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* Question 1

Bill is 65 years old and has just been diagnosed with type 2 diabetes. He returns to
discuss the condition. What would you tell him about diabetic retinopathy?
a) He should see an ophthalmologist straight away for a thorough eye
examination
Correct
b) It is safe to wait 2 years after diagnosis for his first ophthalmologist referral
c) His age is the biggest risk factor for diabetic retinopathy
d) Retinopathy is an uncommon complication of type 2 diabetes
e) None of the above

At diagnosis, one in six patients with Type 2 diabetes has retinopathy. If untreated,
this progresses to cause retinal scarring, contraction of the vitreous humour and
retinal detachment. Eventually about 85% of all patients will show signs of
retinopathy, the biggest risk factors being duration of diabetes and glycaemic
control. All patients with diabetes should be screened for retinopathy at the time of
diagnosis, and then at least every two years thereafter. Laser therapy is very
effective and halves the risk of visual loss from diabetic retinopathy.
(National Health and Medical Research Council. Management of diabetic retinopathy.
Clinical practice guidelines. Commonwealth of Australia, 1997
Available:
www7.health.gov.au/nhmrc/publications/pdfcover/cp56covr.htm )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section8/chap
ter99/99a.jsp%3Fregion%3Dmerckcom&word=diabetic&word=retinopathy&domain=
www.merck.com#hl_anchor )

Question 2
Complete the following sentence: 'In the first few days of a low calorie diet in the
management of obesity ...'
a) More fat than water is lost
b) Most of the weight lost is water
c) Lean body mass is not affected
Incorrect. The correct answer is (b).
d) Glycogen stores are retained
e) Sodium loss is reduced

When treating obesity with caloric restriction, the initial marked weight loss is largely

due to fluid loss, but these changes tend not to persist. During the first 24 hours or
so energy is derived mainly from catabolism of carbohydrate in the form of glycogen
stored, in association with water, chiefly in the liver. As glycogen is degraded to
glucose and then carbon dioxide and water, there is significant water release and
excretion. Once glycogen stores have been depleted, glucose synthesis depends on
gluconeogenesis from breakdown of protein. Finally, only when the glucagon:insulin
ratio in the blood is high enough to promote significant fat breakdown does fat in
adipose tissue stores become the main source of energy for tissue metabolism with
consequent sustained weight loss.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=60260 )

* Question 3
Akira, a long standing patient of your practice wants to discuss a friend of his who
has had his toenail removed because of a melanoma. Which of the following
statements about subungual melanoma is CORRECT?
a) This is a common form of malignant melanoma
b) It usually has a good prognosis
c) Removal of the nail may be curative
d) Five year survival depends mainly on tumour thickness
Correct
e) This form of melanoma rarely metastasises

Melanoma located on the palm, sole or nail bed is called acral lentiginous type and
accounts for 2-8% of all malignant melanomas, with subungual melanoma being
rare. Lifetime risk of melanoma is approaching 1:50, higher if fair-complexioned, a
history of blistering childhood sunburn, multiple melanocytic naevi or dysplastic
naevi, and a positive family history. Although melanoma is much less common in
non-white groups, their proportion of acral type is 30-50%. Because of the location,
they are often diagnosed late so have a poorer outcome. Prognosis is mainly
dependent on tumour thickness and stage as identified by nail bed biopsy. Treatment
involves removal of the digit clear of the margin.
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 1209-12 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section10/cha
pter126/126d.jsp%3Fregion%3Dmerckcom&word=melanoma&domain=www.merck.
com#hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=62135&searchStr=melanoma#searchT

erm )
(Medscape (Registration is free)
Available:
www.medscape.com/viewarticle/448503?src=search )

Question 4
Jim, who has type 2 diabetes, states that he has been advised by another doctor to
have laser treatment to both eyes. He does not see the need as his vision is fine.
What advice would you offer him?
a) To have the procedure as quickly as possible
b) That if he doesn't proceed his vision will eventually deteriorate
c) That treatment may result in worsening of night vision
d) That it is usually performed under local anaesthetic
e) All of the above
Correct

Laser therapy is performed using an apparatus similar to a slit lamp. Patients rarely
require admission to hospital. If a large amount of photocoagulation is planned,
regional anaesthetic is used. Laser therapy is very effective and halves the risk of
visual loss from diabetic retinopathy. If untreated, proliferative retinopathy can
cause sudden visual loss in one or both eyes. The new blood vessels bleed onto the
retinal surface causing scarring, contraction of the vitreous humour and retinal
detachment.
(National Health and Medical Research Council. Management of diabetic retinopathy.
Clinical practice guidelines. Commonwealth of Australia, 1997
Available:
www7.health.gov.au/nhmrc/publications/pdfcover/cp56covr.htm )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section8/chap
ter99/99a.jsp%3Fregion%3Dmerckcom&word=diabetic&word=retinopathy&domain=
www.merck.com#hl_anchor )

Question 5
A 25 year old man presents with a non-tender swelling on the right side of the neck,
followed by a similar swelling on the left side two weeks later. He has recently
suffered from periodical fever, malaise and weight loss. Physical examination shows
enlarged lymph nodes in the neck, axillae and groins, and a spleen palpable 2 cm
below the left costal margin. Chest X-ray shows bilateral moderately enlarged hilar
nodes. The haemoglobin is 105 G/L (130 - 180), and leucocytes number 11 x 109

G/L (4.3 - 10.8 x 109) with a normal distribution of white cells. The red cells appear
normochromic and normocytic.
What is the MOST LIKELY diagnosis?
a) Aleukaemic leukaemia
b) Hodgkin's disease
Correct
c) Infectious mononucleosis
d) Non-Hodgkin's Lymphoma (NHL)
e) Secondary syphilis

Hodgkin's disease usually presents with painless cervical lymphadenopathy. The


disease can spread to involve the other parts of the reticuloendothelial system such
as the liver and spleen. It is commonly accompanied by anaemia (normochromic,
normocytic), fever, anorexia and weight loss. Non-Hodgkins Lymphoma presents
with symptoms and signs similar to Hodgkin's Disease, but at a much later stage of
life. Mean age of onset for Hodgkin's disease is 31 years; mean ages for NHL are 6570 years. Aleukaemic leukaemia usually presents with anaemia, thrombocytopaenia
and granulocytopaenia. Infectious mononucleosis is associated with a sore throat,
myalgia, arthralgia and a maculo-papular rash.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=65965&searchStr=hodgkin's+disease#
65965 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section11/cha
pter139/139b.jsp%3Fregion%3Dmerckcom&word=hodgkin's&word=disease&domain
=www.merck.com#hl_anchor )

Question 6
The diagnosis of Hodgkin's disease should be confirmed by:
a) Lymph node biopsy
Correct
b) Repeat blood film and ESR
c) Bone marrow aspiration
d) Biopsy of the spleen
e) Thoraco-abdominal CT scan

Hodgkin's disease is established by the review of an adequate lymph node biopsy

specimen by an expert pathologist. Staging will involve all of the following:- careful
history and examination, full blood examination, ESR and biochemical analysis
including LDH, CT scan of chest, abdomen, and pelvis, and bone marrow biopsy.
Patients may also undergo a PET or gallium scan. Staging laparotomy is rarely
performed.
(Harrison's Online
Available:
www.accessmedicine.com/content_main.aspx?aID=65965#65965 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section11/cha
pter139/139b.jsp%3Fregion%3Dmerckcom&word=hodgkin's&word=disease&domain
=www.merck.com#hl_anchor )

Question 7
The specific microscopic feature which should be looked for in the investigation of
Hodgkin's Disease is:
a) A large atypical lymphocyte
b) A lymphoblast
c) A myelocyte
d) A Reed-Sternberg cell
Correct
e) A Langhan's giant cell

Hodgkin's disease is characterised by a predominance of small lymphocytes and, less


commonly, large Reed-Sternberg cells. Reed-Sternberg cells are the histological
hallmark of the disease, they are large malignant lymphoidal cells with
multilobulated nuclei and prominent inclusion-like nucleoli.
(Harrison's Online
Available:
www.accessmedicine.com/content_main.aspx?aID=65965#65965 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section11/cha
pter139/139b.jsp%3Fregion%3Dmerckcom&word=hodgkin's&word=disease&domain
=www.merck.com#hl_anchor )
Question 8
Anna, a 3 year old child, develops pustular lesions on her face which subsequently
form a honey-coloured crust and start spreading. You diagnose impetigo. Which of
the following statements would be included in your advice to her parents?

a) Since Anna is otherwise well, she may attend her child care centre
b) There is no danger of spread to family members
c) Topical treatment will not usually be sufficient to achieve cure
d) Anna must be isolated until the lesions have completely resolved
Incorrect. The correct answer is (e).
e) Lesions should be adequately covered to reduce self-inoculation

Impetigo is usually caused by group A streptococci, other streptococci or Staph


aureus. It is usually highly contagious, so precautions must be taken to reduce
spread. This will include covering the lesions, careful hand washing, and disposal of
items used near the lesions. If impetigo is mild, topical antiseptic cleansing with
removal of crusts is indicated. Persistent lesions often respond to topical mupirocin
applied three times a day for 7-10 days. If extensive or causing systemic symptoms
oral antibiotics should be used eg phenoxymethylpenicillin if a Streptococcus is
suspected as the primary infection and flu(di)cloxacillin if Staph aureus is suspected.
Exclusion from child care is only necessary up to 24 hours after antibiotic treatment
begins.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section19/cha
pter265/265a.jsp%3Fregion%3Dmerckcom&word=impetigo&domain=www.merck.co
m#hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=56803&searchStr=impetigo#56803 )
Question 9
Which of the following is INCORRECT in relation to medication usage in diabetics?
a) Aspirin may worsen diabetic retinopathy
Correct
b) Metformin is the agent of choice in the overweight patient
c) Sulphonylureas are contraindicated in pregnancy
d) Insulin may improve outcomes following myocardial infarction
e) Beta blockers may increase the risk of hypoglycaemic episodes

Aspirin will not worsen diabetic retinopathy. Trials have shown that there is no
benefit or harm with aspirin in diabetic retinopathy. Sulfonylureas are
contraindicated in pregnancy because of their effect on the foetus. Metformin
improves glucose uptake by skeletal muscle cells and has favourable effects on
weight and the lipid profile. It is therefore the agent of choice for overweight
patients. Beta blockers affect glucose metabolism and may mask early signs of
hypoglycaemia. Beta blockers should not be used in patients with labile insulin-

dependent diabetes mellitus. Even mild hyperglycaemia increases the risk of


extension of damage to myocardium following an infarct. Studies show that tight
control of blood glucose level using insulin post-AMI improves outcomes.
(Clement S et al (2004) Management of diabetes and hyperglycaemia in hospitals.
Diabetes Care, 27: 553-591
Available:
care.diabetesjournals.org/cgi/content/full/27/2/553 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section2/chap
ter13/13a.jsp%3Fregion%3Dmerckcom&word=management&word=of&word=diabet
es&domain=www.merck.com#hl_anchor )
Question 10
A man aged 54 years complains of weakness, lassitude, low back pain and 5kg loss
of weight over six months. Physical examination is normal. Urinalysis shows protein.
Blood count shows: haemoglobin 110g per L (130 - 180) with red cells
normochromic and normocytic, white cell count 7.5 x 109 per L (4.3 - 10.8) with a
normal differential count; E.S.R. is 102mm in one hour; Serum protein 98 G per L
(55 - 80), x-rays show a generalised demineralisation of the vertebrae and sharply
defined osteolytic lesions in the skull. Which of the following investigations is MOST
LIKELY to be helpful in establishing the diagnosis?
a) Bone marrow biopsy
b) Bone scan
c) Prostatic biopsy
d) Serum calcium and alkaline phosphatase
e) Thoraco-abdominal CT scan
Incorrect. The correct answer is (a).

Multiple myeloma is characterised by the presence of paraprotein in the serum


produced by abnormal proliferating plasma cells and Bence-Jones protein, comprising
light chain components of immunoglobulins in the urine. Clinically, it results in bone
destruction, bone marrow infiltration and renal impairment. ESR and serum protein is
raised, and proteinuria is present. Skeletal survey shows characteristic lytic lesions,
easily seen on the skull. Bone marrow aspirate shows characteristic infiltration by
plasma cells. Definitive diagnosis depends on identification of abnormal paraprotein
with or without immunoglobulin light chains in the serum or urine. This is done by
immunoelectrophoresis.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=66024&searchStr=multiple+myeloma )
(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/mmanual/section11/chapter140/140d.jsp )

Question 11
Six year old Melanie has been brought to your surgery with a graze on her knee
sustained 3 days ago. Her mother says the lesion has increased in size and is now
partly covered by a thick golden crust and exudes serous fluid. The surrounding skin
is inflamed and her temperature is 38.5 degrees Celsius. Which of the following
antibiotics would be MOST effective in treating Melanie?
a) Phenoxymethylpenicillin
b) Amoxycillin
c) Flucoxacillin
Correct
d) Doxycycline
e) Erythromycin

This is a superficial wound which has become impetigenous, ie like impetigo. In


addition the infection has spread to the surrounding skin and is causing systemic
effects. The causative organism is most likely Staph aureus. Flucloxacillin (or
dicloxacillin) is the most appropriate antibiotic.
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 898 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section10/cha
pter112/112h.jsp%3Fregion%3Dmerckcom&word=impetigo&domain=www.merck.co
m#hl_anchor )

Question 12
Maria comes in to discuss her husband's diabetes with you. She has read about the
glycaemic index (GI) of food and wants to know more about it, so she can cook the
right foods for him. Which of the following facts is INCORRECT?
a) Hommus (chickpea salad dip) has one of the lowest GIs
b) Boiled potatoes have a GI equivalent to 50G glucose
c) Carbohydrates that are quickly digested have a higher GI
d) The same amount of carbohydrate may show a wide variation in GI
e) High GI foods increase metabolism and assist in weight loss
Correct

The GI is measured by the ability of a particular carbohydrate food to raise the blood
glucose level on a scale of 1-100 where 50gm glucose is 100. Various factors affect
the GI of a food, including the size of the starch particles, ratio of amylose to
amylopectin, and the presence of fibre, fat, protein and organic acids. Wholegrain
foods and legumes have a low GI compared with refined cereals and breads. Lower
GI foods are slower to digest and improve satiety. They assist in weight management
and have a protective effect against diabetes and heart disease.
(University of Sydney, GI Website
Available:
www.glycemicindex.com/ )
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 8 )

Question 13
Which of the following pathological features is associated with multiple myeloma?
a) Increased plasma alkaline phosphatase
b) Decreased plasma acid phosphatase
c) Increased serum globulin
Correct
d) Decreased serum beta2 microglobulin
e) Decreased serum calcium

A raised serum globulin is characteristically found in patients with multiple myeloma.


The condition is due to overproduction of a single immunoglobulin species from a
clone of malignant plasma cells. These antibodies may not be biologically active, but
can cause problems clinically because of hyperviscosity of the blood, leading to
thrombotic phenomena, and deposition in tissues such as the kidney, leading to renal
failure. There is hypercalcaemia due to lysis of bone, but plasma alkaline
phosphatase and acid phosphatase levels are usually normal. A rise in beta2
microglobulin correlates with myeloma cell mass and a worse prognosis.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=66024&searchStr=multiple+myeloma )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section11/chapter140/140d.jsp )

Question 14
Complete the following sentence: 'The term 'keratitis' refers to inflammation of the
...'

a) Keratinised layer of the skin


b) Germinal layer of the nailbed
c) Glans penis
d) Cornea
Correct
e) Eyelids

Keratitis is inflammation of the cornea; other corneal lesions include


keratoconjunctivitis, keratoconus and keratectasia. The term "keros" (meaning
horny) is also used to describe layers of skin and of the nails.
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 562 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section8/chap
ter96/96c.jsp%3Fregion%3Dmerckcom&word=keratitis&domain=www.merck.com#h
l_anchor )

Question 15
Susan comes to see you concerned about her 68 year old mother who has recently
been diagnosed with type 2 diabetes. Her mother is refusing to make any dietary or
lifestyle changes, insisting that tablets will keep everything under control. Which of
the following advice would be appropriate to give Susan about her mother's
condition?
a) This form of diabetes is often mild and strict adherence to medication regimes
will usually be sufficient in those over 65 years of age
b) It is difficult to adjust to life with a chronic illness and encouragement to
gradually make changes over the next few years will suffice
c) There may already be complications present so it is essential that diet, exercise
and good blood sugar control be adhered to
Correct
d) It is only when diabetes is insulin-requiring that the issue of complications
necessitates tighter control
e) It may be necessary to do a mini mental state examination to exclude early
dementia as a reason for poor compliance

Type 2 diabetes is not a mild disease. About one third of those surviving 15 years
will require insulin to treat symptoms or complications. Complications such as
diabetic retinopathy, nephropathy, neuropathy, macro and microvascular disease
occur in both types of diabetes. In order to prevent complications, the patient needs
to achieve strict glycaemic control through weight loss, diet, and medication as
needed. Self-monitoring is essential. All patients with diabetes should know and
practice routine foot care. They are at risk of damage because of vascular disease,

neuropathy, increased risk of infection and slower healing. Podiatrists can implement
preventative therapy at an early stage.
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 189-200 )
(Yeap BB (2001) Primary care Diabetes: what options are there? Australian Family
Physician, 30: 1123-1128 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section2/chap
ter13/13a.jsp%3Fregion%3Dmerckcom&word=diabetes&domain=www.merck.com#
hl_anchor )

Question 16
In patients with multiple myeloma what is the MOST COMMON clinical course?
a) Steady progression over 2-5 years with complications
b) Gradual development of myelofibrosis
c) A remitting/relapsing course over many years
d) Rapid decline and death within 1-2 years
Incorrect. The correct answer is (a).
e) Chronic phase followed by acute terminal leukemia

The majority of patients with multiple myeloma experience progression of the


disease with complications, including anaemia, renal failure, pathological fractures,
infections, neurological manifestations and bleeding. Only 10% will have an indolent
course with slow disease progression over many years. In young people, it is an
aggressive disease which may be rapidly fatal (within 1 year). The advent of bone
marrow transplant has improved survival rates significantly.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=66024&searchStr=multiple+myeloma )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section11/chapter140/140d.jsp )

Question 17
Complete the following sentence: 'The skin condition that is COMMONLY responsible
for persistent dandruff is ...'
a) Irritant dermatitis

b) Seborrhoeic dermatitis
Correct
c) Tinea capitis
d) Lichen planus
e) Pityriasis versicolor

Seborrhoeic dermatitis is a chronic inflammation of the skin characterised by


erythema and scaling. It occurs in areas of skin where sebaceous glands are most
active, and therefore is common on the face and scalp. It can also affect the centre
of the chest and back, axilla, groin and perianal area.
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 1221 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section10/cha
pter111/111d.jsp%3Fregion%3Dmerckcom&word=dandruff&domain=www.merck.co
m#hl_anchor )

Question 18
Tom is a 70 year old diabetic and has recently started on insulin. Which of the
following statements about insulin pens is INCORRECT?
a) The dose should be delivered quickly and pen immediately withdrawn
b) Short, fine needles of 29-31 guage allow virtually pain-free injections
c) Pens can now deliver more than one type of insulin
d) Cartridges containing clouded insulin must be changed when 12 units remain
e) All but one of the insulin pens in Australia are made by Novo-Nordisk
Incorrect. The correct answer is (a).

Insulin pens make insulin injections simpler, since drawing up and mixing are not
necessary and so multiple daily injections are easier. They are very easy to use "just insert the needle and press the button". The button will not depress if the
cartridge is empty. In clouded insulin gently tilting the cartridge several times allows
a small glass ball to mix the solution. Once less than 12 units remains there is not
enough solution for the mixing ball to function optimally. The injection should be
given slowly and the needle should be left in place for six seconds after injection.
(Information on a brand of insulin pen - Novo Nordisk
Available:
www.novonordisk.com/diabetes/public/insulinpens/flexpen/quickguide/view.asp?Id=
2238&audioStatus=on )
(The Royal Children's Hospital Diabetes Manual
Available:

www.rch.org.au/diabetes_manual/manual.cfm?doc_id=2733#devices )
(Australian Prescriber 2002;25(6):136-8
Available:
www.australianprescriber.com/magazines/vol25no6/pdfs/Dunning.pdf )

* Question 19
Roy, 84 years of age, returns for review of test results taken to investigate his
tiredness. His total protein is elevated with a monoclonal rise in the gammaglobulin
fraction. The full blood count, renal function studies, and X rays are all normal. There
are no urinary Bence Jones proteins. Referral for a bone marrow biopsy shows <10%
plasma cells. Which of the following statements about his condition is INCORRECT?
a) His tiredness is due to hypothyroidism which is often associated with this
condition
b) Up to 10% of people over 75 years of age have similar findings
Incorrect. The correct answer is (a).
c) He has about 1% chance per year of developing multiple myeloma
d) Life expectancy is shorter by 2 years due to this abnormality
e) There may be an associated carcinoma of prostate, kidney or gastrointestinal
tract

Monoclonal gammopathy of uncertain significance (MGUS) is occasionally associated


with other conditions such as non-lymphoreticular neoplasms, chronic inflammation
or infection, and thyrotoxicosis. With a low risk of progression, clinical and blood test
review is necessary every 6-12 months. All the other statements are correct.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=66024&searchStr=multiple+myeloma )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section11/chapter140/140b.jsp )

Question 20
Complete the following sentence: 'Dandruff commonly presents in....................'
a) Childhood
b) Adolescence
c) Early adulthood
Incorrect. The correct answer is (b).
d) Middle age

e) Old age

Dandruff is caused by seborrhoeic dermatitis which becomes most prominent when


the sebaceous glands are most active. This occurs most commonly in adolescence.
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 1221 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section10/chapter111/111d.jsp )

Question 21
Betty, aged 55 years, has diabetes and comes in for her annual eye checkup. Which
of the following statements about the eye in diabetes is CORRECT?
a) If the patient doesn't have symptoms, the examination is likely to be negative
b) Fundoscopy without pupillary dilatation is adequate for screening purposes
Incorrect. The correct answer is (c).
c) A normal red reflex makes the presence of a cataract unlikely
d) Pupillary reflex is unaffected by diabetes
e) Assessment of refractive error is not a routine part of the diabetic eye check

At diagnosis, one in six patients with Type 2 diabetes has retinopathy and eventually
about 85% will develop this complication. Irrespective of symptoms, all patients with
Type 2 diabetes should be screened on diagnosis, and then at least every two years
thereafter. Examination includes checking red reflex for cataracts, dilating the pupils
and performing fundoscopy to observe the macula, optic disc, and other areas. Blood
glucose concentration should also be checked. Dense cataracts cause the red reflex
to be totally obscured; smaller cataracts will be seen as opacities against the red
reflex. Refractive errors occur as the lens shape alters with changes in blood glucose
concentrations.
(National Health and Medical Research Council. Management of diabetic retinopathy.
Clinical practice guidelines. Commonwealth of Australia, 1997
Available:
www7.health.gov.au/nhmrc/publications/pdfcover/cp56covr.htm )
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 847-859 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section8/chapter99/99a.jsp )

* Question 22

A 60 year old man presents with severe abdominal pain, shock, moderate abdominal
rigidity and intense back pain. Which of the following diagnoses is MOST LIKELY?
a) Acute retrocaecal appendicitis
b) Leaking aortic aneurysm
Correct
c) Renal colic
d) Acute cholecystitis
e) Collapse of L4 vertebral body

A leaking abdominal aortic aneurysm typically presents with severe abdominal pain,
shock, abdominal rigidity and intense lower back pain. It can be mistaken for renal
colic, acute cholecystitis, and retrocaecal appendicitis. However circulatory shock is
not usually present in these conditions. The BP may be increased due to pain.
Collapse of the L4 vertebral body results in more localised pain without shock.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section16/cha
pter211/211a.jsp%3Fregion%3Dmerckcom&word=abdominal&word=aortic&word=a
neurysm&domain=www.merck.com#hl_anchor )
(Way LW, Doherty GM (2003) Current Surgical Diagnosis & Treatment, 11th Ed,
McGraw-Hill, NY, 830-5 )

Question 23
Which of the following pathological changes is MOST LIKELY to occur in x-irradiated
skin?
a) Telangiectasis
b) Melanoma
Incorrect. The correct answer is (a).
c) Keloid formation
d) Excessive hair growth
e) Chronic hyperpigmentation

Telangiectasia (dilated superficial blood vessels), is the most visible aspect of chronic
radiation dermatitis. The changes following radiotherapy are permanent in the long
run, and also include epidermal atrophy and changes in hyalinization and hair
growth.
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 1413-5 )
(Harrison's Online

Available:
www.accessmedicine.com/content.aspx?aID=57087&searchStr=telangiectasis#searc
hTerm )
(NHS Best Practice Statement: Skin Care of Patients Receiving Radiotherapy, April
2004 pp 11-13
Available:
www.nhshealthquality.org/nhsqis/files/20373%20NHSQIS%20Best%20Practice.pdf )

Question 24
In haemolytic jaundice, bilirubin is absent from the urine because plasma bilirubin is:
a) Not usually elevated
b) Deposited in skin and sclera
c) Unconjugated and not water soluble
Correct
d) All protein bound and thus not filterable
e) Converted by the liver to urobilinogen

In haemolytic jaundice there is an increased breakdown of red blood cells leading to


increased production of bilirubin in reticulo-endothelial cells. As this occurs prior to
the bilirubin reaching the liver (where it gets conjugated with glucuronic acid), the
increased plasma bilirubin is unconjugated and not water soluble. It will therefore
not pass into the urine. Urinary urobilinogen is increased because there is more
bilirubin available for conversion to urobilinogen by gut bacteria, and urobilinogen is
water soluble.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=55401 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section4/chapter38/38b.jsp )

* Question 25
A patient who has been treated with a preparation containing horse serum develops
urticaria followed by swelling of the tongue and dyspnoea. Which of the following is
the MOST APPROPRIATE immediate treatment?
a) Tracheotomy
b) Subcutaneous adrenaline
Correct
c) Intravenous hydrocortisone

d) Intravenous promethazine (Phenergan)


e) Oxygen therapy

This is acute angio-oedema and there is a risk of upper airways closure and
anaphylaxis, so subcutaneous adrenaline should be given first.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section12/cha
pter148/148b.jsp%3Fregion%3Dmerckcom&word=anaphylaxis&domain=www.merck
.com#hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=94009
Available:
www.accessmedicine.com/content.aspx?aID=94027&searchStr=angioneurotic+edem
a)

Question 26
Which of the following statements about adolescent girls with suspected iron
deficiency anaemia is INCORRECT?
a) Early symptoms can include problems with academic performance
b) The onset of menstruation is the main contributor to this condition
Incorrect. The correct answer is (c).
c) A normal plasma ferritin level excludes the diagnosis
d) The blood film shows a microcytic, hypochromic picture
e) Coeliac disease is a possible cause

Iron deficiency is common in adolescent girls with a prevalence of 9%. A low plasma
ferritin indicates low total body stores of iron. However, ferritin is an acute phase
reactant, so its plasma level is increased by acute or chronic inflammation. This may
mask iron deficiency. Early symptoms of iron deficiency include changes in cognitive
function and memory, decreased concentration and fatigue.
(BMJ Online
Available:
bmj.bmjjournals.com/cgi/content/full/314/7077/360?maxtoshow=&HITS=10&hits=1
0&RESULTFORMAT=&fulltext=iron+deficiency+anaemia&andorexactfulltext=and&sea
rchid=1110174591601_20880&stored_search=&FIRSTINDEX=0&sortspec=relevance
&resourcetype=1 )

Question 27

Which of the following conditions is MOST LIKELY to arise in an actinic keratosis?


a) Malignant melanoma
b) Squamous cell carcinoma
Correct
c) Basal cell carcinoma
d) Kerato-acanthoma
e) Bowen's disease

Squamous cell carcinoma develops in solar keratosis over a long period of time. The
rate of malignant change is thought to be 1/1, 000.
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 1196-7 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section10/cha
pter126/126c.jsp%3Fregion%3Dmerckcom&word=solar&word=keratosis&domain=w
ww.merck.com#hl_anchor )

Question 28
With regard to Hepatitis C in Australia, which of the following statements is
INCORRECT?
a) About 16,000 new infections are occurring in Australia each year
b) Around 83% of existing infections are due to sharing equipment used to inject
illicit drugs
c) Couples in which one partner is hepatitis C positive are advised to always use
condoms to avoid sexual transmission
Correct
d) For mothers who are hepatitis C positive, breastfeeding is encouraged unless
nipples are cracked or bleeding
e) This infection is now the most common reason for liver transplantation in
Australia

Although there is some uncertainty about hepatitis C being transmitted sexually, it is


not classified as an STD (sexually transmitted disease). If it occurs, sexual
transmission is rare and probably more likely if there is blood-to-blood contact
during sex. With a new or casual partner or in case of possible blood-to-blood
contact, safe sex practices should always be used to protect against a range of STDs.
All the other statements are correct. Further information may be found in the
reference.
(Hepatitis C Council of NSW

Available:
www.hepatitisc.org.au/quickref/factsheet.html )

Question 29
In which of the following conditions are nails MOST COMMONLY affected?
a) Systemic lupus erythematosis (SLE)
b) Psoriasis
Correct
c) Iron deficiency
d) Infective endocarditis (IE)
e) Hypoalbuminaemia

Psoriasis commonly affects the nails. Pitting of the nails, occurs in 25% of patients.
Other effects include hyperkeratosis, ridging, and onycholysis i.e. separation of the
distal nail from the nail bed (which is often mistaken for fungal paronychia). Splinter
haemorrhages and telangiectasia occur in SLE; spoon-shaped nails (koilonychia) in
iron deficiency; splinter haemorrhages and clubbing in IE; and white nails
(leukonychia) in hypoalbuminaemia.
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 1196-7 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section10/cha
pter117/117b.jsp%3Fregion%3Dmerckcom&word=psoriasis&domain=www.merck.co
m#hl_anchor )
(Talley & O'Connor, ISBN: 0864331444. CLINICAL EXAMINATION 4th Edition, A
Systematic Guide to Physical Diagnosis. MacLennan + Petty)

Question 30
Moira is a 70 year old woman who presents with abdominal discomfort for 6 months.
On examination she has generalized lymphadenopathy and splenomegaly. What is
the MOST LIKELY diagnosis?
a) Acute lymphoblastic leukaemia
b) Acute myeloid leukaemia
c) Hodgkin's lymphoma
d) Infectious mononucleosis
e) Chronic lymphocytic leukaemia
Correct

Chronic lymphocytic leukaemia is a disease of late middle-aged and elderly people. It


may be asymptomatic in the early stages and is often diagnosed on a routine blood
count. Symptoms, which are insidious in onset, include lethargy, fevers, loss of
weight and infections. Signs include moderate enlargement of the lymph nodes, liver
and spleen.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=65842 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section11/cha
pter138/138c.jsp%3Fregion%3Dmerckcom&word=chronic&word=lymphoid&word=le
ukemia&domain=www.merck.com#hl_anchor )

Question 31
Miriam has recently developed bloating and heartburn after meals. On reviewing her
medications which of the following is UNLIKELY to be a cause of this new problem:
a) Iron supplements
Incorrect. The correct answer is (c).
b) Progestogen therapy
c) An ACE inhibitor
d) A non-steroidal ant-inflammatory drug (NSAID)
e) Long term tetracycline

While ACE inhibitors may cause nausea, more common adverse effects are
hypotension, cough, dizziness and hyperkalemia. Abdominal pain and nausea are
common side effects of iron supplements. Bloating and nausea are commonly
reported with progestogen therapy. Dyspepsia, nausea and diarrhoea are commonly
reported by users of NSAIDs and these are contra-indicated in those with peptic
ulcer disease. Oesophageal ulceration can occur with tetracycline, thus patients are
advised not to lie down within one hour of taking a dose.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=90661&searchStr=abdominal+bloating
#searchTerm )
( Rang HP, Dale MM, Ritter JM (1995) Pharmacology, Third Ed. Churchill Livingstone,
Melbourne, p 315-6)

* Question 32

Which one of the following is NOT characteristic of an upper motor neurone lesion?
a) Clonus
b) Extensor plantar response
c) Intact superficial reflexes
Correct
d) Increased tone
e) Hyperactive tendon reflexes

The following signs result from lesions in the motor system proximal to the alpha
motor neurone: spasticity (hypertonia predominant in flexors of arms and extensors
of legs which is of a clasp-knife nature); paralysis or weakness predominantly of
extensors in arms and flexors in legs; hyperreflexia; extensor plantar response;
clonus and Hoffmann's reflex. The extensor plantar response is an example of loss of
a superficial reflex.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=53044&searchStr=upper+motor+neuro
n+lesion#searchTerm )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section14/cha
pter165/165c.jsp%3Fregion%3Dmerckcom&word=upper&word=motor&word=neuro
n&word=lesion&domain=www.merck.com#hl_anchor )

Question 33
Francesco Napoli, aged 46 years, presented complaining of years of gastrooesophageal reflux. He was found to have positive Helicobacter pylori antibodies.
Regarding H. pylori, which of the following statements is CORRECT?
H. pylori:
a) Is the most common bacterial infection of humans worldwide
b) Is positive in about 60% of adult Australians
c) Infects humans from a reservoir in healthy domestic animals
d) Causes peptic ulcer disease and duodenal cancer
Incorrect. The correct answer is (a).
e) Is present in >80% of patients with non-ulcer dyspepsia

Some parts of the world, particularly developing countries have 80-90% prevalence
of H pylori infection in adults. Australian prevalence is about 30-40%. Most infections
are acquired in childhood from a parent. Humans are the only reservoir. This
infection is a known cause of peptic ulceration and the organism is now classified as

a biological carcinogen due to its strong connection with gastric cancer. Only 25-50%
of people with non-ulcer dyspepsia are positive for H pylori and most will not have
resolution of symptoms after H pylori eradication.
(Gastroenterological Society of Australia
Available:
www.gesa.org.au/members_guidelines/helicobacter/index.htm )

Question 34
Mrs Elaine Wu underwent endoscopy for recent onset of dyspepsia. The biopsy
verified the presence of Helicobacter pylori-positive gastric ulceration. She is not
allergic to any medication. The MOST APPROPRIATE first line therapy is:
a) A histamine type 2 receptor antagonist for 6 to 8 weeks
b) A proton pump inhibitor (PPI) for 4 to 6 weeks
c) Ranitidine-bismuth-citrate 400mg bd, amoxycillin 1G bd, and clarithromycin
500mg bd for 7 days
d) PPI bd, amoxicillin 1G bd, and clarithromycin 500mg bd for 7 days
Correct
e) PPI bd, clarithromycin 500mg bd, and metronidazole 400mg bd for 7 days

Acceptable triple therapy regimens for the eradication of H.pylori vary depending on
the availability of medications and the incidence of resistance to antibiotics used. In
Australia, metronidazole-resistant strains are now common (>50%) and
metronidazole can no longer be recommended for first-line therapy if there is no
allergy to penicillins. The combination of a standard dose of PPI, amoxicillin 1G and
clarithromycin 500mg all delivered bd for 7 days gives an eradication rate of >90%.
It is available as a single script on the Pharmaceutical Benefits Scheme as either
"Klacid Hp7" or "Nexium Hp7". In penicillin hypersensitivity the amoxicillin is
replaced with metronidazole 400mg bd with efficacy 80-85%. In treatment failure,
there may be attempts to conduct bacterial culture and sensitivity testing. Otherwise
a trial of quadruple therapy using a PPI, bismuth subcitrate, metronidazole and
tetracycline for 10-14 days will give 75% chance of eradication.
See references for further discussion about when to consider H pylori testing and
eradication and how to follow up treated patients.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section19/cha
pter268/268b.jsp%3Fregion%3Dmerckcom&word=h.&word=pylori&domain=www.m
erck.com#hl_anchor )
(Murtagh J (2003) General Practice. Third ed. McGraw-Hill, Sydney, p 524-5 )
(Gastroenterological Society of Australia
Available:
www.gesa.org.au/members_guidelines/helicobacter/index.htm )

* Question 35
A 67 year old man presented three days after a stent was inserted for the treatment
of persistent angina. He now complains of a persisting "different" chest pain and
shortness of breath on exertion. On examination you find he is pale and slightly
sweaty with: pulse rate 110 regular with pulsus paradoxus; BP 100/90; T 38.0
degrees Celsius; pedal oedema; bilateral basal crepitations in his chest; and a JVP
elevated 3cm. Heart sounds are dual. The MOST LIKELY cause of his condition is:
a) Hospital acquired pneumonia
b) Post-infarct left ventricular remodelling with failure
c) Extension of the infarct secondary to stent failure
d) Pericarditis with tamponade
e) Bacterial endocarditis
Incorrect. The correct answer is (d).

Pericarditis is a recognised, although uncommon, complication of invasive cardiac


treatments. The patient can lose the pain of angina, only to have it replaced by a
more vague chest discomfort. Inflammatory pericarditis results in an effusion which
can rapidly escalate into tamponade. None of the other options would show signs of
biventricular failure this quickly.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section16/cha
pter209/209b.jsp%3Fregion%3Dmerckcom&word=pericarditis&domain=www.merck.
com#hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=81771&searchStr=pericarditis#searchT
erm )

* Question 36
A 60 year old engineer was admitted to hospital because of fever, cough, and
pleuritic chest pain. His temperature was 40 degrees Celsius. Physical examination
and x-ray of the chest indicated right lower lobar pneumonia. Sputum smear and
culture demonstrated pneumococci. Treatment with intravenous penicillin was
commenced. After several days, fever and leucocytosis decreased and x-ray of the
chest showed some clearing of infiltrate. On the 7th hospital day, his temperature
spiked to 39.4 degrees Celsius, there was an increase in cough and dyspnoea. X-ray
of the chest showed an increase in pulmonary infiltrate. Which of the following is the
MOST LIKELY explanation of this clinical picture?
a) Development of pneumococcal resistance to penicillin

b) Laboratory contamination of the original culture


c) Superinfection by a different type of bacteria
d) Adverse effect of antibiotic therapy
e) Pulmonary thromboembolism
Incorrect. The correct answer is (d).

This clinical picture demonstrates deterioration in the patient's condition. Drug fever,
or serum sickness, usually occurs on the 7th to 12th day of antibiotic therapy and
can produce unexpected fevers, skin rash and an eosinophilic pulmonary infiltrate. It
is commonly due to penicillins, nitrofurantoin, sulphonamides, thiazides and tricyclic
antidepressants. As he had been improving over 6 days, it is unlikely that the
original specimens were contaminated, nor that the organisms had had the
opportunity to develop resistance. Pulmonary embolism does not cause a high fever.
Superinfection is commonly due to gram-negative bacteria, fungi or resistant
staphylococci and usually appears on the 4th or 5th day.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section12/cha
pter148/148e.jsp%3Fregion%3Dmerckcom&word=drug&word=fever&domain=www.
merck.com#hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=84138 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section6/chapter76/76c.jsp )

Question 37
Which of the following is NOT a likely complication from gastro-oesophageal reflux
disease?
a) Achalasia of the oesophagus
b) Ulcerative oesophagitis
c) Barrett's oesophagus
d) Adenocarcinoma of the oesophagus
Incorrect. The correct answer is (a).
e) Oesophageal stricture

Achalasia is a motility disorder of the lower oesophagus of unknown cause and is


unrelated to gastro-oesophageal reflux disease (GORD). It is characterised by a
dilated lower oesophagus in the presence of a tight lower oesophageal sphincter
which does not respond to normal peristalsis. GORD leads to chronic inflammation of

the lower oesophagus, which in turn can ulcerate or cause a fibrosed stricture.
Barrett's oesophagus (or metaplasia) is also a result of long-standing GORD,
occurring in 10% of patients with reflux. 10% of patients with Barrett's go on to
dysplastic then malignant change (adenocarcinoma) of the oesophagus.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section3/chap
ter20/20f.jsp%3Fregion%3Dmerckcom&word=achalasia&domain=www.merck.com#
hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=89425&searchStr=gastroesophageal+r
eflux+disease )

Question 38
Which of the following is NOT a feature of Parkinson's disease?
a) Bradykinesia
b) Rigidity
c) Difficulty starting a movement
d) Hypophonia
Incorrect. The correct answer is (e).
e) Intention tremor

Parkinsonism is a syndrome consisting of tremor, rigidity and bradykinesis. The


tremor is most marked at rest, coarser than cerebellar tremor and is seen as a pill
rolling of thumb over fingers. Bradykinesis involves slowness in initiating and
executing movement and speech. The gait is characterised by a shuffling forward
with flexed trunk (called a festinant gait). Speech is hypophonic with a characteristic
monotonous, stuttering dysarthria.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section14/cha
pter179/179e.jsp%3Fregion%3Dmerckcom&word=parkinsonism&domain=www.merc
k.com#hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=105531
Available:
www.accessmedicine.com/content.aspx?aID=105700 )

Question 39

Brian and his wife are contemplating a trip across Africa. Which of the following
situations is most likely to put them at risk of contracting typhoid fever?
a) Intimate contact with an infected person
b) Eating contaminated food
Correct
c) Swimming in contaminated water
d) Contact with an infected dog
e) Scratches from infected wildlife

Salmonella typhi is spread primarily through consumption of contaminated food or


water. It has no known animal host other than humans. Intimate contact with
infected persons is a relatively uncommon mode of transmission. Swimming in
contaminated water would not lead to infection unless the water was ingested.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section13/cha
pter157/157d.jsp%3Fregion%3Dmerckcom&word=typhoid&word=fever&domain=ww
w.merck.com#hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=71306&searchStr=enteric+fever )

Question 40
If a patient is said to have odynophagia you would assume that:
a) It is painful to swallow
Correct
b) It is painful to speak
c) The patient has trouble swallowing and hearing
d) The patient has aberrant taste sensations
e) There is incoordinate action of the oesophagus

Odynophagia is pain during swallowing as opposed to a difficulty swallowing


(dysphagia). It is usually a symptom of mucosal destruction.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section3/chap
ter20/20c.jsp%3Fregion%3Dmerckcom&word=odynophagia&domain=www.merck.co
m#hl_anchor )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=89372&searchStr=odynophagia#89372
)