Question No.

1 :

Portal hypertensive gastropathy can result in chronic gastro-intestinal bleeding.

What is the best way to prevent it?

a. Propranolol

b. Omeprazole

c. Antacids

d. Pantoprazole

e. Amlodipine

Correct Answer & Detail

Correct Answer: a. Propranolol

Answer Detail:
Propranolol or nadolol is drug of choice for prevention of
gastrointestinal bleeding in portal hypertensive gastropathy.

None of the other medication help in prevention of bleeding

from gastrointestinal in patients with portal hypertensive
gastropathy.
Question No. 2 :

A 34-year-old male presented for your advice regarding recurrent pilonidal sinus after
surgical treatment performed 4 months ago. What is the most appropriate advice to
the patient to avoid recurrence?

a. Keep plastic bandages on for another 2 months

b. Refer to another GP

c. Review the patient daily for 2 weeks

d. Take advice from hospital director

e. Shave the area and keep it clean

Correct Answer & Detail

Correct Answer: e. Shave the area and keep it clean

Answer Detail:
Pilonidal sinus is a skin condition in the midline of the natal
cleft. A primary pit forms in the midline, caused by a hair
follicle that has become infected, into which loose hairs
enter to create a track or abscess.

Prevention from recurrent pilonidal sinus disease:

1- Keep the area clean and dry.

2- Avoid sitting for a long time on hard surfaces.
3- Remove hair from the area
Question No. 3 :

Which of the following statement regarding obsessive compulsive disorder is

incorrect?

a. It is a form of anxiety disorder

b. Compulsions are purposeful and intentional behaviours

c. Mild OCD is regarded as normal in response to stress

d. Cognitive behaviour therapy is cornerstone of treatment

e. SSRIs are contraindicated

Correct Answer & Detail

Correct Answer: e. SSRIs are contraindicated

Answer Detail:
Obsessive compulsive disorder is a type of anxiety
disorder.Anxiety is associated with obsessive thoughts and
compulsive rituals.
Compulsions are repetitive purposeful and intentional
behaviours conducted in response to an obsession to
prevent a bad outcome for the person.
Mild obsessional or compulsive behaviour can be considered
as normal response to stress.
Optimal management includes a combination of cognitive
behavioral therapy,response and exposure therapy and
SSRIs.
SSRIs (selective serotonin re-uptake inhibitors) are the the
treatment of choice for obsessive compulsive disorder.
Question No. 4 :

A 70-year-old male presented to hospital for evaluation of his ascites in background of

chronic alcoholism. He developed generalized abdominal pain and altered mental
status while in hospital.

What is the most likely diagnosis?

a. Acute bowel obstruction

b. Hepatorenal syndrome

c. Worsening ascites

d. Spontaneous bacterial peritonitis

e. Urinary tract infection

Correct Answer & Detail

Correct Answer: d. Spontaneous bacterial peritonitis

Answer Detail:
This patient has clinical diagnosis of spontaneous bacterial
peritonitis. The diagnosis of spontaneous bacterial peritonitis
should be suspected in any person with ascites who develop
any of the following symptoms:

a. Fever.
b. Altered mental status.
c. Elevated white blood cell count.
d. Abdominal pain or discomfort.

Therefore, it is necessary to have a high degree of clinical

suspicion, and peritoneal taps are important for making the
diagnosis.
Question No. 5 :

A 56-year-old lady presented,feeling tired and generalized weakness for last 3 months.
She is non-smoker and non-alcoholic.
On routine blood work up she was found to have hypercalcemia and elevated serum
PTH level. Serum phosphate was in low normal range and serum alkaline phosphatase
was elevated.Circulating vitamin-D level is also elevated. This patient is a potential
candidate for surgery.
Which one of the following is not an indication for surgery in this patient?

a. Serum calcium is >0.25 mmol/litre above upper limit of normal

b. An episode of life-threatening hypercalcaemia

c. Nephrolithiasis

d. Creatinine clearance less than 60ml/min

e. Headache

Correct Answer & Detail

Correct Answer: e. Headache

Answer Detail:
This patient has developed hypercalcemia secondary to
primary hyperparathyroidism.Most common cause of
primary hyperparathyroidism is parathyroid adenoma.

Surgery is recommended if the patient meets any one of the

following criteria:

1.Serum calcium is more than 0.25 mmol/liter above upper

limit of normal.

2.Any complication of primary hyperparathyroidism like

nephrolithiasis,bone erosions of osteitis fibrosa cystica.

3.An episode of acute primary hyperparathyroidism with life-

threatening hypercalcemia.

4.Significant reduction in creatinine clearance.

5.Reduction in bone mass at any site as determined by bone

densitometry and creatinine clearance less than 60 ml/min.

Headache is a non-specific symptom and is not an indication

for surgery in parathyroid adenoma patients.
Question No. 6 :

An 83-year-old woman is brought in hospital due to increasing confusion over last

few days. She lives alone at her home. CT scan of the head (click on the attachment)
was performed.

What is the most likely diagnosis?

Question Attachments

a. Epidural hematoma

b. Subdural hematoma
 c. Intracerebral haematoma

d. Subarachnoid haemorrhage

e. No evidence of injury noted

Correct Answer & Detail

Correct Answer: a. Epidural hematoma

Answer Detail:
The correct answer is a. CT scan of the head shows epidural
hematoma.

CT scan of the head without contrast is a standard for initial

evaluation of all patients with potential intracranial
trauma/haematoma.

The subdural fluid collection is usually crescentic in shape

and can cross suture lines.

In epidural hematoma, head CT (non-contrast) shows a

biconvex shape density as blood pushes on the brain surface
and blood does not cross suture lines.Here CT scan of head
shows epidural hematoma.
Question No. 7 :

Which of the following is the most common cause of death after burn injury in
Australia?

a. Respiratory failure

b. Cardiac failure

c. Renal failure

d. Delayed wound healing

e. Shock
Correct Answer & Detail

Correct Answer: e. Shock

Answer Detail:
The most common cause of death after burn injury is septic
shock leading to multiple organ failure.Infection leading to
septic shock is the most common complication of burns and
is the major cause of death in burn victims.
Septic shock by definition is about 43 to 54 percent of fluid
loss.Septic shock is best defined by a systolic blood pressure
less than 90 mmHg or a mean arterial pressure less than 65
mmHg after a crystalloid fluid challenge of 30 ml per kg
body weight in a patient with severe sepsis.
Respiratory failure,cardiac failure and renal failure can be
the sequel of septic shock.However non of them is the most
common cause of death in burn patients in isolation.
Question No. 8 :

Which one of the following is not a side effect of long term combined-hormone
replacement therapy (HRT)?

a. Myocardial infarction

b. Reduced cognitive function

c. Deep vein thrombosis

d. Pulmonary embolism

e. Increased risk of bowel cancer

Correct Answer & Detail

Correct Answer: e. Increased risk of bowel cancer
Answer Detail:
Harmful effects of long-term combined hormone
replacement therapy include:

1-Increased risk of acute coronary syndromes.

2-Stroke.

3-Pulmonary embolism.

4-Deep venous thrombosis.

5-Reduced cognitive functions.

Benefits of HRT include decreased osteoporosis and

decreased risk of bowel cancer. So option e is correct
answer.

Risk of bowel cancer is not increased,rather decreased with

long term use of combined hormone replacement therapy.
Question No. 9 :

A 73-year old male presented with left leg swelling and was found to have deep vein
thrombosis in calf as well as in popliteal and femoral veins on Doppler ultrasound.He
had not history of deep vein thrombosis in the past.

What is the best initial treatment?

a. Angioplasty

b. Angiography

c. Warfarin

d. Heparin
 e. Aspirin

Correct Answer & Detail

Correct Answer: d. Heparin

Answer Detail:
The correct answer is d.

All patients with deep vein thrombosis are given

anticoagulants. Initially an injectable heparin
(unfractionated or low molecular weight) is given followed
by warfarin started within 24 to 48 hours.

Inadequate anticoagulation in the first 24 to 48 hours may

increase risk of recurrence or pulmonary embolism.

After starting warfarin, daily INR is tested and heparin is

continued until INR is in therapeutic range (2-3 in this case).

Once INR is in therapeutic range, heparin can be

discontinued and warfarin should be continued for 6
months.Patient should see GP regularly for INR monitoring.
Question No. 10 :

A 75-year-old male developed productive cough, high grade fever and confusion over
last 2 days. Past medical history include Alzheimer's dementia,type 2 diabetes
mellitus and hypertension.

On examination, his temperature is 38.4c,blood pressure is 140/80,respiratory rate is

30/min ,oxygen saturation 93% and heart rate is 120/min. On chest auscultation,
crackles are heard in both lung fields. Chest X-ray shows infiltrates in both lung
fields. Blood tests show mild renal impairment and leukocytosis.

What is the most appropriate treatment?

 a. Ceftriaxone

b. Azithromycin

c. Benzyl pencillin

d. Benzyl pencillin and azithromycin

e. Admit to intensive care unit

Correct Answer & Detail

Correct Answer: d. Benzyl pencillin and azithromycin

Answer Detail:
The correct answer is d.

The severity of community acquired pneumonia is assessed

by CURB-65 score.

The CURB-65 score is an acronym for each of the risk

factors measured. Each risk factor scores one point, for a
maximum score of 5:

- Confusion of new onset.

- Urea greater than 7 mmol/l.
- Respiratory rate of 30 breaths per minute or greater.
- Blood pressure less than 90 mmHg systolic or diastolic
blood pressure 60 mmHg or less.
- Age 65 or older.

This patient has got CURB-65 score of 4 ( confusion, renal

failure, respiratory rate 30/min and age more than 65). If a
patient has CURB-65 score more than 3, an inpatient
treatment for community acquired pneumonia is necessary.

So this patient should be started on empirical therapy for

community acquired pneumonia which include intravenous
benzyl penicillin and azithromycin.
Question No. 11 :

Which of the following organism is the most common cause of urinary tract infections
in children?

a. Proteus mirabilis

b. E.coli

c. Staph aureus

d. Enterobacter

e. Pseudomonas

Correct Answer & Detail

Correct Answer: b. E.coli

Answer Detail:
Between 80 to 90% of urinary tract infections are caused by
E.coli in children.

Other organisms may include Klebsiella pneumonia,Proteus

mirabilis,staphylococci species, pseudomonas and
enterobacters.
Question No. 12 :

A 32-year-old office secretary presents with symptoms of premenstrual syndrome

associated with severe mastalgia.
What is the best treatment?
 a. Mafenamic acid

b. Danazol

c. Spironolactone

d. Bromocriptine

e. Vitamin E

Correct Answer & Detail

Correct Answer: b. Danazol

Answer Detail:
Danazol is the treatment of choice when a patient presents
with signs and symptoms of pre-menstrual syndrome
associated with severe mastalgia or breast pain.

Use danazol 200 mg daily from onset of symptoms to the

onset of menses.

Mafenamic acid is the treatment of choice for premenstrual

syndrome associated with dysmenorrhoea.

Spironolactone is the treatment of choice for premenstrual

syndrome associated with fluid retention.Use daily for three
days before expected onset of symptoms to day one of
menstruation.

There is no evidence to suggest the use of bromocriptine for

premenstrual symptoms.There is very weak evidence to
suggest vitamin E use in PMS.
Question No. 13 :
A 53-year-old Australian man known to have atrial fibrillation is found to occasional
rapid ventricular tachycardia on telemetry monitoring. It is non-sustained and resolves
spontaneously.
There are many such episodes on overnight cardiac monitoring.
Patient is fully conscious with GCS 15/15. His blood pressure is 155/90. No
electrolyte abnormality is found on blood tests and echocardiography is normal.
Which of the following medications would be the most appropriate first line therapy
to prevent further episodes of this cardiac rhythm?

a. Lisinopril

b. Verapamil

c. Bisoprolol

d. Amiodarone

e. Digoxin

Correct Answer & Detail

Correct Answer: d. Amiodarone

Answer Detail:
Amiodarone is drug of choice for management and
prevention of ventricular tachycardia in a conscious patient.

In ventricular tachycardia/fibrillation where a patient loses

consciousness,urgent defibrillation would be required.

All other options are not helpful in this situation and if used
increase the risk of harm to the patient.
Question No. 14 :

A 57-year-old male presents with fever, right upper quadrant pain, hypotension and
tachycardia. On examination, there is right upper quadrant pain.

Blood tests show leukocytosis and mildly elevated bilirubin. You suspect gallbladder
sepsis.

Which of the following is the cause of the septic shock?

 a. Staphylococcus aureus

b. Pseudomonas aeruginosa

c. Enterococcus faecalis

d. Escherichia coli

e. Treponema pallidum

Correct Answer & Detail

Correct Answer: d. Escherichia coli

Answer Detail:
The correct answer is d.

This patient has suspected clinical diagnosis of acute

infective cholecystitis. It is caused by bacteria in about 50-
80% patients with acute cholecystitis.

Acute inflammation of the gallbladder wall usually follows

obstruction of the cystic duct by a stone.

The organisms most frequently isolated by culture of

gallbladder bile in these patients include Escherichia coli,
Klebsiella spp, Streptococcus spp, and Clostridium spp.
Question No. 15 :

All of the following are associated with increased risk of carcinoma cervix except?

a. All women who had been sexually active in past

b. All women who are sexually active now

c. Age more than 25 years at first sexual intercourse

d. Multiple sexual partners

 e. Genital wart virus infection

Correct Answer & Detail

Correct Answer: c. Age more than 25 years at first sexual

intercourse
Answer Detail:
Risk factors for carcinoma of cervix include:
1-All women who are or ever have been sexually active.
2-Early age at first sexual intercourse.
3-Multiple sexual partners.
4-Genital warts virus infection.
5-Cigarette smoking.
Age over 25 at first sexual intercourse decreases the risk of
getting carcinoma cervix.
Question No. 16 :

A 56-year-old female presented with painless left parotid swelling.It has been slowly
increasing in size for last three years.Fine needle biopsy reported it to be pleomorphic
adenoma.What is the best treatment?

a. Superficial parotidectomy

b. Simple enucleation

c. Total parotidectomy

d. Chemotherapy

e. Radiotherapy
Correct Answer & Detail

Correct Answer: a. Superficial parotidectomy

Answer Detail:
Superficial parotidectomy is the treatment of choice for
pleomorphic adenoma arising in the parotid gland.
After simple enucleation,recurrence rate is 20 to 45 percent
while with superficial parotidectomy recurrence rates are
reduced to less than five percent.
Total parotidectomy is more extensive procedure and does
not reduce the risk of recurrence.Also it is associated with
higher rates of facial nerve dysfunction.
Chemotherapy and radiotherapy both are not required as
pleomorphic adenoma is benign tumour.
Question No. 17 :
A 48-year old male with history of hypertension,type II diabetes mellitus and
ischemic heart disease,presented with upper respiratory tract infection.
He was on enalapril,aspirin,metformin and metoprolol.He was prescribed amoxicillin
which helped initially however on 3rd day of therapy,he developed swelling of the
pharynx,oral cavity and difficulty to breath.

What is the most likely cause of the symptoms?

a. Amoxicillin

b. ACE inhibtor

c. Metformin

d. Aspirin

e. Metoprolol

Correct Answer & Detail

Correct Answer: a. Amoxicillin

Answer Detail:
This patient has developed signs and symptoms suggestive
of angioedema.

Angioedema can be caused by amoxicillin and ACE

inhibitors.

However as this patient was already on ACE inhibitor and

there is no possible interaction between amoxicillin and ACE
inhibitors,so amoxicillin is the most likely culprit of these
symptoms.

Amoxicillin can rarely cause immunologic reaction which

include rash (most frequent symptom, usually
maculopapular), erythema, urticaria, contact dermatitis,
fever, anaphylactic shock, angioedema, bronchospasm,
interstitial nephritis, haemolytic anaemia, eosinophilia,
serum sickness-like syndrome, exfoliative dermatitis,
Stevens-Johnson syndrome and toxic epidermal necrolysis.

Neutropenia may be partly immune-mediated.

Question No. 18 :

A 28-year-old female presented at 38 weeks of gestation with labour pains since last 8
hours.
Vaginal examination shows that cervix is 7cm dilated and fully effaced.
On amniotomy,there is greenish vaginal fluid. Cardiotocography shows fetal heart rate
of 140 beats per minute with accelerations and early deceleration. Beat to beat
variability is 5-7 beats with good contractions.
What will be your most appropriate next step in management of this patient?

a. Immediate cesarean section

b. Continuous cardiotocography monitoring for next 24 hours

c. Fetal scalp blood sampling

d. Start oxytocin

e. Immediate assisted vaginal delivery

Correct Answer & Detail

Correct Answer: c. Fetal scalp blood sampling

Answer Detail:
This child is in respiratory distress. Amniotomy showed
greenish fluid which suggest meconium staining.

Meconium stained liquor is one of the signs of the fetal

distress during labour so it should be monitored by
continuous cardiotocography.

If cardiotocography remains normal then the labour may

proceed to spontaneous vaginal delivery.

If there is minor abnormality(early deceleration) on

cardiotocography as in above scenario then the most
appropriate next would be to do fetal scalp blood sampling
to see blood pH and or lactate level.

The decision to do immediate cesarean section or assisted

vaginal delivery depends on the results of fetal scalp blood
sampling and cervical dilation.

Oxycontin will worsen the condition of fetal distress so its

not a suitable next step for this patient.
Question No. 19 :

A 17-year-old male presented with right testicular pain for 2 days. On

examination,scrotum is tender and swollen. Spermatic cord is thickened and one can
go above the lump.

What is the most appropriate next step?

 a. Surgery

b. Ultrasound

c. Urine microscopy and culture

d. Full blood count

e. CT scan

Correct Answer & Detail

Correct Answer: a. Surgery

Answer Detail:
The correct answer is a.

A painful scrotum should be taken seriously.This is because

of the possibility of testicular torsion, which can cause
infarction (death of the testicle by cutting off its blood
supply) in a matter of 4-6 hours.

Physical examination demonstrates a swollen, tender and

firm hemiscrotum with a short and thickened spermatic cord
when testicular torsion is present.

According to Australian guidelines,no person younger than

18-years should be diagnosed as suffering from acute
epididymo-orchitis until the testis has been exposed at
operation and torsion excluded.So option A is correct here.

Role of ultrasound to distinguish between testicular torsion

and epididymo-orchitis is controversial as it can not reliably
detect changes that are diagnostic of an early torsion.
A technetium-99 m scan can differentiate between the two
conditions-in torsion,testis is avascular while it is
hyperaemic in epididymo-orchitis.

Once torsion of testis has been ruled out,full blood

count,urine microscopy and chlamydia antigen detection test
are done to find out the cause of epididymo-orchitis.It can
be treated by antibiotics.
Question No. 20 :

You are requested to assess a 60-year-old man for risk of thromboembolism while he
is due to have his left knee replacement.
Which of the following increases risk of thromboembolism in this patient during his
hospital stay?

a. Cardiac failure

b. Past bowel resection for toxic megacolon

c. Irritable bowel syndrome

d. Stage two kidney disease

e. Transient ischemic attack three years back with full recovery in twenty four hours

Correct Answer & Detail

Correct Answer: a. Cardiac failure

Answer Detail:
Patients on surgical ward are at high risk of
thromboembolism and so are assessed well during
perioperative period.

Cardiac failure is this list is significantly associated with high

risk of venous thromboembolism (VTE) along with
immobilization required for knee replacement.
Past bowel resection for toxic megacolon is not a risk factor
for VTE however acute bowel inflammation does carries risk
of VTE.

Stage two kidney disease and irritable bowel syndrome has

little association with VTE.

Stroke with immobility increases risk of VTE however

transient ischemic attack with full recovery is not a major
risk of VTE.
Question No. 21 :

A 32-year-old male presents to your office following trauma to the left eye.On slit-
lamp examination, hyphema in the anterior chamber is noted.

What is the most appropriate next step in the management?

a. Refer to ophthalmologist immediately

b. Give antibiotics and organize follow up in a week

c. Advise icepacks and review in emergency department tomorrow

d. Prescribe NSAIDs and follow up in 3 days

e. Drain hyphaema in the emergency

Correct Answer & Detail

Correct Answer: a. Refer to ophthalmologist immediately

Answer Detail:
The correct answer is a.

Hyphema is presence of blood in the anterior chamber.It

occurs usually following a trauma to the eye.If there is no
history of trauma,suspect non-accidental injury in children
or blood dyscrasia.
Urgent ophthalmology review is mandatory on the same day
(Australian Therapeutic guidelines).

While awaiting ophthalmology review, the patient is placed

on bed rest with the head elevated 30 to 45 and is given an
eye shield to protect the eye from further trauma.Also start
close monitoring of intraocular pressure.

Hyphema may be followed by recurrent bleeding, glaucoma,

and blood staining of the cornea.Any of these three may
may result in permanent vision loss.

So,an ophthalmologist should attend to the patient as soon

as possible.

Oral and topical NSAIDs are contraindicated because they

may contribute to recurrent bleeding.

Draining hyphema in emergency department is not

recommended and it should be done by an ophthalmologist
in the operation theatre.
Question No. 22 :

A 32-year-old lady presented to your office with strong depressive mood

swings,irritability and loss of enjoyment in her usual activities. She developed these
symptoms after the birth of her first baby and did not improve for last 2 weeks. She
has no family history of postnatal depression.
What is the risk of developing depression in post-natal period during subsequent
pregnancy?

a. 30%

b. 2%

c. 5%

d. 65%

e. No risk of relapse present

Correct Answer & Detail

Correct Answer: a. 30%

Answer Detail:
The risk of relapse of depression in subsequent pregnancy
during post-natal period is between 20 percent and 40
percent in a woman with past history of depression in the
postnatal period.

Topic overview:

Signs and symptoms of postnatal depression (symptoms

lasting for more than 2 weeks) include:

-Shame, guilt, failure, inadequacy.

-Hopelessness.
-Tearfulness and persistent low mood.
-Exhaustion.
-Fear of being rejected by the partner.
-Fear of harm to the partner or the baby.
-Insomnia or excessive sleep.
-Poor self care.

Risk factors for post-natal depression include:

-Personal or family history of depression.

-Difficulties in relationship or being single.
-Lack of practical and emotional support.
-Stressful life events.
-Personal history of substance misuse.
-History of post-natal depression.
Question No. 23 :

A 56-year old male with history of type II diabetes mellitus for last 10 years is found
to have LDL cholesterol 5 mmol/l and serum total cholesterol 5.5 mmol/l.

What is the best initial therapy?

a. Diet and exercise

b. Statins

c. Ezetimibe

d. Fibrates

e. Fish oil

Correct Answer & Detail

Correct Answer: b. Statins

Answer Detail:
This patient has long standing diabetes mellitus for last 10
years and falls in high risk category of cardiovascular
disease.
LDL cholesterol is elevated (normal is less than 4 mmol/l).

In this situation,HMGCoA reductase inhibitors,statins,are the

first line drugs to use.These lower the LDL cholesterol to an
acceptable target range.

Diet and exercise are first line options in patients who are
asymptomatic and low risk for cardiovascular disease.
Statins are extremely efficacious and more than 90% of
patients can tolerate them with negligible or no adverse
effects.

Fish oil and fibrates are used to treat hypertriglyceridemia.

Ezetimibe inhibits the absorption of dietary cholesterol.
Ezetimibe lowers LDL by approximately 15% and is
considered in patients who do not tolerate statins.
Question No. 24 :

A 23-year-old African male presented at your clinic,after taking co-trimoxazole,with

pallor and increasing darkness of colour of urine.
Blood tests showed hemoglobin 90 g/L with reticulocyte count 5%. Both direct and
indirect Coomb's test are negative. Serum electrophoresis showed type A
haemoglobin. There is no family history of such presentation.

What is the most likely diagnosis?

a. Glucose-6-phosphate dehydrogenase deficiency

b. Autoimmune haemolytic anaemia

c. Sickle cell anaemia

d. Thalassemia

e. Hereditary spherocytosis

Correct Answer & Detail

Correct Answer: a. Glucose-6-phosphate dehydrogenase

deficiency
Answer Detail:
The correct answer is a.
This patient has normal type of hemoglobin(hemoglobin A)
on serum electrophoresis.So sickle cell disease and
thalassemia are unlikely diagnosis.

Coombs test is negative which rules out the possibility of

autoimmune haemolytic anemia.So in this situation most
likely diagnosis is G6PD deficiency.

Glucose-6-phosphate dehydrogenase deficiency is an X-

linked enzyme defect common in blacks and can lead to
haemolysis after acute illness or intake of oxidant drugs like
co-trimoxazole.An increased reticulocyte count is a criterion
for haemolysis but is not specific for haemolysis.

Hereditary spherocytosis is unlikely diagnosis in absence of

family history of such presentation.
Question No. 25 :

A 28-year-old primigravida presented at 41 completed weeks of gestation. She has

signs and symptoms of labour.
What is the most appropriate next step in her management?

a. Induce labour

b. Wait for spontaneous vaginal delivery

c. Urgent cesarean delivery

d. Elective cesarean delivery

e. Check blood pressure

Correct Answer & Detail

Correct Answer: a. Induce labour

Answer Detail:
The correct answer is a.

This patient is at 41 weeks of gestation with signs and

symptoms of labour. The most appropriate next step would
be to induce labour.

All other options (waiting for spontaneous vaginal delivery,

urgent and elective cesarean section and checking blood
pressure) are not correct answers.
Question No. 26 :

You are interviewing a 17-year-old female with anorexia nervosa.She believes she is
over weight despite the fact that her BMI is 16.5.This is an example of which of the
following?

a. Over-valued idea

b. Delusion

c. Hallucination

d. Exaggeration

e. Illusion

Correct Answer & Detail

Correct Answer: a. Over-valued idea

Answer Detail:
Over valued idea is held strongly,with less than delusional
intensity.It usually preoccupies the individuals mental
life,compared to many delusions and is ego-
syntonic,compared to most obsessions.

It often develops in an abnormal personality.It causes

disturbed functioning or distress to the patient and others.
Examples of over-valued ideas include:
1-Body dysmorphic disorder.
2-Anorexia nervosa.
3-Hypochondriasis.

Delusion is a fixed false belief which is unshakable.It is

characteristic of psychosis.

Hallucinations constitute perceptional abnormality and is

seen in psychosis.

Illusion is seeing an object and conceptualizing it to

something different.
Question No. 27 :

All of the following are contraindications to use nitrates except?

a. Systolic blood pressure less than 90 mmHg

b. Heart rate less than 50 beats per minute

c. Heart rate greater than 100 beats per minute

d. Known left ventricular infarction

e. Severe aortic stenosis

Correct Answer & Detail

Correct Answer: d. Known left ventricular infarction

Answer Detail:
The correct answer is d.
Contraindications to use nitrates include:

- Systolic blood pressure less than 90 mmHg.

- Heart rate less than 50 beats per minute.
- Heart rate greater than 100 beats per minute.
- Known right ventricular infarction.
- Severe aortic stenosis.

Nitrates are also contraindicated in hypertrophic

cardiomyopathy.

If nitrates given in any of the above mentioned situation can

lead to cardiac decompensation and hemodynamic
instability.

However in the absence of above contraindications, nitrates

can be safely used in patients with previous history of left
ventricular infarcts.
Question No. 28 :

A 45-year-old male presented with sharp,burning,stabbing pain in lateral aspect of the

right foot.You suspect L5-S1 radiculopathy.Which of the following is lost in L5-S1
disc prolapse?

a. Knee jerk

b. Dorsiflexion of big toe and foot

c. Plantar flexion

d. Eversion of foot

e. Ankle jerk
Correct Answer & Detail

Correct Answer: e. Ankle jerk

Answer Detail:
A herniation of the disc between the L5 and S1 vertebrae
will impinge on the S1 spinal nerve, which exits between the
S1 and S2 vertebrae.In L5-S1 disc prolapse,ankle reflex is
lost.A brief description of signs and symptoms of nerve root
involvement at each level in lumbar region is given below.
1. T12-L1-Pain in inguinal region and medial thigh.
2. L1-2- Pain in anterior and medial aspect of upper
thigh- slight weakness in quadriceps
3. L2-3-Pain in anterolateral thigh and weakness of
quadriceps leading to weak of knee reflex.
4. L3-4-Pain in posterolateral thigh and anterior tibial
area with diminished knee reflex.
5. L4-5-Pain dorsum of foot with weak dorsiflexion of big
toe and foot.
6. L5-S1-Pain in lateral aspect of foot with absent ankle
jerk.
Question No. 29 :

A 37-year-old obese women is with BMI 40,normotensive and normal serum sugar
level.She comes for advice regarding her pregnancy.
On a urine dipstix examination,she was tested positive for glucose.
What advice would you give her?

a. In the early part of your pregnancy you will be checked for pre-existing diabetes and at
26 weeks you will be checked for gestational diabetes
b. A change of life style and diet before getting pregnant

c. She should not get pregnant at all

d. Start insulin immediately

e. Check urinary proteins

Correct Answer & Detail

Correct Answer: a. In the early part of your pregnancy you

will be checked for pre-existing diabetes and at 26 weeks
you will be checked for gestational diabetes
Answer Detail:
The best advice to this patient will be to counsel about risks
associated with pregnancy because of obesity.

However management of pregnancy with associated obesity

in Australia needs to have a follow up at high risk pregnancy
clinic by obstetrician and a diabetes specialist.

In this patient an oral glucose tolerance test will be done at

26 weeks of pregnancy with advice on controlling weight by
diet and life style modification.

All obese patients are particularly tested for pre-existing

diabetes in the early part of their pregnancy.

Advising her not to get pregnant is inappropriate.

Only diet and life style modification do a little help in morbid

obesity.

Starting insulin without making a diagnosis is also wrong.

Checking urinary proteins is not indicated at this stage

however can be done as part of general work up.
Question No. 30 :

A 52-year-old male was prescribed digoxin for atrial fibrillation and a thiazide
diuretic for hypertension.In 4 weeks time,he presented with palpitations, nausea and
vomiting.
What is the most appropriate next step in his management?

a. Cease thiazide diuretic and and give postassium

b. Give potassium only

c. Cease both digoxin and thiazide

d. Cease digoxin and replace potassium

e. Change thiazide diuretic to spironolactone and send the patient home

Correct Answer & Detail

Correct Answer: d. Cease digoxin and replace potassium

Answer Detail:
The correct answer is d.

Digoxin is positive ionotropic and increases the force of

myocardial contraction and simultaneously, decrease oxygen
consumption.

Digoxin binds to and inhibits the sodium/potassium-ATPase

(sodium pump) within the plasma membrane of cardiac
myocytes.
This inhibition increases the intracellular sodium content
which in turn increases the intracellular calcium content
which leads to increased cardiac contractility.

Thiazide diuretics when given to patient for any

indication,are prone to cause hypokalemia.
In presence of hypokalemia,even usual doses of digoxin can
cause digoxin toxicity. Steps to manage digoxin toxicity
include:
- Cease digoxin.
- Correct hypokalemia according to severity.
- Start cardiac monitoring for any rhythm disturbance and
treat any rhythm abnormalities accordingly.
- Check digoxin level and other electrolytes in the blood.
- In certain cases,(with severe haemodynamic compromise),
Fab fragments of digoxin-specific antibodies may be
required.

In this case,thiazide diuretic should also be changed to

potassium-sparing diuretics or some other class of anti-
hypertensive medication on discharge.
Question No. 31 :

Hypercalcemia is not associated with which one of the following conditions?

a. Sarcoidosis

b. Secondary hyperparathyroidism

c. Leukaemia

d. Vitamin D overdose

e. Hyperthyroidism

Correct Answer & Detail

Correct Answer: b. Secondary hyperparathyroidism

Answer Detail:
The correct answer is b.

Common causes of hypercalcemia include:

- Sarcoidosis
- Malignancy like lymphoma, leukemia
- Hyperthyroidism
- Vitamin D overdose

Secondary hyperparathyroidism occurs in patients with

vitamin D deficiency, renal failure and osteomalacia.
Hypocalcaemia seems to be the common denominator in
initiating the development of secondary
hyperparathyroidism. So option b is the correct response.
Question No. 32 :

A 24-year-old lady comes to your office for prescription of oral contraceptive

pills.She has history of epilepsy for last 5 years and has been taking carbamazepine
since then.She is seizure free since last 6 months.

What will you advise her?

a. Cease carbamazepine

b. Reduce the dose of carbamazepine

c. Prescribe low dose oral contraceptive pills (micrgynon 30)and follow up in three months

d. Prescribe high dose oral contraceptive pills (microgynon 50)

e. Advise her to use condoms only

Correct Answer & Detail

Correct Answer: d. Prescribe high dose oral contraceptive

pills (microgynon 50)
Answer Detail:
The correct answer is d.
A woman with epilepsy during her reproductive age requires
special consideration regarding contraception.

This patient is stable with carbamazepine and has been

seizure free for 6 months.So it is important to continue this
medication for prevention of recurrent seizures in future.
However antiepileptic drugs like carbamazepine, phenytoin
and phenobarbital induce liver enzymes and reduce the
efficacy of oral contraceptive pills by 40%.
There is 6% failure rate when low dose oral contraceptive
pills (microgynon 30) are used in women taking anti-
epileptic medications.

According guidelines of RACGP,in such situation,oral

contraceptive pills with high oestrogen content (Microgynon
50) should be used to minimize the risk of pill failure.

Even then there is small risk of unplanned pregnancy and

barrier methods can be considered along with microgynon
50 after discussion with the patient.
Anti epileptic drugs which can induce liver enzymes and
cause pill failure include
phenytoin,carbamazepine,barbiturates and topiramate.

If an unplanned pregnancy happens in patient taking above

listed medications,there is high risk of teratogenicity which
include cleft lip or palate,cardiac anomalies,neural tube
defects and hypospadias.

Reducing the dose of carbamazepine or ceasing it may

cause relapse of seizure.
Although condoms are best to prevent sexually transmitted
infections,still these have high failure rate(2-15 percent)
and are not safe to use in patients are taking anti-epileptic
pills.
Question No. 33 :

A young woman presented for your advice on her choice of oral contraceptive pills.
She does not want to use any other method. Past medical history include hypertension
and diet managed type II diabetes mellitus.

What will you prescribe her?

a. Biphasic oral contraceptive pills

b. Progestogen only pills

c. Triphasic oral contraceptive pills

d. Oestrogen only pills

e. No contraception possible

Correct Answer & Detail

Correct Answer: b. Progestogen only pills

Answer Detail:
Following are the conditions in which progestogen-only
methods are suitable include:

1-Hypertension
2-Superficial thrombophlebitis
3-History of thromboembolism
4-Biliary tract disease
5-Thyroid disease
6-Epilepsy
7-Diabetes without vascular disease.

Progestogen-only methods are contraindicated in suspected

pregnancy, breast cancer and undiagnosed vaginal bleeding.
Relative contraindications are active viral hepatitis and
severe chronic liver disease.
Question No. 34 :

A 6-year-old girl is brought to your office with her parents. Her parents are worried
about her pubic hair and early puberty. She is health otherwise.
On examination, there are tanner stage 1 pubic hair ( villous,absent pigmented or
coarse hair). There is no breast growth and her height is normal for her age.

Which ONE of the following is the most appropriate next step in the examination?

a. Follow up visit in 6 months

b. Check serum FSH/LH

c. Bone age X-ray

d. Pelvic CT scan

e. Vaginal examination with the help of nurse

Correct Answer & Detail

Correct Answer: a. Follow up visit in 6 months

Answer Detail:
The correct answer is a.

This patient has developed isolated growth of pubic hair

before the age of 8 years. It is also called premature
adrenarche.

Usually there is no virilization and there is no breast

development. No investigations are required in most of the
cases and only follow up is required in case child starts
developing any features of congenital adrenal hyperplasia.
Precocious puberty is characterized by appearance of
following features before the age of 8 years in girls:

- Development of secondary sexual characteristics.

- Accelerated growth velocity.
- Inappropriate sexual behaviour.
- Mood disorders.

Investigations of suspected precocious puberty in a child

include serum FSH,LH,testosterone ( males), estradiole
(females).

Consider bone age x-ray (left wrist and elbow) and MRI if
FSH and LH are increased.
Question No. 35 :

A mother brings her 3 year-old male Aboriginal child for passing loose stools over last
2 weeks.The child lost 2 kg weight after the onset of diarrhoea. Child looks
fatigued.Clinical examination is remarkable for mild dehydration.

What is the most likely diagnosis?

a. Lactose intolerance

b. Food poisoning

c. Coeliac disease

d. Cystic fibrosis

e. Giardiasis

Correct Answer & Detail

Correct Answer: e. Giardiasis

Answer Detail:
The correct answer is e.

This child has signs and symptoms consistent with diagnosis

of Giardiasis.It is caused by a parasite called as Giardia
lamblia.

Symptoms of Giardiasis include:

1. Diarrhoea, which may be watery, usually lasting more

than 1-2 weeks.
2. Weight loss.
3. Frequent loose or pale, greasy stools which may float
in the toilet bowl.
4. Fatigue.

Lactose intolerance may develop in 20-40% of cases of

giardiasis and last several weeks.However it is not primary
diagnosis here.

Coeliac disease presents after introduction of glutin-

containing solid diet in a child during weaning.It starts
during first year of life.

Cystic fibrosis presents with frequent respiratory and

gastrointestinal infections from the birth.This child was
previously healthy,so cystic fibrosis is unlikely diagnosis.
Question No. 35 :

A mother brings her 3 year-old male Aboriginal child for passing loose stools over last
2 weeks.The child lost 2 kg weight after the onset of diarrhoea. Child looks
fatigued.Clinical examination is remarkable for mild dehydration.

What is the most likely diagnosis?

a. Lactose intolerance
 b. Food poisoning

c. Coeliac disease

d. Cystic fibrosis

e. Giardiasis

Correct Answer & Detail

Correct Answer: e. Giardiasis

Answer Detail:
The correct answer is e.

This child has signs and symptoms consistent with diagnosis

of Giardiasis.It is caused by a parasite called as Giardia
lamblia.

Symptoms of Giardiasis include:

1. Diarrhoea, which may be watery, usually lasting more

than 1-2 weeks.
2. Weight loss.
3. Frequent loose or pale, greasy stools which may float
in the toilet bowl.
4. Fatigue.

Lactose intolerance may develop in 20-40% of cases of

giardiasis and last several weeks.However it is not primary
diagnosis here.
Coeliac disease presents after introduction of glutin-
containing solid diet in a child during weaning.It starts
during first year of life.

Cystic fibrosis presents with frequent respiratory and

gastrointestinal infections from the birth.This child was
previously healthy,so cystic fibrosis is unlikely diagnosis.
Question No. 36 :

All of the following are contraindication to perform lumbar puncture except?

a. Altered level of consciousness

b. Localized infection in lumbar region

c. INR 5.5

d. Unstable child

e. APTT 60 seconds

Correct Answer & Detail

Correct Answer: e. APTT 60 seconds

Answer Detail:
Contraindications to perform lumbar puncture include:

- Unstable patient.
- Altered level of consciousness.
- Space occupying lesion in brain.
- Localized infection in lumbar region.
- Coagulopathy is also a contraindication to perform lumbar
puncture as it enhances the risk of bleeding into meningeal
cavity.
INR of 5.5 is abnormal and high risk of bleeding.Normal INR
value is less than 1 in patients who are not on warfarin.

APTT is usually less than 60 seconds in normal individuals.It

is not a contraindication to perform lumbar puncture in this
case.
Question No. 37 :

Which of the following is correct about combination of long acting beta 2 agonist
with an inhaled corticosteroids in children with asthma?

a. Reduces severe exacerberations

b. Increases severe exacerberations

c. No effect on asthma overall

d. Excellent for exercise induced asthma

e. Long acting beta2 agonists decrease the need for inhaled steroids

Correct Answer & Detail

Correct Answer: b. Increases severe exacerberations

Answer Detail:
The correct answer is b.

Combination of long acting beta 2 agonist with an inhaled

corticosteroid significantly increases the risk of asthma
exacerbations in children.

The possible mechanism by which this happens is thought

that long acting beta 2 agonists induces tolerance to short
acting beta2 agonists.This results in diminished response to
child norma rescue therapy with salbutamol.
Leukotriene receptor antagonists are superior to long acting
beta 2 receptor agonists for step-up therapy in exercise
induced asthma.

Long acting beta 2 agonists increase the need of inhaled

corticosteroids in children and child is required to be on
inhaled steroids continuously.
Question No. 38 :

A 48-year-old woman with past history of hysterectomy comes to discuss about

hormone replacement therapy for her post-menopausal symptoms and risk of her
getting breast cancer because of hormone replacement therapy.
Which of the following is best advice for her?

a. Use of oestrogen-alone HRT for up to seven years appears to have no effect on risk of
breast cancer
b. Postmenopausal women with low BMI (<25) have a lower relative risk of developing
breast cancer associated with oestrogen-only HRT than those women with higher BMI
c. There is consistent evidence indicating that tibolone may be associated with an increased
risk of breast cancer
d. She does not need Hormone replacement therapy

e. She should use hormone replacement therapy only for few weeks

Correct Answer & Detail

Correct Answer: a. Use of oestrogen-alone HRT for up to

seven years appears to have no effect on risk of breast
cancer
Answer Detail:
Women who have undergone hysterectomy should be
advised that the use of oestrogen alone has no effect on risk
of breast cancer if used for up to seven years.
For all women,the risk of breast cancer may be increased
with increased duration of use of hormone replacement
therapy.

Post-menopausal women with low BMI less than 25 have a

higher relative risk of getting breast cancer associated with
oestrogen-only hormone replacement therapy,than women
with higher BMI.

There is very inconsistent evidence indicating that tibolone

may be associated with an increased risk of breast
cancer.Tibolone is used both as hormone replacement
therapy and for treatment of endometriosis.

Giving her advice that she does not need hormone

replacement therapy is not correct.

She needs HRT to improve her symptoms.She can use HRT

for longer duration as compared to women who still have
uterus and are at risk of developing uterine carcinoma.
Question No. 39 :

Which of the following is regarded as the most important clinical examination finding
in a child with acute viral bronchiolitis?

a. Fever

b. Expiratory wheeze

c. Nasal discharge

d. Inspiratory crackles

e. Cough with productive sputum

Correct Answer & Detail

Correct Answer: d. Inspiratory crackles
Answer Detail:
In a patient with acute viral bronchiolitis,typical history
includes nasal discharge,fever and wheezy cough,and
examination findings show inspiratory crackles and/or
expiratory wheeze.

In most of Europe and Australasia,the presence of

inspiratory crackles is regarded as the more important
examination finding,and the diagnosis is usually limited to
the first 12 months of life.
Question No. 40 :

A 77-year-old woman presented with low back pain. She has history of colon cancer
surgery 5 years ago. On examination she is tender at T7-T8 level. There is no history
of trauma. Investigations show elevated PTH and alkaline phosphatase. What is the
most likely diagnosis?

a. Malignant metastasis

b. Multiple myeloma

c. Musculoskeletal back pain

d. Vertebral Fracture

e. Disc prolapse

Correct Answer & Detail

Correct Answer: d. Vertebral Fracture

Answer Detail:
Alkaline phosphatase levels are usually elevated in
hyperparathyroidism. So this patient have primary
hyperparathyroidism and is high risk for fracture
biochemically. Also she is postmenopausal and high risk of
fracture due to osteoporosis. So d is correct.
Intact PTH concentrations are generally undetectable or very
low in hypercalcaemia of malignancy and are elevated or
high-normal in primary hyperparathyroidism. So option a is
incorrect.

It is unlikely multiple myeloma as there is no information

regarding osteolytic bone lesions, hypercalcaemia, anemia
and renal failure. So option b is incorrect.

There are multiple causes of elevation of serum alkaline

phosphatase including bone disease, liver disease, and
pregnancy. Alkaline phosphatase is elevated in conditions
associated with high bone turnover. These include Pagets
disease, hyperthyroidism, fractures and
hyperparathyroidism.

PTH is secreted almost instantaneously in response to very

small reductions in serum ionized calcium, which are sensed
by the calcium-sensing receptor. The increase in PTH release
raises the serum calcium concentration toward normal via
three actions.
1- Increased bone resorption, which occurs within
minutes after PTH secretion increases.
2- Increased intestinal calcium absorption mediated by
increased production of calcitriol, the most active form of
vitamin D, which occurs days after PTH secretion increases.
3- Decreased urinary calcium excretion due to stimulation
of calcium reabsorption in the distal tubule, which occurs
within minutes after PTH secretion increases.

It is uncommon for patients with hypercalcaemia of

malignancy to have elevated PTH levels.
Question No. 41 :

What is most common cause of hepatitis C in Australia?

 a. Blood transfusions

b. Intravenous drug abuse

c. Needle stick injuries at workplace

d. Vertical transmission from mother to baby

e. Male to male sexual transmission

Correct Answer & Detail

Correct Answer: b. Intravenous drug abuse

Answer Detail:
The correct answer is b.

Most common cause of hepatitis C in Australia is intravenous

drug abuse in the community.

Intravenous drug abusers are at the highest risk of acquiring

hepatitis C and other infections like HIV,hepatitis B and
syphilis by needle sharing and using already used needles.
Question No. 42 :

A 47-year-old male presented with history of abdominal bloating, belching and

diarrhoea since last 3 months. He is truck driver by profession and drives from
Sydney to Melbourne every week. He had colonoscopy 12 months ago and it was
normal.

What will you do next?

a. Repeat colonoscopy

b. Sigmoidoscopy

c. Abdominal CT scan

d. Check stool for ova and cyst

e. Reassure him that nothing is wrong

Correct Answer & Detail

Correct Answer: d. Check stool for ova and cyst

Answer Detail:
The correct answer is d.

This patient is at high risk for exposure to parasitic intestinal

infestations due to long distance drive and difficulty in
maintaining hygiene.His signs and symptoms are consistent
with clinical diagnosis of Giardiasis however it need to be
confirmed by stool examination for ova and cyst.

Prominent early symptoms of giardiasis include diarrhoea,

abdominal pain, bloating, belching, flatus, nausea, and
vomiting.

Repeat colonoscopy, sigmoidoscopy and abdominal CT scan-

none of them is required at this stage.
Question No. 43 :

You are working in department of respiratory diseases.One of your patients,Mr John

is undergoing right total hip replacement in a week.
He has been on steroids for last 3 years for his chronic obstructive pulmonary disease.

What you would offer him during and before operation?

a. Give increased dose of steroids both before and during operation

b. With-hold steroids at least 24 hours before operation

c. Continue same dose of steroids

d. Change oral to IV steroids

e. Call endocrinologist to discuss the matter

Correct Answer & Detail

Correct Answer: c. Continue same dose of steroids

Answer Detail:
The correct answer is c.

Patients receiving therapeutic doses of corticosteroids

(COPD,asthma,rheumatoid arthritis) who undergo a surgical
procedure do not routinely require stress doses of
corticosteroids so long as they continue to receive their
usual daily dose of corticosteroid.

Patients receiving physiologic replacement doses of

glucocorticoids (Addisons disease) and undergoing surgery
should receive an additional 50 mg of hydrocortisone
intraoperatively.This dose should be continued for 48 to 72
hours postoperatively at an interval of 8 hours in patients
undergoing major surgery.
Question No. 44 :

All of the following are causes of raised intracranial pressure except?

a. Hepatic encephalopathy

b. Obstructed venous return due to thrombus

c. Cerebral oedema occuring in response to brain injury

d. Subdural haematoma

e. Hypocarbia

Correct Answer & Detail

Correct Answer: e. Hypocarbia
Answer Detail:
Raised intra-cranial pressure is an important finding in acute
care settings.

Common causes include:

- Cerebral edema occurring in response to brain
injury(meningitis).
- Epidural,subdural and intracerebral hematomas.
- Obstructed venous return from intracranial veins due to
thrombus or emboli and hepatic encephalopathy.

Hypercapnia(excess carbon dioxide in the blood) causes

vasodilation of cerebral vessels,and hence results in a rise in
intra-cranial pressure.

However hypocarbia also called hypocapnea,does not cause

rise in intra-cranial pressure.
Question No. 45 :

All of the following are features of bipolar disorder except?

a. Flight of ideas

b. Persistantly elevated mood for more than one week

c. Delusions of grandiosity

d. Decrease in goal directed activities

e. Impairment of occupational functioning

Correct Answer & Detail

Correct Answer: d. Decrease in goal directed activities

Answer Detail:
Features of bipolar disorder include flight of ideas,persistent
elevation of mood for more than a week,delusions of
grandiosity or superiority and increase in goal directed
activities either at home or at work.
This all must be associated with impairment of social or
occupational functioning.
Question No. 46 :

A 73-year-old male, type ll diabetic, presented with sudden onset of horizontal

diplopia, better at near and worse at distance. On examination, left eye is deviated
towards medial side.

What is the most likely diagnosis?

a. 3rd nerve palsy

b. 6th nerve palsy

c. 4th nerve palsy

d. 2nd nerve palsy

e. Facial fracture

Correct Answer & Detail

Correct Answer: b. 6th nerve palsy

Answer Detail:
Sixth nerve palsy causes isolated weakness of abduction.
Patients with sixth cranial nerve palsies primarily complain
of horizontal diplopia.
On examination there is an esotropia (inward deviation) that
is worsened with gaze into the field of the weak lateral
rectus muscle. Abduction is commonly limited on the side of
the lesion.
Poorly controlled diabetes is a predisposing factor.

The 3rd cranial nerve supplies the levator muscle of the

eyelid and four extraocular muscles: the medial rectus,
superior rectus, inferior rectus, and inferior oblique. These
muscles adduct, depress, and elevate the eye.
Patients with acute acquired third nerve palsy usually
complain of the sudden onset of binocular horizontal,
vertical, or oblique diplopia and a droopy eyelid.

A person with 4th nerve palsies may complain of binocular

(present with both eyes open) vertical diplopia and/or
subjective tilting of objects (torsional diplopia).

The affected eye usually is extorted because the superior

oblique muscle is an intorter of the eye. Objects viewed in
primary position or especially in down-gaze may appear
double when going down a flight of stairs so that the child
does not know which step to select).
Question No. 47 :

A 49-year-old male presents with epigastric pain worse at night and before
meals.Eating and drinking milk improves the symptoms.
He has history of drinking alcohol 4 to 6 standard drinks every day.He smokes about
30 cigarettes /day for last 10 years.
He has history of chronic back pain and often uses on the counter NSAIDS. He was
prescribed antacids for 4 weeks which has not really helped despite of his efforts to
modify life style.
What is best next step in his management?

a. Test for H.pylori

b. Upper GI endoscopy

c. Consider proton pump inhibitors for four weeks and then review

d. Continue life style modification and antacids

e. Make an appointment to help to quit smoking

Correct Answer & Detail

Correct Answer: a. Test for H.pylori

Answer Detail:
Any male who is less than 55 year-old presents with
dyspepsia should be encouraged to stop NSAIDS,modify life
style and try antacids for four weeks.
If there is no improvement,patient must be tested for
H.pylori status.

If H.pylori status is negative,treat with proton pump

inhibitors or H2-receptor blockers for 4 weeks and then
review.

If H.pylori is positive,treat it by H.pylori eradication regime

and review in 4 weeks.

Any male who has alarming symptoms or new onset of

dyspepsia after the age of 55,should have upper GI
endoscopy before any further treatment is commenced.

Quitting smoking is important and must be addressed

however primary issue of duodenal ulceration takes a
priority in management.
Question No. 48 :

A 35-year old male with known history of type 1 diabetes mellitus presented with
feeling generally unwell. He has not taken his insulin since yesterday as the chemist
shop close to his home was closed and he could not get his medication.He was
diagnosed with diabetic ketoacidosis.
Which of the following is the most urgent requirement for the patient in diabetic
ketoacidosis?

a. Infusion of sodium bicarbonate

b. Dextrose 5% infusion
 c. Infusion of normal saline

d. Glucagon

e. Insulin subcutaneously

Correct Answer & Detail

Correct Answer: c. Infusion of normal saline

Answer Detail:
The most urgent goals in a patient with diabetic ketoacidosis
are rapid intravascular volume repletion, correction of
hyperglycemia and acidosis, and prevention of
hypokalaemia.

Intravascular volume should be restored rapidly to raise

blood pressure and ensure glomerular perfusion. Once
intravascular volume is restored, remaining total body water
deficits are corrected more slowly, typically over about 24
hours.

Initial volume repletion in adults is typically achieved with

rapid intravenous infusion of 1 to 3 L of 0.9% saline
solution, followed by saline infusions at 1 L/h or faster as
needed to raise BP, correct hyperglycaemia, and keep urine
flow adequate.

Adults with DKA typically need a minimum of 3 L of saline

over the first 5 hours.

Dextrose and insulin intravenous infusion is also needed to

treat hyperglycemia however fluid replacement take priority
in emergency situation.
Question No. 49 :
A 3-year-old child is brought to your clinic with history of non-healing cold abscess in
submandibular area. Initially there was painless lymph node enlargement in that area
and then it erupted an abscess. Antibiotics given previously has not helped much.

What is the most appropriate treatment?

a. Surgical excision of the abscess and underlying lymph node

b. Incision and drainage

c. Antibiotics

d. Continue wound care

e. Clean the wound and apply topical antibiotics

Correct Answer & Detail

Correct Answer: a. Surgical excision of the abscess and

underlying lymph node
Answer Detail:
The correct answer is a.

This patient has clinical features consistent with cold abscess

caused by mycobacterium avium-intracellulare
scrofulaceum.

It is seen between the age 2-3 and it starts as lymph node

enlargement for 4-6 weeks. Then the lymph node erupts
into a cold abscess. It is painless and common sites of
involvement include submandibular, tonsillar and preauricle
nodes.

It is invariably unilateral and confined to one lymph node

group. The abscess not responsive to antibiotics and
requires surgical excision of the abscess and underlying
lymph node.
Question No. 50 :

A 32-year-old female presented with acute shortness of breath and tachycardia.There

is no history of fever.On examination, she has clear chest and no leg swelling. She is
on oral contraceptive pills and her mother had deep vein thrombosis at the age of 35.

What is the initial choice of investigation in a patient suspected pulmonary embolism?

a. Chest X-ray

b. CT pulmonary angiogram

c. V/Q scan

d. Doppler venous ultrasound

e. Coagulation studies

Correct Answer & Detail

Correct Answer: a. Chest X-ray

Answer Detail:
The chest X-ray is the initial choice of investigations in any
patient suspected to have pulmonary embolism.
The role of chest X-ray in the investigation of pulmonary
embolism is to exclude other pathologies that mimic PE.
Chest X-ray is mostly normal in patients with PE.

In well-established PE, chest X-ray abnormalities include

focal oligemia (Westermark's sign), a peripheral wedged-
shaped density above the diaphragm (Hampton's hump),
and an enlarged right descending pulmonary artery (Palla's
sign).
CT pulmonary angiogram is the investigation of choice for
diagnosis of pulmonary embolism. However this is not the
initial choice of investigation in suspected pulmonary
embolism.

Lung scanning (V/Q) has become a second-line diagnostic

test for pulmonary embolism, used mostly for patients who
cannot tolerate intravenous contrast.