Question No.

1 :

A 65-year-old male,commercial driver by profession, presented with left hemiparesis

and left homonyms hemianopia.He is making good recovery.

Which of the following is most appropriate step regarding driving?

a. Permanent restriction to drive

b. Driving assessment supervised by an occupational therapist

c. Do not drive for two weeks

d. Refer to neurologist to decide for fitness to drive

e. Continue driving until police is notified

Correct Answer & Detail

Correct Answer: b. Driving assessment supervised by an

occupational therapist
Answer Detail:
The correct answer is b.

A person is unfit to drive following a stroke or transient

ischemic attack until the resolution of neurological deficit.

Once there is no residual deficit and there is minimal risk of

recurrence by commencing secondary prophylaxis, patient
should be assessed by an occupational therapist for fitness to
drive.

Any patient who has persistent hemianopia after stroke,

he/she must be assessed by an occupational therapist as well
as an ophthalmologist fitness to drive.
After assessment it will be decided whether this patient fulfills
the requirements to continue driving a commercial vehicle.
Question No. 2 :

A 28-year-old female presented at 38 weeks of gestation with labour pains since last 8
hours.
Vaginal examination shows that cervix is 7cm dilated and fully effaced.
On amniotomy,there is greenish vaginal fluid. Cardiotocography shows fetal heart

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 rate of 140 beats per minute with accelerations and early deceleration. Beat to beat
variability is 5-7 beats with good contractions.
What will be your most appropriate next step in management of this patient?

a. Immediate cesarean section

b. Continuous cardiotocography monitoring for next 24 hours

c. Fetal scalp blood sampling

d. Start oxytocin

e. Immediate assisted vaginal delivery

Correct Answer & Detail

Correct Answer: c. Fetal scalp blood sampling
Answer Detail:
This child is in respiratory distress. Amniotomy showed
greenish fluid which suggest meconium staining.

Meconium stained liquor is one of the signs of the fetal distress

during labour so it should be monitored by continuous
cardiotocography.

If cardiotocography remains normal then the labour may

proceed to spontaneous vaginal delivery.

If there is minor abnormality(early deceleration) on

cardiotocography as in above scenario then the most
appropriate next would be to do fetal scalp blood sampling to
see blood pH and or lactate level.

The decision to do immediate cesarean section or assisted

vaginal delivery depends on the results of fetal scalp blood
sampling and cervical dilation.

Oxycontin will worsen the condition of fetal distress so its not

a suitable next step for this patient.
Question No. 3 :

Which of the following is most common complication of gastroesophageal reflux

disease?

a. Iron deficiency anaemia

b. Metaplasia from squamous to columnar epithelium

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 c. Oesophagitis

d. Benign stricture

e. Esophageal adenocarcinoma

Correct Answer & Detail

Correct Answer: c. Oesophagitis
Answer Detail:
The correct answer is c.

Most common complication of gastro-oesophageal reflux

disease is esophagitis.

Barrett's esophagus(metaplasia from squamous to columnar

epithelium)occurs in approximately 10% of patients with
GERD.

With Barrett’s esophagus,there is 40% increase in occurrence

of esophageal adenocarcinoma.
Benign stricture is next most common complication after
esophagitis and required endoscopic removal.
Iron deficiency is very rarely seen with GERD.
Question No. 4 :

A 35-year old female brought her brother to you for assessment of the acute back
pain.She requested for a medical certificate for her to show her employer as she took
the day off to bring her brother to your clinic.

What is the most appropriate response?

a. Issue her certificate

b. Issue a medical certificate to her brother and ask her to show it to her employer

c. Make a separate appointment to discuss the matter

d. Tell her that this is illegal to act upon her request

e. Refer her to another colleague

Correct Answer & Detail

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 Correct Answer: a. Issue her certificate
Answer Detail:
The correct answer is a.

According to Australian Medical Association guidelines,only the

patient’s treating doctor can issue a carer’s certificate.

So you should issue her a carer’s certificate.However carer’s

certificates should only be issued with the consent of the
patient.It is not your responsibility to determine who may
qualify as a carer.
Question No. 5 :

A 56-year-old lady presented,feeling tired and generalized weakness for last 3

months.
She is non-smoker and non-alcoholic.
On routine blood work up she was found to have hypercalcemia and elevated serum
PTH level. Serum phosphate was in low normal range and serum alkaline phosphatase
was elevated.Circulating vitamin-D level is also elevated. This patient is a potential
candidate for surgery.
Which one of the following is not an indication for surgery in this patient?

a. Serum calcium is >0.25 mmol/litre above upper limit of normal

b. An episode of life-threatening hypercalcaemia

c. Nephrolithiasis

d. Creatinine clearance less than 60ml/min

e. Headache

Correct Answer & Detail

Correct Answer: e. Headache

Answer Detail:
This patient has developed hypercalcemia secondary to
primary hyperparathyroidism.Most common cause of primary
hyperparathyroidism is parathyroid adenoma.

Surgery is recommended if the patient meets any one of the

following criteria:

1.Serum calcium is more than 0.25 mmol/liter above upper

limit of normal.

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 2.Any complication of primary hyperparathyroidism like
nephrolithiasis,bone erosions of osteitis fibrosa cystica.

3.An episode of acute primary hyperparathyroidism with life-

threatening hypercalcemia.

4.Significant reduction in creatinine clearance.

5.Reduction in bone mass at any site as determined by bone

densitometry and creatinine clearance less than 60 ml/min.

Headache is a non-specific symptom and is not an indication

for surgery in parathyroid adenoma patients.
Question No. 6 :

A 35-year-old woman presents to your office with history of post-coital bleeding. The
bleeding is 5-6 ml after each sexual activity. She never had Pap smear. Abdominal
and pelvic ultrasound is normal. What is the most appropriate next step?

a. Do a pap smear

b. Do a pap smear in 6 months

c. Check coagulation profile

d. Transvaginal ultrasound

e. Give tranexamic acid

Correct Answer & Detail

Correct Answer: a. Do a pap smear

Answer Detail:
Differential diagnosis of post-coital bleeding include:

1- ​Cervical erosion
2- ​Cervical polyp
3- ​Presence of IUCD
4- ​Cervical cancer
5- ​Intra-uterine cancer

Cervical cancer must be ruled out in this patient and in all age
groups coming with post-coital bleeding over the age of 35.

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 A pap smear should be taken using the speculum carefully not
to provoke bleeding if it has not been taken in previous 3
months.
Question No. 7 :

A 4-year old male child is brought by his mother as he is complaining of pain in right
upper quadrant for last 2 years.She also mentioned that child has recently lost some
weight and has decreased appetite.

On examination you noticed a mass in the right upper quadrant.Mother has history of
familial adenomatous polyposis since the age of 25.

What is the most likely diagnosis?

a. Hepatoblastoma

b. Wilms’ tumor

c. Hepatocellular carcinoma

d. Pancreatic tumour

e. Neuroblastoma

Correct Answer & Detail

Correct Answer: a. Hepatoblastoma

Answer Detail:
The correct answer is a.

This child has signs and symptoms consistent with diagnosis of

hepatoblastoma.This tumour usually occurs in children under 5
years.
The most common symptoms is abdominal distension with
right sided abdominal pain and the most common sign is mass
in right upper quadrant.
Those children born with family history of familial
adenomatous polyposis are considered to be at high risk of
developing hepatoblastoma.
The children suffering from this malignant liver tumour also
lose appetite and weight,develop vomiting and
jaundice.However jaundice is very rare finding.

Wilms tumour or nephroblastoma, is the most common

childhood abdominal malignancy and the most common
manifestation is an asymptomatic abdominal mass.Abdominal
tenderness and palpable abdominal mass at flank level is

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 found on examination.
Nephroblastoma may cause hypertension and hematuria due
to local invasion of kidney tissues.

Hepatocellular carcinoma is not seen in children under 5 years

of age.Pancreatic tumours are extremely rare in this age group
as well.

Neuroblastoma is seen usually in children younger than 5

years and most commonly diagnosed tumour in infants less
than 1 year of age.
It may cause bone pain and lump in the abdomen,chest and
neck.It can involve bilateral adrenal gland and cause
abdominal distension.
Question No. 8 :

Which of the following is not a feature of schizophrenia?

a. Hallucinations

b. Flight of ideas

c. Loosening of associations

d. Delusions

e. Disorganized behaviour

Correct Answer & Detail

Correct Answer: b. Flight of ideas
Answer Detail:

Flight of ideas is a feature of hypomania as a part of bipolar

presentation.Schizophrenia is characterized by
delusions,hallucinations,loosening of associations and
disorganized behaviour.
Question No. 9 :

A 67-year-old male is admitted in oncology ward.You are called to see him as he

became confused and developed nausea and vomiting. Laboratory investigations
indicate severe hypercalcemia.

All of the following are associated with hypercalcemia except?

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 a. Multiple myeloma

b. Carcinoma lung

c. Renal cell carcinoma

d. Squamous cell carcinoma of the head and neck

e. Basal cell carcinoma

Correct Answer & Detail

Correct Answer: e. Basal cell carcinoma
Answer Detail:
The correct answer is e.

Paraneoplastic syndromes are commonly associated with

hypercalcemia. Commonly associated malignancies include
multiple myeloma,lung cancer, breast cancer,renal cell cancer
and,squamous cell carcinoma of the head and neck.

Hypercalcemia causes confusion, dehydration,nausea and

vomiting.Basal cell carcinoma is not associated with
hypercalcemia.
Question No. 10 :

A 6-month-old child with expiratory wheeze has been given 6 puffs of salbutamol
during an acute asthma attack with poor response.

Which of the following is next step in the management?

a. Repeat 6 puffs of salbutamol

b. Give 4 puffs of ipratropium bromide

c. Give oral steroids

d. Give intravenous steroids

e. Give inhaled steroids

Correct Answer & Detail

Correct Answer: a. Repeat 6 puffs of salbutamol
Answer Detail:
The correct answer is a.

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 Asthma is less common in less than 12 months of
age.However some babies do present with asthma which is
poorly responsive to bronchodilators.
Give oxygen inhalation while giving beta-2 agonist like
salbutamol.

Mild asthma attack can still be managed by salbutamol.

Initially give 6 puffs and the wait to see the response to

treatment after 20 minutes.Repeat salbutamol (reliever) by
puffer (6 puffs) and spacer if needed-maximum three times in
total.

Ipratropium (an anticholinergic drug) can be added however

maximum 2 puffs in children less than 5 years.Role of
ipratropium is controversial and it should be considered if
asthma is severe.

Oral prednisolone 1 mg/kg should also be given for first 3 days

after the asthma attack.

Steroids have minimal role in acute management of asthma

however should be considered to prevent relapse and re-
admission with asthma attack.Oral suspension form of steroids
is available in Australia which can be used.

Once the episode of asthma is over,patient should be reviewed

daily for revision of management plan.
Question No. 11 :

A 53-year-old Aboriginal Australian male presented with ST-segment elevation

myocardial infarction and you plan to do reperfusion therapy.

Which of the following must be avoided in this situation?

a. Streptokinase

b. Reteplase

c. Alteplase

d. Tenecteplase

e. Urokinase

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 Correct Answer & Detail
Correct Answer: a. Streptokinase
Answer Detail:
The correct answer is a.

Thrombolytics are very suitable for reperfusion therapy in ST-

segment elevation myocardial infarction.

Any of the above can be used in an Aboriginal,Torres Straight

Islander and Pacific Islander populations except streptokinase.

Streptokinase is an inappropriate choice in Indigenous

Australian patients because many have high levels of anti-
streptokinase IgG level and are resistant to streptokinase
reperfusion therapy.
So it should be avoided to prevent treatment failure.
Question No. 12 :

A 70-year-old male has been having unexplained falls for 6 months. Now he
developed axial rigidity, dysphagia and vertical gaze abnormality.

What is the most likely diagnosis?

a. Parkinson’s disease

b. Supranuclear palsy

c. Alzheimer’s disease

d. Cerebellar stroke

e. Vascular dementia

Correct Answer & Detail

Correct Answer: b. Supranuclear palsy
Answer Detail:
The correct answer is b.

This patient has developed classic features of progressive

supranuclear palsy. Main features of this disease include
unexplained falls, axial rigidity, dysphagia and vertical gaze
deficits.
Patient may also develop slow movements due to muscle
rigidity.

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 Parkinson’s disease is characterized by resting tremors,
cogwheel rigidity, bradykinesia and festinating gait. Visual
problems are not associated with Parkinson’s disease.

Cerebellar stroke can result in ataxia, falls, past pointing,

positive Romberg’s sign and nystagmus. This is unlikely
diagnosis in this patient.
Question No. 13 :

A 59-year-old male presented with acute chest pain which lasted for 30 minutes.He
felt tightness in the chest.Pain was radiating into the throat,left arm and epigastrium.
Electrocardiography showed non-specific T-wave inversion without any ST segment
abnormality.Laboratory tests showed elevated troponin.

Which ONE of the following is the best management?

a. Proton pump inhibitors

b. Thrombolysis

c. Repeat ECG

d. Heparin

e. Cardiac catheterization

Correct Answer & Detail

Correct Answer: d. Heparin

Answer Detail:
The correct answer is d.

This patient has clinical diagnosis of non-ST segment elevation

myocardial infarction (NSTEMI).

In this situation patient typically presents with signs and

symptoms suggestive of acute myocardial infarction with no
ECG changes and elevated troponin.

ECG may show non-specific abnormalities like ST segment

depression,T-wave inversion.The amount of troponin in the
blood reflects the extent of myocardial damage.

The aim of management of NSTEMI is to prevent new

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 thrombus formation which may occlude coronary artery and
cause extensive myocardial damage in high risk patients.

Treatment options include heparin in therapeutic doses

(requires dose adjustment in renal impairment).
Also commence aspirin, clopidogril and a beta-blocker at the
same time if there is no contraindication to these drugs.

Thrombolysis is mainstay of treating ST-segment elevation

myocardial infarction.

Repeat ECG is required if initial ECG does not show any acute
changes and cardiac enzymes are not elevated.

Cardiac catheterization is the passage of a catheter through

peripheral arteries or veins into cardiac chambers and
coronary arteries.It can be used to do various tests like
angiography,endomyocardial biopsy,measurement of cardiac
output etc.
Question No. 14 :

A 45-year-old man presented with new onset of dysphagia and hoarseness for last 8
weeks. He also reported rapidly enlarging neck mass. On examination, you found 5
cm thyroid nodule.

What will you do help in making diagnosis?

a. Esophagoscopy

b. Indirect laryngoscopy

c. Ultrasound

d. Biopsy of the thyroid gland

e. CT head and neck

Correct Answer & Detail

Correct Answer: d. Biopsy of the thyroid gland
Answer Detail:
The correct answer is d.

This patient has clinical diagnosis of anaplastic thyroid

carcinoma with metastatic features.

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 The primary symptom of anaplastic cancer is a gradually
enlarging neck mass, occurring in about 85 percent of
patients.

The enlarging thyroid tumor may cause neck pain and

tenderness, and compression (or invasion) of the upper
aerodigestive tract, resulting in dyspnea, dysphagia,
hoarseness and cough.

The diagnosis of anaplastic cancer is usually established by

cytological examination of cells obtained by fine needle
aspiration biopsy or of tissue obtained by large needle or
surgical biopsy.
Ultrasonography can be used to guide fine needle aspiration of
solid, non-necrotic tumor.

All other options are helpful for staging of the thyroid cancer
once confirmed on biopsy.
Question No. 15 :

A 39-year-old lady presented with second episode of seizure within one week. An
EEG confirmed the diagnosis of epilepsy.She has been started on carbamazepine.

She asked you when can she drive?

a. Within 12 months after review

b. Within 4 weeks

c. She cannot drive as long as she is on carbamazepine

d. She can drive as long as she is on carbamazepine

e. Call the police and notify them to cancel her licence

Correct Answer & Detail

Correct Answer: a. Within 12 months after review
Answer Detail:
If a patient has been diagnosed with epilepsy for the first time,
a conditional licence may be considered by the driver licensing
authority subject to at least annual review, taking into account
information provided by the treating doctor as to whether the
following criteria are met:

1- ​The person has been treated for at least 6 months.

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 2- ​There have been no seizures in the preceding six
months.

3- ​If any seizures occurred after the start of treatment,

they happened only in the first 6 months after starting
treatment and not in the last six months.

4- ​ The person follows medical advice, including

adherence to medication.

It is the responsibility of the driving licence holder to notify the

police about the conditions applied due to medical illness.
Question No. 16 :

Which of the following joint is most commonly affected in pseudogout?

a. Ankle

b. Knee

c. Elbow

d Wrist

e. Carpometacarpal

Correct Answer & Detail

Correct Answer: b. Knee

Answer Detail:
Pseudogout develops when calcium pyrophosphate dihydrate
crystals deposit in the cartilage of a joint.

The crystals are then released into the fluid in the joint.
This causes joint pain and swelling.

It most commonly affects the knees. So b is the correct

answer.

Pseudogout can also affect the elbows, ankles and wrists.

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 Pseudogout attacks can be sudden in onset and the symptoms
may last for days or weeks.
Question No. 17 :

Which of the following is the most important single warning sign of diminishing
blood volume within first 4 hours post-partum?

a. Decrease in blood pressure

b. Tachycardia

c. Tachypnoea

d. Sweating

e. Vomiting

Correct Answer & Detail

Correct Answer: b. Tachycardia

Answer Detail:
For early recognition of postpartum hemorrhage,routine
observation of all postpartum women for blood loss, fundal
tone,blood pressure and pulse is carried out during the first 4
hours after delivery.

The most important single sign of diminishing blood volume

and mild shock is tachycardia which often precedes a fall in
blood pressure.

Weakness, sweating and tachypnoea may accompany

this.Vomiting is not of any significance for early recognition of
shock usually.
Question No. 18 :

A Pap smear of a 55-year-old lady shows glandular abnormalities.What is the best

next step in her management?

a. Refer for colposcopy

b. Repeat Pap smear in two years

c. Refer to medical oncologist

d. Repeat Pap smear in four to six weeks

e. No further action needed

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 Correct Answer & Detail
Correct Answer: a. Refer for colposcopy
Answer Detail: When a Pap smear report shows glandular
abnormalities,including adenocarcinoma in situ,refer for
colposcopy which should be performed by a gynecologist with
expertise in suspected malignancies or by a gynecological
oncologist.
Question No. 19 :

A young female presented with dysuria, vaginal discharge and post-coital

bleeding.She was diagnosed with chlamydia.She was happy to get her own treatment
however she refused to tell her husband.

What will you do in this situation?

a. Tell her husband

b. Tell her husband GP

c. Do nothing

d. Notify the department of health

e. Tell her husband once she leaves

Correct Answer & Detail

Correct Answer: d. Notify the department of health
Answer Detail:
Chlamydia is a notifiable disease and it must be reported to
the department of health within 5 days of diagnosis.

It is legal requirement to protect the public from harm.

The department of health team will devise a method to contact

possible contacts.

Reassure patient that confidentiality will be maintained by

using the name code during contact tracing.
Question No. 20 :

A 74-year-old male presented with inability to speak, facial weakness and right sided
paralysis. CT scan shows ischemic stroke involving more than 65% left hemisphere.
His wife do not want any active invasive management.
However his son tells you to do everything.

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 What will you do in this situation?

a. Tell the wife that it is too soon to decide on discontinuing the life support

b. Do the treatment as it is an emergency

c. Call guardianship court

d. Give intravenous nutritional support

e. Give nasogastric fluids and noninvasive treatment

Correct Answer & Detail

Correct Answer: e. Give nasogastric fluids and noninvasive
treatment
Answer Detail:
This patient has big ischemic stroke and need urgent
treatment and intensive monitoring for possible
hemicraniotomy. This situation is a contraindication to
thrombolysis due to risk of hemorrhagic transformation.

The consent should be obtained from following people where

the patient is incapable of consenting to medical treatment
and has not had a guardian appointed.

1- ​A guardian of the person needing the treatment.

2- ​The spouse or de facto partner of the person needing
the treatment.

3- ​A person who, on a regular basis, provides or arranges

for domestic services and support to the person needing the
treatment but does not receive remuneration for doing so.

4- ​A person who is the nearest relative (other than the

spouse or de facto partner) of the person needing.

5- ​Any other person who maintains a close personal

relationship with the person needing treatment.

6- ​A person prescribed in the regulations.

So in this situation, the patient himself cannot consent to the

treatment due to stroke and his spouse would be the person
who can make decision about provision of health care. So
option e is correct response.
Question No. 21 :

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 A 39-year-old woman presented with dizziness after coming from gym. ECG shows
sinus bradycardia with no av-block. What is the most appropriate next step?

a. Transcutaneous pacemaker

b. Atropine

c. Adrenaline

d. Trans-venous pacing

e. Amiodarone

Correct Answer & Detail

Correct Answer: b. Atropine
Answer Detail:
Symptomatic bradycardia exists when the following 3 criteria
are present:

1- ​The heart rate is slow.

2- ​The patient has symptoms.
3- ​The symptoms are due to the slow heart rate.

Atropine is the first drug used to treat bradycardia in the

bradycardia algorithm. It is classified as an anticholinergic
drug and increases firing of the SA Node by blocking the action
of the vagas nerve on the heart resulting in an increased heart
rate.

The dosing for Atropine is 0.5 mg IV every 3-5 minutes as

needed, and the maximum total dosage that can be give is 3
mg.

If atropine fails to alleviate symptomatic bradycardia,

transcutaneous pacing should be initiated. Transvenous pacing
requires a specialist treatment.
Question No. 22 :

Which one of the following can be an alarming sign in a 2 month old infant?

a. Inability to smile at people

b. Inability to hold neck

c. Inability to explore things by holding, feeling and looking at them in their hands and putting
them in their mouths

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 d. Does not appear to recognise their mother

e. Does not appear interested in activities around them

Correct Answer & Detail

Correct Answer: a. Inability to smile at people

Answer Detail:
The correct answer is a.

It is an alarming sign when a 2-months old child is unable to

do following things:

1. ​Does not respond to loud sounds.

2. ​Does not watch things as they move.

3. ​Does not smile at people.

4. ​Does not bring hands to mouth.

5. ​Can not hold head up when pushing up when on

tummy.

So if a child at 2 months of age does not smile at people-it is a

concerning thing for a mom and needs thorough evaluation.

Neck holding is achieved by 3-months.

Ability to explore things by holding, feeling and looking at

them in their hands and putting them in their mouths is
achieved by 6 months of age.

A skill to recognize mother’s face is achieved by 9 months of

age.

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 If a child by 9 months of age,does not appear interested in
activities around them,it is abnormal and requires further
evaluation.
Question No. 23 :

A 49-year-old man with 30 pack year history of smoking and gastro-oesophageal

reflux disease presented with difficulty in swallowing for last 6 months.
Initially he was unable to swallow solids and gradually he is unable to swallow
liquids.
He also feels very lethargic and has lost weight 15kg during last 3 months.
On clinical examination,he looks pale and anaemic.
Which of the following is the next best step in his evaluation?

a. CT scan of chest and abdomen

b. Barium swallow

c. Esophagoscopy

d. Bronchoscopy

e. Chest X-ray

Correct Answer & Detail

Correct Answer: b. Barium swallow

Answer Detail:
This patient has the most likely diagnosis of oesophageal
malignancy.Progressive dysphagia and weight loss of short
duration are the initial symptoms in the vast majority of
patients. Dysphagia initially occurs with solid foods and
gradually progresses to include semisolids and liquids.

Barium swallow is done first to find narrowing site of

lesion(shelf or annular lesion)–localizes tumour.The sensitivity
of barium radiography for detecting esophageal strictures is
greater than that of endoscopy.

Esophagoscopy and biopsy for tissue diagnosis and

resectability/extent of tumour is the second most important
choice of investigation.

Bronchoscopy is often the part of work up of esophageal

malignancy for upper and mid esophageal lesions due to high
incidence of spread to tracheobronchial tree.

The extent of tumor spread to the mediastinum and para-

aortic lymph nodes should be assessed by CT scans of the

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 chest and abdomen and by endoscopic ultrasound.

Chest X-ray, bone scan and liver functions test are done for
staging and are not required as the initial part of
investigations.
Question No. 24 :

Which of the following is not a risk factor for isolated spontaneous abortion?

a. Age more than 35 years

b. Cigarette smoking

c. High doses of caffeine

d. Uterine adhesions

e. Retroverted uterus

Correct Answer & Detail

Correct Answer: e. Retroverted uterus

Answer Detail:
Risk factors for spontaneous abortion include:

- Age more than 35 years.

- Smoking.
- High doses of caffeine.
- Uterine abnormalities like leiomyoma, adhesions.
- Viral infections.
- Thrombophilia.
- Chromosomal abnormalities.

Sub-clinical thyroid disorder,sub-clinical diabetes mellitus and

retroverted uterus have not shown to cause spontaneous
abortions.
A retroverted uterus is a uterus that is tilted backwards
instead of forwards. So e is the correct response.
Question No. 25 :

Which of the following is most likely to affect interpretation of the pulmonary artery
occlusion pressure trace?

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 a. Right ventricular outflow tract obstruction

b. Tricuspid regurgitation

c. Mitral regurgitation

d. Pulmonary vein obstruction

e. Aortic stenosis

Correct Answer & Detail

Correct Answer: d. Pulmonary vein obstruction

Answer Detail:
The correct answer is d.

Pulmonary artery occlusion or wedge pressure is the pressure

measured by wedging a pulmonary catheter with an inflated
balloon into a small pulmonary arterial branch.

Pulmonary vein stenosis in adult patients is now most

commonly associated with prior radiofrequency ablation
procedures for atrial fibrillation.

Pulmonary disease and respiratory failure may cause the PAWP

to exceed the left ventricular end-diastolic pressure due to
constriction of small veins in hypoxic lung segments.
Question No. 26 :

A 52-year-old male was started on a combination of thiazide diuretic and beta-blocker

for essential hypertension 3 months ago.He now presented with polyuria, polydipsia
and his blood sugar is found to be 18 mmol/l.

What is the next step in his management?

a. Stop thiazide and re-assess

b. Start oral hypoglycaemic agent

c. Start insulin treatment

d. Start insulin as well as oral hypoglycaemic agent

e. Refer to endocrinologist

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 Correct Answer & Detail

Correct Answer: a. Stop thiazide and re-assess

Answer Detail:
Thiazide diuretic–induced hyperglycaemia occurs primarily
through the reduction in total body potassium (hypokalemia)
and the subsequent decreased insulin secretion.

This effect is largely dose-dependent and reversed by

potassium replacement or drug discontinuation. So option A is
correct. On re-assessment, hyperglycaemia is usually found to
be reversible.

The hyperglycaemic effects of ß-blocking agents are less clear,

but are likely explained through the diminution of pancreatic
ß-cell insulin release.

Treatment with other antihypertensive agents, including a

thiazide diuretic, did not increase the risk for developing DM.

Given the proven cardiovascular benefits of ß-blockers and

thiazide diuretics, appropriate clinical use should continue
despite the potential risks.
Question No. 27 :

A 78-year-old male presented with history of fall, expressive dysphasia and left sided
upper and lower limb weakness. CT scan (non-contrast) of the head was performed.
(Click on the image).

What is the most likely lesion?

Question Attachments

a. Right middle cerebral artery infarct

b. Left middle cerebral artery infarct

c. Right anterior cerebral artery infarct

d. Left anterior cerebral artery infarct

e. Posterior circulation infarct

Correct Answer & Detail

Correct Answer: a. Right middle cerebral artery infarct

Answer Detail:
The correct answer is a.

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 Middle cerebral artery syndrome is a condition whereby the
blood supply from the middle cerebral artery (MCA) is
restricted, leading to a reduction of the function of the portions
of the brain supplied by that vessel: the lateral aspects of
frontal, temporal and parietal lobes, the corona radiata, globus
pallidus, caudate and putamen.

The MCA is the most common site for the occurrence of

ischemic stroke.

Contralateral hemiparesis and hemisensory loss of the face,

upper and lower extremities is the most common presentation
of MCA syndrome.

CT scan of the head shows infarct in territory of right middle

lobe infarct-temporo-parietal region.

Infarcts look grayish and hemorrhages look white on the non-

contrast CT.
Question No. 28 :

A 56-year-old man presented with the fever, headache, jaw and tongue claudication
when chewing and a transient episode of double vision 24 hours ago.
On examination, scalp is tender. ESR is 100mm/h. What is the most appropriate
management?

a. CT Head

b. MRI scan of head

c. Nonsteroidal anti-inflammatory drugs

d. Prednisolone

e. Paracetamol

Correct Answer & Detail

Correct Answer: d. Prednisolone

Answer Detail:
Giant cell arteritis is most commonly characterized by following
clinical features:

1- ​Fever
2- ​Anemia

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 3- ​High ESR
4- ​Headaches in a patient over the age of 50
years.Headache is the predominant symptom and may be
associated with a tender, thickened, or nodular artery, which
may pulsate early in the disease.

5- ​Features of systemic inflammation including malaise,

fatigue, anorexia, weight loss, sweats, and arthralgias.

6- ​Scalp pain and claudication of the jaw and tongue.

Characteristic laboratory findings include:

1- ​Elevated ESR.
2- ​ Normochromic or slightly hypochromic anemia.
3- ​Liver function abnormalities-increased alkaline
phosphatase levels.
Giant cell arteritis and its associated symptoms are sensitive
to glucocorticoid therapy.
Treatment should begin with prednisone, 40–60 mg/d for 1
month, followed by a gradual tapering.
When ocular signs and symptoms occur, consideration should
be given for the use of methylprednisolone 1000 mg daily
intravenously for 3 days to protect remaining vision.
Question No. 29 :

What is the incidence of alcohol related dementia is Australia?

a. 10 %

b. 5%

c. 90%

d. 80%

e. 35%

Correct Answer & Detail

Correct Answer: b. 5%
Answer Detail:
Incidence of alcohol-related dementia in Australia is 5% of
total dementia population.

Incidence of vascular dementia is 10% and dementia of

Alzheimer type is about 80 to 85% of total dementia
population.

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 Question No. 30 :

A 52-year-old male comes to your office for prostate cancer screening.He is worried
about prostate cancer as one of his friends at work got prostate cancer at the age of
55.He is otherwise quite fit person and has no urinary symptoms.

What is the most appropriate advice for him?

a. All men over the age of 50 should have yearly prostate screening as per national prostate
screening programme
b. Men at 50 with no family history of prostate cancer should seek voluntary annual
assessments in the form of a prostate specific antigen and a digital rectal examination
c. Men at 40 with no family history of prostate cancer should seek voluntary annual
assessments in the form of a prostate specific antigen and a digital rectal examination
d. Biopsy of prostate gland is indicated

e. Make an appointment in six months to review again

Correct Answer & Detail

Correct Answer: b. Men at 50 with no family history of
prostate cancer should seek voluntary annual assessments in
the form of a prostate specific antigen and a digital rectal
examination
Answer Detail:
The correct answer is b.

There is no prostate screening program on national level in

Australia.

However,there are recommendations by Prostate Cancer

Foundation of Australia that all men at age of 50 with no
family history of prostate cancer should have annual prostate
specific antigen (PSA) levels and yearly digital rectal exam on
voluntary basis.

Similarly all men at age of 40 with family history of prostate

cancer should have annual PSA levels and yearly digital rectal
exam. These are recommendations and not guidelines.

According to RACGP guidelines, screening for prostate cancer

should be considered if a patient is concerned about. However
patient should be fully informed about risks and benefits.

Biopsy is invasive procedure and not advised for screening

purpose.Review is six months is not appropriate.

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 This patient should have prostate specific antigen level and
digital rectal examination done now as he is above 50 year
with no family history of prostate cancer. Also he fits the
criteria for screening as per RACGP guidelines.
Question No. 31 :

A 50-year-old male with history of long-standing diabetes mellitus presents with right
ankle swelling and pain for a month.
X-ray of the foot shows periarticular swelling with normal joint space. He is afebrile.

Which of the following is the most likely cause?

a. Gout

b. Osteoporosis

c. Osteoarthritis

d. Septic arthritis

e. Diabetic amyotrophy

Correct Answer & Detail

Correct Answer: a. Gout

Answer Detail:
The correct answer is a.

This patient had an episode of mono-articular gout a month

ago which has not completely resolved yet.

History and X-ray findings (periarticular swelling with normal

joint space) are very suggestive of gout.

Initially joint space is preserved however periarticular swelling

shows presence of ongoing inflammatory changes.
Sclerosis and joint-space narrowing are seen in in long-
standing chronic gout.

Diabetic amyotrophy results from diabetic neuropathy.It

causes asymmetric weakness and pain in one leg including
thigh and buttock.It results in atrophy and wasting of the limb.
It is seen in long-standing type-II diabetes mellitus.

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 DEXA (dual-energy x-ray absorptiometry) is a most useful tool
to measure bone density to confirm diagnosis of osteoporosis.

X-ray changes of osteoarthritis include narrowing of joint

space,subchondral sclerosis and osteophytes.These changes
are seen years after the onset of osteoarthritis.

Septic arthritis is an emergency and presents with red hot

swollen joint in a febrile patient. However this patient has sub-
acute presentation and has no fever. Also joint space is
preserved.
Question No. 32 :

Mini-pill (progesterone-only) is safe to use a contraceptive method in all of the

following situations except?

a. Previous pulmonary embolism

b. Endometriosis

c. Ovarian cysts

d. Hypertension

e. Biliary tract disease

Correct Answer & Detail

Correct Answer: c. Ovarian cysts

Answer Detail:
By using mini-pills,functional but asymptomatic ovarian cysts
sometimes develop.They usually disappear spontaneously and
surgery is not required.It is advised not to use progesterone
only pills if a female already has ovarian cysts.
Mini-pills are safe to use in patients with previous history of
thrombo-embolism,endometriosis,hypertension and biliary
tract disease.
Other contraindications to use of the mini-pill include
malabsorption syndromes, previous sex steroid-dependent
cancers(breast cancer), undiagnosed vaginal bleeding,
previous ectopic pregnancy and severe active liver disease.
Question No. 33 :

Which of the following is a degenerative disease of the central nervous system caused
by infectious proteins?

a. Creutzfeldt-Jakob disease

b. Alzheimer’s disease

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 c. Parkinson’s disease

d. Cushing disease

e. Guillain-Barré syndrome

Correct Answer & Detail

Correct Answer: a. Creutzfeldt-Jakob disease
Answer Detail:
Creutzfeldt-Jakob disease or CJD is caused by infectious
protein particles called prion.It occurs at the age around mid
seventies and presents with dementia and clonus.This disease
is progressive and death occurs generally within a year of
onset of symptoms.CJD is found throughout the world.
Question No. 34 :

A 19-year-old girl presents to the emergency department after attempted suicide by

cutting her forearm with a sharp device.
She has history of three such attempts in last six months.She has great difficulty in
maintaining relationship although she is apparently very reasonable.
She becomes angry with you when you ask her why she tried to harm herself and said
”I cut myself in front of every one,this is my life,I have full control over myself”.
She is on olanzapine 20mg daily at night for last one year and she recently decreased
the dose to 10mg and she feels she does not need any medication.
Which of the following is the most likely diagnosis?

a. Antisocial personality disorder

b. Borderline personality disorder

c. Histrionic personality disorder

d. Adjustment disorder

e. Narcissistic personality disorder

Correct Answer & Detail

Correct Answer: b. Borderline personality disorder

Answer Detail:
This patient has typical presentation of borderline personality
disorder.

The essential feature of Borderline Personality Disorder is a

pervasive pattern of instability of interpersonal relationships,
self-image, and affects, and marked impulsivity that begins by

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 early adulthood and is present in a variety of contexts.

Multiple suicidal attempts and volatile behaviours with no

insight are very characteristic of this disorder. There is a
pattern of unstable and intense interpersonal relationships
characterized by alternating between extremes of idealization
and devaluation.

The manipulative behavior characteristic of antisocial

personality disorder is directed at gaining power or material
gratification, whereas patients with borderline personality
disorder are manipulative for the purpose of gaining the
concern of caretakers. Patients with antisocial personality
disorder are also more emotionally stable and aggressive
compared to patients with borderline personality disorder.

Affective instability as well as manipulative and attention-

seeking behavior can occur in both histrionic personality
disorder and borderline personality disorder. The two disorders
can be distinguished by symptoms that occur only in
borderline personality disorder, such as self-destructive
behavior, frequent angry disruptions in relationships, and
chronic feelings of emptiness.

The essential feature of Narcissistic Personality Disorder is a

pervasive pattern of grandiosity, need for admiration, and lack
of empathy that begins by early adulthood and is present in a
variety of contexts. Individuals with this disorder have a
grandiose sense of self-importance .They routinely
overestimate their abilities and inflate their accomplishments,
often appearing boastful and pretentious. They are often
preoccupied with fantasies of unlimited success, power,
brilliance, beauty, or ideal love.

The essential feature of Antisocial Personality Disorder is a

pervasive pattern of disregard for, and violation of, the rights
of others that begins in childhood or early adolescence and
continues into adulthood. For this diagnosis to be given, the
individual must be at least age 18 years and must have had a
history of some symptoms of Conduct Disorder before age 15
years.
Question No. 35 :

A 32-year-old woman presented with 3 month history of joint pain in both hands and
stiffness lasting for hours once she wakes up in the morning every day. She also
reported disturbed sleep due to the nocturnal pain.
On examination, you notice swelling around metacarpophalangeal (MCP) and
proximal interphalangeal (PIP) joint.

Which ONE of the following is the drug of choice to reduce the synovial
inflammation and prevent joint damage?

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 a. Fish oil

b. Naproxen

c. Methotrexate

d. Sulfasalazine

e. Hydroxychloroquine

Correct Answer & Detail

Correct Answer: c. Methotrexate

Answer Detail:
The correct answer is c.

This patient has presented with signs and symptoms of

rheumatoid arthritis. The criteria to diagnose rheumatoid
arthritis includes following:

- ​Symptoms duration more than 6 weeks.

- ​Early morning stiffness for more than 1 hour.
- ​Arthritis in three or more joints.
- ​Bilateral compression tenderness of the
metatarsophalangeal joints.

- ​Symmetry of the areas affected.

- ​Rheumatoid factor, Anti-CCP antibody positivity.

There role of non-steroidal anti-inflammatory drugs to reduce

the pain and inflammation is well known in patients with
rheumatoid arthritis. However, they do not prevent the joint
damage and are associated with many side effects.

Standard initial therapy with disease-modifying anti-rheumatic

drugs helps to prevent damage to the joint in any patient with
the rheumatoid arthritis.

Methotrexate is the drug of choice as initial monotherapy. If

disease remission is not achieved, increase the dose of
methotrexate or consider combination therapy with other
agents like sulfasalazine and hydroxychloroquine.

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 Question No. 36 :

A young female intern accidentally pricked herself with the needle while taking blood
sample from an HIV positive patient.

What would be the most appropriate next step?

a. Give antiretroviral drugs for 4 weeks

b. Test both patient and doctor for HIV viral load now

c. Do not allow doctor to draw blood for 3 months

d. Give her intravenous immunoglobulins

e. Educate her that risk of disease transmission is very low

Correct Answer & Detail

Correct Answer: a. Give antiretroviral drugs for 4 weeks
Answer Detail:
The correct answer is a.

In the situation of needle stick injury and exposure to an HIV

positive person, post-exposure HIV prophylaxis is
recommended.

Provision of post exposure prophylaxis should not be delayed

while establishing the source status.Early initiation of post-
exposure prophylaxis (PEP), as soon as possible after
exposure, is strongly recommended. PEP should not be offered
more than 72 hours after exposure.

A 28-day course of PEP is recommended. This health care

worker should have follow-up HIV antibody testing at baseline,
6 weeks and 3 months, and up to 6 months, along with tests
for other blood-borne viruses as above.

Recommendations for occupational post-exposure prophylaxis

include a basic regimen of two nucleoside/nucleotide reverse
transcriptase inhibitors for most HIV exposures, and an
expanded regimen with the addition of a third drug when the
exposure poses an increased risk for transmission.

Examples of antiretroviral drug combinations include

(lamivudine+zidovudine), or (emtricitabine+tenofovir).

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 Question No. 37 :

A 34-year-old male presented for your advice regarding recurrent pilonidal sinus after
surgical treatment performed 4 months ago. What is the most appropriate advice to
the patient to avoid recurrence?

a. Keep plastic bandages on for another 2 months

b. Refer to another GP

c. Review the patient daily for 2 weeks

d. Take advice from hospital director

e. Shave the area and keep it clean

Correct Answer & Detail

Correct Answer: e. Shave the area and keep it clean
Answer Detail:
Pilonidal sinus is a skin condition in the midline of the natal
cleft. A primary pit forms in the midline, caused by a hair
follicle that has become infected, into which loose hairs enter
to create a track or abscess.

Prevention from recurrent pilonidal sinus disease:

1- ​Keep the area clean and dry.

2- ​Avoid sitting for a long time on hard surfaces.
3- ​Remove hair from the area
Question No. 38 :

A 35-year-old woman presented with breech presentation confirmed on ultrasound at

37 weeks of gestation. External cephalic version has failed.

What is the most appropriate next step in her management?

a. Steroids

b. Elective cesarean delivery at 38 weeks of gestation

c. Emergency cesarean delivery

d. Induce labour now

e. Consider vitamin K

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 Correct Answer & Detail

Correct Answer: b. Elective cesarean delivery at 38 weeks of

gestation
Answer Detail:
The correct answer is b.

In breech presentation diagnosed around 32 weeks of

gestation, there is possibility of spontaneous version to
cephalic presentation.

If this does not happen, external cephalic version is considered

(after doing an ultrasound).
If external cephalic version fails due to any reason, arrange an
elective cesarean section at 38-39 weeks of gestation or
vaginal delivery if suitable to do so.
Question No. 39 :

A 35-year-old lady had Pap smear at your clinic a year ago which was reported as low
grade squamous intraepithelial lesion.You repeated Pap smear after 12 months again
and report was unchanged.
What is the next best step in her management?

a. Refer for colposcopy

b. Repeat Pap smear in 12 months

c. Do Pap smear every three months

d. Advise the patient for safe sex practices to reduce the risk of cervical cancer

e. No action needed

Correct Answer & Detail

Correct Answer: a. Refer for colposcopy

Answer Detail:
If the woman is more than 30 year old and Pap smear is
positive for low grade squamous intraeithelia lesion,repeat Pap
smear in 12 months.

If after 12 months,report shows still the same low grade

squamous intraepithelial lesion,then refer the patient for
colposcopy.

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 Question No. 40 :

All of the following are associated with Shigella except?

a. Bloody diarrhoea with fever

b. Hemolytic uremic syndrome

c. Antibiotics are usually required to treat shigella dysentry

d. Shigella cannot survive the acidic environment of stomach and rarely cause infection

e. Toxin as well as invasiveness of the organism involves the pathogenesis

Correct Answer & Detail

Correct Answer: d. Shigella cannot survive the acidic

environment of stomach and rarely cause infection
Answer Detail:
The correct answer is e.

Fever with bloody or non-bloody diarrhoea might be associated

with Shigella infection.Haemolytic uraemic syndrome may
result from Shigella infection and can cause microangiopathic
haemolytic anaemia, thrombocytopenia, and acute renal
failure.

Antibiotics are usually required to treat shigella

dysentry.Because of the ready transmissibility of Shigella,
current public health recommendations in the Australia are
that every case be treated with antibiotics.Ciprofloxacin is
recommended as first-line treatment.

Shigella has dual pathogenic mechanism as organism is very

invasive and produces toxins which can produce severe bloody
diarrhoea and systemic features.

Shigella can survive through acidity of the stomach

environment and relatively few organisms can cause the
infection.
Question No. 41 :

In which of the following situations,nalaxone is indicated?

a. Benzodiazepine dependence

b. Refractory ventricular fibrillation

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 c. Loss of consciousness post head injury

d. Opioid overdose with respiratory depression

e. Respiratory arrest secondary to carbon dioxide retention

Correct Answer & Detail

Correct Answer: d. Opioid overdose with respiratory

depression
Answer Detail:
Opioid poisoning causes respiratory depression,pinpoint pupils
and coma followed by respiratory arrest.

Nalaxone is an opioid antagonist which rapidly reverses its

effect.The timely use of nalaxone will prevent the need for
intubation in case of respiratory depression.

The initial dose of nalaxone is 400mcg if given IV,800mcg if

given IM or subcutaneously.

The duration of action of nalaxone is 45 to 70 minutes.

Question No. 42 :

A 42-year-old woman came to your clinic for advice. She is a secretary in an office
and she smokes. She does self-breast examination every month and clinical
examination of her breast by her general practitioner every 2 years. She also does
some physical activity at work and during leisure time.

Which ONE of the following is will lower the risk of breast cancer?

a. Smoking

b. Self-breast examination

c. Physical activity at work

d. Clinical breast examination

e. All of the above

Correct Answer & Detail

Correct Answer: c. Physical activity at work

Answer Detail:

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 The correct answer is c.

There has been a consistent evidence that physical activity at

work and during leisure time reduces the risk of breast cancer
by 20-40% in women of both reproductive and non-
reproductive age.

Self-breast examination and regular clinical examination of the

breast is no longer is recommended as evidence suggest that
these tools do not decrease the number deaths from breast
cancers.

Smoking increases the risk of developing breast cancer.

Question No. 43 :

An 18-year-old female accompanied by her mother presented to your clinic as she had
an episode of milk discharge from her breasts while playing a game.She has not been
sexually active so far.She has been quite worried since this episode and has been
spending most of her time inside the home.She has been on risperidone 6 mg daily for
her schizophrenia since last one year.

What is the most appropriate advice?

a. Start clozapine and slowly wean off risperidone

b. Continue risperidone

c. Add bromocriptine

d. Switch to quetiapine and slowly wean off risperidone

e. Switch to olanzapine and slowly wean off risperidone

Correct Answer & Detail

Correct Answer: d. Switch to quetiapine and slowly wean off

risperidone
Answer Detail:
The correct answer is d.

Out of given options,switching to quetiapine is the safest

option while weaning off risperidone slowly. Clozapine is a last
option considering side-effects profile. Olanzapine should be
avoided as well as it causes obesity and metabolic
problems.Also it can cause hyperprolactinemia.

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 Hyperprolactinemia is a common adverse effect of
antipsychotic medications.
Symptoms of hyperprolactinemia include gynaecomastia,
galactorrhoea, sexual dysfunction,infertility and
amenorrhoea.Long term problems with hyperprolactinemia
include reduced bone mineral density and osteoporosis.

This patient has developed galactorrhoea as a result of long

term antipsychotic use.Antipsychotic drugs can elevate serum
prolactin levels through inhibition of the dopaminergic
pathways.Hyperprolactinemia is mediated by D2 blockade in
the hypothalamic infundibular system.

First generation antipsychotics and second generation atypical

antipsychotics result in hyperprolactinemia.
Prolactin-raising atypical antipsychotics include risperidone,
paliperidone and amisulpride.

Prolactin-sparing antipsychotics include quetiapine,clozapine

and olanzapine.

Risperidone has high affinity for D2 receptors so it elevates

prolactin significantly.Quetiapine has low D2 receptor affinity
and does not cause hyperprolactinemia.

Olanzapine has moderate D2 receptor affinity only and causes

increased level of prolactin at high doses.However at usual
doses it is prolactin-sparing and does not cause
hyperprolactinemia.It also has higher potential for weight gain
and diabetes mellitus.

Clozapine also does not elevate prolactin and is very effective

for treatment of positive as well as negative symptoms of
schizophrenia.

Bromocriptine is dopamine agonist and adding this will

increase behavioural symptoms and can worsen psychosis. It
is not recommended in the treatment of antipsychotics induced
hyperprolactinemia.
Question No. 44 :

A 5-year-old child is brought by his mother with failure to thrive.Mother describes

that child has been having chest infections since birth and has never been healthy for
longer than two months.Clinical diagnosis after multiple investigations carried out for
frequent chest infections, was bronchiectasis. Child also has history of chronic
diarrhoea since birth.Sweat chloride test confirms the diagnosis of cystic
fibrosis.Which of the following statement is true about this presentation?

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 a. Medium survival rate is 10 years

b. Diabetes if present is not associated with diabetic ketoacidosis

c. Pregnancy is associated with high morbidity and mortality

d. Recovery of sperm from the testis can be achieved in up to one percent of cases for in vitro
fertilization
e. Osteoporosis is present is up to five percent individuals

Correct Answer & Detail

Correct Answer: b. Diabetes if present is not associated with

diabetic ketoacidosis
Answer Detail:
This patient has signs and symptoms suggestive of cystic
fibrosis.

The classic or typical form of cystic fibrosis is diagnosed if a

patient demonstrates clinical disease in one or more organ
systems and has elevated sweat chloride (more than 60
mmol/L). Most of these patients have disease manifestations
in multiple organ systems (pancreas, upper and lower
respiratory tract, and male reproductive tract).

Cystic fibrosis is the most common life-shortening autosomal

recessive disease among Caucasian populations. The usual
presenting symptoms and signs include persistent pulmonary
infection, pancreatic insufficiency, and elevated sweat chloride
levels.

Diabetes Mellitus seen in cystic fibrosis patients usually needs

no insulin and is not associated with diabetic ketoacidosis.

Medium survival rate for cystic fibrosis in Australia is 35 years.

Pregnancy in a woman with cystic fibrosis is not associated
with increased high morbidity and mortality even though
forced expiratory volume in 1 second(FEV1) is less than 40%.
Still management of the pregnancy in consultation with a
specialist is highly recommended.

Up to 95 percent of males with cystic fibrosis have

azoospermia.

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 Clinically significant reductions in bone density are present in
up to 30 percent of patients with cystic fibrosis across all age
groups. Osteoporosis is seen in up to 75 percent of adults with
cystic fibrosis.Several different mechanisms appear to
contribute to the bone disease, including malabsorption of
vitamin D, poor nutritional status, physical activity,
glucocorticoid therapy, and delayed pubertal maturation or
hypogonadism.
Question No. 45 :

A 32-year-old female presented in a regional Australian hospital with an acute

shortness of breath,tachycardia and sweating after landing from a long-distance flight
from California.She is at 34 week of gestation.

Which of the following is the best investigation in this situation?

a. CT pulmonary angiogram

b. Electrocardiography

c. Urgent delivery by Cesarean section

d. D-dimers

e. Ventillation-perfusion scan

Correct Answer & Detail

Correct Answer: a. CT pulmonary angiogram

Answer Detail:
The correct answer is a.

This patient is at high risk for developing pulmonary embolism

and deep vein thrombosis due to pregnancy and long-distance
flight.
Clinical features are highly suggestive of pulmonary
embolism.In this situation D-dimers are not helpful.

D-dimers are only helpful when the test is negative and should
only be requested if the chances of pulmonary embolism are
very low.

Formal chest X-ray and Doppler ultrasound to rule out deep

vein thrombosis are still helpful in further management.In the
presence of signs and symptoms of pulmonary embolism,
however a definitive test should be done as soon as possible.

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 There are two most definitive tests,ventilation-perfusion
scintigraphy (VQ) and computed tomography pulmonary
angiography (CTPA) scans.

The fetal radiation dose from CT pulmonary angiography is

substantially less than that from ventilation perfusion scan in
all trimesters.
So CTPA is the preferred modality for imaging of suspected
pulmonary embolism in pregnancy.

Urgent delivery by Cesarean section is not advised until

mother starts deteriorating.Pulmonary embolism can be
managed well by heparin and enoxaparin during pregnancy
and symptoms resolve quickly after the treatment.

Electrocardiography should be performed in this situation

which may show sinus tachycardia with S1Q3T3. However this
is not commonly seen and a normal ECG can not rule out
pulmonary embolism.
Question No. 46 :
You have just seen an asymptomatic lady with 3 small stones in her gallbladder.

Which of the following statement is best advice regarding prognosis of asymptomatic

gallstones?

a. Patients with asymptomatic gallstones become symptomatic at a rate of about 2 percent per
year
b. Most common symptom when developed is less likely to be biliary colic

c. Once biliary symptoms begin, they are less likely to recur

d. About 40 to 50 percent of patients develop gallstone pancreatitis every year

e. Right lower quadrant pain is most common site for pain

Correct Answer & Detail

Correct Answer: a. Patients with asymptomatic gallstones

become symptomatic at a rate of about 2 percent per year
Answer Detail:
The correct answer is a.

Patients with asymptomatic gallstones become symptomatic at

a rate of about 2% per year.

The symptom that develops most commonly is biliary colic

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 rather than a major biliary complication.

About 1 to 2% of patients per year develop complications from

gallstones:

- Cholecystitis.
- Choledocholithiasis.
- Cholangitis.
- Gallstone pancreatitis.

Right upper quadrant pain is a key symptom of pain associated

with gall stones.
Question No. 47 :

A 44-year-old man presented with 24 hour history of ipsilateral facial paralysis, ear
pain and erythematous vesicular rash in the auditory canal and auricle.

What is the most appropriate treatment?

a. Oral acyclovir and prednisolone

b. Oral prednisolone

c. Methotrexate

d. Clindamycin

e. Gabapentin

Correct Answer & Detail

Correct Answer: a. Oral acyclovir and prednisolone

Answer Detail:
The correct answer is a.

This patient presented with signs and symptoms suggestive of

Ramsay Hunt Syndrome. The most appropriate treatment is
oral acyclovir and prednisolone.

Ramsay Hunt syndrome is characterized by varicella zoster

virus reactivation leading to the triad of ipsilateral facial
paralysis, ear pain, and vesicles in the auditory canal and
auricle.

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 The syndrome consists of facial and neck pain, auditory
symptoms, and facial palsy associated with the reactivation of
latent varicella zoster virus in the facial nerve and geniculate
ganglion.

If symptoms have been present for less than 72 hours,

antiviral therapy can be added to prednisolone.
Question No. 48 :

A 48-year-old man comes to your clinic to discuss about his risk of getting bowel
cancer.
He is asymptomatic otherwise and has no personal history of bowel cancer,colorectal
adenomas or ulcerative colitis.
His mother died at the age of 80 with urosepsis and his father died of myocardial
infarction at the age of 59.
However his second cousin was diagnosed of bowel cancer at the age of 56.
What is most appropriate advice to this patient?

a. FOBT every year starting at the age of 50

b. FOBT every two years starting at the age of 50

c. Urgent colonoscopy referral

d. Sigmoidoscopy

e. Colonoscopy now and then every five year

Correct Answer & Detail

Correct Answer: b. FOBT every two years starting at the age

of 50
Answer Detail:
If a patient is:
-asymptomatic
-no personal history of bowel cancer, colorectal adenoma or
ulcerative colitis
-no confirmed family history of colorectal cancer in first degree
relative or second degree relative with colorectal cancer
diagnosed at the age of 55 over.
Such person should have FOBT every 2 years.
So this patient qualifies this criteria and should have foecal
occult blood test every 2 years at the age of 50.

Urgent colonoscopy referral is not required at this stage.

Sigmoidoscopy is usually combined with double contrast

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 barium enema to enhance the usefulness in bowel cancer
screening.However this is not the case here.
Colonoscopy every five years is needed in patients who are at
high risk of getting colorectal cancer.
Question No. 49 :

Which of the following is the most frequent cause of an elevated level of thyroid
stimulating hormone with a hard nodular thyroid?

a. Follicular carcinoma

b. Follicular adenoma

c. Papillary carcinoma

d. Ana-plastic carcnoma

e. Hashimoto thyroiditis

Correct Answer & Detail

Correct Answer: e. Hashimoto thyroiditis

Answer Detail:
The most frequent cause of an elevated level of TSH with a
hard, nodular thyroid is Hashimoto's thyroiditis.

Hashimoto's thyroiditis is characterized clinically by gradual

thyroid failure, goitre formation, or both.The usual course of
Hashimoto's thyroiditis is gradual loss of thyroid function with
elevation of thyroid stimulating hormone.

All other options are associated with hard thyroid nodule with
normal thyroid stimulating hormone.

Most of the malignant tumours are usually asymptomatic in

early course and usually do not change thyroid function by
themselves.

A history of rapid growth, a thyroid nodule or fixation of the

nodule to surrounding tissues, new onset hoarseness or vocal
cord paralysis, or the presence of ipsilateral cervical
lymphadenopathy should all raise the suspicion that a nodule
may be malignant.

Follicular thyroid cancer is the second most common type of

thyroid cancer after papillary thyroid cancer. Follicular cancer

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 tends to occur in an older population when compared with
other differentiated thyroid cancers. Its peak incidence is
between ages 40 and 60 years.

Diagnosis of follicular carcinoma is suspected in the presence

of cold nodule without change in thyroid functions. The actual
diagnosis of follicular thyroid cancer requires pathologic
evaluation of the thyroid after surgery, and the identification of
tumour capsule and/or vascular invasion.

Anaplastic cancer is a rare but very rapidly invasive

malignancy which involves trachea, oesophagus very quickly in
few weeks.
Question No. 50 :

A 38-year-old woman presented to hospital with history of gradually increasing

fatigue over last 6 months. She reported more fatigue in the evening than in the
morning. Now she developed double vision, ptosis and, weakness of chewing and
swallowing. She occasionally becomes breathless due to fatigue. Serum anti-
acetylcholine receptor antibodies are positive.

Which ONE of the following treatment is useful for all grades of this clinical
condition?

a. Thymectomy

b. Plasmapheresis

c. Neostigmine

d. Corticosteroids

e. Physiotherapy

Correct Answer & Detail

Correct Answer: d. Corticosteroids

Answer Detail:
The correct answer is d.

This patient has developed symptoms of severe myasthenia

gravis and requires appropriate treatment. Corticosteroids are
useful for all grades of myasthenia gravis and should be
considered especially in severe myasthenia gravis.

Anticholinesterase drugs (neostigmine) produce at least partial

improvement in most myasthenia patients, although
improvement is complete in only a few. These should be used

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 only for mild to moderate disease.
Plasmapheresis is the treatment of choice for acute
myasthenia gravis crisis.

Thymectomy is recommended for myasthenia gravis in

younger patients with hyperplasia of thymus even if not
confirmed pre-operatively.

Physiotherapy is generally not very helpful in myasthenia

gravis due to easy fatigability.

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