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 e) clozapine Incorrect. The correct answer is (d).

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. (Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 498-500 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109485 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 Incorrect. The correct answer is (d). d) Bronchogenic carcinoma 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. (Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 453 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109485 ) 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 ) (Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 1301-1304 ) 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. (Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 1118-1120 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=68374 ) 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. (Australian Medicines Handbook Pty Ltd (2004) Australian Medicines Handbook Adelaide AMH Available: www.amh.net.au/ ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109485 ) 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. (Way LW, Doherty GM. (2003) Current Surgical Diagnosis & Treatment. Lange Medical Publications, McGraw-Hill, NY, p 319-339 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=62433&searchStr=breast+cancer 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 Incorrect. The correct answer is (d). d) One hour before the extraction 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. (Prophylactic antibiotics in children. Canadian Paediatric Society Paediatrics & Child Health 1999; 4(7):490-494 Available: www.cps.ca/english/statements/ID/id99-05.htm#Protection ) 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 b) Side effect of drug

c) Impaired insight d) Transference e) Hallucinations Incorrect. The correct answer is (c).

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. (Bloch, S., Singh, B.S. (1998) Foundations of Clinical Psychiatry. Melbourne University Press, Melbourne, p 77-78 ) (Sadock BJ, Sadock VA. eds (2003) Synopsis of Psychiatry, 9th ed. Lippincott William & Wilkins p 287 ) 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. (Murtagh J. (2003) General Practice. Third edition. McGraw-Hill, Sydney, p 980 ) (Merck Manual of Diagnosis and Treatment Available: www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section18/cha pter242/242b.jsp%3Fregion%3Dmerckcom&word=intraductal&word=breast&word=c ancer&domain=www.merck.com#h1_anchor )

Question 10 Which of the following drugs, causes stimulation of cardiac contraction with LEAST vasoconstrictor effect? a) Adrenaline b) Isoprenaline Correct 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. (Rang HP, Dale MM, Ritter JM (1995) Pharmacology, 3rd ed. Churchill Livingstone, Edinburgh, Chap 7, p 168, 175 ) (Murtagh J., (2003), General Practice, McGraw-Hill, Sydney, p 789, 1333 ) 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 Correct c) Regression d) Repression e) Projection

Suppression refers to the conscious or 'semi-conscious' decision of an emotionally mature, 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 Correct b) Be complicated by a staphylococcal infection c) Require a short course of oral antibiotics 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. (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 13 Which of the following statements about patent ductus arteriosus is INCORRECT? a) It occurs frequently as an isolated phenomenon b) Cyanosis is usually present Correct 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%. (Sadock BJ, Sadock VA. eds (2003) Synopsis of Psychiatry, 9th ed. Lippincott William & Wilkins p 482 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109494&searchStr=schizophrenia#109 494 ) 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 Correct d) Weakness of the leg e) Smooth shiny skin on the leg below the knees

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

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. (Diclemente, Carlo C, & Prochaska, James O. (1995). An Empirical Typology of Subjects within Stage of Change. Addictive Behaviours, 20 (3), 299-320. Available: www2.msstate.edu/~bhunt/Stages_of_Change_Theory/precontemplation.html ) (Merberg B. The Health Coach Available: www.healthcoach4u.com/Ezine/ezine20011228.html ) 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 ) (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 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 Correct c) Females seek health care facilities more than males d) Males die more in accidents and violence than the females 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 Incorrect. The correct answer is (e). c) Continuous ECG monitoring d) Commencement of a statin drug 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 c) Thyroglossal cyst Incorrect. The correct answer is (d). 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 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 Correct

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#search Term ) 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 Incorrect. The correct answer is (e). d) A deep wound to the hand e) A large superficial abrasion on the thigh of a 22 year old

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 gastrooesophageal 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 Incorrect. The correct answer is (b). b) Autonomic dysregulation due to her diabetes c) Papillary necrosis 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 Correct 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

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&andorexactfulltex t=and&searchid=1105664191269_1846&stored_search=&FIRSTINDEX=0&sortspec= relevance&resourcetype=1 ) * 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 b) Digoxin IV c) Verapamil IV d) Lignocaine IV e) DC cardioversion Incorrect. The correct answer is (d).

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 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 Correct

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 d) Application of topical mupirocin Incorrect. The correct answer is (c). 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 c) Family history is a major risk factor for Alzheimer disease Correct 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 b) Atrial fibrillation c) Atrial premature beats d) Sinus arrhythmia Incorrect. The correct answer is (b). 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 Incorrect. The correct answer is (d). c) Intense throbbing character d) Duration 4 hours to a week 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 d) Pathology test for rubella antibody titre e) Application of topical steroids Incorrect. The correct answer is (c).

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 )