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)


  Hepatitis A

  Hepatitis B

  Ascending cholangitis

  Paracetamol toxicity

  Alcoholic hepatitis

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?


  Excisional biopsy

  Percutaneous core biopsy

  Fine needle aspirate for cytology

  Lumpectomy and axillary node clearance

  Incisional biopsy

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?


  Apply topical steroid cream

  Organise review in 3 months

  Apply topical 5-fluoruracil (5FU)

  Organise excisional biopsy

  Apply liquid nitrogen

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?


  Mallory-Weiss tear

  Dueodenal ulcer

  Oesophagitis

  Oesophageal varices

  Diffuse gastritis

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?


  Normal-sized kidneys on ultrasound

  Normocytic anaemia

  Raised serum phosphate

  Hypertension

  Low serum calcium

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:


  aerobic exercise 3 days per week

  a low salt diet

  alcohol cessation

  Calcium supplementation, 1000 mg/day

  avoiding paracetamol

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?


  Left optic neuritis

  Left acute closed angle glaucoma

  Left retinal vein thrombosis

  Temporal arteritis

  Left retinal detachment

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?


  Coeliac disease

  Irritable bowel syndrome

  Ulcerative colitis

  Crohn's disease

  Diverticulitis

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?


  Azathioprine

  Acyclovir

  Flucloxacillin

  Ceftraxone

  Morphine

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?


  Malignant melanoma

  Basal cell carcinoma

  Squamous cell carcinoma

  Keratocanthoma

  Seborrhoeic keratosis

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?


  Ultrasound

  Helical CT of the breast

  MRI

  Mammography

  Lymphoscintography of the left breast

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?


  Oval fat bodies

  Muddy brown casts

  Red cell casts

  White cell casts

  Oxalate crystals

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?


  Intestinal angina

  Crohn's disease of terminal ileum

  Carcinoma of the caecum

  Chronic appendicitis

  Ulcerative colitis

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?


  Hyperthyroidism

  Conn's syndrome (mineralocorticoid excess)

  Addison's disease (adrenocortical failure)

  Hyperparathyroidism

  Cushing's syndrome (adrenocortical excess)

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?


  Choledocolithiasis

  Acute pancreatitis

  Acute cholecystitis

  Carcinoma of the head of the pancreas

  Biliary colic

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?


  Enterovirus

  Neisseria meningitidis

  Cryptococcus neoformans

  Streptococcus pneumoniae

  Mycobacterium tuberculosis

17

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


  Three hours

  Three months

  Three years

  Three weeks

  Three days

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?


  Migraine

  Cluster headache

  Chronic meningitis

  Temporal arteritis

  Intracranial tumour

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?


  Warfarin

  Aspirin + clopidogrel

  Carotid endarterectomy

  Angiotensin converting enzyme inhibitor

  Aspirin

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?


  Remove all venous and arterial lines

  Repeat blood cultures to exclude a contaminant

  Urgent CT scan of abdomen

  Return patient to theatre for repeat laparotomy

  Start broad spectrum antibiotics

21

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


  Acoustic neuroma

  Acoustic trauma

  Meniere's disease

  Congential deafness

  Presbycusis

22

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


  Serum iron

  Transferrin saturation

  Elevated HbA2 level

  Normal serum ferritin

  Microcytic red cells

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?


  High CSF protein content and low glucose

  Malignant cells on cytology

  Elevated CSF pressure

  Marked lymphocytosis

  Presence of crytococcal antigen

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?


  Cervical radiculopathy

  Peripheral neuropathy

  Ulnar nerve lesion at the wrist

  Carpal tunnel syndrome

  Ulnar neuropathy at the elbow

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?


  Acute myeloid leukaemia

  Chronic lymphocytic leukaemia

  Chronic myeloid leukaemia

  Hairy cell leukaemia

  Multiple myeloma

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?


  Viral meningitis

  Intracranial aneurysm

  Migraine

  Temporal arteritis

  Subarachnoid haemorrhage

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?


  Operable cataract is present in the right eye

  Severe background retinopathy is likely

  The patient has suffered a recent vitreous haemorrhage

  He has open-angle glaucoma

  The patient's glasses need updating

28

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


  LDL of 2.5 mmol/L

  HDL of less than 1.5 mmol/L

  Smoking 30 cigarettes per day

  High dietary fat intake

  Stress

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?


  Dissecting aortic aneurysm

  Aortic aneurysm

  Massive deep venous thrombosis

  Silent myocardial infarction

  Atrial fibrillation

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?


  Radial nerve compression neuropathy

  Compartment syndrome

  Musculocutaneous nerve palsy

  Peripheral neuropathy due to alcohol

  Mononeuritis multiplex

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?


  Ventricular fibrillation

  Atrial fibrillation

  Ventricular tachycardia

  Atrial flutter

  Supraventricular tachycardia

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?


  Subacute thyroiditis

  Supperative thyroiditis

  Factitious thyrotoxicosis

  Toxic multinodular goitre

  Thrytoxicosis from Grave's disease

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?


  Endotracheal intubation

  Indirect laryngoscopy

  Lung scan

  Measurement of blood gases

  Exploration of the wound

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?


  Lung abscess

  Bronchectasis

  Recurrent staphylococcal pneumonia

  Tuberculosis

  Empyema

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?


  Inadequate replace of thyroxine

  Inadequate nutrition

  Inadequate replacement of testosterone

  Over-replacement with hydrocortisone

  Lack of growth hormone

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?


  Sputum cytology

  Sputum microsopy with staining for acid fast bacilli

  Fine needly aspiration of the mass

  CT scan of thorax

  Bronchoscopy

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?


  Haematoma of the scrotum

  Contusion and haemorrhage of the perineal muscles

  Rupture of the urethra

  Rupture of the bladder

  Fractured pelvis

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?


  Refer him to an orthopadic surgeon

  Exaplain the natural history of the condition, prescribe simple analgesia and tell him to remain as active as he can tolerate

  Organise an X-ray of the lumbar spine

  Prescribe an NSAID

  Tell him to rest in bed for 3 days then to gradually resume activity

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?


  Chronic renal failure

  Pyelonephritis

  Post-streptococcal glomerulonephritis

  Minimal change disease

  IgA nephropahy

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?


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

  Commence D-penicillamine

  Perform an antinuclear antibody test

  Commence a calcium channel blocker

  Commence aspirin

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?


  Reflux nephropahy

  Familial glomerulonephritis

  IgA nephropathy

  SLE

  Post-streptococcoal glomerulonephritis

42

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


  Hypotension, pallor, sweating

  Tremor, bounding pulse, sweating

  Confusion, agitation, tachypnoea D Drowsiness, tachycardia, sweet-smelling breath

  Central cyanosis, agitation, tremor

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?


  Rupture of the interventricular septum

  Bacterial endocarditis

  Rupture of a mitral valve cusp

  Cardiac tamponade due to pericarditis

  Pulmonary embolus

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?


  Diffuse interstitial lung disease

  Asthma

  Chronic bronchitis

  Ischaemic heart disease

  Hypercholesterolaemia

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?


  Lymphoma

  Pagent's disease

  Metastasis from breast carcinoma

  Ewings sarcoma

  Osteosarcoma