1. Acute Pseudocyst 4cms. Not painful, after 3-4 weeks of acute bout of pancreatitis.

What do you do
next?

A. Observe
B. Endoscopic decompression
C. Open surface decompression

2. Ovarian Cyst during pregnancy 5 cms. What do you do next?

A. Follow up after 6 weeks with USG

B. Laparotomy
C. Laparoscopy

3. Right Homonymous Hemianopia. Where is the lesion?

A. Right occipital
B. Left occipital
C. Right Parietal
D. Left parietal

4. Typical DKA scenario in kid with high blood sugars in the ED in the morning with confusion. What do
you do next?

A. ABG
B. CXR
C. Urine routine

5. Recurrent Pilonidal sinus in a person after surgical treatment performed 6 months ago. What is the
most appropriate advice to the patient?

A. Shave the area and keep it clean

6. Young patient with acute episode of Schizophrenia with severe hallucinations in rural australia. What
is the most appropriate next step in management?

A. Local mental health crisis team for evaluation

B. Some irrelevant options about educating the family members and stuff

7. Acute attack of rheumatic knee pain in an oldie with knee pain unilateral asymmetric. What is the
most likely diagnosis. No redness or tenosynovitis. No prior history of osteoarthritis. No fever.

A. Gout
B. Pseudogout (By diagnosis of exclusion)
C. Rheumatiod arthritis
D. Septic arthritis
E. Ankylosing arthritis

1
8. Investigation of choice (MRI) after non healing neuropathic ulcer on the right foot (ulcer on the head
of 3rd or 4th toe)

9. A (21 years old) young lady present to your clinic and she is asking if she can be tested for the HPV
serology. What is you most appropriate advice to this young lady?

A. HPV serology is not advisable

B. It is useful only in women younger than 21
C. It is important in evaluating the viral load in patients previously infected with HPV

10. Remove the toe nail due to big hematoma (No other sensible options). Hematoma was covering the
entire nail bed of the right toe and the history was saying that patient had banged his toe during a minor
accident while snow skiing.

11. A patient with leg pain which increases with movement (walking ). ABI has been done for this patient
and is about 1.2, what is the most appropriate step in evaluating this patient?

A. Arteriography
B. Venography
C. USG duplex
D. Lymphangiogram

12. Nephrotic syndrome in a 30 years old guy with proteinuria, now presents with flank pain, no fever,
no tenderness or guarding or rigidity. RFTs are deteriorating. Diagnosis of this patient is?

A. Renal venous thrombosis (A complication of Nephrotic syndrome in adults with deteriorating

RFTs)
B. Peri renal abcess
C. Kidney stones

13. One liner, what is the most common location of Endometriosis in the female genital tract?

A. ovary

14. A middle age patient with Low back pain without any red signs or symptoms, complains of pain
increasing after working long hours as a manual labourer, lifting heavy weights. What is the most
appropriate next step in management of this patient?

A. PCM
B. MRI
C. CT Scan
D. CT Myelogram
E. X ray

15. Bronchial asthma in kids, how do we know it is an acute attack??

2
 A. Use of accessory muscles of respiration

16. Treatment of patient with SLE?

A. Hydroxy chloroquine
B. Methotrexate
C. cyclosporin

17. Posterior coloumn syndrome (similar presentation as the one with the patient in Diabetes
neuropathy with “glove and stocking type of anesthesia” – proper words given in the examination). No
Focal neurological deficits, no fever, no history of STDs or trauma. All typical features of Sub acute
combined degeration of the spinal cord.. Read this syndrome well.. as this one is easily recognizable.

A. Vit B12 (Is the answer, bcoz it gives similar neuropathy as Diabetes)
B. Other irrelevant options like – Syphilis, Spinal cord Transection etc..)

18. A patient with Panic disorder with SOB will have which one of the following features??

A. Difficulty breathing (this one is the answer)

B. Incidence is same in Men and women
C. Metabolic alkalosis
D. Some other option
E. All of the above

19. A patient with previous history of Molar pregnancy. Now this is her 2nd pregnancy and at 8 weeks
her uterus size is 14 weeks. What is the most likely diagnostic modality of choice?

A. USG
B. B HCG
C. Other irrelevant options

20. A female living with her mother and her alcoholic husband. There is history of family discord and the
lady is thinking of putting her mother in the elder home. On examination of the patient, there are newer
marks of purpura and the mother is depressed, not talking to you. Which of the following is the most
likely diagnosis?

A. Elder abuse
B. Senile purpura
C. Allergic reaction
D. Solar keratosis

21. SSRI and amphetamines can cause which of the following side effect, which should be warned to the
patient who is a drug abuser and is taking SSRI because of depression.

A. Irreversible psychosis
B. Other useless options

3
22. A 8 months old kid is brought by his mother with cyanosis, breathlessness and mild fever. The
infection started with mild URTI type signs and has been continuing since 10 days. Now there are LRTI
type grunting and sub coastal recession etc.. (typical signs and symptoms + history of Bronchiolitis). RR =
44. What is the most appropriate next step in the management of this kiddo??

A. Nebulised adrenaline
B. IV fluids
C. Antibiotics
D. Oxygen supplementation
E. Observe

23. A young patient (17 years old) had a visit to your clinic with some complains (no info about the
nature of complains mentioned). She specifically requests you to please keep her visit and her info
confidential. Next day her mother calls your clinic and asks you about her health condition as she is
worried coz her daughter appears to be little sad lately. What is your duty in this situation?

A. Cannot disclose patients info

B. Give all details
C. Tell her that she need not worry as there is no emergency situation
D. Tell her that she is not depressed

24. Typical question about Uterine inversion with all the details mentioned and shit easy to diagnose..
Felt like I was doing something wrong.. coz easy questions had started appearing now !!!

25. A preganant patient with history of Post Partum depression in previous pregnancies, what do you
advice now so as to prevent it happening again?

A. visit the physician (follow up) after delivery

B. Prophylactic anti depressants
C. Prophylactic psychotheraphy
D. Termination of pregnancy

26. Question about (Epididymo orchitits – not given) in a 25 years old patient with a picture of swollen
testis (left side) of a 6 year old kid with the infection and fever + tenderness. Asking for the causative
organism?

A. E. coli
B. Chlyamidia T. (sexually active male) – question with unmatched picture.. LOL..
C. N.G.

27. Contraception of choice for a lady who has just delivered vaginally a full term male baby. She plans
to breast feed the kid for atleast 1 year and is asking for the most appropriate contraception of choice
which does not effect her breast milk.

A. POPills contraception with breast feeding starting at 6 weeks post partum

4
 B. Other option with similar POPills with different dates of beginning
C. Combination OCPills

28. Dialectal psychotherapy for patient with Borderline personality disorder with history of recurrent
suicidal attempts.

29. Old recall, a patient with walderstoms macroglobulinemia (a cancer with immunosuppressive
treatment basically) with past history of chicken pox, now presents with rash on the abdomen. The
patient is on amoxicillin antibiotic. What is the most likely diagnosis? (the rash was discrete papules with
red ring bottoms and fluid filled tops.. clearly distinguishable as varicella, you cannot see patients face –
coz not given.. or else it would be so easy to recognize this one.. but still its easy)

A. Varicella infection reactivation

B. Fixed drug eruption
C. Drug allergy
D. Angio edema

30. MM (multiple myeloma) with LBP with Anemia with hypercalcemia in an old age patient = diagnosis

31. 25% risk reduction in prostate question with answer = 50

32. A patient with occult bleeding per rectum with normal UGI series and normal colonoscopy. What do
you do next?

A. Capsule endoscopy
B. Repeat colonoscopy
C. Sigmiodoscopy
D. Laparotomy

33. A Driver with chronic diarrhea since 3 months, colonoscopy done last year was normal. No fever no
mal-absorption. What is the next investigation of choice for this patient?  stool for ova and cyst

34. Patient with cental lung mass on chest xray with spiculations and mild pleural effusion. RR = 28, no
fever, mild tachycardia and DOE. No edema feet or JVP. On pleural tapping proteins = 40 grams. Which
of the following is the most likely diagnosis?

A. Ca lung (with proteins > 40 gms - exudate)

B. Pneumonia
C. Pneumoconiosis
D. Interstitial lung disease

35. A patient with recent bout of influenza for 10 days now complains of right sided hypochondriac
abdominal pain. On examination patient is not breathless and there is no redness of that area. There is
however mild tenderness which can be elicited, no rebound no guarding, no rigidity, No joint complains,
no hiccups. No history of trauma. What is the most likely diagnosis of this patient?

5
 A. Lung abscess
B. Empyema
C. Diaphragmatic trauma
D. Sub capsular hematoma of the liver

36. A scenario with multiple joint pain and multiple values given as follows: ANA +, ds DNA -, RF +, Ro (La)
+. What is the most likely diagnosis of this patient?

A. Sjogren syndrome
B. Mixed connective tissue disorder
C. SLE
D. Rheumatiod arthritis

37. One liner question asking about the most appropriate way of DM screening after 50 years of age?

A. every 1 years with FBS

B. every three years with OGTT
C. And other irrelevant options

38. An old age patient with Ogivilie syndrome (pseudo obstruction of the colon), flatus tube is already in
place, cecum = 14cms, what is the next step in management of this patient?

A. colonoscopic decompression
B. Laparotomy
C. laparosopy

39. A baby with very Low apgar score of 3. What is the most likely most appropriate next step in
management of this kiddo?

A. O2 with face mask ???? (I marked this one)

B. Suction of nose and mouth ????
C. Immediate cardiac massage
D. Intubation and ventilation

40. A patient with history of alzheimers dementia have now started with dis inhibitions and
inappropriate behavior like peeing in the pot in the mall and other similar things. No history of trauma
or fever. What is the most likely diagnosis of this patient?

A. UTI
B. Worsening of dementia
C. Subdural hematoma
D. Secondary Depression

6
41. Typical question of fat embolism with long bones fracture and SOB on 3rd day with confusion and
chest petechiae and Xray showing diffuse broncho vascular markings. What is the best modality of
investigation for proper diagnosis of this patient?

A. CTPA – fat embolism

B. VA QC
C. D Dimer

42. Pulmonary embolism in a patient with low eGRF value (i.e., another way of saying that that patient
has kidney failure, they changed it from low creatinine clearance to this mumbo jumbo). What is the
most important diagnostic modality of this patient?

A. Va Qc with kidney failure (normal eGFR = 125ml/min, here it was about 60ml/min)
B. CTPA
C. MRI

43. A 10 years old kid with 20 WBCs / HPF (they changed it from WBCs/ml to WBCs/HPF = but still means
the same thing) and 105 Ecoli + bacteruria. What is the treatment of choice for this kid

A. NFT for UTI

B. No option of cephalexin
C. Do nothing

44. A 6 years old obese kid with all obese family members. They don’t exercise and neither eat healthy
food in the family. They are hardcore non vegetarians and would like to get help for the obesity of their
child. What is the most likely treatment of the obesity of the child?

A. Family therapy for obesity of all family members

B. Diet clinic reference
C. Stop non vegetarian and stick to veg diet (reduce the intake of fats and increase intake of
proteins)

45. A patient after vaginal birth is complaining of difficulty walking with the right leg and also is
complaining of some tingling numbness. She had a prolonged labor and was in lithotomy position for
more than 10 hours. Compression of a nerve is suspected. What is the most likely the muscle effected
for causing these signs and symptoms.

A. Extensor halluces longus

46. A 65 years old female presents with dark colored nipple discharge.(The only question from blue
book). There is no palpable lumps and breast skin is normal. All other examination is normal. What is the
most likely diagnosis of this patient?

A. Breast cancer in 65 years old with bloody nipple discharge (intraductal carcinoma)
B. Intraductal papilloma

7
 C. Infectious mastitis
D. Mammary duct ecteasia

47. A Female patient who is 26 weeks pregnant present with her husband to your clinic, you notice that
she does not talks much, answers your questions with minimal yes/no. On examination you notice
multiple vaginal lacerations and petechiae in the pubic area. What is the your most likely next step.

A. Call police
B. Confront the husband about possible spouse abuse
C. Advice not to have sex until the baby is born
D. Examine the lady alone in privacy (in a separate room)

48. Typical question of Kawasaki disease with all the features given with skin denuding rash on palms
and soles of a 5 year old kid with red tongue and conjunctivitis + lymphadenopathy + high grade fever.
What is the best approach for this patient?

A. Aspirin + IVIG + 2D ECHO

B. Other similar options containing Steriods

49. A 45 years old patient presents with chronic cervical ulcer, which reappears frequently but is not
painful. It sometimes causes her dyspareunia and bleeds after coitus. What is the most appropriate step
in the diagnosis of this patient is?

A. Biopsy of the ulcer

B. Treat with antibiotics
C. Treat with antifungals
D. Reassure

50. Photograph of bilateral conjunctivitis given without pus, with mild exudation. No redness of nose or
surrounding areas (pupils normal). Patient has family history of hay fever and himself has bronchial
asthma since childhood + flexural eczema. Patient is allergic to amoxicillin. What is the most likely
diagnosis of this patient?

A. Allergic conjunctivitis
B. Drug allergy / reaction
C. Periorbital cellulitis
D. Other

51. A Kid with ADHD on sertraline + dextro amphetamine has lately become more irritable and difficult
to console. Given in the typical scenario of 3-4 lines. At last they asked why is this all due to?

A. s/e of sertraline ???? (I marked this one)

B. NMS in the kid
C. Serotonin syndrome in kid
D. A consitutent of the ADHD syndrome

8
 E. s/e of dextro amphetamine

52. A patient with depression on Sertraline with your treatment, now has been prescribed with tramadol
tablets for acute gastroenteritis and vomiting. Patient develops signs of serotonin syndrome. What is the
next most important step in management of this patient?

A. Stop Tramadol
B. Stop sertraline
C. Other options (I don’t remember)

53. A 26 weeks pregnant lady infected with Parvo B19 virus. Given in the clinical case scenario. Asking
about what do you do next in the management of this patient?

A. USG
B. Amniocentesis and fluid culture

54. A 45 years old patient with recurrent rectal fistula. No other complains, no joint pain, no altered
bowel habits, no arthritis. In the history nothing suggests crohn’s disease. He complains of occasional
soiling of underwear. What is this most likely due to?

A. Anal gland infection

B. Peri rectal hematoma

55. A patient after parathyroid surgery for its adenoma complains of peri – oral tingling numbness (only
this much given in the question scenario. What is the diagnosis of this patient?

A. Tetany
B. Other irrelevant options

56. A patient with history of 25 pack year cigarette smoking. He had tried quitting once before, did not
smoke after that for a month but had a relapse latter. He has good will power and understands all the
benefits and side effects of his bad habit and has been through psychotherapy. What is the most
important step in helping the patient quit his smoking habit apart from making him sign the contract of
date of quitting smoking.

A. Nicotene replacement therapy

B. Psychotherapy again

57. A question about microscopic poly angitis (I got that after excluding other options, please read about
that one).

58. A pregnant lady comes to you at term, she has started with her contractions, after admitting her to
the wards you are monitoring her with CTG. She ruptures her membranes spontaneously when her
cervical dilatation is about 4 cms. Baby is in normal position and the labor is proceeding normally. Baby’s
head is visible. But you notice that the liquor was meconium stained. What is true regarding this
situation?

9
CTG showed baseline heart beat about = 120 bpm

Beat variability of about 5 beats every 2-4 mins

No deaccelerations

A. The baby has very low chances of being under distress (<1%)
B. Low risk of baby being under distress (<10% probability) and fetal scalp sampling should be
done **** (I marked this one as it made sense during the exam, as compared to all other
options)
C. Increase infusion of oxytocin so as to hasten the delivery in lieu of fetal distress (>50%
probability)
D. CTG is normal ******************* (may also be correct option)
E. Let the labor progress normally as there is no indications of fetal distress

59. Multiple sclerosis may be initially mis diagnosed as?

A. Polyneuritis (I changed my answer to this – feels aweful)

B. Conversion disorder ( Answer is this)
C. Other easily excludable options

Other new topics that I can remember are:

60. Blood tinged saliva with lesion in probably posterior nasopharynx (I don’t remember other options,
please read post nasal drip topic carefully)

61. partial phimosis with yellow white lumps at tip of penis of a kid (with penile shaft inflammation):
Answer shud be  1% hydrocortisone cream (I wrote: urgent surgical reference)

62. Umbilical cord granuloma (3mm small), treatment shud be  silver nitrate cream (I wrote
something else which I can’t remember)

63. Interstitial Nephritis

64. Osteoarthritis treatment  codeine probably the answer, read pain management options in OA
(after excluding other options)

65. Sign of delayed maturation in kid of 12 months, Answer should be  unable to understand “NO”(I
wrote: inability to follow a two step command)

66. Hirschprungs disease presenting with constipation in a kid

67. Torsades des pointes etiology of having this rhythm in a patient

68. Important question when counseling a patient with probable signs and symptoms of panic attack
with agoraphobia (I wrote: ask question - have you ever felt anxious)

10
69. post viral chronic fatique syndrome diagnostic criteria

70. A child in rural aussie had OPV vaccine, now has come to urban areas (and the clinic has no OPV but
only IPV). What to do?

A. arrange OPV and continue vaccination

B. Continue with IPV ************(I chose this option)
C. Other irrelevant options.. No option of catch up vaccination

71. Duodenal ulcer patient with spicy foods + drinking alcohol 3-4 drinks (per week or per day – I don’t
remember as I cudnt pay attention.. one of my last 10 questions) + over weight + past history of h.pylori
infection + other risk factors. What is the most important risk factor treating which shall cause reduction
in pain because of this ulcer?

A. Stopping spicy foods **************** (I chose this one, as I was running out of time)
B. Stop/reduce alcohol to 2 std drinks per day************* (may be the answer, dunno)
C. Treatment with anti H Pylori drugs
D. Reduce weight

72. Apart from treating a patient with post partum blues (only mentioned, it did not say whether its
depression reaction or psychosis), what is important to do to achieve better outcomes?

A. Involve family members during counseling ********** (I chose this one)

B. Tell her to continue breast feeding for a longer time
C. Inform the doctor if any intentions of harming the baby come in mind

73. A old patient with redness of face and neck area only.. no arms involved and no pemberton’s sign.
No visible neck swelling and no history of hoarseness or horner syndrome. Just this much information
given. Asking for the diagnostic investigation of choice?

A. Chest X ray ************* (I chose this one)

B. Blood picture
C. TSH, T3 and T4
D. CT head and neck

74. What is thing of most concern in a 6 weeks old baby?

A. Total bilirubin of 280 mmoles

B. ALP of 1200 units ********* (I chose this one, but this may be normal for growing kids)
C. Unconjugated hyper bilirunemia *********** (may be this one coz this = hemolytic anemia)

Question 1

11
Patients suffering from schizophrenia may experience both positive and negative symptoms. All of the
following are negative symptoms EXCEPT:

a) Anhedonia

b) Hallucinations

c) Lack of motivation

d) Emotional blunting

e) Alogia

Ans.B

Hallucinations are abnormal perceptions, e.g. hearing voices speaking about the patient, and/or giving
instructions to do certain things. They represent additional phenomena and, therefore, are classified as
positive symptoms. Delusions (false ideas) is the other major group of positive symptoms. In contrast,
each of the other options represents a loss or diminution of a mental function, e.g. anhedonia is a loss of
capacity for pleasure.

Question 2

Martha was born at 35 weeks gestation. She required phototherapy for jaundice whilst in hospital.
Martha is being breast-fed and is beginning to gain weight. She is now two months old. Regarding
routine childhood vaccination which of the following statements is CORRECT?

a) Vaccinations due to be given at two months of age should be postponed until Martha is at least 13
weeks old to allow for her prematurity.

b) Martha's past history of jaundice is not a contraindication to oral polio vaccine.

c) Vaccines for intramuscular injection should be given into the buttock in a premature baby.

d) Breast-feeding is a contraindication to vaccination.

e) It is not necessary to immunise Martha against hepatitis B.

Ans.B A history of jaundice after birth is not a contraindication to any of the vaccines in the standard
schedule.

Vaccination should not be postponed because of prematurity. The fact that a child is breast-fed is not a
contraindication to vaccination. Vaccines should never be given into the buttocks. The anterolateral
thigh is the preferred site for vaccination in infants under 12 months of age. The deltoid region is the
preferred site in older children (those who have commenced walking) and in adults. Martha would be

12
due to receive vaccination against hepatitis B at the age of two months according to the current
standard vaccination schedule.

* Question 3

Maud is a 70 year old who presents with acute peri-umbilical abdominal pain gradually increasing in
intensity. She is vomiting profusely and develops watery diarrhoea with flecks of blood after an hour of
pain. Examination of the abdomen reveals localised periumbilical tenderness with some rigidity. Rectal
examination is normal. An irregular pulse is noted and an ECG is recorded (shown below).

The MOST LIKELY diagnosis is:

a) Acute appendicitis

b) Acute pancreatis

c) Perforated peptic ulcer

d) Biliary colic

e) Mesenteric artery occlusion

Ans.E The clinical presentation is typical of mesenteric artery occlusion. This occurs most commonly in
patients with atrial fibrillation leading to embolism. The ECG shows atrial fibrillation. Arteriography will
show the vascular occlusion.

* Question 4

A 15 year old young man has sudden onset of severe pain in his right lower abdomen commencing 2
hours ago. He has vomited several times in the last hour. He is rolling on the bed, stating that the pain is
going down into his groin. T 37.1 degrees Celcius, P 110min, BP 135/ 80. Abdomen - soft, no rebound.
Tender right testicle. Your immediate management is:

a) i/v fluids and antibiotics

b) arrange urgent ultrasound examination

13
c) i/v metoclopramide (maxolon)

d) refer for emergency surgery

e) arrange for intravenous pyelogram (IVP)

Ans.D The sudden onset of severe pain in the lower abdomen, groin or scrotum, in a young male under
25 years, should be considered to be testicular torsion until proved otherwise. This is a surgical
emergency, as infarction of the testis can occur quickly, and surgical exploration should be undertaken
urgently. This patient has no fever, nor tenderness of the epididymis to indicate epididymo-orchitis.
Antibiotic treatment will not help. Colour doppler ultrasound may show increased blood flow in
infection and the absence of flow in advanced torsion. However, these are not reliable findings, and the
investigation would waste valuable time. The vomiting is related to the pain, and would be alleviated by
appropriate analgesia. Metoclopramide is not an immediate priority. The clinical picture is highly
suggestive of testicular torsion rather than renal colic, thus IVP is not the appropriate immediate
management

* Question 5

In a 3 year old child with signs and symptoms suggestive of bacterial meningitis, which of the following is
the BEST initial management?

a) Erythromycin IV

b) Gentamicin IV

c) Ceftriaxone IV

d) Phenoxymethylpenicillin oral

e) Amoxycillin oral

Ans.C If bacterial meningitis is suspected clinically it is vital to immediately administer an appropriate

antibiotic prior to urgent transfer to hospital, as meningococcal meningitis may be rapidly fatal. The drug
of choice would be benzylpenicillin 60mg/kg up to 3g IV or IM, or ceftriaxone 50mg/kg up to 2g IV in
patients hypersensitive to penicillin or when further drug treatment may be delayed.

Question 6

Atypical antipsychotic (eg. olanzapine) drugs have certain advantages compared to the typical psychotic
drugs (eg. Chlorpromazine) in the treatment of schizophrenia. All of the following are advantages of
atypical drugs EXCEPT:

a) Improved therapeutic effect on positive symptoms

14
b) Improved therapeutic effect on negative symptoms

c) Reduced potential for acute extrapyramidal symptoms

d) Reduced potential for longer-term extrapyramidal symptoms

e) Improved therapeutic effect in some treatment-resistant patients

Ans. A Both the typical and atypical antipsychotic drugs have a beneficial effect on positive symptoms in
schizophrenia. However, they differ with regard to negative symptoms. Atypical antipsychotics are much
better at combating these. The other options are true for the atypical drugs.

Question 7

Which of the following statements regarding undescended testes is CORRECT?

a) The testes are undescended at birth in 40% of boys.

b) Once the testis is palpable in the scrotum it will remain so.

c) Descent is unlikely to occur after 1 year of age.

d) Orchidopexy should be delayed until late childhood.

e) The undescended testis is at reduced risk of malignancy.

Ans.C Testes which are undescended at birth may well descend into the scrotum during the first two
weeks of life, however descent is unlikely to take place after the age of one. 2% of boys born at full-term,
and 20% of premature males, have undescended testes. A testis which was palpable in the scrotum in
infancy may ascend and become impalpable due to failure of the spermatic cord to elongate at the same
rate as body growth. Orchidopexy is best performed by 12-18 months of age as spermatogenesis in the
undescended testis is impaired after the age of two years. The undescended testis is at 5-10 times
greater risk of developing malignancy (seminoma).

Question 8

An aspirate in an acutely painful, swollen knee shows the following:

white cell count 4100/uL (< 2000/uL)

red blood cells ++

no crystals

no organisms cultured

15
What is your interpretation of these results?

a) Inflammation is more likely

b) Traumatic tap - cannot be interpreted

c) Gonococcal arthritis

d) Tuberculosis arthritis

e) Viral arthritis

Ans.A Normal synovial fluid contains less than 2000 white blood cells per microlitre. Inflammation
causes counts of 3000 or higher. Inflammation can also cause red blood cells to migrate into the joint
fluid.

Question 9

Concerning prostate cancer, which ONE of the following is INCORRECT?

a) The majority of carcinomas arise in the peripheral zone of the gland

b) The prostate specific antigen (PSA) is elevated in all prostate cancers greater than 1.5 cm

c) Metastatic spread to pelvic lymph nodes occurs early

d) Radionuclide bone scan is not a reliable method of detecting bony metastases

e) Prostate cancers usually appear as hypoechoic nodules on transrectal ultrasound

Ans.B A normal PSA occurs in up to 20% of cancers, including tumours greater than 1.5 cm. Prostate
cancer is the second most common cause of cancer deaths in men in Australia. The majority of prostate
cancers- usually adenocarcinomas- arise in the peripheral zone of the gland, and metastasise early to
pelvic lymph nodes. Bony metastases are also common. Bone scan is unreliable at detecting bony
metastases when the prostate specific antigen (PSA) is <20ng/ml. The commonest pattern for prostate
cancer on transrectal ultrasound is of hypoechoic nodules. This pattern may also be seen in prostatic
hypertrophy or prostatitis.

Question 10

Which ONE of the following atypical antipsychotic drugs is optimal as first line therapy in managing the
first episode of schizophrenia in a patient?

a) Risperidone

16
b) Olanzapine

c) Quetiapine

d) Amuisulpride

e) Clozapine

Ans.B Olanzapine is the drug of choice for treatment of first episode schizophrenia, since it does not
cause extrapyramidal symptoms at therapeutic doses, and is useful for combating affective symptoms,
including depression. Its major disadvantage is weight gain. The other drugs listed carry a greater risk of
extrapyramidal symptoms and other side effects.

Question 11

Ara, 5 years old, presents with a painless limp. You suspect Perthes' disorder. Which of the following
statements is CORRECT?

a) Hip mobility is usually reduced, particularly adduction and external rotation

b) Ultrasound is required to make a definitive diagnosis

c) The white cell count and C reactive protein (CRP) are usually raised

d) Progress is assessed with serial radiological examination

e) Osteotomy is the treatment of choice

Ans.D Perthes disorder is most common in 4-8 year olds. On examination hip mobility is reduced,
particularly abduction in flexion. Xray confirms the diagnosis showing widening of the joint space,
decalcification of the metaphysis and a dense slightly flattened femoral head. There is no need for
testing white cell count or CRP as these are normal. In most cases the prognosis is excellent with the
child only be cautioned to avoid prolonged walking or exercise. Progress is assessed by clinical
examination and serial radiological examinations. Where there are severe changes containment of the
femoral head is the treatment of choice and this usually requires a plaster cast or orthosis. Osteotomy of
the pelvis or femur is only rarely required.

Question 12

Significant protein-energy malnutrition is likely to lead to increased postoperative complications and

prolonged recovery times. In assessing a patient's nutritional status, which ONE of the following findings
would be of MOST concern?

a) bony shoulder girdle sharply outlined

17
b) weak grip strength

c) an elevated white cell count in a patient with multiple trauma

d) at the biceps skin fold, the dermis can be felt between finger and thumb

e) recent weight loss of >5kg

Ans.B Assessment of physiological function is of most importance, as weight loss without evidence of
physiological abnormality is probably of no consequence. Physical weakness (as shown by weak grip
strength) and poor respiratory muscle function increase the risk of post-operative pneumonia.

When the bony shoulder girdle is sharply outlined, and tendons of eg biceps and triceps are readily
palpable, the patient is likely to have lost more than 30% of total protein stores. Loss of body fat is often
readily apparent on looking at the patient, and a biceps skinfold where the dermis can be felt between
finger and thumb indicates that the body mass has less than 10% fat. Metabolic stress can occur from
trauma, sepsis or ongoing inflammation. The trauma patient may well have near normal stores of
protein and fat to call on in the short term.

Question 13

In Australia, all of the following are risk factors for suicide, EXCEPT:

a) Schizophrenia

b) Family history of suicide

c) Social disadvantage

d) Female

e) Youth

Ans.D Males, particularly young men and elderly single men, are at greater risk of suicide than women
who generally have better social support structures than their male contemporaries.

* Question 14

A 15kg child with a known food allergy to peanuts suddenly develops anaphylaxis. The RECOMMENDED
immediate management is:

a) 0.1ml of Adrenaline 1:1000 by deep intramuscular injection

b) 0.1ml of Adrenaline 1:10,000 by deep subcutaneous injection

18
c) 0.15ml of Adrenaline 1:1000 by deep intramuscular injection

d) 0.15ml of Adrenaline 1:1000 by subcutaneous injection

e) 0.15ml of Adrenaline 1:10,000 by deep intramuscular injection

Ans.C Adrenaline 1:1000 is recommended as it is readily available, and this concentration contains 1mg
of adrenaline per ml. The recommended dose of 1:1000 adrenaline is 0.01mg/kg body weight by deep
intramuscular injection, so a 15kg patient would require 0.15ml.

Question 15

Which ONE of the following is a mass population screening test which has been demonstrated to
significantly reduce cancer mortality?

a) annual faecal occult blood testing in the over 50 age group

b) annual colposcopy in sexually active women

c) annual CA125 in post menopausal women

d) annual colonoscopy in siblings of patients with colon cancer

e) 2 yearly mammography in women in the 35-45 age group

Ans.A There have been at least 3 randomised control screening trials which show that faecal occult
blood testing every 1-2 years in the over 50 population reduces the mortality from colorectal cancer by
around 20%. Colposcopy is a diagnostic, not a screening test. The appropriate screening test for sexually
active women is the Papanicolaou (Pap) smear. CA125 levels may be raised in asymptomatic women
with ovarian cancer but there is not, as yet, any evidence for its benefit as a mass screening measure.
Colonoscopy for siblings of patients with colorectal cancer may reduce their mortality, but this is
'selective' screening- targeting a high-risk group.

While mammography in the 50-70 age group has been shown to reduce mortality by around 30%, the
benefit for women in the 40-50 range is quite small, and there is little evidence for benefit in still
younger women.

Question 16

All of the following groups are at higher risk than average of depression, EXCEPT:

a) Women

b) Postpartum women

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c) Young rural males

d) Urban males

e) Adolescents

Ans.D Men living in urban areas are not especially at risk of depression. However, young men living in
rural areas are at greater risk because of social isolation. Women, particularly in the postpartum period,
and adolescents are also more vulnerable to depression.

Question 17

14 month old Mark is brought in to see you. He has had high fevers and a mild runny nose for three days
but has still been quite active. Mark's temperature has returned to normal today but he has now
developed a red maculopapular rash on his trunk. The MOST LIKEY diagnosis is:

a) Measles

b) Chicken pox

c) Erythema infectiosum

d) Rubella

e) Roseola infantum

Ans.E Roseola infantum is a viral infection usually affecting patients between the ages of 6-18 months.
The patient typically develops high fever up to 40 degrees Celsius, but is otherwise not particularly
unwell. There may be mild cervical lymphadenopathy and pharyngitis. After three days the temperature
usually returns suddenly to normal and the patient develops a red macular or maculopapular non-
desquamating rash which is truncal, usually sparing the face and limbs. The rash abates within two
days.(Hull D and Johnston D. (1990) Essential Paediatrics. 2nd ed. Churchill Livingstone, p90. )

* Question 18

A 50 year old woman has had major abdominal surgery yesterday. You are called to see her urgently as
she has symptoms of shock. Which ONE of the following examination findings is of MOST concern?

a) the patient is restless and confused

b) Temperature 39.2 degrees Celsius

c) pulse 130, sinus tachycardia

20
d) urine output over past 4 hours of 120ml

e) BP 80/45 mm Hg

Ans.E The above signs taken together suggest a picture of shock, probably septic shock. Hypotension
(defined as systolic BP <90mm Hg, or >40mm Hg fall from baseline level) is a sinister development and
requires urgent attention. It is often a LATE manifestation of circulatory failure. Thus it is the most
alarming of these findings, and the one most indicative of the urgency of this situation.

Question 19

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 poor and he has lost 6 kg in weight
since discharge from hospital eight weeks ago following treatment for myocardial infarction. He has lost
interest in his hobbies and is not taking his medications. He has been a type 2 diabetic for 12 years. On
examination he shows signs of mild cardiac failure. The result of an HbA1C test is 10.5% (target <7%).
Which ONE of the following is the MOST likely cause of Arthur's condition.

a) Senile dementia

b) Uncontrolled diabetes

c) Depression

d) Silent reinfarction

e) Chronic fatigue syndrome

Ans.C Arthur is showing several typical features of depression, viz insomnia, loss of interest in
pleasurable activities, loss of appetite and loss of weight. Depression following myocardial infarction is
well recognised and increases the risk of complications and death. Such patients are less likely to
observe instructions regarding medications, making their situation worse. Arthur's diabetes is poorly
controlled, as shown by the elevated HbA1C level but this is insufficient to explain his condition. The
other options could contribute to the clinical picture shown by Arthur but are less likely to be the cause
of his condition.

* Question 20

Aidan, a 3 month old boy, presents with paroxysms of coughing associated with cyanosis, lethargy and
poor feeding for several days. On examination, between episodes of coughing, he is afebrile and
examination is normal. What is the NEXT step in management?

a) Admission to hospital

b) Nasopharyngeal aspirate and review in 24 hours

21
Incorrect. The correct answer is (a).

c) Immunisation at this visit with DTP and review in 24 hours

d) Erythromycin syrup and review in 24 hours

e) Trial of salbutamol by mask

Ans.A The clinical picture suggests respiratory infection with Bordetella pertussis. The history of cyanosis
associated with the coughing suggests the need for admission, but in addition, children under 6 months
of age usually require hospital admission for pertussis because of the risk of complications.
Complications include respiratory arrest, bacterial pneumonia and encephalitis.

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 infectivity.

Question 21

Simon aged 4 months is diagnosed with pertussis. What is the MOST APPROPRIATE management of
Simon's parents?

a) Immediate booster immunisations for pertussis

b) A 10 day course of erythromycin

c) Commence a 3 dose pertussis revaccination schedule

d) Arrange nasopharyngeal swabs

e) Immediate immunisation with pertussis immunoglobulin

Ans.B All household contacts of patients with pertussis should receive erythromycin for 10 days to
prevent further spread of the disease. Cotrimoxazole is recommended for those intolerant of
erythromycin.

An initial or booster dose of pertussis vaccine should be considered for children aged up to 8 years. This
is not required for adults nor is it necessary for them to recommence a full vaccination schedule. Babies
under 2 months of age who have been exposed are best vaccinated early.

Passive immunisation with pertussis immunoglobulin is not effective in the prevention of pertussis.
Isolation is not required for household contacts.

Question 22

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Which of the following conditions is the COMMONEST anxiety disorder encountered in general practice?

a) Generalised anxiety disorder

b) Phobic disorder

c) Obsessive compulsive disorder

d) Panic disorder

e) Post-traumatic stress disorder

Ans. A Generalised anxiety disorder is the commonest anxiety 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

Which of the following is NOT a diagnostic feature accompanying anxiety in generalised anxiety disorder
(GAD)?

a) Restlessness

b) Fatigue

c) Difficulty concentrating

d) Muscle tension

e) Loss of appetite

Ans.E Loss of appetite is not a feature of GAD. The DSM-IV criteria include 3 or more of the following in
addition to anxiety and worry: restlessness, fatigue, difficulty concentrating, irritability, muscle tension,
and sleep disturbance.

Question 24

Martin, aged 50 years, complains of insomnia for two weeks. He says this relates to anxiety about
problems at work which surround the end of the financial year. While he is describing his problem, he is
excited and agitated. On examination, his pulse rate is 75/min and BP 135/95 mm Hg. Which of the
following behavioural therapies would be MOST helpful to Martin?

a) Cognitive therapy

b) Sleep restriction therapy

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c) Stimulus control therapy

d) Relaxation therapy

e) Interpersonal therapy

Ans.D The successful treatment of insomnia depends on both behavioural and pharmacological
approaches. Relaxation therapy would be the most useful behavioural therapy for Martin, because he
displays exaggerated arousal - emotional, cognitive and physiological, shown by his mental approach
when describing the problem and his physiological response in terms of pulse rate and BP. Progressive
muscle relaxation aims to reduce somatic arousal and attention focussing techniques (e.g. on tranquil
situations) to reduce cognitive and emotional arousal. (See reference for descriptions of other options,
except interpersonal therapy which is not an accepted form of behavioural therapy.)

Question 25

Doris is a 74 year old woman whose husband has died suddenly a week ago. She seeks your help in
dealing with insomnia which has been troubling her since her husband's death. She has tried an over-
the-counter 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?

a) Temazepam

b) Zopiclone

c) Zolpidem

d) Amitriptyline

e) Any of the above

Ans.E There is a well defined role for short-term use of a hypnotic medication in a situation like sudden
bereavement. None of the drugs listed stands out as the best hypnotic with few side effects.
Temazepam is the most often prescribed hypnotic in Australia. However, benzodiazepines have
generally fallen from favour because of their addictive properties if taken for more than several weeks.
Zopiclone and zolpidem share some of the properties of benzodiazepines but have fewer adverse effects.
Amitriptyline is a tricyclic antidepressant which is a useful hypnotic in lower doses than are used for
depression

Question 26

24
Insomnia is defined as inability to:

a) Fall asleep

b) Maintain sleep

c) Sleep at normal times

d) Obtain good quality sleep

e) Obtain enough sleep

Ans.D Insomnia is the commonest sleep disorder and is defined as poor quality sleep which often results
in daytime symptoms, including fatigue, irritability, problems with concentration and memory, and
feeling unwell. The other options describe features of various insomnia syndromes but do not define the
overall problem.

Question 27

Miriam, aged 67 years, presents with insomnia for two weeks. She has tried several over-the-counter
medications but has not received any benefit. Further questioning reveals that she is feeling unusually
worried about her health, is also irritable and restless and has generalised muscle tension. You have
known Miriam for 5 years since you joined this practice. She has previously complained of 'arthritis' of
the hips and knees, back pain and gastro-oesophageal reflux on various occasions. Which of the
following drugs would be MOST suitable for treating Miriam.

a) Amitriptyline

b) Diazepam

c) Venlafaxine

d) Paroxetine

e) Fluoxetine

Ans.D Miriam is suffering from generalised anxiety disorder (GAD). Paroxetine is a selective serotonin
reuptake inhibitor (SSRI) which has been shown to be effective in the treatment of GAD. Fluoxetine is
also an SSRI but has not been shown to be of particular value in treating GAD. Amitriptyline is a tricyclic
antidepressant and diazepam is a benzodiazepine. Both types of drugs can be used for treating GAD, but
have major disadvantages in terms of side affects. Venlafaxine is a serotonin and noradrenaline
reuptake inhibitor (SNRI) but to date its efficacy in the treatment of GAD has not been demonstrated.

25
Question 28

The prevalence of insomnia in the Australian community is about:

a) 10%

b) 20%

c) 30%

d) 40%

e) 50%

Ans.C The prevalence of insomnia in Australia is about 30%. The situation is similar in other
industrialised nations. Male sufferers outnumber females by 1.3 to 1 in the 40+ years age group. Other
factors which increase the prevalence of insomnia are old age, unemployment and lower socio-
economic status. The majority of patients have a co-existing disorder, such as depression or generalised
anxiety, and often present with fatigue or daytime sleepiness rather than insomnia.

Question 29

Which of the following is a cause of primary insomnia?

a) Obstructive sleep apnoea

b) Restless legs syndrome

c) Behavioural conditioning

d) Sleep phase disorder

e) Bereavement

Ans.C In primary insomnia there is no pre-existing cause of sleep disorder as there is, for example, in
obstructive sleep apnoea, restless legs syndrome, sleep phase disorder and bereavement. With
behavioural conditioning or behaviours impairing sleep the patient has developed a habit of doing things
immediately before bedtime which are not conducive to sleep, such as sitting in bed watching television.
With the other options there is another established condition or situation which disrupts sleep. Hence
insomnia is regarded as secondary in these cases.

Question 30

Patients suffering from generalised anxiety disorder (GAD) often go undiagnosed for years because they:

26
a) Deliberately conceal their anxiety

b) Inadvertently play down their anxiety

c) More often present with somatic complaints

d) Are misdiagnosed as having depression

e) Tend to keep away from doctors

Ans.C Patients with GAD are frequently not diagnosed for years because they tend to present with
associated somatic complaints, such as asthma, back pain, migraine, allergies, and gastrointestinal
disorders and often consume a large amount of medical resources before the diagnosis is made. They
are not deliberately concealing things from their doctors - they simply do not appreciate the significance
of their feelings. Patients with GAD may also have clinical depression which can further complicate the
issue.

Question 31

All of the following are effective first line topical treatments for severe dandruff EXCEPT:

a) Selenium sulphide

b) Zinc pyrithione

c) Betamethasone

d) Miconazole

e) Ketoconazole

Ans.C Dandruff, pityriasis capitis and seborrhoeic dermatitis are related conditions on a continuum of
severity. Pityrosporidium ovale is a fungus which has been implicated in the development of these
conditions. Eradication of the fungus has been shown to relieve the symptoms of the condition.
Selenium sulphide, zinc pyrithione, miconazole and ketoconazole are all first line treatments which can
be used once weekly to daily depending on severity. Topical application of betamethasone lotion is
effective but only considered if there has been little response to the first line treatments.

Question 32

Amy, a young girl, is worried about a rash on her face which has been there for a few weeks. It is not
itchy and has slowly increased in size. On examination it looks scaly (see figure).

27
The MOST LIKELY diagnosis is:

a) Tinea corporis

b) Impetigo

c) Pityriasis versicolor

d) Psoriasis

e) Dermatitis

Ans.A In children, tinea commonly involves the hair, face and body. Tinea corporis is recognised by its
scaly, erythematous edge with clearing centre. Dermatitis and psoriasis can mimic tinea and where the
clinical picture is uncertain a fungal scraping confirm tinea. Impetigo may present with blisters that leave
a brown crust; or erosions with yellow crusts but without blistering. Pityriasis versicolor presents as well
demarcated pale or tan-coloured macules usually on the upper trunk.

Question 33

After referral to a paediatric oncologist, Bronwyn is diagnosed as having acute lymphoblastic leukaemia
(ALL). Both her parents are very distressed and visit you to find out more about this condition. Which of
the following statements about acute lymphoblastic leukaemia is INCORRECT?

a) 75% of children with ALL are cured

b) An initial intense course of treatment lasting approximately 4-6 weeks is required

28
c) Intrathecal therapy is required only if the disease has spread to the spine

d) Relapse rates are of the order of 30%

e) Remission rates are of the order of 95%

Ans.C Intrathecal therapy is now given to all children with ALL. Prior to blanket intrathecal therapy, up
to 60% of children had a relapse due to CNS disease. The use of blanket CNS therapy has reduced the
CNS relapse rate to less than 10%.

(Robinson, M.J. (1990), Practical Paediatrics, Churchill Livingstone, 2nd ed, p 364-365 )

(Braunwald, E., Fauci, A.S., Isselbacher, K.J.& Kasper l et al. (2001), Harrison's Principles of Internal
Medicine, 15th ed, McGraw-Hill, New York, Chap 112 )

* Question 34

Mary is an attendant at a local accommodation centre and has an intensely itchy rash on her wrists and
arms that has been present for the past few days (see figure).

She has recently bought a new watch and wonders if this is the cause of the problem. The MOST LIKELY
diagnosis is:

a) Papular urticaria

b) Tinea

c) Contact dermatitis

d) Eczema

e) Scabies

29
Ans.E Scabies is a skin infestation by the mite Sarcoptes scabiei. It is generally spread by skin to skin
contact such as in crowded areas, poverty, sexual contact and casual contact. The mite can live for 2
days outside the human body, so infection by contact with bed linen and other infected material is
possible. Intense itch is characteristic of the condition - if it is not itchy, it is not scabies. Distinct
erythemato-papular itchy nodules are due to an allergic reaction to the mite, its faeces and its larvae.
0.5-1.0cm "burrows" can often be found on the fingers and wrist. Contact dermatitis to her watch would
produce a local contact dermatitis.

Question 35

Which of the following statements about routine immunisation is CORRECT?

a) If more than 3 months elapses between triple antigen injections the series should be restarted to
obtain adequate immunisation

b) The first triple antigen injection should always be half dose (1/2 cc) to reduce allergic reactions

c) A convulsion following acellular pertussis triple antigen vaccine (DTPa) does not contraindicate its
further use

d) Tetanus booster injections should be repeated every 3 years

e) Measles vaccine should be given at 6 months of age to protect the child as soon as possible

Ans.C

A convulsion, in the presence or absence of fever, occurring after DTPa vaccination, does not
contraindicate completion of the course with DTPa-containing vaccine. The only adverse events which
contraindicate further doses of pertussis containing vaccine are:

encephalopathy within 7 days and an immediate severe allergic reaction.

It is now recommended that, after a full primary course of childhood vaccination, a single booster of
tetanus toxoid is administered at age 50 years only (unless required sooner for managing a tetanus-
prone wound). Measles, mumps and rubella immunisation is recommended at 12 months of age. Triple
antigen (DPT) immunisation is recommended at 2, 4, 6 and 18 months of age. The first dose should not
be reduced.

* Question 36

The MOST appropriate treatment for first degree atrioventricular (AV) heart block is:

a) An artificial pacemaker

30
b) Isoprenaline hydrochloride (Isuprel)

c) Atropine

d) Digoxin

e) Requires no treatment

Ans.E First degree AV block often does not require any treatment. Acute treatment of extreme
bradycardia or second degree AV block (Mobitz type II) may require atropine or isoprenaline, but
temporary pacing is the preferred treatment. Permanent pacing is recommended for distal block
(Mobitz type 2) because of frequent early progression to third-degree atrioventricular block. Most
patients with third degree (complete) AV block will require permanent cardiac pacing. Drugs such as
digoxin may be the cause of an AV block and need to be ceased or the dose reduced.

Question 37

Melissa, a 49 year old woman, presents with loss of libido which has been worsening over the past 12
months. She takes a combined oral contraceptive tablet, and a selective serotonin reuptake inhibitor
(SSRI) for depression. She is a non smoker but drinks 1-2 glasses of wine a night. Which of the following
advice would you offer Melissa to help her regain her libido?

a) Change to a progestagen only oral contraceptive

b) Change to an oestrogen only oral contraceptive

c) Reduce her alcohol intake

d) Change antidepressant medication

e) Undertake cognitive behavioural therapy

Ans.D Various medications may cause loss of libido, including antidepressants like the SSRIs. The
remedy is to change to a different class of antidepressant. Excess alcohol consumption can have a
deleterious effect on libido, however Melissa's intake is within recommended limits for adult females.
Changing the oral contraceptive would be unlikely to help. Cognitive behavioural therapy would be the
next step if suitable pharmacotherapy cannot be established.

Question 38

In assessing a patient for adult-onset asthma, which of the following is FALSE?

a) There is usually a history of past or present cigarette smoking

31
b) There is usually a long history of atopic disease

c) Attacks can be triggered by chemical and physical agents

d) The asthma tends to be more chronic than episodic

e) The associated cough can be harsh, suffusing and non-productive

Ans.B Adult onset asthma is non-atopic, although patients can 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 not to have long spells of being
'puffer free', but regular inhaled steroids are very effective in controlling the condition. The cough can
keep the patient awake all night, along with the rest of the family.

Question 39

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 repeatedly asks where he is and how he comes to
be there. He has short term memory loss but knows his identity and is fully conscious. He recovers from
his memory loss after 6 hours. Neurological examination is normal. His blood pressure is 165/96 sitting.
The MOST LIKELY diagnosis is:

a) Hypertensive encephalopathy

b) Richardson-Steele syndrome

c) Alzheimer's disease

d) Transient global amnesia

e) Complex partial seizure

Ans.D The most likely diagnosis is transient global amnesia. This is a syndrome in which a previously well
person suddenly becomes confused and amnesic. The attacks are usually spontaneous. The patient
appears bewildered and repeatedly asks questions about present and recent events. Orientation for
person and sometimes place is preserved but recent memory is impaired and the patient cannot recall
new information after a few minutes delay. Attacks usually last 24 to 48 hours. Recovery is complete
and recurrence occurs in about 20% of patients. The cause is a mystery. Complex partial seizures are
brief and the individual loses conscious contact with the environment. Post-ictal amnesia is common if
the seizure becomes generalised.

Richardson Steele Syndrome (or progressive supranuclear palsy) resembles Parkinson's disease in that
there is a disturbance of balance and gait, with rigidity of the trunk and neck muscles. Alzheimer's
disease is a progressive form of dementia which does not resolve. Hypertensive encephalopathy is an

32
acute syndrome where severe hypertension is associated with headache, vomiting, convulsions,
confusion, stupor and coma.

Question 40

Which of the following factors would NOT be a poor prognostic indicator for joint replacement in hip
osteoarthritis in a 65 year old man?

a) Age

b) A BMI of 33

c) Associated diabetes

d) Presence of osteoporosis

e) A previous joint replacement

Ans.A Poor prognostic indicators for joint replacement include: age less than 50 years, diabetes, obesity,
high demand, poor bone quality, previous joint surgery and poor general health. Since Michael is 65
years old his age would not be a poor prognostic indicator.

33