Week 6

Question 1 Mrs B is 55 years old and presents because of painful mouth ulcers (see figure). You diagnose aphthous ulcers. She is otherwise well. Which of the following statements about aphthous ulcers is INCORRECT?

Reproduced with permission, Hong Kong Government, Department of Health, Tooth Club, 2003. a) The cause is rarely found b) There is often a family history c) The ulcers often begin in childhood d) They are often an indicator of Behcet's syndrome e) Aphthous ulcers may present like herpetic vesicles (d). Behcet's syndrome is a systemic condition with recurrent multiple apthous ulcers AND two of the following: - recurrent genital ulceration, eye lesions, skin lesions or positive pathergy test (non-specific inflammatory skin reaction following intradermal saline injection). Recurrent apthous ulceration in isolation is not associated with Behcet's syndrome. The other statements concerning apthous ulcers are all true. (Fitzpatrick, T.B. Johnson, R.A. et al (Eds) (1993) Color Atlas and Synopsis of Clinical Dermatology 2nd ed p458 New York McGraw Hill ) (Murtagh J (1997) General Practice. McGraw-Hill, Sydney ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec08/ch112/ch112b.htm Question 2

The drug of choice for treatment of erysipelas is:

a) Penicillin b) Methicillin c) Ampicillin d) Tetracycline e) None of the above A. Erysipelas is a form of superficial cellulitis of the skin with lymphatic involvement. It is almost always caused by Strep pyogenes and therefore the treatment of choice is penicillin (cephalexin can be used in penicillin allergic patients). (Therapeutic Guidelines 1998. Therapeutic Guidelines Antibiotic. Therapeutic Guidelines Limited.) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section10/chapter112/112e.htm ) * Question 3 Which of the following criteria enable a clear distinction to be made between haemorrhage and thrombosis in a patient with a cerebrovascular accident? a) The progress of the clinical features b) The degree of loss of consciousness c) The abruptness of onset d) The presence or absence of headache e) None of the above E. Intracerebral haemorrhages tend to be dramatic and accompanied by a severe headache. However, there really is no clinical way of reliably distinguishing between an

intracerebral haemorrhage and a thromboembolic infarction, as both produce a sudden

focal deficit. (Braundwald, E. Fauci, A.S. et al (Eds.) (2001) Harrison's Principles of Internal Medicine 15th Ed. McGraw-Hill, New York, Chap 361 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: http://www.merck.com/pubs/mmanual_home2/sec06/ch086/ch086c.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec06/ch086/ch086d.htm ) * Question 4 Bel is 20 years old and has had one allergic reaction to a bee sting. She states that there is a family history of bee sting allergy . Which of the following is NOT useful advice for Bel? a) Do not drink out of an open soft drink can that has been left outdoors b) Have a supply of antihistamines on hand c) Insect repellents are useful to prevent bee stings d) Do not walk barefoot around swimming pools e) Always carry an adrenalin 1:1000 injection, e.g. EpiPen, and know how to use it C. Insect repellents have not been shown to be useful in preventing bites from stinging insects. Anyone with a known allergy to stinging insects should know how to administer adrenalin 1:1000 subcutaneously and have it with them at all times. EPIpen is a commercial preparation which is supplied with an auto-injection device. Avoiding behaviours likely to lead to a sting - such as those mentioned in the options and avoiding colourful clothes and perfumes which attract insects - is also important. (Glaspole, I., Douglass, J. Czarny, D. & O'Hehir, R. (1997) Stinging insect allergies. Australian Family Physician, 26 (12) December, p 1395-1401. )

(Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 398 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch398/ch398_p22.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section23/chapter308/308d.htm ) * Question 5 John is a 30 year old professional athlete who suddenly develops persistent dull upper left chest pain which is not related to exertion. Although not related to respiration, it causes mild restriction in breathing. There were no related respiratory or cardiac symptoms; he is not distressed and is afebrile. Which of the following diagnoses is LEAST likely? a) Spontaneous pneumothorax b) Functional chest pain (anxiety neurosis) c) Costo-chondral syndrome d) Muscle strain e) Pleurodynia ( Bornholm's disease) E. Bornholm's disease is due to an infection by Coxackie B virus. It is often associated with an acute upper respiratory tract infection with fever, pleuritic chest pain and upper abdominal pain. These pains can be severe and associated with tachypnoea. A spontaneous pneumothorax, functional chest pain, costochondritis or acute muscular strain would be more likely in this patient. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 193 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch193/ch193_p07.html ) Question 6 Which of the following statements concerning bee sting allergy is CORRECT? a) If a patient has had a life-threatening episode in the past, he or she is at risk of a future one b) A mild reaction in the past puts a patient at risk of a future life threatening episode c) Wasps only sting once d) A bee sting is smaller in volume than a wasp sting e) A raised serum IgG persists for years in those at risk of anaphylaxis A. A previous life-threatening reaction is an indicator that a similar episode may occur in the future. Reactions don't necessarily escalate. Wasps produce a smaller volume of sting, but are capable of stinging multiple times. Serum IgE levels remain elevated in those at risk of an anaphylactic reaction. IgG appears protective. (Glaspole, I., Douglass, J. Czarny, D. & O'Hehir, R. (1997) Stinging insect allergies. Australian Family Physician, 26 (12) December, p 1395-1401. ) (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 398 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch398/ch398_p20.html ) Question 7

The nephrotic syndrome can be caused by all of the following EXCEPT: a) Minimal change disease (lipoid nephrosis) b) Amyloidosis c) Membranous glomerulonephropathy d) Diabetic nephropathy e) Renal vein thrombosis E. Renal vein thrombosis is more likely to be a complication of nephrotic syndrome rather than a cause. In nephrotic patients the blood is more coagulable than normal and the circulation may be sluggish owing to hypovolaemia, both of which are likely to induce thrombosis. The other options, together with focal and segmental glomerulosclerosis, are responsible for 90% of cases of nephrotic syndrome. They are all conditions which disturb the structure or function of the glomerular basement membrane. (Braundwald, E. Fauci, A.S. et al (Eds.) (2001) Harrison's Principles of Internal Medicine 15th Ed. McGraw-Hill, New York, Chap 274 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section17/chapter224/224c.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/tables/224tb7.htm )

Causes of nephritic syndrome

Question 8

Bill, aged 35 years, has been unwell for 2 days with severe abdominal cramps and diarrhoea. He visited friends living on a farm during the previous week. He stated that on inspection of his stool there appeared to be blood in it. What is the significance of blood in the stool? a) A viral illness is unlikely b) This makes a bacterial cause more likely c) This should be documented on the pathology request slip d) Establishing the causative organism is worthwhile e) All of the above E. The presence of blood in the stool of a patient with a constitutional illness is strongly suggestive of a bacterial infection. Identification of the causal bacteria is usually desirable for clinical and public health reasons. Most of the conditions are reportable to the relevant state health department. In some cases fulminant infection can occur and treatment based on antibiotic sensitivities of the organisms will be required. Many of these bacteria (Yersinia, Campylobacter, Shigella etc) can lead to a systemic illness with polyarthropathy. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 42 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch042/ch042_p10.html ) (Australian Family Physician (1997) Vol. 26. (11), November - 1329 ) * Question 9 Abdul is a 58 year old man who presents with transient episodes of vertigo, slurred speech, diplopia, and paresthesia. Which of the following is the MOST likely diagnosis? a) Basilar artery insufficiency b) Anterior communicating artery aneurysm c) Hypertensive encephalopathy d) Pseudobulbar palsy e) Occlusion of the middle cerebral artery A. Transient ischaemic attacks involving the posterior brain circulation, i.e. the basilar artery, are characterised by diplopia, vertigo, vomiting, dysarthria, ataxia and hemisensory loss. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 361 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch361/ch361_p04.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec06/ch080/ch080b.htm )

Question 10 Andrew, aged 60 years, complains of traces of blood in his stool for the past few weeks. Which of the following is the MOST likely cause? a) Diverticulosis b) Cancer of the rectum c) Haemorrhoids d) Angiodysplasia e) Colitis C. Haemorrhoids and/or anal fissures are the commonest and therefore most likely causes of traces of fresh blood in the stool. These are easily identified by physical examination. However, there are a number of other more serious pathologies which must be excluded, including colorectal cancer diverticulosis, angiodysplasia and colitic conditions. These can be diagnosed by a combination of rectal examination, sigmoidoscopy and colonoscopy plus biopsy.(Australian Family Physician (1997) Vol. 26. (11), November 1329 )(Braundwald, E. Fauci, A.S. et al (Eds) (2001) Harrison's Principles of Internal Medicine 15th ed. McGraw-Hill, New York, Chap 44 )(Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th editionAvailable: www.merck.com/pubs/mmanual_home2/sec09/ch119/ch119b.htm )(Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch130/ch130b.htm ) Question 12 Which of the following pathogens causing gastrointestinal infection is NOT associated with bloody diarrhoea? a) Listeria monocytogenes b) Campylobacter spp c) Yersinia enterocolitica d) Salmonella serovars e) Shigella A. Listeria monocytogenes usually only causes illness in immunocompromised patients and pregnant women. L. monocytogenes is quite unlike most food-borne pathogens in that it does not cause gastrointestinal symptoms but causes invasive infections like meningitis, septicaemia, and chorioamniitis leading to stillbirth. Gastrointestinal infections by all the other pathogens listed result in bloody diarrhoea to varying degrees. (Australian Family Physician (1997) Vol. 26. (11), November - 1329 ) (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 42 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch042/ch042_p10.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec17/ch190/ch190k.htm )

Question 13 The erythrocyte sedimentation rate (ESR) is raised in all of the following EXCEPT: a) The puerperium b) Polycythemia rubra vera Correct c) Infancy d) Pregnancy e) Chronic hepatitis B. The ESR is a non-specific indicator of inflammatory and neoplastic disease. The ESR increases with age and is raised in pregnancy, the puerperium and in anaemia. It is increased in acute and chronic inflammatory disease and neoplastic disease. A low ESR (<1mm/hour) may be seen in polycythaemia rubra vera and sickle cell disease. The Creactive protein is a more sensitive early indicator of an acute phase response.(McPherson J ed. (1997). Manual of use and Interpretation of Pathology Tests. 2nd ed. Australia. The Royal College of Pathologists of Australasia. ) (ESR at Medline Plus Available: http://www.nlm.nih.gov/medlineplus/ency/article/003638.htm#What%20abnormal%20re sults%20mean ) Question 14 Which of the following statements about weight loss is CORRECT? a) Dieting reduces the basal metabolic rate (BMR) b) Dieting increases the BMR c) Exercise decreases appetite d) Inactivity increases appetite e) None of the above (a). Changes to a person's stable weight, either an increase by forced feeding, or a decrease by food restriction (dieting), induce compensatory physiological responses that resist these changes. Thus with low calorie regimes the BMR decreases to limit energy expenditure and appetite increases, factors which complicate the process of weight loss for the dieter. Exercise generally increases appetite in response to the fall in blood glucose caused by exercise. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 77 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch077/ch077_p07.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section1/chapter5/5a.htm ) Question 15 Which of the following is the MOST COMMON pathological condition associated with aortic aneurysms? a) Atherosclerosis b) Syphilitic aortitis c) Trauma d) Rheumatic aortitis e) Cystic medial necrosis

A. Atherosclerosis is the most common pathological condition associated with aortic aneurysms. The other options are also associated with aortic aneurysms but are less common. (Braundwald, E. Fauci, A.S. et al (Eds.) (2001) Harrison's Principles of Internal Medicine 15th Ed. McGraw-Hill, New York, Chap 247 ) (Burkitt HG, Quick C & Gatt D. (1996) Essential Surgery Problems, Diagnosis and Management. 2nd ed. New York U.S.A. Churchill Livingstone. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec03/ch035/ch035b.htm ) Question 16 Bob has had moderately raised plasma cholesterol and triglyceride concentrations for 6 months and you have advised him to start on medication since dietary measures, including abstaining from alcohol, have had minimal effect. Investigations have shown that he has a raised plasma very low density lipoprotein (VLDL) level, i.e. he has type IV hyperlipoproteinaemia. Which of the following medications would you prescribe? a) Cholestyramine b) Gemfibrozil c) Simvastatin d) Nicotinic acid e) Fish oil B. Gemfibrozil is a fibrate which is the class of drugs recommended for treatment of type IV hyperlipoproteinaemia. It stimulates lipoprotein lipase activity and thereby strips triglycerides from VLDL, causing VLDL degradation and lowering of VLDL levels, with consequent lowering of plasma cholesterol and triglyceride levels. The mode of action and recommended indications for use of the other options are discussed in the reference below. (Rang HP, Dale MM, Ritter JM (1995) Pharmacology 3rd ed. Churchill Livingstone, Edinburgh, Chap 15, p326 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/tables/15tb1.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/tables/15tb2.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section2/chapter15/15e.htm ) Question 17 In which of the following conditions does angina pectoris occur in the absence of coronary artery disease: a) Mitral stenosis b) Mitral insufficiency c) Coarctation of the aorta d) Aortic stenosis e) Aortic insufficiency

D. In severe aortic stenosis when the aortic orifice is reduced to one-third or less of its normal size, angina pectoris may occur because of insufficient perfusion of the coronary arteries. This is usually associated with fainting and dyspnoea. (Braundwald, E. Fauci, A.S. et al (Eds.) (2001) Harrison's Principles of Internal Medicine 15th Ed. McGraw-Hill, New York, Chap 236 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec03/ch028/ch028f.htm ) Question 18 Whole body zinc stores may be depleted in all of the following EXCEPT: a) Coeliac disease b) Diabetes mellitus c) Alcoholism d) Vegetarianism e) Acquired immunodeficiency syndrome (AIDS) D. Zinc is an essential component of many enzyme systems including carbonic anhydrase, alcohol dehydrogenase and alkaline phosphatase. The best dietary sources are meat, shellfish and legumes; zinc in grains is less available for absorption. Zinc deficiency occurs in a variety of conditions (including all the other options listed above) but not vegetarianism. Vegetarians obtain adequate amounts of zinc from legumes, nuts and cereals. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 75 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch075/ch075_p16.html ) (Haslett C, Chilvers, E (eds) Davidson's Principles and Practice of Medicine 18th ed. (1999) Churchill Livingston Edinburgh ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section1/chapter4/4e.htm ) Question 19 A man aged 55 years begins to develop progressive dementia and is admitted to hospital because of a convulsive episode. On examination the patient has weakness of the right side of his body and a positive grasp reflex on the same side. The MOST LIKELY diagnosis is: a) A temporal lobe tumour on the right side b) A temporal lobe tumour on the left side c) A pre-frontal tumour on the left side d) A pre-frontal tumour on the right side e) A posterior fossa tumour on the left side

C. Involvement of the prefrontal area of the brain is often associated with impairment of executive functions (decision-making, disinhibited actions, impairment of concentration and memory). The emergence of developmentally primitive reflexes such as grasping,

rooting and sucking are seen mainly in patients with large structural lesions of the frontal cortex. The right-sided hemiparesis and grasp reflex point to a left-sided lesion. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 370 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch370/ch370_p01.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section14/chapter171/171c.htm ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/tables/171tb4.htm ) Question 20 Non haem iron absorption is promoted by all of the following EXCEPT: a) A high phosphate content of the diet b) The acid content of the stomach c) Vitamin C taken with a meal d) Iron deficiency e) Erythroid hyperplasia A. A high phosphate content of the diet inhibits iron absorption by forming insoluble iron phosphates. All the other factors mentioned promote iron absorption. Acid and vitamin C keep iron in the ferrous form. Iron deficiency and erythroid hyperplasia influence iron absorption through unknown mechanisms via the gut. (Rang HP, Dale MM, Ritter JM (1995) Pharmacology, 3rd ed. Churchill Livingstone, Edinburgh, Chap 23, p 476-7 ) (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 105 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch105/ch105_p03.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section1/chapter4/4b.htm ) Question 21 Paul is a 45 year old man with an acute myocardial infarction. He develops a sinus bradycardia of 38/minute with frequent ventricular extrasystoles. The IMMEDIATE treatment of choice is: a) Intravenous propranolol b) Immediate direct current c) Intravenous morphine d) Intravenous atropine sulphate e) Intravenous lignocaine (Xylocard) D. Atropine should be the initial agent at doses of 0.5mg IV every 5 minutes until the desired response is achieved by removing vagal inhibition Transcutaneous cardiac pacing is indicated if the above is not effective (bradycardia remains <40/min), with internal pacing being the definitive treatment for progressive or persistent bradycardias.

(Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 229 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch229/ch229_p09.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section16/chapter205/205o.htm ) Question 22 All of the following features are consistent with haemolytic uraemic syndrome (HUS) EXCEPT: a) Haemolytic anaemia b) Thrombocytopaenia c) Fever d) Neurological deficits e) Renal dysfunction (uraemia) C. Fever is not part of the haemolytic uraemic syndrome. This is a condition in which it is thought a strain of E.coli produces a verotoxin which causes a haemolytic anaemia and a thrombotic microangiopathy of the renal endothelium resulting in acute renal failure. (Braundwald, E. Fauci, A.S. et al (Eds.) (2001) Harrison's Principles of Internal Medicine 15th Ed. McGraw-Hill, New York, Chap 108 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec09/ch122/ch122b.htm ) Question 23 Which of the following triads of clinical features is found in beri beri? a) Angular fissures, glossitis, neuropathy b) Oedema, glossitis, neuropathy c) Cardiac failure, glossitis, neuropathy d) Cardiac failure, oedema, glossitis e) Cardiac failure, neuropathy, oedema E. Beri beri is due to vitamin B1 (thiamin) deficiency. It is now mainly confined to the poorest areas of SE Asia. Neuropathy presents as stiffness, numbness and weakness of the legs and loss of ankle reflexes, progressing to polyneuropathy involving the trunk and arms. Thiamin deficiency impairs cardiac energy metabolism leading to cardiac failure and oedema. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 75 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch075/ch075_p16.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section1/chapter3/3j.htm

Question 24

Inorganic lead poisoning is associated with all of the following laboratory features EXCEPT: a) Basophilic stippling of red cells b) Increased red cell protoporphyrin level c) Microcytic hypochromic anaemia d) Uraemia e) Aminoaciduria (c). The anaemia of lead poisoning is usually normochromic normocytic. The other options are all features of lead poisoning, due to toxic effects on erythropoieses and on the kidney. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 395 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch395/ch395_p04.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/tables/226tb1.htm ) Question 25 Sheila is a 19 year old woman who presents with ascites, high venous pressure and a small quiet heart. Which of the following surgical procedures would be MOST likely to relieve her problem? a) Mitral commissurotomy b) Closure of the foramen ovale c) Ligation of a patent ductus arteriosus d) Correction of coarctation of aorta e) Pericardiectomy E. Sheila has constrictive pericarditis in which the pericardial cavity is obliterated and dense scar tissue encases and constricts the heart. Diastolic filling of the ventricles is limited resulting in a decrease in cardiac output. The right ventricular diastolic pressure is increased, leading to venous hypertension which in turn produces hepatomegaly, ascites and peripheral oedema. Prompt pericardiectomy is the treatment of choice. This corrects the hemodynamic abnormalities and patients improve rapidly with a massive diuresis. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 239 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch239/ch239_p05.html ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec03/ch030/ch030c.htm ) Question 26 Tom is a 30 year old agricultural worker who works with organophosphates. He presents with acute pain in the right iliac fossa. You suspect acute appendicitis but are concerned about the risk of a laparotomy BECAUSE: a) There is a risk of erroneous diagnosis b) There is a tendency to prolonged bleeding post-operatively c) There is an increased hazard in general anaesthesia

d) There is a likelihood of delayed healing of the wound e) There is a possibility of mental disorder after operation C. Organophosphates irreversibly inhibit acetylcholinesterase and cause accumulation of acetylcholine at muscarinic and nicotinic receptors. In general anaesthesia, muscle relaxant drugs like prostigmine cause reversible blockade of cholinesterase. Should a patient have absorbed subclinical doses of organophosphates (e.g. in agricultural work with pesticides), there is increased risk of excessive neuromuscular blockade with use of muscle-relaxants, and the patient may show signs of toxicity, or may continue to be paralysed beyond the duration of the anaesthetic agent given. (Rang HP, Dale MM, Ritter JM (1995) Pharmacology, 3rd ed. Churchill Livingstone, Edinburgh, Chap 6, p 140 ) (Braundwald, E. Fauci, A.S. et al (Eds.) (2001) Harrison's Principles of Internal Medicine 15th Ed. McGraw-Hill, New York, Chap 396 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/tables/307tb3p.htm ) Question 27 Pamela is a 55 year old woman who comes to see you for dietary advice. She is an estimated 10kg above her ideal body weight and is keen to reduce this before the summer. Your approach would include: a) A very low calorie diet (400-600 kcal/day) b) A very low calorie diet and exercise c) A low calorie diet (>800 kcal/day) d) A low calorie diet and exercise e) A low calorie diet and appetite suppressant tablets D. All of the above options will result in short term weight loss. However, the object should be to reach her ideal body weight within a reasonable period of time and to maintain it. This is best accomplished with a low calorie diet and exercise. The reduction in calories is best achieved through restricting saturated fats and their replacement with fruit, vegetables and whole grains. A reduction of 1000 kcal/day will result in weight loss of approximately 1 kg/week. Thus Sheila should be able to reach her goal in about 10 weeks. Experience with very low calorie diets shows that few people can maintain this level of caloric restriction. The use of appetite suppressants seldom leads to sustained weight loss. (Glasziou P, Rowan S & Del Mar C. (1997) Managing the overweight and obese - a low fat approach. Australian Family Physician. Vol 26, No 11. November, p 1259 - 1263. ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/section1/chapter5/5a.htm ) * Question 28 The FIRST sign of salicylate poisoning in children is usually: a) Delirium b) Coma c) Hyperventilation d) Hyperpyrexia e) Convulsions

C. Aspirin has a two-fold toxic effect. First, it inhibits oxidative phosphorylation leading to a metabolic acidosis. The increased hydrogen ion concentration of the extracellular fluid stimulates the respiratory centre of the brain to cause hyperventilation. This is the primary effect in children. Second, aspirin directly stimulates the respiratory centre to cause hyperventilation leading to a respiratory alkalosis. This phenomenon is seen mainly in adults. (Rang HP, Dale MM, Ritter JM (1995) Pharmacology, 3rd ed. Churchill Livingstone, Edinburgh, Chap 12, p 253 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual/tables/307tb3p.htm ) * Question 29 Charles is a 48 year old businessman who presents for a general check-up and mentions that he is experiencing occasional fluttering sensations in his chest. A routine electrocardiograph (see figure) is taken.

Your first line of management should be: a) Reassurance b) Digoxin c) Captopril d) Beta blockade e) Quinidine A. The ECG shows Charles has premature atrial ectopic beats. Often these are asymptomatic. They may, however, be sensed as an irregularity or heaviness of the heart beat. Treatment is not normally required, unless the ectopic beats provoke more significant arrhythmias. In such a situation Beta-blockade may be effective. (Braundwald, E. Fauci, A.S. et al (Eds.) (2001) Harrison's Principles of Internal Medicine 15th Ed. McGraw-Hill, New York, Chap 230 ) (Beers, M.H.& Berkhow, R. (eds) (1999), The Merck Manual of Diagnosis and Treatment, 17th edition Available: www.merck.com/pubs/mmanual_home2/sec03/ch027/ch027b.htm ) Question 30 James is a 50 year old woodcutter whom you treated for a Colles' fracture two days ago. His wife telephones asking you to prescribe a sleeping tablet for him because James is having difficulty in sleeping. Which of the following is the MOST appropriate next step? a) Suggest she gives James a nightcap of whisky b) Prescribe a short-acting benzodiazepine c) Describe some relaxation exercises for James to do immediately before bedtime d) Prescribe an analgesic such as paracetamol and codeine combination e) Ask James to come to the surgery so you can check the plaster

E. The prudent action is to ask James to come to the surgery to check the plaster and the condition of his hand as soon as possible, since it may be that his problem is related to swelling around the fracture site with increased pressure inside the plaster cast. This can lead to an adverse outcome unless the pressure is relieved soon. Once this is ruled out or dealt with, the next issue to be addressed is adequate pain relief. In most cases, once adequate pain relief is ensured, insomnia will no longer be a problem. If insomnia does persist, a short-acting benzodiazepine may be prescribed for no more than 7-10 days to avoid development of dependency. An alcoholic nightcap is not a good idea, as it usually causes the patient to wake during the night and have difficulty getting back to sleep. (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, chap 27 Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/co_chapters/ch027/ch027_p10.html ) (Braunwald, E., Fauci, A.S., Isselbacher , K.J & Kasper l et al.(2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Editorials Available:http://harrisons.accessmedicine.com/serverjava/Arknoid/amed/harrisons/ex_editorials/edl2316_p01.html ) Question 31 The interossei muscles of the hand are supplied by: a) The radial nerve b) The median nerve c) The ulnar nerve d) All of the above e) None of the above C. The ulnar nerve (c8- T1) supplies the adductors and abductors of the fingers, the adductor of the thumb, the medial two lumbricals and the muscles of the hypothenar eminence. (Braunwald, E., Fauci, A.S., Isselbacher, K.J.& Kasper L et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Chap 381 ) (Dudley, H. (1991), Scott An Aid to Clinical Surgery, Churchill Livingstone, 4th edition, p66 ) * Question 32 Which of the following situations is a CONTRAINDICATION to immunisation with a live attenuated vaccine? a) Pregnancy b) Diarrhoea c) Mild acute febrile illness d) Current antibiotic therapy e) Breast feeding A. Pregnancy is a valid contraindication to immunisation with a live attenuated vaccine eg oral polio infection. Exposure to HIV, other immunodeficiency states and immunosuppressant treatments are also contraindications. Diarrhoea, minor acute illnesses, antibiotic therapy and breast feeding are not valid contraindications.

(Braunwald, E., Fauci, A.S., Isselbacher, K.J. & Kasper L et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Chaps 122, Table 122-8 ) (The Department of Health and Aged Services, Australia (2000), The Australian Immunisation Handbook, 7th ed, Australia, p29-34 ) Question 33 Brenda brings Jake, her 2 month old son for his first Triple antigen injection. Which of the following statements is CORRECT in relation to the acellular pertussis vaccine? a) It causes a lower incidence of fever, crying and irritability b) The costs are the same as whole cell vaccine c) It provokes a stronger immune reaction d) It works against the bacteria rather than the toxin e) It provides protection against P. bronchiseptica A. Acellular pertussis is part of DTPa and DTPa-hepB vaccines. Triple antigen vaccine containing acellular pertussis has similar efficacy to that of whole cell pertussiscontaining vaccines, but causes significantly less reaction with a much lower incidence of fever, irritability and local reactions. The cost is greater. The vaccine targets the toxin rather than the bacteria. (Braunwald, E., Fauci, A.S., Isselbacher, K.J. & Kasper L et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Chap 122, 152 ) (NHMRC. (2000), The Australian Immunisation Handbook, 7th ed, Canberra, Australian Government Publishing Service, p173-4 Available: http://immunise.health.gov.au/handbook_7.pdf ) (Thompson, S.C. (1997), New advances and horizons in immunisation, Australian Family Physician, vol 26 no 8, August, p 919-24 ) * Question 34 An obese man, aged 60 years, is admitted unconscious with a diagnosis of cerebral thrombosis. The most important IMMEDIATE management is: a) Insertion of an indwelling catheter b) Commencement of anticoagulant therapy c) Physiotherapy to prevent hypostatic pneumonia d) Insertion of an intravenous drip to prevent dehydration e) Positioning him on alternate sides 2 hourly A. An indwelling catheter allows monitoring of fluid status as well as allowing urinary drainage. IV fluid therapy is not urgent due to the potential to exacerbate brain swelling, in the acute phase. Anticoagulant therapy is of no value in treating a fully developed and completed CVA, and should be used only in transient ischaemic attacks or developing progressive thrombosis. The other measures of physiotherapy and nursing care should follow. (Braunwald, E., Fauci, A.S., Isselbacher, K.J. & Kasper L et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Chap 361 ) * Question 35 Which of the following statements about simple febrile convulsions is CORRECT? a) It usually occurs between 6-8 years of age b) Prognosis is poor c) The risk of developing epilepsy is 10%

d) The convulsions last less than 15 min e) Investigation with lumbar puncture and CT is essential D. Simple febrile convulsions last less than 15 minutes. They usually occur between 3 months and 5 years, with most occurring between 17 and 23 months of age. There is no difference in IQ at age 7 years between children who have had a febrile convulsion and their seizure- free siblings. The risk of developing epilepsy following a simple febrile convulsion is 0.9% at age 7 years. (Braunwald,E., Fauci, A.S., Isselbacher, K.J., Kasper L et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Chap 360 ) (Walsh, P. (1996), Febrile Convulsions, The Australian Paediatric Review, vol 6, no3, September, p 1-2 ) (Febrile convulsions: Prodigy guidelines Available:http://www.prodigy.nhs.uk/TheBook/BookPDF/Admin/TheBookPDFFiles/Gui dance/F/FebrileConvulsion.pdf ) Question 36 The MOST helpful diagnostic test to evaluate a potentially enlarging pituitary neoplasm is: a) Cerebral angiography b) Serial serum prolactin concentration c) MRI d) Computer assisted colour spectrum visual field plotting e) CT scan with contrast C. Once identified, pituitary neoplasms should be evaluated by an MRI scan. This gives information regarding pressure effects on surrounding structures and the need for surgical treatment. Serum prolactin estimation gives information about anterior pituitary function, but not size. Angiography is unnecessarily invasive and CT is not as sensitive as MRI. Visual field plotting will document any damage to the optic tract - an unwanted outcome. (Braunwald, E., Fauci, A.S., Isselbacher, K.J. & Kasper L et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Chap 370 ) (MRI scan showing pituitary adenoma at Otolaryngology Houston. Available: http://www.ghorayeb.com/PituitaryMRI.html ) * Question 37 Katie, a twelve year old school girl, collapses suddenly at school, and is transported by ambulance with dextrose drip (60/ml min.) inserted. On examination, dolls eye reflexes are present and she is not responding to painful stimulus. Her vital signs are as follows: Resp. rate 14/min Pulse rate 50/min Sa02 100 % B/P 180/110 What is the NEXT step of management? a) Arrange for urgent scan b) Stop her dextrose infusion and start a saline infusion c) Give steroids d) Intubate the patient e) Neurosurgical consultation

C. Katie has raised intracranial pressure as indicated by the hypertensive response in the presence of bradycardia and coma. Glucocorticoid steroids (eg dexamethasone) are most effective in reducing raised intracranial pressure and should be given first before the other measures. Katie will need a neurosurgical consultation and an urgent CT scan or MRI to diagnose the cause of increased intracranial pressure. Intubation will be required if her airway becomes compromised. Mannitol (IV) and hyperventilation to an arterial pCO2 of 25-30 mmHg may also be useful in controlling raised intracranial pressure. (Braunwald, E., Fauci, A.S., Isselbacher, K.J.& Kasper L et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Chap 376 ) (Guidelines for the Management of Raised Intracranial Pressure in Children. College of Physicians and Surgeons at Manitoba Available: http://www.umanitoba.ca/colleges/cps/Guidelines_and_Statements/912.html ) * Question 38 The defect in visual fields MOST commonly associated with a pituitary tumour is: a) Crossed homonymous hemianopia b) Central scotoma c) Bitemporal hemianopia d) Total blindness in one field e) Peripheral concentric constriction and enlargement of the blind spot C. As a pituitary tumour extends upwards from the diaphragma sellae and compresses the optic chiasm, it classically causes superior quadrantic defects followed by bitemporal hemianopia. It can however cause any variety of visual field defects, including unilateral (or bilateral) field defects in all quadrants, due to the variable position of the chiasm above the pituitary. (Murtagh, J. (1999), General Practice, Second edition, McGraw Hill Companies Australia, p 714 ) (Braunwald, E., Fauci, A.S., Isselbacher, K.J. & Kasper L et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Chap 370 ) (Kattah J. (2002) Pituitary Tumours. At eMedicine.com. Available: http://www.emedicine.com/NEURO/topic312.htm ) Question 39 Which of the following statements about immunisation is CORRECT? a) If a child has a cold, they can't be vaccinated b) Fever is an uncommon adverse event after immunisation c) If a reaction is suspected, a test dose should be used d) An anaphylactic reaction to egg is not a contraindication to MMR vaccine e) Pre-term infants have an inadequate antibody response D. An anaphylactic reaction to egg is not a contraindication to MMR vaccine. Infants with minor colds without high fever can be safely immunised. Vaccination should only be postponed if a child is acutely unwell or has a high fever (above 38.5 degrees Celsius). A fever (low grade temperature) is a common adverse effect after immunisation. Test doses are not recommended, they are just as likely to produce an adverse event as the full dose. Premature infants should receive their vaccinations at the same age as term infants, ie first dose of hepatitis B vaccine at birth and then DTPa-hep B, HIB and polio vaccinations at 2 months after birth (no correction for gestation).

(NHMRC. (2000), The Australian Immunisation Handbook, 7th ed, Canberra, Australian Government Publishing Service, p252-60 ) (Braunwald, E., Fauci, A.S., Isselbacher, K.J.& Kasper L et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York, Chap 122 ) (Department of Health and Ageing: Commonly asked questions about Immunisation. Available:http://immunise.health.gov.au/faq.htm ) * Question 40 Which of the following would be MOST helpful in distinguishing cerebral infarction from cerebral neoplasm? a) History of headache b) Hemiplegia c) Chronology of development d) Carotid bruit e) Focal abnormality on electroencephalogram C. Chronology of development is the most important factor in differentiating cerebral infarction from cerebral neoplasm. Cerebral infarction tends to be a simple, sudden event or a series of stepwise events within hours to days. In comparison, neoplasms tend to be preceded by symptoms such as headache, progressive cognitive decline, seizures and vomiting, and may feature steadily progressive neurological signs. The other options are all variably present in both conditions and are not diagnostic. (Braundwald, E. Fauci, A.S. et al (Eds.) (2001) Harrison's Principles of Internal Medicine 15th Ed. McGraw-Hill, New York, Chap 361 ) 22 questions were answered correctly. 18 questions were answered incorrectly. 0 questions were unjudged by the system. 40 questions were attempted. 40 questions are available in this quiz. 12 questions were Mastery questions. 7 Mastery questions were correctly answered in this quiz. List of Incorrect Questions * Question 4 * Question 5 Question 10 Question 11 Question 14 Question 16 Question 18 Question 22 Question 23 Question 24 Question 25 * Question 28 Question 33 * Question 34 Question 1

Question 36 * Question 37 Question 39 List of Correct Questions Question 2 * Question 3 Question 6 Question 7 Question 8 * Question 9 Question 12 Question 13 Question 15 Question 17 Question 19 Question 20 Question 21 Question 26 Question 27 * Question 29 Question 30 Question 31 * Question 32 * Question 35 * Question 38 * Question 40 List of Questions Skipped