Question 1

Tom, aged 18 years, presents with a typical first episode of schizophrenia. Which of
the following antipsychotic medications is the treatment of choice for him?

a) chlorpromazine

b) haloperidol

c) thioridazine

d) olanzapine
Correct

e) clozapine

Olanzapine, risperidone and quetiapine are three of the new so-called atypical
antipsychotic medications. These are now preferred (over traditional antipsychotic
drugs like chlorpromazine, haloperidol and thioridazine) as first line therapy in first
episode schizophrenia, because of improved efficacy and reduced incidence of
psychomotor retardation, a well-known and troubling side effect of these
medications. Clozapine is an atypical antipsychotic drug recommended for
schizophrenic patients who prove resistant to other antipsychotic medications.

Question 2
Pete, aged 54 years, has been a heavy smoker for most of his adult life. He
complains about coughing up blood first thing in the morning. The MOST IMPORTANT
condition to exclude is:

a) Bronchiectasis

b) Recurrent pulmonary emboli

c) Leukaemia

d) Bronchogenic carcinoma
Correct

e) Laryngeal cancer

Smokers are prone to develop a range of diseases including:
atherosclerotic cardiovascular disease,
various cancers (lung, larynx, oral, oesophagus, bladder, kidney, pancreas,
stomach, cervix)
chronic obstructive pulmonary disease
peptic ulcer.


As bronchogenic carcinoma has a much more aggressive course than the other
options, a bronchoscopy should be performed as soon as possible.
Question 3
Sarah, a 40 year old woman whose husband has a plasma cholesterol of 6.9 mmol/l
(normal <5.5mmol/l) wants to know which oil she should use in meal preparation for
her spouse. Which of the following would you advise?

a) It makes little difference which cooking oil she uses

b) She should use either canola or sunflower oil
Correct

c) Any margarine is suitable

d) Choose an oil rich in saturated fat over one rich in unsaturated fats

e) None of the above

Epidemiological studies have shown reduced mortality from cardiovascular causes
associated with diets containing increased levels of mono- and polyunsaturated fatty
acids. Canola oil, like olive oil, has a high concentration of monounsaturated fatty
acids, while sunflower oil is rich in n-6 polyunsaturated fatty acids. For lowering of
plasma cholesterol levels, the National Heart Foundation of Australia recommends
that saturated fat in the diet be replaced with a combination of mono- and
polyunsaturated fats.

(National Heart Foundation Statement on Dietary Fats 1999
Available: www.heartfoundation.com.au/downloads/Dietary_Fats_1999.pdf )
Question 4
The diagnosis of acute gonorrhoea in a male is ideally made by:

a) Gonococcal complement fixation test

b) VDRL reaction

c) Dark ground illumination of urethral pus

d) Gram stain and culture of urethral pus
Correct

e) Prostatic massage

The gonococcal organism is rapidly identified by gram stain and culture of urethral
pus. Dark ground illumination is a method for demonstrating the presence of
Treponema pallidum. VDRL is used for the diagnosis of syphilis. Prostatic massage is
an unreliable method of obtaining a test sample for acute gonorrhoea.
Question 5
A COMMON side effect of the atypical antipsychotic drug, olanzapine, is:

a) Neutropenia

b) Hypotension

c) Sexual dysfunction

d) Weight gain
Correct

e) Parkinsonism

Weight gain of between 4kg and 9kg is a common side effect of treatment with
olanzapine. Neutropaenia is a rare side effect. Sexual dysfunction can occur through
medication with major tranquillisers and selective serotonin reuptake inhibitors
(SSRI) antidepressants. Parkinsonism tends to occur with long-term use of major
tranquillisers, especially phenothiazines and butyrophenones.
Available: www.amh.net.au/ )
Question 6
June, aged 38 years, has a family history of breast cancer and seeks advice about
her risk of developing the disease. All of the following are indicative of moderate to
high risk EXCEPT:

a) Two 2 individuals on the one side of the family affected with breast cancer

b) One 1 family member with ovarian cancer diagnosed before the age of 50
years
Incorrect. The correct answer is (d).

c) One 1 or 2 family member with bilateral breast cancer

d) One 1 family member diagnosed with breast cancer at 60 years of age

e) One 1 and one 2 family member diagnosed with ovarian cancer

Only about 10% of human breast cancers are due to a germline mutation (of genes
p53, BRCA-1, BRCA-2). The other 90% are due to somatic mutations, often of the
same genes as are involved in the familial varieties. A family history of one 1 family
member diagnosed with breast cancer at 60 years of age (ie. over the age of 50
years) places June at average or only slightly increased risk (1.5 times higher than
population average). All the other options place June at a moderate to high risk.

Question 7
A patient with a past history of rheumatic fever requires oral amoxycillin cover for a
tooth extraction. The optimum time for commencing this is:

a) One week before the extraction

b) Two days before the extraction

c) The day before the extraction

d) One hour before the extraction
Correct

e) Immediately after the extraction

The risk of endocarditis in patients with valvular heart disease stems from the
bacteremia introduced by the extraction. Antibiotics need only cover this period of
time and therefore are given orally one hour before the extraction.
Question 8
A 40 year old female undergoing treatment for schizophrenia, is admitted repeatedly
for not taking her prescribed medication. She has delusional ideas, claiming she
communicates with angels and, as she does not consider herself to be ill, believes
that she should not have to take any medication. The CORRECT term for the latter
phenomenon is:

a) Therapeutic delusions
Incorrect. The correct answer is (c).

b) Side effect of drug

c) Impaired insight

d) Transference

e) Hallucinations

Impaired insight is one of the cardinal signs of psychotic illness. It describes the
situation where the patient lacks a realistic awareness of self and the relationship of
self to others. Delusions are beliefs held, despite proof to the contrary. Hallucinations
are abnormal sensory perceptions and are usually auditory in schizophrenia.
Transference is a psychoanalytical term referring to transfer by a patient of
subconscious or conscious feelings onto the therapist.
Question 9
The MOST COMMON cause of a blood-stained discharge from the nipple of a 45 year
old woman is:

a) Gynaecomastia

b) Duct papilloma
Correct

c) Paget's disease of the nipple

d) Fibroadenoma

e) None of the above

A blood stained discharge from the nipple is commonly caused by an intraductal
papilloma. Less common causes are an intraductal carcinoma and mammary
dysplasia.
Gynaecomastia is breast enlargement in the male and may be associated with
discharge, depending on the underlying cause. Paget's disease of the nipple usually
presents with a dry, eczematous rash of the nipple. Fibroadenoma tends to present
with an asymptomatic discrete, mobile breast lump.
Question 10
Which of the following drugs, causes stimulation of cardiac contraction with LEAST
vasoconstrictor effect?

a) Adrenaline
Incorrect. The correct answer is (b).

b) Isoprenaline

c) Pitressin

d) Ephedrine

e) Noradrenaline

Isoprenaline works almost exclusively on beta receptors causing increased rate and
strength of cardiac contractions (B1) and vasodilatation (B2). All the other drugs
listed cause significant vasoconstriction.
Question 11
While counselling a patient, a therapist becomes aware that the patient is avoiding
discussion of certain topics, and is steering away from topics he finds uncomfortable.
Which of the following types of behaviour is the patient exhibiting?

a) Resistance

b) Suppression

c) Regression

d) Repression
Incorrect. The correct answer is (b).

e) Projection

Suppression refers to the conscious or 'semi-conscious' decision of an
emotionallymature, healthy adult to postpone dealing with conflict.
Resistance refers to the conscious and informed decision of a patient not to change
behaviour or comply with treatment.
Regression refers to return to an earlier stage of developmental function.
Repression refers to the mechanism by which ideas, impulses or emotions which
the person finds painful or unacceptable are forced out of consciousness and
forgotten.
Projection refers to the unconscious attribution to others of one's own
unacknowledged feelings, thoughts or characteristics.

(Sadock BJ, Sadock VA. eds (2003) Synopsis of Psychiatry, 9th ed. Lippincott William
& Wilkins p 208 )
Question 12
A traumatic perforation of the ear that has occurred in wet conditions such as
swimming or waterskiing will often:

a) Be associated with a purulent discharge

b) Be complicated by a staphylococcal infection

c) Require a short course of oral antibiotics
Incorrect. The correct answer is (a).

d) Not heal spontaneously

e) Require surgical repair

A traumatic perforation of the tympanic membrane (ear drum) that occurs in wet
conditions eg. swimming or waterskiing will generally become infected and be
associated with purulent discharge. Pseudomonas is more likely to be the offending
organism than staphylococcus. A short course of topical antibiotics is indicated, as is
analgesia. Most traumatic perforations heal spontaneously, but may take up to 9
months. Surgical repair is indicated for the rare failure to heal.
* Question 13
Which of the following statements about patent ductus arteriosus is INCORRECT?

a) It occurs frequently as an isolated phenomenon
Incorrect. The correct answer is (b).

b) Cyanosis is usually present

c) It causes a pansystolic 'machinery' murmur at the upper left sternal edge

d) There is a wide pulse pressure

e) Treatment is by surgical closure

Cyanosis is not usually present unless a right to left shunt develops. Patent ductus
arteriosus is usually an isolated problem occurring most commonly in females. There
are often no symptoms until later in life, when heart failure or infectious endocarditis
develops. Clinical signs include a continuous murmur and a bounding peripheral
pulse with wide pulse pressure due to shunting of blood from the aorta to the
pulmonary artery.

(Robinson MJ, Robertson DM. Eds. (2003) Practical Paediatrics, 5th ed, Churchill
Livingstone, Sydney, p 319-320 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=81122&searchStr=patent+ductus+arte
riosus
Question 14
Where both parents have schizophrenia, what is the probability of their child
developing schizophrenia?

a) More than 90%

b) About 70%

c) About 40%
Correct

d) About 10%

e) Less than 1%

Pooled data from a number of family studies show that the risk of schizophrenia is
about 40% for each child of two schizophrenic parents. The incidence in the general
community is about 1%.
Question 15
Which of the following tympanic membrane perforations, if left untreated, is NOT
likely to progress to significant complications?

a) Continuously discharging central perforation

b) Large dry central perforation

c) Marginal perforation with discharge

d) Perforation associated with a cholesteatoma

e) Perforation that is surrounded by granulation tissue
Incorrect. The correct answer is (b).

A dry central perforation will not progress to complications, even if it does not heal.
Surgical repair is therefore elective and not mandatory. The other types of
perforation are not 'safe' and require specialist attention. A continuously discharging
central perforation indicates granulation and a risk of osteitis and bone destruction.
Marginal perforation carries the same risk.
A cholesteatoma is not a neoplasm but a cystic lesion containing amorphous debris
(and sometimes spicules of cholesterol). It is formed through chronic infection and
perforation of the eardrum with ingrowth of squamous epithelium, forming a nest
which becomes cystic. By progressive enlargement a cholesteatoma can erode the
ossicles, labyrinth and adjacent bone and carries the risk of cerebral abscess
formation and meningitis.

(Murtagh J. (2003) General Practice. Third edition. McGraw Hill, Sydney. p 549-561 )

(Fagen P., Patel N. (2002). A hole in the drum: an overview of tympanic membrane
perforations. Australian Family Physician, 31: 707-710
Available: www.racgp.org.au/afp/downloads/pdf/august2002/20020801fagan.pdf )
* Question 16
Which one of the following features is UNLIKELY to be due to arterial ischaemia?

a) Pain along the buttock and thigh after exertion

b) Weakness of the buttock and thigh

c) Shooting pain from buttock along the back of the leg to calf

d) Weakness of the leg

e) Smooth shiny skin on the leg below the knees
Incorrect. The correct answer is (c).

Diffuse pain, weakness and paralysis are all signs of arterial ischaemia.
Characteristically the pain is a cramp-like ache due to the release of pain-inducing
metabolites in muscle. Due to the aetiology, the pain is diffuse and cannot be
localised, as can the shooting pain of nerve irritation.

(Way LW, Doherty GM. (2003) Current Surgical Diagnosis & Treatment. Lange
Medical Publications, McGraw-Hill, NY, p 815-824 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=83436&searchStr=peripheral+vascular
+diseases )
Question 17
When someone is referred to as being in the pre-contemplation stage with regard to
a change in behaviour, this means s/he is:

a) Resistant to change

b) Preparing for change

c) Receptive to change
Incorrect. The correct answer is (e).

d) Looking forward to specific advice

e) Has not yet considered change

Pre-contemplation is the first stage in a model of behavioural change that helps the
clinician assess the likelihood that a patient will be receptive to an intervention. At
the pre-contemplation stage the patient has not yet considered change as an option.
The other options all indicate that the patient is aware of the process of change.
Question 18
Epistaxis is UNLIKELY to arise from:

a) Injury to the turbinates

b) Spontaneous bleeding from Little's area

c) Anticoagulation therapy

d) Enlarged adenoids
Correct

e) Nasal fracture

Enlarged adenoids do not usually cause epistaxis. In 90% of cases, epistaxis arises
from Little's area, the lower anterior portion of the nasal septum, and responds to
first aid. A fracture commonly causes epistaxis. Rarely, it can be associated with
medical conditions.

(Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 1328 )
* Question 19
Harold, aged 24 years, presents with fatigue, shortness of breath on exercise and
orthopnoea. On examination there are signs of moderate left-sided heart failure. A
grade III pansystolic murmur is heard most prominently at the apex and radiating
into the left axilla. Which of the following conditions is the MOST LIKELY diagnosis?

a) Mitral stenosis

b) Mitral regurgitation
Correct

c) Aortic stenosis

d) Aortic regurgitation

e) Tricuspid stenosis

Mitral regurgitation presents as fatigue, exertional dyspnoea and orthopnoea. It is
associated with a pansystolic murmur loudest at the apex but radiating over the
praecordium and into the axilla. It may also be associated with a short mid-diastolic
flow murmur following a third heart sound, due to the rapid flow of blood into the
dilated left ventricle. The second heart sound is normal.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=81307&searchStr=mitral+valve+insuffi
ciency )
Question 20
Stephen, aged 18 years, presents with spontaneous epistaxis. What is the FIRST
STEP in managing Stephen?

a) Direct pressure to the lower nose for two minute intervals
Incorrect. The correct answer is (b).

b) Position Stephen so that he is sitting and leaning forward

c) Application of topical local anaesthetic

d) Cautery of bleeding vessel

e) Nasal packing with gauze

The initial steps are to position the patient sitting forward to prevent blood dripping
down the throat; and to compress the cartilaginous portion of nose (Little's area) for
5-10 minutes without interruption (constant checking is likely to interfere with
haemostasis and restart bleeding).
If this is ineffective, application of local anaesthetic (traditionally cocaine for its
vasoconstrictive properties) will facilitate packing of the nose with ribbon gauze,
Foley's catheter or similar devices. Only in extreme cases would surgery be needed.

(Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 1328 )

(Pashen D, Stevens M. (2002) Management of epistaxis in general practice.
Australian Family Physician 31
Available: www.racgp.org.au/afp/downloads/pdf/august2002/20020801pashen.pdf )
Question 21
What is the cause of the GREATER life expectancy at birth of females than males in
Australia'?

a) Males exercise more than females

b) Genetic and biological differences

c) Females seek health care facilities more than males

d) Males die more in accidents and violence than the females
Incorrect. The correct answer is (b).

e) Employment stress is more for males

Genetic and biological factors play a role together with environmental factors in
causing the greater life expectancy of females at birth.

(Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section21/cha
pter293/293a.jsp%3Fregion%3Dmerckcom&word=life&word=expectancy&domain=w
ww.merck.com#hl_anchor )
Question 22
Which of the following is CORRECT? Epistaxis is often:

a) A sign of underlying nasal disease

b) Influenced by environmental conditions
Correct

c) Attributable to posterior nasal causes

d) Associated with congenital causes of bleeding

e) Copious unless promptly treated

Epistaxis is very common and is not usually a sign of underlying disease.
Environmental factors predisposing to epistaxis include pollens causing allergic
rhinitis, the irritant effects of some nasal sprays, nose picking and hot, dry, air
dessicating the nasal mucosa and rendering it more friable. In 90% of cases bleeding
is from Little's area, i.e. anterior nasal septum. While systemic causes, such as
bleeding diatheses and hypertension are important causes of severe haemorrhage,
they are rare, as is life threatening bleeding.

(Pashen D, Stevens M. (2002) Management of epistaxis in general practice.
Australian Family Physician 31
Available: www.racgp.org.au/afp/downloads/pdf/august2002/20020801pashen.pdf )

(Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 1328 )
* Question 23
Victor, a 36 year old man, has known ischaemic heart disease. He complains of a
recent increase in frequency of chest pain and presents with a prolonged episode of
chest pain. There are no ECG changes on your initial assessment. Management
includes all of the following EXCEPT:

a) Admission to hospital

b) Plasma troponin measurement

c) Continuous ECG monitoring

d) Commencement of a statin drug
Incorrect. The correct answer is (e).

e) Begin thrombolytic therapy

Clinically this patient has unstable angina pectoris (UAP). Management should
include continuous ECG monitoring,-admission to hospital and plasma troponin
measurement to exclude myocardial infarction. The Heart Foundation guidelines
2000-2002 state that immediate commencement of a statin reduces risk in UAP, as
does aspirin and antithrombotic agents such as heparin. Use of thrombolytics in UAP
is not indicated since they are ineffective and may be harmful. If there is no
improvement in 24-48 hours, cardiac catheterisation and angioplasty are indicated.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=82486&searchStr=unstable+angina#8
2486 )

(National Heart Foundation
Available: www.heartfoundation.com.au/index.cfm?page=35 )
Question 24
Moira, a 21 year old woman, presents with an enlarged lower cervical lymph node.
Biopsy shows thyroid glandular tissue. The MOST LIKELY diagnosis is:

a) Ectopic thyroid

b) Adenoma of lateral thyroid
Incorrect. The correct answer is (d).

c) Thyroglossal cyst

d) Metastasis from thyroid carcinoma

e) Lymphadenoid goitre

Thyroid cancer typically presents as a nodule in the gland but can present as an
enlarged cervical node, as in this case. Surgical removal of involved nodes is usually
curative, especially in young patients. They are sensitive to TSH and so thyroxine
can be used to suppress them. The cervical nodes lie more lateral in the neck than is
usual for ectopic thyroid tissue or an adenoma. Similarly, thyroglossal cysts lie in the
midline between the thyroid gland and the base of the tongue, and move when the
tongue is protruded. Lymphadenoid goitre is due to Hashimoto's thyroiditis.

(Way LW, Doherty GM. (2003) Current Surgical Diagnosis & Treatment. Lange
Medical Publications, McGraw-Hill, NY, p 305-307 )

(Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section13/cha
pter155/155b.jsp%3Fregion%3Dmerckcom&word=perinephric&word=abscess&doma
in=www.merck.com#hl_anchor )
Question 25
Which of the following usually results in a left homonymous hemianopia?

a) Damage to the left optic nerve
Incorrect. The correct answer is (e).

b) A pituitary tumour

c) Damage to the right optic nerve

d) A lesion of the left optic radiation

e) A lesion of the right optic tract

Lesions of the optic tracts cause homonymous hemianopic visual field defects. A
lesion of the right optic tract causes a left homonymous hemianopia, i.e. left half of
visual field lost in both eyes. Damage to the optic nerve results in a unilateral
blindness while damage to the optic radiation results in a quadrantic field defect. A
pituitary tumour causes a bitemporal hemianopia.

(Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 849 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=53505&searchStr=hemianopia
Question 26
Which one of the following situations will NOT require prophylactic antibiotics to
manage a wound:

a) An elderly debilitated patient

b) The wound is more than 8 hours old

c) The patient has alcoholic liver disease

d) A deep wound to the hand

e) A large superficial abrasion on the thigh of a 22 year old
Correct

Wounds treated appropriately and early do not need antibiotics. Antibiotics may be
needed if the following risk factors are present:
delayed presentation
contamination
compromised patient, debilitated or general ill health
wounds in areas where infection may have serious consequences, eg hands
patients in whom presence of bacteremia may have serious consequences, eg
prosthetic heart valves or orthopaedic appliances


(Way LW, Doherty GM. eds. (2003) Current Surgical Diagnosis & Treatment. 11th ed.
Lange Medical Publications, McGraw-Hill, NY, p 120-122 )
* Question 27
Malcolm, a 55 year old man, presented with worsening symptoms of gastro-
oesophageal reflux disorder (GORD) despite following your lifestyle advice. You
referred him for a gastroscopy which has not revealed any abnormality. He still
complains of bloating and heartburn. Which of the following is the MOST
APPROPRIATE advice?

a) Reflux has been excluded as a cause of his symptoms

b) He should see a dietician to review possible food allergies

c) Endoscopy detects the presence of reflux in only 60-80% of patients

d) He should begin a trial of a proton pump inhibitor (PPI)
Correct

e) He should have a repeat endoscopy in 6 months

About 50% of patients with significant symptoms of GORD have no abnormality on
endoscopy. A good response to a PPI is as good as 24 hour pH monitoring to confirm
the diagnosis. True food allergies are uncommon (1-2% of adults) and typically
cause skin reactions, nausea, vomiting, diarrhoea or anaphylaxis. Other reactions are
non-immune and are called food intolerance or idiosyncrasy.

(Murtagh J., (2003), General Practice, Third ed, McGraw-Hill, Sydney, p 849 )

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=89425 )
Question 28
Sarah is a 28 year old diabetic patient who presents with a recent history of fever
and increased urinary frequency. Urine culture shows E. coli sensitive to ampicillin
and gentamycin with which she is treated intravenously. However, a week later she
is still having fever and the same urinary symptoms. Blood culture reveals motile
E.coli.
All of the following are likely to be causes for her symptoms EXCEPT:

a) In vivo resistance of the organism

b) Autonomic dysregulation due to her diabetes

c) Papillary necrosis
Incorrect. The correct answer is (b).

d) Inadequate dosage of antibiotic

e) Perinephric abscess

Clinical failure of antimicrobial therapy may be due to inadequate dose, accelerated
drug inactivation, poor penetration to a site of infection, undrained abscess, poor
host defences, dead tissue, superinfection by another pathogen, or development of
drug resistance.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=68140&searchStr=perinephric+abscess
#68140 )

(Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section13/cha
pter155/155b.jsp%3Fregion%3Dmerckcom&word=perinephric&word=abscess&doma
in=www.merck.com#hl_anchor )
Question 29
The aim of surgery in patients with perforation and infection of the tympanic
membrane is to:

a) Restore hearing
Incorrect. The correct answer is (b).

b) Produce a dry, safe, waterproof ear

c) Improve the appearance of the drum

d) Prevent further perforation

e) Restore Eustachian tube function

The aim of myringoplasty is to produce a dry, 'safe', waterproof ear to which a
hearing aid may be fitted. 'Safe' implies free of risk of cholesteatoma. Myringoplasty
may not restore hearing, as this also depends on Eustachian tube function. The
appearance of the drum is obviously unimportant, nor will surgery prevent
recurrence of perforation.

(Fagen P., Patel N. (2002). A hole in the drum: an overview of tympanic membrane
perforations. Australian Family Physician, 31: 707-710
Available: www.racgp.org.au/afp/downloads/pdf/august2002/20020801fagan.pdf )
Question 30
John, a 58 year old overweight plumber, complains of lack of energy towards the
middle of the day. He has to get up twice at night to pass urine and wants a check
for prostate cancer. The MOST LIKELY cause of his symptoms is:

a) Psychogenic polydipsia

b) Diabetes insipidus

c) Diabetes mellitus
Correct

d) Hypercalcaemia

e) Chronic renal failure

The classical symptoms of type 1 diabetes mellitus are polydipsia, polyuria,
polyphagia, fatigue and loss of weight. In type 2 diabetes mellitus, patients have
insulin resistance related to obesity, rather than loss of weight. The other options
listed also cause polyuria, but are less likely in the circumstances described.

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=55698 )

(Murtagh J., (2003), General Practice, Third ed, McGraw-Hill, Sydney, p 189-191 )
Question 31
Which of the following statements about post-traumatic stress disorder, is correct?

a) It develops in every person who is affected with the same severe stressful
event

b) Signs and symptoms usually occur between 1 and 6 months after the stressful
event

c) Alcohol abuse reduces the likelihood of its development

d) It seldom occurs in assaulted spouses in domestic violence

e) Debriefing and counselling are insufficient as initial treatment
Incorrect. The correct answer is (b).

According to DSM-IV, the person must have experienced an event outside the range
of usual human experience that would be markedly distressing to anyone. Signs and
symptoms usually occur between 1 and 6 months of the stressful event.
Not every person who suffers the same stressful event will develop post-traumatic
stress disorder, and there are some known protective factors, such as being part of a
group involved in a traumatic event. Risk factors include alcohol and drug abuse,
previous history of depression and previous history of sexual abuse. Victims of
domestic violence can develop post-traumatic stress disorder.
Short term counselling and debriefing are effective treatments. Some sufferers will
also require drug therapy.

(Sadock BJ, Sadock VA. eds (2003) Synopsis of Psychiatry, Lippincott Williams &
Wilkins p 623-632 )

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=109209 )

(Summerfeld D (2001) BMJ, 322: 95-98
Available:
http://bmj.bmjjournals.com/cgi/content/full/322/7278/95?maxtoshow=&HITS=10&h
its=10&RESULTFORMAT=&fulltext=posttraumatic+stress+disorder&andorexactfullte
* Question 32
Herman is a 57 year old man who is recovering from a hitherto uncomplicated
myocardial infarction. On the fourth day he complains of sudden onset of
palpitations. Initial examination confirms a tachycardia with blood pressure of
140/80. The ECG shows the following rhythm (see figure).

The first line treatment for this patient is:

a) Carotid sinus massage
Incorrect. The correct answer is (d).

b) Digoxin IV

c) Verapamil IV

d) Lignocaine IV

e) DC cardioversion

This ECG shows ventricular tachycardia with a rate of 150 b.p.m. There is a rapid
ventricular rhythm with broad, abnormal QRS complexes. Since his blood pressure is
well maintained, medical treatment is indicated as first line approach. Lignocaine IV
or sotalol IV or amiodarone IV can be used. DC cardioversion is required if medical
therapy is unsuccessful. If the cardiac output and blood pressure are very depressed,
emergency DC cardioversion must be considered. Carotid sinus massage is not
indicated in this setting because there is a high likelihood of carotid artery disease
which makes the procedure dangerous. Also the arrhythmia is unlikely to be a
supraventricular tachycardia with bundle branch block. If untreated the ventricular
tachycardia may rapidly progress to a ventricular fibrillation.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=80287&searchStr=tachycardia%2c+ve
ntricular#80287 )

(Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section16/cha
pter205/205h.jsp%3Fregion%3Dmerckcom&word=ventricular&word=tachycardia&do
main=www.merck.com#hl_anchor )

(Murtagh J., (2003), General Practice, Third ed, McGraw-Hill, Sydney, p 782-790 )
Question 33
Which of the following is INCORRECT with regard to the management of syphilis?

a) The diagnosis should be confirmed with treponemal tests
Incorrect. The correct answer is (e).

b) Intramuscular injection (IMI) of penicillin is the treatment of choice

c) Serological and clinical review should be done at six and 12 months

d) The patient should be tested for other STDs

e) Sexual contacts should be clinically examined for features of syphilis

Syphilis should be confirmed on diagnosis with specific tests such as FTA-Abs. IMI
benzathine penicillin as a single dose followed by procaine penicillin IMI daily with
probenecid for 10 days is the first line treatment for syphilis. Follow up with
serological and clinical review is recommended, as is the need to test for other
STD's. Recent sexual contacts may not have clinical features of syphilis but should be
treated.

(Ooi, C., Dayan, L. (2002), Syphilis: Diagnosis and management in General Practice,
Australian Family Physician, 31:
Available: www.racgp.org.au/afp/downloads/pdf/july2002/20020701ooi.pdf )

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=73039 )

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=73083 )
Question 34
Daryl is a 3 year old boy who presents with lesions at the corner of his mouth and
ulcers in the mouth (see image below).

These have developed rapidly over a few days and he is febrile and not eating.
Daryl's management should include:

a) Commencement of oral metronidazole

b) Commencement of oral flucloxacillin

c) Commencement of famciclovir
Correct

d) Application of topical mupirocin

e) Application of topical corticosteroid

This is an example of herpes simplex infection (primary herpetic gingivostomatitis).
Regional lymphadenopathy, fever, headache and malaise may also be present.
Where there is difficulty eating or swallowing oral famciclovir, valaciclovir or aciclovir
should be commenced. Systemic analgesics and topical anaesthetic agents, eg
lignocaine gel can be used and chlorhexidine mouthwashes may prevent secondary
infection. Topical corticosteroids are contraindicated.

(Polano, M. et al (1992), Color Atlas and Synopsis of Clinical Dermatology, 2nd ed,
New York, McGraw-Hill )

(Murtagh, J. (2003), General Practice, Third ed, McGraw-Hill, Sydney, p 910-911,
1179-80)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=74294&searchStr=herpesviral+gingivos
tomatitis+and+pharyngotonsillitis#74294
Question 35
Maria brings Amy, her 6 month old daughter, who has never been immunised, to see
you. Maria states that she is using homoeopathic drops. Which of the following
concepts is it important to ensure that Maria understands?

a) Vaccine preventable diseases are still prevalent

b) Side effects of the disease are greater than side effects of the vaccine

c) The acellular form of the pertussis vaccine reduces the incidence of side effects

d) Amy could still be fully immunised with conventional vaccines

e) All the above
Correct

Maria needs to appreciate all the concepts listed in the options. Moreover, she needs
to be made aware that-homeopathic 'immunisation' has not been proven to give
protection against infectious diseases-only conventional immunisation produces a
measurable immune response. The Australian Immunisation Handbook has a table
which clearly shows a comparison of the effects of vaccines versus the much greater
morbidity of the diseases against which they protect.

(NHMRC (2003), The Australian Immunisation Handbook, 8th ed, Canberra,
Australian Government Publishing Service
Available: http://immunise.health.gov.au/handbook.htm
Available: http://www1.health.gov.au/immhandbook/ )

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=67321 )
Question 36
Which of the following statements regarding dementia is CORRECT?

a) One in nine Australians in the group aged >85 suffers from dementia

b) Dementia affects one in four people aged 80-85
Incorrect. The correct answer is (c).

c) Family history is a major risk factor for Alzheimer disease

d) Vascular disease is the most common cause of dementia

e) Dementia is no more common in the indigenous population than in the general
community

Age and family history are the two most common risk factors for dementia. One in
15 Australians aged 65 and over has dementia. In people aged 80-85 years, it
affects 1 in 9 people. In those over 85 years, it affects 1 in 4. Alzheimer's disease is
the most common cause of dementia. In the most recent assessment of indigenous
Australians, 10% of those aged 65 and over were found to have dementia and
another 10% were suspected of having it.

(The Alzheimer's Association. Australian Dementia Facts (2002), Australian Family
Physician, vol, 31
Available: www.racgp.org.au/document.asp?id=6144 )

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=105251 )

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=105270 )
* Question 37
Edith is a 70 year old woman who presents with palpitations. Her ECG is shown
below.

What is the diagnosis?

a) Atrial flutter
Incorrect. The correct answer is (b).

b) Atrial fibrillation

c) Atrial premature beats

d) Sinus arrhythmia

e) 1st degree AV block

This ECG shows atrial fibrillation. There are no p waves and the rhythm is irregularly
irregular which causes the patient to perceive palpitations.

(Murtagh J., (2003), General Practice, Third ed, McGraw-Hill, Sydney, p 785-788 )

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=80153 )
Question 38
The clinical features of classical migraine include all of the following EXCEPT:

a) Unilateral temporofrontal distribution

b) Retro-orbital and occipital radiation

c) Intense throbbing character

d) Duration 4 hours to a week
Correct

e) Associated with nausea and vomiting

Migraine attacks last 4-72 hours (average 6-8 hours), but never as long as a week.

(Murtagh J., (2003), General Practice, Third ed, McGraw-Hill, Sydney, p 612-616 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=51922&searchStr=migraine#51922 )
Question 39
Malcolm, aged 25 years, presents complaining of feeling unwell with a painful ulcer
on his penis. He has tender inguinal lymphadenopathy on examination. What is the
MOST LIKELY diagnosis?

a) Primary genital herpes

b) Primary syphilis

c) Secondary syphilis

d) Recurrent genital herpes

e) Chancroid
Incorrect. The correct answer is (a).

Primary genital herpes is the most likely cause of a painful ulcerative lesion on his
penis. It begins as multiple vesicles which ulcerate and can become secondarily
infected. Recurrent genital herpes episodes tend to become milder and less frequent
over time. The primary lesion of a syphilitic ulcer is painless and usually persists for
4-6 weeks and heals spontaneously. Chancroid produces multiple painful exudative
nonindurated ulcers.

(Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 1120-1122 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=74298&searchStr=genital+herpes#742
98 )

(Harrison's Online
Available: www.accessmedicine.com/content.aspx?aID=68331 )
Question 40
A 24 year old married woman presents with patches of a scaly coppery pink macular
rash over the trunk. The rash has been present for one week. The patches are oval,
of different sizes, and appear to be spreading. The patches are arranged along the
skin creases. She feels well. There are no other abnormal findings. Which of the
following is the MOST APPROPRIATE management?

a) Application of benzyl benzoate lotion

b) Prescription of antihistamines

c) Reassurance as it is a self limiting condition
Correct

d) Pathology test for rubella antibody titre

e) Application of topical steroids

The description is typical of Pityriasis rosea and management is usually reassurance
only as this is a self-limiting condition and disappears in 4-10 weeks. Calamine lotion
can be used if there is an associated itch and topical steroids are only rarely used in
the presence of moderately severe itch.

(Fitzpatrick, T.B. Johnson, R.A. et al (Eds) (1993) Color Atlas and Synopsis of Clinical
Dermatology 2nd ed p56 New York McGraw Hill )

(Murtagh J (2003) General Practice. Third ed, McGraw-Hill, Sydney, p 1172-1173 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=56798&searchStr=pityriasis+rosea#56
798 )