2011 Semester 8

1

A 21 year old university student, who arrived back in Australia one week ago after a 3 month holiday in Vietnam and Combodia, 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 1gm 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 hepattis A or B. On examination her temperature is 37.9°C. She has scleral icterus and mild right upper quadrant tenderness. Investigations show:

Bilirubin78 µmol/L(<19)
Alkaline phsphatase125 IU/L(15-120)
ALT1362 IU/L(<45)
Albumin37 g/L(35-50)


2

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 in the lesion. Which of the following is the most appropriate next step?


3

A 73 year old woman is referred to a dermatologist for treatment of a lesion on her right cheek. On examination she has a 1 cm diameter, raised, ulcerated lesion on her right cheek which has 'pearly' edges. There is no reaction in the surrounding tissues. it is mobile and there is no lymphadenopathy. What is the most appropriate treatment?


4

A 55 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. The next two vomits each contained about half a cupful of bright blood. He has mild upper abdominal discomfort. What is the most likely source of his bleeding?


5

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


6

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:


7

A previously well 33 year old accountant presents to his general practioner concerned about reduced vision over the preceding 24 hours. He has not had any pain or an injury. On examination his visual acuit 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?


8

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?


9

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, temperature 37.4°C, respiration 12/minute. He has multiple, clustered vesicular lesions on an erythematous base that correspond to the area of pain. What is the most appropriate therapy at this time?


10

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. It has a central keratin core. There is no reaction in the surrounding tissues. It is not fixed to any other structures and there is no lymphadenpathy. What is the most likely diagnosis?


11

A 23 year old administrative assistant present to her general practitioner distressed because she found a lump in her 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 materal grandmother was diagnosed with breast cancer at the age of 68. On examination, she has a non-tender mobile 1cm 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?


12

A 22 year-old shop assistant presents to her general practitioner with a rash on both cheeks that worsens when she goes out in the sen even if she wears a hat and sunscreen. She has also had several weeks of intermittent fevers and joint aches. As part of your assessment you organise microscopy of her urine. What findings would most help you to distinguish between systemic lupus erythematosis (SLE) and rheumatoid arthritis, as a cause of her presentation?


13

A 43 year old man presents with intermittent loose bowel motions for 6 months associated with episodes of colicky central abdominal pain. Physical examination reveals tenderness in the right iliac fossa and an anal fissure. Which one of the following is the most likely diagnosis?


14

A 32 year old woman presents with tiredness and is found to have hyperkalaemia. Which one of the following conditions is MOST commonly associated with hyperkalaemia?


15

A 70 year old woman presents to the Emergency Department 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 ulatrasound is performed and shows a thin walled gallbladder with multiple stones, a dilated bile duct and no stones visible with the duct. The pancreas could not be adequately visualised due to bowel gas. Which on eof the following is the most likely cause of her problems?


16

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 (N=0) and 200 mononuclear cells (N<5), protein 0.8 g/? (<0.45) and glucose 4.0 mmol/L (<4.5). Which one of the following organisms is the MOST likely pathogen?


17

The radiation dose received by a patient having a frontal chest radiograph is approximate equivalent to the average natural background radiation received in:


18

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 unconfortable and he has some tenderness when he brushes his hair. Which one of the following is the most likely diagnosis?


19

A 68 year old, right handed man has a transient episode of speech disturbance and right arm weakness, lasting 30 minutes. He has a history of treated hypertension and type 2 diabetes. He has an irregular pulse, blood pressure 140/80 mmHg and a normal neurological examination. Investigation results include a normal CT brain scan, 15-50% carotid stenosis on duplex Doppler ultrasound and atrial fibrillation confirmed on ECG. Which one of the following would be the most appropriate stroke prevention approach?


20

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 bottles at 12 hours. Which one of the following should be initial management?


21

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


22

Which one of the following findings would distinguish β-thalassemia trait from iron deficiency?


23

A 23 year old woman presents with gradual onset of blurred vision in both eyes. Visual acuity is 6/24 in both eyes. Both visual fields show concentric peripheral visual loss and enlarged blind spots. Fundoscopy reveals the presence of bilateral marked papilloedema. A cerebral CT scan, performed with the administration of contrast, is normal. Which one of the following is a lumbar puncture MOST likely to show?


24

A 42 year old previously well lady presents with numbness, tingling, and weakness in the right hand. Examination reveals obvious wasting of the dorsal interossei, weakness thumb adduction and finger adduction and abduction, sensory disturbance involving the ring and little finger, and weakness of distal interphalangeal flexion in the ring and little finger. Which one of the following is the MOST likely diagnosis?


25

A 78 year old man presents with fatigue. Physical examination reveals generalised lymphadenopathy and splenomegaly. His full blood examination reveals:

TestResultNormal
Hb98 g/L135 - 180
WCC75 x 109/L4.0 - 11.0
Lymphocytes75 x 109/L1.5 - 4.0
Platelets108 x 109/L150 - 450
Which one of the following is the MOST likely diagnosis?


26

A 52 year old woman presents with 24 hours of gradual onset right frontal headache ("behind the right eye") with associated diplopia. On examination she has a right ptosis, her right pupil is larger than the left and sluggishly reactive to light, and her right eye is deviated inferiorly and laterally. She has no other neurological deficit. CT scan of the brain is normal. Which one of the following is the MOST likely diagnosis?


27

A 42 year old man with type 1 diabetes mellitus has an unaided vision in his right eye of 6/36. His right eye vision is 6/12 wearing his present glasses. Using a pin-hole over his glasses, his right eye visual acuity is 6/6. This suggests which one of the following?


28

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


29

An 83 year old man presents with the sudden onset of a cold, painful right leg. Examination reveals no pulses below the femoral artery on the right side. The right leg is white and cold to touch. The patient is unable to plantarflex or dorsiflex the ankle. Passive dorsiflexion results in pain. Which one of the following is the most likely underlying cause of this condition?


30

A 20 year old man presents to the emergency department complaining of inability to extend his right wrist for the last three days. On the night prior to developing his symptoms he was out with friends and had been drinking heavily. He cannot remember the latter part of the evening but woke up at a friend's house. He had apparently fallen asleep slouched supine on a chair. On examination, his vital signs and urinalysis are normal. The arm is not tender or tense to alpation. The only positive findings are an ibaility to extend his wrist and figers of his right hand sensory loss over the back of his hand and forearm. Which one of the following is the MOST likely diagnosis?


31

A 68 year old woman presents to the Emergency Department with chest pain followed by sudden collapse with loss of consciousness. She has a rapid weak pulse. Her ECG shows a regular wide complex tachycardia. Which one of the following is the mostly likely diagnosis?


32

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 ratei fo 120 beats/min and a tender diffuse goitre. She is mildly anaemia (Hb 109 g/L; normal range 115-160) with an elevated peripheral blood white cell count (14.3 x 109/L; normal range 4.0 - 11.0). Investigations to find a source of infection are negative. Her free T4 is 43 pmol/L (NR: 12 - 23 pmol/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?


33

Twelve hours after a subtotal thyroidectomy for thrytoxicosis, a 32 year old woman becomes restless, cyanosed and develops a stridor. Which one of the following is the most appropriate course of action?


34

A 32 year old man presents with a history of chronic productive cough, occasionally associated with fever, and copious, purulent sputum often streaked with blood. On examination he is clubbed. Chest X-ray reveals streaky infiltrates in both lung fields. Which one of the following is the most likely diagnosis?


35

A 25 year old man has been under long-term follow up for hypopituitarism as the result of the treatment of a very large 3rd ventricular brain tumour presenting at the age of 12 years. He was treated by the insertion of a ventricular-peritoneal shunt to reduce hydrocephalus and craniospinal irratidation. Over the past year his standing height has decreased by 6cm. His serum biochemistry including calcium, phosphate and albumin are normal. His replacement endocrine medication of hydrocortisone, thryoxine and mixed testosterone esters are unchanged. X-rays of his spine reveal marked osteoporosis. This is confirmed by dual photon absorptionometry which shows markedly reduced bone mass in the spine and neck of femur. Which one of the following is the MOST likely cause of his osteoporosis?


36

A frail 75 year old man presents with cough productive of sputum and a new right hilar mass on chest X-ray. Which one of the following is MOST appropriate initial investigation to establish the diagnosis?


37

A 74 year old man falls astride a low fence receiving a blow to his perineum. Subsequently his temperature is elevated and he has gradual increased swelling of the perineum and genitalia. Which one of the following is the most likely diagnosis?


38

A 28 year old man presents with 2 days of acute low back pain. The pain does not radiate. Which one of the following is the MOST appropriate management plan?


39

A 7 year old Aboriginal bow presents with dark urine and puffy eyes, 3 weeks after a middle ear infection. Which one of the following is the MOST likely diagnosis?


40

A 26 year old woman presents with a history of colour change in her fingers in the cold for several years. These changes have been more severe this winter and she has had chillblains as a result. She has no other features of scleroderma. Which one of the following alternatives is the most appropriate management?


41

A 13 year old girl presents with severe hypertension and renal failure. She is found to have small, irregular-shaped kidneys on ultrasound examination. Which one of the following is the MOST likely diagnosis?


42

Which one of the following combinations best describes the clinical features of hypercapnia?


43

A 74 year old woman in hopsital 4 days after a myocardial infarction suddenly becomes distressed. On examination she is very short of breath. She has a sinus tachycardia, a normal JCP, crepitations at her lung bases and a long systolic murmur (not previously noted) at her cardiac apex that radiates to the axilla. Which one of the following is the most likely cause of her diagnosis?


44

A 30 year old man is frequently woken at 3:00am by coughing and with a tight feeling in the chest. He has no other symptoms. Which one of the following is the MOST likely diagnosis?


45

A 65 year old woman presents with aching pain in the right thigh. The pain is worse at night. An X-ray of the femur reveals a lytic lesion in the distal right femur. Which one of the following is the most likely diagnosis?