Past Gen Med

Question 1

1. A 20 year old patient presents with a history of being unwell with increasing breathlessness. Clinical examination reveals a clear chest to auscultation. Chest xray is shown. Blood gas results are shown. Blood gas results on AIR: pH 7.10 (ref 7.35 – 7.45) PaCO 16 mmHg (ref 35 – 45) PaO 120 mmHg (ref 80 – 110) Bicarbonate 4.8 mmol/L (ref 22 – 30).
   From the options provided, how would you describe the blood gas analysis?

Metabolic alkalosis with impaired gas exchange
Respiratory alkalosis with impaired gas exchange
Respiratory alkalosis with normal gas exchange
Normal acid base balance and gas exchange
Metabolic acidosis with normal gas exchange
Respiratory acidosis with impaired gas exchange
Metabolic alkalosis with normal gas exchange
Respiratory acidosis with normal gas exchange
Metabolic acidosis with impaired gas exchange

Answer 1

Metabolic acidosis with normal gas exchange

pH low is (acidosis) and cannot be explained by a high carbon dioxide, therefore this is metabolic acidosis.

A = 150-16/0.8 = 130
130-120 = 10mmHg
Normal Aa gradient

Question 2

2. A 70 year old man has had increasing breathlessness on exertion and at night, coming on over a few months. He worked in a woodmill. His only previous history is diabetes mellitus from which he takes tablets and tries to keep to his diet. He gave up smoking when the diabetes was diagnosed 12 years ago. He started as a teenager and smoked 20 a day. JVP raised and no ankle oedema. The chest xray is show
   Further investigations are undertaken and results shown. Left pleural aspirate protein 10g/L, Serum protein
   70g/L (ref 60-80).
   From the options provided, what is the most likely cause of this person’s pleural effusion?
   Tuberculosis
   Cardiac failure.

Parapneumonic effusion.
Empyema (non-TB).
Primary pleural malignancy.
Nephrotic syndrome.
Vasculitis.
Lung Malignancy.
Pulmonary infarct

Answer 2

Cardiac failure.

Serum protein 10, ratio 1:7 therefore transudate –> CHF or Nephrotic

Question 3

3. A 60 year old man pr-esents with haemoptysis and green sputum that
   has been increasing. He considers himself to have been quite well until
   the last few months since he had a chest infection. He saw his GP
   examined him and prescribed treatment. He originally felt a bit better for
   a course of antibiotics so did not complete these and did not attend a
   chest x-ray that his GP had requested. He thinks that he drinks and
   smokes more than he should do. He now feels sweaty and has been
   coughing up copious green sputum with specks of blood. His chest x-is
   shown. His Mantoux test is 0mm. From the options provided, what is the
   most likely cause of his haemoptysis?
   Bronchitis
   Bronchiectasis
   Pulmonary TB
   Lung abscess
   Pulmonary haemosiderosis
   Pneumonia
   Pulmonary AV malformation
   Pulmonary infarct
   Bronchial carcinoma

Answer 3

Lung abscess

Question 4

A 63 year old man presents with a 3-4 month history of increasing breathlessness on exertion. He also complains of general fatigue and tiredness. His only medical history is of previous peptic ulcer disease and he has never smoked. There are no abnormal findings on respiratory or cardiac examination apart from a sinus tachycardia of 90/min. His chest x-ray is shown. Spirometry is shown

FEV1 = 3.1L 89% predicted
FVC = 4.1 (84% predicted)

TLC = 5 (95%)
RV = 1.25 (85%)

Gas transfer
DLco (30%)
KCO (33%)

From the options provided, what is the most likely diagnosis?
Anaemia
COPD
Hyperventilation syndrome
Left ventricular failure
Occupational asthma
Pneumothorax
Pulmonary fibrosis
Pulmonary hypertension
Venous thrombo-embolism

Answer 4

Anaemia

Question 5

A 60 year old man present with recurrent haemoptysis associated with green sputum production. This bleeding has occurred every time his cough gets worse in the winter for the past 5 years. He has had a cough, productive of white and yellow sputum, since he started smoking as a teenager. He suffered with his chest all his life and missed a lot of school because of an episode of severe pneumonia. From the options provided, what is the most likely cause of his haemoptysis?
Pulmonary infarct

Pulmonary TB
Pulmonary haemosiderosis
Lung abscess
Bronchitis
Bronchial carcinoma
Pneumonia
Pulmonary AV malformation
Bronchiectasis

Answer 5

Bronchiectasis

Question 6

A 50 year old man has developed chest pain for the first time today. This came on whilst he was running for the bus. He is previously well and takes tablets for blood pressure, which is well controlled. He is sweating. On examination, pulse 100 bpm, BP 100/60. Oxygen saturation 97% breathing air. Heart sounds normal. Chest clear to auscultation. His ECG is shown.

Shows ST elevation in II,V2,3,4,5,6, reciprocal depression in III, AvF

Answer 6

Anterior MI

Question 7

A patient presents with increasing fatigue. Biochemical testing is consistent with chronic renal failure with hyperkalaemia (6.5mmol/L). From the options provided, which abnormality would you expect to see on the ECG?
Frequent atrial ectopics
R-on-T ectopics
Ventricular fibrillation
Complete heart block
Tall peaked T waves
Prominent U waves
Shortened PR interval
Inverted T waves Asystole

Answer 7

Tall peaked T waves

Question 8

A 75 year old man who has a history of prior myocardial infarction presents to the emergency department after collapsing whilst gardening. There was no prodrome and he felt fine on arrival in E.D. 10 minutes after his arrival he feels dizzy again He is alert , his BP is 80/50mmHg. His heart rate is 170/min. A 12 lead ECG is performed.

Shows VT

Answer 8

Urgent DC cardioversion with anaesthetic support

Question 9

A 58 year-old man has had an acute inferior myocardial infarction. His initial treatment included aspirin, pain relief and thrombolysis. 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.
Digoxin
Atropine
Adrenaline
Frusemide
Verapamil (calcium channel blocker)
Atenolol (beta blocker)
Saline infusion
Amiodarone
Quinapril (ACE inhibitor)

Answer 9

Atropine

Question 10

A 21-year-old female with Turner’s syndrome is reviewed prior to dental surgery. On examination her blood pressure is 118/80 mmHg and she has a soft systolic murmur at the second right intercostals space. From the options provided, what is the most likely underlying cause for the murmur?
Ventricular septal defect
Mitral regurgitation
Aortic stenosis
Aortic regurgitation
Patent ductus arteriosus
Mitral valve prolapse
Coarctation of the aorta
Mitral stenosis
Atrial septal defect

Answer 10

Coarctation of the aorta

Question 11

A 21yo woman of Asian ethnicity is started on carbamazepine for partial seizures. She presents to her GP 6 days later feeling generally unwell with a widespread rash and fevers. Her GP diagnoses a drug reaction and reassures her that the problem will resolve within a week and prescribes some hydrocortisone cream. The woman attends the emergency department 3 days later as she had developed jaundice and was feeling very weak. Her BP in the ED was 68/48. The rash is now almost conuent, and looks like measles. It does not aect her eyes or mouth. What is the most likely diagnosis?
Type 4 hypersensitivity reaction (simple maculopapular rash).
Hand foot and mouth syndrome.
Urticaria.
DRESS syndrome (Drug Rash/reaction with Eosinophilia and Systemic Symptoms).
Measles.
Viral exanthem.
Stevens- Johnson syndrome.
Toxic epidermal necrolysis

Answer 11

DRESS syndrome (Drug Rash/reaction with Eosinophilia and Systemic

Question 12

A 50 year old man is found to have asymptomatic hypertension.This has partially responded to treatment with a maximum dose of an ACE inhibitor (cilazapril) but the addition of a second drug is required to achieve better control. He has a history of gout. From the options provided, which is the most appropriate drug to add?
Metoprolol
Methyldopa
Doxazosin
Enalapril
Bendrouazide
Candesartan
Atenolol
Amlodipine
Clonidine

Answer 12

Amlodipine (CCB)

Question 13

A 70 year old lady attends her GP with a feeling of fatigue. She has put on weight. Her clothes do not fit as well. She takes metformin and gliclazide for her diabetes and a beta blocker and calcium antagonist for her hypertension. Examination confirms the ankle oedema. JVP is not raised. Clinically there are no murmurs or evidence of pulmonary oedema. BP 110/80. Kidneys are not palpable and there are no bruits. Blood results are given. From the options provided, what is the most likely cause of the renal dysfunction?

Platelet 150 (150-400)
Sodium 140 (135-145)
K+ 3.5 (3.2-4.5)
Urea 6.3 (2.5-6.7)
Creatinine 80 (60-120)
Glucose 15 (3.5-9.0)
Albumin 23 (35-50)

Renal hypoperfusion causing renal failure
Drug therapy causing renal failure
Diabetic nephropathy causing renal failure
Renal tubular acidosis
Hypertensive nephropathy causing nephrotic syndrome
Hypoadrenalism
Drug therapy causing nephrotic syndrome
Hypertensive nephropathy causing renal failure
Diabetic nephropathy causing nephrotic syndrome

Answer 13

Diabetic nephropathy causing nephrotic syndrome

Question 14

14. Regarding human sleep, which of the following is NOT correct?
    Total sleep time is highest in infants, decreases through childhood then remains constant through adulthood.
    With normal aging (child to older adult) there is an increase in slow wave sleep, decreased spontaneous awakening and reduced arousals.
    The recommended normal sleep requirement varies by age but for adults is 7-9 hours per night. Circadian timing is normally governed by the release of melatonin which is increased during the night and suppressed with exposure to bright light.
    Core temperature, blood pressure and total energy expenditure declines during sleep.

With normal aging (child to older adult) there is a reduction in slow wave sleep, increased spontaneous waking and arousals.
Recovery sleep following sleep restriction has increased % of slow wave sleep and REM.
Sleep restriction (decreased total sleep) increases energy expenditure, appetite and calorie consumptions.

Answer 14

With normal aging (child to older adult) there is an increase in slow wave sleep (deep sleep), decreased spontaneous awakening and reduced arousals.

e.g. in fact, as we get old, we sleep less deep and wake up a lot more

Question 15

A 64 year old man presents because of his wife’s concern that he is having repeated episodes of sleep apnoea / stopping breathing. He has treated hypertension and 4 years ago suffered from a myocardial infarction. He sleeps 7-8 hours per night and wakes unrefreshed. His Epworth Sleepiness Score is 10/24. His weight has decreased by 5 kg over the last 5 years to a BMI of 23 kg/m2. He drinks 2 standard alcohol drinks / day. Examination neck circumference of 37 cm, no tonsil hypertrophy, Mallampati score of 1 and no retrognathia. He is referred for a sleep study (Figure 1.) His Apnoea Hypopnoea Index is 45 / hour
Regarding the diagnosis and initial management, which of the following is most correct?
He has mild central sleep apnea occurring on transition between sleep and wake. Stopping alcohol should resolve this.
He has severe OSA – the Mallampati score of 1 and absence of retrognathia will mean there is little chance of treatment success using a Mandibular Advancement Splint.
He has mild OSA so initial management should focus on provoking factors – weight loss, stop drinking alcohol, avoiding sleeping on back.
He has severe OSA – the Mallampati score or 1 increases the chance of surgical success with Uvulo palato-pharyngoplasty (UPPP).
He has severe central sleep apnoea which commonly occurs as part of Cheyne Stokes Respiration – he needs clinical evaluation for heart failure as this is the most common cause.
He has severe idiopathic central sleep apnoea. Nasal CPAP should be trialled.
He has severe OSA – the Mallampati score or 1 and retrognathia increase the likelihood of conservative treatment (particularly weight loss) being successful

Answer 15

He has severe central sleep apnoea which commonly occurs as part of Cheyne Stokes Respiration – he needs clinical evaluation for heart failure as this is the most common cause.

Question 16

16. A 72 year old European woman presents to ED. She has had 6 episodes of syncope in the past week. One episode occurred while lying in bed. She has no warning before the events occur. There have been no witnesses but she has not been incontinent and has not bitten her tongue. She feels ne afterwards. She takes aspirin and 95mg of metoprolol CR for hypertension. On examination her BP is 156/88, her pulse is 46/min and her heart sounds are normal with no murmurs.
    From the following options what is the next best management step?
    Discharge on an additional anti-hypertensive agent.
    Start her on an anticonvulsant.
    Arrange an echocardiogram.
    Request an EEG (Electroencephalogram).
    Discharge with advice to increase fluid intake.
    Discharge and advise to stop metoprolol.
    Admit to hospital for cardiac monitoring.
    Discharge and arrange for a holter monitor.
    Arrange a CT head scan

Answer 16

Admit to hospital for cardiac monitoring.

Question 17

A 68 year old 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 given select the most appropriate next step in management?

Commence IV heparin
Arrange an electrocardiograph
Lower her blood pressure
Give a stat dose of low dose aspirin

Arrange a CT brain scan
Arrange an echocardiogram
Commence digoxin
Arrange a carotid ultrasound
Commence thrombolysis

Answer 17

Arrange a CT brain scan

Question 18

18. Alan is a 75 year old man who had a squamous cell carcinoma of his right upper lobe (T2, No, Mo) resected 2 years ago. He presents with a 4 week history of increasing mid–lumbar back pain and bi lateral leg weakness. A CT scan of his spine shows bone metastases (in at least 4 vertebrae) and spinal cord compression (L1-L2).
    What is the best initial management?
    Surgical debulking of metastases and stabilisation of the spine.
    Chemotherapy – as his lung cancer cell type is typically highly responsive.
    Commence iv dexamethasone and radiation treatment.
    Intravenous cephalosporin to prevent infection.
    A trial of Ibubrofen.
    Manipulative therapy to improve spine alignment (by Physiotherapist or Osteopath). Wait for the results of tumour markers and MRI scan (3-4 days).
    None of the above.

Answer 18

Commence iv dexamethasone and radiation treatment.

Question 19

This 60 year old man presents
with a 4 month history of lethargy
and cough. He has no bone pain.
His finger is shown. (shows clubbing)
Blood results are shown.
Corrected calcium 2.8 mmol/L (ref
2.1-2.5)
Phosphate normal

Alkaline phosphatase elevated
Sodium normal
Potassium normal

From the options provided, what is the most likely reason of his electrolyte abnormality?
Small cell carcinoma of the lung with bone metastases
Sarcoidosis
Tuberculosis
Small cell carcinoma of the lung with ADH production
Small cell carcinoma with oestrogen production
Small cell carcinoma of the lung with ACTH production
Squamous cell carcinoma of the lung with PTH related peptide production
Small cell carcinoma of the lung with PTH production
Squamous cell carcinoma of the lung with bone metastases - is this not the right answer because phosphate is normal?

Answer 19

Squamous cell carcinoma of the lung with bone metastases OR IS IT PTHrP???

Question 20

20. Radiation treatment that is delivered via a linear accelerator for the treatment of malignancy is generally in the form of:
    Ultraviolet light.
    Electrons.
    Protons.
    Neutrons.
    Gamma rays.
    Xrays/Photons.
    Heat.
    Ultrasound. None of the above

Answer 20

Xrays/Photons.

Question 21

Mr B is a 55 yr man with known chronic kidney disease due to diabetes. His creatinine is stable at 212 µmol/l (60-110 µmol/l), eGFR 31 ml/min/1.73m2. He has a haemoglobin of 97 g/L (115-155 g/L) and a ferritin of 20 µg/l (20-200 µg/l). Which of the following is MOST correct?

Erythropoietin is not required because the haemoglobin is too high
This is likely anaemia of chronic disease and doesn’t require treatment
He should have a blood transfusion to protect his kidney function
An iron infusion should be given before starting Erythropoietin
Erythropoietin is not required because he only has stage 3 CKD

Answer 21

An iron infusion should be given before starting Erythropoietin

Question 22

Question 3
A 67yo woman presents acutely hypoxic with an SpO2 of 75%, due to an exacerbation of her longstanding COPD. She has previously required an ICU stay with intubation for Type 2 respiratory failure. How would you prescribe her supplemental oxygen therapy?

Chart target saturations 92-96%, and prescribe 6-15L/min via a Hudson mask
Chart target saturations 88-91%, and prescribe 15L/min oxygen through a non-rebreather mask for 30 minutes, then reassess Went with prescribing 15L over 1-2L because she previously needed an ICU admission with intubation
Chart target saturations 88-91%, and prescribe 15L/min via a non-rebreather until in target range, then change to nasal prongs 0.5-2L/min. Reassess at 30 minutes Didn’t read this had reassess at 30 minutes as well whoops, probably the better choice since they could get to appropriate sats in like 10 minutes
Chart target saturations 92-96%, and prescribe 6-10L/min via nasal prongs, then reassess at 30 minutes
Chart target saturations 88-91%, and prescribe 1-2L/min oxygen through nasal prongs for 30 minutes then reassess

Answer 22

?

Question 23

6. A 23-year-old woman presents with a history of moderately severe shortness of breath which came on that morning at work.

She has a background of asthma and takes regular inhaled corticosteroids. Her only other medication is the oral contraceptive pill. She recently started work as a telephonist in a call centre. There are no other symptoms.

Her respiratory rate is 26/min and her oxygen saturation breathing room air is 92%. Her chest is clear to auscultation.

From the options provided, what is the most likely diagnosis?

Anaemia

COPD

Hyperventilation syndrome

Pulmonary fibrosis

Pneumothorax
Pulmonary hypertension

Left ventricular failure

Occupational asthma

Pulmonary embolism

Answer 23

?

Question 24

A 54 year old man presents because of concern about his driving. He has noticed his eyes briefly closing (micro-sleep) driving home from work in the evening. He is getting 7-8 hours sleep per night and wakes unrefreshed. His Epworth Sleepiness Score is 15/24. His weight has increased by 5 kg over the last 5 years to a BMI of 35 kg/m2. He drinks 4 standard alcohol drinks / day. His wife no longer shares the same room to sleep because of concern about loud snoring and breathing pauses. Examination: neck circumference of 45 cm, no tonsil hypertrophy, Mallampati score is 4 and he has retrognathia.

He is referred for a sleep study (Figure 1.)

His Apnoea Hypopnoea Index is 45 / hour

OSA - shows breathing muscle movement while nasal flow has stopped. CSA would show muscle movements stopping as the cause of the apnoea.

Regarding the diagnosis and initial management which of the following is most correct?

He has severe OSA – the Mallampati score of 4 and presence of retrognathia will mean there is little chance of treatment success using a Mandibular Advancement Splint.
He has mild OSA so initial management should focus on provoking factors – weight loss, stop drinking alcohol, avoiding sleeping on back.
He has mild central sleep apnea occurring on transition between sleep and wake. Stopping alcohol should resolve this.
He has severe OSA – the Mallampati score or 4 and retrognathia increase the likelihood of conservative treatment (particularly weight loss) being successful.
He has severe OSA – the Mallampati score of 4 decreases the likelihood of surgical success with a UPPP. Nasal CPAP should be traialed but now realise it might be UPPP bc it says nasal CPAP and he is snoring
He has severe idiopathic central sleep apnoea. Nasal CPAP should be trialled.
He has severe OSA – the Mallampati score or 4 increases the chance of surgical success with Uvulopalatopharyngoplasty (UPPP). Wouldn’t a mallampati of 4 mean there is oropharyngeal airway obstruction and UPPP would open the airway?Agreed, just didn’t read the answer fully above
He has severe central sleep apnoea which commonly occurs as part of Cheyne Stokes Respiration – he needs clinical evaluation for heart failure which is the most common cause.

Answer 24

?

Question 25

A 25-year-old male attends for eye surgery for anterior dislocation of the lens.

On examination. he is tall, has a blood pressure of 134/84 mmHg and has a mid-systolic click with murmur at the apex. From the options provided. what is the most likely underlying cause for the murmur?

Patent ductus arteriosus

Atrial septal defect

Ventricular septal defect

Aortic stenosis

Mitral valve prolapse

Aortic regurgitation

Coarctation of the aorta

Mitral stenosis

Answer 25

Bro has marfans (mitral valve prolaspe)

Question 26

A 78yo woman with AF is taking rivaroxaban for stroke prevention. She presents to ED with a severe headache and a CT scan shows:

Which statement is true?

The ICH was caused by hypertension. Rivaroxaban increased the bleeding time
The ICH was caused by hypertension. Rivaroxaban increased the bleeding time. The reversal agent should be used
The ICH was caused by hypertension and the dose of rivaroxaban being too high
The ICH was caused by an aneurysm.
The intracerebral haemorrhage (ICH) was caused by the rivaroxaban dose being too high. The reversal agent should be used.

Answer 26

The ICH was caused by hypertension. Rivaroxaban increased the bleeding time

Question 27

A 53yo man presents with malaena for 4 days. His past medical history includes a pulmonary embolism 3 months ago, for which he is taking dabigatran 150mg twice daily. He had a recent diarrhoeal illness, and appears hypovoleamic. Which option below is likely to represent his clinical condition?

A: eGFR up, INR down, thrombin up, Hb down
B: eGFR down, INR down, thrombin up, Hb up
C: eGFR up, INR up, thrombin down, Hb down
D: eGFR down, INR up, thrombin down, Hb down
E: eGFR down, INR up, thrombin up, Hb down

Answer 27

eGFR down, INR up, thrombin down, Hb down

Question 28

In weighing up peritoneal dialysis vs haemodialysis as a treatment option for end stage renal failure, which of these statements is LEAST correct?

Bacteraemia is more common if patients are dialysing through a vascath than a fistula
Peritonitis can mean patients have to change to haemodialysis
Both haemodialysis and peritoneal dialysis can be managed at home
Patients are likely to have a more restricted diet on haemodialysis than peritoneal dialysis
Creatinine and urea are usually lower in haemodialysis patients than in peritoneal dialysis patients

Answer 28

Creatinine and urea are usually lower in haemodialysis patients than in peritoneal dialysis patients

I think its about equal, HD would reach a peak just before treatment

Question 29

A 17yo man with asthma is admitted with shortness of breath, wheeze and cough. He is emergently given inhaled salbutamol through a spacer, oral prednisone 40mg, and admitted to HDB for close observation. Which statement below is true?

The most common cause of asthma exacerbations is bacterial LRTI
Beta blockers would be safe to give him for migraine prevention
Prednisone should always be given in the evening, as it can cause drowsiness
High dose inhaled salbutamol can cause hyperkalaemia
High dose inhaled salbutamol acts as a Beta1 & Beta2 agonist causing tachycardia

Answer 29

High dose inhaled salbutamol acts as a Beta1 & Beta2 agonist causing tachycardia

Question 30

A 78-year-old male is admitted for inguinal hernia repair. He has noticed some mild breathlessness.

On examination, his blood pressure is 110/90 mmHg and auscultation reveals a harsh systolic murmur at the second right intercostal space radiating to the neck

From the options provided, what is the best course of action to take?

This is most likely an innocent murmur and the patient can continue on and have his inguinal hernia repair with no need for cardiology assessment
This murmur suggests aortic stenosis and an ECHO is required prior to the operation occurring
This murmur suggest mitral regurgitation and an ECHO is required prior to the operation occurring
This murmur suggests mitral regurgitation and an exercise test is required prior to any consideration of surgery
This murmur suggests aortic stenosis but further assessment can wait until after he has had his surgery
This is most likely an innocent murmur, but he should have an ECHO done before his operation, even though it will delay it
This is most likely an innocent murmur, the patient can have his surgery, and he should be referred for cardiology assessment after his operation
This murmur suggests mitral regurgitation but further assessment can wait until after he has had his surgery
This murmur suggests aortic stenosis and an exercise test is required prior to any consideration of surgery

Answer 30

This murmur suggests aortic stenosis and an ECHO is required prior to the operation occurring

Question 31

Which of the following is most consistent with IgA nephropathy?

Oedema, hypercholesterolaemia and hypoalbuminaemia
Hypercholesterolaemia, hypertension and chronic renal impairment
Chronic renal impairment, oedema and proteinuria
Acute renal impairment, hypertension and oedema
Acute renal impairment, hypertension and haematuria
Chronic renal impairment, proteinuria and haematuria

Answer 31

Chronic renal impairment, proteinuria and haematuria