* Question 3

Maud is a 70 year old who presents with acute peri-umbilical abdominal pain
gradually increasing in intensity. She is vomiting profusely and develops
watery diarrhoea with flecks of blood after an hour of pain. Examination of
the abdomen reveals localised periumbilical tenderness with some rigidity.
Rectal examination is normal. An irregular pulse is noted and an ECG is
recorded (shown below).

The MOST LIKELY diagnosis is:

a) Acute appendicitis
b) Acute pancreatis
c) Perforated peptic ulcer
d) Biliary colic
e) Mesenteric artery occlusion

Ans.E The clinical presentation is typical of mesenteric artery occlusion. This

occurs most commonly in patients with atrial fibrillation leading to embolism.
The ECG shows atrial fibrillation. Arteriography will show the vascular
occlusion.

* Question 4
A 15 year old young man has sudden onset of severe pain in his right lower
abdomen commencing 2 hours ago. He has vomited several times in the last
hour. He is rolling on the bed, stating that the pain is going down into his
groin. T 37.1 degrees Celcius, P 110min, BP 135/ 80. Abdomen - soft, no
rebound. Tender right testicle. Your immediate management is:
a) i/v fluids and antibiotics
b) arrange urgent ultrasound examination
c) i/v metoclopramide (maxolon)
d) refer for emergency surgery
e) arrange for intravenous pyelogram (IVP)

Ans.D The sudden onset of severe pain in the lower abdomen, groin or
scrotum, in a young male under 25 years, should be considered to be testicular
torsion until proved otherwise. This is a surgical emergency, as infarction of
the testis can occur quickly, and surgical exploration should be undertaken
urgently.
 This patient has no fever, nor tenderness of the epididymis to indicate
epididymo-orchitis. Antibiotic treatment will not help. Colour doppler
ultrasound may show increased blood flow in infection and the absence of
flow in advanced torsion. However, these are not reliable findings, and the
investigation would waste valuable time.
The vomiting is related to the pain, and would be alleviated by
appropriate analgesia. Metoclopramide is not an immediate priority. The
clinical picture is highly suggestive of testicular torsion rather than renal
colic, thus IVP is not the appropriate immediate management.

* Question 5
In a 3 year old child with signs and symptoms suggestive of bacterial
meningitis, which of the following is the BEST initial management?
a) Erythromycin IV
b) Gentamicin IV
c) Ceftriaxone IV
d) Phenoxymethylpenicillin oral
e) Amoxycillin oral

Ans.C If bacterial meningitis is suspected clinically it is vital to immediately

administer an appropriate antibiotic prior to urgent transfer to hospital, as
meningococcal meningitis may be rapidly fatal. The drug of choice would be
benzylpenicillin 60mg/kg up to 3g IV or IM, or ceftriaxone 50mg/kg up to 2g
IV in patients hypersensitive to penicillin or when further drug treatment may
be delayed.

* Question 14
A 15kg child with a known food allergy to peanuts suddenly develops
anaphylaxis. The RECOMMENDED immediate management is:
a) 0.1ml of Adrenaline 1:1000 by deep intramuscular injection
b) 0.1ml of Adrenaline 1:10,000 by deep subcutaneous injection
c) 0.15ml of Adrenaline 1:1000 by deep intramuscular injection
d) 0.15ml of Adrenaline 1:1000 by subcutaneous injection
e) 0.15ml of Adrenaline 1:10,000 by deep intramuscular injection

Ans.C Adrenaline 1:1000 is recommended as it is readily available, and this

concentration contains 1mg of adrenaline per ml. The recommended dose of
1:1000 adrenaline is 0.01mg/kg body weight by deep intramuscular injection,
so a 15kg patient would require 0.15ml.

* Question 18
A 50 year old woman has had major abdominal surgery yesterday. You are
called to see her urgently as she has symptoms of shock. Which ONE of the
following examination findings is of MOST concern?
a) the patient is restless and confused
b) Temperature 39.2 degrees Celsius
c) pulse 130, sinus tachycardia
d) urine output over past 4 hours of 120ml
e) BP 80/45 mm Hg

Ans.E The above signs taken together suggest a picture of shock, probably
septic shock. Hypotension (defined as systolic BP <90mm Hg, or >40mm Hg
fall from baseline level) is a sinister development and requires urgent
attention. It is often a LATE manifestation of circulatory failure. Thus it is the
most alarming of these findings, and the one most indicative of the urgency of
this situation.

Question 20
Aidan, a 3 month old boy, presents with paroxysms of coughing associated
with cyanosis, lethargy and poor feeding for several days. On examination,
between episodes of coughing, he is afebrile and examination is normal. What
is the NEXT step in management?
a) Admission to hospital
b) Nasopharyngeal aspirate and review in 24 hours
c) Immunisation at this visit with DTP and review in 24 hours
d) Erythromycin syrup and review in 24 hours
e) Trial of salbutamol by mask

Ans.A The clinical picture suggests respiratory infection with Bordetella

pertussis. The history of cyanosis associated with the coughing suggests the
need for admission, but in addition, children under 6 months of age usually
require hospital admission for pertussis because of the risk of complications.
Complications include respiratory arrest, bacterial pneumonia and
encephalitis.
Salbutamol has not been shown to be helpful in a child of this age and is
of no benefit. Immunisation at a later date should be encouraged even if the
child has had pertussis. Erythromycin is not curative but may reduce
infectivity.

Question 34
Mary is an attendant at a local accommodation centre and has an intensely
itchy rash on her wrists and arms that has been present for the past few days
(see figure).

She has recently bought a new watch and wonders if this is the cause of the
problem. The MOST LIKELY diagnosis is:
a) Papular urticaria
b) Tinea
c) Contact dermatitis
d) Eczema
e) Scabies

Ans.E Scabies is a skin infestation by the mite Sarcoptes scabiei. It is

generally spread by skin to skin contact such as in crowded areas, poverty,
sexual contact and casual contact. The mite can live for 2 days outside the
human body, so infection by contact with bed linen and other infected
material is possible.
Intense itch is characteristic of the condition - if it is not itchy, it is not
scabies. Distinct erythemato-papular itchy nodules are due to an allergic
reaction to the mite, its faeces and its larvae. 0.5-1.0cm "burrows" can often
be found on the fingers and wrist. Contact dermatitis to her watch would
produce a local contact dermatitis.

Question 36
The MOST appropriate treatment for first degree atrioventricular (AV) heart
block is:
a) An artificial pacemaker
b) Isoprenaline hydrochloride (Isuprel)
c) Atropine
d) Digoxin
e) Requires no treatment
Ans.E First degree AV block often does not require any treatment. Acute
treatment of extreme bradycardia or second degree AV block (Mobitz type II)
may require atropine or isoprenaline, but temporary pacing is the preferred
treatment. Permanent pacing is recommended for distal block (Mobitz type 2)
because of frequent early progression to third-degree atrioventricular block.
Most patients with third degree (complete) AV block will require permanent
cardiac pacing. Drugs such as digoxin may be the cause of an AV block and
need to be ceased or the dose reduced.

Question 13
Which of the following statements about patent ductus arteriosus is
INCORRECT?
a) It occurs frequently as an isolated phenomenon
b) Cyanosis is usually present
c) It causes a pansystolic 'machinery' murmur at the upper left sternal edge
d) There is a wide pulse pressure
e) Treatment is by surgical closure

Ans.B Cyanosis is not usually present unless a right to left shunt develops.
Patent ductus arteriosus is usually an isolated problem occurring most
commonly in females. There are often no symptoms until later in life, when
heart failure or infectious endocarditis develops. Clinical signs include a
continuous murmur and a bounding peripheral pulse with wide pulse
pressure due to shunting of blood from the aorta to the pulmonary artery.

Question 16
Which of the following features is UNLIKELY to be due to arterial
ischaemia?
a) Pain along the buttock and thigh after exertion
b) Weakness of the buttock and thigh
c) Shooting pain from buttock along the back of the leg to calf
d) Weakness of the leg
e) Smooth shiny skin on the leg below the knees

Ans.C Diffuse pain, weakness and paralysis are all signs of arterial ischaemia.
Characteristically the pain is a cramp-like ache due to the release of pain-
inducing metabolites in muscle. Due to the aetiology, the pain is diffuse and
cannot be localised, as can the shooting pain of nerve irritation.
Question 19
Harold, aged 24 years, presents with fatigue, shortness of breath on exercise
and orthopnoea. On examination there are signs of moderate left-sided heart
failure. A grade III pansystolic murmur is heard most prominently at the
apex and radiating into the left axilla. Which of the following conditions is the
MOST LIKELY diagnosis?
a) Mitral stenosis
b) Mitral regurgitation
c) Aortic stenosis
d) Aortic regurgitation
e) Tricuspid stenosis

Ans.B Mitral regurgitation presents as fatigue, exertional dyspnoea and

orthopnoea. It is associated with a pansystolic murmur loudest at the apex but
radiating over the praecordium and into the axilla. It may also be associated
with a short mid-diastolic flow murmur following a third heart sound, due to
the rapid flow of blood into the dilated left ventricle. The second heart sound
is normal.

Question 23
Victor, a 36 year old man, has known ischaemic heart disease. He complains
of a recent increase in frequency of chest pain and presents with a prolonged
episode of chest pain. Management includes all of the following EXCEPT:

a) Admission to hospital
b) Plasma troponin
c) Continuous ECG monitoring
d) Thrombolytic therapy and oral aspirin
e) Continuous IV nitroglycerin infusion

Ans.E Clinically this patient has unstable angina. Management should include
continuous ECG monitoring, admission to hospital and plasma troponin to
exclude myocardial infarction. Continuous IV nitroglycerin infusion should
only be used when required. If there is no improvement in 24-48 hours,
cardiac catheterisation and angioplasty are indicated.

uestion 27
Malcolm, a 55 year old man, presented with symptoms of gastro-oesophageal
reflux disorder (GORD). You referred him for a gastroscopy which has not
revealed any abnormality. He still complains of bloating and heartburn.
Which of the following would you advise?
a) Reflux has been excluded as a cause of his symptoms
b) A trial of medication is inappropriate
c) Endoscopy detects the presence of reflux in only 60-80% of patients
d) It is important to treat his symptoms with a trial of medication
e) He should have a repeat endoscopy in 6 months

Ans.D Some patients have symptoms of gastroesophageal reflux disease but do

not have endoscopic evidence of reflux or oesophagitis. A trial of medication is
the treatment of choice as many patients will still respond to this.

Question 32

Herman is a 57 year old man who is recovering from a hitherto uncomplicated

myocardial infarction. On the fourth day he complains of sudden onset of
palpitations. Initial examination confirms a tachycardia with blood pressure
of 140/80. The ECG shows the following rhythm (see figure).

The first line treatment for this patient is:

a) Carotid sinus massage
b) Digoxin IV
c) Verapamil IV
d) Lignocaine IV
e) DC cardioversion
P wave duration ≤ 0.12 s
PR interval 0.12–0.22 s
QRS complex duration ≤ 0.10 s
Corrected QT (QTc) ≤ 0.44 s in males
≤ 0.46 s in female
QTcB = QT/√2(R − R) Bazett’s square root formula
QTcF = QT/√3(R − R) Fridericia’s cube root formula
Ans.D This ECG shows ventricular tachycardia with a rate of 150 b.p.m.
There is a rapid ventricular rhythm with broad, abnormal QRS complexes.
Since his blood pressure is well maintained, medical treatment is indicated as
first line approach. Lignocaine IV or sotalol IV or amiodarone IV can be used.
DC cardioversion is required if medical therapy is unsuccessful. If the cardiac
output and blood pressure are very depressed, emergency DC cardioversion
must be considered.

Question 37

Edith is a 70 year old woman who presents with palpitations. Her ECG is
shown below.

What is the diagnosis?

a) Atrial flutter
b) Atrial fibrillation
c) Atrial premature beats
d) Sinus arrhythmia
e) 1st degree AV block
Ans.B This ECG shows atrial fibrillation. There are no p waves and the
rhythm is irregularly irregular which causes the patient to perceive
palpitations.

Question 4
Clarice, 26 years, presents to you concerned because she has noticed that a
dark mole on her thigh has become enlarged, slightly lumpy and itchy over
the last two months. You suspect it may be a malignant melanoma. The
MOST APPROPRIATE initial management would be to:
a) Ask Clarice to return for review in three months
b) Take a incisional biopsy of the lesion for histopathology
c) Treat the lesion using liquid nitrogen
d) Remove the lesion using laser
e) Undertake an elliptical excision clear of the margin for histopathology

Ans E If a malignant melanoma is suspected then an accurate pathological

report is required to guide further management. For this reason it is
important that the initial management involves complete removal of the lesion
without destruction of the tissue. Early detection and removal of melanomas
leads to better outcomes (Clark's level one and two melanomas have a five
year prognosis of >90%). If a melanoma is diagnosed then referral to a plastic
surgeon is necessary for a wide local excision involving a margin of 1-3 cm
and to a depth of the deep fascia.

Question 6
Benny has always loved to go clubbing, and often after a few drinks at the end
of a night of dancing, he ends up having casual sex with someone he meets at
the nightclub.
Benny had his first hepatitis B serology testing done last week. These are his
test results:
HBsAg = positive
HBsAb = negative
IgM HBcAb = positive
HBeAg = positive.
What is the MOST LIKELY cause of these results?
a) Benny has been vaccinated in the past for hepatitis B and is now immune
b) Benny has had hepatitis B infection sometime in the past and it has
resolved, leaving him with life-long immunity
c) Benny is a hepatitis B carrier
d) Benny has acute or current hepatitis B infection
e) Benny has early liver cirrhosis

Ans.D Benny is HBsAg positive which occurs 1-6 months after exposure to the
hepatitis B virus and indicates acute infection. If HBsAg persists after 6
months, it defines carrirer status.
HBsAb is not present (it would be positive following vaccination).
IgM HBcAb is present in acute infection only (IgG HBcAb is present in highly
infective carriers and in acute infection).
HBeAg is present and implies high infectivity in recent infection and carriers.
Benny needs education about hepatitis B, safe sex & drug use

* Question 7
The clinical features associated with raised intracranial pressure include all of
the following EXCEPT:
a) morning headache
b) vomiting
c) presence of papilloedema
d) decrease in conscious state
e) falling blood pressure with a falling pulse
Ans.E Rising blood pressure (not falling) in combination with a falling pulse
rate is a classical feature of rising intracranial pressure known as the Cushing
response.
Headache occurs as a result of the deformation of intracranial blood vessels
and dural membranes which arises from conditions which give rise to raised
intracranial pressure.
The headache is worst in the morning (as is vomiting) and is
aggravated by coughing, sneezing or stooping. When present papilloedema
(swelling of the nerve fibres of the optic disc) is highly suggestive of raised
intracranial pressure. A decrease in conscious state commencing with
confusion and progressing through various grades of coma is also seen with
increasing intracranial pressure.

Question 9
Which of the following is FALSE regarding neural tube defects and folate
before and during pregnancy?
a) Folate intake should be increased at least one month before and three
months after conception
b) Most women before and during pregnancy need 0.5mg folate daily
c) Women on anti-epileptic medication may require 5mg folate daily before
and during pregnancy
d) Folate reduces the incidence of neural tube defects which occur at the rate
or 1:5000 pregnancies
e) Women with a family history of neural tube defects need more folate
before and during pregnancy

Ans.D Pregnant women are at increased risk of folate deficiency due to the
high demand of the developing foetus. Deficiency in the first few weeks of
pregnancy can cause neural tube defects in the newborns. Neural tube defects
occur at a rate of 1:500 pregnancies. The other options are true.

* Question 10
Pamela aged 45 years, attends having found a lump in the upper outer
quadrant of her right breast two days ago. She is concerned about the
likelihood of cancer. In order to diagnose the nature of the lump you invoke
the use of the "triple test" or "triple assessment". The triple test consists of:

a) Clinical examination, mammography, magnetic resonance imaging (MRI)

b) Mammography, ultrasound, fine needle biopsy
c) Clinical examination, mammography, fine needle biopsy
d) Clinical examination, ultrasound, magnetic resonance imaging (MRI)
e) Ultrasound, fine needle biopsy, magnetic resonance imaging (MRI)

Ans.C Management of breast lumps is now based on the triple test, which
combines the results of clinical examination, mammography (+/- ultrasound)
and fine needle aspiration biopsy. When combined, these tests give a
sensitivity of 95-99% in the diagnosis of breast lumps.

Question 22
Beth, aged 6 months, is brought to see you by her mother who has noticed her
eyes are not always lined up. You are concerned Beth may have a squint
(strabismus). Which of the following statements regarding strabismus is
CORRECT?

a) Investigation is unnecessary in this age group as strabismus improves with

time
b) By the age of 6 months Beth's eyes should be constantly well aligned
c) Strabismus is rarely a marker of other ocular disease
d) Strabismus is not associated with amblyopia
e) The corneal light reflex is a reliable test to diagnose strabismus

Ans B A baby's eyes should be constantly well aligned by the age of 5 to 6

months. Intermittent ocular deviation should be investigated if present at six
months, as it may be a marker of severe underlying ocular or neurologic
disease. It should never be assumed that the strabismus will be outgrown. The
corneal light reflex test should not be relied upon to diagnose or exclude
strabismus. The cover test is a more accurate diagnostic test. Strabismus may
lead to amblyopia, which in turn may result in permanent loss of vision if it is
not corrected by 4 to 6 years of age.

Question 25
Robyn, aged 43 years, is known to have gallstones. On this occasion she
presents with the acute onset of severe pain which was at first central in
location but has now moved to the right costal margin and radiates to the
back. She is pyrexic, slightly tachycardic and has tenderness over the area of
the gall bladder but no rigidity of the abdomen. The MOST APPROPRIATE
MANAGEMENT would be to:
a) Allow her to return home and review her in two to three days allowing
time for the attack to settle
 b) Admit her to hospital and treat her with IV fluids and antibiotics
c) Refrain from use of opiates due to risk of addiction
d) Admit her to hospital for immediate surgery
e) Aim to delay the operation for several weeks to months

Ans B Robyn has acute cholecystitis. Initial management includes IV fluids

and nil by mouth, pain relief with parenteral opiate administration and a
short, intensive course of antibiotics. The patient is monitored and immediate
operation is ONLY indicated if the fever does not settle or symptoms worsen.
Immediate operation is not warranted, as there is no indication of perforation
of the gall bladder or peritonitis. However, early operation for acute
cholecystitis is now recommended compared to delaying surgery.

* Question 26
Kari is 7 months old and has not received any immunisations. She presents
with two weeks of paroxysmal coughing and vomiting, but is relatively happy
between paroxysms. You suspect she may have whooping cough (pertussis).
Kari lives at home with her mother, father and older brothers, aged 2 and 4
years. Neither of her brothers have been immunised against pertussis. Choose
the BEST INITIAL MANAGEMENT option from the list below.
a) Arrange to have Kari admitted to hospital and isolated immediately
b) Report the family to the child protection agency in your state for failing to
immunise their children
c) Vaccinate Kari immediately with DTPa-hepB or DTPa
d) Prescribe oral erythromycin for Kari and the whole family
e) Take a nasopharangeal aspirate for diagnosis, and await confirmation of
diagnosis prior to starting any other treatment measures

Ans D Whilst it is important to obtain a laboratory diagnosis of pertussis, this

should not delay treatment, which should be commenced after appropriate
nasopharangeal aspirate or serological samples are collected. Kari should be
treated with erythromycin 10mg/kg/dose up to 250mg orally 6 hourly for 10
days, as should all household and other close contacts.
Hospitalisation and isolation are unnecessary unless the clinical
condition of the patients warrants inpatient management. Catch-up
vaccination should be addressed, but is not the most immediate concern here.
There is no requirement to report the family to authorities if they are
conscientious objectors to immunisation.
Question 30
Esther is 7 years old. She presents with a large yellow crusted lesion on her
left cheek and similar yellow crusted lesions along her left lower jawline. She
has no lesions or rash elsewhere and is otherwise well. Which is the MOST
ACCURATE statement regarding this condition?
a) Herpes simplex is the likely causative organism
b) It is important not to disturb the crusts
c) Esther should be screened for immune deficiency
d) Topical mupirocin is an appropriate treatment
e) Oral antibiotics should be commenced as early as possible to prevent
septicaemia developing

Ans D The most likely diagnosis is impetigo, with the ruptured vesicles that
form yellow crusts and weeping erosions being quite typical of the lesions.
Herpes simplex has a different clinical presentation. In childhood, primary
HSV infection usually presents as severe acute gingivostomatitis. Impetigo is a
very common, highly contagious infection, and does not suggest an underlying
immune deficiency. The usual pathogen is Staphylococcus aureus, or
Streptococcus pyogenes. For mild or localised impetigo, topical mupirocin 2%
ointment or cream 3 times daily for 7 days is appropriate treatment. Whilst
oral antibiotics may be indicated for more widespread infection, septicaemia
is not a usual sequelae of this common condition. Bathing the lesions to
remove the crusts may be helpful.

Question 32
One minute after birth an infant shows deep cyanosis of the trunk and limbs,
makes no reaction to a catheter inserted into the nose, is limp but takes an
occasional gasp. What is the Apgar score?
a) 0
b) 1
c) 2
d) 3
e) Insufficient data

Ans E The table below shows the data required to determine an Apgar score.
The scenario given lacks information about the heart rate. Other data given
are compatible with a score of 0.
Apgar Score 0 1 2
Sign
Heart rate absent <100 beats/min >100 beats/min
Respiratory absent irregular, weak cry regular, strong cry
effort
Muscle tone flaccid some flexion of upper well flexed, active
extremities motion
Reflex no response grimace cough or sneeze
irritabilities
Colour central peripheral cyanosis completely pink
cyanosis

Question 40
Lulu is a three year old child who has swallowed kerosene and is brought
immediately to the hospital casualty department. Which of the following
measures should be undertaken in the immediate management of Lulu's
problem?
a) Gastric lavage
b) An emetic
c) Chest x-ray
d) Intravenous saline
e) Methicillin

Ans C Kerosene is an aliphatic, highly volatile hydrocarbon which is poorly

absorbed from the gastrointestinal tract. Pneumonitis through aspiration of
fumes is the predominant toxic mechanism in children and respiratory
distress can be severe and occur rapidly. While a chest xray is not useful for
the prediction of lung involvement, serial chest xrays are important to
monitor progression. In children who present with lethargy, fever or
respiratory signs in the first 4 hours 80% develop pneumonitis.
Gastrointestinal irritation is common with nausea and vomiting. There may
also be a high fever within 30 minutes of ingestion.
Management should be conservative and decontamination (emesis or gastric
lavage) should not be attempted - it merely increases the risk of aspiration,
and development of pneumonitis. IV saline may be required if haemolysis
from the kerosene occurs and hypotension develops.

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
d) Lisinopril
e) Felodipine

D. Linisopril is an angiotensin-converting enzyme inhibitor. 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. At present,
there is no general agreement on the timing of beta blocker (propanolol)
therapy. It is currently reserved for those patients who remain symptomatic
whilst on maximal therapy with other agents.

* 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
c) Patient with nocturnal symptoms only
d) Patient with bloating after meals
e) Patient has water-brash

B. 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.

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
b) Atrial septal defect (ASD)
c) Innocent pulmonary ejection murmur
d) Ventricular septal defect (VSD)
e) Patent ductus arteriosus (PDA)

B. 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.

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

E. 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 myomas and polyps,
intrauterine contraceptive devices and congenital malformations (eg.
bicornuate and septate uterus).

Question 31
In a child with chickenpox which of the following drugs is MOST LIKELY to
cause Reye's syndrome?
a) Paracetamol
b) Aspirin
c) Codeine
d) Penicillin
e) Prednisolone

B. 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.

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

A. 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.

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
e) Metered dose inhaler with a spacer and face mask

E. 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.

Question 38
In iritis (uveitis) the pupil is:
a) Eccentric and reacts briskly to light
b) Concentric dilated and reacts briskly to light
c) Eccentric and reacts sluggishly to light
d) Concentric, constricted and reacts sluggishly to light
e) Concentric, dilated and reacts sluggishly to light

D. In iritis the pupil is concentric, constricted and sluggish. The signs of acute
anterior iritis are pupillary miosis and perilimbal flush. The ciliary body
constricts due to irritation and therefore is less able to respond quickly to
light.

Question 40
Trevor, a male infant weighing 2.4 kg at birth after a normal labour, 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
e) Rh incompatibility

E. 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 and physiological jaundice occur between days 2-5. Biliary
atresia presents with jaundice after the first week of life.

Question 3
Which of the following criteria enable a clear distinction to be made between
haemorrhage and thrombosis in a patient with a cerebrovascular accident?
a) The progress of the clinical features
b) The degree of loss of consciousness
c) The abruptness of onset
d) The presence or absence of headache
e) None of the above

E. Intracerebral haemorrhages tend to be dramatic and accompanied by a

severe headache. However, there really is no clinical way of reliably
distinguishing between an intracerebral haemorrhage and a thromboembolic
infarction, as both produce a sudden focal deficit.

* Question 4
Bel is 20 years old and has had one allergic reaction to a bee sting. She states
that there is a family history of bee sting allergy . Which of the following is
NOT useful advice for Bel?
a) Do not drink out of an open soft drink can that has been left outdoors
b) Have a supply of antihistamines on hand
c) Insect repellents are useful to prevent bee stings
d) Do not walk barefoot around swimming pools
e) Always carry an adrenalin 1:1000 injection, e.g. EpiPen, and know how to
use it
C. Insect repellents have not been shown to be useful in preventing bites from
stinging insects. Anyone with a known allergy to stinging insects should know
how to administer adrenalin 1:1000 subcutaneously and have it with them at
all times. EPIpen is a commercial preparation which is supplied with an auto-
injection device. Avoiding behaviours likely to lead to a sting - such as those
mentioned in the options and avoiding colourful clothes and perfumes which
attract insects - is also important.

* Question 5
John is a 30 year old professional athlete who suddenly develops persistent
dull upper left chest pain which is not related to exertion. Although not
related to respiration, it causes mild restriction in breathing. There were no
related respiratory or cardiac symptoms; he is not distressed and is afebrile.
Which of the following diagnoses is LEAST likely?
a) Spontaneous pneumothorax
b) Functional chest pain (anxiety neurosis)
c) Costo-chondral syndrome
d) Muscle strain
e) Pleurodynia ( Bornholm's disease)

E. Bornholm's disease is due to an infection by Coxackie B virus. It is often

associated with an acute upper respiratory tract infection with fever, pleuritic
chest pain and upper abdominal pain. These pains can be severe and
associated with tachypnoea. A spontaneous pneumothorax, functional chest
pain, costochondritis or acute muscular strain would be more likely in this
patient.

Question 9

Abdul is a 58 year old man who presents with transient episodes of vertigo,
slurred speech, diplopia, and paresthesia. Which of the following is the MOST
likely diagnosis?

a) Basilar artery insufficiency

b) Anterior communicating artery aneurysm

c) Hypertensive encephalopathy
d) Pseudobulbar palsy

e) Occlusion of the middle cerebral artery

Bulbar palsy
Synonyms: lower motor neurone dysarthria, neuromuscular dysarthria, atrophic bulbar paralysis.

Bulbar relates to the medulla. Bulbar palsy is the result of diseases affecting the lower cranial nerves
(VII - XII). A speech deficit occurs due to paralysis or weakness of the muscles of articulation which are
supplied by these cranial nerves. The causes of this are broadly divided into: 1)Muscle disorders.
2)Diseases of the motor nuclei in the medulla and lower pons. 3)Diseases of the intramedullary nerves
of the spinal cord. 4)Diseases of the peripheral nerves supplying the muscles.

• Lips - tremulous
• Tongue - weak and wasted and sits in the mouth with fasciculations
• Drooling - as saliva collects in the mouth and patient is unable to swallow (dysphagia)
• Palatal movements are absent
• Dysphonia - rasping tone due to vocal cord paralysis; nasal tone if bilateral palatal
paralysis
• Articulation - difficulty pronouncing r; unable to pronounce consonants as dysarthria
progresses

Causes:

• Diphtheria
• Poliomyelitis
• Motor neurone disease e.g. progressive bulbar palsy (features of pseudobulbar palsy may also
be present)
• Syringobulbia
• Cerebrovascular events of the brainstem
• Brainstem tumours
• After radiotherapy for nasopharyngeal carcinoma
• After surgery for acoustic neuroma
• Guillain-Barré syndrome

Pseudobulbar palsy
Synonyms: upper motor neurone dysarthria, spastic dysarthria.

Pseudobulbar palsy results from disease of the corticobulbar tracts. Bilateral tract damage must occur
for clinically evident disease as the muscles are bilaterally innervated.

• Tongue - paralysed, no wasting initially and no fasciculations; "Donald duck" speech;

unable to protrude
• Palatal movements absent
• Dribbling persistently
• Facial muscles - may also be paralysed
• Reflexes - exaggerated e.g. jaw jerk
• Nasal regurgitation may be present
• Dysphonic
• Dysphagic
• Emotional lability may also be present
There may also be neurological deficits in the limbs e.g. increased tone, enhanced reflexes and
weakness. Causes:

• Cerebrovascular events e.g. bilateral internal capsule infarcts

• Demyelinating disorders e.g. multiple sclerosis
• Motor neurone disease
• High brainstem tumours
• Head injury
• Neurosyphilis
A. Transient ischaemic attacks involving the posterior brain circulation, i.e.
the basilar artery, are characterised by diplopia, vertigo, vomiting,
dysarthria, ataxia and hemisensory loss.

Question 28
The FIRST sign of salicylate poisoning in children is usually:
a) Delirium
b) Coma
c) Hyperventilation
d) Hyperpyrexia
e) Convulsions

• The following 4 categories are helpful for assessing the potential severity and
morbidity of an acute, single event, nonenteric-coated, salicylate ingestion:
o Less than 150 mg/kg - Spectrum ranges from no toxicity to mild toxicity
o From 150-300 mg/kg - Mild-to-moderate toxicity
o From 301-500 mg/kg - Serious toxicity
o Greater than 500 mg/kg - Potentially lethal toxicity

Pathophysiology
The toxic effects of salicylates are complex. Respiratory centers are directly stimulated.
Salicylates cause an inhibition of the citric acid cycle and an uncoupling of oxidative
phosphorylation. In addition, lipid metabolism is stimulated, while amino acid metabolism is
inhibited. Catabolism occurs secondary to the inhibition of ATP-dependent reactions with
the following results:

• Increased oxygen consumption

• Increased carbon dioxide production
• Accelerated activity of the glycolytic and lipolytic pathways
• Depletion of hepatic glycogen
• Hyperpyrexia

Acid-base disturbances vary with age and severity of the intoxication. Initially, a respiratory
alkalosis develops secondary to direct stimulation of the respiratory centers. This may be
the only consequence of mild salicylism. The kidneys excrete potassium, sodium, and
bicarbonate, resulting in alkaline urine.

Metabolic effects

A severe metabolic (ketolactic) acidosis with compensatory respiratory alkalosis may

develop with severe salicylate intoxication. A paradoxical aciduria (hydrogen ion excretion)
occurs with the depletion of sodium bicarbonate and potassium.

Infants rarely present with a pure respiratory alkalosis. Respiratory alkalosis with a
compensatory (high anion gap) metabolic acidosis defines the next stage in moderate-to-
severe intoxication. Potassium moves from the intracellular space to the extracellular space.
Excretion of hydrogen ions produces acidic urine.

C. Aspirin has a two-fold toxic effect. First, it inhibits oxidative

phosphorylation leading to a metabolic acidosis. The increased hydrogen ion
concentration of the extracellular fluid stimulates the respiratory centre of the
brain to cause hyperventilation. This is the primary effect in children. Second,
aspirin directly stimulates the respiratory centre to cause hyperventilation
leading to a respiratory alkalosis. This phenomenon is seen mainly in adults.

* Question 29
Charles is a 48 year old businessman who presents for a general check-up and
mentions that he is experiencing occasional fluttering sensations in his chest.
A routine electrocardiograph (see figure) is taken.

Your first line of management should be:

a) Reassurance
b) Digoxin
c) Captopril
d) Beta blockade
e) Quinidine

A. The ECG shows Charles has premature atrial ectopic beats. Often these
are asymptomatic. They may, however, be sensed as an irregularity or
heaviness of the heart beat. Treatment is not normally required, unless the
ectopic beats provoke more significant arrhythmias. In such a situation Beta-
blockade may be effective.

Question 32
Which of the following situations is a CONTRAINDICATION to
immunisation with a live attenuated vaccine?
a) Pregnancy
b) Diarrhoea
c) Mild acute febrile illness
d) Current antibiotic therapy
e) Breast feeding

A. Pregnancy is a valid contraindication to immunisation with a live

attenuated vaccine eg oral polio infection. Exposure to HIV, other
immunodeficiency states and immunosuppressant treatments are also
contraindications. Diarrhoea, minor acute illnesses, antibiotic therapy and
breast feeding are not valid contraindications.

Question 34
An obese man, aged 60 years, is admitted unconscious with a diagnosis of
cerebral thrombosis. The most important IMMEDIATE management is:
a) Insertion of an indwelling catheter
b) Commencement of anticoagulant therapy
c) Physiotherapy to prevent hypostatic pneumonia
d) Insertion of an intravenous drip to prevent dehydration
e) Positioning him on alternate sides 2 hourly

A. An indwelling catheter allows monitoring of fluid status as well as allowing

urinary drainage. IV fluid therapy is not urgent due to the potential to
exacerbate brain swelling, in the acute phase. Anticoagulant therapy is of no
value in treating a fully developed and completed CVA, and should be used
only in transient ischaemic attacks or developing progressive thrombosis. The
other measures of physiotherapy and nursing care should follow.

* Question 35
Which of the following statements about simple febrile convulsions is
CORRECT?
a) It usually occurs between 6-8 years of age
b) Prognosis is poor
c) The risk of developing epilepsy is 10%
d) The convulsions last less than 15 min
e) Investigation with lumbar puncture and CT is essential

D. Simple febrile convulsions last less than 15 minutes. They usually occur
between 3 months and 5 years, with most occurring between 17 and 23
months of age. There is no difference in IQ at age 7 years between children
who have had a febrile convulsion and their seizure- free siblings. The risk of
developing epilepsy following a simple febrile convulsion is 0.9% at age 7
years.

Question 37
Katie, a twelve year old school girl, collapses suddenly at school, and is
transported by ambulance with dextrose drip (60/ml min.) inserted. On
examination, dolls eye reflexes are present and she is not responding to
painful stimulus. Her vital signs are as follows:
Resp. rate 14/min
Pulse rate 50/min
Sa02 100 %
B/P 180/110
What is the NEXT step of management?
a) Arrange for urgent scan
b) Stop her dextrose infusion and start a saline infusion
c) Give steroids
d) Intubate the patient
e) Neurosurgical consultation

C. Katie has raised intracranial pressure as indicated by the hypertensive

response in the presence of bradycardia and coma. Glucocorticoid steroids (eg
dexamethasone) are most effective in reducing raised intracranial pressure
and should be given first before the other measures. Katie will need a
neurosurgical consultation and an urgent CT scan or MRI to diagnose the
cause of increased intracranial pressure. Intubation will be required if her
airway becomes compromised. Mannitol (IV) and hyperventilation to an
arterial pCO2 of 25-30 mmHg may also be useful in controlling raised
intracranial pressure.

* Question 38
The defect in visual fields MOST commonly associated with a pituitary
tumour is:
a) Crossed homonymous hemianopia
b) Central scotoma
c) Bitemporal hemianopia
d) Total blindness in one field
e) Peripheral concentric constriction and enlargement of the blind spot
C. As a pituitary tumour extends upwards from the diaphragma sellae and
compresses the optic chiasm, it classically causes superior quadrantic defects
followed by bitemporal hemianopia. It can however cause any variety of
visual field defects, including unilateral (or bilateral) field defects in all
quadrants, due to the variable position of the chiasm above the pituitary.

Question 40
Which of the following would be MOST helpful in distinguishing cerebral
infarction from cerebral neoplasm?
a) History of headache
b) Hemiplegia
c) Chronology of development
d) Carotid bruit
e) Focal abnormality on electroencephalogram

C. Chronology of development is the most important factor in differentiating

cerebral infarction from cerebral neoplasm. Cerebral infarction tends to be a
simple, sudden event or a series of stepwise events within hours to days. In
comparison, neoplasms tend to be preceded by symptoms such as headache,
progressive cognitive decline, seizures and vomiting, and may feature steadily
progressive neurological signs. The other options are all variably present in
both conditions and are not diagnostic.

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
b) As Type 2 diabetes has just been diagnosed he won't need a referral for 5
years
c) Retinopathy is not a problem in Type 2 diabetes
d) Retinopathy is a rare complication of diabetes
e) None of the above

A. 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. All patients with Type 2 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.

Question 3
Brian, a long standing patient of your practice wants to discuss a friend of his
who has just had his nail removed because of a melanoma. Which of the
following statements about malignant melanoma is CORRECT?
a) This is a very common condition
b) It is rarely fatal
c) Removal of the nail constitutes a cure
d) Mean survival time post diagnosis is 12 months
e) This condition does not metastasise

D. Melanomas which occur on the palms, soles or nail bed are called acral
melanomas and are quite rare. Because of their position, they are not found
until quite late, and hence have a very poor prognosis. They spread locally
and metastasise to regional lymph nodes. Biopsy with removal of the entire
digit is the definitive treatment.

Question 19
Blood-stained discharge from the nipple of a 45 year old woman is MOST
LIKELY due to:
a) Gynaecomastia
b) Duct papilloma
c) Paget's disease of the nipple
d) Fibroadenoma
e) None of the above

B. Duct papilloma typically presents with a unilateral serosanguineous or

bloody nipple discharge. Paget's disease of the nipple presents with a chronic
eczematous eruption indicating an underlying malignancy. Gynaecomastia
(benign enlargement of the male breast) and fibroadenoma (smooth round
asymptomatic breast lump) are not associated with blood stained nipple
discharge.

Question 22
A 60 year old man presents with severe abdominal pain, shock, moderate
abdominal rigidity and intense lower back pain. Which of the following
diagnoses is MOST LIKELY?
a) Acute retrocaecal appendicitis
b) Leaking aortic aneurysm
c) Renal colic
d) Acute cholecystitis
e) Collapse of L4 vertebral body

B. 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.

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
c) Intravenous hydrocortisone
d) Intravenous promethazine (Phenergan)
e) Oxygen therapy

B. This is acute angio-oedema and there is a risk of upper airways closure, so

subcutaneous adrenaline should be given first.

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
d) Increased tone
e) Hyperactive tendon reflexes
C. 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.

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

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.

* 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. The patient had a
history of allergy to penicillin, and therefore tetracycline therapy was
instituted. 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) Normally resolving pneumococcal pneumonia
b) Laboratory contamination of original culture
c) Superinfection
d) Side effect of therapy
e) Pulmonary thromboembolism

D. This clinical picture demonstrates deterioration in the patient's condition,

and is not part of normally resolving pneumonia. 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. Although more commonly due to penicillins it can be caused by
tetracycline. As he had initially improved, it is unlikely that the original
specimens were contaminated. 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.

Question 2
A 21 year old man walks into your surgery with his head tilted sideways, his
eyes rolled up and his tongue sticking out. He speaks with difficulty but says
that he has been 'stuck' in this position since taking a new medicine a few
hours ago 'for his nerves'. You should administer:
a) Diazepam
b) Benztropine
c) Chlorpromazine
d) Phenytoin
e) Haloperidol

B. The presentation described is an acute dystonic reaction, which involves a

spasmodic torticollis, (where the head is pulled and held to the left or right by
one or other sternomastoid), upward drawn eyes and an open mouth
(oromandibular dystonia). It may occur (particularly in young men) within a
few days of starting a neuroleptic medication. Treatment is with the
anticholinergic medication eg. benztropine. The dystonias are a group of
disorders involving prolonged spasms of muscle contraction. Spasmodic
torticollis is one type, as is trismus (clenched jaw) and Blepharospasm
(involuntary contraction of the orbicularis oculi). In isolation, the dystonias
are usually of unknown cause and treatment is difficult.
Question 5
You are called to see a 78 year old woman with a three-week history of
headaches and depressive symptoms. She relates that 24 hours ago the vision
in her right eye suddenly dimmed. Today the visual acuity in the eye is limited
to perception of hand movements only, compared with 6/6 in the left eye. She
is not known to be a diabetic and her blood pressure is only minimally
elevated. Which of the following possible causes of her visual loss require
IMMEDIATE investigation and treatment to prevent blindness in the other
eye?
a) Detached retina
b) Central retinal artery occlusion
c) Central vein occlusion
d) Acute glaucoma
e) Temporal arteritis

E. Temporal arteritis is an uncommon disease of the elderly and is

characterised by the classic complex of fever, anaemia, high ESR and
headaches in an elderly person. It is closely associated with polymyalgia
rheumatica. Temporal arteritis is the most common manifestation of a
systemic vasculitis. Headache is the predominant symptom and may be
associated with a thickened or nodular artery. A serious complication, as
described in this lady, is ocular involvement - ischaemic optic neuritis. Most
patients have head or eye symptoms for months before objective eye
involvement. Acute glaucoma causes a red, painful eye, reduced vision and a
fixed, mid- dilated pupil which may be slightly ovoid. The pain may be severe
and associated with nausea and vomiting. Acute glaucoma may be preceded
by blurred vision or haloes around lights. It is a uniocular attack due to
blockage of drainage of aqueous fluid from the anterior chamber via the canal
of Schlemm. Urgent treatment with hyperosmotic agents is necessary to
reduce the intraocular pressure.

Question 6
Which of the following is INCORRECT?
a) The incidence of haemochromatosis in Australia is 1:200
b) C282Y homozygotes account for more than 90% of haemochromatosis in
Australia
c) The majority of patients with one copy each of the C282Y and H63D
mutation never develop haemochromatosis
 d) 90% of C282Y homozygotes develop symptoms of the disorder at some
stage in their lives
e) Carriers of one copy of the altered gene are generally healthy

D. Studies estimate that up to 50% of C282Y homozygotes will remain

symptom free throughout their life.

Question 10
A 21 year old female patient presents with lower abdominal pain and
tenderness at 14 weeks of gestation. Her temperature is 38.5 degrees Celsius.
The most important diagnosis to EXCLUDE is:
a) Pyelonephritis
b) Threatened abortion
c) Ectopic pregnancy
d) Degeneration of a uterine fibroid
e) Appendicitis
E. Appendicitis is the commonest surgical emergency and has its maximum
incidence between 20 and 30 years of age. In pregnancy it occurs mainly in the
second trimester. Pain is generally higher and more lateral than typical
appendicitis. Ectopic pregnancy occurs approximately one in every 100
clinically recognised pregnancies. The classical triad of ectopic pregnancy
includes amenorrhoea (65-80%), lower abdominal pain (95+%) and abnormal
vaginal bleeding (65-85%). Degeneration of a uterine fibromyoma typically
occurs in the second trimester of pregnancy and is due to ischaemic necrosis.
In threatened abortion there is vaginal bleeding. Pain is usually not a
significant feature unless the cervix is beginning to open. Pyelonephritis can
mimic acute appendicitis in pregnancy.

* Question 11
A patient presents with a recurrent severe hemicranial nocturnal headache
which lasts for 60 minutes and occurs regularly every 3 weeks. The headache
is accompanied by a blocked nose and watering eye. The MOST LIKELY
diagnosis is:
a) Tension headache
b) Migraine
c) Sinusitis
d) Cluster headache
e) Trigeminal neuralgia
D. Cluster headache has a four-fold higher incidence in men than women. It is
characterised by constant unilateral orbital pain, with onset usually within 2-3
hours of falling asleep. The pain is intense and steady with lacrimation,
blocked nostril then rhinorrhoea and sometimes miosis, ptosis, flush and
oedema of the cheek, all lasting approximately an hour or two. It tends to
occur nightly for several weeks or a few months, followed by complete
freedom for months or even years. The response to inhaled oxygen can be
dramatic.

Question 17
Sudden onset of unilateral orbital pain, photophobia, lacrimation and
blepharospasm suggests a diagnosis of:
a) Open-angle glaucoma
b) Iritis
c) Temporal arteritis
d) Blepharitis
e) Vitreous haemorrhage

B. Acute iritis presents with pain of acute onset, photophobia, blurred vision,
lacrimation, circumcorneal redness (ciliary congestion) and a small pupil
(initially from iris spasm). Talbot's test is positive: pain increases as the eyes
converge (and pupils constrict). The slit lamp reveals white precipitates on the
back of the cornea and anterior chamber pus (hypopyon). Open angle
glaucoma is painless and largely asymptomatic until there is visual field loss;
temporal arteritis causes pain in the temporal area, not in the orbit;
blepharitis is inflammation of the eyelids; vitreous haemorrhage can present
with visual field loss depending on the size of the haemorrhage and it is
generally painless.

Question 23
Which finding is INCONSISTENT in this report of a cerebrospinal fluid
(C.S.F.) examination?
a) Elevated protein
b) Normal chloride
c) Elevated glucose
d) No red cells
e) Gross excess of polymorphonuclear leucocytes
C. A lumbar puncture consistent with a diagnosis of pyogenic meningitis
contains excessive polymorphs, with protein at 1.5g/l (aseptic less than 1.5g/l)
and glucose at less than 2/3 the plasma level. There are no red cells unless it is
a bloody tap (ie. Artefact due to piercing blood vessel).

Question 32
Jane is brought into the surgery after being struck in the eye with a tennis
ball. On examination you note blood in the anterior chamber of the eye.
Which of the following statements regarding her management is
INCORRECT?
a) Analgesia containing aspirin is contraindicated
b) Management is directed at avoiding the risk of secondary haemorrhage
c) Emetics may be required
d) Decreased visual acuity necessitates the exclusion of other ocular damage
coexisting with the hyperaemia
e) Jane should be referred to an ophthalmologist for urgent review and
management

C. The management of hyphaema is aimed at preventing secondary

haemorrhage which can cause the anterior chamber to be filled with blood
and severe secondary glaucoma to develop. Thus aspirin-containing analgesics
should be avoided (due to the risk of increased bleeding) and management
includes strict bed-rest in hospital. Although reduced visual acuity can occur,
it is important to exclude other ocular damage through specialist referral if
this occurs. Vomiting needs to be prevented NOT induced, as it raises
intraocular pressure and increases the risk of secondary bleeding.

* Question 33
The MOST LIKELY venous source of fatal pulmonary embolism is:
a) Iliofemoral
b) Subclavian
c) Saphenous
d) Pelvic
e) Popliteal

A. Most pulmonary emboli arise from proximal deep vein thrombosis (deep
veins of lower limb, pelvis and inferior vena cava). Less frequently,
thromboses of the upper arm are the source. Saphenous vein thrombosis
seldom results in clinically obvious pulmonary embolism. Also, in order for
the thrombus to cause fatality, it has to be large enough to either cause
obstruction in the right atrium or of the right ventricular outflow tract. It
therefore would have to originate in a large vein.

Question 37
A 40 year old Vietnamese man who arrived in Darwin 6 weeks prior, presents
with 5 days of headache, fever and malaise. What is the MOST LIKELY
diagnosis?
a) Malaria
b) Typhoid fever
c) Dengue fever
d) Filariasis
e) Meningococcal meningitis

A. Malaria is endemic in South-east Asia and a clinical presentation such as

this should be regarded as malaria until proven otherwise. Its symptoms are
usually non-specific, with headache, fevers and malaise being the most
common symptoms. Typhoid fever has an incubation period of 7 to 21 days,
with an average of 14 days. Although headache and fever are common
symptoms, one would expect other symptoms such as abdominal pain and
diarrhoea. Dengue fever has an incubation period of only 5-8 days, followed
by sudden headache, fevers and severe myalgias ("The Dandy Walker
Syndrome"). A rash typically develops on the third to fifth day. Filiariasis
(due to Wucheria bancrofti) can present as a lymphangitis, with recurrent
fever and inflammation overlying the affected lymphatic vessel. Finally
meningococcal meningitis has a rapid clinical course and the patient would be
unlikely to present with such a long clinical history. Photophobia, neck
stiffness and altered conscious state could also be expected.

Question 40
The most important muscle used for inspiration is:
a) External intercostal muscle
b) Diaphragm
c) Scalene muscles
d) Rectus abdominis
e) Internal intercostal muscles
B. In resting healthy individuals, contraction of the diaphragm is responsible
for the majority of inspiration. Clinically, it is important to remember that
that the diaphragm is innervated by the C3/4/5 spinal segments, (mostly C4/5)
via the phrenic nerves. Loss of function of this segment, either from trauma or
metastatic malignancy, will result in the loss of the function of the diaphragm
and all intercostal muscles. The patient will die of respiratory exhaustion in
three days unless respiration is supported. Unilateral phrenic nerve damage
(i.e. bronchogenic carcinoma), causes unilateral hemi diaphragmatic paralysis
which can cause a 20% loss of inspiratory effort. This is, remarkably, quite
asymptomatic.

Question 1
Intestinal sugar malabsorption following gastroenteritis may be suspected if
the child has:
a) Vomiting each time the particular sugar is eaten
b) A stool pH of 6
c) Salmonella in the faeces
d) Glycosuria and excess sugar in the faeces
e) Recurrence of diarrhoea

E. Sugar tolerance (usually lactose) is recognised by the reappearance of

diarrhoea when milk is reintroduced to the diet. It occurs more often in the
younger infant. The stools become watery and frothy and tend to excoriate the
buttocks. Fluid stools may be positive for reducing sugars such as such as
lactose/glucose but not sucrose. Sugar intolerance is not associated with any
particular pathogen.
Approximately 50% of infants under 6 months who have required
hospitalisation for gastroenteritis require a low lactose formula at the time of
discharge.

* Question 2
Following appendicectomy 10 days previously, a patient presents with fever
and mucus diarrhoea. The MOST LIKELY cause is:
a) Viral gastroenteritis
b) Pelvic abscess
c) Staphylococcal enteritis
d) Giardiasis
e) Abscess around appendiceal stump
B. Passage of mucus with diarrhoeal stool and fever in a patient recovering
from peritonitis (appendicitis being the most common cause), is
PATHOGNOMIC of pelvic abscess. It should be therefore be thought of first
and either treated or excluded. Viral gastroenteritis causes a fluid, not mucus
diarrhoea.
Staphyloccoccal enteritis would be a fulminating, severe illness with more
worrying signs than just change in stool. Giardia causes a fatty, large, pale,
offensive stool with undigested vegetable material (peas, carrots and corn) in
an otherwise well individual. An abscess around the appendiceal stump would
cause signs of a localised peritonitis.

Question 4
An 5 month old infant is brought to the emergency department with a few
hours history of intermittent screaming and drawing up his knees. He has
vomited twice. He is pale, clammy and tired. He also started vomiting. No
abnormality is found on abdominal examination. What is the MOST LIKELY
diagnosis?
a) Gastro-enteritis
b) Intussusception
c) Urinary tract infection (UTI)
d) Hirschsprung's disease
e) Pyloric Stenosis

B. Intussusception occurs when one segment of the bowel passes inwards

inside the adjacent distal bowel. It is the most common cause of intestinal
obstruction between 3 months old to 6 years old (rarely after 36 months old).
The peak incidence in infants is 4-7 months. In typical cases there is sudden
onset, in a previously well child, of severe paroxysmal pain which recurs at
frequent intervals and is accompanied by straining effects and loud cries.
Vomiting usually occurs once or twice in the first hours and then reappears
once obstruction is established. About half will pass red currant jelly stools.
Initially, physical examination may be normal, but a sausage-shaped mass in
the right upper abdomen is found in more than half of infants in the first few
hours. Later on abdominal distension and increased tenderness may conceal
the mass. Hirschprung's disease (aganglionic megacolon) usually presents in
the neonate but at a later age tends to present as chronic constipation with
overflow soiling. Pyloric stenosis usually commences between 3 to 6 weeks of
age and is rare in infants older than 11 weeks. It is associated with projectile
vomiting.

Question 10
In the newborn physiological jaundice is a diagnosis of exclusion. Which of the
following factors is CONSISTENT with a diagnosis of physiological jaundice?
a) Onset within the first 24 hours
b) Unwell infant
c) Jaundice improves with increased feeds and hydration
d) Preterm infant
e) Jaundice lasting longer than 2 weeks

C. Physiological jaundice is often aggravated by deficient feeding and so

increased feeds/fluids is often all that is necessary to improve physiological
jaundice. Factors suggesting that a pathological cause for the jaundice should
be actively sought include: jaundice within the first 24 hours; jaundice
persisting 7-10 days in a full-term infant; the sick infant; high levels of serum
bilirubin. More serious causes of jaundice include gram negative septicaemia,
biliary atresia or Rh incompatibility.

* Question 11
A 65-year-old woman presents with fluid abdominal enlargement to the
xiphisternum. On clinical examination this is thought to be due to an ovarian
cyst. The MOST APPROPRIATE next step in management is:
a) Laparotomy
b) Paracentesis to obtain cells for cytology
c) Laparoscopy
d) Cytotoxic drug therapy
e) Plain x ray of the abdomen

A. As the clinical diagnosis infers a risk of malignancy, diagnosis should be

established by laparotomy with full removal of the mass if possible. Cytotoxic
drug therapy may only be indicated after histological diagnosis and staging
are confirmed. Paracentesis may not give a histological diagnosis and may
spill malignant cells into the peritoneum. Laparoscopy would be of no
diagnostic or therapeutic benefit, and may be procedurally impossible. Plain
X ray of the abdomen is of very limited use, and may only be of help in the
case of a teratoma.

Question 14
Mrs Jones suffers with rheumatoid arthritis which is at present well
controlled. She is concerned about a rash on her hands which she has only
recently noticed. It is itchy. Clinically you suspect that this is lichen planus.
Which of the following is INCORRECT?
a) Lichen planus commonly occurs on the wrists, shins and lower back
b) The rash could have been precipitated by recent gold injections
c) A lichenoid eruption begins within a few days of commencing the
causative medication
d) This rash could have been precipitated by non steroidal anti-
inflammatory drugs (NSAIDs)
e) This rash could be related to blood pressure medication

C. Lichenoid drug eruptions may occur after drug therapy has commenced
but it takes months not days and takes some time to resolve. Gold, NSAIDS,
antimalarials, the antihypertensive captopril and thiazide diuretics can
precipitate the reaction.

Question 19
The MOST COMMON cause of visible bright blood on a child's stool is:
a) Colitis
b) Rectal polyp
c) Intussusception
d) Fissure-in-ano
e) Peptic ulcer

D. In an otherwise well child, the commonest cause of visible bright blood on a

child's stool is fissure-in-ano usually due to the passage of a large motion. The
fissure can be seen by gently parting the anus. Pain is a distinguishing feature.
The commonest cause of blood mixed with stool in an unwell child is
gastroenteritis caused by pathogenic bacteria. Non-infectious inflammatory
colitis is rare in childhood, as are rectal polyps. The clinical signs of
intussusception are of a sudden onset of severe colicky abdominal pain in a
child most commonly between 3 months and 7 months of age. In about 50%
there is passage of red currant jelly stools. Peptic ulcer disease is very unusual
in childhood.

* Question 20
The BEST SIMPLE estimate of the extent of blood loss in a patient who has
recently suffered a large upper gastrointestinal bleed is:
 a) Volume of loss by history
b) Observation of the amount of melena
c) Monitoring of the pulse rate
d) Hypotension when the patient sits up
e) The admission of haematocrit

D. blood loss is haemodynamically significant (>500ml), the patient may feel

faint and show pallor. There will be reduced circulating blood volume, which
will be evident as postural hypotension. Volume loss cannot be estimated by
history or by observation; melena may not occur for hours after the bleed.
Tachycardia may be due to, or exacerbated by, anxiety and pain; haematocrit
may not change after a sudden bleed until haemodilution occurs. In larger
centres, central venous pressure monitoring would be instituted.

Question 24
The daily fluid requirement of a healthy 4.5 kg (4500 g) 2 month-old infant in
a temperate climate is:
a) 400 ml
b) 500 ml
c) 675 ml
d) 1250 ml
e) 1500 ml

C. Oral fluid requirements for infants 0-1 year old is 150ml/kg/day .

Question 32
The INITIAL management of a spontaneous pneumothorax in a patient
without dyspnoea at rest and a uniform 2 cm separation of the lung from the
chest wall on a radiograph should consist of:
a) Observation
b) Single needle aspiration
c) Positive pressure respiration
d) Underwater drainage
e) Underwater drainage with suction

A. A small pneumothorax can be managed with observation and avoidance of

situations likely to reduce atmospheric pressure (i.e. flying). Where the lung is
halfway to the heart border or more, or the pneumothorax occupies 30% of
the pleural space, aspiration with or without drainage by intercostal
catheterisation is indicated. Flying is avoided because the reduction in extra-
thoracic pressure would make the pneumothorax worse.

Question 34
A 20 year old man was admitted to hospital because of the sudden onset of
intense headache and neck stiffness. For the past 4 years, the patient had had
occasional focal motor seizures on the right side of the body. Which of the
following is the MOST likely diagnosis?
a) Ruptured saccular (berry) aneurysm
b) Hypertensive cerebral haemorrhage
c) Haemorrhagic infarction
d) Haemorrhage in cerebral neoplasm
e) Arteriovenous malformation of brain

E. This young man presents with symptoms consistent with an acute

subarachnoid haemorrhage. 80% of subarachnoid haemorrhages are caused
by ruptured aneurysms (usually congenital Berry aneurysms), with the second
biggest cause (5%) being AV malformations. 85% of Berry aneurysms occur
around the Circle of Willis with possible warning signs being 3rd or 6th nerve
palsies, pain behind the eye and other symptoms consistent with an expanding
mass in this area. AV malformations are present from birth but usually
present with symptoms between 10 and 30 years of age. Chief clinical
symptoms and signs are headache, seizure and those associated with rupture.
Focal seizures that become generalised occur in 30% of cases. The past history
of focal motor seizures would suggest the presence of an arteriovenous
malformation over the other causes mentioned.

Question 4
Eve is 9 weeks pregnant. She presents with a history of 24 hours of
intermittent dark blood loss staining her underwear. On vaginal examination,
the uterus is the expected size and the cervical os is closed and non-tender.
You should advise her that:
a) she is likely to have miscarried
b) approximately half of all pregnant women suffer bleeding during the first
trimester
c) she requires admission to hospital for a D&C
d) there is a higher incidence of congenital malformations in fetuses where
bleeding occurred in the first trimester
e) she should have an ultrasound
E. Eve has a threatened abortion as the os is closed and there is no history of
passage of products of conception. This occurs in 25% of pregnancies and half
of these progress to spontaneous abortion. For those who carry the pregnancy
to term there is however no increased risk of congenital malformation. An
ultrasound examination will be helpful, as it will demonstrate the presence (or
absence) of a foetus appropriately sized for dates. The demonstration of a
foetal heart is very reassuring. At 9 weeks, when a foetal heartbeat is present
and not slow, 90% of pregnancies will continue despite bleeding.

Question 6
Vera Smith, aged 61, has noticed a swelling in the front of her neck, which is
enlarging quite rapidly. She is otherwise well, without symptoms of
hypothyroidism or hyperthyroidism. On examination she has a multinodular
goitre, with a dominant nodule of 4 cm diameter in the right upper pole of her
thyroid gland. Of the following investigations, which is the MOST important?
a) TSH, T3, T4
b) ultrasound Scan
c) fine Needle Biopsy of dominant nodule
d) CT scan
e) nuclear Medicine Scan

C.The incidence of malignancy in a dominant thyroid nodule is approximately

7%, and the fine needle biopsy is the appropriate investigation to exclude
malignancy. Vera has several features consistent with a thyroid malignancy,
including a rapidly growing solitary lump, her age (over 60) and the fact that
the dominant nodule is >3cm. Detection or exclusion of malignancy is the
MOST important issue initially.
Thyroid function tests must also be performed routinely even though the
patient is clinically euthyroid but they do not help in determining malignancy.
Ultrasound scan adds little to clinical examination, but may be used to guide
the biopsy needle. CT scan may be useful to assess retrosternal extension, but
there are currently no symptoms of this problem. Nuclear medicine scan is
useful to determine the functional status of a nodule but carcinoma cannot be
excluded on the basis of radionuclide scan.

Question 10
A 26-year-old G3P2 who is 30 weeks gestation telephones you to say that she
has had an episode of bright red vaginal bleeding. It occurred several hours
ago and she has had no associated symptoms. She estimates she lost about a
teaspoon of blood. What would be the MOST APPROPRIATE IMMEDIATE
management?
a) tell her to call back if it happens again
b) tell her to come in immediately for further evaluation
c) make her an appointment at your next antenatal clinic
d) send her directly for an ultrasound examination
e) ask her to monitor fetal movements for the next 24 hours and to ring you
tomorrow

C. Although this bleeding may have a benign cause it is important to recognise

that she may have a placenta praevia or have had a placental abruption. Both
of these conditions require urgent attention because of the risk of maternal
and fetal morbidity and mortality. The patient should be examined (vital
signs, examination of the uterus and foetus and a sterile speculum
examination to assess the nature of the bleeding and whether or not the os is
closed). An ultrasound to assist in confirmation of the diagnosis will be
necessary as part of your evaluation but should occur only after the patient
has been assessed and is stable.

Question 15
Michael Peters, aged 12, sustained a blow to his left temple when he fell while
climbing a tree. He was dazed, but able to recount what had happened. An
hour later he complained of an increasingly severe headache and vomited
once, and then was brought to hospital. His pulse is now 54 bpm, BP 130/90
mm Hg and he is drowsy and confused. His left pupil is larger than his right.
Which is the MOST appropriate advice to give Michael's parents?
a) Michael probably has a skull fracture, and will need an urgent skull x ray
b) Michael has severe concussion, and will be observed closely overnight
c) Michael requires emergency surgery as soon as possible
d) Michael requires an urgent CT scan of his head as he may have bleeding
into his brain
e) Michael is gravely ill and has only a 50% chance of survival of bleed

C. The history of the injury is highly suggestive of an extradural (epidural)

haematoma. Although Michael did not lose consciousness initially, his
condition has deteriorated rapidly and significantly. He is now bradycardic,
hypertensive and his pupil is dilated on the side of the injury. His level of
consciousness is also deteriorating. An extradural haematoma will result in
death if not evacuated promptly.
There is approximately 75% chance he will have a fracture overlying the
haematoma, but skull x ray is not indicated. There may be 'concussive' injury
to the underlying brain but the life-threatening factor is the raised
intracranial pressure from the extradural haematoma.While it would be ideal
to have a CT scan, the rapidly deteriorating condition means that emergency
surgery should not be delayed.
Michael is clearly gravely ill, but the mortality from SAH is around 10% for
obtunded patients and 40% for patients who are comatose prior to surgery.
Prognosis is better for young patients, but deteriorates with associated other
intracranial injuries and with delay between injury and surgical intervention.

Question 26
Felicia is a 15 month old girl. She has symptoms and signs consistent with a
viral upper respiratory tract infection (URTI), including a fever of 38.8
degrees Celsius. Her weight is 11kg. Which of the following is CORRECT
regarding the prescription of oral paracetamol in this case?
a) daily dose should not exceed 90mg/kg/day
b) dosage should be calculated at 30mg/kg/dose 4 hourly
c) dosage should be calculated at 15mg/kg/dose 6 hourly
d) dosage should be calculated at 20mg/kg/dose 6 hourly
e) daily dosage should not exceed 60mg/kg/day

A. Daily oral paracetamol dosage should not exceed 90mg/kg/day, up to a

maximum of 4g. 60mg/kg/day is the maximum dosage for infants aged less
than 6 months. The recommended paracetamol dose in children is 15mg/kg
orally every 4 hours, or 20mg/kg rectally every 6 hours.

Question 33
When treating a premenopausal woman who has irregular cycles, severe hot
flushes and no contraindications to hormone replacement therapy the MOST
APPROPRIATE therapy is:
a) continuous oestrogen therapy
b) continuous combined (oestrogen and progestogen) therapy
c) sequential oestrogen therapy
d) sequential combined (oestrogen and progestogen) therapy
e) continuous progestogen therapy

D. Hormone replacement therapy is indicated in women who are suffering

from severe menopausal symptoms provided they have no contraindications
to its use.
Sequential combined HRT is the best option for premenopausal women who
do not require contraception as it can alleviate symptoms and control
irregular cycles.
The use of continuous or sequential unopposed oestrogen is associated with
endometrial hyperplasia and the development of endometrial cancer and is
contraindicated in women who have not had a hysterectomy. Continuous
combined HRT is recommended for the treatment of symptoms in women
who are more than one year postmenopausal. These women will probably
remain amenorrhoeic on such a regimen. Progestogen alone is not always
effective at treating menopausal symptoms.

Question 35
Teresa, 25 years, presents having experienced an episode of postcoital
bleeding two days ago. What is the MOST APPROPRIATE management?
a) reassure her and ask her to return if it recurs
b) undertake cauterisation of the cervix to prevent further bleeding
c) treat her with metronidazole gel to eradicate infection
d) send her to the emergency department for immediate assessment
e) undertake diagnostic cervical cytology and screening for sexually
transmitted diseases

E. Postcoital bleeding is a serious symptom that could be indicative of

cervical pathology. It is not an emergency requiring assessment in hospital.
Common causes of postcoital bleeding include a cervical erosion, an infection
such as chlamydia and other less common pathologies in this age group such
as a cervical polyp. Medical practitioners must however ensure that they
exclude precancerous or cancerous lesions of the cervix by making sure that
cervical cytology (Pap smear) is performed as well as appropriate STI
(sexually transmitted infection) screening. If the bleeding is recurrent, or the
cervix looks abnormal colposcopy is recommended. Cauterisation of the
cervix is sometimes performed if a friable cervical erosion is present, bleeding
is recurrent and other cervical pathology has been excluded.

Question 39
Angelina, 27 years G3 P2, has a transverse lie at 36 weeks gestation. Should
her membranes rupture what would be the MOST APPROPRIATE
MANAGEMENT?
a) advise her to come in to labour ward when contractions are five minutely
b) lie her down on her side and take her straight to the operating theatre for
a caesarean section
 c) wait for the head to engage with contractions and proceed to a normal
vaginal delivery
d) commence intravenous augmentation of labour in order to facilitate a
swift delivery
e) instruct the patient to adopt the knee chest position (kneeling with head
down) and transfer her to theatre for an immediate caesarean section

E. Cord prolapse occurs when the umbilical cord lies beside or in front of the
presenting part. It is more common in malpresentations, polyhydramnios,
during breech deliveries and with premature rupture of the membranes. It is
an obstetric emergency, as the umbilical vessels constrict once exposed to the
extrauterine environment. Unless the cervix is fully dilated and an immediate
operative vaginal delivery can be conducted, an emergency caesarean section
is required. During the transfer to theatre the woman should be positioned so
that gravity can assist in keeping the presenting part off the cord, i.e the knee
- chest position. The presenting part should also be pushed up and away from
the cord digitally in order to reduce pressure on the cord.

Question 5 Wasting of the thenar muscles as an isolated sign is MOST likely

due to:
a) Syringomyelia
b) Median nerve compression at the wrist
c) Motor neurone disease
d) Ulnar nerve lesion
e) C7-T1 lesion

BBB
Question 9
Sue aged 3 years is having frequent episodes of wheeze, despite daily inhaled
sodium cromoglycate, and regular inhaled salbutamol. What would be the
next MOST appropriate step in establishing satisfactory control of Sue's
asthma?
a) Prescribe inhaled corticosteroid
b) Increase sodium cromoglycate dose
c) Review the diagnosis
d) Substitute large volume spacer
e) Check compliance

AAA
Question 12
Mary, aged 55 years, presents with stiffness of her hips and shoulders, low
grade fever, headaches and malaise. There is no objective evidence of
arthritis. Her erythrocyte sedimentation rate is 65 mm/hr. The MOST
LIKELY cause of this presentation is:
a) Subacute thyroiditis
b) Polymyalgia rheumatica
c) Rheumatoid arthritis
d) Influenza
e) Rheumatic fever

BBB
Question 14
Jeremy is 45 years of age and hobbles into your surgery with a swollen knee.
He states that it has slowly become worse during the past 3 days. He can't
remember any trauma. He is in a lot of pain with an obvious joint effusion.
The MOST IMPORTANT diagnostic procedure to undertake is:
a) X-ray of knee
b) Serum uric acid level
c) Aspiration of the joint
d) Full blood count
e) Urinary uric acid

CCC
Question 22
June, aged 69 years, is brought to see you by her daughter who is concerned
that she has been increasingly forgetful over recent months, and appears to be
losing interest in her usual activities. She is also agitated at times. As part of
your assessment, you perform a Mini Mental State examination and diagnose
dementia. All of the following are reversible causes of dementia EXCEPT:
a) Hypothyroidism
b) Alcohol abuse
c) Thiamine deficiency
d) Vitamin B12 deficiency
e) Vascular dementia

EEE
Question 31
Upper motor neurone lesions are characterised by all of the following
EXCEPT:

a) Loss of voluntary movements

b) Increased stretch reflexes
 c) Increased muscle tone
d) Rapid wasting of affected muscles
e) Extensor plantar responses

DDD
*Question 36
Bob, aged 7 years, is brought to see you because he is complaining of colicky
abdominal pains. He has a rash on the back of his legs, buttocks and extensor
surface of his forearms. Urinalysis reveals proteinuria and haematuria. The
MOST LIKELY diagnosis is:
a) Systemic lupus erythematosus
b) Anaphylactoid purpura (Henoch Schonlein purpura)
c) Post-streptococcal glomerulonephritis
d) Polyarteritis nodosa
e) Dermatomyositis

BBB
Question 41
A man presents unwell to Casualty and the following results are obtained
from pathology: Urea 15 mmol/L (N 2.0 - 8.5); glucose 5.0 mmol/L (3.5-7.9);
Bicarbonate 39 mmol/L (N 20-29); sodium 140mmol/L (135-145); serum
potassium 2.4 mmol/L (N 3.5 - 5.0). The most likely cause of these
disturbances in your patient is:

a) Acute nephritis
b) Severe vomiting
c) Dehydration
d) Diabetes mellitus
e) Chronic renal failure

BBB
* Question 42
Which of the following can result from a snake bite?
a) Coagulopathy
b) Rhabdomyolysis
c) Neurotoxicity
d) Hyperkalaemia
e) All of the above

EEE
Question 46
Prolonged, persistent bradyarrhythmia associated with atrio-ventricular
heart block is BEST treated with which of the following?
a) An artificial pacemaker
b) Isoprenaline hydrochloride
c) Disopyramide
d) Cisapride
e) All of the above
AAA
Question 51
The risk of a baby dying of SIDS is reduced by all of the following EXCEPT:
a) Removing soft toys from the cot
b) Dressing the baby appropriately for the weather
c) Lying the baby prone
d) Not using baby pillows
e) Apnoea alarms

CCC
Question 55
A 70 year old presents with acute central and peri-umbilical abdominal pain
which gradually increases in intensity. She is vomiting profusely and develops
watery diarrhoea with flecks of blood. Examination of the abdomen reveals
localised periumbilical tenderness with some rigidity. Rectal examination is
normal. An irregular pulse is noted and an ECG reveals Atrial Fibrillation.
Optimal management should be:
a) Nasogastric suction and intravenous fluids
b) Intramuscular Pethidine and review
c) Intravenous Cephalosporin
d) Intravenous Somatostatin
e) Surgical intervention

EEE
Question 56 In making a diagnosis of a transmural myocardial infarction
from an electrocardiographic tracing, the MOST SIGNIFICANT finding is:
a) Prolongation of the PR interval
b) The presence of pathological Q waves
c) A raised ST segment in V leads
d) Inverted T waves
e) Depression of the ST segment in affected leads
BBB
* Question 57 All the following statements concerning Paget's disease of the
nipple are correct EXCEPT:-
a) The basic lesion is an intra-ductal carcinoma
b) The nipple epithelium is infiltrated with cancer cells
c) The tumour can always be detected on careful clinical examination
d) The first symptom is often itching or burning of the nipple
e) The diagnosis is readily established by biopsy of the erosion

CCC
Question 59 Which of the following is the most useful observation to
EXCLUDE the diagnosis of fracture of the neck of the femur?
a) Normal buttock contour
b) Quadriceps tone
c) Absence of local tenderness of the hip joint
d) Absence of crepitus of the hip
e) Normal range of movement in the hip

EEE
* Question 60 Which of the following statements is MOST characteristic of
mid-trimester bleeding?
a) It is of little consequence
b) It is related to early effacement and tearing of small vessels
c) Praevia or abruption will be found in 25% of cases
d) There is a risk of concealed bleeding
e) None of the above

DDD
Question 69 Katelyn Norris, aged 20, has returned for the results of her Pap
smear. This is reported as CIN 2. The MOST APPROPRIATE management
is:
a) Repeat smear after treating infection
b) Repeat smear after 3 months
c) Cryotherapy to the cervix
d) Colposcopy and biopsy
e) Cone biopsy

DDD
* Question 70 Which is the BEST indication of successful treatment of the
nephrotic syndrome?
 a) Loss of oedema
b) A normal serum creatinine
c) Absence of urinary protein
d) Massive diuresis
e) Normal blood pressure

CCC
Question 72 A 32 week pregnant woman comes for the first time with BP of
180/125, proteinuria > 8g, with no oedema. All of the following are true
EXCEPT:
a) MgSO4 infusion should be started prophylactically
b) Hydralazine, either IV or orally, should be given
c) She should be delivered by LSCS within 48 hrs
d) Betamethasone should be given.
e) Continuous CTG monitoring is imperative

CCC
Question 76 What is the MOST EFFECTIVE treatment for a bleeding
cavernous haemangioma in a 2-month-old infant?

a) Injection of sclerosant
b) Excision
c) Radiotherapy
d) Diathermy
e) Pressure dressing

EEE
Question 79 Which of the following effectively distinguishes delirium from
other psychological disturbances?
a) Memory impairment
b) Hallucinations
c) Thought disorder
d) Clouded consciousness
e) Severe anxiety

DDD
Question 83
Which of the following is CORRECT in relation to severe reflux in infants less
than 12 months old?
a) Infants have reflux only after feeds
b) The oesophagus of normal infants is not exposed to gastric acid
c) Irritability caused by reflux is more common in infants under 3 months of
age
d) Nutrient loss may be present although weight loss is uncommon
e) Failure to thrive does not occur

DDD
*Question 85
Lyn is worried about her 12 month old child as it sometimes appears that her
eye is turned. Which of the following statements is INCORRECT?
a) Amblyopia(dimness of sight) is generally preventable if strabismus is
diagnosed and treated early
b) The standard period of eye patching required to reverse amblyopia is 4
weeks
c) Strabismus is more common in the premature infant
d) Assessment of the symmetry of the infant corneal light reflex may detect
squint
e) The cover test may be necessary to elicit squint

BBB
* Question 86
A 5 yr old child presented with acute onset of three weeks' duration of
vomiting in the morning associated with headache. His father is concerned
that he has been lacking in energy lately. The MOST LIKELY cause for his
symptoms is:
a) Glioblastoma
b) Astrocytoma
c) Medulloblastoma
d) Migraine
e) Meningioma

CCC
Question 90
Concerning Q Fever (Coxiella burnetti), which of the following is TRUE?
a) Only abattoir floor workers are at risk of infection
b) The rash is pathognomonic
 c) It is spread through contaminated cuts
d) It is easily treated with sulphonamides
e) Persistent infection can result in endocarditis

EEE
* Question 91
Mrs Yoshida presents with her 4 year old son, Takahiro. She is concerned
that he has had consistently pale malodorous greasy bulky stools and suffers
painful abdominal bloating for some weeks now. She says he has become
irritable. He was breast-fed up until 10 weeks of age and then transferred to
formula and cereals, followed by a traditional Japanese diet. He was quite
well until they came to live in Australia one month ago. Clinically, he is
afebrile with no abdominal abnormalities. The MOST LIKELY cause for his
diarrhoea is:
a) Coeliac disease from wheat-derived cereal
b) Giardia
c) Blastocystis hominis
d) Milk allergy
e) Maternal/child anxiety due to environmental upheaval

AAA
* Question 92 A patient slips on a wet floor at work and falls heavily on his
buttocks. He complains of back pain, but is able to walk. His only complaint is
that his penis and scrotum feel numb. The MOST APPROPRIATE step in
further assessment is:
a) X-ray of the lumbar spine
b) Test power of lower limbs
c) Rectal examination
d) Quietly investigate the possibility of malingering
e) CT lumbar spine.

CCC

* Question 93
A 5 month old boy presents with his parents. They are concerned that he may
have a "lazy eye". The confrontation test was positive. The MOST
APPROPRIATE management would be:
a) Reassure the parents that the condition is self-limiting
b) Refer for CT of the head
 c) Instruct parents in a set of exercises to be done daily to strengthen the bad
eye
d) Patch the good eye
e) Refer to an Ophthalmologist

EEE
Question 95
Which of the following conditions may have a fatal outcome?
a) Angry looking napkin rash
b) Blue spots on the buttocks
c) Blue spots on the buccal mucosa
d) Diamond shaped area of hair loss on the scalp
e) Variable-aged bruises with demarcated edges

EEE
* Question 96
Regarding sciatic pain, which of the following is TRUE?
a) It is only felt in the buttock
b) It can occur in the absence of disc prolapse
c) The pain is referred to the anterior thigh
d) It is usually cured by operation
e) Groin pain is highly suggestive of nerve entrapment

EEE
Question 100
A three year old child has a generalized seizure lasting 3 minutes. He has a
temperature of 38.5 degrees Celsius. After 30 minutes, he is seen to be playing
happily with his mother. The MOST APPROPRIATE next step in
management is:
a) Arrange outpatient neurological review with EEG
b) Perform lumbar puncture
c) Arrange for FBE, blood cultures and chest X-ray
d) Commence valproate prophylactically
e) None of the above

EEE
Question 104
Terri is 16 years old and wishes to take the contraceptive pill. The BEST
clinical predictor of post-pill amenorrhoea is:
 a) Oestrogen dose in the pill
b) Age since menarche
c) Use of sequential formulations
d) Duration of regular cycling
e) Serum FSH and oestradiol mid-cycle

DDD
* Question 105
The MOST COMMON cause of chronic pancreatitis is:
a) Virus infection
b) Gallstones
c) Alcohol
d) Carcinoma
e) Illicit IV drug use

CCC
* Question 106
Jenny is three years old. At this age she should be able to:
a) Ride a three-wheeler bike
b) Create a tower of 8 cubes
c) Do up her own buttons
d) Name four colours
e) Tie shoe laces

AAA
* Question 107
Elsie Warne, an 82 year old woman, has been a Nursing Home resident since
suffering a Right parietal CVA three years prior. On presentation, she is
obese and appears demented. Her BP is 160/100, pulse 60regular, and she has
macroglossia and coarse skin. Her cholesterol is 12.4mmol/L. Her sudden
death, three weeks later, was MOST LIKELY caused by:
a) Complete heart block
b) Hypertension induced Cerebrovascular accident
c) Excessive thyroxine replacement
d) Acute myocardial infarction
e) Chronic obstructive sleep apnoea syndrome

CCC
Question 110
In children, an innocent cardiac murmur has all of the following attributes
EXCEPT:
a) Variation in loudness with change in posture
b) Murmur heard in early diastole
c) An ejection click
d) Absence of a thrill
e) Continuous murmur through systole and diastole

CCC
Question 112
A Pap report reads "No cervical columnar cells seen. No cellular
abnormalities seen. Red blood cells and bacteria present. Inflammatory-type
smear". This result is not reliable because:
a) The transitional layer was not sampled
b) Inflammation was present
c) The smear was traumatic
d) A spatula was used instead of a cytobrush
e) It is clinically irrelevant

AAA
* Question 113
Concerning children with asthma, all of the following are recommended
EXCEPT:
a) Education of the parents
b) Development of asthma care plans
c) Ready use of oral prednisolone
d) Access to "reliever" at the child's discretion
e) Desensitization to allergens orally or parenterally

EEE
* Question 114
Heidi Brown, a 22 year old teacher, presented complaining of increasing
dysmenorrhoea and deep dyspareunia. Clinically, the speculum exam was
normal, but there was a feeling of discomfort on the left with bimanual
examination. Heidi's problem is MOST LIKELY due to:
a) Pelvic inflammatory disease
b) Pre-menstrual syndrome
c) Psychological problems
d) Endometriosis
e) Fibroid necrosis
DDD
Question 116
Mr John Hill is a 25 year-old optometrist with no previous history of health
problems and no significant family history. He presents with a 1 month
history of alternating bowel habit, with bloating and pain, flatulence,
abdominal distension, the passage of mucus without blood rectally and a
feeling of incomplete evacuation. He gains relief from his symptoms with
defecation and it never troubles him at night. He has not lost any weight and
his appetite is unchanged. He finds that his abdominal discomfort is
interfering with his work. He has recently taken on a large debt. Which of the
following is CORRECT?
a) Colonoscopy is indicated to exclude malignancy
b) He should be managed with reassurance and education
c) Small bowel biopsy is indicated to exclude Crohn's disease
d) A full blood screen, including CEA and HIV serology is required
e) His symptoms will settle after the debt is under control

BBB
* Question 117
The patient above presented feeling unwell with a mild fever. The rash had
appeared the day before. The condition is:

a) Erythema marginatum
b) Erythema infectiosum
c) Erythema nodosum
d) Erythema multiforme
e) Erythema ab igne

DDD
Question 120
Signs of left ventricular failure consist of all of the following EXCEPT:
a) Gallop rhythm
b) Low volume pulse
c) Pedal oedema
d) Basal crepitations
e) Paroxysmal nocturnal dyspnoea

CCC
Question 124
This lesion has been present at the root of this patient's neck for ten months.
Its appearance is most consistent with a:

a) Nodular melanoma
b) Pigmented basal cell carcinoma
c) Seborrheic keratosis
d) Hutchinson's melanotic freckle
e) Squamous cell carcinoma

BBB
* Question 125
Jordan Miller, aged 19, is bought to Emergency after fainting while running a
100 metre sprint at his Athletics Club. He is extremely fit, and exercises
frequently. He states that it was the second time he "blacked out" while
running. There are no other symptoms except a 2/6 systolic bruit along the left
sternal edge best heard with standing. Which of the following is the MOST
LIKELY diagnosis?
a) Hypertrophic obstructive cardiomyopathy
b) Aortic stenosis
c) Atrial myxoma
d) Prolapsing mitral valve
 e) Re-entrant tachycardia

AAA
Question 43
Peta, aged 3, presents distressed with an acute attack of asthma. She is treated
with salbutamol via MDA and face-mask. She improves symptomatically, but
becomes breathless and wheezy again after 90 minutes. The next MOST
APPROPRIATE step in management would be:-
a) Double the dose of Salbutamol
b) Repeat Salbutamol and commence oral steroids
c) Assess with spirometry
d) Measure Oxygen saturation to determine need for hospitalization
e) Commence I.V. Aminophylline

BBB
Question 46
A 58 year old lady presents with painless jaundice. Physical examination of
the abdomen is unremarkable. The results of her blood tests are:
Liver function tests: Bilirubin 90 umol/L (<21), ALP 650 U/L (30-115), GGT
540 U/L (<31), ALT 55 U/L (<41), AST 45 U/L (<41), alb 35g/L (35-50)
Full blood Count, Electrolytes, Urea and Creatinine are normal.
The next most useful investigation would be:
a) Abdominal CT scan
b) Oral cholecystogram
c) Upper abdominal ultrasound
d) ERCP
e) Assay conjugated/unconjugated bilirubin

CCC
* Question 47
On the second post operative day following a right hemicolectomy, a 68 year
old patient has a urine output of 10mls per hour over the past 5 hours. On
examination he is alert, T37.5 degrees Celcius, P105, BP110/70. Abdomen is
soft and nontender. All other examination findings are unremarkable and the
catheter isn't blocked. Intial management would be to:
a) Check the patient's Electrolytes, Urea and Creatinine
b) remove the catheter
c) increase IV Fluid rate
d) give 40mg IV Frusemide and check urine output again in one hour
e) commence him on oral fluids
CCC
Question 56
When assessing a patient in Emergency with suspected diabetic ketoacidosis,
which of the following is NOT true:-
a) Ketoacidosis may occur with infection only in the presence of fever
b) Nausea and vomiting are common presentations
c) Abdominal pain can be so severe as to suggest an acute surgical abdomen
d) Hypotension and tachycardia can be present
e) Kussmaul breathing is a classical sign

AAA
* Question 57
George Weston is a 48 year old man who has a strong family history of
premature death from myocardial infarction in the males on his father 's side.
He has been treated for hypertension for the past 2 years. For the past 2 years
his blood pressure had been well controlled with a healthy diet, regular
excercise and an ACE inhibitor. However, when he comes for a 6 month
review and renewal of his prescription, his blood pressure is noted to be
150/90. The blood pressure is noted to be high on 3 separate occasions. All of
the following are possible causes for loss of control of his blood pressure
except:
a) He has been taking diclofenac over the past 2 weeks for an ankle sprain
b) He recommenced smoking since he lost his job 2 months ago
c) He has gone back to heavy alcohol ingestion
d) He has been on sibutramine to help him lose weight
e) He has been having trouble sleeping since he lost his job and has been
taking temazepam prescribed by another doctor

EEE
Question 59
Ms Bowden presents with her two year-old daughter, Melanie, who has
recently spent a week at her father 's farm. She has been troubled by intense
itching of her arms, trunk and buttocks. The appearance of the rash is shown
in the photograph above. Other members of Melanie 's father 's family have
similar troubles, and are being treated by the naturopath with a grass seed
ointment. The MOST LIKELY diagnosis is:-
a) Atopic eczema
b) Ringworm (tinea corporis)
c) Contact dermatitis
 d) Scabies
e) Flea bites

DDD
Question 63
From birth to four years of age, the MOST LIKELY setting for childhood
injury is:-
a) Home
b) Child Care Centre
c) Motor Vehicle
d) Community recreational venues (i.e. parks and gardens)
e) Non-child safe residences (i.e. grandparent 's homes)

AAA
Question 66
When taking a history regarding tinnitus, which of the following is MOST
SIGNIFICANT?
a) Is it rhythmical
b) Does it change with posture?
c) Is it affected by hot or cold fluids?
d) Does it disappear while sleeping?
e) Is there a family history?

AAA
Question 69
Mr Scott is a 58 year old diabetic patient with a BP of 150/95 and BMI of 29.
All of the following are true except
a) An ACE inhibitor would be the first choice as an antihypertensive agent
b) his blood pressure should be reduced to less than 140/90
c) he should have an annual spot urine test to check for microalbuminuria
d) Target HBA1C is less than 7%
e) Metformin is the most appropriate oral hypoglycaeimic for this patient

BBB
* Question 70
Bill Randall, a 58 year-old interstate truck driver, presents because of sudden
onset of diplopia and pain in the right orbit. His BP is 138/88, BMI is 32, and
his abdominal girth is 124cm. Examination reveals right sided ptosis and
ophthalmoplegia, with normal pupillary constriction to light. The MOST
APPROPRIATE initial investigation is:-
 a) CT Head
b) Carotid duplex ultrasound
c) 24hr ambulatory BP assessment
d) random glucose
e) VDRL and TPHA

AAA
Question 78
Jane is 15 years old and has not yet had a menstrual period. She denies any
sexual activity. Examination reveals breast and pubic hair development
consistent with her age, and normal genitalia. The MOST APPROPRIATE
management would be:-
a) FSH/LH, prolactin; ultrasound pelvis
b) Reassurance that development is normal and cycles should commence
soon
c) Commence the oral contraceptive pill to induce the HPO axis to cycle
d) Check karyotype
e) Inquire about behaviour associated with eating disorders

BBB
Question 80
Georgina Hassard is a 47 year old woman who presents with menorrhagia of
four cycles duration. Her initial management would include all of the
following EXCEPT:-
a) Transvaginal ultrasound
b) FBC, Iron studies and TFT 's
c) Referral for Hysteroscopy and endometrial biopsy
d) Prescription for combined oral contraceptive pill
e) Advice that the cause of the bleeding may not be found

DDD
Question 89
Which of the following statements regarding cervical intraepithelial neoplasia
(CIN) is FALSE?
a) Risk is increased if first intercourse occurs at an early age
b) HPV types 16 and 18 are causative agents
c) Cigarette smoking increases risk
d) All women who show squamous metaplasia will go onto develop CIN
e) Peak incidence of CIN is between ages 30 and 40
DDD
* Question 90
Sally Hyde 's mother noticed a "lump " on her back when she bent forwards
to pick up her beach towel. Sally is 14 years old, and your examination
revealed an obvious Right sided protrusion of ribs and scapula with forward
flexion. X-ray verified bone age of 14yrs, and a 25 degree scoliosis between T4
andL1. The MOST APPROPRIATE management is:-
a) Observe and review in one year
b) Commence a guided exercise programme
c) Have a body brace fitted
d) Referral to specialist Back School
e) Referral to Scoliosis Clinic for assessment

EEE
Question 95
Which of the following statements regarding Methicillin-resistant
Staphylococcus aureus is FALSE?
a) It is almost endemic in modern hospitals
b) Most patients acquire the infection while in hospital
c) MRSA is more virulent than flucloxacillin-resistant Staph. Aureus
d) Long-stay surgical patients are at high risk
e) Failure of eradication is largely due to poor barrier nursing

CCC
Question 97
The neonate whose x-ray is shown opposite presented with vomiting and
irritability. The film strongly suggests:-
a) Duodenal atresia
b) Pyloric stenosis
c) Jejunal atresia
d) Inefficient burping
e) Malrotation with volvulus

BBB
Question 99
Helen Jones is a 19 year-old secretary who presents with a one year history of
painless post-coital bleeding. She takes a tri-sequential contraceptive pill.
Clinical examination is normal except for a degree of cervical erosion. Her
Pap smear is reported as "inflammatory ". The MOST APPROPRIATE
management is:-
a) Repeat smear after treatment with triple-sulpha cream
b) Change OCP to a more oestrogenic balance
c) Reassure, but review in six months
d) Refer for colposcopy
e) Change OCP to a more progestogenic balance

DDD
Question 100
The LEAST LIKELY problem a woman with fibroids is likely to suffer from
is:
a) Abnormal uterine bleeding
b) Pelvic pain
c) Urinary retention
d) Constipation
e) Reproductive dysfunction

CCC
Question 106
Mr Brown presents complaining of blood in his toilet bowl after defaecation.
Digital rectal examination detects a mobile mass and proctoscopy reveals a
1.5cm x 2.0cm sessile polyp. Colonoscopy reveals the rest of the colon is clear.
The polyp is completely removed by snare diathermy, and histology reveals a
villous adenoma. The MOST APPROPRIATE recommendation re further
management is:-
a) Review colonoscopy in 12 months
b) Re-excision with wide margins
c) AP resection
d) Anterior resection of the rectum
e) Sigmoidoscopy with wide, superficial diathermy of the area

AAA
Question 112
The most sensitive indicator of future risk of insulin resistance in males is:-
a) Body Mass Index
b) Family History
c) Random glucose
d) Diet with greater than 30% fat content
e) Hip-waist ratio
EEE
Question 115
The MOST APPROPRIATE first line of treatment of Roger 's condition is:-
a) ice packs
b) gentle manipulation of the foreskin distally
c) amoxycillin and clavulinic acid
d) nil - it settles spontaneously if left alone
e) referral to paediatric surgeon

EEE
Question 119
Splenectomy as early management for ITP should be avoided in which of the
following groups of patients:-
a) Those with normal marrow function
b) Children
c) Those who fail to respond to corticosteroids
d) Those with a very large, vascular spleen
e) Those with selective IgA deficiency

BBB
* Question 120
A patient has persisting symptoms of regurgitation despite healing of his
oesophageal ulcers after 12 weeks of omeprazole therapy. The MOST
APPROPRIATE management would be:-
a) Advise further dietary modification
b) Double the dose of omeprazole
c) Recommend fundoplication
d) Suggest a trial of alginate "raft " therapy
e) Add cisapride 20mg twice daily
CCC