2018 hard Flashcards
A 25 year-old male football player presents to the General Practitioner. For the past few months he has noticed increasing pain in his right knee with physical activity. In his last game, he twisted his knee in a tackle and has been unable to bear weight on that leg thereafter.
which is the most likely and why?
a. Popliteal (Baker’s) cyst
b. Ruptured posterior cruciate ligament
c. Torn medial meniscus
d. Tibio-femoral osteoarthritis
e. Chondrocalcinosis of the knee joint
Torn medial meniscus: menisci provide structural stability fro femur on tibia for weight-bearing
PCL: may= instability or pain on some movement but not unable to weight bear
OA: chronic, stiffness and pain
chondrocalcinosis: CaPO4 deposits, chornic, inflammatory
popliteal cyst: fluid collection behind knee, chronic conditions, tightness and pain, no acute pain or trouble weight-bearing
A 36 year-old female fell whilst playing netball. After she had caught the ball, she suddenly stopped, pivoted to pass the ball and fell to the ground in pain. Her knee became swollen quickly. She presents to the Emergency Department with signs of injury to the anterior cruciate ligament. A plain radiograph is complete and found normal.
Which of the following statements regarding physical examination and this injury is correct?
a. It is commonly associated with a haemarthrosis
b. Joint line tenderness is a necessary diagnostic feature
c. The tibia is likely to be able to be subluxed posteriorly
d. Valgus instability (opening of the medial joint under stress) is diagnostic
A. It is commonly associated with haematrhosis
process of elimination
jt line tenderness is not necessary for diagnosis
posterior not ACL prevents tibia from being subluxed posteriorly
MCL causes valgus instability
A 65 year-old male complains to a doctor about vague upper abdominal discomfort. He is slightly overweight and has smoked 20 cigarettes a day for over 40 years. Physical examination of the abdomen was difficult due to his obesity and he was sent for an ultrasound. This revealed the presence of two gallstones and a 5.5cm abdominal aortic aneurysm.
While undergoing a stress test the patient had a sudden onset of back pain and felt faint. He is transferred to the Emergency Department and is noted to be pale and sweaty, with a systolic blood pressure of 90mmHg. An aneurysm is present but difficult to feel on examination and his femoral pulses are weak.
Which of the following is the most appropriate management for this patient?
a. Obtain a blood sample for cardiac enzymes and amylase
b. Resuscitate with iv fluids to maintain BP of > 140mmHg
c. Insert a large bore iv canula but restrict fluids
d. Order a plain abdominal X-ray and check serum amylase
e. Urgent coronary angiography
insert a large bore IV cannula and restrict fluids
A 65 year-old male complains to his doctor about vague upper abdominal discomfort. He is slightly overweight and has smoked 20 cigarettes a day for over 40 years. Physical examination of the abdomen was difficult due to his obesity and he was sent for an ultrasound. This revealed the presence of two gallstones and a 5.5cm abdominal aortic aneurysm.
Aneurysm size is a pointer towards risk of rupture as a result of which of the following?
a. Tension in the aneurysm wall is proportional to the radius multiplied by the pressure
b. Tension in the aneurysm wall is inversely proportional to the radius
c. Turbulence in the sac causes increased mechanical stress
d. Greater kinetic energy is dissipated as blood flows through the aneurysm sac
e. Impedance mismatch at the aortic bifurcation leads to reflected pressure waves
and why
tension in aneurysm wall is proportional to radius mu;tipied by pressure
Law of LePlace: tension of enurysm (any cylindrical structure) is proportionate to internal P x radius. As radius increases- wall tension increases, making it more prone to rupture.
A 14 year-old girl had been slapped over the left ear during an argument with her mother. On examination, almost one-third of the tympanic membrane is perforated. There is some dried blood in the meatus but no signs of infection.
Which of the following is the most appropriate treatment for this patient?
a.. Observation
b. Oral antibiotics
c. Antibiotic eardrops
d. Surgical repair of the tympanic membrane
observation- tympanic membrane will heal spontaneously and no Abx indicated unless there is evidence of infection
A frail 93 year-old female slipped and fell in her nursing home when getting out of a chair. She was admitted to hospital and an X-ray showed a subcapital fracture of the right hip with slight displacement.
Which of the following surgical procedures is most appropriate for this patient?
a. Internal fixation of the fracture with screws within 24 hours
b. Internal fixation of the fracture with screws after 1-2 weeks
c. Replacement of the head of the femur with a prosthesis within 24 hours
d. Replacement of the head of the femur with a prosthesis after 1-2 weeks
and why
replacement of head of femur with prosthesis w.in 24hrs
- surgery should be done ASAP and head must be replaces because its blood supply via femoral neck has been compromised= risk of avascular necrosis
An 88 year-old female who resides in an aged care facility is found lying on the floor of her room in considerable pain. Her left leg appears shorter than her right.
Which of the following findings would be most likely on a plain radiograph of the affected hip?
a. posterior disclocation of hip
b. Undisplaced inter-trochanteric fracture of the femur
c. Sub-trochanteric fracture of the femur
d. Spiral fracture of the shaft of the femur
e. Displaced sub-capital fracture of the femoral neck
displaced sub-capital #of femoral neck
shortened leg= displaced #
NOF # is most common elderly
Which of the following complications of a closed tibial fracture would be most likely to occur at 24 hours following injury?
a. Haemorrhage
b. Infection of the calf muscles
c. Paraesthesia of the foot
d. Compartment syndrome
e. Rupture of the Achilles tendon
and why
compartment syndrome
CLOSED #: gradual increase in intra-compartmental pressure (over 24hrs or so) due to oedema in contused muscle. This increased P= reduced material flow and tissue ischemia. Surgical emergency needing urgent fasciotomy.
A 30 year-old female complains of dysphagia that she developed while eating a fish steak. A plain soft tissue X-ray of the neck is performed and no foreign body is seen.
Which of the following complications is this patient most at risk of developing if a missing bone perforates the oesophagus?
a. Persistent dysphagia
b. Acute pharyngitis
c. Haematemesis
d. Mediastinitis
e. Recurrent vomiting
and why
mediastinitis
(most severe and likely complication of oesophageal perforation)
note: oesophagus is also located in posterior mediastinum
A 48 year-old male injured his back lifting heavy objects at the factory where he works. An MRI of his spine shows some evidence of disc protrusion. His symptoms include pain which radiates down the backside of the right leg to the ankle. Further examination reveals loss of the ankle jerk.
Which nerve has most likely been compressed by the extrusion of disc material in this patient?
a. Protruded disc material arising from his lower thoracic spine and pressing on the spinal cord
b. Compression of the L5 nerve root by extruded disc material
c. Compression of the L3 nerve root by extruded disc material
d. Pathology affecting the femoral nerve
and why
Compression of the L5 nerve root by extruded disc material.
Sciatic nerve distribution: foot drop/ loss of ankle jerk/ sciatical down back of R leg to ankle
sciatic n originates from L4-S3
A 64 year-old asymptomatic male is concerned that he could have prostate cancer and undergoes a Prostrate Specific Antigen (PSA) test. The result is 4.1 nanograms (reference range: 0-4 nanograms).
Which of the following is the most appropriate interpretation of this result for the patient?
a. Probably have prostate cancer, and should have a biopsy
b. Test is abnormal and should be repeated
c. Test is within the age adjusted range but should be repeated
d. If rectal examination is normal then you don’t have prostate cancer
e. Test is virtually normal, come back next year
and why- what would be more correct
e. test is virtually normal, repeat in one year.
asx patient: so do DRE and repeat PSA in 3-6 months. Safety net: advise to come back if sx.s arise. Explain other activities that could raise PSA (advise not to do these before coming in for the test). PSA velocity would be more useful
A 55 year-old male presents with a 24 hour-history of painless reddish-brown urine. Voided urine cytology is reported as showing very atypical cells. An intravenous urogram report reads as follows: “Normal plain abdominal X- ray, but an irregular filling defect in the renal pelvis.”
Which of the following is the most likely underlying cause of this patient’s problem?
a. calculus
b. blood clot
c. RCC
d. transitional cell cancer
e. aneurysm
why
TCC: macroscopic painless haematuria, filling defect and atypical cells on cytology
blood clot: may cause filling defect and haematuria but no atypical cells
calculi: main= PAIN and may have hematuria, no atypical cells
aneurysm: haematuria if rupture but no atypical cells
RCC: more likely to present with tumour itself in kidney rather that just a filling defect and may cause hematuria
Which of the following is the most effective component in the management of full-thickness burns and necrotising wound infections?
a. Debridement
b. Systemic anti-inflammatory drugs
c. Prophylactic antibiotics
d. Quantitative cultures of burn biopsies
e. Isolation units
debridement
Friends bring a 15 year-old male to the Emergency Department. He has visual hallucinations dilated pupils, and his speech is slurred. The group had been in a high school party a few hours before.
Which of the following substances most likely caused this reaction?
a. Amphetamines
b. Cocaine
c. Ethanol
d. Lysergic acid diethylamide (LSD)
e. Tricyclic anti-depressants
LSD (only hallucinogen)
A 36 year-old male describes a 12 month-history of chronic hyper arousal. This consists of chronic anxiety, irritability, insomnia, and increased startle. He also reports feeling emotionally detached from others and describes frequent nightmares and recurrent intrusive recollections of atrocities he witnessed while deployed as a peace keeper in the Middle East.
Which of the following regarding this patient’s symptoms is correct?
a.He is in no need of treatment because they will naturally remit
b. He can be effectively treated with tricyclic antidepressants
c. He can only be treated with cognitive-behaviour therapy
d. He can only be treated with psychoanalysis
why and more correct answer would be?
MOST correct answer: B in this list. But ideally combined SSRI and psychotherapy (CBT), EMDR and group therapy for PTSD
. Patients receiving clozapine must be monitored frequently for the occurrence of which of the following?
a. Agranulocytosis
b. Aplastic anaemia
c. Hepatitis
d. Hyperprolactinemia
e. Tardive dyskinesia
and why, describe what the condition is
agranulocytosis
- occurs in 1% of clozapine w.o monitoring. Life threatening and the most serious side effect of clozapine. Also heart/ cardiac monitoring: cardio/ resp, seizures
What is agranulocytosis? extremely low levels of granulocytes: neutrophils, basophils and eosinophils. Significantly neurotpenia.= increased susceptibility to ifnections
. The genetic predisposition to schizophrenia is usually transmitted as which of the following?
a. A multifactorial trait
b. An autosomal dominant trait
c. An autosomal recessive trait
d. An X-linked dominant trait
e. An X-linked recessive trait
multifactorial
Which of the following is the most prevalent anxiety disorder?
a. General Anxiety Disorder
b. Obsessive-Compulsive Disorder
c. Post-traumatic Stress Disorder (PTSD)
d. Simple Phobia
e. Social Phobia
GAD
Which substance would most likely be blocked during reuptake in a patient who is taking tricyclic antidepressants?
a. Dopamine
b. Gamma aminobutyric acid (GABA)
c. Glutamate
d. Norepinephrine
e. Substance P
norepinephrine
most TCAs act as serotonin- norepinephrine reuptake inhibitors (like SNRIs)
* BUT unlike SNRIs- tricyclics have antichilinergic, antihistaminergic and cardiotoxic effects
Which of the following is NOT a currently accepted hypothesis for contributing to the aetiology of ADHD (Attention Deficit Hyperactivity Disorder)?
a. Background of social deprivation
b. Brain injury
c. Genetic factors
d. Insufficient dietary intake of omega fatty acids
e. Problems with Neurotransmitter metabolism
insufficient dietary intake of omega fatty acids
The antipsychotic effects of phenothiazines such as chlorpromazine are attributable to blockade of which of the following?
a. Adrenergic receptors
b. Dopaminergic receptors
c. Histarninergic receptors
d. Muscarinic receptors
e. Serotoninergic receptors
Dopaminergic receptors
1st generation antipsychotics are known as D2 antaonists (the basis for the dopamine theory of schizophrenia) which inhibit neurotransmission in the 4 dopaminergic pathways in the brain
4 dopamine pathways
* mesolimbc (+ve sx.s)
* mesocortical (-ve sx.s)
* nigrostriatal (extrapyramidal and tardive dyskinesia)
* tuberoinfundibular (hyperprolactinaemia)
A nine year-old boy presents with a history of being active since birth. He was active as an infant and as a toddler and was into everything. He ran before he walked. In the primary grades at school, he was impulsive, talking out of turn and he was very noisy. Although he did well in the early grades, in grade four he is not finishing assignments and he is becoming socially ostracised. He knows the answers to questions but will not take the time to do written work. He is very untidy and poorly organised.
Which of the following disorders is this patient likely to have?
a. Adjustment disorder with disturbance of conduct
b. Attention Deficit Hyperactivity Disorder (ADHD)
c. Developmental reading and spelling disorder
d. Pervasive Developmental Disorder (PDD)
e. Tourette’s Disorder (Multiple Tic Disorder)
ADHD
A 36 year-old male describes a 12 month-history of chronic hyper-arousal. This consists of chronic anxiety, irritability, insomnia, and increased startle. He also reports feeling emotionally detached from others and describes frequent nightmares and recurrent intrusive recollections of atrocities he witnessed while deployed as a peace keeper in the Middle East.
Which of the following disorders is this patient most likely to have?
a. Adjustment disorder with mixed emotional features
b. Chronic fatigue syndrome
c. Dysthymia
d. Post-traumatic stress disorder
e. Generalised anxiety disorder
PTSD
A 40 year-old man presents to his family doctor complaining of polydipsia, polyuria and nocturia. Investigations reveal the following results:
serum osmolality: 270 mOsm/kg (normal: 280-290 mOsm/kg)
serum sodium: 130 mmol/L (normal: 135-145 mmol/L)
serum glucose: 5.0 mmol/L (normal: 4.4-6.1 mmol/L)
24-hour urine osmolality: 50 mOsm/kg of water (normal: 500-850 mOsm/kg)
Which of the following is the patient’s most likely diagnosis?
a. Chronic renal failure
b. Compulsive water drinker (psychogenic polydipsia)
c. Diabetes mellitus
d. Nephrogenic diabetes insipidus
e. Neurogenic or central diabetes insipidus
and why
compulsive water drinker (psychogenic polydipsia)
DI would give raised serum Na
chronic renal failure: increase serum osmolality
DM raised serum glucose
Which of the following symptoms in a bereaved person suggests a diagnosis of major depression?
a. Insomnia with early morning awakening
b. Ruminations of personal worthlessness
c. Severe emotional liability with depressed mood
d. Visual hallucinations in which the deceased person appears at night
e. Wish to be dead along with the deceased
ruminations of personal worthlessness
A 36 year-old male describes a 12 month-history of chronic hyperarousal. This consists of chronic anxiety, irritability, insomnia, and increased startle. He also reports feeling emotionally detached from others and describes frequent nightmares and recurrent intrusive recollections of atrocities he witnessed while deployed as a peace keeper in Eastern Europe.
Which neuroanatomical structures play the most important role in producing this patient’s symptoms?
a. Basal ganglia and their frontal lobe projections
b. The amygdala and cerebellum.
c. The limbic system and its major projections.
d. The temporal lobe and its corticocortical projections.
limbic system and its major projections- involved in motivation, emotion, learning and memory unlike other options listed
A four day-old girl was operated on for low intestinal obstruction. The clinical picture was a history of bile stained vomiting with general abdominal distension. Distended loops of intestine could be visualised through the anterior abdominal wall and visible peristalsis was present. Rectal examination revealed a blind pouch.
What is the most likely underlying cause of this patient’s intestinal obstruction?
a. Annular pancreas
b. Failure of formation of the descending colon
c. Lack of sacral parasympathetic nerves
d. Pyloric stenosis
e. The cloacal membrane did not break down
cloacal membrane did not break down
obvious sign= blind pouch on DRE
A three year-old boy presents with recurrent urinary tract infections.
Which of the following is this patient’s most likely diagnosis?
a. Bifid ureter
b. Posterior urethral valves
c. Struvite (“staghorn”) stones
d. Vesicoureteric reflux
e. Wilm’s tumour
vesicoureteric reflux
Two weeks after birth, a neonate began to vomit forcefully after feedings. The vomiting was projectile in nature.
Which of the following is this neonate’s most likely diagnosis?
a. A malignant tumour
b. Atresia of the duodenum
c. Atresia of the stomach
d. Gastric stenosis
e. Pyloric stenosis
pyloric stenosis
Which of the following side effects is LEAST likely to be associated with prednisone therapy in a six year-old patient?
a. Decreased appetite
b. Growth retardation
c. Hypertension
d. Increased body hair
e. Personality changes
decreased appetite- CS likley to INCREASE not decrease appetite
A five day-old baby boy presents with prolonged jaundice, micropenis and hypoglycemia. Which of the following is the most likely diagnosis?
a. Congenital cardiopathy
b. Congenital hypothyroidism
c. Growth hormone deficiency
d. Neonatal hyperthyroidism
e. Neonatal infection
GH deficiency
- GH deficiency also leads to hypoglycaemia (GH raises blood glucose)
An eight year-old girl presents with secondary nocturnal enuresis. Diabetes insipidus (DI) is suspected and a 12-hour water deprivation test is ordered.
Which of the following results is NOT consistent with the diagnosis of DI?
a. High serum osmolality
b. Hyponatremia
c. Low serum vasopressin concentrations in the presence of dilute urine and dehydration
d. Low urine osmolality
e. Weight loss of 5 % during the 12 hour test
hyponatremia
DI= ADH insufficiency (vasopressin) which leads to passage of large volumes of DILUTE (=dehydration)= increase serum Na and HIGH serum osmolality and LOW urine osmolality
. Parents’ consistency, predictability and reliability are crucial conditions for the successful resolution of which developmental dilemma?
a. Autonomy vs. shame and doubt
b. Basic trust vs. mistrust
c. Identity vs. identity diffusion
d. Industry vs. inferiority
e. Initiative vs. guilt
basic trust vs mistrust (Erikson’s stages of psychosocial development for infants 0-1.5 years.
. A 12 year-old girl is anxiously waiting for her pubertal development to start.
Which of the following will be the first sign?
a. Axillary hair
b. Breast budding
c. Increase in height velocity
d. Menstruations
e. Pubic hair
breast budding (thelarche)
A previously well 14 month-old child, presents with a history of sudden onset of cough and wheeze. On examination, there is evidence of reduced air entry and wheeze over the right lung.
Which of the following is the most likely diagnosis?
a. Asthma
b. Bronchiolitis
c. Congenital airway abnormality
d. Inhaled foreign body
e. Pneumonia
why
Inhaled foreign body.
Most common incidence of bronchiolitis is below age of 2. Sudden onset sx.s, previously playing with toys. Localized presentation. Not generally unwell.
Which of the following is the LEAST common characteristic of Turner’s syndrome?
a. 45 X karyotype
b. Cardiopathy
c. Low posterior hairline
d. Primary ovarian failure
e. Severe mental retardation
severe mental retardation
Most cases have good verbal and reading skills, although social intelligence may be slightly impaired