RMH Semester 8 2006

1

A 50 year old cleaner presents with aching legs. She quit smoking last year after a 10 pack year history. She drinks one stubby of light beer each evening after work. On examination she has dilated tortuous veins over both lower limbs. Which one of the following physical findings would be most likely in the lower limb of this patient?


2

A 55 year old man calls an ambulance after 3 hours of central crushing chest pain which radiates into his left arm. He is given aspirin, sublingual glyceryl trinitrate (Anginine) and intravenous morphine and brought to the Emergency Department. On arrival he says his pain is improved but still present. He is pale and sweaty. His vital signs are pulse 112/minute and regular, BP 90/50, respiratory rate 24/minute, temperature 37.2°C. His jugular venous pressure is visible 4 cm above the sternal angle. He has a gallop rhythm on cardiac auscultation. There are crackles audible in the lower third of both lung fields. His initial ECG shows ST elevation in leads I, 11, aVL, and V1-V6. The therapy most likely to improve survival is:


3

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: Bilirubin 78 µmol/L (<19) Alkaline phsphatase 125 IU/L (15-120) ALT 1362 IU/L (<55) AST 985 IU/L (<45) Albumin 37g/L (35-50) Which of the following is the most likely diagnosis?


4

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


5

A 60 year old woman presents to her general practitioner one evening. She had woken with pain beneath her right costal margin that morning. The pain lasted about an hour. She now feels generally unwell. On examination she looks tired and flushed. Her vital signs are pulse 92/minute, BP 140/95, respiration 18/minute, T 37.9°C. She is prescribed paracetamol (up to 2 tablets four times daily) and arrangements made for her to have some blood tests in the morning. The results are: Full blood examination: normal, other than white cell count 8.3 x 109/L (normal: 2.0- 7.50) Liver function tests: Bilirubin 58 µmol/L (<19) Alkaline phosphatase 147 IU/L (15-120) ALT 162 lUlL (<55) AST 101 IU/L (<45) ALbumin 46 g/L (35-50) Which of the following would be the most appropriate next step in her assessment?


6

An 83 year old woman, weighing about 45 kg, is brought by ambulance to the Emergency Department with a suspected fractured neck of femur, after falling in her nursing home. She was given morphine 15 mg intravenously by the ambulance officers during the transit to the hospital. On examination, she is drowsy and poorly responsive to questions. Her left leg is shortened and externally rotated. Other than drowsiness, there is no apparent neurological abnormality. Which of the following clinical findings would be most consistent with her drowsiness being due to the morphine rather than another cause?


7

A 5o year old previously well accountant presents to the Emergency Department after vomiting a moderate amount of bright blood. He has vomited three times. The first vomitus contained bile stained fluid. lhe next two vomits each contained about half a cupful of bright blood. He has mild upper abdoninal discomfort. What is the most likely source of his bleeding?


8

You a re the surgical intern in a busy general surgical unit. During your morning ward round, one of your patient1, a 55 year old man who had a right hemicolectomy to remove a carcinoma of the caecum 6 days ago, says he has been short of breath since waking that morning. He has no chest pain or cough. Although he has been a heavy smoker (20 cigarettes per day for 35 years), he has had an uneventful postoperative course up until now. On examination his vital signs are pulse 110/minute, respiration 28/minute, BP 115/70, T 37.7°C. His oxygen saturation is 88% on room air. His jugular venous pressure is visible 5cm above the sterna I angle. His ape:< beat is not displaced. There is a palpable cardiac impulse at the right sterna! edge. Cardiac auscultation is normal. Percussion and auscultation of the lung fields are normal apart from some crackles in both lung bases which clear on coughing. There is no calf tenderness and no ankle or sacral oedema. What of the following is the most appropriate treatment?


9

A 62 year old woman presents to her general practitioner for routine review. She has type 2 diabetes and osteoarthritis. Her medications are metformin, glibenclamide, atorvastatin, ibuprofen and aspirin. Three months ago, her serum creatinine was normal and her HbA 1 c was 6.9. On this occasion her serum creatinine is twice normal and her HbA1c is 7.2. Her BP is 130/85. What therapy adjustment does she most need?


10

A 39 year old previously well advertising executive is brought to the Emergency Department by his wife 30 minutes after the abrupt onset of severe headache while he was watching television. He vomited and became drowsy. He smokes 10 cigarettes/day and drinks 2-3 glasses of beer or wine most days. There is no history of trauma. On examination he is confused and drowsy. He has neck stiffness and bilateral papilloedema. An urgent CT scan brain shows blood in the interhemispheric fissure, the Sylvian fissures and the third ventricle. What is the most likely underlying cause of his haemorrhage?


11

A 42 year-old teacher is diagnosed with mild hypertension by his general practitioner based on 3 readings of 140-150/90-100. He does not smoke. He drinks 1 stubby of beer most evenings, and takes occasional paracetamol for headaches. His BMI is 27 and BP 142/94. Physical examination is otherwise normal. The change that will most benefit him is:


12

A 52 year-old Nigerian immigrant presents to his general practitioner frustrated that he has been unable to control his blood pressure. His hypertension was initially managed with thiazide diuretics and lifestyle modification. About 6 months ago, his general practitioner had added an ACE inhibitor, now at full dose, but his high blood pressure has persisted. He also takes metformin for recent-onset type 2 diabetes. Today his BP is 174/100 with pulse of 88/minute. At this time, the best medication to add to his regimen would be:


13

A 39 year-old computer programmer presents with sensory loss in her right leg that has been worsening over the past 2 days. She has hypertension treated with a beta-blocker and ibuprofen for osteoarthritis of her hands. She has smoked 20 cigarettes per day for the last 15 vears but is trying to quit because she has developed a bothersome morning cough. On detailed history, she had a funny episode of vision change several years ago. She thought she was going colour blind, but then her vision returned to normal. Family history is notable for early osteoarthritis in her mother and grandmother. In addition to sensory loss in her right leg, the physical finding most likely to be present in this woman is:


14

A 53 year-old woman with T2N3M1 recurrent breast cancer presents to her rural Emergency Department 10 days after her most recent cycle of chemotherapy with fever to 39o C and rigors. She lives on a farm and has felt well enough to watch the sheep giving birth and has been helping to feed the chocks. Her daughter's family has been visiting and the 2-year-old twins had "croup" last week and were seen by the local paediatrician. On examination, she appears very fatigued and ill, a~d most of ~he _history is obtained from her husband. Her temperature is confirmed. BP 90/58, pulse 120/mmute, resp1rat1on 20/minute. A subconjunctival haemorrhage is present on the left eye. Lymph node exam reveals multiple shotty nodes in the cervical chain posteriorly. In addition to a full blood examination (FBE), what is the most important additional investigation at this time?


15

A 64-year-old businessman presents to the Emergency Department with 8 hours of palpitations, chest pressure, and mild shortness of breath. He takes hydrochlorothiazide for mild hypertension, ibuprofen irregularly for osteoarthritis, and atorvastatin for hyperlipidemia. On examination he looks uncomfortable. His vital signs are pulse140/minute, BP 142/88, respiration 20/minute, T 37.1°C. Eyes show bilateral lid lag. His thyroid gland is nodular and twice normal size. Cardiovascular examination reveals a JVP of 3cm above the sterna! edge, apex beat not displaced, two normal heart sounds with a 2/6 ejection murmur at the left lower sterna! border. Ankle reflexes are 2+ and symmetrical. The most likely additional physical finding in this patient would be:


16

A 25 year old solicitor with asthma is brought to the Emergency Department by ambulance from her work with severe shortness of breath. She is pale, distressed and sitting upright. She is unable to provide a history due to shortness of breath. The ambulance officers tell you that she had become increasingly short of breath at work, despite repeated use of her salbutamol inhaler. Which of the following physical signs is most consistent with imminent respiratory arrest?


17

A 75 year old previously well woman is brought to the Emergency Department following a fall onto her outstretched right hand when walking in the street. She is in pain and has a tender deformity just above her right wrist. X-Ray of the right forearm reveals an undisplaced fracture of the distal radius (a Colle's fracture). She is given analgesia and a forearm plaster is applied. She returns to the Emergency Department the following day complaining of increased pain in her forearm. On examination the fingers of her right hand are cyanosed, cold and there is reduced sensation to light touch. What is the most appropriate management?


18

A previously well 33 year old accountant presents to his general practitioner concerned about reduced vision over the preceding 24 hours. He has not had any pain or an injury. On examination his visual acuity is 6/18 in the left eye and 6/6 in the right eye. Both visual fields are intact. The left pupillary reaction is sluggish but the right pupil reacts normally. Eye movements are normal. The left optic disc is swollen with blurred margins. The right optic disc has a normal appearance. Which of the following is the most likely diagnosis?


19

An 81 year old Greek woman who does not speak English is brought to the Emergency Department by her son. He says that she has been complaining of severe pain in her right leg for the last 6 hours. She has also become increasingly confused. He says that his mother normally lives in Greece and flew to Melbourne for a family visit seven days ago. She has a past history of temporal arteritis for which she normally takes prednisolone 4mg daily but she did not bring her tablets with her to Australia. On examination she appears agitated and in pain. Her right leg is cold, pale and cyanosed. No pulses are palpable below the femoral artery on the right. The femoral, popliteal and posterior tibial pulses are palpable on the left but the dorsalis pedis pulse is not. There is a bruit audible over the left femoral artery. What is the most likely diagnosis?


20

A 43 year old van driver is reviewed in Surgical Outpatients 2 months after a prolonged hospital admission following a high speed motor vehicle accident in which he sustained multiple fractures and extensive soft tissue injuries. He has made a good recovery but describes difficulty using his right hand. On examination there is mild wasting of the thenar eminence and weakness of abduction of the thumb. All reflexes are intact. He has diminished pin-prick sensation over the palmar surface of the hand, thumb, index finger, middle finger and the lateral half of the ring finger. What is the most likely diagnosis?


21

A 61 year old grocer with a 20 year history of type 2 diabetes mellitus is brought to the Emergency Department by his wife, after waking in the middle of the night with shortness of breath. He states that he has not had any chest pain. He is a former smoker with a 50 pack year history. On examination he looks unwell and distressed. His periphery is cool. His vital signs are pulse 45/minute, BP 100/70, respiration 32/minute and T 37.2°C. His apex beat is not palpable. He has two heart sounds and no murmurs. He has crackles to the mid-zones bilaterally in his lungs. The most important initial investigation to perform to determine the diagnosis is:


22

A 23 year old university student presents to Student Health with a 12 week history of abdominal bloating, variable bowel habit and intermittent cramping lower abdominal pain. The pain is relieved by defecation or by passing wind per rectum. Her appetite and weight are unchanged. Clinical examination is normal. What is the most likely diagnosis?


23

A 73 year old woman with generalized sun damage to her skin is referred to a dermatologist due to a 3cm diameter skin lesion on her right cheek. She is very distressed. She is adamant that 6 weeks ago there was no lesion in evidence and that this lesion has grown extremely rapidly over that period. On examination she has a 3cm diameter, dome shaped, pink, fleshy tumour. lt has a central keratin core. There is no reaction in the surrounding tissues. lt is not fixed to any other structures and there is no lymphadenopathy. What is the most likely diagnosis?


24

An 88 year old man is brought to the Emergency Department by ambulance after a fall in his backyard. He was found on the ground by a neighbour who had heard him calling out for help. He was unable to rise from the ground. On examination he is alert and oriented, but in pain. His right leg is externally rotated, shorter than the left leg and is too painful to move. He has no other injuries. The most likely diagnosis is:


25

A 73 year-old man presents to his general practitioner with 2 months of fatigue with a 3 kg weight loss. Conjunctivae and nails are pale. Cardiovascular examination shows a 2/6 ejection murmur. Abdominal examination is normal. One 0.5 cm cervical node is mobile and non-tender, and shotty inguinal lymph nodes are present bilaterally. The prostate is enlarged to twice normal and is smooth and non-tender. Initial blood tests reveal:

TestResultNormal Range
Haemoglobin
WCC
Platelets
MCV
Iron
Ferritin
ESR
92 g/L
8.5 X 109/L
300 X 109/L
75
4 µmol/L
6 µg/L
49mm
(135-170)
(4.0-11.0)
(150-450)
(80-95)
(9-30)
(9-136)
(<12)
What is the most appropriate investigation at this time?


26

A 69 year-old man is admitted for a radical prostatectomy. On day 2 post-operatively, he develops severe left-sided flank pain that extends from his back around to his umbilicus. His vital signs are BP 149/94, pulse 92/minute, T 37.4°C, respiration 12/minute. He has multiple, clustered vesicular lesions on an erythematous base that correspond with the area of pain. What is the most appropriate therapy at this time?


27

A 46 year old woman with rheumatoid arthritis for 15 years presents to her general practitioner with a 12 hour history of a red hot swollen left knee joint. What investigation is most likely to be diagnostic of the cause of her knee problem?


28

A 34 year-old dairy farmer presents with increasing shortness of breath for 6 months so that she can no longer jog or climb stairs easily. She has also noticed her fingers turning blue and white in the cold, and they feel increasingly tight. She does not smoke. Her only medication is the oral contraceptive pill. Examination shows a thin woman with respiratory rate of 24/minute and oxygen saturation of 89% on room air. She has bilateral diffuse fine crackles in her lungs. What is the most likely underlying mechanism of her lung problem?


29

A 23 yr old administrative assistant presents to her general practitioner distressed because she found a lump in her left breast 2 days earlier. The lump is not painful or tender and she has no nipple discharge. Her menstrual period finished one day ago. Her maternal grandmother was diagnosed with breast cancer at the age of 68. On examination, she has a non-tender mobile 1 cm nodule in the outer aspect of the left breast. There is no axillary lymphadenopathy. What is the most appropriate test to use to investigate the cause of her breast lump?


30

An 86 year old woman is aphasic following a recent stroke. She has an indwelling urinary catheter in situ. She is afebrile with a good urine output. She has a culture of a catheter specimen of her urine, as part of the routine management of her catheter. Her urine is positive for Klebsiella pneumoniae, which is resistant to cephalothin, and sensitive to gentamicin, ciprofloxacin and imipenem. What is the most appropriate next step in her care?


31

A 27 year old primary school teacher presents to her general practitioner with a 6 month history of passing 2-3 loose pale motions per day, with associated abdominal discomfort and bloating, weight loss of 8kg, lethargy and recurrent mouth ulcers. On examination she is pale with no other abnormality. Her general practitioner requests an lg A endomysia! antibody which is positive. She is referred for a small bowel biopsy. What histological finding is most likely on her small bowel biopsy?


32

A medical colleague asks you to assess a woman with suspected early chronic open-angle glaucoma. If this diagnosis is correct which one of the clinical features do you most expect to elicit on assessment of this woman?


33

A 32 year old plumber presents to the Emergency Department with a two day history of fever, headache and photophobia. There is no rash. A lumbar puncture is performed and CSF analysis reveals 220 white blood cells with 20 polymorphs and 200 mononuclear cells, elevated protein 0.8 g/L (2.8-4.0) and glucose 4.0 mmoi/L (2.8-4.0). Which one of the following organisms is the MOST likely pathogen?


34

A 68 year old man presents with a 4 week history of severe headache. He has also felt vaguely unwell, lost Skg 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 ?


35

A 70 year old woman in the Intensive Care Unit spikes a fever of 38.5°C on day 7 post laparotomy for ruptured diverticulum and fecal peritonitis. Blood cultures isolate a coagulase negative staphylococcus in 2 of 2 bottles at 12 hours. Which one of the following should be the initial management?


36

A 65 year old woman presents to casualty following an episode of copious rectal bleeding. The blood was plum coloured. She becomes hypotensive, but responds to resuscitation and the bleeding ceases spontaneously. Which one of the following is MOST likely to be found on investigation?


37

Which one of the following is characteristic of sensorineural hearing impairment affecting predominantly the low frequencies?


38

Which one of the following statements about radiotherapy is most correct?


39

A previously fit man aged fifty presents with a three day history of continuous peri-anal pain. He can't sit down without discomfort. On examination there is induration in the left peri-anal region associated with gross tenderness to palpation. The tenderness prevented the possibility of a rectal examination. Which one of the following is the most likely diagnosis?


40

Which one of the following features can differentiate between a hydrocoele and an epididymal cyst, on clinical examination?


41

A 28 year old woman presents to her local hospital with a 1 week history of widespread bruising, bleeding gums and petechiae. Examination is unremarkable with the exception of numerous bruises, palatal and skin petechiae. FBE is normal apart from platelets of 7 x1 09/L (normal range 150- 450). A bone marrow examination is performed and a diagnosis of idiopathic thrombocytopenic purpura (ITP) is made. Which one of the following statements is correct?


42

Which one of the following is the strongest risk factor for development of ischaemic heart disease?


43

A 48 year old office worker presents to the Emergency Department with a 4-week history of fever (with profuse night sweats), malaise and nausea. Her symptoms have not responded to two courses of antibiotics prescribed by her general practitioner. Over the same time, she has had a sore throat with pain radiating to the ears. On examination, she has a temperature of 38.5°C, a pulse rate of 120 beats/min and a tender diffuse goitre. She is mildly anaemic (Hb 109 g/L; normal range 115 - 160) with an elevated peripheral blood white cell count (14.3 x 1 09/L; normal range 4.0- 11.0). Investigations to find a source of infection are negative. Her free T4 is 43 pmoi/L (NR: 12-23 pmoi/L) and the serum TSH is unmeasurable (< 0.05 mU/L). Technetium (99mTc) scan of the thyroid does not show any uptake of the isotope. Given the clinical features and the serum assay results, which one of the following is the MOST likely diagnosis?


44

Twelve hours after a sub-total thyroidectomy for thyrotoxicosis, a 32 year old woman becomes restless, cyanosed and develops a stridor. Which one of the following is the MOST appropriate course of action?


45

Which one of the following is most important in slowing down the progression of chronic renal failure due to lgA nephropathy?