2018 hard

Question 1

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

Answer 1

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

Question 2

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

Answer 2

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

Question 3

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

Answer 3

insert a large bore IV cannula and restrict fluids

Question 4

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

Answer 4

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.

Question 5

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

Answer 5

observation- tympanic membrane will heal spontaneously and no Abx indicated unless there is evidence of infection

Question 6

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

Answer 6

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

Question 7

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

Answer 7

displaced sub-capital #of femoral neck

shortened leg= displaced #
NOF # is most common elderly

Question 8

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

Answer 8

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.

Question 9

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

Answer 9

mediastinitis
(most severe and likely complication of oesophageal perforation)

note: oesophagus is also located in posterior mediastinum

Question 10

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

Answer 10

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

Question 11

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

Answer 11

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

Question 12

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

Answer 12

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

Question 13

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

Answer 13

debridement

Question 14

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

Answer 14

LSD (only hallucinogen)

Question 15

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?

Answer 15

MOST correct answer: B in this list. But ideally combined SSRI and psychotherapy (CBT), EMDR and group therapy for PTSD

Question 16

. 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

Answer 16

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

Question 17

. 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

Answer 17

multifactorial

Question 18

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

Answer 18

GAD

Question 19

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

Answer 19

norepinephrine

most TCAs act as serotonin- norepinephrine reuptake inhibitors (like SNRIs)
* BUT unlike SNRIs- tricyclics have antichilinergic, antihistaminergic and cardiotoxic effects

Question 20

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

Answer 20

insufficient dietary intake of omega fatty acids

Question 21

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

Answer 21

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)

Question 22

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)

Answer 22

ADHD

Question 23

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

Answer 23

PTSD

Question 24

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

Answer 24

compulsive water drinker (psychogenic polydipsia)

DI would give raised serum Na

chronic renal failure: increase serum osmolality

DM raised serum glucose

Question 25

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

Answer 25

ruminations of personal worthlessness

Question 26

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.

Answer 26

limbic system and its major projections- involved in motivation, emotion, learning and memory unlike other options listed

Question 27

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

Answer 27

cloacal membrane did not break down

obvious sign= blind pouch on DRE

Question 28

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

Answer 28

vesicoureteric reflux

Question 29

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

Answer 29

pyloric stenosis

Question 30

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

Answer 30

decreased appetite- CS likley to INCREASE not decrease appetite

Question 31

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

Answer 31

GH deficiency

• GH deficiency also leads to hypoglycaemia (GH raises blood glucose)

Question 32

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

Answer 32

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

Question 33

. 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

Answer 33

basic trust vs mistrust (Erikson’s stages of psychosocial development for infants 0-1.5 years.

Question 34

. 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

Answer 34

breast budding (thelarche)

Question 35

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

Answer 35

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.

Question 36

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

Answer 36

severe mental retardation

Most cases have good verbal and reading skills, although social intelligence may be slightly impaired

Question 37

. A concerned mother brings in her 16 year-old daughter because she has never had a menstrual period. On examination, the girl is 153 cm tall with mature adult breast development but no pubic and axillary hair. Vaginal examination is difficult and the doctor is unable to identify a cervix nor palpate a uterus.

Which of the following is the most likely diagnosis of this patient?

a. Congenital adrenal hyperplasia with 21-hydroxylase deficiency
b. Imperforate hymen
c. Turners syndrome
d. Kallmanns syndrome
e. Complete androgen insensitivity syndrome

why

Answer 37

Complete androgen insensitivity syndrome.

Also known as testicular feminization syndrome. XY karyotype- peripheral tissue lack receptors to testosterone. Male 2ndary sexual characteristics do NOT develop but no internal female genitalia and foreshortened vagina.

Question 38

Which of the following endometrial cancer risk factors is NOT directly associated with chronic estrogen stimulation?
a. Obesity
b. Polycystic ovary syndrome
c. Granulosa cell tumor
d. Hypertension
e. Oestrogen replacement therapy

why

Answer 38

HTN (not DIRECTLY)

obesity= excess peripheral adipose tissue= course of oestrogen synthesis

Question 39

Which of the following causes of diarrhoea will result in the presence of polymorph nuclear leucocytes in the stool?

a. Infection due to Giardia lamblia
b. Acute staphylococcal food poisoning
c. Tropical sprue
d. Infection due to Campylobacter jejuni
e. Coeliac sprue (gluten-sensitive enteropathy)

explain

Answer 39

infection due to campylobacter jejuni (only bacteria in the options which usually elicits neutrophil response)

Question 40

A 46 year-old female visits the General Practitioner with her husband who is 35 years-old. She has regular cycles and her husband’s sperm count is normal. They are very interested in becoming parents. She had two children in a previous marriage. They have had unprotected intercourse for one year without results.

For this couple, which of the following would be the most productive approach to a pregnancy?
a. Wait for another year since the infertility is of short duration
b. Intrauterine insemination
c. In vitro fertilization/ICSI
d. Superovulation with gonadotropins with intrauterine insemination
e. Donor oocyte IVF

Answer 40

donor oocyte IVF

46, this woman may be approaching menopause, and therefore has a limited reserve of oocytes. Oocyte donation would therefore be the most efficacious solution, compared to option d.

Question 41

Withdrawal bleeding following the administration of a progestin implies that the patient has which of the following conditions?
a. Chronic endometritis
b. Impaired estrogen receptors
c. Normal levels of pituitary gonadotropins
d. Normal serum prolactin level
e. None of the above

explain

Answer 41

normal levels of pituitary gonadotropins

Progestin challenge test: progestin administered maintains endometrium proliferation. When it is stopped= drop in progesterone and excess ostrogen= endometrium to shed= withdrawal bleed (normal response).

This indicates normal pituitary function and normal levels of endogenous oestrogen.
- hypothalamus- pituitary- gonadotropin (LH, FSH)
- these hormones stimulate ovaries to stimulate oestrogen

chronic endometritis would not be associated with normal withdrawal bleed

Impaired oestrogen receptors: prevent endometrium from responding to oestrogen, no withdrawal bleed.

Normal serum prolactin not directly related to withdrawal bleeds and won’t impact outcome of test.

Question 42

A 39 year-old gravida-1, para-1 female has profuse vaginal bleeding for 21 days. She normally has menses occurring every 28 days and lasting five days. Physical examination, including pelvic exam, is normal. A pregnancy test is negative.

Which of the following is the most appropriate next step in management of this patient?
a. Administration of intravenous oestrogens
b. Administration of oral contraceptives
c. Administration of prostaglandin inhibitors
d. Endometrial sampling
e. Hysterectomy

Answer 42

endometrial sampling

Question 43

A gravida 2 para 1 mother presents for her first prenatal visit at 24 weeks gestational age. The fundal height, measured in centimeters from the symphysis pubis to the top of the fundus is 21cm.

Which of the following is the next best step in her management?

a. Arrange for obstetrical ultrasound
b. Ask her to return in two weeks to repeat the measurement
c. Counsel her to increase her dietary intake and return in four weeks
d. Repeat the measurement at her next prenatal visit scheduled in four weeks
e. None of the above

and why

Answer 43

arrange for obstetrical USS

Fundal height from umbilicus should generally match week of gestation. Since this is abnormal- do an abdo USS

Question 44

. A 27 year-old woman is six months pregnant with her second child but has a past history of asymptomatic bacteriuria.
Which of the following diseases is LEAST likely to be included in routine antenatal testing?
a. Asymptomatic bacteriuria
b. Hepatitis B
c. Measles
d. Rubella
e. Syphilis

Answer 44

asymptomatic bacterueria

Question 45

. Which of the following lung volumes and/or capacities is decreased in a normal pregnancy?
a. Respiratory rate
b. Tidal volume
c. Vital capacity
d. Residual volume

why

Answer 45

residual volume will decrease

RR increased due to increased metabolic demand

tidal volume and vital capacity generally increased due to widened thoracic circumference

the elevation and splinting of diaphragm determines residual volume and is therefore decreased

Question 46

. A 48 year-old female presenting with lower abdominal discomfort for about nine months, is diagnosed with bilateral solid ovarian tumors with ascites on ultrasonography. She has had regular menstrual cycles. Upper gastro-intestinal endoscopy reveals an ulcerative growth in stomach.
Which of the following is the most likely diagnosis?

a. Carcinoma stomach with Krukenberg tumour
b. Carcinoma of uterus
c. Primary ovarian malignancy
d. Carcinoma of the small intestine

Answer 46

carcinoma in stomach with Krukenberg tumour

Krukenberg tumours carcinoma of GI origin met.s to one or both ovaries. Ovarian cancer does NOT met.s to GI

Question 47

For the investigation of sexually transmitted infection, cervical swabs should be obtained for the diagnosis of which of the following?
a. Trichomonas infection
b. Candida infection
c. Herpes simplex infection
d. Gonococcal infection and Chlamydial infection
e. Syphilis

explain

Answer 47

gonococcal infections and chlamydia: cervical swab

trichomonas: HIGH vaginal swab, frothy green/ yellow foul-smelling d/c

candida: high vaginal swab, no smell, cottage cheese (vaginal thrush)

herpres: NAAT and sawb of ulcer

phyphilis and HIV= serology

Question 48

Which of the following is NOT a commonly used method of detecting the status of the Fallopian tubes?
a. Hysterosalpingography
b. Tubal biopsy
c. Laparoscopy and dye study
d. Hysterosonography
e. Tubal insufflation

Answer 48

tubal biopsy

• main issue= fallopian tube patency which cannot be assessed by biopsies which don’t look at the tubes in their entirety

Question 49

. A 32 year-old female presents with a long-term history of menorrhagia. Investigations reveal no cause for the menorrhagia and a diagnosis of dysfunctional uterine bleeding is made.
Which method would most effectively control this patient’s uterine bleeding?
a. Curettage
b. Drugs inhibiting prostaglandin synthesis
c. Hysterectomy
d. Oral contraceptive pill
e. Progesterone injections

Answer 49

COCP

Question 50

. Which of the following changes does NOT occur in the urinary system of pregnant women?
a. There is a marked increase in the glomerular filtration rate.
b. Glycosuria is common because the tubular reabsorption capacity is exceeded.
c. Serum concentrations of uric acid and creatinine are higher as a result of the presence of the foetus. d. Vascular reactivity to angiotensin II is reduced in pregnancy.
e. There is dilatation of the ureters and renal pelvis.

why

Answer 50

serum concentration of uric acid and creatinine are higher as a result of foetus

due to fetus- CO and renal blood low is higher= higher eGFR and lower serum creatinine and uric acid

Question 51

In the azoospermic male, the diagnosis of testicular failure can be made by the finding of elevated levels of which of the following?

a. Prolactin
b. Follicle stimulating hormone (FSH)
c. Testosterone
d. Oestradiol
e. Inhibin

why

Answer 51

FSH

Question 52

Oxygenated blood from the umbilical vein enters the foetal circulation via which of the following?
a. Portal sinus and ductus venous
b. Inferior vena cava
c. Intrahepatic artery
d. Lesser hepatic vein
e. Ductus arteriosus

draw foetal circulation

Answer 52

postal sinus and ductus venosus

umbilical vein brings oxygenated blood into foetal circulation. Joins portal sinus at the porta hepatis–> ductus venosus–> IVC

Question 53

A 48 year-old patient with a history of chronic duodenal peptic ulcers, presents with a recent episode of malaena.
Which of this patient’s gastrointestinal arteries would be most susceptible to bleeding?
a. Left gastric artery
b. Right gastric artery
c. Gastroduodenal artery
d. Right gastro-epiploic artery
e. Short gastric artery

Answer 53

gastroduodenal aa

Question 54

A 48 year-old male with known alcoholic liver disease presents to the Emergency Department with jaundice and an upper gastrointestinal bleed. Initial blood work shows that his INR (normalised prothrombin) time is increased to 2.1.

What is the most likely underlying cause of this patient’s coagulation disturbance?

a. Dietary deficiency of vitamin K

b. Vitamin K degradation by intestinal bacteria

c. Factor XII deficiency

d. Impaired synthesis of vitamin K-dependent coagulation factors

e. Impaired synthesis of factor VIII by the liver

why

Answer 54

Impaired synthesis of vitamin K-dependant coagulation factors.

Increased INR indicates deficiency in the extrinsic coagulation pathway. ETOH hx= liver cirrhosis which means factor II, VII, IX and X are deficient (vitamin-K- dependent clotting factors)

Question 55

. Which gastrointestinal finding is LEAST likely in a patient diagnosed with gallstone disease?
a. Gallbladder cancer
b. Cholangitis
c. Acute cholecystitis
d. Chronic pancreatitis
e. Biliary colic

Answer 55

gallbladder cancer

Question 56

Which lesion would be most likely in a patient who exhibits hyper-reflexia of both lower extremities?
a. Infarct of the dominant motor strip
b. Thalamic hemorrhage
c. Demyelinating plaque in the dorsal midbrain
d. Thoracic spinal cord compression
e. Cerebellar stroke

explain

Answer 56

Bilateral UMN lesion.
infarct of dominant motor strip: contralateral motor deficits

thalamic haemorrhage can present w/ range of motor sx.s but unlikely to be exclusive hyperreflexia in lower extremities.

cerebellar stroke more likely to produce ataxia and balance issues

Question 57

An 18 year-old female complains that a condom broke during sexual intercourse. Coitus occurred one day ago when she was at mid-cycle. She does not wish to be pregnant and will terminate the pregnancy if menses does not occur.
What advice would you give her?
a. Unprotected midcycle coitus has a 5% pregnancy risk
b. Little can be done, since sperm have already entered the cervical mucus
c. She should douche with betadine to destroy the sperm.
d. Post coital emergency contraception is >95% effective.

Answer 57

post coital emergency contraception is >95% effective

Question 58

26 year-old female presents with chronic asthma.
Which of the following parameters is reduced in a patient with asthma?
a. Forced expiratory volume in 1 sec
b. Vital capacity
c. Haemoglobin concentration
d. Lung compliance
e. All of the above

why

Answer 58

FEV1

reduced due to premature closure of hyper-reactive airways in asthma

Question 59

A full examination of a newborn revealed a small opening at the umbilicus which appeared to be leaking scant amounts of clear fluid.
What is this patient’s most likely underlying embryonic pathology?

a. Patent Urachus (Allantois)
b. Patent Yolk Sac stalk
c. Failure of closure of the anterior (ventral) body wall
d. Cloacal atresia

Answer 59

patent urachus (allantois)

communication between bladder and umbilicus remains patent which= clear fluid coming out of the umbilicus in newborn (urine)

Question 60

For the past year a 55 year-old female has taken hormone replacement therapy (HRT). Her natural menopause was two years ago. She’s otherwise very well with no significant past medical history. Although vaginal dryness and discomfort with penile entry is now much better (since taking the HRT), she really misses her former desire to be sexual, especially as her relationship is otherwise excellent. She also wishes her body was more responsive - genitally, the feelings seem so reduced and breast touching is no longer sexual at all.
For the case described above what HRT would you consider advising?
a. Oestrogen plus androgen plus progesterone
b. Oestrogen plus androgen
c. Androgen plus progesterone
d. Oestrogen plus progesterone

why

Answer 60

a. oestrogen+ androgen+ progesterone

focus on sexual dysfunction and reduced libido so although standard therapy is oestrogen and progesterone–> add androgen (testosterone)

Question 61

A couple present with male infertility characterised by a semen analysis with a sperm count of 14 million sperm per ml, 25% motility, and 23% normal forms. The husband’s physical examination and hormone studies are normal.
Which of the following is the appropriate initial therapy?
a. Clomiphene citrate
b. Varicocelectomy
c. In vitro fertilization
d. Intrauterine insemination with washed husband’s sperm
e. Insemination with donor sperm

why

Answer 61

intrauterine insemination with washed husband’s sperm

motility and morphology of sperm= suboptimal. Lower limit of sperm count generally 15million/ mil. Therefore IUI= least invasive 1st option for this couple.

Question 62

A nodule is defined as a palpable, solid lesion, greater than 1 cm in diameter - usually found in the dermal or subcutaneous tissue, and the lesion may be above, level with, or below the skin surface. It extends deeper than a papule, which is defined as less than 1cm.
37. Which of the following is the most common major manifestation of the first episode of rheumatic fever?
a. Carditis
b. Chorea
c. Subcutaneous nodules
d. Polyarthritis
e. Erythema marginatum

explain

Answer 62

polyatrhtisi

Rheumatic fever is an autoimmune response to infection w/ group AS strep. Usually a throat infection or skin sores which preceded it by a few weeks. Initial sx.s is fever with jt pain/ swelling- why its called rheumatic fever.

Question 63

A patient presents with a rash that consists of raised, red, rounded lesions about 2cm in diameter. These lesions would best be described as which of the following?
a. Macules
b. Patches
c. Papules
d. Nodules
e. Plaques

Answer 63

nodules

Question 64

A 63 year-old male with a history of progressive exercise intolerance is found dead. His medical history reveals fasting blood glucose measurements from 8.0 to 11.7 mmol/L (reference range: 3.5 to 5.4 mmol/L) for the past 20 years.
Which of the following is most likely to be the immediate cause of death in this man?
a. Myocardial infarction
b. Nodular glomerulosclerosis
c. Cerebral hemorrhage
d. Hyperosmolar coma
e. Right lower leg gangrene

Answer 64

MI

Question 65

Which of the following events is most likely associated with transient ischaemic attacks?
a. Arterial thrombosis
b. Arterial embolism
c. Arterial haemorrhage
d. Arterial spasm

Answer 65

arterial embolism

Question 66

Which of the following events is most likely associated with atrial fibrillation?
a. Arterial thrombosis
b. Arterial embolism
c. Arterial haemorrhage
d. Arterial spasm

Answer 66

arterial embolism

Question 67

Which of the following events is most likely associated with atherosclerosis?
a. Arterial thrombosis
b. Arterial embolism
c. Arterial haemorrhage
d. Arterial spasm

Answer 67

arterial thrombosis

Question 68

Which of the following events is most likely associated with diabetes mellitus?
a. Arterial thrombosis
b. Arterial embolism
c. Arterial haemorrhage
d. Arterial spasm

Answer 68

arterial thrombosis

Question 69

An 80 year-old male presents to a General Practitioner to report sudden loss of vision in his left eye. Further examination reveals a normal right eye and abnormality in the left eye.

Which finding would be most likely when performing a vision test in this patient’s left eye?

a. Subconjunctival haemorrhage
b. Cells and flare in anterior chamber
c. Posterior vitreous detachment
d. Pale, swollen left optic disc
e. Drusen and retinal pigment epithelial defects at the left macula

explain

Answer 69

pale, swollen L optic disc= indicates anterior ischemic optic neuropathy= sudden visual loss caused by retinal aa occlusion for example

all other options= not SUDDEN visual loss

subconjuctival haemorrhage= being condition caused by minor trauma orinctreased pressure

cells and flare in anterior chamber= anterior uveitis, present with pain, redness and photophobia

posterior vitrous detachment: usually floaters and flashes

drusen and retinal pigment…= age-related macular degeneration, progressive central visual loss not sudden

Question 70

An 80 year-old male presents to a General Practitioner to report sudden loss of vision in his left eye. Further examination reveals a normal right eye and abnormality in the left eye.

On visual field testing you are most likely to find which of the following?
a. Left central scotoma
b. Right homonymous hemianopia
c. Right homonymous hemianopia with macula sparing
d. Left nasal step
e. Left peripheral visual field constriction

why

Answer 70

Left central scotoma.

homonymous hemianopia affect both eyes.
D and E less likely as they are more likely due to chronic conditions

Question 71

A 78 year-old female who lives alone, is not eating properly and seems to have no energy. She has difficulty climbing stairs and is breathless on minimal exertion. On examination, she is pale with a mild tachycardia of 105 beats per minute. She has mild pitting ankle oedema. The results of her full blood count are given below.

Reference Range
Haemoglobin 110g/L (135-180)
White Cell Count 8.0 x 109/L (4 - 11)
Platelets 229 x 109/L (140 – 400)
Haematocrit 0.31 (0.39 - 0.52)
Mean Corpuscular Volume 110fL (80 – 100)

Which of the following nutritional deficiencies is most likely?
a. Iron
b. Magnesium
c. Thiamine
d. Folate

Answer 71

folate deficiency

macrocytic anaemia typically due to B12 and/ or folate deficiency

Question 72

A 70 year-old male is found collapsed at home by his daughter. She calls an ambulance to transport him to hospital. On admission he is noted to be awake but appears confused, unable to answer questions and has paresis of his right arm and right leg. He is diagnosed as having sustained a stroke.

For the speech defect expressive (motor) aphasia, which of the following is the expected physical finding?
a. Understands written and spoken words, speaks slowly and laboriously (non-fluent), small grammatical words omitted

b. Understands written and spoken words, makes errors with word usage in speech, at best incomprehensible, at worst, is capable of repeating aloud following slow dictation

c. Understands written and spoken words, experiences difficulty with articulation and/or phonation

d. Does not properly comprehend the spoken or written word, self-generated speech is full of jargon, but may repeat aloud the spoken word or copy the written word

Answer 72

A. understands written and spoken words, speaks slowly and laboriously (non-fluent), small grammatical words omitted

= expressive (Broca’s aphasia)

vs
d. global aphasia (wernicke’s and broca’s)

c. more describes issue with peripheral n, muscle of vocal cord injury

Question 73

An intoxicated 23 year-old male presents to the Emergency Department after punching his hand through a window during a bar fight. Examination reveals a deep, transverse laceration on the palmar aspect of the wrist, 2 cm proximal to the wrist crease. He complains of numbness in the 2nd and 3rd fingers, and severe pain. He believes the bones in his hand are broken which is confirmed by further investigations. He is admitted to the Surgical Ward for repair.
Three days following discharge, he returns to the doctor, complaining of redness and swelling at the wound site. His axillary body temperature is 38 degrees centigrade.
Upon return to the doctor, what is the priority initial course of action?
a. Admission for observation and elevation of the limb
b. Immediate return to the operating theatre
c. Full blood count and blood culture analysis
d. Initiate antibiotic treatment
e. Arrange outpatient review with surgeon

Answer 73

most appropriate INITIAL= FBC and blood culture

Question 74

A 45 year-old male was brought to the Emergency Department in an ambulance. On arrival, he was found to be in shock. Further investigations determined he was experiencing acute haemorrhagic pancreatitis.

Which physiological change most likely occurred prior to this patient’s haemorrhage?

a. Release of lipase and phospholipase
b. Acute interstitial inflammation
c. Release of elastase
d. Activation of kinins
e. Activation of complement system

explain

Answer 74

release of elastase

acute hamorrhagic pancreatitis most likely occurs when large concentrations of elastatse are activated within the pancrea and start to digest arterial vessels with high proportion of elastase in their walls

Question 75

In a patient with severe facial trauma, endotracheal intubation is not feasible.
Which type of incision would be most appropriate to use in order to quickly and simply establish an airway?
a. Thyrohyoid membrane
b. Sternohyoid muscle
c. Isthmus of the thyroid gland
d. Cricothyroid membrane

Answer 75

cricothyroid membrane

Question 76

. A 35 year-old construction site worker, with an unknown immunisation history, was admitted to hospital following traumatic amputation of the thumb while working.
Which of the following would be the most appropriate to administer to this patient?
a. Tuberculin test
b. Tetanus immunoglobulin
c. Varicella zoster immunoglobulin
d. Platelet transfusion
e. Fresh frozen plasma

Answer 76

tetanus Ig

Question 77

A 30 year-old motorcyclist had a head-on collision with a truck on the highway when riding at a speed of 80 km/hr. He was found to be unconscious, BP 100/50 mmHg, pulse 60/minutes. There was very shallow breathing and no spontaneous movement of the four limbs was observed. There was an open wound on his left leg with deformity.

Which of the following is the first step to be taken in the Emergency Department?

a. Protect the cervical spine with proper immobilisation
b. Blood transfusion
c. Insert a chest drain
d. Check X-ray of the leg
e. Dress the open wound

Answer 77

protect cervical spine with proper immobilisation

Question 78

A 50 year-old psychiatric patient attempted suicide by jumping from the fifth floor. He was resuscitated on the scene of the accident and brought to the Emergency Department with the following condition:
Conscious, blood pressure was 70/50 mm Hg, pulse 120/minute, his abdomen was distended, there was blood stained discharge from his external urethral meatus and the left lower leg was shortened and externally rotated.
Which of the following would be the most likely first line of action?
a. Insert a large bore catheter to his veins for rapid fluid infusion
b. Check the X-ray of his left leg
c. Dress the external urethral meatus
d. Look for abdominal injuries
e. Insert a chest drain

Answer 78

insert large bore catheter to his veins for rapid fluid infusion

Question 79

. A 30 year-old lady with no history of chronic headache presented to the Emergency Department with severe acute onset headache that is associated with nausea and vomiting.
Which of the following management plans is NOT appropriate?
a. She likely suffers from her first episode of migraine and no further investigation is needed
b. An urgent CT head is needed to rule out subarachnoid hemorrhage
c. Temperature should be taken to look for fever
d. Fundoscopy should be performed to look for papilloedema
e. The drug history should be taken

Answer 79

NOT appropriate: she likely suffers from her 1st episode migrane, no further Ix

Question 80

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 is the most appropriate initial course of action for this patient?
a. Refer the patient to an orthopaedic surgeon
b. Organise an MRI scan to confirm diagnosis
c. Admit patient for immediate ligament reconstruction
d. Simple analgesia, compression bandage and application of ice

Answer 80

organise an MRI scan to confirm diagnosis

Question 81

If severe headache occurs soon after head injury, what is (are) the most useful investigation(s) that need(s) to be arranged urgently?
a. Blood culture and lumbar puncture
b. Electroencephalogram
c. ESR and alkaline phosphatase
d. Skull X-ray and CT head scan
e. Blood ethanol level

Answer 81

skull X-ray and CT head

Question 82

A 65 year-old male with a history of ischaemic heart disease and hiatus hernia, feels bloated after a conference dinner and tries to vomit. Soon afterwards he experiences severe retrosternal pain and collapses.

Which of the following is the most likely diagnosis?
a. Inferior myocardial infarction
b. Biliary colic
c. Gastric volvulus
d. Oesophageal rupture
e. Dissection of ascending aorta

explain

Answer 82

oesophageal rupture= Boerhaave syndrome; full thickness tear of the oesophagus due to sudden increase in intra-oesophageal pressure with relatively negative intra-thoracic pressure.
As may occur with forced vomiting.

Septic shock can rapidly supervene as gastric contents leak into mediastinum.

Question 83

A 30 year-old male had a head-on collision with a truck on the highway when riding at a speed of 80 km/hr. He was found to be unconscious, BP 100/50 mmHg, pulse 60/minute. There was very shallow breathing and no spontaneous movement of the four limbs was observed. There was an open wound on his left leg with deformity.
What is the next step to be taken after the first step that had been done in the Emergency Department?
a. Perform a secondary survey
b. Check X-ray of the spine and pelvis
c. Book urgent CT scan
d. Bring the patient to Operating room for fixation of fractures
e. Put a cast on the leg

Answer 83

perform 2ndary survery (1st step)

Question 84

An adolescent girl has been receiving high doses of daily prednisone for the past two-months for nephrotic syndrome.
Which of the following side effects is LEAST likely to be associated with her drug therapy?
a. Facial acne
b. Full cheeks (“moon facies”)
c. Glycosuria
d. Posterior capsular cataracts
e. Diarrhoea

Answer 84

diarrhoea- not a commonly described side-effect of pred

Question 85

A 66 year-old male presents to the hospital with angina pectoris. He is administered a medication which acts by virtue of releasing nitric oxide and his symptoms are relieved.
Which of the following drugs was this patient most likely administered?
a. Histamine
b. Acetylcholine
c. Hydrochlorthiazide
d. Propranolol
e. Nitroglycerin

Answer 85

nitroglycerin

Question 86

. Carbidopa is used in the treatment of Parkinson’s disease for which of the following reasons?
a. To increase L-dopa levels by inhibiting CYP3A4
b. To reduce the metabolism of L-dopa in the brain
c. To reduce the metabolism of L-Dopa in the periphery
d. To reduce the excretion of L-Dopa by the kidney
e. To potentiate the action of bromocriptine by inhibiting CYP3A4

Answer 86

to reduce metabolism of L-dopa in the periphery. It is a peripheral decarbolyase inhibitor to reduce side effects associated with peripheral dopamine.

Question 87

. A 76 year-old female with known cardiomyopathy and poor left ventricular function, presents to the Emergency Department with palpitations, dyspnoea at rest and dizziness. Her pulse rate is 148/minute and irregularly irregular. Her ECG shows an irregularly irregular rhythm with no P waves and normal QRS complexes.
Which of the following drugs would be the most appropriate for the long-term control of the ventricular rate in this patient?
a. Digoxin
b. Verapamil
c. Metoprolol
d. Amiodarone
e. Adenosine

Answer 87

metoprolol

B-blockers shown to be more effective than digoxin for rate control in AF.
Amiodarone is possible but more side effects.

Question 88

A 45 year-old male presents to the Emergency Department with rapid regular palpitations that came on while he was exercising. He is found to have a pulse rate of 148/minute and regular, with a BP of 105/60. His ECG shows a regular tachycardia with no P waves and with normal QRS complexes.
Which of the following drugs would be the most appropriate for the acute management of this patient?
a. Digoxin
b. Verapamil
c. Metoprolol
d. Lignocaine
e. Adenosine

why

Answer 88

tachycardia with NO P waves and normal QRS= SVT
tx for SVT is adenosine

Question 89

A 40 year-old female presents with a 12 month-history of painful vasospastic change in the hands that occurs during cold weather. She also has symptoms of oesophageal reflux. Examination reveals telangiectasiae on her hands and a persisting ulcer on the right index finger.
Which of the following medications would most likely improve this patient’s peripheral circulation?
a. Nifedipine
b. Propranolol
c. Digoxin
d. Prednisone
e. Clonidine

why

Answer 89

nifedipine= CCB causes vasodilation and is appropriate

Question 90

Which of the following is the treatment of choice for serious infections due to methicillin-resistant Staphyloccus aureus (MRSA)?
a. Cloxacillin
b. Cefazolin
c. Clindamycin
d. Chloramphenicol
e. Vancomycin

Answer 90

vancomycin