Question No.

1 :

A 50-year old man presents to your clinic with erectile dysfunction. He is obese with
BMI 32. He is heavy drinker and smoker. After advice on reducing alcohol intake and
smoking cessation, what is the next most important step?

a. Weight reduction

b. Check blood sugar

c. Measure serum lipids

d. Measure liver function tests

e. Review in 6 months

Correct Answer & Detail

Correct Answer: b. Check blood sugar

Answer Detail:
When the first signs of erectile dysfunction happen, there is
often an unknown underlying cause such as diabetes,
hypertension or high cholesterol.
Erectile dysfunction may be an early marker of subclinical
metabolic and vascular disease.
After taking a history of sexual function and general medical
factors and doing physical examination, following are the
first line investigations in any patient with erectile
dysfunction.
1- Blood glucose level
2- Free testosterone level
3- Thyroid function tests
4- Prolactin level
5- Luteinizing hormone
Other blood tests (not first line) to consider include liver
function tests, serum cholesterol and renal function tests.
Question No. 2 :

A 67-year-old lady is brought by her husband as she is not behaving as usual.She

forgets things and has few falls as usual.The woman was mumbling something and
her expressions were flat.Husband also said that she would fall asleep suddenly
anywhere.

What is the most likely diagnosis?

a. Alzheimers dementia

b. Lewy body dementia

c. Fronto-temporal dementia

d. Senile dementia

e. Schizophrenia

Correct Answer & Detail

Correct Answer: c. Fronto-temporal dementia

Answer Detail:
The correct answer is c.

This patient has presented with features of frontotemporal

dementia (FTD). Clinical features of FTP include:

1-Coarsening of personality as manifested by disregard for

social conventions, slovenly appearance, impatience and
irritability, argumentativeness, lewd and tactless remarks,
child-like and impulsive actions, loss of empathy and
concern for others, compulsions, and rigid adherence to
routines.
2-Poor emotional processing is detectable in all 3
frontotemporal dementia (FTD) subtypes, and is an
important clinical feature in behavioural-variant FTD and
semantic dementia.

3-In FTD, changes in personality, language, habits, and

activity generally precede the development of memory
impairment, disorientation, or apraxias.

Lewy body dementia is characterized by any two of visual

hallucinations, spontaneous Parkinsonism and fluctuation in
the mental state. Personality and comportment are
relatively preserved.Visual hallucinations are very rare in
FTD.

The dementia of Alzheimers type is characterized by early

loss of short term memory, insidious onset and progressive
decline in intellect.
Question No. 3 :

Cognitive behavioural therapy is useful in all of the follwing conditions except?

a. Phobias

b. Psychosis

c. Depression

d. Insomnia

e. Sleep walking

Correct Answer & Detail

Correct Answer: e. Sleep walking

Answer Detail:
Cognitive behavioural therapy is useful in many psychiatric
conditions including:

- Psychosis.
- Phobias.
- Depression.
- Insomnias.
- Eating disorders.

Sleep walking is the area where CBT does not show

encouraging results.

The basis of CBT is to educate the patient and teach basic

skills to control the symptoms.
Patient eventually identifies maladaptive thoughts and
feelings and makes an effort to change them.
Question No. 4 :

A 20-month-old baby is brought in by his parents with chronic diarrhoea and weight
loss.
On examination,the baby has growth retardation,muscle wasting and distended
abdomen with hyperactive bowel sounds.
Chest examination is clear.
Laboratory investigations show decrease serum iron or folate levels.
Patient has been on lactose free diet for 3 days without resolution of symptoms.
What is most likely diagnosis?

a. Primary lactose intolerance

b. Celiac Disease

d. Cystic fibrosis

e. Bacterial Over growth

Correct Answer & Detail

Correct Answer: b. Celiac Disease

Answer Detail:
Coeliac disease presents as sever malabsorption syndrome
in children less than 2 years of age with chronic
diarrhea,failure to thrive,muscle wasting and hyperactive
bowel sounds.
This patient is classic picture of coeliac disease.

Primary lactose tolerance is due to deficiency of lactase in

small intestine and is a malabsorption syndrome presenting
with abdominal pain,bloating, distension,flatulence and
watery diarrhoea.
It usually resolves with lactose free diet for about 2 weeks.

Cystic fibrosis is an inherited autosomal recessive disease

and is the most common cause of bronchiectasis and chronic
suppurative lung disease in Caucasian children.

It is a multisystem disease that involves

lungs,gastrointestinal tract,pancreas,liver,sinuses,sweat
glands and reproductive system.

Bacterial overgrowth in the small bowel causes diarrhoea

and nutrient malabsorption.Most patients with bacterial
overgrowth have intestinal stasis associated with underlying
anatomical abnormalities including strictures, jejunal
diverticulosis, motility disorders and various operations that
create blind loops.
Clinical manifestations of bacterial growth include
diarrhoea,weight loss and anaemia due to vitamin B12
deficiency.
Question No. 5 :

Vitamin B12 deficiency is associated with all of the following situations except?
 a. Metformin therapy

b. Autoimmune gastritis

c. Gastrectomy

d. Terminal ileum disease

e. Pregnancy

Correct Answer & Detail

Correct Answer: e. Pregnancy

Answer Detail:
Vitamin B12 deficiency is usually caused by the absence of
intrinsic factor.It is commonly seen in autoimmune
gastritis,after gastrectomy and by resection or disease of
the terminal ileum.
Milder vitamin B12 deficiency can result from metformin
therapy or a combination of inadequate dietary intake,poor
gastric mixing and small intestinal bacterial overgrowth,
particularly in elderly people.
Pure dietary deficiency is rare,and is usually only seen in
strict vegetarians.
In pregnancy it not common to see vitamin B12 deficiency
until patient has any of the above mentioned issues before
pregnancy.
Question No. 6 :

Which one of the following is not the differential diagnosis of the lump in posterior
triangle of the neck?

a. Cystic hygroma

b. Branchial cyst

c. Bronchial cyst

d. Pancoast tumour
 e. Cervical rib

Correct Answer & Detail

Correct Answer: b. Branchial cyst

Answer Detail:
The correct answer is b.

Branchial cyst is seen in the upper part of the anterior

triangle of the neck.

All other options (cystic hygroma, bronchial sinuses and

cyst, Pancoast tumour, and cervical rib) are present in the
posterior triangle of the neck.
Question No. 7 :

An 18-year-old mother brings her 5 month old child in the emergency

department.Mother is concerned that child has been crying excessively since
yesterday and she noticed today that child was unable to move the left arm.
There is no external bruising.Mother does not remember any history of trauma to the
child.X-ray showed mid-shaft fracture of the humerus.

What is the most appropriate next step?

a. Social worker review

b. Admission to hospital

c. Discharge and follow up with GP

d. Analgesia and external manipulation in emergency department

e. Notify police
Correct Answer & Detail

Correct Answer: b. Admission to hospital

Answer Detail:
The correct answer is b.

This child has most likely diagnosis of non-accidental injury

to left humerus which has resulted in fracture.

In this case,there has been delay in seeking advice (child

crying since yesterday) and mother is denying any trauma
to the baby.A fracture is an evidence that physical trauma
has happened.

So the most appropriate things to do include admission to

the hospital (do not discharge this patient home as risk of
further injuries is high), orthopedics review and notification
to child protection services.

Child protection services can be contacted any time

throughout Australia.

Notification of suspected child abuse is mandatory and later

on,if no child abuse is proven,health practitioners are
protected by Australian National Law from any legal action
by parents.

Social worker review and notification to police not

required.Any external manipulation in children must be
guided by orthopedic team.
Question No. 8 :

Which ONE of the following is unlikely to require ant-D administration in an Rh

negative woman who have not actively formed their own Anti-D?
 a. Threatened abortion before 12 weeks of gestation

b. Spontaneous abortion

c. External cephalic version

d. Significant closed intra-abdominal trauma

e. Termination of pregnancy

Correct Answer & Detail

Correct Answer: a. Threatened abortion before 12 weeks

of gestation
Answer Detail:
The correct answer is a.

There is insufficient evidence to suggest that a threatened

miscarriage before 12 weeks gestation requires Anti-D.

Indications to use ant-D in all Rh negative women who have

not actively formed their own Anti-D include:

-Spontaneous abortion.
-External cephalic version.
-Significant closed intra-abdominal trauma.
-Termination of pregnancy.
-Chorionic Villus Sampling.
-Ectopic pregnancy.
-Threatened abortion after 12 weeks of gestation.
Question No. 9 :
A 29-year-old lady at 32 weeks of gestation presents with regular uterine
contractions.Cardiotocography shows live fetus with regular accelerations.Blood
pressure is 200/120 mmHg. Liver function shows mildly raised serum alkaline
phosphatase.Sterile speculum examination shows foul smelling fluid leaking out of
vagina.

Which of the following is the next best step in this situation?

a. Suppression of labour is started by giving oral nifedipine with two further doses if
contractions still persist
b. Intravenous salbutamol should be used as first line drug to stop uterine contractions

c. Both nifedipine and salbutamol are indicated in this patient

d. Further investigations are needed to find whether this patient needs tocolysis or not

e. Tocolysis is absolutely contraindicated in this patient

Correct Answer & Detail

Correct Answer: e. Tocolysis is absolutely contraindicated

in this patient
Answer Detail:
This patient has clinical presentation of preterm labour with
active uterine contractions.

She has high blood pressure and abnormal liver function

tests which is clue towards severe pre-eclampsia.

Tocolysis is contraindicated in pre-eclampsia and eclampsia.

After the rupture of membranes it is recommended not to

suppress uterine contractions with any medication.
Nifedipine and salbutamol in combination increase
cardiovascular side effects and should be avoided.
Question No. 10 :

A 36-year-old lady with 5 year history of hypertension is keen to become pregnant.

She has never been pregnant before. She has stopped using contraception recently.
She has past medical history of asthma. Her only medication is ramipril 10 mg daily.
Her blood pressure is 130/85.

What is the most appropriate initial management of her hypertension?

a. Cease ramipril and start methyldopa

b. Cease ramipril and start atenolol

c. Cease ramipril and start irbesartan

d. Cease ramipril, start hydralazine

e. Continue ramipril

Correct Answer & Detail

Correct Answer: a. Cease ramipril and start methyldopa

Answer Detail:
The correct answer is a.

Pre-pregnancy counselling and management of chronic

hypertension is essential.

Some commonly prescribed anti-hypertensive drugs are

contraindicated or best avoided before conception and
during pregnancy.
These include ACE inhibitors, angiotensin receptor
antagonists, diuretics and most beta blockers.
Methyldopa is a drug of first choice for control of mild to
moderate hypertension in pregnancy and is the most widely
prescribed antihypertensive for this indication.

Hydralazine can be used in pregnancy for hypertensive

emergencies.

Angiotensin receptor blockers and ACE inhibitors both are

teratogenic in first trimester and can result in foetal renal
dysfunction, oligohydramnios and skull hypoplasia in second
and third trimesters.

Diuretics can cause foetal electrolyte disturbances and

reduction in maternal blood volume.

Beta blockers (except labetalol) can cause foetal bradycardia

and long term use can result in growth restriction.

Calcium channel antagonists (except nifedipine) should be

avoided in pregnancy due to risk of maternal hypotension
and foetal hypoxia.
Question No. 11 :

A 6-month-old male is brought to your office by his mother with persistence bouts of
cough for last 2 weeks.There is history of vomiting after coughing episodes. Child
develops cyanosis during coughing.

What is the most appropriate next step?

a. Nasopharyngeal aspirate and review in 24 hours

b. Immunisation at this visit with dTP and review in 24 hours

c. Erythromycin syrup and review in 24 hours

d. Trial of Salbutamol by mask

e. Admission to hospital
Correct Answer & Detail

Correct Answer: e. Admission to hospital

Answer Detail:
The correct answer is e.

The clinical picture suggests respiratory infection with

Bordetella pertussis.

The history of cyanosis associated with the coughing

suggests the need for admission to hospital.

In addition, children under 6 months of age usually require

admission for pertussis because of the risk of complications
like respiratory arrest, bacterial pneumonia and encephalitis.

Salbutamol has not been shown to be helpful in a child with

pertussis.Immunization at a later date should be encouraged
even if the child has had pertussis.
Erythromycin is not curative but may reduce infectivity.
Question No. 12 :

Which of the following is not an indication of electro-convulsive therapy?

a. Recurrent depression

b. Substantial suicide risk

c. Ineffective antidepressant medication

d. Refusal to eat and drink

e. Severe personal neglect

Correct Answer & Detail

Correct Answer: a. Recurrent depression

Answer Detail:
The primary indications for electro-convulsive therapy
include:

1- Major depression, especially with melancholia, catatonic

or psychotic features. ECT is a highly effective treatment for
major depression, demonstrating remission rates of more
than 60% when the most effective forms of ECT are used.

2- High suicidal risk.

3- Failure to eat or drink adequately; or when there has

been inadequate response to antidepressant medication.

4- Mania where other strategies fail to gain remission

5- Schizophrenia with acute features where other strategies

have fail to gain remission.

ECT however is not required in recurrent depression which

can be treated usually with antidepressants (SSRIs,TCAs)
and if it is treatment resistant, then ECT might be
considered.
Question No. 13 :

A 35-year-old woman returned from an overseas holiday 7 days ago, now presents to
your clinic complaining of fever, periorbital pain, joint pain, lymphadenopathy and
rash over the body.
What is the most likely diagnosis?

a. Leptospirosis

b. Dengue fever

c. Ross river fever

d. Brucellosis

e. Malaria

Correct Answer & Detail

Correct Answer: b. Dengue fever

Answer Detail:
The correct answer is b.

This patient has classic presentation of dengue fever.

Classic dengue fever is an acute febrile illness accompanied

by headache, retro-orbital pain,lymphadenopathy and
marked muscle and joint pains, which evoked the term
"break-bone fever.

Symptoms typically develop between 4 and 7 days after the

bite of an infected mosquito, although the incubation period
may range from 3 to 14 days.

Rash is usually associated with dengue fever due to

thrombocytopenia.

Differential diagnosis:
Leptospirosis presents with the abrupt onset of fever, rigors,
myalgias and headache in 75 to 100% of patients, after an
incubation period of two to 26 days (average 10 days).
From 25 to 35% of cases have an associated non-productive
cough and approximately 50% experience nausea, vomiting
and diarrhoea.

Symptomatic Ross river fever infection presents in one of

the 3 ways:

1-Acute febrile illness with arthritis and rash.

2- Acute fever, rash, or arthritis alone.
3- Chronic polyarthritis or polyarthralgia.

Malaria should be suspected in patients with any febrile

illness if they have had exposure to a region where malaria
is endemic.
The initial symptoms of malaria are nonspecific and may
also include tachycardia, tachypnea, chills, malaise, fatigue,
diaphoresis, headache, cough, anorexia, nausea, vomiting,
abdominal pain, diarrhoea, arthralgias, and myalgias.
Question No. 14 :

Which of the following is not used to reduce iron overload in children who require
frequent blood transfusions in patients with sickle cell anaemia?

a. Subcutaneous deferoxamine

b. Splenectomy

c. Drinking tea with meals

d. Erythrocytopheresis

e. Doing regular evening exercise

Correct Answer & Detail

Correct Answer: e. Doing regular evening exercise

Answer Detail:
The correct answer is e.

Chelation therapy with subcutaneous or intravenous

deferoxamine has been standard therapy for transfusional
iron over load.Oral iron chelators are also available and are
in clinical use.

Splenectomy is done primarily in patients with thalassemia

who have hypersplenism which results in premature
destruction of RBCs and increased transfusions
requirements.

Drinking tea with meal reduces dietary iron absorption and

may be helpful in patients with diseases such as thalassemia
intermedia.

Automated erythrocytopheresis rather than repeated simple

transfusions may markedly reduce transfusional iron loading
in patient with sickle cell disease.

Doing regular exercise might be good for patient's general

well being of the patient,it does not reduce iron overload.
Question No. 15 :

A 35-year old female brought her brother to you for assessment of the acute back
pain.She requested for a medical certificate for her to show her employer as she took
the day off to bring her brother to your clinic.

What is the most appropriate response?

 a. Issue her certificate

b. Issue a medical certificate to her brother and ask her to show it to her employer

c. Make a separate appointment to discuss the matter

d. Tell her that this is illegal to act upon her request

e. Refer her to another colleague

Correct Answer & Detail

Correct Answer: a. Issue her certificate

Answer Detail:
The correct answer is a.

According to Australian Medical Association guidelines,only

the patients treating doctor can issue a carers certificate.

So you should issue her a carers certificate.However carers

certificates should only be issued with the consent of the
patient.It is not your responsibility to determine who may
qualify as a carer.
Question No. 16 :

A 25-year-old female came to your clinic due to a breast lump of her left breast.
Patient claimed the lump is tender on palpation and movable.
You find that these changes are due to hormonal changes.
She is concerned about her risk of having breast cancer.Her mother died of breast
cancer at 45 years old and one of her aunt died of ovarian cancer.

All of the following are the risk indicator of familial breast-ovarian cancer except?

a. Individual with age onset of cancer > 50 years old

b. Two first-degree or second-degree relatives on one side of the family with ovarian or
breast cancer
c. Individuals with ovarian cancer

d. Breast cancer in a male relative

 e. Individuals with bilateral or multifocal breast cancer

Correct Answer & Detail

Correct Answer: a. Individual with age onset of cancer >

50 years old
Answer Detail:
The correct answer is a.

Familial breast-ovarian cancer syndrome is characterized by

a mutation in either of the two genes-BRCA1 and BRCA2.

It results in strong predisposition for breast and ovarian

cancer. Also there is co-existence of breast and ovarian
cancer in the same family.

The following are the risk indicator of familial breast

-ovarian cancer syndrome:

1. Two first-degree or second-degree relatives on one

side of the family with ovarian or breast cancer.

2. Individuals with age of onset of cancer less than 50

years.

3. Individuals with bilateral or multifocal breast cancer.

4. Individuals with ovarian cancer.

5. Breast cancer in a male relative.

6. Jewish ancestry

Cancer after the age of 50 years is less likely familial.

Question No. 17 :

A 24-year-old woman comes for first antenatal visit at 10 weeks of her gestational
age. Which of the following investigations will change management at this gestational
age?

a. HIV screening

b. Group B streptococcus

c. Glucose challenge test

d. Varicella antibodies

e. Preeclampsia

Correct Answer & Detail

Correct Answer: a. HIV screening

Answer Detail:
This woman is in her first trimester of pregnancy. Human
immune deficiency virus testing would make significant
difference to her further management at this visit.

All pregnant women should be recommended to have HIV

screening at the first antenatal visit however every women
should be educated about implications of positive and
negative blood findings.

A standard schedule of antenatal visits is referred to as

every four weeks until 28 weeks' gestation, then every two
weeks until 36 weeks, then every week until 40 weeks or
delivery.

In the absence of risk factors, screening for gestational

diabetes should be performed at 26 weeks of gestation. All
women not known to have gestational diabetes mellitus,
should have a 75g per oral glucose tolerance test at 24-28
weeks of gestation.

The glucose challenge test lacks both sensitivity and

specificity and is no longer part of the diagnostic algorithm.

Checking for varicella antibodies is recommended in first

trimester antenatal visit if there is no history or uncertain
history of previous illness.

The use of intrapartum prophylaxis with antibiotics

(penicillin) given to women at risk of transmission of group
B streptococcus to their newborns, prevents early onset
sepsis and is cost effective.

For the screening approach, GBS carriage is best predicted

by prenatal screening at 35-37 weeks gestation.
Question No. 18 :

A 50-year-old male with past medical history of alcohol abuse developed gross
tremors, agitation and hallucinations.

What is the most appropriate treatment?

a. Haloperidol

b. Chlorpromazine

c. Amitriptylin

d. Benzodiazepine

e. Paracetamol
Correct Answer & Detail

Correct Answer: d. Benzodiazepine

Answer Detail:
The correct answer is d.

This patient has signs and symptoms consistent with

delirium tremens. It commences within 72-96 hours of
alcohol cessation.

Delirium tremens is characterised by gross tremors and

fluctuating levels of agitation, hallucinations, disorientation
and impaired attention. Fever, tachycardia and dehydration
may be present.

The most appropriate treatment for hallucinations and other

symptoms of delirium tremens is diazepam.

Neuroleptics and tricyclic antidepressants can lower seizure

threshold, and result in higher mortality because of a
prolonged QT interval.

Paracetamol is not useful in the management of delirium

tremens.
Question No. 19 :

A 43-year-old male visits you to discuss his hepatitis B serology report.Report shows
HBcAb and HBsAb are positive while HBsAg is negative.

What is the most appropriate next step?

a. No further action needed

 b. Offer hepatitis B immunization

c. Interferon and antiviral therapy

d. Liver function tests

e. Refer to a specialist for further management

Correct Answer & Detail

Correct Answer: a. No further action needed

Answer Detail:
Report shows HBcAb and HBsAb are positive while HBsAg is
negative.This means that patient is immune from hepatitis B
virus (exposure in the past).

This patient has already developed antibodies which protect

against hepatitis B infection.

If all of HBcAb,HBsAg and HBsAb are negative,it means

patient has neither been exposed to hepatitis B in the past
and is still non-immune.

In such situation,hepatitis B immunization can be offered.

Interferon and antiviral therapy are cornerstone of hepatitis

C treatment.

Liver function tests are required if patient is found to have

HbsAg positive or if there is evidence of acute hepatitis B.

Referral to specialist is not required is patient does not need

any treatment.
Question No. 20 :

Which of the following statement is incorrect regarding raloxifene?

a. It prevents post-menopausal bone loss

b. It prevents non-vertebral fractures

c. It prevents vertebral fractures

d. It increases the incidence of hot flushes

e. It reduces the risk of breast cancer

Correct Answer & Detail

Correct Answer: b. It prevents non-vertebral fractures

Answer Detail:
Raloxifene is a selective oestrogen receptor modulator
(SERM) that prevents postmenopausal bone loss.

Raloxifene reduces the risk of vertebral fractures but it does

not prevent non-vertebral fractures.

It increases the incidence of hot flushes.

It reduces the risk of breast cancer however it increases the

risk of deep venous thrombosis and causes a small increase
in the risk of death after stroke.
Question No. 21 :

A-56-year-old male with history of short-sidedness presented with sudden onset of

floaters, flashes and painless loss of vision in right eye.Patient complains as if a
curtain came down over the eye.

What is the next step in the management?

 a. Immediate referral to ophthalmologist

b. Use a patch to cover the eye and review tomorrow as first patient

c. Refer to neurologist clinic in the area

d. Call the air ambulance and refer the patient to a tertiary health centre

e. Observe patient in ward for 48 hours and monitor the progress

Correct Answer & Detail

Correct Answer: a. Immediate referral to ophthalmologist

Answer Detail:
Retinal detachment may be in patients with history of
trauma, diabetic retinopathy, myopia and cataract surgery.

The patient with a detached retina usually present with

sudden onset of floaters, flashes and field defects, and
reports painless loss of vision with 'dark shadow' in the
affected eye.

Blurred vision in one eye may get worse.Patient usually

explains if a curtain came down over the eye.

Immediate ophthalmologist referral is mandatory in this

situation for sealing of retinal tears.

Small holes are treated with laser or freezing probe. Surgical

intervention is needed for true retinal reattachment.
Question No. 22 :

A 12-year-old male child is brought in hospital by his mother with acute shortness of
breath and wheeze. He has background history of asthma and uses inhalers as
required.

Which of the following is the best bed side measure to assess the severity of asthma?
 a. Severity of wheezing

b. Response to inhalers

c. Degree of dyspnoea

d. Peak expiratory flow rate

e. Pulmonary function tests

Correct Answer & Detail

Correct Answer: d. Peak expiratory flow rate

Answer Detail:
The correct answer is d.

The peak expiratory flow rate (PEFR, also known as a peak

flow) is the maximal rate that a person can exhale during a
short maximal expiratory effort after a full inspiration.

In patients with asthma, the PEFR percent predicted

correlates reasonably well with the percent predicted value
for the forced expiratory volume in one second (FEV1).

Peak flow meters have a limited role in establishing the

diagnosis of asthma in the office.However, they are very
useful in measuring the severity of asthma exacerbation.
Peak flow readings are higher when patients are well, and
lower when the airways are constricted

Severity of wheeze is not reliable sign of severity of asthma.

Severe asthma usually presents with silent chest and low
grade wheeze.
Response to inhalers and degree of dyspnoea are also very
unreliable signs to assess the severity of asthma.A patient
with mild asthma may be equally breathless as with severe
asthma.

Pulmonary function testing is done at specialized centres

and is required to diagnose asthma. However peak flow
measurement is quick and useful in emergency situation to
assess the severity of asthma.
Question No. 23 :

A 65-year-old Marcello appears pale and lethargic and her clinical tests done on last
appointment indicate that she is suffering from primary hypothyroidism.
Today her blood tests indicate TSH is 4 (0.4-5 mIU/L) T3, Free T4 low normal
levels.She is currently on levothyroxine 75 microgram daily for last 6 weeks.
What is your best next step in her management?

a. Keep it as 75 microgram daily

b. Increase to 100 microgram daily

c. Change it to 150 microgram daily

d. Keep it as 75 microgram daily however on alternate days

e. Review and follow up TSH level in 2 weeks

Correct Answer & Detail

Correct Answer: b. Increase to 100 microgram daily

Answer Detail:
In primary hypothyroidism (high TSH,low free T4),the TSH
alone can be used to monitor therapy.

The aim should be to maintain the TSH at the lower end of

the normal range (0.4-5 mIU/L).
Symptoms may be best relieved when the TSH is at the
lower end of this range.

It takes at least 4 weeks for the TSH to stabilize after a

change in thyroxine dose and so any testing of TSH should
be done at least 4-6 weeks after the change.

This patient has come for follow up in 6 weeks of starting

thyroxine treatment.

TSH in normal range with persistence of symptoms and low

normal T3, free T4.
It is an indication to increase the dose of thyroxine by 25
mcg and review again in 4 to 6 weeks.

Keeping it at 75mcg or making it on alternate days is likely

to worsen the symptoms.

Changing it to 150 mcg is too high dose and may result in

complications.
Question No. 24 :

A 35-year-old woman presented with breech presentation confirmed on ultrasound at

37 weeks of gestation. External cephalic version has failed.

What is the most appropriate next step in her management?

a. Steroids

b. Elective cesarean delivery at 38 weeks of gestation

c. Emergency cesarean delivery

d. Induce labour now

e. Consider vitamin K
Correct Answer & Detail

Correct Answer: b. Elective cesarean delivery at 38 weeks

of gestation
Answer Detail:
The correct answer is b.

In breech presentation diagnosed around 32 weeks of

gestation, there is possibility of spontaneous version to
cephalic presentation.

If this does not happen, external cephalic version is

considered (after doing an ultrasound).
If external cephalic version fails due to any reason, arrange
an elective cesarean section at 38-39 weeks of gestation or
vaginal delivery if suitable to do so.
Question No. 25 :

A 20-year-old female in 18th week of her pregnancy presented with right iliac fossa
pain on getting up from a chair and has been coughing and sneezing.On examination
there is no mass palpable and there is no rebound tenderness.

What is the most likely cause?

a. Round ligament strain

b. Acute appendicitis

c. Allergic reaction

d. Ruptured ectopic pregnancy

e. Ectopic pregnancy

Correct Answer & Detail

Correct Answer: a. Round ligament strain
Answer Detail:
The correct answer is a.

This patient has symptoms and signs suggestive of round

ligament strain.It is considered a normal finding during
pregnancy and does not require any intervention.

The symptoms of round ligament pain include a sharp,

sudden spasm in the right iliac fossa and the pain lasts for a
few seconds.Other symptoms of round ligament strain may
include sneezing,coughing,laughing and rolling over in bed.

Ectopic pregnancy and rupture of ectopic pregnancy is

usually seen in first trimester.It is unlikely diagnosis in this
patient as she is in second trimester of her pregnancy.

Although appendicitis presents with pain in right iliac fossa

but it does not cause coughing and sneezing.Also it causes
tenderness and rebound tenderness in right iliac fossa.
Question No. 26 :

A 39-year-old woman presented with dizziness after coming from gym. ECG shows
sinus bradycardia with no av-block. What is the most appropriate next step?

a. Transcutaneous pacemaker

b. Atropine

c. Adrenaline

d. Trans-venous pacing

e. Amiodarone
Correct Answer & Detail

Correct Answer: b. Atropine

Answer Detail:
Symptomatic bradycardia exists when the following 3
criteria are present:
1- The heart rate is slow.
2- The patient has symptoms.
3- The symptoms are due to the slow heart rate.

Atropine is the first drug used to treat bradycardia in the

bradycardia algorithm. It is classified as an anticholinergic
drug and increases firing of the SA Node by blocking the
action of the vagas nerve on the heart resulting in an
increased heart rate.

The dosing for Atropine is 0.5 mg IV every 3-5 minutes as

needed, and the maximum total dosage that can be give is 3
mg.

If atropine fails to alleviate symptomatic bradycardia,

transcutaneous pacing should be initiated. Transvenous
pacing requires a specialist treatment.
Question No. 27 :

Which ONE of the following is the most common cause of acute limb ischemia?

a. Congestive cardiac failure

b. Smoking

c. Vasculitis

d. Embolism

e. Thrombosis
Correct Answer & Detail

Correct Answer: e. Thrombosis

Answer Detail:
The correct answer is e.

Thrombosis is the most common cause of acute limb

ischemia.Both native coronary vessels and bypass grafts can
get blocked due to thrombosis.

In the lower limbs, thrombotic occlusion accounts for more

than 80% of cases.

Occlusion from embolism is less common than occlusion

from thrombosis, in part due to the decline in the incidence
of rheumatic heart disease and the treatment of atrial
fibrillation with anticoagulants.

Atrial fibrillation is associated with at least two thirds of all

peripheral emboli, and clot is found most commonly in the
left atrial appendage.

All other options can increase the risk of acute limb ischemia
however these not very common.
Question No. 28 :

A 32-year-old woman came to see you at your clinic. She has two children previously
and is now planning to start contraceptive pills. She has history of epilepsy and is
stable on two drugs.

Which one of the following anti-epileptic drugs do not affect the efficacy of hormonal
contraceptive pills?

a. Topiramate
 b. Carbamazepine

c. Primidone

d. Levetiracetam

e. Phenytoin

Correct Answer & Detail

Correct Answer: d. Levetiracetam

Answer Detail:
The correct answer is d.

Enzyme inducing anti-epileptic drugs can reduce the efficacy

of hormonal contraceptives. These induce hepatic p-450
enzyme system and increase the clearance of contraceptive
steroids. The level of sex-hormone binding globulin is
increased which in turn decreases the level of free
circulating hormones.

Following drugs reduce the efficacy of hormonal

contraceptive pills with a mechanism described above:

- Phenobarbitone.
- Primidone.
- Phenytoin.
- Carbamazepine.
- Oxcarbazepine.
- Topiramate.

Following antiepileptic drugs are non-inducers and do not

affect the efficacy of hormonal contraceptive pills:
- Valproic acid.
- Gabapentin.
- Levetiracetam.
- Pregabalin.
- Vigabatrin.

If we have to use hormonal contraceptive methods in

patient taking enzyme inducing drugs, increase the dose of
estrogen in the pill or consider mirena or barrier method as
an alternative.
Question No. 29 :

You are a locum GP obstetrician at a rural hospital and serving mostly female
population.You are expert in dealing with early diagnosis of endometriosis based on
clinical symptoms.
Which of the following is most common symptom of endometriosis?

a. Dysmenorrhoea

b. Dysuria

c. Infertility

d. Deep dyspareunia

e. Painful abdominal bloating

Correct Answer & Detail

Correct Answer: a. Dysmenorrhoea

Answer Detail:
Symptoms suspicious of endometriosis include:

- Dysmenorrhea in 60 to 80 percent cases.

- Dysuria in just 5 percent.
- Infertility in about 30-50 percent.
- Deep dyspareunia in about 40 to 50 percent of the cases.
- Painful abdominal bloating is seen in 10 to 40 percent of
cases.

Dysmenorrhea is by far the most common symptoms in

patients with endometriosis.
Question No. 30 :

A 34-year-old lady presents with pain and swelling around wrist and hand joints for
last 3 months.Joints are usually stiff in the morning for more than 1 hour.You suspect
she might be suffering from rheumatoid arthritis.
Which of the following statement is correct regarding diagnosis of rheumatoid
arthritis?

a. Anti-CCP antibodies are less specific than rheumatoid factor for the presence of
rheumatoid arthritis
b. Anti-CCP antibodies have better sensitivity as compared to rheumatic factor for
diagnosis of rheumatoid arthritis
c. A positive result for anti-CCP antibodies appears to be a poor predictor of greater disease
severity than a positive result for rheumatoid factor
d. Anti-CCP assay has a sensitivity of 50-60 percent and specificity of 95-98% for the
development of rheumatoid arthritis in young age
e. Anti-CCP assay can be used to screen for rheumatoid arthritis in healthy individuals in
the absence of clinical symptoms

Correct Answer & Detail

Correct Answer: d. Anti-CCP assay has a sensitivity of 50-

60 percent and specificity of 95-98% for the development of
rheumatoid arthritis in young age
Answer Detail:
Anti-CCP antibodies are more specific than rheumatoid
factor for the presence of rheumatoid arthritis.
Anti-CCP antibodies have equal sensitivity as compared to
rheumatic factor for diagnosis of rheumatoid arthritis.

A positive result for anti-CCP antibodies appears to be a

better predictor of greater disease severity than a positive
result for rheumatoid factor.

Anti-CCP assay has a sensitivity of 50-60 percent and

specificity of 95-98 percent for the development of
rheumatoid arthritis in young age.

Neither Anti-CCP assay nor rheumatic factor should be used

to screen for rheumatoid arthritis in healthy individuals in
the absence of clinical symptoms.
Question No. 31 :

A 45-year-old alcoholic male presents with acute upper abdominal pain which is
steady and is located in right upper quadrant and mid-epigastrium. Patient is also
complaining of nausea and vomiting.He is sitting on bed bending forward.
On examination epigastrium is slightly tender with fever and tachycardia.

Which of the following is most likely diagnosis?

a. Acute cholecystitis

b. Acute pancreatitis

c. Acute gastritis

d. Acute gastro-oesophageal reflux disease.

e. Alcohol intoxication

Correct Answer & Detail

Correct Answer: b. Acute pancreatitis

Answer Detail:
The correct answer is b.

This patient has developed acute pancreatitis. A patient with

acute pancreatitis usually develops acute upper abdominal
pain at the beginning.The pain may be noted in epigastrium
and right upper quadrant.

The abdominal pain is usually accompanied by nausea and

vomiting in approximately 90 percent of
patients.Restlessness and agitation is noted. Relief of pain
occurs on bending forward.There may also be fever and
tachycardia.

Acute pancreatitis secondary to alcohol frequently occurs

one to three days after a binge drinking.It can also occur
after cessation of drinking.

Acute cholecystitis causes pain in right upper quadrant,

fever and leukocytosis. Murphys sign is positive usually.
Patient is asked to inspire deeply while you are palpating the
area of gall bladder fossa.
Patients with acute cholecystitis may experience increased
discomfort and hold in mid-inspiration. Abdominal
examination shows voluntary and involuntary guarding.

Acute gastritis usually presents with pain in epigastrium with

nausea and vomiting. However this patient has symptoms
and signs suggestive of acute pancreatitis.

Acute alcohol intoxication can lead to acute pancreatitis

however it usually happens 24 to 72 hours to develop acute
pancreatitis. Acute alcohol intoxication usually presents with
behavioural changes and change in mental state.
Question No. 32 :
Which of the following features does not help to differentiate mania from hypomania?

a. Delusions

b. Hallucinations

c. Functional impairment

d. Need for hospitalization

e. Elevated mood

Correct Answer & Detail

Correct Answer: e. Elevated mood

Answer Detail:
Mania is differentiated from hypomania by following
features:

1- Minimum 7 days of symptoms (4 days for hypomania).

2- Marked functional impairment (no functional
impairment in hypomania).
3- Delusions and hallucinations (absent in hypomania).
4- Patient often requires hospitalization (hospitalization is
less commonly required in hypomania).

Elevated mood is seen both in mania and hypomania and

does not help to differentiate between the too.

Patients who have experienced an episode of mania are

diagnosed as having bipolar I disorder, whereas those with
only hypomanic episodes are said to have bipolar II
disorder.
Question No. 33 :

Which of the following anti-psychotic medication increases the risk of type II diabetes
mellitus,raises the level of triglycerides in blood and has no effect on serum
cholesterol level?

a. Risperidone

b. Quetiapine

c. Amisulpride

d. Haloperidol

e. Olanzapine

Correct Answer & Detail

Correct Answer: e. Olanzapine

Answer Detail:
The correct answer is e.

All atypical antipsychotics cause weight gain,metabolic

disturbances and hyperprolactinemia.

Olanzapine is associated with faster and greater weight

gain.
Olanzapine increases the risk of type II diabetes mellitus
and raises the level of serum triglycerides.It has no effect on
serum cholesterol level.

The risk of development of type II diabetes mellitus is much

less with risperidone,quetiapine and amisulpride.
Haloperidol is typical antipsychotic and is notorious to cause
extrapyramidal side effects.It does not cause significant
weight gain.
Question No. 34 :

You are a ward call resident at night duty.One of the nurses calls you as she has given
a patient an injection of paracetamol twice by mistake.

What is best next step in this situation?

a. Consult with toxicology registrar

b. Discuss with your on call consultant and report the matter to chief executive officer

c. Take a blood sample for paracetamol concentration within 30 minutes and contact a
poisons information centre for advice
d. Start the patient acetylcysteine immediately and do serum paracetamol level

e. No further action needed

Correct Answer & Detail

Correct Answer: c. Take a blood sample for paracetamol

concentration within 30 minutes and contact a poisons
information centre for advice
Answer Detail:
The correct answer is c.

In this case intravenous paracetamol has been given twice

in controlled environment by mistake.Usual dose of
paracetamol is one gram at a time.So this patient has likely
been given two grams instead.So it is less likely to cause
toxicity.

However it is standard practice in Australia to take a blood

sample for paracetamol concentration within 30 minutes and
contact a poisons information centre for advice.
Discussing the matter with toxicology registrar is not
required until serum paracetamol level is quite elevated.

Discussing the issue with consultant might be alright

however reporting it to chief executive officer is not required
at this stage.

If serum paracetamol level is elevated,then chief executive

officer should be notified.Incident is usually reported to
nurse unit manager or team leader by nurse herself.
Question No. 35 :

A 37-year-old male comes to emergency department complaining of double vision

and weakness in both legs for last six hours.He has been experiencing blurred vision
for quite some time.
On clinical examination you find exaggeration of reflexes and increase tone in
muscles consistent with upper motor neuron lesion.He is vitally stable.
A non-contrast CT scan of the head was performed which excluded any haemorrhage
and raised intracranial pressure.His mother was diagnosed with primary progressive
multiple sclerosis at the age of 50.
Which of the following is best next step in management of this patient?

a. Lumbar Puncture

b. MRI scan of brain and spinal cord

c. CT scan is the only investigation recommended in this case

d. Admit to hospital for intravenous steroids

e. Start thrombolytic therapy

Correct Answer & Detail

Correct Answer: d. Admit to hospital for intravenous

steroids
Answer Detail:
This patient has signs and symptoms consistent with
multiple sclerosis.
The typical patient with multiple sclerosis presents as a
young adult with two or more clinically distinct features of
neuronal dysfunction with at least partial resolution.

Optic neuritis is the most common type of involvement of

the visual pathways.Patient may present with sensory,motor
and undifferentiated clinical presentations.

As this patient has severe symptoms,immediate intravenous

steroids are indicated as next step and this requires
admission to hospital.

Family history of multiple sclerosis raises strong suspicion of

diagnosis of multiple sclerosis in the presence of visual
symptoms and weakness of legs.

As there is no rise in intra-cranial pressure,lumbar puncture

can be performed to find out oligoclonal IgG in cerbrospinal
fluid.

MRI scan is indicated now as white matter changes are

present usually in a patient with symptoms of multiple
sclerosis however there is usually some delay in getting it
organized. So this patient should be commenced on steroids
while awaiting for MRI scan.
CT scan is quite helpful to rule out other pathologies
including hemorrhage than multiple sclerosis in emergency
department.

MRI scan,lumbar puncture and visual evoked potentials can

be done after admitting the patient and starting intravenous
steroids.
Thrombolytic therapy is not indicated as patient has clear
symptoms of multiple sclerosis.
Question No. 36 :

At which week of gestations,a pregnant lady without family history of diabetes

mellitus should get her gestational diabetes status checked?

a. 10 weeks

b. 15 weeks

c. 20 weeks

d. 28 weeks

e. First antenatal visit

Correct Answer & Detail

Correct Answer: d. 28 weeks

Answer Detail:
Screening for gestational diabetes mellitus in a patient with
no family history of diabetes is usually done at 24 to 28
weeks.

It can be done even earlier at first antenatal visit if she is at

high risk with positive family history of diabetes mellitus.
Question No. 37 :

An elderly lady visits your office after she has a fracture of her right wrist.She says
that she crashed into a wall and she has lost her peripheral vision which she did not
notice previously.Her pupils are constricted and fundoscopy is difficult.

What do you do next?

a. Send her home after treating her wrist fracture

 b. Send her home after treating her eye problem

c. Do an urgent CT scan

d. Do blood sugar levels

e. Ask her not to drive

Correct Answer & Detail

Correct Answer: c. Do an urgent CT scan

Answer Detail:
The correct answer is c.

This patient has trauma to the wrist while she hit herself to
a wall.Acute loss of peripheral vision with constricted pupils
constitute the possibility of concussion head injury.

CT scan of the head is immediately needed to rule out the

possibility of acute brain injury.It is not clear whether
patient had stroke and then due to loss of vision,met a
trauma or trauma led to acute brain injury and loss of
peripheral vision.

Once CT scan of head has been done,further management

can be organized in liaison with ophthalmologist.Treating
wrist fracture,checking blood sugar and advice on driving
follows CT scan.

Moderate and severe cases of peripheral vision loss create

the sensation of seeing through a narrow tube,a condition
commonly referred to as "tunnel vision.
Question No. 38 :
A 49-year-old male with history of previous ischemic stroke presented to emergency
after motor vehicle accident.
He is expected to undergo emergency surgery for compound fracture of right
femur.Regular medication include aspirin,metoprolol,allopurinol and paracetamol.
How you go for perioperative management?

a. Stop aspirin immediately and proceed for surgery

b. Stop aspirin after one week of surgery

c. Give cryoprecipitate during surgery

d. Platelets infusion during surgery

e. Give fresh frozen plasma

Correct Answer & Detail

Correct Answer: d. Platelets infusion during surgery

Answer Detail:
Aspirin causes irreversible platelet dysfunction and should
be ceased 7 to 10 days before any elective procedure.

However in emergency surgical interventions, according to

Australian Red Cross Blood Service guidelines, consider
platelets transfusion during emergency surgery.

Aspirin can also dysfunction the infused platelets however

there are evidences which suggest some benefits of platelets
transfusion to reduce the likelihood of bleeding.
The bleeding tendency in platelet dysfunction defects is
extremely variable and the platelet count is not a reliable
indicator.

Stopping aspirin immediately is not helpful in emergency as

it takes 7 to 10 days to form new platelets and replace the
old dysfunctional platelets.
Similarly stopping aspirin after a week is also not required.

Cryoprecipitate contains factor VIII,fibrinogen,factor

XIII,von Willebrand factor and fibronectin from fresh frozen
plasma.It is used in coagulation factors deficiencies.
Aspirin does not affect coagulation system.It inhibits
platelets only.

Fresh frozen plasma is also rich in coagulation factors and

does not contain platelets and so not useful in this patient.
Question No. 39 :

A 20-year-old girl is unable to concentrate at work and fears she will lose her job.She
recently has stopped listening songs and she says she becomes tearful and anxious
easily.
Further history reveals that she missed a road-traffic accident and was about to hit a
pole 3 weeks ago.She is happy otherwise with her family life.
Which of the following is the most likely diagnosis?

a. Adjustment disorder

b. Depression

c. Normal grief reaction

d. Psychosis

e. Post-traumatic stress disorder

Correct Answer & Detail

Correct Answer: a. Adjustment disorder

Answer Detail:
This patient has developed adjustment disorder.This is
differentiated from post-traumatic disorder by intensity of
the stressors.
In post-traumatic stress disorder, the stressor must be of an
extreme (like life-threatening) nature.In contrast,in
adjustment disorder, the stressor can be of any severity.

In this case,the stressor was not life threatening as she

missed to hit the pole (did not injured herself) and other
symptoms of post-traumatic disorder are absent.

She is not re-experiencing traumatic event and there are no

flashbacks of the memory.So this patient has diagnosis of
adjustment disorder.

Criteria to diagnose adjustment disorder include:

- Development of emotional or behavioral symptoms in

response to an identifiable stressor(s) occurring within 3
months of the onset of the stressor.

- The reaction may take the form of either marked distress

in excess of what would be expected or significant
impairment in social or occupational functioning.

- The disturbance may not have persisted for longer than 6

months after the termination of the stressor.

- The diagnosis of adjustment disorder is not used when

symptoms conform to the specific criteria for another mental
disorder (excluding personality disorder or developmental
disorder); nor is it used when current distress represents
but one instance of a general pattern of overreaction to
stressors.
For this reason, adjustment disorder is a diagnosis of
exclusion.
Depression,normal grief reaction and psychosis are
extremely unlikely diagnosis in the situation.
Question No. 40 :

A 62-year-old male presented with fever, left flank pain and generally unwell. Urine
microscopy and culture confirms the presence of urinary tract infection. CT scan of
kidney shows acute pyelonephritis and polycystic kidneys.

Which of the following medication is preferred because of good cyst penetration?

a. Fluoroquinolones

b. Penicillins

c. Aminoglycoside

d. Macrolides

e. Tetracycline

Correct Answer & Detail

Correct Answer: a. Fluoroquinolones

Answer Detail:
The correct answer is a.

Lipid-soluble antimicrobials such as trimethoprim-

sulfamethoxazole and fluoroquinolones that have good cyst
penetration are the preferred therapy for infected kidney
and infected liver cysts in a patient with polycystic kidney
disease.

All other options including penicillins, aminoglycosides,

macrolides and tetracycline do not have good cyst
penetration.
Question No. 41 :
A 50-year-old Aboriginal male presented to the emergency department, feeling
generally unwell. He has past medical history of type 2 diabetes mellitus, poorly
controlled hypertension, 30 pack year history of smoking, diabetic nephropathy and
peripheral neuropathy. His current medications include frusemide, ramipril,
metformin, amlodipine and pregabalin.
On examination, he has developed significant fluid overload with significant
peripheral edema. Also he is quite confused.
Blood tests show sever hyperkalemia, metabolic acidosis and glomerular filtration
rate of 6ml/min/1.73m2. The medical management remained ineffective for first 4
hours.

What will you consider next?

a. Decrease protein intake

b. Increase diuretics and wait for the effect for at least 24 hours

c. Monitor potassium every 4 hourly

d. Urgent renal dialysis

e. Restrict intravenous fluids

Correct Answer & Detail

Correct Answer: d. Urgent renal dialysis

Answer Detail:
The correct answer is d.

This patient has developed severe renal failure and has

poorly responded to medical treatment. The most
appropriate next step in his management would be to
consider urgent renal dialysis.

Criteria for initiating or maintaining dialysis include:

- The presence of uremic symptoms.

- The presence of hyperkalemia unresponsive to
conservative measures.
- Persistent extracellular volume expansion despite
diuretic therapy.
- Acidosis refractory to medical therapy.
- A bleeding diathesis.
- A creatinine clearance or estimated glomerular
filtration rate (GFR) below 10 mL/min per 1.73 m2.
Question No. 42 :

A 60-year old male with 30 pack year history smoking presented with history of left
leg pain for last 6 months. Pain is worsened by walking and improves by rest. There is
no pain at rest.
On examination, blood pressure is high, BMI is high and decreased pulsation in the
dorsalis pedis artery of the left. There is no gangrene or ulcer on both legs. Ankle
brachial index is 0.7.

What is the most appropriate management?

a. Smoking cessation, exercise and follow up in 3 months

b. Smoking cessation, exercise and ACE inhibitor

c. Aspirin, metoprolol and statin

d. Doppler venous ultrasound

e. Refer to vascular surgery

Correct Answer & Detail

Correct Answer: b. Smoking cessation, exercise and ACE

inhibitor
Answer Detail:
This patient has clinical feature (intermittent claudication,
history of smoking, obesity, and hypertension and low ankle
brachial index) consistent with diagnosis of peripheral
vascular disease.
There are no features of critical limb ischemia (rest pain,
gangrene, so this patient does not referral to vascular
surgery.

This patient needs management of risks of atherosclerosis-

exercise for obesity, smoking cessation and angiotensin
converting enzyme inhibitor.

Smoking cessation improves walking distance, doubles 5

year survival rate and reduces the incidence of
postoperative complications.
Physical activity also improves walking time and walking
distance.

Using angiotensin converting enzyme inhibitor-ramipril also

increases pain-free walking distance and maximum walking
time.

Statins are lipid lowering agents and reduces rate of

myocardial infarction, stroke and revascularization. These
increase pain-free walking distance should be prescribed in
all patients with peripheral vascular disease.

Aspirin should not be used in patients with peripheral

vascular disease without clinically evident cardiovascular
disease. There is no reduction in vascular events in
asymptomatic subjects with a low ABI randomized to daily
aspirin.

Clopidogrel is superior to aspirin and reduces risk of

worsening or systemic complications of peripheral vascular
disease by 24 %.
Beta blockers should be used with caution and should only
be used for cardiovascular indications other than peripheral
vascular disease.
Question No. 43 :

A 29-year-old female presented with blurry vision and swelling of eyelid after being
hit by squash ball into left orbit during play.
The examination shows eyelid swelling, decreased visual acuity and vertical diplopia
of left eye that disappears when right eye is closed.

Which of the following is the most likely cause of this presentation?

a. Orbital floor fracture

b. Zygomatic fracture

c. Nasal bone fracture

d. Superior orbital wall fracture

e. Tripod fracture

Correct Answer & Detail

Correct Answer: a. Orbital floor fracture

Answer Detail:
The correct answer is a.

This is the case of blow out fracture which means the

fracture of the walls of orbit.
The most commonly fractured part is inferior orbital wall or
orbital floor because this is the thinnest part and is
represented by decreased visual acuity,binocular vertical
diplopia,eyelid swelling and ipsilateral hyperaesthesia.

Enopthalmos is a late feature that can be seen after edema

settles.
The zygomatic bone forms the lateral part of orbit.This is
fractured in blow to the lateral side of face as in road traffic
accidents.It is presents as horizontal diplopia,mallar
flattening and difficulty in opening mouth.

The nasal bone forms the medial orbital wall and its fracture
is associated with horizontal diplopia,cerebrospinal fluid
leakage and epistaxis.

Superior orbital wall fracture can present as vertical diplopia

but its less common and is accompanied by skull fracture.

Tripod fracture also known as zygomaticomaxillary complex

fracture, involves inferior and lateral walls and is
represented by mixed features like
vertical/horizontal/oblique diplopia,difficulty in mastication
and other features.
Question No. 44 :

A 50-year old farmer sought consult due to a dark mole on his left cheek, which
become enlarged, slightly lumpy and itchy over the last 4 months. What is the most
appropriate initial management in this patients presentation?

a. Undertake an elliptical excision clear of margin for histopathology

b. Treat lesion using liquid nitrogen

c. Ask patient to return for review in 3 months

d. Remove the lesion using laser

e. Take an incisional biopsy of the lesion for hispathology

Correct Answer & Detail

Correct Answer: a. Undertake an elliptical excision clear of
margin for histopathology
Answer Detail:
The presentation of the patient is suggestive of a malignant
melanoma of the face thus an accurate pathological report is
required to guide further management.
For this reason it is important that the initial management
involves complete removal of the lesion without destruction
of the tissue.
Early detection and removal of melanomas leads to better
outcomes. In this case, elliptical excision clear of margin for
histopathology must be undertaken.

If a melanoma is diagnosed then referral to a plastic

surgeon is necessary for a wide local excision involving a
margin of 1-3 cm and to a depth of the deep fascia.
Question No. 45 :

A 20-year-old female otherwise healthy,presents with mild fatigue,lethargy for last 2

months.Laboratory work up shows microcytic hypochromic anemia hypocalcemia
and raised INR.

Which of the following investigations will help in diagnosis?

a. Liver function tests

b. Serum magnesium

c. Serum transglutaminase antibodies

d. MRI abdomen

e. CT abdomen

Correct Answer & Detail

Correct Answer: c. Serum transglutaminase antibodies

Answer Detail:
The correct answer is c.

This patient has laboratory investigations with suspected

diagnosis of coeliac disease.

Coeliac disease is sensitivity to gluten that results in

inflammation and atrophy of the mucosa of the small
intestine.

Clinical manifestations include malabsorption with symptoms

of diarrhoea,steatorrhea, and nutritional and vitamin
deficiencies.

Common laboratory finding in a patient with coeliac disease

include:

a. Iron deficiency anemia (microcytic hypochromic)

b. Vitamin K malabsorption-resulting in Vitamin K
deficiency.It results in prolonged prothrombin time and
raised INR.
c. Folic acid and Vitamin B12 deficiency
d. Calcium and vitamin D deficiency resulting in
osteopenic bone disease.

The most common serologic markers used for coeliac

disease screening are serum immunoglobulin A (IgA)
endomysial antibodies and IgA tissue transglutaminase
antibodies.

Many studies have found the sensitivity and specificity of

testing for IgA endomysial and transglutaminase antibodies
to be greater than 95%.
Intestinal biopsy is confirmatory and is required in most
cases at specialist centres.

CT and MRI abdomen is not required. In this

situation,checking serum magnesium will not be helpful to
diagnose the disease.
Question No. 46 :

Which ONE of the following complications of acute diverticulitis carries the highest
mortality rate?

a. Bleeding

b. Abscess

c. Peritonitis

d. Perforation

e. Intestinal obstruction

Correct Answer & Detail

Correct Answer: d. Perforation

Answer Detail:
The correct answer is d.

The complications of acute diverticulitis disease include:

- Bleeding especially in elderly.

- Bowel perforation.
- Intra-abdominal abscess.
- Peritonitis.
- Fistula formation.
- Intestinal obstruction.

Bowel Perforation with generalized peritonitis may result in

following situations:

- Rupture of a diverticular abscess into the peritoneal

cavity.
- Free rupture of an inflamed diverticulum with fecal
contamination of the peritoneum.

Although only 1 to 2 percent of patients with acute

diverticulitis have a perforation with purulent or fecal
peritonitis, mortality rates approach 20 percent. This
mortality rate is highest as compared to other complications
of acute diverticulitis.

In patients with a free perforation, the abdomen is

distended and diffusely tender to light palpation. There is
diffuse guarding, rigidity, and rebound tenderness, and
bowel sounds are absent.
Question No. 47 :

Which of the following is correct regarding secondary nocturnal enuresis in children?

a. This is most common form of bed wetting

b. It can be caused by bladder infection

c. It has strong genetic component

d. Most common cause is neurological developmental delay

e. Children with ADHD are more likely to suffer from enuresis

Correct Answer & Detail

Correct Answer: b. It can be caused by bladder infection

Answer Detail:
Nocturnal enuresis is called secondary when a child has
been dry for a period of 6 months or more and then re
starts bed wetting.

Only option related to secondary nocturnal enuresis in this

case is bladder infection.

Primary nocturnal enuresis is the most common cause of

bed wetting in children.

It has strong genetic link with high incidence in families

having one or two parents with nocturnal enuresis.

Neurological developmental delay is the most common

cause of primary nocturnal enuresis.

Children with ADHD are 2.5 times more likely to suffer from
primary nocturnal enuresis.
Question No. 48 :

A 35-year-old man with background history of bipolar disorder, has been stable on
lithium over last 6 months. His serum lithium level is 1.0 mmol/L today.

How often will you monitor lithium in future?

a. Every 12 months

b. Every 3 months

c. Every 6 months

d. Every week

e. Every 5 years
Correct Answer & Detail

Correct Answer: b. Every 3 months

Answer Detail:
The correct answer is b.

Once a patient has been stable on lithium for 6 months with

a serum lithium level being in therapeutic range, consider
measuring lithium level every 1 to 3 months afterwards.
Normal lithium level is 0.8 mmol/L to 1.4 mmol/L.

All other answers are incorrect.

Question No. 49 :

A 30-year-old woman is concerned about breast cancer has her mother was diagnosed
with breast cancer at the age of 48. Clinical examination of the breast is normal.

What is the most appropriate advice for her?

a. Mammography every year from the age of 40

b. Mammography every 2 years from age of 50-69

c. Refer to surgeon

d. Refer for genetic studies

e. Reassure her that she is not at high risk of breast cancer

Correct Answer & Detail

Correct Answer: a. Mammography every year from the

age of 40
Answer Detail:
The correct answer is a.

If a woman has a first degree relative less than 50 years of

age diagnosed with breast cancer, she should have
mammography every year from the age of 40.

All other options are incorrect.

Question No. 50 :

Which of the following is an indication to initiate treatment of HIV in an

asymptomatic patient known to have HIV infection?

a. CD4 cell count less than 350 per microlitre

b. HIV viral load of less than 100000 copies per ml

c. Chronic hepatitis C

d. Non-pregnant female positive for HIV infection

e. HIV infection associated with neuropathy

Correct Answer & Detail

Correct Answer: a. CD4 cell count less than 350 per

microlitre
Answer Detail:
Indications to start treatment of HIV in an asymptomatic
patient known to have HIV infection include:
CD4 count less than 350 per microlitre
HIV viral load more than 100,000 copies per ml
HIV infection associated with hepatitis B infection
HIV associated nephropathy.
If HIV positive patient becomes pregnant, even CD4 count is
greater than 350/microlitre, treatment should be started.
Association with hepatitis C and neuropathy is not criteria to
start treatment for HIV.