MasterDeck - all questions Flashcards by Maia Cunningham

An 8 year old European boy presents with painful swelling of the hands and feet.
On examination he is jaundiced and pale. He has splenomegaly.
Blood film confirms target cells.
From the options provided, what is the most likely diagnosis?
▪ Anaemia of chronic disease
▪ Autoimmune haemolytic anaemia
▪ Coeliac disease
▪ Glucose-6-phosphate dehydrogenase deficency
▪ Hypothyroidism
▪ Iron deficiency
▪ Pernicious anaemia
▪ Sickle-cell anaemia
▪ Sideroblastic anaemia
▪ Thalassaemia
▪ Vitamin B12 deficiency

Sickle Cell

Target cells=hyposplenism. Pain+swelling bc sickle RBCs block capillary

How well did you know this?

Not at all

Perfectly

An 18 year old European female complains of colicky abdominal pain and vomiting and fever. She is normally well. Recently she started on oral contraceptives
On examination she has a generalised tender abdomen. Bowel sounds are present but reduced. She has weakness in her arms and legs peripherally.
Urine is positive for red blood cells and protein. Urine microscopy is negative. Pregnancy test is negative.
From the options provided, what is the most likely diagnosis?
▪ Acute cholecystitis
▪ Acute cystitis
▪ Acute intermittent porphyria
▪ Acute pyelonephritis
▪ Bladder carcinoma
▪ Carcinoma of the kidney
▪ Ectopic pregnancy
▪ Mesenteric infarction
▪ Pancreatitis
▪ Renal vein thrombosis
▪ Ureteric calculus

Acute intermittent porphyria

How well did you know this?

Not at all

Perfectly

A 60 year old Maori man with diabetes has some frequency of urine. There is no dysuria or abdominal pain. He has had diabetes for 20 years and control has been suboptimal. He is otherwise well.
On digital rectal examination, his prostate is not enlarged. Neurological examination of his legs reveals peripheral neuropathy, with no signs of spinal cord disease.
Urine analysis reveals proteinuria but no infection. Electrolytes are normal.
From the options provided, what is the most appropriate investigation?
▪ Cystourethroscopy
▪ Dynamic scintigraphy
▪ Excretion urography
▪ Nerve conduction studies
▪ Plain KUB film
▪ Pressure-flow studies
▪ Retrograde ureterography
▪ Serum urea and electrolytes
▪ Ultrasonography
▪ Urethrography

Pressure-flow studies

How well did you know this?

Not at all

Perfectly

The parents of a previously well 15 year-old Asian girl are woken at 2 am one morning by her making “strange noises”. She had been up late that evening studying for a coming exam.
They find her in bed. She is confused and has a laceration to the side of her tongue. She has been incontinent of urine. After some reassurance she settles quickly to sleep and is back to her normal self the next morning.
Which one of the following investigations is likely to be the most useful?
▪ CT Scan of the head
▪ Electrocardiogram (ECG)
▪ Electroencephalogram (EEG)
▪ Glucose tolerance test
▪ Lumbar puncture
▪ Magnetic resonance imaging (MRI) of the head
▪ Mid stream urine sample (MSU)
▪ Psychological assessment
▪ Urine toxicology

EEG

How well did you know this?

Not at all

Perfectly

A 10 year old NZ European boy develops rapid onset of peripheral oedema with weight gain of 6 kg over a two week period. He has no associated symptoms or signs.
On examination he is normotensive and has significant oedema. Investigations reveal normal renal function, and urinalysis reveals moderate hyaline casts, proteinuria +++ and no red cells. . From the options provided, indicate the most likely diagnosis.
▪ Amyloidosis
▪ Diabetic nephropathy.
▪ Focal and segmental glomerulosclerosis
▪ Goodpasture’s syndrome
▪ Henoch Schonlein purpura
▪ IgA nephropathy
▪ Membranous glomerulonephritis
▪ Minimal change nephrotic syndrome
▪ Post infectious glomerulonephritis
▪ Systemic lupus erythematosus

Minimal change disease

How well did you know this?

Not at all

Perfectly

A 39 year old NZ European man has been admitted to the ward with a fractured femur sustained whilst he was driving a car. He has been the driver in several other crashes.
Of the provided tests, select the best screening test to identify alcohol dependence.
▪ AUDIT questionnaire
▪ Blood screen for macrocytosis
▪ Hepatomegaly
▪ Liver Function Tests
▪ Mean Corpuscular Volume
▪ Mini-mental state examination
▪ Serum Folate estimation
▪ Vitamin B12 estimation

AUDIT

Alcohol use disorder identification test

How well did you know this?

Not at all

Perfectly

A 66 year old Australian man presents with severe central chest pain radiating through to his back. He is a smoker and has been treated for many years for hypertension although he was often lost to follow up.
On examination: he is distressed. His skin is pale, cold and sweaty. Pulse 92 per minute regular, BP 154/96. JVP is normal. Examination of the chest and heart sounds is normal. Abdominal examination is normal. ECG is normal. Chest x-ray shows widening of the mediastinum. Cardiac enzymes are normal.
Of the options provided, select the most appropriate diagnosis.
▪ Acute myocardial infarction
▪ Aortic dissection
▪ Cardiac tamponade
▪ Malignant hypertension
▪ Myocarditis
▪ Pancreatitis
▪ Pericarditis
▪ Pulmonary embolism
▪ Unstable angina
▪ Vertebral collapse fracture

Aortic dissection

Descending aorta dissections can have high bp

How well did you know this?

Not at all

Perfectly

A 57 year old Maori woman has a 6-month history of difficulties with her voice, which has become increasingly hoarse. She has a 40-year history of smoking and takes the occasional glass of wine. She describes occasional choking when drinking fluids, and more recently has had increasing shortness of breath and a niggly cough.
Examination reveals a breathy voice and reduced breath sounds at the left lung base.
From the options given select the most likely cause of her voice problems.
▪ Acute laryngitis
▪ Croup / Laryngotracheobronchitis
▪ Epiglottitis / Supraglottitis
▪ Recurrent respiratory papillomatosis
▪ Reflux laryngotracheitis
▪ Squamous cell carcinoma of larynx
▪ Vocal cord nodules
▪ Vocal cord palsy

Vocal cord palsy

Impingement of recurrent laryngeal nerve by cancer

How well did you know this?

Not at all

Perfectly

A 4 year old NZ European girl has a 24-hour history of an increasingly painful throat. She is refusing to drink and eat and seems to have trouble swallowing her saliva.
Examination findings include inspiratory stridor, drooling of saliva, use of accessory muscles of respiration and pyrexia 37.8 degrees C and a muffled voice.
From the options given select the most likely diagnosis.
* Acute laryngitis
* Croup / Laryngotracheobronchitis
* Epiglottitis / Supraglottitis
* Recurrent respiratory papillomatosis
* Reflux laryngotracheitis
* Squamous cell carcinoma of larynx
* Vocal cord nodules
* Vocal cord palsy

Inflammation of epiglottis

By Haemophilus Influenzae type B

How well did you know this?

Not at all

Perfectly

A 20 year old NZ European woman has had unusual irregular vaginal bleeding for the last few weeks. She has no other symptoms and has no relevant past medical history.
She is just about to go overseas and would like to have contraception which gives her good control of her periods.
From the options given select the most appropriate next step in management.
▪ Cervical punch biopsy
▪ Cervical smear
▪ Colposcopy
▪ Combined oral contraceptive
▪ Curettage (D & C)
▪ Depoprovera injection
▪ Full blood count
▪ Intrauterine contraceptive device
▪ Pelvic ultrasound
▪ Pregnancy test
▪ Progestogen only contraceptive pill
▪ Vaginal/cervical swabs

Pregnancy test

How well did you know this?

Not at all

Perfectly

An 18 year old European woman has had abdominal pain for the last four hours. Initially the pain was an aching, crampy pain in the region of her umbilicus. It then moved into the right lower quadrant and became sharp and constant in nature. She has vomited twice. Half an hour ago the pain got much worse and this was followed closely by collapse and shock.
Abdominal examination reveals signs of generalised peritonitis. White cell count is raised. An erect chest x-ray is performed.
Which one of the following options is the CXR predominantly performed to detect?
▪ Aortic aneurysm
▪ Distension of the large bowel
▪ Ectopic pregnancy
▪ Fluid levels in the small bowel
▪ Free air under the diaphragm
▪ Pneumonia
▪ Pulmonary embolus
▪ Tension pneumothorax

Free air under diaphragm

How well did you know this?

Not at all

Perfectly

A 64 year old NZ European man has had several episodes of severe left iliac fossa pain accompanied by fever and constipation. These have usually settled with antibiotics. He presents with a similar episode but this time the constipation is absolute and he is unable to pass flatus.
His abdomen is distended with increased bowel sounds.
Erect abdominal xray shows fluid levels and distension of the caecum and ascending colon.
After initial resuscitation he progresses to laparotomy at which a resection of the sigmoid colon is performed. The pathologist report is shown below.
From the options, select the most likely diagnosis.
▪ Cancer of the colon
▪ Carcinoid tumour
▪ Crohn’s disease
▪ Diverticulitis
▪ Ischaemic colitis
▪ Purgative abuse
▪ Pseudomembranous colitis
▪ Sigmoid volvulus
▪ Ulcerative colitis

Diverticulitis

Outpouches of bowel with acute inflammation, settles with antibiotic

How well did you know this?

Not at all

Perfectly

A 45 year old European woman develops loss of vision in the left eye, with slight pain on eye movement and slight tenderness. Colour vision seems particularly affected with desaturation.
Examination reveals a left afferent pupillary defect.
Of the options, select the most likely diagnosis.
▪ Acute closed-angle glaucoma
▪ Anterior ischaemic optic neuropathy
▪ Central retinal vein occlusion
▪ Diabetic maculopathy
▪ Iritis
▪ Occipital cortex infarct
▪ Open-angle glaucoma
▪ Optic neuritis
▪ Retinal detachment
▪ Senile macular degeneration

Optic neuritis

Colour desaturation points to this

How well did you know this?

Not at all

Perfectly

A 55 year old Maori man is admitted to the Cardiology ward for percutaneous insertion of a pacemaker. He has a long-standing history of atrio-ventricular block that has caused excessive fatigue, breathlessness and occasional episodes of syncope. After the procedure he complains of breathlessness.
On examination: his pulse is regular, 90 beats per minute, respiratory rate 30 per minute, blood pressure 140/85 mmHg. He has diminished breath sounds on the left side.
From the options provided, select which test would give the most specific information in support of your clinical diagnosis?
▪ Carotid Doppler
▪ Chest X-ray
▪ Coronary angiography
▪ Electrocardiogram
▪ Pulmonary functions tests
▪ Transoesophageal echocardiogram
▪ Serum troponin levels
▪ Ventilation-perfusion (V/Q) scan

How well did you know this?

Not at all

Perfectly

A 32 year old European woman is in labour at 30 weeks gestation in her first pregnancy. She has been given tocolytic agents but it seems as if she will deliver the baby soon despite this.
From the options given select which drug, if given to the mother at this stage, is most likely to benefit the baby.
▪ Beractant
▪ Betamethasone
▪ Bromocriptine
▪ Diazepam
▪ Ergometrine
▪ Magnesium sulphate
▪ Morphine
▪ Oxytocin
▪ Progesterone
▪ Prostaglandin
▪ Propanolol

Betamethasone

Promotes surfactant production for baby

How well did you know this?

Not at all

Perfectly

A 58 year old NZ European man has had an acute inferior myocardial infarction. His initial treatment included oxygen, aspirin, pain relief and streptokinase. Two hours after admission his heart rate is 40 beats per minute in sinus rhythm. BP 88/50. He is pale and sweaty.
From the options provided, select the most appropriate medication.
▪ Adrenaline
▪ Amiodarone
▪ Atenolol (beta blocker)
▪ Atropine
▪ Bendrofluazide
▪ Digoxin
▪ Dobutamine
▪ Frusemide
▪ Quinapril (ACE inhibitor)
▪ Saline infusion
▪ Verapamil ( calcium channel blocker)

Atropine

Increases HR

How well did you know this?

Not at all

Perfectly

A mother phones to tell you that her three year old NZ European son swallowed an undetermined amount of paracetamol and spontaneously vomited several times shortly thereafter. The child still feels nauseous but is apparently much better. From the options, select the main risk for this child.
* Cardiac arrhythmia
* Chemical pneumonitis
* Diarrhoea
* Liver failure
* Oro-pharyngeal burns
* Seizures
* Skin rash

Liver failure

How well did you know this?

Not at all

Perfectly

A 54 year old NZ European woman has multiple liver masses.
A fine needle aspiration (FNA) of one of the masses is reported as follows: “FNA, liver mass: malignant epithelial cells are present consistent with metastatic squamous cell carcinoma”.
Of the options provided, which is the most likely source of the malignant cells?
▪ Breast carcinoma
▪ Bronchogenic carcinoma
▪ Colonic carcinoma
▪ Gastric carcinoma
▪ Ovarian carcinoma
▪ Pancreatic carcinoma
▪ Primary liver carcinoma
▪ Renal cell carcinoma

Bronchogenic carcinoma

Smoker cancer

A 26 year old European man presents with intermittent cramping abdominal pain and bloody diarrhoea for one month.
Colonoscopy shows friable red mucosa in the descending colon, sigmoid colon and rectum. The remainder of the colon is normal. Biopsies are taken.
The histology report reads: “Sections from the descending colon, sigmoid and rectum show glandular cryptitis with crypt abscess formation. The lamina propria contains increased plasma cells. There is focal gland branching and goblet cell depletion. Paneth cell metaplasia is noted. No granulomata or dysplasia are seen. Sections from the proximal colon and terminal ileum are normal.”
Of the options provided, select the most likely diagnosis.
▪ Amoebiasis
▪ Crohn’s disease
▪ Cryptosporidium
▪ Diverticular disease
▪ Ischaemic colitis
▪ Pseudomembranous colitis
▪ Salmonella
▪ Shigella
▪ Ulcerative colitis

A healthy 16 year old Indian high school student was observed to collapse when standing at school assembly. She was pale and unresponsive with small irregular jerking movements of the distal extremities for fifteen seconds. She roused quickly and within three minutes felt completely normal.
Of the options provided, select the most likely cause of her collapse.
▪ Addison’s disease (hypoadrenalism)
▪ Cardiac ventricular arrhythmia
▪ Cardiac atrial arrhythmia
▪ Carotid sinus syncope
▪ Complex partial seizure
▪ Generalised tonic clonic seizure
▪ Migraine
▪ Phaeochromocytoma
▪ Syncopal seizure
▪ Transient ischaemic attack (TIA)
▪ Vasovagal syncope

Vasovagal syncope

A 33 year old Samoan woman has had three days of vaginal bleeding and mild lower abdominal pain. Her last menstrual period was seven weeks ago, but her menstrual cycle has been irregular.
On examination: her temperature is 37.2 degrees C, pulse 96 per minute and BP 110/70. Pelvic examination reveals mild discomfort in the left adnexa.
A urinary hCG is positive. Ultrasound shows an empty uterus, and a left sided ovarian cyst. There is free fluid in the pelvis.
Of the options provided, select the most appropriate diagnosis.
▪ Appendicitis
▪ Constipation
▪ Dysmenorrhea
▪ Ectopic pregnancy
▪ Endometriosis
▪ Haemorrhagic ovarian cyst
▪ Mittelsmercz
▪ Salpingitis
▪ Threatened miscarriage
▪ Torsion of ovary

Ectopic

A 67 year old NZ European man presents with pain and stiffness in his shoulder and hip girdles for the last two weeks.
On examination he cannot get up from a chair. He has proximal weakness due to pain in all 4 limbs. There are no other abnormal neurological findings besides his weakness.
Of the options provided, which medication is most likely to ease his symptoms?
* Amitriptyline
* Aspirin
* Indomethacin
* Methadone
* Paracetamol
* Paroxetine
* Prednisone
* Propranolol

Prednisone

Polymyalgia Rheumaticia

A 68 year old NZ European woman presents to the Emergency Department with the sudden onset of left hemiparesis.
Her pulse is 128 per minute, irregularly irregular. She has a bruit over her right carotid artery. Her blood pressure is 196/110 mmHg in the right arm and 188/104 mmHg in the left arm. She is fully conscious but slightly confused.
From the options provided, select the most appropriate next step in management.
▪ Arrange a carotid ultrasound
▪ Arrange a CT brain scan
▪ Arrange an echocardiogram
▪ Commence digoxin
▪ Commence IV heparin
▪ Commence thrombolysis
▪ Commence aspirin
▪ Lower her blood pressure

CT brain scan

Suspicious of stroke

A 36 year old NZ European woman attends Surgical Outpatients with recurrent episodes of right upper quadrant pain and tenderness accompanied by intermittent jaundice.
The surgeon thinks she may have a stone in her common bile duct.
Which of the following investigations would be the most appropriate to perform next in testing this hypothesis?
▪ CT Scan of the abdomen
▪ Endoscopic retrograde cholangiopancreatography (ERCP)
▪ Intravenous cholangiogram
▪ Liver function tests
▪ Plain xray of the abdomen
▪ Ultrasound scan of the biliary system
▪ Urinary bilirubin
▪ 99mTC-HIDA scan

A recently married 36 year old NZ European woman was treated for a simple cystitis four weeks ago with a week of amoxycillin. Ten days ago she developed fever and lower abdominal pain. This was accompanied by watery diarrhoea with mucus and some blood. On examination of her abdomen she is tender in both lower quadrants. Sigmoidoscopy shows a hyperaemic rectal mucosa with plaque-like lesions. From the options provided, what is the most likely diagnosis? ▪ Acute Crohn's colitis ▪ Amoebic dysentry ▪ Campylobacter infection ▪ Pseudomembranous colitis ▪ Salmonella gastroenteritis ▪ Shigella infection ▪ Typhoid fever ▪ Ulcerative colitis

Pseudomembranous colitis

A 50 year old NZ European man is being investigated for painless haematuria. Urine cytology shows atypical cells. An ultrasound shows an irregular filling defect in the renal pelvis. Which of the following is most appropriate next step in management? * CT scan of the abdomen and chest * MRI scan of the kidney * Open renal biopsy * Percutaneous renal biopsy * Retrograde pyelogram and brush biopsy.

A 38 year old NZ European woman has a two month history of passing four or five bowel motions a day with some blood and mucous. The bowel motions are accompanied by tenesmus and urgency. She had a similar episode 12 months which was treated with an antispasmodic drug. She had a cholecystectomy 12 years ago. A maternal aunt died recently of cancer of the colon. She has general mild tenderness of the abdomen and rectal examination reveals blood on the examining finger. Which of the following is the most likely diagnosis. * Carcinoma of the left side of the colon * Carcinoma of the rectum * Diverticular disease * Ileo-caecal Crohn's disease * Irritable bowel syndrome * Rectal polyp * Ulcerative colitis

WAn 18 year old NZ European male mountain-biker fell during a downhill race. Assessment one hour later reveals a small right pneumothorax, a closed fracture of the right femur and a painful distending abdomen with fluid noted on ultrasound, suggesting blood. She is given 2 litres of Hartmann's immediately, her BP rising to 105/78, and is taken directly to the operating room where she is anaesthetised and intubated and the abdomen opened. About 1100 mls of blood and clot are evacuated and a liver laceration found which has stopped bleeding. At this point her HR is noted to be increasing, her BP drops to 70/56 and her oxygen saturation falls to 82% despite 100% inspired oxygen. From the options provided, select the most likely mechanism for shock. * Bleeding into the cranial cavity. * Bleeding into the pleural cavity. * Brainstem injury. * Hypovolaemic shock from occult pelvic or abdominal source. * Inadequate replacement for external haemorrhage. * Myocardial infarction. * Neurogenic shock. * Pericardial tamponade. * Rapid heart rate preventing adequate diastolic filling. * Secondary myocardial dysfunction from prolonged hypovolaemic shock. * Tension pneumothorax

Tension pneumothorax | Recent trauma that had pneumothorax

A 22 year old NZ European woman has just had a low forceps delivery for 2nd stage delay in her first pregnancy. The third stage appeared uncomplicated however she continues to bleed heavily. The bleeding continues despite administration of oxytocin. From the options provided, indicate the most likely cause for bleeding. ▪ Atonic uterus ▪ Cervical tear ▪ Disseminated intravascular Coagulation ▪ Retained products of conception ▪ Ruptured uterus ▪ Uterine inversion ▪ Vaginal laceration ▪ Vulval haematoma

Vaginal laceration | Low forceps delivery

A 2 year old Samoan girl, has been non-specifically unwell for 2 weeks. Five days ago she finished a course of amoxycillin for otitis media. She presents following a 10 minute generalised tonic-clonic seizure. 60 minutes later is still drowsy and irritable when roused. Her temperature is 37.8 oC. She has mild neck stiffness and early papilloedema bilaterally but no focal neurological signs. CXR is normal and a CT scan is arranged. Other investigations are detailed below. From the options provided, select the most appropriate diagnosis. ▪ Bacterial meningitis ▪ Cerebral abscess ▪ Cerebral leukaemia ▪ Cryptococcal meningitis ▪ Herpes encephalitis ▪ Infective endocarditis ▪ Partially treated bacterial meningitis ▪ Subdural empyema ▪ Tuberculous meningitis ▪ Viral meningitis

TB meningitis | Need acid-fast medium

A 48 year old woman who lives in a heavily industrial European city is visiting her family in New Zealand for the first time. Her family is concerned about her cough and persuade her to see a doctor. She has produced a quarter of a cup of green (and sometimes bloody) sputum daily for the last 6 years. She is a cigarette smoker. Examination shows halitosis, finger clubbing and bilateral inspiratory and expiratory crepitations. From the options provided, indicate the most likely diagnosis. * Asthma * Allergic bronchopulmonary Aspergillosis * Bird fancier lung disease * Bronchiectasis * Chronic bronchitis * Cystic fibrosis * Farmer's lung * Gastro-oesophageal reflux * Interstitial lung disease * Occupational asthma

Bronchiecstasis

A four month old Maori girl presents during the summer months with a 3-day history of low-grade fever, clear nasal discharge and cough. In the last 24 hours she has been breathing fast and feeding poorly. On examination she has a non-toxic appearance, her respiratory rate is 60/minute, her chest is hyperinflated with mild recession. Auscultation reveals generalised inspiratory crackles. From the options provided, indicate the most likely causative pathogen. * Adenovirus * Bordetella pertussis * Haemophilus influenzae Type B * Influenza * Legionella pneumophila * Measles * Mycoplasma pneumoniae * Parainfluenza 3 * Respiratory syncytial virus * Streptococcus pneumoniae * Streptococcus pyogenes * Unencapsulated haemophilus sp

RSV | Bronchiolitis

A two year old NZ European boy has had fever and a worsening limp for the last 3 days. There is no history of recent illness, trauma or skin lesions. He complains of right groin pain and has an antalgic gait On examination he lies quietly with his right leg flexed and externally rotated. He has point tenderness in the right inguinal region. Because of discomfort hip movement is limited but only by 10 degrees. His temperature is 38 degrees C and his pulse is 140 per minute. His blood Count is available below. From the options given indicate the most likely diagnosis. * Acute haematogenous osteomyelitis * Brodie's abscess * Chronic osteomyelitis * Discitis * Osteochondritis * Septic arthritis * Sickle cell * Transient synovitis of the hip * Tuberculous arthritis

Osteomyelitis

A 27 year old NZ European man saw his GP five days ago with cough and "flu-like" symptoms. He was diagnosed as having a viral respiratory tract infection and advised to take it easy for a few days and drink lots of fluids. Today his cough has got worse and he feels "really crook" . He is getting pain in the left side of his chest and occasionally in his left shoulder. He smokes 25 cigarettes per day. His temperature is 38.3 oC. On chest examination there is dull percussion note and bronchial breathing over the left lower lung field. From the options provided, indicate the most likely diagnosis. ▪ Atopic asthma ▪ Allergic bronchopulmonary aspergillosis ▪ Bird fancier lung disease ▪ Bronchiectasis ▪ Chronic bronchitis ▪ Cystic fibrosis ▪ Farmer's lung ▪ Gastro-oesophageal reflux ▪ Pulmonary fibrosis ▪ Lobar pneumonia ▪ Occupational asthma

Lobar pneumonia

Five years ago Bill and Jean's daughter died at a national surgical centre and they are concerned that she may have been buried without her heart. Apparently well when she was born she soon developed breathing and feeding difficulties. Transposition of the great arteries was recognised on day 3 of life. An arterial switch operation was done but she died a few days later. At no time was there any concern about the standard of care that was given to this baby. Enquiries about her body and heart were made recently via her GP and the local hospital but these records are incomplete and no report has been forthcoming. Jean's parents are seeking assistance from someone who has the authority to obtain the information they want. From the options provided, indicate the most appropriate to contact next. ▪ The Chairman of the Hospital Ethics Committee ▪ The Chairman of the Medical Council of New Zealand ▪ The Chairman of the New Zealand Medical Association ▪ The Coroner ▪ The Director General of Health ▪ The Health and Disability Commissioner ▪ The Hospital Constable ▪ The local Member of Parliament ▪ The Medical Protection Society ▪ The Minister of Health ▪ The Ombudsman ▪ The Registrar of Births, Deaths and Marriages

A 50 year old NZ European man's wife died of bowel cancer 12 months ago. They had been married for 27 years. He has found it difficult coming to terms with her death and often wakes at night and feels her presence. He gets an overwhelming feeling of sadness when he realises she is not. He asks if some sleeping tablets might help. Although he returned to work a month after her death he still feels that he is unable to make the same degree of effort there as he used to. He has been reluctant to resume contact with their mutual friends, but has seen some of them at times over the last 6 months. From the options given indicate the most likely diagnosis. ▪ Alcohol abuse ▪ Adjustment disorder with depressed mood ▪ Benzodiazepine dependency ▪ Bipolar disorder ▪ Delirium ▪ Generalised anxiety disorder ▪ Grief reaction ▪ Major depression ▪ Normal adjustment ▪ Obsessive compulsive disorder ▪ Schizophrenia ▪ Side effects of analgesia

? | Not depression.. either adjustment disorder or normal

A full term Asian male infant was delivered five days ago by forceps following a normal pregnancy. Yesterday he developed a bilateral eye discharge. The discharge began as a thin serosanguinous film, but is now thick and grossly purulent. During the last few hours pre-orbital swelling has appeared. Despite these findings he is vigorous and breast-feeding well. A gram stain report from his eye discharge is received and confirms the presence of infection. From the options provided, indicate the most likely diagnosis. * Blepharitis * Chlamydial conjunctivitis * Gonococcal conjunctivitis * Haemophilus conjunctivitis * Hordoleum * Lacrimal abscess * Orbital cellulitis * Peri-orbital cellulitis * Pneumococcal conjunctivitis * Staphylococcal conjunctivitis * Uveitis

Chlamydial conjunctivitis

A 26 year old Indian teacher is complaining of weakness, tiredness and fatigue. He is getting some right sided pain in his inguinal region, particularly he thinks, after he has a few drinks when he goes out on a Saturday night. His blood results are detailed below. From the options given select the most likely diagnosis. ▪ Chronic Fatigue Syndrome ▪ Congestive Heart Failure ▪ Dementia ▪ Depression ▪ Diabetes Mellitus ▪ Fibromyalgia ▪ Iron deficiency anaemia ▪ Lymphoma ▪ Pernicious anaemia ▪ Polymyalgia Rheumatica ▪ Obstructive sleep apnoea ▪ Somatisation disorder

Lymphoma

A 60 year old NZ European man with insulin-dependent diabetes, presents with burning pain in both lower limbs. It is particularly severe at night. On examination he has stocking anaesthesia and decreased vibration sense in both legs. His peripheral pulses are present. From the options given select the most appropriate drug therapy. ▪ Amitriptyline ▪ Aspirin ▪ Indomethacin ▪ Methadone ▪ Paroxetine ▪ Prednisone ▪ Propranolol TCAs, particularly Amitriptyline, are somewhat effective at treating diabetic peripheral neuropathy.

Amitriptyline | TCA

A 33 year old obese European woman is admitted with an attack of pyelonephritis. E. coli is identified in the urine. Gentamycin is chosen to treat her. Indicate which of the following pharmacokinetic factors should be used to calculate the initial dosage of drug. ▪ Actual body weight ▪ Amount of first-pass metabolism ▪ Degree of protein binding ▪ Drug clearance ▪ Half-life ▪ Ideal body weight ▪ The volume of distribution

Ideal body weight

Mrs FJ is a 24 year old Maori secondary school teacher. She is in early pregnancy at 7 weeks and experiencing right iliac fossa pain. Following assessment her doctor makes a clinical diagnosis of tubal pregnancy. Indicate the findings that give most support for the clinical diagnosis. * Empty uterus, beta HCG negative * Empty uterus, beta HCG is low for gestation * Endometrial thickness <4 mm, beta HCG negative * Gestation sac 6 weeks, beta HCG appropriate for dates * Retained products <3 cm, low beta HCG * Small sac in uterus, beta HCG consistent with dates * Twin gestation sacs in uterus high beta HCG * Uterus contains sac = 10/40 size, normal beta HCG for 7/40 * Uterus with snowstorm effect, hyper-echoic contents with high beta HCG

* Empty uterus, beta HCG is low for gestation | Ectopic

A 75 year old NZ European woman presented to A&E after a fall. Her Colles fracture was reduced and set without problems, however, results of screening blood tests to rule out pathological causes for the fall showed a serum sodium 120 mmol/L and the calculated osmolality was decreased. FBC and all other routine serum biochemistry were within normal range. Her only other past history is that she has been depressed and has been on Fluoxetine for the last 6 months with good effect. Examination showed normal BP and tissue turgor. What is the next and most appropriate step to investigate the following patient's serum sodium abnormality? * CT head scan * Fluoxetine drug concentration * Ultrasound scan of renal tract * Urine Na+ and osmolality * Urine Na+ and K+ * Serum ADH levels

Urine Na+ and osmolality | SIADH (compare urine and plasma osmolality)

A 38 year old Chinese man presents complaining of dizziness. He describes episodes of rotational vertigo which lasts about 20 seconds. These occur mainly when getting out of bed or when turning in bed. From the options provided, what is the most likely diagnosis? ▪ Bacterial labyrinthitis ▪ Benign paroxysmal positional vertigo ▪ Hyperventilation ▪ Meniere's disease ▪ Multiple sclerosis ▪ Ramsay Hunt syndrome ▪ Vertebrobasilar insufficiency ▪ Vestibular schwannoma (Acoustic Neuroma) ▪ Vestibulotoxicity ▪ Viral vestibular neuronitis (Acute Vestibular Failure)

BPPV

A 56 year old North American woman is getting increasing pain in her right hip so that she dreads weight-bearing. The pain is present at night and on movement, despite regular paracetamol and codeine. Three years ago she underwent a left mastectomy for breast cancer and she is still taking adjuvant tamoxifen. Xray of the right hip shows a large lytic lesion in the neck of her right femur with likely pathological fracture. From the options provided, indicate the treatment most likely to relieve pain and stabilise the right femur. * Bishosphonate * CMF (cyclophosphamide, methotrexate, fluorouracil) chemotherapy * Docetaxel chemotherapy * Internal fixation * Letrozole (aromatase inhibitor) therapy * Morphine regularly as MST * Prednisone * Radiation * Tamoxifen (anti oestrogen) therapy - increase dose