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DIRECTIONS TO CANDIDATES

Paper 2 – Clinical Applications

h Time allowed: 3 HOURS

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2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 1


h The following questions are A-type
(single-best answer).

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corresponding to the alternative which
you consider to be the best answer.

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[ ] refer to normal ranges.

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2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 2


QUESTION 1

A 56-year-old man suffers a community cardiac arrest. Cardiopulmonary resuscitation (CPR) is started
by a bystander and continued by ambulance paramedics who arrive five minutes later. He is intubated
and given adrenaline. His initial rhythm is ventricular fibrillation (VF). On arrival in the emergency
department he remains in VF despite three direct current shocks en route.

Giving which of the following agents is most likely to result in a successful defibrillation?

A. Metoprolol.

B. Bretyllium.

C. Amiodarone.

D. Bicarbonate.

E. Magnesium.

QUESTION 2

A 47-year-old male has recently learnt that his brother has been diagnosed with Huntington’s disease
(HD). He is unaware of others in his family with HD, however his parents died in a car accident in their
mid-40s. He is examined and found to be neurologically normal. He does not want to be tested for the
HD mutation, however he wishes to know what the chance is that he may develop HD later in life. The
age-related penetrance of HD in a 47-year-old who has inherited the mutation responsible is 50%,
rising to 100% by 70 years of age.

What is his future risk of developing features of Huntington’s disease?

A. 1 in 1 chance.

B. 1 in 2 chance.

C. 1 in 3 chance.

D. 1 in 4 chance.

E. No chance.

QUESTION 3

Use of which of the following drug classes is most likely to lead to the onset of Type 2 diabetes?

A. Atypical antipsychotic drugs.

B. Beta-Blockers.

C. Thiazides.

D. Monoamine Oxidase inhibitors.

E. Tricyclic antidepressants.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 3


QUESTION 4

Which of the following factors is the strongest contraindication to the use of interferon in the treatment
of viral hepatitis:

A. disease acquisition during childhood.

B. Child-Pugh category C status.

C. serum alanine transaminase levels <2 times normal.

D. hepatitis e antigen negative infection.

E. immunocompromised status.

QUESTION 5

A 79-year-old female living in her own home has had falls every week for the last six months and as a
result has fractured her radius and a lumbar vertebra. She has a past history of hypertension,
cataracts, depression and ischaemic heart disease and now mobilizes with a pick up frame. Which of
the following interventions will reduce her future risk of falling the most?

A. Vitamin D supplementation.

B. Withdrawal of antihypertensive medications.

C. Excision of cataracts.

D. Exercise programme.

E. Home visit and modifications by occupational therapist.

QUESTION 6
9
A healthy 24-year-old primigravida is noted to have isolated thrombocytopenia (platelets 100 x10 /L)
on a full blood examination performed at 32 weeks gestation. She has no prior history of
thrombocytopenia, and is normotensive. Her urinalysis is unremarkable.

Which of the following is the most likely explanation for this abnormality?

A. Pre-eclampsia.

B. Gestational Thrombocytopenia.

C. Anti-phospholipid syndrome.

D. Thrombotic Thrombocytopenic Purpura.

E. Immune Thrombocytopenic Purpura.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 4


QUESTION 7

A 38-year-old man, born in Thailand and living in Australia for the past two years, presents to the
emergency department with his first generalized seizure. A head CT scan is performed as shown
below and shows multiple calcified lesions.

Management should focus on which of the following?

A. Seizure prevention.

B. Parasite eradication.

C. Transmission reduction.

D. Surgical removal.

E. Bowel decontamination.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 5


QUESTION 8

A 23-year-old man has end-stage renal failure secondary to immunogobulin A (IgA) nephropathy. He
is managed with three times per week haemodialysis. When reviewed in clinic you discover he has
not been taking any of his oral medications and has the following serum results:

Calcium (corrected): 1.96 mmol/l [2.20 – 2.55]


Phosphate 2.2 mmol/l [0.8 – 1.5]
Parathyroid hormone 45 pmol/l [1.0 – 7.0]

The most appropriate initial treatment of these abnormalities is:

A. a low phosphate diet.

B. low phosphate dialysis.

C. oral calcitriol.

D. oral phosphate binders.

E. high calcium dialysis.

QUESTION 9

A 54-year-old female presents with a three month history of symmetrical polyarthralgia. The following
laboratory results are obtained:

Antinuclear antibody (ANA) positive, titre: 1/160, pattern: speckled


titre 1/640, pattern: cytoplasmic
Antibodies to extractable nuclear antigens (ENAs) positive anti-SS-A (Ro)
Antibodies to ribosomal p protein positive
Anti-double stranded DNA antibody (anti-dsDNA) 4 IU/mL [0-5]
Anti-cyclic citrullinated peptide (anti-CCP) negative
Rheumatoid factor (RF) 45 IU/mL [0-20]

Which of the following is the most likely diagnosis?

A. Rheumatoid arthritis.

B. Systemic lupus erythematosus.

C. Sjogren’s syndrome.

D. Mixed connective tissue disease.

E. Systemic sclerosis.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 6


QUESTION 10

A 62-year-old female presents with severe central chest pain unrelated to exertion. She is given
sublingual nitrates in the ambulance and the pain resolves 15 minutes later. The ECG is normal. The
first troponin is normal. She is observed in a chest pain unit. The second troponin is normal.

What is the next most appropriate investigation?

A. Upper gastrointestinal (GI) endoscopy.

B. Myocardial perfusion study.

C. Coronary angiography.

D. Exercise stress test.

E. CT coronary angiography.

QUESTION 11

A 75-year-old woman presents with a twelve-month history of deteriorating behaviour and memory and
increasing social withdrawal. She has been tearful and emotional with poor quality sleep. A diagnosis
of depression has been made by her general practitioner, and she has been commenced on Sertraline
50mg / day with a limited response over the last eight weeks. Neurological examination reveals normal
tone and no pyramidal findings. She scores 21/30 on a minimental state examination. Thyroid
stimulating hormone, full blood count, urea and electrolytes, calcium and liver function tests are
normal. Cranial CT Scan shows age related involutional change. Her EEG demonstrates diffuse
symmetrical slowing over both fronto-temporal head regions with an excess of delta activity.

The most likely diagnosis is:

A. undertreated Major depression.

B. diffuse Lewy body disease with associated depression.

C. Alzheimers type dementia with associated depression.

D. Creutzfeldt Jakob disease with associated depression.

E. depression with hysterical conversion disorder.

QUESTION 12

Apart from end-stage renal failure, which of the following occurs most frequently in patients with adult
polycystic kidney disease?

A. Mitral valve prolapse.

B. Renal infection.

C. Ischaemic heart disease.

D. Pancreatic cysts.

E. Cerebral aneurysm rupture.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 7


QUESTION 13

Shown below on the same graph are two ROC (receiver operating characteristic) curves. These are
representations of scores for two questionnaires designed to screen for early dementia compared to
an actual diagnosis determined within the following five years.

Which is the best way to compare the accuracy of the two questionnaires?

A. Sensitivity at A2 vs Sensitivity at B2.

B. Specificity at A1 vs Specificity at B1.

C. Likelihood ratios at A1 vs Likelihood ratios at B1.

D. Sensitivity & Specificity at A2 vs B1.

E. AUCA vs AUCB (Area under the curve).

QUESTION 14

A 65-year-old woman with longstanding rheumatoid arthritis and osteoporosis presents with a mid
thoracic crush fracture. She has a history of two previous crush fractures and has been taking
alendronate 70mg weekly for three months. She has a normal serum calcium, phosphate, albumin
and 25 hydroxy-vitamin D. She has taken prednisolone in the past.

Which of the following treatments is most appropriate for future fracture prevention?

A. Continue alendronate and add raloxifene.

B. Cease alendronate and commence intravenous pamidronate.

C. Continue alendronate.

D. Cease alendronate and commence strontium ranelate.

E. Cease alendronate and commence risedronate.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 8


QUESTION 15

In patients with type 1 diabetes mellitus the greatest benefit in using a long-acting insulin analogue is
in reducing which of the following?

A: Diabetic retinopathy.

B: Nocturnal hypoglycaemia.

C: Insulin hypersensitivity.

D: Preprandial hyperglycaemia.

E Microalbuminuria.

QUESTION 16

A 25-year-old has adrenocorticotrophic hormone -dependent Cushing’s Syndrome. He has a normal


MRI scan of the pituitary fossa. Which of the following is the most useful next investigation?

A. High dose dexamethasone suppression test.

B. CT scan adrenal glands.

C. Petrosal sinus sampling.

D. Thoracic CT scan.

E. Corticotrophin Releasing Hormone (CRH) test.

QUESTION 17

A 75-year-old presents with progressive dysphagia for solids and liquids over two years. There has
been no episodes of bolus impaction. There has been a two kilogram weight loss over six months.
Oesophageal manometry demonstrates increased teritiary wave activity and decreased amplitude of
contractions. The most likely diagnosis is:

A. ulcerative reflux oesophagitis.

B. presbyoesophagus.

C. achalasia.

D. scleroderma.

E. diffuse oesophageal spasm .

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 9


QUESTION 18

A 68-year-old woman was found to have an elevated white cell count on routine full blood
examination. On examination she is well and has no palpable lymphadenopathy or organomegaly.
Lymphocyte surface markers show that the cells express CD5, CD19, CD20 (dim), CD23 and kappa
light chains (dim).

Full Blood Examination:


Haemoglobin 127 g/L [122-170]
9
White Cells 76.2 x10 /L [4-11]
9
Platelets 120 x10 /L [150-400]
9
Neutrophils 3.7 x10 /L [2-4]
9
Lymphocytes 57.0 x10 /L [1-3.5]
9
Monocytes 1.2 x10 /L [0.4-1.0]
9
Eosinophils 0.3 x10 /L [0-0.4]
9
Smear Cells 14.0 x10 /L -

Which of the following is the most appropriate management?

A. Rituximab.

B. Fludarabine.

C. Observation.

D. Chlorambucil.

E. Prednisolone.

QUESTION 19

A 55-year-old male with a history of controlled hypertension treated with metoprolol presents with
anaphylaxis characterised by hypotension, laryngeal oedema and generalised urticaria occurring 20
minutes after eating a seafood banquet. He remains hypotensive (systolic BP < 90mmHg) despite
repeated intramuscular boluses of adrenaline to a total dose of 1.3mg, intravenous infusion of
crystalloid 1000mL, and intravenous injection of ranitidine 50mg and promethazine 25mg.

Which of the following is the most appropriate next step in management?

A. Further intravenous infusion of crystalloid 1000mL.

B. Intravenous injection of hydrocortisone100mg.

C. Further intramuscular adrenaline 0.5mg.

D. Intravenous injection of 0.3mg adrenaline.

E. Intravenous injection of glucagon 5mg.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 10


QUESTION 20

A 60-year-old man has been identified as HIV (human immunodeficiency virus) positive for at least
15 years. On antiretroviral therapy, his viral load is undetectable and his CD4 count is 220. He also has
vascular risk factors. His partner describes memory impairment of six months duration and a change
in personality. On mental state examination, he is irritable but is attentive and orientated. He has an
expressive dysphasia and some impairment of short-term memory. A CT scan of the brain
demonstrates mild cerebral atrophy but no evidence of opportunistic infection or cerebral malignancy.

Which of the following features in the history, examination and investigations is most suggestive of a
diagnosis other than HIV dementia as the cause of his cognitive impairment?

A. Short-term memory impairment.

B. Dysphasia.

C. Personality change.

D. CD4 count.

E. Undetectable viral load.

QUESTION 21

A 28-year-old female has developed end-stage renal failure secondary to reflux nephropathy.
Which of the following options is most likely to provide best long term survival for the patient?

A. Nocturnal home haemodialysis.

B. Peritoneal dialysis.

C. Living related transplant from her healthy 62-year-old father.

D. Cadaveric transplant from a 30-year-old donor.

E. Living unrelated transplant from her 30-year-old husband.

QUESTION 22

A 70-year-old woman is admitted to a rural hospital with chest pain of three hours duration. ECG
shows anterior ST elevation with Q waves. She is given oral aspirin and intravenous plasminogen
activator. One hour later she still has pain despite nitrates and ST elevation persists. Her heart rate is
102/min, blood pressure 150/110, there are bibasal crackles with oxygen saturation 98%.

What should be the next step in her management?

A. Intravenous heparin.

B. Intravenous beta-blocker.

C. Oral clopidogrel.

D. Intravenous frusemide.

E. Oral diltiazem.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 11


QUESTION 23

A 50-year-old male has chronic liver disease secondary to Hepatitis B infection. Previous endoscopy
has revealed large oesophageal varices. Blood results are:

Albumin 32 g/L [38-55]


Prothrombin Time 14 seconds [8-12]
9
Platelet count 70 x 10 /L [150-450]

On routine review, his alpha fetoprotein is 300 ng/mL [0-15]. His abdominal computed tomography
(CT) scan is shown below.

The optimal treatment for this condition is:

A. chemoembolisation.

B. liver transplantation.

C. cryotherapy.

D. local resection.

E. radiofrequency ablation.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 12


QUESTION 24

A 21-year-old man with a history of injecting drug use is admitted to the Intensive Care Unit with a
severe bilateral pneumonia. He has a recent history of recurrent skin boils which have been difficult to
treat. He has received a number of courses of oral antibiotics for these lesions with little effect. He is
intubated and gram stain of the endotracheal aspirate shows Gram positive cocci. Sputum cultures
show a heavy growth of Staphylococcus aureus with sensitivities to follow. He is treated with
intravenous ceftriaxone and a macrolide.

What is the most appropriate additional treatment?

A. Flucloxacillin.

B. Rifampicin.

C. Meropenem.

D. Vancomycin.

E. Gentamicin.

QUESTION 25

A 72-year-old woman who is taking warfarin for an embolic stroke secondary to atrial fibrillation
presents to the emergency department after a simple fall. On examination she has a few small bruises
on her legs but is otherwise well. Her pulse is 68 bpm and irregular and her blood pressure is 175/95
mmHg. Her full blood examination is normal however her serum creatinine is elevated at 170 mcg/L
[50-100 mcg/L] and her INR is elevated at 7.1.

In addition to regular monitoring, which of the following is the best management strategy for her
elevated international normalised ratio (INR)?

A. Withhold warfarin.

B. Withhold warfarin and administer Vitamin K1.

C. Withhold warfarin and administer Vitamin K1 and prothrombin complex concentrate.

D. Withhold warfarin and administer Vitamin K1, prothrombin complex concentrate with fresh
plasma.

E. Withhold warfarin and administer prothrombin complex concentrate with fresh plasma.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 13


QUESTION 26

A 33-year-old female presents with headache followed by reduced level of consciousness. Her CT
scan is shown below.

She has a systolic blood pressure (SBP) of 180mmHg and a Glasgow Coma Score of 8/15. Which of
the following is the most appropriate initial management?

A. Hypothermia.

B. Control SBP to below 120mmHg.

C. Nimodipine infusion.

D. Recombinant activated factor VII.

E. Orotracheal intubation for airway protection.

QUESTION 27

A 65-year-old male is referred with progressive shortness of breath on exercise. Lung function testing
shows a parenchymal restrictive abnormality and a high-resolution thoracic computed tomographic
scan reveals basal and peripheral fibrosis. He has worked all his life in the banking industry and has
no significant medication history.

What is the most appropriate initial management?

A. High dose oral corticosteroids.

B. Moderate dose oral corticosteroids and azathioprine.

C. Referral for an open lung biopsy.

D. Lung function monitoring.

E. N-acetyl cysteine.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 14


QUESTION 28

An effective treatment is available for your patient, which you believe has advantages over existing
treatments. It is expensive and has no funding source, so if selected, your patient would have to pay.

The most appropriate approach is:

A. not to disclose unfunded option to avoid patient’s financial harm.

B. not to disclose unfunded option as all treatments should be funded.

C. to disclose unfunded option to offer informed choice.

D. to disclose if you judge the patient to be able to pay.

E. to recommend unfunded option to give patient the best treatment.

QUESTION 29

A patient with long standing type 1 diabetes presents has the appearances on fundoscopy shown
below.

Which of the following therapeutic strategies is most likely to preserve his long-term vision?

A. Tight blood pressure control.

B. Aspirin.

C. Tight blood glucose control.

D. Vitrectomy.

E. Pan-retinal photocoagulation.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 15


QUESTION 30

The product information for a new anticonvulsant states that in normal individuals it has a volume of
distribution of around 2L/kg, hepatic clearance of 5L/hour, a renal clearance of 8L/hour, respiratory
clearance of 2L/hour and has 98% protein binding. The usual half-life is stated to be six hours. The
usual dose is 100 mg four times a day.

When considering efficacy, safety and compliance, what is the best dosing regime to try in someone
with end stage renal disease on haemodialysis?

A. 100 mg once per day.

B. 50 mg four times a day.

C. 100 mg three times a day.

D. 100 mg twice a day.

E. 50 mg four times a day and 100 mg after dialysis.

QUESTION 31

A 30-year-old female presents to an Emergency Department with acute breathlessness. The forced
expiratory volume in one second (FEV1) is 3.00 (predicted 4.00) litres and forced vital capacity (FVC)
is 3.75 (predicted 5.00) litres.

Arterial blood gases show:


pH = 7.47
PaO2 = 95
PaCO2 = 32
HCO3 = 36 mEq/litre.

The most likely cause of the results is:

A. pulmonary thromboembolism.

B. bulimia.

C. acute asthma.

D. salicylate overdosage.

E. hyperventilation syndrome.

QUESTION 32

For which of the following presentations of inflammatory bowel disease is infliximab of most benefit?

A. Ulcerative colitis refractory to treatment with azathiaprine.

B. Crohn’s disease with perianal fistulae.

C. Pouchitis refractory to antibiotic treatment.

D. Fulminant ulcerative colitis.

E. Small bowel Crohn’s disease with previous stricturoplasty.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 16


QUESTION 33

A 54 year-old man undergoes primary angioplasty and stent of a total right coronary artery occlusion
after presenting with ST elevation inferior infarction. A 70% stenosis is noted in the mid left anterior
descending (LAD) artery; no other stenosis is evident. He is treated with antiplatelet therapy, a beta
blocker and a statin and undergoes a limited exercise test two days later. He completes a submaximal
exercise test (approximately 9 METS [Metabolic equivalent units]) without symptoms; heart rate
reaches 120/min (75% predicted maximal) and blood pressure 170 systolic. Planar ST depression first
appears at 7 METS and is maximal at 1.5mm in leads V3-V6 at peak.

What should be the next step in his management?

A. LAD stent.

B. Coronary bypass surgery.

C. Dipyridamole sestamibi scan.

D. Exercise echo.

E. Medical treatment.

QUESTION 34

A 22-year-old male suffered a traumatic spinal cord injury at the level of the fifth cervical vertebra with
subsequent quadriplegia 12 weeks ago. He is noted to have the following biochemical abnormalities.

Sodium 139 mmol/L [134-145 mmol/L]


Calcium 2.86 mmol/L [2.15-2.55 mmol/L]
Albumin 40 [40-50 g/L]
Ionized Calcium 1.8 [1.14-1.27 mmol/L]
Creatinine 150 mmol/L [70-110 micromol/L]

The most likely explanation for these abnormalities is:

A. vitamin D in nasogastric feed.

B. chronic renal failure.

C. calcium-containing antacid use.

D. immobilization.

E. rhabdomyolysis.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 17


QUESTION 35

A 42-year-old woman with human immunodeficiency virus (HIV) infection presents to the emergency
department with a six week history of general malaise, fever, night sweats and loss of 5kg weight. She
was born in Papua New Guinea but came to Australia five years ago. She takes zidovudine,
lamivudine and nevirapine. Her viral load is undetectable and CD4 count is 0.41 x 109/L [0.45-1.4 x
109/L]. Examination is unremarkable.

Her Chest X-ray shows patchy consolidation in the left upper zone as shown below.

What is the most likely cause of the radiological changes?

A. Pneumocystis pneumonia (PCP).

B. Mycobacterium avium complex (MAC).

C. Mycobacterium tuberculosis (MTB).

D. Burkholderia pseudomallei.

E. Cytomegalovirus (CMV).

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 18


QUESTION 36

An 80-year-old female has a routine ECG which is shown below. She is living independently in her
own home and has no symptoms of dyspnoea or chest pain. Her BP is 165/90 mmHg.

Which of the following management strategies is most appropriate for her arrhythmia?

A. Amiodarone.

B. Sotalol.

C. Direct current cardioversion.

D. Metoprolol.

E. Flecainide.

QUESTION 37

A 65-year-old woman, established on haemodialysis for nine months, is maintained on erythropoietin


4,000 units twice a week intravenously. Previously her haemoglobin (Hb) had remained steady in the
range of 105 – 115 gm/L. She now presents with a Hb of 89 gm/L on routine testing. There have
been no changes to her erythropoietin dose or other medications. Her mean corpuscular volume
(MCV) is 84 fL [78-98], her serum iron is 13 µmol/l [13-35], iron saturation is 18% [15-46], serum
9
ferritin is 630 µg/l [20-300] and her reticulocyte count is 30 x 10 /L [12-100].

Which of the following is the most likely cause for her erythropoietin resistance?

A. Inflammation.

B. Pure red cell aplasia.

C. Vitamin B12 deficiency.

D. Iron deficiency.

E. Hyperparathyroidism.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 19


QUESTION 38

In untreated patients with hyperuricaemia, which of the following medications is most likely to
precipitate an attack of gout?

A. Thyroxine.

B. Allopurinol.

C. Frusemide.

D. Hydrochlorothiazide.

E. Pyrazinamide.

QUESTION 39

A randomised trial compared aspirin plus clopidogrel with aspirin alone given to over 15000 patients
with either established vascular disease or multiple risk factors. The two treatments were similar
overall (event rate 6.8% vs. 7.3%, p=0.22). The investigators performed 20 prespecified analyses in
subgroups defined by different baseline variables. The uncorrected p-value for the comparison of the
treatment effect between symptomatic and asymptomatic patients was 0.046.

Which of the following statements most accurately summarises this subgroup finding:

A. the subgroup effect is significant because the comparison was pre-specified.

B. with 20 subgroup analyses, the chance of a p value under 0.05 is over 50%.

C. the subgroup effect is almost significant after correction for 20 subgroup analyses.

D. the subgroup effect suggests a benefit in symptomatic patients which should be tested in a
further trial.

E. the subgroup effect would have been significant if the trial had been larger.

QUESTION 40

Which of the following is the most common long-term side effect of radiation treatment of pituitary
tumours?

A. Stroke.

B. Cranial nerve palsy.

C. Optic apparatus damage.

D. Second intracranial tumour.

E. Hypopituitarism.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 20


QUESTION 41

A 58-year-old woman has been unwell for several weeks with back pains. She has no past medical
history of note. She is a smoker of 25 pack years. On examination she is tender over the mid thoracic
spine and over several ribs. The rest of the examination is unremarkable. Blood tests show:

Hb 105 g/l [115-170]


Erythrocyte sedimentation rate 80 mm/hr [< 25]
Corrected Calcium 3.5 mmol/l [2.15-2.57]
Creatinine 0.11 mmol/l [0.4-0.10]
Alkaline Phosphatase 125 IU/l [40-130]
Parathormone 1.1 pmol/l [1.6-6.2]

A CXR shows lytic lesions in several thoracic vertebrae with clear lung fields. Spinal X-rays confirm
several lytic vertebral lesions. Immunoglobulins are normal. Serum and urine electrophoresis and
immunoelectrophoresis are negative. Mammography is normal. CT scanning of chest and abdomen
shows the vertebral lesions but no other masses, no organomegaly and no lymphadenopathy. Thyroid
and pelvic ultrasound are normal. A bone scan shows no increased uptake.

Which of the following tests should next be performed?

A. 24 hour urine calcium.

B. Bone marrow examination.

C. Biopsy of a bone lesion.

D. Vitamin D levels.

E. Parathyroid hormone related peptide levels.

QUESTION 42

A 45-year-old male develops a blistering skin rash as shown below during treatment with co-
trimoxazole. A diagnosis of drug allergy is suspected.

Which of the following is the most appropriate next step?

A. Skin testing with trimethoprim.

B. Skin testing with sulphamethoxazole.

C. Oral challenge with co-trimoxazole.

D. RAST (radioallergosorbent test) for co-trimoxazole.

E. No further investigations necessary.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 21


QUESTION 43

A 56-year-old man is referred for assessment of resistant hypertension. Blood pressure readings at his
general practitioner’s surgery have been between 145 and 172 mmHg systolic and 86 and 98 mmHg
diastolic despite various combinations of up to two anti-hypertensive agents at a time. He has no other
vascular risk factors. He has no family history of hypertension. Examination does not reveal any
clinical findings suggesting a secondary cause of hypertension. He has normal creatinine and
electrolytes. An ECG and trans thoracic echocardiogram are normal

What is the most appropriate next investigation?

A. Aldosterone : renin ratio.

B. Magnetic resonance angiography of renal arteries.

C. Ambulatory blood pressure recording.

D. Renal ultrasound.

E. Urine testing for drug compliance.

QUESTION 44

A 51-year-old man presents with unstable angina. His mother died at age 58 years as a result of a
myocardial infarction and his 48-year-old brother, who smoked heavily and was overweight, survived a
heart attack two years previously. After discharge he consults the internet and, when reviewed,
expresses concern that he may have familial hypercholesterolemia and that there could be a risk that
his son, aged 11 years, may also be at risk of heart attack at an early age.

What finding would give you greatest concern that the patient is correct and that is a need to consider
further the possibility that other members of his family are at risk of early onset coronary vascular
disease?

A. Arcus cornealis.

B. Tendinous xanthomata.

C. LDL (lowdensity lipoprotein) cholesterol of 7.8 mmol/litre [<3.0 mmol/L].

D. Xanthelasma.

E. His son’s LDL cholesterol level is 1.5 standard deviations above the mean for 11
year olds.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 22


QUESTION 45

A 74-year-old woman with severe heart failure (NYHA Class III) due to longstanding hypertension is
now stable on frusemide, metoprolol and perindopril. Blood pressure is 140/75 mmHg; ECG shows
sinus rhythm with left bundle branch block (QRS duration 130 mSec).

Which of the following would provide the greatest improvement in her survival probability?

A. Add digoxin.

B. Change metoprolol to carvedilol.

C. Add candesartan.

D. Implant a biventricular pacemaker.

E. Add spironolactone.

QUESTION 46

A 72-year-old man presents to hospital having woken from sleep with paroxysmal nocturnal dyspnoea.
This is his second presentation to hospital with this problem. He is known to have ischaemic heart
disease and an echocardiogram performed during his last admission revealed a left ventricular
ejection fraction of 25%. The respiratory parameters from a polysomnographic sleep study are shown
below.

Nasal P: affected by artefact so disregard


Therm: Nasal airflow
Thor: Thoracic respiratory inductance plethysmography bands
Abdo: Abdominal inductance plethymography bands
Sum: summed signal from Thor and Abdo
Leg: leg movement sensor
Db: decibels

The most likely explanation for the changes are:

A. Cheyne-Stokes respiration (periodic breathing).

B. obstructive sleep apnoea.

C. periodic leg movement disorder.

D. upper airway resistance syndrome.

E. obesity hypoventilation syndrome.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 23


QUESTION 47

A 26-year-old female has been found to be homozygous for the HFE gene C282Y polymorphism,
when screened for haemochromatosis. Her serum ferritin is 18 micrograms/L [15-200 micrograms/L]
and her transferrin saturation is 82% [< 45%]. Her haemoglobin is 120 g/L [120-160 g/L]

Which of the following is the most appropriate next step in her management?

A. Venesection.

B. Observation.

C. Liver biopsy.

D. Imaging of liver for iron loading.

E. Desferrioxamine.

QUESTION 48

Dialysis patients have a high mortality, with average survival in the order of 40-50% at five years. For
a new patient commencing dialysis, the most likely cause of death will be:

A. infection.

B. malignancy.

C. electrolyte abnormality.

D. cardiovascular event.

E. withdrawal from dialysis.

QUESTION 49

An 65-year-old man is on chronic haemodialysis. He complains of crampy lower abdominal pain and
passes blood per rectum three times over two hours. Colonoscopy demonstrates normal rectal
mucosa and inflammation from the proximal sigmoid to transverse colon. The most likely cause of the
inflammation is:

A. salmonella infection.

B. ischaemic colitis.

C. clostridium difficile colitis.

D. diverticulitis.

E. Crohn's colitis.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 24


QUESTION 50

A 60-year-old man, previously well, presents with a two day history of word finding difficulty,
vagueness and irritability. After a generalized tonic clonic seizure he is brought to the emergency
department. Neurological examination reveals a confused and irritable man, who is uncooperative
with the clinical examination. Reflexes are symmetrically brisk with bilaterally downgoing plantar
responses. His CT scan is normal. His cranial MRI scan is shown below.

The most likely diagnosis is:

A. herpes simplex encephalitis.

B. intracerebral haemorrhage.

C. middle cerebral artery stroke.

D. paraneoplastic limbic encephalitis.

E. cerebral vasculitis.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 25


QUESTION 51

A 75-year-old man has psoriatic arthritis with recurrent secondary skin infections. He presents with
progressive jaundice and itch. His liver function tests show:

bilirubin 260 µmol/L [3–18 µmol/L]


alkaline phosphatase 312 U/L [60– 119 U/L]
aspartate aminotransferase (AST) 59 U/L [12–36 U/L]
alanine aminotransferase (ALT) 90 U/L [5–40 U/L]
γ-glutamyl tranferase (GGT) 238 U/L [6– 65 U/L],

His INR is normal. Investigations for an aetiology including viral serology and an ultrasound revealed
no diagnosis. A drug related cause is suspected.

His recent medications included


• Methotrexate 15 mg weekly for five years
• Folic acid 5mg weekly
• Paracetamol 500mg QID – “for years”
• Flucloxacillin 250mg QID for 14 days, one month prior to presentation.
• Diclofenac 25mg one to two tablets as required – last dose three days ago
• Simvastatin 40 mg daily – commenced two months ago.

The most likely drug to cause this hepatotoxic reaction is:

A. methotrexate.

B. paracetamol.

C. flucloxacillin.

D. diclofenac.

E. simvastatin

QUESTION 52

A 20-year-old female presents with a one month history of malaise, nausea, abdominal pain, itch and
polyarthralgia. She gives no history of recent use of prescribed or illicit drugs. Examination reveals
jaundice, multiple bruises, and tender hepatomegaly. Laboratory results are consistent with an acute
hepatocellular injury, with a polyclonal increase in IgG (immunoglobulin G) of 32g/L (6.1-15.5).
Serological tests for hepatitis A, B, and C viruses are negative. Histopathological findings on liver
biopsy are of a periportal mixed mononuclear cell infiltrate of plasma cells, lymphocytes and
eosinophils consistent with an autoimmune hepatitis.

Which of the following autoantibodies, if present, is most predictive of a poor clinical and biochemical
response to therapy?

A. Anti-nuclear antibody.

B. Anti-smooth muscle antibody (F-actin–specific).

C. Anti-mitochondrial antibody.

D. Anti-liver-kidney microsomal antibody.

E. Atypical perinuclear anti-neutrophil cytoplasmic antibody.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 26


QUESTION 53

An 82-year-old male has had Parkinsons disease for ten years. His current medications include
levodopa/carbidopa and pergolide. For the last 18 months he has been in high level care (nursing
home) because of his immobility but can still walk five-ten metres with a forearm support frame. His
mini-mental state examination (MMSE) is 26/30. For the last three-six months he has had increasing
problems with hallucinations of people coming into his room and has repeatedly accused his family
members of stealing money from his bank account.

The most appropriate first step in the management of his hallucinations and paranoia is:

A. commence risperidone.

B. commence clozapine.

C. cease pergolide.

D. reduce dose of levodopa/carbidopa.

E. commence trimethoprim.

QUESTION 54

A 55-year-old woman presents with vague abdominal pain. Her CT scan is shown below.

A biopsy of the lesion shows spindle shaped cells. The most likely diagnosis is:

A. adenocarcinoma of esophagus.

B. gastrointestinal stromal tumour.

C. linitis plastica.

D. adrenal tumour.

E. renal cell tumour (hypernephroma).

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 27


QUESTION 55

A 45-year-old human immunodeficiency virus-1 (HIV-1)-infected male who has been followed without
anti-retroviral therapy for 12 months is referred for assessment and further management. He has no
HIV-related symptoms or signs. Baseline evaluation and counselling is performed.

Which of the following findings provides the strongest indication to initiate anti-retroviral therapy
immediately?

A. CD4 cell count 300 per cubic millimeter.

B. Plasma HIV-1 viral load 100,000 copies/mL.

C. Decline of CD4 cell count from 350 to 300 per cubic millimetre over 12 months.

D. Evidence of drug-resistant HIV variants in HIV genotyping.

E. Active hepatitis C infection on serologic testing.

QUESTION 56

A previously well 25-year-old man is admitted unconscious following a suspected overdose. He


withdraws to pain and has dilated pupils that react sluggishly. His heart rate is 120/minute and he has
decreased bowel sounds. His ECG is shown above. The presentation is most consistent with
overdose of which of the following drugs?

A. Potassium.

B. Amitryptyline.

C. Lithium.

D. Cocaine.

E. Dextropropoxyphene.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 28


QUESTION 57

A 23-year-old man presents with numbness involving the right fifth digit and ulnar border of the hand
and distal forearm. On examination there is no evidence of muscle wasting. There is weakness of
right finger abduction and adduction (Grade 4/5), abductor pollics brevis (Grade 4/5), flexor pollicis
longus (Grade 4/5) and finger extensor (Grade 4/5). Other muscles groups are normal. Sensation is
th
reduced along the ulnar border of the forearm and hand involving the 5 digit. Reflexes are
symmetrical and preserved. The remainder of the neurological examination is normal.

The most likely diagnosis is:

A. ulnar neuropathy at the elbow.

B. C7 radiculopathy.

C. lower trunk brachial plexopathy.

D. C8 radiculopathy.

E. radial nerve palsy.

QUESTION 58

A 45-year-old woman receiving total parenteral nutrition for short bowel syndrome through a
Hickman’s catheter presents with fever, sweats and rigors. Three sets of blood cultures grow Candida
albicans.

Which of the following is the most appropriate management?

A. Remove the catheter, no antibiotics required.

B. Remove the catheter, commence flucytosine.

C. Leave catheter in situ, commence voriconazole.

D. Leave catheter in situ, commence amphotericin B.

E. Remove the catheter, commence amphotericin B.

QUESTION 59

A 75-year-old female complains of frequent urinary incontinence that occur mostly when bending over
or lifting heavy objects. She has been wearing incontinence pads for nearly one year. The initial step
in the management of her incontinence is:

A. topic vaginal oestrogen.

B. oral imipramine.

C. oral duloxetine.

D. pelvic muscle training.

E. tension free vaginal tape.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 29


QUESTION 60

A 65-year-old man with a history of paroxysmal atrial tachycardia who has been treated with
amiodarone for five years presents with worsening palpitations. Thyroid function tests show the
following results:

FT4 45pmol/l [10-24]


FT3 10pmol/l [ 2.5-6]
TSH <0.03mIU/l [ 0.4-4]

He is commenced on Carbimazole 10mg tds but fails to improve and three weeks later his thyroid
function tests are as follows:

FT4 100pmol/l
FT3 14pmol/l
TSH <0.03mIU/l

Which of the following is the most likely cause of this patient’s thyrotoxicosis?

A. Graves Disease.

B. Type 1 (iodine-induced) amiodarone induced thyrotoxicosis.

C. Type 2 (inflammatory) amiodarone induced thyrotoxicosis.

D. Subacute viral thyroiditis.

E. Toxic multinodular goitre.

QUESTION 61

A 30-year-old previously fit childcare worker presents with a four-week history of a non-productive
cough. Clinical examination is normal. The most likely diagnosis is:

A. Gastro-oesophageal reflux disease.

B. Hypersensitivity pneumonitis.

C. Post nasal drip syndrome.

D. Pertussis infection.

E. Asthma.

QUESTION 62

A “reasonably well” (normal performance status) patient with non-haemorrhagic cerebral metastases
from breast carcinoma presents with spontaneous lower limb venous thrombosis and pulmonary
embolism. Which of the following is the most appropriate long term management regime?

A. Dalteparin.

B. Inferior vena caval filter.

C. Warfarin.

D. Graduated compression stockings.

E. Aspirin.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 30


QUESTION 63

A 64-year-old man presents with renal impairment (serum creatinine 300 umol/l), haematuria and
proteinuria. He is anti-neutrophil cytoplasmic antibody (ANCA) positive and a renal biopsy reveals a
focal necrotising glomerulonephritis consistent with vasculitis. He is commenced on prednisolone and
cyclophosphamide orally. Six weeks later he represents with macroscopic haematuria. He is afebrile
and his creatinine is 225 umol/l.

The most appropriate next management step is:

A. IV antibiotics.

B. cystoscopy.

C. IV methylprednisolone.

D. repeat renal biopsy.

E. change cyclophosphamide to mycophenolate.

QUESTION 64

In the Western population, body mass index (BMI) has significantly increased over the past 40 years in
all age groups. Most of this is accounted for by:

A. increased caloric intake.

B. increased working hours.

C. increased maternal participation in the workforce.

D. increased use of passive entertainment.

E. decreased exercise.

QUESTION 65

A 24-year-old man awakens with right shoulder/trapezius discomfort. The pain persists for two weeks,
and he is then aware of weakness of right shoulder movements. On examination he has a full range
of movement of his cervical spine without pain. He is unable to actively abduct his right arm past 45°,
and has Grade 0/5 power of right deltoid and infraspinatus. Upper extremity power is otherwise
normal, with normal biceps, triceps and brachioradialis reflexes. Sensory examination is normal. A
cervical magnetic resonance imaging (MRI) scan and right shoulder ultrasound are normal.

The most likely diagnosis is:

A. herpes zoster radiculopathy.

B. C5 radiculopathy.

C. rotator cuff injury.

D. inflammatory brachial plexopathy.

E. suprascapular neuropathy.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 31


QUESTION 66

Which of the following is most likely to increase serum phosphate in chronic renal failure?

A. Calcium trisilicate.

B. Calcitriol.

C. Cinacalcet.

D. Calcitonin.

E. Alendronate.

QUESTION 67

A 60-year-old male with no significant past or family history presents for anti-hypertensive medication.
With regard to his risk of colon cancer, which of the following is the most appropriate strategy?

A. Dietary advice.

B. CT colography.

C. Annual digital rectal examination.

D. Annual faecal occult blood test.

E. Five yearly colonoscopy.

QUESTION 68

The most common side effect of antiangiogenesis agent anticancer treatments is:

A. hypotension.

B. hypertension.

C. bleeding.

D. clotting.

E. cerebrovascular accidents.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 32


QUESTION 69

A 49-year-old woman with a 25 year history of type 1 diabetes mellitus presents with progressive mid
foot pain and swelling over six months. An X-ray of the affected foot is shown below.

The most likely diagnosis is:

A. Osteoarthrititis.

B. Neuropathic arthropathy.

C. Osteomyelitis.

D. Gout.

E. Rheumatoid arthritis.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 33


QUESTION 70

An 82-year-old ex-smoker with chronic obstructive pulmonary disease has increasing ankle edema
and breathlessness. Arterial blood gas analysis shows a PO2 of 57mmHg on breathing air. His chest
X-ray is shown below.

The treatment that is most likely to improve his survival is:

A. long-term oxygen therapy.

B. inhaled long acting beta agonists.

C. inhaled corticosteroids.

D. angiotensin converting enzyme inhibitor.

E. angiotensin receptor blocker.

QUESTION 71

In a woman with Graves disease, which of the following is associated with an increased relative risk of
developing Graves ophthalmopathy?

A. Pregnancy.

B. Young age.

C. High titre microsomal antibodies.

D. Smoking.

E. Previous thyroid surgery.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 34


QUESTION 72

A 62-year-old non-smoking woman is admitted with a 24-hour history of fever, rigors, cough and
breathlessness. A left lower lobe pneumonia is diagnosed on Chest X-ray and she is commenced on
intravenous ampicillin and oral clarithromycin. The next day she has improved clinically and
Streptococcus pneumoniae is isolated from blood cultures taken on admission. The isolate is found to
have a minimal inhibitory concentration (MIC) for penicillin of 0.125mg/L (intermediate resistance).

What is the most appropriate antibiotic for ongoing managemnet?

A. Vancomycin.

B. Moxifloxacin.

C. Ceftriaxone.

D. Ampicillin.

E. Cephalothin.

QUESTION 73

A 62-year-old woman with history of breast cancer treated with surgery, chemotherapy and
radiotherapy three years earlier presents with the following abnormality.

The most likely diagnosis is:

A. cellulitis.

B. radiation recall.

C. tumour recurrence.

D. inflammatory breast cancer.

E. Paget’s disease.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 35


QUESTION 74

A 28-year-old male has the following biochemical findings 24 hours after suffering a thoracic gun shot
wound resulting in hypovolemic shock, requiring massive blood transfusion.

AST 3800 U/L [5-55 U/L]


Alkaline Phosphatase 69 U/L [0-130 U/L]
ALT 6400 U/L [5-55 U/L]
Gamma GT 90 U/L [0-60 U/L]
Bilirubin 20 micromole/L [0-18 micromole/L]
LDH 1800 U/L [<220 U/L]
Creatinine 180 micromole/L [70-110 micromol/L]

The most likely explanation for these findings is:

A. halothane hepatitis.

B. hepatic vein transection.

C. transfusion reaction.

D. hepatic congestion.

E. ischaemic hepatitis.

QUESTION 75

A 67-year old diabetic woman has end-stage renal failure managed by continuous ambulatory
peritoneal dialysis. She presents with abdominal pain, low grade fever and cloudy dialysate. On
examination she has mild generalised abdominal tenderness and guarding but does not appear
particularly unwell. She is admitted to the ward and started on intra-peritoneal cephalexin. The
subsequent day, her dialysate culture grows enterococci, E coli and Klebsiella species.

The most appropriate management step is:

A. exploratory laparotomy.

B. add intraperitoneal Ampicillin.

C. removal of the Tenckhoff catheter.

D. intraperitoneal gentamicin.

E. change to intravenous antibiotics.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 36


QUESTION 76

A 28-year-old woman presents with a three month history of numbness of the hands and feet. On
examination, upper and lower extremity reflexes are symmetrically brisk with bilaterally downgoing
plantar responses. Upper extremity power is normal with a normal sensory examination. There is mild
weakness of ankle dorsiflexion bilaterally with reduced sensation to pin prick to the level of the ankles.
Joint position sense is normal. Vibration sense is impaired to the level of the tibial tuberosity bilaterally.
Her MRI scan is shown below.

The most likely diagnosis is:

A. syringomyelia.

B. spinal demyelination.

C. spinal cord ependymoma.

D. subacute combined degeneration of the cord.

E. chronic inflammatory demyelinating polyneuropathy.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 37


QUESTION 77

A 90-year-old female has osteoarthritis and early dementia. She is living at home with her daughter
th
who is her full time carer. Screening tests on her 90 birthday include an mid stream urine (MSU),
which showed bacteriuria (mixed growth) and pyuria.

Which of the following strategies is most appropriate?

A. Single dose of amoxycillin.

B. Five day course of trimethoprim.

C. Topical estrogen cream.

D. No intervention.

E. Repeat MSU in three months.

QUESTION 78

Which of the following situations is most likely to result in a false negative FDG-PET
(Fluorodeoxyglucose-Positron Emission Tomography) scan when restaging a patient with aggressive
lymphoma post-chemotherapy?

A. Necrosis at site of previous involvement.

B. Fibrosis at site of previous involvement.

C. Brown fat.

D. Uncontrolled diabetes.

E. Recent surgery.

QUESTION 79

A 72-year-old man admitted to hospital with a liver abscess was initially treated with intravenous
ceftriaxone alone. Cultures from a percutaneous aspirate specimen subsequently grow Streptococcus
milleri. On day seven he developed profuse, watery diarrhoea (eight bowel actions per day) associated
with fever and abdominal pain. A stool specimen has been taken. In addition to changing to a narrow
spectrum antibiotic, what is the most appropriate treatment while waiting for the result?

A. Intravenous clindamycin.

B. Oral vancomycin.

C. Oral metronidazole.

D. Oral ciprofloxacin.

E. Intravenous vancomycin.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 38


QUESTION 80

A 26-year-old man presents with a six month history of profound fatigue after a viral illness. Extensive
investigations have not found a primary cause for the fatigue. Which of the following treatment options
is most likely to improve his fatigue?

A. Educational material explaining chronic fatigue.

B. A supervised graded exercise program.

C. Selective serotonin re-uptake inhibitors.

D. Low dose prednisolone.

E. Supportive primary care.

QUESTION 81

A 58-year-old smoker presents with a new diagnosis of hypertension. His BP has been difficult to
control with levels of 190/110 despite amlodipine 10 mg/day and prazosin 5 mg bd. On examination
he has a loud abdominal bruit. His CT scan reveals a 1.5 cm left adrenal mass. Laboratory
investigations reveal:
Sodium 138 mmol/l [135-145]
Potassium 4.8 mmol/l [3.5 – 5.5]
Bicarbonate 23 mmol/l [22 – 28]
Creat 105 umol/l [< 120]

The most likely cause of his hypertension is:

A. Conns syndrome.

B. phaeochromocytoma.

C. essential hypertension.

D. renal artery stenosis.

E. Cushings syndrome.

QUESTION 82

A 56-year-old farmer with a history of chronic mid and lower back pain is admitted with a two week
history of fevers, rigors, general malaise and excruciating mid-thoracic back pain. On examination he
th
has a temperature of 38.5 degrees Celsius and tenderness to palpation over the 6th and 7 thoracic
vertebrae. The rest of the examination is unremarkable. Full blood count shows a white cell count of
13.0 x 10^9/L [4.0–11.0] with a neutrophilia [10.2 x 10^9/L]. C reactive protein is 190 u/L [<5]) and
ESR 69 mm/hr [<20]. Blood cultures are pending.

Which of the following investigations is most likely to establish the diagnosis?

A. Radionuclide bone scan.

B. MRI of spine.

C. CT scan of spine.

D. Plain X-rays of spine.

E. Labelled white cell scan.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 39


QUESTION 83

A 60-year-old man, with a past history of hypertension, type 2 diabetes and a 20 pack year history of
smoking, presents with sudden onset of headache and a mild left sided hemiparesis. His cranial CT
scan is shown below.

The most likely diagnosis is:

A. cerebral metastasis.

B. hypertensive haemorrhage.

C. amyloid angiopathy.

D. arteriovenous haemorrhage.

E. giant cerebral aneurysm.

QUESTION 84

A 26-year-old male is involved in a motor vehicle accident, following which he undergoes extensive
surgery including a laparotomy for suspected ruptured bowel and decompression surgery on his legs
for compartment syndrome. He receives multiple antibiotics including gentamicin and ampicillin, and
parenteral feeding. Ten days later, after discharge to the general ward, he develops mild oliguria but a
rapidly rising serum creatinine. Obstruction is excluded on a renal ultrasound examination.

The most likely cause of his acute renal failure is:

A. penicillin related interstitial nephritis.

B. rhabdomyolysis.

C. hypovolaemia related to his injuries.

D. aminoglycoside-related acute tubular necrosis.

E. intratubular calcium deposition.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 40


QUESTION 85

A 67-year-old man with longstanding rheumatoid arthritis treated with methotrexate, prednisolone and
celecoxib presents unwell with fatigue and anorexia. On examination his arthritis is quiescent but he
has two mouth ulcers. His full blood examination is shown below.

Hb 102 g/L [115-150]


MCV 101.2 fL [80-96]
MCH 29.1 pg [27-33]
MCHC 350 g/L [320-360]
9
WCC 1.4x10 [4-11]
9
Neutrophils 0.5x10 [2-5]
9
Plt 90x10 [150-400]
ESR 67 mm per hour [<22]

The most appropriate drug to administer is:

A. folic acid.

B. filgrastim.

C. folinic acid.

D. cholestyramine.

E. prednisolone.

QUESTION 86

A 50-year-old woman undergoes breast conserving surgery for a breast cancer found on self-
examination. Histology shows an invasive ductal carcinoma, moderately differentiated, 22mm in size,
oestrogen receptor positive, progesterone receptor negative and HER-2 positive. Sentinel node biopsy
is negative.

What further treatment will have the greatest impact on her survival probability?

A. Chemotherapy and tamoxifen.

B. Trastuzamab alone.

C. Aromatase inhibitor.

D. Chemotherapy and trastuzamab.

E. Tamoxifen followed by an aromatase inhibitor.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 41


QUESTION 87

A 90-year-old male resident of a nursing home has severe dementia. He is bedbound, mute, doubly
incontinent and requires full nursing care. He has a large pressure area over one buttock. He has had
two recent admissions to hospital with aspiration pneumonia and has been placed on thickened fluids
to try to prevent aspiration. He does not have any close family members. Now he does not co-operate
with feeding and when food is placed in his mouth he does not swallow it. In the absence of any
advance directives, the most appropriate approach to the management of his hydration and nutrition
is:

A. percutaneous endoscopic gastrostomy (PEG) tube feeding.

B. nasogastric tube feeding.

C. intravenous fluids.

D. overnight subcutaneous fluids.

E. mouth care.

QUESTION 88

A 56-year-old male presents with chest pain and the ECG shown below. The symptoms have been
present for 45 minutes. A facility with acute angioplasty capability is located 180 minutes travel time.
There is no contraindication to thrombolysis.

The most appropriate management of this patient is:

A. aspirin, heparin and immediate transfer for acute angioplasty.

B. aspirin, heparin and tirofiban and transfer for acute angioplasty.

C. immediate thrombolysis.

D. immediate thrombolysis and transfer for acute angioplasty.

E. ibuprofen.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 42


QUESTION 89

A 50-year-old obese male (body mass index (BMI) = 36 Kg/m2) presents to the emergency
department complaining of breathlessness ten hours after returning from the United Kingdom by
airline. Physical examination is normal and arterial oxygen saturation on room air is 96%. His chest
X-ray is normal. The sensitive d-dimer is negative.

The most appropriate next step in management is:

A. CT pulmonary angiogram.

B. no further intervention.

C. venous doppler ultrasound of the lower limbs.

D. ventilation-perfusion scan.

E. pulmonary angiography.

QUESTION 90

A 58-year-old woman presents with a long history of low back pain without radicular features. Over the
last three months, her low back pain has been associated with a feeling of weakness in both legs on
standing for five minutes or after walking 50 metres. There is no disturbance of bladder or bowel
function. General and neurological examination are normal. Her lumbar MRI scan (sagittal T2) is
shown below.

Her symptoms are most likely due to:

A. spinal cord compression.

B. S1 radiculopathy.

C. lumbar spinal stenosis.

D. facet joint cyst.

E. infective discitis.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 43


QUESTION 91

A 70-year-old man comes for out-patient review for his chronic obstructive pulmonary disease
(COPD). Which of the following is the best predictor of mortality?

A. Forced expiratory volume in 1 second (FEV1) of 50% predicted.

B. Recent hospital admission with an acute exacerbation of COPD.

C. Arterial oxygen concentration (PaO2) between 55mm – 65mm Hg.

D. Functional capacity measured by 6 minute walk distance.

E. Arterial carbon dioxide concentration (PaCO2) of 47 mm Hg.

QUESTION 92

Among patients with phospholipid antibodies, which of the following factors most increases the risk of
developing new thrombotic events?

A. History of recurrent foetal loss.

B. Prior stroke.

C. Increasing antibody titre.

D. Recent discontinuation of warfarin therapy.

E. Cigarette smoking.

QUESTION 93

A 26-year-old man recently returned from an overseas holiday, presents with a two day history of joint
o
pain. On examination his temperature is 38.1 C, he has two small pustular lesions on his left hand,
th
evidence of tenosynovitis of the left 4 flexor tendon and an effusions in the right knee.

Which diagnosis best explains this clinical pattern?

A. Reactive arthritis.

B. Parvovirus infection.

C. Gonococcal arthritis.

D. Staphylococcal arthritis.

E. Sub acute bacterial endocarditis.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 44


QUESTION 94

A 45-year-old man is brought to the emergency department by his wife. She describes one week of
withdrawn “odd” behaviour. He has refused to go to work and eaten little. In the most recent 24 hours
he has become mute. There is no prior psychiatric or medical history. On examination he seems alert
but is mute and his affect is flat. He has a non-verbal localizing response to pain but does not respond
to commands. He looks in the opposite direction when asked to follow finger movements and actively
resists efforts to open his mouth. Limb tone is increased and catalepsy (waxy flexibility) is present. His
limbs can be moved to an awkward posture that will be maintained for some minutes.

The most likely explanation is:

A. an affective psychosis.

B. a schizophreniform psychosis.

C. malingering.

D. an organic brain syndrome.

E. a conversion disorder.

QUESTION 95

A patient with known lung cancer presents with nausea and lethargy. His serum sodium is 119
mmol/L. Which of the following sets of results is most consistent with a diagnosis of the syndrome of
inappropriate antidiuretic hormone (ADH) secretion?

Serum osmolality Urine osmolality Urine sodium


(mosmol/kg) (mosmol/kg) (mmol/L)
N [275-290]
A 275 50 60
B 275 80 10
C 275 180 60
D 298 50 10
E 298 180 60

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 45


QUESTION 96

In a randomised trial 39,876 women aged over 45 years were assigned either aspirin 100mg on
alternate days or placebo, and were followed for 10 years for a first major cardiovascular event. The
results are shown in the figure below. Which statement best summarises the study results?

A. The probability that aspirin is better than placebo is 13%.

B. The absolute difference in events between aspirin and placebo is 2%.

C. The relative risk reduction with aspirin is 26%.

D. Regardless of treatment, 98% of women remained event-free over 10 years.

E. Regardless of treatment, the probability of an event over 10 years is 13%.

QUESTION 97

A 63-year-old man presents with a six-month history of gradual onset of right hand weakness.
On examination there is wasting of the intrinsic muscles of the right hand. Power is normal proximally,
with weakness of right finger extensors, right finger abduction and adduction, and right flexor pollicis
longus (all Grade 3/5). There is milder weakness of right forearm pronation and right wrist extensors
(Grade 4/5). The right triceps and finger jerks are brisk relative to the left sided reflexes. The biceps
and brachioradialis reflexes are symmetrical. Sensory examination is normal. A cervical magnetic
resonance imaging (MRI) scan is normal.

The most likely diagnosis is:

A. multiple sclerosis.

B. motor neurone disease.

C. brachial plexopathy.

D. thoracic outlet syndrome.

E. mononeuritis multiplex.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 46


QUESTION 98

A 68-year-old female develops pulmonary edema and myocardial infarction during general anesthesia
for parathyroidectomy. Her coronary arteries are normal at coronary angiography.
While ventilated in ICU significant problems in hemodynamic control due to hypertension occur. Her
abdominal CT scan is shown below.

Which of the following is the most appropriate treatment for her hypertension?

A. Beta-blockers.

B. Angiotensin II converting enzyme inhibitors.

C. Nitrates.

D. Alpha-blockers.

E. Calcium channel blockers.

QUESTION 99

A 72-year-old man presents with a right sided headache for two weeks. On examination he is tender
over the temporal artery. His erythrocyte sedimentation rate (ESR) is 82 mm/hr [0-22].

Which is the most appropriate next investigation?

A. Ultrasound of temporal artery.

B. Temporal artery biopsy.

C. Platelet count.

D. Retinal photography.

E. Serum protein electrophoresis.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 47


QUESTION 100

A 44-year-old male with a 15-pack year cigarette smoking history and no history of occupational dust
exposure presents with a four-year history of breathlessness on exercise.

* outside the Normal range

Which of the following best explains the lung function abnormalities?

A. Extrinsic allergic alveolitis.

B. Idiopathic pulmonary fibrosis.

C. Emphysema and pulmonary vascular disease.

D. Emphysema.

E. Emphysema and sarcoidosis.

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 48


Adult Medicine

Paper 2 – Clinical Applications

Answers

1 C 34 D 67 D
2 C 35 C 68 B
3 A 36 D 69 B
4 B 37 A 70 A
5 D 38 B 71 D
6 B 39 B 72 D
7 A 40 E 73 C
8 D 41 B 74 E
9 B 42 E 75 A
10 D 43 C 76 B
11 C 44 B 77 D
12 C 45 E 78 D
13 E 46 A 79 C
14 C 47 B 80 B
15 B 48 D 81 C
16 C 49 B 82 B
17 B 50 A 83 B
18 C 51 C 84 D
19 E 52 D 85 C
20 B 53 C 86 D
21 C 54 B 87 E
22 B 55 B 88 C
23 B 56 B 89 B
24 D 57 C 90 C
25 B 58 E 91 B
26 E 59 D 92 D
27 D 60 C 93 C
28 C 61 D 94 D
29 E 62 A 95 C
30 D 63 B 96 D
31 E 64 A 97 B
32 B 65 D 98 D
33 E 66 B 99 B
100 E

2007 FRACP Written Examination Paper 2 - Clinical Applications Adult Medicine 49