2019

ST GEORGE – SUTHERLAND
BPT NETWORK

TRIAL EXAM

24th January 2019

Candidate Name:________________________
INSTRUCTIONS TO CANDIDATES

Time allowed: 3 hours

Number of questions: 100

Question type: 96 single best answer MCQs (best of 5 options)

4 extended matching MCQs

The first 40-45 questions in this trial exam are Paper A (Medical Sciences) style questions, so you should
aim to work through these relatively quickly, aiming to finish the first 45 questions in 45-60 minutes. The
remaining questions are Paper B (Clinical Applications) type questions, which are a bit longer and take
more time to read. You should leave 2 hours for these questions. There are 4 extended matching MCQs
at the end.

Use only lead pencil to complete the answer sheet

Your name and candidate number MUST be entered clearly on the answer sheet

Write your name on the front of the paper so that we can return the paper to you with answer booklet next
week.

The answer sheet will be read by an optical page reader so please make sure you fill in the response boxes
on the answer sheet with care. Keep the answer sheet clean and avoid making any marks outside of the
response boxes. If you decide to change an answer, make sure you erase the old response completely.

Good luck!

2
QUESTION 1

A patient with acute fulminant myocarditis is most likely to present with which one of the
following symptoms?

A. Dyspnoea
B. Palpitations
C. Chest pain
D. Syncope

QUESTION 2

Which one of the following asbestos related lung diseases requires the most significant
and prolonged exposure to asbestos?

A. Pleural plaques

B. Asbestosis

C. Lung cancer

D. Mesothelioma

QUESTION 3

Which one of the following statements about primary hyperparathyroidism is TRUE?

A. Fatigue, depression, and impaired memory are infrequent complications.

B. In most asymptomatic patients, the serum and urine biochemical profiles remain
stable for years.
C. Patients with normocalcaemic hyperparathyroidism usually do not develop skeletal
complications.
D. Caused by hyperplasia of parathyroid glands in 50% of cases

QUESTION 4

The absorption of which one of the following is affected by resection of the terminal
ileum?

A. Calcium
B. Bile salts
C. Folate
D. Phosphate
3
QUESTION 5

Which of the following is an absolute contraindication to peritoneal dialysis?

A. Intra-abdominal adhesions.
B. Dementia.
C. Living in a rural location.
D. Diabetes.

QUESTION 6

Which one of the following is a manifestation of systemic lupus erythematosus?

A. Haemolytic anaemia
B. Leucocytosis
C. Lymphocytosis
D. Thrombocytosis

QUESTION 7

Concerning anthracycline toxicity, which one of the following statements is correct?

A. Occurs in less than 1% of patients receiving anthracycline chemotherapy

B. Occurs within the first month after the induction of the chemotherapy
C. Responds poorly to medical therapy
D. Often asymptomatic

QUESTION 8

What is the main reason for lifelong follow up of Hodgkin survivors?

A. Monitoring for relapse

B. Monitoring for psychosocial wellbeing as part of a cancer survivorship program
C. Monitoring for secondary malignancies
D. Early intervention and referral for allogeneic transplantation in the event of
Hodgkin relapse

4
QUESTION 9

Which of the following toxins produced by microorganisms causes harm to the infected
human by persistent activation of adenylate cyclase?

A. Bacillus anthracis toxin

B. Clostridium tetani toxin
C. Staphylococcal toxin
D. Vibrio cholera toxin

QUESTION 10
Which one of the following statements about essential tremor is TRUE?

A. Its prevalence is higher among women than among men.

B. It does not occur in childhood.
C. The age at onset has a bimodal distribution.
D. Essential tremor is often familial with a typically autosomal recessive pattern

QUESTION 11

In which one of the following clinical situations should antiphospholipid-antibody testing

be performed?

A. Foetal loss before 10 weeks of gestation

B. Venous thrombosis in a young patient
C. Severe thrombocytopenia
D. Unexplained shortening of the activated partial-thromboplastin time

QUESTION 12

Dementia is LEAST likely to be a feature in which one of the following conditions?

A. Huntington’s disease
B. Progressive supranuclear palsy
C. Motor neuron disease
D. Multiple sclerosis

5
QUESTION 13

What is the primary aim of Phase 1 clinical trials in the drug development process?

A. Determine a safe dose for further clinical studies and to study the
pharmacokinetics of the drug
B. Demonstrate that the drug is effective
C. Evaluate the safety and efficacy of the drug
D. Determine a safe dose and obtain the first evidence of efficacy

QUESTION 14

Which one of the following drugs is MOST likely to inhibit the metabolism of warfarin?

A. Oral contraceptive pill

B. Omeprazole
C. Rifampicin
D. Amlodipine

QUESTION 15

If sickle cell anaemia has a frequency of 1 in 4,900 in a community, what is the carrier
rate in the same community?

A. 1 in 70
B. 1 in 10
C. 1 in 60
D. 1 in 35

QUESTION 16

Which one of the following statements about hypertrophic cardiomyopathy (HCM) is true?

A. It is inherited in an autosomal recessive pattern.

B. Life expectancy is substantially reduced in most affected patients.
C. The phenotypic expression and clinical course of the condition are highly variable.
D. Rare disease seen in 1 patient/100,000 population.

6
QUESTION 17

Which of the following statements best describes the functional residual capacity (FRC) of
the lung?

A. FRC is the volume of gas at which the tendency of the lungs to collapse and the
tendency of the chest wall to expand are equal
B. FRC is the volume of gas remaining in the lungs after the maximal expiratory effort
C. Unilateral paralysis of the diaphragm will halve the FRC
D. In patients with decreased lung volume, the addition of continuous positive airway
pressure (CPAP) increases tidal volume but not the FRC

QUESTION 18

Ustekinumab is a drug recently been approved on the PBS for the management of
moderate to severe Crohn’s disease. Which of the following best describes its
mechanism of action?

A. Blocks the α4β7 integrin

B. Blocks MAdCAM-1
C. Blocks IL-23 & IL 12
D. Blocks the α4 sub-unit of integrins

QUESTION 19

What is the risk of developing superimposed pre-eclampsia on essential hypertension in

pregnancy?

A. 5%

B. 15%

C. 25%

D. 50%

7
QUESTION 20

Which of the following is true in regards to BRAF mutated metastatic melanoma?

A. The MAPK pathway is activated in almost all cutaneous melanomas

B. BRAF mutations are present in less than 20% of all patients with metastatic
melanoma
C. BRAF mutations are more common in patients with chronic sun damage
D. BRAF mutated melanomas are associated with a worse prognosis

QUESTION 21

Which one of the following is a Gram-positive organism that exists intracellularly?

A. Listeria monocytogenes
B. Staphylococcus aureus
C. Clostridium perfringens
D. Streptococcus pyogenes

QUESTION 22

Which of the following statements about dapagliflozin (a new diabetes drug) is TRUE?

A. It slows gastric emptying and suppresses glucagon secretion

B. Gastrointestinal side effects can limit use
C. Can be used safely in diabetic patients in ESRF
D. Increases the risk of genitourinary infections

QUESTION 23

Monoclonal antibodies against Calcitonin gene related peptide (CGRP) have proven
efficacy in which of the following?

A. Chronic Migraine Prevention

B. Parathyroid hormone suppression
C. Chronic neuralgic pain
D. Suppression of tumour angiogenesis

8
QUESTION 24

Which one of the following findings has not been associated with scurvy?

A. Bruising.

B. Orthostatic hypotension.

C. Peripheral neuropathy.

D. Macrocytic Anaemia.

QUESTION 25

Which one of the following statements about post-transplantation lymphoproliferative

disease (PTLD) is TRUE?

A. In adults, the incidence of PTLD is not influenced by the type of organ transplanted
B. PTLD has not been reported to develop later than 15 years after transplantation.
C. PTLD is characterized by a high incidence of extranodal involvement.
D. Recipients of renal transplants have the highest incidence of PTLD

QUESTION 26

The Australian Institute of Health Welfare regularly releases data on life expectancy and
death rates in Australia. The 2016 data was released in June 2018. The leading cause of
death for Australian women in 2016 was

A. Coronary artery disease

B. Dementia and Alzheimer’s disease
C. Cerebrovascular disease
D. Lung cancer

QUESTION 27
Which one of the following statements about human immunodeficiency virus (HIV)-
associated kidney disease is true?

A. The incidence of this disease is not changed by the use of antiviral therapy
B. The kidney is not a reservoir for HIV nucleic acids
C. The typical histological findings on renal biopsy are focal glomerulosclerosis
D. Is caused by direct infection of the kidney by the HIV virus

9
QUESTION 28

Which of the following rheumatologic agents is safe in pregnancy?

A. Methotrexate
B. Leflunomide
C. Hydroxychloroquine
D. Mycophenolate mofetil

QUESTION 29

A new treatment is being tested for efficacy. A randomised controlled trial is performed
and gives the following results:

Number of patients Number of deaths

New treatment 1000 6
Control 1000 8

The number needed to treat to prevent one death is:

A. 500
B. 300
C. 2
D. 1.3

QUESTION 30

Which one of the following statements about idiopathic pulmonary fibrosis is TRUE?

A. It is known to recur after lung transplantation

B. Guidelines recommend the use of prednisone in combination with azathioprine and
oral N-acetylcystiene
C. There are no available therapies that slow disease progression
D. Its incidence is increasing

QUESTION 31

Which of the following chemotherapeutic drugs prolongs the QT interval?

A. Cisplatin
B. Paclitaxel
C. Vorinostat
D. Cyclophosphamide
10
QUESTION 32

Which of the following is a direct thrombin inhibitor?

A. Rivaroxaban
B. Dabigatran
C. Apixaban
D. Edoxaban

QUESTION 33

Which of the following is NOT a cardiac complication related to radiation therapy?

A. Aortic dissection
B. Cardiomyopathy
C. Pericardial disease
D. Conduction defects

QUESTION 34

Which one of the following is the strongest stimulator of gastrin secretion?

A. Glucagon
B. Vasoactive inhibitory peptide (VIP)
C. Adrenaline
D. Calcitonin

QUESTION 35

A drug has a volume of distribution of 40 litres. To rapidly achieve a plasma

concentration of 10mg/L what intravenous loading dose should be administered?

A. 0.25mg
B. 0.4mg
C. 4mg
D. 400mg

11
QUESTION 36

In patients with Chronic Kidney Disease which of these is a feature increased risk of rapid
progression?

A. Blood pressure on 24h ambulatory monitoring of 125/75mmHg

B. >1.5g of proteinuria in 24h
C. Serum calcium level <2.2mmol/L
D. Low serum Vitamin D level.

QUESTION 37

The pedigree for a rare genetic disease is shown below:

The most likely mode of inheritance is:

A. X-linked
B. Autosomal dominant
C. Autosomal recessive
D. Mitochondrial

QUESTION 38

Which one of the following physiological changes commonly occurs with non-invasive
ventilation in a patient with respiratory failure and chronic obstructive pulmonary disease?

A. Alveolar recruitment improving oxygenation

B. Reduced left ventricular preload
C. Reduced airway resistance
D. Reduced bronchial secretions

12
QUESTION 39

Which one of the following hormones increases appetite?

A. Glucagon
B. Leptin
C. Glucagon-like peptide 1
D. Ghrelin

QUESTION 40

Conventional needle electromyography (EMG) is UNLIKELY to be diagnostically useful in

which of the following conditions?

A. Inflammatory myopathy
B. Cervical radiculopathy
C. Peripheral neuropathy
D. Myasthenia gravis

QUESTION 41

Which one of the following patients should have a Coronary Artery Calcium Score?

A. Asymptomatic 75 year old male about to undergo surgery for a total hip
replacement
B. Asymptomatic 65 year old male with a 10 year history of diabetes who wants to
know his risk of a heart attack
C. Asymptomatic 60-year-old man with hypertension and a positive family history of
CAD who is considering commencing statin therapy.
D. Asymptomatic 60 year old male with peripheral vascular disease about to undergo
femoral-popliteal bypass

13
QUESTION 42

A 55 yo man has a 12mm sessile tubulovillous adenoma removed from his colon on
screening colonoscopy after a positive FOBT test on the National Bowel Cancer
Screening Program. The bowel preparation for the colonoscopy was adequate. If he
remains asymptomatic, when should he have his next polyp surveillance colonoscopy?

A. 1 year
B. 3 years
C. 5 years
D. 10 years

QUESTION 43

Which one of the following statements about acute pyelonephritis in adults is TRUE?

A. All available studies show that bacteraemia occurs in less than 10% of cases.
B. Half of affected patients do not have bladder symptoms.
C. With appropriate care, resolution of clinical manifestations may require up to 5
days.
D. Fever is seen in >95% of patients.

QUESTION 44

Which one of the following statements about the p53 protein is TRUE?

A. P53 functions by directly repairing DNA molecules

B. Activation of p53 results in DNA mutation
C. Activation of p53 leads to arrest in the G1 phase of the cell cycle
D. P53 protein is an oncogene that is inactivated by cell hypoxia

QUESTION 45

A 55 yo man presents with undergoes a CXR as part of a life insurance medical

assessment. He is a non-smoker and does not have any symptoms. His CXR is shown
below. A CT was then performed and is also shown. His lung functions tests show FEV1
85% predicted, FVC 86% predicted and a FEV1/FVC ratio of 79%.

14
The next investigation to perform is:

A. ACE level
B. Bronchoscopy
C. EBUS biopsy
D. VATS biopsy

QUESTION 46

A 35-year-old man presents with acute onset ataxia, left homonymous hemianopia,
gazed evoked nystagmus, skew deviation and slurred speech. The syndrome that this
likely represents is:

A. Wallenberg’s syndrome
B. Claude midbrain syndrome
C. Top of the basilar syndrome
D. Bendedikt midbrain syndrome

QUESTION 47

A 35 yo woman presents with a 3-day history of headaches and vomiting. She was
diagnosed gastro-oesophageal reflux disease 12 months ago and Raynaud’s
phenomenon 2 years ago.

On examination her blood pressure is elevated at 225/145 mmHg, her pulse is 80/min.
She has changes of sclerodactyly affecting her fingers, dorsum of hands and has
evidence of thickened, tight skin over the anterior chest wall.

Relevant investigations are shown below

Hb 110 g/L
WCC 8.5 x 109/L
Platelets 75 x 109/L
Blood film Schistocytes, low platelets

15
Urea 10 mmol/L
Creatinine 140 umol/L (eGFR 42 ml/min)
U/A: Protein ++, blood and other markers all –ve

Which of the following is the most appropriate treatment?

A. Captopril
B. Sodium nitroprusside
C. Pulse methylprednisolone
D. Cyclophosphamide

QUESTION 48

A new screening test for colon cancer, which involves stool testing of DNA for oncogenes
is being developed. Which of the following is the best measure of how successful the
screening test is?

A. The death rates of patients directly due to the colon cancer

B. The median survival of the patients following treatment of the colon cancer
C. The disease-free survival following treatment of colon cancer
D. How many early cancers are detected

QUESTION 49

A 72-year-old man with shortness of breath undergoes right heart catheterisation to

further investigate for the cause of his symptoms. A Swann Ganz catheter is floated from
the right jugular vein to the pulmonary artery where a balloon is inflated and pulmonary
capillary wedge pressures are obtained. The following results were obtained.

Right atrium - mean 20mmHg (normal 3-5mmHg)

Right ventricle - systolic 55mmHg (15-30mmHg), diastolic 5mmHg (1-7mmHg)
Pulmonary artery - systolic 55mmHg (15-30mmHg), mean 39mmHg (9-19mmHg)
Pulmonary capillary wedge - mean 9mmHg (4-12mmHg)

Which of the following statements is most reasonable based on the results of the right
heart catheterisation?

A. The cause of his shortness of breath is likely to be severe mitral regurgitation

B. The results indicate a significant pulmonary arteriovenous shunt
C. A trial of a phosphodiesterase inhibitor is indicated at this time
D. Left ventricular dysfunction is very unlikely to be the cause of his shortness of
breath

16
QUESTION 50

A drug with a narrow therapeutic index is highly protein bound and cleared by oxidative
metabolism followed by urinary excretion of the inactive metabolite.

The type of drug interaction most likely to cause problems with toxicity of this drug is:

A. Displacement of the drug from plasma proteins

B. Inhibition of cytochrome P450 enzymes
C. Inhibition of glucuronyltransferase
D. Reduction in glomerular filtration rate

QUESTION 51

A 55 yo woman presents with arthralgia, fatigue and a rash over her lower limbs as
shown in the picture below. She has chronic hepatitis C and is infected with the genotype
1 HCV virus. She does not take any other medications. Her neurological examination is
normal including power, reflexes and sensation. There is no evidence of arthritis. Her
blood tests show normal FBC, EUCs. Her urinalysis is negative from blood or protein.
Her bilirubin, INR and albumin are normal. Her LFTs show ALT 128 U/L and AST 95 U/L
with normal GGT and ALP.

What is the most appropriate treatment?

A. Oral prednisone
B. Sofosbuvir and ledipasvir
C. Pulse methylprednisolone
D. Rituximab
17
QUESTION 52

A 38 yo woman presents with a bilateral macular rash over her legs and reports easy
bruising over the last few months. She has also noticed gum bleeding every time she
brushes her teeth. She is otherwise well and does not have any other medical problems.
She had one normal pregnancy and gave birth to a healthy baby girl 3 years ago.

On examination she has petechiae over both lower limbs and bruising on her abdominal
wall and arm. There is no evidence of lymphadenopathy.

Her bloods tests show Hb 130 g/L, WCC 7.5 x 109/L and platelet count 22 x 109/L. Her
MCV and MCH are normal. Blood film shows large and giant platelets. There are no
schistocytes and there is no clumping of platelets.

Which of the following tests should be performed?

A. Bone marrow biopsy

B. HIV serology
C. Anti-platelet antibodies
D. Lupus anticoagulant and anti-cardiolipin antibodies

QUESTION 53

What is the yearly rate of falls for community-dwelling people aged over 65 years?

A. 1 in 3
B. 1 in 5
C. 1 in 10
D. 1 in 20

QUESTION 54

An X-linked recessive disorder has an incidence in males of 1 in 100. What would be the
expected incidence of affected homozygous females?

A. 1 in 1000
B. 1 in 4000
C. 1 in 10,000
D. 1 in 40,000

18
QUESTION 55

20-year-old female presents with headache and abdominal discomfort. She had tonsillitis
one month ago. BP is 148/100mmHg. Creatinine is 174umol/L and urine contains protein
2+ and blood 2+. ASOT and Anti-DNase B are pending. Which test result would be most
consistent with Post-Streptococcal glomerulonephritis?

A. Low C3, normal C4

B. Elevated IgA
C. Positive double stranded DNA anti-bodies (dsDNA)
D. Eosinophilia

QUESTION 56

A 39-year-old woman presents with 3 months of amenorrhea and lethargy. She is not
taking medications. On examination she appears well and no major abnormality is
detected. Investigations reveal LH = 22 mU/L (2-10 mU/L), FSH = 31 mU/L (2-8 mU/L),
oestradiol 80 pmol/L (180-500 pmol/L), prolactin = 820 mU/L (<520 mU/L). The MOST
LIKELY cause of her amenorrhea is:

A. Pregnancy
B. Prolactinoma
C. Non-secretory pituitary adenoma
D. Premature menopause

QUESTION 57

A 20-year-old woman with a history of injecting drug use was treated for latent syphilis in
August 2015 with two doses of benzathine penicillin one week apart. She did not attend
for follow-up in 2016 and her syphilis serology has been repeated as below. She is well
with no abnormalities on examination including neurological, cardiovascular and ocular
examination. Her human immunodeficiency virus (HIV) antibody test is negative.

Serial serological testing is as follows:

Date VDRL
titre TPHA FTA-Abs

01/08/2015 1:64 reactive reactive

04/11/2015 1:32 reactive reactive
01/02/2016 1:16 reactive reactive
03/05/2018 1:32 reactive reactive

19
Which is the most appropriate next step in management of this woman?

A. A second course of treatment with penicillin.

B. Lumbar puncture.
C. Anti-cardiolipin antibody estimation
D. Repeat VDRL in three months.

QUESTION 58

A 75-year-old woman with moderate Alzheimer’s disease, who lives alone with extensive
unpaid support from her neighbour over many years, presents with a fall and fractured
right neck of femur. She is delirious in the emergency department. She has no enduring
guardian appointed. Who is the appropriate person to consent for surgery to repair her
hip?

A. The neighbour
B. The guardianship tribunal
C. The daughter who lives in London and has not been to Australia for 5 years, and
has not been in regular contact with her mother.
D. Her solicitor who is the executor of her will

QUESTION 59

A 38 yo lady presents to her GP with a cough after starting ACE inhibitor for
hypertension. Her GP ceases the ACEI and organises a CT chest, which shows a 6mm
pulmonary nodule in the left lower lobe as shown below. She is a lifelong non-smoker
and denies previous exposure to asbestos. She doesn’t have any underlying lung
disease and is otherwise well. There is no family history of lung cancer. Her cough has
now resolved and she is completely asymptomatic. Her physical examination is normal.

20
Which of the following is the most appropriate next step in her management?

A. CT guided biopsy of the lung lesion

B. Bronchoscopy
C. CT abdomen/pelvis
D. Repeat CT chest in 12 months

QUESTION 60

A 75-year-old woman has the following molecular pathology performed on her resected
right-sided stage III colorectal cancer.
MLH1: loss of staining
PMS2: loss of staining
MSH2: normal staining
MSH6: normal staining
BRAF V600E: Positive
k-ras mutation testing: wild-type

Which of the following is TRUE?

A. She has Lynch syndrome

B. If she required systemic therapy for relapsed disease then a monoclonal antibody
EGFR antagonist would be appropriate
C. If she required systemic therapy for relapsed disease then checkpoint inhibitor
immunotherapy such as a PD1 antagonist would be ineffective
D. Adjuvant chemotherapy is more likely to provide a benefit for this woman than a
similar patient with a MSI-L adenocarcinoma

QUESTION 61

Which of the following is NOT involved in the Alternative Complement Pathway?

A. Surfaces of bacteria, viruses, other microbes

B. IgA immune complexes

C. C3 Nephritic factor

D. Ficolins 1-3

21
QUESTION 62

56-year-old man on maintenance azathioprine for ANCA-positive vasculitis develops

severe tophaceous gout. He has had a week of colchicine and steroids with some effect
however he requires a long-term agent to control his symptoms. Which of the following
would be your first line in this gentleman.

A. Allopurinol
B. Probenacid
C. Indomethacin
D. Raspuricase

QUESTION 63

A study was conducted which examined the efficacy of a new drug for patients with
STEMIs. A double-blind, randomised, placebo-controlled trial found that the 30-day
mortality associated with this condition was 7.5% for the control group and 5% for the
treatment group. Which of the following is correct?

Absolute risk Relative risk

reduction reduction
A 2.5% 5%
B 5% 33%
C 50% 5%
D 2.5% 33%

QUESTION 64

An 86 year-old retired Pastor presents with 6-month history of unsteady gait with
recurrent falls. He has started using walking cane in the last 6 months. He also reports
intermittent tingling in lower limbs for many years. Background history is significant for
coronary artery disease with multiple coronary stents. He is an ex-smoker, and had
previous significant alcohol consumption in his younger days. He was started on
amiodarone for atrial fibrillation following a Holter monitor.

On examination, there is weakness of left dorsiflexion, with dampened reflexes

throughout. His Romberg’s test is positive, and there is a distal to proximal gradient loss
of temperature and vibration sense. His CSF examination reveals protein 0.51 g/L,
glucose 4 mmol/L, white cell 2. His nerve conduction studies are shown below.

22
What is the most likely diagnosis to explain his recent presentation?

A. Amiodarone-related peripheral neuropathy

B. Alcohol related peripheral neuropathy
C. Multifocal motor neuropathy with conduction block
D. Chronic inflammatory demyelinating polyneuropathy

QUESTION 65

An 85-year-old man presents with fatigue. He has a history of hypertension and

osteoarthritis. He is otherwise asymptomatic. He denies constipation, change in weight,
anxiety, tremor, palpitations or heat/cold intolerance. His blood pressure is 145/90 and
pulse 80 / min and regular. His thyroid is not palpable on examination. The rest of his
examination is normal including reflexes.

His bloods show normal FBC, EUC, and LFTs. His TFTs are as follows:

TSH: 6.1 mIU/L (normal 0.27 – 4.0)

Free T4 16.8 pmol/L (normal 12 – 22)

23
Which of the following is the most appropriate management?

A. Start levothyroxine
B. Repeat TSH and free T4
C. Thyroid ultrasound
D. Measure total triiodothyronine (T3) level

QUESTION 66

A 28-year-old woman presents with chronic anaemia, which was first noticed by a general
practitioner 6 years ago on routine blood tests. She is otherwise well. She has heavy
menstrual periods but eats good amounts of red meat and green leafy vegetables. Her
aunt had anaemia of unknown cause. Her blood tests show

Hb 102 g/L, WCC 5 x 109/L, platelets 230 x 109/L

MCV 67 (80-100)
Iron studies: Fe 25 umol/L, Sats 20%, transferrin 60 umol/L, ferritin 200 mcg/L

Haemoglobin electrophoresis shows a normal pattern on migration of haemoglobin A and

normal levels of Haemoglobin A2 and Haemoglobin F.

What is the most likely diagnosis?

A. α–thalassaemia trait
B. Iron deficiency
C. β– thalassaemia minor
D. Anaemia of chronic disease

QUESTION 67

A 50yo woman with metastatic cervical cancer has developed renal failure secondary to
ureteric obstruction. She usually takes MS Contin (long acting morphine) 90mg BD with
Ordine (morphine liquid) 3mls of 10mg /ml for breakthrough. She has been requiring
three breakthrough doses per day. Her opioid is changed to hydromorphone as this is
safer in renal failure. The best estimate of the equivalent oral 4-hourly dose is

A. 4mg
B. 18mg
C. 6mg
D. 9mg

24
QUESTION 68

A 42yo male collapses and has a cardiac arrest in the shopping centre. There has been
no preceding chest pain, palpitations. His rhythm strip shows VF arrest. He has no past
medical history. He was resuscitated successfully. Which of the following is the MOST
LIKELY cause?

A. Hypertrophic obstructive cardiomyopathy

B. Long QT syndrome
C. Ischaemic heart disease
D. Brugada syndrome

QUESTION 69
A 41 yo woman presents with a 12-month history of intermittent lower abdominal pain,
bloating and constipation. The pain is worse just before a bowel movement and often
improves after defaecation. She opens her bowels once every 2-3 days, which has been
the pattern of her bowel movements all her adult life. She finds that avoiding gluten
improves the bloating but has not made a difference to the pain or constipation. She
takes Benefibre with marginal benefit. She has a family history of bowel cancer with her
grandfather being diagnosed with the disease at the age of 70. Her maternal aunt has
coeliac disease. Her physical examination, serum calcium and TSH are normal. Her
AXR is shown below.

25
Which of the following is the most appropriate management?

A. Colonoscopy
B. Gastroscopy and small bowel biopsies
C. Serum anti- tissue transglutaminase antibodies (Anti-TTG Ab)
D. 1000mL of Glycoprep (polyethylene glycol)

QUESTION 70

A 48-year-old man presents via the emergency department with an STEMI. The cath-lab
is activated and he gets taken for primary PCI. This is done via a femoral artery approach
with minimal contrast used. He has normal renal function immediately following the
procedure and good restoration of coronary blood flow. Prior to discharge on day 3 his
renal function is rechecked and he has a creatinine of 600umol/L and new foot pain.
What is the most likely cause for this acute deterioration in renal function?

A. Contrast induced nephropathy

B. LV dysfunction secondary to STEMI with cardio-renal failure
C. Atheroembolic renal disease
D. Acute gout

QUESTION 71

A 60 yo lady is admitted with an infective exacerbation of COPD. She is now on day 5 of

oral prednisone and antibiotics. She has a 45-pack year history of smoking but ceased 3
years ago. Her FEV1 before this admission was 48% predicted. Although, her cough
and dyspnoea have improved, she remains dyspnoeic on exertion. On examination, her
oxygen saturations are 91% on room air. There is mild expiratory wheeze and reduced
breath sounds bilaterally. Her lungs are otherwise clear. Which of the following is the
most appropriate next step in management?

A. Another 5 days of oral prednisone

B. Sleep study
C. Low flow oxygen 2L/min
D. Pulmonary rehabilitation

QUESTION 72

A new drug is being investigated in a bioavailability study. The area under the plasma
concentration versus time curve (AUC) after an intravenous dose of 20mg is 100mg/mL.
The AUC after an oral dose of 50mg is 200mg/mL.

26
The oral bioavailability of the drug is

A. 60%
B. 70%
C. 80%
D. 90%

QUESTION 73

With regard to the treatment of behavioural disturbance related to dementia,

cholinesterase inhibitors are most likely to improve which one of the following?

A. Punching
B. Apathy
C. Wandering
D. Screaming

QUESTION 74

A 30-year-old woman presents to the emergency department with acute shortness of

breath on exertion. She notes a childhood history of successfully treated Ewing’s
sarcoma. She also had childhood asthma. On examination she has a BMI of 35. She
appears breathless at rest. She is tachycardic and has bibasal crackles. The best
differential diagnosis is:

A. Recurrence of her asthma

B. Sleep apnoea with pulmonary hypertension
C. Cardiac failure
D. Pulmonary fibrosis

QUESTION 75

A young man presents with a febrile illness, sore throat and cervical lymphadenitis for 7
days. His history indicates he is at risk for HIV. The most sensitive test for diagnosis of
acute HIV is:

A. HIV RNA viral load

B. Combined HIV p24 antigen/HIV antibody test
C. HIV western blot antibody test
D. CD4 subset estimation.

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QUESTION 76

A 65-year-old man is admitted for reversal of his stoma after previous bowel resection. He
has a background of Type 2 diabetes on oral hypoglycaemic agents. His surgery is
unfortunately delayed due to emergency cases resulting in prolonged fasting by the
patient. Before his surgery he is found to be unwell and bloods are taken. He is noted to
have a severely reduced serum bicarbonate level of <10mmol/L despite there being no
diarrhoea. He is acidotic with a normal lactate. His blood ketone levels are elevated
to >5. His Blood glucose however is 4.2 mmol/L. Which of the following drugs is the
precipitator of his euglycaemic ketoacidosis?

A. Gliclazide
B. Metformin
C. Pioglitazone
D. Dapagliflozin

QUESTION 77

A 76-year-old man presents with non-ischaemic cardiomyopathy, NYHA Class III

symptoms and a LV ejection fraction of 25%. His medications include ramipril, carvedilol,
spironolactone, frusemide and allopurinol. He has a prophylactic implanted cardioverter
defibrillator that has never discharged a shock.

On examination, his heart rate is 71bpm, blood pressure is 105/75mmHg, central venous
pressure is mildly elevated at 6cm above the sternal notch, there is mild pitting oedema to
the ankles and there are occasional crackles bibasally. Saturations are 96% on room air
after mobilising from the waiting area.

What is the next appropriate step in his management?

A) Add ivabridine
B) Add valsartan/sacubitril
C) Cease ramipril and add valsartan/sacubitril
D) Make no changes to current medications

QUESTION 78

A 54-year-old truck driver presents to hospital with severe respiratory failure requiring
ventilation on a background of increasing peripheral oedema, rash and arthralgias over
the past 6 weeks. He has no significant past medical history and is an ex-smoker. His
urinalysis shows blood +++ and protein +++. His blood pressure is 150/90 mmHg.

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His metacarpophalangeal joints are swollen without warmth or erythema. CXR is shows
diffuse bilateral infiltrates.

ANA is negative, complement levels normal and rheumatoid factor negative. His ANCA is
positive with a perinuclear pattern. Skin biopsy of the rash shows non-granulomatous
necrotizing small vessel vasculitis without immune complexes on immunofluorescence.

Which of the following is the most likely diagnosis?

A. IgA vasculitis
B. Granulomatosis with polyangiitis
C. Thromboangiitis obliterans
D. Microscopic polyangiitis

QUESTION 79

A 78 yo man presents with bright red rectal bleeding. He describes opening his bowel
earlier in the afternoon, passing soft brown stool and two to three cup fulls of bright red
blood. He has been a little off his food and describes fevers and chills over the last week.

His background history includes hypertension, hypercholesterolaemia, peripheral

vascular disease for which he is on aspirin and an abdominal aortic aneurysm treated by
endovascular stent 2 years ago.

On examination, his BP is 110/80 mmHg, pulse 110/min regular with a temperature of

38.1 °C. There is mild epigastric tenderness but his abdomen is soft without any
evidence of peritonism. His blood tests how Hb 90 g/L and white cell count of 15 x 109/L
with a normal platelet count.

What is the next most appropriate investigation?

A. CT scan with contrast

B. Gastroscopy
C. Colonoscopy
D. Admission to hospital for monitoring

QUESTION 80

A 50-year-old woman has a long history of Rheumatoid Arthritis with intermittent use of
DMARDS. She has been poorly compliant with treatment. She now presents with
progressive proteinuria with a 24hour urine protein >4g and hyaline casts. Her serum
albumin is 30 g/L. Her BP is 120/80 mmHg. Her serum creatinine is 60 umol/L.

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What is the most likely cause of her proteinuria?

A. Secondary Amyloidosis
B. Membranous Nephropathy
C. IgA Glomerulonephritis
D. Focal Segmental Glomerulosclerosis

QUESTION 81

Which one of the following combinations represents a compatible transfusion?

A. Blood group B positive receiving A positive packed cells

B. Blood group B positive receiving AB positive packed cells
C. Blood group B positive receiving O positive plasma
D. Blood group B positive receiving AB negative plasma

QUESTION 82

Reduced levels of C3 and/or C4 is typical in all of the following EXCEPT?

A. Post-infectious GN

B. Infective endocarditis

C. IgA nephropathy

D. Cryoglobulinaemia

QUESTION 83

A 52-year-old woman presents with status epilepticus preceded by 3 weeks of

behavioural abnormalities. She is afebrile. Her CSF study shows 100 lymphocytes,
protein of 700 mg/L and glucose of 3 mg/L. Her infective screen is negative. Her MRI
brain reveals bilateral temporal hyperintensities. The limbic encephalitis
antibody/antibodies that this presentation most closely resembles is:

A. Gamma amino butyric acid (GABA) receptor antibodies

B. N methyl D aspartate (NMDA) receptor antibody
C. Leucine rich glioma inactivated protein 1 (LGI-1) receptor antibody
D. Contactin associated protein 2 (CASPR 2) receptor antibody

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QUESTION 84

A 35 yo lady presents with worsening asthma. She has a history of allergic rhinitis and
asthma since childhood. Her asthma has been previously well controlled. However, over
the last 12 months, her symptoms have deteriorated with worsening wheeze, productive
cough with dark sputum. She states she is adherent to asthma medications and her
inhaler technique has been assessed. She was recently admitted with pneumonia and
initially responded to antibiotics and a tapering course of steroids. However, her
symptoms have recurred over the last fortnight after completion of steroid wean. On
examination, she has diffuse wheeze and reduced air entry in the right upper zone. Her
blood tests show a total WCC of 11.2 x 109/L and a differential, which shows an elevated
eosinophil count. Her repeat CXR is shown below.

What is the most likely diagnosis?

A. Cystic fibrosis
B. Allergic bronchopulmonary aspergillosis
C. Eosinophilic granulomatosis with polyangiitis
D. Hypersensitivity pneumonitis

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QUESTION 85

A 42 yo woman presents with a 3-week history of intermittent upper abdominal pain,

increasing abdominal distension and fatigue. She is otherwise well and does not take
any medications apart from the oral contraceptive pill.

On examination, he temperature is 37.2, BP 110/75, pulse 100/min, sats 95% on RA and

RR 14/min. She has tender hepatomegaly of 20cm and shifting dullness. She is not
jaundice and there are no peripheral stigmata of chronic liver disease.

Her bloods show

Hb 120 g/L Bilirubin 21 umol/L (5-22)

WCC 12 x 109/L ALP 150 U/L (38 – 126)
Platelets 350 x 109/L GGT 80 U/L (0-55)
AST 190 U/L (< 35)
ALT 280 U/L (< 35)
Albumin 38 g/L (35 – 55)

Liver US shows thrombosis of all three hepatic veins with hepatomegaly and ascites.

Which of the following abnormalities is most likely to explain this condition?

A. A positive antiphospholipid antibody

B. Factor V Leiden
C. Increased thrombotic risk of OCP
D. JAK 2 mutation

QUESTION 86

A 30-year-old healthy lady has two brothers with Haemophilia A, which is an X-linked
recessive disorder. Her parents are both healthy. She is recently married (non-
consanguineous) and seeks counseling regarding the risk to her future children. The risk
is closest to which of the following options?

A. 1 in 4 for a son and close to zero for a daughter

B. 1 in 2 for both sons and daughters
C. 1 in 2 for a son and close to zero for a daughter
D. 1 in 4 for both sons and daughters

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QUESTION 87

A 45-year-old woman with known metastatic colorectal cancer is admitted with a

complete large bowel obstruction with crampy abdominal pain, abdominal distension and
vomiting. Her bowels have not opened for 4 days. Her regular medications include coloxyl
and senna 2 tablets nocte, Oxycontin 10mg BD and metoclopramide 10mg TDS. Which
of the following drugs is LEAST LIKELY to be used to control the symptoms of her bowel
obstruction?

A. Morphine
B. Methylnaltrexone
C. Ranitidine
D. Dexamethasone

QUESTION 88

A 74-year-old female presents with palpitations and a narrow complex tachycardia.

Continuous rhythm recording was performed whilst a drug was administered.

Which of the following statements are correct?

A. A trans-oesophageal echocardiogram should have been performed to clear the left

atrial appendage of thrombus prior to attempting to terminate the tachycardia.
B. The drug should be re-administered.
C. Myocardial ischaemia is likely present and may be due to the elevated ventricular
rates, underlying coronary artery disease or the drug’s acute effect.
D. The drug terminated the arrhythmia but only momentarily.

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QUESTION 89

A 56 yo lady presents with epigastric discomfort, nausea and 5kg of weight loss over 3
months. She has been on rabeprazole 20mg once daily without any improvement in
symptoms. Her physical examination is normal apart from very mild epigastric
tenderness.

She undergoes a gastroscopy, which shows nodular raised areas throughout the antrum.
Biopsies from this area show mucosa-associated lymphoid tissue (MALT) lymphoma.
There is also Helicobacter pylori gastritis present in the biopsies and her CLO test is
positive. A CT scan shows a slightly thickened gastric antrum but no evidence of
lymphadenopathy or other abnormalities.

Which of the following is the most appropriate management?

A. Distal gastrectomy
B. 2 weeks of clarithromycin, amoxycillin and rabeprazole
C. Rituximab based chemotherapy
D. Chemotherapy without rituximab

QUESTION 90

A 66-year-old man with metastatic adenocarcinoma of the lung is admitted to acute

hospital for management of pain, nausea and constipation. He is currently ECOG 2. Over
the course of the admission, his wife reports that he is hallucinating and is confused at
times. His observations are within normal limits as is his clinical examination. His bloods
show Cr 92umol/L, Corrected Calcium 2.57mmol/L, WCC 8.65x109 /L and CRP 16mg/L.
His chest X-ray is unchanged. He continues on oral medications for pain and nausea,
which are currently well controlled. The most appropriate management for his symptom of
delirium is

A. Oral Risperidone twice a day

B. Ceasing opioids
C. Ensure glasses and hearing aids are in place, promote natural sleep, reorientation
and education for family.
D. Commencement of intravenous antibiotics

QUESTION 91

A patient is brought to the emergency department by ambulance, confused with clouded

consciousness. Arterial blood gases, labelled as taken breathing room air, reveal the
following:

PaO2 65 mmHg
PaCO2 63 mmHg
pH 7.22
Base excess -2 mmol/L
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Which of the following clinical scenarios is most consistent with these results?

A. A patient with an acute exacerbation of COPD who was given high flow
supplemental oxygen in the ambulance

B. A patient with a narcotic drug overdose

C. Results indicate that the patient must have been breathing supplemental oxygen
when the gases were taken

D. A patient with advancing idiopathic pulmonary fibrosis and pneumonia

QUESTION 92

While similar in their action beta-blockers, now referred to as BABAs (Beta adrenergic
blocking agents), are not all metabolised equally. Which of the following is the correct
pairing.

A. Atenolol – hepatic excretion

B. Metoprolol – CYP2D6
C. Carvedilol – renal excretion
D. Bisoprolol – CYP450

QUESTION 93

A 76-year-old man presents with hypotension, fever and oliguria. His presenting
creatinine is 280umol/L. He is fluid resuscitated and treated with broad-spectrum
antibiotics. He grows G-rods in his blood cultures in keeping with E-coli. His ACE inhibitor
and diuretics are withheld and there is a slow but gradual improvement in renal function.
By day 3 of his admission his renal function had normalised to a creatinine of 80umol/L.
On the day of discharge 10 days following presentation he reports not passing much
urine and his creatinine is now 700umol/L. A renal biopsy is performed demonstrating
acute tubular injury. What is the most likely cause of this?

A. Ongoing sepsis
B. Contrast given in ED on arrival for CT abdomen
C. Gentamycin toxicity
D. Ongoing effects of long acting ACE inhibitor

35
QUESTION 94

A 65 yo man presents with sudden onset headache, left sided retro-orbital pain and
diplopia which as been present for the last 10 hours. He denies any other medical
problems apart from root canal surgery a week ago. His only medication is Panadeine
Forte.

On examination, his blood pressure is 150/90, pulse 90/min and respiratory rate 15
breaths/min. He is febrile 38.8 C. He has a left proptosis. His left pupil is dilated with a
°

sluggish response to light. He has left-sided cranial nerve palsies affecting CN III, IV and
VI. The rest of his examination is normal. His blood tests show elevated WCC, CRP and
ESR.

What is the most likely diagnosis?

A. Vertebral artery dissection

B. Carotid artery dissection
C. HSV encephalitis
D. Cavernous sinus thrombosis

QUESTION 95

A 62 yo man presents with a 2-month history of an increasingly sore throat. He is

referred to an ENT surgeon and undergoes nasopharyngeal endoscopy. The scope
reveals a large mass arising from the right base of tongue, with biopsies confirming SCC.
CT scan of the neck shows a large lesion that extends across the midline and invades the
extrinsic muscle of the tongue on the right and abuts and encases the right carotid artery.
There are multiple enlarged cervical lymph nodes on both sides of the neck, with the
largest measuring 4cm. There is no evidence of disease elsewhere. He has a history of
heavy alcohol intake, hypertension and chronic renal impairment with a creatinine of 170
umol/L (eGFR 35-40 ml/min)

What is the most appropriate treatment?

A. Radiotherapy alone
B. Combination of cisplatin and radiotherapy
C. Combination of cetuximab and radiotherapy
D. Bevacizumab

36
QUESTION 96

A 28 yo woman presents with a known prolactinoma falls pregnant. She is currently 12

weeks gestation. The prolactinoma was diagnosed 3 years ago when she presented with
amenorrhoea. Her prolactin level at diagnosis was 205 ug/L. She was commenced on
bromocriptine with return of menstrual periods. The prolactinoma was 1.5cm at diagnosis
and stable around the same size on last MRI imaging 12 months ago. She ceased
bromocriptine as soon as she found out she was pregnant.

She is currently asymptomatic. She denies headache and her visual fields are normal on
physical examination with confrontation.

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

A. Repeat pituitary MRI

B. Restart bromocriptine
C. Formal visual field testing
D. Check serum prolactin level

EXTENDED MATCHING MCQS

The following 4 questions are extending matching MCQ questions

37
EXTENDED MATCHING MCQS
Questions 97 – 100 are extending matching MCQ questions

The answers to the next four questions need to be selected from the options below.
There is only one correct answer to each question. Please consider all 8 options for each
question and select the correct answer. Please note that an answer option can be
selected more than once during the next four questions (ie. two questions can have the
same answer)

Answer options:

A. Anti ds DNA Ab
B. Anti CCP Ab
C. Anti Scl70 Ab
D. Anti centromere Ab
E. Anti RNA polymerase III Ab
F. Anti U1-RNP Ab
G. Anti Jo-1 Ab
H. Anti Cardiolipin Ab

QUESTION 97

A 40 yo man woman presents with a 6-month history of Raynaud’s phenomenon and

dysphagia. Her fingers have this appearance on examination. An x-ray of her fingers is
also shown below. Which of the following antibodies is most commonly associated with
this disorder?

38
QUESTION 98

A 52 yo man presents with arthralgia and exertional dyspnoea. He has a history of

Raynaud’s phenomenon and has noticed increasing muscle pain and weakness in his
limbs over the last 4 months. Her CK is elevated at 1800 and ANA is positive at 1: 1200.
A picture of his hands and HRCT are shown below. Which antibody is most commonly
associated with this condition?

QUESTION 99

Which of the above autoantibodies is a strong risk factor for scleroderma renal crisis?

QUESTION 100

Which of the above autoantibodies is associated with mixed connective tissue disease?

THE END!! WELL DONE!!!

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