamila urgently to the psychiatric
withdrawal of TCADs cardiovascular symptoms are not ward of the local hospital
common. Withdrawal from benzodiazepines is more
likely to be associated with cardiovascular symptoms d) Ask Shamila if she has made any suicidal
including palpitations, flushing and hyperventilation. plans

e) Commence cognitive behavioural therapy


immediately
Question 32

Mandy ingested 30grams of paracetamol 18 hours ago,


and she is slightly nauseous and tearful but otherwise Answer: D
asymptomatic. Mandy is an adult Caucasian female, 65
When patients have suicidal thoughts, the treating
kg, with no pre-existing illnesses. She is a non-smoker,
doctor should take careful note of the context. Patients
does not drink alcohol and is on no other medications.
who have made definite plans to commit suicide, or who
She has no known allergies. You ordered some
have obtained the means with which to carry it our, e.g.
investigations when Mandy arrived at the hospital and
a weapon, are at much greater risk of killing themselves
they show that she has elevated hepatic transaminases
than those who have simply contemplated the matter in
(ALT, AST), prolonged prothrombin time and
theory. In cases where there is serious intent to commit
hypoglycaemia. Which of the following is TRUE?
suicide, the patient should be regarded as seriously
a) Mandy should be given N-acetyl cysteine depressed and referred for urgent specialist attention.
How this is achieved will differ in different areas. In
some cases the best approach may be to refer the Answer: D
patient to the local mental health crisis team. Where
such a team does not exist, urgent referral to a The Mini Mental State Examination is the appropriate
psychiatrist or urgent admission to a psychiatric facility test to examine the patient's orientation. It will detect
is indicated. cognitive impairment, whether due to dementia,
depression or delerium. Differentiating these three
conditions will usually be possible by a thorough history
and examination.
Question 34

Marty is a 42 year old man who presents complaining of


chronic headaches. He says he has come to see you only Question 36
because his wife insisted. On questioning he is not very
informative but admits to having a few beers after work Tom is a 65 year old man who presents with fatigue and
most days. On examination you note his complexion is poorly localised muscular aches and pains in the back
flushed, there is facial telangiectasia and some and legs. You suspect that he may be depressed but he
periorbital puffiness. His BP is 150/95 mm Hg. You denies feelings of depression. Which of the following
suspect that Marty's problems relate to hazardous alternatives would be the BEST way of confirming your
drinking. Which ONE of the following strategies would be preliminary diagnosis?
best for obtaining confirmation of your suspicions?
a) Discuss Tom's symptoms with his wife
a) Confront Marty outright and demand the
b) Administer a standardised depression
truth about his drinking
questionnaire
b) Phone Marty's wife while he is with you and
c) Undertake a therapeutic trial of
ask her about his drinking
antidepressant medication
c) Administer an Alcohol Use Disorders
d) Refer Tom to a psychiatrist
Identification Test (AUDIT)
e) All of the above
d) Take a blood sample for a carbohydrate
deficient transferrin (CDT) test

e) Take a blood sample for a blood alcohol Answer: B


concentration (BAC) measurement
A number of standardised questionnaires are available
for the detection of depression. Among the simplest are
those promoted by the Beyond Blue website, designed
Answer: C
to assist GPs in the diagnosis of depression, viz the K10
Patients with a drinking problem often do not openly and SPHERE questionnaires. The other options could all
acknowledge how much they are drinking, so other be helpful but are not recommended diagnostic
means have to be employed to determine whether they strategies in themselves. Referral to a psychiatrist is
are drinking hazardously. The best approach is to only recommended for problematic or severe cases.
administer a questionnaire (such as AUDIT or CAGE)
which explores the patient's drinking pattern and its
potential effects on his/her life. Obtaining corroborative Question 37
information from family members is also helpful but
should not be the main approach to obtaining Molly is a 34 year old woman who presents with chronic
information. Laboratory tests are also useful but there is back pain following a fall at work one year ago. She is
a considerable incidence of false seeking a repeat prescription for oxycodone
(Oxycontin), a powerful long-acting opiate analgesic.
negatives. The CDT test is relatively insensitive - it She is not receiving any other mode of treatment and is
requires a consumption level of 60 or more g of alcohol not undertaking back exercises. Molly is a trained nurse
per day to record a positive result. The BAC will only be but has been unemployed since the accident because of
positive if the patient has been consuming alcohol disabling pain and is seeking a disability pension. What
during the preceding hours before the test. would be the most appropriate NEXT STEP toward
solving Molly's problem?

a) Provide a repeat prescription to reduce the


Question 35
number of times she needs to come to see you
Myra is an 80 year old woman who is brought to your
b) Help her complete the necessary paperwork
consulting room by her daughter and son-in-law who are
for the pension
concerned that she may have dementia because of her
increasing forgetfulness. Which ONE of the following c) Detail her drug use and assist her to switch
initial strategies would be best to determine whether to non-narcotic analgesia
Myra may have dementia?
d) Refer her to a multi-disciplinary pain clinic
a) Take blood to measure thyroid function
e) Encourage her to begin back strengthening
b) Do a thorough neurological examination exercises
c) Do a general physical examination including
urinalysis
Answer: D
d) Establish rapport and administer the Mini
Mental State Examination Molly's problem is chronic because of its duration. Her
case raises several issues: (i) How severe is her pain
e) Take a medication history and administer and does she really need a powerful analgesic? (ii) Is
the Alcohol Use Disorders Identification Test she misusing her prescription because she has become
dependent? (iii) What is the best approach to her Answer: A
problem? The best way of answering these questions is
to refer her to a multi-disciplinary pain clinic, where she The next step is to confirm or dispel your suspicions of
can obtain the benefit of assessment and advice by domestic violence by directed but non-judgemental
appropriate experts, as necessary, e.g. orthopaedic questions about the domestic situation, in particular how
surgeon, anaesthetist (specialising in pain Cherie and her husband work out disagreements;
management), psychiatrist. The other options could whether she feels safe at home, and so on. It is
assist but are unlikely to provide a solution to Molly's preferable to question both parties if possible. Once a
problems. diagnosis of domestic violence is made, it is important to
establish a supportive doctor-patient relationship and
formulate a safety plan with the victim, including
provision of information about abuse, the likelihood of
Question 38 recurrence, access to shelters and support groups etc.
The option of informing the police and State authorities
Roberto is a 67 year old patient who is depressed
should be discussed and appropriate action taken
following the recent death of his wife, and has moved to
according to the circumstances of the case. The prime
live with his daughter and son-in-law, because of
consideration in domestic disputes is the safety of the
difficulty in coping with living alone. You prescribe
victim and the children.
fluoxetine, a selective serotonin reuptake inhibitor
(SSRI), but after 6 weeks of treatment, Roberto is still
depressed. What is the MOST LIKELY reason for
Roberto's failure to respond? Question 40

a) A different SSRI would have been effective Muriel is an 85 year old nursing home resident. The
nursing staff are concerned about her, as she has
b) SSRIs are not the appropriate type of drug vomited several times today and this afternoon
for this patient complains of abdominal pain. She is not clear about its
location, but it appears to be right-sided. She does not
c) He has severe depression requiring specialist
have a fever. Which of the following statements is
management
CORRECT?
d) He has psychotic depression requiring
a) It is important to have a high index of
electroconvulsive therapy (ECT)
suspicion for gall bladder disease
e) His bereavement and loss of independence
b) Muriel has early gastroenteritis
have not been dealt with
c) Appendicitis is less common in elderly
patients, but the risk of perforation is
Answer: E
also low
In patients like Roberto, psychological reactions to
d) The most likely diagnosis is mesenteric
changed life conditions are likely to play an important
ischaemia
part in the causation of depression. He has suffered
bereavement and the loss of his independence, both of e) Muriel probably has diverticulitis, as 85% of
which are likely to be significant factors. Hence , cases involve the ascending colon
psychological approaches to management (e.g. cognitive
behavioural therapy) are more appropriate.

Answer: A

Question 39 Elderly patients may present very differently from their


younger counterparts and their abdominal pain is
Cherie is a 38 year old married woman with two young frequently misdiagnosed. However, approximately 35-
children. She consults you because of anxiety which she 50% of patients older than 65 have gallstones, and may
attributes to 'the kids getting on my nerves.' You notice have associated biliary tract disease. The mortality rate
that she has a black eye and bruising of her left for elderly patients with cholecystitis is approximately
forearm, consistent with a defence injury. When asked 10%, so a high index of suspicion for gall bladder
for an explanation, she says she walked into the door of disease is important, especially as symptoms and signs
an open cupboard in the dark, when getting up to attend are often not classical. Although relatively common, a
to the younger child at night. You suspect domestic positive diagnosis of gastroenteritis should only be made
violence. What is your next step in making a diagnosis? after other potential causes have been considered and
rejected.- Gastroenteritis in this age group should be a
a) Non-judgemental questioning about
'diagnosis of exclusion'. Appendicitis is less common in
domestic conditions
the elderly, with only 10% of cases being in the over 60
b) Report suspicions to the police age group. However, the risk of perforation is
approximately 50%. Mesenteric ischaemia is rare, but
c) Report suspicions to relevant State authority has a high mortality. Vomiting and diarrhoea are often
present, but the pain in this condition is severe.
d) Provide information about shelters and Diverticular disease is common in the elderly, but
support groups diverticulitis- involving at least micro-perforation of the
colon, - occurs in 85% of cases in left(descending)
e) Offer family counselling
colon.
Block 6

Question 1 Answer: B
A 35 year old primigravida who's pregnancy had been Pityriasis rosea is a common mild acute inflammatory
uncomplicated, presents at 36 weeks with moderate condition of the skin mainly affecting young adults. The
oedema, BP155/95 mm Hg and ++ proteinuria. Which cause is unknown, but a virus is suspected. The oval
ONE of the following measures would you recommend? salmon-pink or copper-coloured eruptions with scaly
margins are confined to the trunk and upper limbs and
a) Bed rest for the remainder of pregnancy are often arranged along the skin creases (resulting an
b) Induction of labour without further delay an appearance of a Christmas tree). Itching is usually
mild. Lesions may be preceded by a 'herald patch' and
c) Vigorous antihypertensive therapy disappear spontaneously in 4-10 weeks. For information
on the other options see the references below.
d) Review again at 37 weeks

e) Urgent referral to a specialist obstetrician


Question 4

Bill is a 52 year old man who presents with nocturnal


Answer: E heartburn that has left him exhausted due to lack of
sleep. Which of the following statements is CORRECT in
This is a high risk patient on two counts, viz. her age at
relation to his gastroesophageal reflux disease (GORD)?
first pregnancy and the fact that she has pre-eclamptic
toxaemia. These require specialist management in the a) Gastric acid hypersecretion is present in all
latter stages of pregnancy and delivery. such patients

b) Disturbed oesophageal motility increases his


risk of oesophagitis
Question 2
c) H2 receptor antagonists are the preferred
Which of the following conditions is FREQUENTLY
medical management
associated with prerenal acute renal failure?
d) Maintaining an oesophageal pH of less than
a) Acute pyelonephritis
3 is optimal
b) Severe dehydration
e) Bile salts are as deleterious to the
c) Rhabdomyolysis oesophageal lining as gastric acid

d) Prostatic hypertrophy

e) Renal artery obstruction Answer: B

The common denominator for virtually all episodes of


gastroesophageal reflux is the loss of the normal
Answer: B gastroesophageal barrier to reflux. This is usually
secondary to a transient or permanent loss of lower
Prerenal acute renal failure is caused by underperfusion oesophageal sphincter resistance (eg. Gastric distension
of the kidneys, e.g. due to dehydration, haemorrhage or with air or food, increased intragastric or intraabdominal
shock. Acute pyelonephritis, rhabdomyolysis and renal pressure, and delayed gastric emptying). Disturbed
artery obstruction are causes of intrinsic acute renal oesophageal motility allows prolonged exposure of the
failure, i.e. the cause lies in the kidney. Prostatic oesophageal lining to acidic fluids which is a major risk
hypertrophy is an example of a postrenal cause of acute factor in the development of oesophagitis in GORD.
renal failure, due to obstruction to the outflow of urine. Gastric acid hypersecretion may be present in some
cases. The preferred medical management when
significant symptoms are present is the use of a proton
Question 3 pump inhibitor which will help to maintain the
oesophageal pH above 4. Bile salts reduce the resistance
This 22 year old girl presents with a rash on her trunk of the oesophageal lining, but are not as deleterious as
which has been present for three days (see figure). It is gastric acid.
mildly itchy. What is the MOST LIKELY diagnosis?

a) Lichen planus
Question 5
b) Pityriasis rosea
Edith is a 75 year old woman who complains that her
c) Lichen simplex eyesight isn't as good as it used to be. While testing,
you notice a lens opacity. Edith has well-controlled Type
d) Atopic dermatitis 2 diabetes and has a past history of polymyalgia
rheumatica 20 years ago. She has osteoarthritis of the
e) None of the above
knees managed with intermittent NSAID therapy. Which
of the following is the MOST significant factor in the Answer: B
development of her cataract?
Difficulty swallowing (or dysphagia) is a functional
a) Advancing age problem and a barium swallow is preferable to an
endoscopy in this instance. Observations on the barium
b) Diabetes mellitus swallow may suggest oropharyngeal or cricopharyngeal
dysfunction (including misdirection of barium into the
c) Steroid therapy
trachea or nasopharynx), prominence of the
d) Radiation cricopharyngeal muscle, a Zenker's diverticulum or a
narrow pharyngeo-oesophageal segment. Disordered
e) Trauma
oesophageal motility or structural abnormalities such as
small diverticula, webs, and minimal extrinsic
impressions of the oesophagus may be recognised only
Answer: A with motion-recording techniques.
Although all the options increase the chance of
cataracts, the most significant factor is advancing age.
About 50% of 65-74 year olds have lens opacities Question 8
increasing to 70% of those 75 years and over.
Francesco is a 52 year old man with a history of
rheumatic fever as a child. He presents with shortness
of breath on exertion without orthopnoea or discomfort
Question 6 at rest. His echocardiogram demonstrates an isolated
mitral stenosis of moderate severity. A typical finding on
Leigh is a 60 year old woman who has been
cardiac catheterisation would be:
hypertensive for 5 years. Her BP now is 160/115 mm
Hg. Recently she has been getting increasingly short of a) Normal left atrial and normal left ventricular
breath. Clinical assessment confirms congestive cardiac diastolic pressures
failure. Which of the following drugs would be preferred
for management? b) High left atrial and normal left ventricular
diastolic pressure
a) Propranolol
c) High left atrial and high left ventricular
b) Verapamil diastolic pressures
c) Diltiazem d) Right ventricular hypertrophy
d) Lisinopril e) Left ventricular hypertrophy
e) Felodipine

Answer: B
Answer: D Mitral stenosis of moderate severity indicates narrowing
of the mitral valve orifice area from 5cm to 2cm
Linisopril is an angiotensin converting enzyme inhibitor
squared. This results in an increased left atrial pressure
(ACEI). This is the treatment of choice, as it lowers
and dilatation of the left atrium but a normal left
systemic vascular resistance and venous pressure and
ventricular pressure. Eventually pulmonary vascular
reduces the levels of circulating catecholamines, thus
pressures may rise with associated worsening of
improving myocardial performance. It is important to
symptoms and
observe for first-dose hypotension. Calcium channel
blockers (e.g. verapamil, diltiazem) may have a then right ventricular hypertrophy may ensue.
detrimental effect on left ventricular function in patients
with heart failure. Non-selective beta blockers such as
propranolol are not well tolerated in heart failure.
However third generation beta blockers such as Question 9
carvedilol as well as beta-1 selective agents metoprolol
Jean, a 52 year old woman, presents with hot flushes
and bisoprolol improve symptoms and exercise tolerance
related to menopause. She has noted a recent loss of
as well as lowering the risk of progression of heart
libido. Which of the following statements concerning the
failure and death. They are started once the ACEI dose
effects of menopause on libido is INCORRECT?
is stable and fluid status is optimal. The beta blocker
starts at a very low dose and is slowly titrated up. a) Sleep deprivation, secondary to hot flushes
and night sweats, can lead to depression

b) Vaginal dryness and painful intercourse due


Question 7
to oestrogen deficiency are common
In which of the following situations would a barium
c) As the menopause approaches, erratic
swallow be preferable to an endoscopy as a FIRST LINE
periods or menorrhagia may impact on sexual
investigation?
desire
a) Patient complains of coughing after meals
d) Oestrogen deficiency heightens sensitivity to
b) Patient complains of difficulty swallowing touch stimuli, causing pain and discomfort

c) Patient with nocturnal symptoms only e) Reduced muscle tone of the pelvic floor can
affect orgasm
d) Patient with bloating after meals

e) Patient has water-brash


Answer: D Answer : C

Clinical manifestations of oestrogen deficiency include: Gastroesophageal reflux is caused by a transient or


permanent loss of lower oesophageal sphincter tone. As
1. Variable length of menses - erratic, frequent a consequence, it more often occurs after meals.
or prolonged - which can impact on sexual Controlling acid secretion at all times with a proton
desire pump inhibitor is the medical treatment of choice. The
other factors may play a role but are not the most
2. Hot flushes and night sweats, which can important.
cause chronic sleep deprivation and potentially
depression

3. Vaginal atrophy which can lead to vaginal Question 12


dryness, dyspareunia and secondary
vaginismus due to fear of intercourse Which of the following describes an ependymoma?

4. Urethral/bladder atrophy and loss of pelvic a) A benign skin lesion of the face
floor muscle tone, which can cause urethral
b) A central nervous system tumour
incontinence. Loss of pelvic floor muscle tone
can also reduce vaginal sensitivity and muscle c) A cystic structure in the upper eyelid
contractions involved in orgasm
d) A patch of discoloured skin
5. Touch aversion or reduced sensitivity to
touch stimuli in genital tissues e) A visible defect in the iris

Question 10 Answer : B

Which of the following statements is CORRECT? In Ependymomas are central nervous system tumours
motor neurone disease there is: affecting the brain and spinal cord, derived from the
single layer of cells (the ependyma) lining the ventricles
a) A long history of remissions and and spinal canal.
exacerbations

b) Sensory loss following a dermatomal


distribution Question 13

c) Focal epilepsy A healthy six year old child without cyanosis or


dyspnoea on exercise is examined for migration to
d) Sparing of lower motor neurons Australia. His pulse is 84 per minute, B.P. 100/60, radial
pulse and jugular venous pressure normal and there is
e) Involvement of upper and lower motor
no evidence of cardiomegaly. On auscultation in the 2nd
neurons
left intercostal space the 1st and 2nd heart sounds are
audible with fixed splitting of the 2nd heart sound and a
midsystolic pulmonary ejection murmur is heard. The
Answer : E MOST likely diagnosis is:

The commonest form of motor neurone disease is a) Pulmonary stenosis


amyotrophic lateral sclerosis (ALS), a sporadic condition
of unknown cause characterised by relentless b) Atrial septal defect (ASD)
progressive degeneration of upper and lower motor
c) Innocent pulmonary ejection murmur
neurones in the spinal cord, the somatic motor nuclei of
the cranial nerves and the motor cortex of the brain. d) Ventricular septal defect (VSD)
The sensory system is not involved. Remission in this
disease is unknown. e) Patent ductus arteriosus (PDA)

Question 11 Answer : B

Joan is a 46 year old woman who has a long past history In an asymptomatic patient an ASD is often diagnosed
of bloating and water brash. She usually takes an as a loud P2 with fixed splitting and an ejection murmur
antacid after her meals. In your advice to Joan you heard in the pulmonary area due to increased blood flow
to the right heart. A VSD large enough to produce these
would explain that the MOST important factor in signs would be symptomatic and usually would cause
managing moderate and severe reflux is: cardiomegaly. Innocent pulmonary ejection murmurs do
not cause fixed splitting of P2, and a PDA causes a
a) Avoidance of alcohol with meals
continuous murmur. In pulmonary stenosis P2 is often
b) Avoidance of spicy food soft or inaudible and the JVP is usually elevated.

c) 24-hour control of acid secretion

d) Limitation of the size of meals

e) Not lying down too soon after meals


Question 14 Answer: B

Female androgen insufficiency syndrome includes all of A wet saline mount is 30-80% sensitive for Trichamonas
the following EXCEPT: vaginalis in symptomatic women. A drop of vaginal
discharge is placed on a slide with 1-2 drops of normal
a) Persistent fatigue saline and examined under high power (x 400). The oval
or flagellated protozoan is seen among a large number
b) Reduced body hair
of white blood cells and epithelial cells. Its erratic,
c) Decreased libido twitching motility may be precipitated by warming the
slide, thus distinguishing it from the similarly sized
d) Blunted motivation polymorphs. Culture is 95% sensitive especially in
asymptomatic men and women, but not widely available
e) Dysphoria and results take 7 to 10 days. Trichomonads are often
reported on Pap smears from the cervix with a
sensitivity of 60 to 70%. However a high false positive
Answer : B rate means further testing is necessary to confirm the
diagnosis. Management involves treatment with
Reduced body hair is not a feature of female androgen metronidazole or tinidazole 2G stat orally. Contacts
insufficiency. The syndrome includes: should also be treated and evaluated for other sexually
transmitted infections.
1. Diminished sense of well being, dysphoric mood
and/or blunted motivation

2. Persistent, unexplained fatigue Question 17

3. Decreased libido, pleasure and sexual receptivity Yee Leng, aged 40 years, is a new patient in your
practice. She tells you she has been experiencing
4. Potential bone loss, decreased muscle strength, migraine headaches for a number of years. Which of the
changes in cognition/memory following features would NOT be consistent with
migraine as a cause of her headaches?

a) Numbness or tingling in one arm and hand


Question 15
b) A headache which lasted 10 days
The SINGLE MOST important diagnostic sign of
developmental dysplasia of the hip in the neonatal c) Pain behind one eye radiating to the neck
period is?
d) Bilateral pain
a) An unusually wide perineal region
e) Vertigo lasting about 30 minutes
b) Asymmetrical skin folds in the thighs

c) Failure of the thighs to abduct readily


Answer: B
d) Failure of the thighs to externally rotate
Migraine attacks can last from hours (most common) to
e) A clunk on abduction of the flexed thigh days, but never weeks. There are several different
clinical patterns of migraine. Attacks can vary from
intermittent headaches, indistinguishable from tension
Answer: E headaches, to discrete episodes that mimic
thromboembolic cerebral ischaemia. Symptoms may
On examination of the newborn a clunk or jerk noticed include visual auras, nausea, vomiting, tingling,
on abduction or adduction of the flexed thigh is generalized headache, vertigo and transient
suggestive of developmental dysplasia of the hip hemiparesis.
(previously called congenital dislocation of the hip).
Ultrasound examination gives useful information as to
the relationship of the femoral head to the acetabulum Question 18
and the existence of any acetabular dysplasia during the
first 3 months of life. If not diagnosed in the neonatal Betty, who is aged 29 years and nulliparous, comes to
period the older child presents with an abnormal gait, a you for a routine Pap smear. The cervix looks healthy
shortened leg on the affected side, asymmetrical and there are no abnormalities on clinical examination.
abductor creases, restricted hip abduction (especially in A week later she returns for the pathology result which
flexion) and a positive trendelenberg's sign. is reported as: 'Abnormal cells are present, consistent
with a diagnosis of carcinoma in situ CIN 3.' What is the
implication of this result?
Question 16
a) Betty has malignancy of the cervix and
To optimise management, trichomoniasis is MOST requires radiotherapy followed by hysterectomy
effectively identified by: and clearance of lymph nodes

a) Cytological examination of a cervical smear b) Betty has a malignancy of the cervix and
hysterectomy is required
b) Microscopic examination of a 'wet prep'
c) The smear should be repeated after Betty
c) Stained smear of vaginal discharge has applied clindamycin vaginal cream for 7
days
d) Culture of vaginal discharge
d) Betty requires a cone biopsy
e) Histological examination of a punch biopsy of
vaginal mucosa e) Betty requires a colposcopy
Answer: E Question 21

Betty needs referral to a gynaecologist for colposcopy Bill, aged 45 years, has been experiencing headaches on
and directed biopsy with definitive treatment if CIN 3 is and off for 5 years. Over the past 2-3 weeks he feels
confirmed. that he has had an almost continuous headache. Which
of the following features would make you suspect a
tension-type headache?
Question 19 a) He is unable to continue with daily work
Mary aged 29 years, has suffered from migraines for b) The headache wakes him in the middle of
three years. She is keen to reduce the frequency of the night
attacks and asks about trigger factors. Which of the
following advice would you NOT offer her? c) It is very rarely bilateral

a) Use relaxation techniques to manage stress d) It is usually bifrontal or bioccipital

b) Eliminate known dietary triggers eg. e) He suffers associated nausea


Chocolate, red wine, MSG

c) Maintain a regular sleep pattern


Answer: D
d) Restrict time watching television to less than
2 hours a day Tension headaches are often bifrontal or bioccipital.
They are believed to be a result of tension within the
e) Avoid oestrogen-containing oral scalp muscles. These headaches are always innocent
contraceptives and can be associated with tight band sensations,
pressure behind the eyes, and throbbing and bursting
sensations. Precipitating factors include worry, noise,
concentrated visual effort, fumes or depression. There
Answer: D
are no abnormal physical signs, other than tenderness
There is no known link between watching television and and tension in the nuchal and scalp muscles.
migraine, except that some programs may be stressful.
The other options refer to recognised trigger factors.
Question 22

George is a nineteen year old man who presents with


Question 20
dysuria. On examination there is a thick yellow urethral
Which of following statements about syphilis is discharge. Which ONE of the following is CORRECT with
CORRECT? regard to gonococcal infection?

a) Syphilis is only acquired through sexual a) Urine PCR is now the gold standard for
contact diagnosing gonococcal urethritis

b) The typical primary lesion of syphilis is a b) Spread to involve the prostate and
painful, hard ulcer on the genitalia epididymis is common

c) Definitive diagnosis is by culture of fluid from c) The incubation period is usually 14 to 21


the ulcer days

d) Signs of secondary syphilis include d) Ceftriaxone IM as a single dose is an


mucocutaneous lesions and non tender effective treatment
lymphadenopathy
e) Pharyngeal gonorrhoea is diagnosed by
e) Once treated there is no need for follow up finding Gram-negative diplococci on a smear

Answer: D Answer: D

Secondary syphilis is marked by mucocutaneous lesions Routine treatment for gonococcal infection is either with
and non tender lymphadenopathy. Syphilis may be ceftriaxone 250 mg IM as a single dose or ciprofloxacin
acquired by skin to skin nonsexual personal contact and 500 mg orally as a single dose. The symptoms of
transplacental infection. The primary lesion of syphilis is gonococcal infection usually appear within 2 to 10 days
a painless, hard chancre on the external genitalia. The of infection, but the incubation period is sometimes
traditional, preferred testing method is dark-field much longer, and some men never develop symptoms.
microscopy. Specimens are taken from active lesions In men, infection can spread to the prostate gland,
and examined directly. Serology should always be taken epididymis, and the testes, although this is not common.
to diagnose syphilis. These tests are complex and Gram-stained smears are only sensitive and specific for
require expert interpretation. Serology is also used to urethral smears in symptomatic men. Culture is still the
monitor the effectiveness of treatment in syphilis. gold standard with >95% sensitivity and the ability to
Penicillin, given by injection, is a very effective test for antibiotic sensitivities. Since the organism dries
treatment. Repeated blood tests are necessary for at out quickly and is fairly fastidious, samples must reach
least a year after treatment to monitor possible the laboratory within 12 hours. PCR testing is validated
treatment failure. for endocervical and first catch urine specimens only but
fails to allow subsequent antibiotic sensitivity testing
which is significant in light of emerging quinolone Question 25
resistance. It has the advantage of not requiring live
organisms, being less invasive as a screening tool and John is a 35 year old man who has had four recent
enabling a check for chlamydia on the same sample. episodes of intense retro-orbital pain. You suspect
PCR tests are 90-100% sensitive and 98-100% specific. cluster headache. Which of the following features would
be LEAST consistent with this diagnosis?

a) He always vomits with the pain


Question 23
b) He has ipsilateral nasal stuffiness
Belinda, aged 44 years, presents complaining of heavy,
prolonged periods (menorrhagia) and severe period pain c) He notices a drooping of the eye on the
(dysmenorrhoea) that has gradually become worse same side as the headache
during the past year. Her periods are still quite regular.
d) Three of the episodes occurred within 2 days
Which of the following possible causes is UNLIKELY?
e) Episodes seem to last from 10 minutes to 2
a) Adenomyosis
hours
b) Endometriosis

c) Uterine cancer
Answer: A
d) Fibromyoma
Cluster headaches are recurrent bouts of excruciating
e) Ovarian failure pain centred around one eye and lasting for minutes to
hours. The affected side of the face and nostril feel
congested. Commonly, there is a transient ipsilateral
Horner's Syndrome. Vomiting may be associated, but is
Answer: E not always present.
Ovarian failure presents as irregularity and scarcity of
menstruation, rather than menorrhagia and
dysmenorrhoea. Adenomysosis, endometriosis, uterine Question 26
cancer and fibromyoma are all possible causes of
menorrhagia and secondary dysmenorrhoea. Other In the treatment of persistent tension-type headaches,
causes include uterine polyps, intra-uterine in which mild analgesics and relaxation techniques are
contraceptive devices, pelvic inflammatory disease and insufficient, which of the following medications would be
cervical stenosis. MOST suitable?

a) Propranolol 40mg at night

Question 24 b) Paroxetine 20mg in the morning

Martha is a 20 year old woman who presents with a c) Amitriptyline 10-75mg at night
vaginal discharge, bilateral painful vesicles and ulcers on
d) Diazepam 2-5mg at night
her external genitalia. There is tender inguinal
lymphadenopathy. She also has systemic symptoms, e) Carbamazepine 100-200mg twice a day
including headache, myalgia and a temperature of 38.5
degrees Celsius. Which of the following is CORRECT?

a) Antiviral agents eradicate the virus Answer: C

b) Antiviral agents have no effect on recurrence In patients in whom simpler treatments, such as
paracetamol, and relaxation techniques, have failed,
c) Antiviral agents do not hasten healing amitriptyline (10-75 mg) at night is indicated in the
treatment of persistent tension headaches. The other
d) Topical lignocaine is beneficial for the pain
medications listed are not indicated. Diazepam (short
e) The primary aim is to keep the lesions clean term use) may be effective in middle-aged men, but
and dry generally should be avoided because of risk of
dependence.

Answer: E
Question 27
This scenario is typical of primary genital herpes. The
primary aim is supportive treatment by keeping lesions Which of the following describes the meaning of
as clean and dry as possible while spontaneous healing trismus?
occurs. Analgesics by mouth are often useful,
a) A grimace
particularly at night time. No treatment is available to
eradicate the virus, but antiviral agents reduce viral b) Tonic spasms of the jaw muscle
shedding from lesions, hasten healing and reduce the
risk of recurrence while being administered. The c) A triad of symptoms
recommended regimen is valaciclovir 500mg twice a day
for 5 days. Topical lignocaine and zinc creams should d) Paralysis of the tongue
not be used.
e) A facial tic
Answer: B Question 30

Trismus is the prolonged tonic spasm of the muscles of Which of the following statements about the
the jaw. It is an involuntary early sign of tetanus. management of chronic pain is INCORRECT?
Prolonged voluntary clenching of the jaw with teeth
grinding is called bruxism, and is associated with a) Depression is often an aggravating factor
emotional stress.
b) Antidepressants are only indicated in clinical
depression

Question 28 c) Psychological assessment is important to a


good outcome
James is a 32 year old man who presents two days after
experiencing his first epileptic seizure. He was well until d) A history of nerve damage may indicate
the seizure which occurred without warning. Since then neuropathic pain
he feels that his left leg has become weaker. James had
e) Opioid medication may be required for some
meningitis as a child, and two years ago sustained a
patients
fractured skull in a motor vehicle accident. There is a
family history of epilepsy (brother and an uncle have
epilepsy). Which of the following groups of
investigations is MOST likely to help in establishing the Answer: B
cause of James' epilepsy?
Antidepressant medication may be helpful in patients
a) Metabolic screen + EEG + plasma with chronic pain even if they do not have depressive
magnesium symptoms. These include patients with diabetic
neuropathy, tension headache, rheumatoid arthritis and
b) Metabolic screen + CT scan + plasma chronic low back pain.
magnesium

c) Metabolic screen + EEG + CT scan


Question 31
d) Metabolic screen + drug screen + EEG
In a child with chickenpox which of the following drugs
e) Metabolic screen + drug screen + CT scan is MOST LIKELY to cause Reye's syndrome?

a) Paracetamol
Answer: C b) Aspirin
A metabolic screen will detect biochemical causes, such c) Codeine
as electrolyte abnormalities, acid base disturbances,
hypocalcaemia etc. The EEG will help establish the d) Penicillin
diagnosis of epilepsy, classify the type and identify the
particular epilepsy syndrome. A CT scan will identify any e) Prednisolone
underlying structural abnormality, e.g. brain tumour. A
drug screen is only necessary if there is reason to
suspect drug abuse. Magnesium is one of the Answer: B
components of the metabolic screen.
Reyes Syndrome involves acute encephalopathy and
fatty infiltration of the liver following an acute viral
infection, including influenza and varicella. Foreign
Question 29
chemicals, especially salicylates (including aspirin), and
Which of the following statements about brain tumours intrinsic metabolic defects have also been implicated.
is CORRECT? The use of salicylates (eg aspirin) during an acute viral
illness such as chicken pox (varicella) increases the risk
a) Frontal lobe tumours present late of Reyes syndrome by as much as 35-fold.

b) Contralateral limb weakness or sensory loss


are due to frontal tumours
Question 32
c) Disturbances of speech are due to
nondominant temporal tumours Turner syndrome includes all of the following features
EXCEPT:
d) Impaired insight is due to midbrain tumours
a) Ovarian agenesis
e) Mood disturbances usually relate to tumours
in the parietal lobe b) Webbing of the neck

c) A predominantly "X0" sex chromosome


pattern
Answer: A
d) The possession of 45 chromosomes
Often frontal lobe tumours remain asymptomatic or
undiagnosed until they are very large, possibly because e) A chromatin-positive buccal smear
local dysfunction of this brain region causes subtle and
non-specific neurological or behavioural deficits.
Answer: E Question 35

Patients with Turner's syndrome characteristically have Mandy, a 4 year old girl, is due to accompany her
a 45 XO chromosome pattern, and streak gonads parents on a flight to England in two months time. Her
(ovarian agenesis). Characteristic features include short mother is worried about the effect of air travel on
stature, webbing of the neck, cubitus valgus, widely Mandy's ears. Which of the following will NOT increase
spaced nipples and puffy hands and feet. The range of the likelihood of ear pain during the flight?
intelligence is normal. A chromatin-positive buccal
smear requires two X chromosomes. One X chromosome a) A recent cold
is randomly inactivated early in embryogenesis.
b) Nasal congestion
Therefore, the buccal smear in Turner's syndrome does
not have a Barr body (ie it is chromatin negative). c) Hay fever

d) Recent otitis media


Question 33 e) Perforation of the ear drum
Sarah is an 8 week old girl who has persistent
regurgitation. Which of the following features suggests
the need for further investigation? Answer: E

a) Sarah is underweight for her age Normal function of the middle ear and tympanic
membrane is maintained by a patent eustachian tube
b) Sarah regurgitates after every meal which keeps the middle ear and external canal pressures
equal.
c) Sarah has episodes of uncontrollable crying
Blockage of the eustachian tube, e.g. with secretions as
d) Sarah arches her back on occasion and stops
in the common cold, results in pressure imbalances
feeding
between the middle and external ear. During air travel,
e) Sarah was born 2 weeks premature the resulting barotrauma may cause pain, deafness,
vertigo, and tinnitus. All the options listed, except (e),
can cause blockage of the eustachian tube.

Answer: A Question 36

Regurgitation after every meal suggests Sue, a three year old girl, presents with shortness of
gastroesophageal reflux, but of itself is not a worrying breath and wheeze that have developed over the last
feature. Underweight for age, however, suggests failure two days. Examination reveals an afebrile, moderately
to thrive and needs investigation. Unsettled and irritable tachypnoeic child with widespread scattered wheezes on
behaviour is very common in the first 6-12 weeks of life. auscultation. You decide to administer a bronchodilator
In isolation it is not a concern. (salbutamol). The recommended method of delivery of
salbutamol for Sue is:

a) Syrup
Question 34
b) Nebuliser
Which of the following is suggested by a history of
transient episodes of vertigo, slurred speech, diplopia, c) Breath activated inhaler
and paraesthesia in a man aged 65 years?
d) Metered dose inhaler with a spacer
a) Basilar artery insufficiency
e) Metered dose inhaler with a spacer and face
b) Anterior communicating artery aneurysm mask

c) Hypertensive encephalopathy

d) Pseudobulbar palsy Answer: E

e) Occlusion of the middle cerebral artery For the treatment of acute asthma in a child <6 years of
age, the recommended mode of delivery of
bronchodilator (salbutamol) is via a metered dose
inhaler and small volume spacer with face mask. For
Answer: A
those >6 years of age, a large volume spacer may be
Episodes of vertigo, diplopia and paraesthesia indicate substituted. Salbutamol administered via these routes
alteration of brainstem function caused by basilar artery has been shown to be equally effective to nebulised
insufficiency. Middle cerebral occlusions usually presents salbutamol. Six puffs of salbutamol via MDI and spacer
with contralateral hemiplegia and homonymous is the equivalent of a 2.5 mg nebule, while 12 puffs
hemianopia. Slurred speech or aphasia may occur in equals a 5mg nebule.
both conditions. Anterior communicating artery
aneurysms are likely to result in emotional lability.
Hypertensive encephalopathy comprises headache,
confusion, stupor or convulsions. Pseudobulbar palsy
presents with dysarthria, dysphagia and emotional
lability.
Question 37 Question 39

In acute iritis (anterior uveitis), the pupil is: The MOST common cause of persistent cough in children
is:
a) Eccentric, constricted and reacts briskly to
light a) Chronic post viral cough

b) Concentric, dilated and reacts briskly to light b) Asthma

c) Eccentric, dilated and reacts sluggishly to c) Post-pertussis


light
d) Gastro-oesophageal reflux
d) Concentric, constricted and reacts sluggishly
to light e) Passive smoking

e) Concentric, dilated and reacts sluggishly to


light
Answer: A

The commonest cause of persistent cough (particularly


Answer: D with a prominent nocturnal component) in children is
post viral. It can also be associated with postnasal drip.
Anterior uveitis typically presents with a unilateral However, care must be taken to exclude asthma which
painful red eye, blurred vision, photophobia and tearing. is a fairly common cause of persistent cough in children.
There is a perilimbal flush and pupillary miosis with a Other less common conditions to be considered include
sluggish response and increased pain during gastrointestinal reflux, passive smoking and post
accommodation to light. This is due to spasm of the pertussis.
ciliary body and iris muscles. Slit lamp examination will
demonstrate keratic precipitates on the cornea. Urgent
treatment is needed to prevent complications.
Question 40

Trevor is a 2.4 kg male infant with Apgars 9:10 after a


Question 38 normal vaginal delivery. He becomes jaundiced at 12
hours of age. Which of the following conditions would be
Oliver, an 8 month old boy, presents with a history of the MOST LIKELY cause of the jaundice?
anorexia and recurrent upper respiratory tract
infections. Physical examination reveals pallor and a) Gram negative septicaemia
splenomegaly. His blood picture shows a hypochromic,
b) Jaundice of prematurity
microcytic anaemia with numerous target cells and
nucleated red cells. What is the MOST LIKELY diagnosis? c) Biliary atresia
a) Thalassaemia major d) Physiological jaundice
b) Iron deficiency anaemia e) Rh incompatibility
c) Glucose-6-phosphate dehydrogenase
deficiency
Answer: E
d) Sideroblastic anaemia
Jaundice appearing in the first 24 hours of life is most
e) Sickle cell anaemia commonly due to haemolytic disease of the newborn
due to incompatibility to Rh, ABO or one of the other
rare antigens. Other causes of early jaundice include
Answer: A transplacental infections such as CMV, toxoplasmosis
and rubella. Jaundice of prematurity, physiological
Thalassaemia major (homozygous beta-thalassaemia) is jaundice and septicaemia present most commonly
a severe disease which presents during the first year of between days 2-5. Biliary atresia presents with jaundice
life with: failure to thrive, intermittent infection, severe after the first week of life.
hypochromic, microcytic anaemia and signs of
extramedullary haemopoiesis (hepatosplenomegaly and
bone expansion). It does not present at birth because
the production of foetal haemoglobin is not affected.
Block 7
Question 1 Answer: E
Mrs B is 55 years old and presents because of painful Intracerebral haemorrhages tend to be dramatic and
mouth ulcers (see figure). You diagnose aphthous accompanied by a severe headache. However, there
ulcers. She is otherwise well. Which of the following really is no clinical way of reliably distinguishing
statements about aphthous ulcers is INCORRECT? between an intracerebral haemorrhage and a
thromboembolic infarction, as both produce a sudden
a) The cause is rarely found focal deficit.
b) There is often a family history

c) The ulcers often begin in childhood Question 4


d) They are often an indicator of Behcet's Bel is 20 years old and has had a Type I allergic reaction
syndrome to a bee sting. She states that there is a family history
e) Aphthous ulcers may present like herpetic of bee sting allergy. Which of the following is NOT useful
vesicles advice for Bel?

a) Do not drink out of an open soft drink can


that has been left outdoors
Answer: D
b) Have a supply of antihistamines on hand
Behcet's syndrome is a systemic condition with
recurrent multiple apthous ulcers AND two of the c) Insect repellents are useful to prevent bee
following: - recurrent genital ulceration, eye lesions, stings
skin lesions or positive pathergy test (non-specific d) Do not walk barefoot around swimming
inflammatory skin reaction following intradermal saline pools
injection). Recurrent apthous ulceration in isolation is
not associated with Behcet's syndrome. The other e) Always carry an adrenalin 1:1000 injection,
statements concerning apthous ulcers are all true. e.g. EpiPen, and know how to use it

Question 2 Answer: C
The drug of choice for treatment of erysipelas is: Insect repellents have not been shown to be useful in
preventing bites from stinging insects. Anyone with a
a) Penicillin known allergy to stinging insects should know how to
b) Methicillin administer adrenalin 1:1000 subcutaneously and have it
with them at all times. EPIpen is a commercial
c) Ampicillin preparation which is supplied with an auto-injection
device. Avoiding behaviours likely to lead to a sting -
d) Tetracycline such as those mentioned in the options and avoiding
colourful clothes and perfumes which attract insects - is
e) None of the above
also important.

Answer: A
Question 5
Erysipelas is a form of superficial cellulitis of the skin
John is a 30 year old professional athlete who suddenly
with lymphatic involvement. It is almost always caused
develops persistent dull upper left chest pain which is
by Strep pyogenes and therefore the treatment of
not related to exertion. There are no associated cardiac
choice is penicillin (erythromycin or cephalexin can be
or respiratory features except for a mild restriction in
used in penicillin allergic patients).
breathing. John is afebrile and otherwise well. Which of
the following diagnoses is LEAST likely?

Question 3 a) Spontaneous pneumothorax

Which of the following criteria enable a clear distinction b) Functional chest pain
to be made between haemorrhage and thrombosis in a
c) Costo-chondral syndrome
patient with a cerebrovascular accident?
d) Muscle strain
a) The progress of the clinical features
e) Pleurodynia ( Bornholm's disease)
b) The degree of loss of consciousness

c) The abruptness of onset


Answer: E
d) The presence or absence of headache
Bornholm's disease is due to an infection by Coxackie B
e) None of the above
virus. It is often associated with an acute upper
respiratory tract infection with fever, pleuritic chest pain a) The causative organism is more likely to be
and upper abdominal pain. These pains can be severe bacterial than viral
and associated with tachypnoea. A spontaneous
pneumothorax, functional chest pain, costochondritis or b) There is a higher risk of complications
acute muscular strain would be more likely in this
c) This may be the first presentation of
patient.
inflammatory bowel disease

d) Stool microscopy and culture to identify the


Question 6 organism is worthwhile

Which of the following statements concerning bee sting e) All of the above
allergy is CORRECT?

a) If a patient has had a life-threatening


Answer: E
episode in the past, he or she is at risk of a
future one The presence of blood in the stool of a patient with a
constitutional illness is strongly suggestive of a bacterial
b) A mild reaction in the past puts a patient at
infection. Identification of the causal bacteria is usually
risk of a future life threatening episode
desirable for clinical and public health reasons. Most of
c) Wasps only sting once the conditions are reportable to the relevant state health
department. In some cases fulminant infection can occur
d) A bee sting is smaller in volume than a wasp and treatment based on antibiotic sensitivities of the
sting organisms will be required. Many of these bacteria
(Yersinia, Campylobacter, Shigella etc) can lead to a
e) A raised serum IgG persists for years in systemic illness with polyarthropathy.
those at risk of anaphylaxis

Question 9
Answer: A
Abdul is a 58 year old man who presents with transient
A previous life-threatening reaction is an indicator that a episodes of vertigo, slurred speech, diplopia, and
similar episode may occur in the future. Reactions don't paraesthesia. Which of the following is the MOST likely
necessarily escalate. Wasps produce a smaller volume of diagnosis?
sting, but are capable of stinging multiple times. Serum
IgE levels remain elevated in those at risk of an a) Basilar artery insufficiency
anaphylactic reaction. IgG appears protective.
b) Anterior communicating artery aneurysm

c) Hypertensive encephalopathy
Question 7
d) Pseudobulbar palsy
The nephrotic syndrome can be caused by all of the
following EXCEPT: e) Occlusion of the middle cerebral artery

a) Minimal change disease (lipoid nephrosis)

b) Amyloidosis Answer: A

c) Membranous glomerulonephropathy Transient ischaemic attacks involving the posterior brain


circulation, i.e. the basilar artery, are characterised by
d) Renal vein thrombosis diplopia, vertigo, vomiting, dysarthria, ataxia and
hemisensory loss.
e) Diabetic nephropathy

Question 10
Answer: D
Andrew, aged 60 years, complains of traces of blood in
Renal vein thrombosis is more likely to be a his stool for the past few weeks. Which of the following
complication of nephrotic syndrome rather than a cause. is the MOST likely cause?
In nephrotic patients the blood is more coagulable than
normal and the circulation may be sluggish owing to a) Diverticulosis
hypovolaemia, both of which are likely to induce
thrombosis. The other options, together with focal and b) Cancer of the rectum
segmental glomerulosclerosis, are responsible for 90%
c) Haemorrhoids
of cases of nephrotic syndrome. They are all conditions
which disturb the structure or function of the glomerular d) Angiodysplasia
basement membrane.
e) Colitis

Question 8
Answer: C
Bill, aged 35 years, has been unwell for 2 days with
severe abdominal cramps and diarrhoea. He visited Haemorrhoids and/or anal fissures are the commonest
friends living on a farm during the previous week. He and therefore most likely causes of traces of fresh blood
stated that on inspection of his stool there appeared to in the stool. These are easily identified by physical
be blood in it. What is the significance of blood in the examination. However, there are a number of other
stool? more serious pathologies which must be excluded,
including colorectal cancer diverticulosis, angiodysplasia d) Pregnancy
and colitic conditions. These can be diagnosed by a
combination of rectal examination, sigmoidoscopy and e) Chronic hepatitis
colonoscopy plus biopsy.

Answer: B
Question 11
The ESR is a non-specific indicator of inflammatory and
Cyanosis is LEAST likely to occur in: neoplastic disease. The ESR increases with age and is
raised in pregnancy, the puerperium and in anaemia. It
a) Ebstein's anomaly (anomalous attachment of is increased in acute and chronic inflammatory disease
tricuspid valve) and neoplastic disease. A low ESR (<1mm/hour) may be
seen in polycythaemia rubra vera and sickle cell disease.
b) Tetralogy of Fallot The C-reactive protein is a more sensitive early indicator
of an acute phase response.
c) Tricuspid atresia

d) Ventricular septal defect


Question 14
e) Transposition of the great vessels
Which of the following statements about weight loss is
CORRECT?
Answer: D
a) Dieting reduces the basal metabolic rate
Cyanotic heart disease occurs when the systemic venous (BMR)
return is directed backward into the systemic circulation
b) Dieting increases the BMR
without transitting the pulmonary vascular bed, i.e.
instead of pure left to right shunting, right to left or bi- c) Exercise decreases appetite
directional shunting occurs.
d) Inactivity increases appetite
Patients with ventricular septal defects do not usually
present with cyanosis. However, if there is a particularly e) None of the above
large defect, pulmonary vascular damage can occur
leading to pulmonary hypertension and right to left
shunting with cyanosis (Eisenmenger's syndrome). The
Answer: A
other options listed are all associated with right to left
shunting and cyanosis. Changes to a person's stable weight, either an increase
by forced feeding, or a decrease by food restriction
(dieting), induce compensatory physiological responses
Question 12 that resist these changes. Thus with low calorie regimes
the BMR decreases to limit energy expenditure and
Which of the following pathogens causing appetite increases, factors which complicate the process
gastrointestinal infection is NOT associated with bloody of weight loss for the dieter. Exercise generally
diarrhoea? increases appetite in response to the fall in blood
glucose caused by exercise.
a) Listeria monocytogenes

b) Campylobacter spp
Question 15
c) Yersinia enterocolitica
Which of the following is the MOST COMMON
d) Salmonella serovars pathological condition associated with aortic aneurysms?
e) Shigella a) Atherosclerosis

b) Syphilitic aortitis
Answer: A c) Trauma
Listeria monocytogenes usually only causes illness in d) Rheumatic aortitis
immunocompromised patients and pregnant women. L.
monocytogenes is quite unlike most food-borne e) Cystic medial necrosis
pathogens in that it does not cause gastrointestinal
symptoms but causes invasive infections like meningitis,
septicaemia, and chorioamniitis leading to stillbirth.
Answer: A
Gastrointestinal infections by all the other pathogens
listed result in bloody diarrhoea to varying degrees. Atherosclerosis is the most common pathological
condition associated with aortic aneurysms. The other
options are also associated with aortic aneurysms but
Question 13 are less common.

The erythrocyte sedimentation rate (ESR) is raised in all


of the following EXCEPT:
Question 16
a) Multiple myeloma
Bob has had moderately raised plasma cholesterol and
b) Polycythaemia rubra vera triglyceride concentrations for 6 months and you have
advised him to start on medication since dietary
c) Macrocytic anaemia measures, including abstaining from alcohol, have had
minimal effect. Investigations have shown that he has a available for absorption. Zinc deficiency occurs in a
raised plasma very low density lipoprotein (VLDL) level, variety of conditions (including all the other options
i.e. he has type IV hyperlipoproteinaemia. Which of the listed above) but not vegetarianism. Vegetarians obtain
following medications would you prescribe? adequate amounts of zinc from legumes, nuts and
cereals.
a) Cholestyramine

b) Gemfibrozil
Question 20
c) Simvastatin
Non haem iron absorption is promoted by all of the
d) Atorvastatin following EXCEPT:
e) Fish oil a) A high phosphate content of the diet

b) Low pH in the stomach


Answer: B c) Vitamin C taken with a meal
Gemfibrozil is a fibrate which is the class of drugs d) Iron deficiency
recommended for treatment of type IV
hyperlipoproteinaemia. It stimulates lipoprotein lipase e) Erythroid hyperplasia
activity and thereby strips triglycerides from VLDL,
causing VLDL degradation and lowering of VLDL levels,
with consequent lowering of plasma cholesterol and
Answer: A
triglyceride levels. The mode of action and
recommended indications for use of the other options A high phosphate content of the diet inhibits iron
are discussed in the references below. absorption by forming insoluble iron phosphates. All the
other factors mentioned promote iron absorption. Acid
and vitamin C keep iron in the ferrous form. Iron
Question 17 deficiency and erythroid hyperplasia influence iron
absorption through unknown mechanisms via the gut.
In which of the following conditions does angina pectoris
occur in the absence of coronary artery disease:

a) Mitral stenosis Question 21

b) Mitral insufficiency Paul is a 45 year old man with an acute myocardial


infarction. He develops a sinus bradycardia of 38
c) Coarctation of the aorta beats/minute with frequent ventricular extrasystoles.
The IMMEDIATE treatment of choice is:
d) Aortic stenosis
a) Intravenous propranolol
e) Aortic insufficiency
b) Immediate direct current cardioversion

c) Intravenous morphine
Answer: D
d) Intravenous atropine sulphate
In severe aortic stenosis when the aortic orifice is
reduced to one-third or less of its normal size, angina e) Intravenous lignocaine
pectoris may occur because of insufficient perfusion of
the coronary arteries. This is usually associated with
fainting and dyspnoea.
Answer: D

Atropine should be the initial agent at doses of 0.5mg IV


Question 18 every 5 minutes until the desired response is achieved
by removing vagal inhibition Transcutaneous cardiac
Whole body zinc stores may be depleted in all of the pacing is indicated if the above is not effective
following EXCEPT: (bradycardia remains <40/min), with internal pacing
being the definitive treatment for progressive or
a) Coeliac disease persistent bradycardias.
b) Diabetes mellitus

c) Alcoholism Question 22
d) Vegetarianism All of the following features are consistent with
haemolytic uraemic syndrome (HUS) EXCEPT:
e) Acquired immunodeficiency syndrome
(AIDS) a) Bloody diarrhoea

b) Thrombocytopaenia
Answer: D c) High fever with rigor
Zinc is an essential component of many enzyme systems d) Neurological abnormalities
including carbonic anhydrase, alcohol dehydrogenase
and alkaline phosphatase. The best dietary sources are e) Acute renal failure
meat, shellfish and legumes; zinc in grains is less
Answer: C Question 25

Haemolytic uraemic syndrome is most common in Tom is a 30 year old agricultural worker who works with
children following a gastrointestinal infection with a toxic organophosphates. He presents with acute pain in the
strain of E.coli. Bloody diarrhoea is the usual presenting right iliac fossa. You suspect acute appendicitis but are
feature followed by haemolysis and renal failure. concerned about the risk of a laparotomy BECAUSE:
Microvascular damage results in profound
thrombocytopaenia and may involve the central nervous a) There is a risk of erroneous diagnosis
system. If fever is present it is usually low-grade. Early
b) There is a tendency to prolonged bleeding
supportive treatment allows a full recovery in 70% of
post-operatively
children but there is a 3-5% mortality and 15-30% will
have chronic renal failure. c) There is an increased hazard in general
anaesthesia

d) There is a likelihood of delayed healing of


Question 23
the wound
Which of the following triads of clinical features is found
e) There is a possibility of mental disorder after
in beri beri?
operation
a) Cardiac failure, glossitis, dermatitis

b) Cardiac failure, neuropathy, dermatitis


Answer: C
c) Glossitis, dermatitis, memory loss
Organophosphates irreversibly inhibit
d) Glossitis, neuropathy, memory loss acetylcholinesterase and cause accumulation of
acetylcholine at muscarinic and nicotinic receptors. In
e) Cardiac failure, neuropathy, memory loss general anaesthesia, muscle relaxant drugs like
prostigmine cause reversible blockade of cholinesterase.
Should a patient have absorbed subclinical doses of
organophosphates (e.g. in agricultural work with
Answer: E
pesticides), there is increased risk of excessive
Beri beri is due to vitamin B1 (thiamin) deficiency. It is neuromuscular blockade with use of muscle-relaxants,
now mainly confined to the poorest areas of SE Asia. and the patient may show signs of toxicity, or may
Neuropathy presents as stiffness, numbness and continue to be paralysed beyond the duration of the
weakness of the legs and loss of ankle reflexes, anaesthetic agent given.
progressing to polyneuropathy involving the trunk and
arms. Thiamin deficiency impairs cardiac energy
metabolism leading to cardiac failure and oedema. Question 26
Chronic thiamine deficiency results in Wernicke's
encephalopathy. Pellagra due to niacin deficiency results Pamela is a 55 year old woman who comes to see you
in glossitis, diarrhoea, dermatitis, and dementia. for dietary advice. She is an estimated 10kg above her
ideal body weight and is keen to reduce this before the
summer. Which of the following strategies would NOT be
appropriate in this situation?
Question 24
a) Advise Pamela against the use of appetite
Sheila is a 19 year old woman who presents with
suppressant medication
ascites, high venous pressure and a small quiet heart.
Which of the following surgical procedures would be b) Encourage daily exercise of at least 30
MOST likely to relieve her problem? minutes with heart rate to 70% of maximum
for her age
a) Mitral commissurotomy
c) Assist Pamela to redefine her goals in terms
b) Closure of the foramen ovale
of non-weight targets such as waist
c) Ligation of a patent ductus arteriosus measurement and improved stamina

d) Correction of coarctation of aorta d) Recommend an 8 week course of a very low


calorie diet (400-600kcal/day) to get started
e) Pericardiectomy
e) Warn Pamela that a diet very low in
carbohydrate is less likely to result in sustained
weight loss
Answer: E

Sheila has constrictive pericarditis in which the


pericardial cavity is obliterated and dense scar tissue Answer: D
encases and constricts the heart. Diastolic filling of the
ventricles is limited resulting in a decrease in cardiac Very low calorie diets are most appropriate when body
output. The right ventricular diastolic pressure is weight is >130% of ideal. They must be supervised by a
increased, leading to venous hypertension which in turn medical officer due to the potential for electrolyte
produces hepatomegaly, ascites and peripheral oedema. imbalance. All the other options are appropriate in this
Prompt pericardiectomy is the treatment of choice. This situation. Behavioural modification that involves simple
corrects the hemodynamic abnormalities and patients and sustainable changes in a person's diet, exercise and
improve rapidly with a massive diuresis. lifestyle routine is likely to be the most effective way to
achieve and maintain an ideal body weight.
Question 27 reassurance is all that is needed. However, if the ectopic
beats provoke more significant arrhythmias, Beta-
The FIRST sign of salicylate poisoning in children is blockade may be effective. Charles would be given
usually: general advice regarding quitting smoking and
minimising alcohol, caffeine and other stimulants such
a) Delirium
as cough medicines.
b) Coma

c) Hyperventilation
Question 30
d) Hyperpyrexia
James is a 50 year old woodcutter whom you treated for
e) Convulsions a Colles' fracture two days ago. His wife telephones
asking you to prescribe a sleeping tablet for him
because James is having difficulty in sleeping. Which of
the following is the MOST appropriate next step?
Answer: C
a) Suggest she gives James a nightcap of
Aspirin has a two-fold toxic effect. First, it inhibits whisky
oxidative phosphorylation leading to a metabolic
acidosis. The increased hydrogen ion concentration of b) Prescribe a short-acting benzodiazepine
the extracellular fluid stimulates the respiratory centre
of the brain to cause hyperventilation. This is the c) Describe some relaxation exercises for
primary effect in children. Second, aspirin directly James to do immediately before bedtime
stimulates the respiratory centre to cause
d) Prescribe an analgesic such as paracetamol
hyperventilation leading to a respiratory alkalosis. This
and codeine combination
phenomenon is seen mainly in adults.
e) Ask James to come to the surgery so you
can check the plaster
Question 28

Chronic inorganic lead poisoning is associated with all of


Answer: E
the following laboratory features EXCEPT:
The prudent action is to ask James to come to the
a) Basophilic stippling of red cells
surgery to check the plaster and the condition of his
b) Increased red cell protoporphyrin level hand as soon as possible, since it may be that his
problem is related to swelling around the fracture site
c) Normochromic normocytic anaemia with increased pressure inside the plaster cast. This can
lead to an adverse outcome unless the pressure is
d) Uraemia relieved soon. Once this is ruled out or dealt with, the
next issue to be addressed is adequate pain relief. In
e) Aminoaciduria
most cases, once adequate pain relief is ensured,
insomnia will no longer be a problem. If insomnia does
persist, a short-acting benzodiazepine may be
Answer: C prescribed for no more than 7-10 days to avoid
development of dependency. An alcoholic nightcap is not
The anaemia of chronic lead poisoning is usually a good idea, as it usually causes the patient to wake
hypochromic microcytic. The other options are all during the night and have difficulty getting back to
features of lead poisoning, due to toxic effects on sleep.
erythropoieses and on the kidney.

Question 31
Question 29
Which of the following situations is a
Charles is a 48 year old businessman who presents for a CONTRAINDICATION to immunisation with a live
general check-up and mentions that he is experiencing attenuated vaccine?
occasional fluttering sensations in his chest. A routine
electrocardiograph (see figure) is taken. a) Pregnancy

Your first line of management should be: b) Breastfeeding


a) Reassurance c) Mild acute febrile illness

b) Referral for cardioversion d) Current antibiotic therapy


c) Begin a trial of verapamil e) Immunodeficiency in a household contact
d) Commence beta-blockade

e) Give lignocaine stat Answer: A

Pregnancy is a valid contraindication to immunisation


with a live attenuated vaccine eg oral polio infection.
Answer: A Exposure to HIV, other immunodeficiency states and
The ECG shows Charles has premature atrial ectopic immunosuppressant treatments are also
beats. Often these are asymptomatic. They may, contraindications. Diarrhoea, minor acute illnesses,
however, be sensed as an irregularity or heaviness of antibiotic therapy and breast feeding are not valid
the heart beat. Treatment is not normally required; contraindications.
Question 32 Answer: A

The interossei muscles of the hand are supplied by: An indwelling catheter allows monitoring of fluid status
as well as allowing urinary drainage. IV fluid therapy is
a) The radial nerve not urgent due to the potential to exacerbate brain
swelling, in the acute phase. Anticoagulant therapy is of
b) The median nerve
no value in treating a fully developed and completed
c) The ulnar nerve CVA. It may be used in transient ischaemic attacks, in a
developing progressive thrombosis, or in prevention of
d) All of the above DVT in a bedridden patient. The other measures of
physiotherapy and nursing care should follow.
e) None of the above

Question 35
Answer: C
Which of the following statements about simple febrile
The ulnar nerve (c8- T1) supplies the adductors and convulsions is CORRECT?
abductors of the fingers, the adductor of the thumb, the
medial two lumbricals and the muscles of the a) It usually occurs between 6-8 years of age
hypothenar eminence.
b) Prognosis depends on the precipitating
illness

Question 33 c) The risk of developing epilepsy is 10%

Brenda brings Jake, her 2 month old son for his first d) The convulsions last less than 15 min
Triple antigen injection. Which of the following
statements is CORRECT in relation to the acellular e) Investigation with lumbar puncture and CT is
pertussis vaccine? essential

a) It provokes a stronger immune reaction

b) The costs are the same as whole cell vaccine Answer: D

c) It causes a lower incidence of fever, crying Simple febrile convulsions last less than 15 minutes.
and irritability They usually occur between 3 months and 5 years, with
most occurring between 17 and 23 months of age. There
d) It works against the bacteria rather than the is no difference in IQ at age 7 years between children
toxin who have had a febrile convulsion and their seizure- free
siblings. The risk of developing epilepsy following a
e) It provides protection against P. simple febrile convulsion is 0.9% at age 7 years.
Bronchiseptica

Question 36
Answer: C
Katie, 12 years of age, collapses suddenly at school, and
Acellular pertussis is part of DTPa and DTPa-hepB is transported by ambulance with dextrose drip inserted.
vaccines. Triple antigen vaccine On examination, a dolls eye reflex is present but she is
not responding to painful stimuli. Her vital signs are as
containing acellular pertussis has similar efficacy to that
follows:
of whole cell pertussis-containing vaccines, but causes
significantly less reaction with a much lower incidence of • Resp. rate 14/min
fever, irritability and local reactions. The cost is greater.
The vaccine targets the toxin rather than the bacteria. • Pulse rate 50/min

• Sa02 100 %

Question 34 • B/P 180/110

An obese man, aged 60 years, is admitted unconscious What is the NEXT step of management?
with a diagnosis of completed stroke confirmed on CT
scanning as due to a cerebral thrombosis. Of the a) Arrange for an urgent head CT scan
following supportive measures, the most important
b) Replace the dextrose with normal saline
IMMEDIATE management is:
c) Intubate and ventilate
a) Insertion of an indwelling urinary catheter
d) Give intravenous corticosteroids
b) Commencement of anticoagulant therapy
e) Draw venous and arterial blood for urgent
c) Physiotherapy to prevent hypostatic
analysis
pneumonia

d) Commencement of intravenous fluids to


prevent dehydration Answer: C
e) Positioning to prevent development of Katie has raised intracranial pressure as indicated by the
decubitus ulcers hypertensive response in the presence of bradycardia
and coma. She is at high risk of herniation and needs
urgent treatment to reduce the intracranial
hypertension. The most rapid effect is achieved by
endotracheal intubation and hyperventilation to reduce Question 39
arterial pCO2 to 30-35mmHg. This will be accompanied
by an intravenous infusion of mannitol. Urgent Which of the following statements about immunisation is
assessment to determine the cause of this presentation CORRECT?
will include blood tests and CT scan. Corticosteroids may
a) If a child has a cold, they can't be vaccinated
be helpful in cases of intracranial tumour or CNS
infection. Specific treatment will be required for b) Fever is an uncommon adverse event after
metabolic abnormalities eg. diabetic ketoacidosis, immunisation
infection or haemorrhage.
c) If a reaction is suspected, a test dose should
be used
Question 37 d) Anaphylaxis to egg is not a contraindication
to MMR vaccine
The defect in visual fields MOST commonly associated
with a pituitary tumour is: e) Pre-term infants have an inadequate
antibody response
a) Crossed homonymous hemianopia

b) Central scotoma
Answer: D
c) Bitemporal hemianopia
An anaphylactic reaction to egg is not a contraindication
d) Total blindness in one field
to MMR vaccine. Infants with minor colds without high
e) Peripheral concentric constriction and fever can be safely immunised. Vaccination should only
enlargement of the blind spot be postponed if a child is acutely unwell or has a high
fever (above 38.5 degrees Celsius). A fever (low grade
temperature) is a common adverse effect after
immunisation. Test doses are not recommended, they
are just as likely to produce an adverse event as the full
dose. Premature infants should receive their
Answer: C
vaccinations at the same age as term infants, ie first
As a pituitary tumour extends upwards from the dose of hepatitis B vaccine at birth and then DTPa-hep
diaphragma sellae and compresses the optic chiasm, it B, HIB and polio vaccinations at 2 months after birth (no
classically causes superior quadrantic defects followed correction for gestation).
by bitemporal hemianopia. It can however cause any
variety of visual field defects, including unilateral (or
bilateral) field defects in all quadrants, due to the Question 40
variable position of the chiasm above the pituitary.
Which of the following would be MOST helpful in
distinguishing cerebral infarction from cerebral
neoplasm?
Question 38
a) History of headache
The MOST helpful diagnostic test to evaluate a
potentially enlarging pituitary neoplasm is: b) Hemiplegia
a) Cerebral angiography c) Chronology of development
b) Serial serum prolactin concentration d) Carotid bruit
c) MRI e) Focal abnormality on electroencephalogram
d) Computer assisted colour spectrum visual
field plotting
Answer: C
e) CT scan with contrast
Chronology of development is the most important factor
in differentiating cerebral infarction from cerebral
neoplasm. Cerebral infarction tends to be a simple,
Answer: C
sudden event or a series of stepwise events within hours
Once identified, pituitary neoplasms should be evaluated to days. In comparison, neoplasms tend to be preceded
by an MRI scan. This gives information regarding by symptoms such as headache, progressive cognitive
pressure effects on surrounding structures and the need decline, seizures and vomiting, and may feature steadily
for surgical treatment. Serum prolactin estimation gives progressive neurological signs. The other options are all
information about anterior pituitary function, but not variably present in both conditions and are not
size. Angiography is unnecessarily invasive and CT is not diagnostic.
as sensitive as MRI. Visual field plotting will document
any damage to the optic tract - an unwanted outcome
Block 8
Question 3
Question 1
Akira, a long standing patient of your practice wants to
Bill is 65 years old and has just been diagnosed with
discuss a friend of his who has had his toenail removed
type 2 diabetes. He returns to discuss the condition.
because of a melanoma. Which of the following
What would you tell him about diabetic retinopathy?
statements about subungual melanoma is CORRECT?
a) He should see an ophthalmologist straight
a) This is a common form of malignant
away for a thorough eye examination
melanoma
b) It is safe to wait 2 years after diagnosis for
b) It usually has a good prognosis
his first ophthalmologist referral
c) Removal of the nail may be curative
c) His age is the biggest risk factor for diabetic
retinopathy d) Five year survival depends mainly on tumour
thickness
d) Retinopathy is an uncommon complication of
type 2 diabetes e) This form of melanoma rarely metastasises
e) None of the above

Answer: D
Answer: A Melanoma located on the palm, sole or nail bed is called
acral lentiginous type and accounts for 2-8% of all
At diagnosis, one in six patients with Type 2 diabetes
malignant melanomas, with subungual melanoma being
has retinopathy. If untreated, this progresses to cause
rare. Lifetime risk of melanoma is approaching 1:50,
retinal scarring, contraction of the vitreous humour and
higher if fair-complexioned, a history of blistering
retinal detachment. Eventually about 85% of all patients
childhood sunburn, multiple melanocytic naevi or
will show signs of retinopathy, the biggest risk factors
dysplastic naevi, and a positive family history. Although
being duration of diabetes and glycaemic control. All
melanoma is much less common in non-white groups,
patients with diabetes should be screened for
their proportion of acral type is 30-50%. Because of the
retinopathy at the time of diagnosis, and then at least
location, they are often diagnosed late so have a poorer
every two years thereafter. Laser therapy is very
outcome. Prognosis is mainly dependent on tumour
effective and halves the risk of visual loss from diabetic
thickness and stage as identified by nail bed biopsy.
retinopathy.
Treatment involves removal of the digit clear of the
margin.

Question 2

Complete the following sentence: 'In the first few days Question 4
of a low calorie diet in the management of obesity ...'
Jim, who has type 2 diabetes, states that he has been
a) More fat than water is lost advised by another doctor to have laser treatment to
both eyes. He does not see the need as his vision is fine.
b) Most of the weight lost is water What advice would you offer him?

c) Lean body mass is not affected a) To have the procedure as quickly as possible

d) Glycogen stores are retained b) That if he doesn't proceed his vision will
eventually deteriorate
e) Sodium loss is reduced
c) That treatment may result in worsening of
night vision
Answer: B d) That it is usually performed under local
anaesthetic
When treating obesity with caloric restriction, the initial
marked weight loss is largely due to fluid loss, but these e) All of the above
changes tend not to persist. During the first 24 hours or
so energy is derived mainly from catabolism of
carbohydrate in the form of glycogen stored, in
association with water, chiefly in the liver. As glycogen Answer: E
is degraded to glucose and then carbon dioxide and
Laser therapy is performed using an apparatus similar to
water, there is significant water release and excretion.
a slit lamp. Patients rarely require admission to hospital.
Once glycogen stores have been depleted, glucose
If a large amount of photocoagulation is planned,
synthesis depends on gluconeogenesis from breakdown
regional anaesthetic is used. Laser therapy is very
of protein. Finally, only when the glucagon:insulin ratio
effective and halves the risk of visual loss from diabetic
in the blood is high enough to promote significant fat
retinopathy. If untreated, proliferative retinopathy can
breakdown does fat in adipose tissue stores become the
cause sudden visual loss in one or both eyes. The new
main source of energy for tissue metabolism with
blood vessels bleed onto the retinal surface causing
consequent sustained weight loss.
scarring, contraction of the vitreous humour and retinal
detachment.
Question 5 with removal of crusts is indicated. Persistent lesions
often respond to topical mupirocin applied three times a
A 25 year old man presents with a non-tender swelling day for 7-10 days. If extensive or causing systemic
on the right side of the neck, followed by a similar symptoms oral antibiotics should be used eg
swelling on the left side two weeks later. He has phenoxymethylpenicillin if a Streptococcus is suspected
recently suffered from periodical fever, malaise and as the primary infection and flu(di)cloxacillin if Staph
weight loss. Physical examination shows enlarged lymph aureus is suspected. Exclusion from child care is only
nodes in the neck, axillae and groins, and a spleen necessary up to 24 hours after antibiotic treatment
palpable 2 cm below the left costal margin. Chest X-ray begins.
shows bilateral moderately enlarged hilar nodes. The
haemoglobin is 105 G/L (130 - 180), and leucocytes
number 11 x 109 G/L (4.3 - 10.8 x 109) with a normal
distribution of white cells. The red cells appear Question 7
normochromic and normocytic.
The diagnosis of Hodgkin's disease should be confirmed
What is the MOST LIKELY diagnosis? by:

a) Aleukaemic leukaemia a) Lymph node biopsy

b) Hodgkin's disease b) Repeat blood film and ESR

c) Infectious mononucleosis c) Bone marrow aspiration

d) Non-Hodgkin's Lymphoma (NHL) d) Biopsy of the spleen

e) Secondary syphilis e) Thoraco-abdominal CT scan

Answer: B Answer: A

Hodgkin's disease usually presents with painless cervical Hodgkin's disease is established by the review of an
lymphadenopathy. The disease can spread to involve the adequate lymph node biopsy specimen by an expert
other parts of the reticuloendothelial system such as the pathologist. Staging will involve all of the following:-
liver and spleen. It is commonly accompanied by careful history and examination, full blood examination,
anaemia (normochromic, normocytic), fever, anorexia ESR and biochemical analysis including LDH, CT scan of
and weight loss. Non-Hodgkins Lymphoma presents with chest, abdomen, and pelvis, and bone marrow biopsy.
symptoms and signs similar to Hodgkin's Disease, but at Patients may also undergo a PET or gallium scan.
a much later stage of life. Mean age of onset for Staging laparotomy is rarely performed.
Hodgkin's disease is 31 years; mean ages for NHL are
65-70 years. Aleukaemic leukaemia usually presents
with anaemia, thrombocytopaenia and Question 8
granulocytopaenia. Infectious mononucleosis is
associated with a sore throat, myalgia, arthralgia and a Which of the following is INCORRECT in relation to
maculo-papular rash. medication usage in diabetics?

a) Aspirin may worsen diabetic retinopathy

Question 6 b) Metformin is the agent of choice in the


overweight patient
Anna, a 3 year old child, develops pustular lesions on
her face which subsequently form a honey-coloured c) Sulphonylureas are contraindicated in
crust and start spreading. You diagnose impetigo. Which pregnancy
of the following statements would be included in your
advice to her parents? d) Insulin may improve outcomes following
myocardial infarction
a) Since Anna is otherwise well, she may
attend her child care centre e) Beta blockers may increase the risk of
hypoglycaemic episodes
b) There is no danger of spread to family
members

c) Topical treatment will not usually be Answer: A


sufficient to achieve cure
Aspirin will not worsen diabetic retinopathy. Trials have
d) Anna must be isolated until the lesions have shown that there is no benefit or harm with aspirin in
completely resolved diabetic retinopathy. Sulfonylureas are contraindicated
in pregnancy because of their effect on the foetus.
e) Lesions should be adequately covered to Metformin improves glucose uptake by skeletal muscle
reduce self-inoculation cells and has favourable effects on weight and the lipid
profile. It is therefore the agent of choice for overweight
patients. Beta blockers affect glucose metabolism and
may mask early signs of hypoglycaemia. Beta blockers
Answer: E
should not be used in patients with labile insulin-
Impetigo is usually caused by group A streptococci, dependent diabetes mellitus. Even mild hyperglycaemia
other streptococci or Staph aureus. It is usually highly increases the risk of extension of damage to
contagious, so precautions must be taken to reduce myocardium following an infarct. Studies show that tight
spread. This will include covering the lesions, careful control of blood glucose level using insulin post-AMI
hand washing, and disposal of items used near the improves outcomes.
lesions. If impetigo is mild, topical antiseptic cleansing
Question 9 following antibiotics would be MOST effective in treating
Melanie?
The specific microscopic feature which should be looked
for in the investigation of Hodgkin's Disease is: a) Phenoxymethylpenicillin

a) A large atypical lymphocyte b) Amoxycillin

b) A lymphoblast c) Flucoxacillin

c) A myelocyte d) Doxycycline

d) A Reed-Sternberg cell e) Erythromycin

e) A Langhan's giant cell

Answer: C

Answer: D This is a superficial wound which has become


impetigenous, ie like impetigo. In addition the infection
Hodgkin's disease is characterised by a predominance of has spread to the surrounding skin and is causing
small lymphocytes and, less commonly, large Reed- systemic effects. The causative organism is most likely
Sternberg cells. Reed-Sternberg cells are the histological Staph aureus. Flucloxacillin (or dicloxacillin) is the most
hallmark of the disease, they are large malignant appropriate antibiotic.
lymphoidal cells with multilobulated nuclei and
prominent inclusion-like nucleoli.

Question 12

Question 10 Maria comes in to discuss her husband's diabetes with


you. She has read about the glycaemic index (GI) of
A man aged 54 years complains of weakness, lassitude, food and wants to know more about it, so she can cook
low back pain and 5kg loss of weight over six months. the right foods for him. Which of the following facts is
Physical examination is normal. Urinalysis shows INCORRECT?
protein. Blood count shows: haemoglobin 110g per L
(130 - 180) with red cells normochromic and a) Hommus (chickpea salad dip) has one of the
normocytic, white cell count 7.5 x 109 per L (4.3 - 10.8) lowest GIs
with a normal differential count; E.S.R. is 102mm in one
hour; Serum protein 98 G per L (55 - 80), x-rays show a b) Boiled potatoes have a GI equivalent to 50G
generalised demineralisation of the vertebrae and glucose
sharply defined osteolytic lesions in the skull. Which of
c) Carbohydrates that are quickly digested
the following investigations is MOST LIKELY to be helpful
have a higher GI
in establishing the diagnosis?
d) The same amount of carbohydrate may
a) Bone marrow biopsy
show a wide variation in GI
b) Bone scan
e) High GI foods increase metabolism and
c) Prostatic biopsy assist in weight loss

d) Serum calcium and alkaline phosphatase

e) Thoraco-abdominal CT scan Answer: E

The GI is measured by the ability of a particular


carbohydrate food to raise the blood glucose level on a
Answer: A scale of 1-100 where 50gm glucose is 100. Various
factors affect the GI of a food, including the size of the
Multiple myeloma is characterised by the presence of starch particles, ratio of amylose to amylopectin, and
paraprotein in the serum produced by abnormal the presence of fibre, fat, protein and organic acids.
proliferating plasma cells and Bence-Jones protein, Wholegrain foods and legumes have a low GI compared
comprising light chain components of immunoglobulins with refined cereals and breads. Lower GI foods are
in the urine. Clinically, it results in bone destruction, slower to digest and improve satiety. They assist in
bone marrow infiltration and renal impairment. ESR and weight management and have a protective effect
serum protein is raised, and proteinuria is present. against diabetes and heart disease.
Skeletal survey shows characteristic lytic lesions, easily
seen on the skull. Bone marrow aspirate shows
characteristic infiltration by plasma cells. Definitive
diagnosis depends on identification of abnormal Question 13
paraprotein with or without immunoglobulin light chains
Which of the following pathological features is
in the serum or urine. This is done by
associated with multiple myeloma?
immunoelectrophoresis.
a) Increased plasma alkaline phosphatase

b) Decreased plasma acid phosphatase


Question 11
c) Increased serum globulin
Six year old Melanie has been brought to your surgery
with a graze on her knee sustained 3 days ago. Her d) Decreased serum beta2 microglobulin
mother says the lesion has increased in size and is now
partly covered by a thick golden crust and exudes e) Decreased serum calcium
serous fluid. The surrounding skin is inflamed and her
temperature is 38.5 degrees Celsius. Which of the
Answer: C diabetes. In order to prevent complications, the patient
needs to achieve strict glycaemic control through weight
A raised serum globulin is characteristically found in loss, diet, and medication as needed. Self-monitoring is
patients with multiple myeloma. The condition is due to essential. All patients with diabetes should know and
overproduction of a single immunoglobulin species from practice routine foot care. They are at risk of damage
a clone of malignant plasma cells. These antibodies may because of vascular disease, neuropathy, increased risk
not be biologically active, but can cause problems of infection and slower healing. Podiatrists can
clinically because of hyperviscosity of the blood, leading implement preventative therapy at an early stage.
to thrombotic phenomena, and deposition in tissues
such as the kidney, leading to renal failure. There is
hypercalcaemia due to lysis of bone, but plasma alkaline
phosphatase and acid phosphatase levels are usually Question 16
normal. A rise in beta2 microglobulin correlates with
In patients with multiple myeloma what is the MOST
myeloma cell mass and a worse prognosis.
COMMON clinical course?

a) Steady progression over 2-5 years with


Question 14 complications

Complete the following sentence: 'The term 'keratitis' b) Gradual development of myelofibrosis
refers to inflammation of the ...'
c) A remitting/relapsing course over many
a) Keratinised layer of the skin years

b) Germinal layer of the nailbed d) Rapid decline and death within 1-2 years

c) Glans penis e) Chronic phase followed by acute terminal


leukemia
d) Cornea

e) Eyelids
Answer: A

The majority of patients with multiple myeloma


Answer: D experience progression of the disease with
complications, including anaemia, renal failure,
Keratitis is inflammation of the cornea; other corneal pathological fractures, infections, neurological
lesions include keratoconjunctivitis, keratoconus and manifestations and bleeding. Only 10% will have an
keratectasia. The term "keros" (meaning horny) is also indolent course with slow disease progression over many
used to describe layers of skin and of the nails. years. In young people, it is an aggressive disease
which may be rapidly fatal (within 1 year). The advent
of bone marrow transplant has improved survival rates
Question 15 significantly.

Susan comes to see you concerned about her 68 year


old mother who has recently been diagnosed with type 2
Question 17
diabetes. Her mother is refusing to make any dietary or
lifestyle changes, insisting that tablets will keep Complete the following sentence: 'The skin condition
everything under control. Which of the following advice that is COMMONLY responsible for persistent dandruff is
would be appropriate to give Susan about her mother's
condition? a) Irritant dermatitis

a) This form of diabetes is often mild and strict b) Seborrhoeic dermatitis


adherence to medication regimes will usually be
sufficient in those over 65 years of age c) Tinea capitis

b) It is difficult to adjust to life with a chronic d) Lichen planus


illness and encouragement to gradually make
e) Pityriasis versicolor
changes over the next few years will suffice
Answer: B
c) There may already be complications present
so it is essential that diet, exercise and good Seborrhoeic dermatitis is a chronic inflammation of the
blood sugar control be adhered to skin characterised by erythema and scaling. It occurs in
areas of skin where sebaceous glands are most active,
d) It is only when diabetes is insulin-requiring
and therefore is common on the face and scalp. It can
that the issue of complications necessitates
also affect the centre of the chest and back, axilla, groin
tighter control
and perianal area.
e) It may be necessary to do a mini mental
state examination to exclude early dementia as
a reason for poor compliance Question 18

Tom is a 70 year old diabetic and has recently started


on insulin. Which of the following statements about
Answer: C
insulin pens is INCORRECT?
Type 2 diabetes is not a mild disease. About one third of
a) The dose should be delivered quickly and
those surviving 15 years will require insulin to treat
pen immediately withdrawn
symptoms or complications. Complications such as
diabetic retinopathy, nephropathy, neuropathy, macro b) Short, fine needles of 29-31 guage allow
and microvascular disease occur in both types of virtually pain-free injections
c) Pens can now deliver more than one type of Answer: B
insulin
Dandruff is caused by seborrhoeic dermatitis which
d) Cartridges containing clouded insulin must becomes most prominent when the sebaceous glands
be changed when 12 units remain are most active. This occurs most commonly in
adolescence.
e) All but one of the insulin pens in Australia
are made by Novo-Nordisk

Question 21

Answer: A Betty, aged 55 years, has diabetes and comes in for her
annual eye checkup. Which of the following statements
Insulin pens make insulin injections simpler, since about the eye in diabetes is CORRECT?
drawing up and mixing are not necessary and so
multiple daily injections are easier. They are very easy a) If the patient doesn't have symptoms, the
to use - "just insert the needle and press the button". examination is likely to be negative
The button will not depress if the cartridge is empty. In
clouded insulin gently tilting the cartridge several times b) Fundoscopy without pupillary dilatation is
allows a small glass ball to mix the solution. Once less adequate for screening purposes
than 12 units remains there is not enough solution for
c) A normal red reflex makes the presence of a
the mixing ball to function optimally. The injection
cataract unlikely
should be given slowly and the needle should be left in
place for six seconds after injection. d) Pupillary reflex is unaffected by diabetes

e) Assessment of refractive error is not a


routine part of the diabetic eye check
Question 19

Roy, 84 years of age, returns for review of test results


taken to investigate his tiredness. His total protein is Answer: C
elevated with a monoclonal rise in the gammaglobulin
fraction. The full blood count, renal function studies, and At diagnosis, one in six patients with Type 2 diabetes
X rays are all normal. There are no urinary Bence Jones has retinopathy and eventually about 85% will develop
proteins. Referral for a bone marrow biopsy shows this complication. Irrespective of symptoms, all patients
<10% plasma cells. Which of the following statements with Type 2 diabetes should be screened on diagnosis,
about his condition is INCORRECT? and then at least every two years thereafter.
Examination includes checking red reflex for cataracts,
a) His tiredness is due to hypothyroidism which dilating the pupils and performing fundoscopy to
is often associated with this condition observe the macula, optic disc, and other areas. Blood
glucose concentration should also be checked. Dense
b) Up to 10% of people over 75 years of age
cataracts cause the red reflex to be totally obscured;
have similar findings
smaller cataracts will be seen as opacities against the
c) He has about 1% chance per year of red reflex. Refractive errors occur as the lens shape
developing multiple myeloma alters with changes in blood glucose concentrations.

d) Life expectancy is shorter by 2 years due to


this abnormality
Question 22
e) There may be an associated carcinoma of
A 60 year old man presents with severe abdominal pain,
prostate, kidney or gastrointestinal tract
shock, moderate abdominal rigidity and intense back
pain. Which of the following diagnoses is MOST LIKELY?

Answer: A a) Acute retrocaecal appendicitis

Monoclonal gammopathy of uncertain significance b) Leaking aortic aneurysm


(MGUS) is occasionally associated with other conditions
c) Renal colic
such as non-lymphoreticular neoplasms, chronic
inflammation or infection, and thyrotoxicosis. With a low d) Acute cholecystitis
risk of progression, clinical and blood test review is
necessary every 6-12 months. All the other statements e) Collapse of L4 vertebral body
are correct.

Answer: B
Question 20
A leaking abdominal aortic aneurysm typically presents
Complete the following sentence: 'Dandruff commonly with severe abdominal pain, shock, abdominal rigidity
presents in....................' and intense lower back pain. It can be mistaken for
renal colic, acute cholecystitis, and retrocaecal
a) Childhood appendicitis. However circulatory shock is not usually
present in these conditions. The BP may be increased
b) Adolescence
due to pain. Collapse of the L4 vertebral body results in
c) Early adulthood more localised pain without shock.

d) Middle age

e) Old age
Question 23 Question 26

Which of the following pathological changes is MOST Which of the following statements about adolescent girls
LIKELY to occur in x-irradiated skin? with suspected iron deficiency anaemia is INCORRECT?

a) Telangiectasis a) Early symptoms can include problems with


academic performance
b) Melanoma
b) The onset of menstruation is the main
c) Keloid formation contributor to this condition
d) Excessive hair growth c) A normal plasma ferritin level excludes the
diagnosis
e) Chronic hyperpigmentation
d) The blood film shows a microcytic,
hypochromic picture
Answer: A
e) Coeliac disease is a possible cause
Telangiectasia (dilated superficial blood vessels), is the
most visible aspect of chronic radiation dermatitis. The
changes following radiotherapy are permanent in the Answer: C
long run, and also include epidermal atrophy and
changes in hyalinization and hair growth. Iron deficiency is common in adolescent girls with a
prevalence of 9%. A low plasma ferritin indicates low
total body stores of iron. However, ferritin is an acute
phase reactant, so its plasma level is increased by acute
Question 24
or chronic inflammation. This may mask iron deficiency.
In haemolytic jaundice, bilirubin is absent from the urine Early symptoms of iron deficiency include changes in
because plasma bilirubin is: cognitive function and memory, decreased concentration
and fatigue.
a) Not usually elevated

b) Deposited in skin and sclera


Question 27
c) Unconjugated and not water soluble
Which of the following conditions is MOST LIKELY to
d) All protein bound and thus not filterable arise in an actinic keratosis?

e) Converted by the liver to urobilinogen a) Malignant melanoma

b) Squamous cell carcinoma

Answer: C c) Basal cell carcinoma

In haemolytic jaundice there is an increased breakdown d) Kerato-acanthoma


of red blood cells leading to increased production of
bilirubin in reticulo-endothelial cells. As this occurs prior e) Bowen's disease
to the bilirubin reaching the liver (where it gets
conjugated with glucuronic acid), the increased plasma
bilirubin is unconjugated and not water soluble. It will Answer: B
therefore not pass into the urine. Urinary urobilinogen is
increased because there is more bilirubin available for Squamous cell carcinoma develops in solar keratosis
conversion to urobilinogen by gut bacteria, and over a long period of time. The rate of malignant change
urobilinogen is water soluble. is thought to be 1/1, 000.

Question 25 Question 28

A patient who has been treated with a preparation With regard to Hepatitis C in Australia, which of the
containing horse serum develops urticaria followed by following statements is INCORRECT?
swelling of the tongue and dyspnoea. Which of the
following is the MOST APPROPRIATE immediate a) About 16,000 new infections are occurring in
treatment? Australia each year

a) Tracheotomy b) Around 83% of existing infections are due to


sharing equipment used to inject illicit drugs
b) Subcutaneous adrenaline
c) Couples in which one partner is hepatitis C
c) Intravenous hydrocortisone positive are advised to always use condoms to
avoid sexual transmission
d) Intravenous promethazine (Phenergan)
d) For mothers who are hepatitis C positive,
e) Oxygen therapy breastfeeding is encouraged unless nipples are
cracked or bleeding

e) This infection is now the most common


Answer: B
reason for liver transplantation in Australia
This is acute angio-oedema and there is a risk of upper
airways closure and anaphylaxis, so subcutaneous
adrenaline should be given first.
Answer: C Question 31

Although there is some uncertainty about hepatitis C Which one of the following is NOT characteristic of an
being transmitted sexually, it is not classified as an STD upper motor neurone lesion?
(sexually transmitted disease). If it occurs, sexual
transmission is rare and probably more likely if there is a) Clonus
blood-to-blood contact during sex. With a new or casual
b) Extensor plantar response
partner or in case of possible blood-to-blood contact,
safe sex practices should always be used to protect c) Intact superficial reflexes
against a range of STDs. All the other statements are
correct. Further information may be found in the d) Increased tone
reference.
e) Hyperactive tendon reflexes

Question 29
Answer: C
In which of the following conditions are nails MOST
The following signs result from lesions in the motor
COMMONLY affected?
system proximal to the alpha motor neurone: spasticity
a) Systemic lupus erythematosis (SLE) (hypertonia predominant in flexors of arms and
extensors of legs which is of a clasp-knife nature);
b) Psoriasis paralysis or weakness predominantly of extensors in
arms and flexors in legs; hyperreflexia; extensor plantar
c) Iron deficiency response; clonus and Hoffmann's reflex. The extensor
plantar response is an example of loss of a superficial
d) Infective endocarditis (IE)
reflex.
e) Hypoalbuminaemia

Question 32
Answer: B Moira is a 70 year old woman who presents with
abdominal discomfort for 6 months. On examination she
Psoriasis commonly affects the nails. Pitting of the nails,
has generalized lymphadenopathy and splenomegaly.
occurs in 25% of patients. Other effects include
What is the MOST LIKELY diagnosis?
hyperkeratosis, ridging, and onycholysis i.e. separation
of the distal nail from the nail bed (which is often a) Acute lymphoblastic leukaemia
mistaken for fungal paronychia). Splinter haemorrhages
and telangiectasia occur in SLE; spoon-shaped nails b) Acute myeloid leukaemia
(koilonychia) in iron deficiency; splinter haemorrhages
and clubbing in IE; and white nails (leukonychia) in c) Hodgkin's lymphoma
hypoalbuminaemia.
d) Infectious mononucleosis

e) Chronic lymphocytic leukaemia


Question 30

Miriam has recently developed bloating and heartburn Answer: E


after meals. On reviewing her medications which of the
following is UNLIKELY to be a cause of this new Chronic lymphocytic leukaemia is a disease of late
problem: middle-aged and elderly people. It may be
asymptomatic in the early stages and is often diagnosed
a) Iron supplements on a routine blood count. Symptoms, which are insidious
in onset, include lethargy, fevers, loss of weight and
b) Progestogen therapy
infections. Signs include moderate enlargement of the
c) An ACE inhibitor lymph nodes, liver and spleen.

d) A non-steroidal ant-inflammatory drug


(NSAID) Question 33
e) Long term tetracycline Francesco Napoli, aged 46 years, presented complaining
of years of gastro-oesophageal reflux. He was found to
have positive Helicobacter pylori antibodies. Regarding
Answer: C H. pylori, which of the following statements is
CORRECT? H. pylori:
While ACE inhibitors may cause nausea, more common
adverse effects are hypotension, cough, dizziness and a) Is the most common bacterial infection of
hyperkalemia. Abdominal pain and nausea are common humans worldwide
side effects of iron supplements. Bloating and nausea
b) Is positive in about 60% of adult Australians
are commonly reported with progestogen therapy.
Dyspepsia, nausea and diarrhoea are commonly c) Infects humans from a reservoir in healthy
reported by users of NSAIDs and these are contra- domestic animals
indicated in those with peptic ulcer disease.
Oesophageal ulceration can occur with tetracycline, thus d) Causes peptic ulcer disease and duodenal
patients are advised not to lie down within one hour of cancer
taking a dose.
e) Is present in >80% of patients with non-
ulcer dyspepsia
Answer: A sounds are dual. The MOST LIKELY cause of his
condition is:
Some parts of the world, particularly developing
countries have 80-90% prevalence of H pylori infection a) Hospital acquired pneumonia
in adults. Australian prevalence is about 30-40%. Most
infections are acquired in childhood from a parent. b) Post-infarct left ventricular remodelling with
Humans are the only reservoir. This infection is a known failure
cause of peptic ulceration and the organism is now
c) Extension of the infarct secondary to stent
classified as a biological carcinogen due to its strong
failure
connection with gastric cancer. Only 25-50% of people
with non-ulcer dyspepsia are positive for H pylori and d) Pericarditis with tamponade
most will not have resolution of symptoms after H pylori
eradication. e) Bacterial endocarditis

Question 34 Answer: D

Mrs Elaine Wu underwent endoscopy for recent onset of Pericarditis is a recognised, although uncommon,
dyspepsia. The biopsy verified the presence of complication of invasive cardiac treatments. The patient
Helicobacter pylori-positive gastric ulceration. She is not can lose the pain of angina, only to have it replaced by a
allergic to any medication. The MOST APPROPRIATE first more vague chest discomfort. Inflammatory pericarditis
line therapy is: results in an effusion which can rapidly escalate into
tamponade. None of the other options would show signs
a) A histamine type 2 receptor antagonist for 6 of biventricular failure this quickly.
to 8 weeks

b) A proton pump inhibitor (PPI) for 4 to 6


weeks Question 36

c) Ranitidine-bismuth-citrate 400mg bd, A 60 year old engineer was admitted to hospital because
amoxycillin 1G bd, and clarithromycin 500mg of fever, cough, and pleuritic chest pain. His
bd for 7 days temperature was 40 degrees Celsius. Physical
examination and x-ray of the chest indicated right lower
d) PPI bd, amoxicillin 1G bd, and clarithromycin lobar pneumonia. Sputum smear and culture
500mg bd for 7 days demonstrated pneumococci. Treatment with intravenous
penicillin was commenced. After several days, fever and
e) PPI bd, clarithromycin 500mg bd, and
leucocytosis decreased and x-ray of the chest showed
metronidazole 400mg bd for 7 days
some clearing of infiltrate. On the 7th hospital day, his
temperature spiked to 39.4 degrees Celsius, there was
an increase in cough and dyspnoea. X-ray of the chest
Answer: D showed an increase in pulmonary infiltrate. Which of the
following is the MOST LIKELY explanation of this clinical
Acceptable triple therapy regimens for the eradication of picture?
H.pylori vary depending on
a) Development of pneumococcal resistance to
the availability of medications and the incidence of penicillin
resistance to antibiotics used. In Australia,
metronidazole-resistant strains are now common b) Laboratory contamination of the original
(>50%) and metronidazole can no longer be culture
recommended for first-line therapy if there is no allergy
to penicillins. The combination of a standard dose of PPI, c) Superinfection by a different type of bacteria
amoxicillin 1G and clarithromycin 500mg all delivered bd
d) Adverse effect of antibiotic therapy
for 7 days gives an eradication rate of >90%. It is
available as a single script on the Pharmaceutical e) Pulmonary thromboembolism
Benefits Scheme as either "Klacid Hp7" or "Nexium
Hp7". In penicillin hypersensitivity the amoxicillin is
replaced with metronidazole 400mg bd with efficacy 80-
85%. In treatment failure, there may be attempts to Answer: D
conduct bacterial culture and sensitivity testing.
This clinical picture demonstrates deterioration in the
Otherwise a trial of quadruple therapy using a PPI,
patient's condition. Drug fever, or serum sickness,
bismuth subcitrate, metronidazole and tetracycline for
usually occurs on the 7th to 12th day of antibiotic
10-14 days will give 75% chance of eradication. See
therapy and can produce unexpected fevers, skin rash
references for further discussion about when to consider
and an eosinophilic pulmonary infiltrate. It is commonly
H pylori testing and eradication and how to follow up
due to penicillins, nitrofurantoin, sulphonamides,
treated patients.
thiazides and tricyclic antidepressants. As he had been
improving over 6 days, it is unlikely that the original
specimens were contaminated, nor that the organisms
Question 35 had had the opportunity to develop resistance.
Pulmonary embolism does not cause a high fever.
A 67 year old man presented three days after a stent
was inserted for the treatment of persistent angina. He Superinfection is commonly due to gram-negative
now complains of a persisting "different" chest pain and bacteria, fungi or resistant staphylococci and usually
shortness of breath on exertion. On examination you appears on the 4th or 5th day.
find he is pale and slightly sweaty with: pulse rate 110
regular with pulsus paradoxus; BP 100/90; T 38.0
degrees Celsius; pedal oedema; bilateral basal
crepitations in his chest; and a JVP elevated 3cm. Heart
Question 37 Question 39

Which of the following is NOT a likely complication from Brian and his wife are contemplating a trip across Africa.
gastro-oesophageal reflux disease? Which of the following situations is most likely to put
them at risk of contracting typhoid fever?
a) Achalasia of the oesophagus
a) Intimate contact with an infected person
b) Ulcerative oesophagitis
b) Eating contaminated food
c) Barrett's oesophagus
c) Swimming in contaminated water
d) Adenocarcinoma of the oesophagus
d) Contact with an infected dog
e) Oesophageal stricture
e) Scratches from infected wildlife

Answer: A
Answer: B
Achalasia is a motility disorder of the lower oesophagus
of unknown cause and is unrelated to gastro- Salmonella typhi is spread primarily through
oesophageal reflux disease (GORD). It is characterised consumption of contaminated food or water. It has no
by a dilated lower oesophagus in the presence of a tight known animal host other than humans. Intimate contact
lower oesophageal sphincter which does not respond to with infected persons is a relatively uncommon mode of
normal peristalsis. GORD leads to chronic inflammation transmission. Swimming in contaminated water would
of the lower oesophagus, which in turn can ulcerate or not lead to infection unless the water was ingested.
cause a fibrosed stricture. Barrett's oesophagus (or
metaplasia) is also a result of long-standing GORD,
occurring in 10% of patients with reflux. 10% of
Question 40
patients with Barrett's go on to dysplastic then
malignant change (adenocarcinoma) of the oesophagus. Which of the following is NOT a feature of Parkinson's
disease?

a) Bradykinesia
Question 38
b) Rigidity
If a patient is said to have odynophagia you would
assume that: c) Difficulty starting a movement
a) It is painful to swallow d) Hypophonia
b) It is painful to speak e) Intention tremor
c) The patient has trouble swallowing and
hearing
Answer: E
d) The patient has aberrant taste sensations
Parkinsonism is a syndrome consisting of tremor, rigidity
e) There is incoordinate action of the and bradykinesis. The tremor is most marked at rest,
oesophagus coarser than cerebellar tremor and is seen as a pill
rolling of thumb over fingers. Bradykinesis involves
slowness in initiating and executing movement and
Answer: A speech. The gait is characterised by a shuffling forward
with flexed trunk (called a festinant gait). Speech is
Odynophagia is pain during swallowing as opposed to a hypophonic with a characteristic monotonous, stuttering
difficulty swallowing (dysphagia). It is usually a dysarthria.
symptom of mucosal destruction.
Block 9
Question 1 chin point trauma. It is essential that all teeth are
checked and that any missing teeth or fragments are
Jeremy has just been born via normal vaginal delivery. located. Radiographs may be necessary to check for
His Apgar scores are being documented. These are the ingestion, inhalation or soft tissue displacement of teeth.
observations made at 1 and 5 minutes of age: 1 minute: Avulsed permanent teeth should be kept in saline, milk
blue and pale; heart rate <100beats/minute; irregular, or the child's saliva and replaced within half an hour.
slow respiration; coughs with stimulation; limp 5 Antibiotics are used only if clinically indicated.
minutes: pink body, blue extremities; heart rate
>100beats/minute; good cry; coughs with stimulation;
active Which of the following BEST indicates Jeremy's
Question 3
Apgar scores at 1 and 5 minutes respectively?
Natalie is 12 years old. She presents with fever, an
a) 4 and 9
exudative pharyngitis, generalised lymphadenopathy
b) 5 and 10 and splenomegaly. This condition is MOST LIKELY
caused by:
c) 3 and 9
a) CMV (cytomegalovirus)
d) 4 and 8
b) Group A streptococcus
e) 5 and 9
c) HSV (herpes simplex virus)

d) RSV (respiratory syncitial virus)


Answer: A
e) EBV (Epstein Barr virus)
1 minute: blue and pale (0); heart rate
<100beats/minute (1); irregular, slow respiration (1);
coughs with stimulation (2); limp (0). Score of 4. 5
Answer: E
minutes: pink body, blue extremities (1); heart rate
>100beats/minute (2); good cry (2); coughs with Natalie is most likely to have glandular fever (infectious
stimulation (2); active (2). Score of 9. Please see mononucleosis) due to Epstein-Barr virus. Pharyngitis is
reference to review Apgar scores. the major symptom, and is exudative in 50% of cases.
Splenomegaly is present in 50 - 75% of cases. CMV may
cause a similar illness, but pharyngitis and adenopathy
Question 2 are less apparent. Pharyngitis due to Group A
Streptococcus usually does not cause splenomegaly.
Richard is 4 years old. He has just fallen over in the HSV may cause gingivostomatitis but it rarely extends to
playground at kindergarten and knocked out (avulsed) the pharynx. RSV is a pathogen affecting the lower
his upper left front tooth. The tooth has been found on respiratory tract.
the ground. Richard's teeth are all primary teeth. He has
not lost any teeth prior to this. Which if the following
statements describes the BEST initial management?
Question 4
a) Immediately replace the tooth in its socket
Janet was born 3 hours ago at 35 weeks gestation. She
taking care to ensure its correct orientation
has clinically apparent Down's syndrome. She has
b) Keep the tooth moist in saline, milk, or passed meconium normally. Janet has vomited several
Richard's saliva and seek dentist review within times, and the vomitus is bile-stained. Which of the
the hour following features would you expect to see on abdominal
x-ray?
c) Carefully examine his mouth to check for
other damage to teeth, bone or soft tissue a) Normal abdominal gas pattern

d) Thoroughly clean the root of the tooth, wrap b) Diffuse bowel distension
in plastic and transport on ice for dental review
c) Multiple dilated loops of bowel and intra-
within 2 hours
abdominal calcifications
e) Prescribe antibiotics, preferably penicillin or
d) Dilated proximal colon and absence of gas in
clindamycin if penicillin-allergic
the pelvic colon

e) Dilated stomach and proximal duodenum


Answer: C with no air distally

Avulsed primary teeth are not usually reimplanted due


to the risk of damage to the developing permanent
Answer: E
tooth. Loss of a primary tooth rarely impacts on future
occlusal development or tooth space. At least 50% of Janet has duodenal atresia, a condition commonly
children will have a dental injury before 12 years of age. associated with other congenital abnormalities including
This may involve luxation of a tooth and soft tissue or Down's syndrome. Abdominal x-rays show the typical
alveolar bone damage or even mandibular fracture in 'double bubble' appearance, due to distension of the
stomach and proximal duodenum with air, and the Answer: C
absence of gas distal to the obstruction. Diffuse bowel
distension suggests meconium plug syndrome or The ductus arteriosus closes in normal term infants at 3
Hirschsprung's disease (congenital megacolon). to 5 days of age. Patent ductus arteriosus is a common
Hirschsprung's disease may also be seen as dilated congenital cardiac abnormality, especially in premature
proximal colon and absence of gas in the pelvic colon. babies. The incidence decreases with increasing maturity
Multiple dilated loops of bowel and intra-abdominal of the baby and is approximately 1:2000 in term infants.
calcifications are seen with jejunoileal atresia or
meconium ileus.
Question 7

Benson is 4 years old. He was recently unwell with an


Question 5
influenza-like illness, from which he appears to have
Phillipa, aged 2 years, has just been diagnosed with recovered completely. Benson has now developed
autism. You are discussing the disorder with her marked periorbital swelling, and some peripheral
distressed parents. Which of the following statements is oedema. He is not unwell, and has no other specific
CORRECT? symptoms. Dipstick testing of Benson's urine reveals
>3+ proteinuria. Which of the following is the MOST
a) Phillipa's parents have a 25% chance of APPROPRIATE next step in the management of this
having another child with autism condition?

b) Autistic children are extremely resistant to a) Renal biopsy


change in routines or patterns of behaviour
b) Commence oral prednisolone
c) The diagnosis of autism is increasing with a
prevalence of approximately 2 per 10,000 c) Commence oral penicillin
children
d) Commence oral diuretic therapy
d) The range of intelligence of children with
e) Reassurance and expectant management
autism is the same as non-autistic children

e) Autistic children often form a strong bond


with their main carer and suffer marked Answer: B
separation anxiety
This presentation characterises a child with nephrotic
syndrome. In young children, this is usually idiopathic
nephrotic syndrome of childhood (minimal change
Answer: B
disease). Renal biopsy is not usually performed unless
Autism is one of a group of diagnoses called Pervasive there is poor response to treatment. The best initial
Developmental Disorders. The incidence is as high as 2- management is corticosteroid treatment. Prednisolone is
6 per 1000 children. Parents of a child with autism have commenced at 2mg/kg/day (maximum 60mg/day) until
a 2-9% chance of having another affected child. Autistic urine protein levels fall to trace or negative levels, or for
disorder presents before the age of 3 years with a maximum of 8 weeks, then therapy is tapered.
sustained impairments in reciprocal social interactions, Diuretics are rarely indicated and should be used with
communication and restricted, stereotypical behaviour extreme care. Antibiotic prophylaxis may be considered
patterns. The lack of attachment or bonding to carers during relapses, and pneumococcal vaccine may be
and resistance to change is typical. Up to 70% will have worthwhile. Expectant management is inappropriate.
IQ's lower than normal. At the other end of the Autism Complications include infection, thromboembolism and
Spectrum Disorders, children with Asperger's Syndrome hypovolaemia and all are treated aggressively. Some
may have normal or high IQ's, no language delay, are advocate prophylactic penicillin whenever there is
more adaptable but show impaired social interaction and severe oedema. Occasionally aspirin may be used to
restricted patterns of behaviour or interests. Early prevent clotting however the main strategy is
diagnosis and treatment has been shown to improve mobilisation and avoidance of dehydration. About 70%
long-term outcomes for many children. of children have relapses but most of these will have
ceased relapsing by 18 years of age. It is very rare for
steroid-sensitive minimal change disease to progress to
chronic renal failure.
Question 6

Olivia is 7 days old. She was born at term in an


uncomplicated normal vaginal delivery. She has a rough Question 8
continuous 'machinery' murmur maximal at the left
sternal edge, second intercostal space. Clinical findings Catherine is a six week old baby. She presents to
are consistent with patent ductus arteriosus (PDA). hospital with a history of vomiting after feeds, which her
When does the ductus arteriosus USUALLY close in a parents describe as projectile. Which of the following
normal term infant? arterial blood gas (ABG) results is CONSISTENT WITH a
diagnosis of pyloric stenosis?
a) With the infant's first inspiration
a) pH 7.41, pCO2 40, pO2 100, HCO3- 24
b) Within one hour of birth
b) pH 7.51, pCO2 48, pO2 90, HCO3 30
c) By day 3 to 5 of life
c) pH 7.50, pCO2 29, pO2 105, HCO3 19
d) By the age of six weeks
d) pH 7.19, pCO2 52, pO2 80, HCO3 18
e) Within the first six months
e) pH 7.28, pCO2 60, pO2 85, HCO3 33
Answer: B Answer: A

Infants with pyloric stenosis develop a hypochloraemic Genu varum (bow-legs) is common in toddlers to the
alkalosis with potassium depletion, secondary to age of 3 years. If asymmetrical or the intercondylar
vomiting. The compensatory respiratory response is distance at the knees when standing is greater than 6
hypoventilation to retain carbon dioxide. The parameters cm, Xray and referral is advisable to exclude the
given in option (a) represent a normal ABG analysis. possibility of Blount's disease or rickets. Genu valgum is
Option (c) represents a respiratory alkalosis with common between 3 and 7 years of age. The majority
metabolic compensation, (d) shows a mixed metabolic improve spontaneously. Refer if the intermalleolar
and respiratory acidosis, and option (e) is an example of distance at the ankles is greater than 8cm when
respiratory acidosis with metabolic compensation. standing. Femoral anteversion usually leads to toeing in
due to excessive internal rotation of the femur.
Corrective footwear is not necessary, nor is
physiotherapy.
Question 9

Steven is 8 years of age. He is miserable and


complaining of a sore throat. He has a fever of 39.2 Question 11
degrees Celsius, tender cervical lymphadenopathy and
tonsillar exudate with no cough. Steven has a Timothy is 2 years old. He presents with a small crop of
documented Type I hypersensitivity reaction to lesions on his left outer thigh, just above the knee. The
penicillin. Which of the following statements describes 20 or so lesions are pale papules ranging in size from 2
the BEST management of Steven's condition? to 5mm in diameter. Each papule has a central
umbilication. They do not seem to be itchy or bothering
a) Regular paracetamol, fluids and expectant Timothy, but his parents are very worried about them.
management Which if the following statements is TRUE?

b) Phenoxymethylpenicillin 250mg orally 12 a) Timothy is being abused, as this is a sexually


hourly for 10 days transmissable disease

c) Amoxycillin 375mg orally 8 hourly for 10 b) A moderately potent topical steroid is the
days treatment of choice

d) Roxithromycin 100mg orally 12 hourly for 10 c) Timothy should be investigated for causes of
days immunodeficiency

e) Cefaclor 250mg orally 8 hourly for 10 days d) Resolution may take from 3 months to 5
years

e) The most likely causative pathogen is human


Answer: D body louse
Steven has tonsillitis and known penicillin allergy. On
the basis that his symptoms are suggestive of Answer: D
streptococcal infection, Steven would benefit from
antibiotics and the best management option is Timothy has molluscum contagiosum. This is a poxvirus,
roxithromycin. Phenoxymethylpenicillin and amoxycillin causing characteristic lesions(firm, smooth, round,
are obviously contraindicated. Cefaclor is also usually flesh-coloured papules with a central indentation
contraindicated on the basis of possible cross-reactivity or 'umbilication'). Chemical therapies are usually
in a patient with a well-documented penicillin allergy. ineffective in treating these lesions, and conservative
Regular paracetamol and fluids may well be of benefit, management is usually best. Resolution may take up to
however antibiotics will improve symptoms and reduce two years. The virus is spread by autoinnoculation, and
the incidence of complications in bacterial tonsillitis. severe or widespread disease may require more active
management. This is a very common disorder in
childhood. It may be spread by sexual contact in
Question 10 adolescents and adults, but is usually acquired from
family members and other children in childhood.
Robert is 4 years of age. He is developing normally and Molluscum contagiosum may be seen in advanced
is of normal height and weight. However his mother is stages of HIV infection, but is not a flag to investigate
concerned as she has noted that he seems to be quite for HIV in this age group.
'knock-kneed'. Robert's physical examination finds an
intermalleolar distance of 6cm when he is standing with
knees together. He is otherwise normal. Which of the Question 12
following statements is CORRECT regarding genu
valgum in this case? Victor is a healthy 6 month old baby. He has a left
hydrocoele, present since birth. It is relatively large and
a) Reassurance is appropriate as this brilliantly transilluminable. Which of the following
represents normal development statements is CORRECT?

b) Robert should be immediately referred for an a) The swelling is usually reducible


orthopaedic opinion
b) The swelling is frequently painful
c) Xray may confirm the cause as femoral
anteversion c) Persistent swelling at 6 months requires
surgical correction
d) Podiatrist advice regarding an appropriate
orthotic should be sought d) The swelling will usually resolve in the first
years of life
e) Physiotherapy has been shown to improve
prognosis if commenced before age 5 e) Aspiration of the swelling is usually curative
Answer: D Answer: B

The natural tendency for the processus vaginalis to close If foreign body aspiration is suspected, the patient
in the first years of life will usually cause resolution of should have a chest x-ray comprising inspiratory and
the hydrocoele. Aspiration may temporarily reduce the forced expiratory views. Inspiratory views may show
swelling but poses a risk for bleeding and secondary localised hyperinflation due to gas trapping distal to the
infection. Surgery is usually only required for a foreign body. The forced expiratory film may show
hydrocoele persisting beyond 2 years of age, unless it is mediastinal shift away from the affected side.
extremely large. A hydrocoele is not reducible, and is Bronchoscopy is indicated if a foreign body is detected,
not usually painful. or if clinical suspicion persists despite negative chest x-
ray.

Question 13
Question 15
Nicholas is 14 years old. He has clinically apparent
Marfan syndrome. Which of the following cardiac Stephanie is 12 months old. She has just begun to walk,
murmurs would you expect to hear on cardiac but keeps falling over. It seems she has one leg slightly
auscultation? longer than the other. You suspect she may have
congenital dislocation of the hip (CDH). Which of the
a) Decrescendo high pitched diastolic murmur following statements regarding this condition is TRUE?
at left sternal edge
a) Ultrasound is the investigation of choice in a
b) Midsystolic ejection murmur at 2nd right child of this age
intercostal space
b) The incidence of CDH is approximately 1:100
c) Low pitched rumbling diastolic murmur at live births
the apex
c) After the first month of life, signs of hip
d) Pansystolic murmur at left sternal edge with instability become more evident
no radiation
d) Use of two or three layers of nappies
e) Continuous machinery murmur at 2nd left (diapers) to splint the hip is frequently
intercostal space beneficial

e) CDH is more common in female than in male


infants
Answer: A

Marfan syndrome is an autosomal dominant connective


tissue disorder with an incidence of about 1 in 10,000, Answer: E
of whom 25% present as a spontaneous mutation.
Aortic dilatation causes aortic regurgitation, the murmur Congenital dislocation of the hip is more common in
of which is usually decrescendo and high-pitched, female than in male infants. The incidence of CDH is
beginning immediately after the second heart sound and approximately 1:1000 live births. After the first month
extending for a variable time into diastole. A2 may be of life, signs of hip instability become less evident,
soft. Mitral valve prolapse may develop very early in life hence the condition is more easily missed after this
presenting as a midsystolic click. With time many go on time. X-ray is the best investigation for suspected CDH
to develop mitral regurgitation with an apical pansystolic at the age of 12 months. Use of multiple nappies is
murmur radiating into the axilla. The other options never indicated as a treatment for this condition, as they
describe, in turn, aortic stenosis, mitral stenosis, are inadequate to obtain proper positioning of the hip.
ventricular septal defect and patent ductus arteriosis
which are not features of Marfan syndrome.
Question 16

Question 14 Trent is 14 years old and a keen athlete. He presents


with left anterior knee pain. Tenderness of the left tibial
Jake is 15 months old. His mother thinks he may have tubercle raises your suspicion of Osgood-Schlatter
inhaled the wheel from a small toy car at a birthday disease. X-ray confirms your diagnosis and excludes
party this afternoon. At the party he choked and other pathology. Trent's coach is keen for him to be
coughed briefly then seemed to settle. However, since treated immediately so he can resume training at full
that time he has seemed a bit wheezy and has been capacity. Which of the following represents the BEST
coughing intermittently. Which of the following would be management option for this condition?
the BEST initial investigation to confirm the presence of
a lower respiratory tract foreign body? a) Reduction or modification of activity

a) Bronchoscopy b) Electrotherapy

b) Chest x-ray c) Corticosteroid injection

c) Arterial blood gases d) Plaster cast immobilisation

d) CT scan e) Surgery

e) White cell count


Answer: A Question 19

Management of Osgood-Schlatter disease is Renee is 5 years old. She had a mild cold with a clear
conservative as this is a self-limiting condition. Ice and runny nose two weeks ago, which required no drug
analgesics are appropriate for acute management of treatment, and has been well since. She presents with a
inflammation. The mainstay of treatment is to modify purpuric rash on the fronts of her legs and feet, and her
the child's level of activity to minimise aggravation of buttocks. The rash was urticarial initially. She appears
the condition. Complete abstinence from activity is well and happy, with no other abnormal clinical findings.
unnecessary and undesirable. Renee's platelet count is normal. What is the MOST
LIKELY diagnosis?

a) Henoch Schonlein purpura


Question 17
b) Meningococcal septicaemia
Christina is 4 years old. She has just been found to have
drunk a good portion of a full bottle of children's c) Idiopathic thrombocytopaenic purpura
paracetamol. Which of the following statements
regarding paracetamol overdose in children is d) Disseminated intravascular coagulation
CORRECT?
e) Aplastic anaemia
a) The risk of hepatotoxicity is greatest in
children under the age of 5 years
Answer: A
b) Paracetamol levels are best measured as
soon as possible post-ingestion Henoch Schonlein purpura is the most common small
vessel vasculitis in children. It is commonly preceded by
c) N-acetylcysteine may be beneficial even
a viral upper respiratory tract infection. Less commonly
when administered more than 24 hours post-
a drug may be implicated in its onset. The rash may be
ingestion
urticarial initially, indurating and becoming purpuric. The
d) Liver function tests are used to assess the extensor surfaces of the feet and legs, arms and the
need for treatment buttocks are frequently involved. New lesions can
appear for 2-4 weeks. This disease can also be
e) Normal liver function tests at 48 hours post associated with fever, polyarthralgia, abdominal pain
ingestion are indicative of patient well being and melaena, proteinuria and haematuria. The platelet
count is usually normal, but may even be elevated.

Answer: C
Question 20
N-acetylcysteine is given to patients whose paracetamol
levels are in the toxic range according to a standard Harvey aged 10 years, was playing football this
nomogram, and may still be beneficial when afternoon when he was heavily tackled. He had to leave
administered more than 24 hours post-ingestion. The the field as he was injured in the incident, and has had
nomogram for calculating the requirement for N- severe left flank pain since. He also complains of some
acetylcysteine therapy is based on paracetamol blood dizziness. Examination confirms left flank tenderness.
levels, not on liver function test parameters. Significant You suspect Harvey may have a ruptured spleen. Which
abnormalities of liver function may not develop until 72 of the following plain abdominal x-ray findings would
hours post-ingestion. The incidence of hepatotoxicity is CONFIRM this diagnosis?
ten times higher in adults and adolescents than in
children under 5 years of age. If paracetamol is ingested a) Loss of the left psoas shadow
in a liquid form, blood levels may be taken two hours
b) Upward displacement of the left
after ingestion to give an accurate toxicity picture,
hemidiaphragm
otherwise the level should be taken at 4 hours post-
ingestion. c) Enlargement of the spleen

d) Fracture of the left lower ribs


Question 18 e) Absence of gas in the splenic flexure
Jordan is 5 years old and has cerebral palsy. He has a
spastic hemiparesis. Which of the following features is
NOT seen with this type of abnormality? Answer: A

a) Hypertonia The left psoas shadow may be obscured by


haemorrhage from a ruptured spleen. Lower rib
b) Fasciculations fractures provide evidence of local trauma but are not
diagnostic of splenic rupture.
c) Hyperreflexia

d) Ankle clonus
Question 21
e) Extensor plantar reflex
Jenny and Sam are beside themselves with worry. Their
Answer: B
son, Justin, is 11 years old and in grade 6 at school.
In spastic cerebral palsy, the motor features are of an They are finding it increasingly difficult to encourage
upper motor neuron abnormality. Fasciculations are Justin to go to school. He frequently complains of being
seen with lower motor neuron dysfunction. The other unwell in the mornings, with recurrent stomachache and
options are correct. headache. His symptoms tend to be less apparent at
weekends and during school holidays, and often improve
as the day goes on when he is allowed to stay at home.
This pattern of behaviour has been typical for Justin for Answer: A
some years, and he has been repeatedly examined and
investigated. No organic cause for his symptoms has Greg is likely to have an acquired autoimmune
been diagnosed. He denies hallucinations. He performs haemolytic anaemia, with the production of cold
well at school, and his teacher says he seems to get agglutinins in response to the EBV. This causes a
along well with his peers, with no evidence of bullying. normochromic normocytic anaemia, as well as the other
Which of the following is the MOST likely cause of features listed. Hypochromic microcytic anaemia is
Justin's school refusal? associated with iron deficiency.

a) Antisocial personality disorder

b) Gender identity disorder Question 24

c) Separation anxiety disorder You are discussing the genetic inheritance of a condition
with a family. Peter and Simone have just learned that
d) Early onset schizophrenia their son, Paul, has Duchenne muscular dystrophy.
Which statement is TRUE regarding the mode of
e) Panic disorder inheritance of this condition?

a) Autosomal dominant
Answer: C b) X-linked recessive
Justin's presentation most likely represents c) Autosomal recessive
developmentally inappropriate separation anxiety. The
absence of a realistic cause for his fear of school and the d) Chromosomal deletion
tendency for his symptoms to abate when allowed to
remain at home, as well as the absence of any organic e) Chromosomal translocation
disease or positive psychotic symptoms (such as voices)
support this.
Answer: B

Duchenne muscular dystrophy is a sex-linked disorder,


Question 22
inherited via an abnormal recessive gene on the X
Alexander is 19 months old. He has not received any chromosome. Thus, only males are affected. Unaffected
childhood immunisations as his parents are female carriers transmit the disease. For children of a
conscientious objectors to vaccination. Alexander has carrier female, there is a 50% chance that each
been unwell for several hours with fever, irritability and daughter will be a carrier, and a 50% chance that each
dysphagia. He presents drooling and leaning forward son will have the disease. Affected males cannot
and is obviously distressed. What is the MOST LIKELY transmit the disease to their sons, but all of their
organism to be causing Alexander's condition? daughters are carriers.

a) Streptococcus pneumoniae

b) Haemophilus influenzae type B Question 25

c) Non-typable Haemophilus influenzae Ngaire is a six week old baby girl. Her parents have
noted a swelling in the right side of her neck. She seems
d) Streptococcus pyogenes well, is breastfed and is gaining weight. Which of the
following should NOT be considered in the differential
e) Staphylococcus aureus diagnosis of a lateral cervical swelling?

a) Acute cervical adenitis


Answer: B b) Branchial cleft cyst
Alexander has classic epiglottitis. All of the listed c) Cystic hygroma
organisms are known to cause epiglottitis. However,
Haemophilus influenzae type B is almost always the d) Sternocleidomastoid muscle haematoma
causative organism in an unimmunised patient.
e) Thyroglossal duct cyst

Question 23
Answer: E
Greg is 7 years old. He has recently had confirmed
glandular fever (Epstein Barr virus). Over the past 3 Thyroglossal duct cyst should not be considered in the
days he has developed weakness, pallor, dark urine and differential diagnosis of a lateral cervical swelling. This
fatigue. On examination, he is jaundiced and has mild congenital abnormality occurs in the midline, between
splenomegaly. Which of the following is NOT a feature the hyoid bone and the suprasternal notch. The other
you would expect to find on laboratory investigation? options may present as a lateral cervical swelling.

a) Hypochromic microcytic anaemia

b) Spherocytes Question 26

c) Nucleated red blood cells Cindy is 3 years old. She celebrated her birthday 3 days
ago, and has been wearing her favourite present, a new
d) Hyperbilirubinaemia necklace. Cindy has now developed a rash on her neck
and anterior chest where the necklace rests against her
e) Elevated LDH skin. The rash is slightly raised, erythematous and itchy.
Which of the following statements best describes the Answer: C
MOST LIKELY explanation for this?
In the previously healthy individual, thrombocytosis
a) Type I hypersensitivity follows splenectomy. Anticoagulant treatment is
required if the platelet count exceeds 10,000x 10*9/L to
b) Type II hypersensitivity prevent thrombotic complications. All of the other
statements are true. Pulmonary dysfunction may ensue
c) Type III hypersensitivity
because of trauma to ribs, the sub-diaphragmatic area
d) Type IV hypersensitivity and the lungs, from the accident. Post-splenectomy
there is a greater susceptibility to overwhelming
e) The rash is unlikely to be related to the bacteraemia because of decreased bacterial clearance,
necklace levels of IgM and opsonisation of encapsulated bacteria.
Pneumovax should be given pre-operatively if possible
and immunisation to Haemophilus influenzae type B and
Meningococcus should be updated. The pancreas may be
Answer: D
damaged at the time of surgery, which could result in a
The rash is most probably a contact dermatitis brought pancreatic cyst or fistula. This may become infected
on by the presence of the necklace. The most likely giving rise to the subphrenic abscess.
cause of Cindy's rash is a Type IV hypersensitivity
reaction.
Question 29
This is a T-cell mediated immune response, and is
usually a delayed response to a specific antigen. Stefan is 7 years old. He has been diagnosed with
Attention Deficit Hyperactivity Disorder (ADHD). After
careful consideration and evaluation, it has been decided
Question 27 to commence him on pharmacological therapy. Which of
the following drugs is NOT used in the treatment of
Rebecca's mother contracted rubella whilst she was ADHD?
pregnant, which was confirmed by serological testing. As
a result Rebecca has been born with congenital rubella a) Dexamphetamine
syndrome. Which of the following is NOT a feature of
b) Methylphenidate
congenital rubella syndrome?
c) Imipramine
a) Growth retardation
d) Clonidine
b) Deafness
e) Diazepam
c) Limb hypoplasia

d) Cardiac defects
Answer: E
e) Mental retardation
Diazepam is not indicated in the treatment of Attention
Deficit Hyperactivity Disorder (ADHD). Dexamphetamine
Answer: C and methylphenidate are psychostimulants and may be
considered as first line therapy. Imipramine is a tricyclic
Congenital infection with rubella causes a number of antidepressant which may be considered as second-line
manifestations, the main ones being: mental therapy only if psychostimulants are not tolerated, are
retardation, cardiac anomalies, growth retardation, contraindicated or are ineffective. Clonidine is widely
ocular anomalies, deafness, cerebral disorders including used, although its effectiveness remains unproven.
chronic encephalitis, and haematologic disorders. Limb
hypoplasia is not usually seen. This may be a feature of
congenital varicella zoster infection.
Question 30

Sally is 6 years old. She is being admitted to hospital for


Question 28 tonsillectomy and adenoidectomy. Informed consent is
being sought from Sally's parents, and the risk of
Eloise, aged 16, has been involved in a serious motor haemorrhage and the possibility of a blood transfusion
vehicle accident in which she has suffered a ruptured being required are discussed. Sally's parents wish to
spleen. Unfortunately her clinical signs deteriorate, and know the risk of Sally contracting hepatitis C via blood
splenectomy is indicated. In obtaining informed consent transfusion. The risk of transmission of hepatitis C via
from Eloise and her parents, you discuss possible post- blood transfusion is:
operative complications. Of the following statements,
each is true EXCEPT a) 1:100

a) There is a possibility of pulmonary b) 1:1,000


dysfunction
c) 1:10,000
b) Pancreatic damage may occur at operation
d) 1:100,000
c) Thrombocytopoenia may follow surgery,
e) 1:1,000,000
requiring platelet transfusion

d) Post splenectomy bacterial infection may be


life-threatening Answer: E
e) A subphrenic abscess may be a later All donor blood products are screened for hepatitis C
complication antibody. The estimated risks for false-negative tests for
hepatitis C on donor blood, and thus the risk of hepatitis Answer: B
C are approximately 1:1,000,000. The Australian Red
Cross Blood Service tests all donations for HCV antibody Daniel almost certainly has an intussusception, which is
as well as nucleic acid PCR so the current estimate of most common in children 3 months to 3 years of age
risk is 1:3,663,000. and typically presents with the features described
above. Air enema is an appropriate investigation and in
ileocolic intussusception, often resolves the abnormality
with less than 10% chance of recurrence. If
Question 31 unsuccessful, urgent surgery is necessary. In infants
presenting with abdominal pain the differential diagnosis
Paulette, a curious toddler aged 18 months is playing
will include colic, gastroenteritis, constipation, urinary
happily with Grandma's sewing box. As her mother
tract infection, volvulus and incarcerated hernia.
approaches, Paulette swallows something she has had in
her mouth. Grandma keeps a variety of objects in this The suspicion of a surgical condition increases if there is
box. Which of the following objects is MOST likely to severe or increasing pain, bile-stained vomitus, guarding
require active intervention if Paulette has swallowed it? or abdominal rigidity and distension. The passage of
blood and mucus producing th so-called "red-currant
a) A two dollar coin
jelly" is often a late feature of ischaemic bowel in either
b) A duck shaped button intussusception or volvulus. Appendicitis is rare in
infants but in young children there is up to an 80% risk
c) A hearing aid disc battery of perforation at the time of diagnosis

d) A safety pin (probably closed)

e) A small marking pencil 3 cm long Question 33

Tasneem has just been born with symptomatic


congenital cytomegalovirus infection (CMV). Which of
Answer: C the following is the MOST COMMON finding in this
condition??
The corrosive nature of the battery can lead to
gastrointestinal erosion and/or perforation. This is a a) Hepatosplenomegaly
particular risk if the battery becomes lodged in the
oesophagus as erosion can begin within six hours of b) Microcephaly
ingestion. The majority of disc batteries, however, do
pass uneventfully through the remainder of gut if they c) Deafness
pass the level of the lower oesophageal sphincter. Coins
d) Chorioretinitis
and round buttons generally pass through the gut
uneventfully .in a child., as do long items less than 6 cm e) Cataracts
There is a very small risk of perforation with sharp
objects such as irregularly shaped buttons, or small
toys, but the majority of these do not require active
intervention. Even open safety pins will usually pass Answer: A
through the gut without harm.
CMV is the world's leading cause of congenital virus
infection. Approximately 1% of all infants are
congenitally infected and CMV infection is symptomatic
Question 32 in 5-10% of these infants. Of symptomatic neonates,
60-80% will have hepatosplenomegaly, petechiae and
Daniel, a previously well 10 month old infant, has been jaundice; 30-50% microcephaly, intra-uterine growth
severely distressed and screaming intermittently for the retardation or prematurity; and the mortality is 20-30%.
last 1-2 hours. The screaming bouts last for 2-3 Survivors have a 90% chance of going on
minutes, and recur every 10- 15 minutes although his
Mum says they are becoming more frequent. He draws to develop sensorineural deafness, mental retardation,
his legs up when he screams appearing to be in pain, seizures and motor delay. Asymptomatic neonates may
and is very flat and lethargic when he is not screaming. later develop microcephaly and psychomotor retardation
He has vomited three times in the last hour, the last with up to 25% becoming deaf. Chorioretinitis occurs in
vomit being a greenish fluid. What is the MOST 20% of symptomatic neonates but cataracts are
appropriate advice to give his worried mother? associated with congenital rubella infection, not CMV.
Since 50-60% of women of childbearing age are carriers
a) Reassurance that colic is a common of CMV, then 40-50% of women are at risk of primary
condition which may respond to simple infection in pregnancy which may be transmitted
treatments and H2 receptor antagonists transplacentally in up to 40%. For carriers, the risk of
reactivation in pregnancy is estimated to be anywhere
b) An air enema is likely to be both diagnostic
from one to 25% but risk of transmission to the foetus
and effective as a treatment in this case
in this case is only 2-5% and is nearly always
c) Admission will be necessary to provide asymptomatic in the neonate
supportive treatment of this severe form of
gastroenteritis
Question 34
d) Treatment includes analgesia and IV fluids
but avoidance of invasive procedures unless Jennifer, age 25 years is concerned as she has been
there is per-rectal blood and mucus trying to fall pregnant for the last three months and has
been unsuccessful. In giving her advice, which of the
e) Urgent surgery is necessary due to the
following statements is CORRECT?
higher risk of appendiceal rupture in this age
group a) Pregnancy occurs in 80% of couples after 12
cycles; in those who have not conceived the
chance is 50% in each year thereafter
b) Healthy young couples have a 10% chance effects. There is some debate as to the significance of
of achieving pregnancy in one menstrual cycle, the slight fall in bone density seen in some studies of
that is, a fecundability of 0.10 women using this form of contraception. Thrombosis is a
side effect of oestrogens rather than progestogens.
c) If a couple less than 30 years of age have
not conceived in 12 months, they have no
chance of conception Question 36
d) With a regular cycle most women of this age Malka, age 16 years, presents with primary
have conceived by 3 months so gynaecological dysmenorrhoea which is preventing her from attending
review is recommended school when she has her period. With regards to the
management of primary dysmenorrhoea which of the
e) Preliminary investigations to confirm following is TRUE?
ovulation and adequate sperm should now be
undertaken by her general practitioner a) Paracetomol is as effective as non-steroidal
anti inflammatory drugs

b) Combined oral contraceptives should not be


Answer: A offered unless the young woman is sexually
Infertility is defined as the failure of conception in a active
couple having regular, unprotected sexual intercourse c) Non steroidal anti inflammatory drugs should
for one year, provided that it is occurring not less than be recommended as first line agents
twice weekly, and menstrual cycles are regular.80% of
couples will be pregnant after 12 cycles. Of those who d) Depo provera is of no assistance in the
have not conceived after 12 cycles, about 50% will management of primary dysmenorrhoea
conceive during a second year of attempted conception.
After this second year of attempted conception, the e) Combined oral contraceptives should not be
chance of conception in those couples remaining is used in conjunction with non-steroidal anti
about 50% in the following four years. The fecundability inflammatories
of a young couple is approximately 0.25, that is, there is
a 20-25% chance of pregnancy for each menstrual
cycle. Fecundability for women declines from about 35 Answer: C
years of age, precipitously after age 40 Young women of
this age with this presenting complaint should have a Primary dysmenorrhoea results from uterine
thorough history taken to exclude obvious causes of vasoconstriction, anoxia, and contractions mediated by
infertility and to reassure the woman that she is normal. prostaglandins. Non steroidal anti inflammatory drugs
It is important to clarify that coitus is achieving (NSAIDS- eg: Naprosyn (mefanemic acid) are
adequate penetration to optimise sperm delivery, and recommended as first line agents in the management of
that timing matches the peak fertile period during her dysmenorrhoea as they inhibit prostaglandin synthesis
menstrual cycle. Pre-pregnancy counselling will include and therefore provide symptomatic relief. Paracetomol is
folate supplementation, rubella immunity and Pap smear not as effective as NSAIDS in this condition due to it's
testing. Investigation of the couple is usually deferred lack of effect on prostaglandin pathways. While it
until 12 months have passed unless the woman is of provides simple analgesia it does not address the
advanced age. causation of the problem. The combined oral
contraceptive pill reduces menstrual flow and inhibits
ovulation and is also effective in the treatment of
dysmenorrhoea. It can be used with NSAIDS, although
Question 35 this is rarely necessary.. The lack of response to NSAIDs
and OCs (or the combination) may increase the
Monique, age 18 years, keeps forgetting to take her
likelihood of a secondary cause for dysmenorrhoea.
combined oral contraceptive pill and is keen to try depot
Depo provera may also prove helpful in the
medroxyprogesterone, as her friend is using it with
management of dysmenorrhoea as it inhibits ovulation
great success. All of the following are side effects of this
and often results in amenorrhoea.
medication EXCEPT:

a) Weight gain
Question 37
b) Depression
Maria, G3P3, 35 years is 4 weeks postpartum and
c) Thrombosis
breastfeeding. She seeks advice regarding postpartum
d) Amenorrhoea contraception. Which of the following isTRUE?

e) Delayed fertility a) Maria should not recommence sexual activity


until at least six weeks postpartum

b) Lactational amenorrhoea is 98% effective for


Answer: C the first 6 months if fully breastfeeding (no
solids) and amenorrhoeic
Depot medroxyprogesterone acetate, marketed as
Depo-Provera and Depo-Ralovera, is an injectable c) Any of the oral contraceptive preparations
progestogen given every 12 weeks +/- 2 weeks. Women may be safely used after 6 weeks post-partum
can suffer from progestogenic side effects such as
weight gain, bloating, and menstrual disturbance. d) Intra-uterine devices (IUDs) should not be
Initially women may suffer from irregular bleeding, used until the uterus is back to normal at 6
however amenorrhoea occurs in 50% of women after 1 months post-partum
year of injections. There is usually a delay in the return
e) Implantable progesterone-only contraception
of fertility until approximately 9 months after the last
(Implanon) is contra-indicated in breastfeeding
dose. Mood changes and acne are less common side-
women
Answer: B following is the CORRECT advice to give Mandy
regarding timing of insertion of an IUD?
Sexual activity can recommence whenever the woman
feels comfortable enough to try it, taking into a) An IUD can be inserted any time during the
consideration the time needed for episiotomies and last 14 days of her menstrual cycle and no
vaginal tears to heal. In terms of contraception, as long additional contraceptive protection is needed
as the woman is fully breastfeeding (no solids) and has
not started menstruating then lactational amenorrhoea b) An IUD should only be inserted whilst Mandy
provides 98% protection against pregnancy. has menstrual bleeding and no additional
Contraception containing estrogen such as the COCP is contraceptive protection is needed
not recommended as it may reduce the volume of breast
c) An IUD can be inserted any time within the
milk. Progestogen only methods of contraceptives are
first 12 days after the start of menstrual
usually recommended as they are safe when
bleeding and no additional contraceptive
breastfeeding. These include the "minipill", depot
protection is needed
injections, Implanon or the Mirena IUD, all of which may
begin from 6 weeks post-partum. IUDs are safe to insert d) An IUD can be inserted at any stage within
6 weeks after a vaginal birth when the uterus has the middle two weeks (14 days) of her
returned to normal size and bleeding associated with the menstrual cycle and no additional contraceptive
birth has stopped. IUDs should be inserted at least 12 protection is needed
weeks after a caesarean birth as there is a slightly
greater risk of perforation of the uterus before this. e) An IUD can be inserted any time during her
menstrual cycle provided she uses 7 days of
additional contraceptive protection after
insertion
Question 38

Sally has come to discuss the combined oral


contraceptive pill (COCP) with you. Which of the Answer: C
following is TRUE regarding some of the non-
contraceptive effects of the COCP? It: A copper-bearing IUD can be inserted any time within
the first 12 days (Day 1 = the first day of menstrual
a) Increases the risk of benign ovarian cysts loss) after the start of menstrual bleeding. No additional
contraceptive protection is needed. The probability of an
b) Reduces the risk of endometrial cancer
existing pregnancy is extremely low before day 12 of the
c) Has no effect on the risk of colorectal cancer menstrual cycle based on the extremely low risk of
ovulation before day 8, plus the copper-bearing IUDs
d) Increases the risk of pelvic inflammatory provide 5-days of emergency contraceptive effect. These
disease recommendations do not apply to hormonal

e) Reduces the risk of invasive breast cancer IUDs as their emergency contraceptive effects if any,
are unknown.

Answer: B
Question 40
The COCP has little effect on benign ovarian cysts. If
anything, they may reduce in size. Ovarian cancer: The Beth wants to start using DMPA as a form of
longer the use of the pill, the greater the protection. contraceptive. Which of the following statements
After more than 10 years on the pill, the risk of ovarian regarding Depot Medroxyprogesterone Acetate (Depo-
cancer may be reduced by 60- 80 %. This protective Provera, Depo-Ralovera, depot MPA, DMPA) is TRUE?
effect appears to last at least 15 years after stopping
the pill. Researchers theorize that the pill may lessen a) DMPA is given as a subcutaneous injection
ovarian cancer risk in part by inhibiting ovulation.
b) DMPA always makes women amenorrhoeic
Endometrial (uterine) cancer: In women using the pill
the risk may be reduced by as much as 50%. This c) DMPA causes a delay in return of fertility
protection also lasts at least 15 years after the pill is
stopped. Colorectal cancer: On the pill the risk may be d) Prolonged DMPA use increases the risk of
reduced by approximately 35%. Researchers believe the endometriosis
protective effect may be due to a reduction in the
concentration of bile acids in the colon. Latest research e) Prolonged DMPA use increases the risk of
suggests that the COCP has no effect on the risk of ovarian cancer
breast cancer. Pelvic inflammatory disease (PID):
Although rarely fatal, this infection can lead to infertility
from scarring of the fallopian tubes. Answer: C
The pill cuts the risk of PID by half. It is believed the pill Depot Medroxyprogesterone Acetate (Depo-Provera or
works by making cervical mucus an unfriendly depot MPA or DMPA) is a long-acting hormonal
environment for disease-causing bacteria. contraceptive which is usually given as an intramuscular
injection once every three months. Disadvantages of
DMPA include changes in the menstrual cycle during
Question 39 treatment, usually resulting in oligomenorrhoea or
amenorrhoea, but sometimes resulting in troublesome,
Mandy has requested you insert a copper-bearing IUD. irregular bleeding, especially in the first few months of
She is 34 years of age, with regular 28 day menstrual use. DMPA can also cause an unpredictable but
cycles and she is in a stable monogamous relationship. temporary delay in return of fertility following
Mandy wants to know when, during her next menstrual treatment. There is increasing evidence for substantial
cycle she should have the IUD inserted. Which of the protection against endometrial cancer, ovarian cancer,
acute pelvic inflammatory disease and endometriosis. bone loss in women using DMPA long-term, who have
There is no evidence for serious long-term complications continuous amenorrhoea and low serum oestradiol
of treatment with DMPA, although there is current levels.
controversy about the possible small risk of increased
Block 10
orbicularis oculi). In isolation, the dystonias are usually
Question 1 of unknown cause and treatment is difficult. Dystonias
as a reaction to medication are much more common in
Prolonged neurological sequelae in infants can occur if
children, for example, metoclopramide (an anti-emetic)
the mother has taken which of the following in the third
results in an acute dystonic reaction in 1% of adults but
trimester?
10% of children less than 10 years of age.
a) Antipsychotics

b) Tricyclic antidepressants
Question 3
c) Anticonvulsants
The interossei of the hand are supplied by:
d) Benzodiazepines
a) The radial nerve
e) Opioids
b) The median nerve

c) The ulnar nerve


Answer: A
d) All of the above
When given in high doses in late pregnancy,
e) None of the above
antipsychotic agents have caused prolonged neurological
disturbances in the newborn infant. Anticonvulsants are
associated with congenital defects rather than
neurological sequelae. Benzodiazepines can cause Answer: C
hypotonia, respiratory depression and hypothermia in
the newborn infant if used during labour in high doses. The nerve supply of the interossei of the hand is from
Withdrawal symptoms in neonates have been reported the deep branch of the ulnar nerve (spinal root C8-T1).
with prolonged maternal use of tricyclic antidepressants.
Opioid analgesics may cause respiratory depression in
the newborn infant. Withdrawal symptoms in the Question 4
newborn have been reported with prolonged use of
opioids. Coral is 55 years old. Her periods ceased 8 years ago.
She now presents with vaginal itch, discharge and
soreness. The MOST LIKELY cause is:
Question 2 a) Candida infection
A 21 year old man walks into your surgery with his head b) Vaginal atrophy
tilted sideways, his eyes rolled up and his tongue
sticking out. He speaks with difficulty but says that he c) Vaginal dermatoses
has been 'stuck' in this position since taking a new
medicine a few hours ago 'for his nerves'. You should d) Gardnerella infection
administer:
e) None of the above
a) Diazepam

b) Benztropine
Answer: B
c) Chlorpromazine
50% of women suffer symptoms of urogenital atrophy in
d) Phenytoin the postmenopausal years. Atrophy of the vaginal
mucosa can lead to vaginal dryness, soreness, pruritus
e) Haloperidol and discharge.

Answer: B Question 5

The presentation described is an acute dystonic 22 year old Melanie presents with a 2 day history of a
reaction, which involves a spasmodic torticollis, (where vaginal discharge, urinary frequency and dyspareunia.
the head is pulled and held to the left or right by one or Which organism is the MOST LIKELY cause of this
other sternomastoid), upward drawn eyes and an open presentation?
mouth (oromandibular dystonia). It may occur
(particularly in young men) within a few days of starting a) Gardnerella
a neuroleptic medication. Treatment is with the
b) HIV
anticholinergic medication eg. Benztropine or
diphenhydramine. If the patient has a contraindication c) Chlamydia trachomatis
to anticholinergics then diazepam may be helpful. The
dystonias are a group of disorders involving prolonged d) Giardia lamblia
spasms of muscle contraction. Spasmodic torticollis is
one type, as is trismus (clenched jaw) and e) Hepatitis B
Blepharospasm (involuntary contraction of the
Answer: C tightening of the skin with increased risk of the
development of squamous cell carcinoma.
Chlamydia trachomatis is an intracellular bacterium.
Genitourinary symptoms caused by this organism
include cervical discharge, cervical bleeding, menstrual
change, abdominal pain, fever, nausea, vomiting, Question 8
urinary frequency and dysuria. Infection rates are
Which of the following is INCORRECT?
highest in the 15-25 year old age group. It is important
to remember Chlamydia may be initially asymptomatic a) The incidence of haemochromatosis in
especially in women and is the leading cause of Australia is 1:200
preventable infertility and ectopic pregnancy. Although it
is important to test for HIV, Melanie's symptoms are not b) C282Y homozygotes account for more than
consistent with a seroconversion type illness. Hepatitis B 90% of haemochromatosis in Australia
also does not present with gynaecological symptoms.
Gardnerella is a simple vaginal infection with no clinical c) The majority of patients with one copy each
sequelae. Giardia is a single celled organism which of the C282Y and H63D mutation never develop
infects the small intestine. haemochromatosis

Question 6 d) 90% of C282Y homozygotes develop


symptoms of the disorder at some stage in
Mr Brown is 70 years old and suffers with severe pain in their lives
his back from osteoarthritis. He also suffers with
emphysema and has had prednisolone for exacerbations e) Carriers of one copy of the altered gene are
of this disease. He is currently on warfarin for a cardiac generally healthy
arrhythmia and is also taking lansoprazole as a
maintenance dose after a duodenal ulcer was diagnosed
4 years ago. Which of the following DOES NOT increase Answer: D
the risk of gastrointestinal side effects from non-
steroidal anti-inflammatory drugs (NSAIDs)? Studies estimate that up to 50% of C282Y homozygotes
will remain symptom free throughout life.
a) Concurrent use of prednisolone

b) Previous duodenal ulcer


Question 9
c) Concurrent use of anticoagulant
You are called to see a 78 year old woman with a three-
d) The fact that he is over 70 years of age week history of headaches and depressive symptoms.
She relates that 24 hours ago the vision in her right eye
e) Male gender
suddenly dimmed. Today the visual acuity in the eye is
limited to perception of hand movements only,
compared with 6/6 in the left eye. She is not known to
Answer: E be a diabetic and her blood pressure is only minimally
elevated. Which of the following possible causes of her
Risk factors for gastro-intestinal side-effects of NSAIDs visual loss require IMMEDIATE investigation and
include age greater than 65 years, previous history of treatment to prevent blindness in the other eye?
peptic ulcer and co-administration of prednisolone and
anti-coagulants. Male gender is not a risk factor. a) Detached retina

b) Central retinal artery occlusion

Question 7 c) Central vein occlusion

A 55 year old woman presents with an itchy purple d) Acute glaucoma


papular rash on her wrist. She is not on any
medications. This is MOST LIKELY to be: e) Temporal arteritis

a) Lichen Planus
Answer: E
b) Lichen Simplex Chronicus
Temporal arteritis is an uncommon disease of the elderly
c) Lichenoid eruption
and is characterised by the classic complex of fever,
d) Lichen Sclerosus anaemia, high ESR and headaches in an elderly person.
It is closely associated with polymyalgia rheumatica.
e) Lichenification Temporal arteritis is the most common manifestation of
a systemic vasculitis. Headache is the predominant
symptom and may be associated with a thickened or
nodular artery. A serious complication, as described in
Answer: A
this lady, is ocular involvement - ischaemic optic
Lichen Planus is an epidermal inflammatory disorder of neuritis. Most patients have head or eye symptoms for
unknown cause characterised by pruritic, violaceous, flat months before objective eye involvement. Acute
tipped papules mainly on the wrists and legs. Lichen glaucoma causes a red, painful eye, reduced vision and
Simplex Chronicus is a thickening of the skin as a result a fixed, mid- dilated pupil which may be slightly ovoid.
of constant scratching, the process of which is called The pain may be severe and associated with nausea and
lichenification. Lichen sclerosus is an unexplained vomiting. Acute glaucoma may be preceded by blurred
vaginal dystrophy characterised by itch and vision or haloes around lights. It is a uniocular attack
hypertrophy. A lichenoid eruption is most typically due due to blockage of drainage of aqueous fluid from the
to a drug reaction. Lichen Sclerosis et Atrophicus is a anterior chamber via the canal of Schlemm. Urgent
condition of the penis and vulva producing atrophy and treatment with hyperosmotic agents is necessary to
reduce the intraocular pressure.
Question 10 Question 12

A 21 year old female patient presents with lower An elderly patient with rheumatoid arthritis has been on
abdominal pain and tenderness at 14 weeks of prednisolone in a dose of 12.5 mg daily for 8 years.
gestation. Her temperature is 38.5 degrees Celsius. The After a fall, she complains of severe pain over her lower
most important diagnosis to EXCLUDE is: thoracic spine and is found to be very tender over T11
and T12. A radiograph shows 'cod-fish' vertebrae, with
a) Pyelonephritis generalised radiolucency of bones and collapse of two
vertebral bodies. Examination of her serum is MOST
b) Threatened abortion
LIKELY to show:
c) Ectopic pregnancy
a) High calcium, low phosphate, raised alkaline
d) Degeneration of a uterine fibroid phosphatase

e) Appendicitis b) Low calcium, high phosphate, normal


alkaline phosphatase

c) Low calcium, low phosphate, raised alkaline


Answer: E phosphatase

Appendicitis is the commonest surgical emergency and d) Low calcium, normal phosphate, normal
has its maximum incidence between 20 and 30 years of alkaline phosphatase
age. In pregnancy it occurs mainly in the second
trimester. Pain is generally higher and more lateral than e) Normal calcium, normal phosphate, normal
typical appendicitis. Ectopic pregnancy occurs alkaline phosphatise
approximately one in every 100 clinically recognised
pregnancies. The classical triad of ectopic pregnancy
includes amenorrhoea (65-80%), lower abdominal pain Answer: E
(95+%) and abnormal vaginal bleeding (65-85%).
Degeneration of a uterine fibromyoma typically occurs in It is most likely the patient has steroid-induced
the second trimester of pregnancy and is due to osteoporosis. Plasma calcium, phosphate and alkaline
ischaemic necrosis. In threatened abortion there is phosphatase are all normal in osteoporosis. If there are
vaginal bleeding. Pain is usually not a significant feature multiple recent fractures, serum alkaline phosphatase
unless the cervix is beginning to open. Pyelonephritis may be elevated.
can mimic acute appendicitis in pregnancy.

Question 13
Question 11 Which of the following may be a good reason for
stopping breast feeding:
A 42 year old man presents with a recurrent severe
hemicranial nocturnal headache which lasts for 60 a) Inverted nipples
minutes and occurs regularly every 3 weeks. The
headache is accompanied by a blocked nose and b) Cracked nipples
watering eye. The MOST LIKELY diagnosis is:
c) Engorged breasts
a) Chronic paroxysmal hemicrania
d) Mastitis
b) Migraine variant headache
e) Breast abscess
c) Chronic sinusitis

d) Cluster headache Answer: E


e) Trigeminal neuralgia Frequent, unrestricted breast feeding day and night is a
treatment for breast engorgement. Improved breast
drainage is important in mastitis and breastfeeding
Answer: D should not be stopped. Breastfeeding can be continued
in the presence of cracked and inverted nipples.
Cluster headache has a four-fold higher incidence in Temporary stoppage of breastfeeding on the affected
men than women. It is characterised by constant side is necessary while surgical drainage of a breast
unilateral orbital pain, with onset usually within 2-3 abscess is carried out.
hours of falling asleep. The pain is intense and steady
with lacrimation, blocked nostril then rhinorrhoea and
sometimes miosis, ptosis, flush and oedema of the Question 14
cheek, all lasting approximately an hour or two. It tends
to occur nightly for several weeks or a few months, A 40 year old physician has had muscle twitching for
followed by complete freedom for months or even years. one year. The twitching occurs predominantly in the
The response to inhaled oxygen can be dramatic. lower extremities. A neurological and general physical
Chronic paroxysmal hemicrania is similar to cluster examination is negative except for these twitchings.
headache in presentation except that it is more common What is the MOST LIKELY diagnosis?
in women, attacks occur at any time day or night lasting
a) Benign fasciculations
2-25 minutes and it always responds to indomethacin.
b) Hypoparathyroidism
Migraine variants include a range of presentations that
are more common in children and often go on to c) Amyotrophic lateral sclerosis
develop a more typical migraine presentation in
adulthood. d) Paramyoclonus multiplex

e) Dystrophia myotonica
Answer: A intercourse should take place prior to the temperature
rise. The purpose of having intercourse on alternate
Diseases of motor neurons or their proximal axons are days is to maximise the sperm count on each
often associated with fasciculations, the spontaneous ejaculation.
firing of an entire motor unit. Fasciculations occur at
times in most normal individuals, and unless weakness
is present, are seldom of any significance. Myoclonus is
a descriptive term for very brief, involuntary, random Question 17
muscular contractions. Myoclonus may involve a single
Sudden onset of unilateral orbital pain, photophobia,
motor unit and simulate a fasciculation, or it may
lacrimation and blepharospasm suggests a diagnosis of:
involve groups of muscles that displace the limb. In
Dystrophia Myotonica there is intellectual impairment, a) Open-angle glaucoma
amongst other associated deficits, and the weakness
starts with the face and extremities. Amyotrophic lateral b) Anterior uveitis
sclerosis (ALS) is characterised by a progressive loss of
motor neurons, both upper and lower motor neurons. c) Temporal arteritis
The first evidence is an insidiously developing
d) Unilateral blepharitis
asymmetric weakness. Hypoparathyroidism often
presents with neurologic involvement - manifesting as e) Vitreous haemorrhage
tetany - eg. Chvostek's sign.

Answer: B
Question 15
Anterior uveitis (acute iritis) presents with pain of acute
Which of the following is of LEAST value in assessing the onset, photophobia, blurred vision, lacrimation,
level of active joint inflammation ('disease activity') in circumcorneal redness (ciliary congestion) and a small
rheumatoid arthritis? pupil (initially from iris spasm). Talbot's test is positive:
pain increases as the eyes converge (and pupils
a) Duration of morning stiffness
constrict). The slit lamp reveals white precipitates on the
b) Presence of tiredness, malaise and weight back of the cornea and anterior chamber pus
loss (hypopyon). Open angle glaucoma is painless and
largely asymptomatic until there is visual field loss;
c) Degree of elevation of the erythrocyte temporal arteritis causes pain in the temporal area, not
sedimentation rate (E.S.R.) in the orbit; blepharitis is inflammation of the eyelids;
vitreous haemorrhage can present with visual field loss
d) Presence of rheumatoid factor in the blood depending on the size of the haemorrhage and it is
generally painless.
e) Strength of hand grip

Question 18
Answer: D
A patient presents with acute gout but has a low serum
Rheumatoid factor (RF) is useful in the diagnosis of
uric acid. Which of the following drugs can be
rheumatoid arthritis and is of prognostic significance;
responsible for a low serum uric acid?
however fluctuations in RF titre have poor correlation
with disease activity. Constitutional symptoms such as a) Colchicine
tiredness, malaise, weight loss and morning stiffness are
good predictors of disease activity. b) Prednisolone

c) Indomethacin

Question 16 d) Naproxyn

In a couple trying to conceive, intercourse should take e) Salicylates


place:

a) As soon as there is a rise in basal


temperature Answer: E

b) 14 days after the onset of the next period Up to 30% of patients with acute gout have a normal
serum uric acid at presentation. This may be due to
c) On alternate days prior to the basal precipitation into crystals in the synovium, an effect of a
temperature rise drug the patient has taken for analgesia. Colchicine,
steroids and NSAIDS reduce inflammation in affected
d) On alternate days after the basal joints but have no effect on serum uric acid levels.
temperature rise Salicylates eg aspirin at doses less than 2g/day increase
serum uric acid levels, but at doses above 4g/day
e) Daily after the basal temperature rise
reduce serum uric acid levels.

Answer: C
Question 19
Ovulation occurs on day 14 (plus or minus 2 days)
The 'benign' jaundice that occasionally occurs in the
before the onset of the next menses. Basal body
third trimester of pregnancy is most CLOSELY related
temperature rises around the time of ovulation and
to:
remains elevated for at least 10 days. By the time the
temperature rise is detected by the patient, they are a) Decreased circulating amounts of albumin to
probably in the infertile phase of the menstrual cycle, so bind bilirubin
b) A specific defect in glucuronide conjugation Question 22

c) An autoimmune process The serum phosphate is MOST LIKELY to be low in which


of the following disorders:
d) High oestrogen and progesterone levels
a) Osteoporosis
e) The use of diuretics in the third trimester of
pregnancy b) Osteomalacia

c) Multiple myeloma

Answer: D d) Polymyalgia rheumatica

In a small number of pregnant women, an intrahepatic e) Paget's disease


cholestasis may appear. It usually occurs in the third
trimester of pregnancy and presents as jaundice and
pruritus. These patients probably have an increased
Answer: B
susceptibility to the hepatic effects of oestrogenic and
progestational hormones. Patients with osteomalacia almost always have
hypophosphataemia. Serum phosphate is normal in
osteoporosis, Paget's disease and polymyalgia
Question 20 rheumatica (PMR). Multiple myeloma may have a
normal or slightly raised phosphate level.
Accommodation of the eyes to NEAR objects is
accompanied by:

a) Loss of binocular vision Question 23

b) Constriction of the pupils Which of the following is NOT TRUE regarding


asymptomatic bacteriuria in pregnant women?
c) Divergence of the visual axes
a) The incidence is 3-7% of all pregnancies
d) Decreased refractive (dioptric) power
b) Defined arbitrarily as greater than 100,000
e) Relaxation of the ciliary muscles bacteria/ml

c) One of the common organisms is


Streptococcus Faecalis
Answer: B
d) Responds to a short course of oral antibiotics
Normal pupillary responses consist of prompt,
symmetric constriction (miosis) on exposure to light or e) Is a clinically unimportant phenomenon
on attempted near convergence. Accommodation
involves the active changing of lens shape to focus near
objects. Light detection by the retina is passed to the Answer: E
brain via the optic nerve and pupil constriction is
mediated by the third cranial nerve (parasympathetic). Approximately 6% of women have asymptomatic
The sympathetic nervous system is responsible for pupil bacteriuria in pregnancy, where there are more than
dilatation via the ciliary nerves. 100,000 bacteria per ml of urine in a mid-stream urine
sample. 30% of patients with asymptomatic bacteriuria
will subsequently develop acute pyelonephritis. There is
an association between pyelonephritis, low birth weight
Question 21
and prematurity. Treatment is with an appropriate
Which finding in this report of a cerebrospinal fluid course of antibiotics. Recurrence can occur in 35% of
(C.S.F.) examination is INCONSISTENT with the other cases. The predominant organisms in subclinical or
results? clinical urinary tract infections in pregnancy are E. coli,
Strep faecalis, Aerobacter, Klebsiella and Proteus.
a) Elevated protein

b) Normal chloride

c) Elevated glucose Question 24


d) No red cells With regard to Tietze's syndrome, which of the following
statements is INCORRECT? Tietze's syndrome is:
e) Gross excess of polymorphonuclear
leucocytes a) Painful, tender swelling of one or more
costochondral joints

Answer: C b) The cause of up to 30% of chest pain


presentations to emergency departments
A lumbar puncture consistent with a diagnosis of
pyogenic meningitis contains excessive polymorphs, c) Most commonly diagnosed before the age of
with protein at 1.5g/l (aseptic less than 1.5g/l) and 40 years
glucose at less than 2/3 the plasma level. There are no
d) Sometimes associated with the development
red cells unless it is a bloody tap (ie. artefact due to
of rheumatoid arthritis later in life
rupture of blood vessel).
e) Often associated with repeated minor chest
trauma such as harsh coughing
Answer: D Question 27

The predominant feature of Tietze's syndrome (also Marion aged 56 years complains of constipation,
called costochondritis) is that of a painful costochondral tiredness, lethargy and lack of energy. She looks puffy
junction with a palpable swelling. It often occurs in in the face, is faintly yellowish in colour and has a pulse
patients with persistent cough and is aggravated by of 56 beats/minute regular. Her full blood count shows
coughing or deep breathing. The 2nd costochondral her haemoglobin is 9.7 g/dl, she has a macrocytosis,
junction is most commonly affected. Women are more lymphocytosis and a raised erythrocyte sedimentation
often affected than men. The usual onset is before age rate (ESR). The MOST LIKELY diagnosis is:
40 years. In the assessment of people presenting with
chest pain, 10-30% will have costochondritis, even in a) Pernicious anaemia
childhood. Although many other conditions such as
b) Carcinoma of the bowel
rheumatoid arthritis may present with involvement of
the costochondral joints, there is no evidence that c) Alcoholism with malnutrition
Tietze's syndrome will progress to any other illness. It
usually follows a fluctuating course with eventual d) Hypothyroidism
resolution. Management might include analgesics, anti-
inflammatory drugs, local heat/ice, avoidance of triggers e) Lymphocytic leukaemia
and local steroid injection.

Answer: D
Question 25
Both pernicious anaemia and primary autoimmune
A mother develops a fever of 38.2 degrees Celsius 3 hypothyroidism can cause lethargy, a yellow tinge to the
days after the delivery of her baby. Which of the skin, lymphocytosis and a macrocytic anaemia with a
following is the MOST LIKELY cause? raised ESR. They often occur simultaneously and are
more common in females. However constipation and
a) Endometritis bradycardia, with puffiness of the face (myxoedema) are
more indicative of hypothyroidism, making this the
b) Dehydration MOST likely diagnosis in this case. One would expect a
microcytic anaemia with carcinoma of the bowel due to
c) Breast engorgement
chronic occult bleeding and more signs of liver disease
d) Deep venous thrombosis with alcoholism and malnutrition. Lymphocytic leukemia
may cause lethargy, lymphocytosis and jaundice, but
e) Urinary tract infection (UTI) none of the other signs.

Answer: A

Puerperal infection affects 2-8% of pregnant women and Question 28


presents with a temperature of greater than 38 degrees
Celsius after the first 24 hours post-partum. In up to In which of the following conditions of the colon is
75% of cases the cause is genital tract infection, with malignant change MOST LIKELY to occur?
endometritis most common, especially in the context of
a) Adenomatous polyp
a prolonged, complicated labour. Dehydration and
breast engorgement may cause a mild pyrexia up to b) Melanosis coli
37.5 degrees. Thrombosis may also cause a low-grade
temperature initially although a septic pelvic thrombo- c) Diverticulitis
phlebitis would present later with high fever. UTI occurs
in 2-4% of post-partum women and usually presents d) Familial polyposis coli
with low grade fever unless there is pyelonephritis.
e) Ulcerative colitis

Question 26
Answer: D
In which spinal cord segments are the motor neurones
Familial Intestinal Polyposis occurs in 1/8000 to 1/14000
responsible for the knee-jerk located?
people in western countries and 50 percent have
a) L1,L2 hundreds to thousands of polyps by age 16. 90% of
affected people will develop carcinoma of the colon by
b) L2,L3 age 45. Between 10% and 20% of adenomatous polyps
show histological evidence of malignancy when
c) L3,L4 removed. The primary genetic defect occurs in the
apoptosis gene p52. The lifetime risk of malignant
d) L4,L5
change in untreated ulcerative colitis is 12%. Melanosis
e) L5,S1 coli is due to laxative abuse and is not pre-malignant in
itself. The association between carcinoma of the colon
and melanosis coli is probably due more to chronic
constipation rather than the staining of the bowel wall
Answer: C from laxatives. Diverticulitis is not associated with
malignant change.
The four muscles of the anterior thigh join to form a
common tendon which inserts into the patella. These
muscles are supplied by the femoral nerve, spinal roots
L3, 4. The quadriceps tendon continues distal to the Question 29
patella as the patellar tendon and it is this tendon which
is stretched in the knee-jerk. Stretching the muscle A 25 year old epileptic woman who had been in good
spindles causes a reflex quadriceps contraction to limit health was admitted to hospital in a comatose condition
the tendon stretch. after the ingestion of 2.0 g of phenobarbitone. On
examination, most reflexes appeared to be intact and c) Chlamydia trachomatis
there was no depression of respiration. Which of the
following forms of therapy would be MOST appropriate? d) Neisseria gonorrhoeae

a) Urgent peritoneal dialysis e) Streptococcus faecalis

b) Alkalinisation of urine Answer: C

c) Prophylactic antibiotics The most common aetiology of epididymitis in males


less than 35 years of age is sexually transmitted
d) Administer analeptics diseases, and Chlamydia is much more common than
the gonococcus. E.coli can be a causative factor in
e) Give IV corticosteroids urinary tract infections especially in older men with
urinary outflow obstruction (benign prostatic
hypertrophy etc). Mumps orchitis and epididymitis are
Answer: B now rare because of widespread vaccination.

Phenobarbitone is a long-acting barbiturate. Peak


plasma levels occur within 2-4 hours. It exerts its effects
Question 32
through depression of the central nervous system. It is a
weak acid and is 50% protein bound. About 75% of the Jane is brought into the surgery after being struck in the
dose is metabolised and the other 25% excreted eye with a tennis ball. On examination you note blood in
unchanged by the kidneys. The half-life in over-dose is the anterior chamber of the eye. Which of the following
80-120 hours. Initial management of barbiturate statements regarding her management is INCORRECT?
overdose requires prompt gastrointestinal
decontamination. Barbiturates are well absorbed by a) Aspirin and non-steroidal anti-
activated charcoal. For all barbiturates, attention should inflammatories drugs (NSAIDs) are
be given to hemodynamic and respiratory support, contraindicated
correction of temperature and electrolyte derangement,
and monitoring for pulmonary complications. Renal b) The main treatment goal is prevention of
elimination of phenobarbitone is enhanced by secondary haemorrhage and glaucoma
alkalinisation of urine to pH 8 and fluid administration
c) Topical mydriatics should be used to permit
with or without mannitol to enhance diuresis.
examination of the posterior chamber

d) Tranexamic acid (Cyklokapron) may be used


Question 30 to stabilise clot formation and prevent
rebleeding
A 32 year old man with ankylosing spondylitis presents
to you for management of his disease. Which of the e) Urgent ophthalmological review is necessary
following clinical features is he LEAST LIKELY to to exclude other ocular damage
complain about?

a) Sudden development of dull low back pain


Answer: C
b) Attacks of pain and photophobia in one eye
Management of hyphaema is directed at prevention of
c) General malaise, fatigue and weight loss secondary haemorrhage within the orbit which carries a
high risk of severe glaucoma. Therefore strict bed rest is
d) Morning stiffness lasting a few hours essential with both eyes covered to reduce eye
movements. Aspirin and NSAIDs are contraindicated.
e) Bilateral hip and shoulder pain Mydriatics would not be used due to the risk of causing
the iris to rebleed. An urgent ophthalmological
assessment is essential. Ongoing review will check for
Answer: A secondary bleeding (20% occur within 2-3 days),
glaucoma and corneal staining. Tranexamic acid may be
The key features of ankylosing spondylitis are the used to stabilise the clot. Glaucoma may develop
insidious onset of back pain and morning stiffness which months or years after the hyphaema has resolved.
improves with exercise, lasting for more than 3 months.
Back pain is the most common presenting symptom,
and it occurs predominantly in young adults.
Question 33
Approximately 25-35% have an arthritis in the hips and
shoulders. Some also have an asymmetric arthritis of The MOST LIKELY venous source of fatal pulmonary
other joints. Younger patients often present with a embolism is:
peripheral enthesitis. Older patients may have more
constitutional symptoms such as fatigue. Up to 30% will a) Iliofemoral
have episodes of acute anterior uveitis and many will
have other extra-articular features. b) Subclavian

c) Saphenous

Question 31 d) Pelvic

In men less than 35 years of age the MOST COMMON e) Popliteal


causative organism in epididymitis is:

a)Mumps virus
Answer: A
b) Escherichia coli
Most pulmonary emboli arise from proximal deep vein
thrombosis (deep veins of lower limb, pelvis and inferior
vena cava). Less frequently, thromboses of the upper diabetics will eventually require insulin therapy, the
arm are the source. Saphenous vein thrombosis seldom early introduction of a small dose of intermediate-acting
results in clinically obvious pulmonary embolism. Also, insulin before bed will often markedly improve control
in order for the thrombus to cause fatality, it has to be and ease anxiety about managing injections.
large enough to either cause obstruction in the right
atrium or of the right ventricular outflow tract. It
therefore would have to originate in a large vein.
Question 36

In trigeminal neuralgia all of the following statements


Question 34 are true EXCEPT:

A patient with moderate to severe emphysema would a) It is most common in middle-aged and
demonstrate all of the following physical signs EXCEPT: elderly persons

a) Distant heart sounds b) Multiple sclerosis must be considered in


younger people
b) A prominent pulmonary second sound
c) There is an associated weakness in the
c) A narrow intercostal angle muscles of mastication

d) Prolonged expiration d) The severe, lancinating pain may last for up


to two minutes
e) Hyperresonance to pulmonary percussion
e) It usually responds well to regular
carbamazepine
Answer: C

Pulmonary emphysema is one of the obstructive types of Answer: C


pulmonary diseases which leads to progressive
hyperinflation of the chest. As a result heart sounds Trigeminal neuralgia is characterised by stabs of intense
become distant, percussion becomes hyper-resonant pain in the distribution of one or more divisions of the
and the intercostal angle enlarges as the chest becomes Trigeminal nerve, lasting 1-2 minutes (up to 15
more barrel shaped. Pulmonary hypertension leads to a minutes). It is usually unilateral (96%). Pain may be
louder second (P2) heart sound. Prolonged expiration or precipitated by touching a trigger point on the face or by
a prolonged forced expiratory time is an important sign eating or talking. It is more common in women than
in the obstructive airways group of diseases. men and in those over 50 years. The cause is unknown.
In younger patients multiple sclerosis should be
considered. If left untreated it can progress, with shorter
and shorter periods of remission. Carbamazepine is
Question 35
usually the first line of pharmacological treatment.
Mrs Leung, aged 68 years, has Type 2 diabetes for Surgical treatment may be necessary if it persists
which she takes metformin 850mg tds and gliclazide despite a trial of other medications, but may cause
160mg bd. Her blood pressure is well controlled on permanent anaesthesia. The motor division of the
candesartan 16mg daily. She has no evidence of heart trigeminal nerve supplies the pterygoid and masseter
failure and is otherwise well. Her HbA1c is now 9.2% muscles. It is not usually affected by trigeminal
(nondiabetic range <6%). Which of the following neuralgia however surgical treatments of this condition
strategies would NOT be an appropriate next step? may result in weakness of mastication in 4% of cases.

a) Commence isophane insulin 10 units before


bed
Question 37
b) Commence rosiglitazone 4mg daily
A 40 year old Vietnamese man who arrived in Darwin 6
c) Refer for dietary and diabetes education to weeks prior, presents with 5 days of headache, fever
review lifestyle factors and malaise. What is the MOST LIKELY diagnosis?

d) Increase her dose of metformin to 1 gram a) Malaria


tds
b) Typhoid fever
e) Increase her dose of gliclazide to 160mg tds
c) Dengue fever

d) Filariasis
Answer: E
e) Meningococcal meningitis
In an older Type 2 diabetic without microvascular
complications, a higher HbA1c may be satisfactory.
However, once the level is greater than 9%, therapy Answer: A
must be reviewed to improve control. It is always
appropriate to review lifestyle factors. In this case the Malaria is endemic in South-east Asia and a clinical
gliclazide dose is already at the recommended presentation such as this should be regarded as malaria
maximum. There is room to increase the metformin until proven otherwise. Its symptoms are usually non-
dose. However a more effective strategy is to add a specific, with headache, fevers and malaise being the
thiazolidinedione. Only rosiglitazone has a most common symptoms. Typhoid fever has an
Pharmaceutical Benefit Scheme Authority listing to be incubation period of 7 to 21 days, with an average of 14
added to dual therapy with metformin and a days. Although headache and fever are common
sulphonylurea. It must be monitored closely for possible symptoms, one would expect other symptoms such as
elevated liver enzymes and heart failure but would be abdominal pain and diarrhoea. Dengue fever has an
expected to lower HbA1c by 1-2%. Since nearly all incubation period of only 5-8 days, followed by sudden
headache, fevers and severe myalgias ("The Dandy Answer: D
Walker Syndrome"). A rash typically develops on the
third to fifth day. Filiariasis (due to Wucheria bancrofti) Facial pain analysis requires a disparate approach.
can present as a lymphangitis, with recurrent fever and Neuralgias, particularly Trigeminal neuralgia, are
inflammation overlying the affected lymphatic vessel. common causes and are more prevalent in women over
Finally meningococcal meningitis has a rapid clinical 50 years. Neuralgias are characterised by paroxysmal,
course and the patient would be unlikely to present with fleeting, almost electric shock-like episodes that are
such a long clinical history. Photophobia, neck stiffness caused by demyelinating lesions of nerves that result in
and altered conscious state could also be expected. the activation of a CNS pain-generating mechanism. The
pain of Trigeminal neuralgia, which can be in any branch
of the Trigeminal nerve, usually lasts a minute or two. A
characteristic feature is the initiation of pain by stimuli
Question 38 applied to certain areas of the face, lips, or tongue, or
by movement of these parts. The adequate stimulus to
Peter presents with a painful left eye associated with a
precipitate an attack is a tactile one and possibly a
sudden loss of vision. Which of the following conditions
tickle, rather than a noxious or thermal stimulus.
is NOT usually associated with pain in or around the
Carbamazepine is the drug of choice for Trigeminal
eye?
neuralgia. Dental pain is common, with provocation by
a) Amaurosis fugax hot, cold or sweet foods being typical. Pain with chewing
itself may be due to Trigeminal neuralgia,
b) Retrobulbar neuritis temporomandibular dysfunction or giant cell arteritis
with jaw claudication.
c) Acute angle closure glaucoma

d) Temporal arteritis
Question 40
e) Anterior uveitis
The most important muscle used for inspiration is:

a) External intercostals
Answer: A b) Diaphragm
Amaurosis fugax is the painless temporary loss of vision c) Scalenes
in one eye associated with an embolus temporarily
lodging in a retinal arteriole. d) Rectus abdominis

e) Internal intercostals

Question 39
Answer: B
A 62 year old housewife presents because of pain in her
left cheek precipitated by eating or touching her face In resting healthy individuals, contraction of the
just under the left eye. This pain lasts for 30 to 60 diaphragm is responsible for the majority of inspiration.
seconds. The patient is most likely to benefit from: Clinically, it is important to remember that that the
diaphragm is innervated by the C3/4/5 spinal segments,
a) Dental attention (mostly C4/5) via the phrenic nerves. Loss of function of
this segment, either from trauma or metastatic
b) Penicillin malignancy, will result in the loss of the function of the
diaphragm and all intercostal muscles. The patient will
c) Blockade of the infraorbital nerve
die of respiratory exhaustion in three days unless
d) Carbamazepine respiration is supported. Unilateral phrenic nerve
damage (i.e. bronchogenic carcinoma), causes unilateral
e) Corticosteroids hemi diaphragmatic paralysis which can cause a 20%
loss of inspiratory effort. This is, remarkably, quite
asymptomatic.

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