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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.
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?
B. Beta-Blockers.
C. Thiazides.
E. Tricyclic antidepressants.
Which of the following factors is the strongest contraindication to the use of interferon in the treatment
of viral hepatitis:
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.
C. Excision of cataracts.
D. Exercise programme.
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.
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.
A. Seizure prevention.
B. Parasite eradication.
C. Transmission reduction.
D. Surgical removal.
E. Bowel decontamination.
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:
C. oral calcitriol.
QUESTION 9
A 54-year-old female presents with a three month history of symmetrical polyarthralgia. The following
laboratory results are obtained:
A. Rheumatoid arthritis.
C. Sjogren’s syndrome.
E. Systemic sclerosis.
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.
C. Coronary angiography.
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.
QUESTION 12
Apart from end-stage renal failure, which of the following occurs most frequently in patients with adult
polycystic kidney disease?
B. Renal infection.
D. Pancreatic cysts.
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?
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?
C. Continue alendronate.
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
D. Thoracic CT scan.
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:
B. presbyoesophagus.
C. achalasia.
D. scleroderma.
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).
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.
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?
B. Dysphasia.
C. Personality change.
D. CD4 count.
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?
B. Peritoneal dialysis.
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%.
A. Intravenous heparin.
B. Intravenous beta-blocker.
C. Oral clopidogrel.
D. Intravenous frusemide.
E. Oral diltiazem.
A 50-year-old male has chronic liver disease secondary to Hepatitis B infection. Previous endoscopy
has revealed large oesophageal varices. Blood results are:
On routine review, his alpha fetoprotein is 300 ng/mL [0-15]. His abdominal computed tomography
(CT) scan is shown below.
A. chemoembolisation.
B. liver transplantation.
C. cryotherapy.
D. local resection.
E. radiofrequency ablation.
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.
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.
D. Withhold warfarin and administer Vitamin K1, prothrombin complex concentrate with fresh
plasma.
E. Withhold warfarin and administer prothrombin complex concentrate with fresh plasma.
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.
C. Nimodipine infusion.
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.
E. N-acetyl cysteine.
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.
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?
B. Aspirin.
D. Vitrectomy.
E. Pan-retinal photocoagulation.
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?
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.
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 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.
A. LAD stent.
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.
D. immobilization.
E. rhabdomyolysis.
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.
D. Burkholderia pseudomallei.
E. Cytomegalovirus (CMV).
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.
D. Metoprolol.
E. Flecainide.
QUESTION 37
Which of the following is the most likely cause for her erythropoietin resistance?
A. Inflammation.
D. Iron deficiency.
E. Hyperparathyroidism.
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:
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.
E. Hypopituitarism.
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:
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.
D. Vitamin D 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.
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
D. Renal ultrasound.
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.
D. Xanthelasma.
E. His son’s LDL cholesterol level is 1.5 standard deviations above the mean for 11
year olds.
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.
C. Add candesartan.
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.
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.
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.
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.
D. diverticulitis.
E. Crohn's colitis.
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.
B. intracerebral haemorrhage.
E. cerebral vasculitis.
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:
His INR is normal. Investigations for an aetiology including viral serology and an ultrasound revealed
no diagnosis. A drug related cause is suspected.
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.
C. Anti-mitochondrial antibody.
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.
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.
C. linitis plastica.
D. adrenal tumour.
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?
C. Decline of CD4 cell count from 350 to 300 per cubic millimetre over 12 months.
QUESTION 56
A. Potassium.
B. Amitryptyline.
C. Lithium.
D. Cocaine.
E. Dextropropoxyphene.
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.
B. C7 radiculopathy.
D. C8 radiculopathy.
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.
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:
B. oral imipramine.
C. oral duloxetine.
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:
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.
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:
B. Hypersensitivity pneumonitis.
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.
C. Warfarin.
E. Aspirin.
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.
A. IV antibiotics.
B. cystoscopy.
C. IV methylprednisolone.
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:
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.
B. C5 radiculopathy.
E. suprascapular neuropathy.
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.
QUESTION 68
The most common side effect of antiangiogenesis agent anticancer treatments is:
A. hypotension.
B. hypertension.
C. bleeding.
D. clotting.
E. cerebrovascular accidents.
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.
A. Osteoarthrititis.
B. Neuropathic arthropathy.
C. Osteomyelitis.
D. Gout.
E. Rheumatoid arthritis.
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.
C. inhaled corticosteroids.
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.
D. Smoking.
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).
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.
A. cellulitis.
B. radiation recall.
C. tumour recurrence.
E. Paget’s disease.
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.
A. halothane hepatitis.
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.
A. exploratory laparotomy.
D. intraperitoneal gentamicin.
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.
A. syringomyelia.
B. spinal demyelination.
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.
D. No intervention.
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?
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.
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?
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]
A. Conns syndrome.
B. phaeochromocytoma.
C. essential hypertension.
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
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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.
B. MRI of spine.
C. CT scan of spine.
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.
A. cerebral metastasis.
B. hypertensive haemorrhage.
C. amyloid angiopathy.
D. arteriovenous haemorrhage.
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.
B. rhabdomyolysis.
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.
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?
B. Trastuzamab alone.
C. Aromatase inhibitor.
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:
C. intravenous 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.
C. immediate thrombolysis.
E. ibuprofen.
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.
A. CT pulmonary angiogram.
B. no further intervention.
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.
B. S1 radiculopathy.
E. infective discitis.
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?
QUESTION 92
Among patients with phospholipid antibodies, which of the following factors most increases the risk of
developing new thrombotic events?
B. Prior stroke.
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,
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evidence of tenosynovitis of the left 4 flexor tendon and an effusions in the right knee.
A. Reactive arthritis.
B. Parvovirus infection.
C. Gonococcal arthritis.
D. Staphylococcal arthritis.
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.
A. an affective psychosis.
B. a schizophreniform psychosis.
C. malingering.
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?
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?
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.
A. multiple sclerosis.
C. brachial plexopathy.
E. mononeuritis multiplex.
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.
C. Nitrates.
D. Alpha-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].
C. Platelet count.
D. Retinal photography.
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.
D. Emphysema.
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