RACGP Bridging Course AMC PDF
RACGP Bridging Course AMC PDF
RACGP Bridging Course AMC PDF
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
b) Olanzapine
c) Quetiapine Answer: B
a) Hip mobility is usually reduced, particularly In Australia, all of the following are risk factors for
adduction and external rotation suicide, EXCEPT:
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
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
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
a) Restlessness Answer: E
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
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
d) 40%
Question 31
e) 50%
All of the following are effective first line topical
treatments for severe dandruff EXCEPT:
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:
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
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:
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
e) Peak incidence is 2-3 years of age a) an ectopic pregnancy is one where there is
implantation outside the uterine cavity
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.
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
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
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
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
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
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
Answer: A
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?
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
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?
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
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) 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
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
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) Less than 1%
Question 12
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
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?
e) Tricuspid stenosis
Answer: C
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.
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
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
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
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.
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
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)
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:
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?
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
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
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?
b) Prescription of antihistamines
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
• 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
Answer: E
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:
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
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) 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
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
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
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
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
e) Osteosarcoma rarely metastasizes to lung d) Presents with polyuria, polydipsia and weight
gain
Question 29
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
b) Agoraphobia
c) Depression
e) Panic disorder
Answer: B
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
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
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?
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
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:
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
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
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
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
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
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
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
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
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 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
d) Prostatic hypertrophy
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
c) Patient with nocturnal symptoms only e) Reduced muscle tone of the pelvic floor can
affect orgasm
d) Patient with bloating after meals
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
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.
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
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) 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) 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
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?
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?
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?
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
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.
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
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
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
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?
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
Which of the following statements concerning bee sting e) All of the above
allergy is CORRECT?
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
b) Amyloidosis Answer: A
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
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.
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
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
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
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
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
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
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
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 %
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
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:
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?
b) A lymphoblast c) Flucoxacillin
c) A myelocyte d) Doxycycline
Answer: C
Question 12
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
e) Eyelids
Answer: A
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
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?
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
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
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
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) 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
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
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
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
a) Bronchoscopy b) Electrotherapy
d) CT scan e) Surgery
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?
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) 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.
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
a) Streptococcus pneumoniae
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?
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.
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
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) 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
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
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
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
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
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) Multiple myeloma
b) Normal chloride
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
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
c) Saphenous
Question 31 d) Pelvic
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
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
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.