Bridging Co
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Question 1
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 Answer: 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.
Answer: 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 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
Answer: 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 male 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 c) i/v metoclopramide (maxolon)
d) refer for emergency surgery
e) arrange for intravenous pyelogram (IVP)
Answer: 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 Answer: 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 drugs (eg. olanzapine) have certain advantages compared to the typical antipsychotic 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
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
Answer: 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.
Answer: 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
year. 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
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
Answer: 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
Answer: 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 b) Olanzapine c) Quetiapine d) Amuisulpride e) Clozapine Answer: 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
Answer: 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 and the only requirement is 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 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
Answer: 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 increases the risk of post-operative pneumonia. When the bony shoulder girdle is sharply outlined, and tendons (eg of 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
Answer: 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
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
Answer: 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 0.01 X 15 = 0.15ml i.m.
Question 15
Which ONE of the following is a mass population screening test which has been demonstrated to reduce cancer mortality significantly?
a) annual faecal occult blood testing in the over 50 age group
b) annual colposcopy in sexually active women c) annual plasma 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
Answer: A
There have been at least 3 randomised control screening trials conducted which show that faecal occult blood testing every 1-2 years in the over 50 year population reduces the mortality from colorectal cancer by around 20%. Colposcopy is a diagnostic, not a screening test. The appropriate screening test for cancer of the cervix in sexually active women is the Papanicolaou (Pap) smear. Plasma 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, by targeting a high-risk group. While mammography in the 50-70 age group has been shown to reduce mortality from breast cancer by around 30%, the benefit for women in the 40-50 age 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 c) Young rural males d) Urban males e) Adolescents
Answer: 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 fever 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 Answer: E
Roseola infantum is a viral infection usually affecting children 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.
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
d) urine output over past 4 hours of 120ml e) BP 80/45 mm Hg
Answer: 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
Answer: 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
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
Answer: A
The clinical picture suggests respiratory infection with Bordetella pertussis. The history of cyanosis associated with the coughing suggests the need for admission to hospital but, in addition, children under 6 months of age usually require 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 to reduce their risk of infection?
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
Answer: 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
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
Answer: 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 Answer: 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 c) Stimulus control therapy d) Relaxation therapy e) Interpersonal therapy
Answer: 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
Answer: 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
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
Answer: 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 long-term treatment Miriam.
a) Amitriptyline b) Diazepam c) Venlafaxine d) Oxazepam e) Fluoxetine Answer: C
Miriam is suffering from generalised anxiety disorder (GAD). Fluoxetine and paroxetine are selective serotonin reuptake inhibitors (SSRI) which have not been shown to be effective in the treatment of GAD. Amitriptyline is
a tricyclic antidepressant; diazepam and oxazepam are benzodiazepines. All three drugs can be used for treating anxiety, but have major disadvantages in terms of side affects and are unsuitable for long-term treatment of GAD. Venlafaxine is a serotonin and noradrenaline reuptake inhibitor (SNRI) which has been 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).
Question 28
The prevalence of insomnia in the Australian community is about: a) 10% b) 20% c) 30% d) 40% e) 50% Answer: 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
Answer: 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:
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
Answer: 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 Answer: 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 mildly itchy and has slowly increased in size. On examination it is a circular lesion which looks scaly around the edges with the center appearing normal(see figure).
The MOST LIKELY diagnosis is: a) Tinea corporis b) Impetigo
c) Pityriasis versicolor d) Psoriasis
Answer: 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 may 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
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%
Answer: 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%.
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 Answer: E
Scabies is a skin infestation by the mite Sarcoptes scabei. 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
Answer: 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
b) Isoprenaline hydrochloride (Isuprel) c) Atropine
d) Digoxin
e) Requires no treatment
Answer: 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 should 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
Answer: 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
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
Answer: 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
Answer: 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 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
Answer: 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.
Question 1
All of the following tests should be part of a routine initial (first trimester) antenatal screen EXCEPT:
a) Full blood examination b) Blood group and antibodies c) Dating ultrasound
d) Syphilis serology
e) Hepatitis B surface antigen
Answer: C
Although there are no official national antenatal 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 visit include the following:
1. Blood group and antibody screen 2. Full blood examination
3. Rubella antibody status 4. Syphilis serology 5. Midstream urine culture 6. Hepatitis B serology 7. HIV Antibody 8. Hepatitis C serology 9. Others to consider: 10. Cervical cytology 11. Haemoglobinopathy screen 12. Varicella antibody
Where the blood group has already been performed it 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 who have had isoimmunisation of any type in the past should be re-screened. Although a previous high rubella antibody titre is generally used to justify exclusion of this investigation from first visit testing, there is some evidence that antibody levels may decline after rubella immunisation, especially since antibody levels are rarely boosted by exposure to wild viruses in the community. All pregnant women should be offered hepatitis C and HIV screening at the first antenatal visit and if necessary after exposure to risk of infection. It is imperative that the woman is provided with appropriate counselling as to the limitations of the testing and the implications of both positive and negative findings. Documented normal 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 2
Martin is 5 years old. His mother reports he has been waking her at night screaming in apparent fear. She is extremely worried. Although Martin is obviously frightened during these episodes, he does not seem fully awake, and she is unable to comfort him or wake him fully. He is sweaty, tachypnoeic and tachycardic. Martin does not recall these episodes in the morning. He is MOST LIKELY suffering from:
a) Nightmares b) Thyrotoxicosis c) Night terrors d) Panic disorder e) Seizure disorder Answer: C
Night terrors are a disorder of arousal from NREM sleep, usually occurring in 3 to 8 year olds. The child wakes only partially, cannot be fully roused or comforted, and will have no recall of the episode. Autonomic symptoms as described are common. With nightmares, the child wakes fully, and frequently has full recall of dreams. Night terrors may be precipitated by anxiety or an experience which has frightened the child prior to sleep.
Question 3
All of the following are associated with the timing of secondary sexual maturation EXCEPT:
a) body weight b) adequate sleep c) phenotype
d) optic exposure to sunlight e) latitude of habitation
Answer: E
Girls must attain a critical body weight (irrespective of height) before sexual maturation will begin. A body weight of 38 - 48 kilograms must be achieved before menses begins and a proportion of body fat of 16-24% is required to sustain ovulatory cycles. Other critical elements to the timing of secondary sexual maturation include adequate sleep and vision. Blind girls have delayed menarche and blind boys have delayed spermatogenesis and ejaculation. Chromosomal abnormalities such as Turner's syndrome result in premature ovarian failure and lack of secondary sexual maturation. Latitude has no impact.
Question 4
Eve is 9 weeks pregnant. She presents with a history of 24 hours of intermittent dark blood loss staining her underwear. On vaginal examination, the uterus is the expected size and the cervical os is closed and non-tender. You should advise her that:
a) she is likely to have miscarried
b) approximately half of all pregnant women suffer bleeding during the first trimester c) she requires admission to hospital for a D&C d) there is a higher incidence of congenital malformations in fetuses where bleeding occurred in the first trimester
e) she should have an ultrasound examination
Answer: E
Eve has a threatened abortion as the cervical os is closed and there is no history of passage of products of conception. This occurs in 25% of pregnancies and half of these progress to spontaneous abortion. For those who carry the pregnancy to term, there is no increased risk of congenital malformation. An ultrasound examination would be helpful, as it could demonstrate 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 present and not slow, 90% of pregnancies will continue despite bleeding.
Question 5
Samantha is 18 months old. She is usually well, with no significant past history, and is up to date with her childhood vaccinations. Samantha has been miserable and unwell for 24 hours with a clear runny nose, and a fever of 39 to 40 degrees Celsius. She has no cough, no diarrhoea or vomiting, and is drinking well, even though her appetite for solids is decreased. Suddenly Samantha has a generalised tonic-clonic seizure, lasting 3 minutes. Which of the following statements regarding febrile convulsions in children is TRUE?
a) most febrile convulsions are focal or partial seizures
b) There is a 10% chance of developing epilepsy
c) the most common cause is CNS infection such as meningitis
d) 30-50% of children have recurrent episodes e) Peak incidence is 2-3 years of age
Answer: D
Febrile convulsions may be recurrent in 30 - 50% of cases, but this does not usually worsen long term prognosis. Most febrile convulsions occur in children aged 3 months to 5 years, the peak incidence being between 6 and 20 months of age. More than 90% of seizures are generalised. Acute upper respiratory tract infections are the most common cause of febrile convulsions. In children under the age of two years if the cause of the febrile convulsion is not obvious, a lumbar puncture must be performed to exclude CNS infections. Only rarely do febrile seizures lead to
epilepsy, the incidence being about 2 - 3%. The chance of developing epilepsy is increased if there is a family history of epilepsy, the child has a pre-existing neurological
abnormality, the child is under one year of age, the seizure is prolonged (greater than 15 minutes) and/or has complex or focal features, or if the child fits more than once in one day.
Question 6
Vera, aged 61 years, has noticed a swelling in the front of her neck, which is enlarging quite rapidly. She is otherwise well, without symptoms of hypothyroidism or hyperthyroidism. On examination she has a multinodular goitre, with a dominant nodule of 4 cm diameter in the right upper pole of her thyroid gland. Of the following investigations, which is the MOST important in assisting diagnosis?
a) Thyroid function tests b) Thyroid ultrasound c) Fine needle biopsy d) Thyroid isotope scan e) CT scan
Answer: C
The incidence of malignancy in a dominant thyroid nodule is approximately 7%, and fine needle biopsy is the appropriate investigation to exclude malignancy. Vera has several features consistent with a thyroid malignancy, including a rapidly growing solitary lump, her age (over 60 years) and the fact that the dominant nodule is >3cm in diameter. Detection or exclusion of malignancy is the MOST important issue initially. Thyroid function tests must also be performed to assess glandular activity, but they
do not help in determining malignancy. Ultrasound scan adds little to clinical examination, but may be used to guide the biopsy needle. CT scan may be useful to assess retrosternal extension of the thyroid, but currently Vera has no symptoms of this problem. Nuclear medicine scan is useful to determine the functional status of a nodule but carcinoma cannot be excluded on the basis of a radionuclide scan.
Question 7
All of the following are true of ectopic pregnancy EXCEPT:
a) an ectopic pregnancy is one where there is implantation outside the uterine cavity
b) the primary risk factor for ectopic pregnancy is a history of salpingitis
c) the prevalence of ectopic pregnancies has decreased over the last 20-30 years
d) ectopic pregnancy is one of the leading causes of maternal mortality
e) less than 50% of women who have an ectopic will subsequently have a successful normal pregnancy
Answer: C
The prevalence of ectopic pregnancies has increased by up to six-fold since 1970. The reason behind this increase may be an increase in the prevalence of sexually transmitted diseases and tubal sterilizations, or that women are conceiving later in life with a corresponding increase in the risk of tubal problems. Ectopic pregnancy remains one of the leading causes of maternal mortality. Probably because of underlying tubal problems, <50% of women who have an ectopic will go on to have a successful intrauterine pregnancy.
Question 8
Regarding urinary tract infection (UTI) in children, which of the following statements is INCORRECT?
a) Diagnosis is based on a colony count of 108 organisms/litre from a bag urine specimen b) Approximately 5% of children will have had a UTI by the age of 10 years, girls more often than boys
c) Infants often present with non-specific fever and failure to thrive, irritability and hypothermia
d) Even one UTI in a child <4 years of age needs a renal ultrasound and micturating cystourethrogram (MCU)
e) Renal scarring on an isotope scan increases the risk of early onset hypertension
Answer: A
By 10 years of age, 2% of boys and 8% of girls will have had at least one UTI. About 25% of these will have vesicoureteric reflux (VUR). Escherichia coli is responsible for more than 80% of childhood UTIs. A bag specimen of urine is only of value excluding a UTI as the sample is easily contaminated. However a clean catch or midstream sample showing >108 colony-forming units per litre is highly suggestive of a UTI. Most children, especially those under 4 years of age with a confirmed UTI require further investigation. This will always involve an ultrasound and for younger patients, an MCU which is necessary to define the grade of VUR. In the case of high grade VUR or a febrile UTI, radioisotope scan will be done 3 months after the UTI has resolved to assess renal scarring. If the scan is abnormal the child is at risk of hypertension and should have blood pressure and urinalysis monitored yearly.
Question 9
Betty, aged 62 years, first noticed a swelling just below and in front of her left ear, a month ago. The overlying skin is normal and the swelling has enlarged rapidly and become painful. She has some "pins and needles" in the skin of her left cheek but is otherwise well. Which of the following is the MOST LIKELY diagnosis?
a) Sjogren's syndrome b) Pleiomorphic adenoma c) Salivary duct calculus d) Metastatic skin cancer e) Acute sialadenitis
Answer: D
The rapid growth of a painful swelling in the region of the parotid gland, suggests a malignant process. 15-20% of parotid tumours are malignant, and in Australia the most common parotid malignancy is metastatic melanoma or squamous cell carcinoma from a skin primary in the head and neck region. Sjorgrens syndrome produces persistent and painful parotid swelling, but growth is usually slow; associated symptoms include dryness of the mouth and eyes. Pleomorphic adenoma is the commonest parotid tumour; it is benign grows slowly and rarely causes pain. Salivary duct calculi produce intermittent swelling of the salivary gland, often during eating; they are more common in the submandibular gland. Acute sialadenitis is salivary gland inflammation presenting as rapid development of erythema, pain, tenderness and swelling often due to infection, most commonly with Staph aureus.
Question 10
A 26-year-old woman (G3P2), who has reached 30 weeks gestation, telephones you to say that she has had an episode of bright red vaginal bleeding. It occurred several hours ago and she has had no associated symptoms. She estimates she lost about a teaspoonful of blood. What would be the MOST APPROPRIATE IMMEDIATE management?
a) Advise rest at home and to call back if bleeding recurs
b) Advise her to attend immediately for further evaluation
c) Reassure her that spotting without other symptoms is unlikely to be significant at this stage
d) Send her directly for urgent ultrasound examination
e) Book an ambulance as this may be a warning of an impending massive bleed
Answer: B
Although this bleeding may have a benign cause, it is important to recognise that she may have a placenta praevia, or have had a placental abruption. Both of these conditions require urgent attention because of the risk of maternal and fetal morbidity and mortality. The patient should be examined (vital signs, examination of the uterus and foetus and a sterile speculum examination) to assess the nature of the bleeding and whether or not the cervical os is closed. An ultrasound examination will be necessary to assist in confirmation of the diagnosis. It should be done only after the patient has been assessed and is stable.
Question 11
Brian is 9 years old. He has been complaining of itchy hands for over a week and is constantly scratching. On inspection, you note a lumpy excoriated rash between several of his fingers on both hands. You suspect Brian may have scabies. Which of the following statements regarding scabies is CORRECT?
a) History taking must include recent travel and contacts with animals including pets
b) Family and close contacts only require treatment if they are symptomatic
c) Persistent itch 5 days after treatment indicates treatment failure
d) Permethrin 5% cream may be used to treat scabies in a child of Brian's age
e) Brian should be excluded from school for seven days, or until the itch has subsided
Answer: D
Permethrin 5% cream is a suitable treatment option in children over the age of 6 months. Sarcoptes scabiei, the mite which causes scabies, is spread by close human contact and is not from animals. All family members and close contacts should be treated, regardless of symptoms. Patients and their families should be advised that the itch does not resolve immediately and may take three weeks to subside. It is unnecessary to repeat treatment for scabies during this time based on persistence of itch. Brian needs to be kept away from school only until he has begun appropriate treatment.
Question 12
Margaret, aged 46 years, is distressed and agitated. She is holding her head, and complaining of 'the worst headache I have ever had'. This headache began suddenly 2 hours ago. She has vomited twice, and is photophobic. Her temperature is 37.8 degrees Celsius, her pulse 110/min and her blood pressure 140/80 mm Hg. Which of the following is the MOST appropriate action?
a) give intravenous fluids, metoclopramide (maxolon) then soluble aspirin
b) request an emergency CT scan of her head c) perform or refer for urgent lumbar puncture d) do not leave the patient unattended in your rooms
e) perform a full clinical neurological assessment
Answer: B
The sudden onset of 'the worst headache' the patient can ever recall, accompanied by vomiting, must raise the suspicion of subarachnoid haemorrhage.(SAH). While this is rare (and only 1 patient in 8 who presents with sudden extreme headache will have a SAH) it is a diagnosis which must not be missed. SAH occurs most frequently in patients under 65 years of age, the majority being in the fourth decade. Women are more frequently affected than men. All patients with this clinical picture require investigation commencing with emergency head CT scan to exclude SAH. Lumbar puncture may be undertaken as the next investigation if the CT scan does not confirm SAH. Blood or xanthochromia in CSF may be detected in a smaller SAH, and meningitis may be excluded. Migraine may be considered after exclusion of SAH and meningitis. Suspected drug seekers should not be left alone in your rooms. However, this is not a typical presentation from a drug-seeker, but that possibility should not be
completely ignored. While clinical examination is always important, detailed neurological assessment is not appropriate initially.
Question 13
In women of reproductive age the most common causes of vaginal irritation and discharge in DESCENDING order of occurrence are:
a) Bacterial vaginosis, candidiasis, trichomonas b) Bacterial vaginosis, candidiasis, herpes simplex
c) Candidiasis, bacterial vaginosis, Chlamydia d) Candidiasis, Chlamydia, herpes simplex e) Chlamydia, bacterial vaginosis, trichomonas
Answer: A
Bacterial vaginosis is the most common cause of vaginal irritation and discharge. It is often misdiagnosed by women and their doctors as "thrush". Proven candidal infections are the second most common, accounting for around 35% of infections. Trichomoniasis is a sexually transmitted disease that causes vaginitis. Chlamydia and gonorrhoea infect the cervix and urethra and do not cause "vaginitis" per se. Herpes may cause vaginal pain and irritation if vesicles occur in the vagina but is not commonly associated with discharge.
Question 14
All of the following may be extra-intestinal features associated with Crohn's Disease EXCEPT:
a) Episcleritis b) Ankylosing spondylitis c) Hepatic steatosis d) Erythema nodosum e) Dermatitis herpetiformis Answer: E
Up to 35% of patients with inflammatory bowel disease have an extra intestinal manifestation. The more common are erythema nodosum, pyoderma gangrenosum, psoriasis, arthritis, ankylosing spondylitis, episcleritis, iritis, conjunctivitis, fatty liver (hepatic steatosis), primary sclerosing cholangitis, cholelithiasis, nephrolithiasis and thromboembolism. Dermatitis herpetiformis is associated with coeliac disease.
Question 15
Michael, aged 12 years, sustained a blow to his left temple when he fell while climbing a tree. He was dazed, but able to recount what had happened. An hour later he complained of an increasingly severe headache, vomited once, and then was brought to hospital. His pulse is now 54 bpm, BP 130/90 mm Hg and he is drowsy and confused. His left pupil is larger than his right. Which is the MOST appropriate advice to give Michael's parents? Michael:
a) will need an urgent CT scan of his head to confirm the diagnosis
b) has a severe concussion and must be observed closely overnight
c) requires urgent neurosurgery to reduce the chance of disability or death
d) will be monitored in ICU until stabilized for surgery in 24 hours
e) is gravely ill and has a 50% chance of survival
Answer: C
The history of the injury is highly suggestive of an extradural (epidural) haematoma. Although Michael did not lose consciousness initially, his condition has deteriorated rapidly and significantly. He is now bradycardic, hypertensive and his pupil is dilated on the side of the injury. His level of consciousness is also deteriorating. An extradural haematoma will result in death if not evacuated promptly. There is approximately 75% chance he will have a fracture overlying the haematoma, but skull x ray is not indicated. There may be 'concussive' injury to the underlying brain but the life-threatening factor is the raised intracranial pressure from the extradural haematoma. While it would be ideal to have a CT scan, the rapidly deteriorating condition means that emergency surgery should not be delayed. Michael is clearly gravely ill, but the mortality from epidural haematoma is 9% for obtunded patients and 20% for those who are comatose prior to surgery. Prognosis is better for young patients, but deteriorates with other associated intracranial injuries and with delay between injury and surgical intervention.
Question 16
Tonsillectomy would be recommended for each of the following patients EXCEPT:
a) Claire, aged 3, has had four episodes of tonsillitis in the last 12 months, each time associated with a febrile convulsion.
b) Sarah aged 4 years, has had six episodes of a sore throat in the last 12 months and now has bilateral large tonsils and enlarged cervical lymph nodes
c) Steven aged 25 years, has recently required incision and drainage of a quinsy (peritonsillar abscess)
d) Olive aged 63 years, has noticed that her right tonsil has enlarged recently. She also has an enlarged cervical lymph node on the right e) Peter, aged 10 years, snores loudly, sometimes "stops breathing" at night and is sleepy at school. He has large tonsils.
Answer: B
It is not unusual for young children to have several episodes of 'sore throat' each year. These could be due to a number of conditions including pharyngitis, laryngitis, tonsillitis (either viral or bacterial), or exposure to irritants like cigarette smoke. Children such as Sarah in the preschool age group frequently have large tonsils, adenoids and cervical glands as part of the normal growth pattern of lymphoid tissue. In these
children a tonsillectomy would not be recommended. In all of the other cases, tonsillectomy is likely to be recommended. Claire's four episodes of (proven) tonsillitis have been accompanied by a worrying if not sinister symptom. Steven's quinsy is a clear indication for tonsillectomy, and Olive may have a malignancy. Peter's snoring and sleep apnoea also justifies tonsillectomy.
Question 17
Cindy is 13 months old. She presents with two days of fever, runny nose and cough. Her cough is becoming increasingly distressing, and she is quite tachypnoeic. On auscultation of her chest you hear some expiratory wheeze and scattered crepitations. Cindy's breathing is obviously laboured and there is rib retraction. You diagnose bronchiolitis. Which of the following statements is CORRECT?
a) Parenteral penicillin is the treatment of choice
b) Chest Xray may show hyperinflation
c) Parainfluenza virus is the most common pathogen
d) Corticosteroids are contraindicated e) Inpatient treatment is often necessary
Answer: B
Chest x-ray findings in bronchiolitis typically include hyperinflation with depression of the diaphragm and horizontal ribs. There may also be streaky hilar shadows, mild interstitial infiltrates and some segmental atelectasis. RSV (respiratory syncitial virus) is by far the most common pathogen, although some cases may be due to the parainfluenza, influenza and adenoviruses. Antibiotics are not indicated. Corticosteroids are not contraindicated, but their use has not been shown to modify the course of the disease. While some very young or very unwell children may require supportive inpatient management, most children with bronchiolitis can be confidently managed as outpatients.
Question 18
Six weeks ago you excised a skin lesion from the cheek of 65 year old Bill. The wound had healed well when you removed the sutures five days later, but the pathology report was not available. You told Bill you would contact him if anything further needed to be done, as he was leaving on an extended holiday. In doing some paperwork today, you discover to your horror, Bill's pathology report, which states: There is a squamous cell carcinoma (SCC) measuring 5 mm in diameter, with a depth of 4 mm. The lesion has been completely excised but extends to within 1mm of one lateral margin, and to within 2 mm of the base of the excision. What is your MOST appropriate course of action?
a) contact Bill urgently, apologising for the delay and explain that he should have further excision as a clearance margin of 5mm in depth and laterally is required to minimise local recurrence or metastasis
b) contact Bill, apologising for your delay, and advise it was a skin cancer (SCC) but it has been completely excised, and there is minimal risk of local recurrence or metastasis
c) do not attempt to contact Bill during his holiday as the matter is not urgent. Clearance of 1mm in all directions is adequate to minimise local recurrence
d) do not disturb Bill as the holiday is important to him, but ensure that you recall him when he returns to discuss options for further surgery e) contact Bill, saying you have just received the report which the laboratory must have lost. Advise him he had a skin cancer (SCC) and that he should have further excision on his return, as there is a very small risk this cancer could spread
Answer: A
Squamous cell carcinomas (SCC) can recur locally, and unlike basal cell carcinomas, they can also metastasise. Local recurrence due to incomplete primary excision is associated with a high rate of subsequent recurrence (23%) and then metastasis to regional lymph nodes (30%). Metastatic SCC has a 33% mortality rate. Lesions less than 2cm in diameter require a 4mm margin for adequate excision with depth through normal underlying fat. Larger lesions may need up to 10mm margins. Clearance for BCC excision is usually adequate at 3mm margins. It is important to accept responsibility for your failure to follow up as planned, and then to recommend further excision. The re-excision should be done quickly. It is not appropriate to blame the pathology laboratory. It is wise to contact your medical defence organisation.
Question 19
Jarrah is a 2 month old Aboriginal boy. He was born at term via an uncomplicated vaginal delivery, and he has been well. He lives with his family in Darwin. His mother has brought him in for his immunisations. Which ONE of the following statements is CORRECT?
a) Jarrah will need to receive the first of his hepatitis A vaccines at 18 months of age b) Limiting information to his mother about risks will improve the chance of completing the schedule
c) Jarrah should have had the BCG vaccine soon after delivery before leaving hospital d) The oral polio vaccine (OPV) provides better immunity than the inactivated type (IPV) in Aboriginal children
e) Jarrah will need his first MMR vaccine at 6 months of age due to his higher susceptibility
Answer: C
Indigenous Australians are at increased risk of acquiring tuberculosis. BCG is recommended for indigenous neonates in 'regions of high incidence' of pulmonary TB, particularly Darwin and the Northern Territory. It is usually given to eligible infants soon after delivery. Aboriginal children in north Australia have a suboptimal response to OPV so there is likely to be improved immunity to polio with the introduction of IPV as part of the funded schedule. Although measles is very common in indigenous communities, the first dose of MMR is administered as usual at 12 months of age. Indigenous children in Far North Queensland are at higher risk of
hepatitis A infection so from 1999 a programme for HepA vaccination was commenced from 18mths of age. Otherwise, the Standard Vaccination Schedule now applies to all Australian children. All parents and guardians must be given appropriate information regarding vaccination so as to be able to give informed consent to vaccination.
Question 20
Patricia, aged 25 years, has been diagnosed with polycystic ovarian syndrome. In counselling this patient regarding long-term consequences the MOST APPROPRIATE advice would be:
a) There are no serious long-term consequences
b) There is an increased risk of endometrial hyperplasia
c) There is an increased risk of cervical cancer d) There is an increased risk of osteoporosis e) There is an increased risk of premature menopause
Answer: B
Polycystic ovarian syndrome is a metabolic condition whose long term consequences include an increased risk of cerebrovascular disease, non insulin dependent diabetes and endometrial hyperplasia .The latter is due to unopposed action of oestrogen in anovulatory cycles .There is no effect on the timing of the onset of menopause and no evidence for an effect on bone density.
Question 21
Sally, aged 14 years, has mitral valve prolapse with regurgitation. For which of the following procedures should she be given antibiotic prophylaxis?
a) urethral catheterisation b) flexible bronchoscopy c) dental examination
d) orthodontic bands placement e) local anaesthetic injection
Answer: D
In patients with mitral valve prolapse with valvular regurgitation antibiotic prohylaxis is required for dental procedures which produce bleeding from the gingiva, mucosa or bone. This includes the placement of orthodontic bands. Prophylaxis is not required for routine dental examination (except where scaling of the teeth is to be performed), nor for the other options listed.
Question 22
Rodney, aged 30 years, a diesel mechanic, presents with a painful right eye. He was using a metal lathe at work last night, and states that he was wearing his safety goggles as required. He was aware that the eye
