RMH Semester 8 2008

1

An 82 year woman is transferred from her nursing home for surgical treatment of a fracture of the neck of the right femur following a fall. Which of the following therapies is most likely to prevent further fracture after discharge?


  Vitamin D supplementation

  Alendronate

  Calcium supplementation

  Glucosamine

  Hormone replacement therapy

2

A 44 year old man who is known to be HIV positive presents with 10 days of dry cough and worsening breathlessness. A recent CD4 count was 180 (normal >500). He is not taking any medications. On examination he is thin, temperature 38°C, respiratory rate 24/minute pulse rate 90/minute, blood pressure 125/80 mmHg. He has crackles in both lung bases. His 0 2 saturation is 94% on room air. The most appropriate therapy is:


  oral co-trimoxazole

  oral roxithromycin

  intravenous ceftriaxone

  oral fluconazole

  intravenous hydrocortisone

3

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?


  Decreased vibration sense

  An ulcer over the medial malleolus

  Absent posterior tibial pulse

  Increased skin pigmentation

  Calf pain on ankle dorsiflexion

4

A 48 year-old man has had type 2 diabetes mellitus for 10 years. He has been on glibenclamide twice daily for many years. Metformin twice daily was added recently. His control was good, but has worsened significantly over the last year despite good compliance. His BMI is stable at 29. His HbA1c is 10%. (good control < 7). What is the best additional therapy at this time?


  An insulin sliding scale

  Rapid insulin with meals

  Insulin pump

  Islet cell transplant

  Night time intermediate insulin

5

A 63 year old man who has smoked for many years presents with shortness of breath. Examination shows a respiratory rate of 22/minute. He is barrel chested and auscultation shows reduced air entry and bibasal wheeze. He has mild ankle oedema. The most likely additional finding on examination would be:


  hypertrophic pulmonary osteoarthropathy

  finger clubbing

  fixed splitting of the second heart sound

  right parasternal heave

  diastolic murmur at the right upper sterna! border

6

A 69 year-old woman with a 10 year history of poorly controlled type 2 diabetes mellitus consults her general practitioner because of difficulty walking for the previous 6 hours. On examination of her gait she is noted to veer to the right. She has right sided disdiadochokinesis and has difficulty performing finger-nose and heel-shin tests on the right side. Which of the following physical findings is most likely to be present in this woman?


  Right facial weakness

  Tongue fasciculation

  A left carotid bruit

  A right homonymous hemianopia

  A right upgoing plantar

7

A 55 year old electrician consults his general practitioner because of increasing intermittent retrosternaf pain over the previous 12 months. The pain is burning, lasts a few minutes and most commonly occurs after eating, although it has come on at rest, particularly at night. lt is usually relieved by antacids. There has been some nausea but no vomiting or difficulty swallowing. He stopped exercising and started aspirin 100 mg/day when he first had the pain because of concern about heart disease. He often eats take away food and has gained 7 kg. His brother and father both had heart attacks in their late fifties. He smokes 10 cigarettes per day. There are no other risk factors for ischaemic heart disease. Clinical examination is normal. What is the most likely diagnosis?


  Pericarditis

  Reflux oesophagitis

  Peptic ulcer disease

  Ischaemic heart disease

  Biliary colic

8

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 7cm above the sterna! 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?


  Pericardial effusion

  Intrapulmonary haemorrhage

  Fluid overload

  Septicaemia

  Cardiogenic shock

9

A 38 year old male with a past history of three ileal resections for Crohn's disease consults his general practitioner because of increasing fatigue. There has been no change from his normal bowel habit. Physical examination is normal apart from a surgical scar on the abdominal wall. A full blood count reveals

Hb
MCV
white cell count
platelets
C-reactive protein
112 g/L
102 fL
3.9 x 1 09/L
145 x 1 09/L
5 mg/L
(normal 130-180)
(80- 94)
(4.0 -11.0)
(150- 450)
(<8.7)
Hypersegmented neutrophils are seen on the blood film. Which of the following is the most appropriate treatment for his anaemia?


  Oral prednisolone

  Oral folic acid

  Oral iron

  Blood transfusion

  Parenteral vitamin 812

10

A 60 year old woman presents with 2 days of severe watery diarrhoea and vomiting. She feels thirsty and gets dizzy when standing up. Her blood pressure is 90/60 mmHg lying down and 70/40 mmHg standing up. Her pulse rate is 100 per minute lying and 125 per minute standing. Her jugular venous pressure is not visible lying down. Her plasma sodium concentration is 150 mmoi/L (normal138-145) and her creatinine is 110 umoi/L (normal). The most appropriate therapy is:


  intravenous 150 mmol/L (normal) saline

  intravenous 5% dextrose

  oral water

  intravenous 500mmol/L (hypertonic) saline

  oral rehydration solution

11

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. lt is mobile and there is no lymphadenopathy. What is the most appropriate management?


  Organise review in 3 months

  Apply topical steroid cream

  Organise excisional biopsy

  Apply liquid nitrogen

  Apply topical 5 fluoruracil (5FU)

12

A 60 year old accountant is investigated for iron deficiency anaemia and is found to have a carcinoma of the caecum. He undergoes a right hemicolectomy and makes a good recovery. Which of the following pathological findings is most important for prognosis?


  Degree of cytological differentiation

  Number of mitotic figures

  Spread to muscularis propria and lymph nodes

  Circumference of the cancer

  Presence of ulceration

13

A 76 year old woman has developed a fever (39.5°C) and rigors 6 hours after a bowel resection for cancer. She is receiving a blood transfusion to replace intra-operative blood loss. She has back pain, is sweaty and says that she feels that something terrible is going to happen. What is the most appropriate first step in her management?


  Give her morphine intravenously

  Give her antihistamines intravenously

  Give her oxygen

  Stop the blood transfusion

  Take blood for blood cultures

14

A 77 year old woman is brought to her general practitioner's surgery by her daughter who is concerned about her mother's increasing confusion. Over recent weeks her mother has complained of being thirsty and nauseated. She has had several episodes of vomiting. She has also experienced constipation and urinary incontinence. She has diet-controlled type 2 diabetes, osteoporosis and mild hypertension. She smoked 20 cigarettes per day for 40 years and quit 10 years ago. She drinks 1 glass of brandy per day. On clinical examination, she is frail and disorientated. She has a dry tongue and reduced skin turgor. Her vital signs are pulse 92/minute and regular, BP 124/66, respiration 16/minute and T37.1°C. Her physical examination is otherwise normal. What is the most likely explanation for her presentation?


  Hypomagnesaemia

  Hyperphosphataemia

  Hypercalcaemia

  Hyponatraemia

  Hypoglycaemia

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, blood pressure 142/88 mmHg, respiration 20/minute, temperature 37.1°C. Eyes show bilateral lid lag. His thyroid gland is nodular and twice normal size. Cardiovascular examination reveals a JVP of 3 cm 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:


  fine symmetrical tremor

  carotid bruits

  pulsus paradoxus

  delayed achilles reflexes

  pericardial rub

16

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?


  X-ray of her cervical spine to exclude a compression fracture

  Divide her plaster cast

  Intramuscular analgesia

  Increase her oral analgesia

  X-ray of her right forearm, looking for displacement of the fracture

17

A 78 year old woman with a past history of atrial fibrillation, ischaemic heart disease, cerebrovascular disease, peripheral vascular disease and peptic ulcer disease develops abdominal pain which gradually increases over 24 hours. On examination she looks unwell and has a temperature of 37.8°C. She has mild generalized abdominal tenderness. No bowel sounds are audible. Investigations reveal an elevated neutrophil count and a low serum bicarbonate. What is the most likely diagnosis?


  Perforated sigmoid carcinoma

  Pyloric stenosis

  Perforated appendix

  Intestinal infarction

  Sigmoid volvulus

18

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?


  Nuclear bone scan

  Blood cultures

  Knee X-ray, supine and weight bearing

  Knee MRI

  Joint aspiration, microscopy and culture

19

A 42 year old previously well nurse presents to her general practitioner. She has felt excessively tired for several weeks and has a 3 day history of fever and spontaneous bruising. She takes no medications. On questioning, she recalls a needle stick injury at work about 7 years ago. On examination she looks pale and unwell. She has bruises on her limbs and trunk and has multiple petechiae. Her vital signs are pulse 120/minute, blood pressure 125/80 mmHg, temperature 39.5°C. The remainder of the examination is unremarkable. Her FBE shows:

Test Normal range Result
Hb
WCC
Neutrophils
Platelets
70 g/1
2.0 X 109/l
0.2 X 109/1
9 X 109/l
115 -160
4.0- 11.0
2.0-7.50
150-450
Which investigation is most likely to confirm the diagnosis?


  CT scan abdomen and thorax

  Human immunodeficiency virus (HIV) 1 serology

  Liver function tests

  Bone marrow biopsy

  Lymph node biopsy

20

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?


  Keratoacanthoma

  Squamous cell carcinoma

  Basal cell carcinoma

  Seborrhoeic keratosis

  Malignant melanoma

21

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 sun 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 erythromatosis (SLE) and rheumatoid arthritis, as a cause of her presentation?


  White cell casts

  Muddy brown casts

  Oxalate crystals

  Oval fat bodies

  Red cell casts

22

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 noticed 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?


  Meniere's Disease

  Presbycusis

  Acoustic Neuroma

  Cholesteatoma

  Otosclerosis

23

A 22 year old woman presents with an acutely swollen tender hot right knee, following minor trauma. She has had previous similar episodes related to minor trauma for many years. Which one of the following is the most likely cause of her problem?


  Idiopathic thrombocytopenic purpura

  von Willebrand's disease

  Rheumatoid arthritis

  Factor XIII deficiency

  Septic arthritis

24

Which one of the following types of optical correction is preferred for the routine recording of 'bestcorrected' Snellen visual acuity?


  A pinhole

  Prism glasses

  Glasses worn for close work and other near tasks

  Low vision aids

  Bifocals or other distance spectacles prescribed for watching TV and driving

25

A 24 year old woman experiences painful visual loss in the right eye with spontaneous recovery over 2 weeks. She has been told that this was likely to be "migraine". Three months later, she has numbness of both legs to the level of the waist, with mild gait unsteadiness. Which one of the following is the most likely diagnosis?


  Vasculitis

  Psychosomatic disorder

  Neurosarcoidosis

  Multiple sclerosis

  Cerebral tumour

26

A 32 year old woman presents with episodes every couple of months of an unusual taste followed by approximately one minute of altered conscious state. During these events she is noted to look perplexed and has some involuntary movements of the mouth and some twisting of the head to one side. Which one of the following is the most likely diagnosis?


  Temporal lobe epilepsy

  Migraine

  Multiple sclerosis with relapses

  Frontal lobe epilepsy

  Primary generalised epilepsy

27

A 48 year old man is in the gymnasium, lifting weights. He experiences the explosive onset of headache and neck pain and is seen shortly afterwards in the Emergency Department. At this stage, he still complains of occipital headache, but there is no evidence of neck stiffness or of any neurological deficit. He is afebrile. A CT brain is normal. Which one of the following is the most important next investigation?


  Full blood examination

  Lumbar puncture

  No further investigation required

  CT scan cervical spine

  MRI brain

28

A 43 year old man presents with intermittent loose bowel actions 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?


  Carcinoma of the caecum

  Crohn's disease of terminal ileum

  Chronic appendicitis

  Ulcerative colitis

  Intestinal angina

29

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?


  Allergic reaction to his shampoo

  Psoriasis

  Atopic eczema

  Contact dermatitis

  Seborrhoeic dermatitis

30

A 50 year old woman presents to her general practitioner with two days of painful defecation associated with bright rectal bleeding. Which one of the following is the most likely diagnosis?


  Anal fistula

  Carcinoma of the rectum

  Acute anal fissure

  First degree haemorrhoids

  Acute peri-anal abscess

31

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


  three weeks

  three years

  three days

  three hours

  three months

32

Which one of the following is the most frequent cause of blood stained nipple discharge?


  Duct ectasia

  Carcinoma

  Mastitis

  Paget's disease of the nipple

  Duct papilloma

33

A 52 year old woman presents with a 4 month history of difficulty walking up stairs, hanging clothes on the line and brushing her hair. She is a heavy smoker, has lost weight and has had recurrent coughing, with occasional haemoptysis. Which one of the following is the most likely diagnosis?


  Chronic fatigue syndrome

  Polymyositis

  Severe motor neuropathy

  Myasthenia gravis

  Motor neurone disease

34

A 70 year old previously well man presents with 2 days of upper abdominal pain, jaundice, dark urine, and pale stools. On examination he is afebrile, has no signs of chronic liver disease, no abdominal tenderness, and a possible enlarged liver. Liver function tests show a cholestatic picture. The most appropriate subsequent investigation is:


  ERCP

  liver biopsy

  full blood examination

  hepatitis serology

  upper abdominal ultrasound

35

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 mHg 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?


  Aspirin

  Carotid endarterectomy

  Aspirin + clopidogrel

  Warfarin

  Angiotensin converting enzyme inhibitor

36

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?


  Cervical radiculopathy

  Ulnar neuropathy at the elbow

  Ulnar nerve lesion at the wrist

  Carpal tunnel syndrome

  Peripheral neuropathy

37

An 83 year old man presents with 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?


  Silent myocardial infarction

  Aortic aneurysm

  Atrial fibrillation

  Massive deep venous thrombosis

  Dissecting aortic aneurysm

38

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 most likely diagnosis?


  Atrial fibrillation

  Supraventricular tachycardia

  Ventricular tachycardia

  Atrial flutter

  Ventricular fibrillation

39

Twelve hours after a subtotal 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?


  Lung scan

  Indirect laryngoscopy

  Measurement of blood gases

  Exploration of the wound

  Endotracheal intubation

40

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 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 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?


  Factitious thyrotoxicosis (taking thyroxine tablets)

  Thyrotoxicosis from Graves' disease

  Suppurative thyroiditis

  Toxic multinodular goitre

  Subacute thyroiditis

41

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 Xray reveals streaky infiltrates in both lung fields. Which one of the following is the most likely diagnosis?


  Bronchiectasis

  Empyema

  Tuberculosis

  Lung abscess

  Recurrent staphylococcal pneumonia

42

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?


  Rupture of the urethra

  Haematoma of the scrotum

  Fractured pelvis

  Rupture of the bladder

  Contusion and haemorrhage of the perineal muscles

43

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?


  Perform an antinuclear antibody test.

  Commence D-penicillamine.

  Advise her to wear gloves and avoid changes in temperature if possible.

  Commence a calcium channel blocker.

  Commence aspirin.

44

A 74 year old woman in hospital4 days after a myocardial infarction suddenly becomes distressed. On examination she is very short of breath. She has a sinus tachycardia, a normal JVP, 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 deterioration?


  Pulmonary embolus

  Rupture of a mitral valve cusp

  Bacterial endocarditis

  Cardiac tamponade due to pericarditis

  Rupture of the interventricular septum

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?


  Ewings sarcoma

  Paget's disease

  Osteosarcoma

  Lymphoma

  Metastasis from breast carcinoma