Question 1

Which of the following statements about Dupuytren's contracture is CORRECT?

a) It is a thickening of the tendon sheath

b) It usually causes flexion contracture of the 2nd and 3rd fingers of the hand
c) It is more common in women than men
d) The mode of inheritance is autosomal recessive
e) It is more common in diabetics
Correct

Dupuytren's contracture is a thickening of the palmar fascia resulting in flexion

contracture of the fingers of the hand particularly the ring and fifth fingers. Its
aetiology is unknown, but it is thought to be familial. It is more common in men than
women. It is more common in alcoholics, diabetics and epileptics treated with
phenytoin.

(Foye PM, Stitik TP (2002) Emedicine

Available:
http://www.emedicine.com/pmr/topic42.htm)

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section5/chap
ter61/61a.jsp%3Fregion%3Dmerckcom&word=dupuytren's&word=contracture&dom
ain=www.merck.com#hl_anchor)

Question 2

Which of the following drugs is contraindicated in a child with known glucose-6-

phosphate dehydrogenase (G6PD) deficiency?

a) Paracetamol
b) Salbutamol
c) Metronidazole
d) Sulphamethoxazole
Correct
e) Prednisolone

Glucose-6-phosphate dehydrogenase deficiency is a genetically inherited enzyme

deficiency which results in acute haemolysis upon exposure to an environmental
stress (viral or bacterial infections), drugs or toxins. Particular drugs may cause
haemolysis in patients deficient in G6PD including Sulphamethoxazole,
nitrofurantoin, primaquine, aspirin and others. Fava beans may also precipitate
haemolysis in a minority of patients.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=64677&searchStr=glucose-6-
phosphate+dehydrogenase+deficiency#64677)

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 174 )

(Beutler E, Luzzatto L, Marradi P. Italian Health Ministry

Available:
rialto.com/favism/brochure.pdf)

Question 3

It has been 18 months since Mary had her heart attack and stroke. She is 81 years
old, slightly anxious, but very independent & mobile, even though she gets a little
short of breath going up stairs.
Increasingly, Mary is fearful of leaving the house, because sometimes as she is due
to leave, she feels dizzy, unsteady, unable to breathe, heavy in the chest, clammy
and her heart races. These symptoms also occur at other times quite unexpectedly.
These 'turns' last about 10 mins and then she feels better, but Mary is really scared
about when they might occur next.
What is the MOST LIKELY diagnosis?

a) Mary has anxiety

b) Mary has a phobia
c) Mary has anxiety with panic attacks
Correct
d) Mary is depressed and has a phobia for shopping centres
e) Mary has anxiety, and ongoing angina

Mary has the classical symptoms of panic attacks with some pre-existing anxiety.
With panic attacks symptoms must peak within 10 min and usually dissipate within
minutes, leaving little to observe, except the person's fear of another terrifying panic
attack. A distinguishing feature of panic disorder is that some of the panic attacks
are unexpected or spontaneous.

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section15/cha
pter187/187b.jsp%3Fregion%3Dmerckcom&word=panic&word=attacks&domain=ww
w.merck.com#hl_anchor)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=109214&searchStr=panic+attacks#109
214)

* Question 4
Clarice, 26 years, presents to you concerned because she has noticed that a dark
mole on her thigh has become enlarged, slightly lumpy and itchy over the last two
months. The MOST APPROPRIATE initial management would be to:

a) Ask Clarice to return for review in three months

b) Take an incisional biopsy of the lesion for histopathology
Incorrect. The correct answer is (e).
c) Treat the lesion using liquid nitrogen
d) Remove the lesion using laser
e) Undertake an elliptical excision clear of the margin for histopathology

If a malignant melanoma is suspected then 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 (Clark's
level one and two melanomas have a five year prognosis of >90%). 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.

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section10/cha
pter126/126d.jsp%3Fregion%3Dmerckcom&word=malignant&word=melanoma&dom
ain=www.merck.com#hl_anchor)

(Way LW, Doherty GM. (2003), Current Surgical Diagnosis and Treatment, 11th ed.
Lange Medical Publications, McGraw-Hill, p 1363-5 )

Question 5

All of the following may be features of Down syndrome (Trisomy 21) EXCEPT:

a) Hypotonia
b) Webbing of the neck
Correct
c) Congenital heart defects
d) Abnormalities of the dermal ridge pattern
e) Epicanthic folds

Webbing of the neck is a feature seen in patients with Turner syndrome. All other
listed features may be present in a patient with Down syndrome.

(Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed. Churchhill
Livingstone, Sydney, p 89-90 )

(Down Syndrome Information Network

Available:
www.down-syndrome.info/topics/keyfacts/key-facts-EN-GB.htm)

(Pediatric Oncall
Available:
www.pediatriconcall.com/fordoctor/DiseasesandCondition/Clinical_features.asp)

* Question 6

Benny has always loved to go clubbing, and often after a few drinks at the end of a
night of dancing, he ends up having casual sex with someone he meets at the
nightclub.

Benny had his first hepatitis B serology testing done last week. These are his test
results:

 HBsAg = positive
 HBsAb = negative
 IgM HBcAb = positive
 HBeAg = positive.

What is the MOST LIKELY cause of these results?

a) Benny has been vaccinated in the past for hepatitis B and is now immune
b) Benny has had hepatitis B infection sometime in the past and it has resolved,
leaving him with life-long immunity
Incorrect. The correct answer is (d).
c) Benny is a hepatitis B carrier
d) Benny has acute or current hepatitis B infection
e) Benny has early liver cirrhosis

Benny is HBsAg positive which occurs 1-6 months after exposure to the hepatitis B
virus and indicates acute infection. If HBsAg persists after 6 months, it defines
carrirer status.
HBsAb is not present (it would be positive following vaccination).
IgM HBcAb is present in acute infection only (IgG HBcAb is present in highly infective
carriers and in acute infection).
HBeAg is present and implies high infectivity in recent infection and carriers.
Benny needs education about hepatitis B, safe sex & drug use

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=91468&searchStr=hepatitis+b#91468)

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section4/chap
ter42/42b.jsp%3Fregion%3Dmerckcom&word=hepatitis&word=B&domain=www.mer
ck.com#hl_anchor)

* Question 7

The clinical features associated with raised intracranial pressure include all of the
following EXCEPT:

a) morning headache
b) vomiting
c) presence of papilloedema
d) decrease in conscious state
e) falling blood pressure with a falling pulse
Correct

Rising blood pressure (not falling) in combination with a falling pulse rate is a
classical feature of rising intracranial pressure known as the Cushing response.
Headache occurs as a result of the deformation of intracranial blood vessels and
dural membranes which arises from conditions which give rise to raised intracranial
pressure. The headache is worst in the morning (as is vomiting) and is aggravated
by coughing, sneezing or stooping. When present papilloedema (swelling of the
nerve fibres of the optic disc) is highly suggestive of raised intracranial pressure. A
decrease in conscious state commencing with confusion and progressing through
various grades of coma is also seen with increasing intracranial pressure.

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/mmanual/section14/chapter177/177b.jsp)

(The University of Adelaide, Australia

Available:
www.health.adelaide.edu.au/paed-neuro/pressure.html)

Question 8

In the first year of life which of the following ECG features may be considered
normal?

a) Right axis deviation

b) Sinus bradycardia
Incorrect. The correct answer is (a).
c) First degree heart block
d) Left bundle branch block
e) ST segment depression

At birth the right ventricular muscle is as thick as the left. This results in an ECG
pattern which would indicate right ventricular hypertrophy, including right axis
deviation. As the apparent right ventricular hypertrophy disappears the ECG takes on
a more adult appearance, and should have an adult pattern by the age of ten years.

(Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed. Churchhill
Livingstone, Sydney, p 489 )

(Thumbnail Guide to Congenital Heart Disease, National University of Singapore

Available:
www.med.nus.edu.sg/paed/medical_education/cardiac_thumbnail/investigations/ecg
.htm)

Question 9

Which of the following is FALSE regarding neural tube defects and folate before and
during pregnancy?

a) Folate intake should be increased at least one month before and three months
after conception
b) Most women before and during pregnancy need 0.5mg folate daily
c) Women on anti-epileptic medication may require 5mg folate daily before and
during pregnancy
Incorrect. The correct answer is (d).
d) Folate reduces the incidence of neural tube defects which occur at the rate or
1:5000 pregnancies
e) Women with a family history of neural tube defects need more folate before
and during pregnancy

Pregnant women are at increased risk of folate deficiency due to the high demand of
the developing foetus. Deficiency in the first few weeks of pregnancy can cause
neural tube defects in the newborns. Neural tube defects occur at a rate of 1:500
pregnancies. The other options are true.

(National Library of Medicine

Available:
www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract
&list_uids=93078811)

(Australian Government. Department of Health and Ageing

Available:
www.health.gov.au/internet/wcms/Publishing.nsf/Content/health-pubhlth-strateg-
folate-fofacts.htm)

* Question 10

Pamela aged 45 years, attends having found a lump in the upper outer quadrant of
her right breast two days ago. She is concerned about the likelihood of cancer. In
order to diagnose the nature of the lump you invoke the use of the "triple test" or
"triple assessment". The triple test consists of:
 a) Clinical examination, mammography, magnetic resonance imaging
b) Mammography, ultrasound, fine needle biopsy
c) Clinical examination, mammography, fine needle biopsy
Correct
d) Clinical examination, ultrasound, magnetic resonance imaging
e) Ultrasound, fine needle biopsy, magnetic resonance imaging

Management of breast lumps is now based on the triple test, which combines the
results of clinical examination, mammography (+/- ultrasound) and fine needle
aspiration biopsy. When combined, these tests give a sensitivity of 95-99% in the
diagnosis of breast lumps.

(Investigating breast changes: What investigations will the doctor suggest? National
Breast Cancer Centre
Available:
www.breasthealth.com.au/breastchanges/investigating.html)

(Way LW, Doherty GM. (2003), Current Surgical Diagnosis and Treatment. Lange
Medical Publications, McGraw-Hill, NY, p 319-339 )

Question 11

On examining Fatima (aged 18 months), whom you are seeing for the first time, you
hear a heart murmur. Which of the following clinical findings would suggest that this
is an innocent heart murmur?

a) The murmur is diastolic

b) The murmur is associated with a thrill
c) The murmur is pansystolic
d) The murmur disappears when the child lies down
Correct
e) The murmur is associated with reduced exercise tolerance

The disappearance of the murmur when the child lies down suggests it is the
innocent murmur known as 'venous hum'. This is a murmur produced by blood flow
through the great veins and is heard at the base of the heart, often just below the
clavicles. It is blowing and continuous in nature. The murmur varies with respiration
and the position of the head, and disappears when the child lies down. The other
features listed are not those of an innocent murmur.

(Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed. Churchhill
Livingstone, Sydney, p 485-7 )

(Innocent heart murmurs. Surgery Door

Available:
www.surgerydoor.co.uk/medical_conditions/Indices/I/innocent_heart_murmurs.htm)
Question 12

Kylie is pregnant. She has smoked 25 cigarettes per day for the past 10 years and
continues to smoke even now she is pregnant. Early in her pregnancy you outline to
her, that, compared with infants born to non-smoking mothers, her infant is more
likely to experience a number of disadvantages. These include all of the following
EXCEPT:

a) Higher perinatal mortality

b) Small for gestational age
c) Greater likelihood of sudden infant death syndrome
d) Developmental lag at least in early years
e) Greater likelihood of developing small teeth with faulty enamel
Correct

Small teeth with faulty enamel is a disorder resulting from excess alcohol intake in
pregnancy and the foetal alcohol syndrome. The other options are all disadvantages
experienced by infants of women who smoke.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=109820&searchStr=pregnancy#109820
)

(Smoking: Pregnancy and infant health, Nelson Maternity Unit, NZ

Available:
www.nelson.planet.org.nz/kyom/p3/)

Question 13

Alison, aged 18 years presents with a mobile, smooth, solid lump of 2 cm diameter
in her left breast. The MOST LIKELY diagnosis is:

a) malignancy
b) fibroadenoma
c) breast cyst
Incorrect. The correct answer is (b).
d) intraductal carcinoma
e) breast abscess

A fibroadenoma is a benign breast condition that arises as an aberration of normal

development and involution. The diagnosis is best made using the triple test.
Indications for removal include patient preference or discomfort, size > 3 cm,
continued growth or lump presenting for the first time > 40 years. Fibroadenomas
may spontaneously disappear or calcify.
(Way LW, Doherty GM. (2003), Current Surgical Diagnosis and Treatment. Lange
Medical Publications, McGraw-Hill, NY, p 341-2 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=62451&searchStr=fibrocystic+disease+
of+breast#62451)

Question 14

Which of the following statements concerning nappy rash is CORRECT?

a) Seborrhoeic dermatitis is the most common cause

b) Management should include liberal use of talcum powder to help keep the
nappy area dry
c) The napkin area should be washed frequently with soap to avoid recurrences
d) Superinfection with Candida tends to involve the flexures
Correct
e) Topical steroids are the mainstay of treatment

Irritant dermatitis is the most common cause of nappy rash and tends to spare the
flexures. Candidiasis will involve the flexures and may extend beyond the napkin
area as 'satellite lesions'. In managing nappy rash, the area should be kept dry, but
powders should be avoided as should soaps and excessive bathing or scrubbing.
Topical corticosteroids should be used with caution to treat specific causes of nappy
rash only, including atopic dermatitis and seborrhoeic dermatitis.

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 1160-1 )

(The Better Health Channel

Available:
www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Nappy_rash?open)

Question 15

The classical signs of congenital rubella (German measles) include all of the following
EXCEPT:

a) Cataract
b) Heart disease
c) Deafness
d) Low birth weight
Incorrect. The correct answer is (e).
e) Koplik's spots

Koplik's spots are typically associated with measles (rubeola) only and not any other
infectious diseases. The other options are features of congenital rubella.

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 905-6 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=76235&searchStr=congenital+rubella+
syndrome#76235)

Question 16

Which of the following statements regarding carcinoma of the lung is CORRECT?

a) Lung cancer is the most common registrable cancer in women

b) Approximately 10% of lung cancers are derived from squamous cells
c) Approximately 60% of lung cancers are adenocarcinomas
d) The majority of lung cancers are asymptomatic at diagnosis
e) Exposure to asbestos increases risk of lung cancer
Correct

Smoking and exposure to asbestos are associated with the development of

squamous cell and adenocarcinoma of the lung. Prostate and breast cancer are the
most common registrable cancers in men and women respectively. Lung cancer is
the most common malignancy causing death in men and second most common in
women after breast cancer although incidence in women is rising. Of lung cancers,
32% are adenocarcinoma, 29% are squamous cell, 9% undifferentiated large cell
and 18% small cell type. Up to 15% of people are asymptomatic of their lung cancer
at diagnosis.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=84224&searchStr=lung+cancer#84224
)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=62283)

(Australian Bureau of Statistics

Available:
www.abs.gov.au/ausstats/abs@.nsf/b06660592430724fca2568b5007b8619/8ddd5ae
d085834daca256f010077be4a!OpenDocument)

(Australian Institute of Health and Welfare

Available:
www.aihw.gov.au/publications/can/ca01/ca01-c00.pdf)

Question 17
Which of the following statements regarding Duchenne muscular dystrophy is
INCORRECT?

a) The usual age of symptom onset is 2-6 years

b) Genetic inheritance is usually X-linked recessive
c) Approximately 25% of patients die by the age of 20 years
Correct
d) A lordotic, waddling gait is a feature
e) Female carriers are usually asymptomatic

75% of patients with Duchenne muscular dystrophy die by age 20, usually from
cardiac or respiratory failure. The other options given are correct for this condition.

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 170 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=108645&searchStr=duchenne's+muscu
lar+dystrophy#108645)

Question 18

Mel always loved playing girls games as a child and had fantasies about being
female. When puberty arrived he was distressed at the physical changes that
occurred in his body, and as soon as he left home he adopted a complete female
appearance and female role in public and private. He obtained a driver's license and
was able to work and live in society as a woman. Mel takes ethinyl estradiol 0.10
mg/day and has nearly completed 2-years of living completely as a woman. Mel has
requested sex reassignment surgery. What is Mel's diagnosis?

a) Transvestite
Incorrect. The correct answer is (e).
b) Cross-dressing homosexual
c) Schizophrenia with gender issues
d) Borderline personality disorder
e) Male transsexual

Male transsexualism is a gender identity disorder in which the male believes he is the
victim of a biologic accident, cruelly imprisoned in a body incompatible with his
subjective gender identity.
Transvestism occurs when heterosexual males dress in women's clothing, and at
least initially this is associated with sexual arousal. Transvestism is a psychiatric
disorder only if the fantasies, urges, or cross-dressing behaviours are associated with
clinically significant distress or recognizable dysfunction. Cross-dressing per se is not
a disorder.
Homosexuality is not a psychosexual disorder but a preference of a sexual partner.
Schizophrenia is not a gender disorder.

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section15/cha
pter192/192c.jsp%3Fregion%3Dmerckcom&word=transsexualism&domain=www.me
rck.com#hl_anchor )

(Spriggs M, (2004) Ethics and the proposed treatment for a 13-year-old with atypical
gender identity. MJA 181: 319-21
Available:
http://www.mja.com.au/public/issues/181_06_200904/spr10337_fm.html)

Question 19

With regards to cryptorchidism (undescended testes), which of the following

statements is CORRECT?

a) It is essential that the testes are returned to their normal position in the
scrotum by the time the boy is five years old
b) Bilateral undescended testes is a more common occurrence than unilateral
undescended testis
c) The lower the arrest in the line of descent of the testis the more hypoplastic it
is
d) Malignancy in the undescended testis is 20-30 times more common than usual
Correct
e) Inguinal hernia is associated with undescended testes in approximately 50% of
cases

Complications of undescended testes include defective spermatogenesis, torsion,

trauma, and malignant degeneration 20-30 times more common even after surgical
placement in the scrotum. Ninety five percent are associated with a patent processus
vaginalis but only 25% develop a clinical hernia. Twenty five percent have bilateral
undescended testes. The testis/es may be intrabdominal, inguinal or high in the
scrotum. The higher the arrest along the line of descent the more hypoplastic the
testis. In order to minimise these complications the testis/es should be placed in
their normal position before the second year of life.

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 1076-7 )

(Way LW, Doherty GM. (2003), Current Surgical Diagnosis and Treatment. Lange
Medical Publications, McGraw-Hill, NY, p 1338-9 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=38174&searchStr=cryptorchidism#381
74)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=380132&searchStr=cryptorchidism#38
0132)

Question 20

Regarding Sudden Infant Death Syndrome (SIDS), which of the following statements
is CORRECT?

a) Positioning a baby prone (on its front) to sleep may reduce the risk
b) The incidence is greater in female infants
c) Maternal smoking has not been shown to be a risk factor
d) Breastfed infants are at greater risk
Incorrect. The correct answer is (e).
e) Infant overheating may be a risk factor

Regarding modifiable risk factors for SIDS, positioning the infant supine (on its back)
to sleep, breastfeeding, avoidance of overheating, and maternal smoking cessation
may reduce risk. Male infants are more at risk from SIDS (the male: female ratio is
approximately 3:2).

(Guidelines for preventive activities in general practice. (2001) 5th ed. Australian
Family Physician, Special Issue, RACGP, S1 5. )

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 941-2 )

(Robinson MJ, Robertson DM. Eds. (2003), Practical Paediatrics, 5th ed. Churchhill
Livingstone, Sydney, p 100-5 )

(Mitchell A. (2000) SIDS: facts and controversies (editorial), MJA 173:173-4

Available:
www.mja.com.au/public/issues/173_04_210800/mitchell/mitchell.html)

Question 21

Regarding pneumothorax, which of the following statements is CORRECT?

a) It is due to the presence of air outside the parietal pleura

b) It may occur spontaneously with or without underlying lung disease
Correct
c) Clinical examination reveals a dull percussion note and absent breath sounds
d) There may be a mediastinal shift towards the side of the pneumothorax
e) Treatment consists of an intercostal drain in the second intercostal space in the
mid axillary line

Pneumothorax is the presence of air between the visceral and parietal pleura. It can
occur as result of trauma or spontaneously. The physical signs of a pneumothorax
are a hyper-resonant percussion note and absent breath sounds. In cases of tension
pneumothorax, there is mediastinal displacement away from the side of the defect.
Treatment is necessary when there is a large enough pneumothorax to inhibit
respiratory activity and involves the insertion of an intercostal drain in the fifth
intercostal space in the midaxillary line or alternatively in the second intercostal
space anteriorly in the midclavicular line.

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section6/chap
ter80/80e.jsp%3Fregion%3Dmerckcom&word=pneumothorax&domain=www.merck.
com#hl_anchor )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=85446&searchStr=pneumothorax#854
46)

* Question 22

Beth, aged 6 months, is brought to see you by her mother who has noticed her eyes
are not always lined up. You are concerned Beth may have a squint (strabismus).
Which of the following statements regarding strabismus is CORRECT?

a) Investigation is unnecessary in this age group as strabismus improves with

time
b) By the age of 6 months Beth's eyes should be constantly well aligned
Correct
c) Strabismus is rarely a marker of other ocular disease
d) Strabismus is not associated with amblyopia
e) The corneal light reflex is a reliable test to diagnose strabismus

A baby's eyes should be constantly well aligned by the age of 5 to 6 months.

Intermittent ocular deviation should be investigated if present at six months, as it
may be a marker of severe underlying ocular or neurologic disease. It should never
be assumed that the strabismus will be outgrown. The corneal light reflex test should
not be relied upon to diagnose or exclude strabismus. The cover test is a more
accurate diagnostic test. Strabismus may lead to amblyopia, which in turn may result
in permanent loss of vision if it is not corrected by 4 to 6 years of age.

(Robinson MJ, Robertson DM. Eds. (2003), Practical Paediatrics, 5th ed. Churchhill
Livingstone, Sydney, p 756-8 )

(Martin FJ, (2001) Management problems in paediatric ophthalmology. AFP

Available:
www.racgp.org.au/document.asp?id=3907)

Question 23
Sean, aged 65 years, presents with a history of painless haematuria over the last
week. Possible causes include all of the following EXCEPT:

a) Cancer within the kidney

b) Use of anticoagulants
Incorrect. The correct answer is (d).
c) Glomerulonephritis
d) Benign prostatic hypertrophy
e) Use of cyclophosphamide

Benign prostatic hypertrophy is associated with difficulty micturating but not

haematuria. Common causes of painless haematuria include malignancy of the renal
pelvis, drugs such as anticoagulants, cyclophosphamide and D- penicillamine, and
glomerulonephritis. Rarely it can result from a bleeding tendency due to inherited
disorders, bleeding secondary to idiopathic thrombocytopenic purpura or Henoch
Schonlein disease, malaria, "jogger's haematuria", schistosomiasis.

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 838-41 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=55691&searchStr=hematuria
Available:
www.accessmedicine.com/content.aspx?aID=88192&searchStr=hematuria#88192)

Question 24

Sam and Mary have two daughters. Their second daughter has Cystic Fibrosis, but
their elder daughter does not. They are considering having another baby. The
likelihood of Sam and Mary having another child with Cystic Fibrosis is?

a) 1 in 2
b) 1 in 4
Correct
c) 1 in 10
d) 1 in 16
e) 1 in 25

Cystic Fibrosis is an autosomal recessive disorder. If a husband and wife are both
carriers of the autosomal recessive gene then each pregnancy has a 25% chance of
resulting in a child who will be homozygous for and thus affected by the disease.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=84748&searchStr=cystic+fibrosis)
(Robinson MJ, Robertson DM. Eds. (2003), Practical Paediatrics, 5th ed. Churchhill
Livingstone, Sydney, p 476-7 )

Question 25

Robyn, aged 43 years, is known to have gallstones. On this occasion she presents
with the acute onset of severe pain which was at first central in location but has now
moved to the right costal margin and radiates to the back. She is pyrexic, slightly
tachycardic and has tenderness over the area of the gall bladder but no rigidity of
the abdomen. The MOST APPROPRIATE MANAGEMENT would be to:

a) Observe her at home for 2 to 3 days to allow this attack to settle

b) Admit her to hospital for treatment with IV fluids and antibiotics
c) Avoid opioid analgesia due to the risk of worsening biliary spasm
d) Admit her to hospital for urgent surgery
e) Treat this episode with the goal of preparing for surgery in 2 to 3 months
Incorrect. The correct answer is (b).

Robyn has acute cholecystitis. Initial management includes IV fluids and nil by
mouth, pain relief with parenteral opiate administration and a short, intensive course
of antibiotics. Although opiates may increase biliary spasm this is not a contra-
indication in view of their excellent analgesic effect. The patient is monitored and
immediate operation is ONLY indicated if the fever does not settle or symptoms
worsen, indicating perforation of the gall bladder or peritonitis. Immediate operation
is not warranted, as there is no indication of perforation of the gall bladder or
peritonitis. However, early operation for acute cholecystitis is now recommended
compared to delaying surgery.

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section4/chap
ter48/48c.jsp%3Fregion%3Dmerckcom&word=acute&word=cholecystitis&domain=w
ww.merck.com#hl_anchor )

(Way LW, Doherty GM. (2003), Current Surgical Diagnosis and Treatment. Lange
Medical Publications, McGraw-Hill, NY, p 607-10 )

* Question 26

Kari is 7 months old and has not received any immunisations. She presents with two
weeks of paroxysmal coughing and vomiting, but is relatively happy between
paroxysms. You suspect she may have whooping cough (pertussis). Kari lives at
home with her mother, father and older brothers, aged 2 and 4 years. Neither of her
brothers have been immunised against pertussis. Choose the BEST INITIAL
MANAGEMENT option from the list below.
 a) Arrange to have Kari admitted to hospital and isolated immediately
Incorrect. The correct answer is (d).
b) Report the family to the child protection agency in your state for failing to
immunise their children
c) Vaccinate Kari immediately with DTPa-hepB or DTPa
d) Prescribe oral erythromycin for Kari and the whole family
e) Take a nasopharangeal aspirate for diagnosis, and await confirmation of
diagnosis prior to starting any other treatment measures

Whilst it is important to obtain a laboratory diagnosis of pertussis, this should not

delay treatment, which should be commenced after appropriate nasopharangeal
aspirate or serological samples are collected. Kari should be treated with
erythromycin 10mg/kg/dose up to 250mg orally 6 hourly for 10 days, as should all
household and other close contacts. This will not shorten the course of the illness in
Kari but will reduce infectivity and eliminate carriage of the Bordatella pertussis
organism in family members.
Hospitalisation and isolation are unnecessary unless the clinical condition of the
patient warrants inpatient management or in infants less than 6 months of age.
Catch-up vaccination should be addressed, but is not the most immediate concern
here. There is no requirement to report the family to authorities if they are
conscientious objectors to immunisation.

(Australian Immunisation Handbook, 8th ed.

Available:
immunise.health.gov.au/handbook.htm)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=67321)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=539218&searchStr=pertussis)

Question 27

Which of the following statements regarding nephroblastoma (Wilms tumour) is

CORRECT?

a) It usually presents as an asymptomatic abdominal mass

b) It is frequently associated with congenital abnormalities
Incorrect. The correct answer is (a).
c) Most patients will be hypertensive at diagnosis
d) Prognosis is worse for stage 1 than for stage 4 tumours
e) The treatment of choice involves chemotherapy prior to surgery
Nephroblastoma is a tumour arising from the kidney and is a common tumour in
children. Most nephroblastomas present as an asymptomatic abdominal mass. Fever
and haematuria and hypertension are present in 20 to 25% of patients. The majority
of Wilms tumours occur sporadically, although rarely there may be associated
malformations and syndromes. Prognosis is worse for stage 4 than for stage 1
tumours. Wilms tumours are first resected, then chemotherapy or radiotherapy may
be administered depending on tumour histology and stage.

(Robinson MJ, Robertson DM. Eds. (2003), Practical Paediatrics, 5th ed. Churchhill
Livingstone, Sydney, p 534-5)

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section19/cha
pter266/266b.jsp%3Fregion%3Dmerckcom&word=wilms&word=tumour&domain=w
ww.merck.com#hl_anchor )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=535624&searchStr=nephroblastoma)

Question 28

Bobby presents with a fracture which is found to be pathological in nature. Further

investigation confirms osteosarcoma. Which of the following statements regarding
osteosarcoma is CORRECT?

a) The peak occurrence of osteosarcoma is in early childhood

b) The tumour usually arises in the midshaft of the tibia
c) The X-ray appearance of osteosarcoma is characteristic
d) Osteosarcoma accounts for 10% of primary malignant bone tumours of
childhood
Incorrect. The correct answer is (c).
e) Osteosarcoma rarely metastasizes to lung

The x-ray appearance of osteosarcoma is quite characteristic with destruction of the

normal bony trabecular pattern and periostial new bone formation with lifting of the
bony cortex to create a Codman triangle. However, a tissue sample is required for
diagnosis. Osteosarcoma accounts for 60% of primary malignant bone tumours in
childhood, and occurs mostly in adolescents and young adults. More than 40% of
tumours arise in the distal femur. At diagnosis a chest CT is essential to look for lung
metastases which may be present in 20% of cases, worsening prognosis.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=535649&searchStr=osteosarcoma%2c
+childhood#535649)
Question 29

Which of the following statements is CORRECT? Type 1 Diabetes Mellitus:

a) Is less common than Type 2 diabetes in adolescents

Incorrect. The correct answer is (c).
b) Is due to immunological damage to pancreatic Alpha cells
c) Occurs in 6% of siblings of an affected person
d) Presents with polyuria, polydipsia and weight gain
e) Can be managed initially with oral hypoglycaemic agents and exercise

Type 1 diabetes mellitus is the most common type of diabetes in people under 40
years of age, including adolescents. Type 1A diabetes mellitus, or immune-mediated
diabetes, results from immunologic damage to the insulin-producing Beta cells of the
pancreatic islets. About 6% of siblings of an affected person also develop Type 1
diabetes. The classic presentation is with symptoms of polyuria, polydipsia and
weight loss. Insulin is the required treatment for Type 1 diabetes.

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 189-192 )

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=99026
Available:
www.accessmedicine.com/content.aspx?aID=99065
Available:
www.accessmedicine.com/content.aspx?aID=99068
Available:
www.accessmedicine.com/content.aspx?aID=99357)

(Genetic Health
Available:
www.genetichealth.com/DBTS_What_Is_Type_1_Diabetes.shtml)

* Question 30

Esther is 7 years old. She presents with a large yellow crusted lesion on her left
cheek and similar yellow crusted lesions along her left lower jawline. She has no
lesions or rash elsewhere and is otherwise well. Which is the MOST ACCURATE
statement regarding this condition?

a) Herpes simplex is the likely causative organism

b) It is important not to disturb the crusts
c) Esther should be screened for immune deficiency
d) Topical mupirocin is an appropriate treatment
 e) Oral antibiotics should be commenced as early as possible to prevent
septicaemia developing
Incorrect. The correct answer is (d).

The most likely diagnosis is impetigo, with the ruptured vesicles that form yellow
crusts and weeping erosions being quite typical of the lesions. Herpes simplex has a
different clinical presentation. In childhood, primary HSV infection usually presents
as severe acute gingivostomatitis. Impetigo is a very common, highly contagious
infection, and does not suggest an underlying immune deficiency. The usual
pathogen is Staphylococcus aureus, or Streptococcus pyogenes. For mild or localised
impetigo, topical mupirocin 2% ointment or cream 3 times daily for 7 days is
appropriate treatment. The lesions must be covered. Whilst oral antibiotics may be
indicated for more widespread infection, septicaemia is not a usual sequelae of this
common condition. Bathing the lesions to remove the crusts may be helpful.

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 898 )

(Robinson MJ, Robertson DM. Eds. (2003), Practical Paediatrics, 5th ed. Churchhill
Livingstone, Sydney, p 721-2 )

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section19/cha
pter265/265a.jsp%3Fregion%3Dmerckcom&word=impetigo&domain=www.merck.co
m#hl_anchor )

Question 31

This pure tone audiogram is recorded from a 12 year old Maori girl complaining of
deafness in her right ear. The MOST likely explanation for this problem is:

a) Debris in the external auditory meatus

Incorrect. The correct answer is (d).
 b) Cholesteatoma
c) Middle ear effusion
d) Toxin-induced nerve damage
e) Necrosis of the ossicular chain

The pure tone audiogram provides measurement of the threshold of hearing at a

variety of frequencies, by air and bone conduction.
The pattern of hearing loss shown on this audiogram is of significant hearing deficit
in the higher frequencies, in the right ear. Air and bone conduction are equally
affected. This is the pattern of sensorineural deafness. The left ear shows a normal
pattern.
Toxin-induced nerve damage is the only option which would produce sensorineural
hearing loss. All of the others would give rise to a conductive deafness, where the
loss would be in the lower frequencies during air conduction. The bone conduction
curve would be normal.

(Hain TC, (2004) Hearing Loss. Northwestern University

Available:
www.dizziness-and-balance.com/disorders/hearing/hearing.html)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=53859&searchStr=hearing+loss%2c+s
ensorineural#searchTerm)

* Question 32

One minute after birth an infant shows deep cyanosis of the trunk and limbs, makes
no reaction to a catheter inserted into the nose, is limp but takes an occasional gasp.
What is the Apgar score?

a) 0
b) 1
c) 2
d) 3
e) Insufficient data
Correct

The table below shows the data required to determine an Apgar score. The scenario
given lacks information about the heart rate. Other data given are compatible with a
score of 0.
Apgar Score 0 1 2
Sign
Heart rate absent <100 beats/min >100 beats/min
Respiratory absent irregular, weak cry regular, strong cry
effort
Muscle tone flaccid some flexion of upper well flexed, active
extremities motion
Reflex no response grimace cough or sneeze
irritabilities
Colour central peripheral cyanosis completely pink
cyanosis

(Robinson MJ, Robertson DM. Eds. (2003), Practical Paediatrics, 5th ed. Churchhill
Livingstone, Sydney, p 311-12 )

(Nemours Foundation. Kids Health for Parents

Available:
kidshealth.org/parent/pregnancy_newborn/pregnancy/apgar.html)

Question 33

In Huntington's disease the mode of inheritance is:

a) X (or sex) linked

Incorrect. The correct answer is (c).
b) Recessive
c) Dominant
d) Isolated genetic mutation
e) None of the above

Huntington's disease is an autosomal dominant condition with full penetrance.

Therefore, the child of an affected parent has a 50% chance of developing the
disease. Onset is usually in middle age.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=105713&searchStr=huntington's+disea
se#105713)

Question 34

Each of the following is characteristic of adult rheumatoid arthritis EXCEPT:

a) Morning stiffness of joints

b) Soft tissue swellings
c) Herberden's nodes
 Correct
d) Subcutaneous nodules at pressure points
e) Symmetrical joint involvement

Heberden's nodes are due to primary osteoarthritis. They are firm swellings
composed of bone and cartilage on the dorsomedial and dorsolateral aspects of the
distal interphalangeal joints in the hand joints.
Rheumatoid arthritis is characterised by symmetrical joint involvement (usually
proximal interphalangeal joints and metacarpophalangeal joints), morning stiffness
greater than an hour, synovial inflammation. Rheumatoid nodules can occur on
extensor surfaces of joints in 20-30% of people with rheumatoid arthritis.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=94428
Available:
www.accessmedicine.com/content.aspx?aID=96043)

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 345-50 )

Question 35

Herman, a 58 year old businessman, finds it difficult to travel by air or train. When
he has no option but to travel, he finds the journey very difficult and gets out of the
aircraft or train as soon as possible. Because of this he mostly avoids travel and this
liability is interfering with his work. What is the MOST LIKELY diagnosis?

a) Social phobia
b) Agoraphobia
Correct
c) Depression
d) Generalised anxiety disorder
e) Panic disorder

Agoraphobia is anxiety about being placed in crowded situations from which escape
might be difficult or embarrassing, e.g. on aircraft or trains. Generalised anxiety
disorder, panic disorder and social phobia are other varieties of anxiety disorders.
Anxiety is frequently a symptom of clinical depression.

(Davies, J. (2000), A Manual of Mental Health Care in General Practice,

Commonwealth Department of Health and Aged Care, p 145-146
Available:
www.health.gov.au/internet/wcms/Publishing.nsf/Content/mentalhealth-resources-
primary-index.htm)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=109209&searchStr=agoraphobia#searc
hTerm)

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 1254-5

Question 36

In which of the following conditions does acute arthritis commonly occur?

a) Rubella
b) Influenza
Incorrect. The correct answer is (a).
c) Measles
d) Infectious mononucleosis
e) Varicella

Acute polyarthritis may occur in rubella, especially in young women. The pain and
swelling involve wrists, fingers and knees. It is most marked during the period of the
rash, but can persist for up to 14 days after other manifestations have disappeared.
Recurrent joint symptoms up to a year have been recorded.
Acute polyarthritis is not one of the usual manifestations or complications of the
other diseases listed.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=96352)

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 905-6 )

Question 37

All of the following characteristics describe the 'ideal' vaccine, EXCEPT?

a) It is heat stable
b) It provides lifelong immunity with a single dose
c) It has minimal adverse reactions
d) It has a good antibody response in the presence of other antigens
Incorrect. The correct answer is (e).
e) It is administered orally

All the characteristics listed in the options are desirable in an 'ideal' vaccine, except
(e). Each vaccine has an appropriate route of administration which determines its
efficacy and probability of side effects. For compliance and ease of administration,
delivery without a hypodermic syringe would be ideal but most vaccines are
ineffective via the oral route. Other desirable features of the 'ideal' include: being
able to combine readily with other antigens, ease of administration and low cost.
Although characteristics of the ideal vaccine are well established, developing and
producing them is often difficult.

(Australian Immunisation Handbook, 8th ed.

Available:
immunise.health.gov.au/handbook.htm)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=67321)

Question 38

Sanjay, a 45-year-old man, presents with a one-year history of progressive ankle

swelling, difficulty with speaking due to an enlarged tongue, pain and paraesthesiae
in the forearm and hand, particularly at night, and easy bruising. What is the MOST
LIKELY diagnosis?

a) Membranous nephritis
b) Allergic reaction
c) Chronic leukaemia
d) Amyloidosis
Correct
e) Hypothyroidism

Amyloidosis involves the deposition of excess amounts of insoluble, fibrous amyloid

protein in the extracellular spaces of organs and tissues. The causes are multiple,
including neoplastic disease, inflammatory disease and advancing age. There is a
rare hereditary form. All organ systems can be involved, with cardiomyopathy,
macroglossia and vessel disease. The other conditions can produce oedema, bruising
and abnormal hormone production, but not the complete clinical picture as described
above. Amyloidosis is usually well advanced by the time it is diagnosed.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=96530)

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section2/chap
ter18/18a.jsp%3Fregion%3Dmerckcom&word=amyloidosis&domain=www.merck.co
m#hl_anchor

Question 39
Amelie is a severely depressed 29-year-old woman with suicidal thoughts who is two
months pregnant. Which of the following approaches to treatment would be MOST
appropriate?

a) Counselling and reassurance

b) Termination of pregnancy
c) Treatment in hospital with monoamine oxidase inhibitor (MAOI)
Incorrect. The correct answer is (e).
d) Treatment at home with tricyclic antidepressant
e) Electroconvulsive therapy (E.C.T) in hospital

In severely depressed pregnant women ECT has been shown to be safe and effective
both antenatally and post partum. Tricyclic antidepressants have been used for over
40 years and are a good choice in a supervised setting but not if the woman is
suicidal because of the risk of overdose. MAOIs have not been shown to be safe in
pregnancy.

(Buist, A. (2000), Managing depression in pregnancy, Australian Family Physician,

vol 29 no 7, July, p 663-667 )

(Murtagh, J. (2003), General Practice. Third ed. McGraw-Hill, Sydney, p 905-6 )

(Sadock BJ, Sadock VA. Eds (2003), Synopsis of Psychiatry, 9th ed. Lippincott,
Williams and Wilkins, NY, p 1138-44)

(NIH Consensus statement on electroconvulsive therapy (1985)

Available:
consensus.nih.gov/cons/051/051_statement.htm#1_What_Is)

* Question 40

Lulu is a three year old child who has swallowed kerosene and is brought
immediately to the hospital casualty department. Which of the following measures
should be undertaken in the immediate management of Lulu's problem?

a) Gastric lavage
b) An emetic
c) Chest x-ray
Correct
d) Intravenous saline
e) Methicillin

Kerosene is an aliphatic, highly volatile hydrocarbon which is poorly absorbed from

the gastrointestinal tract. Pneumonitis through aspiration of fumes is the
predominant toxic mechanism in children and respiratory distress can be severe and
occur rapidly. While a chest xray is not useful for the prediction of lung involvement,
serial chest xrays are important to monitor progression. In children who present with
lethargy, fever or respiratory signs in the first 4 hours 80% develop pneumonitis.
Gastrointestinal irritation is common with nausea and vomiting. There may also be a
high fever within 30 minutes of ingestion.
Management should be conservative and decontamination (emesis or gastric lavage)
should not be attempted - it merely increases the risk of aspiration, and
development of pneumonitis. IV saline may be required if haemolysis from the
kerosene occurs and hypotension develops.

(Sahasrabudhe RM, Gogtay NJ, Lahiri KR et al (2004) Kerosene (hydrocarbon)

poisoning in children: something absolutely preventable, King Edward memorial
Hospital, India
Available:
www.kem.edu/dept/clinical_pharmacology/adverse_event_month_case/case_march2
004.htm)

(Nagi NA, Abdullah ZA (1995) Kerosene poisoning in children in Iraq. Postgraduate

medical Journal, 71: 419-422
Available:
pmj.bmjjournals.com/cgi/content/abstract/71/837/419)