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    r i d g i n g

    C o u r s e M C Q s

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    Block 1

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    Question 1

    Patients suffering from schizophrenia may experienceboth positive and negative symptoms. All of thefollowing 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. hearingvoices speaking about the patient, and/or givinginstructions to do certain things. They representadditional phenomena and, therefore, are classified aspositive symptoms. Delusions (false ideas) is the othermajor group of positive symptoms. In contrast, each ofthe other options represents a loss or diminution of amental function, e.g. anhedonia is a loss of capacity forpleasure.

    Question 2

    Martha was born at 35 weeks gestation. She required

    phototherapy for jaundice whilst in hospital. Martha isbeing breast-fed and is beginning to gain weight. She isnow two months old. Regarding routine childhoodvaccination which of the following statements isCORRECT?

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

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

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

    d) Breast-feeding is a contraindication tovaccination.

    e) It is not necessary to immunise Marthaagainst hepatitis B.

    Answer: B

    A history of jaundice after birth is not a contraindicationto any of the vaccines in the standard schedule.Vaccination should not be postponed because ofprematurity. The fact that a child is breast-fed is not acontraindication to vaccination. Vaccines should neverbe given into the buttocks. The anterolateral thigh is thepreferred site for vaccination in infants under 12 monthsof age. The deltoid region is the preferred site in olderchildren (those who have commenced walking) and inadults. Martha would be due to receive vaccinationagainst hepatitis B at the age of two months accordingto the current standard vaccination schedule.

    Question 3

    Maud is a 70 year old who presents with acute peri-umbilical abdominal pain gradually increasing inintensity. She is vomiting profusely and develops waterydiarrhoea with flecks of blood after an hour of pain.Examination of the abdomen reveals localisedperiumbilical tenderness with some rigidity. Rectalexamination is normal. An irregular pulse is noted andan 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 arteryocclusion. This occurs most commonly in patients withatrial fibrillation leading to embolism. The ECG showsatrial fibrillation. Arteriography will show the vascularocclusion.

    Question 4

    A 15 year old male has sudden onset of severe pain inhis right lower abdomen commencing 2 hours ago. Hehas vomited several times in the last hour. He is rollingon the bed, stating that the pain is going down into hisgroin. T 37.1 degrees Celcius, P 110min, BP 135/ 80.Abdomen - soft, no rebound. Tender right testicle. Yourimmediate 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 provedotherwise. This is a surgical emergency, as infarction ofthe testis can occur quickly, and surgical explorationshould be undertaken urgently. This patient has nofever,

    nor tenderness of the epididymis to indicate epididymo-orchitis. Antibiotic treatment will not help. Colourdoppler ultrasound may show increased blood flow ininfection and the absence of flow in advanced torsion.However, these are not reliable findings, and theinvestigation would waste valuable time. The vomiting isrelated to the pain, and would be alleviated byappropriate analgesia. Metoclopramide is not an

    Block 1

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

    e) Prostate cancers usually appear ashypoechoic nodules on transrectal ultrasound

    Answer: B

    A normal PSA occurs in up to 20% of cancers, includingtumours greater than 1.5 cm. Prostate cancer is thesecond most common cause of cancer deaths in men inAustralia. The majority of prostate cancers- usuallyadenocarcinomas- arise in the peripheral zone of thegland, and metastasise early to pelvic lymph nodes.Bony metastases are also common. Bone scan isunreliable at detecting bony metastases when theprostate specific antigen (PSA) is

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    Question 14

    A 15kg child with a known food allergy to peanutssuddenly develops anaphylaxis. The RECOMMENDEDimmediate management is:

    a) 0.1ml of Adrenaline 1:1000 by deep intramuscularinjection

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

    c) 0.15ml of Adrenaline 1:1000 by deep intramuscularinjection

    d) 0.15ml of Adrenaline 1:1000 by subcutaneousinjection

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

    Answer: C

    Adrenaline 1:1000. is recommended as it is readilyavailable, and this concentration contains 1mg ofadrenaline per ml. The recommended dose of 1:1000adrenaline is 0.01mg/kg body weight by deepintramuscular injection, so a 15kg patient would require0.01 X 15 = 0.15ml i.m.

    Question 15

    Which ONE of the following is a mass populationscreening test which has been demonstrated to reducecancer mortality significantly?

    a) annual faecal occult blood testing in the over50 age group

    b) annual colposcopy in sexually active womenc) annual plasma CA125 in post menopausalwomen

    d) annual colonoscopy in siblings of patientswith colon cancer

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

    Answer: A

    There have been at least 3 randomised control screeningtrials conducted which show that faecal occult bloodtesting every 1-2 years in the over 50 year populationreduces the mortality from colorectal cancer by around20%. Colposcopy is a diagnostic, not a screening test.The appropriate screening test for cancer of the cervix insexually active women is the Papanicolaou (Pap) smear.Plasma CA125 levels may be raised in asymptomaticwomen with ovarian cancer but there is not, as

    yet, any evidence for its benefit as a mass screeningmeasure. Colonoscopy for siblings of patients withcolorectal 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 beenshown to reduce mortality from breast cancer by around30%, the benefit for women in the 40-50 age range isquite small, and there is little evidence for benefit in stillyounger women.

    Question 16

    All of the following groups are at higher risk thanaverage 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 ofdepression. However, young men living in rural areasare at greater risk because of social isolation. Women,particularly in the postpartum period, and adolescentsare also more vulnerable to depression.

    Question 17

    14 month old Mark is brought in to see you. He has hadhigh fever and a mild runny nose for three days but hasstill been quite active. Mark's temperature has returnedto normal today but he has now developed a redmaculopapular rash on his trunk. The MOST LIKEYdiagnosis is:

    a) Measles

    b) Chicken pox

    c) Erythema infectiosum

    d) Rubella

    e)Roseola infantum

    Answer: E

    Roseola infantum is a viral infection usually affectingchildren between the ages of 6-18 months. The patienttypically develops high fever up to 40 degrees Celsius,but is otherwise not particularly unwell. There may bemild cervical lymphadenopathy and pharyngitis. Afterthree days the temperature usually returns suddenly tonormal and the patient develops a red macular ormaculopapular non-desquamating rash which is truncal,usually sparing the face and limbs. The rash abateswithin two days.

    Question 18

    A 50 year old woman has had major abdominal surgeryyesterday. You are called to see her urgently as she hassymptoms of shock. Which ONE of the followingexamination 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

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    Answer: E

    The above signs taken together suggest a picture ofshock, probably septic shock. Hypotension (defined assystolic BP 40mm Hg fall from baselinelevel) is a sinister development and requires urgentattention. It is often a LATE manifestation of circulatoryfailure. 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 reluctantlybecause his wife feels 'he has not been himself since hecame home and is not sleeping properly.' His appetite ispoor and he has lost 6 kg in weight since discharge fromhospital eight weeks ago following treatment formyocardial infarction. He has lost interest in his hobbiesand is not taking his medications. He has been a type 2diabetic for 12 years. On examination he shows signs ofmild cardiac failure. The result of an HbA1C test is10.5% (target

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    Question 23

    Which of the following is NOT a diagnostic featureaccompanying 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-IVcriteria include 3 or more of the following in addition toanxiety and worry: restlessness, fatigue, difficultyconcentrating, irritability, muscle tension, and sleepdisturbance.

    Question 24

    Martin, aged 50 years, complains of insomnia for twoweeks. He says this relates to anxiety about problems atwork which surround the end of the financial year. Whilehe is describing his problem, he is excited and agitated.On examination, his pulse rate is 75/min and BP 135/95mm Hg. Which of the following behavioural therapieswould 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 bothbehavioural and pharmacological approaches. Relaxationtherapy would be the most useful behavioural therapyfor Martin, because he displays exaggerated arousal -emotional, cognitive and physiological, shown by hismental approach when describing the problem and hisphysiological response in terms of pulse rate and BP.Progressive muscle relaxation aims to reduce somaticarousal and attention focussing techniques (e.g. ontranquil situations) to reduce cognitive and emotionalarousal. (See reference for descriptions of other options,except interpersonal therapy which is not an acceptedform of behavioural therapy.)

    Question 25

    Doris is a 74 year old woman whose husband has diedsuddenly a week ago. She seeks your help in dealingwith insomnia which has been troubling her since herhusband's death. She has tried an over-the-counterpreparation which she obtained at the local pharmacybut 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 ahypnotic medication in a situation like suddenbereavement. None of the drugs listed stands out as thebest hypnotic with few side effects. Temazepam is themost often prescribed hypnotic in Australia. However,benzodiazepines have generally fallen from favourbecause of their addictive properties if taken for morethan several weeks. Zopiclone and zolpidem share someof the properties of benzodiazepines but have feweradverse effects. Amitriptyline is a tricyclicantidepressant which is a useful hypnotic in lower dosesthan 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 isdefined as poor quality sleep which often results in

    daytime symptoms, including fatigue, irritability,problems with concentration and memory, and feelingunwell. The other options describe features of variousinsomnia syndromes but do not define the overallproblem.

    Question 27

    Miriam, aged 67 years, presents with insomnia for twoweeks. She has tried several over-the-countermedications but has not received any benefit. Furtherquestioning reveals that she is feeling unusually worriedabout her health, is also irritable and restless and hasgeneralised muscle tension. You have known Miriam for

    5 years since you joined this practice. She haspreviously complained of 'arthritis' of the hips andknees, back pain and gastro-oesophageal reflux onvarious occasions. Which of the following drugs would beMOST 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 serotoninreuptake inhibitors (SSRI) which have not been shownto be effective in the treatment of GAD. Amitriptyline is

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    a tricyclic antidepressant; diazepam and oxazepam arebenzodiazepines. All three drugs can be used fortreating anxiety, but have major disadvantages in termsof side affects and are unsuitable for long-termtreatment of GAD. Venlafaxine is a serotonin andnoradrenaline reuptake inhibitor (SNRI) which has beenshown to be effective in the long-term treatment ofGAD. However, it is important that patients also receiveappropriate psychotheraphy, viz-cognitive behaviouraltherapy (CBT).

    Question 28

    The prevalence of insomnia in the Australian communityis 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 the40+ years age group. Other factors which increase theprevalence of insomnia are old age, unemployment andlower socio-economic status. The majority of patientshave a co-existing disorder, such as depression orgeneralised anxiety, and often present with fatigue ordaytime 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 ofsleep disorder as there is, for example, in obstructivesleep apnoea, restless legs syndrome, sleep phasedisorder and bereavement. With behaviouralconditioning or behaviours impairing sleep the patienthas developed a habit of doing things immediatelybefore bedtime which are not conducive to sleep, suchas sitting in bed watching television. With the otheroptions there is another established condition orsituation which disrupts sleep. Hence insomnia isregarded as secondary in these cases.

    Question 30Patients 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 foryears because they tend to present with associatedsomatic complaints, such as asthma, back pain,migraine, allergies, and gastrointestinal disorders andoften consume a large amount of medical resourcesbefore the diagnosis is made. They are not deliberatelyconcealing things from their doctors - they simply do notappreciate the significance of their feelings. Patientswith GAD may also have clinical depression which canfurther complicate the issue.

    Question 31

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

    a) Selenium sulphide

    b) Zinc pyrithione

    c) Betamethasone

    d) Miconazole

    e) Ketoconazole

    Answer: C

    Dandruff, pityriasis capitis and seborrhoeic dermatitisare related conditions on a continuum of severity.Pityrosporidium ovale is a fungus which has beenimplicated

    in the development of these conditions. Eradication ofthe fungus has been shown to relieve the symptoms ofthe condition. Selenium sulphide, zinc pyrithione,miconazole and ketoconazole are all first line treatmentswhich can be used once weekly to daily depending onseverity. Topical application of betamethasone lotion iseffective but only considered if there has been littleresponse to the first line treatments.

    Question 32

    Amy, a young girl, is worried about a rash on her facewhich has been there for a few weeks. It is mildly itchyand has slowly increased in size. On examination it is acircular lesion which looks scaly around the edges withthe center appearing normal(see figure).

    The MOST LIKELY diagnosis is:

    a) Tinea corporis

    b) Impetigo

    c) Pityriasis versicolor

    d) Psoriasis

    e) Dermatitis

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    Answer: A

    In children, tinea commonly involves the hair, face andbody. Tinea corporis is recognised by its scaly,erythematous edge with clearing centre. Dermatitis andpsoriasis can mimic tinea and where the clinical pictureis uncertain a fungal scraping may confirm tinea.Impetigo may present with blisters that leave a browncrust, or erosions with yellow crusts but without

    blistering. Pityriasis versicolor presents as welldemarcated pale or tan-coloured macules usually on theupper trunk.

    Question 33

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

    a) 75% of children with ALL are cured

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

    c) Intrathecal therapy is required only if thedisease 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% ofchildren had a relapse due to CNS disease. The use ofblanket CNS therapy has reduced the CNS relapse rateto less than 10%.

    Question 34

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

    She has recently bought a new watch and wonders ifthis is the cause of the problem. The MOST LIKELYdiagnosis is:

    a) Papular urticaria

    b) Tinea

    c) Contact dermatitis

    d) Eczema

    e) Scabies

    Answer: E

    Scabies is a skin infestation by the mite Sarcoptesscabei. It is generally spread by skin to skin contactsuch as in crowded areas, poverty, sexual contact andcasual contact. The mite can live for 2 days outside the

    human body, so infection by contact with bed linen andother infected material is possible. Intense itch ischaracteristic of the condition - if it is not itchy, it is notscabies. Distinct erythemato-papular itchy nodules aredue to an allergic reaction to the mite, its faeces and itslarvae. 0.5-1.0cm "burrows" can often be found on the

    fingers and wrist. Contact dermatitis to her watch wouldproduce a local contact dermatitis.

    Question 35

    Which of the following statements about routineimmunisation is CORRECT?

    a) If more than 3 months elapses betweentriple antigen injections the series should berestarted to obtain adequate immunisation

    b) The first triple antigen injection shouldalways be half dose (1/2 cc) to reduce allergicreactions

    c) A convulsion following acellular pertussistriple antigen vaccine (DTPa) does notcontraindicate its further use

    d) Tetanus booster injections should berepeated 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 notcontraindicate completion of the course with DTPa-containing vaccine. The only adverse events whichcontraindicate further doses of pertussis containingvaccine are:

    • encephalopathy within 7 days and

    • an immediate severe allergic reaction.

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

    Question 36

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

    a) An artificial pacemakerb) Isoprenaline hydrochloride (Isuprel)

    c) Atropine

    d) Digoxin

    e) Requires no treatment

    Answer: E

    First degree AV block often does not require anytreatment. Acute treatment of

    extreme bradycardia or second degree AV block (Mobitztype II) may require atropine or isoprenaline, buttemporary pacing is the preferred treatment. Permanentpacing is recommended for distal block (Mobitz type 2)because of frequent early progression to third-degreeatrioventricular block. Most patients with third degree(complete) AV block will require permanent cardiac

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    pacing. Drugs such as digoxin may be the cause of anAV block and should be ceased or the dose reduced.

    Question 37

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

    a) Change to a progestagen only oralcontraceptive

    b) Change to an oestrogen only oralcontraceptive

    c) Reduce her alcohol intake

    d) Change antidepressant medication

    e) Undertake cognitive behavioural therapy

    Answer: D

    Various medications may cause loss of libido, includingantidepressants like the SSRIs. The remedy is to changeto a different class of antidepressant. Excess alcoholconsumption can have a deleterious effect on libido,however Melissa's intake is within recommended limitsfor adult females. Changing the oral contraceptive wouldbe unlikely to help. Cognitive behavioural therapy wouldbe the next step if suitable pharmacotherapy cannot beestablished.

    Question 38

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

    a) There is usually a history of past or presentcigarette smoking

    b) There is usually a long history of atopicdisease

    c) Attacks can be triggered by chemical andphysical agents

    d) The asthma tends to be more chronic thanepisodic

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

    Answer: B

    Adult onset asthma is non-atopic, although patients canhave attacks precipitated by aspirin, viruses, cold airand coughing itself. A history of smoking is nearlyubiquitous, but the connection to the development ofadult-onset asthma is not yet understood. Patients tendnot to have long spells of being 'puffer free', but regularinhaled steroids are very effective in controlling thecondition. The cough can keep the patient awake allnight, along with the rest of the family.

    Question 39

    A 61 year old farmer with a history of hypertensionpresents with an amnesic episode of sudden onset.When assessed he is perplexed and bewildered, andrepeatedly asks where he is and how he comes to bethere. He has short term memory loss but knows hisidentity and is fully conscious. He recovers from hismemory loss after 6 hours. Neurological examination is

    normal. His blood pressure is 165/96 sitting. The MOSTLIKELY 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 personsuddenly becomes confused and amnesic. The attacksare usually spontaneous. The patient appearsbewildered and repeatedly asks questions about presentand recent events. Orientation for person andsometimes place is preserved but recent memory isimpaired and the patient cannot recall new informationafter a few minutes delay. Attacks usually last 24 to 48hours. Recovery is complete and recurrence occurs inabout 20% of patients. The cause is a mystery. Complexpartial seizures are brief and the individual losesconscious contact with the environment. Post-ictalamnesia is common if the seizure becomes generalised.Richardson Steele Syndrome (or progressivesupranuclear palsy) resembles Parkinson's disease inthat there is a disturbance of balance and gait, withrigidity of the trunk and neck muscles. Alzheimer'sdisease is a progressive form of dementia which doesnot resolve. Hypertensive encephalopathy is an acutesyndrome where severe hypertension is associated withheadache, vomiting, convulsions, confusion, stupor andcoma.

    Question 40

    Which of the following factors would NOT be a poorprognostic indicator for joint replacement in hiposteoarthritis in a 65 year old man?

    a) Ageb) 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 agewould not be a poor prognostic indicator.

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    Question 1

    All of the following tests should be part of a routineinitial (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 antenatalscreening guidelines in Australia, there are a set ofrecommendations by the Royal Australian and NewZealand College of Obstetricians and Gynaecologists.Tests to be offered at the first trimester initial antenatalvisit 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 itdoes not need to be repeated. However, the antibody

    screen should be repeated at the beginning of eachpregnancy, and all Rhesus negative women and all thosewho have had isoimmunisation of any type in the pastshould be re-screened. Although a previous high rubellaantibody titre is generally used to justify exclusion ofthis investigation from first visit testing, there is someevidence that antibody levels may decline after rubellaimmunisation, especially since antibody levels are rarelyboosted by exposure to wild viruses in the community.All pregnant women should be offered hepatitis C andHIV screening at the first antenatal visit and if necessaryafter exposure to risk of infection. It is imperative thatthe woman is provided with appropriate counselling asto the limitations of the testing and the implications ofboth positive and negative findings. Documented normalcervical cytology within the preceding 18 months maybe used to delay repeat screening if there is no clinicalindication for another Papanicolaou smear. Routinevaginal ultrasound during the first trimester is notrecommended except where the viability of thepregnancy is in question such as when the woman hashad first trimester bleeding.

    Question 2

    Martin is 5 years old. His mother reports he has beenwaking her at night screaming in apparent fear. She isextremely worried. Although Martin is obviouslyfrightened during these episodes, he does not seem fullyawake, and she is unable to comfort him or wake himfully. He is sweaty, tachypnoeic and tachycardic. Martindoes not recall these episodes in the morning. He isMOST 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 wakesonly partially, cannot be fully roused or comforted, andwill have no recall of the episode. Autonomic symptomsas described are common. With nightmares, the childwakes fully, and frequently has full recall of dreams.Night terrors may be precipitated by anxiety or anexperience which has frightened the child prior to sleep.

    Question 3

    All of the following are associated with the timing ofsecondary 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 ofheight) before sexual maturation will begin. A bodyweight of 38 - 48 kilograms must be achieved beforemenses begins and a proportion of body fat of 16-24%is required to sustain ovulatory cycles. Other criticalelements to the timing of secondary sexual maturationinclude adequate sleep and vision. Blind girls havedelayed menarche and blind boys have delayedspermatogenesis and ejaculation. Chromosomalabnormalities such as Turner's syndrome result inpremature ovarian failure and lack of secondary sexualmaturation. Latitude has no impact.

    Block 2

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    Question 4

    Eve is 9 weeks pregnant. She presents with a history of24 hours of intermittent dark blood loss staining herunderwear. On vaginal examination, the uterus is theexpected 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 womensuffer bleeding during the first trimester

    c) she requires admission to hospital for a D&C

    d) there is a higher incidence of congenitalmalformations in fetuses where bleedingoccurred in the first trimester

    e) she should have an ultrasound examination

    Answer: E

    Eve has a threatened abortion as the cervical os isclosed and there is no history of passage of products ofconception. This occurs in 25% of pregnancies and halfof these progress to spontaneous abortion. For thosewho carry the pregnancy to term, there is no increasedrisk of congenital malformation. An ultrasoundexamination would be helpful, as it could demonstratethe presence (or absence) of a foetus appropriatelysized for dates. The demonstration of a foetal heart isvery reassuring. At 9 weeks, when a foetal heartbeat ispresent and not slow, 90% of pregnancies will continuedespite bleeding.

    Question 5

    Samantha is 18 months old. She is usually well, with nosignificant past history, and is up to date with herchildhood vaccinations. Samantha has been miserableand unwell for 24 hours with a clear runny nose, and afever of 39 to 40 degrees Celsius. She has no cough, nodiarrhoea or vomiting, and is drinking well, even thoughher appetite for solids is decreased. Suddenly Samanthahas a generalised tonic-clonic seizure, lasting 3 minutes.Which of the following statements regarding febrileconvulsions in children is TRUE?

    a) most febrile convulsions are focal or partialseizures

    b) There is a 10% chance of developingepilepsy

    c) the most common cause is CNS infectionsuch 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% ofcases, but this does not usually worsen long termprognosis. Most febrile convulsions occur in childrenaged 3 months to 5 years, the peak incidence beingbetween 6 and 20 months of age. More than 90% of

    seizures are generalised. Acute upper respiratory tractinfections are the most common cause of febrileconvulsions. In children under the age of two years ifthe cause of the febrile convulsion is not obvious, alumbar puncture must be performed to exclude CNSinfections. Only rarely do febrile seizures lead to

    epilepsy, the incidence being about 2 - 3%. The chanceof developing epilepsy is increased if there is a familyhistory of epilepsy, the child has a pre-existingneurological

    abnormality, the child is under one year of age, theseizure is prolonged (greater than 15 minutes) and/orhas complex or focal features, or if the child fits morethan once in one day.

    Question 6

    Vera, aged 61 years, has noticed a swelling in the frontof her neck, which is enlarging quite rapidly. She isotherwise well, without symptoms of hypothyroidism orhyperthyroidism. On examination she has a multinodulargoitre, with a dominant nodule of 4 cm diameter in theright upper pole of her thyroid gland. Of the followinginvestigations, which is the MOST important in assistingdiagnosis?

    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 thyroidnodule is approximately 7%, and fine needle biopsy isthe appropriate investigation to exclude malignancy.Vera has several features consistent with a thyroidmalignancy, including a rapidly growing solitary lump,her age (over 60 years) and the fact that the dominantnodule is >3cm in diameter. Detection or exclusion ofmalignancy is the MOST important issue initially. Thyroidfunction tests must also be performed to assessglandular activity, but they

    do not help in determining malignancy. Ultrasound scanadds little to clinical examination, but may be used toguide the biopsy needle. CT scan may be useful toassess retrosternal extension of the thyroid, butcurrently Vera has no symptoms of this problem.Nuclear medicine scan is useful to determine thefunctional status of a nodule but carcinoma cannot beexcluded on the basis of a radionuclide scan.

    Question 7

    All of the following are true of ectopic pregnancyEXCEPT:

    a) an ectopic pregnancy is one where there isimplantation outside the uterine cavity

    b) the primary risk factor for ectopic pregnancyis a history of salpingitis

    c) the prevalence of ectopic pregnancies hasdecreased over the last 20-30 years

    d) ectopic pregnancy is one of the leadingcauses of maternal mortality

    e) less than 50% of women who have anectopic will subsequently have a successfulnormal pregnancy

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    Answer: C

    The prevalence of ectopic pregnancies has increased byup to six-fold since 1970. The reason behind thisincrease may be an increase in the prevalence ofsexually transmitted diseases and tubal sterilizations, orthat women are conceiving later in life with acorresponding increase in the risk of tubal problems.Ectopic pregnancy remains one of the leading causes of

    maternal mortality. Probably because of underlying tubalproblems,

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    a) History taking must include recent travel andcontacts with animals including pets

    b) Family and close contacts only requiretreatment if they are symptomatic

    c) Persistent itch 5 days after treatmentindicates treatment failure

    d) Permethrin 5% cream may be used to treatscabies in a child of Brian's age

    e) Brian should be excluded from school forseven days, or until the itch has subsided

    Answer: D

    Permethrin 5% cream is a suitable treatment option inchildren over the age of 6 months. Sarcoptes scabiei,the mite which causes scabies, is spread by close humancontact and is not from animals. All family members andclose contacts should be treated, regardless ofsymptoms. Patients and their families should be advisedthat the itch does not resolve immediately and may take

    three weeks to subside. It is unnecessary to repeattreatment for scabies during this time based onpersistence of itch. Brian needs to be kept away fromschool only until he has begun appropriate treatment.

    Question 12

    Margaret, aged 46 years, is distressed and agitated. Sheis holding her head, and complaining of 'the worstheadache I have ever had'. This headache begansuddenly 2 hours ago. She has vomited twice, and isphotophobic. Her temperature is 37.8 degrees Celsius,her pulse 110/min and her blood pressure 140/80 mmHg. 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 yourrooms

    e) perform a full clinical neurologicalassessment

    Answer: B

    The sudden onset of 'the worst headache' the patientcan ever recall, accompanied by vomiting, must raisethe suspicion of subarachnoid haemorrhage.(SAH).While this is rare (and only 1 patient in 8 who presentswith sudden extreme headache will have a SAH) it is adiagnosis which must not be missed. SAH occurs mostfrequently in patients under 65 years of age, themajority being in the fourth decade. Women are morefrequently affected than men. All patients with thisclinical picture require investigation commencing withemergency head CT scan to exclude SAH. Lumbarpuncture may be undertaken as the next investigation ifthe CT scan does not confirm SAH. Blood orxanthochromia in CSF may be detected in a smallerSAH, and meningitis may be excluded. Migraine may beconsidered after exclusion of SAH and meningitis.

    Suspected drug seekers should not be left alone in yourrooms. However, this is not a typical presentation froma drug-seeker, but that possibility should not be

    completely ignored. While clinical examination is alwaysimportant, detailed neurological assessment is notappropriate initially.

    Question 13

    In women of reproductive age the most common causesof vaginal irritation and discharge in DESCENDING orderof occurrence are:

    a) Bacterial vaginosis, candidiasis, trichomonas

    b) Bacterial vaginosis, candidiasis, herpessimplex

    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 vaginalirritation and discharge. It is often misdiagnosed bywomen and their doctors as "thrush". Proven candidalinfections are the second most common, accounting foraround 35% of infections. Trichomoniasis is a sexuallytransmitted disease that causes vaginitis. Chlamydiaand gonorrhoea infect the cervix and urethra and do notcause "vaginitis" per se. Herpes may cause vaginal painand irritation if vesicles occur in the vagina but is notcommonly 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 diseasehave an extra intestinal manifestation. The morecommon are erythema nodosum, pyodermagangrenosum, psoriasis, arthritis, ankylosing spondylitis,episcleritis, iritis, conjunctivitis, fatty liver (hepaticsteatosis), primary sclerosing cholangitis, cholelithiasis,nephrolithiasis and thromboembolism. Dermatitisherpetiformis is associated with coeliac disease.

    Question 15

    Michael, aged 12 years, sustained a blow to his lefttemple when he fell while climbing a tree. He wasdazed, but able to recount what had happened. An hourlater he complained of an increasingly severe headache,vomited once, and then was brought to hospital. Hispulse is now 54 bpm, BP 130/90 mm Hg and he isdrowsy and confused. His left pupil is larger than hisright. Which is the MOST appropriate advice to giveMichael's parents? Michael:

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    a) will need an urgent CT scan of his head toconfirm the diagnosis

    b) has a severe concussion and must beobserved closely overnight

    c) requires urgent neurosurgery to reduce thechance of disability or death

    d) will be monitored in ICU until stabilized forsurgery in 24 hours

    e) is gravely ill and has a 50% chance ofsurvival

    Answer: C

    The history of the injury is highly suggestive of anextradural (epidural) haematoma. Although Michael didnot lose consciousness initially, his condition hasdeteriorated rapidly and significantly. He is nowbradycardic, hypertensive and his pupil is dilated on theside of the injury. His level of consciousness is alsodeteriorating. An extradural haematoma will result in

    death if not evacuated promptly. There is approximately75% chance he will have a fracture overlying thehaematoma, but skull x ray is not indicated. There maybe 'concussive' injury to the underlying brain but thelife-threatening factor is the raised intracranial pressurefrom the extradural haematoma. While it would be idealto have a CT scan, the rapidly deteriorating conditionmeans that emergency surgery should not be delayed.Michael is clearly gravely ill, but the mortality fromepidural haematoma is 9% for obtunded patients and20% for those who are comatose prior to surgery.Prognosis is better for young patients, but deteriorateswith other associated intracranial injuries and with delaybetween injury and surgical intervention.

    Question 16

    Tonsillectomy would be recommended for each of thefollowing patients EXCEPT:

    a) Claire, aged 3, has had four episodes oftonsillitis in the last 12 months, each timeassociated with a febrile convulsion.

    b) Sarah aged 4 years, has had six episodes ofa sore throat in the last 12 months and nowhas bilateral large tonsils and enlarged cervicallymph nodes

    c) Steven aged 25 years, has recently required

    incision and drainage of a quinsy (peritonsillarabscess)

    d) Olive aged 63 years, has noticed that herright tonsil has enlarged recently. She also hasan enlarged cervical lymph node on the right

    e) Peter, aged 10 years, snores loudly,sometimes "stops breathing" at night and issleepy at school. He has large tonsils.

    Answer: B

    It is not unusual for young children to have severalepisodes of 'sore throat' each year. These could be dueto a number of conditions including pharyngitis,laryngitis, tonsillitis (either viral or bacterial), orexposure to irritants like cigarette smoke. Children suchas Sarah in the preschool age group frequently havelarge tonsils, adenoids and cervical glands as part of thenormal growth pattern of lymphoid tissue. In these

    children a tonsillectomy would not be recommended. Inall of the other cases, tonsillectomy is likely to berecommended. Claire's four episodes of (proven)tonsillitis have been accompanied by a worrying if notsinister symptom. Steven's quinsy is a clear indicationfor tonsillectomy, and Olive may have a malignancy.Peter's snoring and sleep apnoea also justifiestonsillectomy.

    Question 17

    Cindy is 13 months old. She presents with two days offever, runny nose and cough. Her cough is becomingincreasingly distressing, and she is quite tachypnoeic.On auscultation of her chest you hear some expiratorywheeze and scattered crepitations. Cindy's breathing isobviously laboured and there is rib retraction. Youdiagnose bronchiolitis. Which of the following statementsis CORRECT?

    a) Parenteral penicillin is the treatment ofchoice

    b) Chest Xray may show hyperinflation

    c) Parainfluenza virus is the most commonpathogen

    d) Corticosteroids are contraindicated

    e) Inpatient treatment is often necessary

    Answer: B

    Chest x-ray findings in bronchiolitis typically includehyperinflation with depression of the diaphragm andhorizontal ribs. There may also be streaky hilarshadows, mild interstitial infiltrates and some segmental

    atelectasis. RSV (respiratory syncitial virus) is by far themost common pathogen, although some cases may bedue to the parainfluenza, influenza and adenoviruses.Antibiotics are not indicated. Corticosteroids are notcontraindicated, but their use has not been shown tomodify the course of the disease. While some veryyoung or very unwell children may require supportiveinpatient management, most children with bronchiolitiscan be confidently managed as outpatients.

    Question 18

    Six weeks ago you excised a skin lesion from the cheekof 65 year old Bill. The wound had healed well when you

    removed the sutures five days later, but the pathologyreport was not available. You told Bill you would contacthim if anything further needed to be done, as he wasleaving on an extended holiday. In doing somepaperwork today, you discover to your horror, Bill'spathology report, which states: There is a squamous cellcarcinoma (SCC) measuring 5 mm in diameter, with adepth of 4 mm. The lesion has been completely excisedbut extends to within 1mm of one lateral margin, and towithin 2 mm of the base of the excision. What is yourMOST appropriate course of action?

    a) contact Bill urgently, apologising for thedelay and explain that he should have furtherexcision as a clearance margin of 5mm in depthand laterally is required to minimise localrecurrence or metastasis

    b) contact Bill, apologising for your delay, andadvise it was a skin cancer (SCC) but it hasbeen completely excised, and there is minimalrisk of local recurrence or metastasis

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    c) do not attempt to contact Bill during hisholiday as the matter is not urgent. Clearanceof 1mm in all directions is adequate tominimise local recurrence

    d) do not disturb Bill as the holiday is importantto him, but ensure that you recall him when hereturns to discuss options for further surgery

    e) contact Bill, saying you have just receivedthe report which the laboratory must have lost.Advise him he had a skin cancer (SCC) and thathe should have further excision on his return,as there is a very small risk this cancer couldspread

    Answer: A

    Squamous cell carcinomas (SCC) can recur locally, andunlike basal cell carcinomas, they can also metastasise.Local recurrence due to incomplete primary excision isassociated 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 4mmmargin for adequate excision with depth through normalunderlying fat. Larger lesions may need up to 10mmmargins. Clearance for BCC excision is usually adequateat 3mm margins. It is important to accept responsibilityfor your failure to follow up as planned, and then torecommend further excision. The re-excision should bedone quickly. It is not appropriate to blame thepathology laboratory. It is wise to contact your medicaldefence organisation.

    Question 19

    Jarrah is a 2 month old Aboriginal boy. He was born atterm via an uncomplicated vaginal delivery, and he hasbeen well. He lives with his family in Darwin. His motherhas brought him in for his immunisations. Which ONE ofthe following statements is CORRECT?

    a) Jarrah will need to receive the first of hishepatitis A vaccines at 18 months of age

    b) Limiting information to his mother aboutrisks will improve the chance of completing theschedule

    c) Jarrah should have had the BCG vaccinesoon after delivery before leaving hospital

    d) The oral polio vaccine (OPV) provides betterimmunity than the inactivated type (IPV) inAboriginal children

    e) Jarrah will need his first MMR vaccine at 6months of age due to his higher susceptibility

    Answer: C

    Indigenous Australians are at increased risk of acquiringtuberculosis. BCG is recommended for indigenousneonates in 'regions of high incidence' of pulmonary TB,particularly Darwin and the Northern Territory. It isusually given to eligible infants soon after delivery.Aboriginal children in north Australia have a suboptimal

    response to OPV so there is likely to be improvedimmunity to polio with the introduction of IPV as part ofthe funded schedule. Although measles is very commonin indigenous communities, the first dose of MMR isadministered as usual at 12 months of age. Indigenouschildren in Far North Queensland are at higher risk of

    hepatitis A infection so from 1999 a programme forHepA vaccination was commenced from 18mths of age.Otherwise, the Standard Vaccination Schedule now

    applies to all Australian children. All parents andguardians must be given appropriate informationregarding vaccination so as to be able to give informedconsent to vaccination.

    Question 20

    Patricia, aged 25 years, has been diagnosed withpolycystic ovarian syndrome. In counselling this patientregarding long-term consequences the MOSTAPPROPRIATE advice would be:

    a) There are no serious long-termconsequences

    b) There is an increased risk of endometrialhyperplasia

    c) There is an increased risk of cervical cancer

    d) There is an increased risk of osteoporosise) There is an increased risk of prematuremenopause

    Answer: B

    Polycystic ovarian syndrome is a metabolic conditionwhose long term consequences include an increased riskof cerebrovascular disease, non insulin dependentdiabetes and endometrial hyperplasia .The latter is dueto unopposed action of oestrogen in anovulatory cycles.There is no effect on the timing of the onset ofmenopause and no evidence for an effect on bonedensity.

    Question 21

    Sally, aged 14 years, has mitral valve prolapse withregurgitation. For which of the following proceduresshould 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 valvularregurgitation antibiotic prohylaxis is required for dentalprocedures which produce bleeding from the gingiva,mucosa or bone. This includes the placement oforthodontic bands. Prophylaxis is not required forroutine dental examination (except where scaling of theteeth is to be performed), nor for the other optionslisted.

    Question 22

    Rodney, aged 30 years, a diesel mechanic, presentswith a painful right eye. He was using a metal lathe atwork last night, and states that he was wearing hissafety goggles as required. He was aware that the eye

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    was a little irritable at the end of his shift, but it was notuntil this morning that it became painful. Onexamination, Rodney's visual acuity is 6/6 in his left eyeand 6/7.5 in the right. No obvious foreign body is seen,but the pupil is slightly distorted. You do not have a slitlamp. Of the following, which is the MOST appropriateinitial action?

    a) Instill antibiotic drops, apply an eye pad and

    check visual acuity in 24 hoursb) Irrigate the eye copiously with sterile salineuntil the pH is neutral

    c) Apply loose fitting eye shields to both eyes,commence antibiotic and antiemetic

    d) Order antero-posterior and lateral facial X-rays

    e) Reassure Rodney that his safety goggleshave prevented serious eye injury

    Answer: C

    The history of eye pain after working with metal andhigh-speed machinery should raise the suspicion ofpenetrating eye injury. This may still occur despitesafety goggles being worn. Not all goggles conform tostandards, and not all workers wear them correctly!Visual acuity is not always greatly reduced, but the pupilcommonly shows a 'tear-drop' deformity. There may behyphaema. Facial X ray and CT may be useful in locatingan intra-ocular pressure. Always check tetanusimmunisation status and give a booster if necessary.

    Question 23

    Warren, aged 40 years, had a malignant melanomaremoved from his thigh last week. Which of thefollowing factors is MOST important in determining hisoverall prognosis?

    a) The depth of invasion of the skin andsubcutaneous tissue

    b) The fact that he has multiple dysplasticnaevi

    c) The diameter of the lesion removed

    d) A family history of malignant melanoma

    e) The site of the lesion- on his lower limb

    Answer: A

    The single most important feature in determining theultimate prognosis in melanoma is the depth of invasionof skin and subcutaneous tissue. Melanoma classificationsystems are based on either the vertical thickness of thelesion in millimetres as in Breslow's classification, or theanatomic level of invasion of the layers of skin as inClark's classification. The diameter of the lesion is not asimportant. Family history, multiple freckles andmelanocytic naevi are risk factors for melanoma, notindicators of prognosis. The site of the lesion is of someprognostic importance; those on the extremities have abetter outlook than those on the trunk or face.

    Question 24

    Which of the following statements about colonisation ofpregnant women by group B Strep is CORRECT?

    a) most pregnant women are colonised

    b) colonisation poses no risk to the woman orfoetus

    c) colonisation is associated with prematurelabour

    d) colonised women are usually symptomatic

    e) diagnosis requires serological testing

    Answer: C

    Group B Strep infection is the leading cause of neonatalinfection, and is implicated in premature labour andother maternal morbidity. 10-30% of women may becolonised with vaginal Group B Strep during pregnancy,but the infection may be transient or intermittent. Itusually causes no symptoms. Transmission to the infantalmost always occurs after the onset of labour, ormembrane rupture. There is little evidence thattreatment earlier in pregnancy is beneficial. However,treatment of women who, test positive at 35-37 weeksgestation, with intrapartum antibiotics has been shownto reduce the incidence of neonatal sepsis significantly.Testing for Group B Strep colonisation of pregnantwomen by vaginal swab is therefore offered by manydoctors in the third trimester.

    Question 25

    Felicia is a 15 month old girl. She has symptoms andsigns consistent with a viral upper respiratory tractinfection (URTI), including a fever of 38.8 degreesCelsius. Her weight is 11kg. Felicia's mother has decidedto use paracetamol to help relieve her symptoms. Whichof the following is CORRECT regarding the dose of oralparacetamol in this case? Daily dose should not exceed:

    a) 90 mg/kg/day

    b) 75 mg/kg/day

    c) 60 mg/kg/day

    d) 45 mg/kg/day

    e) 30 mg/kg/day

    Answer: C

    The recommended oral or rectal paracetamol dose is15mg/kg every 4 to 6 hours. In an unsupervisedcommunity setting, dosage is limited to 60 mg/kg/dayfor up to 48 hours. Up to 90 mg/kg/day can be usedunder medical supervision with review after 48 hours. Itwas believed that doses >150mg/kg/day werenecessary for hepatotoxicity but sick children 90mg/kg/day for more than one dayare at higher risk

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    Question 26

    All of the following are causes of secondaryamenorrhoea EXCEPT:

    a) Diabetes

    b) Drug abuse

    c) Eating disorders

    d) Asherman's syndrome

    e) Autoimmune disorders

    Answer: A

    Secondary causes of amenorrhoea and oligomenorrhoeainclude eating disorders, drug abuse, Asherman'ssyndrome (intrauterine adhesions), thyroid or adrenaldysfunction, uterine or vaginal obstruction, familial earlymenopause, chromosomal abnormalities andautoimmune disorders. Diabetes is not a cause.

    Question 27

    Muriel, aged 80 years, fell onto her outstretched righthand sustaining a Colles' fracture. Which of the followingis the most frequent LATE complication of this fracturefor a patient of her age?

    a) delayed union of the fracture

    b) ischaemic necrosis of the distal fragments

    c) neuralgic pain in the arm and hand

    d) stiffness of the wrist and fingers

    e) ulnar nerve weakness

    Answer: D

    Joint stiffness is common following a Colles' fracture,especially after prolonged immobilisation. All of theother complications are relatively uncommon. Union isusually not delayed but there may be a degree of mal-union. Appropriate management of the elderly patientwith a Colles' fracture includes early mobilisation aimedat restoring function.

    Question 28

    Amanda, aged 24 years, is HIV positive. She has justgiven birth to twin sons, George and Harry, by normalvaginal delivery. Regarding vertical transmission of HIVfrom mother to baby, which ONE of the followingstatements is INCORRECT?

    a) the first born twin is more likely to beinfected than is the second born twin

    b) higher rates of transmission are likely withlow maternal CD4 lymphocyte count

    c) breast feeding is a possible route of verticaltransmission

    d) high maternal plasma HIV RNA increases

    transmission risk

    e) transmission to the foetus is most likely inthe antenatal period

    Answer: E

    Studies indicate that maternal transmission of HIV tothe infant is most likely in the perinatal period. Theother options are correct. Advanced maternal disease isalso a risk factor for increased transmission risk.

    Question 29

    Which of the following statements concerning a retainedplacenta is CORRECT?

    a) antibiotic cover is rarely necessary after amanual removal of placenta

    b) the third stage of labour takes on averagetwo hours to complete

    c) when delivering the placenta the doctor ormidwife should pull the cord upwards

    d) there is no association between placentapraevia and placenta accreta

    e) oxytocics and continuous cord tractionenable delivery of most placentas within 10minutes

    Answer: E

    The third stage of labour (when the placenta isdelivered) is normally completed within 30 minutes. Ifnot, it is unlikely to occur spontaneously. With the useof oxytocics and gentle continuous downward cordtraction, 97% of third stages are complete within 10minutes. Antibiotic cover is necessary for manualremoval of the placenta, because of passage of the handfrom a non-sterile (vagina) to a sterile (uterus)environment. Placenta accreta (where placental villipenetrate the uterine wall preventing separation) occursmore commonly in cases of placenta praevia and aftercaesarean section.

    Question 30

    Hazel, aged 40 years, has a month-long history of aburning pain in the middle of her right foot. She says it's"as though I'm standing on a sharp stone". The painradiates into the tips of her toes. Pressure applied to thedorsum of the head of the third metatarsal reproducesher pain, but there is no other abnormality noted. Whatis the MOST likely diagnosis?

    a) Interdigital (Morton's) neuroma

    b) Plantar fasciitis

    c) Gout

    d) Peripheral neuropathy

    e) Stress fracture of the third metatarsal

    Answer: A

    Interdigital neuroma represents a gradual and persistentthickening of the perineurium of one, or less commonlytwo or more interdigital nerves. Hazel's history is

    typical, as is the examination finding of reproduction ofthe pain by direct pressure over over the head of themetatarsal. Plantar fasciitis causes primarily heel pain.

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    The absence of heat, redness or swelling over themetatarsal heads makes gout and rheumatoid arthritisunlikely. Peripheral neuropathy is usually associatedwith nocturnal paraesthesia, dysaesthesia and burningpain across the sole of the foot but is unlikely to beaffected by dorsal pressure on a metatarsal head. Stressfractures of the metatarsals cause pain that is felt alongthe shafts of the metatarsals, and is unlikely to radiateto the tips of the toes.

    Question 31

    With regard to symptoms of the severe form of thepremenstrual syndrome (premenstrual dysphoricdisorder) which of the following is CORRECT? Thesymptoms:

    a) are confined to the late luteal phase of themenstrual cycle

    b) may eventually extend throughout the wholemenstrual cycle

    c) disappear within hours of the onset ofmenstruation

    d) may fluctuate and disappear altogether insome cycles

    e) may present as an exacerbation ofendogenous depression

    Answer: A

    While premenstrual syndrome is the term commonlyused to describe the constellation of symptoms prior toperiods, Premenstrual Dysphoric Disorder is a muchmore specific condition listed by the American

    Psychiatric Association in the Diagnostic and StatisticalManual of Mental Disorders (DSM-IV). The diagnosticcriteria for PMDD are:

    A. At least five of the following symptoms (one of whichmust be 1, 2, 3 or 4, below) must be present in themajority of menstrual cycles in the last year. Symptomsshould be isolated to the late luteal phase of themenstrual cycle and remit within days of onset ofmenses.

    1. Markedly depressed mood, feelings ofhopelessness, self-deprecating thoughts

    2. Marked anxiety, tension, feelings of being"keyed up" or "on edge"

    3. Marked affective lability

    4. Persistent and marked anger or irritability orincreased interpersonal conflicts

    5. Decreased interest in usual activities

    6. Subjective sense of difficulty concentrating

    7. Lethargy, easy fatigability, marked lack ofenergy

    8. Marked change in appetite

    9. Marked change in sleep pattern

    10. Subjective sense of being overwhelmed orout of control

    11. Physical symptoms (e.g., breast tendernessor swelling, headaches, joint or muscle pain,sensation of bloating, weight gain)

    B. Symptoms cause marked interference with work,school, usual social activities, or relationships withothers.

    C. The problem is not an exacerbation of the symptomsof a chronic condition (e.g., major depressive disorder).

    D. The above criteria must be confirmed by prospectivedaily ratings during at least three consecutive

    symptomatic cycles to confirm a provisional diagnosis.

    Question 32

    Classic symptoms of endometriosis include all of thefollowing EXCEPT:

    a) pelvic pain

    b) dysmenorrhoea

    c) dyspareunia

    d) oligomenorrhoea

    e) infertility

    Answer: D

    Endometriosis is the presence of endometrial tissueoutside the uterine cavity. It causes pelvic pain,dysmenorrhoea, dyspareunia and infertility.Oligomenorrhoea is not associated with endometriosis.

    Question 33

    For a perimenopausal woman who has irregular cycles,severe hot flushes and no contraindications to hormonereplacement therapy the MOST APPROPRIATE therapyis:

    a) continuous oestrogen therapy

    b) continuous combined (oestrogen andprogestogen) therapy

    c) sequential oestrogen therapy

    d) sequential combined (oestrogen andprogestogen) therapy

    e) continuous progestogen therapy

    Answer: D

    Hormone replacement therapy (HRT) is indicated inwomen who are suffering from severe menopausalsymptoms, provided they have no contraindications toits use. Sequential combined HRT is the best option forperimenopausal women who do not requirecontraception and for women in the first 2 years aftermenopause. It can alleviate symptoms and controlirregular cycles. The use of continuous or sequentialunopposed oestrogen is associated with endometrialhyperplasia and the development of endometrial cancerand is contraindicated in women who have not had ahysterectomy. Continuous combined HRT isrecommended for symptomatic women more than 2years post menopause; 50% will have irregular bleedingfor the first 6 months but 90% are amenorrhoeic after12 months. Progestogen alone is not always effective at

    treating menopausal symptoms. The issues surroundingpotential complications of HRT must always be fullydiscussed before commencing therapy.

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    Question 34

    Sherri, aged 56 years, complains that she loses controlof her "waterworks" when she puts her key in the frontdoor. Given this history, which form of incontinence isshe MOST LIKELY to have?

    a) stress incontinence

    b) urge incontinence

    c) overflow incontinence

    d) incontinence from a urinary fistula

    e) incontinence secondary to a neuropathicbladder

    Answer: B

    Urge incontinence occurs when there is an inability todelay micturition and may be precipitated by varioustriggers including the sound of running water or placinga key in the door when arriving home. Stressincontinence occurs when the intra-abdominal pressureis raised as with coughing or sneezing. Overflowincontinence is due to obstruction and may besecondary to uterovaginal prolapse or a hypotonicbladder as in a neuropathic bladder. A urinary fistula isassociated with continuous dribble of urine or leakage ofsmall amounts on effort.

    Question 35

    Teresa, aged 25 years, presents having experienced anepisode of postcoital bleeding two days ago. What is theMOST APPROPRIATE management?

    a) Reassure her and ask her to return ifbleeding recurs

    b) Undertake cauterisation of the cervix toprevent further bleeding

    c) Treat her with metronidazole gel to eradicateinfection

    d) Send her to the emergency department forimmediate assessment

    e) Do a Pap smear and screen for sexuallytransmitted infections

    Answer: E

    Postcoital bleeding is a serious symptom that could beindicative of cervical pathology. It is not an emergencyrequiring assessment in hospital. Common causes ofpostcoital bleeding include a cervical erosion, aninfection such as chlamydia and other less commonpathologies, such as a cervical polyp. Medicalpractitioners must however ensure that they excludeprecancerous or cancerous lesions of the cervix bymaking sure that cervical cytology (Pap smear) isperformed as well as appropriate STI (sexuallytransmitted infection) screening. If the bleeding isrecurrent, or the cervix looks abnormal, colposcopy isrecommended. Cauterisation of the cervix is sometimesperformed if a friable cervical erosion is present,

    bleeding is recurrent and other cervical pathology hasbeen excluded.

    Question 36

    Cheryl, aged 28 years, (G1P0), presents at 8 weeksgestation complaining of constant nausea and vomiting.Which of the following statements about nausea andvomiting in pregnancy is CORRECT?

    a) Less than 30% of women suffer nausea andvomiting in pregnancy

    b) Metoclopramide (antiemetic) iscontraindicated in pregnancy

    c) Women should try to have frequent smallfeeds to control nausea

    d) Nausea and vomiting should subside by 9weeks gestation

    e) Nausea and vomiting in the evening pointsto a more sinister cause

    Answer: C

    At least two thirds of women experience nausea duringthe first trimester, and 50% experience vomiting.Symptoms can occur at any time of the day, althoughclassically they predominate in the morning. Thesesymptoms usually subside by 12-16 weeks gestation.The best advice for women is to take small frequentmeals but, if the symptoms persist antiemetics such asmetoclopramide can be used safely.

    Question 37

    Which of the following elements on an antenatalcardiotocograph (CTG) at term is considered"abnormal"?

    a) Accelerations of 15 beats per minute lasting15 seconds

    b) One reactive movement in a 20 minute CTGrecording

    c) Decelerations during Braxton Hickscontractions

    d) Variability in foetal heart rate beat-to-beat

    e) Baseline heart rate of 120-160 beats perminute

    Answer: C

    Decelerations occurring after contractions are ominous,particularly if they are prolonged. A healthy CTG showsa baby that is moving and having acceleration ofheartbeat after movement. The beat to beat variabilityis indicative of an intact central nervous system.

    Question 38

    Melinda has just started to menstruate (experienceperiods). She is age 16 and has Down syndrome(Trisomy 21). She wants to know all about her periodsand why she has to bleed. Which of the followingstatements should you NOT tell Melinda regarding

    menstruation (periods)?

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    a) Most females start having their periodsbetween the ages of 9 and 16

    b) Other body changes may be happening whenperiods start. Breasts get bigger and hair startsto grow under arms and around the vagina

    c) A period will occur about once a month andwill last for several days (about 3 to 7 days)

    d) The blood that comes out with a period isclean and healthy and it is normal

    e) Tampons must be used during periods toavoid bleeding onto underwear and clothes

    Answer: E

    All the other statements are true and helpful when afemale with a potential learning disability starts learningabout her menstruation. Tampons can be particularlyconvenient for certain activities, such as swimming, butthey are not essential and are not recommended forwomen who cannot comfortably manage their own

    menstrual self-care. If tampons are to be used it isworth checking instructions are understood beforeencouraging practice.

    Question 39

    Angelina, aged 27 years (G3 P2), has a transverse lie at36 weeks gestation. Should her membranes rupture,what would be the MOST APPROPRIATE MANAGEMENT?

    a) Advise attendance at the Delivery Suitewhen contractions are 5 minutes apart

    b) Attempt an external cephalic version to allowsafer vaginal delivery

    c) Wait for contractions to establish as this willprobably correct the lie

    d) Augment the labour with intravenousoxytocin to facilitate swift delivery

    e) Place in the knee-chest position and organiseemergency Caesarian section

    Answer: E

    Cord prolapse occurs when the umbilical cord lies besideor in front of the presenting part. It is more common in

    malpresentations, polyhydramnios, during breechdeliveries and with premature rupture of the membranesIt is an obstetric emergency, as the umbilical vesselsconstrict, once exposed to the extrauterineenvironment. Unless the cervix is fully dilated and animmediate operative vaginal delivery can be conducted,an emergency caesarean section is required. During thetransfer to theatre the woman should be positioned sothat gravity can assist in keeping the presenting part offthe cord, i.e the knee - chest position (kneeling withhead down). The presenting part should also be pusheddigitally up and away from the cord which should beplaced wholly within the vagina.

    Question 40

    In counselling a woman regarding use of the mini pill(progestogen only contraceptive pill, POP) which of thefollowing is CORRECT?

    a) The menstrual cycle will be unaffected bythe POP

    b) The main mode of action is to thickencervical mucous

    c) Active pills are taken for 21 of 28 days toallow a withdrawal bleed

    d) A delay of 12 hours in taking the POP doesnot affect efficacy

    e) Contraceptive efficacy of the POP isequivalent to combined pill in all women

    Answer: B

    The principal mode of action of the progestogen only pill

    is thickening of cervical mucus. In about one third ofwomen the minipill will also inhibit ovulation but in themajority this is not the case. As a result of the variabilityof the effect of the POP on ovulation and the effects ofprogesterone on the endometrium, menstrual cyclesmay be regular, irregular or spotting can occurthroughout the cycle in POP users. Women take theminipill everyday without a break (28 active pills with noinactive pills) in the same three-hour period each day inorder to maintain maximal efficacy. In general, it is lessefficacious than combined oral contraception because itdoes not uniformly inhibit ovulation. However, in olderwomen who are less fertile and who use the POPcorrectly, the efficacy of the POP can approximate thatof combined oral contraception.

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    Question 1

    Tom, aged 18 years, presents with a typical first episodeof schizophrenia. Which of the following antipsychoticmedications is the treatment of choice for him?

    a) chlorpromazine

    b) haloperidol

    c) thioridazine

    d) olanzapine

    e) clozapine

    Answer: D

    Olanzapine, risperidone and quetiapine are three of thenew so-called atypical antipsychotic medications. Theseare now preferred (over traditional antipsychotic drugslike chlorpromazine, haloperidol and thioridazine) as firstline therapy in first episode schizophrenia, because ofimproved efficacy and reduced incidence of psychomotorretardation, a well-known and troubling side effect ofthese medications. Clozapine is an atypical antipsychoticdrug recommended for schizophrenic patients who proveresistant to other antipsychotic medications.

    Question 2

    Pete, aged 54 years, has been a heavy smoker for mostof his adult life. He complains about coughing up bloodfirst thing in the morning. The MOST IMPORTANTcondition to exclude is:

    a) Bronchiectasis

    b) Recurrent pulmonary emboli

    c) Leukaemia

    d) Bronchogenic carcinoma

    e) Laryngeal cancer

    Answer: D

    Smokers are prone to develop a range of diseasesincluding:

    • atherosclerotic cardiovascular disease,

    • various cancers (lung, larynx, oral, oesophagus,bladder, kidney, pancreas, stomach, cervix)

    • chronic obstructive pulmonary disease

    • peptic ulcer.

    As bronchogenic carcinoma has a much more aggressivecourse than the other options, a bronchoscopy should be

    performed as soon as possible.

    Question 3

    Sarah, a 40 year old woman whose husband has aplasma cholesterol of 6.9 mmol/l (normal

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    Question 5

    A COMMON side effect of the atypical antipsychotic drug,olanzapine, is:

    a) Neutropenia

    b) Hypotension

    c) Sexual dysfunction

    d) Weight gain

    e) Parkinsonism

    Answer: D

    Weight gain of between 4kg and 9kg is a common sideeffect of treatment with olanzapine. Neutropaenia is arare side effect. Sexual dysfunction can occur throughmedication with major tranquillisers and selectiveserotonin reuptake inhibitors (SSRI) antidepressants.Parkinsonism tends to occur with long-term use of majortranquillisers, especially phenothiazines andbutyrophenones.

    Question 6

    A patient with a past history of rheumatic fever requiresoral amoxycillin cover for a tooth extraction. Theoptimum time for commencing this is:

    a) One week before the extraction

    b) Two days before the extraction

    c) The day before the extraction

    d) One hour before the extraction

    e) Immediately after the extraction

    Answer: D

    The risk of endocarditis in patients with valvular heartdisease stems from the bacteremia introduced by theextraction. Antibiotics need only cover this period oftime and therefore are given orally one hour before theextraction.

    Question 7

    June, aged 38 years, has a family history of breastcancer and seeks advice about her risk of developing thedisease. All of the following are indicative of moderate tohigh risk EXCEPT:

    a) Two 2° individuals on the one side of thefamily affected with breast cancer

    b) One 1° family member with ovarian cancerdiagnosed before the age of 50 years

    c) One 1° or 2° family member with bilateralbreast cancer

    d) One 1° family member diagnosed withbreast cancer at 60 years of age

    e) One 1° and one 2° family memberdiagnosed with ovarian cancer

    Answer: D

    Only about 10% of human breast cancers are due to agermline mutation (of genes p53, BRCA-1, BRCA-2). Theother 90% are due to somatic mutations, often of thesame genes as are involved in the familial varieties. Afamily history of one 1° family member diagnosed withbreast cancer at 60 years of age (ie. over the age of 50years) places June at average or only slightly increased

    risk (1.5 times higher than population average). All theother options place June at a moderate to high risk.

    Question 8

    A 40 year old female undergoing treatment forschizophrenia, is admitted repeatedly for not taking herprescribed medication. She has delusional ideas,claiming she communicates with angels and, as shedoes not consider herself to be ill, believes that sheshould not have to take any medication. The CORRECTterm for the latter phenomenon is:

    a) Therapeutic delusions

    b) Side effect of drug

    c) Impaired insight

    d) Transference

    e) Hallucinations

    Answer: C

    Impaired insight is one of the cardinal signs of psychoticillness. It describes the situation where the patient lacksa realistic awareness of self and the relationship of selfto others. Delusions are beliefs held, despite proof to thecontrary. Hallucinations are abnormal sensoryperceptions and are usually auditory in schizophrenia.Transference is a psychoanalytical term referring totransfer by a patient of subconscious or consciousfeelings onto the therapist.

    Question 9

    The MOST COMMON cause of a blood-stained dischargefrom the nipple of a 45 year old woman is:

    a) Gynaecomastia

    b) Duct papilloma

    c) Paget's disease of the nippled) Fibroadenoma

    e) None of the above

    Answer: B

    A blood stained discharge from the nipple is commonlycaused by an intraductal

    papilloma. Less common causes are an intraductalcarcinoma and mammary dysplasia. Gynaecomastia isbreast enlargement in the male and may be associatedwith discharge, depending on the underlying cause.

    Paget's disease of the nipple usually presents with a dry,eczematous rash of the nipple. Fibroadenoma tends topresent with an asymptomatic discrete, mobile breastlump.

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    Question 10

    Which of the following drugs, causes stimulation ofcardiac contraction with LEAST vasoconstrictor effect?

    a) Adrenaline

    b) Isoprenaline

    c) Pitressin

    d) Ephedrine

    e) Noradrenaline

    Answer: B

    Isoprenaline works almost exclusively on beta receptorscausing increased rate and strength of cardiaccontractions (B1) and vasodilatation (B2). All the otherdrugs listed cause significant vasoconstriction.

    Question 11

    While counselling a patient, a therapist becomes awarethat the patient is avoiding discussion of certain topics,and is steering away from topics he finds uncomfortable.Which of the following types of behaviour is the patientexhibiting?

    a) Resistance

    b) Suppression

    c) Regression

    d) Repression

    e) Projection

    Answer: B

    Suppression refers to the conscious or 'semi-conscious'decision of an emotionally mature, healthy adult topostpone dealing with conflict. Resistance refers to theconscious and informed decision of a patient not tochange behaviour or comply with treatment. Regressionrefers to return to an earlier stage of developmentalfunction. Repression refers to the mechanism by whichideas, impulses or emotions which the person findspainful or unacceptable are forced out of consciousnessand forgotten. Projection refers to the unconsciousattribution to others of one's own unacknowledgedfeelings, thoughts or characteristics.

    Question 12

    A traumatic perforation of the ear that has occurred inwet conditions such as swimming or waterskiing willoften:

    a) Be associated with a purulent discharge

    b) Be complicated by a staphylococcal infection

    c) Require a short course of oral antibiotics

    d) Not heal spontaneously

    e) Require surgical repair

    Answer: A

    A traumatic perforation of the tympanic membrane (eardrum) that occurs in wet conditions eg. swimming orwaterskiing will generally become infected and beassociated with purulent discharge. Pseudomonas ismore likely to be the offending organism thanstaphylococcus. A short course of topical antibiotics isindicated, as is analgesia. Most traumatic perforations

    heal spontaneously, but may take up to 9 months.Surgical repair is indicated for the rare failure to heal.

    Question 13

    Which of the following statements about patent ductusarteriosus is INCORRECT?

    a) It occurs frequently as an isolatedphenomenon

    b) Cyanosis is usually present

    c) It causes a pansystolic 'machinery' murmurat the upper left sternal edge

    d) There is a wide pulse pressure

    e) Treatment is by surgical closure

    Answer: B

    Cyanosis is not usually present unless a right to leftshunt develops. Patent ductus arteriosus is usually anisolated problem occurring most commonly in females.There are often no symptoms until later in life, whenheart failure or infectious endocarditis

    develops. Clinical signs include a continuous murmurand a bounding peripheral pulse with wide pulsepressure due to shunting of blood from the aorta to thepulmonary artery.

    Question 14

    Where both parents have schizophrenia, what is theprobability of their child developing schizophrenia?

    a) More than 90%

    b) About 70%

    c) About 40%

    d) About 10%

    e) Less than 1%

    Answer: C

    Pooled data from a number of family studies show thatthe risk of schizophrenia is about 40% for each child oftwo schizophrenic parents. The incidence in the generalcommunity is about 1%.

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    Question 15

    Which of the following tympanic membrane perforations,if left untreated, is NOT likely to progress to significantcomplications?

    a) Continuously discharging central perforation

    b) Large dry central perforation

    c) Marginal perforation with discharge

    d) Perforation associated with a cholesteatoma

    e) Perforation surrounded by granulation tissue

    Answer: B

    A dry central perforation will not progress tocomplications, even if it does not heal. Surgical repair istherefore elective and not mandatory. The other typesof perforation are not 'safe' and require specialistattention. A continuously discharging central perforationindicates granulation and a risk of osteitis and bonedestruction. Marginal perforation carries the same risk.A cholesteatoma is not a neoplasm but a cystic lesioncontaining amorphous debris (and sometimes spicules ofcholesterol). It is formed through chronic infection andperforation of the eardrum with ingrowth of squamousepithelium, forming a nest which becomes cystic. Byprogressive enlargement a cholesteatoma can erode theossicles, labyrinth and adjacent bone and carries the riskof cerebral abscess formation and meningitis.

    Question 16

    Which one of the following features is UNLIKELY to bedue to arterial ischaemia?

    a) Pain along the buttock and thigh afterexertion

    b) Weakness of the buttock and thigh

    c) Shooting pain from buttock along the back ofthe leg to calf

    d) Weakness of the leg

    e) Smooth shiny skin on the leg below theknees

    Answer: C

    Diffuse pain, weakness and paralysis are all signs ofarterial ischaemia. Characteristically the pain is acramp-like ache due to the release of pain-inducingmetabolites in muscle. Due to the aetiology, the pain isdiffuse and cannot be localised, as can the shooting painof nerve irritation.

    Question 17

    When someone is referred to as being in the pre-contemplation stage with regard to a change inbehaviour, this means s/he is:

    a) Resistant to change

    b) Preparing for change

    c) Receptive to change

    d) Looking forward to specific advice

    e) Has not yet considered change

    Answer: E

    Pre-contemplation is the first stage in a model ofbehavioural change that helps the clinician assess thelikelihood that a patient will be receptive to anintervention. At the pre-contemplation stage the patienthas not yet considered change as an option. The otheroptions all indicate that the patient is aware of theprocess of change.

    Question 18

    Epistaxis is UNLIKELY to arise from:

    a) Injury to the turbinates

    b) Spontaneous bleeding from Little's area

    c) Anticoagulation therapy

    d) Enlarged adenoids

    e) Nasal fracture

    Answer: D

    Enlarged adenoids do not usually cause epistaxis. In90% of cases, epistaxis arises from Little's area, thelower anterior portion of the nasal septum, andresponds to first aid. A fracture commonly causesepistaxis. Rarely, it can be associated with medicalconditions.

    Question 19

    Harold, aged 24 years, presents with fatigue, shortnessof breath on exercise and orthopnoea. On examination

    there are signs of moderate left-sided heart failure. Agrade III pansystolic murmur is heard most prominentlyat the apex and radiating into the left axilla. Which ofthe following conditions is the MOST LIKELY diagnosis?

    a) Mitral stenosis

    b) Mitral regurgitation

    c) Aortic stenosis

    d) Aortic regurgitation

    e) Tricuspid stenosis

    Answer: B

    Mitral regurgitation presents as fatigue, exertionaldyspnoea and orthopnoea. It is associated with apansystolic murmur loudest at the apex but radiatingover the praecordium and into the axilla. It may also beassociated with a short mid-diastolic flow murmurfollowing a third heart sound, due to the rapid flow ofblood into the dilated left ventricle. The second heartsound is normal.

    Question 20

    Stephen, aged 18 years, presents with spontaneousepistaxis. What is the FIRST STEP in managing Stephen?

    a) Direct pressure to the lower nose for twominute interval

    b) Position Stephen so that he is sitting andleaning forward

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    c) Application of topical local anaesthetic

    d) Cautery of bleeding vessel

    e) Nasal packing with gauze

    Answer: B

    The initial steps are to position the patient sittingforward to prevent blood dripping down the throat; andto compress the cartilaginous portion of nose (Little'sarea) for 5-10 minutes without interruption (constantchecking is likely to interfere with haemostasis andrestart bleeding). If this is ineffective