Question No.

1 :

A 55-year-old male finds it hard to perform his duties and is concerned about his
health.He has been heavy smoker for last 15 years.
On examination there is ankle edema,massive hepatomegaly,splenomegaly and ascites
JVP is elevated and it rises with inspiration and drops with expiration.

Which of the following is most likely diagnosis?

a. Cardiac temponade

b. Budd Chiari Syndrome

c. Superior venacaval obstruction

d. Constrictive pericarditis due to tuberculosis in past

e. Hepatic cirrhosis

Correct Answer & Detail

Correct Answer: d. Constrictive pericarditis due to

tuberculosis in past
Answer Detail:
The correct answer is d.

This patient has signs and symptoms suggestive of constrictive

pericarditis. Elevated jugular venous pressure which rises with
inspiration and drops with expiration is called paradoxical JVP
or Kussmaul’s sign.Other signs of constrictive pericarditis
include massive hepato-splenomegaly,ascites and peripheral
edema.

Hepatic cirrhosis is unlikely as in cirrhosis liver is shrunk and

smaller in size.This patient has massive hepatomegaly.
In superior venacaval obstruction JVP is raised however
pulsation is absent. This patient has raised JVP which is
pulsatile.Also it does not cause peripheral ankle edema and
ascites.

Budd Chiari syndrome is caused by a clot obstructing the

hepatic vein.Hepatic vein thrombosis can be acute in 20% of
the cases causing fatigue,right upper quadrant pain,mild
jaundice,tender hepatomegaly and ascites.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 1 of 48
 Cirrhosis may develop leading to massive ascites,variceal
bleeding and hepato-pulmonary syndrome. However it does
not cause raised JVP which is a feature of right heart failure.It
is commonly seen in high risk thrombotic conditions like
malignancy,anti-phospholipid antibody syndrome,protein C or
S deficiency,pregnancy etc.

Cardiac temponade can result in paradoxical JVP pulsations

however rest of the findings do not correlate with the
diagnosis.
Question No. 2 :

You are working in a GP clinic.One of your female patients invites you for a dinner
outside with clearly romantic intentions.You feel she is attracted towards you.
How will you proceed?

a. Accept the offer and plan a meeting outside

b. Decline the request and continue doctor-patient relationship

c. Decline the request and discontinue doctor-patient relationship

d. Tell her that its inappropriate meet her outside but still I will manage to come

e. Notify the management for in-appropriate behaviour of the patient but still continue doctor-
patient relationship

Correct Answer & Detail

Correct Answer: c. Decline the request and discontinue
doctor-patient relationship
Answer Detail:
There are certain situations when a doctor-patient relationship
can be terminated.
These include:

- Professional boundary violations by the patient or doctor.

- Unacceptable behaviour of the patient like verbal
abuse,threatened or actual violence and harassment.

This patient has violated the boundary where it is hard to

continue health care in professional manners.
So according to guidelines by Australian Medical Association,in
such situations doctor-patient relationship should be
terminated however with due respect for the patient.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 2 of 48
 Patient should be notified and offered to transfer a copy of her
medical record to new health care provider.

Ending the doctor-patient relationship should not be

misinterpreted by the patient as an act of discrimination based
on gender, sexual preference, race, marital status, disability,
age and HIV status.

Also you should continue care if the patient is suffering an

acute illness.
In such situation the patient is entitled to have appropriate
continuity of care and doctor-patient relationship should not be
terminated.
Question No. 3 :

A-48-year-old lady was found to have low serum sodium on day 3 after cranial
surgery.Her laboratory investigations are given below:
Serum sodium-117mmol/L
Plasma osmolality-205 mosm/kg
Urine osmolarity-525 mosm/kg
What is the most likely diagnosis?

a. Diabetes inspidus

b. SIADH

c. Water intoxication

d. Dehydration

e. Renal failure

Correct Answer & Detail

Correct Answer: b. SIADH
Answer Detail:
The syndrome of inappropriate ADH secretion (SIADH) is
defined as less-than-maximally-dilute urine in the presence of
plasma hypo-osmolality (hyponatremia) without volume
depletion or overload.

Findings in SIADH:

1- ​A low serum osmolality

2- ​An inappropriately elevated urine osmolality (above
100 mosmol/kg and usually above 300 mosmol/kg)

3- ​A urine sodium concentration usually above 40 meq/L

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 3 of 48
 Diabetes inspidus is characterized by polydipsia due to
decrease formation of ADH (Central DI) or resistance to ADH
(nephrogenic DI). Urine osmolarity is usually below
250mosm/L.

A low plasma sodium concentration (less than 137 meq/L) with

a low urine osmolality (less than the plasma osmolality) is
usually indicative of water overload due to primary polydipsia.

A high-normal plasma sodium concentration (greater than 142

meq/L, due to water loss) points toward diabetes inspidus,
particularly if the urine osmolality is less than the plasma
osmolality.

Dehydration increases both serum as well as urine osmolality.

Question No. 4 :

A 55-year-old woman presents with history of weight loss, heat intolerance and
palpitations. On examination, a large multinodular goitre is found.Pemberton’s sign is
positive. Blood tests show low TSH and elevated free T4.

What is the definitive treatment?

a. Surgery

b. Antithyroid drugs

c. High dose radio-iodine

d. Beta blockers

e. Calcium channel blockers

Correct Answer & Detail

Correct Answer: a. Surgery
Answer Detail:
The correct answer is a.

This patient has biochemical diagnosis of hyperthyroidism with

large multinodular goitre. Pemberton’s sign is positive in
retrosternal goitre.

Where a large goitre is producing significant tracheal

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 4 of 48
 obstruction or narrowing; surgery is the preferred treatment
after euthyroidism is achieved with antithyroid drugs.

Patients with multinodular goitre will respond to thionamide

medication, but definitive treatment with surgery is generally
preferred.
Question No. 5 :

A 60-year-old lady presented with difficulty in climbing stairs at home for about 6
months.She is not on hormone replacement therapy and never used bisphosphonates
before.
She has esophagitis secondary to long-standing gastro-oesophageal reflux disease.
What would be the next step in her management?

a. Alendronate

b. Raloxifene

c. Paracetamol

d. Zolendronic acid

e. Methotrexate

Correct Answer & Detail

Correct Answer: d. Zolendronic acid
Answer Detail:
Bisphosphonates are first line medication for prevention of
osteoporosis in post-menopausal women.
These inhibit bone resorption and preserve bone mass.These
also decrease vertebral and hip fractures by 50 percent.

Oral bisphosphonates cause esophagitis and drugs like

alendronate are contraindicated in this case and should be
avoided.

Zoledronic acid is an alternate parenteral bisphosphonate and

is used when oral bisphosphonates are contraindicated.

For example, oral bisphosphonates should be avoided when a

patient is unable to stay upright for at least 30 minutes after a
dose or have an oesophageal disorder that precludes use of an
oral bisphosphonates or patient is experiencing intolerable
gastrointestinal upset or other oesophageal adverse effects.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 5 of 48
 Raloxifene is a selective oestrogen receptor modulator (SERM).
It is appropriate for treatment of osteoporosis in women who
have contraindication to both oral and intravenous
bisphosphonates.
It reduces vertebral fractures by about 50 percent but has not
been shown to reduce non-vertebral fractures.

Methotrexate has no use in prevention of

osteoporosis.Paracetamol can be used for pain relief when
required.However it is not helpful in prevention of
osteoporosis.
Question No. 6 :

Which one of the following is a condition when breast feeding can be stopped?

a. Engorged breasts

b. Inverted nipples

c. Cracked nipples

d. Breast abscess

e. Mastitis

Correct Answer & Detail

Correct Answer: d. Breast abscess
Answer Detail:
In breast abscess, continue breast feeding from both breasts.
If breast feeding is not possible due to location of the incision,
milk should be expressed from the breast. Breast feeding may
be discontinued until abscess is resolved.

Engorged breast occurs when milk supply comes on so quickly

that the breast become swollen, hard and tender. The blood
supply and other fluids accumulate in the breast tissue. Breast
feeding should be continued. Proper breast feeding the baby
on demand is key in managing this condition.

Inverted nipple inverts into the breast instead of pointing

towards the baby when baby tries to suck from it. The best
approach is good preparation with prolonged breast contact
and feeding prior to milk coming in. Breast feeding should be
continued in mothers with inverted nipples.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 6 of 48
 Cracked nipples are usually caused by the baby clamping on
the end of the nipple rather than applying jaw behind the
nipple.Breast feeding should be continued. The best approach
is to rest the nipple for 1-2 feeds, express the milk from the
effected breast by hand and then feed the expressed milk to
the baby. Start feeding gradually with short feeds.

Mastitis is cellulitis of the interlobular connective tissue of the

breast. It is mainly associated with cracked nipples or poor
milk drainage in lactating mother. The infecting organism is
Staphylococcus aureus. Breast feeding from the affected side
can be continued as infection is confined to the interstitial
breast tissue.
Question No. 7 :

An 18-month old female infant is brought to your clinic due to an onset of red
maculopapular rash on her trunk.Symptoms reported by mother include high grade
fever and mild coryza for last 3 days however she has still been quite active.
Her temperature has returned to normal today.

What is the most likely diagnosis?

a. Roseola Infantum

b. Rubella

c. Measles

d. Chicken pox

e. Erythema Infectiosum

Correct Answer & Detail

Correct Answer: a. Roseola Infantum
Answer Detail:
The correct answer is a.

Roseola infantum is a viral infection usually affecting children

between the ages of 6-18 months.

The patient typically develops high fever up to 40 degrees

Celsius, but is otherwise not particularly unwell. There may be
mild cervical lymphadenopathy and pharyngitis.

After three days, the temperature usually returns suddenly to

normal and the patient develops a red macular or
maculopapular non-desquamating rash which is truncal,

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 7 of 48
 usually sparing the face and limbs. The rash abates within two
days.

Rubella (German measles) is a viral infection typically

characterized by rash, fever, and lymphadenopathy. The rash
is usually an erythematous, discrete maculopapular
exanthema that begins on the face and spreads caudally. It
usually disappears within three days but may persist for eight
days.

The exanthema of measles is a maculopapular, blanching rash

beginning on the face and spreading cephalocaudally and
centrifugally to involve the neck, upper trunk, lower trunk, and
extremities.

The clinical manifestations of varicella (chicken pox) in healthy

children generally develop within fifteen days after the
exposure and typically include a prodrome of fever, malaise, or
pharyngitis, loss of appetite, followed by the development of a
generalized vesicular rash, usually within 24 hours.
The vesicular rash of varicella, which is usually pruritic,
appears in successive crops over several days. The patient
with varicella typically has lesions in different stages of
development on the face, trunk and extremities.

Erythema infectiosum (human parvovirus B19) also referred to

as "fifth disease" since it represents one of six common
childhood exanthems, each named in order of the dates they
were first described.
The illness begins with nonspecific prodromal symptoms, such
as fever, coryza, headache, nausea, and diarrhoea.These
constitutional symptoms coincide with onset of viremia.
Two to five days later, the classic erythematous malar rash
appears (the so-called slapped cheek rash) with relative
circumoral pallor. This facial rash is often followed by a
reticulated or lacelike rash on the trunk and extremities.
Question No. 8 :

Which of the following is the indication to perform cervical cerclage at 14 weeks of

gestation?

a. 2 or more consecutive prior second trimester pregnancy losses

b. Short cervix at <24 weeks with no prior preterm birth

c. One preterm birth before 34 weeks

d. Carcinoma cervix

e. Vaginal polyp

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 8 of 48
 Correct Answer & Detail
Correct Answer: a. 2 or more consecutive prior second
trimester pregnancy losses
Answer Detail:
A minority of recurrent second trimester abortions are due to
cervical insufficiency exclusively.

Cervical cerclage is a preventive measure and is performed at

12 to 14 weeks of gestation.

Indications of cervical cerclage include:

- Two or more consecutive prior second trimester pregnancy

losses or
- Three or more preterm births before 34 weeks of gestation.

Short cervix less than 24 weeks of gestation without any

preterm birth is not a reason to do cerclage.
Similarly carcinoma cervix and vaginal polyp are also not
indications to perform cerclage.
Question No. 9 :

Which of the following is not a complication of untreated scaphoid fracture?

a. Non-union

b. Avascular necrosis

c. Carpal instability

d. Osteoarthritis

e. Osteomyelitis

Correct Answer & Detail

Correct Answer: e. Osteomyelitis
Answer Detail:
Scaphoid fractures if left untreated leads to following
complications:

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 9 of 48
 - Non-union.
- Avascular necrosis.
- Carpal instability.
- Osteoarthritis.

Osteomyelitis is infection of bone tissue and is not a

complication of scaphoid bone fracture.
Question No. 10 :

Mr John,a 48 year-old man with known history of chronic back pain comes to your
clinic complaining of pain radiating to the hip,anterior thigh,medial aspect of knee
and calf.
On examination,sensory impairment is noted over medial calf.Knee jerk is also
diminished.
Which of the following is most likely diagnosis?

a. L4 radiculopathy

b. L5 radiculopathy

c. S1 radicuolpathy

d. L5-S1 radiculopathy

e. Sciatica

Correct Answer & Detail

Correct Answer: a. L4 radiculopathy
Answer Detail:
This patient has symptoms of L4 radiculopathy.

In L5 radiculopathy,pain usually is referred to posterolateral

buttock,posterior thigh and lateral leg.

In S1 radiculopathy,pain radiates through posterior

buttocks,posterior calf and lateral foot.Ankle jerk is diminished
as well in S1 radiculopathy.

L5-S1 radiculopathy is mixture of both lesions.

Sciatica is involvement of sciatic nerve causing shooting

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 10 of 48
 radiating pain through posterior thigh and posterior leg to little
toe.
Question No. 11 :

Which of the following is correct regarding shoulder dystocia?

a. Most cases can be resolved by hyperflexion the foetal thighs onto the abdomen

b. It is not associated with maternal diabetes mellitus

c. Arrest occurs at pelvic inlet

d. Erb palsy

e. Increased possibility of shoulder dystocia if epidural anaesthesia given

Correct Answer & Detail

Correct Answer: d. Erb palsy

Answer Detail:
Shoulder dystocia most commonly occurs when the
bisacromial (breadth of the shoulders) diameter exceeds the
diameter of the pelvic inlet. This typically results in a bony
impaction of the anterior shoulder against the maternal
symphysis pubis. Arrest does not occur at pelvic inlet.

Maternal diabetes mellitus and foetal macrosomia both are risk

factor for shoulder dystocia. Possibility of shoulder dystocia is
increased if epidural anaesthesia is used during labour.

he foetal legs are then abducted and hyperflexed against the

women’s abdomen so that her knees are upwards towards her
ears. (McRoberts manoeuvre).

The most common foetal injury is brachial plexus palsies

including Erb’s palsy. This is correct response.
Question No. 12 :

A 50-year-old man is admitted to the hospital for a 2-day history of fever and
abdominal pain. His medical history include cirrhosis due to chronic hepatitis C,
oesophageal varices, ascites, and minimal hepatic encephalopathy.
His medications are frusemide, spironolactone, nadolol, lactulose, zinc, vitamin A,
and vitamin D.

On physical examination, temperature is 36.5°C, blood pressure is 110/60 mm Hg,

pulse rate is 90/min, and respiration rate is 18 /min.Abdominal examination discloses
distension consistent with ascites. The abdomen is non-tender to palpation. Diagnostic
paracentesis is consistent with spontaneous bacterial peritonitis.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 11 of 48
 Which of the following is the most appropriate treatment?

a. Cefotaxime

b. Ciprofloaxacin

c. Large-volume paracentesis

d. Increase dose of frusemide and spironolactone

e. Cefotaxime and albumin

Correct Answer & Detail

Correct Answer: e. Cefotaxime and albumin
Answer Detail:
The correct answer is e.

Spontaneous bacterial peritonitis should be suspected in

patients with cirrhosis who develop signs or symptoms such as
fever, abdominal pain, altered mental status, abdominal
tenderness, or hypotension.

In addition, patients with ascites admitted to the hospital for

other reasons should also undergo paracentesis to look for
evidence of spontaneous bacterial peritonitis.

Patients with spontaneous bacterial peritonitis are at risk of

developing hepatorenal syndrome. Intravenous albumin has
been shown to reduce the rate of renal failure.

In patients with spontaneous bacterial peritonitis, the

concomitant use of intravenous albumin with antibiotic therapy
is associated with a survival benefit compared with antibiotic
therapy alone.

So the most appropriate treatment is cefotaxime and albumin

in this situation.
Question No. 13 :

A 45-year-old woman presented with repeated cleansing of her kitchen floor and
excessive hand washing for last 3 months. She has past medical history alcohol
withdrawal,acute pain,iron deficiency anemia and body dysmorphic disorder.
Which one of the following puts patient at high risk for developing obsessive
compulsive disorder?

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 12 of 48
 a. Avoiding alcohol

b. Acute pain

c. Vitamin B12 deficiency

d. Iron deficiency anaemia

e. Body dysmorphic disorder

Correct Answer & Detail

Correct Answer: e. Body dysmorphic disorder

Answer Detail:
Following health conditions if present increase the risk of
developing obsessive compulsive disorder:

1- ​Anxiety
2- ​Depression
3- ​Alcohol or substance misuse
4- ​Eating disorders
5- ​Body dysmorphic disorders
6- ​Chronic physical health problems (For example, skin
problems due to excessive hand washing).

Avoiding alcohol helps to improve symptoms of obsessive

compulsive disorder.

Risk of obsessive compulsive disorder does not rise in the

presence of vitamin B12 deficiency, acute pain and iron
deficiency anemia.
Question No. 14 :

A 32-year-old male was assaulted on his face at a local club on a Saturday night.He
was brought in by ambulance to the emergency department for further assessment.

On examination you find painful swollen eyelids,black eye and infra-orbital

paraesthesia.

Which of the following is the single most important sign of orbital fracture?

a. Trismus

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 13 of 48
 b. Local tenderness

c. Diplopia

d. Numbness in the lip and chin

e. Epistaxis

Correct Answer & Detail

Correct Answer: c. Diplopia
Answer Detail:
The correct answer is c.

Orbital fracture is characterized by subconjunctival and

periorbital haematoma.
Diplopia commonly occurs when the orbital walls are
fractured.Restricted eye movements,particular on vertical
gaze,result in diplopia. Infraorbital paraesthesia or anaesthesia
can occur when a fracture of the orbital floor affects the
infraorbital nerve.

Fractures of the zygoma and zygomatic arch commonly

present with a trismus,because the zygoma or the arch is
pushed down onto the coronoid process of the mandible,which
cannot move freely anteriorly.

People with mandibular fractures often have pain and difficulty

opening their mouths and may have numbness in the lip and
chin

Epistaxis is a feature of nasal bone fractures.

Question No. 15 :

A young sexually active female presented with with malodorous gray vaginal
discharge with burning and itching.

Which of the following is most likely cause?

a. Candida albicans

b. E.coli

c. Neisseria gonorrhoea

d. Gardenerella vaginalis

e. Chlamydia trachomatus

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 14 of 48
 Correct Answer & Detail

Correct Answer: d. Gardenerella vaginalis

Answer Detail:
The correct answer is d.

Bacterial vaginosis presents with malodorous gray and thin

vaginal discharge.Usually fishy odor is present which become
stronger when discharge is alkaline after coitis and menses.
Pruritus and itching are commonly seen.

Most common cause is thought to be anaerobic pathogens

including Gardnerella vaginalis.

Bacterial vaginosis increases the risk of following complications

in females:

- Pelvic inflammatory disease.

- Postpartum endometritis.
- Chorioamnionitis.
- Preterm birth.

So this patient must be treated with metronidazole.Treatment

of asymptomatic partner is not necessary.

Candida albicans causes thick white vaginal discharge with

vulvar pruritis and dyspareunia.
Question No. 16 :

A 25-year-old lady with history of completed vaccinations when she was 13 year old
presented for medical advice.She is planning to travel to India in next few weeks.

What vaccination you must consider for her?

a. Pneumococcal

b. Meningococcal

c. Tetanus toxoid and diphtheria

d. Typhoid

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 15 of 48
 e. Cholera

Correct Answer & Detail

Correct Answer: c. Tetanus toxoid and diphtheria

Answer Detail:
The correct answer is c.

In Australia, until the age of 13,she must have received

vaccines against polio, hepatitis
B,measles,mumps,rubella,diphtheria,pertussis,tetanus,H.influe
nza and human papilloma virus.

However protection against tetanus requires an initial course

of 3 injections followed by a booster every 10 years. So she is
due to have tetanus toxoid booster. This applies to all travelers
to all countries.

Cholera vaccine is not officially recommended by WHO because

it has only limited effectiveness.Vaccine against typhoid is can
be considered while travelling to India due to poor standards
of sanitation if patient volunteers.

Pneumococcal vaccine should only be considered only in high

risk individuals.
Question No. 17 :

A 22-year-old presented to your clinic for antenatal care at 14 weeks of gestation. She
is Rh negative and her baby is Rh positive. She is worried about her risk of
developing complications and is keen to know preventive measures.

All of the following are indications of giving Anti-D immunoglobulin except?

a. Ectopic pregnancy

b. After threatened miscarriage

c. After spontaneous abortion

d. External cephalic version

e. Preformed Anti-D antibodies not due to administration of Rh Anti-D

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 16 of 48
 Correct Answer & Detail

Correct Answer: e. Preformed Anti-D antibodies not due to

administration of Rh Anti-D
Answer Detail:
The correct answer is e.

If preformed Anti-D are presented on serology and there is no

history of Rh Ant-D administration, do not give Anti-D.

Universal prophylaxis with Rh D immunoglobulin to Rh D

negative women with no preformed anti-D antibodies at 28
and 34 weeks gestation is generally regarded as best practice.

Rh D immunoglobulin should be offered to every Rh D negative

woman following delivery of an Rh D positive baby.

Other indications for giving Anti-D immunoglobulin include:

- ​After threatened abortion.

- ​After spontaneous abortion.
- ​Following ectopic pregnancy
- ​Events leading to increased risk of feto-maternal
hemorrhage. These include amniocentesis, chorionic villous
sampling, external cephalic version, antepartum hemorrhage
etc.
Question No. 18 :

A 25-year-old woman is concerned about her risk of colorectal cancer. Her

grandfather was diagnosed with colorectal cancer at the age of 60, her father was
diagnosed with colorectal cancer at the age of 62 and her brother is diagnosed with
colorectal cancer at the age of 55. What will you advise her?

a. Bronchoscopy every 5 year from now

b. Mammography every 2 year after age of 35

c. Breast ultrasound every year

d. CT abdomen every 5 year

e. Colonoscopy every 2 year from now

Correct Answer & Detail

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 17 of 48
 Correct Answer: e. Colonoscopy every 2 year from now
Answer Detail:
Currently in Australia, it is recommended to have 2-yearly
colonoscopy for people from age of 25-30 years if there is
family history of colorectal carcinoma:

- ​Three or more first or second degree relatives with

colorectal carcinoma at any age.

- ​Two or more first or second degree relatives diagnosed

with colorectal carcinoma before the age of 50 years.

- ​A family member where genetic studies identify a high

risk.

So this patient qualifies for 2-yearly colonoscopy as her 3

family members have colorectal carcinoma after the age of 50.
So option e is correct.
All other options are incorrect.
Question No. 19 :

A 29-year-old lady with history of second trimester pregnancy losses presented at 16

weeks of gestation with backache, pre-menstrual-like cramping and increased vaginal
discharge for last one week.
On pelvic examination cervix is dilated 4cm and effaced 80%.

What is most likely diagnosis?

a. Placental abruption

b. Twin pregnancy

c. Cervical insufficiency

d. Beginning of new menstrual cycle

e. Placenta previa

Correct Answer & Detail

Correct Answer: c. Cervical insufficiency
Answer Detail:
The correct answer is c.

This woman has signs and symptoms suggestive of cervical

insufficiency.Clinical features include pelvic
pressure,premenstrual-like cramping,backache,and increased

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 18 of 48
 vaginal discharge.These symptoms usually persist over several
days or weeks.

Cervical insufficiency is seen between 14-20 weeks of

gestation.

Findings on physical examination include a soft effaced cervix,

with minimal dilation.
Advanced clinical presentation is characterized by cervix which
is more than 4 cm dilated and more than 80% effaced.

Placental abruption is painful vaginal bleeding which could lead

to shock.Placenta previa is painless vaginal bleeding which
could lead to shock as well.Both of these are not feature of
cervical insufficiency.

Twin pregnancy can be associated with

anemia,polyhydromnios,large for gestational age and more
severe hyperemesis gravidarum.

Beginning of new menstrual cycle after abortion is expected

however cervical dilation and effacement absent during normal
menstruation.
Question No. 20 :

A 37-year old woman presented with ascending paralysis and she is diagnosed with
Guillain-Barre syndrome. Which of the following is the most appropriate way to
monitor her oxygenation?

a. Forced vital capacity

b. Forced expiratory capacity in 1 sec

c. Arterial blood gases

d. Pulse oximetry

e. Oxygen saturation

Correct Answer & Detail

Correct Answer: a. Forced vital capacity

Answer Detail:
Supportive care is extremely important in Guillain-Barre
syndrome (GBS) since up to 30 percent of patients develop
neuromuscular respiratory failure requiring mechanical

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 19 of 48
 ventilation.

Thus, close respiratory monitoring with frequent measurement

of vital capacity is carried out in each case.

Spirometry is used to measure forced vital capacity every 4-6

hours in the hospital and any changes are noted. Intubation is
indicated if forced vital capacity is less than 20 ml/kg.

Oxygenation status in a patient with Guillain-Barre syndrome

cannot be relied on pulse oximetry and blood gases alone.
Question No. 21 :

An 83-year old male presented with acute pulmonary edema after Non-ST segment
elevation myocardial infarction. Medications include on ramipril, metformin and
metoprolol before this admission.
Initially he required high doses of frusemide, oxygen and heparin infusion.
On 4th day since admission; he was still having bi-basal crackles and it was decided
to put him on regular spironolactone.

Which one of the following is the most important thing to monitor in this patient?

a. Serum calcium

b. Serum potassium

c. Fasting blood sugar

d. Daily Chest X-ray

e. Daily weight

Correct Answer & Detail

Correct Answer: b. Serum potassium

Answer Detail:
The risk of developing hyperkalaemia is significantly increased
when angiotensin-ll-receptor blockers or ACE inhibitors are
combined with potassium-sparing diuretics like spironolactone.

So daily serum potassium should be measured at the start of

therapy while patient remains in the hospital.
On discharge from the hospital, patient should be educated
about the side effects.

Daily weight measurement helps to identify the amount of fluid

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 20 of 48
 gain or loss in a patient with heart failure however measure
potassium level is more imperative than daily weights. Option
a,c and d are incorrect.
Question No. 22 :

A 48-year-old man comes to your clinic to discuss about his risk of getting bowel
cancer.
He is asymptomatic otherwise and has no personal history of bowel cancer,colorectal
adenomas or ulcerative colitis.
His mother died at the age of 80 with urosepsis and his father died of myocardial
infarction at the age of 59.
However his second cousin was diagnosed of bowel cancer at the age of 56.
What is most appropriate advice to this patient?

a. FOBT every year starting at the age of 50

b. FOBT every two years starting at the age of 50

c. Urgent colonoscopy referral

d. Sigmoidoscopy

e. Colonoscopy now and then every five year

Correct Answer & Detail

Correct Answer: b. FOBT every two years starting at the age
of 50
Answer Detail:
If a patient is:
-asymptomatic
-no personal history of bowel cancer, colorectal adenoma or
ulcerative colitis
-no confirmed family history of colorectal cancer in first degree
relative or second degree relative with colorectal cancer
diagnosed at the age of 55 over.
Such person should have FOBT every 2 years.
So this patient qualifies this criteria and should have foecal
occult blood test every 2 years at the age of 50.

Urgent colonoscopy referral is not required at this stage.

Sigmoidoscopy is usually combined with double contrast

barium enema to enhance the usefulness in bowel cancer
screening.However this is not the case here.
Colonoscopy every five years is needed in patients who are at
high risk of getting colorectal cancer.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 21 of 48
 Question No. 23 :

A 32-year-old male presented with 3 day history of headache, fever, malaise,

myalgias, nausea, vomiting and anorexia. Now he started developing blanching rash
initially involving wrists and ankles and then spread over legs, trunk, palms and soles.

Patient visited Flinder Islands (Australia) few weeks ago. What is the most likely
diagnosis?

a. Rocky mountain spotted fever

b. Meningitis

c. Syphilis

d. Q fever

e. Henoch schonlein purpura

Correct Answer & Detail

Correct Answer: a. Rocky mountain spotted fever
Answer Detail:
The correct answer is a.

This patient has classic presentation of Rocky Mountain

spotted fever. Spotted fever is the most common infection that
occurs after tick bite.
For first 3 days, patient develops fever, headache, malaise,
myalgia, nausea, vomiting, and anorexia as the most common
symptoms.

Rash appears during first 3 days and appear first on the wrists
and ankles and then on the remainder of the extremities and
the trunk. Involvement of the palms and soles is considered
important for diagnosis of Rocky Mountain spotted fever.

In Q fever (caused by C. burnetii), patient develops fever,

extreme fatigue, photophobia and retro-orbital severe
headache. Patient can also develop cough, nausea, vomiting,
and diarrhoea. Rash is rare finding in Q fever and is usually
nonspecific.

Other options including meningitis, syphilis and Henosh

Shonelin purpura are very unlikely given these clinical
features.
Question No. 24 :

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 22 of 48
 A 27-year-old male known to be heroin-addict comes to your clinic for a prescription
of diazepam as he is planning to kick of his heroin addiction.He is asymptomatic at
the movement.

What would be your course of action?

a. Prescribe him a dose of diazepam for two weeks

b. Tell him that diazepam is not used for this purpose

c. Prescribe him diazepam and he should collect his tablet on daily basis from a pharmacy

d. Give him nalexone

e. Refer him to a drug rehabilitation centre

Correct Answer & Detail

Correct Answer: e. Refer him to a drug rehabilitation centre

Answer Detail:
The correct answer is e.

This patient is motivated to kick off his heroin addiction,so this

opportunity should be used to refer him to drug rehabilitation
centre.

In Australia, most detoxification provided to heroin-dependent

persons is provided in rehabilitation centres. Detoxification is
often followed by cognitive-behavioural therapy,
psychotherapy and counselling for the patient.So this the best
advice.

Benzodiazepines are associated with fatal and non-fatal opioid

overdose among heroin users.There is high a risk of
benzodiazepine dependence especially in drug abuser and a
prescription longer than 5 days is discouraged. A patient with
acute withdrawal symptoms can still have 5 days of
benzodiazepine from a GP if GP finds withdrawal symptoms at
clinic.

Telling the patient that diazepam is not used for management

of heroin withdrawal symptoms is incorrect as benzodiazepines
such as diazepam may be recommended for opiate withdrawal
especially if there is co-morbid alcohol withdrawal.
Benzodiazepines may temporarily ease the anxiety, muscle
spasms, and insomnia associated with opioid
withdrawal.However this is preferably used in acute withdrawal

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 23 of 48
 while patient is in drug rehabilitation programe.

A severe withdrawal reaction is sometime precipitated if the

patient has recently used heroin or another opioid. It is
recommended that naltrexone should not be commenced until
seven to 10 days after the last use of heroin.

Methadone maintenance is an evidence based programme

which reduces heroin consumption,death from drug
overdose,HIV infection and crime activity.It is very safe to
commence and most commonly used long-term programme
for management of heroin addiction in Australia.
Question No. 25 :

A 32-year-old office secretary presents with symptoms of premenstrual syndrome

associated with severe mastalgia.
What is the best treatment?

a. Mafenamic acid

b. Danazol

c. Spironolactone

d. Bromocriptine

e. Vitamin E

Correct Answer & Detail

Correct Answer: b. Danazol
Answer Detail:
Danazol is the treatment of choice when a patient presents
with signs and symptoms of pre-menstrual syndrome
associated with severe mastalgia or breast pain.

Use danazol 200 mg daily from onset of symptoms to the

onset of menses.

Mafenamic acid is the treatment of choice for premenstrual

syndrome associated with dysmenorrhoea.

Spironolactone is the treatment of choice for premenstrual

syndrome associated with fluid retention.Use daily for three
days before expected onset of symptoms to day one of
menstruation.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 24 of 48
 There is no evidence to suggest the use of bromocriptine for
premenstrual symptoms.There is very weak evidence to
suggest vitamin E use in PMS.
Question No. 26 :

A 56-year-old male with acute limb ischemia is on heparin infusion of

1130units/hour.Which one of the following method is used for monitoring?

a. Prothrombin time

b. Bleeding time

c. INR

d. Activated partial thromboplastin time

e. Fibrinogen level

Correct Answer & Detail

Correct Answer: d. Activated partial thromboplastin time

Answer Detail:
The activated partial thromboplastin time (aPTT) is used to
assess the integrity of the intrinsic coagulation pathway
(prekallikrein, high molecular weight kininogen, factors XII, XI,
IX, VIII) and final common pathway (factors II, V, X, and
fibrinogen), and to monitor heparin therapy.
The goal of maintenance heparin therapy is to maintain the
aPTT in the range of 1.5 to 2.5 times the patient's aPTT
baseline value.

APTT is used to monitor heparin infusion rate 6-hourly initially

and when in therapeutic range (65-100 seconds) every 24-
hourly,while INR is used to monitor warfarin therapy.

Bleeding time is normally between 1-9 minutes and if

prolonged may indicate blood vessel defects,platelet
aggregation defect and thrombocytopenia.

Prothrombin time normal range for someone who is not taking

a blood thinner medication is 11 - 13.5 seconds.

Prolonged PT means failure of clotting mechanism like Vitamin

K deficiency,factor VII deficiency,factor X deficiency factor
II(prothrombin)deficiency etc.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 25 of 48
 Question No. 27 :

A mother brings her 4 months old male baby with lump on the upper mid-abdomen
and crying. On examination it is epigastric hernia. Pain is reproducible on palpation.

What will you advise her?

a. Surgical repair now

b. Surgical repair after 6 months

c. Conservative management until 4 years of age

d. Reassure mother

e. Prescribe paracetamol and review in 4 weeks

Correct Answer & Detail

Correct Answer: a. Surgical repair now

Answer Detail:
The correct answer is a.

This child has developed epigastric hernia. Epigastric hernias

are a type of hernia that develop in the upper mid-abdomen,
between the sternum and the umbilicus.

Epigastric hernia is unlikely to close naturally and is more

likely to incarcerate and cause pain by strangulation.

Indications of urgent surgical repair include pain which is

reproducible on palpation of hernia. If a child presents with
epigastric hernia and without pain, the surgical repair should
be considered after the age of 6 months of age.
Question No. 28 :

Which of the following joint is most commonly affected in pseudogout?

a. Ankle

b. Knee

c. Elbow

d Wrist

e. Carpometacarpal

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 26 of 48
 Correct Answer & Detail
Correct Answer: b. Knee
Answer Detail:
Pseudogout develops when calcium pyrophosphate dihydrate
crystals deposit in the cartilage of a joint.

The crystals are then released into the fluid in the joint.
This causes joint pain and swelling.

It most commonly affects the knees. So b is the correct

answer.

Pseudogout can also affect the elbows, ankles and wrists.

Pseudogout attacks can be sudden in onset and the symptoms

may last for days or weeks.
Question No. 29 :

Psycho-dynamic psychotherapy is useful in which one of the following conditions?

a. Phobias

b. Anxiety disorder

c. Obsessive compulsive disorder

d. Depression

e. Schizophrenia

Correct Answer & Detail

Correct Answer: c. Obsessive compulsive disorder

Answer Detail:
The correct answer is c.

Psychodynamic psychotherapy is used to address the

emotional conflicts and internal stressors which often fuel the
symptoms of obsessive compulsive disorder.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 27 of 48
 Psychodynamic psychotherapy is also effective for patients
with borderline and avoidant personality disorders.This helps
the patient to recognize the feeling states in themselves and
think about the effect of their behaviours on other people.

Cognitive behavioural therapy helps to deal with

depression,phobias,schizophrenia and anxiety disorder.
Question No. 30 :

A 49-year-old female is found to have a thyroid nodule. Blood tests show normal
TSH. What is the most appropriate next step?

a. Thyroid scan

b. Ultrasound

c. CT scan

d. FNAC

e. Thyroid autoantibodies

Correct Answer & Detail

Correct Answer: b. Ultrasound

Answer Detail:
This patient has developed a thyroid nodule and is in
euthyroidism. The next step is confirm the nature of the
nodule and locate one nodule for biopsy. This is best done by
an ultrasound as first line investigation in this situation.

Thyroid scan is not required in this situation as there is no

hyperfunctioning of the thyroid nodule. CT scan is only
required when there are symptoms suggestive of retrosternal
goitre or compression of structures in the neck including
trachea.
Question No. 31 :

Mother of a 3-year-old female has past medical history of asthma and eczema. She
comes to you as she is concerned of the risks of her baby of getting the same diseases.
What will you advise her to do to prevent her baby getting the atopy?

a. Avoid monosodium glutamate in foods

b. Avoid contact with sheepskin clothes

c. Get rid of dust mites

d. Do nothing

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 28 of 48
 e. Give baby anti-histamines

Correct Answer & Detail

Correct Answer: b. Avoid contact with sheepskin clothes

Answer Detail:
Current evidence suggests that exposure to dust mite allergen
can be minimised by:

1- ​Encasing mattresses, pillows and blankets/doonas in

dustproof covers.

2- ​Polishing floors (or linoleum) and replacing carpet.

3- ​ ashing bed clothes in hot water (more than 55
W
degree centigrade) weekly.

4- ​Not using sheepskin bedding.

Anti-histamines and avoiding mono-sodium glutamate in food
is not recommended for minimizing the risk of atopy in the
child.
Question No. 32 :

A mother brings her 10-year old son and is concerned that her son gets bullied at
school as other children call him “fat”.She informs you that her son had always been
large for his age and this has been the case since he was five years.

What is the most appropriate first line investigation to consider?

a. Liver function tests

b. CT scan

c. Thyroid stimulating hormone

d. Serum testosterone

e. Early morning cortisol

Correct Answer & Detail

Correct Answer: c. Thyroid stimulating hormone

Answer Detail:
The correct answer is c.

This patient is a child with obesity since last 5 years.It is very

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 29 of 48
 important to rule out endocrine causes of obesity in children.

Hypothyroidism is the first thing to be ruled out amongst

endocrine causes.So serum TSH (thyroid stimulating hormone)
level would be the most appropriate next step in the
management of this patient.

Juvenile hypothyroidism is often characterized by obesity,mood

changes, slowing of growth, reduced school performance,
constipation and myxoedema (puffy facial features).The
symptoms and signs may be subtle and easily missed.

Cushing’s syndrome can also cause obesity with large trunk

and thin limbs.Early morning cortisol and overnight
dexamethasone suppression tests should be considered next if
thyroid function tests are normal.

If there is any evidence of precocious puberty as well,then

serum testosterone is one of the first line investigations in a
male child.
MRI and CT scan are considered if biochemical diagnosis of an
central endocrine cause is established.
Question No. 33 :

A 14-year-old boy is brought to the emergency department with fever and painful,
tender warm knee joint. He does not move his limb and does not allow anyone to
touch it. On inspection, there is visible soft tissue redness and swelling around the
joint.

What is the most likely diagnosis?

a. Osteomyelitis

b. Septic arthritis

c. Perthe’s disease

d. Traumatic injury

e. Osteonecrosis

Correct Answer & Detail

Correct Answer: b. Septic arthritis

Answer Detail:
The correct answer is b.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 30 of 48
 This child has clinical diagnosis of septic arthritis. Septic
arthritis is characterized by following main features:

- ​Fever
- ​Acute onset of limp or refusal to use limb.
- ​Pain on movement and at rest.
- ​Limited range or loss of movement.
- ​Soft tissue redness and swelling often present

The child with osteomyelitis the lower extremity is

characterized by following features:

- ​Sub-acute onset of limp.

- ​Localized pain and pain on movement.
- ​Tenderness.
- ​Soft tissue redness and swelling may be absent.
- ​Fever may be absent.

Referral to orthopedic surgeon is required based on clinical

diagnosis of septic arthritis or osteomyelitis in children.
Question No. 34 :

A 75-year-old male presented with complaint of paleness of the fingers when he is on

bed. On examination, all upper limb and lower limb pulses are palpable.
What could be the cause?

a. Diabetes mellitus

b. Polycythaemia Vera

c. Thrombocythemia

d. Arterial occlusion

e. Thrombocytopenia

Correct Answer & Detail

Correct Answer: d. Arterial occlusion

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 31 of 48
 Answer Detail:
Colour change (paleness) of extremities fingers and toes in
response to cold or stress is called Raynaud phenomenon if a
secondary cause is present,or Raynaud's disease if no cause is
found.

Raynaud's phenomenon is characterized by episodic digital

ischemia, manifested clinically by the sequential development
of digital blanching, cyanosis, and rubor of the fingers or toes
after cold exposure and subsequent rewarming.

Arterial occlusive diseases like atherosclerosis of the

extremities is a common causes of Raynaud's phenomenon in
men above 70 years. So option d is correct response here.
All other options are incorrect.
Question No. 35 :

A-25 year old woman takes an overdose of paracetamol. She presents to the
emergency department after 4 hours. What would be the next step in management?

a. IV N-acetyl cysteine

b. Gastric lavage and activated charcoal

c. IV fluids

d. Liver transplantation

e. Gastric Lavage

Correct Answer & Detail

Correct Answer: a. IV N-acetyl cysteine

Answer Detail:
Decontamination using activated charcoal is indicated in adult
patients if all of the following criteria are met:

1- ​Presentation within 1 hour

2- ​Cooperative patient
3- I​ ngestion of greater than 10g or 200mg/kg (whichever
is less)
So this patient does not need gastric lavage and charcoal.

As this patient presented within 4 hours, it is reasonable to

check serum paracetamol level. So out of the above given
options, option A would be the correct choice if her serum

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 32 of 48
 paracetamol level is elevated.

There is no benefit in measuring paracetamol level earlier than

4 hours. It is safe to wait for the paracetamol level to decide
on the need for N-Acetyl Cysteine (NAC) in all cases that
present within 8 hours of ingestion.

NAC is the drug of choice for paracetamol intoxication.

Patients who present beyond 8-hours after a toxic ingestion /

symptoms of toxicity (right upper quadrant pain or tenderness,
nausea, vomiting) should be commenced on NAC immediately.
The decision to continue or cease NAC is then based on the
paracetamol level.

Delaying NAC administration beyond 8 hours is associated with

a progressive increased risk of liver injury. Liver transplant
should be considered if there is fulminant liver failure.
Question No. 36 :

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

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 33 of 48
 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. ​ wo first-degree or second-degree relatives on one side

T
of the family with ovarian or breast cancer.

2. I​ ndividuals 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. 37 :

A 30-year-old woman presented with nausea and vomiting during pregnancy. She has
past medical history of migraine.
What is the most appropriate management?

a. Paracetamol

b. Paracetamol and codein

c. Codein and metoclopramide

d. Codein and promethazine

e. Sumatriptan

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 34 of 48
 Correct Answer & Detail

Correct Answer: c. Codein and metoclopramide

Answer Detail:
The correct response is c.

This patient has severe migraine and should be given

metoclopramide and codein.Metoclopramide is safe to use in
pregnancy, and may be added to paracetamol to increase its
effectiveness.

Opioid pain relievers such as codeine have not been associated

with an increase in birth defects or miscarriage. Long term use
of codein can lead to dependence in the mother and
withdrawal signs in the baby.

Paracetamol alone or with codein would not stop vomiting. So

option a and b both are incorrect.

Dihydroergotamine and the triptans should be avoided

throughout pregnancy.
Question No. 38 :

What is the most common cause of urinary tract obstruction in the newborn?

a. Urinary tract infection

b. Posterior urethral valves

c. Horse-shoe kidney

d. Vesico-urethral reflux

e. Phimosis

Correct Answer & Detail

Correct Answer: b. Posterior urethral valves

Answer Detail:
The most common cause of urinary tract obstruction in a
newborn is posterior urethral valves.These are commonly seen
in male infants. So b is the correct response here.

The obstruction is frequently associated with high intra-

vesicular pressure which may damage the renal parenchyma if
left untreated.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 35 of 48
 Urinary tract infection is not commonly seen at birth and less
likely to cause urinary tract obstruction if there is no
anatomical abnormality.

Horse-shoe kidneys are associated with increased tendency to

stone formation.

Vesicourethral reflux is congenital abnormality in which urine is

pushed up to ureter and cause kidney damage due to poor
valve mechanism.

Phimosis is the narrowing of distal foreskin which prevents its

retraction over the glans of the penis.
Question No. 39 :

A 75-year-old presented with high grade fever, dry cough, headache, diarrhoea and
confusion. Past medical history include smoking, type 2 diabetes mellitus and
hypertension.
Chest X-ray shows left upper lobe pneumonia. Blood tests show normal blood sugar,
hyponatremia and abnormal liver function tests.

What is the most likely diagnosis?

a. Viral gastroenteritis

b. Aspiration pneumonia

c. Sepsis

d. Legionnaires disease

e. Acute tuberculosis

Correct Answer & Detail

Correct Answer: d. Legionnaires disease

Answer Detail:
The correct answer is d.

The symptoms of Legionnaires disease include some or all of

the following symptoms:

- ​Fever (up to 40ºC).

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 36 of 48
 - ​Chills, aching muscles and joints.
- ​Dry cough.
- ​Headache (often severe).
- ​Diarrhoea.
- ​Vomiting.
- ​Confusion.

A Legionella infection is more common in the middle aged and

older persons and in immunocompromised person. Men are
affected more commonly than women.

Factors that increase your risk include smoking, type 2

diabetes mellitus, cancer, excessive alcohol consumption and
being over 50.

Blood tests often show hyponatremia and deranged liver

function tests. Chest X-ray may show consolidation.

Other options are incorrect as this is very classic presentation

of legionnaire’s disease.
Question No. 40 :

Which of the following is the most common cause of bleeding per rectum in two and
half year-old child?

a. Anal fistula

b. Anal fissure

c. Crohn’s disease

d. Ulcerative colitis

e. Acute gastroenteritis

Correct Answer & Detail

Correct Answer: b. Anal fissure
Answer Detail:
Anal fissure is the most common cause of bleeding per rectum
in children.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 37 of 48
 Anal fistula and Crohn’s disease do not cause bleeding per
rectum in majority of the cases.

Acute gastroenteritis and ulcerative colitis can cause bleeding

per rectum however these are not the most common causes in
paediatric age group.
Question No. 41 :

Mrs Robbins,a 60-year-old lady comes to see you for her “tummy pains”.Pain is
localized in epigastric region and is worse after eating food and relieved by antacids.It
has been there for last 2 years and is getting worse.
She is non smoker non-alcoholic.She has not seen any doctor for last five years as she
feels healthy.

Which of the following is the best next step in her management?

a. Test for H.pylori

b. Refer for upper GI endoscopy

c. Consider four weeks of H2 receptor blockers

d. Consider four weeks of PPIs

e. Consider life style modification

Correct Answer & Detail

Correct Answer: b. Refer for upper GI endoscopy

Answer Detail:
The correct answer is b.

This patient has persistent epigastric pain which get worse

with food. It has been there for 2 years and is now getting
worse.The possibility of upper gastrointestinal malignancy can
not be ruled out in long standing dyspepsia.

She is above 55 year of age.So she needs a referral to

gastroenterologist for upper GI endoscopy.

Any patient who is elder than 55 years and develops persistent

symptoms of dyspepsia must have upper GI endoscopy as a
first step. H.pylori can be tested after biopsy from stomach
tissue during endoscopy.
Question No. 42 :

A 35-year old female brought her brother to you for assessment of the acute back

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 38 of 48
 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

patient’s treating doctor can issue a carer’s certificate.

So you should issue her a carer’s certificate.However carer’s

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. 43 :

Mr Tom, a 42 year-old Burmese patient is brought in by his wife because of

adjustment issues since last 2 years.Mr Tom had business in USA for thirteen years
and then he married his current partner two years ago.The family decided to move and
stay in Australia and start a new business.They have tried a lot however business is
not working well and he is not earning as much money as he wishes.This situation
compels him to earn money via gambling at Casino.
On interaction,Mr Tom is polite and wants to discuss his issues in detail.He is not
reluctant to discuss any issue of his life and feels anxious over her wife bossy style at
home and wishes a leading role in the family according to his culture.Patient is not
suicidal or homicidal.He is not depressed and is not "hearing voices".He does not
have paranoid delusions about anybody or anything.
He has undergone for non pharmacological treatment including
counselling,relaxation,problem-solving,stress management,and cognitive behaviour
therapy.However nothing has worked so far and he is becoming more anxious.
What will be the next step in management?

a. Intermittent use of diazepam for two weeks

b. Continuous use of diazepam 10mg at night for two weeks

c. Prescribe Venalfaxine regularly and increase dose until better response

d. Start selective serotonin reuptake inhibitors

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 39 of 48
 e. No need of medication, continue cognitive behavioural therapy

Correct Answer & Detail

Correct Answer: a. Intermittent use of diazepam for two
weeks
Answer Detail:
This patient has diagnosis of adjustment disorder with anxious
mood.

Adjustment disorder is most commonly associated with

anxiety.

It is a time-limited syndrome with onset and resolution related

to exposure to a stressor.

Diagnostic criteria for adjustment disorder with anxious mood

includes the onset of anxiety symptoms within 3 months of
identifiable stressors which:

1- Are time-limited,for example, persist for less than 6

months, once the stressor or its consequence have terminated.

2- Are not due to another identifiable mental disorder.

3- Are not part of a continuing pattern of overreaction to

stress,impaired social or occupational functioning.

4- Are in excess of normal expectations of reaction to the

stressor.

The primary treatments for adjustment disorder with anxious

mood are non-pharmacological including
counselling,relaxation,problem-solving,stress
management,and cognitive behaviour therapy.

If there is no response to non pharmacological treatment then

intermittent low dose diazepam can be prescribed for two
weeks.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 40 of 48
 Intermittent regime is preferred over regular regime when
prescribing diazepam.

Counsel the patient to take diazepam only when he need.

Daily doses of diazepam should not exceed 20mg a day.

Question No. 44 :

Which of the following statement is correct regarding anti–glomerular basement

membrane disease?

a. Antibodies are directed aganist non-collagenous domain of type IV collagen

b. Antibodies are directed against collagenous domain of type IV collagen

c. Type IV collagen is found in skeletal muscle

d. It is most commonly seen in people above 50

e. If treated with steroids,relapses are very common

Correct Answer & Detail

Correct Answer: a. Antibodies are directed aganist non-

collagenous domain of type IV collagen
Answer Detail:
Anti–glomerular basement membrane disease is also known as
Goodpasture’s disease.

It is caused by the development of auto-antibodies against

non-collagenous domain of type IV collagen.

Type IV collagen is also found in the lung and haemoptysis

may also be a feature,particularly in smokers.

Young males are most commonly affected,but it can occur at

any age or in any gender.

Treatment options include plasma exchange,corticosteroids

and cytotoxic therapy.

If treatment is started early,the disease can be cured and

relapses are rare.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 41 of 48
 Patients present with macroscopic hematuria progressing
rapidly to oliguria and renal failure if left untreated.
Question No. 45 :

A 48-year-old Asian male is booked for cholecystectomy tomorrow.He has been on

steroid therapy for a last 3 years for systemic lupus erythematosis.

Which of the following is not included in his management?

a. Give 100 mg IV hydrocortisone

b. Give 100 mg hydrocortisone intra-operatively

c. Give 100mg IV hydrocortisone IV 6-8 hourly for first 24 hours

d. Start oral hydrocortisone when patient tolerates diet after surgery

e. Only give hydrocortisone if there is hypotension or hypothermia during surgery

Correct Answer & Detail

Correct Answer: e. Only give hydrocortisone if there is

hypotension or hypothermia during surgery
Answer Detail:
The correct answer is e.

To cover surgical stress,patients on steroids need adequate

steroid replacement.These patients must be watched carefully
for steroid insufficiency and infection as fever response is
suppressed by steroids and wound breakdown.

Following regime is practiced in patients who are steroid

dependent for their treatment:

1-Give intravenous 100 mg hydrocortisone pre-operatively and

100 mg IV hydrocortisone intra-operatively.

2-During first 24 hours post-op give intravenously 100 mg

hydrocortisone 6-8 hourly.This can be reduced by half over the
next 48 hours.

3-Then change it to oral when patient tolerates oral diet.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 42 of 48
 Giving steroids only when hypotension or hypothermia
develops is not correct.It needs to be prevented by the above
steroids regime in any patient who is on long term steroids
and is undergoing surgery.
Question No. 46 :

A 12-month old male child is brought tour office by his mother. He has history of
anaphylactic reaction to egg 6 months ago.

Which of the vaccines he would need under medical supervision in hospital settings
and in split doses?

a. Measles, mumps, rubella vaccine

b. Influenza vaccine

c. Inactivated polio vaccine

d. Pneumococcal vaccine

e. Hepatitis A vaccine

Correct Answer & Detail

Correct Answer: b. Influenza vaccine

Answer Detail:
The correct answer is b.

All patients who have anaphylactic reaction to egg, should

receive following vaccines in split doses under medical
supervision in hospital settings.

- ​Influenza
- ​Yellow fever
- ​Q fever

All patients who have allergy to egg but not the anaphylactic
reaction, can be given above vaccines as single dose.

MMR (measles, mumps, and rubella) vaccine can be given

safely to children who have egg allergy. This vaccine is made
from chicken fibroblasts and not from egg proteins.
Question No. 47 :

Which of the following is/are the symptoms of vertebrobasilar arterial insufficiency?

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 43 of 48
 a. Amaurosis fugax

b. Diplopia, nystagmus, ataxia and visual disturbance

c. Contralateral hemiplegia and Horner’syndrone

d. Pure motor hemiparesis

e. Ipsilateral blindness

Correct Answer & Detail

Correct Answer: b. Diplopia, nystagmus, ataxia and visual
disturbance
Answer Detail:
Vertebrobasilar circulation supplies cerebellum,brainstem and
occipital lobes.Occlusion of this circulation may cause
diplopia,nystagmus and visual disturbances.

Other symptoms which might be caused by vertebrobasilar

artery occlusion include:

- Cortical blindness-A patient with cortical blindness has no

vision but the response of his/her pupil to light is intact (as the
reflex does not involve the cortex).
- Ataxia.
- Dysarthria.
- Dysphasia.
- Ipsilateral hemiplegia.

Infarction of the brainstem can cause lateral medullary

syndrome (posterior inferior cerebellar artery occlusion).It
causes ipsilateral Horner’s syndrome,ipsilateral
ataxia,nystagmus,vertigo and crossed pattern sensory loss.

Amaurosis fugax is loss of vision secondary to retinal artery

emboli.Symptoms include the sudden loss of vision in one eye.
This usually only lasts seconds but may last several minutes.
Some patients describe the loss of vision as a gray or black
shade coming down over their eye.

Pure motor hemiparesis and pure sensory hemianesthesia both

are seen in lacunar infarcts.
Question No. 48 :

A 59-year-old Caucasian grossly obese male presents with hoarse voice and chronic

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 44 of 48
 nocturnal cough for last three months.

He also complains of heartburn after meals,on lying down and relieved by

antacids.He also complains of belching,acid brash when he has slept for few hours at
night.Upper GI endoscopy was done which was normal.

What is the next best step in the management of this patient?

a. 24-hour esophageal pH monitoring with manometry

b. Decrease weight

c. Barium swallow

d. Avoid meal three hours before sleep

e. Consider four weeks of PPIs and then review

Correct Answer & Detail

Correct Answer: a. 24-hour esophageal pH monitoring with

manometry
Answer Detail:
The correct answer is a.

This patient has typical symptoms of gastroesophageal reflux

disease.

Indications to investigate gastroesophageal reflux disease

include:

- Age more than 55 years.

- Persistence of symptoms more than 4 weeks.
- Dysphagia.

24-hour esophageal pH monitoring with manometry is

investigation of choice to diagnose gastro-esophageal reflux
disease.

Barium swallow is useful in suspected diagnosis of hiatal

hernia and esophageal strictures.

Decreasing weight,avoiding meals for three hours before sleep

and avoiding alcohol and hot citrus fruits does help with the

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 45 of 48
 symptoms however,after making a certain diagnosis of GERD.

Proton pump inhibitors may be required to alleviate the

symptoms after ruling out serious causes of these symptoms
in this age group.
Question No. 49 :

Which one of the following elaborates the mechanism of action of sulfonylureas ?

a. Stimulates beta cell proliferation

b. Stimulates conversion of proinsulin to insulin and C-peptide

c. Stimulates insulin secretion

d. Enhances insulin binding to the beta cell insulin receptor

e. Stimulate insulin synthesis

Correct Answer & Detail

Correct Answer: c. Stimulates insulin secretion
Answer Detail:
The correct answer is c.

Sulphonylureas stimulates pancreatic beta cells and cause

secretion of insulin.

Sulphonylureas are the most widely used drugs for the

treatment of patients with type 2 diabetes.The action of
sulphonylureas results in increased responsiveness of beta
cells to both glucose and non-glucose secretagogues (such as
amino acids),resulting in more insulin being released at all
blood glucose concentrations.

Thus,sulfonylureas are useful only in patients with some beta

cell function.Sulfonylureas may also have extrapancreatic
effects, one of which is to increase tissue sensitivity to
insulin,but the clinical importance of these effects is minimal.

Examples of sulfonylureas include gliclizide, glimepiride,

glipizide etc.
Question No. 50 :

A-72-year-old male presented with severe chest pain radiating to his back. On cardiac
examination you notice diastolic murmur. Chest X-ray shows wide mediastinum.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 46 of 48
 ECG shows acute inferior myocardial infarction. What is the most appropriate
management?

a. Give alteplase

b. Give aspirin and intravenous morphine

c. Give morphine, B-blocker and arrange for trans-oesophageal echocardiogram

d. Refer the patient to cardiology clinic

e. Consider urgent MRI of the cervical and thoracic spine

Correct Answer & Detail

Correct Answer: c. Give morphine, B-blocker and arrange for

trans-oesophageal echocardiogram
Answer Detail:
This patient has clinical symptoms suggestive of aortic
dissection and ECG findings suggestive of ST segment
elevation acute myocardial infarction.

Aortic dissection is generally suspected from the history and

physical examination as follows:

1- ​ brupt onset of thoracic or abdominal pain with a

A
sharp, tearing and/or ripping character

2- ​Mediastinal and aortic widening on chest radiograph

3- ​A variation in pulse (absence of a proximal extremity
or carotid pulse) and/or blood pressure (more than 20 mmHg
difference between the right and left arm).

Suspected aortic dissection including any neurological sign is

an absolute contraindication to thrombolysis due to high risk of
bleeding. So this patient cannot be given alteplase.

The best treatment is morphine for pain relief, beta blocker to

keep systolic blood pressure less than 120mmHg and urgent
trans-oesophageal echocardiogram (TOE) to confirm the
diagnosis of aortic dissection. CT angiogram is another choice
of investigation if TOE is not available.

Aortic dissection is of two types:

Type A-Involves ascending aorta. Can extend distally ad
infinitum. Surgery is usually indicated.
Type B-Involves aorta beyond left subclavian artery only. Often

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 47 of 48
 managed medically with blood pressure control.

A dissection that involves the ascending aorta can induce one

or more of the following:

1- ​Acute aortic valve regurgitation, leading to a diastolic

decrescendo murmur, hypotension, or heart failure.

2- ​Acute myocardial ischemia or myocardial infarction

(MI) due to coronary occlusion. The right coronary artery is
most commonly involved.

3- ​ ardiac tamponade and sudden death due to rupture

C
of the aorta into the pericardial space.

4- ​A considerable variation (more than 20 mmHg) in

systolic blood pressure between the arms.

5- ​Neurologic deficits, including stroke or decreased

consciousness due to direct extension of the dissection into the
carotid arteries or diminished carotid blood flow.

6- ​Horner syndrome if there is compression of the

superior cervical sympathetic ganglion.

7- ​Vocal cord paralysis and hoarseness due to

compression of the left recurrent laryngeal nerve.

https://lookaside.fbsbx.com/file/11.doc?token=AWwfggtyKaBGJ…V2_DDCYRQXUIpojFm4p8FRiA65TOvC2L0aQJ1m1uuS-zDjqO2x 7/7/17, 10`39

Page 48 of 48