Question 1

A 35 year old primigravida who's pregnancy had been uncomplicated, presents at 36

weeks with moderate oedema, BP155/95 mm Hg and ++ proteinuria. Which ONE of
the following measures would you recommend?

a) Bed rest for the remainder of pregnancy

Incorrect. The correct answer is (e).
b) Induction of labour without further delay
c) Vigorous antihypertensive therapy
d) Review again at 37 weeks
e) Urgent referral to a specialist obstetrician

This is a high risk patient on two counts, viz. her age at first pregnancy and the fact
that she has pre-eclamptic toxaemia. These require specialist management in the
latter stages of pregnancy and delivery.

(Murtagh, J. (2003), General Practice, Third ed. Churchill Livingstone, Sydney, p

1048-9)

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/mmanual/section18/chapter252/252d.jsp#A018-252-
1195 )

Question 2

Which of the following conditions is FREQUENTLY associated with prerenal acute

renal failure?

a) Acute pyelonephritis
b) Severe dehydration
Correct
c) Rhabdomyolysis
d) Prostatic hypertrophy
e) Renal artery obstruction

Prerenal acute renal failure is caused by underperfusion of the kidneys, e.g. due to
dehydration, haemorrhage or shock. Acute pyelonephritis, rhabdomyolysis and renal
artery obstruction are causes of intrinsic acute renal failure, i.e. the cause lies in the
kidney. Prostatic hypertrophy is an example of a postrenal cause of acute renal
failure, due to obstruction to the outflow of urine.

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section17/cha
pter222/222b.jsp%3Fregion%3Dmerckcom&word=prerenal&word=renal&word=failu
re&domain=www.merck.com#hl_anch )

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=87201&searchStr=prerenal+acute+ren
al+failure#87201 )

Question 3

Bill is a 52 year old man who presents with nocturnal heartburn that has left him
exhausted due to lack of sleep. Which of the following statements is CORRECT in
relation to his gastroesophageal reflux disease (GORD)?

a) Gastric acid hypersecretion is present in all such patients

b) Disturbed oesophageal motility increases his risk of oesophagitis
Correct
c) H2 receptor antagonists are the preferred medical management
d) Maintaining an oesophageal pH of less than 3 is optimal
e) Bile salts are as deleterious to the oesophageal lining as gastric acid

The common denominator for virtually all episodes of gastroesophageal reflux is the
loss of the normal gastroesophageal barrier to reflux. This is usually secondary to a
transient or permanent loss of lower oesophageal sphincter resistance (eg. gastric
distension with air or food, increased intragastric or intraabdominal pressure, and
delayed gastric emptying). Disturbed oesophageal motility allows prolonged
exposure of the oesophageal lining to acidic fluids which is a major risk factor in the
development of oesophagitis in GORD. Gastric acid hypersecretion may be present in
some cases. The preferred medical management when significant symptoms are
present is the use of a proton pump inhibitor which will help to maintain the
oesophageal pH above 4. Bile salts reduce the resistance of the oesophageal lining,
but are not as deleterious as gastric acid.

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=89425&searchStr=gastroesophageal+r
eflux+disease )

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/mmanual/section3/chapter20/20g.jsp )

* Question 4

Leigh is a 60 year old woman who has been hypertensive for 5 years. Her BP now is
160/115 mm Hg. Recently she has been getting increasingly short of breath. Clinical
assessment confirms congestive cardiac failure. Which of the following drugs would
be preferred for management?

a) Propranolol
b) Verapamil
c) Diltiazem
Incorrect. The correct answer is (d).
d) Lisinopril
e) Felodipine

Linisopril is an angiotensin converting enzyme inhibitor (ACEI). This is the treatment

of choice, as it lowers systemic vascular resistance and venous pressure and reduces
the levels of circulating catecholamines, thus improving myocardial performance. It
is important to observe for first-dose hypotension. Calcium channel blockers (e.g.
verapamil, diltiazem) may have a detrimental effect on left ventricular function in
patients with heart failure. Non-selective beta blockers such as propranolol are not
well tolerated in heart failure. However third generation beta blockers such as
carvedilol as well as beta-1 selective agents metoprolol and bisoprolol improve
symptoms and exercise tolerance as well as lowering the risk of progression of heart
failure and death. They are started once the ACEI dose is stable and fluid status is
optimal. The beta blocker starts at a very low dose and is slowly titrated up.

(Murtagh, J. (2003), General Practice, Third ed. Churchill Livingstone, Sydney, p

1290-4)

( Current Crawford Cardiology

Available:
www.accessmedicine.com/content.aspx?aID=157683&searchStr=congestive+heart+
failure#157683 )

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section16/cha
pter199/199a.jsp%3Fregion%3Dmerckcom&word=hypertension&domain=www.merc
k.com#hl_anchor )

( Harrison's Online
Available:
www.accessmedicine.com/updatesContent.aspx?aID=395602&searchStr=beta+block
ers+in+heart+failure#searchTerm )

* Question 5

In which of the following situations would a barium swallow be preferable to an

endoscopy as a FIRST LINE investigation?

a) Patient complains of coughing after meals

 b) Patient complains of difficulty swallowing
Correct
c) Patient with nocturnal symptoms only
d) Patient with bloating after meals
e) Patient has water-brash

Difficulty swallowing (or dysphagia) is a functional problem and a barium swallow is

preferable to an endoscopy in this instance. Observations on the barium swallow
may suggest oropharyngeal or cricopharyngeal dysfunction (including misdirection of
barium into the trachea or nasopharynx), prominence of the cricopharyngeal muscle,
a Zenker's diverticulum or a narrow pharyngeo-oesophageal segment. Disordered
oesophageal motility or structural abnormalities such as small diverticula, webs, and
minimal extrinsic impressions of the oesophagus may be recognised only with
motion-recording techniques.

(Murtagh, J. (2003), General Practice, Third ed. Churchill Livingstone, Sydney, p

528-31)

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section3/chap
ter20/20b.jsp%3Fregion%3Dmerckcom&word=dysphagia&domain=www.merck.com
#hl_anchor )

Question 6

This 22 year old girl presents with a rash on her trunk which has been present for
three days (see figure). It is mildly itchy. What is the MOST LIKELY diagnosis?
Reproduced with permission, John Woodward, 2003.

a) Lichen planus
b) Pityriasis rosea
Correct
c) Lichen simplex
d) Atopic dermatitis
e) None of the above

Pityriasis rosea is a common mild acute inflammatory condition of the skin mainly
affecting young adults. The cause is unknown, but a virus is suspected. The oval
salmon-pink or copper-coloured eruptions with scaly margins are confined to the
trunk and upper limbs and are often arranged along the skin creases (resulting an an
appearance of a Christmas tree). Itching is usually mild. Lesions may be preceded by
a 'herald patch' and disappear spontaneously in 4-10 weeks. For information on the
other options see the references below.

(Murtagh J (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 1172-3)

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section10/cha
pter117/117c.jsp%3Fregion%3Dmerckcom&word=pityriasis&word=rosea&domain=w
ww.merck.com#hl_anchor )

Question 7
Edith is a 75 year old woman who complains that her eyesight isn't as good as it
used to be. While testing, you notice a lens opacity. Edith has well-controlled Type 2
diabetes and has a past history of polymyalgia rheumatica 20 years ago. She has
osteoarthritis of the knees managed with intermittent NSAID therapy. Which of the
following is the MOST significant factor in the development of her cataract?

a) Advancing age
Correct
b) Diabetes mellitus
c) Steroid therapy
d) Radiation
e) Trauma

Although all the options increase the chance of cataracts, the most significant factor
is advancing age. About 50% of 65-74 year olds have lens opacities increasing to
70% of those 75 years and over.

(Murtagh, J. (2003) General Practice, Third ed. Churchill Livingstone, Sydney, p 851-
2)

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section8/chap
ter97/97a.jsp%3Fregion%3Dmerckcom&word=cataract&domain=www.merck.com#h
l_anchor )

Question 8

Francesco is a 52 year old man with a history of rheumatic fever as a child. He

presents with shortness of breath on exertion without orthopnoea or discomfort at
rest. His echocardiogram demonstrates an isolated mitral stenosis of moderate
severity. A typical finding on cardiac catheterisation would be:

a) Normal left atrial and normal left ventricular diastolic pressures

b) High left atrial and normal left ventricular diastolic pressure
c) High left atrial and high left ventricular diastolic pressures
d) Right ventricular hypertrophy
Incorrect. The correct answer is (b).
e) Left ventricular hypertrophy

Mitral stenosis of moderate severity indicates narrowing of the mitral valve orifice
area from 5cm to 2cm squared. This results in an increased left atrial pressure and
dilatation of the left atrium but a normal left ventricular pressure. Eventually
pulmonary vascular pressures may rise with associated worsening of symptoms and
then right ventricular hypertrophy may ensue.
( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=81251 )

( Merck Manual of Diagnosis and Therapy

Available:
www.merck.com/mrkshared/mmanual/section16/chapter207/207b.jsp )

Question 9

Jean, a 52 year old woman, presents with hot flushes related to menopause. She has
noted a recent loss of libido. Which of the following statements concerning the
effects of menopause on libido is INCORRECT?

a) Sleep deprivation, secondary to hot flushes and night sweats, can lead to
depression
b) Vaginal dryness and painful intercourse due to oestrogen deficiency are
common
c) As the menopause approaches, erratic periods or menorrhagia may impact on
sexual desire
d) Oestrogen deficiency heightens sensitivity to touch stimuli, causing pain and
discomfort
Correct
e) Reduced muscle tone of the pelvic floor can affect orgasm

Clinical manifestations of oestrogen deficiency include:

1. Variable length of menses - erratic, frequent or prolonged - which can impact

on sexual desire
2. Hot flushes and night sweats, which can cause chronic sleep deprivation and
potentially depression
3. Vaginal atrophy which can lead to vaginal dryness, dyspareunia and
secondary vaginismus due to fear of intercourse
4. Urethral/bladder atrophy and loss of pelvic floor muscle tone, which can cause
urethral incontinence. Loss of pelvic floor muscle tone can also reduce vaginal
sensitivity and muscle contractions involved in orgasm
5. Touch aversion or reduced sensitivity to touch stimuli in genital tissues

(Murtagh, J. (2003), General Practice, Third ed. Churchill Livingstone, Sydney, p

1008-17)

( Reddish, S. (2002), Loss of libido in menopausal women, Australian Family

Physician, vol 31, no 5, p 427-432
Available:
http://www.racgp.org.au/document.asp?id=6305 )

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section18/cha
pter236/236a.jsp%3Fregion%3Dmerckcom&word=menopause&domain=www.merck
.com#hl_anchor )

Question 10

Which of the following statements is CORRECT? In motor neurone disease there is:

a) A long history of remissions and exacerbations

b) Sensory loss following a dermatomal distribution
c) Focal epilepsy
d) Sparing of lower motor neurons
e) Involvement of upper and lower motor neurons
Correct

The commonest form of motor neurone disease is amyotrophic lateral sclerosis

(ALS), a sporadic condition of unknown cause characterised by relentless progressive
degeneration of upper and lower motor neurones in the spinal cord, the somatic
motor nuclei of the cranial nerves and the motor cortex of the brain. The sensory
system is not involved. Remission in this disease is unknown.

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=105942 )

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section14/cha
pter183/183b.jsp%3Fregion%3Dmerckcom&word=motor&word=neuron&word=disea
se&domain=www.merck.com#hl_anchor

Question 11

Joan is a 46 year old woman who has a long past history of bloating and water
brash. She usually takes an antacid after her meals. In your advice to Joan you
would explain that the MOST important factor in managing moderate and severe
reflux is:

a) Avoidance of alcohol with meals

b) Avoidance of spicy food
c) 24-hour control of acid secretion
d) Limitation of the size of meals
Incorrect. The correct answer is (c).
e) Not lying down too soon after meals
Gastroesophageal reflux is caused by a transient or permanent loss of lower
oesophageal sphincter tone. As a consequence, it more often occurs after meals.
Controlling acid secretion at all times with a proton pump inhibitor is the medical
treatment of choice. The other factors may play a role but are not the most
important.

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=89425 )

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/mmanual/section3/chapter20/20g.jsp )

Question 12

Which of the following describes an ependymoma?

a) A benign skin lesion of the face

b) A central nervous system tumour
Correct
c) A cystic structure in the upper eyelid
d) A patch of discoloured skin
e) A visible defect in the iris

Ependymomas are central nervous system tumours affecting the brain and spinal
cord, derived from the single layer of cells (the ependyma) lining the ventricles and
spinal canal.

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=106695 )

* Question 13

A healthy six year old child without cyanosis or dyspnoea on exercise is examined for
migration to Australia. His pulse is 84 per minute, B.P. 100/60, radial pulse and
jugular venous pressure normal and there is no evidence of cardiomegaly. On
auscultation in the 2nd left intercostal space the 1st and 2nd heart sounds are
audible with fixed splitting of the 2nd heart sound and a midsystolic pulmonary
ejection murmur is heard. The MOST likely diagnosis is:

a) Pulmonary stenosis
Incorrect. The correct answer is (b).
b) Atrial septal defect (ASD)
 c) Innocent pulmonary ejection murmur
d) Ventricular septal defect (VSD)
e) Patent ductus arteriosus (PDA)

In an asymptomatic patient an ASD is often diagnosed as a loud P2 with fixed

splitting and an ejection murmur heard in the pulmonary area due to increased blood
flow to the right heart. A VSD large enough to produce these signs would be
symptomatic and usually would cause cardiomegaly. Innocent pulmonary ejection
murmurs do not cause fixed splitting of P2, and a PDA causes a continuous murmur.
In pulmonary stenosis P2 is often soft or inaudible and the JVP is usually elevated.

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section19/cha
pter261/261b.jsp%3Fregion%3Dmerckcom&word=atrial&word=septal&word=defect
&domain=www.merck.com#hl_anchor )

Question 14

Female androgen insufficiency syndrome includes all of the following EXCEPT:

a) Persistent fatigue
b) Reduced body hair
c) Decreased libido
d) Blunted motivation
e) Dysphoria
Incorrect. The correct answer is (b).

Reduced body hair is not a feature of female androgen insufficiency. The syndrome
includes:

1. Diminished sense of well being, dysphoric mood and/or blunted motivation

2. Persistent, unexplained fatigue
3. Decreased libido, pleasure and sexual receptivity
4. Potential bone loss, decreased muscle strength, changes in cognition/memory

( Reddish, S. (2002), Loss of libido in menopausal women, Australian Family

Physician, vol 31, no 5, p 427-432
Available:
http://www.racgp.org.au/document.asp?id=6305 )

(Murtagh, J. (2003), General Practice, Third ed. Churchill Livingstone, Sydney, p

1008-17)
Question 15

The SINGLE MOST important diagnostic sign of developmental dysplasia of the hip in
the neonatal period is?

a) An unusually wide perineal region

b) Asymmetrical skin folds in the thighs
Incorrect. The correct answer is (e).
c) Failure of the thighs to abduct readily
d) Failure of the thighs to externally rotate
e) A clunk on abduction of the flexed thigh

On examination of the newborn a clunk or jerk noticed on abduction or adduction of

the flexed thigh is suggestive of developmental dysplasia of the hip (previously called
congenital dislocation of the hip). Ultrasound examination gives useful information as
to the relationship of the femoral head to the acetabulum and the existence of any
acetabular dysplasia during the first 3 months of life. If not diagnosed in the
neonatal period the older child presents with an abnormal gait, a shortened leg on
the affected side, asymmetrical abductor creases, restricted hip abduction (especially
in flexion) and a positive trendelenberg's sign.

(Robinson, M.J and Robertson D.M., (eds) (2003), Practical Paediatrics, 5th ed.
London. Churchill Livingstone, Sydney p 239-40)

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 703-4)

( Way Current Surgery

Available:
www.accessmedicine.com/content.aspx?aID=378257&searchStr=hip+dislocation%2
c+congenital#378257 )

Question 16

To optimise management, trichomoniasis is MOST effectively identified by:

a) Cytological examination of a cervical smear

b) Microscopic examination of a 'wet prep'
Correct
c) Stained smear of vaginal discharge
d) Culture of vaginal discharge
e) Histological examination of a punch biopsy of vaginal mucosa

A wet saline mount is 30-80% sensitive for Trichamonas vaginalis in symptomatic

women. A drop of vaginal discharge is placed on a slide with 1-2 drops of normal
saline and examined under high power (x 400). The oval or flagellated protozoan is
seen among a large number of white blood cells and epithelial cells. Its erratic,
twitching motility may be precipitated by warming the slide, thus distinguishing it
from the similarly sized polymorphs. Culture is 95% sensitive especially in
asymptomatic men and women, but not widely available and results take 7 to 10
days. Trichomonads are often reported on Pap smears from the cervix with a
sensitivity of 60 to 70%. However a high false positive rate means further testing is
necessary to confirm the diagnosis. Management involves treatment with
metronidazole or tinidazole 2G stat orally. Contacts should also be treated and
evaluated for other sexually transmitted infections.

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section13/cha
pter164/164e.jsp%3Fregion%3Dmerckcom&word=trichomonas&domain=www.merc
k.com#hl_anchor )

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=78213 )

( Western Sydney Area Health Service - Sexual Health

Available:
www.wsahs.nsw.gov.au/services/sexualhealth/index.htm )

Question 17

Yee Leng, aged 40 years, is a new patient in your practice. She tells you she has
been experiencing migraine headaches for a number of years. Which of the following
features would NOT be consistent with migraine as a cause of her headaches?

a) Numbness or tingling in one arm and hand

b) A headache which lasted 10 days
Correct
c) Pain behind one eye radiating to the neck
d) Bilateral pain
e) Vertigo lasting about 30 minutes

Migraine attacks can last from hours (most common) to days, but never weeks.
There are several different clinical patterns of migraine. Attacks can vary from
intermittent headaches, indistinguishable from tension headaches, to discrete
episodes that mimic thromboembolic cerebral ischaemia. Symptoms may include
visual auras, nausea, vomiting, tingling, generalized headache, vertigo and transient
hemiparesis.

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 612-6)

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=51922&searchStr=migraine#51922 )

Question 18

Betty, who is aged 29 years and nulliparous, comes to you for a routine Pap smear.
The cervix looks healthy and there are no abnormalities on clinical examination. A
week later she returns for the pathology result which is reported as: 'Abnormal cells
are present, consistent with a diagnosis of carcinoma in situ CIN 3.' What is the
implication of this result?

a) Betty has malignancy of the cervix and requires radiotherapy followed by

hysterectomy and clearance of lymph nodes
b) Betty has a malignancy of the cervix and hysterectomy is required
c) The smear should be repeated after Betty has applied clindamycin vaginal
cream for 7 days
d) Betty requires a cone biopsy
Incorrect. The correct answer is (e).
e) Betty requires a colposcopy

Betty needs referral to a gynaecologist for colposcopy and directed biopsy with
definitive treatment if CIN 3 is confirmed.

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 951-6)

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section18/cha
pter241/241c.jsp%3Fregion%3Dmerckcom&word=pap&word=smaer&domain=www.
merck.com#hl_anchor )

Question 19

Mary aged 29 years, has suffered from migraines for three years. She is keen to
reduce the frequency of attacks and asks about trigger factors. Which of the
following advice would you NOT offer her?

a) Use relaxation techniques to manage stress

b) Eliminate known dietary triggers eg. Chocolate, red wine, MSG
c) Maintain a regular sleep pattern
d) Restrict time watching television to less than 2 hours a day
Correct
e) Avoid oestrogen-containing oral contraceptives

There is no known link between watching television and migraine, except that some
programs may be stressful. The other options refer to recognised trigger factors.

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 612-6)

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=51922&searchStr=migraine#51922 )

Question 20

Which of following statements about syphilis is CORRECT?

a) Syphilis is only acquired through sexual contact

b) The typical primary lesion of syphilis is a painful, hard ulcer on the genitalia
c) Definitive diagnosis is by culture of fluid from the ulcer
d) Signs of secondary syphilis include mucocutaneous lesions and non tender
lymphadenopathy
Correct
e) Once treated there is no need for follow up

Secondary syphilis is marked by mucocutaneous lesions and non tender

lymphadenopathy. Syphilis may be acquired by skin to skin nonsexual personal
contact and transplacental infection. The primary lesion of syphilis is a painless, hard
chancre on the external genitalia. The traditional, preferred testing method is dark-
field microscopy. Specimens are taken from active lesions and examined directly.
Serology should always be taken to diagnose syphilis. These tests are complex and
require expert interpretation. Serology is also used to monitor the effectiveness of
treatment in syphilis. Penicillin, given by injection, is a very effective treatment.
Repeated blood tests are necessary for at least a year after treatment to monitor
possible treatment failure.

( Ooi, C., Dayan, L. (2002) Syphilis: Diagnosis and management in General Practice,
Australian Family Physician, vol 31, no 7, p 629-634.
Available:
www.racgp.org.au/document.asp?id=9110 )

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/mmanual/section13/chapter164/164d.jsp )

Question 21
Bill, aged 45 years, has been experiencing headaches on and off for 5 years. Over
the past 2-3 weeks he feels that he has had an almost continuous headache. Which
of the following features would make you suspect a tension-type headache?

a) He is unable to continue with daily work

b) The headache wakes him in the middle of the night
c) It is very rarely bilateral
d) It is usually bifrontal or bioccipital
Correct
e) He suffers associated nausea

Tension headaches are often bifrontal or bioccipital. They are believed to be a result
of tension within the scalp muscles. These headaches are always innocent and can
be associated with tight band sensations, pressure behind the eyes, and throbbing
and bursting sensations. Precipitating factors include worry, noise, concentrated
visual effort, fumes or depression. There are no abnormal physical signs, other than
tenderness and tension in the nuchal and scalp muscles.

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 611-2)

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=51917&searchStr=tension+headache )

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section14/cha
pter168/168d.jsp%3Fregion%3Dmerckcom&word=tension&word=headache&domain
=www.merck.com#hl_anchor )

( American Family Physician 2002:66(5):797-805

Available:
www.aafp.org/afp/20020901/797.html )

Question 22

George is a nineteen year old man who presents with dysuria. On examination there
is a thick yellow urethral discharge. Which ONE of the following is CORRECT with
regard to gonococcal infection?

a) Urine PCR is now the gold standard for diagnosing gonococcal urethritis
b) Spread to involve the prostate and epididymis is common
c) The incubation period is usually 14 to 21 days
d) Ceftriaxone IM as a single dose is an effective treatment
Correct
 e) Pharyngeal gonorrhoea is diagnosed by finding Gram-negative diplococci on a
smear

Routine treatment for gonococcal infection is either with ceftriaxone 250 mg IM as a

single dose or ciprofloxacin 500 mg orally as a single dose. The symptoms of
gonococcal infection usually appear within 2 to 10 days of infection, but the
incubation period is sometimes much longer, and some men never develop
symptoms. In men, infection can spread to the prostate gland, epididymis, and the
testes, although this is not common. Gram-stained smears are only sensitive and
specific for urethral smears in symptomatic men. Culture is still the gold standard
with >95% sensitivity and the ability to test for antibiotic sensitivities. Since the
organism dries out quickly and is fairly fastidious, samples must reach the laboratory
within 12 hours. PCR testing is validated for endocervical and first catch urine
specimens only but fails to allow subsequent antibiotic sensitivity testing which is
significant in light of emerging quinolone resistance. It has the advantage of not
requiring live organisms, being less invasive as a screening tool and enabling a check
for chlamydia on the same sample. PCR tests are 90-100% sensitive and 98-100%
specific.

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 1119-20)

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/mmanual/section13/chapter164/164b.jsp )

( MJA 1997; 166:468

Available:
www.mja.com.au/public/issues/may5/skov/skov.html )

( Western Sydney Area Health Service - Sexual Health

Available:
www.wsahs.nsw.gov.au/services/sexualhealth/index.htm )

( Family Practice Notebook

Available:
www.fpnotebook.com/ID200.htm )

* Question 23

Belinda, aged 44 years, presents complaining of heavy, prolonged periods

(menorrhagia) and severe period pain (dysmenorrhoea) that has gradually become
worse during the past year. Her periods are still quite regular. Which of the following
possible causes is UNLIKELY?

a) Adenomyosis
b) Endometriosis
c) Uterine cancer
d) Fibromyoma
e) Ovarian failure
 Correct

Ovarian failure presents as irregularity and scarcity of menstruation, rather than

menorrhagia and dysmenorrhoea. Adenomysosis, endometriosis, uterine cancer and
fibromyoma are all possible causes of menorrhagia and secondary dysmenorrhoea.
Other causes include uterine polyps, intra-uterine contraceptive devices, pelvic
inflammatory disease and cervical stenosis.

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 984-6)

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section18/cha
pter235/235e.jsp%3Fregion%3Dmerckcom&word=menorrhagia&domain=www.merc
k.com#hl_anchor )

Question 24

Martha is a 20 year old woman who presents with a vaginal discharge, bilateral
painful vesicles and ulcers on her external genitalia. There is tender inguinal
lymphadenopathy. She also has systemic symptoms, including headache, myalgia
and a temperature of 38.5 degrees Celsius. Which of the following is CORRECT?

a) Antiviral agents eradicate the virus

b) Antiviral agents have no effect on recurrence
c) Antiviral agents do not hasten healing
d) Topical lignocaine is beneficial for the pain
e) The primary aim is to keep the lesions clean and dry
Correct

This scenario is typical of primary genital herpes. The primary aim is supportive
treatment by keeping lesions as clean and dry as possible while spontaneous healing
occurs. Analgesics by mouth are often useful, particularly at night time. No
treatment is available to eradicate the virus, but antiviral agents reduce viral
shedding from lesions, hasten healing and reduce the risk of recurrence while being
administered. The recommended regimen is valaciclovir 500mg twice a day for 5
days. Topical lignocaine and zinc creams should not be used.

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 1120-2)

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section13/cha
pter164/164k.jsp%3Fregion%3Dmerckcom&word=genital&word=herpes&domain=w
ww.merck.com#hl_anchor )
Question 25

John is a 35 year old man who has had four recent episodes of intense retro-orbital
pain. You suspect cluster headache. Which of the following features would be LEAST
consistent with this diagnosis?

a) He always vomits with the pain

Correct
b) He has ipsilateral nasal stuffiness
c) He notices a drooping of the eye on the same side as the headache
d) Three of the episodes occurred within 2 days
e) Episodes seem to last from 10 minutes to 2 hours

Cluster headaches are recurrent bouts of excruciating pain centred around one eye
and lasting for minutes to hours. The affected side of the face and nostril feel
congested. Commonly, there is a transient ipsilateral Horner's Syndrome. Vomiting
may be associated, but is not always present.

(Murtagh, J. (2003) General Practice, Third ed. McGraw-Hill, Sydney, p 616)

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=52036&searchStr=cluster+headache#5
2036 )

Question 26

In the treatment of persistent tension-type headaches, in which mild analgesics and

relaxation techniques are insufficient, which of the following medications would be
MOST suitable?

a) Propranolol 40mg at night

b) Paroxetine 20mg in the morning
c) Amitriptyline 10-75mg at night
Correct
d) Diazepam 2-5mg at night
e) Carbamazepine 100-200mg twice a day

In patients in whom simpler treatments, such as paracetamol, and relaxation

techniques, have failed, amitriptyline (10-75 mg) at night is indicated in the
treatment of persistent tension headaches. The other medications listed are not
indicated. Diazepam (short term use) may be effective in middle-aged men, but
generally should be avoided because of risk of dependence.

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 611-2)

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=51917&searchStr=tension+headache#
51917 )

( American Family Physician 2002:66(5):797-805

Available:
www.aafp.org/afp/20020901/797.html )

Question 27

Which of the following describes the meaning of trismus?

a) A grimace
b) Tonic spasms of the jaw muscle
Correct
c) A triad of symptoms
d) Paralysis of the tongue
e) A facial tic

Trismus is the prolonged tonic spasm of the muscles of the jaw. It is an involuntary
early sign of tetanus. Prolonged voluntary clenching of the jaw with teeth grinding is
called bruxism, and is associated with emotional stress.

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=69991 )

Question 28

James is a 32 year old man who presents two days after experiencing his first
epileptic seizure. He was well until the seizure which occurred without warning. Since
then he feels that his left leg has become weaker. James had meningitis as a child,
and two years ago sustained a fractured skull in a motor vehicle accident. There is a
family history of epilepsy (brother and an uncle have epilepsy). Which of the
following groups of investigations is MOST likely to help in establishing the cause of
James' epilepsy?

a) Metabolic screen + EEG + plasma magnesium

b) Metabolic screen + CT scan + plasma magnesium
c) Metabolic screen + EEG + CT scan
Correct
d) Metabolic screen + drug screen + EEG
e) Metabolic screen + drug screen + CT scan
A metabolic screen will detect biochemical causes, such as electrolyte abnormalities,
acid base disturbances, hypocalcaemia etc. The EEG will help establish the diagnosis
of epilepsy, classify the type and identify the particular epilepsy syndrome. A CT scan
will identify any underlying structural abnormality, e.g. brain tumour. A drug screen
is only necessary if there is reason to suspect drug abuse. Magnesium is one of the
components of the metabolic screen.

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=104150
Available:
www.accessmedicine.com/content.aspx?aID=104251 )

Question 29

Which of the following statements about brain tumours is CORRECT?

a) Frontal lobe tumours present late

Correct
b) Contralateral limb weakness or sensory loss are due to frontal tumours
c) Disturbances of speech are due to nondominant temporal tumours
d) Impaired insight is due to midbrain tumours
e) Mood disturbances usually relate to tumours in the parietal lobe

Often frontal lobe tumours remain asymptomatic or undiagnosed until they are very
large, possibly because local dysfunction of this brain region causes subtle and non-
specific neurological or behavioural deficits.

( Way Current Surgery

Available:
www.accessmedicine.com/content.aspx?aID=375092&searchStr=malignant+neoplas
m+of+frontal+lobe#375092 )

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/mmanual/section14/chapter177/177b.jsp )

Question 30

Which of the following statements about the management of chronic pain is

INCORRECT?

a) Depression is often an aggravating factor

b) Antidepressants are only indicated in clinical depression
Correct
 c) Psychological assessment is important to a good outcome
d) A history of nerve damage may indicate neuropathic pain
e) Opioid medication may be required for some patients

Antidepressant medication may be helpful in patients with chronic pain even if they
do not have depressive symptoms. These include patients with diabetic neuropathy,
tension headache, rheumatoid arthritis and chronic low back pain.

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=51538&searchStr=chronic+pain )

* Question 31

In a child with chickenpox which of the following drugs is MOST LIKELY to cause
Reye's syndrome?

a) Paracetamol
b) Aspirin
Correct
c) Codeine
d) Penicillin
e) Prednisolone

Reyes Syndrome involves acute encephalopathy and fatty infiltration of the liver
following an acute viral infection, including influenza and varicella. Foreign chemicals,
especially salicylates (including aspirin), and intrinsic metabolic defects have also
been implicated. The use of salicylates (eg aspirin) during an acute viral illness such
as chicken pox (varicella) increases the risk of Reyes syndrome by as much as 35-
fold.

( Hay Current Pediatrics

Available:
www.accessmedicine.com/content.aspx?aID=533071&searchStr=reye+syndrome )

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=92464&searchStr=reye+syndrome#92
464 )

Question 32

Turner syndrome includes all of the following features EXCEPT:

 a) Ovarian agenesis
b) Webbing of the neck
c) A predominantly "X0" sex chromosome pattern
d) The possession of 45 chromosomes
e) A chromatin-positive buccal smear
Correct

Patients with Turner's syndrome characteristically have a 45 XO chromosome

pattern, and streak gonads (ovarian agenesis). Characteristic features include short
stature, webbing of the neck, cubitus valgus, widely spaced nipples and puffy hands
and feet. The range of intelligence is normal. A chromatin-positive buccal smear
requires two X chromosomes. One X chromosome is randomly inactivated early in
embryogenesis. Therefore, the buccal smear in Turner's syndrome does not have a
Barr body (ie it is chromatin negative).

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=100334&searchStr=turner's+syndrome
#100334 )

( Better Health Channel, Victorian Government

Available:
www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Turner's_syndrome?open )

* Question 33

Sarah is an 8 week old girl who has persistent regurgitation. Which of the following
features suggests the need for further investigation?

a) Sarah is underweight for her age

Correct
b) Sarah regurgitates after every meal
c) Sarah has episodes of uncontrollable crying
d) Sarah arches her back on occasion and stops feeding
e) Sarah was born 2 weeks premature

Regurgitation after every meal suggests gastroesophageal reflux, but of itself is not a
worrying feature. Underweight for age, however, suggests failure to thrive and needs
investigation. Unsettled and irritable behaviour is very common in the first 6-12
weeks of life. In isolation it is not a concern.

( Hay Current Pediatrics

Available:
www.accessmedicine.com/content.aspx?aID=531726&searchStr=gastroesophageal+
reflux+disease )
(Robinson, M.J and Robertson D.M., (eds) (2003), Practical Paediatrics, 5th ed.
Churchill Livingstone, Sydney p 693-700)

Question 34

Which of the following is suggested by a history of transient episodes of vertigo,

slurred speech, diplopia, and paraesthesia in a man aged 65 years?

a) Basilar artery insufficiency

Correct
b) Anterior communicating artery aneurysm
c) Hypertensive encephalopathy
d) Pseudobulbar palsy
e) Occlusion of the middle cerebral artery

Episodes of vertigo, diplopia and paraesthesia indicate alteration of brainstem

function caused by basilar artery insufficiency. Middle cerebral occlusions usually
presents with contralateral hemiplegia and homonymous hemianopia. Slurred speech
or aphasia may occur in both conditions. Anterior communicating artery aneurysms
are likely to result in emotional lability. Hypertensive encephalopathy comprises
headache, confusion, stupor or convulsions. Pseudobulbar palsy presents with
dysarthria, dysphagia and emotional lability.

( Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=105051&searchStr=basilar+artery+occ
lusion#105051 )

Question 35

Mandy, a 4 year old girl, is due to accompany her parents on a flight to England in
two months time. Her mother is worried about the effect of air travel on Mandy's
ears. Which of the following will NOT increase the likelihood of ear pain during the
flight?

a) A recent cold
b) Nasal congestion
c) Hay fever
d) Recent otitis media
e) Perforation of the ear drum
Correct

Normal function of the middle ear and tympanic membrane is maintained by a patent
eustachian tube which keeps the middle ear and external canal pressures equal.
Blockage of the eustachian tube, e.g. with secretions as in the common cold, results
in pressure imbalances between the middle and external ear. During air travel, the
resulting barotrauma may cause pain, deafness, vertigo, and tinnitus. All the options
listed, except (e), can cause blockage of the eustachian tube.

(Murtagh, J. (2003), General Practice, Third ed. McGraw-Hill, Sydney, p 552-5)

( American Academy of Otolaryngology. Ears, altitude and Airplane Travel.

Available:
http://www.sinuscarecenter.com/bareraao.html )

( American Hearing Research Foundation

Available:
www.american-hearing.org/name/barotrauma.html )

* Question 36

Sue, a three year old girl, presents with shortness of breath and wheeze that have
developed over the last two days. Examination reveals an afebrile, moderately
tachypnoeic child with widespread scattered wheezes on auscultation. You decide to
administer a bronchodilator (salbutamol). The recommended method of delivery of
salbutamol for Sue is:

a) Syrup
b) Nebuliser
c) Breath activated inhaler
d) Metered dose inhaler with a spacer
Incorrect. The correct answer is (e).
e) Metered dose inhaler with a spacer and face mask

For the treatment of acute asthma in a child <6 years of age, the recommended
mode of delivery of bronchodilator (salbutamol) is via a metered dose inhaler and
small volume spacer with face mask. For those >6 years of age, a large volume
spacer may be substituted. Salbutamol administered via these routes has been
shown to be equally effective to nebulised salbutamol. Six puffs of salbutamol via
MDI and spacer is the equivalent of a 2.5 mg nebule, while 12 puffs equals a 5mg
nebule.

( National Asthma Foundation (2002), National Asthma Handbook 2002, 5th ed,
Australia, National Asthma Council Australia LTD., p30 (see drug delivery devices)
Available:
www.nationalasthma.org.au/publications/amh/amhcont.htm )

Question 37
Oliver, an 8 month old boy, presents with a history of anorexia and recurrent upper
respiratory tract infections. Physical examination reveals pallor and splenomegaly.
His blood picture shows a hypochromic, microcytic anaemia with numerous target
cells and nucleated red cells. What is the MOST LIKELY diagnosis?

a) Thalassaemia major
b) Iron deficiency anaemia
c) Glucose-6-phosphate dehydrogenase deficiency
d) Sideroblastic anaemia
e) Sickle cell anaemia
Incorrect. The correct answer is (a).

Thalassaemia major (homozygous beta-thalassaemia) is a severe disease which

presents during the first year of life with: failure to thrive, intermittent infection,
severe hypochromic, microcytic anaemia and signs of extramedullary haemopoiesis
(hepatosplenomegaly and bone expansion). It does not present at birth because the
production of foetal haemoglobin is not affected.

( Hay Current Pediatrics

Available:
www.accessmedicine.com/content.aspx?aID=535012&searchStr=thalassemia+major
#535012 )

* Question 38

In acute iritis (anterior uveitis), the pupil is:

a) Eccentric, constricted and reacts briskly to light

b) Concentric, dilated and reacts briskly to light
Incorrect. The correct answer is (d).
c) Eccentric, dilated and reacts sluggishly to light
d) Concentric, constricted and reacts sluggishly to light
e) Concentric, dilated and reacts sluggishly to light

Anterior uveitis typically presents with a unilateral painful red eye, blurred vision,
photophobia and tearing. There is a perilimbal flush and pupillary miosis with a
sluggish response and increased pain during accommodation to light. This is due to
spasm of the ciliary body and iris muscles. Slit lamp examination will demonstrate
keratic precipitates on the cornea. Urgent treatment is needed to prevent
complications.

(Murtagh, J. (2003), General Practice, Third ed. McGraw- Hill, Sydney, p 566-9)

( Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section8/chap
ter98/98a.jsp%3Fregion%3Dmerckcom&word=uveitis&domain=www.merck.com#hl
_anchor )

( eMedicine
Available:
www.emedicine.com/emerg/topic284.htm )

Question 39

The MOST common cause of persistent cough in children is:

a) Chronic post viral cough

b) Asthma
Incorrect. The correct answer is (a).
c) Post-pertussis
d) Gastro-oesophageal reflux
e) Passive smoking

The commonest cause of persistent cough (particularly with a prominent nocturnal

component) in children is post viral. It can also be associated with postnasal drip.
However, care must be taken to exclude asthma which is a fairly common cause of
persistent cough in children. Other less common conditions to be considered include
gastrointestinal reflux, passive smoking and post pertussis.

( Faniran et al. (1998) Persistent Cough- Is it asthma? Arch Dis Child 1998;79: 411-
414
Available:
adc.bmjjournals.com/cgi/content/full/archdischild%3b79/5/411?ijkey=81b48e13ad1
e87689ea9fe89beedef8cc6743c5f%20 )

* Question 40

Trevor is a 2.4 kg male infant with Apgars 9:10 after a normal vaginal delivery. He
becomes jaundiced at 12 hours of age. Which of the following conditions would be
the MOST LIKELY cause of the jaundice?

a) Gram negative septicaemia

b) Jaundice of prematurity
c) Biliary atresia
d) Physiological jaundice
Incorrect. The correct answer is (e).
e) Rh incompatibility
Jaundice appearing in the first 24 hours of life is most commonly due to haemolytic
disease of the newborn due to incompatibility to Rh, ABO or one of the other rare
antigens. Other causes of early jaundice include transplacental infections such as
CMV, toxoplasmosis and rubella. Jaundice of prematurity, physiological jaundice and
septicaemia present most commonly between days 2-5. Biliary atresia presents with
jaundice after the first week of life.

(Robinson, M.J and Robertson D.M., (eds) (2003), Practical Paediatrics, 5th ed.
Churchill Livingstone, Sydney p 323-6)

( Current Pediatric Diagnosis & Treatment, 17th Edition. Hay et al.

Available:
www.accessmedicine.com/content.aspx?aID=525089&searchStr=jaundice%2c+neon
atal#525089 )