Week 9

* Question 1 Intestinal sugar malabsorption following gastroenteritis may be suspected if the child has: a) Vomiting each time the particular sugar is eaten b) A stool pH of 6 c) Salmonella in the faeces d) Glycosuria and excess sugar in the faeces e) Recurrence of diarrhoea E. Sugar tolerance (usually lactose) is recognised by the reappearance of diarrhoea when milk is reintroduced to the diet. It occurs more often in the younger infant. The stools become watery and frothy and tend to excoriate the buttocks. Fluid stools may be positive for reducing sugars such as such as lactose/glucose but not sucrose. Sugar intolerance is not associated with any particular pathogen. Approximately 50% of infants under 6 months who have required hospitalisation for gastroenteritis require a low lactose formula at the time of discharge. (Robinson, M.J, and Robertson, D.M (Ed) (1998) Practical Paediatrics. 4th Ed. Churchill Livingstone. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section3/chapter30/30b.htm ) * Question 2 Following appendicectomy 10 days previously, a patient presents with fever and mucus diarrhoea. The MOST LIKELY cause is: a) Viral gastroenteritis b) Pelvic abscess c) Staphylococcal enteritis d) Giardiasis e) Abscess around appendiceal stump B. Passage of mucus with diarrhoeal stool and fever in a patient recovering from peritonitis (appendicitis being the most common cause), is PATHOGNOMIC of pelvic abscess. It should be therefore be thought of first and either treated or excluded. Viral gastroenteritis causes a fluid, not mucus diarrhoea. Staphyloccoccal enteritis would be a fulminating, severe illness with more worrying signs than just change in stool. Giardia causes a fatty, large, pale, offensive stool with undigested vegetable material (peas, carrots and corn) in an otherwise well individual. An abscess around the appendiceal stump would cause signs of a localised peritonitis. (Mann, C.V. and Russell, R.C.G. (1992) Bailey and Loves Short practice of Surgery 21st Ed. London Chapman and Hall ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch132/ch132c.htm ) Question 3 A 26 year old builder presents with diarrhoea, indigestion, anorexia and malaise. The additional clinical features illustrated on the diagram are most compatible with: a) Ankylosing spondylitis b) Ulcerative colitis

c) Crohn's disease d) Adenocarcinoma of the colon

e) Reiter's disease C. Crohn's disease is a chronic inflammatory bowel disease with multiple extra-colonic manifestations. The effects of ulcerative colitis are largely limited to the colon. Longterm complications of ulcerative colitis include colonic carcinoma. Disorders associated with IBD but running independent courses include ankylosing spondylitis, sacroiliitis, and primary sclerosing cholangitis. Reiter's disease is characterised by urethritis, conjunctivitis and an asymmetrical arthritis. (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch126/ch126b.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch129/ch129c.htm ) * Question 4 An 5 month old infant is brought to the emergency department with a few hours history of intermittent screaming and drawing up his knees. He has vomited twice. He is pale, clammy and tired. He also started vomiting. No abnormality is found on abdominal examination. What is the MOST LIKELY diagnosis? a) Gastro-enteritis b) Intussusception c) Urinary tract infection (UTI) d) Hirschsprung's disease e) Pyloric Stenosis

B. Intussusception occurs when one segment of the bowel passes inwards inside the adjacent distal bowel. It is the most common cause of intestinal obstruction between 3 months old to 6 years old (rarely after 36 months old). The peak incidence in infants is 47 months. In typical cases there is sudden onset, in a previously well child, of severe paroxysmal pain which recurs at frequent intervals and is accompanied by straining effects and loud cries. Vomiting usually occurs once or twice in the first hours and then reappears once obstruction is established. About half will pass red currant jelly stools. Initially, physical examination may be normal, but a sausage-shaped mass in the right upper abdomen is found in more than half of infants in the first few hours. Later on abdominal distension and increased tenderness may conceal the mass. Hirschprung's disease (aganglionic megacolon) usually presents in the neonate but at a later age tends to present as chronic constipation with overflow soiling. Pyloric stenosis usually commences between 3 to 6 weeks of age and is rare in infants older than 11 weeks. It is associated with projectile vomiting. (Hutson JM, Beasley SW, Woodward AA. (Eds.) (1992) Jones' Clinical Paediatric Surgery. Diagnosis and Management. Blackwell Scientific Publications Carlton Australia p 121 - 122. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch132/ch132d.htm ) Question 5 A 70 year old woman with a history of good health presents with a four week history of intermittent abdominal pain. On general inspection she appears jaundiced and has several scratch marks. Rectal examination reveals pale stool. The liver functions tests are: bilirubin 821 umol/L (<25) alkaline phosphatase 630 U/L (30-85) aspartate phosphatase 65 U/L (7-40) gamma glutamyl transferase 460 U/L (5-65) The MOST APPROPRIATE initial investigation to determine the cause would be: a) Cholecystogram b) Abdominal ultrasound c) Magnetic resonance imaging d) Retrograde cholangiopancreatography e) Liver isotope scan B. The history, examination and results are suggestive of obstructive jaundice, with an elevated bilirubin, mild elevation of AST reflecting minimal liver cell damage, ALP elevation and GGT elevation. The common causes of cholestasis in a woman of this age are stones and tumours, especially pancreatic tumours. Ultrasound is the most simple, cost-effective, non-invasive imaging modality. (Royal College of Pathologists of Australia (1997) Manual of Use and Interpretation of Pathology Tests 2nd Edition Melbourne RCPA ) (Henry, M.M and Thompson, J.N. (Eds) (2001) Clinical Surgery London W.B. Saunders ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section4/chapter48/48d.htm )

(Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section4/chapter48/48g.htm ) Question 6 An uncommon condition that can present with acute abdominal pain may show the

features as illustrated. This condition is: a) Tabes dorsalis b) Addison's disease c) Hyperparathyroidism d) Acute intermittent porphyria e) Wilson's disease D. Acute intermittent porphyria results from a deficiency in porphobilinogen (PBG) deaminase which is involved in haem synthesis. Symptoms result from the effect on the nervous system. Urine becomes reddish brown due to excess porphyrins especially after standing the urine in the light. Porphyria is precipitated by factors such as hormones, drugs (especially those inducing hepatic ALA synthase and cytochrome P450 enzymes) and dieting. Diagnosis depends on measurement of PBG in urine. (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section2/chapter14/14b.htm ) Question 7 Jenny, aged 7 years, has a one day history of abdominal pain and diarrhoea. She doesn't feel hungry. She has a temperature of 37.9 degrees Celsius, and her abdomen is generally tender. What is the MOST LIKELY diagnosis? a) Appendicitis b) Constipation with overflow c) Gastroenteritis d) Lactose intolerance

e) Urinary tract infection C. The presenting symptoms of gastroenteritis involve poor feeding, with or without vomiting, followed rapidly by diarrhoea. The stool frequency varies. With increasing anorexia, vomiting and diarrhoea, the child becomes lethargic and signs of dehydration with accompanying metabolic acidosis appear. (Robinson, M.J, and Robertson, D.M (Ed) (1998) Practical Paediatrics. 4th Ed. Churchill Livingstone. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch122/ch122a.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section3/chapter28/28f.htm ) Question 8 Ischiorectal abscess COMMONLY leads to: a) Anal carcinoma b) Anal stricture c) Haemorrhoids d) Anal fissure e) Anal fistula E. Ischiorectal abscess commonly points and drains into the anal canal, causing an anal fistula. The fistula can be single or horseshoe (two or more draining sites) if the abscess spreads through the peri-anal fat. To prevent fistula formation the ischio-rectal abscess needs to be diagnosed early and treated aggressively by surgery, not antibiotics alone. None of the other conditions are associated with ischiorectal abscess or fistula formation. Crohn's disease should be considered in chronic intractable infection and complex fistulae. (Henry, M.M and Thompson, J.N. (Eds) (2001) Clinical Surgery London W.B. Saunders (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section3/chapter35/35d.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section3/chapter35/35e.htm ) Question 9 A 32 year old housewife presents with an 18 month history of fluctuating symptoms of polyarthritis (especially in the hands), night sweats, mouth ulcers, a facial rash and pleuritic chest pain. The MOST LIKELY diagnosis is: a) Acquired immunodeficiency disorder b) Rheumatic fever c) Systemic lupus erythematosus d) Tuberculosis e) Rheumatoid arthritis

C. Systemic lupus erythematosus (SLE) usually occurs in women (90%) and can present with fever, erythematous skin rash, polyarthritis, evidence of renal disease and intermittent pleuritic pain. Antinuclear antibody (ANA) is positive in 98% with anti-ds DNA being highly specific for SLE. Early SLE can be mistaken for other forms of connective tissue disorders especially rheumatoid arthritis if arthritic symptoms predominate. Rheumatic fever manifests with migratory polyarthritis, chorea and carditis. (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section5/chapter50/50e.htm ) * Question 10 In the newborn physiological jaundice is a diagnosis of exclusion. Which of the following factors is CONSISTENT with a diagnosis of physiological jaundice? a) Onset within the first 24 hours b) Unwell infant c) Jaundice improves with increased feeds and hydration d) Preterm infant e) Jaundice lasting longer than 2 weeks C. Physiological jaundice is often aggravated by deficient feeding and so increased feeds/fluids is often all that is necessary to improve physiological jaundice. Factors suggesting that a pathological cause for the jaundice should be actively sought include: jaundice within the first 24 hours; jaundice persisting 7-10 days in a full-term infant; the sick infant; high levels of serum bilirubin. More serious causes of jaundice include gram negative septicaemia, biliary atresia or Rh incompatibility. (Robinson, M.J, and Robertson, D.M (Ed) (1998) Practical Paediatrics. 4th Ed. Churchill Livingstone. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section19/chapter260/260i.htm ) * Question 11 A 65-year-old woman presents with fluid abdominal enlargement to the xiphisternum. On clinical examination this is thought to be due to an ovarian cyst. The MOST APPROPRIATE next step in management is: a) Laparotomy b) Paracentesis to obtain cells for cytology c) Laparoscopy d) Cytotoxic drug therapy e) Plain x ray of the abdomen A. As the clinical diagnosis infers a risk of malignancy, diagnosis should be established by laparotomy with full removal of the mass if possible. Cytotoxic drug therapy may only be indicated after histological diagnosis and staging are confirmed. Paracentesis may not give a histological diagnosis and may spill malignant cells into the peritoneum. Laparoscopy would be of no diagnostic or therapeutic benefit, and may be procedurally impossible. Plain X ray of the abdomen is of very limited use, and may only be of help in the case of a teratoma. (McCarthy, A. and Hunter, B. (1998) Churchill's Mastery of Medicine Obstetrics and Gynaecology. Edinburgh Churchill Livingstone )

(Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section18/chapter241/241b.htm ) Question 12 A 24 year old man presents with a 6 week history of a very painful ankle and 12 weeks of low back pain, worse at rest and relieved by activity. About 6 months ago he had an episode of urethritis.

The features outlined on the diagram are MOST COMPATIBLE with: a) Lyme disease b) Gonococcal arthropathy c) Ankylosing spondylitis d) Bacterial prostatitis e) Reiter's syndrome E. Reiter's Syndrome is a seronegative spondyloarthritis associated with HLA-B27 having features of urethritis, conjunctivitis and asymmetrical poly- or oligo-arthritis. Two forms predominate: sexually transmitted (Chlamydia most often implicated) or dysenteric. Differentiation from gonococcal infection can be made by positive gonococcal cultures with rapid response to antibiotics; arthritis and skin lesions may resemble those of ankylosing spondylitis, psoriatic arthritis or Behcet's disease. (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section5/chapter51/51b.htm ) Question 13 With respect to food allergies in children which of the following is FALSE: a) Most true food allergies or intolerances are outgrown by the age of 5 b) Skin prick testing for allergy cannot be performed in infants c) Allergic reactions to food can occur up to 48 hours post ingestion d) Egg, milk and peanuts are the most common food allergies in children

e) Allergic reactions may occur immediately on ingestion of foods B. Despite the widely held opinion, skin prick testing can be reliably undertaken in infants. All the other options are true for food allergies. (Robinson, M.J, and Robertson, D.M (Ed) (1998) Practical Paediatrics. 4th Ed. Churchill Livingstone. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section12/chapter148/148b.htm ) * Question 14 Mrs Jones suffers with rheumatoid arthritis which is at present well controlled. She is concerned about a rash on her hands which she has only recently noticed. It is itchy. Clinically you suspect that this is lichen planus. Which of the following is INCORRECT? a) Lichen planus commonly occurs on the wrists, shins and lower back b) The rash could have been precipitated by recent gold injections c) A lichenoid eruption begins within a few days of commencing the causative medication d) This rash could have been precipitated by non steroidal anti-inflammatory drugs (NSAIDs) e) This rash could be related to blood pressure medication C. Lichenoid drug eruptions may occur after drug therapy has commenced but it takes months not days and takes some time to resolve. Gold, NSAIDS, antimalarials, the antihypertensive captopril and thiazide diuretics can precipitate the reaction. (Bruce, F. (1997) Could it be a drug eruption? Australian Family Physician Vol26, No6, June 1997 pp689-695 ) (Kumar, P and Clark, M.(1992) Clinical Medicine 2nd Ed London, Bailliere-Tindall pp1010-1011 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section10/chapter117/117d.htm ) Question 15 A 30 year old woman presents with tender nodules on her legs, arthralgia of the knees and ankles, malaise, cough and sore eyes. The findings are summarised in the diagram.

Your provisional diagnosis is: a) Lymphoma b) Pulmonary tuberculosis c) Bronchial carcinoma d) Infective endocarditis e) Sarcoidosis E. Sarcoidosis is a multi-system granulomatous disorder causing multiple non-caseating granulomas occurring mainly in mediastinal and peripheral lymph nodes. Symptoms depend on site of involvement but commonly fever, weight loss, and arthralgia/polyarthritis. It may be diagnosed in patients with typical CXR findings, however tissue biopsy is necessary if symptomatic to exclude lymphoma and TB. The most reliable indicator of favourable prognosis is onset with erythema nodosum. Treatment with corticosteroids may be necessary. (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section21/chapter288/288a.htm ) Question 16 Which of the following statements concerning inguinal hernia in an infant aged 3 months is TRUE? a) Strangulation is uncommon b) Surgery should be postponed until 5 years of age c) The hernia will disappear by 1 year d) Surgery is only indicated if bilateral herniae are present e) Operation is best performed as soon as possible E. Inguinal hernias in infants are usually diagnosed on the basis of a history of lump visible in the groin which comes and goes often with cough or straining. There may be no hernia on examination or perhaps only a thickened spermatic cord. Surgery is necessary in all cases because of the danger of strangulation, which occurs most commonly in the first six months of life. It should be performed as soon as possible. Surgical exploration of the other side is usually undertaken as the majority of infants under 1 year of age have a contralateral sac (50% boys, 75% girls).(Hutson JM, Beasley SW, Woodward AA.

(Eds) (1992) Jones' Clinical Paediatric Surgery. Diagnosis and Management. Blackwell Scientific Publications Carlton Australia p 172. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section17/chapter219/219c.htm ) Question 17 A woman aged 43 years presents with painless jaundice, loss of appetite and weight, itching and right subcostal tenderness. You suspect an obstructive basis. This would be supported by urine containing: a) Excess bilirubin and excess urobilinogen b) Excess bilirubin and normal urobilinogen c) Excess bilirubin but low urobilinogen d) Normal bilirubin and excess urobilinogen e) Normal bilirubin and low urobilinogen C. In obstructive jaundice, serum bilirubin increases to the extent that conjugated bilirubin is excreted in the urine. Normally, conjugated (post-hepatic) bilirubin passes through the common bile duct to the small intestine where it is converted to stercobilinogen, causing the normal dark stools. Urobilinogen is synthesised from resorbed stercobilinogen and is water-soluble and excreted in the urine. Conjugated bilirubin, that cannot reach the small bowel, is resorbed into the circulation. It is not albumin bound, so it is excreted in the urine, hence dark urine. Stercobilinogen is thus not formed, hence low urobilinogen in the urine and pale stools. Measurement of urinary urobilinogen is no longer considered a useful test. (Henry, M.M and Thompson, J.N. (Eds) (2001) Clinical Surgery London W.B. Saunders (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section4/chapter48/48d.htm ) Question 18 A 45 year old female accountant consults you because she has had occasional bouts of nausea with bloating and a sense of fullness in her upper abdomen. She has recently been promoted at work and has been taking aspirin for occasional headaches. Which of the following could explain her symptoms? a) Reflux oesophagitis b) Gastric carcinoma c) Chronic peptic ulcer d) Functional dyspepsia e) All of the above E. These symptoms (nausea, bloating and fullness) are non-specific, and can be experienced in a wide range of upper GI conditions, along with non-gastrointestinal conditions such as environmentally-induced emotional stress. As such, they are not good differentiating symptoms and all the conditions above would have to be considered as differential diagnoses. (Chamberlain, E.N. and Ogilvie, C.M. (1967) Symptoms and Signs in Clinical Medicine An Introduction to Medical Diagnosis 8th Ed. Bristol John Wright and Sons ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition

Available: www.merck.com/pubs/mmanual_home2/sec09/ch121/ch121d.htm ) * Question 19 The MOST COMMON cause of visible bright blood on a child's stool is: a) Colitis b) Rectal polyp c) Intussusception d) Fissure-in-ano e) Peptic ulcer D. In an otherwise well child, the commonest cause of visible bright blood on a child's stool is fissure-in-ano usually due to the passage of a large motion. The fissure can be seen by gently parting the anus. Pain is a distinguishing feature. The commonest cause of blood mixed with stool in an unwell child is gastroenteritis caused by pathogenic bacteria. Non-infectious inflammatory colitis is rare in childhood, as are rectal polyps. The clinical signs of intussusception are of a sudden onset of severe colicky abdominal pain in a child most commonly between 3 months and 7 months of age. In about 50% there is passage of red currant jelly stools. Peptic ulcer disease is very unusual in childhood. (Hutson JM, Beasley SW, Woodward AA. (Eds) (1992) Jones' Clinical Paediatric Surgery. Diagnosis and Management. Blackwell Scientific Publications Carlton Australia. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch130/ch130c.htm ) * Question 20 The BEST SIMPLE estimate of the extent of blood loss in a patient who has recently suffered a large upper gastrointestinal bleed is: a) Volume of loss by history b) Observation of the amount of melena c) Monitoring of the pulse rate d) Hypotension when the patient sits up e) The admission of haematocrit D. blood loss is haemodynamically significant (>500ml), the patient may feel faint and show pallor. There will be reduced circulating blood volume, which will be evident as postural hypotension. Volume loss cannot be estimated by history or by observation; melena may not occur for hours after the bleed. Tachycardia may be due to, or exacerbated by, anxiety and pain; haematocrit may not change after a sudden bleed until haemodilution occurs. In larger centres, central venous pressure monitoring would be instituted. (Henry, M.M and Thompson, J.N. (Eds) (2001) Clinical Surgery London W.B. Saunders (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section11/chapter127/127b.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch132/ch132b.htm )

Question 21 Which of the following disorders is NOT a premalignant condition? a) Gastric atrophy b) Colonic polyp c) Cirrhosis d) Diverticulosis of the jejunum e) Ulcerative colitis D. Diverticulosis of the jejunum is an uncommon, benign condition. Gastric atrophy (especially if associated with Vitamin B12 deficiency) predisposes to gastric carcinoma. Cirrhosis, especially if caused by Hepatitis B, predisposes to hepatoma. Colonic polyps can undergo malignant change in the stalk of the polyp. Chronic ulcerative colitis (especially if untreated or inadequately treated) has a risk occurrence of colonic carcinoma of about 12%. (Mann, C.V. and Russell, R.C.G. (1992) Bailey and Loves Short practice of Surgery 21st Ed. London Chapman and Hall ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch128/ch128b.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch131/ch131h.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section4/chapter47/47c.htm ) Question 22 The MOST COMMON cause of iron deficiency anaemia in Australian children is: a) Worms b) Malabsorption c) Dietary d) Peptic ulceration e) Occult blood loss from a Meckel's diverticulum C. Inadequate intake of iron rich foods is the most common cause of iron deficiency in children in Australia. Blood loss and malabsorption can cause iron deficiency anaemia but are rare in children. (Robinson, M.J, and Robertson, D.M (Ed) (1998) Practical Paediatrics. 4th Ed. Churchill Livingstone. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section11/chapter127/127c.htm ) Question 23 Which of the following is TRUE of common bile duct stones? a) They do not occur once the gall bladder is removed b) They are always multiple c) The resulting jaundice is always constant d) The resulting jaundice is always painless e) None of the above

E. Duct stones can occur after a cholecystectomy. The patient can be asymptomatic but common bile duct stones usually cause intermittent symptoms of pain, jaundice and fever (Charcot's triad). Stones can be single or multiple. (Mann, C.V. and Russell, R.C.G. (1992) Bailey and Loves Short practice of Surgery 21st Ed. London Chapman and Hall ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec10/ch140/ch140b.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section4/chapter48/48d.htm * Question 24 The daily fluid requirement of a healthy 4.5 kg (4500 g) 2 month-old infant in a temperate climate is: a) 400 ml b) 500 ml c) 675 ml d) 1250 ml e) 1500 ml C. Oral fluid requirements for infants 0-1 year old is 150ml/kg/day . (Robinson, M.J, and Robertson, D.M (Ed) (1998) Practical Paediatrics. 4th Ed. Churchill Livingstone. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section19/chapter259/259d.htm ) Question 25 A previously healthy 80-year old male presents with intermittent nausea and vomiting, weight loss and dull pain under the right costal margin. On examination he is afebrile. He has bile in his urine, yellow conjunctivae and tenderness under the right costal margin, with palpable gall bladder. He has an A.S.T. of 100 units/L (7-40) and a serum alkaline phosphatase of 400 units/L (30-85). The MOST LIKELY diagnosis is: a) Infective hepatitis b) Acute cholecystitis c) Hepatic cirrhosis d) Carcinoma of the head of the pancreas e) Stone in the common bile duct D. This presentation is one of obstructive jaundice, better termed cholestasis. In a man of this age malignancy, such as carcinoma of the head of the pancreas, would be the most likely cause. It is important to distinguish extra hepatic from intra hepatic causes of cholestasis. Extra hepatic cholestasis is suggested by biliary or pancreatic pain, rigors or a palpable gall bladder. Acute cholecystitis may not be associated with jaundice, and the patient would most likely be febrile with a tender gallbladder (positive Murphy's sign). A stone in the common bile duct may be quite asymptomatic, and may only cause symptoms and signs if it fully obstructed the duct, usually at the papilla. Biliary colic would be present in such a case, and it would not explain his weight loss. Intra hepatic cholestasis would be suggested by symptoms of hepatitis, a significant drug and alcohol

history or signs of chronic liver disease. Cirrhosis of any cause would show other clinical and biochemical signs of hepatocellular damage, and one would usually expect the AST to be quite high (of course this is not the case in very late stage cirrhosis and laboratory test results should not be relied upon alone). (Henry, M.M and Thompson, J.N. (Eds) (2001) Clinical Surgery London W.B. Saunders ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch131/ch131k.htm ) Question 26 Maria, 31, has haemochromatosis with gene testing showing she is a C282Y homozygote. Which statement is CORRECT? a) Testing of Maria's first degree relatives should be done even if they have no symptoms b) Repeated fasting transferrin saturation greater than 45% is the earliest marker of iron overload c) Vitamin C supplements are recommended to avoid iron overload d) Maria should be counselled that her children are also likely to be affected e) Transferrin saturation and ferritin levels should be checked every three months A. First degree relatives of patients with haemochromatosis should have genetic testing, even if iron studies are normal, as they may still have the disorder and be at future risk of iron overload. Ferritin is the best marker of iron overload and a raised transferrin saturation is not uncommon in oral iron therapy in normal individuals. In haemochromatosis iron and vitamin C supplements are avoided as they can result in iron overload. Whether the children of a C282Y homozygote woman are affected depends on her partner. If the father does not carry the altered gene, the children will most likely be unaffected carriers. Maria should have her transferrin saturation and ferritin checked every two years. Question 27 Maria, 31, has haemochromatosis and is a C282Y homozygote. Maria's husband, George undergoes the HFE gene test for haemochromatosis and is found to be a H63D heterozygote (carrier). Which is INCORRECT about Maria and George's children? a) Each child has a 50% chance of being a compound heterozygote b) Each child has a 50% chance of being a C282Y heterozygote (carrier) c) No child will be a C282Y homozygote d) Children that are compound heterozygote have a high lifetime risk of developing iron overload e) Predictive genetic testing of children should only be done if a child is symptomatic D. Only about 1% of people with the compound heterozygote genotype will develop iron overload during their lifetime. (Newstead, J., Delatycki, M. and Aitken, MA. (2002) Haemochromatosis and family testing; What should a GP do? Australian Family Physician Vol. 31, No. 7, June, p 533537. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section11/chapter128/128a.htm )

Question 28 On third day after birth, a 2 kg baby has bilirubin level of 35 umol/L (normal is less than 25 umol/L). Which of the following is CORRECT? a) The most likely cause is immaturity of liver enzymes b) The condition is usually exacerbated by breast feeding c) Kernicterus is common if untreated d) This level is an indication for urgent exchange transfusion e) The most likely cause is immaturity of kidney function A. In the first 3 to 4 postnatal days, normal infants have a physiological increase in serum unconjugated bilirubin. This is due to a number of reasons including immaturity of several liver enzymes, increased bilirubin production and reabsorption from an active enterohepatic circulation. Physiological jaundice is often aggrevated by deficient feeding and so increased feeds/fluids often improve the jaundice. This level of serum bilirubin is not an indication for exchange transfusion. Kernicterus (bilirubin encephalopathy) is not common occurring at much higher and more prolonged bilirubin levels. (Robinson, M.J, and Robertson, D.M (Ed) (1998) Practical Paediatrics. 4th Ed. Churchill Livingstone. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section19/chapter260/260i.htm ) Question 29 Which of the following primary malignancies COMMONLY causes osteosclerotic metastases of the spine? a) Prostate b) Breast c) Lung d) Kidney e) Thyroid A. Prostatic malignant cells produce Endothelin-1 which promotes osteoblast activity, causing osteosclerotic (thickened bone) lesions. All the other malignancies produce osteolytic lesions, either by direct invasion and destruction of bone and perhaps by some unknown mechanism of stimulating osteoclastic activity. (Holland, J.F. and Blast, R.L. Editors (1997) Cancer Medicine 4th Ed. Vol 2 USA Williams and Wilkins ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec06/ch088/ch088c.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section17/chapter233/233f.htm ) Question 30 Concerning osteoarthritis in people aged 60-70 years, which of the following statements is INCORRECT? a) Osteoarthritis is the commonest form of arthritis b) About 40% of people aged 60-70 have evidence of osteoarthritis

c) There is very little evidence that anti-inflammatory drugs modify the osteoarthritic process d) Medical therapy has focused on symptomatic relief e) COX-2 inhibitors reduce gastrointestinal side effects but retain the risk of renal toxicity B. Autopsy studies suggest at least 60% of people aged 60-70 years have evidence of osteoarthritis. Osteoarthritis is the commonest form of arthritis, and medical treatment focuses on symptomatic relief with anti-inflammatory drugs (which do not modify the asteoarthritic process). While COX-2 inhibitors do reduce the risk of gastro-intestinal side-effects they retain the risk of renal toxicity. (Phoon, S.and Manolios, N. (2002) Glucosamine: A nutraceutical in osteoarthritis. Australian Family Physician Vol. 31, No. 7, July, pp 539-541. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section5/chapter52/52a.htm ) Question 31 Mr. Jones, aged 20, presents one morning complaining of a 10-day cough. He is producing a small amount of yellowish sputum. He has mild exertional dyspnoea and was a bit wheezy the night before. He smokes 10-15 cigarettes per day and has no past history of respiratory illness. On examination he is afebrile, with a pulse of 80/min, BP 125/80. The cardiovascular system is normal. His chest is resonant with scattered wheeze. What is the MOST LIKELY cause of Mr Jones' symptoms? a) Viral Respiratory Tract Infection b) Bronchitis c) Asthma d) Mycoplasma e) Sinusitis C. The cardinal sign in asthma is a widespread wheeze as a result of partial airway obstruction. The other very common sign of asthma in adults is an irritable cough (Cough Variant Asthma). Asthma is diagnosed with spirometry. Bronchitis is usually preceded by an upper respiratory tract infection in a young man this age, and frequently has little or no respiratory signs. Mycoplasma has many and varied presentations, from the patient who is slightly unwell to the patient who has a toxic presentation - diagnosing mycoplasma requires clinical skill. Sinusitis presents with facial pain and occasionally an irritable cough. Viral infections generally only cause symptoms for 5-6 days. (Hope et al. (1993) Oxford Handbook of Clinical Medicine 3rd Ed Oxford, Oxford University Press p 344 ) (Talley, N and O'Connor, S. (1992) Clinical Examination 2nd Ed Sydney, Maclennan and Petty p 115 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec04/ch044/ch044a.htm ) * Question 32 The INITIAL management of a spontaneous pneumothorax in a patient without dyspnoea at rest and a uniform 2 cm separation of the lung from the chest wall on a radiograph should consist of:

a) Observation b) Single needle aspiration c) Positive pressure respiration d) Underwater drainage e) Underwater drainage with suction A. A small pneumothorax can be managed with observation and avoidance of situations likely to reduce atmospheric pressure (i.e. flying). Where the lung is halfway to the heart border or more, or the pneumothorax occupies 30% of the pleural space, aspiration with or without drainage by intercostal catheterisation is indicated. Flying is avoided because the reduction in extra-thoracic pressure would make the pneumothorax worse. (Hope, J et al. (1994) Oxford Handbook of Clinical Medicine 3rd Ed Oxford, Oxford University Press p 356 ) (Murtagh, J. (1994). General Practice, McGraw-Hill Sydney p 315 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec04/ch052/ch052d.htm ) Question 33 Betty is a 78 year old active bowler who is suffering visual loss due to macular degeneration. Which of the following statements regarding macular degeneration is INCORRECT? a) The greatest risk factor is age b) It is a preventable cause of blindness c) In most patients drusen deposits are seen in the macula before loss of vision d) Central vision is affected e) Increased risk exists in patients with high myopia B. Senile or age-related macular degeneration accounts for 20% of blindness in Caucasians. It causes bilateral loss of central vision. White round spots (drusen) are seen on fundoscopy. The process is not preventable, but a few may be treated with laser. It is more common with increasing age and in those with myopia. (Lim and Constable (1992) Colour Atlas of Ophthalmology 2nd Ed Singapore, PG Publishing ) (Murtagh, J (1994). General Practice, McGraw-Hill Book Company Sydney ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section8/chapter99/99b.htm ) * Question 34 A 20 year old man was admitted to hospital because of the sudden onset of intense headache and neck stiffness. For the past 4 years, the patient had had occasional focal motor seizures on the right side of the body. Which of the following is the MOST likely diagnosis? a) Ruptured saccular (berry) aneurysm b) Hypertensive cerebral haemorrhage c) Haemorrhagic infarction d) Haemorrhage in cerebral neoplasm e) Arteriovenous malformation of brain

E. This young man presents with symptoms consistent with an acute subarachnoid haemorrhage. 80% of subarachnoid haemorrhages are caused by ruptured aneurysms (usually congenital Berry aneurysms), with the second biggest cause (5%) being AV malformations. 85% of Berry aneurysms occur around the Circle of Willis with possible warning signs being 3rd or 6th nerve palsies, pain behind the eye and other symptoms consistent with an expanding mass in this area. AV malformations are present from birth but usually present with symptoms between 10 and 30 years of age. Chief clinical symptoms and signs are headache, seizure and those associated with rupture. Focal seizures that become generalised occur in 30% of cases. The past history of focal motor seizures would suggest the presence of an arteriovenous malformation over the other causes mentioned. (Isselbacher, K.J. (Ed) (1994) Harrison's Principles of Internal Medicine 13th Ed. McGraw Hill. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section14/chapter174/174c.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section14/chapter174/174d.htm ) Question 35 In a patient with a left upper lobe bronchogenic carcinoma, which one of the following MOST STRONGLY suggests it is inoperable: a) Brachial neuritis b) Hypertrophic pulmonary osteoarthropathy (HPOA) c) Hypercalcaemia d) Horner's syndrome e) Cushing's syndrome D. All of the options reflect severe illness. These carcinomas cause peripheral neuropathies, and secrete hormones such as ACTH, PTH and ADH. HPOA can also be associated with cystic fibrosis. However, Horner's syndrome (and Pancoast's syndrome) are signs of metastatic disease, and surgery would not be an option. (Haslett C and Chilvers E (Eds) (1999) Davidson's Principles and Practice of Medicine 18th edition Churchill Livingston London ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section6/chapter81/81b.htm ) Question 36 You are performing a routine eye screening test on Mr George Penn (aged 45) and note his tonometry reading is 22 mmHg. Which of the following statements regarding primary open angle glaucoma (POAG) is INCORRECT? a) A tonometry reading of less than 22 mmHg does not exclude the diagnosis of POAG b) Characteristic optic disc changes include an increased cup disc ratio of >0.6 in either or both eyes c) Initially there is a progressive loss of peripheral vision d) Side effects of drugs commonly used in treatment may be serious

e) It would be the commonest cause of blindness in our community if left untreated C. Normal intra-ocular pressure is between 5 and 21mmHg. Up to 10% of the population over the age of 40 have raised intraocular pressure without visual field loss, known as ocular hypertension. Raised ocular pressure associated with visual field loss is strongly indicative of primary open angle glaucoma. It accounts for 10% of blindness in most countries, and is treatable if detected early. As intraocular pressure rises the optic cup enlarges and a cup/disc ratio greater than 0.5 or asymmetry glaucoma should be suspected. Drugs used in the therapy of glaucoma include timolol (a beta-blocker with the risk of heart failure and exacerbation of asthma) and acetazolamide (with side effects of hypokalemia and paraesthesia). The field defects in glaucoma are arcuate scotomata, centred around the blind spot and then the nasal field. Loss of peripheral vision and tunnel vision, develops late in the disease. (Lim, A and Constable, I. (1992) Colour Atlas of Ophthalmology 2nd Ed. Singapore PG Publishing p 52, 53 ) (Collier, J, Longmore, J and Harvey, J. (1993). Oxford Handbook of Clinical Specialties 3rd Ed. Oxford, Oxford University Press p 502, 503 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section8/chapter100/100b.htm ) Question 37 In a patient with symptoms of asthma, spirometry characteristically shows: a) Forced vital capacity is increased, but the forced expiratory volume in 1 second is normal b) Forced vital capacity is normal, but the forced expiratory volume in 1 second is reduced c) Forced vital capacity is increased, but the forced expiratory volume in 1 second is reduced d) Forced vital capacity is reduced, but the forced expiratory volume in 1 second is normal e) Forced vital capacity is reduced, but the forced expiratory volume in 1 second is reduced B. Asthma is an obstructive airways disease. There is little difference between the forced vital capacity (FVC) of the lungs between a normal subject and one with airways obstruction, however the amount of air exhaled in the first second (FEV1) is substantially less in the obstructive airways patient. The normal FEV1/FVC ratio is around 80%. In obstructive airways disease this ratio falls proportional to the severity of the obstruction. (Guyton, A (1991) Textbook of Medical Physiology. Philadelphia, WB Saunders Company p 455-456 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec04/ch044/ch044a.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section6/chapter64/64a.htm )

Question 38 A 14 year old boy presents with a long history of recurrent upper respiratory tract infections and recurrent viral gastroenteritis. Although the bacterial respiratory infections respond to antimicrobial therapy, illnesses recur quickly as a result of new infection by other pathogens. Other than suffering recurrent allergic rhinitis and vernal conjunctivitis (spring catarrh), he is well. The MOST LIKELY cause is an immunoglobulin deficiency of: a) IgA b) IgG c) IgG2 d) IgE e) IgM A. IgA accounts for 19% of the total serum immunoglobulin and is found in saliva, intestinal secretions and respiratory secretions. It plays a major role in the immune defence over the mucosal surfaces of the body. Secretory IgA is vital in the protection from enteroviruses in the gut. Selective IgA deficiency affects between 1 in 400 and 1 in 700 individuals, with clinical pictures ranging from asymptomatic to recurrent sinus, lung and gastro-intestinal infections. (Macleod, J (1985). Davidson's Principles and Practice of Medicine 14th Ed. Churchill Livingstone p 23 ) (McCance, K and Huether, S. (1990). Pathophysiology - the Biologic Basis for Disease in adults and Children. The C.C. Mosby Company p 267 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section12/chapter147/147c.htm ) Question 39 Which of the following is NOT a risk factor for primary open angle glaucoma? a) Diabetes b) Hypermetropia c) Hypertension d) Family history of glaucoma e) Age greater than 40 B. Open angle, or primary glaucoma is more common in persons over the age of 40, those with a family history of glaucoma (10 times greater risk), those with hypertension and diabetics. Myopia, rather than hypermetropia is a predisposing factor. (Collier, J, Longmore, J, and Harvey, J. (1993) The Oxford Handbook of Clinical specialties 3rd Ed Oxford, Oxford University Press p 502 ) (Berkow, R et al (1992) The Merck Manual of Diagnosis and Therapy 16th Ed Merck Research Laboratories p 2387 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section8/chapter100/100b.htm ) Question 40 Which statement about Weber's test in the clinical assessment of hearing is CORRECT? a) Weber's test is often unreliable b) In conductive deafness, sound is lateralised to the asymptomatic ear

c) In sensorineural deafness, sound is referred to the deafer ear d) Ear wax in the left ear can cause lateralisation of sound to the right ear in the absence of other pathology e) It is particularly useful in cases of mixed conductive and sensorineural deafness A. Weber's is not a completely reliable test for conductive or sensorineural hearing testing. It is performed by placing a vibrating tuning fork in the middle of the forehead. The patient is then asked to identify whether the sound localizes to one side or whether is it heard equally on both sides. In unilateral sensorineural deafness the sound is located to the good side. In conductive deafness the sound is localised to the bad side (as if the sensitivity of the nerve has been turned up to compensate for poor air conduction). Thus significant wax would cause lateralisation to the affected ear not the opposite as this is a case of conductive hearing loss. In theory, Weber's test bypasses air conduction, using bone conduction to transmit sound to the inner ear. The other clinical hearing test worth reviewing is the Rinne's test. (Hope, R.A. et al (1994) Oxford Handbook of Clinical Medicine. 3rd Ed. Oxford University Press ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section7/chapter82/82b.htm ) 27 questions were answered correctly. 13 questions were answered incorrectly. 0 questions were unjudged by the system. 40 questions were attempted. 40 questions are available in this quiz. 11 questions were Mastery questions. 6 Mastery questions were correctly answered in this quiz.

-------------------------------------------------------------------------------List of Incorrect Questions Question 3 Question 7 * Question 14 * Question 24 Question 27 Question 29 Question 31 * Question 32 * Question 34 Question 37 Question 39 Question 40 * Question 2

List of Correct Questions * Question 4 Question 5 Question 6 Question 8 Question 9 * Question 10 * Question 11 Question 12 Question 13 Question 15 Question 16 Question 17 Question 18 * Question 19 * Question 20 Question 21 Question 22 Question 23 Question 25 Question 26 Question 28 Question 30 Question 33 Question 35 Question 36 Question 38

* Question 1