RMH Semester 8 2007


A 74-year man presents with headache. His wife has commented that he looks flushed over the last 6 months. He is an ex-smoker (70 pack years). On examination he has a hyperinflated chest with generalized poor air entry, a prolonged expiratory phase and scattered expiratory wheeze. Abdominal examination is normal. The Sa02 is 90% on room air. The hemoglobin is 185g/L (130-180), hematocrit 0.57 (0.39-0.54), WCC 14x10^9/L (4-11) and platelet count 350 x 10"9/L (150-400). The serum erythropoietin level is elevated. The most likely diagnosis is:


20 year old man presents to the emergency department after a motor vehicle accident. He is bleeding internally and needs an urgent blood transfusion. The blood pressure is 70mmHg systolic. His blood group is type A negative. Group A negative blood is in very short supply and will not be available for several hours. lt is most appropriate to give the patient which of the following?


A 75 year old woman develops fever (39.5°C) and rigors while receiving a blood transfusion 2 days after a right hemicolectomy for cancer of the colon. She has back pain and says that she feels that something terrible is going to happen. On examination she is sweaty and tachypnoeic. She has a 1/6 systolic cardiac murmur at the mid-sterna! border which does not radiate. Her abdomen is soft and non-tender with normal bowel sounds. The most likely diagnosis is:


A 50 year old woman presents to her general practitioner with two days of painful defaecation associated with bright rectal bleeding. She· has had alternating constipation and diarrhoea for several years. She also has rheumatoid arthritis treated with methotrexate and low dose prednisolone. Her maternal grandmother developed colorectal cancer at the age of 67. Which one of the following is the MOST likely diagnosis?


A 24 year old motor bike rider is involved in an accident While riding his bike. He is bought by ambulance to the Emergency Department where you make a diagnosis ofa fracture through the midshaft of his left tibia based on the clinical findings. Which one of the following will have the most impact on this patient's management?


A 32 year old woman presents with fatigue and is found to have white irregular patches of skin on her hands and face and dark pigmentation over her appendicectomy scar. On examination her BP is 120/80 lying and 102/56 standing. Electrolytes testing shows: Na 131 mmol/L (normal 135 - 145) and K 5.8 mmoi/L (normal 3.5 to 5.0). Which one of the following investigations is most likely to confirm the diagnosis?


A 75 year old man with a past history of a myocardial infarction, atrial fibrillation, triple coronary artery bypass grafts and a left carotid endarterectomy following a TIA presents to the Emergency Department after passing four bloody stools in 24 hours. He has had niild lower abdominal discomfort over this time. He takes warfarin, metoprolol, perindopril and atorvastatin. There is a strong family history of colorectal cancer (two brothers who developed colon cancer in their late 60s) and his sister and son have Crohn's disease. His 6 year old grandson was treated recently for Giardia infection. On examination his pulse is irregularly irregular at a rate of 96/minute, BP 100/70, respiration 16/minute, T 37.6°C. He has mild left lower abdominal tenderness. What is the most likely cause of his bleeding?


You are working as an intern in the Orthopaedic ward. One of your patients, a 23 year old motorcyclist, complains of numbness in his left hand 4 days after sustaining multiple limb and rib fractures in a high speed accident. On examination he has weakness of abduction of the fingers. The biceps, brachioradialis and triceps reflexes are all present and equal in both arms. There is numbness over the palmar surface of the medial border of the hand, the little finger and the medial half of the ring finger. What is the most likely diagnosis?


A 17 year old student presents to her general practitioner with a 6 month history of passing 5-7 loose motions per day. She describes intermittent right lower abdominal pain, night sweats, lack of energy, weight loss of 5kg and intermittent pain and swelling in her knees and ankles. Blood tests performed at her initial visit demonstrate: Full blood examination:

TestResult Normal range\
C-reactive protein
85 g/L
88 fL
8.3 X 10^9/L
54.5 mg/L
31 g/L
What histological finding is most likely on her ileal biopsies at colonoscopy?


A 65 year old woman is brought to the Emergency Department by her husband because of a 24 hour history of colicky central abdominal pain. She has been unable to keep food or liquid down and has vomited bile stained fluid several times over the last 6 hours. She has not used her bowels over this time. On examination she is in obvious pain. Her vital signs are PR 110/minute, BP 130/80, RR 20/minute, T 36.7°C, She has dry mucous membranes and her jugularvenous pressure is only visible when she lies flat. Abdominal examination reveals mild generalized distension but there is no tenderness or organomegaly. She has active high pitched bowel sounds. The most appropriate initial investigation is:


A 25 year old woman with severe asthma is brought to the Emergency Department by her husband with increasing shortness of breath despite repeated use of her salbutamol inhaler. On arrival she is distressed, unable to speak and unwilling to lie down. On examination RR 38/minute, BP 100/70 and PR 130/minute. Auscultation of her chest reveals widespread wheeze. She is given oxygen, continuous nebulised salbutamol and hydrocortisone 100mg i/v. Twenty minutes after admission she is less distressed and slightly drowsy. Her respiratory rate is 16/minute, BP 100/70 and pulse 120/minute. Repeat auscultation of the chest reveals soft breath sounds without wheeze. Arterial blood gases on 50% oxygen show:


(normal, 36-44mmHg)
(7.35- 7.45)
(21 - 30)
The most appropriate therapy is:


A 60 year old barmaid presents to her general practitioner with a 4 week history of painless jaundice, pruritus, pale stools, dark urine and 6 kg weight loss. In the preceding month she has taken a course of amoxicillin / clavulanic acid (Augmentin) for a chest infection and has commenced a trial of diclofenac (Voltaren) for back pain. She had a right hemicolectomy to remove a carcinoma of the caecum 5 years previously. She drinks two cans of full strength beer most nights. She smokes 20 cigarettes/day. On examination she is icteric. Her vital signs are PR 84/minute, BP 135/85, RR 14/minute, T 37.2°C. There are no peripheral signs of liver disease. Abdominal examination is normal. Investigations show:

Alkaline phosphatase
37 g/L
525 IU/L
50 IU/L
Ultrasound demonstrates a dilated, empty gall bladder, dilatation of the common bile duct (10 mm) and increased echogenicity throughout the liver. What is the most likely cause of her jaundice?


A 17 year old girl presents with bruising, epistaxis and menorrhagia. She has never had any operations or dental extractions. The only finding on examination is scattered bruising on both legs which she sustained during a game of hockey, The FBE is unremarkable. The APTT is 40 seconds (26-34), and the INR is 1.2 (<1.3). The investigation most likely to confirm the diagnosis is:


A 56 year old woman presents with increasing pain in the right groin and anterior thigh over the past 6 months. The pain is worse with walking and improved by sitting. The most likely source of the pain is:


A 51 year old woman develops right pleuritic chest pain, cough, and shortness of breath three days after a laparotomy to remove a sigmoid cancer. On examination her PR is 104, her BP is 135/85, her RR is 26 and her T is 38.2°C. Her oxygen saturation is 86% while breathing room air. The JVP is visible 2cm above the sternal angle. She has a right subclavian catheter. The apex beat is in the 5th left intercostal space in the mid-clavicular line. Cardiac auscultation is normal. Examination of the chest reveals reduced percussion note and coarse crackles over the right lower lung field; A set of blood gases are taken while she is breathing room air: pH 7.48, p02 70 mmHg, pC02 36 mmHg, HC03 26mmoi/L. The most likely cause of her shortness of breath is:


While working as the night resident you are called to see a 60 year old man in the Oncology ward who has become hypotensive. He has been admitted for rehydration and following a poor response to chemotherapy for non-small cell lung cancer. On examination he is drowsy. His PR is 104/minute, his BP is 90/65, his RR is 22 breaths/minute, and his T is 37.2°C. His,oxygen saturation is 90% on room air. The jugular venous pressure is visible ?cm above the sternal angle; The apex beat is impalpable. On cardiac auscultation his heart sounds are just audible and you cannot hear any additional sounds or murmurs. Examination of the lungs is normal. ECG is normal except for generalized low voltage QRS complexes. What is the most likely diagnosis?


A 32 year old plumber consults his general practitioner because of 2 months of lethargy and night sweats. He has also had a non-productive cough overthis period. He has not been short of breath. One week ago he developed painful red lumps on both shins. He smokes 30 cigarettes/day. On examination his PR is 80/minute, his BP is 130/80, his RR is 16 breaths/minute, and his T is 36.5°C. Examination of the lungs is normal. The general practitioner orders a chest X-Ray (see below). The most likely diagnosis is:


A 21 year old university student, who arrived back in Australia one week ago after a 3 month holiday in Vietnam and Cambodia, consults her general practitioner because of three days of dull, constant right costal margin pain, malaise and anorexia. She noticed dark urine that morning. She has taken 1 gm paracetamol 6 hourly for the last 72 hours. She has not been sexually active for 6 months and denies any intravenous drug use, blood transfusions, needlestick injuries, tattoos or body piercing. She drinks 4 glasses of full strength beer each day. She has not been vaccinated against hepatitis A or B. On examination her temperature is 37.9°C. She has scleral icterus and mild right upper quadrant tenderness. Investigations show:

Alkaline phosphatase
125 IU/L
1362 UI/L
985 IU/L
37 g/L
Which of the following is the most likely diagnosis?


A 35 year old accountant, with long standing glomerulonephritis presents for review, after being lost to follow up for 2 years. He feels unwell and has a poor appetite. He has been consuming protein supplements on the advice of his partner, who is a naturopath. He has not been nauseated but has a mild itch. On examination he is pale. His blood pressure is 150/90 and PR 78. His JVP is not raised and he has no oedema. His Hb is 86g/L (normal 120-160 g/L). His plasma creatinine is 560umoi/L (normal <110 umoi/L), urea 35 mmoi/L (normal 3-7), Potassium 5.1 mmoi/L (normal 3.5-5.0), Calcium 2.0 mmoi/L (normal2.2-2.5) Phosphate 2.0 mmoi/L (normal 0.7-1.4.) The most appropriate next intervention is:


A 32 year old woman presents with 6 weeks of worsening pain in the hands, wrists and ankles with prolonged early morning stiffness. Examination reveals swelling in the metacarpophalangeal and proximal interphalangeal joints bilaterally. The test most likely to confirm the diagnosis is:


A 42 year old man presents to the E.D. after falling while learning to snowboard. He fell with his hand outstretched behind him. The hand is not deformed. He is tender over the thenar eminence and the 'snuff box'. Thumb and 5th finger opposition is weak due to pain. Neurovascular examination is normal. The most likely diagnosis is:


A 70 year old retired policeman presents with sudden onset of speech difficulty. On examination he is alert but seems frustrated by his inability to say what he wants. He is able to follow verbal and written commands. Which of the following is most likely to be found on further examination of this man?


A 19 year old apprentice metal worker presents with acute painful visual loss in his right eye. He has no significant past medical history. On examination he has reduced visual acuity in the right eye (able to count fingers). His eye movements are painful but not limited. The eye looks normal and fundoscopy shows a swollen right disc. The most likely diagnosis is:


A 69 year-old woman with post-polio syndrome since childhood, type 2 diabetes for 7 years (last HgbA1C 8.8% (recommended < 7), and hypertension for 10 years is seen in the clinic because of burning feet exacerbated by warm weather and hot showers. She drinks 2 glasses of wine per night. She has been on a very low calorie liquid diet and has lost 20 kg over 6 months. She takes metformin, paracetamol, and hydrochlorothiazide. On examination she is obese (BMI 32). Reflexes are absent at the ankles and vibration sense is absent and light touch is diminished in the toes and feet. The most likely cause of her symptoms is:


A 50 year old cleaner presents with a firm, irregular 1.5cm lump in the left breast. Axillary examination is normal. Mammography demonstrates micro calcification on the lesion. Which of the following is most appropriate next step?


A 17 year old girl with anorexia nervosa presents with dizziness and is found to have a Hb of 95 g/L (110-160), MCV 72 fL (80-100), MCH 24 pg (27-32), serum iron 7 umol/L (9-27), transferrin saturation 15% (20-50), serum ferritin 8 ug/L (15-200) and reticulocyte count 15 x 10^9/L (20-75). You diagnose iron deficiency and start her on oral Ferrogradumet. Which of the following parameters would be the best measure of response to therapy at one week?


A 61 year old woman presents to the Emergency Department with severe epigastric pain and vomiting. The pain came on rapidly three hours earlier. lt is severe arid radiates through to her back. She has vomited large amounts of bile stained fluid. She has a past history of one episode of biliary colic but she did not want surgery at that time. On examination she lopks unwelL Her vital signs are pulse 110/minute, BP 110/80, respiratory rate 18/minute, temperature 37.1°C. Abdominal examination reveals tenderness and guarding in the upper abdomen. There is no rigidity or organomegaly. Bowel sounds are present. What investigation is most likely to yield the diagnosis?


A 30 year old woman with a six year history of type 1 diab~tes mellitus is referred to a renal physician as she has developed severe bilateral ankle oedema and swelling of her hands. Clinical examination reveals a BP 125/80 and confirms her oedema. There is no other abnormality. She has no retinopathy. Analysis of her 24 hour urine collection shows no blood and.7g/day proteinuria. The renal physician treats her with oral prednisolone. Her oedema and proteinuria resolve completely within three weeks. What is the most likely diagnosis?


A 46 year old executive presents to his general practitioner with six months of poor penile erections. He is otherwise well except for mild hypertension treated with hydrochlorothiazide. He reports waking occasionally with an erection in the morning. His examination findings are unremarkable. His BP is 130/75. The most likely cause of his erectile problems is:


A 35 year old previously well engineer presents to his general practitioner with a 4 day history of fever, rigors, generalised aches and pains, headache, mild diarrhoea and dry cough He returned one week ago from a 4-week trip to Papua New Guinea and the Soloman Islands. While away he ate local foods and drank bottled water. He had no pre-travel vaccination or medications. On examination he looks unwell. His vital signs are pulse 110/minute, BP 115/75, respiration 18/minute, T 39°C. He does not have a rash. Abdominal examination reveals 2cm spleen palpable below the left costal margin. Cardiovascular and respiratory examinations are normal. What of the following is the most likely diagnosis?


A thin, unkempt 71 year old man is brought to a general practitioner by his daughter who is concerned that he is tired and not eating well. He has not seen adoctor for many years. He says he is feeling very tired. He has lost his appetite and often feels nauseated. The. doctor performs a thorough examination and arranges a number of blood tests. The results show that tie has a serum creatinine of 0.79 mmol/L (normal 0.05-0.11). Which one of the following findings most strongly suggests that his raised creatinine is due to chronic renal failure, rather than acute renal failure? ·


A 60 year old non smoking man, who used to work in an asbestos mine, presents. with a 6 month history of productive cough. He is also worried about not feeling quite right mentally with feelings of disorientation and forgetfulness. Physical examination reveals: weight 65kg, BP 140/90, JVP 1-2 cm above sternal angle and no other abnormality.

K3.3 mmol/L(3.4-5.5)
Urea3 mmol/L(3.5- 7.6)
Creatinine0.06 mmoi/L(0.05-0.11)
What is the most likely cause of his condition?


A 75 year old woman with a five year history of atrial fibrillation and idiopathic dilated cardiomyopathy is brought to her general practitioner by her daughter because she has noticed that her mother has been bumping into the furniture while walking around the house over the last 2 days. On examination her (corrected) visual acuity is 6/9 in both eyes. Both visual fields are intact but when simultaneous bitemporal visual stimuli are presented she only recognizes the stimulus on the right. The pupils react briskly to light and accommodation. Eye movements are normal. Fundoscopy is normal in both eyes. What is the site of the lesion that is causing this woman's visual problem?


A 24 year-old woman with rheumatoid arthritis presents to her general practitioner with right lower quadrant abdominal pain of 6 hours duration with associated nausea and vomiting. She is on methotrexate weekly and 1 mg of prednisolone daily. Her rheumatoid arthritis affects the joints of her hands, knees, and neck. Physical examination reveals fever of 39°C, right lower quadrant abdominal tenderness and rebound. Joint examination reveals active synovitis in her hands and decreased flexion and extension of her neck. Her blood tests reveal:

TestResultNormal Range
0.12 mmol/L
63 mmol/L
6.0 mmol/L
lt has been decided that laparoscopic appendicectomy is required. What is the issue of greatest importance related to her anaesthetic and her rheumatoid arthritis?


A 53 year old car factory worker presents to his general practitioner with gradual onset of tinnitus and hearing loss in his left ear. He has also not,iced feelings of "pins and needles" affecting the left side of his face. The reason for coming to the doctor today is that he has had several episodes in which the room seems to be moving around him. On examination, he is alert and his vital signs are normal. Neurological examination reveals bilateral nystagmus, mild weakness and reduced sensation on the left side of his face, decreased hearing in his left ear and intention tremor on the left. What is the most likely diagnosis?


A 57 year old factory worker presents to his general practitioner with a one month history of persistent dull left sided chest pain and increasing shortness of breath. The pain is not related to exercise and is annoying but. not severe. He has been a smoker of 20 cigarettes/day for the last 40 years and has a chronic cough that has been a little worse lately. His sputum is clear and has not contained any blood. He has lost Skg in weight. On examination his vital signs are normaL He is not pale, cyanosed or clubbed. His trachea is midline. He has a localised wheeze and a few inspiratory crackles best heard over his left upper chest anteriorly. Chest X-ray and CT scan reveal left hilar enlargement and a 4 cm diameter rounded density in his left upper zone. Sputum cytology is negative for malignancy and acid fast bacilli. A bronchoscopy is performed and bronchial washings obtained which are also negative. ACT guided needle biopsy of the lung mass is performed. Below is an H & E stained section of the biopsy. What diagnosis is confirmed by this biopsy?


A 33 year old woman is troubled by brief episodes of rotary vertigo or lying down. Which one of the following is the most likely diagnosis?


An 82 year old man presents with recurrent episodes of dizziness and one episode of syncope associated with slow pulse, and spontaneous recovery. His current ECG shows atrial fibrillation with ventricular response rate of 80/min. Which one of the following is the most likely cause of his dizziness and syncope?


A 72 year-old man presents to the Emergency Department unable to urinate for the past 24 hours. He reports lower abdominal pain and recent difficulties starting his urinary stream. Which one of the following abdominal findings is rnost likely to confirm your clinical diagnosis?


Which one of the following methods is the most reliable way of confirming tracheal placement of an endotracheal tube?


An 83-year-old man with a history of hypertension, hypercholesterolemia, type 2 diabetes mellitus and. smoking, is seen in the Emergency Department with a three hour history of right-sided weakness and difficulties with speech. On examination, he is alert with dysphasia and a right hemiparesis. He has an irregularly irregular pulse. Which one of the following is the most likely diagnosis?


A 30 year old man presents with severe 'dandruff and pruritus of the scalp. Scaling also affects his eyelids. Which one of the following is the most likely cause?


A 70 year old woman presents to the Emergency Departm~nt with a 24 hour history of right upper quadrant pain and fever. On examination she is jaundiced, febrile and tender under the right costal margin. An abdominal ultrasound is performed and shoWs a thin walled gallbladder with multiple stones, a dilated bile duct and no stones visible within the duct. The pancreas could not be adequately visualised due to bower gas. Which one of the following is the most likely cause of her problems?


A 68 year old man presents with a 4 week history of severe headache. He has also felt vaguely unwell, lost 5kg in weight and has ache in the neck and shoulders. He remarks that wearing a hat is uncomfortable and he has some tenderness when he brushes his hair. Which one of the following is the most likely diagnosis?


Which one of the following actions is the mechanism by which warfarin exerts its anticoagulant effect?