* 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 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 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
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.
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
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 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
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.
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
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 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
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 13
Which of the following statements about patent ductus arteriosus is INCORRECT?
a) It occurs frequently as an isolated phenomenon b) Cyanosis is usually present
c) It causes a pansystolic 'machinery' murmur at the upper left sternal edge d) There is a wide pulse pressure
e) Treatment is by surgical closure
Ans.B Cyanosis is not usually present unless a right to left shunt develops. Patent ductus arteriosus is usually an isolated problem occurring most commonly in females. There are often no symptoms until later in life, when heart failure or infectious endocarditis develops. Clinical signs include a continuous murmur and a bounding peripheral pulse with wide pulse pressure due to shunting of blood from the aorta to the pulmonary artery. Question 16
Which of the following features is UNLIKELY to be due to arterial ischaemia?
a) Pain along the buttock and thigh after exertion b) Weakness of the buttock and thigh
c) Shooting pain from buttock along the back of the leg to calf d) Weakness of the leg
e) Smooth shiny skin on the leg below the knees
Ans.C Diffuse pain, weakness and paralysis are all signs of arterial ischaemia. Characteristically the pain is a cramp-like ache due to the release of pain-inducing metabolites in muscle. Due to the aetiology, the pain is diffuse and cannot be localised, as can the shooting pain of nerve irritation.
Question 19
Harold, aged 24 years, presents with fatigue, shortness of breath on exercise and orthopnoea. On examination there are signs of moderate left-sided heart failure. A grade III pansystolic murmur is heard most prominently at the apex and radiating into the left axilla. Which of the following conditions is the MOST LIKELY diagnosis?
a) Mitral stenosis b) Mitral regurgitation c) Aortic stenosis
d) Aortic regurgitation e) Tricuspid stenosis
Ans.B Mitral regurgitation presents as fatigue, exertional dyspnoea and orthopnoea. It is associated with a pansystolic murmur loudest at the apex but radiating over the praecordium and into the axilla. It may also be associated with a short mid-diastolic flow murmur following a third heart sound, due to the rapid flow of blood into the dilated left ventricle. The second heart sound is normal.
Question 23
Victor, a 36 year old man, has known ischaemic heart disease. He complains of a recent increase in frequency of chest pain and presents with a prolonged episode of chest pain. Management includes all of the following EXCEPT: a) Admission to hospital
b) Plasma troponin
c) Continuous ECG monitoring
d) Thrombolytic therapy and oral aspirin e) Continuous IV nitroglycerin infusion
Ans.E Clinically this patient has unstable angina. Management should include continuous ECG monitoring, admission to hospital and plasma troponin to exclude myocardial infarction. Continuous IV nitroglycerin infusion should only be used when required. If there is no improvement in 24-48 hours, cardiac catheterisation and angioplasty are indicated.
uestion 27
Malcolm, a 55 year old man, presented with symptoms of gastro-oesophageal reflux disorder (GORD). You referred him for a gastroscopy which has not
revealed any abnormality. He still complains of bloating and heartburn. Which of the following would you advise?
a) Reflux has been excluded as a cause of his symptoms b) A trial of medication is inappropriate
c) Endoscopy detects the presence of reflux in only 60-80% of patients d) It is important to treat his symptoms with a trial of medication e) He should have a repeat endoscopy in 6 months
Ans.D Some patients have symptoms of gastroesophageal reflux disease but do not have endoscopic evidence of reflux or oesophagitis. A trial of medication is the treatment of choice as many patients will still respond to this.
Question 32
Herman is a 57 year old man who is recovering from a hitherto uncomplicated myocardial infarction. On the fourth day he complains of sudden onset of palpitations. Initial examination confirms a tachycardia with blood pressure of 140/80. The ECG shows the following rhythm (see figure).
The first line treatment for this patient is: a) Carotid sinus massage
b) Digoxin IV c) Verapamil IV d) Lignocaine IV e) DC cardioversion P wave duration ≤ 0.12 s PR interval 0.12–0.22 s QRS complex duration ≤ 0.10 s Corrected QT (QTc) ≤ 0.44 s in males ≤ 0.46 s in female
QTcB = QT/√2(R − R) Bazett’s square root formula
Ans.D This ECG shows ventricular tachycardia with a rate of 150 b.p.m. There is a rapid ventricular rhythm with broad, abnormal QRS complexes. Since his blood pressure is well maintained, medical treatment is indicated as first line approach. Lignocaine IV or sotalol IV or amiodarone IV can be used. DC cardioversion is required if medical therapy is unsuccessful. If the cardiac output and blood pressure are very depressed, emergency DC cardioversion must be considered.
Question 37
Edith is a 70 year old woman who presents with palpitations. Her ECG is shown below.
What is the diagnosis? a) Atrial flutter b) Atrial fibrillation
c) Atrial premature beats d) Sinus arrhythmia e) 1st degree AV block
Ans.B This ECG shows atrial fibrillation. There are no p waves and the rhythm is irregularly irregular which causes the patient to perceive palpitations.
Question 4
Clarice, 26 years, presents to you concerned because she has noticed that a dark mole on her thigh has become enlarged, slightly lumpy and itchy over the last two months. You suspect it may be a malignant melanoma. The MOST APPROPRIATE initial management would be to:
a) Ask Clarice to return for review in three months
b) Take a incisional biopsy of the lesion for histopathology c) Treat the lesion using liquid nitrogen
d) Remove the lesion using laser
e) Undertake an elliptical excision clear of the margin for histopathology
Ans E If a malignant melanoma is suspected then an accurate pathological report is required to guide further management. For this reason it is important that the initial management involves complete removal of the lesion
without destruction of the tissue. Early detection and removal of melanomas leads to better outcomes (Clark's level one and two melanomas have a five year prognosis of >90%). If a melanoma is diagnosed then referral to a plastic surgeon is necessary for a wide local excision involving a margin of 1-3 cm and to a depth of the deep fascia.
Question 6
Benny has always loved to go clubbing, and often after a few drinks at the end of a night of dancing, he ends up having casual sex with someone he meets at the nightclub.
Benny had his first hepatitis B serology testing done last week. These are his test results:
HBsAg = positive HBsAb = negative IgM HBcAb = positive HBeAg = positive.
What is the MOST LIKELY cause of these results?
a) Benny has been vaccinated in the past for hepatitis B and is now immune b) Benny has had hepatitis B infection sometime in the past and it has resolved, leaving him with life-long immunity
c) Benny is a hepatitis B carrier
d) Benny has acute or current hepatitis B infection e) Benny has early liver cirrhosis
Ans.D Benny is HBsAg positive which occurs 1-6 months after exposure to the hepatitis B virus and indicates acute infection. If HBsAg persists after 6 months, it defines carrirer status.
HBsAb is not present (it would be positive following vaccination).
IgM HBcAb is present in acute infection only (IgG HBcAb is present in highly infective carriers and in acute infection).
HBeAg is present and implies high infectivity in recent infection and carriers. Benny needs education about hepatitis B, safe sex & drug use
* Question 7
The clinical features associated with raised intracranial pressure include all of the following EXCEPT:
a) morning headache b) vomiting
c) presence of papilloedema d) decrease in conscious state
Ans.E Rising blood pressure (not falling) in combination with a falling pulse rate is a classical feature of rising intracranial pressure known as the Cushing response.
Headache occurs as a result of the deformation of intracranial blood vessels and dural membranes which arises from conditions which give rise to raised intracranial pressure.
The headache is worst in the morning (as is vomiting) and is aggravated by coughing, sneezing or stooping. When present papilloedema (swelling of the nerve fibres of the optic disc) is highly suggestive of raised intracranial pressure. A decrease in conscious state commencing with confusion and progressing through various grades of coma is also seen with increasing intracranial pressure.
Question 9
Which of the following is FALSE regarding neural tube defects and folate before and during pregnancy?
a) Folate intake should be increased at least one month before and three months after conception
b) Most women before and during pregnancy need 0.5mg folate daily
c) Women on anti-epileptic medication may require 5mg folate daily before and during pregnancy
d) Folate reduces the incidence of neural tube defects which occur at the rate or 1:5000 pregnancies
e) Women with a family history of neural tube defects need more folate before and during pregnancy
Ans.D Pregnant women are at increased risk of folate deficiency due to the high demand of the developing foetus. Deficiency in the first few weeks of pregnancy can cause neural tube defects in the newborns. Neural tube defects occur at a rate of 1:500 pregnancies. The other options are true.
* Question 10
Pamela aged 45 years, attends having found a lump in the upper outer quadrant of her right breast two days ago. She is concerned about the likelihood of cancer. In order to diagnose the nature of the lump you invoke the use of the "triple test" or "triple assessment". The triple test consists of: a) Clinical examination, mammography, magnetic resonance imaging (MRI) b) Mammography, ultrasound, fine needle biopsy
d) Clinical examination, ultrasound, magnetic resonance imaging (MRI) e) Ultrasound, fine needle biopsy, magnetic resonance imaging (MRI)
Ans.C Management of breast lumps is now based on the triple test, which combines the results of clinical examination, mammography (+/- ultrasound) and fine needle aspiration biopsy. When combined, these tests give a sensitivity of 95-99% in the diagnosis of breast lumps.
Question 22
Beth, aged 6 months, is brought to see you by her mother who has noticed her eyes are not always lined up. You are concerned Beth may have a squint (strabismus). Which of the following statements regarding strabismus is CORRECT?
a) Investigation is unnecessary in this age group as strabismus improves with time
b) By the age of 6 months Beth's eyes should be constantly well aligned c) Strabismus is rarely a marker of other ocular disease
d) Strabismus is not associated with amblyopia
e) The corneal light reflex is a reliable test to diagnose strabismus
Ans B A baby's eyes should be constantly well aligned by the age of 5 to 6 months. Intermittent ocular deviation should be investigated if present at six months, as it may be a marker of severe underlying ocular or neurologic disease. It should never be assumed that the strabismus will be outgrown. The corneal light reflex test should not be relied upon to diagnose or exclude strabismus. The cover test is a more accurate diagnostic test. Strabismus may lead to amblyopia, which in turn may result in permanent loss of vision if it is not corrected by 4 to 6 years of age.
Question 25
Robyn, aged 43 years, is known to have gallstones. On this occasion she presents with the acute onset of severe pain which was at first central in location but has now moved to the right costal margin and radiates to the back. She is pyrexic, slightly tachycardic and has tenderness over the area of the gall bladder but no rigidity of the abdomen. The MOST APPROPRIATE MANAGEMENT would be to:
a) Allow her to return home and review her in two to three days allowing time for the attack to settle
b) Admit her to hospital and treat her with IV fluids and antibiotics c) Refrain from use of opiates due to risk of addiction
d) Admit her to hospital for immediate surgery
e) Aim to delay the operation for several weeks to months
Ans B Robyn has acute cholecystitis. Initial management includes IV fluids and nil by mouth, pain relief with parenteral opiate administration and a short, intensive course of antibiotics. The patient is monitored and immediate operation is ONLY indicated if the fever does not settle or symptoms worsen. Immediate operation is not warranted, as there is no indication of perforation of the gall bladder or peritonitis. However, early operation for acute cholecystitis is now recommended compared to delaying surgery.
* Question 26
Kari is 7 months old and has not received any immunisations. She presents with two weeks of paroxysmal coughing and vomiting, but is relatively happy between paroxysms. You suspect she may have whooping cough (pertussis). Kari lives at home with her mother, father and older brothers, aged 2 and 4 years. Neither of her brothers have been immunised against pertussis. Choose the BEST INITIAL MANAGEMENT option from the list below.
a) Arrange to have Kari admitted to hospital and isolated immediately
b) Report the family to the child protection agency in your state for failing to immunise their children
c) Vaccinate Kari immediately with DTPa-hepB or DTPa d) Prescribe oral erythromycin for Kari and the whole family
e) Take a nasopharangeal aspirate for diagnosis, and await confirmation of diagnosis prior to starting any other treatment measures
Ans D Whilst it is important to obtain a laboratory diagnosis of pertussis, this should not delay treatment, which should be commenced after appropriate nasopharangeal aspirate or serological samples are collected. Kari should be treated with erythromycin 10mg/kg/dose up to 250mg orally 6 hourly for 10 days, as should all household and other close contacts.
Hospitalisation and isolation are unnecessary unless the clinical condition of the patients warrants inpatient management. Catch-up vaccination should be addressed, but is not the most immediate concern here. There is no requirement to report the family to authorities if they are conscientious objectors to immunisation.
Question 30
Esther is 7 years old. She presents with a large yellow crusted lesion on her left cheek and similar yellow crusted lesions along her left lower jawline. She has no lesions or rash elsewhere and is otherwise well. Which is the MOST ACCURATE statement regarding this condition?
a) Herpes simplex is the likely causative organism b) It is important not to disturb the crusts
c) Esther should be screened for immune deficiency d) Topical mupirocin is an appropriate treatment
e) Oral antibiotics should be commenced as early as possible to prevent septicaemia developing
Ans D The most likely diagnosis is impetigo, with the ruptured vesicles that form yellow crusts and weeping erosions being quite typical of the lesions. Herpes simplex has a different clinical presentation. In childhood, primary HSV infection usually presents as severe acute gingivostomatitis. Impetigo is a very common, highly contagious infection, and does not suggest an underlying immune deficiency. The usual pathogen is Staphylococcus aureus, or Streptococcus pyogenes. For mild or localised impetigo, topical mupirocin 2% ointment or cream 3 times daily for 7 days is appropriate treatment. Whilst oral antibiotics may be indicated for more widespread infection, septicaemia is not a usual sequelae of this common condition. Bathing the lesions to remove the crusts may be helpful.
Question 32
One minute after birth an infant shows deep cyanosis of the trunk and limbs, makes no reaction to a catheter inserted into the nose, is limp but takes an occasional gasp. What is the Apgar score?
a) 0 b) 1 c) 2 d) 3
e) Insufficient data
Ans E The table below shows the data required to determine an Apgar score. The scenario given lacks information about the heart rate. Other data given are compatible with a score of 0.
Apgar Score Sign
Heart rate absent <100 beats/min >100 beats/min Respiratory
effort
absent irregular, weak cry regular, strong cry
Muscle tone flaccid some flexion of upper extremities
well flexed, active motion
Reflex irritabilities
no response grimace cough or sneeze
Colour central
cyanosis
peripheral cyanosis completely pink
Question 40
Lulu is a three year old child who has swallowed kerosene and is brought immediately to the hospital casualty department. Which of the following measures should be undertaken in the immediate management of Lulu's problem? a) Gastric lavage b) An emetic c) Chest x-ray d) Intravenous saline e) Methicillin
Ans C Kerosene is an aliphatic, highly volatile hydrocarbon which is poorly absorbed from the gastrointestinal tract. Pneumonitis through aspiration of fumes is the predominant toxic mechanism in children and respiratory distress can be severe and occur rapidly. While a chest xray is not useful for the prediction of lung involvement, serial chest xrays are important to monitor progression. In children who present with lethargy, fever or respiratory signs in the first 4 hours 80% develop pneumonitis.
Gastrointestinal irritation is common with nausea and vomiting. There may also be a high fever within 30 minutes of ingestion.
Management should be conservative and decontamination (emesis or gastric lavage) should not be attempted - it merely increases the risk of aspiration, and development of pneumonitis. IV saline may be required if haemolysis from the kerosene occurs and hypotension develops.
Question 4
Leigh is a 60 year old woman who has been hypertensive for 5 years. Her BP now is 160/115 mm Hg. Recently she has been getting increasingly short of
breath. Clinical assessment confirms congestive cardiac failure. Which of the following drugs would be preferred for management?
a) Propranolol b) Verapamil c) Diltiazem d) Lisinopril e) Felodipine
D. Linisopril is an angiotensin-converting enzyme inhibitor. This is the treatment of choice, as it lowers systemic vascular resistance and venous pressure and reduces the levels of circulating catecholamines, thus improving myocardial performance. It is important to observe for first-dose hypotension. Calcium channel blockers (e.g. verapamil, diltiazem) may have a detrimental effect on left ventricular function in patients with heart failure. At present, there is no general agreement on the timing of beta blocker (propanolol) therapy. It is currently reserved for those patients who remain symptomatic whilst on maximal therapy with other agents.
* Question 5
In which of the following situations would a barium swallow be preferable to an endoscopy as a FIRST LINE investigation?
a) Patient complains of coughing after meals b) Patient complains of difficulty swallowing c) Patient with nocturnal symptoms only d) Patient with bloating after meals e) Patient has water-brash
B. Difficulty swallowing (or dysphagia) is a functional problem and a barium swallow is preferable to an endoscopy in this instance. Observations on the barium swallow may suggest oropharyngeal or cricopharyngeal dysfunction (including misdirection of barium into the trachea or nasopharynx), prominence of the cricopharyngeal muscle, a Zenker's diverticulum or a narrow pharyngeo-oesophageal segment. Disordered oesophageal motility or structural abnormalities such as small diverticula, webs, and minimal extrinsic impressions of the oesophagus may be recognised only with motion-recording techniques.
Question 13
A healthy six year old child without cyanosis or dyspnoea on exercise is examined for migration to Australia. His pulse is 84 per minute, B.P. 100/60, radial pulse and jugular venous pressure normal and there is no evidence of cardiomegaly. On auscultation in the 2nd left intercostal space the 1st and 2nd
heart sounds are audible with fixed splitting of the 2nd heart sound and a midsystolic pulmonary ejection murmur is heard. The MOST likely diagnosis is:
a) Pulmonary stenosis
b) Atrial septal defect (ASD)
c) Innocent pulmonary ejection murmur d) Ventricular septal defect (VSD)
e) Patent ductus arteriosus (PDA)
B. In an asymptomatic patient an ASD is often diagnosed as a loud P2 with fixed splitting and an ejection murmur heard in the pulmonary area due to increased blood flow to the right heart. A VSD large enough to produce these signs would be symptomatic and usually would cause cardiomegaly. Innocent pulmonary ejection murmurs do not cause fixed splitting of P2, and a PDA causes a continuous murmur. In pulmonary stenosis P2 is often soft or inaudible and the JVP is usually elevated.
Question 23
Belinda, aged 44 years, presents complaining of heavy, prolonged periods (menorrhagia) and severe period pain (dysmenorrhoea) that has gradually become worse during the past year. Her periods are still quite regular. Which of the following possible causes is UNLIKELY?
a) Adenomyosis b) Endometriosis c) Uterine cancer d) Fibromyoma e) Ovarian failure
E. Ovarian failure presents as irregularity and scarcity of menstruation, rather than menorrhagia and dysmenorrhoea. Adenomysosis, endometriosis, uterine cancer and fibromyoma are all possible causes of menorrhagia and secondary dysmenorrhoea. Other causes include uterine myomas and polyps, intrauterine contraceptive devices and congenital malformations (eg. bicornuate and septate uterus).
Question 31
In a child with chickenpox which of the following drugs is MOST LIKELY to cause Reye's syndrome?
a) Paracetamol b) Aspirin
c) Codeine d) Penicillin e) Prednisolone
B. Reyes Syndrome involves acute encephalopathy and fatty infiltration of the liver following an acute viral infection, including influenza and varicella.
Foreign chemicals, especially salicylates (including aspirin), and intrinsic metabolic defects have also been implicated. The use of salicylates (eg aspirin) during an acute viral illness such as chicken pox (varicella) increases the risk of Reyes syndrome by as much as 35-fold.
Question 33
Sarah is an 8 week old girl who has persistent regurgitation. Which of the following features suggests the need for further investigation?
a) Sarah is underweight for her age b) She regurgitates after every meal
c) She has episodes of uncontrollable crying
d) She arches her back on occasion and stops feeding e) Sarah was born 2 weeks premature
A. Regurgitation after every meal suggests gastroesophageal reflux, but of itself is not a worrying feature. Underweight for age, however, suggests failure to thrive and needs investigation. Unsettled and irritable behaviour is very common in the first 6-12 weeks of life. In isolation it is not a concern.
Question 36
Sue, a three year old girl, presents with shortness of breath and wheeze that have developed over the last two days. Examination reveals an afebrile, moderately tachypnoeic child with widespread scattered wheezes on auscultation. You decide to administer a bronchodilator (salbutamol). The recommended method of delivery of salbutamol for Sue is:
a) Syrup b) Nebuliser
c) Breath activated inhaler
d) Metered dose inhaler with a spacer
e) Metered dose inhaler with a spacer and face mask
E. For the treatment of acute asthma in a child <6 years of age, the recommended mode of delivery of bronchodilator (salbutamol) is via a
metered dose inhaler and small volume spacer with face mask. For those >6 years of age, a large volume spacer may be substituted. Salbutamol administered via these routes has been shown to be equally effective to nebulised salbutamol. Six puffs of salbutamol via MDI and spacer is the equivalent of a 2.5 mg nebule, while 12 puffs equals a 5mg nebule.
Question 38
In iritis (uveitis) the pupil is:
a) Eccentric and reacts briskly to light
b) Concentric dilated and reacts briskly to light c) Eccentric and reacts sluggishly to light
d) Concentric, constricted and reacts sluggishly to light e) Concentric, dilated and reacts sluggishly to light
D. In iritis the pupil is concentric, constricted and sluggish. The signs of acute anterior iritis are pupillary miosis and perilimbal flush. The ciliary body constricts due to irritation and therefore is less able to respond quickly to light.
Question 40
Trevor, a male infant weighing 2.4 kg at birth after a normal labour, becomes jaundiced at 12 hours of age. Which of the following conditions would be the MOST LIKELY cause of the jaundice?
a) Gram negative septicaemia b) Jaundice of prematurity c) Biliary atresia
d) Physiological jaundice e) Rh incompatibility
E. Jaundice appearing in the first 24 hours of life is most commonly due to haemolytic disease of the newborn due to incompatibility to Rh, ABO or one of the other rare antigens. Other causes of early jaundice include transplacental infections such as CMV, toxoplasmosis and rubella. Jaundice of prematurity and physiological jaundice occur between days 2-5. Biliary atresia presents with jaundice after the first week of life.
Question 3
Which of the following criteria enable a clear distinction to be made between haemorrhage and thrombosis in a patient with a cerebrovascular accident?
a) The progress of the clinical features b) The degree of loss of consciousness c) The abruptness of onset
d) The presence or absence of headache e) None of the above
E. Intracerebral haemorrhages tend to be dramatic and accompanied by a severe headache. However, there really is no clinical way of reliably distinguishing between an intracerebral haemorrhage and a thromboembolic infarction, as both produce a sudden focal deficit.
* Question 4
Bel is 20 years old and has had one allergic reaction to a bee sting. She states that there is a family history of bee sting allergy . Which of the following is NOT useful advice for Bel?
a) Do not drink out of an open soft drink can that has been left outdoors b) Have a supply of antihistamines on hand
c) Insect repellents are useful to prevent bee stings d) Do not walk barefoot around swimming pools
e) Always carry an adrenalin 1:1000 injection, e.g. EpiPen, and know how to use it
C. Insect repellents have not been shown to be useful in preventing bites from stinging insects. Anyone with a known allergy to stinging insects should know how to administer adrenalin 1:1000 subcutaneously and have it with them at all times. EPIpen is a commercial preparation which is supplied with an auto-injection device. Avoiding behaviours likely to lead to a sting - such as those mentioned in the options and avoiding colourful clothes and perfumes which attract insects - is also important.
* Question 5
John is a 30 year old professional athlete who suddenly develops persistent dull upper left chest pain which is not related to exertion. Although not related to respiration, it causes mild restriction in breathing. There were no related respiratory or cardiac symptoms; he is not distressed and is afebrile. Which of the following diagnoses is LEAST likely?
a) Spontaneous pneumothorax
b) Functional chest pain (anxiety neurosis) c) Costo-chondral syndrome
d) Muscle strain
e) Pleurodynia ( Bornholm's disease)
E. Bornholm's disease is due to an infection by Coxackie B virus. It is often associated with an acute upper respiratory tract infection with fever, pleuritic chest pain and upper abdominal pain. These pains can be severe and associated with tachypnoea. A spontaneous pneumothorax, functional chest pain, costochondritis or acute muscular strain would be more likely in this patient.
Question 9
Abdul is a 58 year old man who presents with transient episodes of vertigo, slurred speech, diplopia, and paresthesia. Which of the following is the MOST likely diagnosis?
a) Basilar artery insufficiency
b) Anterior communicating artery aneurysm c) Hypertensive encephalopathy
d) Pseudobulbar palsy
e) Occlusion of the middle cerebral artery Bulbar palsy
Synonyms: lower motor neurone dysarthria, neuromuscular dysarthria, atrophic bulbar paralysis. Bulbar relates to the medulla. Bulbar palsy is the result of diseases affecting the lower cranial nerves (VII - XII). A speech deficit occurs due to paralysis or weakness of the muscles of articulation which are supplied by these cranial nerves. The causes of this are broadly divided into: 1)Muscle disorders. 2)Diseases of the motor nuclei in the medulla and lower pons. 3)Diseases of the intramedullary nerves of the spinal cord. 4)Diseases of the peripheral nerves supplying the muscles.
• Lips - tremulous
• Tongue - weak and wasted and sits in the mouth with fasciculations
• Drooling - as saliva collects in the mouth and patient is unable to swallow (dysphagia) • Palatal movements are absent
• Dysphonia - rasping tone due to vocal cord paralysis; nasal tone if bilateral palatal paralysis
• Articulation - difficulty pronouncing r; unable to pronounce consonants as dysarthria progresses
Causes:
• Diphtheria
• Poliomyelitis
• Motor neurone disease e.g. progressive bulbar palsy (features of pseudobulbar palsy may also be present)
• Syringobulbia
• Cerebrovascular events of the brainstem
• Brainstem tumours
• After radiotherapy for nasopharyngeal carcinoma
• After surgery for acoustic neuroma
• Guillain-Barré syndrome
Pseudobulbar palsy
Synonyms: upper motor neurone dysarthria, spastic dysarthria.
Pseudobulbar palsy results from disease of the corticobulbar tracts. Bilateral tract damage must occur for clinically evident disease as the muscles are bilaterally innervated.
• Tongue - paralysed, no wasting initially and no fasciculations; "Donald duck" speech; unable to protrude
• Palatal movements absent • Dribbling persistently
• Facial muscles - may also be paralysed • Reflexes - exaggerated e.g. jaw jerk • Nasal regurgitation may be present • Dysphonic
• Dysphagic
There may also be neurological deficits in the limbs e.g. increased tone, enhanced reflexes and weakness. Causes:
• Cerebrovascular events e.g. bilateral internal capsule infarcts
• Demyelinating disorders e.g. multiple sclerosis
• Motor neurone disease
• High brainstem tumours
• Head injury
A. Transient ischaemic attacks involving the posterior brain circulation, i.e. the basilar artery, are characterised by diplopia, vertigo, vomiting, dysarthria, ataxia and hemisensory loss.
Question 28
The FIRST sign of salicylate poisoning in children is usually: a) Delirium
b) Coma
c) Hyperventilation d) Hyperpyrexia e) Convulsions
• The following 4 categories are helpful for assessing the potential severity and morbidity of an acute, single event, nonenteric-coated, salicylate ingestion:
o Less than 150 mg/kg - Spectrum ranges from no toxicity to mild toxicity o From 150-300 mg/kg - Mild-to-moderate toxicity
o From 301-500 mg/kg - Serious toxicity
o Greater than 500 mg/kg - Potentially lethal toxicity Pathophysiology
The toxic effects of salicylates are complex. Respiratory centers are directly stimulated. Salicylates cause an inhibition of the citric acid cycle and an uncoupling of oxidative
phosphorylation. In addition, lipid metabolism is stimulated, while amino acid metabolism is inhibited. Catabolism occurs secondary to the inhibition of ATP-dependent reactions with the following results:
• Increased oxygen consumption
• Increased carbon dioxide production
• Accelerated activity of the glycolytic and lipolytic pathways
• Depletion of hepatic glycogen
• Hyperpyrexia
Acid-base disturbances vary with age and severity of the intoxication. Initially, a respiratory alkalosis develops secondary to direct stimulation of the respiratory centers. This may be the only consequence of mild salicylism. The kidneys excrete potassium, sodium, and bicarbonate, resulting in alkaline urine.
Metabolic effects
A severe metabolic (ketolactic) acidosis with compensatory respiratory alkalosis may develop with severe salicylate intoxication. A paradoxical aciduria (hydrogen ion excretion) occurs with the depletion of sodium bicarbonate and potassium.
Infants rarely present with a pure respiratory alkalosis. Respiratory alkalosis with a compensatory (high anion gap) metabolic acidosis defines the next stage in
moderate-to-severe intoxication. Potassium moves from the intracellular space to the extracellular space. Excretion of hydrogen ions produces acidic urine.
C. Aspirin has a two-fold toxic effect. First, it inhibits oxidative phosphorylation leading to a metabolic acidosis. The increased hydrogen ion concentration of the extracellular fluid stimulates the respiratory centre of the brain to cause hyperventilation. This is the primary effect in children. Second, aspirin directly stimulates the respiratory centre to cause hyperventilation leading to a respiratory alkalosis. This phenomenon is seen mainly in adults. * Question 29
Charles is a 48 year old businessman who presents for a general check-up and mentions that he is experiencing occasional fluttering sensations in his chest. A routine electrocardiograph (see figure) is taken.
Your first line of management should be: a) Reassurance
b) Digoxin c) Captopril d) Beta blockade e) Quinidine
A. The ECG shows Charles has premature atrial ectopic beats. Often these are asymptomatic. They may, however, be sensed as an irregularity or heaviness of the heart beat. Treatment is not normally required, unless the ectopic beats provoke more significant arrhythmias. In such a situation Beta-blockade may be effective.
Question 32
Which of the following situations is a CONTRAINDICATION to immunisation with a live attenuated vaccine?
a) Pregnancy b) Diarrhoea
c) Mild acute febrile illness d) Current antibiotic therapy
e) Breast feeding
A. Pregnancy is a valid contraindication to immunisation with a live attenuated vaccine eg oral polio infection. Exposure to HIV, other immunodeficiency states and immunosuppressant treatments are also contraindications. Diarrhoea, minor acute illnesses, antibiotic therapy and breast feeding are not valid contraindications.
Question 34
An obese man, aged 60 years, is admitted unconscious with a diagnosis of cerebral thrombosis. The most important IMMEDIATE management is:
a) Insertion of an indwelling catheter
b) Commencement of anticoagulant therapy
c) Physiotherapy to prevent hypostatic pneumonia
d) Insertion of an intravenous drip to prevent dehydration e) Positioning him on alternate sides 2 hourly
A. An indwelling catheter allows monitoring of fluid status as well as allowing urinary drainage. IV fluid therapy is not urgent due to the potential to exacerbate brain swelling, in the acute phase. Anticoagulant therapy is of no value in treating a fully developed and completed CVA, and should be used only in transient ischaemic attacks or developing progressive thrombosis. The other measures of physiotherapy and nursing care should follow.
* Question 35
Which of the following statements about simple febrile convulsions is CORRECT?
a) It usually occurs between 6-8 years of age b) Prognosis is poor
c) The risk of developing epilepsy is 10% d) The convulsions last less than 15 min
e) Investigation with lumbar puncture and CT is essential
D. Simple febrile convulsions last less than 15 minutes. They usually occur
between 3 months and 5 years, with most occurring between 17 and 23 months of age. There is no difference in IQ at age 7 years between children
who have had a febrile convulsion and their seizure- free siblings. The risk of developing epilepsy following a simple febrile convulsion is 0.9% at age 7 years.
Question 37
Katie, a twelve year old school girl, collapses suddenly at school, and is transported by ambulance with dextrose drip (60/ml min.) inserted. On examination, dolls eye reflexes are present and she is not responding to painful stimulus. Her vital signs are as follows:
Resp. rate 14/min Pulse rate 50/min Sa02 100 %
B/P 180/110
What is the NEXT step of management? a) Arrange for urgent scan
b) Stop her dextrose infusion and start a saline infusion c) Give steroids
d) Intubate the patient
e) Neurosurgical consultation
C. Katie has raised intracranial pressure as indicated by the hypertensive response in the presence of bradycardia and coma. Glucocorticoid steroids (eg
dexamethasone) are most effective in reducing raised intracranial pressure and should be given first before the other measures. Katie will need a neurosurgical consultation and an urgent CT scan or MRI to diagnose the cause of increased intracranial pressure. Intubation will be required if her airway becomes compromised. Mannitol (IV) and hyperventilation to an arterial pCO2 of 25-30 mmHg may also be useful in controlling raised intracranial pressure.
* Question 38
The defect in visual fields MOST commonly associated with a pituitary tumour is:
a) Crossed homonymous hemianopia b) Central scotoma
c) Bitemporal hemianopia d) Total blindness in one field
C. As a pituitary tumour extends upwards from the diaphragma sellae and compresses the optic chiasm, it classically causes superior quadrantic defects followed by bitemporal hemianopia. It can however cause any variety of visual field defects, including unilateral (or bilateral) field defects in all quadrants, due to the variable position of the chiasm above the pituitary. Question 40
Which of the following would be MOST helpful in distinguishing cerebral infarction from cerebral neoplasm?
a) History of headache b) Hemiplegia
c) Chronology of development d) Carotid bruit
e) Focal abnormality on electroencephalogram
C. Chronology of development is the most important factor in differentiating cerebral infarction from cerebral neoplasm. Cerebral infarction tends to be a simple, sudden event or a series of stepwise events within hours to days. In comparison, neoplasms tend to be preceded by symptoms such as headache, progressive cognitive decline, seizures and vomiting, and may feature steadily progressive neurological signs. The other options are all variably present in both conditions and are not diagnostic.
Question 1
Bill is 65 years old and has just been diagnosed with type 2 diabetes. He returns to discuss the condition. What would you tell him about diabetic retinopathy?
a) He should see an ophthalmologist straight away
b) As Type 2 diabetes has just been diagnosed he won't need a referral for 5 years
c) Retinopathy is not a problem in Type 2 diabetes d) Retinopathy is a rare complication of diabetes e) None of the above
A. At diagnosis, one in six patients with Type 2 diabetes has retinopathy. If untreated, this progresses to cause retinal scarring, contraction of the vitreous humour and retinal detachment. Eventually about 85% of all patients will
show signs of retinopathy. All patients with Type 2 diabetes should be screened for retinopathy at the time of diagnosis, and then at least every two years thereafter. Laser therapy is very effective and halves the risk of visual loss from diabetic retinopathy.
Question 3
Brian, a long standing patient of your practice wants to discuss a friend of his who has just had his nail removed because of a melanoma. Which of the following statements about malignant melanoma is CORRECT?
a) This is a very common condition b) It is rarely fatal
c) Removal of the nail constitutes a cure
d) Mean survival time post diagnosis is 12 months e) This condition does not metastasise
D. Melanomas which occur on the palms, soles or nail bed are called acral melanomas and are quite rare. Because of their position, they are not found until quite late, and hence have a very poor prognosis. They spread locally and metastasise to regional lymph nodes. Biopsy with removal of the entire digit is the definitive treatment.
Question 19
Blood-stained discharge from the nipple of a 45 year old woman is MOST LIKELY due to:
a) Gynaecomastia b) Duct papilloma
c) Paget's disease of the nipple d) Fibroadenoma
e) None of the above
B. Duct papilloma typically presents with a unilateral serosanguineous or bloody nipple discharge. Paget's disease of the nipple presents with a chronic eczematous eruption indicating an underlying malignancy. Gynaecomastia (benign enlargement of the male breast) and fibroadenoma (smooth round asymptomatic breast lump) are not associated with blood stained nipple discharge.
A 60 year old man presents with severe abdominal pain, shock, moderate abdominal rigidity and intense lower back pain. Which of the following diagnoses is MOST LIKELY?
a) Acute retrocaecal appendicitis b) Leaking aortic aneurysm
c) Renal colic
d) Acute cholecystitis
e) Collapse of L4 vertebral body
B. A leaking abdominal aortic aneurysm typically presents with severe abdominal pain, shock, abdominal rigidity and intense lower back pain. It can be mistaken for renal colic, acute cholecystitis, and retrocaecal appendicitis. However circulatory shock is not usually present in these conditions. The BP may be increased due to pain. Collapse of the L4 vertebral body results in more localised pain without shock.
Question 25
A patient who has been treated with a preparation containing horse serum develops urticaria followed by swelling of the tongue and dyspnoea. Which of the following is the MOST APPROPRIATE immediate treatment?
a) Tracheotomy
b) Subcutaneous adrenaline c) Intravenous hydrocortisone
d) Intravenous promethazine (Phenergan) e) Oxygen therapy
B. This is acute angio-oedema and there is a risk of upper airways closure, so subcutaneous adrenaline should be given first.
Question 32
Which one of the following is NOT characteristic of an upper motor neurone lesion?
a) Clonus
b) Extensor plantar response c) Intact superficial reflexes d) Increased tone
C. The following signs result from lesions in the motor system proximal to the alpha motor neurone: spasticity (hypertonia predominant in flexors of arms and extensors of legs which is of a clasp-knife nature); paralysis or weakness predominantly of extensors in arms and flexors in legs; hyperreflexia; extensor plantar response; clonus and Hoffmann's reflex. The extensor plantar response is an example of loss of a superficial reflex.
Question 35
A 67 year old man presented three days after a stent was inserted for the treatment of persistent angina. He now complains of a persisting "different" chest pain and shortness of breath on exertion. On examination you find he is pale and slightly sweaty with: pulse rate 110 regular with pulsus paradoxus; BP 100/90; T 38.0 degrees Celsius; pedal oedema; bilateral basal crepitations in his chest; and a JVP elevated 3cm. Heart sounds are dual. The MOST LIKELY cause of his condition is:
a) Hospital acquired pneumonia
b) Post-infarct left ventricular remodelling with failure c) Extension of the infarct secondary to stent failure d) Pericarditis with tamponade
e) Bacterial endocarditis
D. Pericarditis is a recognised, although uncommon, complication of invasive cardiac treatments. The patient can lose the pain of angina, only to have it replaced by a more vague chest discomfort. Inflammatory pericarditis results in an effusion which can rapidly escalate into tamponade. None of the other options would show signs of biventricular failure this quickly.
* Question 36
A 60 year old engineer was admitted to hospital because of fever, cough, and pleuritic chest pain. His temperature was 40 degrees Celsius. Physical examination and x-ray of the chest indicated right lower lobar pneumonia. Sputum smear and culture demonstrated pneumococci. The patient had a history of allergy to penicillin, and therefore tetracycline therapy was instituted. After several days, fever and leucocytosis decreased and x-ray of the chest showed some clearing of infiltrate. On the 7th hospital day, his temperature spiked to 39.4 degrees Celsius, there was an increase in cough and dyspnoea. X-ray of the chest showed an increase in pulmonary infiltrate.
Which of the following is the MOST LIKELY explanation of this clinical picture?
a) Normally resolving pneumococcal pneumonia b) Laboratory contamination of original culture c) Superinfection
d) Side effect of therapy
e) Pulmonary thromboembolism
D. This clinical picture demonstrates deterioration in the patient's condition, and is not part of normally resolving pneumonia. Drug fever, or serum sickness, usually occurs on the 7th to 12th day of antibiotic therapy and can produce unexpected fevers, skin rash and an eosinophilic pulmonary infiltrate. Although more commonly due to penicillins it can be caused by tetracycline. As he had initially improved, it is unlikely that the original specimens were contaminated. Pulmonary embolism does not cause a high fever. Superinfection is commonly due to gram-negative bacteria, fungi or resistant staphylococci and usually appears on the 4th or 5th day.
Question 2
A 21 year old man walks into your surgery with his head tilted sideways, his eyes rolled up and his tongue sticking out. He speaks with difficulty but says that he has been 'stuck' in this position since taking a new medicine a few hours ago 'for his nerves'. You should administer:
a) Diazepam b) Benztropine c) Chlorpromazine d) Phenytoin e) Haloperidol
B. The presentation described is an acute dystonic reaction, which involves a spasmodic torticollis, (where the head is pulled and held to the left or right by one or other sternomastoid), upward drawn eyes and an open mouth (oromandibular dystonia). It may occur (particularly in young men) within a few days of starting a neuroleptic medication. Treatment is with the anticholinergic medication eg. benztropine. The dystonias are a group of disorders involving prolonged spasms of muscle contraction. Spasmodic torticollis is one type, as is trismus (clenched jaw) and Blepharospasm (involuntary contraction of the orbicularis oculi). In isolation, the dystonias are usually of unknown cause and treatment is difficult.
Question 5
You are called to see a 78 year old woman with a three-week history of headaches and depressive symptoms. She relates that 24 hours ago the vision in her right eye suddenly dimmed. Today the visual acuity in the eye is limited to perception of hand movements only, compared with 6/6 in the left eye. She is not known to be a diabetic and her blood pressure is only minimally elevated. Which of the following possible causes of her visual loss require IMMEDIATE investigation and treatment to prevent blindness in the other eye?
a) Detached retina
b) Central retinal artery occlusion c) Central vein occlusion
d) Acute glaucoma e) Temporal arteritis
E. Temporal arteritis is an uncommon disease of the elderly and is characterised by the classic complex of fever, anaemia, high ESR and headaches in an elderly person. It is closely associated with polymyalgia rheumatica. Temporal arteritis is the most common manifestation of a systemic vasculitis. Headache is the predominant symptom and may be associated with a thickened or nodular artery. A serious complication, as described in this lady, is ocular involvement - ischaemic optic neuritis. Most patients have head or eye symptoms for months before objective eye involvement. Acute glaucoma causes a red, painful eye, reduced vision and a fixed, mid- dilated pupil which may be slightly ovoid. The pain may be severe and associated with nausea and vomiting. Acute glaucoma may be preceded by blurred vision or haloes around lights. It is a uniocular attack due to blockage of drainage of aqueous fluid from the anterior chamber via the canal of Schlemm. Urgent treatment with hyperosmotic agents is necessary to reduce the intraocular pressure.
Question 6
Which of the following is INCORRECT?
a) The incidence of haemochromatosis in Australia is 1:200
b) C282Y homozygotes account for more than 90% of haemochromatosis in Australia
c) The majority of patients with one copy each of the C282Y and H63D mutation never develop haemochromatosis
d) 90% of C282Y homozygotes develop symptoms of the disorder at some stage in their lives
e) Carriers of one copy of the altered gene are generally healthy
D. Studies estimate that up to 50% of C282Y homozygotes will remain symptom free throughout their life.
Question 10
A 21 year old female patient presents with lower abdominal pain and tenderness at 14 weeks of gestation. Her temperature is 38.5 degrees Celsius. The most important diagnosis to EXCLUDE is:
a) Pyelonephritis
b) Threatened abortion c) Ectopic pregnancy
d) Degeneration of a uterine fibroid e) Appendicitis
E. Appendicitis is the commonest surgical emergency and has its maximum incidence between 20 and 30 years of age. In pregnancy it occurs mainly in the second trimester. Pain is generally higher and more lateral than typical appendicitis. Ectopic pregnancy occurs approximately one in every 100 clinically recognised pregnancies. The classical triad of ectopic pregnancy includes amenorrhoea (65-80%), lower abdominal pain (95+%) and abnormal vaginal bleeding (65-85%). Degeneration of a uterine fibromyoma typically occurs in the second trimester of pregnancy and is due to ischaemic necrosis. In threatened abortion there is vaginal bleeding. Pain is usually not a significant feature unless the cervix is beginning to open. Pyelonephritis can mimic acute appendicitis in pregnancy.
* Question 11
A patient presents with a recurrent severe hemicranial nocturnal headache which lasts for 60 minutes and occurs regularly every 3 weeks. The headache is accompanied by a blocked nose and watering eye. The MOST LIKELY diagnosis is: a) Tension headache b) Migraine c) Sinusitis d) Cluster headache e) Trigeminal neuralgia
D. Cluster headache has a four-fold higher incidence in men than women. It is characterised by constant unilateral orbital pain, with onset usually within 2-3 hours of falling asleep. The pain is intense and steady with lacrimation, blocked nostril then rhinorrhoea and sometimes miosis, ptosis, flush and oedema of the cheek, all lasting approximately an hour or two. It tends to occur nightly for several weeks or a few months, followed by complete freedom for months or even years. The response to inhaled oxygen can be dramatic.
Question 17
Sudden onset of unilateral orbital pain, photophobia, lacrimation and blepharospasm suggests a diagnosis of:
a) Open-angle glaucoma b) Iritis
c) Temporal arteritis d) Blepharitis
e) Vitreous haemorrhage
B. Acute iritis presents with pain of acute onset, photophobia, blurred vision, lacrimation, circumcorneal redness (ciliary congestion) and a small pupil (initially from iris spasm). Talbot's test is positive: pain increases as the eyes converge (and pupils constrict). The slit lamp reveals white precipitates on the
back of the cornea and anterior chamber pus (hypopyon). Open angle glaucoma is painless and largely asymptomatic until there is visual field loss; temporal arteritis causes pain in the temporal area, not in the orbit; blepharitis is inflammation of the eyelids; vitreous haemorrhage can present with visual field loss depending on the size of the haemorrhage and it is generally painless.
Question 23
Which finding is INCONSISTENT in this report of a cerebrospinal fluid (C.S.F.) examination?
a) Elevated protein b) Normal chloride c) Elevated glucose d) No red cells
C. A lumbar puncture consistent with a diagnosis of pyogenic meningitis contains excessive polymorphs, with protein at 1.5g/l (aseptic less than 1.5g/l) and glucose at less than 2/3 the plasma level. There are no red cells unless it is a bloody tap (ie. Artefact due to piercing blood vessel).
Question 32
Jane is brought into the surgery after being struck in the eye with a tennis ball. On examination you note blood in the anterior chamber of the eye. Which of the following statements regarding her management is INCORRECT?
a) Analgesia containing aspirin is contraindicated
b) Management is directed at avoiding the risk of secondary haemorrhage c) Emetics may be required
d) Decreased visual acuity necessitates the exclusion of other ocular damage coexisting with the hyperaemia
e) Jane should be referred to an ophthalmologist for urgent review and management
C. The management of hyphaema is aimed at preventing secondary haemorrhage which can cause the anterior chamber to be filled with blood and severe secondary glaucoma to develop. Thus aspirin-containing analgesics should be avoided (due to the risk of increased bleeding) and management includes strict bed-rest in hospital. Although reduced visual acuity can occur, it is important to exclude other ocular damage through specialist referral if this occurs. Vomiting needs to be prevented NOT induced, as it raises intraocular pressure and increases the risk of secondary bleeding.
* Question 33
The MOST LIKELY venous source of fatal pulmonary embolism is: a) Iliofemoral
b) Subclavian c) Saphenous d) Pelvic e) Popliteal
A. Most pulmonary emboli arise from proximal deep vein thrombosis (deep veins of lower limb, pelvis and inferior vena cava). Less frequently, thromboses of the upper arm are the source. Saphenous vein thrombosis seldom results in clinically obvious pulmonary embolism. Also, in order for
