Year VIA I :X3111 Papa November 2007

MONASH Universi -y
Medi ine, Nursing & Health Sciences

4th Year NIBBS

VIA EXAMINATION PAPER
23 NOVEMBER 2007
INSTRUCTIONS TO CANDIDATES
CANDIDATES ARE REMINDED THAT THEY SHOULD HAVE No BOOKS, NOTES, PAPER, MOBILE PHONES
OR OTHER MATERIAL IN TIIEIR POSSESSION.

READING TIME:

10 MINUTES DURATION

EXAM DURATION:

3 HOURS DURATION
INSTRUCTIONS TO CANDIDATES

There are 87 questions to he attempted. Each question has only one correct answer. You are advised to attempt each
question but if you genuinely do not know the answer, indicate this by marking the question number. Marks are not
deducted for incorrect answers.
THREE answer sheets (Monash University General Purpose Answer Sheet) and a Short Answer Question booklet are to
he used for this paper.
You MUSE use BOLD SIDES of Answer Sheet I and elearls mark it as Pest No. I
You MUST use BO HI SIDES of Answer Sheet 2 and clear!' mark it as Test No. 2
You MUST use BOTI I SIDES of Answer Sheet 3 and clearls mark it as l ist No. 3
The exam paper is made up of EMQ, NICQ and short answer miestions (SAQ's)

The candidate number in the bottom left section of Page I of the General Purpose Answer Sheet must be completed.
Your number is x our Monash student II) number.
You should also complete your name in the top left hand section of the answer sheet and the subject and date details below
that for identification purposes.
Answer sheets must be completed by using black/blue pen or pencil. Any white out/erasure must be complete and without
smudge.

CANDIDATES MUST NOT REMOVE THIS PAPER FROM

Page I of 27

THE

EXAM ROOM

Year VIA Exam Paper November 2007

Questions 1 2
For each of the following patients who develop significant pain, select the most likely diagnosis.

K.
C.
I).

Acute gout
Acute herpes zoster
Osteoporotic crush fracture
Carcinoma of the pancreas
Deep vein thrombosis
Gastro-oesophageal reflux
Liver metastases
Mucositis

Questio n

I.
.1.

NI.
N.
0.
P.

Osteoarthritis
Pancoast syndrome
Pathological fracture
Pulmonary embolus
Peptic ulceration
Rib metastases
Septic arthritis
Vertebral metastases

A male patient. aged 40. is being treated for acute lymphocytic leukemia. Overnight he has developed
a very painfill toot. Walking to the bathroom he stubs his toe and screams with pain. 1 le says he tried
to sleep with his foot outside the bedclothes.
On examination, he is afebrile. the area around Is metatarsal phalangeal joint is red and swollen and
light touch is excruciating. Full blood examination (H3E) and C reactive protein (CRP) are unchanged.

Question 2
A male patient, aged 75, has had a right hemi-colectomy 2 years ago and developed asymptomatic
bone metastases 3 month, ago. For the past 2 days, he has had pain in his left leg, much worse on
weight bearin g . On examination, there is local tenderness and significant hip pain on rocking the
lemur.

Questions 3 5
For each of the following patients, select the most likely underlying cause of their diabetes.
A.
B.

E.

Acromegaly
Carcinoma of the pancreas
Chronic pancreatitis
Cushing's syndrome
Cystic fibrosis
Haemochromatosis

G.

H.
I.
I.
K.

Lipo-atrophic diabetes
Myotonia dystrophica
Phaeochromocytoma
Type I diabetes immune-mediated
Type 2 diabetes mellitus

Question 3
A 30 year old man presents with 3 weeks of thirst, polyuria and 4 k g weight loss. I lis only past history
includes treated coeliac disease. Examination reveals a lean man with ketonuria but no other abnormal
findings. Full ward test of the urine shows 3+ ketones and fasting laboratory glucose is 18 nunol.L.
(normal range < 5.5 mmol/litre).

Question 4
A 55 year old alcoholic man with known cirrhosis of the liver presents with 3 months of thirst,
polyuria and 3 kg of weight loss. l le gives a history of recurrent abdominal pain over the last 4 years.
Full ward test of the urine shows 1 ketones, 2 glucose. Fasting blood glucose is 14 !ninon (normal
range < 5.5 nunollitre). Plain abdominal X-rays show patchy areas of calcification in the epigastrie
region. Transferrin saturation is within the normal range at 32%.

Page 2 of 27

Vin VIA Exam Paper November 2007

Question 5
An obese 30 year old woman presents with recurrent genito-urinary thrush. Examination also shows
velvety pigmented areas on her upper back and in both axillae. She has a long standing history of
oligomenorrhoea. Her mother and grandmother both had diabetes treated with oral agents. Full ward
test of the urine shows 2-u glucose, no ketones and fasting laboratory glucose is 14 mmoUL. (normal
range < 5.5 nunoUlitre).
Question 6
Choose the most likely diagnosis from the options below.
Congestive Cardiac Failure
Diabetes insipidus
Diabetes mellitus
I lypercalcaemia
Primary hyperaldosteronism
Prostatism
G. Psychogenic polydypsia
A 50 year old woman complains of nocturia twice a night. She has been previously well and says she
is not taking medication. BP is 160/95 and she has some muscle weakness. Examination is otherwise
normal. Fasting blood glucose is 5.9 munoll. (normal range < 5.5 mmolllitre) and serum electrolytes
are normal apart from a serum potassium of 2.9 mmol/L. (normal range 3.5 - 5.0 mmollitre)
Questions 7 8

For each patient with dyspnoea, select the most likely diagnosis.

G.
II.
I.
J.

Acute myocardial infarction

Acute pulmonary oedema
Asthma
Bronchiolitis
Congestive cardiac failure
COPD
Croup
Epiglottitis
Fibrosing alvcolitis
Hyperventilation
lschaemic heart disease
Lobar pneumonia

N.
0.

Q.
K.

U.

V.

w.
X.

Obesity
Pulmonary embolism
Pulmonary fibrosis
Right pleural effusion
Right middle lobe consolidation
Right upper lobe collapse
Right upper lobe consolidation
Ri ght pneumothorax
Right basal bronchiectasis
Superior vena caval obstnuction
Tuberculosis
Whooping cough (pertussis)

Question 7
A 60 year old male smoker presents with dyspnoea, haemoptysis and weight loss. On examination, he
is afebrile. Trachea is deviated to the right side, chest expansion reduced in right upper zones,
percussion note dull at the right apex and breath sounds softened in the upper zones on the right side.
Jugular Venous Pressure (JVP) is clearly visible at 3cm and fluctuating.
Question 8

An s0 year old man presents with progressive dyspnoea over recent months. He is afebrile, trachea is
midline, chest expansion reduced on the right side, percussion note stony dull at the right base and
breath sounds absent at the right base. Jugular Venous Pressure is 2 cm.
Page 1 of 27

C Year VIA Exam Paper November 2007

Questions 9 10
For each patient v, ith an intellectual disability presenting to your general practice, select the most
likely diagnosis.

C.
D.

Alzheimer's dementia
Autism
Behaviour due to cause of disability
Bipolar disorder
Dental disease
Depression
Fragile X Syndrome
Frontal lobe syndrome

Gastroesophageal reflux
.1. I leafing impairment
K. Learned behaviour
L. Mania
NI. Oppositional Defiant Disorder
N. Personality Disorder
0. Thyroid dysfunction
P. Vision impairment

Question 9
A 25 year old man with Down Syndrome and a moderate intellectual disability is accompanied to your
general practice by a support worker from his home. The house staff are concerned at his aggressive
outbursts. Ile has lived in the house about 12 months. At first he was cheerful and took great pleasure
from joining in with the house social activities. Over the last 6 months, he has become non compliant,
no longer joins in activities and refuses to do chores around the house. Last week he hit a stall' member
who was trying to get him out of bed in the morning.
Question III
A 60 year old woman with an intellectual disability of unknown cause spent much of her early life in
Kew Residential Services, and recently mmcd into a Community Residential Unit in your practice
area. She is first brought to see you late on a Friday afternoon, with a laceration to her finehead
sustained when he fell at home. Staff report she is tripping more frequently and has had a number of
and
falls recently. but not injured herself significantly before now. She used to enjoy watching
looking through magazines, but these activities seem to no longer he of interest to her. She is a
cheerful. sociall y engaging woman who enjoys outings with other residents from her home. She is
generall y independent in her personal care.
Question I I
For the following patient, select the most appropriate management option.
Advise that Pap smears are no longer required for this patient
Prescribe oral hormone replacement therapy
Recommend Pap smear today, and every 2 years until aged 70
Recommend vaginal vault smear every 2 years until age 70
Refer fir colposcopy and biopsy
Refer Ibr hysteroseopy and endometrial biopsy
G. Refer for total hysterectomy
II. Repeat the Pap smear in six months
Repeat the Pap smear in two years
Treat with oral antiviral medication
Treat with topical vaginal imidazole cream (such as Canesten)
Treat with topical vaginal oestrogen
A female patient aged 57, has not had any periods for the past 4 years. She presents v. ith 10 days of
intermittent va g inal spotting. She has always had normal Pap smears and the last one was 4 months
ago. )n examination. she has obvious vaginal atrophy but no other abnormalities.

Page 4 of 27

Ycar VIA Exam Paper November 2007

Question 12
For this patient presentin g with chest pain, select the most likely diagnosis.
K. Musculo-skeletal pain
L. Oesophageal spasm
M. Pericarditis
N. Pleurisy
0. Pneumothorax
Psychogenic
Pulmonary embolism
Rib fracture
Rib metastasis

Acute myocardial infarct

An gina pectoris
Bornholm disease
Carcinoma lung
Costoehondritis
Dissecting aortic aneurysm
G. Domestic violence
II. Gastro-oesophageal reflux
I. Herpes zoster
Mediastinitis

A.
B.
C.
D.

A male patient. a ged 29, complains of 24 hours of quite severe central chest pain associated with fever.
He has been unwell with a flu-like illness for a few days before the pain started.
Question 13
A 2 year old girl has a one year history of recurrent episodes which cause concern for her parents.
During these episodes she cries, becomes apnoeic and centrally cyanosed. and falls to the ground.
There are no clonic movements or incontinence. She recovers in a few minutes and returns to her
usual self. These events characteristically occur sporadically and Ibllow a minor injury or being upset.
I ler general health is good and development is normal for her age.
The most appropriate management would be to:
Admit to hospital for observation
Arrange a CT scan of the head
Arrange an echocardiograph
Arrange an electroencephalograph (EEG)
E. Indicate that no investigations are required
Question 14
A 6 month old infant presents with mild cyanosis and a mid-systolic murmur. He has cardiac
catheterization for possible congenital heart disease. The following results of oxygen saturation and
heart chamber pressures while breathing air were obtained.
P02

Right atrium
Right sentricle
Pulimartery
Lett atrium
Left ventricle
Aorta

65
78
78
98
78
80

(N 67%)
(N 69%)
(N 69%)
(N >95%)
(N>95%)
(N>95%)

mean BP (mm Hg)

8
(NR -2 to 6)
80
(NR 14-38)
20
(NR 12-28)
7
(NR 3-11 )
(NR80-140)
79
82
(NR 60-105)

The most likely diagnosis is:

Atrial Septal Defect
Patent ducrus aneriosus
Tetralogy of Pal lot
Transposition of the Great Vessels
E. Ventricular Septal Defect
Question IS
Pace 5 of 27

J ` Year VIA Exam Paper November 2007

A 3 month old baby boy is brou ght to you because of noisy breathing. This was first noted within the
first three weeks of life. The baby has been well and feeds nomially and has gained 240gms per week.
Examination reveals a well infant but there is a marked respiratory "crowing" noise on inspiration. He
has suprasternal retraction and intercostals recession. This is worse when he is crying and settles when
he is asleep.
The most likely diagnosis is:
A. Bronchiolitis
IL Laryngotracheomalacia
C. Obstruction from an enlarged thyroid gland
I). Spasmodic croup
E. Submucous cleft palate
Question 16
A nine year old boy presents with a long history of asthma. In the past year, he has had 5 acute attacks
of cough. wheeze and breathlessness each lasting about one week. He has had no interval symptoms.
You see him one month alter his most recent attack of asthma. l le is completely well. You perform
spirometry.
Of the t011owing, what would he the most likely expected lung function results for this boy at this
time?
Increase in Forced Expired Volume I f- I' V I)/ Vital Capacity (VC) ratio after administration of a
bronchodilator
Normal FEV 1 and Forced Vital Capacity (PVC) but decreased PEVI/VC
C. Normal FEV I , PVC and PEW VC ratio
I). Normal PVC but decreased FEV, and FEVINC
E. Significant improvement int : EV, after administration of a bronchodilator
Question 17
A 13 year old girl is brought to you by her mother after the teacher complained that her coughing is so
had it disrupts the class and she has to be sent outside. tier coughing is harsh and croaky and is not
associated A ith sputum production. The coughing also frequently stops her from exercising. She does
not cough at night. What is the most likely cause of this patient's recurrent coughing?
Cough variant asthma
Post-viral cough
Psychogenic cough
Tuberculosis
E. Whooping cough syndrome

Page 6 of 27

4' Year VlA Exam Paper November 2007

()nestle!' 18
A full term baby aged two hours has severe respiratory distress. On auscultation over the left side of
the thorax, breath sounds cannot he heard, the heart sounds are faint. A nasogastric tube is passed and
chest X-ray (shown) is taken.

Which of the following is the most likely diagnosis?

Diaphragmatic hernia
Idiopathic respiratory distress syndrome
C. Isolated dextrocardia
1), Left pneumothorax
E. Oesophageal atresia
Questions 19 - 20
For the following patients presenting with jaundice, select the most likely diagnosis.

E.
F.
G.

Acute hepatitis A
Alcoholic hepatitis
Ascending cholangitis
Carcinoma of the head of the pancreas
Choledocholithiasis
Chronic hepatitis C
Glucose 6-Phosphate dehydrogenase (G6PD)
deficiency

1.

.1.
h.
L.

M.

I lepatoma
Infectious Mononucleosis
Liver Abscess
Metastatic adenocarcinoma
Primary B I iary Cirrhosis
Sickle cell anaemia

Question 19
A 70 year old man presents with weight loss. He has lost 8 kg in the last 3 months. He is icteric but
abdominal (gastrointestinal) examination is otherwise unremarkable. Urinalysis shows glycosuria and
bilimbinuria.
Question 20
A 60 year old man presents with anorexia. weight loss of 7 kg over 3 months, lethargy and vague right
hypochondrial discomfort. On examination, he is jaundiced, and has 5 tingerbrcadths of palpable
irregular liver below the right costal margin. A fmn 2 cm lymph node is palpable in the left
supraclavicular

Page 7 of 27

4' Year VIA Exam Paper November 2007

Questions 21- 22
For the following clinical presentations, select the most appropriate next step in management.
Inhaled short acting beta2-agonist as required
Inhaled steroids by DPI or MDI twice daily
Inhaled long acting beta2-agonist twice daily
Inhaled long acting anti-cholinergic by DPI once daily
Oral theophylline
Oral leukotriene receptor antagonist
G. Intramuscular adrenaline
II. Inhaled adrenaline
I. Intravenous adrenaline
3. Oral prednisolone
K. Oral antihistamine
Abbreviations
MDI metered dose inhaler
DPI - dry powder inhaler
Question 21
.\ 42 n car old storeman has had moderate persistent asthma since childhood. Ile has never required
hospital admissions but has had a couple of presentations to emergency department with acute asthma.
le has been on maintenance inhaled budesonide 400 meg twice daily for about 5 years, and in
combination with etOrmeterol 12 mcg, twice daily for the last year. A recent chest infection has led to
increased wheeze and shortness of breath V, tilt daily activity, as well as night time waking.
Question 22
A 25 year old lawyer has a peanut allergy and has had mild asthma since early childhood. lie usually
takes inhaled salbutatnol as required. which is about once a month. This evening, he was at a
restaurant, and ate an entree with stony sauce. Within minutes, he developed lip and tongue itching and
swelling associated with Isheeze and chest tightness. Ile presents sweaty and short of breath with a
thready pulse and a blood pressure of 90 mmHg systolic.
Question 23
Which ONE of the following statements is incorrect?
A potassium sparing diuretic can cause cardiac arrhythmias if combined with an angiotensin
converting enzyme antagonist
Loop diuretics coIll Monty cause increased magnesium levels
Spironolactone can cause gynaecomastia
Thiazides and loop diuretics can cause weakness
E. Thiazide diuretics can cause hyponatraemia (reduced sodium)

Question 24
Which of the following statements is incorrect?
Glucocorticosteroids can precipitate or exacerbate diabetes
Initial treatment of Type 2 diabetes can include diet and exercise without the use of drugs
Metfonnin can cause lactic acidosis
Sulphonylureas such as glibenclatnide can cause hypoglycaemia
E. The biguanidine metformin stimulates beta cells of the pancreas to produce more insulin

Page 8 of 27


4' Year VIA Exam Paper Noem/x1 2007

Questions 25
Which most important feature would you look for on physical examination of a 17 year old patient
whose mother suspects that she has taken her grandmother's digoxin?
A. Cardiac arrhythmias, hypertension, dilated G.
pupils
II. Constipation, constricted pupils, sweating, H.

hyperventilation

Double vision, disturbance in colour
I.

vision, haematemesis, constipation
Drooping eyelids and double vision
I
I leadache, tremor, bradycardia.

constricted pupils, flushed dry skin
Hypotension, tachycardia, mania,
hypothermia, profuse sweating

Nausea and liver failure

Nausea, disturbance in colour vision, slowing
of atrioventricular conduction
Reduced bowel sound, increased temperature.
dilated pupils. flushed dry skin
Respiratory depression, constricted pupils
Tinnitus, vomiting, deafness, vertigo

Question 26

E.

20 year old female

20 year old male
30 year old female
30 year old male
45 year old female

F.
C.

45 year old male

60 year old ICmale
60 year old male
70 year old female
70 year old male

Which of the above individuals is most likely to present with non lethal self harm'
Questions 27-30

From the following list of findings on Mental State Examination, select the most appropriate
alternative for the description given.
A.
B.

E.
F.
G.
H.
1.

Auditory hallucination
Compulsion
Confabulation
Delusion
Depersonalisation
Depressed mood
Derealisation
Illusion
Interpretation of themes

J.
K.

Labile mood
Magical thinking
Obsession
M. Poor eye contact
N. Pressure of speech
0. Restricted affect
P. Suicidal ideation
Q. Tangentiality
R. Thought alienation

Question 27
A young woman often thinks that she sees her mother out or the corner of her eye in the evening. Her
mother sits there in the corner, watching T.V. and knitting socks, just like she always used to. The
young woman misses her mother terribly since she died last month.
Question 28

Despite the tact that you are a locum and have not seen him before, Jack, a 76 year old widower
attending the practice for a routine check, greets you like an old friend. Ile enthusiastically asks what
you have been doing since last Samrday when he saw you at the Pub and you had a few drinks after
the football.
Page 9 of 27

Year VIA Exam Paper November 2007

Question 29
Despite having attended your practice lin many years the office seems different to Gareth today. lie
can't say what is different, but sitting there feels uncomfortable to him. He is concerned about his
upcoming university exams. but that doesn't explain the feeling. It is almost as if your office has been
copied.
Question 30
Madge, aged 73 and living alone, complains that the people in the flat upstairs are always talking about
her. Not only do they talk to each other about how much weight she needs to lose, but they also seem
to know exactly what is in her fridge.
Question 31
When the metabolic activity of an organ increases, blood flow through the arterioles supplying that organ
increases. . p his response is referred to as active hyperemia and occurs because:
A. Cardiac output has been increased in anticipation of the increased metabolic demand
II. 'Hie capillaries within the organ dilate
The smooth muscle of the arterioles relaxes in response to local chemical factors
The veins leaving the organ dilate, allowing more blood to enter them
E. There is an increase in activity in the sympathetic nerves which innervate the arterioles

Question 32

John is involved in a fight outside a nightclub. During the fight. his assailant stabs him in the chest
with a knife, penetrating the chest wall and puncturing the pleural cavit y . The thoracic cage would be
expected to adopt a:
A. Deflated (contracted) position because the intrapleural pressure is more negative than normal
R. Deflated position because the intrapleural pressure is higher than normal
C. llyperintlated (expanded) position because the intrapleural pressure is more negative than normal
U. Hyperintlated position because the intrapleural pressure is higher than normal
E. I lyperintlated position because the intrapulmonary pressure is higher than normal

Page 10 of 27

e `A= VIA Exam Paper November 2007

Questions 33 - 35

A 70 year old woman slips and falls in the supermarket. On admission to hospital, the resident notes
her left lower limb is externally rotated. Subsequent X-ray reveals a fractured neck of the femur.
A.
B.
C.
D.

G.
H.

Acetabular labrum
Branches of the trochanteric
anastomosis
Behaviour due to cause of disability
Femoral and sciatic nerves
Femoral artery
Femoral nerve
Femur
Gluteus maximus
Gluteus medius and minims
Greater trochanter

K.
L.

I lamstrings
Mucus (iliopsoas)

M.
N.
0.

L5 spinal nerve
Obturator nerve
Pubic symphysis
Rectus femur's
Sciatic nerve
Superior gluteal artery
Superior gluteal nerve

Q.
R.
S.

Which of the above is the most likely option?

Question 33
Union of the fracture is commonly compromised by damage to which structure?
Question 34
The most likely cause of the external rotation is spasm of which structure?
Question 35
At discharge following treatment and a short stay in hospital she complains to her doctor about her
awkward gait. He observes her and notes a positive Trendelenberg sign. The most likely cause of this
is weakness of which structure?
Question 36
n.
B.
C.
D.
E.

Axillary nerve
C5 spinal nerve
Deltoid
Infraspinatus
Medial pectoral nerve

F.
G.
II.
I.
J.

Radial nerve
Rotator cuff
Supraspinatus
'Frapczius
Ulnar nerve

A 70 year old woman is coining down the stairs in her unit when she falls on the bottom step. She
places her arm out straight to soften the fall. She immediately experiences acute pain and is unable to
move her shoulder. On X-ray, the shoulder joint is Ibund to be dislocated.
Before reducing her dislocation, the orthopaedic registrar expresses concern about brachial plexus
damage. He examines cutaneous sensation over deltoid and notes reduced sensation over a small area.
Which structure listed above is likely to have been damaged?

P.ige I I nf 27

Year VIA Exam Paper Notemher 2007

A patient presents with a laceration to the wrist.

Questions 37-38
A.
B.

Deep hranch of ulnar nerve

Median nerve
Recurrent branch of median nerve
Recurrent branch of ulna nerve

E.
F.
G.

Superficial branch of radial nerve

Superficial fibular nerve
Ulnae nerve

Question 37
A patient presents with laceration A. On examination, he complains he cannot make a fist and has loss
of sensation on the medial side of the hand and medial 1 1/2 fingers. Winch nerve is most likely to be
damaged?
Question 38
A patient presents with laceration 13. On examination, he has loss of sensation on the lateral side of the
palm and lateral digits and cannot oppose the thumb to the fingers. Which nerve is most likely to be
damaged'?

Question 39
As you are about to perform a lumbar puncture on a young adult. your supervisor questions the level at
which the spinal cord ends.
Select the most appropriate response from the list below.
A.
B.

E.

L1/2
L3
L3/4
L5
LS'S l

F.
G.
II.

I.

SI
S2

S3/4
S4/5

rage 12 of 27

e Year VIA Exam Paper Noxember 2007

Question 40

The following table summarises a study of ophthahnoscopy performed by physicians specializing in

the care of diabetics. Opluhahnoscopy was also performed by an experienced ophthalmologist, who
was unaware of the results of the examination undertaken by the physicians. Assume that examination
by the ophthalmologist is the "gold standard" for a diagnosis of diabetic retinopathy.

Ophthalmologists
Retinopathy

Normal
retina

I otal

I_

21

24

26

33

47

Retinopathy
Physicians

Normal retina
Total

14

The above study suggests that the expected probahili y of diabetic retinopathy following an apparently
normal examination by a physician specializing in diabetes would be approximately:
2/26 = 8%
2/14 = 14%
9/33 = 27%
9/21 = 43%
E. 24/26 92%
Question 41
A 58 year old female patient presents with tiredness, shortness of breath and nausea. The attending
registrar orders an ECG. The finding of ST segment elevation in leads II. III and a VF would be
consistent with:
Acute inferior myocardial infarction
Acute anterior myocardial infarction
Past anterior myocardial infarction
Past lateral myocard ia infarction
Past posterior myocardial infarction
Past inferior myocardial infarction
Question 42
A.
B.

E.

Acute inflammation
Acute myocardial infarction
Apoptosis
Atheroma
Chronic Inflammation

F.
G.

n.

Collateral circulation
Embolism
Myocardial ischaemia
Pulnionary embolism
Venous thrombosis

The following case history involves a change in the environment of a tissue. From the list above, select
the most appropriate answer.
A 75 year old man has a history of tightness in the chest after physical exertion such as walking up
stairs. The tightness has been getting worse for several weeks. Ile now presents with severe chest pain
for 6 hours. He is admitted to hospital. and dies three hours later. What is the most likely cause of
death?
Page 13 of 27

4 Year VIA Exam Paper November 2007

Question 43 - 46

F.

Brachial artery
Deep branch of radial nerve
Median nerve
Midshaft of humerus
Prolunda brachii artery
Radial artery

.1.
K.

Radial nerve
Sup:1116a( branch of radial nerve
Supracondylar region of humerus
Sur g ical neck of humerus
Ulnar nerve

Homer is a 12 year old g ang member who has stolen a rival gang's doughnuts. They grab him and
force his arm up behind his back until a loud crack is heard. Subsequently. he is unable to extend his
wrist. I lomer's x-ray is shown

Question 43
The structure injured leadin g to the lack of wrist extension is?
Question 44
What other smicture is also at risk?

Page 14 of 27

S' Year VIA Exam Paper Ntnember 2007

Following treatment for the above injury, I lomer fell on his way out of Emergency, went hack in, and
was x-rayed again. The x-ray is shown.

Question 45
The most important structure in immediate danger is?
Question 46
What other structure is also in danger?
Question 47
A 42 year old with a history of heavy drinking of alcohol presents following a tooth extraction with
prolonged bleeding (>30 minutes) that doesn't stop after packing.
Choose the most likely diagnosis.
A.
B.

E.

Disseminated intravascular coagulopathy

Haemophilia A
I lenoch - Schonlein Purpura
Idiopathic Thrornbocytopenia Purpura
Liver disease

F.
G.
H.
1.

Page IS of 27

Localised trauma
Vitamin K deficiency
Von Vi I lebrand's Disease
Wartiirin usage

4' Year VIA lixml Paper November 2007

Question 48 - 50
For each of the follow ing patients with menstrual disturbances, select the most likely diagnosis. Each
option may be used once, more than once, or not at all.

C.
I).
E.
F.

Adenomyosis
Asherman's syndrome
Bicomuate uterus
Cervical polyp
lindometrial carcinoma
Ilndometriosis
Endometriotic cyst
Fibroid

I lypothyroidism
Menopause
Pelvic Inflammatory Disease
L. Polycystic ovary syndrome
M. Pregnancy
N. Primary dysmenorrhoea
0. Tubo-ovarian mass

Question 48
I lelen, a 48 year old woman. has noted a gradual change in her periods with her cycle now down to 3
weekly and the loss of so much blood that there is leaking despite the use of a tampon and very thick
pads. On examination, her 13MI is 37 and her uterus is bulky. tier vaginal ultrasound reveals an
endometrial thickness of 15mm.
Question 49
A 25 year old presents with irregular periods. A history reveals that her mother also had irregular
periods. Also like her mother, she is obese.
Question 511
Jennifer, a 32-year-old woman. presented Mr a repeat prescription of her oral contraceptive pill. I ler
last period was 2 weeks ago though her last 3 periods had been very light. She also noted new
symptoms of stretch marks on her abdomen and nocturia. On examination, she had a mass arising from
her pelvis measuring I berm from her symphysis pubis.
Questions 51 - 52
For each of the following clinical presentations, select the most likely cause to explain the symptoms
outlined.
A.
B.

E.

Anal Fissure
Anal Fistula
External Haemorrhoids
Perianal Warts
Proctalgia Fugax

F.
G.
H.
J.

Prolapsing Ilacmorrhoids
Rectal Cancer
Rectal intussusception with solitary rectal ulcer
Rectal Prolapse
Villous adenoma (Polyps) of the rectum

Question 51
A 53 year old women complains of the recent onset of loose bowel actions over the last three months,
though she has been regular most of her life. She notices blood mixed with the stools when she goes
to flush the toilet and the feeling as though she has not completed a bowel action. There is no pain. tier
mother died at the age of 75 in Croatia and the doctors told the family that she had cancer in the liver,
though she had no surgery.
Question 52
An 80 year old veteran presents with intermittent rectal bleeding and mucous discharge from the
rectum. There has also been a recent change in bowel habits, with a tendency towards diarrhoea. He
had been prescribed digoxin for myocardial failure and the recent tests by the family doctors revealed
that the potassium level was well below the normal range and he was commenced on potassium
replacement.
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4" Year VIA Exam Paper Nocember 2037

Question 53
Localized pain and involuntary guarding is due to:
Distension of the visceral peritoneum
Irritation of somatic nerves running between external oblique and internal oblique
Local irritation of the parietal peritoneum
Parasympathetic hyperstimulation
E. Spasm of rectus abdominus in anticipation of painful stimuli
Question 54
A 5 year old boy has developed a swollen right knee and is febrile 3 days after a fall in the schoolyard.
On examination. the right knee is swollen and red. The child screams with pain when the affected
joint is moved.
Which one of the t011owing would be the most likely diagnosis?
Fracture of the tibial plateau
Ilacmarthrosis of the knee joint
Juvenile chronic arthritis (JCA)
Septic arthritis
E. Osteosarcoma
Question 55
A previously well 2 year old girl presents with a 3 week history of bruising, lethargy and irritability.
On examination, she has numerous bruises of ditlerein ages and has an easily palpable li cr and
spleen. A lull blood examination reveals:
lib
MCV
WCC
Platelets

76g/1
79f1
1.3 x 109/L
26x 109/L

(105 - I 40WI)
(70-86 tl)
(5-I5 x 1 09/L)
( 150-450 x109/L)

Which one of the fbIlowing investigations would he the most appropriate next step?
Bone marrow aspirate and trephine
Serum iron, iron binding capacity and transferrin saturation
Scrum anti-nuclear factor and anti-DS DNA antibodies
Serum Factor VIM and von Willebrand factor levels
E. Serum anti-platelet antibodies

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44 Year VIA Exam Paeci No.elaher 2007

Questions 56 - 58
From the followin g list of mood disorders, select the most appropriate alternative (Or the scenario
described.
A.
B.
C.
).

G.

Adjustment disorder with depressed

mood
Agitated depression
Agoraphobia with panic attacks
Agoraphobia without panic attacks
Bipolar affective disorder depressive
episode
Delirium
Generalised anxiety disorder

H.

Major depressive episode

I.
.1.
K.
I..

Major depressive episode with psychotic features

Mixed affective disorder
Normal grief reaction
Organic affective disorder
Post psychotic depression
Sehizotiffective disorder

Question 56
A 55 year old man is feeling guilty about his wife's death. It was more than a ycar ago but he still
asked himself why he hadn't done more for her when she was clearly suffering from cancer. His
friends are supportive and concerned for him. They are concerned that he isn't eating properly and
keep dropping food around and trying to get him out of the home. He doesn't particularly want to go
and, in any case, his clothes don't lit any more.
Question 57
Alex. a 69 year old retired pharmacist. had seemed to be his usual self at the golf club last w.eekend.
Attending you today without an appointment, he is very agitated and confused, continually talking
about how he can't find his golf buggy.
Question 58
A female patient is not happy in herself. She can't lose weight no matter how little she eats and feels
slow and lethargic. I ler favourite necklace no longer tits. She avoids going out because she is self
conscious about her appearance. It was bad enough that a friend mistook her for her husband on the
telephone the other day.
Questions 59 - 60

Ateleetasis

Deep venous thrombosis

Drug reaction
I). Epidural abscess

Pelvic abscess
Peritonitis

G.
H.
1.
K.

Pneumonia
Thrombophlebitis
Upper respiratory tract infection
Urinary tract infection
Wound infection

For each of the following patients with fever, select the most likely cause from the options above.
Question 59
A 75 year old man. who smokes 20 cigarettes per day and has ischaemic heart disease, has undergone
an anterior resection for carcinoma of the rectum. On the first post-operative day. he has a temperamre
of 3g.2C.
Question 60
The same 75 year old man feels generally unwell starting day 7 post operatively. He has lower
abdominal pain and some distension, is anorexic, develops swinging fevers to 39C, and has IL coli on
blood culture.

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e Year VIA Exam Paper Noember 2007

Question 61
A 65 year old kornan complains of neck pain after lifting heavy groceries. She has pain in the neck
radiating down the right arm to the middle linger. You find weakness of elbow extension. mild
weakness of wrist extension and adduction and mild weakness of finger extension. The triceps reflex is
absent.
What is the likely site of the lesion?
Brachial plexus
C5 root
C6 root
C7 root
Cs root
Cerebral hemisphere
Median nerve, "carpal tunnel"
Multiple cervical nerve roots
Radial nerve in the radial groove
Uttar nerve
Question 62
A 45 year old woman with poorly controlled hypertension presents in the Emergency Department with
a stroke. Further testing after admission shows a marked fluent dysphasia, jargon speech, and a right
homonymous hemianopi a.
Select the most likely anatomical location for the underlying event.
Cerebellar
Frontal cortex
Medullary
Occipital cortex
Parietal cortex
Pontine
Suheortical
Temporo-parietal cortex
Quest ion 63

Bert, a 69 year old retired timber worker, developed intense spinning sensations, sweating and
vomiting as he turned over in bed. Over the next two weeks, he had several similar attacks when
getting out of bed or on sudden turning. lie had been deaf for many years. He had fully recovered from
a myocardial infarction two months earlier.
Select the most likely diagnosis.
Acoustic neuronia
Benign paroxysmal positional vertigo
Cardiac arrhythmia
Cerebellar tumour
Hydrocephalus
Meniere's disease
Migraine
Multiple sclerosis
Venebrobasilar transient ischaemic attacks
Vestibular neuronitis

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6' Year VIA Fxam Papa Nuxember 2007

Question 64
15 year old known diabetic presented with acute onset of shaking of his left hand when he tried to use
it and unsteadiness of his gait of 2 days duration. His examination showed dysarthric speech. Ile had
difficult y performing finger to nose testing on the left but was normal on the right. His gait was ataxic.
Select the most likely type.
Postural tremor
Cerebellar tremor
Parkinsonian tremor
Ruhral tremor
Orthostatic tremor
Neuropathic tremor
Question 65

A 25 year old woman complains of a three-day history of right-sided weakness. Two years ago she had
subacute impairment of vi sion in the left eye that cleared up over three weeks.
Select the most likely diagnosis.
13rain abscess
Hemorrhagic stroke, cerebral hemorrhage
C'. Ischemic stroke, cardiac embolism
D. lschemic stroke, carotid stenosis
1.eft brainstem glioma
I'. Left frontal lobe tumor
G. Low grade glioma
II. Metastatic brain tumor
I. Multiple sclerosis
I. Subdural hematoma
Question 66
Sodium valproate or ethosuximide
Sodium valproate
No treatment advised
Carbamatepine or sodium valproate
E. Phenytoin, carbamazepine or sodium valproate
F. Folic acid
A man aged 26 had his first tonic clonic seizure in his sleep. He had been drinking heavily during the
day and had been sleep-deprived for several days. There was no family history of epilepsy.
Examination was normal. His MRI scan and EEG were normal. Which of the above treatment options
do you advise?
Question 67
A 23-year old NA man complains of episodes of right-sided throbbing headache associated with nausea
and vomiting, photophobia and phonophohia. What is the most likely diagnosis?
Migraine without aura ("common migraine")
Acute muscle tension type headache
Temporal artcritis
Subaraelmoid hemorrhage
E. Intracerebral hemorrhage

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e Year VIA Exam Pam November 2007

Question 68
A 17 year old boy, who is usually very lit because he plays basketball, is taken to the Emergency
Department by his mother, after coining home from school early because of severe right-sided chest
pain. It came on suddenly while he was sitting in class, and is worse with each breath. He has felt
slightly short of breath, but otherwise feels well. What is the most likely diagnosis?
Angina pectoris
Aortic dissection
Costochondritis
Myocardial infarction
Oesophageal retlux
Oesophageal spasm
Peptic ulcer
Pleurisy
Pneumonia
Pncumothorax
Pulmonary embolism
Post-herpetic neuralgia
Panic attack disorder
Referred pain from T4 radiculopathy
Question 69 -70
For each of the following patients, select the most likely diagnosis.
Anaemia
Asthma
Diabetic keto-acidosis
Exacerbation of COPD
Non-cardiogenic pulmonary oedema
Panic attack
Pneumonia
Pneurnothorax
Pulmonary canholus
Tuberculous pleural effusion
K. Valvular heart disease
Question 69

A 62 y ear old male with a 40-pack year history of cigarette smoking presents to the Emergency
Department with acute worsening of dyspnoea. He speaks in short sentences and on examination has
mild central cyanosis, a regular pulse rate of 120/min and a respiratory rate of 40/min. His trachea is
slightly displaced to the right, he has diminished breath sounds on the right side and coarse posterior
bilateral expiratory crackles more pronounced at the left side.
Question 70
A 35 year old marathon runner presents to the emergency room w ith acute onset of shortness of breath
7 days after undergoing anhroscopy to his left knee for chronic pain. He required a Zimmer splint
post-operatively for 2 days. The patient has mild central cyanosis and a pulse rate of 110 per minute.
Examination of the chest was unremarkable.

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J ` Year VIA Exam Paper November 2007

Question 71
Adrian. a 5 year old boy, is taken to the GP because of a recurrent cough. He and his sister have
recent]) had colds. His cough, which is dry in nature, has got worse since starting school 2 months
ago. His parents have noted that he coughs during the night. His teacher has commented that he gets
coughing spasms whilst running in the playground but these resolve quite quickly on resting.
On examination, he is of normal height although overweight (BMI 28). On auscultation. his breath
sounds arc vesicular with no added sounds. What is the most likely diagnosis?
Asthma
Bronchiolitis
Bronchitis
Congestive heart failure
Croup
Cystic fibrosis
Epiglottitis
Pneumonia
I. Psychogenic cough
T. Tonsillitis
Questions 72 - 73
A 40 year old male attends his GP for his 'annual check-up . . Ile has recently seen television
advertisements promoting prostate cancer awareness. ITe wonders whether he should have a prostate
specific antigen (PSA) test for prostate cancer.
You wonder; how accurate is the PSA test in diagnosing prostate cancer compared to the gold standard
investigation? 'You perform a MFDLINE search and retrieve a randomised controlled trial (RCT) that
reports the following test information in a cohort of 40 year old men.

PSA test
Positive (+)
Negative (-)

Prostate cancer
Absent (-)
Present (+)
25
25
75
75
100
100

50
150
200

QtRnaion 72

using the data from the table above, what is the sensitivity and specificity of the NA test in this
cohort of men?
Sensitivity = 50%, Specificity = 50%
Sensitivity = 75%, Specificity = 25%
Sensitivity 100%, Specificity = 50%
Sensitivity = 25%, Specificity = 75%
E. Sensitivity 75%, Specificity 75%
Question 73
There has been some debate within the medical community as to whether selenium has a protective
benefit against prostate cancer. You perlbrm a MEDLINE search and identify a randomised controlled
trial (R(T). Critically appraising the article you identify that once randomised. patients were able to
decipher whether they were consuming the selenium or placebo supplements. This introduces what
form of bias to the study?
Performance bias
Selection bias
Detection bias
Attrition bias
E. Recall bias
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4' Year VIA Baal Paper November 2007

Questions 74 - 75
Ms RT is a 21 year old student who is a 'pack a day' cigarette smoker and has a history of childhood
bronchitis, chest tightness, wheezing and shortness of breath. Recently, she was at nightclub and
suffered a severe asthma attack. She has been searching the Internet to identify whether her smoking
increased her risk of developing asthma. She brings to you an article which recruited 500 university
students, 250 of who were smokers and 250 of who were non-smokers, and followed them for 10
years. It identified that the risk of developing asthma was higher in participants with a history of
smoking compared to non-smokers (RR=1.80; 95%Cl: 1.67-1.93).
Question 74
What type of design best represents the above mentioned study?
Case-control study
Systematic review with a meta-analysis
Cohort study
Randomised controlled trial
E. Cross-sectional study
Question 75
Select the statement that best describes the results cited in the above example (RR=I .80; 95%Cl: 1.671.90);
The difference between developing asthma in smokers versus non-smokers is 20%. This is a
significant difference
The risk of developing asthma is increased by 20% in participants with a history of smoking,
compared to those without a history of smoking. This is a statistically significant difference
Of 2 participants that have a history of smoking. at least I will develop asthma
If this study were repeated several times, there is a 5% chance that the 'true' chance for
developing asthma due to smoking would be between 67% and 93%
E. The risk of developing asthma is increased by 80% in participants with a history of smoking,
compared to those without a history of smoking. This is a statistically significant increase in
risk
Question 76
Miranda is a 14 year old girl who is brought to see you by her mother. She seems very unwell with a
history 3 weeks ago of an upper respiratory tract infection followed in the last week by weight loss,
urinary frequency, irritability and confusion. On examination, she looks very unwell being agitated,
tachypnoeic and confused. Her heart rate is 120/min, respiratory rate is 26, blood pressure is 100/70
and temperature is 35.1 tympanic. Her lips and oral mucosa are dry.
Select the most appropriate working diagnosis.
Lower lobe pneumonia
Upper respiratory tract infection
Chronic obstructive airways disease
Cardiac failure
Depression
Urinary tract infection
G. Infectious mononucleosis
II. Pharyngitis
Sleep apnoea
Hypothyroidism
Diabetes mellitus
Head injury
M. Dementia

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4' Yeau VIA Exam l'agra Nueinbrr 2007

Questions 77 - 78
For each diabetic patient presenting to your general practice with pain in the foot, select the most
likely diagnosis.
Achilles tendonitis
Bunion
Callus
Chilblains
Corn
Flat feet
Foreign body
Gout
I. Ingrown toenail

J. Metatarsalgia
K.. Morton's neuroma
Osteoarthritis
Osteold osteoma
N. Peripheral ne ropathy
0. Peripheral vascular disease
Plantar faselitis
Plantar wart
K. Stress fracture of metatarsal

Question 77
Irena Raloski, aged 61, has had Type 2 diabetes for 3 years. This has not been well controlled and her
MA lc last month was 9% (ideal c 7%). She presents with 3 months of worsening burning pain in
both feet. There arc no obvious aggravating or relieving factors. On examination, she looks tired and
lethargic. Pulse is 78 and regular, BP 150/95, temperature 36.5 and weight 95kg.
Question 78
Yvonne Yan. aged 66, has had Type 2 diabetes for 14 years and has smoked 20 cigarettes per day
since she was I8 years old. She presents with a few weeks of pain in her left foot. The pain wakes her
at night and is relieved by getting out of bed.
Question 79
A 58 year old man with longstanding diabetes mellitus treated with Metformin and Rosiglitazonc
attended for routine annual review two months ago. Ills urinary album secretion on spot urine testing
was elevated. There were no other significant findings on examination or routine testing and he was
commenced on Perindopril. lie has since had a persistent cough and this is to be ceased.
Select the most appropriate new medication to add to his management.
Atenolol
Calcium supplements
Captopril
Codeine phosphate
Diltiazem
Felodipine
G. halapainide
II. Irbesartan
Phenoxymethylpenici II in
Prazosin
Prednisolone
Propranolol

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4'. Year VIA Exam Paper November 2007

Question 80
A 76 year old woman with type 2 diabetes mellitus complains of some months of bilateral heaviness
and numbness in her legs and feet, with occasional sharp shooting pains into her toes lasting only
seconds. On examination, she has a tentative, slightly high-stepping gait, is Romberg positive, has
markedly reduced touch and pin prick sensation over her lower legs and feet, normal heel-shin test and
foot tapping and otherwise normal neurological examination.
Select the most likely neurological condition explaining her presentation.
Acoustic neuroma
Autonomic neuropathy
Bilateral conical CVAs
Cerebellar infarction
Cerebellar stroke
Demyclinating disease
Lateral arnyotrophic sclerosis
Park inson's Disease
1. Peripheral mononeuropathy
Peripheral polyneuropathy
Spinal cord tumour
L. Spinal cord infarction
Question 81
A 55 year old man is found to have a perforatin g ulcer of the sole of his right foot on routine Diabetes
review. He denies any discomfort. On examination, the ulcer is circular, punched out in appearance, 4
mm in diameter and situated over the head of the first metatarsal. It is surrounded by a rim of
thickened skin and there are no adjacent inflammatory changes. Pedal Doppler ratios are (L) = 0.96.
(R)= 0.98
Select the most likely underlying cause of his leg ulcer.
Artefactual
Arterial
Basal cell carcinoma
Decuhitus ulcer
Intravenous drug abuse
Malnutrition
Marjolin's ulcer
Neuropathic
Osteomyelitis
Scleroderma
Sickle Cell Disease
Squarnous cell carcinoma
Traumatic
Tropical
0. Tubercular
P. Venous

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4' Year VIA Exam Paper November 2007

Question 82
A 61 year old gentleman with known diabetes mellitus presents with a painful, small, penetrating ulcer
over the lateral malleolus of the left leg which has been present for about 6 weeks. Sensory
examination of the lower limbs is unremarkable. Doppler ratios are (L) = 0.50, (R) = 0.55. His diabetes
is otherwise under good control.
Select the most appropriate initial management of their leg ulcer, in addition to cessation of smoking.
A. Elevate leg when at rest, non-adherent dressing, compression bandage, keep mobile
13. Non-adhereni dressing, mild compression bandage, keep mobile
Non-adherent dressing, duplex ultrasound scan of lower limb and referral to vascular surgeon
Non-adherent dressing and keep mobile
Appropriate oral antibiotic and non-adherent dressing
Non-adherent dressing and vitamin C
G. Non-adherent dressing, followed by skin graft
Fl. Non-adherent dressing. duplex ultrasound scan of lower limb and vasodilatory medication
I. Non-adherent dressing. mild compression bandage, keep mobile, add ACEI to medication
QUESTIONS 83 87 MUST IW ANSWERED ON THE SAQ ANSWER SHEH'S PROVIDED.
ANSW ER kCII QUESTION ON A SEPARATE ANSW ER SII VET
Question 83
3 marks
Briefly discuss in what circumstances a person under the age of 18 may provide a valid legal consent
to medical treatment.
DO NOT SPEND ANY MORE IIIAN 3 MINUTES ON THIS ANSWER.
Question 84

4 marks
13rietly explain the role of the "person responsible" under the Victorian Guardianship Act 1986 (as
amended)
b) Identify 4 individuals listed in the category of "person responsible" under the Victorian
Guardianship Act 1986 (as amended)
Question 85
2 marks

In an end of life decision-making context, identify those persons who arc legally entitled to refuse
medical treatment on behalf of an incompetent patient
Question 86
5 marks
Read the following scenario and answer the question below.
Dr Carol Newson works in a large general practice in Brunswick in inner Melbourne. Part of the
clinic's responsibility is to provide GP services to the nearby Stewart Lodge, a boarding house for
people with mild mental and cognitive disability.
Janice knows Dr Carol well. One of the stall' of Stewart Lodge takes her to the clinic because she is
coughing. On examining her lungs, Dr Carol notices a large raised mole on her back. which looks like
a melanoma. She tries to explain to Janice that she needs to make another appointment for an excision.
'but Janice says that the mole doesn't hurt, and that she is afraid of needles..lanice's parents are dead.
and she has lost contact with her siblings. The staff member of Stewart Lodge makes an appointment
for her, but Janice does not return.
What ethical issues are raised by the incident described?
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Year VIA Exam Paper November 2007

Question 87
5 marks
A second year student was in a group of 8 students observing a ward round in a general surgical ward.
One of the patients was an elderly man who was recoverin g from surgery to remove a large skin cancer
from his arm. The clinical tutor told the students to perform an abdominal examination on this patient
(one of the students' tasks on this clinical visit was to practice abdominal examination), and went over
to the patient's bed and said "Mr A ... these students arc going to come over and have a look at your
tummy. They need to learn how to do that. It won't hurt." Mr A looked a bit confused, but did not
respond, and just nodded. When the first student approached to do the examination, and started to talk
to Mr A, it became clear that he did not understand English very well at all. The student hesitated, and
looked to the clinical tutor tbr guidance. She said, "Yes, go ahead. it's fine". So one after another, each
student performed the examination on Mr A. Our student was number 5 in line, and by this stage, Mr
A was changing in his demeanour from resigned passive compliance, to showing signs of
unwillingness- turning awa y . muttering to himscIf(in a language which no-one understood), and so on.

What ethical issues arc raised by this incident? What would you do in student number five's position?
NOW GO BACK AND CHECK YOUR ANSWERS. CHECK THAT YOU HAVE PUT YOUR
NAME AND STUDENT ID ON 'Ell MCO ANSWER GRIDS AND STUDENT II) ONLY ON
TILE SAO ANSWER SHEETS.

Page 27 of 27