Question 34

Which of the following is suggested by a history of transient episodes of vertigo,

slurred speech, diplopia, and paraesthesia in a man aged 65 years?
a) asilar artery insufficiency
Correct
b) !nterior communicating artery aneurysm
c) "ypertensive encephalopathy
d) #seudobulbar palsy
e) $cclusion of the middle cerebral artery
%pisodes of vertigo, diplopia and paraesthesia indicate alteration of brainstem
function caused by basilar artery insufficiency& 'iddle cerebral occlusions usually
presents with contralateral hemiplegia and homonymous hemianopia& (lurred speech
or aphasia may occur in both conditions& !nterior communicating artery aneurysms
are li)ely to result in emotional lability& "ypertensive encephalopathy comprises
headache, confusion, stupor or convulsions& #seudobulbar palsy presents with
dysarthria, dysphagia and emotional lability&
Question 35
'andy, a 4 year old girl, is due to accompany her parents on a flight to %ngland in
two months time& "er mother is worried about the effect of air travel on 'andy*s
ears& Which of the following will +$, increase the li)elihood of ear pain during the
flight?
a) ! recent cold
b) +asal congestion
c) "ay fever
d) -ecent otitis media
e) #erforation of the ear drum
Correct
+ormal function of the middle ear and tympanic membrane is maintained by a patent
eustachian tube which )eeps the middle ear and e.ternal canal pressures e/ual&
loc)age of the eustachian tube, e&g& with secretions as in the common cold, results
in pressure imbalances between the middle and e.ternal ear& 0uring air travel, the
resulting barotrauma may cause pain, deafness, vertigo, and tinnitus& !ll the options
listed, e.cept 1e), can cause bloc)age of the eustachian tube&
2 Question 36
(ue, a three year old girl, presents with shortness of breath and whee3e that have
developed over the last two days& %.amination reveals an afebrile, moderately
tachypnoeic child with widespread scattered whee3es on auscultation& 4ou decide to
administer a bronchodilator 1salbutamol)& ,he recommended method of delivery of
salbutamol for (ue is5
a) (yrup
b) +ebuliser
c) reath activated inhaler
d) 'etered dose inhaler with a spacer
e) 'etered dose inhaler with a spacer and face mas)
Correct
6or the treatment of acute asthma in a child 76 years of age, the recommended
mode of delivery of bronchodilator 1salbutamol) is via a metered dose inhaler and
small volume spacer with face mas)& 6or those 86 years of age, a large volume
spacer may be substituted& (albutamol administered via these routes has been
shown to be e/ually effective to nebulised salbutamol& (i. puffs of salbutamol via
'09 and spacer is the e/uivalent of a :&5 mg nebule, while ;: puffs e/uals a 5mg
nebule&
Question 3<
$liver, an = month old boy, presents with a history of anore.ia and recurrent upper
respiratory tract infections& #hysical e.amination reveals pallor and splenomegaly&
"is blood picture shows a hypochromic, microcytic anaemia with numerous target
cells and nucleated red cells& What is the '$(, >9?%>4 diagnosis?
a) ,halassaemia ma@or
Correct
b) 9ron deficiency anaemia
c) AlucoseB6Bphosphate dehydrogenase deficiency
d) (ideroblastic anaemia
e) (ic)le cell anaemia
,halassaemia ma@or 1homo3ygous betaBthalassaemia) is a severe disease which
presents during the first year of life with5 failure to thrive, intermittent infection,
severe hypochromic, microcytic anaemia and signs of e.tramedullary haemopoiesis
1hepatosplenomegaly and bone e.pansion)& 9t does not present at birth because the
production of foetal haemoglobin is not affected&
2 Question 3=
9n acute iritis 1anterior uveitis), the pupil is5
a) %ccentric, constricted and reacts bris)ly to light
b) Concentric, dilated and reacts bris)ly to light
c) %ccentric, dilated and reacts sluggishly to light
d) Concentric, constricted and reacts sluggishly to light
Correct
e) Concentric, dilated and reacts sluggishly to light
!nterior uveitis typically presents with a unilateral painful red eye, blurred vision,
photophobia and tearing& ,here is a perilimbal flush and pupillary miosis with a
sluggish response and increased pain during accommodation to light& ,his is due to
spasm of the ciliary body and iris muscles& (lit lamp e.amination will demonstrate
)eratic precipitates on the cornea& Drgent treatment is needed to prevent
complications&
Question 3E
,he '$(, common cause of persistent cough in children is5
a) Chronic post viral cough
b) !sthma
Incorrect. The correct answer is (a).
c) #ostBpertussis
d) AastroBoesophageal reflu.
e) #assive smo)ing
,he commonest cause of persistent cough 1particularly with a prominent nocturnal
component) in children is post viral& 9t can also be associated with postnasal drip&
"owever, care must be ta)en to e.clude asthma which is a fairly common cause of
persistent cough in children& $ther less common conditions to be considered include
gastrointestinal reflu., passive smo)ing and post pertussis&
2 Question 4F
,revor is a :&4 )g male infant with !pgars E5;F after a normal vaginal delivery& "e
becomes @aundiced at ;: hours of age& Which of the following conditions would be
the '$(, >9?%>4 cause of the @aundice?
a) Aram negative septicaemia
b) Gaundice of prematurity
c) iliary atresia
d) #hysiological @aundice
e) -h incompatibility
Correct
Gaundice appearing in the first :4 hours of life is most commonly due to haemolytic
disease of the newborn due to incompatibility to -h, !$ or one of the other rare
antigens& $ther causes of early @aundice include transplacental infections such as
C'H, to.oplasmosis and rubella& Gaundice of prematurity, physiological @aundice and
septicaemia present most commonly between days :B5& iliary atresia presents with
@aundice after the first wee) of life&
Question ;
'rs is 55 years old and presents because of painful mouth ulcers 1see figure)& 4ou
diagnose aphthous ulcers& (he is otherwise well& Which of the following statements
about aphthous ulcers is 9+C$--%C,?
-eproduced with permission, "ong ?ong Aovernment, 0epartment of "ealth, ,ooth
Club, :FF3&
a) ,he cause is rarely found
b) ,here is often a family history
c) ,he ulcers often begin in childhood
d) ,hey are often an indicator of ehcet*s syndrome
e) !phthous ulcers may present li)e herpetic vesicles
Incorrect. The correct answer is (d).
ehcet*s syndrome is a systemic condition with recurrent multiple apthous ulcers
!+0 two of the following5 B recurrent genital ulceration, eye lesions, s)in lesions or
positive pathergy test 1nonBspecific inflammatory s)in reaction following intradermal
saline in@ection)& -ecurrent apthous ulceration in isolation is not associated with
ehcet*s syndrome& ,he other statements concerning apthous ulcers are all true&
Question :
,he drug of choice for treatment of erysipelas is5
a) #enicillin
Correct
b) 'ethicillin
c) !mpicillin
d) ,etracycline
e) +one of the above
%rysipelas is a form of superficial cellulitis of the s)in with lymphatic involvement& 9t
is almost always caused by (trep pyogenes and therefore the treatment of choice is
penicillin 1erythromycin or cephale.in can be used in penicillin allergic patients)&
2 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) ,he progress of the clinical features
b) ,he degree of loss of consciousness
c) ,he abruptness of onset
Incorrect. The correct answer is (e).
d) ,he presence or absence of headache
e) +one of the above
9ntracerebral haemorrhages tend to be dramatic and accompanied by a severe
headache& "owever, there really is no clinical way of reliably distinguishing between
an intracerebral haemorrhage and a thromboembolic infarction, as both produce a
sudden focal deficit&
PHARMACOLOGIC TREATMENT OF ANXIETY DISORDERS
Anxiety and anxiety disorders are common clinical problems. The twelve-month community prevalence rates for the major
anxiety disorders range from 0.7% for obsessive-compulsive disorder to .!% for panic disorder.
"
#ntreated anxiety may
be a significant source of distress and impairment. Anxiety disorder may be effectively managed by pharmacologic
treatment$ psychotherapy$ or a combination of medication and therapy. The initial selection of specific pharmacologic
treatment is often based on the anticipated duration of the anxiety. Acute %and time-limited& anxiety can often be managed
with short-term ben'odia'epine therapy. (hronic anxiety is often better managed with medications in the antidepressant
class.
Treatment should be selected after a careful review of specific drug indications$ adverse effects$ drug-drug interactions$
cost$ and clinician experience. )atients should be informed of the ris*s and benefits of suitable pharmacologic agents.
+ith all antidepressants$ especially selective serotonin reupta*e inhibitors %,,-.s& and venlafaxine$ the clinician should
review the potential for idiosyncratic increase in anxiety and agitation. Additionally$ patients should be aware of the
potential for the rare emergence of suicidal ideation.

,ince ,,-.s and ben'odia'epines can produce significant

withdrawal syndromes$ patients should be instructed about the need to taper medications under a physician/s care$ should
they decide to discontinue their medications.
!
Role of benzodiazepines
Acute stress-related anxiety can result in the development of adjustment disorder with anxious mood. )hysicians may
encounter patients with high anxiety related to medical illness. 0or example$ an excessively anxious patient awaiting the
result of biopsy may meet criteria for adjustment disorder. The diagnosis of adjustment disorder re1uires that the patient2s
anxiety level exceed that expected for the stressor. ,ince adjustment disorder with anxious mood often improves with
time$ a limited duration of pharmacologic treatment is indicated. 0or milder acute anxiety$ a process of observation may be
appropriate to monitor an expected resolution of symptoms over time.
3en'odia'epines produce a rapid-onset anxiolytic effect and may be the agents of choice for adjustment disorder with
anxiety with an anticipated duration of treatment of less than 4 wee*s. 5any ben'odia'epines also have intravenous
formulations that can be used in the emergency room or preoperatively. 6owever$ clinicians should review the ris* for
ben'odia'epine misuse before prescribing. This ris* is increased for patients with a personal history of alcohol abuse or
illicit substance dependence. 7ther ris* factors for misuse include a family history of alcohol abuse or family history of
substance dependence. 0inally$ ben'odia'epine therapy should be avoided in patients with antisocial personality disorder.
,ince ben'odia'epines have limited effect on depression$ these agents should not be used as monotherapy for patients
with anxiety in the context of significant depression.
+hen using ben'odia'epines to treat acute anxiety$ dosage titration is re1uired to limit ris* of adverse effects. 6igher daily
doses of ben'odia'epines may raise ris* of falls and other types of accidents. The ability to form memories can be
impaired during the time ben'odia'epines are in the blood. )atients should not drin* alcohol while ta*ing
ben'odia'epines.
Role of sele!i"e se#o!onin #e$p!a%e in&ibi!o#s
(hronic anxiety should produce a search for a specific anxiety disorder diagnosis. 8enerali'ed anxiety disorder$ panic
disorder$ social phobia$ obsessive-compulsive disorder$ and posttraumatic stress disorder are common causes of chronic
anxiety. ,,-.s appear to be effective across many of the specific anxiety disorders. The ,,-.s include fluoxetine$
sertraline$ paroxetine$ fluvoxamine$ citalopram$ and escitalopram. ,ome of these agents have specific indications
approved by the #, 0ood and 9rug Administration %09A& for individual anxiety disorder diagnostic categories. 6owever$
most head-to-head comparisons between agents in the ,,-. class find similar response rates for individual anxiety
disorder categories.
:

Although the ,,-.s appear to have e1ual efficacies for anxiety disorders$ a trial with a second ,,-. may be indicated
after failure with the first ,,-.. ,ome individual patients appear to respond better to one ,,-. than to another. The only
valid way to determine which ,,-. will produce a response in a particular patient is to perform clinical trials.
Role of o!&e# an!idep#essan! o'po$nds
Tricyclic antidepressants %T(As& have been effective for the treatment of many anxiety disorders. .mipramine has been
studied and found to be effective in a variety of anxiety states. (lomipramine has an 09A indication for the treatment of
obsessive-compulsive disorder. Although T(As have clinical effectiveness for many anxiety disorders$ their limited
tolerability and toxicity in overdose ma*e them second-line agents for many patients.
;ewer antidepressants are available with good tolerability and serve as reasonable alternatives to T(As and ,,-.s.
<enlafaxine is a dual-action reupta*e inhibitor that bloc*s the reupta*e of both serotonin and norepinephrine. .t has been
approved by the 09A for the treatment of generali'ed anxiety disorder$ social phobia$ and panic disorder.
=
9uloxetine is
also a dual-action reupta*e inhibitor> it has not yet received extensive study in the treatment of anxiety disorders.
5onoamine oxidase inhibitors %5A7.s& such as phenel'ine and tranylcypromine appear to have significant anti-anxiety
properties. These agents may be considered for patients with social phobia or posttraumatic stress disorder. 5A7.s can
produce hypertensive crisis in interactions with some drugs and foods with high tyramine content. This interaction limits
their usefulness except in patients whose symptoms are refractory to other treatment.
Role of o!&e# a(en!s
A host of other pharmacologic agents from other drug classes may be helpful in the management of anxiety. 3uspirone is
an agent that may prove helpful in generali'ed anxiety disorder. )regabalin and gabapentin are anti-epileptic drugs with
structures similar to gamma-aminobutyric acid %8A3A&. These agents have limited abuse potential and may have a role in
the treatment of anxiety disorders.
4
Their role in anxiety management is li*ely to emerge with further clinical trials.
,ome clinicians have found anticholinergic agents such as diphenhydramine or hydroxy'ine as helpful in managing
anxiety. #se of these drugs should be limited in geriatric populations because of the ris* of memory impairment and
anticholinergic delirium.
The agents in the atypical antipsychotic class$ including risperidone$ olan'apine$ 'iprasidone$ 1uetiapine$ and aripipra'ole$
may be considered for patients with treatment-resistant anxiety disorders.
7
Atypical antipsychotic augmentation of an
,,-. in posttraumatic stress disorder and obsessive-compulsive disorder may provide incremental clinical improvement.
T#ea!'en! ($idelines
8uidelines for treatment of anxiety disorders provide additional details about pharmacologic treatment. Available
guidelines cover all of the major anxiety disorder categories.? 8uidelines are also available for some of the individual
anxiety disorder categories and for management of anxiety in primary care populations.
@$"0

2 Question 4
el is :F years old and has had a ,ype 9 allergic reaction to a bee sting& (he states
that there is a family history of bee sting allergy& Which of the following is +$, useful
advice for el?
a) 0o not drin) out of an open soft drin) can that has been left outdoors
Incorrect. The correct answer is (c).
b) "ave a supply of antihistamines on hand
c) 9nsect repellents are useful to prevent bee stings
d) 0o not wal) barefoot around swimming pools
e) !lways carry an adrenalin ;5;FFF in@ection, e&g& %pi#en, and )now how to use it
9nsect repellents have not been shown to be useful in preventing bites from stinging
insects& !nyone with a )nown allergy to stinging insects should )now how to
administer adrenalin ;5;FFF subcutaneously and have it with them at all times&
%#9pen is a commercial preparation which is supplied with an autoBin@ection device&
!voiding behaviours li)ely to lead to a sting B such as those mentioned in the options
and avoiding colourful clothes and perfumes which attract insects B is also important&
2 Question 5
Gohn is a 3F year old professional athlete who suddenly develops persistent dull
upper left chest pain which is not related to e.ertion& ,here are no associated cardiac
or respiratory features e.cept for a mild restriction in breathing& Gohn is afebrile and
otherwise well& Which of the following diagnoses is >%!(, li)ely?
a) (pontaneous pneumothora.
Incorrect. The correct answer is (e).
b) 6unctional chest pain
c) CostoBchondral syndrome
d) 'uscle strain
e) #leurodynia 1 ornholm*s disease)
ornholm*s disease is due to an infection by Co.ac)ie virus& 9t is often associated
with an acute upper respiratory tract infection with fever, pleuritic chest pain and
upper abdominal pain& ,hese pains can be severe and associated with tachypnoea& !
spontaneous pneumothora., functional chest pain, costochondritis or acute muscular
strain would be more li)ely in this patient&
Question 6
Which of the following statements concerning bee sting allergy is C$--%C,?
a) 9f a patient has had a lifeBthreatening episode in the past, he or she is at ris) of
a future one
Correct
b) ! mild reaction in the past puts a patient at ris) of a future life threatening
episode
c) Wasps only sting once
d) ! bee sting is smaller in volume than a wasp sting
e) ! raised serum 9gA persists for years in those at ris) of anaphyla.is
! previous lifeBthreatening reaction is an indicator that a similar episode may occur
in the future& -eactions 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&
Question <
,he nephrotic syndrome can be caused by all of the following %IC%#,5
a) 'inimal change disease 1lipoid nephrosis)
b) !myloidosis
c) 'embranous glomerulonephropathy
d) -enal vein thrombosis
Correct
e) 0iabetic nephropathy
-enal vein thrombosis is more li)ely to be a complication of nephrotic syndrome
rather than a cause& 9n nephrotic patients the blood is more coagulable than normal
and the circulation may be sluggish owing to hypovolaemia, both of which are li)ely
to induce thrombosis& ,he other options, together with focal and segmental
glomerulosclerosis, are responsible for EFJ of cases of nephrotic syndrome& ,hey
are all conditions which disturb the structure or function of the glomerular basement
membrane&
Question =
ill, aged 35 years, has been unwell for : days with severe abdominal cramps and
diarrhoea& "e visited friends living on a farm during the previous wee)& "e stated
that on inspection of his stool there appeared to be blood in it& What is the
significance of blood in the stool?
a) ,he causative organism is more li)ely to be bacterial than viral
b) ,here is a higher ris) of complications
c) ,his may be the first presentation of inflammatory bowel disease
d) (tool microscopy and culture to identify the organism is worthwhile
e) !ll of the above
Correct
,he presence of blood in the stool of a patient with a constitutional illness is strongly
suggestive of a bacterial infection& 9dentification of the causal bacteria is usually
desirable for clinical and public health reasons& 'ost of the conditions are reportable
to the relevant state health department& 9n some cases fulminant infection can occur
and treatment based on antibiotic sensitivities of the organisms will be re/uired&
'any of these bacteria 14ersinia, Campylobacter, (higella etc) can lead to a systemic
illness with polyarthropathy&
2 Question E
!bdul is a 5= year old man who presents with transient episodes of vertigo, slurred
speech, diplopia, and paraesthesia& Which of the following is the '$(, li)ely
diagnosis?
a) asilar artery insufficiency
Correct
b) !nterior communicating artery aneurysm
c) "ypertensive encephalopathy
d) #seudobulbar palsy
e) $cclusion of the middle cerebral artery
,ransient ischaemic attac)s involving the posterior brain circulation, i&e& the basilar
artery, are characterised by diplopia, vertigo, vomiting, dysarthria, ata.ia and
hemisensory loss&
Question ;F
!ndrew, aged 6F years, complains of traces of blood in his stool for the past few
wee)s& Which of the following is the '$(, li)ely cause?
a) 0iverticulosis
b) Cancer of the rectum
Incorrect. The correct answer is (c).
c) "aemorrhoids
d) !ngiodysplasia
e) Colitis
"aemorrhoids andKor anal fissures are the commonest and therefore most li)ely
causes of traces of fresh blood in the stool& ,hese are easily identified by physical
e.amination& "owever, there are a number of other more serious pathologies which
must be e.cluded, including colorectal cancer diverticulosis, angiodysplasia and
colitic conditions& ,hese can be diagnosed by a combination of rectal e.amination,
sigmoidoscopy and colonoscopy plus biopsy&
Question ;;
Cyanosis is >%!(, li)ely to occur in5
a) %bstein*s anomaly 1anomalous attachment of tricuspid valve)
b) ,etralogy of 6allot
c) ,ricuspid atresia
d) Hentricular septal defect
e) ,ransposition of the great vessels
Incorrect. The correct answer is (d).
Cyanotic heart disease occurs when the systemic venous return is directed bac)ward
into the systemic circulation without transitting the pulmonary vascular bed, i&e&
instead of pure left to right shunting, right to left or biBdirectional shunting occurs&
#atients with ventricular septal defects do not usually present with cyanosis&
"owever, if there is a particularly large defect, pulmonary vascular damage can occur
leading to pulmonary hypertension and right to left shunting with cyanosis
1%isenmenger*s syndrome)& ,he other options listed are all associated with right to
left shunting and cyanosis&
Question ;:
Which of the following pathogens causing gastrointestinal infection is +$, associated
with bloody diarrhoea?
a) >isteria monocytogenes
Correct
b) Campylobacter spp
c) 4ersinia enterocolitica
d) (almonella serovars
e) (higella
>isteria monocytogenes usually only causes illness in immunocompromised patients
and pregnant women& >& monocytogenes is /uite unli)e most foodBborne pathogens
in that it does not cause gastrointestinal symptoms but causes invasive infections
li)e meningitis, septicaemia, and chorioamniitis leading to stillbirth& Aastrointestinal
infections by all the other pathogens listed result in bloody diarrhoea to varying
degrees&
Question ;3
,he erythrocyte sedimentation rate 1%(-) is raised in all of the following %IC%#,5
a) 'ultiple myeloma
b) #olycythaemia rubra vera
Correct
c) 'acrocytic anaemia
d) #regnancy
e) Chronic hepatitis
,he %(- is a nonBspecific indicator of inflammatory and neoplastic disease& ,he %(-
increases with age and is raised in pregnancy, the puerperium and in anaemia& 9t is
increased in acute and chronic inflammatory disease and neoplastic disease& ! low
%(- 17;mmKhour) may be seen in polycythaemia rubra vera and sic)le cell disease&
,he CBreactive protein is a more sensitive early indicator of an acute phase response&
Question ;4
Which of the following statements about weight loss is C$--%C,?
a) 0ieting reduces the basal metabolic rate 1'-)
b) 0ieting increases the '-
c) %.ercise decreases appetite
d) 9nactivity increases appetite
e) +one of the above
Incorrect. The correct answer is (a).
Changes to a person*s stable weight, either an increase by forced feeding, or a
decrease by food restriction 1dieting), induce compensatory physiological responses
that resist these changes& ,hus with low calorie regimes the '- decreases to limit
energy e.penditure and appetite increases, factors which complicate the process of
weight loss for the dieter& %.ercise generally increases appetite in response to the fall
in blood glucose caused by e.ercise&
Question ;5
Which of the following is the '$(, C$''$+ pathological condition associated with
aortic aneurysms?
a) !therosclerosis
Correct
b) (yphilitic aortitis
c) ,rauma
d) -heumatic aortitis
e) Cystic medial necrosis
!therosclerosis is the most common pathological condition associated with aortic
aneurysms& ,he other options are also associated with aortic aneurysms but are less
common&
Question ;6
ob 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& 9nvestigations have
shown that he has a raised plasma very low density lipoprotein 1H>0>) level, i&e& he
has type 9H hyperlipoproteinaemia& Which of the following medications would you
prescribe?
a) Cholestyramine
b) Aemfibro3il
c) (imvastatin
d) !torvastatin
Incorrect. The correct answer is ().
e) 6ish oil
Aemfibro3il is a fibrate which is the class of drugs recommended for treatment of
type 9H hyperlipoproteinaemia& 9t stimulates lipoprotein lipase activity and thereby
strips triglycerides from H>0>, causing H>0> degradation and lowering of H>0>
levels, with conse/uent lowering of plasma cholesterol and triglyceride levels& ,he
mode of action and recommended indications for use of the other options are
discussed in the references below&
Question ;<
9n which of the following conditions does angina pectoris occur in the absence of
coronary artery disease5
a) 'itral stenosis
b) 'itral insufficiency
c) Coarctation of the aorta
d) !ortic stenosis
Correct
e) !ortic insufficiency
9n severe aortic stenosis when the aortic orifice is reduced to oneBthird or less of its
normal si3e, angina pectoris may occur because of insufficient perfusion of the
coronary arteries& ,his is usually associated with fainting and dyspnoea&
Question ;=
Whole body 3inc stores may be depleted in all of the following %IC%#,5
a) Coeliac disease
b) 0iabetes mellitus
Incorrect. The correct answer is (d).
c) !lcoholism
d) Hegetarianism
e) !c/uired immunodeficiency syndrome 1!90()
Linc is an essential component of many en3yme systems including carbonic
anhydrase, alcohol dehydrogenase and al)aline phosphatase& ,he best dietary
sources are meat, shellfish and legumesM 3inc in grains is less available for
absorption& Linc deficiency occurs in a variety of conditions 1including all the other
options listed above) but not vegetarianism& Hegetarians obtain ade/uate amounts of
3inc from legumes, nuts and cereals&
Question ;E
! man aged 55 years begins to develop progressive dementia and is admitted to
hospital because of a convulsive episode& $n e.amination the patient has wea)ness
of the right side of his body and a positive grasp refle. on the same side& ,he '$(,
>9?%>4 diagnosis is5
a) ! temporal lobe tumour on the right side
b) ! temporal lobe tumour on the left side
c) ! preBfrontal tumour on the left side
Correct
d) ! preBfrontal tumour on the right side
e) ! posterior fossa tumour on the left side
9nvolvement of the prefrontal area of the brain is often associated with impairment of
e.ecutive functions 1decisionBma)ing, disinhibited actions, impairment of
concentration and memory)& ,he emergence of developmentally primitive refle.es
such as grasping, rooting and suc)ing are seen mainly in patients with large
structural lesions of the frontal corte.& ,he rightBsided hemiparesis and grasp refle.
point to a leftBsided lesion&
Question :F
+on haem iron absorption is promoted by all of the following %IC%#,5
a) ! high phosphate content of the diet
b) >ow p" in the stomach
c) Hitamin C ta)en with a meal
d) 9ron deficiency
e) %rythroid hyperplasia
Incorrect. The correct answer is (a).
! high phosphate content of the diet inhibits iron absorption by forming insoluble
iron phosphates& !ll the other factors mentioned promote iron absorption& !cid and
vitamin C )eep iron in the ferrous form& 9ron deficiency and erythroid hyperplasia
influence iron absorption through un)nown mechanisms via the gut
Question :;
#aul is a 45 year old man with an acute myocardial infarction& "e develops a sinus
bradycardia of 3= beatsKminute with fre/uent ventricular e.trasystoles& ,he
9''%09!,% treatment of choice is5
a) 9ntravenous propranolol
b) 9mmediate direct current cardioversion
Incorrect. The correct answer is (d).
c) 9ntravenous morphine
d) 9ntravenous atropine sulphate
e) 9ntravenous lignocaine
!tropine should be the initial agent at doses of F&5mg 9H every 5 minutes until the
desired response is achieved by removing vagal inhibition ,ranscutaneous cardiac
pacing is indicated if the above is not effective 1bradycardia remains 74FKmin), with
internal pacing being the definitive treatment for progressive or persistent
bradycardias&
Question ::
!ll of the following features are consistent with haemolytic uraemic syndrome 1"D()
%IC%#,5
a) loody diarrhoea
b) ,hrombocytopaenia
Incorrect. The correct answer is (c).
c) "igh fever with rigor
d) +eurological abnormalities
e) !cute renal failure
"aemolytic uraemic syndrome is most common in children following a
gastrointestinal infection with a to.ic strain of %&coli& loody diarrhoea is the usual
presenting feature followed by haemolysis and renal failure& 'icrovascular damage
results in profound thrombocytopaenia and may involve the central nervous system&
9f fever is present it is usually lowBgrade& %arly supportive treatment allows a full
recovery in <FJ of children but there is a 3B5J mortality and ;5B3FJ will have
chronic renal failure&
Question :3
Which of the following triads of clinical features is found in beri beri?
a) Cardiac failure, glossitis, dermatitis
b) Cardiac failure, neuropathy, dermatitis
c) Alossitis, dermatitis, memory loss
d) Alossitis, neuropathy, memory loss
Incorrect. The correct answer is (e).
e) Cardiac failure, neuropathy, memory loss
eri beri is due to vitamin ; 1thiamin) deficiency& 9t is now mainly confined to the
poorest areas of (% !sia& +europathy presents as stiffness, numbness and wea)ness
of the legs and loss of an)le refle.es, progressing to polyneuropathy involving the
trun) and arms& ,hiamin deficiency impairs cardiac energy metabolism leading to
cardiac failure and oedema& Chronic thiamine deficiency results in Wernic)e*s
encephalopathy& #ellagra due to niacin deficiency results in glossitis, diarrhoea,
dermatitis, and dementia&
Question :4
Chronic inorganic lead poisoning is associated with all of the following laboratory
features %IC%#,5
a) asophilic stippling of red cells
b) 9ncreased red cell protoporphyrin level
c) +ormochromic normocytic anaemia
Correct
d) Draemia
e) !minoaciduria
,he anaemia of chronic lead poisoning is usually hypochromic microcytic& ,he other
options are all features of lead poisoning, due to to.ic effects on erythropoieses and
on the )idney&
Question :5
(heila is a ;E year old woman who presents with ascites, high venous pressure and a
small /uiet heart& Which of the following surgical procedures would be '$(, li)ely to
relieve her problem?
a) 'itral commissurotomy
b) Closure of the foramen ovale
c) >igation of a patent ductus arteriosus
d) Correction of coarctation of aorta
e) #ericardiectomy
Correct
(heila has constrictive pericarditis in which the pericardial cavity is obliterated and
dense scar tissue encases and constricts the heart& 0iastolic filling of the ventricles is
limited resulting in a decrease in cardiac output& ,he right ventricular diastolic
pressure is increased, leading to venous hypertension which in turn produces
hepatomegaly, ascites and peripheral oedema& #rompt pericardiectomy is the
treatment of choice& ,his corrects the hemodynamic abnormalities and patients
improve rapidly with a massive diuresis&
Question :6
,om is a 3F year old agricultural wor)er who wor)s with organophosphates& "e
presents with acute pain in the right iliac fossa& 4ou suspect acute appendicitis but
are concerned about the ris) of a laparotomy %C!D(%5
a) ,here is a ris) of erroneous diagnosis
b) ,here is a tendency to prolonged bleeding postBoperatively
c) ,here is an increased ha3ard in general anaesthesia
d) ,here is a li)elihood of delayed healing of the wound
Incorrect. The correct answer is (c).
e) ,here is a possibility of mental disorder after operation
$rganophosphates irreversibly inhibit acetylcholinesterase and cause accumulation of
acetylcholine at muscarinic and nicotinic receptors& 9n general anaesthesia, muscle
rela.ant drugs li)e prostigmine cause reversible bloc)ade of cholinesterase& (hould a
patient have absorbed subclinical doses of organophosphates 1e&g& in agricultural
wor) with pesticides), there is increased ris) of e.cessive neuromuscular bloc)ade
with use of muscleBrela.ants, and the patient may show signs of to.icity, or may
continue to be paralysed beyond the duration of the anaesthetic agent given&
Question :<
#amela is a 55 year old woman who comes to see you for dietary advice& (he is an
estimated ;F)g above her ideal body weight and is )een to reduce this before the
summer& Which of the following strategies would +$, be appropriate in this
situation?
a) !dvise #amela against the use of appetite suppressant medication
b) %ncourage daily e.ercise of at least 3F minutes with heart rate to <FJ of
ma.imum for her age
c) !ssist #amela to redefine her goals in terms of nonBweight targets such as waist
measurement and improved stamina
d) -ecommend an = wee) course of a very low calorie diet 14FFB6FF)calKday) to
get started
Correct
e) Warn #amela that a diet very low in carbohydrate is less li)ely to result in
sustained weight loss
Hery low calorie diets are most appropriate when body weight is 8;3FJ of ideal&
,hey must be supervised by a medical officer due to the potential for electrolyte
imbalance& !ll the other options are appropriate in this situation& ehavioural
modification that involves simple and sustainable changes in a person*s diet, e.ercise
and lifestyle routine is li)ely to be the most effective way to achieve and maintain an
ideal body weight&
2 Question :=
,he 69-(, sign of salicylate poisoning in children is usually5
a) 0elirium
b) Coma
c) "yperventilation
Correct
d) "yperpyre.ia
e) Convulsions
!spirin has a twoBfold to.ic effect& 6irst, it inhibits o.idative phosphorylation leading
to a metabolic acidosis& ,he increased hydrogen ion concentration of the e.tracellular
fluid stimulates the respiratory centre of the brain to cause hyperventilation& ,his is
the primary effect in children& (econd, aspirin directly stimulates the respiratory
centre to cause hyperventilation leading to a respiratory al)alosis& ,his phenomenon
is seen mainly in adults
2 Question :E
Charles is a 4= year old businessman who presents for a general chec)Bup and
mentions that he is e.periencing occasional fluttering sensations in his chest& !
routine electrocardiograph 1see figure) is ta)en&
4our first line of management should be5
a) -eassurance
b) -eferral for cardioversion
c) egin a trial of verapamil
Incorrect. The correct answer is (a).
d) Commence betaBbloc)ade
e) Aive lignocaine stat
,he %CA shows Charles has premature atrial ectopic beats& $ften these are
asymptomatic& ,hey may, however, be sensed as an irregularity or heaviness of the
heart beat& ,reatment is not normally re/uiredM reassurance is all that is needed&
"owever, if the ectopic beats provo)e more significant arrhythmias, etaBbloc)ade
may be effective& Charles would be given general advice regarding /uitting smo)ing
and minimising alcohol, caffeine and other stimulants such as cough medicines&
Question 3F
Games is a 5F year old woodcutter whom you treated for a Colles* fracture two days
ago& "is wife telephones as)ing you to prescribe a sleeping tablet for him because
Games is having difficulty in sleeping& Which of the following is the '$(, appropriate
ne.t step?
a) (uggest she gives Games a nightcap of whis)y
b) #rescribe a shortBacting ben3odia3epine
c) 0escribe some rela.ation e.ercises for Games to do immediately before bedtime
d) #rescribe an analgesic such as paracetamol and codeine combination
e) !s) Games to come to the surgery so you can chec) the plaster
Correct
,he prudent action is to as) Games to come to the surgery to chec) 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& ,his can lead to an adverse outcome unless the pressure is relieved soon& $nce
this is ruled out or dealt with, the ne.t issue to be addressed is ade/uate pain relief&
9n most cases, once ade/uate pain relief is ensured, insomnia will no longer be a
problem& 9f insomnia does persist, a shortBacting ben3odia3epine may be prescribed
for no more than <B;F days to avoid development of dependency& !n alcoholic
nightcap is not a good idea, as it usually causes the patient to wa)e during the night
and have difficulty getting bac) to sleep&
Question 3;
,he interossei muscles of the hand are supplied by5
a) ,he radial nerve
b) ,he median nerve
c) ,he ulnar nerve
Correct
d) !ll of the above
e) +one of the above
,he ulnar nerve 1c=B ,;) supplies the adductors and abductors of the fingers, the
adductor of the thumb, the medial two lumbricals and the muscles of the hypothenar
eminence&
2 Question 3:
Which of the following situations is a C$+,-!9+09C!,9$+ to immunisation with a
live attenuated vaccine?
a) #regnancy
Correct
b) reastfeeding
c) 'ild acute febrile illness
d) Current antibiotic therapy
e) 9mmunodeficiency in a household contact
#regnancy is a valid contraindication to immunisation with a live attenuated vaccine
eg oral polio infection& %.posure to "9H, other immunodeficiency states and
immunosuppressant treatments are also contraindications& 0iarrhoea, minor acute
illnesses, antibiotic therapy and breast feeding are not valid contraindications&
Question 33
renda brings Ga)e, her : month old son for his first ,riple antigen in@ection& Which of
the following statements is C$--%C, in relation to the acellular pertussis vaccine?
a) 9t provo)es a stronger immune reaction
Incorrect. The correct response is (c).
b) ,he costs are the same as whole cell vaccine
c) 9t causes a lower incidence of fever, crying and irritability
d) 9t wor)s against the bacteria rather than the to.in
e) 9t provides protection against #& bronchiseptica
!cellular pertussis is part of 0,#a and 0,#aBhep vaccines& ,riple antigen vaccine
containing acellular pertussis has similar efficacy to that of whole cell pertussisB
containing vaccines, but causes significantly less reaction with a much lower
incidence of fever, irritability and local reactions& ,he cost is greater& ,he vaccine
targets the to.in rather than the bacteria&
2 Question 34
!n obese man, aged 6F years, is admitted unconscious with a diagnosis of completed
stro)e confirmed on C, scanning as due to a cerebral thrombosis& $f the following
supportive measures, the most important 9''%09!,% management is5
a) 9nsertion of an indwelling urinary catheter
Correct
b) Commencement of anticoagulant therapy
c) #hysiotherapy to prevent hypostatic pneumonia
d) Commencement of intravenous fluids to prevent dehydration
e) #ositioning to prevent development of decubitus ulcers
!n indwelling catheter allows monitoring of fluid status as well as allowing urinary
drainage& 9H fluid therapy is not urgent due to the potential to e.acerbate brain
swelling, in the acute phase& !nticoagulant therapy is of no value in treating a fully
developed and completed CH!& 9t may be used in transient ischaemic attac)s, in a
developing progressive thrombosis, or in prevention of 0H, in a bedridden patient&
,he other measures of physiotherapy and nursing care should follow
2 Question 35
Which of the following statements about simple febrile convulsions is C$--%C,?
a) 9t usually occurs between 6B= years of age
b) #rognosis depends on the precipitating illness
c) ,he ris) of developing epilepsy is ;FJ
d) ,he convulsions last less than ;5 min
Correct
e) 9nvestigation with lumbar puncture and C, is essential
(imple febrile convulsions last less than ;5 minutes& ,hey usually occur between 3
months and 5 years, with most occurring between ;< and :3 months of age& ,here is
no difference in 9Q at age < years between children who have had a febrile
convulsion and their sei3ureB free siblings& ,he ris) of developing epilepsy following a
simple febrile convulsion is F&EJ at age < years&
Question 36
,he '$(, helpful diagnostic test to evaluate a potentially enlarging pituitary
neoplasm is5
a) Cerebral angiography
b) (erial serum prolactin concentration
Incorrect. The correct answer is (c).
c) '-9
d) Computer assisted colour spectrum visual field plotting
e) C, scan with contrast
$nce identified, pituitary neoplasms should be evaluated by an '-9 scan& ,his gives
information regarding pressure effects on surrounding structures and the need for
surgical treatment& (erum prolactin estimation gives information about anterior
pituitary function, but not si3e& !ngiography is unnecessarily invasive and C, is not
as sensitive as '-9& Hisual field plotting will document any damage to the optic tract
B an unwanted outcome&
2 Question 3<
?atie, ;: years of age, collapses suddenly at school, and is transported by
ambulance with de.trose drip inserted& $n e.amination, a dolls eye refle. is present
but she is not responding to painful stimuli& "er vital signs are as follows5
-esp& rate ;4Kmin
#ulse rate 5FKmin
(aF: ;FF J
K# ;=FK;;F
What is the +%I, step of management?
a) !rrange for an urgent head C, scan
Incorrect. The correct answer is (c).
b) -eplace the de.trose with normal saline
c) 9ntubate and ventilate
d) Aive intravenous corticosteroids
e) 0raw venous and arterial blood for urgent analysis
?atie has raised intracranial pressure as indicated by the hypertensive response in
the presence of bradycardia and coma& (he is at high ris) of herniation and needs
urgent treatment to reduce the intracranial hypertension& ,he most rapid effect is
achieved by endotracheal intubation and hyperventilation to reduce arterial pC$: to
3FB35mm"g& ,his will be accompanied by an intravenous infusion of mannitol&
Drgent assessment to determine the cause of this presentation will include blood
tests and C, scan& Corticosteroids may be helpful in cases of intracranial tumour or
C+( infection& (pecific treatment will be re/uired for metabolic abnormalities eg&
diabetic )etoacidosis, infection or haemorrhage&
2 Question 3=
,he defect in visual fields '$(, commonly associated with a pituitary tumour is5
a) Crossed homonymous hemianopia
b) Central scotoma
c) itemporal hemianopia
Correct
d) ,otal blindness in one field
e) #eripheral concentric constriction and enlargement of the blind spot
!s a pituitary tumour e.tends upwards from the diaphragma sellae and compresses
the optic chiasm, it classically causes superior /uadrantic defects followed by
bitemporal hemianopia& 9t can however cause any variety of visual field defects,
including unilateral 1or bilateral) field defects in all /uadrants, due to the variable
position of the chiasm above the pituitary&
Question 3E
Which of the following statements about immunisation is C$--%C,?
a) 9f a child has a cold, they can*t be vaccinated
b) 6ever is an uncommon adverse event after immunisation
c) 9f a reaction is suspected, a test dose should be used
d) !naphyla.is to egg is not a contraindication to ''- vaccine
Correct
e) #reBterm infants have an inade/uate antibody response
!n anaphylactic reaction to egg is not a contraindication to ''- vaccine& 9nfants with
minor colds without high fever can be safely immunised& Haccination should only be
postponed if a child is acutely unwell or has a high fever 1above 3=&5 degrees
Celsius)& ! fever 1low grade temperature) is a common adverse effect after
immunisation& ,est doses are not recommended, they are @ust as li)ely to produce an
adverse event as the full dose& #remature infants should receive their vaccinations at
the same age as term infants, ie first dose of hepatitis vaccine at birth and then
0,#aBhep , "9 and polio vaccinations at : months after birth 1no correction for
gestation)&
2 Question 4F
Which of the following would be '$(, helpful in distinguishing cerebral infarction
from cerebral neoplasm?
a) "istory of headache
b) "emiplegia
c) Chronology of development
Correct
d) Carotid bruit
e) 6ocal abnormality on electroencephalogram
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& 9n comparison, neoplasms
tend to be preceded by symptoms such as headache, progressive cognitive decline,
sei3ures and vomiting, and may feature steadily progressive neurological signs& ,he
other options are all variably present in both conditions and are not diagnostic&