Week 4

Questi on 1 Audrey is a 61 year old widow who lives alone. She has become very anxious about leaving her house to go shopping, or to attend appointments, like visits to the doctor, since viewing a TV new story about the rise in daytime home burglary. She finds that she has to check and recheck that she has closed and locked all windows and doors over and over again, before she can reduce her anxiety enough to leave her house. This usually takes more than an hour. Some weeks, she does not go out at all, because she still feels anxious after this extensive checking procedure. In such cases her daughter does her shopping for her. Audrey does not have anxiety about other things. What is the most likely diagnosis? a) Generalised anxiety disorder b) Obsessive compulsive disorder c) Posttraumatic stress disorder d) Agoraphobia Incorrect. The correct answer is (b). e) Panic disorder Audrey displays the features of obsessive compulsive disorder. This is characterised by (a) obsessive thoughts and/or compulsive behaviour that impair everyday functioning, e.g. fears of contamination by germs, repeated handwashing, checking windows and doors etc; (b) the disruptive behaviours are undertaken to relieve the anxiety, and (c) they take up more than one hour per day. The other conditions listed are also forms of anxiety disorders (see refs). (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109340 ) (Current Diagnosis and Treatment in Psychiatry. Ebert, Loosen and Nurcombe Available: www.accessmedicine.com/content.aspx?aID=28345 )
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* Question 2 Mavis is 82 years old and recently she fell, landing face down on the floor. She was very shaken and had bruising about her lower face. Two weeks later her family started to notice that Mavis seemed very withdrawn and was sleeping a lot more than usual. Mavis would spend the whole day in bed and she was not really herself.

When her family visited, she was increasingly abrupt and moody. Mavis was usually very gentle and quietly spoken. What is the MOST LIKELY diagnosis? a) Subdural haemorrhage b) Extradural haemorrhage Incorrect. The correct answer is (a). c) Dementia d) Stroke e) TIA Subdural haemorrhage may be insidious in onset, and the elderly are particularly susceptible due to brain shrinkage. A history of trauma may not be recalled (50% of cases) and a fluctuating level of consciousness occurs in 35% of cases. Headaches, localised neurological symptoms and a change of personality may also occur. (Hope, R.A., Longmore, J.M., Hodgetts,T.J.& Ramrakha, P.S.(Ed) (1997) Oxford Handbook of Clinical Medicine. London Oxford University Press, pp 440 ) (The Merck Manual of Diagnosis and Therapy 17th edition Available: www.merck.com/pubs/mmanual_home2/sec06/ch087/ch087e.htm )
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Question 3 Jane (age 28) and her husband, Mike, have been trying to have a child for 18 months. Mike has one child with a previous partner. Jane's menses started at age 12 and they have always been infrequent, irregular and sometimes very heavy. Jane used the combined oral contraceptive pill (Diane 35) for 10 years but stopped all contraceptives 2 years ago. Recently Jane has been trying to lose weight. At a height of 165cms, she weighs 85kg. On examination Jane appears normal but she relies heavily on waxing to remove embarrassing facial and lower abdominal hair. What is the MOST LIKELY diagnosis? a) Endometriosis b) Post-pill infertility c) Polycystic ovarian syndrome Correct d) Pituitary prolactinoma e) Hypothyroidism Polycystic ovarian syndrome (PCOS) is characterized by oligoamenorrhoea, hirsutism, acne, infertility, obesity and insulin resistance. Menarche occurs at the usual time and androgen excess becomes apparent during puberty with development and persistence of hirsutism and/or acne. Diagnosis is largely based on clinical evaluation. Endometriosis is more associated with dysmenorrhoea than irregular cycles. Prolactinoma and hypothyroidism may cause oligoamenorrhoea but not androgen excess. Prolonged use of the combined oral contraceptive pill is not associated with infertility after the cessation of its use.

(Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=100104 ) (Basic and Clinical Endocrinology, 7th edition. Greenspan & Gardner Available: www.accessmedicine.com/content.aspx?aID=38486 )
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Question 4 Mr Davy has had severe intermittent pain in the right side of his back, radiating into his right groin and to the tip of his penis. It has been present for the last 6 hours. He feels continuously nauseous, and with every spasm of pain, he feels he cannot lie still but must move around. Sometimes, curling himself into a tight ball helps. He has had one similar, but less severe episode of pain one year ago that resolved spontaneously. On examination he is afebrile and his urine has only a trace of red blood cells. What is the MOST LIKELY diagnosis? a) Appendicitis b) Urinary tract infection c) Pyelonephritis d) Ureteric calculi Correct e) Diverticular disease Renal calculi (stones) may be asymptomatic. However calculi in the ureters commonly cause pain from the loin, into the groin and/or pain in the tip of the penis. There is usually no penile redness or discharge and few other abdominal signs are present, unless urinary obstruction is occurring with urethral calculi. Haematuria and loin tenderness are common. (Hope, R.A., Longmore, J.M., Hodgetts,T.J.& Ramrakha, P.S.(Ed) (1997) Oxford Handbook of Clinical Medicine. London Oxford University Press, pp 376 & 377 ) (The Merck Manual of Diagnosis and Therapy 17th edition Available: www.merck.com/pubs/mmanual/section17/chapter221/221a.htm )
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Question 5 John is a 28 year old unemployed man with multiple complaints, including headache, low backache, upper abdominal pain, pain in both feet, nausea, bloating, impotence

and weakness in both forearms and left leg. Physical examination shows no abnormal clinical signs. Previous investigations including chest X-ray, full blood count, biochemical profile and abdominal ultrasound show no abnormality. What is the MOST LIKELY diagnosis? a) Factitious illness b) Munchausen's syndrome c) Conversion disorder d) Hypochondriasis Incorrect. The correct answer is (e). e) Somatisation disorder In somatisation disorder the patient has multiple physical complaints referable to different organ systems, including at least four pain, two gastrointestinal, one sexual and one pseudoneurological symptom(s) which are not consistent with any specific diagnosis. There is significant impairment of social, occupational or other important area of functioning. Treatment involves behaviour modification and limitation of further investigations. (See ref for descriptions of other types of somatoform disorders listed). (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109461 )
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* Question 6 Myra, a 38 year old bank teller, presents with a painful right lower leg. On examination, she has some dilated, tortuous veins mostly on the posterior and lateral aspects of her calf. There is an area of redness and heat over one of these veins, and a firm cord like lump in the vein, 3 cm long, which is tender to touch. The MOST correct statement is: a) Myra requires antibiotic treatment with flucloxacillin b) There is a small risk of extension into deep veins c) Myra should have subcutaneous low molecular weight heparin while awaiting a venous Doppler scan Incorrect. The correct answer is (b). d) This condition is unrelated to her occupation e) The condition is unlikely to resolve without specific treatment Myra has superficial thrombophlebitis, a relatively common problem. In this particular site, it is likely to be in the short saphenous vein system and the risk of extension to the deep system via perforating veins is small. However, it is not negligible. If deep vein extension is suspected it would be preferable to confirm this by doppler ultrasound before commencing anticoagulants. Varicose veins have many risk factors, one of which is prolonged standing. This increases hydrostatic pressure

leading to chronic venous distension and secondary valvular incompetence. Women are particularly susceptible as the vein walls become more distensible under the cyclic influence of progesterone.The condition is likely to resolve spontaneously over a few days. Non-steroidal anti-inflammatory agents may be used to reduce pain and local inflammation, and graduated compression stockings may be helpful if the condition does not resolve quickly. Thrombophlebitis is not usually infective however antibiotics may be used in the case of persistent or severe symptoms. (Tjandra,J; Clunie,G; Thomas, R (2001) Textbook of surgery 2nd Ed Blackwell Science, Asia Melbourne. pp570-572 ) (Feied,C (2001) Varicose Veins and Spider Veins Available: www.emedicine.com/derm/topic475.htm ) (Feied,C (2002) Superficial Thrombophlebitis Available: http://www.emedicine.com/emerg/topic582.htm )
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Question 7 Little Andrew, aged 18months, was 'helping' Dad in the shed, when he began screaming and rubbing his eyes. He had climbed onto the workshop bench, on which was kept a variety of potential ocular hazards. Which of the following substances is potentially MOST harmful to Andrew's eyes? a) Methylated spirits b) Superglue c) Acetic acid Incorrect. The correct answer is (e). d) Dog shampoo e) Powdered cement Cement is alkaline, and alkaline burns are more dangerous than those from other chemicals. Alkali has the potential to penetrate the cornea and gain access to the anterior chamber, causing uveitis, secondary glaucoma and cataract. Alcohols and solvents cause severe pain initially but although the epithelium is burnt, it tends to regenerate quickly. Superglue, while it may cause distress in gluing eyelids together, is actually not harmful to the eye- in fact it is sometimes used in treatment of corneal wounds. The weak acid, and the dog shampoo, will both cause more irritation than actual damage. First aid treatment for any substance splashed into an eye is profuse irrigation. (Azar,D; Martin,F (2002) Eye injuries in Children - what to do Medicine Today September 2002, Vol3 No 9 pp42-46 ) (Cameron P(ed) (2000) Textbook of Adult Emergency Medicine. Churchill Livingstone

Edinburgh p448 ) (Reenstra-Buras W (2002) Burns, Ocular Available: www.emedicine.com/emerg/topic736.htm )

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Question 8 Fred is a 74 year old hypertensive man who has been found to have a 55mm fusiform abdominal aortic aneurysm, discovered when he had an abdominal ultrasound for right flank pain two days ago. Of the following, which is NOT a risk factor for rupture of Fred's aneurysm? a) Persistently elevated mean arterial pressure b) The fact that he still smokes 15 cigarettes/day c) His chronic obstructive pulmonary disease d) The fact that Fred is male e) The size of the aneurysm Incorrect. The correct answer is (d). Risk factors for the development of an abdominal aortic aneurysm (AAA) include smoking, increasing age, hypertension, family history, chronic obstructive pulmonary disease (COPD) and being male. Risk factors for AAA rupture are an elevated mean arterial pressure, continuing to smoke, more severe COPD and having an aneurysm that is either rapidly enlarging or is measured at >50mm diameter. Although women have a lower incidence of AAAs which tend to be smaller, they have a much higher risk of rupture. In this scenario, the flank pain may well be an indicator of expansion of the aneurysm. (Tjandra,J; Clunie,G; Thomas, R (2001) Textbook of surgery 2nd Ed Blackwell Science, Asia Melbourne. pp557-560 ) (O'Connor, R (2002) Aneurysms, Abdominal Available: www.emedicine.com/emerg/topic27.htm ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=83366&searchStr=abdominal+aortic+a neurysm#83366 ) (Current Surgical Diagnosis and Treatment, 11th edition. Way & Doherty Available: www.accessmedicine.com/content.aspx?aID=374097&searchStr=abdominal+aortic+ aneurysm#374097 ) (American Family Physician 2000; 61(3)

Available: www.aafp.org/afp/20000201/tips/39.html ) (eMedicine Available: www.emedicine.com/radio/topic2.htm )

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Question 9 Colin is 22 years old. His right arm was amputated above the elbow when it became caught in the industrial mulcher he was using. His mate tied his own T shirt firmly around the stump and brought him to hospital. On arrival, 15 minutes later, the T shirt is soaked, and blood is trickling out. Colin is pale, his skin is cool and clammy, and he looks anxious. His pulse is 110 beats/min and his BP 130/95 mmHg. His respiratory rate is 20 breaths/min. Capillary refill time is 5 seconds. You are able to insert an intravenous cannula in his left arm. Which fluid orders are MOST appropriate in this circumstance? a) 1 litre Normal saline as a bolus, then 1 Litre 4% dextrose in 1/5N saline b) 2 units O negative blood Incorrect. The correct answer is (e). c) 500ml normal saline d) 500ml colloid e) 1.5 L Normal saline Colin is a young adult, apparently fit. His signs indicate that he has suffered a class 2 haemorrhage, and has lost approximately 15-30% of his total blood volume or 7501500ml. So far his body has compensated well, but this may not be sustained. He requires replacement of volume and the most commonly recommended fluid is an isotonic crystalloid such as normal saline. O negative blood is not required in this situation. There would normally be time to obtain cross matched blood if bleeding could not be controlled. Hypotonic saline/dextrose solutions are not appropriate. These fluids are used to maintain fluid balance in a normovolaemic, normonatraemic patient and do not restore intravascular volume in the volume-depleted patient.500ml of normal saline is not sufficient. While there are some theoretical advantages to using colloid as the replacement fluid, there is little evidence of improved outcome from using this instead of crystalloid. 500ml of colloid is not sufficient on its own. 1-2 litres as the initial bolus, for an adult of average build is appropriate in this circumstance, then the patient's response should be assessed. (Cameron P(ed) (2000) Textbook of Adult Emergency Medicine. Churchill Livingstone Edinburgh p26 ) (Kolecki,P (2001) Shock, Hypovolaemic Available: www.emedicine.com/emerg/topic532.htm )

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* Question 10 Brendon is a 35 year old man who has been involved in a motor vehicle accident. He was wearing his seat belt, but it did not hold and he was thrown against the steering wheel. He is anxious and increasingly dyspnoeic. His pulse is 126 beats/minute and his BP 105/70mm Hg. There appears to be diminished excursion of his right chest wall, and the breath sounds are hard to hear on the right. There is hyperresonance to percussion on of the right chest. Your IMMEDIATE response should be? a) Arrange an urgent chest X ray Incorrect. The correct answer is (d). b) Perform rapid sequence induction and intubate c) Insert a thoracostomy tube in the right fifth intercostal space in the anterior axillary line d) Insert a wide bore needle in the right second intercostal space e) Insert a wide bore needle in the left second intercostal space Brendon has almost certainly developed a right tension pneumothorax, as indicated by his increasing dyspnoea , and the physical signs described above. This is a lifethreatening condition which requires urgent management. Decompression with a wide-bore needle in the second intercostal space, in the midclavicular line of the affected side is potentially life-saving, and allows time for the more complex procedure of the tube thoracostomy to follow. Tension pneumothorax is a clinical diagnosis, and emergency treatment should not be delayed for X ray confirmation. Intubation and ventilation may turn a simple pneumothorax into one under tension. It is not indicated in this situation. (Tjandra,J; Clunie,G; Thomas, R (2001) Textbook of surgery 2nd Ed Blackwell Science, Asia Melbourne. p622 ) (Cameron P(ed) (2000) Textbook of Adult Emergency Medicine. Churchill Livingstone Edinburgh p74 ) (Bjerke, S (2002) Tension Pneumothorax Available: www.emedicine.com/med/topic2793.htm )
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* Question 11 Mary, aged 65, had a laparotomy for resection of a bowel cancer seven days ago. She has been progressing well, but has just noticed some pinkish fluid leaking from her wound. Which of the following is TRUE regarding this situation?

a) This complication occurs in 10% of older patients undergoing abdominal surgery b) The wound will require urgent surgical repair c) There is a mortality rate of 1% associated with this complication d) If the wound breaks down, it must heal by secondary intention e) The appropriate management is intravenous antibiotics Incorrect. The correct answer is (b). The serosanguinous discharge heralds dehiscence of the wound, and after undertaking any necessary resuscitation and preparations for theatre, Mary should return to theatre as soon as possible. Early wound dehiscence is a serious complication, usually occurring around the 7th to 10th post-operative day. It occurs in fewer than 1% of laparotomy wounds but can have a mortality of around 30%. Risk factors include poor nutritional state, malignancy, obesity, prolonged surgery, infection or coughing. The wound cannot be left to heal by secondary intention. Intravenous antibiotics may form part of the management but will not suffice alone. (Tjandra,J; Clunie,G; Thomas, R (2001) Textbook of surgery 2nd Ed Blackwell Science, Asia Melbourne. p30 ) (GP Notebook Available: www.gpnotebook.co.uk/simplepage.cfm?ID=-1402273779 )
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Question 12 Kevin, a 45 year old labourer, had a laparotomy five years ago when he suffered a ruptured appendix. He has recently noticed a dragging sensation in the region of his scar, especially when lifting heavy objects at work, and now presents with a swelling of 1.5 cm diameter in the medial end of his scar. Concerning Kevin's problem, which of the following is TRUE? a) Kevin's lean, muscular body type predisposes him to this problem b) The fact that the scar is paramedian and in the lower abdomen predisposes to this problem Incorrect. The correct answer is (d). c) The problem is of nuisance value only, as only fatty tissue protrudes into the swelling d) Kevin should have surgical repair as soon as convenient e) Kevin should wear an abdominal support garment to prevent complications Kevin has an incisional hernia, which is a protrusion of abdominal contents into the subcutaneous plane through a defect at the site of a previous incision. Incisional herniae should be repaired as soon as convenient because they can increase in size over time and may become very difficult to repair. More particularly, as with most herniae, they may become irreducible, with possible obstruction and strangulation of

abdominal contents including bowel. Incisional herniae are more common in obese patients in whom there is fatty infiltration of the tissues, increased intra- abdominal pressure and reduced muscle tone. They are more common in midline and upper abdominal scars. There is no evidence that any supportive garment will prevent complications in an incisional hernia although it may relieve discomfort. (Tjandra,J; Clunie,G; Thomas, R (2001) Textbook of surgery 2nd Ed Blackwell Science, Asia Melbourne. pp392-393 ) (GP Notebook Available: www.gpnotebook.co.uk/simplepage.cfm?ID=-375783402 )
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Question 13 Peter is 47 years of age and presents with a single episode of bright red bleeding per rectum (PR). which he noticed after passing a bowel motion this morning. He is unaware of any significant family history of colorectal problems. On examination Peter has some obvious haemorrhoids but nothing else of note on rectal or proctoscope examinations. What is the MOST appropriate advice for Peter? a) In view of his age he should have a colonoscopy to investigate this bleeding b) As there is an obvious cause for his bleeding, no further investigation is needed at present c) As he has no significant family history of colorectal disease, he only needs reassurance d) Monitoring with 6 monthly faecal occult blood testing (FOBT) is required e) He should have a trial of increased fibre in his diet and review the haemorrhoids in 3 months Incorrect. The correct answer is (a). As increasing age is a risk for colorectal cancer, a patient over the age of 40 who presents with PR bleeding should have a digital rectal examination and be investigated by colonoscopy. If this is not available a flexible sigmoidoscopy and double contrast barium enema would be satisfactory. Rectal bleeding is a common symptom of haemorrhoids, but a rectal neoplasm may also cause PR bleeding. Even in the presence of obvious haemorrhoids patients at increased risk for colorectal cancer should be investigated. FOBT is a screening test , not a diagnostic investigation. (Tjandra,J; Clunie,G; Thomas, R (2001) Textbook of surgery 2nd Ed Blackwell Science, Asia Melbourne. p250 ) (Australian guidelines - NHMRC Available: www7.health.gov.au/nhmrc/publications/synopses/cp62syn.htm )

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Question 14 Florence, aged 50, has decided to have a haemorrhoidectomy after months of unsuccessful conservative management of her haemorrhoids. In obtaining informed consent, you discuss with her the potential complications of haemorrhoidectomy. Which of the following is the LEAST likely complication? a) Urinary retention Incorrect. The correct answer is (c). b) Post-operative bleeding c) Sepsis d) Faecal incontinence e) Pain Sepsis is fortunately a very rare complication of hemorrhoidectomy. Urinary retention occurs in approximately 5-10% of cases and may be due to spinal anaesthesia and/or the use of IV fluids and urinary catheter intraoperatively. Bleeding is uncommon but may be severe. It can occur in the first 24 hours or 7 to 10 days later due to local infection. Pain is fairly common and may be severe. It is associated with faecal impaction and incontinence. Later rare complications include fissures, fistulae and anal stenosis. (Tjandra,J; Clunie,G; Thomas, R (2001) Textbook of surgery 2nd Ed Blackwell Science, Asia Melbourne. p252 ) (Thornton, S (2002) Hemorrhoids Available: www.emedicine.com/med/topic2821.htm ) (Current Surgical Diagnosis and Treatment, 11th edition. Way & Doherty Available: www.accessmedicine.com/content.aspx?aID=373272&searchStr=hemorrhoid#37327 2)
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Question 15 Brian, a 52 year old man, walks awkwardly into your rooms. He complains of severe pain, which he indicates as being quite deep in his rectum. He says the pain began earlier in the day but has become much worse in the last hour and he it feels like 'something coming down' in his back passage. Which of the following statements MOST accurately describes Brian's condition? a) Brian has a thrombosed external haemorrhoid

b) Brian's deep pain is due to prolapsing internal haemorrhoids Incorrect. The correct answer is (e). c) Brian has a rectal prolapse d) Brian has grade three haemorrhoids e) Brian has strangulated internal haemorrhoids The pain from strangulated internal haemorrhoids is typically felt as a deep pain. Prolapsing internal haemorrhoids can cause perianal pain by causing a spasm of the anal sphincter complex. If the haemorrhoids become trapped by the spasm, they become engorged with secondary venous and later arterial thrombosis, and become irreducible. This is known as 'strangulation' and results in deep seated pain, especially if necrosis and ulceration occur. The pain of thrombosed external haemorrhoids is felt perianally. Rectal prolapse is rarely painful. Brian's haemorrhoids are now irreducible, so are no longer grade 3 (require manual reduction). (Tjandra,J; Clunie,G; Thomas, R (2001) Textbook of surgery 2nd Ed Blackwell Science, Asia Melbourne. p252 ) (Thornton, S (2002) Hemorrhoids Available: www.emedicine.com/med/topic2821.htm )
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Question 16 Jason is a 30 year old mature age medical student. He has been hospitalised following a haematemesis due to a Mallory-Weiss tear. Jason asks for an explanation about Mallory-Weiss tears. Which of the following statements is FALSE? a) Mallory-Weiss tears are tears in the mucosa of the lower oesophagus b) Haematemesis in Mallory-Weiss tears is always preceded by retching or vomiting c) Bleeding from Mallory-Weiss tears stops spontaneously in 80-90% of patients d) Alcoholic binge drinking may be associated with Mallory-Weiss tears e) Haematemesis is not a universal symptom of a Mallory Weiss tear Incorrect. The false response is (b). The classical presentation of Mallory-Weiss syndrome is haematemesis from a tear in the oesophagus, brought on by prolonged vomiting of any cause. It is often associated with alcoholic excess but this is NOT always the case. Haematemesis may occur without prior retching or vomiting. The tear is typically a longitudinal one in the mucosa of the lower oesophagus close to the gastro-oesophageal junction. The bleeding settles spontaneously in 80-90% of cases of Mallory-Weiss tears. Not all MW tears present with haematemesis. In a small proportion, melaena, haematochezia, syncope or abdominal pain are the presenting symptoms.

(Tjandra,J; Clunie,G; Thomas, R (2001) Textbook of surgery 2nd Ed Blackwell Science, Asia Melbourne. pp117-118 ) (Song, L-M (2002) Mallory-Weiss Tear Available: www.emedicine.com/med/topic3428.htm )
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Question 18 Hugo did not realise until he volunteered to be a kidney donor that he had been born with only one kidney. Which ONE of the following statements is TRUE? a) Hugo's condition is known as Potter's syndrome b) Unilateral renal agenesis is uncommon c) Usually in unilateral renal agenesis there are still two ureters d) In unilateral renal agenesis the solitary kidney maintains normal renal function Correct e) Hugo needs an annual ultrasound scan of his solitary kidney Unilateral renal agenesis is not uncommon and the solitary kidney compensates by hypertrophy and maintains normal renal function. It is usually accompanied by ureteral agenesis. Potter's syndrome is bilateral renal agenesis and it is fatal. (The Merck Manual of Diagnosis and Therapy 17th edition Available: www.merck.com/pubs/mmanual/section19/chapter261/261j.htm )
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Question 19 Jane is 45 years of age and she has noticed the following changes in herself over the last 4 months. She has lost weight, her eyes feel dry, but they are constantly watering and she feels irritable and 'on edge' and occasionally experiences palpitations. Her periods have become irregular, her hair is thinning and her fingernails seem very brittle. Her father and older sister experienced the same symptoms when they were 40 years of age. What is the MOST LIKELY diagnosis? a) Graves' disease b) Toxic adenoma c) Simple diffuse goitre d) Multi-nodular goitre e) Hashimoto's thyroiditis

Incorrect. The correct answer is (a). Graves' disease is characterized by hyperthyroidism and one or more of the following: goitre, exophthalmos, and pretibial myxoedema. It is an auto-immune disorder that has a genetic component and commonly presents in women aged 40 50 years. Toxic adenoma can occur at any age.It usually presents as a single thyroid nodule not a goitre, and hyperthyroidism. Simple diffuse goitre occurs mostly in younger women aged 15-25 years. The thyroid gland is enlarged but the person is euthyroid. Multi-nodular goitre is often a simple diffuse goitre that has progressed as the person has become 'middle-aged' or elderly. The goitre is 'lumpy', not diffusely enlarged and initially the person is euthyroid but may become hyperthyroid in the long-term. Sometimes it causes difficulty with swallowing and breathing if large. Hashimoto's thyroiditis is a chronic inflammation of the thyroid caused by autoimmune factors. It causes painless enlargement of the thyroid gland or fullness in the throat and many patients have hypothyroidism when first seen. Other forms of autoimmune disease are common. (The Merck Manual of Diagnosis and Therapy 17th edition Available: www.merck.com/pubs/mmanual/section2/chapter8/8d.htm ) (The Merck Manual of Diagnosis and Therapy 17th edition Available: www.merck.com/pubs/mmanual/section2/chapter8/8f.htm#A002-008-0274 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=98103&searchStr=graves'+disease#98 103 Available: www.accessmedicine.com/content.aspx?aID=98238&searchStr=nontoxic+multinodul ar+goiter#98238 )
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Question 20 Amanda, 47 years, has noticed her right eyelid is higher than her left and her right eye seems more prominent. She first noticed she can apply her mascara to her left eyelashes easier if she tilts her head back and looks upward. Her contact lenses still fit perfectly. Amanda is otherwise well with no other symptoms or signs. What is the MOST LIKELY diagnosis? a) Bell's palsy b) Hyperthyroidism c) Myasthenia gravis d) Horner's syndrome Correct e) Optic nerve glioma

Ptosis is drooping of the upper eyelid associated with an inability to elevate the lid completely. Nerves from the sympathetic chain innervate the superior tarsal muscle causing unilateral partial ptosis that can be overcome by looking upward. Horner's syndrome includes unilateral partial ptosis, ipsilateral constricted pupil and ipsilateral lack of sweating of the face. Myasthenia gravis usually causes bilateral partial ptosis. Hyperthyroidism causes protruding eyes (proptosis/ exophthalmos) which may be unilateral. Bell's palsy (VII nerve paralysis) prevents the patient from forcefully closing their eyes and they have bilateral wide palpebral fissures. Optic nerve glioma causes painless progressive proptosis. (Hope, R.A., Longmore, J.M., Hodgetts,T.J.& Ramrakha, P.S.(Ed) (1997) Oxford Handbook of Clinical Medicine. London Oxford University Press, pp 54 & 542 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=53519 )
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* Question 21 Michelle needs a transfusion after a major motor vehicle accident. In the accident her pelvis was fractured, both femurs have mid-shaft fractures and she sustained a hemothorax requiring a chest drain. Michelle was trapped for an hour before the fire rescue could cut her out of her vehicle. Michele has blood group O Rh positive. Which of the following statements is TRUE? a) Michelle has type A antigens on her red blood cells b) Naturally occurring A and B antigens are called isoagglutinins c) Michelle has anti-A and anti-B antibodies Correct d) Persons with Type O blood are "universal recipients" e) Michelle lacks the D antigen The ABO blood group system is the most important in transfusions. Persons with Type O blood are "universal donors" because their red blood cells lack A or B antigens. Type O individuals produce their own anti-A and anti-B. However, their cells are not recognised by any naturally occurring anti-A or anti-B antibodies (otherwise known as isoagglutinins), when their red blood cells are transfused. The Rh system is the second most important blood group system in pretransfusion testing. Rh 'positive' individuals have the D antigen of the Rh system, while people lacking the D antigen are Rh 'negative'. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=66158 )

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Question 22 Karen is a 21 year old university student. She is accompanied to your consulting rooms by two women friends who observed her collapse this morning in a bathroom of their university residence. Karen tells you that soon after she woke today she suddenly began feeling unwell, with intense fear, palpitations, sweating, shortness of breath, nausea and tingling in her fingers. . She does not remember anything after entering the bathroom. This is the third similar attack that she has experienced during the past two months. After the first attack, she worried that she 'might be going crazy' but postponed seeking medical advice for fear of being institutionalised, like one of her aunts who has schizophrenia. She does not smoke, drink alcohol or use illicit drugs. The only medication she takes is paracetamol occasionally for headaches. On examination you find: PR 85/min, BP 135/95 mm Hg, moist palms, shallow respiration, no abnormal physical findings. Of the following, which is the MOST LIKELY diagnosis? a) Agoraphobia b) Posttraumatic stress disorder c) Generalised anxiety disorder Incorrect. The correct answer is (d). d) Panic disorder e) Acute psychosis Karen's story displays the features of a panic attack which is the cardinal manifestation of panic disorder. Patients with panic disorder experience repeated unexpected attacks of intense, disabling anxiety. In between attacks they experience at least one month of worry about having further attacks and/or fear of losing control, going mad or dying. Agoraphobia is an irrational fear of being trapped in a place from which escape is impossible. Patients with posttraumatic stress disorder are repeatedly distressed by re-experiencing highly traumatic events. Generalised anxiety disorder involves persistent excessive and/or unrealistic worry accompanied by other signs and symptoms, such as muscle tension, restlessness and feeling on edge. Acute psychosis is a severe mental disturbance involving hallucinations and/or delusions. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109212 )
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Question 23 Sue is 30 years old and concerned she will get breast cancer because her mother had breast cancer diagnosed when she was 45 years of age. Which of the following statements is TRUE regarding breast cancer? a) BRCA1 and BRCA2 mutations account for 60% of breast cancer cases

b) Sue does not have an increased risk of breast cancer because her mother had breast cancer c) Breast cancer is a disease of younger women d) Sue should have bilateral mastectomies to prevent breast cancer developing e) If Sue does develop breast cancer she is most likely to develop it after she is 50 years of age Correct Although mutations in BRCA1 and BRCA2 are associated with an increased risk of breast cancer, and the lifetime risk of developing breast cancer in women who have these mutations approaches 80%, these lesions account together for less than 10% of breast cancer cases. Women who have first-degree relatives who have developed breast cancer do have an increased risk of developing breast cancer themselves, and if their first-degree relative with breast cancer was diagnosed before age 50 they have a higher risk of developing breast cancer than women whose first-degree relative was diagnosed after age 50. However, in all cases, breast cancer is uncommon in young women. Furthermore, most women with affected first-degree relatives with breast cancer who themselves develop breast cancer do so after 50 years of age In the absence of mutations in BRCA1 or BRCA2, the risk associated with a positive family history does not seem of sufficient magnitude to justify routine bilateral mastectomy. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=62420 ) (RACGP Guidelines for preventive activities in general practice Available: www.racgp.org.au/redbook/breast_cancer.asp ) (National Breast Cancer Centre Available: www.nbcc.org.au/bestpractice/screening/index.html )
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Question 24 At birth Sammy has a cleft lip but otherwise looks normal. Sammy's parents are very distressed about this, and are concerned to know if Sammy has anything else wrong which they cannot see yet, or that may develop when he's older. Which of the following is TRUE? a) Sammy is likely to have Pierre Robin syndrome and a cleft lip is just part of this syndrome b) Sammy has a cleft lip due to his mother's use of antidepressants c) Sammy is likely to have this isolated abnormality and no other problems except the cleft lip Correct

d) Sammy is likely to have congenital dislocation of the hips as well as his cleft lip e) Cleft lip and cleft palate are associated with talipes (clubfoot deformities) The cleft may vary from involvement of the soft palate only, to a complete cleft of the soft and hard palates, the alveolar process of the maxilla, and the lip. The mildest form is a bifid uvula. These children have normal intelligence and development. Cleft lip with or without cleft palate occurs in 1:700-1000 live births, more often in Asian groups and less often in African Americans; more often in males. Cleft palate alone occurs in 1:2000 across all races with slightly more females affected. There may be genetic and environmental factors including maternal smoking and use of alcohol, retinoic acid and anticonvulsants. Associated anomalies occur in about 15 to 20% of cases of cleft lip with or without cleft palate but in 50% of cases of cleft palate alone. Pierre Robin syndrome typically presents with micrognathia (small mandible) and a cleft soft palate. Congenital dislocation of the hip seems to be secondary to laxity of the ligaments around the hip or to in utero positioning. Clubfoot (talipes) deformities, result in the foot being plantar flexed, inverted, and markedly adducted. Neither of these congenital abnormalities is associated with cleft lip or palate. (The Merck Manual - Second home edition Available: www.merck.com/pubs/mmanual/tables/261tb3.htm ) (The Merck Manual - Second home edition Available: www.merck.com/pubs/mmanual/section19/chapter261/261g.htm ) (Seattle Children's Hospital Craniofacial Center Available: craniofacial.seattlechildrens.org/conditions/cleft_lip.asp ) (March of Dimes Birth Defects Foundation Available: www.marchofdimes.com/professionals/681_1210.asp )
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Question 25 Mandy has had migraines since she was a teenager. They are the classical migraine with a prodrome when she is clumsy, yawns a lot, is tired, has a stiff neck and feels irritable. Then she gets the aura, with 'sparks' in her vision. Then she gets a severe headache that starts at the back of her neck and moves to one of her temple areas and then her forehead. She feels sick and wants to curl up in bed, in a dark room, and let the headaches pass, which it usually does in about 6 hours. Which of the following statements is TRUE regarding migraine headaches? a) Migraine headaches are equally common in women and men b) In Australia 30% of the population have migraine headaches

c) Migraine is rare in children less than 10 years of age d) The most common form of migraines has a prodrome and an aura e) Migraine is accompanied by nausea in 90%, vomiting in 60% and diarrhoea in 15% of attacks Correct There are two main types of migraine: classical migraine (migraine with aura) and common migraine (migraine without aura), the latter accounting for the majority of migraine headaches. About 10% of the population in Australia have migraine. Migraine usually starts during the teenage years or early adult life and occurs more commonly in women than men (ratio 3:1). In children the incidence is 3-7%. Migraine may be accompanied by a variety of symptoms other than the typical nausea, vomiting and photophobia. (Arnold, P (2000). Home Medical Guide to Migraine and other Headaches. Dorling Kindersley Publishers, Sydney. ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=51922 ) (Brain Foundation "Headache Australia" Available: www.headacheaustralia.org.au/types_of_headache/migraine )
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Question 26 Dimitri is a 45 year old man who presents with insomnia. He goes to sleep at night without difficulty, but wakes frequently from distressing dreams in which he is being forced to watch people being tortured. Then he has great difficulty in going back to sleep. Dimitri has been in Australia for two years, having emigrated from Kosovo, where he was imprisoned for a year. His wife says he had a 'bad experience' while in detention, but will not talk about it. Over the past six weeks, he has become irritable, prone to outbursts of anger and has begun drinking heavily. This has led to marked tension in the home and Dimitri's workplace. Which of the following is the probable cause of Dimitri's distress? a) Acute stress disorder b) Posttraumatic stress disorder Correct c) Panic disorder d) Phobic disorder e) Generalised anxiety disorder Posttraumatic stress disorder is an anxiety disorder of more than one month's duration, consequent upon a severe traumatic experience in the individual's past,

and which s/he now re-experiences in one or more ways (e.g. flashbacks or dreams). This is accompanied by avoidance of stimuli which recall the event, numbing of the individual's responsiveness, symptoms of arousal (e.g. insomnia) and distress or social/occupational impairment.(see refs for full diagnostic criteria). In contrast , an acute stress disorder develops soon after the traumatic experience. A panic attack is the cardinal manifestation of panic disorder. Patients experience intense, disabling anxiety and may fear they are losing control, going mad or dying. Generalised anxiety disorder involves persistent excessive and/or unrealistic worry, accompanied by other signs and symptoms, such as muscle tension, restlessness and feeling on edge. Patients with phobic disorders display marked fear of objects or situations which provoke an immediate anxiety reaction. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109336 )
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* Question 27 Jane is 24 years of age and 10 weeks pregnant with her first child. She has just been diagnosed with her first ever urinary tract infection. Which drug would you choose to treat Jane's urinary tract infection? a) Trimethoprim b) Cephalexin Correct c) Amoxycillin d) Norfloxacin e) Erythromycin The important time for teratogenic effects of drugs given in pregnancy is in the first trimester. All drugs, if possible should be avoided in the first 12 weeks of pregnancy. However if Jane has a urinary tract infection she requires treatment. Trimethoprim and norfloxacin (usually used to treat pyelonephritis) are category B3 drugs in pregnancy and should be avoided. Amoxycillin and Cephalexin are both category A in pregnancy, however amoxycillin is only recommended if susceptibility of the organism is proven. Erythromycin is also category A but unsuitable in the management of urinary tract infections. (Therapeutic Guidelines: Antibiotic Guidelines, Version 11, 2000. Therapeutic Guidelines Limited, p196 and appendix 7 ) ( Current Obstetric and Gynecologic Diagnosis and Treatment, 9th edition, DeCherney and Nathan Available: www.accessmedicine.com/content.aspx?aID=304580&searchStr=urinary+tract+infe ction+and+pregnancy#304580 )

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Question 28 May was found at home in a coma and brought into hospital, where she is now recovering well. May is 80 years of age, and she has been well most of her life, but in the last 5 years she has gained about 10kg in weight. During the past week or two, before she was brought into hospital, May has been tired, sleepy, 'dry as a chip', forever running to the toilet to pass urine, and yet she had been unable to drink enough to satisfy her thirst. What was the MOST LIKELY diagnosis when May was brought into hospital? a) Diabetic ketoacidotic coma Incorrect. The correct answer is (d). b) Hypoglycaemic coma c) CVA with coma d) Hyperosmolar non-ketotic coma e) Hypothyroid crisis Hyperosmolar non-ketotic coma (HONC) occurs in elderly patients with Type 2 diabetes mellitus, but the history of diabetes is usually unknown. It has an insidious onset that includes polyuria and polydipsia, severe dehydration, and an impaired level of consciousness, which correlates with plasma osmolality. Coma is usually associated with an osmolality >440mmol/l. Respiration is usually normal. Patients may rarely present with a CVA, seizures or an MI, but the underlying disorder is primarily diabetes. Blood glucose is usually >40mmol/l, there is severe hypernatraemia and dehydration, with a relatively normal arterial pH, unless there is coexisting lactic acidosis. Rehydration and insulin are the mainstays of treatment and causes of infection should be sought as well as ECG changes consistent with infarct or ischaemia. Diabetic ketoacidotic coma only occurs in Type 1 diabetes. Hypoglycaemic coma has more rapid onset than HONC. The preceding symptoms of sympathetic overactivity or cerebral compromise, resulting from hypoglycaemia, rapidly progress to coma, if untreated. Hypoglycaemic coma commonly occurs in well-controlled diabetic patients, and is due to their diabetic medications eg: longer acting sulphonylureas. However blood glucose should always be tested (dipstick and laboratory confirmation) in an unconscious patient (diabetic or not) and hypoglycaemia assumed to be the cause of any coma, until proven otherwise. (Ramrakha,P.S., Moore, K.P. (Ed) (1997) Oxford Handbook of Acute Medicine. London Oxford University Press, p 430-441 ) (The Merck Manual of Diagnosis and Therapy 17th edition Available: www.merck.com/pubs/mmanual/section2/chapter13/13b.htm Available: www.merck.com/mrkshared/mmanual/section2/chapter13/13d.jsp )

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Question 29 Mike has come to you to discuss vasectomy. He is 45 years of age, and he has three children to his current partner Sam. Sam has tried many different contraceptives, but none have been satisfactory. She has finally told Mike he has to do something about contraception for them now they have had all the children they want. Mike is very nervous about any type of surgery, especially if it involves his genital area. He has never been near a surgeon in his life. Which of the following statements is CORRECT? Vasectomy: a) Is not as permanent as male sterilisation b) Is not effective immediately Correct c) Is totally functionally reversible d) May be followed by a reduced testosterone level e) May result in a reduced volume of semen production Vasectomy is sterilisation of the male and it involves a small incision in the scrotal skin under local anaesthetic. The vas deferens is separated from its blood supply and approximately 1cm of it is removed between ligatures. Post-vasectomy it takes up to 3 months for the sperm to be eliminated from the ejaculate (the volume of sperm in the vas deferens between the point of excision and the tip of the penis). Vasectomy is to be considered irreversible as microsurgery may repair the vas deferens, but sperm function may never return ( due to the production of sperm antibodies). There is no change to male testosterone levels, balding patterns or libido. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=56577 ) (Collier, JAB. Longmore, JM.(1989) Oxford Handbook of Acute Medicine. 2nd Ed London Oxford University Press, p 68 ) ( Current Obstetric and Gynecologic Diagnosis and Treatment, 9th edition, DeCherney and Nathan Available: www.accessmedicine.com/content.aspx?aID=310173&searchStr=vasectomy#31017 3) (FPA Health Available: www.fpahealth.org.au/sex-matters/factsheets/51.html )
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Question 30 Pamela, an 18 year old first year music student, complains of disabling anxiety. She says she has always been 'nervous in front of strangers', but her problem has been aggravated since she started her music studies. She feels well during the weekend, but is very anxious during the week, and wonders whether she should withdraw from the course. Her main problem is fear of solo performances. Her tutor requires all students to perform solo each week without prior warning for of a group of staff members . Pamela finds this very unnerving. She cannot think or play properly under these conditions, and has 'frozen' and burst into tears on more than one occasion. Which of the following is the most likely diagnosis? a) Generalised anxiety disorder b) Panic disorder c) Phobic disorder Correct d) Obsessive compulsive disorder e) Posttraumatic stress disorder The features of phobic disorder are (a) a marked persistent fear of objects or situations, exposure to which provokes an immediate anxiety reaction that may take the form of a panic attack; (b) avoidance behaviour to avoid the phobic stimulus; and (c) anxiety is provoked only in specific situations. Pamela has a social phobia, characterised by fear of social or performance situations, where she is exposed to unfamiliar individuals, or to possible evaluation by others. Medication with selective serotonin reuptake inhibitors (SSRIs) may be helpful, but the mainstay of management is behaviourally focussed psychotherapy. Generalised anxiety disorder, panic disorder, obsessive compulsive disorder and posttraumatic stress disorder are other anxiety disorders each with its characteristic presentation (see refs). (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109297 )
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Question 31 Alison has been taking the tricyclic antidepressant drug (TCAD) amitriptyline for 6 years. She started taking it when her husband John passed away with cancer. Alison is "much better" now, as she has adapted to life without John. She is sleeping well, her appetite has returned, and even though she still desperately misses John, she no longer avoids neighbours and friends, and she feels less like crying every minute of the day. Alison stopped her amitriptyline suddenly last week without consultation with her doctor. Which of the following is NOT common after abrupt cessation of TCADs? a) Cholinergic activation - abdominal cramps, diarrhoea and vomiting

b) Sleep disturbance - insomnia and vivid dreams c) Somatic distress - flu-like symptoms and headache d) Cardiovascular symptoms - palpitations and arrhythmias e) Psychiatric symptoms - anxiety and agitation Incorrect. The correct answer is (d). All the other options are withdrawal syndromes associated with withdrawal from tricyclic antidepressant drugs. TCADs can cause adverse effects such as orthostatic hypotension, conduction defects and arrhythmias while they are being used. However upon withdrawal of TCADs cardiovascular symptoms are not common. Withdrawal from benzodiazepines is more likely to be associated with cardiovascular symptoms including palpitations, flushing and hyperventilation. (Collier, JAB. Longmore, JM.(1989) Oxford Handbook of Acute Medicine. 2nd Ed London Oxford University Press, p 366 ) (Australian Prescriber Available: www.australianprescriber.com/index.php?content=/magazines/vol24no1/antidepress ants.htm )
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* Question 32 Mandy ingested 30grams of paracetamol 18 hours ago, and she is slightly nauseous and tearful but otherwise asymptomatic. Mandy is an adult Caucasian female, 65 kg, with no pre-existing illnesses. She is a non-smoker, does not drink alcohol and is on no other medications. She has no known allergies. You ordered some investigations when Mandy arrived at the hospital and they show that she has elevated hepatic transaminases (ALT, AST), prolonged prothrombin time and hypoglycaemia. Which of the following is TRUE? a) Mandy should be given N-acetyl cysteine Correct b) Mandy will develop renal failure within 12 hours c) Mandy should be given oral methionine d) Other commonly prescribed medication taken at the time of a paracetamol overdose will not alter subsequent liver damage e) FFP (fresh frozen plasma) is the treatment of choice when the prothrombin time is abnormal following paracetamol overdose N-acetyl cysteine (iv) is given to all severe paracetamol overdoses (>10grams) presenting with symptoms or abnormal investigations (liver function tests (LFTs), prothrombin time (PT)). All patients with paracetamol plasma levels on or above the "Normal" treatment line (when plasma paracetamol levels are plotted against time in hours), presenting up to 24hours following ingestion, should also be given N-acetyl cysteine.

Only patients presenting within 10-12 hours, who are allergic to N-acetyl cysteine, should be given oral methionine. Oliguria and renal failure generally occur late (day 3 following ingestion) following paracetamol overdose. However 10% of patients develop acute renal failure from acute tubular necrosis. Vitamin K, 10mg, given intravenously (iv) is preferable in paracetamol overdose and FFP (fresh frozen plasma) should be avoided, unless there is active bleeding. FFP may make future management, including liver transplant more difficult. Patients on enzyme-inducing drugs (e.g. phenytoin, carbamazepine, rifampicin, phenobarbitone) or those who are malnourished (e.g. anorexia, alcoholism) develop paracetamol toxicity and require intervention at lower plasma paracetamol levels than previously healthy patients on no enzyme-inducing medications. (Ramrakha,P.S., Moore, K.P. (Ed) (1997) Oxford Handbook of Acute Medicine. London Oxford University Press, p 662-665 ) (St Vincent's Hospital Sydney, Division of Clinical Pharmacology Available: www.sydpath.stvincents.com.au/tests/ClinPharmFrames/ParacetamolBody.htm ) (University of Adelaide Pharmacology Department Available: www.health.adelaide.edu.au/Pharm/para0001.htm )
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* Question 33 Shamila is a 16 year old schoolgirl who consults you because she is very unhappy at home and says she is considering suicide. You assess her as being clinically depressed. Which ONE of the following strategies would you adopt NEXT to deal with the threat of suicide in this case? a) Refer Shamila to a psychiatrist b) Referral to a local mental health crisis team Incorrect. The correct answer is (d). c) Admit Shamila urgently to the psychiatric ward of the local hospital d) Ask Shamila if she has made any suicidal plans e) Commence cognitive behavioural therapy immediately When patients have suicidal thoughts, the treating doctor should take careful note of the context. Patients who have made definite plans to commit suicide, or who have obtained the means with which to carry it our, e.g. a weapon, are at much greater risk of killing themselves than those who have simply contemplated the matter in theory. In cases where there is serious intent to commit suicide, the patient should be regarded as seriously depressed and referred for urgent specialist attention. How this is achieved will differ in different areas. In some cases the best approach may be to refer the patient to the local mental health crisis team. Where such a team does not exist, urgent referral to a psychiatrist or urgent admission to a psychiatric facility

is indicated. (Jeffrys D (2003) Depression in children and adolescents. Medical Observer, 16 May, 36-37 ) (RACGP. Guidelines for preventive activities in general practice. Updated 5th ed. May 2002, Special Issue, p 45. ) (Ebert Current Psychiatry Available: www.accessmedicine.com/content.aspx?aID=31505&searchStr=suicidal+ideation#3 1505 )
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Question 34 Marty is a 42 year old man who presents complaining of chronic headaches. He says he has come to see you only because his wife insisted. On questioning he is not very informative but admits to having a few beers after work most days. On examination you note his complexion is flushed, there is facial telangiectasia and some periorbital puffiness. His BP is 150/95 mm Hg. You suspect that Marty's problems relate to hazardous drinking. Which ONE of the following strategies would be best for obtaining confirmation of your suspicions? a) Confront Marty outright and demand the truth about his drinking b) Phone Marty's wife while he is with you and ask her about his drinking c) Administer an Alcohol Use Disorders Identification Test (AUDIT) d) Take a blood sample for a carbohydrate deficient transferrin (CDT) test e) Take a blood sample for a blood alcohol concentration (BAC) measurement Incorrect. The correct answer is (c). Patients with a drinking problem often do not openly acknowledge how much they are drinking, so other means have to be employed to determine whether they are drinking hazardously. The best approach is to administer a questionnaire (such as AUDIT or CAGE) which explores the patient's drinking pattern and its potential effects on his/her life. Obtaining corroborative information from family members is also helpful but should not be the main approach to obtaining information. Laboratory tests are also useful but there is a considerable incidence of false negatives. The CDT test is relatively insensitive - it requires a consumption level of 60 or more g of alcohol per day to record a positive result. The BAC will only be positive if the patient has been consuming alcohol during the preceding hours before the test. (Latt N, Saunders JB (2002) Alcohol misuse and dependence: assessment and management. Australian Family Physician, 31: 1079-1085 Available: www.racgp.org.au/document.asp?id=9013)

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Question 35 Myra is an 80 year old woman who is brought to your consulting room by her daughter and son-in-law who are concerned that she may have dementia because of her increasing forgetfulness. Which ONE of the following initial strategies would be best to determine whether Myra may have dementia? a) Take blood to measure thyroid function b) Do a thorough neurological examination c) Do a general physical examination including urinalysis d) Establish rapport and administer the Mini Mental State Examination Correct e) Take a medication history and administer the Alcohol Use Disorders Identification Test The Mini Mental State Examination is the appropriate test to examine the patient's orientation. It will detect cognitive impairment, whether due to dementia, depression or delerium. Differentiating these three conditions will usually be possible by a thorough history and examination. (Popplewell P, Phillips P (2002) Is it dementia? Australian Family Physician, 31: 319321 Available: www.racgp.org.au/document.asp?id=6129 )
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* Question 36 Tom is a 65 year old man who presents with fatigue and poorly localised muscular aches and pains in the back and legs. You suspect that he may be depressed but he denies feelings of depression. Which of the following alternatives would be the BEST way of confirming your preliminary diagnosis? a) Discuss Tom's symptoms with his wife b) Administer a standardised depression questionnaire Correct c) Undertake a therapeutic trial of antidepressant medication d) Refer Tom to a psychiatrist e) All of the above A number of standardised questionnaires are available for the detection of depression. Among the simplest are those promoted by the Beyond Blue website,

designed to assist GPs in the diagnosis of depression, viz the K10 and SPHERE questionnaires. The other options could all be helpful but are not recommended diagnostic strategies in themselves. Referral to a psychiatrist is only recommended for problematic or severe cases. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109349 ) (BeyondBlue website Available: www.beyondblue.org.au/index.aspx?link_id=1.4 )
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* Question 37 Molly is a 34 year old woman who presents with chronic back pain following a fall at work one year ago. She is seeking a repeat prescription for oxycodone (Oxycontin), a powerful long-acting opiate analgesic. She is not receiving any other mode of treatment and is not undertaking back exercises. Molly is a trained nurse but has been unemployed since the accident because of disabling pain and is seeking a disability pension. What would be the most appropriate NEXT STEP toward solving Molly's problem? a) Provide a repeat prescription to reduce the number of times she needs to come to see you b) Help her complete the necessary paperwork for the pension c) Detail her drug use and assist her to switch to non-narcotic analgesia d) Refer her to a multi-disciplinary pain clinic e) Encourage her to begin back strengthening exercises Incorrect. The correct answer is (d). Molly's problem is chronic because of its duration. Her case raises several issues: (i) How severe is her pain and does she really need a powerful analgesic? (ii) Is she misusing her prescription because she has become dependent? (iii) What is the best approach to her problem? The best way of answering these questions is to refer her to a multi-disciplinary pain clinic, where she can obtain the benefit of assessment and advice by appropriate experts, as necessary, e.g. orthopaedic surgeon, anaesthetist (specialising in pain management), psychiatrist. The other options could assist but are unlikely to provide a solution to Molly's problems. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=51538 ) (Medical Journal of Australia Available: www.mja.com.au/public/issues/180_02_190104/bog10461_fm.html)

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* Question 38 Roberto is a 67 year old patient who is depressed following the recent death of his wife, and has moved to live with his daughter and son-in-law, because of difficulty in coping with living alone. You prescribe fluoxetine, a selective serotonin reuptake inhibitor (SSRI), but after 6 weeks of treatment, Roberto is still depressed. What is the MOST LIKELY reason for Roberto's failure to respond? a) A different SSRI would have been effective b) SSRIs are not the appropriate type of drug for this patient c) He has severe depression requiring specialist management Incorrect. The correct answer is (e). d) He has psychotic depression requiring electroconvulsive therapy (ECT) e) His bereavement and loss of independence have not been dealt with In patients like Roberto, psychological reactions to changed life conditions are likely to play an important part in the causation of depression. He has suffered bereavement and the loss of his independence, both of which are likely to be significant factors. Hence , psychological approaches to management (e.g. cognitive behavioural therapy) are more appropriate. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109349 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=32332 )
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* Question 39 Cherie is a 38 year old married woman with two young children. She consults you because of anxiety which she attributes to 'the kids getting on my nerves.' You notice that she has a black eye and bruising of her left forearm, consistent with a defence injury. When asked for an explanation, she says she walked into the door of an open cupboard in the dark, when getting up to attend to the younger child at night. You suspect domestic violence. What is your next step in making a diagnosis? a) Non-judgemental questioning about domestic conditions b) Report suspicions to the police c) Report suspicions to relevant State authority

Incorrect. The correct answer is (a). d) Provide information about shelters and support groups e) Offer family counselling The next step is to confirm or dispel your suspicions of domestic violence by directed but non-judgemental questions about the domestic situation, in particular how Cherie and her husband work out disagreements; whether she feels safe at home, and so on. It is preferable to question both parties if possible. Once a diagnosis of domestic violence is made, it is important to establish a supportive doctor-patient relationship and formulate a safety plan with the victim, including provision of information about abuse, the likelihood of recurrence, access to shelters and support groups etc. The option of informing the police and State authorities should be discussed and appropriate action taken according to the circumstances of the case. The prime consideration in domestic disputes is the safety of the victim and the children. (Australian Government Office for Women Available: ofw.facs.gov.au/padv/ ) (Royal Australian College of General Practitioners Available: www.racgp.org.au/document.asp?id=861 Available: www.racgp.org.au/document.asp?id=2918 )
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Question 40 Muriel is an 85 year old nursing home resident. The nursing staff are concerned about her, as she has vomited several times today and this afternoon complains of abdominal pain. She is not clear about its location, but it appears to be right-sided. She does not have a fever. Which of the following statements is CORRECT? a) It is important to have a high index of suspicion for gall bladder disease b) Muriel has early gastroenteritis c) Appendicitis is less common in elderly patients, but the risk of perforation is also low d) The most likely diagnosis is mesenteric ischaemia Incorrect. The correct answer is (a). e) Muriel probably has diverticulitis, as 85% of cases involve the ascending colon Elderly patients may present very differently from their younger counterparts and their abdominal pain is frequently misdiagnosed. However, approximately 35-50% of patients older than 65 have gallstones, and may have associated biliary tract disease. The mortality rate for elderly patients with cholecystitis is approximately 10%, so a high index of suspicion for gall bladder disease is important, especially as

symptoms and signs are often not classical. Although relatively common, a positive diagnosis of gastroenteritis should only be made after other potential causes have been considered and rejected.- Gastroenteritis in this age group should be a 'diagnosis of exclusion'. Appendicitis is less common in the elderly, with only 10% of cases being in the over 60 age group. However, the risk of perforation is approximately 50%. Mesenteric ischaemia is rare, but has a high mortality. Vomiting and diarrhoea are often present, but the pain in this condition is severe. Diverticular disease is common in the elderly, but diverticulitis- involving at least microperforation of the colon, - occurs in 85% of cases in left(descending) colon. (Bryan, ED (2003) Abdominal pain in Elderly Persons Available: www.emedicine.com/emerg/topic931.htm )
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