ckt answers

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Year 5 Clinical Knowledge Test 18 August, 2006Each question must be attempted. Each question has only 1 correct answer

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1. A 56 year old man presents to the Emergency Department with a 3 day history of central chestdiscomfort which has been waking him at night. He is currently pain free. He smokes 30 cigarettesper day and has a history of hypertension but compliance with medications has been erratic. Herecalls similar symptoms 3 months ago, but only in the first few minutes of walking after meals. If heslowed down, the pain would disappear and allow him to complete his walk without any furthersymptoms.

Which one of the following is the most appropriate management?

A. Admit to the Coronary Care Unit for urgent thrombolysisB. Advise the patient on how to use anginine and antacids, then arrange exercise stress ECG

Test and upper GIT endoscopyC. Arrange exercise stress ECG test as soon as possibleD. Patient should be referred for upper GIT endoscopyE. Perform a 12-lead ECG and check cardiac enzymes

2. A 75 year old woman is on no medication and has had nine episodes of syncope over the past threeweeks. Examination shows a heart rate of 40bpm, blood pressure 180/100mmHg with a soft ejectionsystolic murmur over the aortic region, not radiating to the carotids.

The most likely explanation of her syncope is:

A. aortic valve stenosisB. complete heart blockC. recurrent systemic emboliD. systemic hypertensionE. vasovagal attack

3. Individuals in population X have a 10% chance of developing ischaemic heart disease in the next 10years. Your local pharmaceutical representative correctly indicates that randomised, placebo-controlled trials show that treatment with drug Y reduces the relative riskof ischaemic heart diseaseby 30%.

The reduction in absolute riskof ischaemic heart disease in the next 10 years associated withtreatment with drug Y (ie. the chance of an individual benefiting from treatment with drug Y) in

population X is approximately:

A. 1%B. 3%C. 7%D. 10%E. 30%


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4. Please review the following ECG. Which one of the following statements is true?

A. Digoxin is contraindicatedB. Early management should include an artificial pacemaker implantC. There is impaired conduction in the left bundle branchD. There is likely to be an obstructed dominant coronary artery

E. This condition is more common in younger patients

5. An elderly hypertensive, smoker with claudication is treated with an ACE inhibitor and there is anunexpected deterioration in renal function. A secondary form of hypertension is suspected. What is

the most likely cause?

A. Coarctation of the aortaB. Cushings syndromeC. PhaeochromocytomaD. Renal artery stenosisE. Hydronephrosis

6. In the management of a patient presenting with severe diabetic ketoacidosis, which one of the

following is the most urgent priority?

A. Intravenous 5% dextrose infusionB. Intravenous bicarbonate administrationC. Intravenous isotonic sodium chloride infusionD. Intravenous potassium chlorideE. Subcutaneous injection of rapidly acting insulin


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7. A 25 year old patient with insulin-dependent diabetes is found unconscious and hypoventilating.There are no other abnormal physical signs. From the following options, which is the mostappropriate initial management?

A. Administration of 10 units of short acting insulin IVB. Administration of 50ml of 50% IV dextrose

C. Encourage the patient swallow a glass of orange juiceD. Insert a urinary catheter to look for glucose and ketonesE. Obtain blood glucose sample and await laboratory results before initiating treatment

8. A 26 year old married woman presents with secondary amenorrhoea; she has previously been well,however is on antidepressant medication. Her LH and FSH levels are normal and a prolactin level istwice the upper limit of normal. A repeat prolactin estimation, performed after the patient has relaxedfor 20 minutes is similarly elevated. The next most appropriate step is to:

A. administer bromocriptine therapy

B. cease her antidepressant medicationC. order a pregnancy testD. order an MRI scan of the pituitaryE. organize a vaginal ultrasound

9. A 20 year old woman with acute thyrotoxicosis is commenced on Carbimazole. After two weeks shedevelops a persistent and worsening sore throat with fever and mouth ulceration. What is the firstand most appropriate test that is required?

A. Blood cultureB. Paul Bunnell testC. Serum immunoglobulinsD. Throat swabE. White blood cell count

10. A patient who has previously been treated with long term prednisolone collapses on returning to theward following elective surgery. He is peripherally shut down with pulse 104bpm and blood pressure82/50mmHg. Which one of the following would suggest a cause other than an Addisonian crisis(acute adrenal failure)?

A. High arterial hydrogen ion concentrationB. HypercalcaemiaC. HyperkalaemiaD. HypernatraemiaE. Hypoglycaemia


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11. A 45 year old man presents with a painful lesion on his left forearm. He states that the lesion hasincreased in size over the past two months. He had a cadaveric renal transplant 10 years before forchronic renal failure of unknown cause, and remains on triple immunosuppression with azathioprine,prednisolone and cyclosporin. On examination he has a 2x2 cm erythematous nodule with a centralkeratinous area. The most likely diagnosis is:

A. fungal infectionB. guttate psoriasisC. impetigoD. lichen planusE. pityriasis rosea

12. A 52 year old man with active ulcerative colitis develops painful skin nodules on his legs. Onexamination there are five lesions in total, each being approximately 4cm in diameter, erythematous,firm and tender. The most likely diagnosis is:

A. erythema multiformeB. erythema nodosumC. furunculosisD. insect bitesE. multiple haemangiomata

13. In a patient with degenerative disc disease in the lumbar spine, a limitation of straight leg raising withthe production of sciatica:

A. indicates nerve root irritation

B. is a common presenting featureC. is a manifestation of a nerve root conduction defectD. is an indication for surgeryE. usually indicates a central disc prolapse

14. A 65 year old woman with long standing rheumatoid arthritis presents for her routine check-up. Shenow reports concern with mid to low back pain, however all is well with her joint disease. She is ondisease modifying drugs including methotrexate and prednisolone. Which one of the following is themost likely cause of her back pain?

A. Ankylosing spondylitisB. PsychogenicC. Rheumatoid arthritis of the axial spineD. Sacro-iliitisE. Vertebral collapse secondary to osteoporosis


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15. A 56 year old man presents with a two day history of a sudden onset painful swollen left knee joint.Aspiration of the joint reveals cloudy fluid. Microscopy shows large number of neutrophils containinga few negatively birefringent crystals. No organisms are seen and culture remains negative afterseveral days. The most likely diagnosis is:

A. gout

B. pseudo-goutC. Reiters diseaseD. septic arthritisE. traumatic knee injury

16. Which one of the following side-effects has been ascribed to calcium entry blocking drugs (calciumantagonists)?

A. DeafnessB. Early cataract formation

C. HyperglycaemiaD. HyperuricaemiaE. Peripheral oedema

17. A 66 year old man with severe psoriasis, hypertension and depression is admitted and found to haveabnormal liver function tests with raised serum transaminases. Which one of his medications listedbelow, is most likely to have caused his hepatic toxicity?

A. AmlodipineB. AspirinC. Fluoxetine

D. LisinoprilE. Methotrexate

18. Tim is a 25 year-old previously well man who presents with a one week history of nausea,vomiting, and mild right-sided abdominal pain. He is mildly icteric and has a temperature of

37.8C. He has right upper quadrant tenderness. Results of his initial investigation include:

Aspartate amino transferase (AST) 400 U/L (


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19. Hepatic encephalopathy may be precipitated in a cirrhotic patient by each of the following,except:

A. infectionB. constipationC. gastrointestinal bleed

D. oral neomycinE. surgery

20. A patient with poorly controlled ulcerative colitis develops abdominal distension a few days after abarium enema and is critically ill. Paradoxically, his stool frequency has decreased. An abdominalradiograph shows a colonic diameter of twice normal size. He is admitted to a high dependency unitand given intravenous fluids and corticosteroids. Daily plain abdominal x-rays are performed. Themost likely diagnosis is:

A. faecal impaction from inspissated barium

B. non malignant stricture of the ascending colonC. pseudopolyposisD. toxic megacolonE. volvulus

21. A 54 year old woman with a past history of primary biliary cirrhosis presents to the EmergencyDepartment following an episode of large volume, painless haematemesis. On general inspection,she has spider naevi and palmar erythema. On examination, the splenic tip is palpable. The mostlikely diagnosis is:

A. duodenal ulcerB. gastric angiodysplasiaC. gastric ulcerD. Mallory-Weiss tearE. variceal haemorrhage

22. A 56 year old man presents with a six month history of epigastric discomfort that is relieved byantacids. Over the past two months he has lost some weight. He smokes 20 cigarettes per day anddrinks 32 units of alcohol per week. The most appropriate management plan is to:

A. commence treatment with a H2 receptor antagonist for six weeks and reviewB. organise an ultrasound scan of abdomenC. provide life-style advice, continue with antacid and review in six weeksD. request a gastroscopyE. test for Helicobacter pyloriand treat if positive


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23. A 70 year old woman presents with a six month history of lethargy and left upper quadrant abdominaldiscomfort. On examination, generalised small lymphadenopathy and moderate splenomegaly isdetected. Full blood examination reveals

haemoglobin 9.0g/dL (12.5 17.5)

WCC 19.0 x 109

/L (4 11)platelets 145 x 10

9 /L (140 - 450)

neutrophils 5.0 x 109 /L (2.0 8.0)

lymphocytes 30.0 x 109 /L (2.0 8.0)

The most likely diagnosis is:

A. acute lymphoblastic leukaemiaB. acute myeloid leukaemiaC. chronic lymphocytic leukaemiaD. Hodgkins DiseaseE. infectious mononucleosis

24. A 75 year old woman on low dose warfarin therapy for chronic atrial fibrillation is admitted to hospitalwith an acute abdomen requiring urgent surgery within four hours. Her International NormalisedRatio (INR) is 2.5 (normal 1). The surgeon requests your advice and therapeutic intervention toprepare this patient for surgery.

Which one of the following would be the single best advice?

A. If patient is on low dose warfarin therapy, she has minimal risk of bleedingB. Patient will require fresh frozen plasma to rapidly correct the INR as well as vitamin K

intravenously. When INR is less than 1.5, surgery can safely go aheadC. Surgery should be delayed for 24 hours to allow withdrawal of warfarin and minimise the

bleeding riskD. The most appropriate therapy for rapid reversal of warfarin is intravenous recombinant factor 8

concentrateE. The patient should receive vitamin K therapy intramuscular, which should reverse the warfarin

effect and allow surgery within four hours

25. Spontaneous petechial haemorrhages are characteristically associated with which one of thefollowing:

A. haemophiliaB. heparin therapyC. platelet count less than 20,000x10

9/L

D. von Willebrands diseaseE. warfarin therapy


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26. In a patient presenting with pleuritic chest pain, all of the following support a diagnosis of pulmonaryembolus, except:

A. an unmatched perfusion defect on a ventilation/perfusion lung scanB. hypoxaemiaC. normal D-dimer level

D. presence of a pleural rub on auscultation of the chestE. sinus tachycardia

27. A 71 year old woman presents with increasing low back pain over six weeks. X-rays show a wedgecompression fracture of L4 together with multiple lytic lesions in the pelvis. Full blood count shows amild pancytopaenia. Liver function tests show an increase in the serum concentration of total proteinand a normal albumin. Calcium is elevated at 3.1mmol/L (2.1 2.6) and renal function is impairedwith a creatinine of 210mol/L (< 120). The most likely diagnosis is:

A. acute myeloid leukaemia

B. metastatic cancer of unknown primary originC. multiple myelomaD. osteoporosisE. primary hyperparathyroidism

28. A 69 year old man presents with a four week history of weight loss, and night sweats. He has nosignificant past medical history. Examination reveals the presence of significant lymphadenopathy inthe cervical and axillary regions. The nodes are firm and measure up to 3cm in diameter. His spleenis easily palpable 16cm beneath the left costal margin. Appropriate management of this man wouldinclude all of the following, except:

A. biopsy of the spleenB. bone marrow examinationC. CT examination of his neck, chest, abdomen and pelvisD. examination of the blood filmE. measurement of serum LDH level

29. Which one of the following is correct regarding a positive HIV antibody test?

A. The patient can transmit the virus through salivaB. The patient has AIDSC. The patient has lifelong infection and infectivityD. The patient should immediately commence combination anti-retroviral chemotherapyE. The patient should commence Pneumocystis cariniiprophylaxis


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30. A medical student has been in Australia for four years and decides to return home to Africa for aholiday. On his return to Australia he has flu-like symptoms with chills, jaundice, muscle aches and ismildly anaemic. After two days of illness he feels increasingly under the weather and is taken to theEmergency Department. What condition should be uppermost in the thoughts of the examiningdoctor?

A. Falciparum malariaB. Hepatitis type AC. HIV infectionD. Type A influenzaE. Typhoid or paratyphoid fever

31. A 29 year old woman had an attack of pleurisy six months ago. She has had recurrent mouth ulcersfor the past two years and more recently she has had night sweats, arthralgia and alopecia. Herhands and wrists are stiff in the morning but improve during the day or after active movements.

Which one of the following investigations is most likely to support your clinical diagnosis?

A. Antinuclear antibodiesB. Chest x-rayC. Erythrocyte sedimentation rateD. Full blood examinationE. Rheumatoid factor

32. A man aged 40 comes to the Emergency Department complaining of a hot red, swollen, painful knee

joint and inability to walk. The diagnosis to exclude first should be:

A. coagulation disorderB. crystal arthritisC. monoarticular rheumatoid arthritisD. septic arthritisE. sustained trauma

33. A 45 year old smoker presents with a one month history of increasing shortness of breath and

haemoptysis. On examination he has dullness to percussion in the right base to mid zone, absentbreath sounds and decreased vocal resonance. This clinical picture is most consistent with:

A. lung fibrosisB. pleural effusionC. pneumothoraxD. pulmonary abscessE. pulmonary consolidation


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34. A 28 year old mechanic presents with a 24 hour history of upper respiratory tract infection followedby sudden onset of chills, rigors and cough. Chest x-ray demonstrates right lower lobe pneumonia.Which one of the following statements is most applicable?

A. Chest x-ray findings makes mycoplasma likely

B. Klebsiella pneumoniaecommonly presents with lobar pneumonia and the patient shouldreceive vancomycin

C. The most likely causative organism is Streptococcus pneumoniaeand the patient shouldreceive intravenous penicillin

D. The most likely organism is Haemophilus influenzaeand the patient should be treated withintravenous ampicillin

E. The patient should receive metronidazole

35. A 19 year old woman presents to the Emergency Department with asthma. She is unable to tell you

her history due to severe breathlessness but her friend tells you she has had asthma all her life, butrecently her regular puffers are not controlling it well. On examination her HR is 126bpm, RR 36bpm,BP 150/70mmHg and her peak flow is 100L/min. She has an oxygen saturation of 98% whilst onoxygen. Her chest is surprisingly quiet on auscultation. You prescribe nebulised salbutamol. Yournext action should be to:

A. arrange a chest x-ray and ECGB. call for senior help immediatelyC. repeat her peak flowD. revisit her in half an hour to assess her reversibility with nebulised salbutamolE. wait for result of arterial blood gases

36. A 25 year old man, who has been previously well, presents with acute onset of dyspnoea. Onexamination he has tracheal deviation to the right with reduced expansion, percussion hyper-resonantreduced breath sounds and reduced tactile vocal fremitus on the left side of the chest. His oxygensaturation is 88% breathing air. You commence oxygen therapy. Which one of the following optionsis the most appropriate next step in management?

A. Commence antibioticsB. Commence increased inspired oxygen via nasal prongsC. Order a spiral CT scan of the chestD. Perform left sided needle thoracostomy

E. Treat with non-invasive positive pressure ventilation via face mask while awaiting chest x-ray


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37. A 50 year old man who smokes 20 cigarettes per day gives a history of two months weight loss andpersistent cough. There are no abnormal physical signs other than a persistent, fixed wheeze in theright upper chest anteriorly. A chest radiograph shows a centrally placed perihilar opacity withradiating streaks. No sputum is available. Which one of the following investigations is most likely toguide your future management of this patient?

A. Bone scanB. Bronchoscopy and biopsyC. Computed tomography scanD. Isotopic ventilation-perfusion scanE. Pulmonary function studies

38. A 45 year old woman presents with a 6 day history of increasing muscular weakness and paresthesiaof hands and feet. On examination there is moderately severe ascending symmetrical weakness oflimb and trunk muscles. There is no wasting. Reflexes are all absent. Initial investigations include a

normal serum CK level and the following CSF findings:cells nilprotein 0.95 g/L (< 0.4)glucose 3.5 mmol/L (2.5 - 4.5)

The most likely diagnosis is:

A. amyotrophic lateral sclerosisB. Guillain-Barr syndromeC. multiple sclerosisD. poliomyelitisE. polymyositis

39. A 70 year-old man, who normally lives alone in a very small apartment, is brought into theEmergency Department in a drowsy state. He is known to drink alcohol. Although he can give someaccount of his past life, he is unclear of the events of the last few weeks. On examination, he hasnystagmus on looking to either side and mild bilateral sixth nerve palsies. The most likely cause forhis current state is:

A. acute alcohol intoxicationB. central pontine myelinolysisC. extradural haematomaD. overdose of amitriptyline

E. Wernickes encephalopathy


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40. A 23 year old woman is brought into the Emergency Department by her boyfriend. She appearsdrowsy. Her boyfriend says she developed a cold last week. She then developed a headache andearlier today complained of photophobia. He came home early to find her in bed. Lumbar punctureshows:

WBC 15 x 106/L (


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44. A girl aged 13 has had a fight with her boyfriend and ingested 6 of her mothers diazepam 5mgtablets. Three hours post ingestion she is drowsy with a Glasgow coma score of 12 and has a pulserate of 80bpm and blood pressure 110/50mmHg. Her oxygen saturation is 98% on room air. Whichone of the following is the most appropriate treatment for this patient?

A. Activated charcoal

B. Close observationC. Gastric lavageD. Intravenous fluidsE. Intravenous flumazenil

45. Which one of the following is the single best investigation when assessing renal function?

A. Creatinine clearanceB. Creatinine excretionC. Serum creatinineD. Serum potassiumE. Serum urea

46. A patient has had a subtotal thyroidectomy. Three hours after surgery she develops severerespiratory distress and an increasingly swollen neck. After calling for more senior help, the correct

treatment is to:

A. administer an anaesthetic and explore the woundB. administer morphine to allay distressC. arrange for intubation of the patient in the ward settingD. high flow humidified oxygen via mask therapyE. open the wound in the ward and divide sutures in the deep fascia

47. Which one of the following techniques is most effective in controlling anterior nasal bleeding from

Littles area?

A. Adrenaline and cocaine pasteB. Digital compression of the naresC. Digital compression over the nasal bonesD. Ice pack to the foreheadE. Insertion of a Foleys catheter


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48. Two days after a total thyroidectomy a 54 year old woman complains of tingling around her mouthand in her hands. The most appropriate initial investigation to guide immediate management of thispatient is:

A. arterial blood gasesB. serum calcium

C. serum parathyroid hormone levelsD. serum urea and electrolytesE. thyroid hormone levels

49. A 25 year old woman presents with full thickness burns to both entire upper limbs and one half of theposterior aspect of her trunk. What percentage burns has she suffered?

A. 5%B. 9%C. 12%D. 27%

E. 50%

50. A 22 year old motorcyclist has been brought into the Emergency Department following a collision.The ambulance staff report a Glasgow coma score of 9, pulse rate 110bpm and blood pressure100/60mmHg. He has a wound of the right lower limb, which is bleeding. What is your first line ofmanagement in this patient?

A. Apply tourniquet to the lower limb

B. Assess his airwayC. Compression to the bleeding pointD. CT scan of the brainE. Insert 2 large bore intravenous cannulae

51. The most appropriate suture for a laceration on the cheek is:

A. Cat gut 2/0B. Nylon 3/0

C. Nylon 6/0D. Nylon 9/0E. Silk 3/0


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52. A 48 year old heavy drinker and smoker has a laparotomy with oversewing of a perforated duodenalulcer. Seventy two hours after surgery he is confused, disorientated and tacypnoeic. Which one ofthe following is the most important initial investigation?

A. Blood alcohol concentrationB. Blood gases

C. Blood screen for disseminated intravascular coagulationD. Liver function testsE. X-ray of abdomen

53. A patient presents to the Emergency Department complaining of colicky abdominal pain and vomitingfor six hours. Plain radiographs of his abdomen show distended loops of small bowel with fluid levels.If laparotomy is indicated, which one of the following intravenous regimens would you prescribe?

A. Balanced electrolyte solution (Hartmanns) 2000ml prior to surgeryB. Balanced electrolyte solution (Hartmanns) 500ml during operationC. 4% dextrose in N/5 saline 2000ml during operationD. 4% dextrose in N/5 saline 500ml prior to surgeryE. 5% dextrose 2000 ml before surgery

54. Four days after a laparotomy for a perforated peptic ulcer, your patients abdominal dressing is notedto be heavily saturated with clear, non purulent fluid. What is the most appropriate management?

A. Commence IV flucloxacillinB. Commence IV penicillinC. Return to theatre to oversew reperforated ulcerD. Return to theatre to repair dehiscence of the muscle layersE. Swab the wound for microscopy and culture

55. The effects of heparin can be reversed by treatment with which one of the following:

A. prostaglandins

B. prostigmineC. protamine sulphateD. thiamineE. Vitamin K


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56. A 72 year old man presents to his GP with a one day history of sudden onset of a painful right eye.The pain is severe and he has vomited twice. The right eye is red with a cloudy cornea. It has anacuity of hand movements only; acuity in the left eye is 6/12. The pupil in the right eye is fixed andsemi-dilated. The most likely diagnosis is:

A. conjunctivitis (acute)

B. glaucoma (acute)C. iritis (acute)D. optic neuritisE. retinal detachment

57. In hospital surgical patients the most common cause of acute oliguric renal failure is:

A. hypovolaemia

B. medication reactionC. pre-existing renal diseaseD. uncontrolled infectionE. urinary obstruction

58. Which one of the following statements is true in planning elective surgery in a patient with type 1diabetes?

A. Diabetes medication should be ceased 24 hours prior to surgeryB. Insulin and saline should be infused continuously during surgeryC. Patients normally treated with diet alone should be given sulphonylureaD. The patient should ideally be put first on the operating listE. There is no need for pre-op fasting

59. A 30 year old man is freed from a car involved in a head on collision. He clearly has extensive facial

fractures. The first priority in his care is to:

A. check for a tension pneumothoraxB. ensure adequate pain reliefC. measure and monitor Glasgow coma scaleD. secure adequate large bore IV accessE. secure airway and stabilise cervical spine


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60. A patient presents with intermittent loose bowel actions for six months associated with episodes ofcolicky central abdominal pain. Physical examination reveals tenderness in the right iliac fossa andan anal fissure. Which one of the following is the most likely diagnosis?

A. Carcinoma of the colonB. Crohns disease

C. Diverticular diseaseD. Irritable bowel syndromeE. Ulcerative colitis

61. An elderly man has been immobile for 3 weeks after a stroke. For one week he has been restlessand has increasing thin, watery, highly offensive stools leaking continually into the bed. His abdomenfeels lumpy and an abdominal x-ray shows a ground glass homogeneous appearance in the pelvis.

Spurious diarrhoea is suspected. What is the most probable cause?

A. Fistula in-anoB. Intestinal hurry from a high osmolar dietC. Pseudomembranous colitisD. Rectal faecal impactionE. Volvulus of the colon

62. A 26 year old man is the driver involved in a high speed head on car crash. His blood pressure is

80/50mmHg, HR 130bpm and he has a raised JVP. Which one of the following is correct?

A. A chest x-ray is necessary to diagnose a tension pneumothoraxB. A CT scan is not necessaryC. A widened superior mediastinum on an AP supine CXR does not confirm aortic

transectionD. He does not require a cervical spine x-rayE. Pericardial drainage is required if his heart sounds are muffled

63. A man in his thirties has a heavy meal with alcohol and vomits shortly afterwards. He has severethoracic and epigastric pain. He becomes breathless and hypotensive. When you see him in theEmergency Department he is noted to have subcutaneous emphysema in the root of the neck on bothsides and a left sided pleural effusion. What intrathoracic event has occurred?

A. Aneurysmal dissectionB. Lower oesophageal ruptureC. Massive pulmonary infarctD. Myocardial infarction with rupture of left ventricular wallE. Tension pneumothorax


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64. A patient returns 48 hours after application of a long leg cast for a fractured tibia, complaining ofsevere pain in the leg with loss of feeling in the foot and inability to dorsiflex the great toe. Yournext step in managing this patient is to:

A. reassure the patient, explaining the degree of pain associated with the fracture with advice togo home and elevate the limb

B. split the cast from top to bottom, including the entire thickness of the webbing orvelband lining so the skin is visible and arrange for admission and leg elevation

C. split the cast from top to bottom, including the entire thickness of the webbing or velband liningso the skin is visible and then wrap cast in crepe bandage to support it and arrange outpatientappointment

D. split the cast partially to relieve swellingE. split the plaster cast but not the webbing or the velband lining

65. A patient presents after sustaining a fall. He has pain in the wrist and a tender anatomical snuff box.Initial management should be:

A. apply ice and bandage firmlyB. immediate bone scan if x-ray is normal and treat according to resultC. mobilise the limb fully, assuming a sprainD. x-ray and immobilise for 10 days prior to repeat x-rayE. x-ray and mobilise fully, if no fracture is found

66. A 25 year old motorcyclist admitted to hospital for a fractured femur is noted to be confused andshort of breath six hours after internal fixation of the fracture. His oxygen saturation is 100% on highflow oxygen. He had no loss of consciousness at the scene and the fracture is his only injury. The

most probable diagnosis is:

A. a fat embolismB. acute pulmonary embolismC. atelectasisD. pneumonia due to aspirationE. pneumothorax

67. An 80 year old woman sustains a fall in the ward while walking to the toilet. On examination her legand foot are externally rotated compared with the opposite limb and there is some shortening. Which

one of the following is the most likely diagnosis?

A. Ankle fractureB. Dislocation of hipC. Fractured neck of femurD. Rami of the pelvis fractureE. Shaft of the femur fracture


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68. Which one of the following is least predictive of a life threatening attack of acute pancreatitis?

A. HypocalcaemiaB. Increased amylaseC. Metabolic acidosisD. Raised white cell count

E. Reduced arterial oxygen tension

69. A 45 year old woman presents with sudden onset of severe abdominal pain. Plain abdominal x-raysshow multiple air fluid levels and distended bowel loops. There is no free gas under the diaphragm.The most likely diagnosis is:

A. abdominal aortic aneurysm ruptureB. cholelithiasis

C. Meckels diverticulumD. perforated peptic ulcerE. strangulated internal hernia

70. Which one of the following combinations is most likely to indicate that a patient has acuteappendicitis?

A. Pain in the right iliac fossa associated with vomiting

B. Peri-umbilical pain associated with several episodes of vomitingC. Right iliac fossa pain associated with a fever of 39.5

oC

D. Right iliac fossa pain associated with local tenderness and guardingE. Right iliac fossa pain associated with profuse diarrhoea and a fever of 37.8

oC

71. Which one of the following indicates complete transection of the cord immediately after spinal cordinjury?

A. Flaccid paralysis and loss of all sensory modalities and reflexes below the involved

segmentsB. Loss of motor power below the involved segments but not of sensationC. Loss of sensation and power below the involved segments but not of leg reflexesD. Loss of sensation below the involved segments but not of motor powerE. Spasticity and hyper-reflexia below the involved segments


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72. The most important clinical observation following head injury is:

A. Babinski reflexB. fundoscopic examinationC. level of consciousnessD. pulse rate

E. state of the pupils

73. A man aged 70 years falls off his bicycle and grazes his face, cheek and forehead. He is temporarilystunned but recovers and has no further problems. Three weeks later he notices that his left foot isdragging. Within hours his left arm is weak and he becomes progressively drowsy. He is taken tohospital and following treatment makes a complete recovery. The most likely diagnosis is:

A. a subdural haematomaB. cerebral embolusC. cervical spinal cord trauma

D. haemorrhage into cerebral tumourE. subarachnoid haemorrhage

74. An 18 year old woman presents with a traumatic tension pneumothorax. Which one of the followingstatements is most applicable?

A. A catheter should be inserted in the 2nd

intercostal space mid-axillary lineB. A plain chest x-ray is necessary before insertion of any tube or cannulaC. An open wide bore IV cannula should be inserted into the 2

ndintercostal space mid-axillary line

D. An open wide bore IV cannula should be inserted into the 2nd

intercostal space mid

clavicular lineE. If a wide bore cannula is inserted it must be connected to underwater seal

75. Which one of the following is true of fractured ribs?

A. They are more common following penetrating trauma rather than blunt traumaB. They frequently require some form of internal fixationC. They occur more often in children than adults subjected to similar injurious forcesD. They rarely involve 1

stand 2

ndribs

E. They usually result in a flail chest

76. Which one of the following is true regarding mammography?

A. It causes excessive radiation exposureB. It is able to differentiate cystic from solid lesionsC. It is more accurate in premenopausal womenD. It is more likely than self examination to detect early cancersE. It is most useful in women who have a palpable breast lump


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77. A 65 year old man presents with a six month history of passing blood stained stools. Proctoscopyreveals 2

nddegree haemorrhoids and sigmoidoscopy shows no other anorectal pathology. The next

step in management for this patient should be to:

A. advise high fibre diet and avoid straining at stoolB. arrange faecal occult blood tests on three stool samplesC. arrange for a colonoscopyD. refer to a surgeon for a haemorrhoidectomyE. treat the haemorrhoids with rubber hand ligation

78. You diagnose a 1cm diameter malignant melanoma on clinical examination of the right calf of a 25year old woman. The next step in managing this patient would be:

A. excisional biopsy of the lesion

B. fine needle aspiration cytologyC. incisional biopsy of the lesionD. pelvic CT scan (with contrast) looking for malignant node involvementE. prescribe a steroid based cream

79. The most important treatment modality in gas gangrene of the lower limb is:

A. hyperbaric oxygen therapyB. intravenous high dose penicillinC. lower limb amputation

D. regular saline dressingsE. urgent surgical debridement

80. A 16 year old boy presents complaining of acute pain in the left testicle. Which one of the following istrue?

A. A normal duplex study excludes torsion of the testicleB. A normal urine test excludes epididymo-orchitisC. If it is normal on examination, the diagnosis is idiopathic scrotal oedemaD. It requires urgent surgical exploration to prevent infarction of the testicle

E. The testicle is rotated in a lateral direction to see if this relieves the pain


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81. A 77 year old woman has undergone a total knee joint replacement forsevere osteoarthritis. Aftertwo weeks the knee is noted to be red, swollen, hot to touch and more painful than in the few daysimmediately after the operation. She is unable to participate in ongoing rehabilitation due to pain.On examination there is evidence of minor wound dehiscence and a purulent discharge which growsmethicillin resistant Staphylococcus aureus (MRSA). She looks well, and her blood pressure is145/85mmHg, pulse rate of 100bpm, and she is febrile at 38.2C.

Which one of the following represents the bestmanagement for this patient?

A. Empirically commence intravenous vancomycinB. Organise a CT scan of the knee to exclude an abscessC. Organise a return to theatre for joint washout and direct examinationD. Organise an ultrasound to exclude a fluid collectionE. Take a deeper wound swab and commence intravenous Vancomycin

82. Which one of the following is true regarding paracetamol?

A. It does not cause hepatotoxicityB. It is a non-steroidal anti inflammatory drugC. It is not antipyreticD. It is usually given in a dose of 200mg to adultsE. It may be given rectally

83. Which one of the following changes would you expect to find in an otherwise fit 25 year old man whohas had a loss of one litre of blood over a period of one hour?

A. A drop in supine systolic blood pressure of 15mmHgB. A drop in supine systolic blood pressure of 30mmHgC. A pulse rate rise from 70 to 120 on standingD. ConfusionE. Restlessness and agitation

84. Which one of the following is correct. Wound healing is likely to be impaired by:

A. administration of prophylactic antibodiesB. closure with absorbable suturesC. debridement of necrotic tissue

D. inversion of skin edgesE. use of an occlusive dressing

85. Which one of the following is correct. A sebaceous cyst (epidermoid cyst):

A. is attached to skinB. is common intraorallyC. is fluctuantD. is transilluminableE. occurs at sites of fusion of dermatomes


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86. A patient with a prosthetic mechanical mitral heart valve and who is on warfarin, is scheduled to havea prostatectomy. The correct management is to:

A. add concurrent low molecular weight heparin to the warfarin regimeB. continue the warfarin until just before surgeryC. discontinue the warfarin at least 5 days prior to surgery and maintain anticoagulation

with low molecular weight heparin un 24 hours prior to surgeryD. discontinue the warfarin two days prior to surgeryE. maintain the warfarin therapy, however check the International Normalized Ratio (INR)

frequently

87. Each of the following are recognised long term side effects of chronic steroid use, except:

A. cataractsB. glucose tolerance impairment

C. hypercholesterolemiaD. osteoporosisE. proximal myopathy

88. Mrs Wales, aged 65 years, has had multiple infective exacerbations of COPD over the past 10 years.She is short of breath on minimal exertion, with evidence of right heart failure, and still smokesoccasionally. Each of the following options should be included in her overall management plan,except:

A. consideration of home oxygenB. flu vaccine annuallyC. optimisation of bronchodilator therapyD. organise Council home helpE. pulmonary rehabilitation

89. Emma is a 14 year old girl who has insulin dependent diabetes mellitus. She monitors her bloodglucose levels 23 times a day at home. Her record book shows blood glucose values between59mmol/L for the past three months. The concentration of glycosylated haemoglobin (HbA1C) is

found to be 15% (normal < 6.4%). Which one of the following statements is most correct?

A. HbA1C level is inconsistent with the glucose levels reportedB. HbA1C level suggests beta thalassaemiaC. She has a high dietary fat intakeD. She has optimal control of her diabetesE. She is taking an inappropriately high insulin dose


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90. An 80 year old man with degenerative back disease has worsening chronic pain. Pain was initiallycontrolled with paracetamol 1g QID. The most appropriate next step in management is to:

A. add meloxicam (Mobic) 7.5mg BDB. add neurontin (Gabapentin) 300mg BDC. change to codeine 30mg QID

D. change to liquid morphine 20mg QIDE. change to piroxicam (Feldene) 20mg

91. Considering terminal restlessness (ie. agitated delirium within a few hours of death), which one ofthe following statements is true?

A. First line treatment is benzodiazepine given by subcutaneous or sublingual route.B. Intravenous or intramuscular are the routes of choice for appropriate treatment.C. It is always easy to differentiate from pain.

D. It is an uncommon problem in a palliative care ward.E. Urinary retention or faecal impaction are not factors which need to be considered.

92. An 85 year old woman has been admitted via the Emergency Department with worsening back painand confusion over the last 7 days. She has previously had severe osteoarthritis, spinal canalstenosis with severe back pain and she sustained a fall approximately 10 days ago. Since the fall shehas not been mobile and has been confined to bed, has not been able to prepare meals and has beenrestricted in toileting due to limitation of movement due to pain.

Management of her delerium includes all of the following, except:

A. assessment of fluid statusB. discussion with the GP about recently commenced drugsC. exclusion of UTID. family meeting to determine how she has been coping at homeE. measurement of serum electrolytes

93. A 75 year old woman complains of pain mainly around the shoulders and hips associated withstiffness, particularly on waking. Examination is normal apart from mild tenderness and stiffnessaround the shoulder and hip joints. Your provisional diagnosis will be most likely confirmed by:

A. ESR >100mmB. muscle biopsyC. rheumatoid factorD. serum Ca/P04/alkaline phosphataseE. x-ray of shoulder and pelvis girdle


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94. A 78 year old man attends your surgery with symptoms of chronic constipation. He has been selfmedicating with camomile tea, avocado, Nulax and bran. You take a medication history and find heis on Norvasc for hypertension as well as Panadeine and Celebrex for arthritis. What is your firststep in managing this patient?

A. Cease the Panadeine

B. Check faecal occult bloodsC. Fluid increaseD. Prescribe MovicolE. X-ray of the abdomen

95. In a patient who has suffered a stroke, which one of the factors listed below gives the bestprognosis for rehabilitation?

A. Denial of paralysed side

B. IncontinenceC. Motor paresis strength 3/5D. NeglectE. Premorbid cognitive impairment

96. A 20 year old male medical student collapses in the autopsy room from the nauseating smell that fillsthe room as the pathologist slits open the abdomen of an elderly man who recently died withperitonitis. At the time of the collapse, one of his colleagues noticed a pulse rate of 30bpm. What is

the most likely cause of his collapse?

A. Epileptic fitB. Panic attackC. Postural hypotensionD. Second degree heart blockE. Vasovagal episode

97. Michael is a 35 year old man who has been working in his shed today. He presents to his GPbecause he thinks something may have entered his right eye when he was hammering some metal,

but he cant feel it there now. On examination, the right eye appears slightly inflamed and visualacuity is (L) 6/6, (R) 6/12. He has an irregular shaped pupil. There is no foreign body to be found,even with eversion of the lids. What is the most appropriate next step in management?

A. Prescribe topical antibiotics and eye pad, and review the next dayB. Prescribe topical antibiotics and review if it doesnt settle within a few daysC. Provide reassurance and explanationD. Refer for orbital x-ray and urgent follow up by ophthalmologistE. Refer to ophthalmologist within days to weeks


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98. A 56 year old woman presents with recent onset of changes to her right nipple that appeareczematous. On examination, she has no obvious lump in either breast. What is the mostappropriate next step in management?

A. Advise against using soap when washing herselfB. Antibiotic treatment and review

C. Arrange mammographyD. Review for repeat examination in a monthE. Steroid cream treatment and review

99. Bruce is a 35 year old man with a known history of excess alcohol use. He presents with a 4 hourhistory of severe epigastric pain which came on quite suddenly. He feels nauseated and has vomitedtwice. On examination, he is pale and sweaty, has temperature of 37.8C, a pulse rate of 110bpm,and extreme tenderness in the epigastrium. He finds that the pain is slightly relieved by sitting

forward. What is the most likely diagnosis?

A. Acute pancreatitisB. CholecystitisC. Gastro-oesophageal refluxD. Peptic ulcerE. Pericarditis

100. Mrs Shand, a 44 year old woman, presents to your clinic on Monday morning. She describes anepisode of severe abdominal pain and vomiting last Saturday night which woke her at about 1.00am.

She called a locum, and has brought a letter from him. The letter states that during the episode ofpain Mrs Shand was afebrile and had abdominal tenderness maximal in the right upper quadrant.She was given an injection of pethidine and fell asleep soon afterwards. When she woke severalhours later, the pain was gone. What is the most likely diagnosis?

A. Biliary colicB. CholecystitisC. Irritable bowel syndromeD. Peptic ulcerE. Renal colic

101. Mr Tyler, aged 29, presents with tiredness and lethargy for six weeks. He also reports pins andneedles in his hands and feet. He has no significant past medical history. He eats a strictly vegandiet, which includes no animal products at all. What is the most appropriate investigation that willassist you in this scenario?

A. Fasting glucoseB. HIV serologyC. Iron studiesD. Thyroid stimulating hormone (TSH)E. Vitamin B12 and folate


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102. Mrs Mahoney is aged 65 and has multiple myeloma. She presents with three days of severe leftsided chest pain which radiates under her left breast. She developed a rash in this area 24 hoursago. She has been taking slow-release oral morphine 10mg bd and naproxen 250mg bd for bonyaches and pains with good relief but these have had no effect on this new pain. What is the mostlikely cause of her pain?

A. Acute herpes zosterB. Osteoporotic crush fractureC. Paraneoplastic syndromeD. Rib metastasesE. T4 nerve root compression

103. You are asked to see a 2 year old girl at your practice. She has a purulent unilateral nasaldischarge. This has been present for six weeks despite two courses of oral cotrimoxazole. Whichone of the following is the most appropriate next step in management of this child?

A. A course of oral flucloxacillinB. Nasal examination under general anaesthesiaC. Nasal swab for microscopy and cultureD. Tobramycin nasal drops t.d.s.E. X-ray of paranasal sinuses

104. A 30 year old woman presents with a history of three days of dysuria. There is no blood, nitrates or

white cells detected in the urine. What is the most appropriate next step in management?

A. Perform an examination of the genitaliaB. Prescribe a urinary alkalinizer (Ural)C. Prescribe an antibiotic, according to Antibiotic GuidelinesD. Prescribe an antifungal creamE. Prescribe paracetamol

105. Brad is a 6 year old boy on chemotherapy for acute myeloid leukaemia. He presents to the

Emergency Department with a temperature of 39.4C. Which one of the following is the mostappropriate management?

A. Administer intravenous gamma globulinB. Administer paracetamol and review in 24 hoursC. Perform septic workup and commence broad spectrum antibioticD. Perform septic workup and monitor his temperatureE. Refer to outpatient clinic with an oral cephalosporin


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106. Sarah is a 16 year old girl who presents with a history of sore throat, fever and enlarged cervicallymph nodes. Examination reveals exudative tonsillitis, generalised adenopathy and a palpablespleen. Which one of the following is the most likely diagnosis?

A. Acute Streptococcal infectionB. Diphtheria

C. Hodgkins diseaseD. Infectious mononucleosisE. Leukaemia

107. A child aged 2 years presents with a 12 week history of a recurrent nocturnal cough which isoccasionally associated with a wheeze and vomiting. Her cough improves transiently afterinhaled bronchodilator. Which one of the following would be the most appropriate method to treather with a bronchodilator?

A. Dry powder inhalerB. MDI (metered dose inhaler) and spacerC. MDI aloneD. MDI and spacer with face maskE. Nebuliser alone

108. Rachel, aged 15, presents with a history of weight loss of 10kg over a three month period, poorconcentration and mood swings. On examination, her BMI is 19, she has postural hypotension, coolperipheries and a soft faecal mass is palpable in the left iliac fossa. Which one of the following is the

most likely cause of her symptoms?

A. Anorexia nervosaB. Hypothalamic tumourC. Inflammatory bowel diseaseD. Severe depressionE. Thyrotoxicosis

109. A 7 year old boy with atopic eczema is brought to the Emergency Department after having eaten foodcontaining peanut. On examination, there is swelling of his tongue and face. He has a spreading

urticarial rash, an audible stridor, rhonchi in his chest and a blood pressure of 60/35mmHg supine.Which one of the following is the most appropriate initial treatment?

A. IM adrenalineB. IV fluidsC. IV hydrocortisoneD. Oral dexamethasoneE. Oral Phenergan


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110. A 6 month old male infant is brought to the Emergency Department with a troublesome cough. Hehas received all of his immunisations including the DTPa vaccine. The cough occurs day and nightand is very distressing, being associated with facial suffusion and not uncommonly vomiting at theend of the coughing episode. He has not been cyanosed. What is the most likely cause of hissymptoms?

A. AdenovirusB. Bordetella pertussisC. Haemophilus influenzae type bD. Mycoplasma pneumoniaeE. Streptococcus pneumoniae

111. Gary is a 48 year old salesman who presents because he is finding it difficult leaving his house. He isworried that he may be contaminated by germs and frequently washes his hands and showersseveral times a day to prevent this. When he leaves his house he needs to count all the bricks of the

fences that he passes. He says it is easier to just stay at home. Which one of the following is themost likely cause of his presentation?

A. Bipolar disorderB. Obsessive Compulsive DisorderC. SchizophreniaD. Social anxiety disorderE. Specific phobia

112. Amanda is a 23 year old woman who was involved in a car accident where two of her friends died.Whenever she drives she cannot stop thinking about the accident, and cannot bear the thought ofbeing in traffic. Amanda has found it increasingly difficult to leave her house. Which one of thefollowing is the most likely cause of her presentation?

A. Dysthymic disorderB. Major depressive disorderC. Post traumatic stress disorderD. Separation anxiety disorderE. Specific phobia

113. Matt is a 20 year old man with five convictions for petty theft. He feels no remorse after stealing thelife savings of an 80 year old woman, saying that life is about looking after number one. Matt has ahistory of truancy at school and a series of unskilled jobs. He left home at age 13 after his mothermoved in with her fourth de-facto partner. Given this pattern of behaviour, what is the most likelydiagnosis?

A. Antisocial personalityB. Borderline personalityC. Histrionic personalityD. Narcissistic personalityE. Passive aggressive personality


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114. Jenny is a 32 year old mother of two children, aged 5 and 7. She reports a two month history ofbroken sleep, tearfulness, feeling down, and over-eating. She states that sometimes she wishes shewas dead and has recently thought about ending her life. Which one of the following is the mostlikely cause of her presentation?

A. Binge eating disorderB. Cyclothymic disorderC. Histrionic personality disorderD. Major depressive disorderE. Post-natal depression

115. Sam is aged 26 and has a past history of depression. He has quit his job as a plumbers apprenticeto spend more time developing his real estate portfolio. He is staying up all night documenting hisplans, which are becoming increasingly disorganised. Which one of the following is the most likely

cause of Sams behaviour?

A. Bipolar disorderB. Cyclothymic disorderC. Histrionic personality disorderD. Schizoid personality disorderE. Schizophrenia

116. Each of the following are side effects of iron tablets, except:

A. constipationB. diarrhoeaC. flatusD. nauseaE. pale coloured stools

117. Osteoporosis risk factors include each of the following, except:

A. malabsorption syndromesB. premature menopauseC. prolonged use of steroids

D. tobacco smokingE. use of marijuana


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118. The benefits of breast feeding include each of the following, except:

A. aids involutionB. meets all the infants nutritional needs for first 12 months of lifeC. protects against infectionD. reduces risk of breast cancer

E. reduces risk of some forms of ovarian cancer

119. Which one of the following organisms is the most common cause of mastitis?

A. Aerobic streptococcusB. Bacteroides fragilisC. Escherichia coliD. Staphylococcus aureusE. Streptococcus viridans

120. Pre-pregnancy investigations should include each of the following, except:

A. CMV immunoglobulin titreB. full blood countC. Pap smear if not performed in last 18 monthsD. rubella immunoglobulin titreE. varicella immunoglobulin titre

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