AMC - MCQ & CLINICAL QUESTION BANK ,SEE TILL LAST MESSAGE

Discussion in 'Australian Medical Council (AMC) EXAM' started by J_simarasinghe, Sep 20, 2006.

Thread Status:
Not open for further replies.
  1. AMC - MCQ & CLINICAL QUESTION BANK ,SEE TILL LAST MESSA

    Hi everyone,

    I have collection of ORIGINAL Australian Medical Council Questions
    ( MCQ and Clinicals) with answers & examiners sheets. 100 % success.
    Collection is from 2000 to 2006.

    Price : A$ 8500 or near offer.

    from administrator :


    kindly post the q/a here , for the benifit of all , instead of selling these questins, posted below is a collection of amc clinicals , see till last message.
  2. asdfg

    asdfg Guest

    max for any course is 5-7000 and u are not allowed to copy their cases....

    stupid........
  3. Yep, I woke up and found that I passed AMC exam.
    :)

    Some of those copies should be dedtroyed by AMC ... :lol:
    but they are not.
    The feedback is from examiners.
  4. excuse me my bad english...

    should have been destroyed by AMC... :lol:
    but somehow , I got it..... :)
  5. Guest

    Guest Guest

    Bad English plus bad attitude (selling papers)

    Keep it to yourself!
  6. SvetlanaM

    SvetlanaM Guest

  7. Gunjarat

    Gunjarat Guest

    Bull...
    :shock:
    You can get all those questions at Westmead Hospital library free of charge.

  8. Faran,

    You wish mate, but there is more buyers than you can imagine.
    :lol:
  9. Guest2346

    Guest2346 Guest

  10. Dr_Lai

    Dr_Lai Guest

    Is it possible to see the questions before bying them.
    I am really interested, I am on waiting list for AMC.
    There is a lot of Australian Medical Council recall papers around , some of them are free of charge, some of them are for sale.

    If you want you can contact me:

    my E-mail: Lai_W@hotmail.com

    Mobile: +402285498
  11. Guest

    Guest Guest

    hello J_simarasinghe , do u have books for the clinical exam like john murtagh's- general practise and patient education?
  12. guest241

    guest241 Guest

    Illegal trade in exam papers
    SOME international medical graduates are paying up to $2000 for questions and answers to Australian Medical Council exam papers in a bid to obtain registration to practise in Australia. The AMC has revealed that the illegal trade — known as the ‘black bank’— involves previous exam candidates memorising the questions and their multiple-choice answers from their tests, then selling them to IMGs still to sit the exam.
  13. Smarty_panty

    Smarty_panty Guest

    Do you have those questions ?

    Hi Samarasinghe,

    You can get tham for less than twice of the price you asking for !


    AMC clinical examination
    3 June 2006, Melbourne ( retest)

    Question 1:

    A young student has a heart murmur coming and going, he comes to you as a GP for diagnosis. He has no cardiac symptoms, no SOB. Everything is normal, no family history of heart problem. General health is fine.

    Tasks:
    1. do a cardiovascular examination. ( please do not cover abdominal examination and lower limbs examination.)
    2. present what you have found to your examiner.
    3. present your diagnosis to your examiner and answer examiner.

    My approach: do the physical examination following the textbook. It was a medical student with no murmur at all. Questions from examiner:
    1. what other physical examination do you want to do? ( I stopped after I auscultated role player.) valsava examination.
    2. if a patient has a murmur coming and going, what do you think? – functional murmur?


    Question 2:
    A young student presents with dry cough, mostly in the morning or at night, general health ok, non smoker.

    Tasks:
    1. do a respiratory examination,
    2. report your finding to your examiner.
    3. answer examiner’s question.

    My approach:
    Again, follow the textbook’s instruction. It was a medical student with no positive finding. I told the examiner that there was no positive finding. Then she asked me what was the diagnosis- asthma.
    Immediately she asked me what else I wanted to do. I said spirometry.
    She handed over a spirometry result: FEV1 decrease, FVC decrease, after bronchodilator, FEV1 increase but lower than normal, FVC increase but lower than normal. I said it was consistent with the diagnosis with asthma.


    Question 3: (same question from April Melbourne 2006)
    A young lady driver has a few car accidents because she can not see the car coming from the intersection.
    Please do a visual examination.
    Tell your examiner what is your finding.
    Make a diagnosis and management plan.

    Please note that MRI is the gold standard of diagnosis.

    Question 4: (same question from November, 2005, Melbourne)
    You are an ED intern, a 45 years old man presented with right upper quadrant abdominal pain for 6 hours, nausea but no vomiting, this is the first attack.
    On examination: temperature 38.3 C, other vital signs normal.
    1. please explain to your patient what is the most likely diagnosis
    2. do the essential investigation.
    3. management plan


    Question 5
    A young student presents with poor sleeping, examination is coming, he is worried about the exam. Recently, his father passed away unexpectedly due to heart attack.
    Please take a history,
    Counsel this patient,
    Make a management plan

    My approach:
    I asked all the questions related to depression anxiety, such as drinking, eating, weight, sex drive, usual interest, the impact of his father’s death on his life. and also the past psychiatric history, drug and alcohol history, medical history, social history including performance at school, family relationship, employment,

    Explain to him: the reaction of bereavement. Emotional support,
    Management: sleeping pill, medical certificate, psychologist counselling.

    Question: how should I use sleeping pill, what is the prevention of heart problem.


    Question 6:
    A 2 year old girl presented with headache, fever for 2 days, father is concerned, he brought his daughter to your GP setting,
    Her father has family history of migraine.
    Please ask for examination finding from examiner. ( no further history taking)
    Manage this case.

    My approach: ask for general appearance. Vital sign, ENT, any rash? Neck stiffness, kernig sign? Other system. – only phalangitis, and bulging ear drum. Sign of dehydration, not drinking well _ from father, but examiner said baby looked well?

    My management plan:
    Explain to father that it may be viral infection however I can not exclude meningitis or other serious infection, so please observe and send to ED if rash, fever increase, drowsy, not drinking well or eating well.


    Question 7
    24 years old lady presents with vaginal bleeding 2 hours after 8 weeks amenorrhoea. General health ok.

    She is obese. You are a GP.
    Please take a history
    Ask for physical examination. ( investigation not available)
    Discuss with examiner about your management plan.

    My approach: she is not planning for family, partner is using condom, she is not on pill, bleeding more than usual. LMP 8 weeks ago. Regular period, no pain, no STD history. No family history of bleeding tendency. Not on any regular medication. PAP smear 6 months ago, normal result. No pregnancy history. No abortion history.
    Now she has no abdominal pain. Only per vaginal bleeding. Has stopped now.

    Physical examination: haemodynamically stable. No tenderness or mass in pelvic, speculum: os close, no bleeding, no polyps or ulcer.

    Examiner asked: what is your diagnosis if beta HCG positive? Threaten miscarriage.
    What other investigation do you want? – U/S
    What if beta HCG negative? Polycystic ovarian disease. Or other bleeding tendency, or problems in the uterus such as PID….


    Question 8
    61 years old bricklayer(male) presents with two years history of back pain and thigh pain? (not remember bilateral or which side)
    Past history: osteoporosis

    Your task:
    1. history taking
    2. ask for physical examination finding
    3. your provisional diagnosis and management plan

    my differential diagnosis:
    1. sciatica – fracture or disc prolapse – malignancy or osteoporosis
    2. osteoarthritis
    3. claudication
    4. trauma?

    I asked the history carefully, first, pain question.
    Then I asked during the last two years, has he been to any doctor? He told me that a doctor told him that he had got spondylosis of spine (x-ray) then I knew it might be osteoarthritis.
    Then I asked examiner the hand examination and shoulder, neck, back, hip, knee etc…
    The examiner told me : heberdon nodes on hand..
    Then I got a clue……

    Management x-ray and referral to rheumatologist…

    I am not sure I am right or not?




    AMC MELBOURNE 29/04/06

    I never realized how difficult it will be to make a recall after the exam. I do not remember all the tasks and some of the examiners questions. Stems were also much longer. So please be careful when you read these questions and find your own answers!!

    NEW QUESTIONS

    1.18 y.o patient comes to your GP practice for insurance purposes. He had asthma when he was 11.
    TASK Do spirometry, calculate FEV1, FVC and ratios. Discuss results with the patient.

    To answer properly I’d look up for spirometry from www.nationalasthma.org.au/html/management/spiro_res/vid_spiro.asp
    Video is there
    FEV1, FVC interpretation, (normal values were provided by examiner)
    Pt asked one question – Do I have asthma?
    Other candidates had Normal result of spirometry and reassured the pt


    .2. Photo dorsum of hand. (Not from AMC book –scaly lesions on whole dorsal surface of hand, red).Pt is a brick layer started new job 6 months ago, comes to your GP practice
    TASK- take Hx, discuss condition with patient.

    Rash has been there for 3 months, 3 months after he started his work, at work does everything with hands, no gloves. Rash very itchy, holidays made it better. Pt loves his job. Brother has psoriasis (to confuse you).

    My answer: contact dermatitis. Examiner expected to hear oral steroids as tx , not only topical steroids and gloves as protection. I told the role-player he does not have to change the job, which he liked. The examiner asked about complications. (My answer cellulitis, treat with oral Flucloxacillin after checking BSL and lymph nodes)
    I’d read at least from Murtagh and Pt’s education re: this topic

    3. 50 y o patient wants some advice about loosing weight,BMI 34, Cushing, hypothyroidism excluded. She will ask you about medications.
    TAKS – discuss with patient. No further Hx

    My answer –still talked re:Family (anybody with diabetes, angina, CVA?- she said no). Reassured-, very good and important that you came, good decision. Spoke re:cardiovascular risk factors Explained the risk of increased weight –heart, DM, CVA again.
    Advised re: Diet ,offered dietician.
    Exercise
    (all the info from Pt’s Edu and www.heartfoundation.com.au)
    And spoke about osteoporosis if she does not exercise
    No smoking and, safe levels of alcohol
    Re medications :said don’t know much about, only they can give you high BP. She was not interested anyway (in contrast to the stem!!!)
    Loose your weight slowly, in a sensible way.
    Examiner asked about surgery – Lap banding of stomach


    4. 50y o man problems with vision, can’t see the signs when driving car signs on the left and right bumping into things and people. You’ re GP.
    TASK – Examine eyes.tell Dx,
    What other investigation would you do.
    (looks like old question – Myopia –Mel NOV 2004), but in this exam the man is 50 y.o.….

    My answer: role-player helped me, saying I can’t see from LEFT and RIGHT.
    Examination Snellen chart- normal,
    Visual fields- bitemporal hemianopia
    Fundoscopy-examiner said normal.
    Accommodation – couldn’t see a thing but said normal
    Pupils reflexes –examiner said normal.
    Eye movement – Normal
    Examiner asked Summarise findings – Bitemporal hemianopia.
    What’s the cause – brain tu, possibly optic chiasm.
    What other tests?- I said CT and P, BP, full neuro examination and baseline bloods.
    Look up Talley.-Theory-from the book, Examination from the DVD- invaluable for any examination (only hip& back not there)


    5. 41 weeks (can’t remember possibly primi ) in labour. Station 0. Baby in OTposition, cervix effaced , 3cm dilation. Passed meconium. You’re GP working inObs Ward of countryside hospital – no obstetrician available.
    TASK- Take Hx from patient, ask examination findings, discuss situation wih pt.
    (Similar to Syd SEPT 2005, or Syd MAY 2004 but changed)

    5. A lot of Interactions with the examiner at this station which makes it harder.
    My answer: I asked how long in labour – Pt said 3 hrs, are you comfortable – dehydration, pain, - pt NO ANcare, esp DM ( sweet drink at 28 weeks) – pt all OK
    Contractions? – examiner said every 3-4 min,getting stronger
    Examiner said Manage
    I said - call another DR in Hospital for 2nd opinion. Check pt GA,hydration, P, BP, T,
    -Put CTG (examiner said– reactive) and LEAVE IT ON.
    -Fetal scalp electrode- Examiner not available- countryside.
    -Asked re:meconium Examiner green , you can’t tell thick or thin
    -I want to re-examine pt- exclude cord prolapse, asses cervix, presenting part.
    examiner – cervix 10cm now, baby between OT and OA,station +1 talk to pt
    Talking was reassurance- canal for baby open, baby turning into good position, moving down. Green stuff passed but does not mean there’s a problem (41 weeks), I’ll keep an eye.
    Examiner also wanted to hear - suction airways of baby, augmentation not required.
    Similar case in Greer – Problem based Obs&Gyne.


    OLD QUESTIONS/PAST RECALL PAPERS INCOMPLETE and CONFUSING

    6. 50 y o women postmenopausal come to your GP practice for the results. Result of microcytic anemia attached
    NO further Hx to be taken.
    TASK ask examiner examination findings,
    Discuss condition with pt (same as Syd MARCH 2005 Retest)

    6. I asked for iron studies-
    Examiner gave me a paper --low Fe, low ferritin, high transferrin, low Fe saturation.Obvious IDA
    I asked for tissue transglutaminase for celiac –
    Examiner – normal and nothing else available. Talk to pt.

    I explained IDA, maybe due to diet,maybe other cause. The woman did not want any tests. The case was really “dealing with difficult Pt/convince her to have the testâ€.
    Explained why loosing iron maybe diet, maybe ulcer,maybe sth more serious, we have to find the cause.
    Pt asked- Can it be sth else??-Not likely we need to find the cause.
    Can you give me Iron? – OK, may improve your symptoms, but still need to find the cause.
    Colonoscopy/gastroscopy invasive but done under sedation so you will comfortable, no pain. If losing iron due to ulcer it’s easily treated, if sthn else/sthn nasty better to know early. Go home/ speak to husband/come back with decision in few days. You really need the tests.
    IDA from P.Devitt


    7.30 yo woman on OCP no period for 2 months, comes to you as GP. NO Ix result available
    TASK further Hx, discuss condition with pt.
    (same as Adel SEPT 2004,but hidden points were Pt is 85kg, wants to be pregnant in 2 yrs)

    7. HX – on Microgynon 30(forgotten to ask for how long!), did not loose/put on weight recently, now 85 kg, periods regular before, no headache/vision probs/nipple discharge, no dry skin/cold intolerance, no acne/funny hair on face/Fhx of PCOS,no gyne procedure, does not .smoke, no meds only Pill.
    I have to ask you sensitive qq- Did you have sex over last 2 months. Yes.

    PE – Examiner all Normal
    Pregnancy test- unavailable

    My answer : explained – exclude pregnancy first , if negative don’t worry, 2 months not significant, no test necessary now
    If you concerned we can stop Pill and wait (use barrier protection) or change Pill to higher estrogen or Triphasic.
    Other option I’d recommend - continue same Pill (as 2 months no period- no reason to worry), see if period back and loose weight over next 2 yrs. You’re overweight pregnancy MAY be complicated by high BP and DM.
    Pt asked “Will I get pregnantâ€- We have to exclude pregnancy now and wait for period to come back. See me in 2-3 weeks.


    8.You’re intern ED, women came 3 days ago-previously on Prozac stopped 3 days ago, started on Zoloft. Today she’s vomiting, jittery, dizzy.
    TASK- take further history, PE from examiner, discuss condition with Pt.
    ( same as Syd AUG 2003)

    8. Still confusing this question, in taking Hx I repeated what was in stem, Pt unwell on Prozac before given Zoloft, unwell today. Did not take any other meds.
    PE – P-normal, BP no postural drop, not dehydrated, CVS< RESP>ABDO NAD, brisk reflexes
    Urine no ketones. Ix not available.
    I explained all due to SE of antidepressant, there’s sthn we call serotonin synd, but usually when 2 antidepr. mixed from different groups, these 2 are SSRI’s . So my Dx is SE of antidepressant.
    Examiner- what will you write in chart?
    Iv line, Nsaline, Metoclopramide.
    Pt asked I can’t sleep. I answered I’ll ask senior (did not know if I could give Valium)


    9. You’re GP. Your patient was 29cm at 30 weeks, now 4 weeks later she’s 30 weeks. Figures may have been different but still decreased growth around 28/34 weeks
    TASK-take further Hx, ask PE and Ix, discuss results with Pt.
    (Similar to Syd May 2004)

    9. In Hx no headache, blurred vision, tummy pain, no hx of infection, ANCare normal –USS 18 weeks, sweet drink 28 weeks. Good diet, no smoking, no iv drugs.
    baby kicking less (I forgot to ask how many kicks/day now!!!)
    PE – P,BP normal Heart sound 140/min. urine dipstick no protein
    I asked for Ix - CTG (examiner says reactive), Doppler (examiner-what you're looking at? - S/D ratio, which artery ?- umbilical)
    BPP - (examiner- which parameters you're looking at ?) tone, breathing etc
    USS - examiner says- baby 10th percentile asymmetric
    What's your Dx? - IUGR
    Talk to Pt. Started explaining and bell rang.
    Funny other candidates got Small for Dates from Ix, to others examiner said- NO Ix available.
    This question still confusing.
    IUGR from Greer.


    OLD QUESTIONS REPEATED

    10. 2 y o boy brought by father to your GP practice 50km from Hospital. Boy had sore throat last 2 days, today drowsy, dehydrated, P-high, BP low, T-40, petechial rash, no neck stiffness. Photo from AMC book.
    TASK - explain condition to father, manage the case.
    (same as Mel FEB 2006 !!)

    10. My answer: it's urgent, so I'll explain very briefly.
    Blood poisoning, very dangerous if not treated,same bug as the one causing
    meningitis. Any allergies to penicillin? Pt - NO
    I do iv line, take blood for culture, give benzylpenicillin 600mg iv, call Ambos, call Registrar in Hospital.
    You' re wife pregnant? Pt -No. OK, so you'll both need meds for prevention 2 tabs. daily for 2 days. Think if anyone kissed, shared food with child over last 10 days. I also need to notify DHS.
    Very good you came, very important, hope the child will be fine.
    Pt asked- can it be sth else? Not likely as child really sick needs to go to ED now, you can go with the child in ambulance.
    Guidelines RCH

    11. Father of 5 months old boy comes to your GP practice re: lumps in Rt groin and another one around belly button. Lumps come and go.
    TASK explain diagnosis and manage the case
    (same as Mel NOV 2005)

    11. My answer: good you came, you child has 2 hernias-weakening of muscles in tummy, explained about testis traveling from tummy to scrotum,channel did not close, can be dangerous if bowel gets stuck outside.
    I am calling surgeon now, for appointment as early as possible.
    Operation possibly within 2 weeks re;lump in groin,about lump around belly button surgeon will decide if he will repairs both together. Normally the one around belly-button can wait until 2/4 years
    If baby crying upset, check tummy if lump-hard - go to ED ASAP.
    Pt asked any SE of anesthetics.? Every medication has SE, but benefit outweighs risk.

    12. Mother 4 weeks baby comes to your GP practice, says baby vomiting everything after feeding. Put on weight since was born. She wants to change to bottle feeding.
    TASK take further Hx, PE, discuss mx with mother
    (same as Adel OCT 2005)

    12. Hx -Baby vomiting not on further questioning not so much, only a bit on the clothes, she props baby up after feeding . Baby hungry 1 hr after feeding (other candidates got 2-3 hrs) then settles.
    Vomit only milk – no blood or green stuff.
    Child happy, development OK, put on weight. Did not feel any lump.
    PE – normal, no lump in tummy.
    Still send you for USS to exclude pyloric stenosis if result OK baby has reflux.
    I explained gastro-esoph. reflux/draw a picture/, very common, gets better with time. Can last up to 9 months.
    Pt asked
    Am I doing sth wrong?-
    Continue breastfeeding as breast milk better for baby and not the cause of this problem.
    You can thicken feeds with Carobel/Gaviscon, keep baby prone 30-60min, elevate the bed 20degrees, and give smaller, more frequent feeds.
    Pt asked - complications of Reflux? – Bell rang
    GORD – from Pt’s Education


    13.40 yo woman (2 episodes of headaches with nausea, photophobia, had CT scan done excluded brain tu), comes to our GP practice for advice.
    TASK- explain migraine, discuss further mx
    (same as Syd AUG 2004)

    13. My answer: Good news, the stress may be gone,as you have no cancer, what you’ve got is migraine.
    Explained re:vessels closing and opening.
    Different causes, usually multiple factors, Chinese food, red wine etc., so write a diary. Pt was teacher a lot of stress in life.
    Management – Aspirin(asked if no pain I tummy)/ Metoclopramide
    if not better Ergotamine (asked her no probs with heart or BP)
    Prophylaxis not required as yet.
    Migraine from Murtagh


    14. Young man comes to ED 2nd episode of severe pain in the back, pain radiating to groin, went away now. 1st episode 2 months ago.
    TASK take further hx, ask Ix, discuss Dx with pt
    (same Syd MARCH 2006!!)

    14. Pain occurred suddenly, very severe, pt moving around to make it better
    No change in urine color.
    Ix asked for dipstick, KUB and helical CT, Dr Gya showed CT with stone.
    Explain the pt - sediment in urine, stone builds up around pain,pain happens when stone moving.
    Dr Gya- what’s mx. Stone is 5mm.
    Answered borderline, maybe pt goes home and wees thru mesh, or lithotripsy. I’ll take blood tests and ask consultant.
    Can he go home? Consultant will decide. (better answer was “not sure as he has not passed the stone last 2 monthsâ€)
    Where do you refer? To surgeon.
    Renal colic from P. Devitt, Senanyake- Common Cases, Pt’s Education


    15.Shoulder examination GP setting. Basketball player had anterior dislocation 6 months ago, comes for check up.
    TASK- examine shoulder give running commentary, answer questions.
    (same Syd MARCH 2004)

    15. Examined the shoulder as from DVD , everything normal, Apprehension test, impingement test negative
    Asked for pin to check patch on the deltoid (examiner says normal)
    Questions from examiner- Which nerve? Axillary
    Which muscle for abduction? Deltoid
    Pt asked can I play? Yes but no dunking
    Examiner asked where you refer? Sport medicine Clinic
    What do you do for recurrent ? Bell rang.

    16. Young women gave birth to child 4 weeks ago, has another baby 30months. Recently unwell, tired (can’t remember what else) You’re GP
    TASK talk to mother, discuss condition(same as Syd JULY 2004)

    Pt tired no time for herself, husband supportive, appetite, sleep, energy down, interest gone, mood low. No hallucinations, dos not think baby has special power, no hx of depression in past. (some candidates got 10kg weight loss). (I forgot risk assessment!)
    Dx explained Postnatal depression/we don’t know why it happens,/maybe hormone changes. Common - happens to 1/7 women after birth
    Come back with husband, try to find time for yourself, see old friends, relaxation,
    Pt does not want to see counselor, psychiatrist. Still referred her to PANDA
    Pt asked – should I breasfeed? Up to you - breast milk good for baby, but takes a lot of your energy so you’ll have to think and decide.
    Come back in few days if not better maybe start antidepressant






    RECALL 29th APRIL 2006 MELBOURNE

    1. Post Natal Depression
    The 28 years old woman came to your GP practice after delay 4 days from appointment. She just gave birth to baby 6 weeks ago has another 10 years old child at home. She complains doesn’t have enough energy and can’t organize herself.
    Take relevant history
    Explain the condition to the patient
    Management

    2. Iron Deficiency Anemia
    Woman 48 years old menopause came to your clinic to get result from her blood test (attached, suggested iron deficiency anemia).
    Ask relevant history
    Explain the condition to the patient
    Management

    3. Side effect of antidepressant
    Woman came to ED feels nausea, vomiting, jittery and unwell. She’s been on fluovoxetine for 3 years and then she came to ED. The doctor gave her Sertraline.
    Take relevant history
    Management


    4. Septicemia
    Father of 4 years old child came to your surgery because his child looks very ill, fever and developed rash (as picture in AMCQ book page 118).O/E GA: looks ill, VS: BP 100/60 Temp : 40 degree RR: 98
    Explain the condition to the patient
    Management
    You know the song guys, explaining condition to the patient, notify health department, prophylaxis for household contact.

    5. Renal stone
    28 years old came to your surgery after having severe abdominal pain 2 hours ago. The pain radiates to his right groin and testicle. He had similar pain 2 months back.
    Explain the condition to the patient ,Order the necessary investigation, Management

    Examiner in this station was very nice. I explained to the patient about stone in his urine passage. I said to examiner I want to order for FBE, U&E, MSU culture and microscopy, abdominal X-ray.
    Examiner asked:
    • What else the investigation you need to order? CT KUB
    • What stones do you think it is? Calcium, Phosphate and Uric acid.
    • What from the blood you want to look? (Examiner pointed the stones so I understand what he wants) Serum Calcium and Phosphate.

    Role player asked :
    • Why do you think I’ve got this condition? Because there’s possibility that you didn’t drink enough water.
    • What else? (Examiner stopped him and said okay you finished earlier you can wait outside.

    6. Management of migraine
    The woman 38 years old came to your surgery with severe headache and vomiting. She had a history of migraine 2 months ago. The CT brain result doesn’t suggest any tumor.
    Take relevant history (no more than 2 minutes)
    Explain the condition to the patient
    Management

    I congratulated the patient and explained to the patient about enlargement of blood vessel on the scalp and tried drawing the picture as well. Then I gave her an advice about lifestyle modification reduce wine, caffeine, smoking, cheese, etc and paracetamol and antiemetic tablet.

    Examiner asked:
    • What if she doesn’t get better? I’ll refer to neurologist and they might give her sumatriptan or ergotamine. You as a GP can give her she said.

    7. Bitemporal hemianopsia
    The man 48 years old came to your surgery. He complained of having visual disturbances. Two days ago he had accident because he didn’t see a truck coming from the side of the road.
    Examine the patient eyes
    Order necessary investigation

    I checked for the visual acuity, visual field and funduscopy.That real patient had visual lost on the lateral side.
    I said to the examiner that he has bitemporal hemianopsia probably due to compression of optic chiasm. (Pituitary adenoma)

    Examiner asked:
    • What are the sign you looked on the patient?
    • What investigation you want to order? FBE, prolactin level, blood sugar, lipid profile, CT brain, 24 hour serum cortisol level, TFT,….
    • What else?
    I wasn’t sure about this station because examiner kept asking what else? Then the bell rang.

    8. Contact dermatitis
    The 32 years old man came to tour surgery. Presented with hand (the picture attached: swelling with sign of dermatitis and infection between the fingers)
    Take relevant history
    Explain the condition to the patient
    Management

    From history the patient said it came suddenly, he doesn’t have any allergy, hay fever or asthma, as well as family history of those conditions. He is a builder and recently he worked with cement. I explained to him that he had an allergy probably due to cement complicated by bacteria. I gave him prednisolone and antibiotic. I talked about referring him to allergic clinic to have a test done and avoidance to the materials that you allergic to. Then report to your employer regarding his condition. There’s possibility that they’ll move you to another department

    Role player asked:
    • How long you going to put me on antibiotic?
    I haven’t answered and bell rang…..

    9. Gastrooesophageal reflux.
    The mother of 1 month old baby came to your surgery because the baby always vomits after feeding. The baby grows and develops well. Mother thinks there’s something wrong with her milk.
    Take relevant history
    Ask examiner examination finding
    Management

    I took further history, the baby’s well so far. Then explaining about GE reflux and drawing a picture. I reassured mother that’s nothing wrong with the baby and the breast milk. And role player asked are you sure that’s my baby’s okay? Bang! I realized I forgot to do PE. I said sorry to examiner then asked GA,VS, ENT, heart and lung, abdominal examination. All normal. Then I said to the patient your baby’s normal, usually this condition will clear up by itself when solid is introduced abut 6 months old. If the condition doesn’t get better you can add corn flour to your milk or gaviscon. I’ll follow her up in 1 week, but if you have any concern come back to see me.


    10. Examine the shoulder and nerve injury.
    The 18 years old student playing in basketball competition. He had shoulder dislocation on the right and nerve injury. He already had an operation fixing it up 6 months ago. He came to your surgery asking you when he can go back playing basketball again.
    Examine the patient
    Advise the patient about returning to the competition

    The examiner was really old and very nice. I started examine the shoulder.

    Examiner asked:
    • What nerve could be injured? Axillary nerve. Go on examine the patient. I examined for sensation on deltoid muscle and power (abduction)
    • What else? The bell rang… I was thinking about radial nerve as well, but not sure. So please check the books.


    11. The woman 26 years old came to your surgery complained of stopping her period after two courses of oral contraceptive pill.
    Ask relevant history
    Ask examiner examination finding and order necessary investigation
    Explain to the patient

    From further history the woman stopped her period suddenly, doesn’t have tummy pain and vaginal discharge. No past history of STD, Hypertension, DM. Family history (-). I asked examiner for Pregnancy test urine and blood, FBE, TFT, FSH, LH, prolactin level, swab. Examiner said good but they are not available. Huh? Okay, I said to the patient I’m waiting the result of the test I ran. If there’s abnormality I’ll refer you to specialist straight away. If they come back normal we’ll wait for another 3 months if your period doesn’t come I’ll refer you to sp. It could be due to stress or side effect of OCP.

    I wasn’t sure about this case. Check it again in the book.


    12. You are HMO in Obstetric and Gynecology department. 41 weeks primigaravida came to ED. She is in labour. O/E cervix dilated 3 cm LOP (in the morning LOT, means tranverse) and meconium stained. ObsGyne registrar and consultatnt are not there. You have to manage her by yourself.
    Ask relevant history
    Ask examiner about examination finding
    Manage the patiet

    13. Primigaravida woman 28 years old came in for routine check up. Four weeks before you checked fundal height 26 cm. Now she came to you and her fundal height 30 cm
    Take history
    Ask examiner examination finding and order the necessary investigation
    (Examiner only will give you what you ask)
    Manage the patient

    14. Weight reduction
    Woman 43 years old BMI 33. She came to you for advice on weight reduction
    Advice the patient
    Answer patient questions regarding medication to lose her weight.

    15. Umbilical And Groin Hernia
    A father of 4 months old baby came to you complaining of a lump in his right side of the abdomen as noticed by the father in the bath comes and go, otherwise the baby is fine.O/E : There’s umbilical hernia 1cm, both testis are in the scrotum
    Ask few clarifying questions
    Manage the condition

    I explained and drew a picture as usual. Then referring the patient to a surgeon and saying possibility of twisting if it’s not corrected and should be in two weeks time. The umbilical hernia, it’ll reduce by itself when the child gets older but if it doesn’t when the child 5 years old, need to have operation done and don’t put anything on it.

    16. Spirometry
    28 years old man with a history of asthma came to you. He has symptom free for 2 years. He hasn’t been using ventolin in the past 2 years.
    Do spirometry
    Explain to the patient the result compare to the expected value

    I gave up in the middle of this station so definitely I failed this station . I had no idea at all. Felt really bad. Read it in the Talley o’Connor.



    Clinical Exam Melbourne Feb 11, 2006

    O&G

    1- 25 yo female patient with more than ten years’ history of DM type 1.
    Task: Pre pregnancy counselling
    Pt asked:
    - How would DM affect my pregnancy?
    - Should I keep taking Insulin?
    - What are the effects on my baby?
    - Would I need a CS?
    Examiner asked:
    - What kinds of blood test are you going to order?



    2- Young university female student wants to start taking OCP.
    Task: OCP Counseling
    Pt asked:
    - What type of OCP is suitable for me?
    - Any side effects associated with OCP?


    3- A primi 38 wks had a convulsion while sitting in the waiting room with her mum to see you, a remote GP.
    Task: Manage this pt and answer the questions raised by her mum
    Her mum asked:
    - What’s wrong with my daughter?
    - How are you going to deal with my daughter?
    - Any harmful effects on my daughter or her baby?


    Paediatrics:

    4- Young mother comes to see you, a GP, enquiring about circumcision.
    Task: Counselling
    Pt asked:
    - What are the benefits of circumcision?
    - What are the contra-indications?
    - What are the complications?


    5- A 9 yo child is just diagnosed Diabetic type 1. His father wants to know more about it.
    Task: Counseling.
    Father asked:
    - What’s the management to my son?
    - Does my son need insulin for the rest of his life?
    - Can my son go to camp with school?
    - How about him overstaying with his mates on weekends?
    6- You, a GP working at remote area, are seeing a young boy who presented with fever and rash (Picture is presented).
    Task: Management and counselling his father

    Examiner asked:
    - What is your provisional diagnosis.? (Septicaemic Meningitis)
    - What’s your management?
    - If allergic to penicillin which AB would you give?
    - If it’s hard to establish iv access, what are you going to do?


    Psychiatry:

    7- Young female comes to see you just because her parents asked her to do so. She denies any abnormality.
    Task: Hx, Dx, and Mx
    Examiner asked:
    - What’s your dx? Why? (Anorexia Nervosa)
    - Would you admit this patient? Why?


    8- 1st episode acute Psychosis: nurse noticed wrist injury, lives with 3 friends
    Note: no more hx required
    - Patient wanted to go home to sleep
    - Patient has auditory hallucination
    - No suicidal ideations
    - Very agitated and swears all the time
    - No insight
    Task: Focused hx and mx.

    Patient asked:
    - Can you give me something to get some sleep?
    Examiner asked:
    - What do you think he has?
    - Would you admit him?
    - What if he refuses to be admitted?
    - What will you give him?
    - What are the side effects of Haloperidol?

    Medicine

    9- A 60 yo lady has been told by a previous GP that she had a murmur, she wants to travel oversees.
    Task: Examine her CVS and report to the examiner your findings.
    Dx: Aortic Stenosis


    10- A 67 yo lady wakes up in the morning with weak Rt arm and slurred speech that lasted for one hour (TIA case)
    Task: Examine the relevant system/s


    11- An asthmatic patient was at a party last night and tried walnut butter for the first time,
    He gets swollen lips and difficulty breathing, and then gets better after taking Ventolin.
    Task: Counseling
    Patient asked:
    - Am I going to get these reactions every time I have walnut butter?
    - What else should I not try?
    - Is there a way to cure or prevent these reactions?
    - Can I go camping?

    12- 45 yo male patient, referred by his GP to see you, feels tired, cardiac problems, abnormal of live function test, bradycardia, non alcoholic, no hx of dark urine,
    Task Ix, Dx, Mx,

    Dx: Haemochromatosis


    Surgery

    13- 50 yo male patient with a swelling in his scalp
    Task: examine, Dx & advice on management.

    Dx: Lipoma


    14- 65 lady had pain for 3 hrs in the morning and bloody diarrhoea, nausea,
    Hx of AF and appendicectomy
    Task Hx, DD

    Mesenteric artery occlusion / ischaemic colitis


    15- An obese male presents to you with pain in the left lower chest,
    Task: Hx, DD

    Pneumothorax / pleurisy / PE / Pneumonia / MI


    16- A middle aged patient fell of his motor bike and fractured his clavicle,
    Task: Management.

    Patient asked:
    - Can I ride my motor bike?
    - Can I drive my car then?
    - How can I have a shower?
    Examiner Asked:
    - What are you going to do for him?
    - How to do the sling?
    - For how long should the patient use the sling?


    Melbourne 11/02/2006

    Medicine
    1./ Heart examination.

    2/ A woman came to you because she had slurred speed and upper limb weakness 2 hours ago. Now, she is normal. Your tasks are:
    • To do physical examination?
    • To discuss the DDx and tests that should be done to confirm the diagnosis with the examiner?

    You do the upper limb examination and talk to the patient for 1 second to prove she does not have any speaking problem. The diagnosis is TIA and to differentiate with other causes, e.g. heart block, hypoglycaemia.

    3/ A 35 yo man came to you because he has developed the chest pain that only radiated to his left arm and his neck. The painful area is in the border between the left chest and abdomen. Your tasks are.
    • To take the history?
    • To take the physical examination and order the tests to have DDx?

    The symptom is only the pain radiating to the left arm. The rest is normal.
    The physical sign has not been detected any abnormal sign. So, DDx are
    a) Angina or MI → ECG, troponin enzyme.
    b) PE or pneumothorax→ chest X-ray and CT scan. CTscan is the best since it can prove PE or pneumothorax quickly and accurately.
    c) Herpes zoster


    4/ A man comes to you since right after eating the nut, he developed throat irritation that was subsided after inhaling antihistamine (I cannot remember the name of medication). Your tasks are:
    • To discuss with him about his problem, as well as another serious problem?
    • MX?

    This is a case of nut allergy. You must refer him to the immunologist. You also warn him about anaphylactic shock with serious symptoms and signs, talk to him about epi-pen, the information of nut allergy in the wallet or bracelet to let the ambulance officer knows his nut problem.
    Q: Will I allergy with other food?
    A: It’s very good question but the specialist will discuss with you when you meet him.


    5/ A man has migrated to a new area. He comes to you with liver enlargement. The US show fatty liver. He does not drink, and smoking. Your task are
    • To take the history?
    • To ask the physical examination and test results from the examiner?
    • DDx?

    This case is haemachromatosis→ because he also has a heart problem and serum iron increased?????- I was not very good for this case.


    Surgery
    1/A woman comes to the hospital because of a serious abdominal pain. Her faeces is brown colour. Your tasks are:
    • To take the history?
    • To ask the physical examination, the test results from the examiner?
    • Mx?

    The woman has 9/10 abdominal pain. Her abdomen is totally distended and rigid. She did not take aspirin or NSAIDs or other medication that can cause gastric bleeding. She only has taken the medication for her heart. Her pulse is irregular- irregular →gut necrosis. It will be confirmed by CTscan and barium enema without preparation.
    Mx:
    1. Call surgeon to admit to theatre (critical error if you do not know).
    2. Morphine, fluid and other resuscitation.
    3. Blood tests and others for preparing surgery.


    2/ A man has had a lump in his head for 2 years. Your tasks are:
    • To do physical examination?
    • To give DDx?

    It is a case of lipoma. You must explain to the patient that the lump is not likely to be a cancer lesion because he has had for 2 years and you cannot find out any lymph nodes in his neck and head. Removing it and studying under microscope will give an accurate answer. Refer to specialist.

    3/ Clavicular broken bone with X-ray film that is very clear cut. Your tasks are:
    • To explain the problem?
    • To discuss the complication and Management?
    • To perform the sling?


    Paediatrics
    1/ A 2 yo boy comes to you because of hypotension, cold temperature, and rash that is illustrated in the picture. He has no neck stiffness.
    Your tasks are:
    • To explain to his father what has happened to him?
    • Mx?

    This is a case of septicaemia. Explain to his parent about the disease. Then, you will call ambulance immediately. During waiting for the ambulance, you draw out his blood into the tube, and then inject ceftriaxone 50mg/ kg (explain why you do not use penicillin because of the anaphylaxis in some people.)
    Q: During waiting the ambulance, if the boy’s vein collapses, what will you do?
    A: Fluid transfusion into the tibia, and IM antibiotic are the basic procedures in the country-side clinic.

    Q: What else will you do?
    A: I will inform to the authorities and prescribe rifampicin to his relative.

    Q: What is the S/E of rifampicin?


    2/ A new case with 2 examiners.
    A boy who develops DM has been discharged. Your tasks to discuss with his father are:
    • What is the kind of DM in his son?
    • Mx
    • Complications? How to avoid?

    Patient education is a good source. You must say his son’s life will be normal if the son follows the advice from the specialist, the dietician and physiotherapist (very important to keep BMI in the normal range). He can go out to camp, to play sport with his teachers’ notice. Talk briefly about the complication, e.g. hyper/hypoglycaemia. Discuss short and long acting insulin briefly and leave the answer for DM specialist since he will prescribe short or long acting insulin.

    Do not scare when you see 2 examiners. Like this case, it was easy to talk.

    3/ A mother comes to you because she want her male baby will have circumcision?
    Candidate should ask what she knows about the circumcision? The mother will say she has heard from her friend.

    Candidate must say circumcision is not common procedure in Australia any more.


    Obstetrics & Gynaecology

    1/ The DM young woman comes to you because she wants to conceive. She has used insulin for a long time and her DM has been controlled very well. She has just married. Your tasks are:
    • To take history?
    • Counselling?
    • To discuss what she wants to know?
    During the conversation, she is normal, no problem occurs. Then, she asks
    Q: Can I conceive? Yes
    Q: What should I do?
    A:I will refer you to DM clinic since you need a DM specialist, a dietician as well as a physiotherapist to prepare you for your pregnancy?
    Q: What will happen to me during the pregnancy if DM is not controlled well?
    Q: What will happen to my baby if DM is not controlled well?


    2/ A young woman comes to you because of contraceptive pill. Your tasks are:
    • To discuss what she wants to know?
    • If she wants, you can outline other contraceptive methods?
    You must discuss about the S/E, complication of the pill. Do not forget to make sure she is not pregnant.
    Q: Can you choose the pills that are suitable for me?
    A: I cannot. I will introduce the advantages and disadvantages of every kind of contraception pills. Then you select the pill that is the most suitable for you.

    Q: Which kind of pills you will prescribe for me?
    A: I will prescribe the lowest dose of pill for you, such as microgynon 20.

    3/ A 35th week pregnant woman got the convulsion in the outpatient clinic. Now she is conscious. Your tasks are:
    • To take the history and to explain what happened to her mother?
    • To take some signs and symptoms from the examiner?
    • To manage the situation?

    The mother said her daughter had had antenatal care very carefully without any abnormality, esp. blood pressure or proteinuria. She did not contract with epilepsy or hypoglycaemia. The examiner says every thing was not available yet. You must know the rule in this case that is the pregnant woman must be treated as a case of eclampsia until you can prove other causes, esp. epilepsy or hypoglycaemia (see that rule in the eclampsia topic from the royal women hospital website).

    Psychiatry
    1/ A teenager girl comes to you because of tiredness. Physical examination is normal. Your tasks are
    • To take the history?
    • To report the psychiatric problems to the examiner?
    • To diagnose and manage the case?

    This is a case of anorexia nervosa in the young girl who eats 3 meals/day with only vegetable. She thinks her thighs are quite big. She has had amenorrhoea. Her BMI is 15 and the signs of dehydration. Otherwise is normal.

    Report to examiner about her behaviour during the conversation, e.g. not eye contact, she tried to cover her body.

    The important sign from the examiner is dehydration. So, Dx is anorexia nervosa and you must admit her immediately to hospital because of dehydration.

    2/ A man who develops psychotic problems with hallucination, delusion and illusion. He was admitted to hospital because of the laceration in his left wrist. Now, he wants to go home and sleeps with sleeping medication. Your tasks are
    • To Talk to the patient to find out the problems?
    • Mx and to discuss with the examiner about his condition?

    Introduction, then you should talk to the patient to satisfy 3 things:
    • You are here to help him.
    • You do everything to calm him down.
    • You persuade him hardly to stay in the hospital.

    The performer disagrees and always wants to go home with sleeping pills. So, talk to the examiner about his risk of suicide (he cut his wrist before he was admitted to the hospital), then you call CAT team to admit him involuntary to the hospital.

    Q: During waiting for CAT team, if the patient becomes violent, what will you do?
    A: I will stay with him during waiting CAT team. If he becomes violent, I will run away because I must be safe first.
    When I have more people (Ideally, 6 people (in Murtag)), I will come back to inject haloperidol to him.

    Q: How to limit the S/E of haloperidol?
    A: I have to use the minimum dose.





    11-Feb 2006 Clinical Examination Melbourne

    Paediatrics

    1. 38/40 pregnant woman comes to see you as a GP and asks about neonatal circumcision.
    Task: Tell your patient about the medical opinion and answer her questions.

    1st pregnancy, no religious reason. Just husband had it done when he was a child.

    Q ‘s from the role player:
    What are the disadvantage and advantage of circumcision?
    What are the contraindications?
    When is the best time to have it done?

    Q’s from the examiner:
    If the patient insists on having it done for her child, what are you going to do?
    Answer: it is patient’s choice. I’ll refer…….

    Circumcision


    2. You are a HMO in the hospital. A 9 yrs old boy is just diagnosed of type I DM. He is still in the hospital.
    Task: talk to the father and answer his concerns.

    Have you heard about DM? – yes. My uncle is a diabetic. I know what it is. I just want to know how long he needs insulin.
    Can my child have normal life?
    Can he go for camping?
    How about playing sport in school?

    Diabetes Type I Juvenile – counselling


    3. GP setting, 50 km away from city. A father brought his 2 yrs old child to see you. Temp 40’c. rash (picture from AMC’s MCQ book page 118). Over the lase a few hours, the child was not interested in eating, lethargy and drowsy. No neck stiffness. No history taking and physical examination.
    Task: manage the case.

    Q’s from examiner:
    If the child is allergy to penicillin, what will you do?
    The child is dehydrated, how are you going to give fluid? – putting IV cannula. What else? –intraosseous infusion.

    Lethargic febrile 2 yr old


    O& G

    1. GP setting. You were interviewing a mother of 38/40 pregnant lady who just had a fit in the waiting room. Now she is not fitting, but a bit drowsy.
    Task: talk to the mother, take the focus history and ask examiner the finding, manage the situation.

    History and examination findings: 1st episode of fit. BP 180/110, urine dipstick – protein +++.

    Q’s from examiner:
    If you don’t have Mg SO4, what are you going to give her?

    Q’s from the mother:
    Can she have any fit again?
    Any dangers to the baby?
    Will she have high blood pressure after delivery?
    Are you going to the hospital with her?

    Eclampsia


    2. GP setting. A 24 yrs old lady, married, asked for different types of OCP.
    Task: history taking, ask examiner the physical finding and give her advice.

    In this case, no CI of OCP. She can have combined OCP. Tell her 7 day’s rule, not protecting her from STD

    Contraception request


    3. GP setting. A 26 yrs old has 15 yrs history of well controlled IDDM. She wanted to get pregnant.
    Task: give her advice and answer her questions.

    Q’s from the role player:
    I want to know how DM affects my pregnant and how pregnant affects my DM.
    If I become pregnant, are you going to look after me?

    Q’s from the examiner:
    When are you going to refer her to endocrinologist, before pregnant or after?
    What do you need to check before she becomes pregnant?

    Pre-pregnancy counselling – diabetic


    Psychiatry

    1. GP setting. A mother of 16 yrs old girl concerned about her daughter’s weight. Last week the weight was 45kg but now is 40 kg. Now you are seeing the girl.
    Task: Take a history and ask examiner the finding
    Tell examiner about your diagnoses and the management.

    Finding —BMI 14, fine hair, dehydration, postural BP drop. No Ix result.

    Anorexia nervosa

    2. GP setting, a young man had a right wrist injury and lived with other young people. You did a limited mental examination as following.
    He had problems with his previous employer, poor sleep, lack of insight, denied any suicidal ideation. He was having hallucination and paranoid. (long stem).
    No more history taking and examination.
    Task: manage the case.


    Q’s from the examiner:
    What do you think about the diagnosis?
    Patient refuses to go to hospital, what are you going to do?
    Under which law you can admit the patient?
    While you are waiting for ambulance, what medication are you going to give? – Diazepam. Which route? -im.
    For other symptoms, which medication are you going to give? – Haloperidol.
    This is a young man, if you give haloperidol, what do you expect? – Extrapyramidal side effect. What medication to revert it?
    What are you going to do if the CAT team comes late?

    Psychotic episode with violence – crisis management


    Medicine and Surgery

    1. GP setting. A middle age lady wants to go for overseas and comes for check up. She has heart murmur for several years, which was told by her previous GP. She was asymptomatic.
    Task : do the physical examination and tell the examiner about you diagnosis.

    Pansystolic murmur at the mitral valve area.
    Q’s from examiner:
    What is the cause of MR?

    Cardiac murmur

    2. One hour ago a 46 yrs old lady had a difficulty in speaking and weakness in right arm. When she was in the waiting room the symptoms resolved. Patient ‘s mother had a stroke.
    Task: examine the relevant systems.

    Dysphasia & upper limb weakness

    3. GP setting. A patient has a lump for several years. Slightly increase in size and asymptomatic.
    Task: take a focus history and do an examination.

    Q’s from examiner:
    What else do you need to examine? – lymph nodes.
    Can it become cancer?
    What is the complication of the lump? – infection
    How do you remove it?

    Subcutaneous lump

    4. GP setting. A patient comes from other city. A letter from his previous GP said that his LFT’s was abnormal. He was not an alcohol drinker, had no history of infectious liver disease. He had permanent pacemaker insertion a few years ago for the bradycardia. LFT’s was GGT , ALT,AST all increased. You have ordered some tests.
    Task: ask the examiner about the Ix result and talk to the patient.

    Q’s from the examiner:
    How often is the venesection done?
    What diet?
    How about the siblings and children of the patient?

    Abnormal liver function tests



    5. A young man had a history of eczema and asthma. Last night in the party after eating a walnut he started having wheezing, SOB and urticaria. He had peanut allergy at 7, 9 and 17 years old. Your diagnosis was nut allergy.
    Task: Explain to him about the diagnosis and how to prevent it happening again, what he can do next time. What test do you confirm the diagnosis.

    Q’s from role player:
    If it happens again, call an ambulance first or give Epipen first?

    Nut induced anaphylaxis


    6. HMO in ED. A 35 yr old man complains of left chest pain.
    Task: history taking and give your DDx.

    Pleuritic chest pain


    7. Acute abdomen pain.
    Task: take a focus history. (pt on Digoxin, some bright red blood in the stool)

    Ask examiner the finding ( irregular pulses, generalised tenderness of abdomen, slight rebound, occasional bowel sounds.)
    Tell what you are going to do

    Acute abdomen


    8. A 25 yr old man fell on outstretched hand. You did the examination. There was tenderness over the right clavicle.
    Task: read X ray

    Tell what you are going to do and manage the condition with the materials provided.

    All materials included a sling and the ones for figure 8.
    Q ‘s from the role player:
    How long do I have it on? – 3 weeks
    Do I have a lump over the collar bone?
    Can I go to work?

    Fractured clavicle



    12/11/2005 Melbourne AMC Clinical exam Recalled by Ling

    Medicine and Surgery
    1. A 40 years old lady, an important player in orchestra, C/O pain, sausage swelling and stiffness in both hands recently and was tested for ANA, ESR and RF and the results showed that she has early rheumatoid arthritis. Today she comes to you (a GP) for the result and tell her your Mx.

    Patient was shocked and knows that it’s a very severe situation because her mother is 62 y/o and has RA for many years ( I explain ‘ early stage, modern medications and more therapy will keep the function well, it varies individually, various ranges. I will refer you to the rheumatologist’ and totally forgot the magic words: early intervention and multi-disciplinary team management.
    Questions:
    Can I continue my career (yes)
    What medications you would give me ( first Brofen and take rest)
    She said, I really can’t take any rest, any other medication can relieve the pain quicker steroids-she’s shocked, ‘Dr, no steroids. My mom took it and I know there are a lot of SE. (Yes, but in short term. It should be OK, but anyway I will refer you to the specialist.) Give leaflet and suggested the Internet. This case looks easy but I was not sure the details of the Disease- modifying agents.( I failed this station.)

    2. A 28 y/o male fell his Left wrist on the floor yesterday and still sore today. He came to ED and you’re a ED HMO. Task: focused P/E, order your Inx and Mx

    On P/E, tenderness in the sniffbox-------I’ll do a X-way
    Examiner asked what’s your possible Dx? (scaphoid #)
    Here is the X-way ( it’s a scaphoid #). This is a picture from AMC which is too clear to be missed.
    Talk to the patient. (I explained and refer him to the Orthopaedics surgeon)
    His Qus:
     What are they going to do for me? (They will put a plaster for you)
     How long do I need to have it ( about 6-8 weeks. But they will assess you regularly. First they may see you in the next 24 hours to check the plaster, the blood circulation and then they may check in 2 weeks when the swelling fades away and sometimes the bone may die because of the poor blood circulation.)
     You mean my hand will return to normal after 8 weeks. (It depends. The surgeon will look after you and I think you will be fine.)
    (Then I asked ‘Do you have any other concerns) No.
    Then examiner remaindered me to wash my hands.

    3. Poorly-controlled DM for several years comes to you for check up. Do relevant P/E on his lower limbs. You may be interrupted by the examiner because of time saving.
    Examiner asked:
     what do you want to check first (peripheral vascular disease), Go ahead. (I did inspection and palpation for pulses.)
     What’s other change? (peripheral neuropathy),Go ahead ( I started with pain sensation check for stocking distribution which disappeared below the mid-tibia, then vibration loss below knee and also proprioception loss on both big toe joints on a role player.
    I hesitated and asked whether I need to do the power and tone. Do as you want. (So when I was doing the reflexes the bell rang).

    4. A 60 y/o male, who is your infrequent patient, came to you (GP) today wanted to enquiry about his wife because he found she is getting more forgetful recently. His wife, a 60 y/o lady, your frequent patient, was seen by you 3 days ago, complaining that her husband found her more forgetful than before. You took Hx and P/E her and found she was normal.
    Task explore the husband regarding the marital issue
    Response to the husband’s concern

    From the beginning, he complained his wife and asked ‘what did you find wrong with my wife. She didn’t tell me anything about it’ (I am sorry I can’t tell you any thing about your wife’s condition without her written permission. It’s patient’s confidentiality.)
    o ( he’s not happy) Why not? I am her husband. It’s me to look after her all the time? (I can understand. But I can’t. What do you find wrong with your wife?)
    o She ‘s terribly forgetful, a lot of trouble. I am afraid she may make fire at home when she cooks. I think she needs to stay in hostel. Doctor, I should do something earlier to put her on the waiting list.( I understand. But it must be assessed by the Aged Care Assessment team. I can’t do the assessment.)
    o I know. That’s why I came to you. I need your referral. (Oh, terrible case.)
    o (I know. But about this issue should ask your wife to make the decision. She is conscious now. She has the right to make her own decision) (This time he didn’t come back straightaway. And I can ask Qu: How about your relation with your wife?)
    o Quite good. We’ve been married for 30 years. Sometimes, ups and downs, but I think every couple are the same. (Do you think it is as fresh as before, like the early time?)
    o ( Laughing) No, Dr, we’ve been married for 30 years already. (Do you have any children? How do they think about your wife?)
    o They agree with me. (I gave up the marital issue. Can you come to see me next time with your wife together?)
    o I don’t think she would come. Last time I force her to come. (Anyway, I can’t give you any information about your wife. I have to repeat again and again. Finally the bell rang.)


    5. A 60 y/o male C/O episodes of palpitation and dizziness recently. His BP 155/96. I can’t remember the other details. (? ED or GP setting)
    Task: focused Hx
    P/E and Investigation from examiner
    Read an ECG at 7th minute

    This is a quite confusing case. I think I asked too much Hx.
    Hx, Palpitations sometime happen at night, not related to exertion, no chest pain (?). no tinnitus and spinning feeling. No target organ damage symptoms (visual problem, SOB, pain in calf or body weakness). No Hx of heart attack or stroke or thyroid disease. No medications. Smoking by 20/day and alcohol by 4-5 glasses of wine since teenage. drinking a lot of caffeine.
    P/E: Bp155/96, p150, regularly, heart and lungs are all normal.
    Examiner asked: What’s the likely cause (Tachycardia)
    Which one (maybe sinus tachycardia, not sure). How is the ECG? (ECG was given. It’s an atrial flutter.)
    Which degree of the block(4 to 1).( bell rang).

    6. A 51 y/o came to ED with severe right upper abdo pain.
    Task: focused Hx , DDx
    Answer patient’s Qu
    Again, a typical acute cholecystitis case.

    7. A 30 y/o male came to ED, C/O terrible headache since yesterday and getting worse.
    Task: focused Hx
    P/E from Examiner
    Mx

    Qu: What’s the reasons for my headache?(DDx)( Then talk to the examiner)
    P/E (T: 38.5℃, neck stiffness, no rashes)
     What are you going to do for the patient (consult my Reg or senior Dr. Admit the patient, give AB.)
     What investigation( FBE, Blood culture)
     What else? (CT head). Why? (Rule out bleeding). No bleeding, what else? (lumber puncture). What tests are you going to do with the fluid (pressure, bacteria staining, culture and biochemistry). OK, patient has a Qu.
     How is about my two kids (9 and 11 years olds) ( I will give all your family members rifimpicin for prevention), The bell rang. I hadn’t finished the whole Mx ( Notification).

    8. A young male had bloody diarrhea for 6 months and had colonoscopy done today. Unfortunately, the surgeon just said the changes exist in the whole large bow which suggests ulcerative colonitis without giving a report. The patient brought the picture of his colon change to you (a GP). Task:talk to patient.
    Explain ( lifetime situation, multidisciplinary Mx, it can be well-controlled)
    Admit to hospital at this moment. Qu from role player:
     How about my diet ( low fibre diet)
     Any operation now ( not this moment, sometimes may need surgeon)
     Can it be other situations according to the picture? (the picture suggests inflammation, can be caused by infective inflammation, like germ infection or Crohn’s disease. But the distribution of the inflammation can tell the difference).
     What’s the complications (bleeding, perforation and higher risk of bowel Ca. Other organs can be affected, such as eye problems, mouth ulcer, skin changes and liver problems.

    O+G
    9. A 28 years old lady come to you for advice of next pregnancy regarding that se had an abortion 2 years ago.
    Task: relevant Hx
    adverse effect to the next pregnancy and evaluation。
     I asked and give possible effect on the future pregnancy:
     how many weeks of pregnancy(14/52), which hospital (RWH),
     any fever after that(no),when get her first period after the procedure( a month);
     any check up by any obstetrician (Yes), How about the periods since then ( as normal as before, about 4 weeks a cycle).
     Blood group (“O†negative), Any anti-D after the procedure (not sure),
     same partner (yes),
     Any diseases: DM, HTN, Blood clotting problems, smoking, alcohol drugs
     Qu from role player: Will it affect my fertility?

    10. A 50 y/o lady C/O hot flush and irregular periods for 11 months. No weight loss or discharge. Two children (20 and 22 y/o). All P/E are normal.
    Task: Mx (no further Hx and P/E)
    I was on the wrong track and gave her OCP, so I fail this station easily and completely.

    11. (GP setting) A 25 y/o Ph D student was 8 weeks of pregnancy. She complained right lower intermittent abdo pain for a week.
    Task: focused Hx, P/E and Inx from examiner, Mx

     Hx: A dull pain at 5-6/10, no fever, no discharge, no burning sensation or frequency passing urine, no diarrhea, no pregnancy reaction symptoms.1st pregnancy, planned, no PHx of PID or STD. Pap smear is normal. no smoking or alcohol.
     P/E: Vital signs are normal. Only superficial tenderness in the right lower abdo. US: normal pregnant sac in uterus, which is compatible with 8 weeks of gestation. A cyst of 5 cm was found in the right ovary, not torsion, not ruptured. Speculum P/E: Os is closed and PV P/E showed tenderness in the right adnex.
     Mx: I will refer you to the obstetrician.
    Patient asked:- They will remove the cyst now? (I don’t think so).

    Paediatrics
    12. Immunization advice for a mother with a 6 weeks old child (her first child). The child is all normal with P/E and growing well. Role player’ Qu:
     First she asked me to talk through the schedule of vaccines from 6 weeks to pre-school
     Is there any reaction after the vaccines ? (Yes, some children may have mild fever or unwell). -How to prevent it? (Paracetomal).
     What is the complication of Pertusis vaccine (encephalopathy). Is there any condition you should not give vaccine (Children with encephalopathy caused by pertusis must not be given any pertusis vaccine)
     Some parents suggested to use diluted protein (a natural way of immunization). Is that the same as the immunization schedule (I haven’t heard this before and not sure its effect but I will check this for you.
     Then she told me she has no Qu for me. I said that ‘I am not sure about the diluted vaccine. Is it recommended?’ The examiner told me ‘No, but you said you will check the book for her. So that’s fine

    13. A young mother bought her 4 years old daughter to your suburban clinic, C/O that her daughter has some rashes in her genital area in the last several weeks and it’s getting worse. She devoiced for a while and looking after her daughter. At weekend her daughter stays with her ex-husband but she refused to go there yesterday. She suspected her daughter was sexually abused by her ex-husband. She has a new boyfriend moved in 5 months ago.
    Task: Give the mother your Mx plan.

    (It looks easy. I need to call Gatehouse now. The question here is how to explain this 2-3 sentence in 8 minutes. I kept repeating that they will take Hx, do P/E and do Investigations. Not sure what else they want.)

    14. A father came to you, worrying about his 5 months old son. He found one lump in his right groin area, which comes out when he’s crying and goes back when he’s sleeping and another lump in his tummy button
    Talk to the father about the Mx (totally repeated case)

    Psychiatry
    15. A 60 y/o lady with right lower abdo pain for 6 weeks and lost 5 Kg in the last 6 weeks. She went to see the doctor (P/E was normal) and was investigated, including, blood tests and colonoscopy, which are normal. Today she came for the results. ( GP setting)
    Task: Take HX for the psychiatry cause
    Give the patient your DDx
    Explain the nature of her condition and Mx.

    Hx: The RL abdo pain for 18 months and getting worse in the last 6 weeks. NO particular event 6 weeks ago. Poor sleep and always wakes up at 3 Am and can’t go back to sleep. Appetite is
  14. 30. A 62-65 year old women presents with a swollen leg. Doppler US confirms diagnosis: DVT. She is on HRT. In addition, she takes Aspirin for headache.
    F/H: mother had DVT, sister some coagulopathy. Question from role examiner is this disease some coagulopathy? What factor of coagulation is affected? What are side effects of heparin & warfarin?




    31. 62-65 y.o woman, FH of DVT .She taking Aspirin for headache, and she is on HRT.Management : DVT in the arm Ox.444, GP 624


    32.History suggestive of ECONOMY CLASS SYNDROME (DVT) was provided for a young male. TASK: Explain condition to the pt (Patient Education). What is Dx & Mx ? Write script for anticoagulation. Examiner asked how I would use Warfarin. Ix. Include INR. Remember prophylactic/therapeutic doses of anticoagulants. Pt. needs to be admitted to the hospital. Clexane/Warfarin/Heparin? I said Warfarin and passed this station.

    Nine question to ask with a swollen leg: Is it in both legs? Any trauma? Any pain? Is she pregnant? Any pitting? Any skin changes? Is she mobile? Past disease/drugs? Any oedema elsewhere?
    Venous thrombosis - is the presence of the thrombus/clot in the deep vein(soleal sinuses). May affect superficial veins/superficial thrombophlebitis or deep veins / DVT. Prolonged venous thrombosis may lead to chr. venous insufficiently with oedema, pain, stasis/pigmentation & dermatisis, and stasis ulceration. Risk factors: increased age, pregnancy, oestrogen/COC & HRT, surgery (esp. cancer surgery and hip/pelvic/orthopaedic surgery), past DVT, malignancy, obesity, immobility, smoking, thrombophilia (primary coagulopathy resulting in propensity to thrombosis). Venous thromboembolism often presents clinically in the second week after surgery (increased blood coagulability after surgery and Symptoms/Signs: DVT may be asymptomatic or as a unilateral leg pain, unilateral calf tenderness, calf swelling (>3 cm than other side is significant!), warmth skin. Pulmonary embolism is serious complication. Life-threatening PE rarely occurs from calf DVT, but risk is very real if iliofemoral segment is involved. DD: cellulitis ruptured Baker’s cyst, lymphoedema, hematoma, mechanical or tumour obstruction. Ix. Duplex Doppler US is Dx in most cases. If in doubt contrast venogram (gold standard for Dx.) should be obtained. Refer all suspected DVT either for acute admission or for acute radiological imaging. Is it single US sufficient? If there is strong clinical suspicion of DVT repeat US after 7 days or confirmed with venography.
    The causes of thrombosis were described by Virchow/his famous triad: 1. change in the vessel wall –intimal damage ( eg. External trauma to the vein during hip replacement) 2. changes in the blood flow-venous stasis (eg. immobility, obesity  risk of DVT however stasis alone does not cause thrombosis, other factor must be present) 3.changes in the constitution of the blood-hypercoagulability (primary hypercoaguable states – def. of antithrombin III, protein C or S should be suspected if there is recent thrombosis. Sec. hypercoaguable states (conditions ass. with thrombosis but the cause is not identified) like pregnancy, puerperium, and Behcet disease.
    Mx. Most pt. is anticoagulated in hospital on Heparin and discharged on oral Warfarin. Take blood for APTT, INR and platelet count. Bed rest, elevate the leg. Heparin 5000 U statim IV, then continuous monitored infusion at least 10 days, aim for PTT = 1.2 – 2 normal. Warfarin for 3-6 months ( risk of further thromboembolism. Target INR-2.5 (2-3). Gradual elastic stocking (If foot pulses OK) should be worn for 2 y. as they  risk of postthrombotic leg sy by 12 %. Surgery indicated in extensive and embolising case.
    PE: air travel/preventing DVT  prolonged international air travel between EU & USA carry risk for DVT. So, exercise body and prevent dehydration. In flight, leg exercise, 3-4 minutes every hour. Foot pumps/ankle circles/ knee lifts. As well occasionally, walk through the cabin as space and time permit.


    Thrombophilia:: is a primary coagulopathy resulting in propensity to thrombosis. Inherited/Activated Protein C resistance- defect in factor V (Leiden). There is increased risk of MI. Antithrombin III def. less common. Acquired: common causes are new progesterone in the Pill and antiphospholipid syndrome when serum antiphospholipids antibodies are found (lupus anticoagulant and/or anticardiolipin antibody) – predisposing to venous and arterial thrombosis, thrombocytopenia and recurrent foetal loss in the women. Ix. FBC with platelets, PT, TT, APTT fibrinogen concentration. Further test: activated protein C resistance(ratio),lupus anticoagulant and anticardiolipin antibodies, ,protein C,S and antithrombin def. Some haematologist going directly for the factor V ( Leiden) and PT gene mutation eg. if already on Warfarin and other results are confusing. Mx. Treat acute thrombosis with heparin, then Warfarin In antithrombin III def. unusually high doses of Heparin may be needed. Prevention: Avoid the Pill ( NB. Screening with blanket exclusion of those with thrombophilia from the Pill is unwise).Advise TED stocking. Risk of recurrent thrombosis following DVT,PE, stroke or TIA if antiphospholipid antibody +ve is ~ 30%/year. Aspirin or Warfarin (INR <3)  risk. Pregnancy is problem, Warfarin is teratogenic.

    33. Old cardiomyopathy. 10 years back he had AF. Now on Warfarin. He comes to you to ask about WARFARIN. How it is works doc? All about warfarin




    34. A 23-y.o lady recently came from along trip found to have an extensive clot over her popliteal veins by a Doppler US. No history of OCP, smoking 15 cig/day, alcohol occasionally. TASK: Explain condition to the pt. Write relevant medication on the prescription sheet. Order any Ix you want.
    Introduced, Explain what is DVT, and emphasise the importance of immediate admission and management. I took very short history: LMP was 8 weeks ago, she is not pregnant. She slept through the whole journey, she did not move her legs, did not take enough fluids, water, juice etc. I ordered baseline coagulation profile esp. APTT and INR and started Heparin 5000 U IV (18 U / kg). Bolus and infusion 25000 U in 500 ml saline, drip rate adjust accordingly to the APTT. Start Warfarin as well and monitor INR after 2-3 days. When INR reach TARGET level, I will withdraw Heparin .I explained how to follow up, blood test, drugs interaction with Warfarin (aspirin) warning sign of Warfarin reaction. Continue Warfarin for 3 months and emphasise importance of contraception during the therapy. Examiner asked: What is a source of drug in Hospital? MIMS, Hospital protocol, senior colleagues. Stop smoking ! OCP  Warfarin activity.


    Brisbane, Session A, Stage 1, 15-16 February 2003


    35. A 43-y.o male presents in ED, abdominal pain for 4 hours TASK: Take history and give Dx.  From history: Central abdominal pain, around umbilicus, sudden onset, vomited a couple of times. severity 8/10, Pulse: 110 – irregularly irregular (AF). BP= 150/90 mmHg, Fever, weight loss .PH: bowel history? History of heart attack and arrhythmia, taking Digoxin. FH: Appendectomy, herniorrhaphy. Pt is obese, drink 1 glass alcohol a day. Not allergic to any medication .O/E: abdomen tender, no mass palpable, PR exam= blood on gloves, dark stool. I said ISCHEMIC COLLITIS (mesenteric artery occlusion) DD: Acute pancreatitis, acute cholecystitis, acute pyelonephritis, renal colic. What Ix. FBC, mesenteric artery angiography, US, ECG. What type of painkiller ? Morphine IM. How you know it is a vascular course? What you will see on AXR? Send him to hospital. Surgery.
    What is general appearance of pt? VS ?

    ► AF with abdominal pain should suggest idea of bowel/intestinal ischaemia usually follows low flow in inf. mesenteric art. territory. Signs: lower left sided abd. pain, and bloody diarrhoea. There is often pyrexia, tachycardia, blood per rectum and leucocytosis. 90% of the time this “ ischemic colitis†resolve but may progress to gangrenous ischaemic colitis. May be previous history previous attack or “ abdominal angina†after meals. The symptoms and progress depend on the extent of the ischaemia, whether it involves just mucosa (in which case is bloody diarrhoea) or transmural involvement (in which case peritonitis –rebound tenderness predominate). In later situation, resuscitation and surgery are required. Dg. test  barium enema may show “thumb-printingâ€, indentation of barium due to submucosal swelling. Contrast CT helpful. Mx. usually conservative with fluid replacement and antibiotics. Strictures are common. Send him to hospital 
    Vomiting is early feature of small bowl obstruction. Vomiting may be later or absent in large bowel obstruction. Absolute constipation is characteristic of both.

    Acute small bowel ischaemia: - occlusion of SMA either from an embolus (low flow states as poor cardiac output, DIC, AF) or thrombosis (commonest) in atherosclerotic artery. Classical clinical triad -1.acute severe abd. pain, 2.no abdominal signs (tenderness, rigidity, absent bowel sound – late findings) 3.rapid hypovolemia (causing shock ).Pain tends to be constant and around Right iliac fossa. Profuse vomiting, watery/bloody diarrhoea in ⅓ of the pt. later. The degree of illness is out of proportion to the clinical signs. Pointers to diagnosis: Hb increased (due to plasma loss), WCC increased , and persistent metabolic acidosis. Early on AXR= “gasless †abdomen. Ct may be helpful while mesenteric arteriography is performed but many dg. are made on laparotomy. CRP: may be elevated intestinal alkaline phosphatase. Mx. Fluid replacement, antibiotics (gentamicin + metronidazole) and heparin. Early surgery may be required as life saving procedure - resection of gangrenous bowel. Prognosis is poor; mortality is high 70 –90%. Early diagnosis (within a few hours) is essential.
    SMA supplies all of the small intestine except sup. portion of duodenum. IMA supplies all the colon and rectum (left)except the right half of the transverse colon.
    In intestinal obstruction is important to asses is it adhesion (from previous abdominal surgery) or if not adhesion is it a tumour? Iv fluids, analgesia, put NG tube down, put catheter, keep eye on urine output (fluid loss in third space). What is normal output? AX-ray, CT scan if not sure gastro/enema


    36. A 78 y.o. Man is seen at his home. His wife tells you that he has been suddenly unwell over the last week, being unable to walk unaided. Over the last 6 months his wife has noticed a gradual but general “ slowing downâ€. his speech is also slow, and monotonous, he walks in a stoper shuffling manner and falls frequently .He has resting tremor in his hands. He requires more assistance with dressing, toileting, and bathing, Dx. PARKINSON’S DISEASE. : Cl. Features: resting tremor, rigidity, bradykinesia, posture, gait. DD: Essential tremor, drug induced Parkinsonism,
    Refer to neurologist for confirmation of diagnosis. Mx: Depend of degree of disability, age of pt, and social, occupational or recreational demands.
    What are causes? Can this man swim, drive, cross the road? What would you do if you know this man came to your surgery driving? How to decide if a person can still drive is not clear-cut, as ability to drive is not clearly linked with Parkinson’s symptoms. The most straightforward way of deciding is when the person with a Parkinson disease decides for himself or herself that it is a time to give up driving. Those who do not give up their driving should adopt strategies to drive at the times and in condition that were less dangerous. Use common sense when you driving. Driving at highways or city driving may not be as safe as driving short distances to and from home.

    Parkinson’s disease : syndrome of tremor, rigidity, bradykinesia (slowness)- is a common extrapyramidal disease of middle to old age. Also known as a “shaking palsy†There is degeneration of substantia nigra and its pathway, results in dopamine deficiency and relative excess of cholinergic transmission in caudate nucleus and putamen, which causes excessive supraspinal excitatory drive. Look for lack of facial expression /mask-like facies. The posture is characteristically flexed. Gait - Ask pt. To rise from chair, wa
  15. 37. 73 year old man, presented in your GP asking you to write a letter to the housing authorities, because he wants to move from his unit. He complaints that neighbours disturbing him. He is pensioner. Past medical history of dermatitis.
    Non-smoker, non-alcoholic. No history of substance abuse.
    Q: Why you want to move? A: You know, my neighbours, always talk about me, they probably plotting against me.Q: How long does it last? A: 2 –3 months. I talked to police but they did not offer me any help. Q: Are you sure that they are plotting against you? A: Yes doctor, I am 100 % sure. Q: Can you hear any voice when no one is presented? A: Yes I can hear my neighbours’ voice. Q: Can you see anything that nobody can see? A: No doctor. Q: Do you think you have extra….? A: No Q: How is your mood? A: It is all right. Q: Are you feeling depressed? A; No Q: Do you worry too much about your daily life? A: I worry only about those neighbours, nothing else worry me. Q: Have you ever visited psychiatrist? NB. 3 years ago, he had trouble relating to his job, so he visited psychiatrist. Q: What treatment he gave to you? A: Just drugs for anxiety and relaxation. Cannot remember name of drug. Q: How long you living on current address (unit)? A: 3 months Q: Where are you lived before? Why you moved? A: Because I had some trouble with neighbours
    No other medical problems. Divorced, 24 years ago. F/H: does not know
    Q: Doctor do you know what is happening with me?
    A: I would like to do some investigation. FBC, U&E, SLE ( ANA, DNA) LFT
    Q: Why? I would like to exclude the chronic medical condition like hypothyroidism, SLE A: I would like to examine: Thyroid Anaemia Respiratory (any basal crackles) CVS Liver Spleen Pedal oedema Q: Doctor, Tell me my diagnosis?
    A: Before diag. I would like to exclude general medication, substance abuse. Also, I would like to talk to the police, neighbours. But at the moment my provisional diagnosis is: SCHIZOPHRENIA D/D: in younger patients consider drugs induced /amphetamine, temporal lobe epilepsy (when condition is brief and where is a evidence of clouding of consciousness), and in older pt. organic brain disease should be excluded as a delirium, dementia, depression. A: I would like to refer you to psychiatrist. I will write referral letter. What is a cause of SCH? What is dopamine theory of SCH? A SCH like disorders can be induced by amphetamine a drug that increase dopamine functions. It is therefore possible that the pathophysiology of SCH involves a disorder of dopaminergic function. However there is a little evidence that abnormal dopaminergic transmission is the cause of SCH. It is currently thought that SCH is neurodevelopment disorder possibly interacting with environmental factors.

    SCH : a disorder characterised by psychotic symptoms such as delusions/usually (but not always) false beliefs and hallucination predominantly auditory/hearing voices. Three types of auditory hallucinations  audible thoughts (hearing one’s own thoughts spoken out loudly), voices heard arguing (usually two or more) and voices giving a running commentaries on the pt’s activities. Symptoms include mixed up thinking /called thought disorder, mixed-up feelings/felling unreal, erratic or bizarre behaviour, and/or volition -apathy and withdrawal. The person has little or no insight into the problem and will often claim that there is nothing wrong. Lack of insight is most common symptoms ~ 97%, then hallucinations ~70%. The most frequent behaviours, social withdrawal ~74 %. Sufferer is unable to distinguish his internal from the outside world. The affected person appears to become withdrawn, vague, and unable to converse normally and logically, unable to answer questions normally. Emotions will appear flat and inappropriate such as laughing at something sad or serious or crying without cause. The person may start neglecting own personal appearance. Abnormalities of pregnancy and labour increase risk of SCH (premature rupture of membranes, low birth weight). Also association with a low social class/social deprivation- Homeless increased risk. General population risk = 1%, one parent with a SCH 10-15%, both parents ~ 40%. Hx. Have you ever heard people speaking when there is no one around? Do you ever hear voices? Have you heard your thoughts out loud? Have you felt people may be against you? Have you felt that TV or radio sens you messages? Do you ever felt that someone spying on you or plotting to hurt you? Mx : Is hospital admission is needed? Treat acute symptoms with neuroleptic (when oral medication is possible and sedation is desirable)– Phenothiazine / Chlorpromazine 100-200 mg /3-4 times daily PO. These usually reduce hallucinations and delusion within 3 weeks but SE: tarditive dyskinesia, apathy, drowsiness, parkinsonism, weight gain, impotence, and rash, jaundice. When oral medication possible but sedation is not necessary or desirable. Chlorpromazine is not recommended for long-term use because of photosensitivity reaction. Haloperidol 5-10 mg bd/PO. When parenteral medication is required – Haloperidol 5-10 mg IV or IM initially up to 20 mg/24 hours. ADD Benztropine 1-2 mg IV or IM (to avoid dystonic reaction).Long-term antipsychotic medication (for chronic SCH) Haloperidol or Thioridazine. If compliance is problem, use Depot preparation  Fluphenazine decanoate 12.5 –75 mg/ every 2-4 weeks. Drug-resistant SCH – consider other causes eg. substance abuse, ECT may help in catatonic pt. and when there are severe depression symptoms associated with. Consider trial of Clozapine monitor blood –agranulocytosis. CI : pt. with myeloproliferative disorders). +ve symptoms/delusions, hallucinations and thought disorders.-ve sy /poverty of thought, apathy, inactivity, social withdrawn and loss of affect.

    38. A university student brought by her parents to the emergency department. She is not sleeping for last couple a days, she is very agitated. She said she had important information for the USA President and CIA about terrorist attack. TASK: Take history and asses her mental state in 6 minutes and give your Dg and DD in 2 minutes.
    Dx. PARANOID SCH

    Does she has persecutory delusions? (Persecutory delusions are common but not specific for SCH). Less common but of greater Dx. significance are delusions of reference (false beliefs that objects, events or people have special personal significance,), delusion of control (the feeling being controlled by an outside agency) and delusions about possession of thought (the idea that thought are being inserted into or withdrawn from the person’s min or broadcast to other people).


    39. A 65-year-old man feeling down - depressed, diagnosed with a schizophrenia taking Haloperidol for last 12 years. He has tremor at rest and lower lip tremor as well. Task: Explain side effect of therapy for Schizophrenia.
    “Typical†antipsychotics/Haloperidol- bind strongly to dopamine D2 receptors and likely to cause movement disorders. Newer “atypical†antipsychotic/Clozapine, Olanzapine, Risperidone-less likely to cause movement disorder and do not cause hyperprolactinemia. ( Psy.340).
    Extrapyramidal ( Antidopaminergic ) effects of antipsychotic drugs:
    • Acute dystonia - occur soon after the treatment begins (days). It is most frequent with butyrophenones and phenotiazines. Clinical features: torticollis, tongue protrusion, grimacing and Oculogyric crisis-ocular muscle spasm and opistotonus-fixed upward gazing of the eyes; “the look-upsâ€. Mx. is with swiftly effective parenteral anticholinergic such as benztropine 2mg IM or IV. If no response dose should be repeated within 30 minutes. Anticholinergic drugs are then continued for a week or longer afterwards. (Anticholinergic antiparkinsonian drugs - benztropine, procyclidine, benzhexol [effective for tremor and rigidity] can cause anticholinergic delirium ACD- agitation, confusion, motor restlessness, dysarthria, myoclonus, hallucination/ visual and convulsions. Systemic manifestation of anticholinergic sy are tachycardia, dry mouth, fever, dilated and sluggishly reactive pupils, blurred vision, reduced or absent bowel sounds with ileus and urinary retention.Mx. Physostigmine salicylate/anticholinesterase inhibitor for uncontrollable ACD, 1-2 mg. Slowly IV over 2-3 minutes. If a toxic response to physostigmine occurs/bronchoconstriction, bradycardia, convulsion reverse it with atropine sulphate(antimuscarinic) 0.5 mg for every 1 mg of physostigmine. If no response repeat after 30 min.
    •Tardive dyskinesia (involuntary movement) puckering of the lips and tongue, chewing and sucking movements, writhing of the arms or legs, akathisia, grimacing). It is late complication of antipsychotic treatment, after many years . It occurs in ~ 15% pt. on long-term treatment. Since it does not always recover when drug is stopped and respond poorly to treatment, prevention is important, keep the dose and duration to the effective minimum.
    • Parkinsonism- is a syndrome of tremor, rigidity, bradykinesia (slowness) and difficulty in stopping and starting walking. Tremor most marked at rest and coarser than cerebellar tremor. Pill rolling. It starts a few weeks from starting the treatment. Parkinson disease is one cause of parkinsonism. Other causes of parkinsonism: neuroleptics(metoclopramide, haloperidol), arteriosclerosis, carbon monoxide poisoning, Wilson’s disease, rare cause is Steel-Richardson-Olszewski sy/absent vertical gaze + dementia. Mx. of drug-induced parkinsonism: it may be unwise to reduce or stop the drug eg. in SCH where relapse can be catastrophic, so try an antimuscarinic i.e. procyclidine 2.5 mg/8h PO. • Akathisia – unpleasant feeling of physical restlessness and need to move. It stars usually in the first two weeks of the treatment. Generally, disappear when dose reduced.• Neuroleptic malignant syndrome- is rare but extremely serious effect. Fluctuating level of consciousness, hyperthermia, muscular rigidity, autonomic disturbance.. Mx. symptomatic, stop the drug cool the pt, fluid balance, No drug proven effectiveness. It is a serious condition, about fifth of pt. die. Other unwanted effects of typical antipsychotic: Antiadrenergic effects/Postural hypotension, Nasal congestion, Inhibition of ejaculation Anticholinergic effects/Dry mouth,  sweating, urinary retention, constipation, blurred vision. Other/arrhythmias, weight gain, amenorrhea, galactorrhea, hypothermia,

    40. 45-year-old taxi driver presented to your GP. C/O: Two days ago pain, redness, swelling, in the right big toe. You diagnosed him GOUT.
    Mx: Indomethacin 25 mg/ tds. You asked for uric acid level. Level was – 0.75
    Patient is smoker, 15 cig/ day, drinks 5 –6 standard beer / day. Moderately obese, uric acid level = 0.75.Has hypertension and taking diuretics (no thiazide, B-blockers).
    Task: Discuss about investigation results & take any relevant history Discuss future management plan. • Condition improved• I explained him gout • Explain how
    Indomethacin helps • After reducing inflammation I will star allopurinol? Why? Explain

    GOUT - crystal arthritis (monosodium urate crystal disease). Is abnormality of uric acid metabolism resulting in hyperuricemia and urate crystal deposition in- joints (acute gouty arthritis), soft tissue (tophi), urinary tract (urate stones). Predisposing factors: FH, obesity, excess alcohol intake, high purine diet, diuretics (frusemide, thiazide diuretics), infection, and leukaemia. May be associated with  risk of HTN or CHD, so screen pt.( check BP).
    Elevated serum uric acid (>0.42 M and >0.36 mmol/L F). Clinical features of acute gout  excruciating pain in the great toe, early hours of morning, red, hot skin over the joint. ) Pt. may have fever Dx:  serum uric acid (up to 30% may be normal). Resolves in < 2 weeks often 2-7 days if treated. The definitive Dx – synovial fluid aspirate –revealed sodium monourate crystals. X-ray shows punched out erosions at joint margins, periarticular erosions, normal joint space but those Ix are not routinely needed. MX. of acute attack - Rest joint, NSAID ( eg. Indomethacin 100mg PO statim, 75 mg 2 hours later, than50 mg tds for 24-48 hours. Caution if PMH of GI problems) or Colchicine 1mg statim PO then 500 mg every 2-3 hours until pain relieved or SE: nausea, vomiting or diarrhoea).NB. Avoid Aspirin! Prevention:  weight, normal diet, avoid alcohol excess/wine and beer, avoid purine rich food (offal, red meat, yeast, oily fish/anchovies, sardines,). Drug prophylaxis - for recurrent attack, for tophi, renal stones or hyperuricemia  Allopurinol 100-300 mg /daily. Commence a 4 weeks after last acute attack. Check uric acid levels after 4 weeks, aim for < 0.38 mmol/L. Add Colchicine 0.5 mg bd for 6 months (to avoid precipitation of the gout).Repeated attacks may accelerate joint damage. Chronic gout  recurrent attack, tophi in pinna, tendons and joints – refer to rheumatologist for on-going treatment. Prescribing NSAID’s- Drugs are for the relief of the symptoms only. On good days, none may be needed. Abdominal pain may be sign of gut problem, stop the tbl. and come for advice. Ulcers may occur with no warning – report black motions at once. Don’t supplement prescribed NSAID’s with ones bought OTC (eg. Ibuprofen). Mixing NSAID’s can increase risk 20 fold. Smoking and alcohol increases NSAID’s risk.
    Pseudo gout (Calcium pyrophosphate deposition).
  16. 41. A young man, comes with his 75 y.o. father who suffering from dementia. He is a professional (lawyer) very busy and he has no time to take care of his father. Father is very sick now, he cannot handle it. TASK: Discuss Mx with his son.
    Dx. DEMENTIA , Depression



    41A. Management case: Patient with ALZHEIMER DISEASE. His son came to you for advice regarding his father
    Question from the Examiner: What you are going to tell family regarding his disease? What is by definition Alzheimer disease? It is a special type of dementia in which there is wasting of some brain cells, the cause of which is uncertain. It is a progressive disease. What are causes of dementia? Dementia is generalised impairment of intellect, memory and personality with NO impairment of consciousness. Dementia is a general term to describe problems with memory and thinking. Prevalence  with age. Causes: Commonest Alzheimer, Multivascular infarct dementia (multiple lacunar infarcts cause generalised intellectual impairment), Lewy bodies dementia (fluctuation but persistent cognitive impairment, Parkinsonism and hallucination. No specific treatment) Pick’s disease alcoholism (B12, thiamine, folate = , hypothyroidism. What drug you will give? Donezepil or Rivastigmine .New drug Galantamine Explain to family how to manage him at home. What daily activities he can do? Can he go outside? There is always the likelihood of accidents with household items such as fire, gas, kitchen knives and hot water. Accident at toilets, in the bath or when crossing roads may be a problem, esp. if dementia is combined with failing sight and hearing. Generally speaking, such people should not motor vehicle. Talk about driving at the end of consultation if pt. or family member did not bring it up. A person with dementia may have difficulty judging distance or direction when driving a car. Always assess a level of support in the home. They should have proper supervision, because they are likely to eat less, neglect their body and develop medical problems/skin ulcers, infections. They need tender, loving care group. I would like to suggest specialised assessment service through local Aged Care Assessment Team (ACAT) or private a consultation with a neurologist, psychiatrist or geriatrician. . Alzheimer Association NSW can refer you to ACAT. They offering support and education program called Living with Memory Loss for pt. and family. Legal and financial matters should be attended to as early as possible when family member has dementia/professional and legal advice regarding Will, Enduring Power of Attorney, and Guardianship(When person is incapable to make decision on his own) etc. Also we can arrange respite care for him? What is that doc? Respite care is a services provided by hostels, nursing homes, local authorities and sometimes hospital. It is a like short break/holiday where they are providing nursing care assistance of ADL, socialise and diversional Th. We can also arrange for him residential respite care, so carer will come to your dad home and help him with daily activities.

    Alzheimer disease  most common form of dementia. About twice is common in the women .Can be divided in clinical stages: The early stage is characterised by short memory loss. In the intermediate stage  pt., become unable to learn and recall new information. Memory of remote events is affected but not totally lost. Pt. may require assistance with bathing eating, dressing etc. In the severe stage  pt. are unable to walk or to perform any activity of daily living, usually totally incontinent. Placement in the long term care facility is often necessary, because they become totally dependant on others for care. The end stage  of Alzheimer’s disease is coma and death usually from infection. Causes of Alzheimer: Unknown, defective genes found on chromosomes 14,19,21 so genetic risk factors. Risk factors: FH, Down’s sy. Life span limited ~ 8-10 y. from onset. Mx. Donezepil /Aricept  5mg/24 hrs. at night, ( anticholinesterase inhibitor/preventing the breakdown of acetylcholine).Rivastigmine/Exelon 1.5 mg bd SE: GI predominantly. The new drug Galantamine (Reminyl). When to start therapy? When MMSE <24
    DD: Depression, hypothyroidism, meningioma, HIV
    Ix.  Should include test for reversible/treatable causes of dementia such as hypothyroidism/T4 and B12 deficiency, VDRL/ syphilis, HIV (if at risk). FBC/ MVC (macrocytosis suggest alcoholism or B12 or folate deficiency) ESR (suggest malignancy), U&E, LFT, GGT, Ca (renal/hepatic failure, malignancy, endocrine causes leading to Ca, T4. CXR (for malignancy) glucose, A CT scan is required to exclude intracranial lesions such as hydrocephalus and meningioma, which may present with a slow onset of dementia or subdural haematoma. Refer to psycho geriatrician for confirmation of Dx, and assessment. Refer to social worker, community support Support carers. Mx. of memory loss- notebook to records “ tasks must doâ€; medication dispenser.
    Dx is usually base on history, lab. Test and exclusion of other causes of dementia. Mini- mental state examination (MMSE): should be performed how do you do? What is your memory like these days? Do you mind if I test it? Orientation (What is a year/season/date/day/month? Score 1 point for each correct answer. Max 5). Where we are? (Country/state/town/hospital/ward). Score 1 point for each correct answer. Max 5.

    Registration What I want to do is give your three things I want you to remember for me. First, I want you to repeat them and in the few minutes, I will ask you how many you can recall. Could you remember it for me; Melbourne , Cricket, Blue .Now first repeat them (Score number of attempts. Correct First try=3 points, Second try=2 points etc). Max 3. I would like to get you to do some things, which interfere with your memory. Attention and Calculation. Could you count loud from 1- 20? Now backwards. Can you spell the word – WORDS for me? Could you spell it backwards? (Score 1 point for each letter in correct order). Max 5. Recall: Now what were those three words I asked you to remember for me? (Score 1 point for each correct answer, Max 3). Language: Sometimes the older people having a trouble remembering the word, right word. Does that ever happen to you? OK. What do you call this? (Show him pen) Score 1pt. Watch. Score 1point. Could you repeat: NO IFS, ANDS OR BUTS. Score 1 point. Could you pick up this paper with you right hand, fold it in half, and put it on the table. Score 3-point max. Can you read what is written on the paper and do what it says? CLOSE YOUR EYES ( written in large letters).Score 1 point. Can you write sentences for me/? Score 1 point. Visuospatial skills: Can you make copy for me? Pentagon. All 10 angles must be presented and two must intersect. Score 1 point. TOTAL= Max 30.Probable cognitive impairment <24
    Definite cognitive impairment <17. Mild Alzheimer ( mild MMSE 18-26). Moderate Alzheimer’s (moderate MMSE 10-17)

    42. Diagnostic case: Young man came to see you. Returned from overseas trip recently. He has RUQ abdominal pain, tenderness & fever. Pain is localised (not radiating) grade 7 (from 1-10). O/E: severe pain, fever, tachycardia. Vital signs: Respiratory & BP = Normal
    P/H: Hepatitis 20 years ago Non-smoker, non-alcohol, no drugs. Examiner asked: What will be your provisional differential diagnosis without investigations?
    A: Probably Acute Cholecystitis (gall bladder empyema) How he gets it? Obstruction of the neck of gallbladder by stone. Bacteria are cultured from the bile in approximately one half –patient with gallstones and unrelieved obstruction may cause an empyema, the common organisms implicated are E.coli, Klebsiella and Streptococcus faecalis. (D/D) Then I asked: Is Murphy sign positive?
    Examiner: You can’t Asses Murphy sign, pain is so severe. Examiner: What investigation you will do? A: X-ray, US, LFT

    Acute cholecystitis  follows stone impaction in the neck of the gall bladder which may cause continuous epigastric / RUQ pain, vomiting, fever, local peritonisms or a GB mass. The main difference from biliary colic is the inflammatory component (local peritonism, fever, WCC ). If stones move to CBD jaundice may occur. (Obstructive jaundice-conjugated bilirubinemia, GGT and ALP , / pale stool & dark urine). Murphy’s sign: Lay 2 fingers over the RUQ. Ask pt. to breathe in. This causes pain and arrest of inspiration. It is only positive if same test in LUQ does not cause the pain. Ix. US/most helpful Ix at this stage (thickened GB wall, pericholecystic fluid and stones). HIDA cholescintigraphy (reveals a blocked cystic duct). LFT are often done in assessment of the pt. with acute cholecystitis (conjugated bilirubinemia, GGT and ALP  suggest a bile duct stone) Mx. patient is admitted to hospital, nil by mouth, NG tube if vomiting, pain relief (Morphine), IV fluids and antibiotics (Cefuroxime 1.5 gr/8 hr IV).The majority of pt. settle on this regimen within a few days. Failure to settle suggests empyema. Some surgeons delay operation for 2-3 months after the attack in expectations that the acute inflammatory reaction will have resolved by then, but many now prefer to do cholecystectomy during the same admission and within 72 hours of attack.
    Cholangitis  (bile duct infection) causing RUQ pain, jaundice and rigors. Cefuroxime (as above) + Metronidazole 500 mg/8 hr PR. Complications of gallstone; in gall bladder: Biliary colic, acute and chronic cholecystitis, Empyema, Ca In the bile duct: obstructive jaundice, pancreatitis (serum amylase ) , Cholangitis. In the gut: Gall stone ileus.

    NB. Biliary colic net pain relief. Cholecystitis/cholangitis need pain relief + antibiotics.
  17. Guest122

    Guest122 Guest

    I love this Good -Samaritian whoever he/she is.
    Common, give us more before next AMC exam.

    I wish you all the best.
  18. YilYoung

    YilYoung Guest

    This is very helpfull.
    Please, put more previous papers on this web site, I am 100 % that people have a huge collection of previous exam papers .
    We can beat a discriminatory & unfair Australian Medical Council Exam on this way only.
    After reading all this previous questions I simply can not believe what did they ask on this exam. Not many staff specialist will know answer.

    YY
  19. gorani

    gorani Guest

    all of the following are the signs of Ischaemia of the lower limb EXCEPT:
    A .Ulcer at Halluces
    B .Intermittent claudication
    c .Rest pain
    d. Ulcer above medial malleolus ***
    e .Hair loss on lower limb

    2. A painful lump in the groin of sudden onset in an otherwise healthy young man is MOST LIKELY to be?
    a. Direct Inguinal hernia
    b .Indirect Inguinal hernia
    c .Femoral hernia
    d. Enlarged groin lymph node
    e. Spigelian hernia
    i'll go for indirect inguinal hernia(more likely to strangulate)..dont know abt spigelian hernia..

    3.A patient had undergone a partial gastrectomy 24 hours ago. His fluid input is 2 Lt and urineoutputs is 2 Lt., Naso gastric aspiration- 700 ml and drain 500 ml. His K is 3.5, Na 130 and Cl is 80.Which of the following is the MOST appropriate fluid replacement regimen?
    a..2L N. saline + 1L 5% Dextrose + 50 mmol KCI
    b.2L N. saline + 2L 5% Dextrose + 50 mmol KCI
    c.3L N. saline + 1L 5% Dextrose + 50 mmol KCI
    d.3L N. saline + 2L 5% Dextrose + 100 mmol KCI****
    e.2L N. saline + 2L 5% Dextrose + 100 mmol KCI
    agreee

    4. A 46 years old woman had left mastectomy done for breast cancer two years ago.Now she comes to you with a painless, firm and mobile lump in her right breast. She is otherwise well. What is the MOST LIKELY diagnosis?
    a.New primary cancer in the right breast
    b Metastases from the previous breast cancer ***
    c.Benign growth
    d.Metastasis from another malignant tumour elsewhere
    e.Lymph node swelling

    there must be some remnants left which gave rise to metastasis
    5. An X ray showing dislocation of shoulder. Which of the following is CORRECT?
    a. Posterior Dislocation of the shoulder.
    b.Sensory loss of the lateral aspect of the arm.**
    c.Weakness of the hand
    d.Sensory loss of the medial aspect of the arm.
    e.Fracture of the Humerus

    6 Which of the following is MOST suggestive of disruption of deep layers of a post operative abdominal wound?
    a. Persistent pain in wound
    b.serosanguineous discharge
    c. Persistent abdominal distension
    d.Gaping in the skin after the removal of the sutures ***
    e.Unexplained fever and tachycardia
    not sure
    i want to disuss about IUGR in gest. DM -
    WILLIAM'S obstetrics says that there in unexplained fetal demise not known to be due to causes like IUGR,placental insuffeciency etc.
    so guys there is "NO IUGR" in gest DM

    PAED
    A 14 years old girl has breast enlargement, normal growth of pubic and axillary hair but she is still
    not menstruating. Which of the following is CORRECT?
    a.She is likely to start menstruating two years after the start of pubic hair growth
    b.She is likely to start menstruating two years after the start of axillary hair growth
    c.She is likely to start menstruating within two years from the time of her breast budding.
    d..She is likely to start menstruating within two years from growth spurt.
    e.This is a case of delayed puberty ***
    thelarche is first to come(which has already developed).last to develop is menarche..so this is a case of pubertal delay


    A 16 years old girl presents with fever, headache and rash on her body. She also has profuse bleeding from all venipuncture sites. What is the MOST probable diagnosis?
    a.Thrombocytopenia
    b.'Disseminated Intravascular coagulation
    c.Henoch Schonlein Purpura ***
    d.Allergic reaction
    why fever in thrombocytopenia?moreover age group belongs to HSP.also know that HSP is one the most common cause of purpura in this age group

    A 12 months old baby has fever. Recently, two other family members had an upper respiratory tract infection. On examination of the baby you find that his body temperature is 37.5 CTand chest auscultation reveals bilateral wheezing. What is the MOST LIKELY cause?
    a.Acute bronchiolitis ***
    b.Viral croup
    c.Bronchial Asthma
    d.Pneumonia
    e.Foreign body
    age group suggests it

    A neonate with cough and fever is found to be grunting. Chest X ray shows round lesions with little pleural effusion. Which of the following is the BEST the treatment?
    a.Crystalline Penicillin ??
    b.Gentamycin
    d.Amoxicillin
    e.Flucloxacillin ***
    as staph is common cause of pneumonia in this age grp.Plz correct me

    A ten years old girl has a history of repeated episodes of hemiparesis from which she recovers completely. What is the MOST LIKELY diagnosis?
    a.Middle cerebral artery occlusion
    b.Petit mal epilepsy **
    c.Migraine ??
    d.Subarachnoid haemorrhage
    migraine is unlikely in this age grp but it rarely presents with hemiparesis...can hemiaparesis be present in petit mal epilepsy..if yes then this is the answer


    The parents with their 10 years old child come to see you with complaints that the child has enuresis since birth. The child has no problems during the day time. Physical examination does not reveal any other abnormality. Which of the following statements is TRUE in more than 20 % of such cases?
    a.He has chronic pyelonephritis
    b.He has congenital abnormalities of the urinary tract
    c.There is an associated family history ****
    d.he has small urinary bladder.
    e.It is associated with spina bifida occulta

    enuresis is frequently found in patients with disturbed family env.

    A 5 years old boy presents with vomiting every morning and morning headache for the last two weeks. What is the MOST LIKELY cause?
    a.Meningitis
    b.Migraine
    c.Craniopharyngioma **
    d.MeduJloblastoma
    e.Wilm's tumour

    will check and tell but most likely the ansewer is craniopha..

    An adolescent boy complains of slight pain in the right knee which gets worse after exercise. On
    examination you find a lump on the tibia tubercle with slight tenderness. The boy can't remember if
    he has had any recent trauma. Which of the following statements is CORRECT?
    a.Reassure that there is nothing wrong
    b.Biopsy should be done to exclude malignancy ***
    c.Knee aspirate shows organism
    d. Osteochondritis is the most likely cause


    A 6 day old baby who is suspected to have Down's syndrome presents with non projectile bilestained vomiting for the last two days. On abdominal examination you find an olive shapedpalpable mass in the epigastrium. Which of the following is the MOST LIKELY diagnosis?
    a.Volvulus
    b.Duodenal Atresia.***
    c.Intussusception
    d.Malabsorption

    A two years old child presents with failure to thrive for the last 6 months and right buttock wasting. He passes bulky stools 2-3 times a day. Which of the following is the MOST appropriate investigation?
    a.C13 breath test
    b.Duodenal biopsy ***
    c.Stool culture
    d.Stool microscopy
    e.Sweat test

    A diabetic mother gives birth to a child weight 4240 gm and with an Apgar score of 7/10. On examination you find cyanosis of his hands and feet and the child is jittery. Axillary temperature measure shows a reading of 37.2 C. His condition improved after meconium aspiration and 100% O2. Which of the following is the MOST LIKELY cause?
    a.Hypoglycaemia
    b.Heart disease ***
    c.Lung disease.
    d.Hyperglycaemia
    e.His jaundice is caused by breast milk.

    cyanotic heart disease may be the cause which is common in baby of diabetic mother

    A six years old boy presents with delayed development of speech after a period of normal development. On examination you find that he avoids eye contact and reveals a history of unusual liking for dinosaurs. Which of the following is the MOST LIKELY diagnosis?
    a.Autism ***
    b.ADHD
    c.Deafness
    regression of normal milestones which are already developed is a feature of autism

    A young woman with anovulatory cycles for the long time is MOST LIKELY to develop which of the following?
    a.Cervical cancer
    b.Endometrial Cancer
    c.Ovarian cancer ***
    d.Vaginal cancer
    e.Cancer of the Vulva


    In which of the following conditions you will find DECREASED amniotic fluid?
    a.Foetus's Bladder neck obstruction of the foetus(renal agenesis)
    b.T.O fistula
    c.Rhesus incompatibity
    d.Multiple pregnancy
    explanation-since baby bathes in amniotic fluid it absorbs and excrets only amniotic fluid.so in renal agenesis no urine is produced therefore amniotic fluid is reduced(oligohydramnios)..in esophageal atresia amniotic fluid is not absorbed causing polyhydramnios


    A 52 years old obese post menopausal woman presents with no signs of Menopause and amenorrhoea. What could be the cause?
    A Low oestrogen and Low FSH
    B High oestrogen and high FSH
    c. Normal oestrogen and high FSH
    d.High oestrogen and low FSH ***
    e.Low oestrogen and High FSH

    since hot flushes and other symptoms are produced due to high amt of FSH..here the case is revrsed

    A 16 years old student asks for a prescription for contraceptive pill. She says she doesn't have sexual partner. Which of the following is the MOST APPROPRIATE management?
    a. Oral contraceptive pill
    b.Minipill
    c.Depot
    d.Oral contraceptive pill + condoms
    e.Call her parents.

    why does she need a contraceptive pill if she has no partner????
    ocp is the best bet for emergencies

    A pregnant woman in 1st trimester is found to have CIN III. What is your NEXT step?
    a. Terminate the pregnancy
    b. Cone biopsy
    c.Hysterectomy
    d.Colposcopy
    e.Observe

    not sure

    14. A pregnant woman in 1st trimester presents with skin dimpling over the right breast. Examination and clinical tests reveals cancer of the right breast. Which of the following is your management?
    a.Terminate the pregnancy
    b.Start radiotherapy
    c.Wait till delivery and then start the treatment ???
    d.Surgery

    if dimpling is present it means it is T4..why surgery if T4...

    A 19 years old female comes to your clinic for consultation. She has never had periods. On examination her breast development is normal. Pubic and axillary hair growth is also normal. The
    development of her genitals is also in normal range. What is the MOST LIKELY cause of her amenorrhea?
    a. Turner's syndrome
    b. Prolactinoma
    c. Absent uterus ***d. Pituitary lesion
    e. Lesion in Hypothalamus

    you cant be sure whether it is imperforate or not

    A 42 years man who is a patient of yours is arrested for attacking his wife in a supermarket. The police come to you and ask you to write a report about this patient. Which of the following is TRUE for good practice?
    a.You will write a report about the patient's bad mental state
    b.You will tell the patient never to come to your surgery again
    c.You will write a general, unbiased and balanced report about health of the patient.
    d.You will tell the police that you don't want to give any reports
    e. Arrange for a meeting with the patient

    please tell me where to read ethics from guys!!!

    Which of the following will cause SEROTONIN syndrome if given together with SSRI like Fluoxetine EXCEPT?
    a.L-tryptophan
    b.Haloperidol
    c.Moclobemide
    'd. Chlorpromazine
    e.Citalopram

    no idea...what is sertonin syndrome

    In Australia , almost every year there are several incidences of bush fire. Usually it is caused by
    young people and teenagers. Which of the following is TRUE?
    a. Juvenile pyromania is the main cause of fires in Australia . ****
    -b. It is due to accidental fire caused by youngster who get scared after the fire starts to
    spread uncontrollably and they run away.
    c.It has no serious consequences
    d.Youngsters like to ignite and play with fire.
    e.It is done to hide crimes

    A schizophrenic woman thinks that she is perfectly well and denies any illness. She also refuses to
    take medication and thinks that she can talk with Angels. What is this called in Psychiatry ?

    a.Lack of insight
    b.Overvalued idea
    c.Rejection
    d.Delusion
    e..Formal thought****









    which is the best nerve in grafting?
    a) median nerve ***
    b)radial nerve
    c) digital nerve
    thicker nerves are better for grafts


    patient presents with sudden rupture of extensor pollicis longus tendon,dx?
    a) tendonities***
    b) tenosynovitis
    c) RA
    not very sure but more likely

    A patient with cancer breast develop osteoprposis.what is the treatment
    a) bisphosphonate ***
    b) cyclical estrogen and progesterone
    c) continuous estrogen and progesterone
    increase diatery calcium 2000g / day

    You are called to review a patient who developed restlessness and difficulty breathing eight hours
    after thyroidectomy. What will you do FIRST?
    a. Endotracheal intubation.
    b.Remove superficial sutures
    c.Remove superficial and deep sutures ***
    d.Salbutamol inhalation as patient probably has Asthma

    A 43 years old man was brought to the emergency department with severe upper abdominal pain
    and signs of shock. Physical examination reveals abdominal wall rigidity and guarding. Which of
    the following is the MOST LIKELY Diagnosis?
    a.Perforated gastric ulcer ***
    b.Penetrating duodenal ulcer
    c. Mesenteric ischemia
    d. Acute pancreatitis

    patient is in shock with upper abdominal pain..guarding and rigidity is suggestive of peritonitis..

    A young male fell from a height but sustained minor injuries. After two hours he lost
    consciousness and was brought to you in Northern Queensland hospital with limited radiographic
    facilities by his friend. On examination you find that his pupils are fixed and dilated. What is our
    NEXT step?
    a.Arrange for transportation to another hospital by helicopter.
    b.Give IV mannitol
    c Give IV corticosteroid d. d Burr holes ***
    case of EDH


    An elderly man came to see you with complaints of sudden pain in the lower back while lifting a heavy box. On examination you find that the lumbar spine has limited movement with pain in his lower back on movement. There are no neurological abnormalities. What is the NEXT investigation that you'll do?
    a.X Ray of the lumbar spine ***
    b.CTScan
    c.MRI of the spine
    d.Lumbar puncture

    A 70 years old woman had Upper GIB. She was on treatment with NSAID for knee pain which was
    stopped a few months ago. You do an endoscopy of upper Gl tract and find a duodenal ulcer with
    recent bleeding. What is the BEST management?
    a.Omeprazol I.V. + Ampicillin + Metronidazole ***
    b.Omeprazol I.V.
    c.Highly selective vagotomy
    d.Vagotomy
    e.Ranitidine I.V. + Ampicillin + Metronidazole

    highly selective vagotomy will only stop the acid secretion.ideally somatostatin infusion or application of adrenaline locally should be done otherwise conventional therapy for ulcer is recommended

    Which of the following is MOST COMMON cause of acute pancreatitis?
    a.Gallstones,
    b.Cholecystitis
    c.Alcohol abuse ***
    d.Spicy food
    e.Gastroenteritis

    What is the MOST COMMON cause of death after burn injury in Australia ?
    a.Shock***
    b.Respiratory failure
    c.Cardiac failure
    d.Renal failure
    most likely hypovolemic shock


    patient presents with sudden rupture of extensor pollicis longus tendon,dx?
    a) tendonities
    b) tenosynovitis
    c) RA

    Probably

    A patient with cancer breast develop osteoprposis.what is the treatment
    a) bisphosphonate
    b) cyclical estrogen and progesterone
    c) continuous estrogen and progesterone
    d)increase diatery calcium 2000g / day

    obvious choice

    You are called to review a patient who developed restlessness and difficulty breathing eight hours
    after thyroidectomy. What will you do FIRST?
    a. Endotracheal intubation.
    b.Remove superficial sutures
    c.Remove superficial and deep sutures
    d.Salbutamol inhalation as patient probably has Asthma

    This is hypoparathyroidism secondary to surgery leading to hypocalcemia and eventually life threatening laryngeal edema


    A young male fell from a height but sustained minor injuries. After two hours he lost
    consciousness and was brought to you in Northern Queensland hospital with limited radiographic
    facilities by his friend. On examination you find that his pupils are fixed and dilated. What is our
    NEXT step?
    a.Arrange for transportation to another hospital by helicopter.
    b.Give IV mannitol
    c Give IV corticosteroid d.
    d Burr holes

    This is epidural hemorrhage - so need burr hole operation. Clue - lucid interval followed by unconciousness.

    An elderly man came to see you with complaints of sudden pain in the lower back while lifting a heavy box. On examination you find that the lumbar spine has limited movement with pain in his lower back on movement. There are no neurological abnormalities. What is the NEXT investigation that you'll do?

    a.X Ray of the lumbar spine
    c.MRI of the spine
    d.Lumbar puncture

    Since the patient is more than 50 years of age - this is a red flag sign (Davidson 19th page [snip]). So patent has to be evaluated with investigation. Patient needs both Xray and MRI(Davidson page [snip]). Since it is the next investigation in the question - I go for xray.



    A 70 years old woman had Upper GIB. She was on treatment with NSAID for knee pain which was
    stopped a few months ago. You do an endoscopy of upper Gl tract and find a duodenal ulcer with
    recent bleeding. What is the BEST management?
    a.Omeprazol I.V. + Ampicillin + Metronidazole
    b.Omeprazol I.V.
    c.Highly selective vagotomy
    d.Vagotomy
    e.Ranitidine I.V. + Ampicillin + Metronidazole

    Bleeding has stopped. So now the patient needs treatment for healing of ulcer as well as eradication therapy for H. pylori.

    Which of the following is MOST COMMON cause of acute pancreatitis?
    a.Gallstones,
    b.Cholecystitis
    c.Alcohol abuse
    d.Spicy food
    e.Gastroenteritis

    What is the MOST COMMON cause of death after burn injury in Australia ?
    a.Shock
    b.Respiratory failure
    c.Cardiac failure
    d.?Renal failure

    Its a guess. I assume that being a country with good medical facilities - fluid resuscitation should be available and shock should be treated. But renal failure in burn can be caused by shock, myoglobinuria, hemoglobinuria etc.

    PAED
    A 14 years old girl has breast enlargement, normal growth of pubic and axillary hair but she is still
    not menstruating. Which of the following is CORRECT?
    a.She is likely to start menstruating two years after the start of pubic hair growth
    b.She is likely to start menstruating two years after the start of axillary hair growth
    c.She is likely to start menstruating within two years from the time of her breast budding.
    d..She is likely to start menstruating within two years from growth spurt.
    e.This is a case of delayed puberty

    Reference Robertson page 156


    A 16 years old girl presents with fever, headache and rash on her body. She also has profuse bleeding from all venipuncture sites. What is the MOST probable diagnosis?
    a.Thrombocytopenia
    b.'Disseminated Intravascular coagulation
    c.Henoch Schonlein Purpura
    d.Allergic reaction

    Meningococcal infection leading to DIC

    A 12 months old baby has fever. Recently, two other family members had an upper respiratory tract infection. On examination of the baby you find that his body temperature is 37.5 CTand chest auscultation reveals bilateral wheezing. What is the MOST LIKELY cause?
    a.Acute bronchiolitis
    b.Viral croup
    c.Bronchial Asthma
    d.Pneumonia
    e.Foreign body

    Viral ailment caused by RSV in children leading to wheezing. Some of these children will go on to develop asthma when adult.

    A neonate with cough and fever is found to be grunting. Chest X ray shows round lesions with little pleural effusion. Which of the following is the BEST the treatment?
    a.Crystalline Penicillin
    b.Gentamycin
    d.Amoxicillin
    e.Flucloxacillin

    I am not sure. But considering that E.coli and gm negative organism are the commonest bacterial etiology in this group - I go for Gentamycin.

    A ten years old girl has a history of repeated episodes of hemiparesis from which she recovers completely. What is the MOST LIKELY diagnosis?
    a.Middle cerebral artery occlusion
    b.Petit mal epilepsy
    c.Migraine
    d.Subarachnoid haemorrhage

    Don't know. Anyone?

    The parents with their 10 years old child come to see you with complaints that the child has enuresis since birth. The child has no problems during the day time. Physical examination does not reveal any other abnormality. Which of the following statements is TRUE in more than 20 % of such cases?
    a.He has chronic pyelonephritis
    b.He has congenital abnormalities of the urinary tract
    c.There is an associated family history
    d.he has small urinary bladder.
    e.It is associated with spina bifida occulta

    A 5 years old boy presents with vomiting every morning and morning headache for the last two weeks. What is the MOST LIKELY cause?
    a.Meningitis
    b.Migraine
    c.Craniopharyngioma
    d.MeduJloblastoma
    e.Wilm's tumour

    Morning headache and morning vomiting suggestive of brain tumor. Medulloblastoma is a common childhood tumor

    An adolescent boy complains of slight pain in the right knee which gets worse after exercise. On
    examination you find a lump on the tibia tubercle with slight tenderness. The boy can't remember if
    he has had any recent trauma. Which of the following statements is CORRECT?

    a.Reassure that there is nothing wrong
    b.Biopsy should be done to exclude malignancy
    c.Knee aspirate shows organism
    d. Osteochondritis is the most likely cause

    This is Osgood Schlatter Diseas. It is self limiting. Only conservative treatment is required in most of the cases. Osteochondritis presents with locked knee, knee effusion etc.(John Murtag 739)

    A 6 day old baby who is suspected to have Down's syndrome presents with non projectile bilestained vomiting for the last two days. On abdominal examination you find an olive shapedpalpable mass in the epigastrium. Which of the following is the MOST LIKELY diagnosis?
    a.Volvulus
    b.Duodenal Atresia.
    c.Intussusception
    d.Malabsorption

    Common complication of Down's syndrome

    A two years old child presents with failure to thrive for the last 6 months and right buttock wasting. He passes bulky stools 2-3 times a day. Which of the following is the MOST appropriate investigation?
    a.C13 breath test
    b.Duodenal biopsy
    c.Stool culture
    d.Stool microscopy
    e.Sweat test

    It seems like a coeliac diseas. But only thing that is puzzling is one sided buttock wasting which should be both sided(Robertson clinical example page 571).

    A diabetic mother gives birth to a child weight 4240 gm and with an Apgar score of 7/10. On examination you find cyanosis of his hands and feet and the child is jittery. Axillary temperature measure shows a reading of 37.2 C. His condition improved after meconium aspiration and 100% O2. Which of the following is the MOST LIKELY cause?
    a.?Hypoglycaemia
    b.Heart disease
    c.Lung disease.
    d.Hyperglycaemia
    e.His jaundice is caused by breast milk.

    Hypoglycemia is common in infant of Diabetic mothers, so is polycythemia. Probably the child was jittery due to hypoglycemia. Not sure though.

    A six years old boy presents with delayed development of speech after a period of normal development. On examination you find that he avoids eye contact and reveals a history of unusual liking for dinosaurs. Which of the following is the MOST LIKELY diagnosis?
    a.Autism
    b.ADHD
    c.Deafness
    Obs

    A young woman with anovulatory cycles for the long time is MOST LIKELY to develop which of the following?
    a.Cervical cancer
    b.Endometrial Cancer
    c.Ovarian cancer
    d.Vaginal cancer
    e.Cancer of the Vulva

    In which of the following conditions you will find DECREASED amniotic fluid?
    a.Foetus's Bladder neck obstruction of the foetus
    b.T.O fistula
    c.Rhesus incompatibity
    d.Multiple pregnancy

    A 52 years old obese post menopausal woman presents with no signs of Menopause and amenorrhoea. What could be the cause?
    A Low oestrogen and Low FSH
    B High oestrogen and high FSH
    c. Normal oestrogen and high FSH
    d.High oestrogen and low FSH •
    e.Low oestrogen and High FSH

    A 16 years old student asks for a prescription for contraceptive pill. She says she doesn't have
    sexual partner. Which of the following is the MOST APPROPRIATE management?
    a. Oral contraceptive pill
    b.Minipill
    c.Depot
    d.Oral contraceptive pill + condoms
    e.Call her parents.

    A pregnant woman in 1st trimester is found to have CIN III. What is your NEXT step?
    a. Terminate the pregnancy
    b. Cone biopsy
    c.Hysterectomy
    d.Colposcopy
    e.?Observe

    14. A pregnant woman in 1st trimester presents with skin dimpling over the right breast. Examination and clinical tests reveals cancer of the right breast. Which of the following is your management?
    a.Terminate the pregnancy
    b.Start radiotherapy
    c.Wait till delivery and then start the treatment
    d.?Surgery

    A 42 years man who is a patient of yours is arrested for attacking his wife in a supermarket. The police come to you and ask you to write a report about this patient. Which of the following is TRUE for good practice?
    a.You will write a report about the patient's bad mental state
    b.You will tell the patient never to come to your surgery again
    c.You will write a general, unbiased and balanced report about health of the patient.
    d.You will tell the police that you don't want to give any reports
    e. Arrange for a meeting with the patient

    Which of the following will cause SEROTONIN syndrome if given together with SSRI like Fluoxetine EXCEPT?
    a.L-tryptophan
    b.Haloperidol
    c.Moclobemide
    'd. Chlorpromazine
    e.Citalopram

    Dont know

    In Australia , almost every year there are several incidences of bush fire. Usually it is caused by
    young people and teenagers. Which of the following is TRUE?

    a. ?Juvenile pyromania is the main cause of fires in Australia .
    b. It is due to accidental fire caused by youngster who get scared after the fire starts to
    spread uncontrollably and they run away.
    c.It has no serious consequences
    d.Youngsters like to ignite and play with fire.
    e.It is done to hide crimes

    A schizophrenic woman thinks that she is perfectly well and denies any illness. She also refuses to
    take medication and thinks that she can talk with Angels. What is this called in Psychiatry ?

    a.Lack of insight
    b.Overvalued idea
    c.Rejection
    d.Delusion
    e..Formal thought disorder [/b]


    You are called to review a patient who developed restlessness and difficulty breathing eight hours
    after thyroidectomy. What will you do FIRST?
    a. ENDOTRACHEAL INTUBATION
    b.Remove superficial sutures
    c.Remove superficial and deep sutures
    d.Salbutamol inhalation as patient probably has Asthma

    This is hypoparathyroidism secondary to surgery leading to hypocalcemia and eventually life threatening laryngeal SPASM(not edema)








    CAUSE OF ACUTE PANCREATITIS

    Gall Stone: At least 30-40% of cases. In some series it has been placed as high as 90%

    Alcoholism: At least 25% of cases






    Lady Talking with the angels

    A schizophrenic woman thinks that she is perfectly well and denies any illness. She also refuses to
    take medication and thinks that she can talk with Angels. What is this called in Psychiatry ?

    a.Lack of insight
    b.Overvalued idea
    c.Rejection
    d.Delusion
    e..Formal thought disorder

    Actually it is lack of insight.

    I am quoting from Oxford Core Psychiatry p18

    "As s technical term insight means a correct awareness of one's own mental condition.

    It is best described in terms of four criteria:

    1. Awareness of oneself as presenting phenomena that other people consider abnormal.
    2. Recognition that these phenomena are abnormal.
    3. Acceptance that these abnormal phenomena are caused by one's own mental illness
    4. Awareness that treatment is required.
  20. gorani

    gorani Guest

    You are called to review a patient who developed restlessness and difficulty breathing eight hours
    after thyroidectomy. What will you do FIRST?
    a. Endotracheal intubation.
    b.Remove superficial sutures
    c.Remove superficial and deep sutures
    d.Salbutamol inhalation as patient probably has Asthma




    A 70 years old woman had Upper GIB. She was on treatment with NSAID for knee pain which was
    stopped a few months ago. You do an endoscopy of upper Gl tract and find a duodenal ulcer with
    recent bleeding. What is the BEST management?
    a.Omeprazol I.V. + Ampicillin + Metronidazole
    b.Omeprazol I.V.
    c.Highly selective vagotomy
    d.Vagotomy
    e.Ranitidine I.V. + Ampicillin + Metronidazole

    The treatment for NSAID induced ulcer includes giving PPI and if pain can not be tolerated give NSAID+PPI. No mention of giving antibiotics. --- Toronto notes

    A two years old child presents with failure to thrive for the last 6 months and right buttock wasting. He passes bulky stools 2-3 times a day. Which of the following is the MOST appropriate investigation?
    a.C13 breath test
    b.Duodenal biopsy*****
    c.Stool culture
    d.Stool microscopy
    e.Sweat test

    Celiac dse does have failure to thrive, muscle wasting and flat buttocks. ----Nelson's pediatrics


    A ten years old girl has a history of repeated episodes of hemiparesis from which she recovers completely. What is the MOST LIKELY diagnosis?
    a.Middle cerebral artery occlusion
    b.Petit mal epilepsy
    c.Migraine ****
    d.Subarachnoid haemorrhage

    Atypical migraine can present with hemisensory loss or hemiparesis ---Adams

    A young woman with anovulatory cycles for the long time is MOST LIKELY to develop which of the following?
    a.Cervical cancer
    b.Endometrial Cancer
    c.Ovarian cancer
    d.Vaginal cancer
    e.Cancer of the Vulva



    A schizophrenic woman thinks that she is perfectly well and denies any illness. She also refuses to
    take medication and thinks that she can talk with Angels. What is this called in Psychiatry ?

    a.Lack of insight ------?????
    b.Overvalued idea
    c.Rejection Havila- yr comment?
    d.Delusion
    e..Formal thought disorder-----????


    patient presents with sudden rupture of extensor pollicis longus tendon,dx?
    a) tendonities-----??
    b) tenosynovitis Trick again
    c) RA-----????

    What is the MOST COMMON cause of death after burn injury in Australia ?
    a.Shock
    b.Respiratory failure
    c.Cardiac failure
    d.?Renal failure

    A 14 years old girl has breast enlargement, normal growth of pubic and axillary hair but she is still
    not menstruating. Which of the following is CORRECT?
    a.She is likely to start menstruating two years after the start of pubic hair growth
    b.She is likely to start menstruating two years after the start of axillary hair growth
    c.She is likely to start menstruating within two years from the time of her breast budding. *****( this one also correct)
    d..She is likely to start menstruating within two years from growth spurt.
    e.This is a case of delayed puberty *******

    A 16 years old girl presents with fever, headache and rash on her body. She also has profuse bleeding from all venipuncture sites. What is the MOST probable diagnosis?
    a.Thrombocytopenia
    b.'Disseminated Intravascular coagulation******( cooldude-U r wrong)
    c.Henoch Schonlein Purpura
    d.Allergic reaction

    Meningococcal infection leading to DIC

    A neonate with cough and fever is found to be grunting. Chest X ray shows round lesions with little pleural effusion. Which of the following is the BEST the treatment?
    a.Crystalline Penicillin******
    b.Gentamycin Havila- your comment
    d.Amoxicillin
    e.Flucloxacillin****

    A ten years old girl has a history of repeated episodes of hemiparesis from which she recovers completely. What is the MOST LIKELY diagnosis?
    a.Middle cerebral artery occlusion
    b.Petit mal epilepsy
    c.Migraine ??????
    d.Subarachnoid haemorrhage

    An adolescent boy complains of slight pain in the right knee which ***gets worse after exercise. On examination you find a lump on the tibia tubercle with slight tenderness. The boy can't remember if
    he has had any recent trauma. Which of the following statements is CORRECT?

    a.Reassure that there is nothing wrong
    b.Biopsy should be done to exclude malignancy ----????something wrong- the boy has symptom

    c.Knee aspirate shows organism
    d. Osteochondritis is the most likely cause

    A two years old child presents with ***failure to thrive for the last 6 months and **right buttock wasting. He passes ***bulky stools 2-3 times a day. Which of the following is the MOST appropriate investigation?
    a.C13 breath test
    b.Duodenal biopsy----???
    c.Stool culture
    d.Stool microscopy
    e.Sweat test ----------------??

    A diabetic mother gives birth to a child weight 4240 gm and with an Apgar score of 7/10. On examination you find cyanosis of his hands and feet and the child is jittery. Axillary temperature measure shows a reading of 37.2 C. His condition improved after meconium aspiration and 100% O2. Which of the following is the MOST LIKELY cause?
    a.Hypoglycaemia******** ( we are sure- cooldude)
    b.Heart disease
    c.Lung disease.
    d.Hyperglycaemia
    e.His jaundice is caused by breast milk.

    A ***young woman with **anovulatory cycles for the long time is MOST LIKELY to develop which of the following?
    a.Cervical cancer
    b.Endometrial Cancer ( age is older)
    c.Ovarian cancer *********
    d.Vaginal cancer
    e.Cancer of the Vulva

    A 52 years old ***obese post menopausal woman presents with **no signs of Menopause and **amenorrhoea. What could be the cause?
    A Low oestrogen and Low FSH
    B High oestrogen and high FSH*****
    c. Normal oestrogen and high FSH
    d.High oestrogen and low FSH
    e.Low oestrogen and High FSH

    A 16 years old student asks for a prescription for contraceptive pill. She says she doesn't have
    sexual partner. Which of the following is the MOST APPROPRIATE management?
    a. Oral contraceptive pill**** ( here in OZ-- sexually active since 11yrof age-- cool-dude-- follow her request)

    b.Minipill ( by the way what is that?-- haven't read)
    c.Depot
    d.Oral contraceptive pill + condoms

    A pregnant woman in 1st trimester is found to have CIN III. What is your NEXT step?
    a. Terminate the pregnancy
    b. Cone biopsy
    c.Hysterectomy help
    d.Colposcopy
    eObserve

    14. A pregnant woman in 1st trimester presents with skin dimpling over the right breast. Examination and clinical tests reveals cancer of the right breast. Which of the following is your management?
    a.Terminate the pregnancy
    b.Start radiotherapy
    c.Wait till delivery and then start the treatment*** ( I can agree with cool-dude)

    Which of the following will cause SEROTONIN syndrome if given together with SSRI like Fluoxetine EXCEPT?
    a.L-tryptophan
    b.Haloperidol
    c.Moclobemide
    'd. Chlorpromazine
    e.Citalopram

    A schizophrenic woman thinks that she is perfectly well and denies any illness. She also refuses to
    take medication and thinks that she can talk with Angels. What is this called in Psychiatry ?

    a.Lack of insight *****( most likely)
    b.Overvalued idea
    c.Rejection
    d.Delusion
    e..Formal thought disorder ****
    A ten years old girl has a history of repeated episodes of hemiparesis from which she recovers completely. What is the MOST LIKELY diagnosis?
    a.Middle cerebral artery occlusion
    b.Petit mal epilepsy
    c.Migraine i think hemiplegic migraine not sure
    d.Subarachnoid haemorrhage









    A 70 years old woman had Upper GIB. She was on treatment with NSAID for knee pain which was
    stopped a few months ago. You do an endoscopy of upper Gl tract and find a duodenal ulcer with
    recent bleeding. What is the BEST management?
    a.Omeprazol I.V. + Ampicillin + Metronidazole
    b.Omeprazol I.V.
    c.Highly selective vagotomy
    d.Vagotomy
    e.Ranitidine I.V. + Ampicillin + Metronidazole

    The treatment for NSAID induced ulcer includes giving PPI and if pain can not be tolerated give NSAID+PPI. No mention of giving antibiotics. --- Toronto notes

    All patients with proven acute or chronic duodenal ulcer and those with gastric ulcer who are H pylori positive should be offered eradicaiton of H. pylori. (Davidson 20th p887)

    Omeprazole for healing of ulcer and amoxy+metro for eradication of H. pylori



    A two years old child presents with failure to thrive for the last 6 months and right buttock wasting. He passes bulky stools 2-3 times a day. Which of the following is the MOST appropriate investigation?
    a.C13 breath test
    b.Duodenal biopsy*****
    c.Stool culture
    d.Stool microscopy
    e.Sweat test

    Celiac dse does have failure to thrive, muscle wasting and flat buttocks. ----Nelson's pediatrics

    A young woman with anovulatory cycles for the long time is MOST LIKELY to develop which of the following?
    a.Cervical cancer
    b.Endometrial Cancer
    c.Ovarian cancer
    d.Vaginal cancer
    e.Cancer of the Vulva


    Development of endometrial carcinoma is related to unopposed action of estrogen. It is more likely to occur in women who are relatively infertile.(LJ 281)












    A young woman with anovulatory cycles for the long time is MOST LIKELY to develop which of the following?
    a.Cervical cancer
    b.Endometrial Cancer
    c.Ovarian cancer
    d.Vaginal cancer
    e.Cancer of the Vulva

    I think I ignored the age factor here. So, now I think ovarian carcinoma should be a better option here. Sorry!

    I am following your questions Bulimia.

    Please note that I have attached references to a lot of my answers.

    Regarding your post op fluid therapy question(Bulimia) - I went through the AMC commentary you referred to. That was a different scenerio. A man who was dehydrated and had pyloric stenosis. This is not the same as post op fluid therapy. I request you to go through the perioperative and postoperative care from SCOTT before you make up your mind.


    a lady came to you at 12 weeks pregnancy for antenatal check.Her 1st child was born with spina bifida.Which of the following investigation would not be useful in assesing the second baby...

    a-maternal triple or tetra test at 16-18 week
    b-amniocentesis for acetylcholine estrase at 11-13 weeks
    c-USG for nuchal fold measurement at 11-13 weeks ??
    d-USG for spinal abnormalities at 16-18 weeks
    e-Do chorion villous sampling at 8-10 weeks ??
  21. gorani

    gorani Guest

    Spigelian hernia

    Spigelian hernia


    A Spigelian hernia is an acquired ventral hernia through the linea semilunaris, the line where the sheaths of the lateral abdominal muscles fuse to form the lateral rectus sheath. Spigelian hernias are nearly always found above the level of the inferior epigastric vessels, and most often occur where the semicircular line - fold of Douglas - cross the linea semilunaris. Commonly, the patient is over the age of 50 years. Men and women are equally affected.

    The patient presents with pain that is localised to the hernial site and is aggravated by any movement that raises intra-abdominal pressure. Later, the pain becomes more dull, constant, and diffuse.

    A soft, reducible mass may be present in the lower abdominal area which disappears on pressure. When the mass is reduced, the hernial orifice can usually be palpated. Diagnosis is more difficult when the hernia dissects within the layers of the abdominal wall - internal and external obliques - or may be located at a distance from the linea semilunaris. Ultrasound and CT scan may help to confirm the diagnosis.

    Spigelian hernias have a high incidence of incarceration and should be repaired. Treatment is by primary aponeurotic closure.
  22. gorani

    gorani Guest

    patient presents with sudden rupture of extensor pollicis longus tendon,dx?
    a) tendonities?
    b) tenosynovitis
    c) RA???

    A patient with cancer breast develop osteoprposis.what is the treatment
    a) bisphosphonate
    b) cyclical estrogen and progesterone
    c) continuous estrogen and progesterone
    increase diatery calcium 2000g / day

    You are called to review a patient who developed restlessness and difficulty breathing eight hours
    after thyroidectomy. What will you do FIRST?
    a. Endotracheal intubation.
    b.Remove superficial sutures
    c.Remove superficial and deep sutures
    d.Salbutamol inhalation as patient probably has Asthma

    A 43 years old man was brought to the emergency department with severe upper abdominal pain
    and signs of shock. Physical examination reveals abdominal wall rigidity and guarding. Which of
    the following is the MOST LIKELY Diagnosis?
    a.Perforated gastric ulcer
    b.Penetrating duodenal ulcer
    c. Mesenteric ischemia
    d. Acute pancreatitis

    A young male fell from a height but sustained minor injuries. After two hours he lost
    consciousness and was brought to you in Northern Queensland hospital with limited radiographic
    facilities by his friend. On examination you find that his pupils are fixed and dilated. What is our
    NEXT step?
    a.Arrange for transportation to another hospital by helicopter.
    b.Give IV mannitol
    c Give IV corticosteroid d. d Burr holes

    An elderly man came to see you with complaints of sudden pain in the lower back while lifting a heavy box. On examination you find that the lumbar spine has limited movement with pain in his lower back on movement. There are no neurological abnormalities. What is the NEXT investigation that you'll do?
    a.X Ray of the lumbar spine
    b.CTScan
    c.MRI of the spine
    d.Lumbar puncture

    A 70 years old woman had Upper GIB. She was on treatment with NSAID for knee pain which was
    stopped a few months ago. You do an endoscopy of upper Gl tract and find a duodenal ulcer with
    recent bleeding. What is the BEST management?
    a.Omeprazol I.V. + Ampicillin + Metronidazole
    b.Omeprazol I.V.
    c.Highly selective vagotomy
    d.Vagotomy
    e.Ranitidine I.V. + Ampicillin + Metronidazole


    Which of the following is MOST COMMON cause of acute pancreatitis?
    a.Gallstones,
    b.Cholecystitis
    c.Alcohol abuse
    d.Spicy food
    e.Gastroenteritis

    What is the MOST COMMON cause of death after burn injury in Australia ?
    a.Shock???
    b.Respiratory failure???
    c.Cardiac failure
    d.Renal failure

    PAED
    A 14 years old girl has breast enlargement, normal growth of pubic and axillary hair but she is still
    not menstruating. Which of the following is CORRECT?
    a.She is likely to start menstruating two years after the start of pubic hair growth
    b.She is likely to start menstruating two years after the start of axillary hair growth
    c.She is likely to start menstruating within two years from the time of her breast budding.
    d..She is likely to start menstruating within two years from growth spurt.
    e.This is a case of delayed puberty


    A 16 years old girl presents with fever, headache and rash on her body. She also has profuse bleeding from all venipuncture sites. What is the MOST probable diagnosis?
    a.Thrombocytopenia
    b.'Disseminated Intravascular coagulation
    c.Henoch Schonlein Purpura
    d.Allergic reaction

    A 12 months old baby has fever. Recently, two other family members had an upper respiratory tract infection. On examination of the baby you find that his body temperature is 37.5 CTand chest auscultation reveals bilateral wheezing. What is the MOST LIKELY cause?
    a.Acute bronchiolitis
    b.Viral croup
    c.Bronchial Asthma
    d.Pneumonia
    e.Foreign body

    A neonate with cough and fever is found to be grunting. Chest X ray shows round lesions with little pleural effusion. Which of the following is the BEST the treatment?
    a.Crystalline Penicillin
    b.Gentamycin
    d.Amoxicillin
    e.Flucloxacillin

    A ten years old girl has a history of repeated episodes of hemiparesis from which she recovers completely. What is the MOST LIKELY diagnosis?
    a.Middle cerebral artery occlusion
    b.Petit mal epilepsy
    c.Migraine
    d.Subarachnoid haemorrhage

    The parents with their 10 years old child come to see you with complaints that the child has enuresis since birth. The child has no problems during the day time. Physical examination does not reveal any other abnormality. Which of the following statements is TRUE in more than 20 % of such cases?
    a.He has chronic pyelonephritis
    b.He has congenital abnormalities of the urinary tract
    c.There is an associated family history
    d.he has small urinary bladder.
    e.It is associated with spina bifida occulta

    A 5 years old boy presents with vomiting every morning and morning headache for the last two weeks. What is the MOST LIKELY cause?
    a.Meningitis
    b.Migraine
    c.Craniopharyngioma
    d.MeduJloblastoma
    e.Wilm's tumour

    An adolescent boy complains of slight pain in the right knee which gets worse after exercise. On
    examination you find a lump on the tibia tubercle with slight tenderness. The boy can't remember if
    he has had any recent trauma. Which of the following statements is CORRECT?
    a.Reassure that there is nothing wrong
    b.Biopsy should be done to exclude malignancy
    c.Knee aspirate shows organism
    d. Osteochondritis is the most likely cause

    A 6 day old baby who is suspected to have Down's syndrome presents with non projectile bilestained vomiting for the last two days. On abdominal examination you find an olive shapedpalpable mass in the epigastrium. Which of the following is the MOST LIKELY diagnosis?
    a.Volvulus
    b.Duodenal Atresia.
    c.Intussusception
    d.Malabsorption

    A two years old child presents with failure to thrive for the last 6 months and right buttock wasting. He passes bulky stools 2-3 times a day. Which of the following is the MOST appropriate investigation?
    a.C13 breath test
    b.Duodenal biopsy
    c.Stool culture
    d.Stool microscopy
    e.Sweat test

    A diabetic mother gives birth to a child weight 4240 gm and with an Apgar score of 7/10. On examination you find cyanosis of his hands and feet and the child is jittery. Axillary temperature measure shows a reading of 37.2 C. His condition improved after meconium aspiration and 100% O2. Which of the following is the MOST LIKELY cause?
    a.Hypoglycaemia
    b.Heart disease
    c.Lung disease.
    d.Hyperglycaemia
    e.His jaundice is caused by breast milk.

    A six years old boy presents with delayed development of speech after a period of normal development. On examination you find that he avoids eye contact and reveals a history of unusual liking for dinosaurs. Which of the following is the MOST LIKELY diagnosis?
    a.Autism
    b.ADHD
    c.Deafness
    Obs

    A young woman with anovulatory cycles for the long time is MOST LIKELY to develop which of the following?
    a.Cervical cancer
    b.Endometrial Cancer
    c.Ovarian cancer
    d.Vaginal cancer
    e.Cancer of the Vulva

    In which of the following conditions you will find DECREASED amniotic fluid?
    a.Foetus's Bladder neck obstruction of the foetus
    b.T.O fistula
    c.Rhesus incompatibity
    d.Multiple pregnancy

    A 52 years old obese post menopausal woman presents with no signs of Menopause and amenorrhoea. What could be the cause?
    A Low oestrogen and Low FSH
    B High oestrogen and high FSH
    c. Normal oestrogen and high FSH *
    d.High oestrogen and low FSH •
    e.Low oestrogen and High FSH

    A 16 years old student asks for a prescription for contraceptive pill. She says she doesn't have
    sexual partner. Which of the following is the MOST APPROPRIATE management?
    a. Oral contraceptive pill
    b.Minipill
    c.Depot
    d.Oral contraceptive pill + condoms
    e.Call her parents.

    A pregnant woman in 1st trimester is found to have CIN III. What is your NEXT step?
    a. Terminate the pregnancy
    b. Cone biopsy
    c.Hysterectomy
    d.Colposcopy
    e.Observe

    14. A pregnant woman in 1st trimester presents with skin dimpling over the right breast. Examination and clinical tests reveals cancer of the right breast. Which of the following is your management?
    a.Terminate the pregnancy
    b.Start radiotherapy
    c.Wait till delivery and then start the treatment
    d.Surgery

    A 19 years old female comes to your clinic for consultation. She has never had periods. On examination her breast development is normal. Pubic and axillary hair growth is also normal. The
    development of her genitals is also in normal range. What is the MOST LIKELY cause of her amenorrhea?
    a. Turner's syndrome
    b. Prolactinoma
    c. Absent uterus d. Pituitary lesion
    e. Lesion in Hypothalamus

    A 42 years man who is a patient of yours is arrested for attacking his wife in a supermarket. The police come to you and ask you to write a report about this patient. Which of the following is TRUE for good practice?
    a.You will write a report about the patient's bad mental state
    b.You will tell the patient never to come to your surgery again
    c.You will write a general, unbiased and balanced report about health of the patient.
    d.You will tell the police that you don't want to give any reports
    e. Arrange for a meeting with the patient

    Which of the following will cause SEROTONIN syndrome if given together with SSRI like Fluoxetine EXCEPT?
    a.L-tryptophan
    b.Haloperidol
    c.Moclobemide
    'd. Chlorpromazine
    e.Citalopram

    In Australia , almost every year there are several incidences of bush fire. Usually it is caused by
    young people and teenagers. Which of the following is TRUE?
    a. Juvenile pyromania is the main cause of fires in Australia .
    -b. It is due to accidental fire caused by youngster who get scared after the fire starts to
    spread uncontrollably and they run away.
    c.It has no serious consequences
    d.Youngsters like to ignite and play with fire.
    e.It is done to hide crimes

    A schizophrenic woman thinks that she is perfectly well and denies any illness. She also refuses to
    take medication and thinks that she can talk with Angels. What is this called in Psychiatry ?

    a.Lack of insight
    b.Overvalued idea
    c.Rejection
    d.Delusion
    e..Formal thought disorder
  23. ElliEL

    ElliEL Guest

    Clinical Exam, May 20th , 2006 Sydney




    1.Febrile Convulsion – talk to pt.



    2.Mid-cycle bleeding on OCP – talk to pt.



    3.Carpal tunnel syndrome – examination



    4.PHOTO lump on the neck – find primary site,/examination/DDx




    5.Benzodiazepines dependency – talk to pt / SE


    6.Delirium – Examine pt / MS/ Mx.



    7.Gastrointestinal system examination – alcoholic pt
    .


    8.Headache/Meningitis – Take History/Examine the pt/ DDx



    9.Enuresis – talk to parents



    10.Pregancy & Pneumonia pt on Doxycycline – History/Examination/Mx
    Change Doxycycline to Erythromycin (Safe or relatively safe during the pregnancy: Amoxycillin/Ampicillin/Cephalosporine/Erythomycin/Rifampicin/
    Trimethoprim/Methyldopa/ - Beischer , p 105)



    11.Pain relief in labour – talk to pt.who is 20/40 pregnant; P0G1.She is very concerned about pain in labour. ( Beischer, p. 411)
    Ask why she is worried about pain? Any particular reason? What is her understanding about pain relief during the labour ? CS / normal labour.
    Discuss pharmacological, sedative ( Diazepam max 20 mg ) and hypnotics, tranquillisers ( major: phenothiazines - chlorpromazine, promethazine, or minor: diazepam ), ( analgesics (non-narcotic: aspirin, paracetamol, codeine; narcotic: pethidine 50-100 mg IM; Morphine 10-15mg IM; SE: respiratory depression, nausea & vomiting, tachycardia, postural hypotension and delayed gastric emptying). Pethidine is preferred and usually given IM 100 mg; it is given by I>V route in some centres either intermittently in small doses 25mg over 1-2 minutes every 1-3 hours or self administered by the women ( PCA – patient controlled analgesia)The usual duration of narcotics drugs is 2-4 hours. Preferably such drugs should not be administered within 1 hour of delivery – and if it is the baby should be given Naloxone ( 0.02mg) IM immediately after birth. During this period inhalation or regional block are preferable; Narcotics are CI in women receiving MAO inhibitors.
    The use of sedatives, hypnotics and minor tranquillisers varies considerably in obstetric practice in different communities. Many practitioners rely on single injection of Pethidine 100 mg IM with either prochlorperazine (Stemetil) 12,5 mg or metoclopramide HCL (Maxolon) 10 mg ± epidural analgesia for pain relief in labour.
    Inhalational analgesics: Nitrous Oxide (NO) in concentration of 50% is equivalent to 15 mg of Morphine. Nitrous oxide/oxygen given by mask “on demandâ€; It is useful for analgesia during the late first stage and second stage (i.e. during delivery) in a 50-70% concentration with the oxygen. In their late fist stage of labour the women sleeps between contractions but rouses and breathes on the mask when the contraction begins. Advantages: safety, reasonable analgesia, on-toxic and non-irritating to respiratory passages, quickly absorbed and eliminated, uterine contractions unaffected (no prolongation of labour or postpartum atonicity), vomiting rare; Disadvantages: requirement of machine to deliver the gas and disorientation of some women ;Occasionally, women will not use the mask because of felling of suffocation or because of disorientation.
    Mention : Local analgesia/Epidural/Paracervical block. Discuss if you have time.

    Epidural nerve block: the local analgesic is injected extrathecally into epidural space; the extent of analgesia is determined largely by the volume and concentration of drug injected; to control pain of late labour, a block of segments T10 – L1 is adequate; for Caesarean section a higher block – T8 or even T6 is needed; low dose epidural analgesia (0.125 Bupivacaine) increases mobility in labour and abolish the urge to push (pushing reflex) but not ability to push so that normal spontaneous delivery is still possible. Although epidural analgesia is associated with a higher incidence of forceps delivery it must be recognised that women who require epidural analgesia for pain relief are more likely to require forces delivery, usually because of dystocia resulting from occipitoposterior position.
    Indication for epidural: pain relief; symptomatic heart disease – the pain and distress of labour is relieved, however extreme care is necessary if women has a fixed cardiac output (e.g. mitral or aortic stenosis, pulmonary hypertension); hypertensive disorders (preeclampsia/eclampsia, chronic hypertension), cerebrovascular disease (intracranial aneurism and angioma are usual indication); incoordinate uterine action (elimination of pain and fear often help normalize the activity); breech and twin delivery( opinion is divide on the value of epidural analgesia in these conditions: the relaxation of pelvic floor is advantageous but the lack of stimulus for the woman to push can lead to a higher interference rate; Contraindications for epidural analgesia: opposition by the woman; Recent antepartum haemorrhage( because compensatory vascular reflexes are partly abolished, sudden haemorrhage may produce marked hypotension; suspected cephalopelvic disproportion; sepsis ( in proposed area of operation);sensitivity to local analgesic agents; DIC ( sever preeclampsia - predispose to haemorrhage in the epidural space ).
    Complication of epidural analgesia: toxicity (from overdosage and/or intravascular injection; hypotension; uterine hypotonia- occurs in 5-10% of women in early labour but usually activity return in 15-30 minutes; collapse (with hypotension and apnoea may be due to toxic effect of the drug); headache (may result from accidental puncture of the dura and leakage of CSF; this can be treated by insertion of epidural at higher level; after the delivery Hartmann solution is infused into epidural catheter; woman should be nursed flat, adequately hydrated ± aspirin, codeine, paracetamol ; loss of sensation may occur in bladder ( causing over distension);loss of bearing -down reflex, resulting in higher incidence of assisted delivery; backache
    Majority of the above complications are rare, however they need experienced personnel in this type of analgesia; Advantages of epidural analgesia: woman alert, cooperative reduced risk of inhalation of vomitus; Disadvantage of epidural analgesia: need for skilled personnel, the occasional serious complication, tendency to slow the labour (particularly second stage) increased incidence of operative delivery; intraoperative nausea, vomiting or restlessness in some women.
    In Caesarean section, regional analgesia has a number of advantages over general anaesthesia – participation of the parents in the birth, better postoperative pain relief, early mobility, less fever, blood loss is 50 % less than with general anaesthesia. Disadvantages are that the method may fail, the woman feels pain and may require a general anaesthetic; it is technically more difficult to extract the infant’s head from the uterus, especially if a Pfannestiniel incision is used, because abdominal muscles are not completely relaxed;
    Paracervical block: LA (6-10 mg of 0.25 Bupivacaine) injected beneath the mucosa of vagina in each lateral fornix. Acupuncture;
    Incidence of serious neurological complications due to epidural analgesia:
    Paraplegia, a severe complication to epidural analgesia – rare.
    Because of the rarity of permanent neurological damage resulting from epidural analgesia, it is difficult to estimate its incidence. In a combined series of more than 50 000 epidural anaesthetics, only three patients suffered permanent leg weakness (0.006% - American Journal of Anaesthesia , Kane 1981)



    12.Obese patent / BMI 45 – counselling




    13.Dizzines/Vertigo 60 yo – history/DDX




    14. CHEST PAIN: – History/ (Pericarditis) DDx: MI/Angina/PE/Aorta dissection

    50-year-old train driver, c/o chest pain. From the history: pain for the last 6 hours, constant, 8/10, radiates to the back (alleviating/aggravating factors?). Non-smoker, had history of chest infection a 3/52 ago. Vital signs – pulse 96 regular, BP 140/97, Temp. 37.4 º C. Physical exam – constant noise during auscultation? Not murmur; probably pleural rub

    ACUTE PERICARDITIS: chest pain, which may be intense, mimicking acute MI, but characteristically sharp, pleuritic and positional (relived by leaning forward) worse on inspiration; fever and palpitations are common
    Common causes: idiopathic; infections (particularly viral – influenza, Coxsackie A/B) acute MI, metastatic neoplasm, radiation therapy for the tumour (up to 20 years earlier), connective tissue disease (SLE, RA) drug reactions (procainamide, hydralazine), “autoimmune “following heart surgery of MI – several weeks/months later (Dressler’s sy).
    Physical Examination: rapid or irregular pulse, coarse pericardial friction rub which may vary in intensity and is loudest with pt. sitting forward.
    Laboratory/ECG: Diffuse ST elevation (concave upwards) usually present in all leads except aVR and V1.CXR: increased size of cardiac silhouette if large (> 250 ml) pericardial effusion is present, with “water bottle†configuration ECHO: most sensitive test for detection of pericardial effusion which commonly accompanies acute pericarditis;
    Treatment: Aspirin 650 –975 mg qid or NSAID (e.g. indomethacin 25 –75 mg qid); for severe refractory pain, Prednisone 40-60mg daily and tapered over several weeks or months. Anticoagulants are relatively contraindicated in acute pericarditis because of risk of pericardial haemorrhage. ( Harrison, p583)


    15.Intusussepction





    16.Intermitent claudications
  24. NadiaAl

    NadiaAl Guest

    AMC MCQ EXAM 2004 Melbourne

    Nadia recollection paper

    (*) - denotes STAR Questions ( 60 questions)
    P - denotes PILOT Questions ( probably will appear as (*) in next exam ? )


    1.All of the following drugs can cause gynecomastia EXCEPT:

    A/ spironolactone
    B/ digoxin
    C/ methyldopa
    D/ furosemide
    E/

    2. Which of the following joints is not included in rheumatic arthritis and is more common in osteoarthritis?

    A/ carpometacarpal joint of the thumb P
    B/ temporomandibular joint
    C/ cervical spine
    D/
    E/

    3. All of the following statements about intravenous solutions are true EXCEPT:

    A/ normal (0.9%) sodium chloride solution has an approximately 150 mmol/l Na + 150 mmol/l Cl
    B/ Hartman solution is sodium lactate which consist sodium 135 mmol, calcium 2 mmol and some potassium
    C/ if 1 litre of Hartman solution is given in 24 hours it will be sufficient for daily potassium requirement (*)
    D/ N/5 contains 30 ml Cl and 30 ml Sodium
    E/ 5 % dextrose …



    4.Hand X – ray, carpal bones, fractured scaphoid. Which of the following is correct:

    A/ it will result in avascular necrosis of distal pole
    B/ internal fixation is best treatment because of malunion
    C/crepe bandage from elbow to the wrist
    D/immobilization from elbow to the end of the thumb for 6 weeks (*)
    E/ plaster from elbow to the wrist

    5.Photo of leg from AMC book ( SU-C130 ) page 262

    A/ chronic infection
    B/ necrotizing fasciitis
    C/chronic venous hypertension (*)
    D/arterial insufficiency
    E/


    6.Patient with a fourth attach of gout in the last 2 years. Knee is swollen, painful. What is most appropriate management?

    A/ allopurinol in the first 24 hours
    B/indomethacin 150 mg in the first 24 hours (*)
    C/hydrocortisone intraarticular
    D/colchicine
    E/


    7.Urticaria can be associated with all of the following EXCEPT:

    A/ vasculitis P
    B/aspirin sensitivity
    C/
    D/
    E/

    8. Which cause shock in gall-bladder sepsis?

    A/staphylococcus aureus
    B/Pseudomonas aeruginosa
    C/Enterococcus faecalis
    D/ Escherichia coli P
    E/


    9.Patient with severe chest pain, radiating to his back. CXR show widened mediastinum, diastolic murmur ECG – acute inferior M.I. What is appropriate Mx?


    A/give streptokinase
    B/give aspirin plus IV morphine
    C/Give morphine, B-blocker and arrange for T O E
    D/
    E/





    10.What is most likely to become chronic?

    A/Hepatitis A
    B/ Hepatitis C (*)
    C/ Hepatitis B
    D/ EBV
    E/

    11.Spinal cors lesion at level L4 – L5 :

    A/ absent knee jerk
    B/ absent ankle jerk
    C/ lost of dorsiflexion of the ankle
    D/ lost of sensation sole of the foot
    E/


    12. Patient with chronic cardiac failure on Captopril for hypertension. On long-term Chlorothiazide.

    A/ sodium is reduced
    B/ K is decreased
    C/cholesterol is increased
    D/
    E/

    13.Patient 3 days after cranial surgery. Na 117, Plasma osmolarity 205 Urine osmolarity 825

    A/ D . III
    B/ S I A D H (*)
    C/water intoxication
    D/
    E/

    14. All of the following are features of Hypercalcemia EXCEPT:

    A/ depression
    B/ diarrhoea
    C/polyuria
    D/ polydipsia
    E/


    15.Which of the following is the most urgent requirement for the patient in D K A:

    A/ infusion of sodium bicarbonate
    B/ 5% dextrose
    C/ infusion of normal saline (*)
    D/ glucagon
    16. Builder come to ER with 15 % of burns, his weight is 80 kg. Which of the following fluid replacement will be required for the first 24 hours?

    A/2 L Hartman + 2 L blood
    B/ 2 L Nacl + 1 L blood
    C/ 3 L Hartmann + 2 L 5 % Dextrose
    D/ 3 L Hartmann + 2 L blood
    E/

    17. After splenectomy for hereditary spherocytosis all can be expected EXCEPT:

    A/ persistence of anaemia
    B/ persistence of spherocytes
    C/ normal RBC life span see Merck P 876
    D/reticulocytosis
    E/

    18. Which of the following is not feature of Mycoplasma pneumoniae:

    A/ headache
    B/pleuritic pain P
    C/temperature
    D/ myalgia
    E/cough

    19.Which of the following drugs if stopped during the operation will cause intra operative hypertension?

    A/clonidine
    B/methyldopa
    C/enalapril
    D/propranolol
    E/felodipine

    20. Peripheral pulse will be increased in all of the following EXCEPT:

    A/ A – V fistulae
    B/Paget disease of the bone
    C/V S D
    D/patent ductus arteriosus
    E/ASD


    21. Q about Pseudobulbar palsy. All is associated EXCEPT:

    A/ gag – reflex ( vagus ) P
    B/
    C/
    D/

    22.Patient playing game, squash court suddenly pain in ankle, no planar flexion, dorsal flexion limited and painful:

    A/ rupture of medial ankle ligament
    B/ complete rupture of Achilles tendon
    C/ rupture of medial head m. solei
    D/
    E/

    23. Well established scientist was on overseas scientific meeting where he should give lecture. Suddenly after bout of diarrhoea, and profound humiliation he left meeting. He start to change his dresses at night, wandering through the streets, his behaviour than change as well. In the morning he is again OK. He realised something is wrong with him and after a few “speech “ therapies he improved.
    His Dg is:

    A/depersonalisation
    B/ SCH
    C/ multiple personality disorder
    D/dementia
    E/

    24. Q. about vascular (multi-infarct) dementia. What is CORRECT?

    A/more common in women than man
    B/start abruptly with…
    C/it may be present with spasticity, tremor and weakness (*)
    D/with cognitive impairment
    E/

    25.Patient 60 y. o. has difficulty walking upstairs. On examination wasting of the biceps brachii spasticity in both legs, bilateral brisk lower limb tendon reflexes .The MOST LIKELY is: (see Q. ME 25 AMC book P. 11)

    A/ late onset of multiple sclerosis
    B/cervical cord protrusion
    C/motor neurone disease
    D/lumbar canal stenosis
    E/

    26.Hypercalcaemia is seen in all of the following EXCEPT:

    A/bone metastasis
    B/. Prim. Hyperparathyroidism
    C/chronic calcificans pancreatitis
    D/
    E/



    27. 20 year old man, with one-week dark urine, nausea, fever. Liver enzymes elevated ALT 750, ALP 150, GGT 350.It is MOST LIKELY:

    A/ choledolithiasis
    B/acute viral hepatitis
    C/biliary obstruction and cholangitis
    D/
    E/

    28.The best way to diagnosed GIARDIASIS is:

    A/ duodenal aspiration of trophozoites
    B/cyst in the stool
    C/
    D/
    E/

    29.Most significant complication of massive blood transfusion (5 L) is:

    A/pulmonary oedema
    B/abnormal coagulation
    C/metabolic acidosis
    D/increase C V P
    E/

    30.Common organism causing cellulitis is:

    A/ group A streptococcus
    B/ group B streptococcus
    C/staphylococcus aureus
    D/
    E/


    31.Child with sore throat, cervical lymphadenopathy, (Clinical picture of Inf. Mononucleosis) what is associated findings:

    A/ ASTO + ve
    B/ atypical lymphocytes P
    C/



    32. Lady with GORD taking H2. What is most of concern regarding her disease ?
    A/ recent weight loss P
    B/dysphagia
    C/



    33.14-y.o girls suddenly collapsed in the school. On admission she is unconscious, pupil unequal, absent gag reflex, Babinski positive, Dolls eye reflex intact, no response to painful stimuli. She has i. v. drip, receiving 5% Dextrose

    Pulse oximetry: saturation 100 % O2 BP: 180/110 mm/Hg
    Respiratory rate: 14/min
    Pulse: 50/min

    You INITIAL management will be:

    A/ arrange for urgent CT scan
    B/ intubate and ventilate
    C/change 5% Dextrose for Normal saline
    D/referral to neurosurgeon
    E/Mannitol i.v. + Dexamethasone

    34. 4 years old child, neck stiffness and fever, CSF shows: Glucose normal. Protein 1.1 Few neutrophils, Lymphocytes 100, no organism seen in CSF. MOST LIKELY is:


    A/ ECHO meningitis
    B/herpes meningitis
    C/Hib meningitis
    D/

    35. Child < 6 month old with pneumonia, pleural effusion, round opacities on CXR.Which of the following drug you should ADD in her management?
    ( Hasn’t been mentioned that she currently receiving any drugs or AB) (Staphylococcus pneumonia)

    A/ crystal penicillin (Paediatric Handbook Melbourne P.499/500)
    B/flucloxacillin (*)
    C/amoxycillin/clavulanic acid
    D/erythromycin

    36.Woman with chronic anovulation has increased risk of:

    A/ endometrial carcinoma (*)
    B/cervical carcinoma
    C/ovarian carcinoma
    D/vulval carcinoma
    E/ vaginal carcinoma


    37.Women 20 y.o. Taking Microgynon 30 , in the month she had two periods one lasted 2 days another lasted 4 days. What is your advice to her?

    A/ continue Microgynon 30 (*)
    B/ change to Mycrogynon 50
    C/Change to triphasic OCP

    38.Women want advice regarding Ocp. On US you discovered 4 cm cyst.

    A/ you will reassure her it is normal – no further investigation is needed
    B/ see her in 6-week time do US to see if cyst is still there P
    C/


    39.18 month old child, breast Tanner 3, no pubic or axillary hair

    A/ idiopathic premature thelarche
    B/
    C/


    40.Baby wheezing, his brother had birthday party 2 days ago

    A/spiral CT
    B/Esophagoscopy
    C/expiratory and inspiratory CXR P
    D/

    41. Treatment of mastalgia, conservative treatment failed:

    A/bromocriptine
    B/Danazol
    C/ocp
    D/oestrogen
    E/progesterone


    42.Regarding Herpes genitalis which of the following is TRUE:

    A/ caused by HSV 1
    B/may be asymptomatic
    C/interferon is contraindicated in pregnancy
    D/ P
    E/


    43.39 week 19 yo primigravida, transverse lie. What you will do next:

    A/ CS
    B/ US
    C/external cardioversion
    D/vaginal exam
    E/



    44. Women 8 week of pregnancy is concerned about Trisomy 21.Which of the following test is SAFEST and the same time most ACCURATE (with minimal risk):

    A/ nuchal fold thickness at 11-12 week (*) sensitivity 80%
    B/amniocentesis at 16 week
    C/triple or quadruple test ( alpha-fetoprotein, B-Hcg, Oestriol ) sensitivity 60%
    D/amniocentesis at 16 week
    E/ CVS at 12 week

    45.Patient, sudden onset of one-sided vertigo. No deafness. MOST LIKELY:

    A/ vestibular neuronitis
    B/Meniere’s disease
    C/Benign positional vertigo
    D/


    46.45-year-old man, when urinating outflow reduced & straining

    A/benign hypertrophy of prostrate P
    B/Carcinoma of prostate
    C/


    47.Q. regarding puberty 11 – 14 y.o. All of the following is true Except:

    A/GnRh are released in pulsatile manner P
    B/Lh are released in pulsatile manner
    C/Increased level of prolactin
    D/pubic hair ?
    E/

    48.All of the following are beneficial in treatment of acute asthma EXCEPT:

    A/ Terbutaline
    B/steroids
    C/salbutamol
    D/sodium cromoglycate (Intal) (*)

    49.Women with jaundice, Ulcerative colitis, Liver enzyme elevated…

    A/ sclerosing cholangitis
    B/
    C/
    D/





    50.All of the following drugs can cause photosensitivity EXCEPT:

    A/ phenothiazine
    B/chlorpromazine
    C/nicotinic acid
    D/Thiamine (B1) deficiency
    E/porphyria


    51.60 yo alcoholic man was absent from home, history of binge drinking for one week Came to the hospital as his wife insisted .He is confused, few bruises on the head, slurred speech, liver palpable 15 cm, Extensor plantar Reflex + ve:

    A/ hepatic encephalopathy
    B/subdural hematoma
    C/Korsakov psychosis
    D/ dementia
    E/central pontine tumour


    52. Which findings are specific in pleural effusion due to TBC?

    A/ mononuclears
    B/ low or absent glucose
    C/ positive acid-fast bacilli
    D/


    53. Question about laparoscopy. See Q 154 may 2002

    A/it is one of diagnostic way how PCO is diagnosed
    B/ vena cava can be damaged but risk is small
    C/ she will experience abdominal an shoulder tip discomfort because of residual CO2


    54.Which type of bone loss in chronic renal failure:

    A/ osteoid fibrosis with osteomalacia
    B/ osteoporosis
    C/


    55.Baby 8 weeks old, eye discharge from left eye, improved on AB but discharge again…

    A/ course of antibiotics was short
    B/ nasolacrimal duct obstruction
    C/
    D/

    56.Uveitis is MOST COMMONLY associated with:

    A/ rheumatoid arthritis
    B/ Reiter’s disease
    C/ankylosing spondylitis

    57.Boy when was 3 y.o and when was in his mother lap had soft heart murmur. You saw him again one year later, when his lying murmur disappeared although he has abdominal pain…MOST LIKELY is:

    A/ innocent venous hum
    B/cardiac failure
    C/
    D/


    58.Which of the following lung carcinoma is common in non-smoker?

    A/ oat-cell carcinoma
    B/small-cell carcinoma
    C/ adenocarcinoma
    D/ alveolar cell carcinoma


    59.Young woman, 28 yo had previous PAP smear normal. Now PAP smear shows: squamous metaplasia. No other abnormalities seen:

    A/you will do colposcopy preceded by biopsy
    B/it is normal process and of sinister importance
    C/it is pre-invasive carcinoma
    D/


    60.Staghorn calculi can be found in all of the following EXCEPT:

    A/recurrent pyelonephritis
    B/chronic infection
    C/prolonged immobilization
    D/hyperuricemia (gout)
    E/


    61.Patient with painful red eye, haze cornea, fixed dilated pupil:

    A/ glaucoma (*)
    B/conjunctivitis
    C/iritis
    D/chronic venous thrombosis
    E/

    62. Man narcotic overdose came to hospital. His ABG will show:
    (See Q ME 52 AMC book P17, similar)

    A/ Ph 7.15 PaCo2 62 PaO2 78 P
    B/ PH 7.25 PaCo2 58 PaO2 85
    C/


    63.Hypovitaminosis and metabolic disturbances are commonly seen in:

    A/ SCH
    B/ bulimia nervosa P
    C/ young adult who skipping meal times
    D/


    64. Most important test for Anorexia nervosa is:

    A/ electrolyte balance and liver function test P
    B/
    C/



    65.Five days after appendectomy patient has tachycardia, fever. MOST LIKELY:

    A/atelectasis
    B/wound infection (*)
    C/D V T
    D/ pelvic abscess
    E/ U T I


    66.8 y.o. Boy came to the hospital at midnight, has acute left scrotal pain since 7 PM.
    You will:

    A/arrange surgical consultation immediately
    B/do US
    C/ do blood culture
    D/
    E/


    67.Innability to draw a Pentagon in Mini-Mental Exam is associated with:

    A/non-dominant parietal lobe
    B/dominant parietal lobe
    C/frontal lobe
    D/hippocampus
    E/hypothalamus
    68.Q. regarding burns what is TRUE:

    A/skin prick test is not sensitive test to determine deep of burns
    B/scald burns are usually superficial unless prolonged contact or if cloth is not removed
    C/
    D/


    69.3 yo boy hyperactive in the kindergarten, teacher complain that child is aggressive towards other children (see May 2002 Q84)

    A/ ADHD
    B/variant of normal
    C/opponent defiance
    D/


    70.Which drug will reverse anti-cholinergic delirium?

    A/physostigmine (*)
    B/haloperidol
    C/benztropine
    D/


    71.Woman SCH, taking therapy for 20 years. Now complaining of dry mouth, mild dystonia. Most probably drug is:

    A/thioridazine
    B/haloperidol P
    C/Flupenzoate decanoate
    D/


    72. 2 yo boy has swollen knee. Which of the following is best test to establish diagnosis:

    A/ fluid aspiration from the joint
    B/blood culture
    C/ X-ray
    D/ ultrasound


    73. How you can differentiate schizoid form disorder from SCH:

    A/ duration of syndromes
    B/gender bias
    C/female more than male
    D/affective syndrome P
    74.Question about male infertility. After 3 day of abstinence ejaculate is:

    Vol 3 ml (2-5 ml)
    Number: <950.000 (>20 million)
    Motility > 10 % (>50 motility)
    Morphology <80 % abnormal (>60 % morphology)


    A/ his fertility is slightly reduced
    B/clomiphene citrate will improve his chances for fertilization
    C/intra-cytoplasmic sperm injection (*)
    D/giving him FSH will improve spermatogenesis.
    E/I V F with one hyper stimulation will give results in more than 20%


    75.Patient with history of hypertension, family members affected as well (MEN II) who test will confirm diagnosis:

    A/urinary 5 HIIH
    B/ urinary vanilmandelic
    C/


    76.4-year-old boy with fever, hepatomegaly, lymphadenopathy, pallor, lethargy, pancytopenia:

    A/ ALL
    B/ infective mononucleosis
    C/


    77.Which of the following is indication for urgent laparotomy:

    A/ free blood in peritoneal cavity P
    B/free gas behind duodenum
    C/subscapulares haematoma of liver
    D/sub capsulated haematoma of spleen
    E/


    78.The least likely to be transmitted from mother to child during childbearing is:

    A/ syphilis
    B/HIV
    C/streptococcus B
    D/gonorrhoea
    E/ P



    79.Regarding Group B streptococcus infection in pregnancy all is true EXCEPT:

    A/ 15 % women will be colonised
    B/ can cause significant maternal or foetal infection
    C/ if infected penicillin during the labour
    D/ she should be given prophylactic penicillin through all pregnancy
    E/


    80. All can be seen in Wernicke encephalopathy EXCEPT:

    A/ tongue fasciculation
    B/ataxia
    C/nystagmus
    D/extraocular muscles weakness
    E/altered consciousness


    81.18 y o girls 4 cm inside the introitus you can see remnant .It is most likely:

    A/ Wolffian duct
    B/ Mullerian duct
    C/hymeneal ring
    D/ Bartholin cyst


    82.Posttraumatic stress disorder (PTSD) can be seen in all of the following EXCEPT:

    A/ it is common in women beaten by husband – in domestic violence (*)
    B/people who watch that like bystanders can experience PTSD
    C/there are personal vulnerability
    D/
    E/


    83.Which of the following is demographic indicator that violence has poor prognosis:

    A/ past history of violence (*)
    B/past history of alcohol abuse
    C/


    84.Poisoning with acetaminophen will cause:

    A/ hepatic injury
    B/ kidney injury
    C/
    D/
    E/



    85.Women, twin pregnancy, all of the following is true EXCEPT:

    A/ acute polyhydroamnios
    B/ asymmetrical growth foetal proportion
    C/ anaemia in pregnancy if no folate given
    D/ premature labour
    E/

    86. 76 y.o. Man with acute left pain, fever, rebound tenderness of abdomen, diarrhea. MOST LIKELY is:

    A /
    B/Chron’s
    C/ ulcerative colitis
    D/ acute ischaemia
    E/diverticulitis (*)


    87.Patient has fever, central chest pain, worse on inspiration, relief sitting forward, ST segment elevated in all EXCEPT in V1 and aVR.Otherwise heart and pulmo exam OK. It is MOST LIKELY:

    A/pericarditis
    B/M I with pericarditis
    C/Pulmonary embolism


    88.Old lady colonic carcinoma, receiving Morphine for pain, has constipation (faecal impaction). She was prescribed Lactulose 3 x day but she didn’t used it. What is next in her Mx?

    A/ arrange surgical consultation
    B/dietary change
    C/laxatives
    D/rectal examination P
    E/


    89.All of the following can cause supraclavicular lump EXCEPT:

    A/breast cancer
    B/stomach cancer
    C/cervical rib
    D/Hodgkin lymphoma
    E/superficial venous thrombosis




    90.Mother bathing child, noticed mass in abdomen laterally.

    A/hepatoma
    B/Willm’s tumour P
    C/

    91.Women 46 yo. Mammogram shows mass, and two US shows cyst in breast. What is next appropriate treatment?

    A/ needle biopsy ( Tru-cut)
    B/needle aspiration (*)
    C/simple mastectomy
    D/Radical mastectomy
    E/ modified mastectomy


    92.Women with a prolonged bleeding. Brother and father said she is a bleeder. Most likely is:

    A/ von Willebrand’s disease
    B/ Haemophilia A
    C/ Lack of factor IX
    D/ Stuart disease


    93. VII nerve palsy LEAST LIKELY occur in:

    A/ acoustic neuroma
    B/chronic parotitis
    C/ parotid carcinoma
    D/


    94.Girl with photophobia, neck stiffness, (clinical picture of meningitis)
    What is most appropriate NEXT step?

    A/ do LP and give her Ceftriaxone P
    B/ sent her home and review for 2 days
    C/ do LP and wait for results


    95.Picture, CT of abdomen, patient vomiting, it could be all of the following EXCEPT:

    A/ splenic cyst
    B/pancreatic cyst
    C/ascites
    D/mesenteric cyst
    E/acute gastric dilatation


    96.Patient with progressive weakness of both hands over the 2 years:

    A/ syringomyelia
    B/ bilateral N ulnaris palsy
    C/ bilateral N. medianus palsy
    D/
    E/


    97. Young woman, breast lump, MOST COMMONLY:

    A/ fibroadenoma P
    B/fibrocystic dysplasia
    C/


    98.Young couple came to you surgery asking for genetic counselling. They planing to have babies, but his mother have bipolar disorder. (BPD). You advice them:

    A/10 % or less is chance to baby to have BPD
    B/they need specific genetic study.
    C/ it is better to adopt baby because risk to have baby with BPD is very high
    D/ she will need amniocenteses during the pregnancy
    E


    99. Which is the most recognised ophthalmic complication of Wernicke encephalopathy:

    A/ B complex deficiency P
    B/ optic nerve neuropathy
    C/

    100.Which statement best describe relation between glycaemia control and diabetic retinopathy:

    A/ strict control of glucose can prevent diabetic retinopathy P (see Merck P 730)
    B/good control can delay diabetic retinopathy
    C/


    101.Women 40 y.o lump in the breast:

    A/ US if nothing found assurance
    B/ mammography
    C/ US + mammography P
    D/



    102.Toddler with intermittent diarrhoea with undigested vegetables, for one week otherwise well.
    MOST LIKELY:

    A/ “Toddler†diarrhoea (*)
    B/ coeliac disease
    C/
    D/

    103.Dermoid cyst (teratoma) consist:

    A/ endoderm + ectoderm
    B/ 3 layer (*)
    C/
    D/


    104.Women, 2 children, with depression on Sertraline. You will tell her:

    A/ her symptoms will improve in one month (*)
    B/
    C/
    D/


    105.What is natural history of severe depression?

    A/ suicide
    B/ partial recovery within 6 months P
    C/
    D/


    106.Ultrasound in jaundice is MOST USEFUL to demonstrate:

    A/ gall stones P
    B/ bile duct
    C/
    D/


    107.Which of the following nerve has best prognosis after injury:

    A/n.digitalis
    B/n.ulnaris
    C/n.radialis
    D/n.medianus
    E/n. peroneus superficialis

    108. 75.yo man with long standing COPD (H/O 60 pack/year?) has been brought to by ambulance from nursing home. On his way to hospital he received Oxygen
    10 L/min by mask. On admission he is unarousable and his ABG MOST LIKELY will be:

    A/ PaO2 85 PaCO2 65 PH 7.15 (*)
    B/ PaO2 68 PaCO2 50 PH 7.45
    C/ PaO2 100 PaCO2 25 PH 7.25
    D PaO2 40 PaCo2 85 PH 7.45
    E/ PaO2 60 PCO2 40 PH 7.35


    109.13-year-old boy has weight (50th percentile)

    A/ advance bone age
    B/ obesity
    C/
    D/
    E/


    110.Mother of 8 months old child came to your surgery and complain that child has intermittent vomiting, sometimes with green/yellow stained (probably bile) Otherwise child is well. Which of the following is appropriate investigation?

    A/ barium meal and follow through
    B/ ultrasound
    C/reassurance
    D/CT scan of abdomen


    111. Abattoir worker developed pain, sweating, and red urine. What is MOST LIKELY?

    A/ brucellosis
    B/ Leptospirosis
    C/ hepatitis
    D/tularaemia


    112.Retrograde blood flow into the vertebral artery can be due to obstruction of:

    A/ internal carotid artery
    B/ proximal subclavian artery
    C/ distal subclavian artery
    D/



    113. Diabetic patient developed ulcer on the foot. MOST LIKELY cause is:

    A/ neuropathic ulcer
    B/atherosclerosis
    C/infection
    D/microvascular disease
    E/


    114.Which of the following tumours is LEAST LIKELY to improve with radiotherapy or chemotherapy:

    A/ Hodgkin lymphoma
    B/ advanced breast carcinoma
    C/ choriocarcinoma
    D/ non- Hodgkin lymphoma


    115.Post exposure immunoglobulins are effective in all EXCEPT:

    A/ mumps
    B/ hepatitis B
    C/ rabies
    D/ rubella
    E/


    116.Five days after delivery mother developed fever 38.7 C. Most common cause is:

    A/endometritis
    B/breast abscess
    C/ breast engorgement
    D/DVT

    117. Which of the following CTG will indicate foetal hypoxia (cord prolapse ?):

    A/ variation in beat < 5 min P
    B/
    C/


    118. What is the MOST COMMON site for Endometriosis ?

    A/ ovarium
    B/ utero-sacral ligament (*)
    C/ Fallopian tube
    D/


    119.Child fallen from the tree a few days ago. Now presented with fever, pain and tenderness over femoral area. It is MOST LIKELY:

    A/ osteomyelitis
    B/ osteosarcoma
    C/
    D/
    E/


    120. 28 y.o. Nursing student with superficial wound on forearm came to you surgery. You suspect that she meddling with a wound. After confronting her you will do next:

    A/ refer her to neuropsychiatrist
    B/ call her nursing college supervisor
    C/
    D/
    E/

    121.Ascites with malignant cell found in it. What is MOST LIKELY to find with it?

    A/ peritoneal deposits on per rectal examination
    B/ supraclavicular lymph nodes
    C/
    D/
    E/


    122. All of the following is correct Sjogren syndrome EXCEPT:

    A/ he will have SS- RO antibodies
    B/ corticosteroids…..
    C/
    D/
    E/
  25. Guest

    Guest Guest

    MCQ AMC

    In assessing progress of a patient with a head injury the MOST IMPORTANT clinical observation is
    (A) examination of the fundi.
    (B) state of the pupils.
    (C) level of consciousness.
    (D) plantar responses.
    (E) blood pressure.


    An anxious mother consults about her 18-month-old child because 'She doesn't seem to hear properly'. The child is otherwise well. Examination of the child's ears, nose and throat appears normal, including response to the noise of a rattle. You SHOULD
    (A) reassure the mother and reassess the child in 6 months time.
    (B) arrange audiometric assessment.
    (C) defer investigation until the child is 3 years of age.
    (D) perform tuning fork tests.
    (E) perform tympanometry.

    A 32-year-old multigravid woman has just been delivered of a 3600 g infant after successful oxytocin induction of labour at 42-weeks of gestation. With gentle traction on the umbilical cord the uterus suddenly inverted and is now approximately 10 cm outside of the introitus. The MOST APPROPRIATE treatment is
    (A) attempt immediate replacement of the uterus.
    (B) remove the placenta and then attempt replacement of the uterus.
    (C) magnesium sulphate 4-6 g intravenously over 5-10 min, then attempt replacement of the uterus.
    (D) terbutaline 0.25 mg subcutaneously, then attempt replacement of the uterus.
    (E) ritodrine hydrochloride 350 ug intravenous bolus, then attempt replacement of the uterus.

    During the first 24 h after a gastrectomy your patient develops a fever of 38.5 degrees C. The MOST LIKELY cause is
    (A) atelectasis.
    (B) urinary tract infection.
    (C) wound infection.
    (D) deep venous thrombosis.
    (E) superficial thrombophlebitis.

    A young woman who is obviously pregnant is found at the side of the road at the site of an automobile accident. She is unresponsive to verbal stimuli. Assessment of her condition should give FIRST PRIORITY to
    (A) respiratory status.
    (B) level of consciousness.
    (C) fetal viability.
    (D) presence of bleeding.
    (E) assessment of possible shock.


    Which one of the following USUALLY resolves spontaneously?
    (A) Small ventricular septal defect in a child aged 12 months.
    (B) Small atrial septal defect in a child aged 3 years.
    (C) Patent ductus in a toddler.
    (D) Aortic coarctation in a premature infant.
    (E) Congenital heart block.


    A multigravida presents at 37 weeks gestation, not in labour, with a breech presentation and ruptured membranes. What should be done INITIALLY?
    (A) Immediate caesarean section.
    (B) Emergency radiological pelvimetry.
    (C) Vaginal examination.
    (D) Set up an oxytocin infusion.
    (E) Urgent ultrasound scan.


    The lesion depicted in the accompanying photograph was present on the back of a 43-year-old builder. You would ADVISE him the lesion
    (A) should be excised because it is malignant and will extend locally but NOT to the draining lymph nodes.
    (B) is benign but is likely to become malignant, so should be excised.
    (C) should be excised because it is malignant and is likely to extend to the draining lymph nodes.
    (D) is benign, but should be excised because it may become an abscess.
    (E) is benign and has no inflammatory or malignant complications and does not need to be excised.


    Nine days after anterior resection of the rectum in an obese 57-year-old man, his left leg becomes swollen with tenderness of the calf. He has a slight fever and tachycardia. The MOST IMPORTANT aspect of his treatment WOULD be
    (A) elevation of the foot of the bed.
    (B) an elastic stocking.
    (C) anticoagulant therapy with heparin.
    (D) insertion of an inferior vena caval filter.
    (E) ligation of the left femoral vein.


    A 30-year-old man is awakened during the night by very severe pain in the right loin. He feels nauseated and sweaty. The pain comes and goes over intervals of about 10 min but seems better when he gets out of bed. He notices bright blood in his urine but does not see or hear a stone being passed. He is afebrile and plain X-ray of his urinary tract shows an opacity 5 mm by 3 mm in the line of the ureter just below the right sacroiliac joint. You SHOULD
    (A) advise him to go to bed to ease the pain.
    (B) send him to a urologist for urgent retrieval of the stone via cystoscopy.
    (C) tell him to drink lots of water, prescribe appropriate analgesia and have him return for a repeat X-ray within 2 days.
    (D) prescribe him allopurinol and a thiazide diuretic straight away.
    (E) advise him to avoid all dairy foods and foods containing calcium.


    A discrete mobile mass in the breast of a 25-year-old woman is MOST LIKELY to be
    (A) carcinoma.
    (B) fibroadenoma.
    (C) intraduct papilloma.
    (D) fibroadenosis.
    (E) fat necrosis.

    In regard to large bowel cancer, all the following statements are true EXCEPT
    (A) the risk of developing bowel cancer is significantly increased in first degree relatives of patients with the disease.
    (B) patients with large bowel cancer have approximately a three-fold increase in the risk of developing a subsequent bowel cancer.
    (C) patients with colonic adenomas have an increased risk of developing bowel cancer.
    (D) tubular adenomas are more likely to become cancers than villous adenomas.
    (E) patients with Crohn colitis have an increased risk of developing cancer of the bowel than normal people.

    Which one of the following maternal conditions generally CONTRAINDICATES epidural anaesthesia in labour?
    (A) Hypertension.
    (B) Previous caesarean delivery.
    (C) Platelet count less than 40x10 9/L (150-40x10 9/L)
    (D) Mitral stenosis.
    (E) Chronic anaemia.

    Ovulation is MOST ACCURATELY CONFIRMED by which one of the following?
    (A) Elevation of plasma progesterone in the luteal phase.
    (B) Biphasic change in the temperature chart.
    (C) Detection of a rise in plasma LH at midcycle.
    (D) Alteration in cervical mucus.
    (E) Plasma oestradiol peak at midcycle.


    65-year-old man develops sudden excruciating interscapular pain radiating into the right lower limb. On physical examination, the right femoral pulse is not felt and the left femoral pulse is weak. There is an aortic diastolic murmur. The blood pressure is 160/90 mmHg, and the pulse rate is 100/min. The MOST LIKELY diagnosis is
    (A) myocardial infarction.
    (B) embolus of the abdominal aorta.
    (C) dissecting aortic aneurysm.
    (D) pulmonary embolus.
    (E) spontaneous pneumothorax.


    A 60-year-old woman is brought to the Emergency Department by her relatives who have noticed that she is 'unwell' and confused. Blood tests are requested and the initial results are: Na 139 mmol/L; K 5.4 mmol/L; Cl 113 mmol/L; HCO3 17 mmol/L; urea 11.5 mmol/L (<8); creatinine .14 mmol/L (<0.11); arterial pH 7.28; paC02 30 mmHg; pa02 90mmHg. Which one of the following statements is CORRECT?
    (A) The anion gap is increased.
    (B) The symptoms and signs are due to uraemia.
    (C) Metabolic acidosis has been documented.
    (D) The results suggest that she has been vomiting excessively.
    (E) An infusion of bicarbonate should be commenced.


    A 34-year-old married woman has sought your advice on chronic and fluctuating food intolerance, accompanied by nausea, vomiting spells, abdominal pain, bloating and diarrhoea. She tells you that she has been "sickly" for most of the last 20 years of her life since puberty, and has had a lot of gynaecological investigations for severe dysmenorrhoea, excessive menstrual bleeding and dyspareunia. She has consulted a number of neurologists for trouble with walking, muscle weakness and fainting spells for which she was prescribed anticonvulsants, with little benefit. A cardiologist had prescribed a beta-blocker for episodes of palpitations accompanied by chest pain and breathlessness, and a rheumatologist had given her a trial of various anti-inflammatory drugs for small joint pain and lumbago with only temporary relief. Your physical examination revealed that she is apparently tense and anxious despite diazepam 15 mg daily, and that she has abdominal scars from a previous appendicectomy and separate hysterectomy. The MOST LIKELY psychiatric diagnosis that this woman has is
    (A) somatisation disorder.
    (B) hypochondriasis.
    (C) conversion disorder.
    (D) Munchausen syndrome.
    (E) factitious illness.



    A healthy non-smoking 19-year-old man, hospitalised for an appendicectomy, is mistakenly given an overdose of his narcotic premedication. He is found unconscious and on auscultation of his chest, he has reduced breath sounds but no added sounds. Emergency chest X-ray is clear. His arterial blood gases (in mmHg), taken while breathing room air are MOST LIKELY to show
    (A) pH - 7.22 PaO2 - 70 PaCO2 - 61.
    (B) pH - 7.23 PaO2 - 90 PaCO2 - 59.
    (C) pH - 7.23 PaO2 - 86 PaCO2 - 30.
    (D) pH - 7.39 PaO2 - 65 PaCO2 - 42.
    (E) pH - 7.39 PaO2 - 75 PaCO2 - 60.


    A placid 4-week-old formula-fed baby has vomited feeds since the first week of life. Her maternal grandmother is convinced that the baby is ill. The mother is also concerned but says that the baby feeds well. You confirm that she has gained weight normally, and find no clinical abnormality. You SHOULD
    (A) reassure the mother and tell her to ignore anyone who says the child is ill.
    (B) explain that the baby probably has gastro-oesophageal reflux.
    (C) arrange barium swallow and meal.
    (D) arrange suprapubic aspiration of urine for microscopy and culture.
    (E) advise that the formula be diluted to make it more digestible.


    The RISK of spontaneous abortion following second trimester amniocentesis is
    (A) 1:50.
    (B) 1:200.
    (C) 1:500.
    (D) 1:1000.
    (E) 1:2000.


    The LEAST likely fracture to occur in a 7-year-old child who falls on an outstretched arm is
    (A) fracture of both bones of the forearm.
    (B) dislocation of the distal radial epiphysis.
    (C) Colles fracture.
    (D) supracondylar fracture.
    (E) greenstick fracture of the ulna.

    A 67-year-old man presents with a history of progressive dysphagia and hoarseness over the preceding 24 h. On examination there is a right Horner syndrome and the right side of the palate does not elevate on phonation. The right gag reflex is absent and the patient cannot produce an explosive cough. These signs and symptoms are MOST LIKELY due to which one of the following?
    (A) A left capsular haemorrhage.
    (B) A meningioma at the foramen magnum.
    (C) Thrombosis of the left posterior inferior cerebellar artery.
    (D) A left cerebello-pontine angle tumour.
    (E) A right-sided brain stem infarction.

    A 19-year-old woman, prescribed a triphasic oral contraceptive for the first time one month ago, complains of frequent spotting. The MOST APPROPRIATE MANAGEMENT is to
    (A) increase the dose of oestrogen.
    (B) increase the dose of progestogen.
    (C) advise alternative contraception.
    (D) continue the medication and review in two months.
    (E) change to a biphasic pill.


    A 27-year-old woman is hospitalised at 36 weeks gestation because of jaundice, haematemesis and increased confusion. For 10 days prior to admission she had nausea, vomiting, lack of appetite and fatigue. Results of laboratory studies are: urea 18 mmol/L (3-8); uric acid 0.6 mmol/L (0.15-0.40); bilirubin 60 umol/L (2-20); alanine aminotransferase (ALT) 240 U/L (5-40); aspartate aminotransferase (AST) 210 U/L (10-45); alkaline phosphatase (ALP) 80 U/L (25-100). Serum ammonia concentration is elevated. The MOST LIKELY diagnosis is
    (A) acute viral hepatitis.
    (B) alcoholic cirrhosis.
    (C) pre-eclampsia.
    (D) acute fatty liver of pregnancy.
    (E) cholestasis of pregnancy.


    A patient lacerates the ulnar nerve just above the wrist. Which one of the following physical findings is MOST LIKELY to be present? Inability to
    (A) extend the wrist.
    (B) flex the wrist.
    (C) flex the distal phalanges of the fourth and fifth digits.
    (D) oppose the thumb and index finger.
    (E) spread the fingers.


    A 73-year-old woman complains of pain mainly in the limb girdles, associated with marked stiffness. Her symptoms are worse in the early hours of the morning and on waking. There is no abnormality on examination apart from mild generalised stiffness of the shoulder and hip joints. Your provisional diagnosis would MOST LIKELY be CONFIRMED by
    (A) X-ray of the pelvis and shoulder girdle.
    (B) serum calcium and phosphorus levels.
    (C) serum alkaline phosphatase level.
    (D) erythrocyte sedimentation rate of 110mm/h.
    (E) latex rheumatoid factor.

    After a pulmonary embolus, which one of the following is MOST LIKELY?
    (A) Low right atrial pressure and low central venous pressure.
    (B) Low systemic arterial blood pressure and low venous pressures.
    (C) High pulmonary venous pressure and pulmonary oedema.
    (D) High right ventricular pressure and high systemic venous pressure.
    (E) High left atrial pressure and functional mitral valve incompetence.

    A 26-year-old man has been under your care after falling 10 m while rock climbing, sustaining bilateral compound tibial fractures and a fractured pelvis. Three days postoperatively, after open reduction and fixation of his tibial fractures, he becomes acutely breathless. A chest X-ray reveals a diffuse bilateral pulmonary infiltrate. He suddenly becomes confused and fearful, believing his food to be poisoned, and that the hospital staff are plotting against him and plan to murder him. The MOST LIKELY explanation for the change in his mental state is
    (A) aspiration pneumonia.
    (B) pulmonary embolism.
    (C) fat embolism syndrome.
    (D) subacute pancreatitis.
    (E) extradural haematoma.


    A previously well boy aged 18 months presents with a 24 h history of cough and wheeze and has a respiratory rate of 35/min. There is a family history of asthma and allergy. Examination shows a boy who is generally well but he has softer breath sounds over the left hemithorax. There are bilateral wheezes, more marked on the left. The APPROPRIATE MANAGEMENT is
    (A) give nebulised salbutamol 4 hourly.
    (B) refer for physiotherapy.
    (C) give amoxycillin.
    (D) arrange inspiratory and expiratory chest x-rays.
    (E) admit to hospital and nurse in 30% oxygen.

    A 28-year-old sales assistant presents with difficulty sleeping. He recounts how he has great difficulty falling asleep, going over the events of the day in his head. When at last he gets to sleep, he wakes often during the night. He sometimes has nightmares and usually feels unrefreshed in the mornings. His sleep disturbance is CHARACTERISTIC of
    (A) borderline personality disorder.
    (B) major depression.
    (C) schizophrenia.
    (D) generalised anxiety disorder.
    (E) nocturnal epilepsy.



    Which one of the following is CORRECT?
    (A) Meatal ulceration is a complication of circumcision.
    (B) The prepuce is fully retractable in 90% of uncircumcised boys aged 6 months.
    (C) Circumcision is the first stage in the repair of hypospadias.
    (D) Neonatal circumcision is safe in haemophilia, because of transplacental passage of factor VIII.
    (E) Neonatal circumcision is painless.


    Cardiac auscultation reveals accentuation of the first heart sound at the apex, accentuation of the second pulmonary sound and a presystolic murmur at the apex. The MOST LIKELY diagnosis is
    (A) pulmonary stenosis.
    (B) mitral stenosis.
    (C) aortic stenosis.
    (D) mitral incompetence.
    (E) functional heart murmur.

    A 65-year-old overweight man complains of recent misty vision on sunny days. His vision, when tested, is 6/18 right and left. Which one of the following is the MOST LIKELY basis of his complaint?
    (A) Chronic simple glaucoma.
    (B) Myopia.
    (C) Cataract.
    (D) Macular degeneration.
    (E) Diabetic retinopathy.


    Of the following factors which is MOST important in determing the overall prognosis in a patient with a malignant melanoma?
    (A) Depth of invasion in the skin and subcutaneous tissues.
    (B) Previous history of irradiation in the area.
    (C) The number of mitotic figures in the microscopic specimen.
    (D) The level of carcinoembryonic antigen.
    (E) Previous history of depigmentation of a pigmented naevus.


    A 32-year-old woman, G5, P4, at 32 weeks gestation is admitted to hospital because of mild, bright red vaginal bleeding amounting to approximately 100 mL. Her last two children were born by lower uterine segment caesarean section. She has no pain or contractions. Vital signs are stable within the normal range. Fetal heart rate is 140 beats/min and regular and the CTG shows no decelerations and good beat to beat variation. Intravenous fluids are started, and blood is drawn for typing, cross-matching, and complete blood count. In addition to bed rest, management at this time SHOULD INCLUDE
    (A) a rectal examination.
    (B) a vaginal examination.
    (C) beta sympathomimetic agents.
    (D) immediate caesarean section.
    (E) observation and further investigation.



    A 40-year-old school teacher has been receiving treatment for depressive symptoms following his wife's desertion. A week after being involved in a traffic accident in which a child was hospitalised with head injuries, he takes an overdose of fifty 25 mg imipramine tablets and a large amount of alcohol. He has previously refused referral to a psychiatrist or voluntary hospitalisation for assessment. Your INITIAL management, after successful medical treatment of his overdose, SHOULD BE to
    (A) increase his imipramine to 150 mg daily.
    (B) change him to a different tricyclic antidepressant.
    (C) contact his wife and try and persuade her to return home.
    (D) arrange involuntary psychiatric hospitalisation, if he still refuses voluntary admission.
    (E) refer him for alcohol counselling.



    In the preoperative evaluation of a person for a possible bleeding tendency the MOST IMPORTANT of the following is
    (A) clotting time.
    (B) bleeding time.
    (C) clinical history.
    (D) prothrombin time of Internaional Normalised Ratio (INR).
    (E) partial thromboplastin time.


    A previously healthy 3-year-old child has a single generalised convulsion lasting 5 min. She is found to have a reddened throat and rectal temperature of 39.7 degrees C, from which she recovers uneventfully in 5 days. Three months later she again becomes febrile with an upper respiratory tract infection. Which one of the following is CORRECT?
    (A) She should be started on oral phenobarbitone.
    (B) She should be put in a bath of cold water.
    (C) 600 mg aspirin should be administered.
    (D) An antibiotic should be administered promptly.
    (E) Most such children will not have a further seizure.


    In a 25-year-old woman with gluten-sensitive enteropathy, which one of the following statements is CORRECT?
    (A) The anaemia is most likely due to Vitamin B12 deficiency.
    (B) The pretreatment biopsy will demonstrate flattened villi and an inflammatory cell infiltrate of periodic acid-Schiff positive macrophages.
    (C) Corn contains gluten and should be excluded from the diet.
    (D) When placed on a strict gluten-free diet, the small bowel histology will improve markedly within 2 weeks.
    (E) There is an association with the development of lymphoma.

    A 22-year-old woman presents with painful dysphagia. There is a past history of Raynaud phenomenon. Upper gastrointestinal endoscopy reveals ulcerative oesophagitis, which proves resistant to double dose (800mg, b.d.) cimetidine therapy. An oesophageal manometry study demonstrates absent peristalsis; the lower oesophageal sphincter is not identified. Which one of the following is the MOST APPROPRIATE treatment?
    (A) Fundoplication.
    (B) Omeprazole.
    (C) Octreotide.
    (D) Pneumatic dilatation of the lower oesophageal sphincter.
    (E) Ranitidine.

    A 75-year-old woman has taken lithium, without complication, for many years. Subsequently a non-steroidal anti-inflammatory drug (NSAID) is prescribed for osteo-arthritis. Over the ensuing weeks she develops ataxia, anorexia, nausea and tremulousness. Which one of the following is CORRECT?
    (A) These features are consistent with NSAID toxicity.
    (B) The main therapeutic measure would be salt restriction.
    (C) Lithium inhibits the clearance of most NSAID from the body.
    (D) Interactions between lithium and NSAID are of little clinical significance.
    (E) These features are consistent with lithium toxicity.


    A 6-year-old girl has had a moderately severe episode of asthma for 36-48 h. She has been treated with inhaled sympathomimetic every 3-4 h but respiratory distress recurs within 2-3 h of the inhalation. The MOST APPROPRIATE additional therapy would be
    (A) oral theophylline.
    (B) a short course of oral corticosteroids.
    (C) a short course of inhaled corticosteroids.
    (D) additional inhaled ipratropium bromide.
    (E) a course of oral antibiotics.


    A patient presents for her first visit in her second pregnancy with a history of a second trimester miscarriage in her previous pregnancy. Which of the events listed below should cause you to suspect that her miscarriage had been DUE TO an incompetent cervix?
    (A) Onset of contractions.
    (B) Rupture of membranes.
    (C) Reduction in fetal movements.
    (D) Vaginal bleeding.
    (E) Purulent vaginal discharge.
  26. Atiq

    Atiq Guest

    >Which of the following conditions may lead to development of an
    exudate within the pleural cavity?
    A. Bacterial pleuritis
    B. Cirrhosis of the liver
    C. Congestive heart failure
    D. Nephrotic syndrome
    E. Protein-losing enteropathy
    Answer
    --------------------------------------------------------------------------------

    2>In which of the following sites do myxopapillary ependymomas most
    frequently occur?
    A. Cerebellum
    B. Conus medullaris
    C. 4th ventricle
    D. Lateral ventricles
    E. Midbrain
    Answer
    --------------------------------------------------------------------------------

    3>A patient has long-standing severe hemolytic anemia characterized by
    hypochromic cells. Electrophoresis studies demonstrate a near complete
    absence of beta chains. Several years later, the patient develops
    cardiac failure. Intracardiac deposition of which of the following
    would be most likely to contribute to the cardiac failure?
    A. Calcium
    B. Iron
    C. Magnesium
    D. Potassium
    E. Sodium
    Answer
    --------------------------------------------------------------------------------

    4>Before being approved by the FDA, a chemical is tested for
    carcinogenicity by examining its mutagenic effects on bacterial
    cells in culture. Which of the following tests is used to make
    this determination?
    A. Ames test
    B. Nitroblue tetrazolium test
    C. Watson-Schwartz test
    D. Widal test
    E. Woellner enzyme test
    Answer
    --------------------------------------------------------------------------------

    5.A sharp instrument passing through the superior orbital fissure
    would most likely sever the
    A. abducens nerve
    B. facial nerve
    C. mandibular nerve
    D. maxillary nerve
    E. middle meningeal artery
    F. ophthalmic artery
    G. optic nerve
    Answer
    --------------------------------------------------------------------------------

    6>An elderly nursing home patient has had multiple small strokes.
    On several occasions she has aspirated food, and neurological
    examination reveals that her gag reflex is absent. These findings
    suggest involvement of the nucleus of which of the following
    cranial nerves?
    A. Facial (VII)
    B. Glossopharyngeal (IX)
    C. Hypoglossal (XII)
    D. Spinal accessory (XI)
    E. Vestibulocochlear (VIII)
    Answer
    --------------------------------------------------------------------------------

    7>A new antifungal medication is being tested in Phase I clinical
    trials. Examination of the pharmacokinetic properties of the drug
    reveals that the half-life of the drug is 6 hours. If a continuous
    intravenous infusion of this drug were started on a research subject,
    how long would it take to reach 75% of steady state?
    A. 3 hours
    B. 6 hours
    C. 9 hours
    D. 12 hours
    E. 18 hours
    F. 24 hours
    Answer
    --------------------------------------------------------------------------------

    8>A leukemia patient who has undergone multiple courses of chemotherapy
    develops herpes simplex encephalitis. Which of the following would you
    expect a CT scan of the patient's brain to show?
    A. Generalized volume loss
    B. Volume loss selectively in the basal ganglia
    C. Volume loss selectively in the brainstem
    D. Volume loss selectively in the cerebellum
    E. Volume loss selectively in the temporal and frontal lobes
    Answer
    --------------------------------------------------------------------------------

    9>An 18-year-old male takes an employment physical examination that is
    remarkable for a systolic murmur preceded by a distinct click on
    auscultation. The patient has unique body features, with unusually
    long legs and long, tapering fingers. An ocular examination reveals
    dislocation of the lens. An abnormality of which of the following
    gene products is thought to underlie this condition?
    A. Collagen
    B. Dystrophin
    C. Elastin
    D. Fibrillin
    E. Myosin b-chain
    Answer
    --------------------------------------------------------------------------------

    10>A third-world patient develops muscle weakness and atrophy with
    fasciculations and hyporeflexia. The patient's condition continues
    to deteriorate, and his legs are eventually permanently paralyzed.
    The virus that can cause these problems is usually spread by which
    of the following routes?
    A. Dirt contact with open wound
    B. Injection
    C. Mosquitoes
    D. Oral-fecal
    E. Puncture wound of the foot
    Answer
    --------------------------------------------------------------------------------

    11>Physical examination of a 45-year-old diabetic patient demonstrates a
    pulsatile abdominal mass. Radiographic studies demonstrate a 10 cm
    diameter aneurysm of the abdominal aorta with foci of calcification
    in the walls. Which of the following is the most likely etiology
    for this aneurysm?
    A. Atherosclerosis
    B. Congenital weakness
    C. Cystic medial necrosis
    D. Syphilis
    E. Vasculitis
    Answer
    --------------------------------------------------------------------------------

    12>A 40-year-old woman is being seen by a physician for the 10th time
    this year for evaluation of vague aches and pains. An extensive prior
    evaluation has excluded the possibility of serious disease. During the
    interview with this patient, she makes repeated statements along the
    lines of, "What I want doesn't matter. Do what you want." And, "I'm
    afraid you won't have time to see me anymore." The traits this
    patient is exhibiting are most consistent with which of the
    following personality disorders?
    A. Dependent
    B. Histrionic
    C. Obsessive-compulsive
    D. Paranoid
    E. Schizoid
    Answer
    --------------------------------------------------------------------------------

    13>A 60-year-old man suddenly becomes completely blind in one eye, and
    angiography demonstrates occlusion of the central retinal artery.
    Which of the following is the most likely cause of the occlusion?
    A. Atheroma or embolism
    B. Cranial (temporal) arteritis
    C. Hypertension
    D. Polycythemia vera
    E. Tumor
    Answer
    --------------------------------------------------------------------------------
    14 A mailman gets a severe bite wound from a pit bull guarding
    a junkyard. The wound is cleansed and he receives a booster
    injection of tetanus toxoid and an injection of penicillin G.
    Several days later, the wound is inflamed and purulent. The
    exudate is cultured on blood agar and yields gram-negative rods.
    Antibiotic sensitivity tests are pending. The most likely agent
    to be isolated is
    A. Bartonella henselae
    B. Brucella canis
    C. Clostridium tetani
    D. Pasteurella multocida
    E. Toxocara canis
    Answer
    --------------------------------------------------------------------------------
    15.A 7-year-old boy is referred to a specialty clinic
    because of digestive problems. He often experiences severe
    abdominal cramps after eating a high fat meal. He is worked
    up and diagnosed with a genetic defect resulting in a deficiency
    of lipoprotein lipase. Which of the following substances would most
    likely be elevated in this patient's plasma following a fatty meal?
    A. Albumin-bound free fatty acids
    B. Chylomicrons
    C. HDL
    D. LDL
    E. Unesterified fatty acids
    Answer
    --------------------------------------------------------------------------------

    16>A 49-year-old woman is in an automobile accident and sustains a closed
    head injury. A CT scan does not show any intracranial hemorrhage, but
    reveals a small tumor at the cerebellopontine angle of the brain.
    Which of the following nerves is most likely to be affected by
    this tumor?
    A. Facial nerve
    B. Glossopharyngeal nerve
    C. Optic nerve
    D. Trigeminal nerve
    E. Vagus nerve
    Answer
    --------------------------------------------------------------------------------

    17>A 47-year-old male patient presents with painful arthritis in the
    right big toe and uric acid renal stones. He has been taking allopurinol
    for his condition. What biochemical defect would likely be found in this
    patient?
    A. A defect in urea synthesis
    B. An abnormality of the purine degradation pathway
    C. An inability to synthesize non-essential amino acids
    D. Defective topoisomerases
    E. Increased levels of leukotrienes
    Answer
    --------------------------------------------------------------------------------

    18>A 3-year-old boy is brought to the emergency department after the acute
    onset of headache, vomiting, nuchal rigidity, and impaired mental status.
    MRI reveals a posterior fossa tumor that fills the 4th ventricle. Surgery
    is immediately started, and intraoperative consultation leads to
    a "frozen section" diagnosis of medulloblastoma. Which of the
    following pathologic mechanisms most likely accounts for this
    child's clinical presentation?
    A. Acute hemorrhage into the 4th ventricle
    B. Alteration of medullary function
    C. Increased intracranial pressure
    D. Infiltration of the cerebellar vermis by the neoplasm
    E. Spread of tumor to the subarachnoid space
    Answer
    --------------------------------------------------------------------------------

    19>A diabetic mother gives birth to a baby who dies in the first week of life.
    Autopsy reveals a severe cardiac malformation. Which of the following is
    the most likely diagnosis?
    A. Atrial septal defect
    B. Coarctation of the aorta
    C. Eisenmenger's syndrome
    D. Tetralogy of Fallot
    E. Transposition of the great arteries
    Answer
    --------------------------------------------------------------------------------

    20>There is a classic zoo story about a cage with three monkeys in it. The
    largest monkey steals the middle-sized monkey's banana. The middle-sized
    monkey then screams with rage, hits the smallest monkey on the head, and
    then steals his banana. The middle-sized monkey is using which of the
    following mechanisms of defense?
    A. Displacement
    B. Projection
    C. Reaction formation
    D. Regression
    E. Repression
    Answer
    --------------------------------------------------------------------------------

    21>A 10-year-old boy has a small tumor in the wall of the right lateral
    ventricle. A biopsy of this tumor is consistent with subependymal giant
    cell astrocytoma. Which of the following lesions may also be present in
    this patient?
    A. Café-au-lait spots
    B. Cortical tubers
    C. Hemangioblastoma
    D. Lisch nodules
    E. Schwannoma of the 8th cranial nerve
    Answer
    --------------------------------------------------------------------------------

    22>Physical examination of a 45-year-old diabetic patient demonstrates a
    pulsatile abdominal mass. Radiographic studies demonstrate a 10-cm
    diameter aneurysm of the abdominal aorta with foci of calcification
    in the walls. Which of the following is the most likely etiology for
    the aneurysm?
    A. Atherosclerosis
    B. Congenital weakness
    C. Cystic medial necrosis
    D. Syphilis
    E. Vasculitis
    Answer
    --------------------------------------------------------------------------------

    23>A 19-year-old female, who recently moved from her family's home in another
    state, is hospitalized for attempting suicide by taking an overdose of
    antidepressant medications. On the third day of her hospital stay, she
    insists, under threat of a lawsuit, that her medications be stopped and
    that she be discharged from the hospital so she "can go home and finish
    the job." Her sensorium is clear. Her physician should
    A. discharge her against medical advice (AMA)
    B. honor her request and release her immediately
    C. obtain an emergency order of detention
    D. release her to go back to her parents' home
    E. sedate her
    Answer
    --------------------------------------------------------------------------------

    24>Which of the following could prevent an allergen from reacting with a
    specific IgE molecule present on the mast cell membrane?
    A. Antihistamine
    B. Blocking antibody
    C. Cromolyn sodium
    D. Epinephrine
    E. Theophylline
    Answer
    --------------------------------------------------------------------------------

    25>During a fight, a 32-year-old man is hit on the back of the neck with a
    chair. A CT scan reveals a bony fragment that penetrated the lateral
    portion of the dorsal columns. Which of the following functions would
    most likely be affected by a lesion at this site?
    A. Fine motor control of the ipsilateral fingers
    B. Motor control of the contralateral foot
    C. Sweating of the ipsilateral face
    D. Proprioception from the ipsilateral leg
    E. Vibratory sense from the ipsilateral arm
    Answer
    --------------------------------------------------------------------------------

    26>A 40-year-old, formerly obese woman presents to her physician. She was
    very proud of having lost 80 lbs. during the previous 2 years, but now
    noticed that her "hair is falling out." On questioning, she reports
    having followed a strict fat-free diet. Her alopecia is probably related
    to a deficiency of which of the following vitamins?
    A. Vitamin A
    B. Vitamin C
    C. Vitamin D
    D. Vitamin E
    E. Vitamin K
    Answer
    --------------------------------------------------------------------------------

    27>A 50-year-old woman presents with a 5-year history of headaches,
    generalized tonic-clonic seizures, and bilateral leg weakness. Skull
    films reveal hyperostosis of the calvarium. Biopsy of the responsible
    lesion shows a whorling pattern of the cells. Which of the following
    is the most likely diagnosis?
    A. Arachnoid cyst
    B. Glioblastoma multiforme
    C. Meningioma
    D. Metastatic breast cancer
    E. Oligodendroglioma
    Answer
    --------------------------------------------------------------------------------

    28>A 53-year-old man develops acute, excruciating chest pain that radiates
    to his back. En route to the emergency room, he becomes unresponsive,
    and is pulseless on arrival. Resuscitation attempts are unsuccessful.
    Autopsy reveals massive hemoperitoneum due to a ruptured aortic
    dissection. There is a jagged intimal tear in the ascending aorta,
    with a dissecting hematoma in the media, extending from the aortic
    valve to the renal arteries. Which feature of this scenario most
    strongly suggests hypertension as the cause of the aortic dissection?
    A. Adventitial tear above renal arteries
    B. Dissection through media
    C. Involvement of major aortic branches
    D. Origin at ascending aorta
    E. Rapid exsanguination
    Answer
    --------------------------------------------------------------------------------

    29>A 68-year-old, well-developed, well-nourished black male presents to
    the emergency department complaining of shortness of breath. He denies
    chest pain. He has no significant past medical history and takes no
    medications. A chest x-ray shows clear lung fields, mild cardiomegaly
    and a widened thoracic aorta with linear calcifications. An MRI of the
    chest shows aortic dilatation in the thorax, extending proximally,
    with atrophy of the muscularis and wrinkling of the intimal surface.
    What is the most likely etiology of this condition?
    A. Atherosclerosis
    B. Hypertension
    C. Marfan's syndrome
    D. Syphilis infection
    E. Takayasu's arteritis
    Answer
    --------------------------------------------------------------------------------

    30>A 60-year-old man presents to a physician because of difficulty in reading
    and coming down stairs, which he attributes to an inability
    to "look down." Physical examination reveals that the patient
    looks around by moving his head rather than his eyes and als
    o shows a distinctive axial rigidity of neck, trunk, and
    proximal limb muscles. He shows poverty of movement and
    dysarthric speech. Mentally, the patient responds very
    slowly but has better memory and intellect than are
    initially apparent. Which of the following pathologic
    findings of the brain would most likely be present?
    A. Depigmentation of the substantia nigra and locus ceruleus
    B. Diffuse cortical atrophy with relative sparing of primary motor and sensory areas
    C. Selective frontal and temporal lobe atrophy
    D. Striking degeneration of the caudate nucleus
    E. Widespread neuronal loss and gliosis in subcortical sites
    Answer
    --------------------------------------------------------------------------------

    31>At which of the following sites is the characteristic triple helical
    structure of the collagen initially formed?
    A. Extracellular space
    B. Golgi body
    C. Nucleus
    D. Rough endoplasmic reticulum
    E. Smooth endoplasmic reticulum
    Answer
    --------------------------------------------------------------------------------

    32>The nucleus that lies immediately medial (and deep) to the uncus is the
    A. amygdala
    B. caudate nucleus
    C. claustrum
    D. hippocampus
    E. putamen
    F. thalamus
    Answer
    --------------------------------------------------------------------------------

    33>A 62-year-old female is brought to the emergency room by her husband
    with complaints of shortness of breath. Which of the following physical
    findings would be the most reliable indicator that she is experiencing
    heart failure?
    A. A third heart sound (S3)
    B. A fourth heart sound (S4)
    C. Ascites
    D. Orthopnea
    E. Pulmonary rales
    Answer
    --------------------------------------------------------------------------------

    34> A couple brings their son in to a specialty clinic for evaluation of
    recurrent bacterial infections involving the respiratory tract. Other
    family members have a similar disorder, as noted in the pedigree above.
    Which of the following is the most likely diagnosis?
    A. Bruton's agammaglobulinemia
    B. Common variable immunodeficiency
    C. DiGeorge syndrome
    D. Hereditary angioedema
    E. Isolated IgA deficiency
    Answer
    --------------------------------------------------------------------------------

    35>Two young boys are playing at a daycare center. One holds a ball on top
    of some blocks that the other child has placed on the floor. The second
    child helps steady the blocks, then the first child lets go of the ball
    , knocking the blocks down to the floor. They both watch and then repeat
    the process. These children are most likely
    A. 10 months old
    B. 16 months old
    C. 18 months old
    D. 24 months old
    E. 48 months old
    Answer
    --------------------------------------------------------------------------------

    36>In which of the following neurodegenerative conditions would you expect
    to observe the phenomenon known as anticipation?
    A. Familial Alzheimer disease (FAD)
    B. Familial amyotrophic lateral sclerosis (ALS)
    C. Huntington disease
    D. Pick disease
    E. Progressive supranuclear palsy
    Answer
    --------------------------------------------------------------------------------


    38>Which of the following antihistamines would be the most appropriate
    treatment for an airline pilot with hay fever?
    A. Chlorpheniramine
    B. Diphenhydramine
    C. Meclizine
    D. Pyrilamine
    E. Terfenadine
    Answer
    --------------------------------------------------------------------------------

    39>A newborn baby has multiple hemorrhages. Clotting studies demonstrate
    an elevated prothrombin time. An abnormality of which of the following
    biochemical processes is likely present in this patient?
    A. Conversion of homocysteine to methionine
    B. Conversion of methylmalonyl CoA to succinyl CoA
    C. Degradation of cystathionine
    D. Formation of gamma-carboxyglutamate residues
    E. Hydroxylation of proline
    Answer
    --------------------------------------------------------------------------------

    40>Examination of an autopsy specimen from a Mexican immigrant demonstrates
    a heart with massive dilation of the aortic root and adjacent aortic arch.
    Opening the aorta reveals a smooth interior wall without obvious lesions.
    If a histological section through the aortic wall is made, which of the
    following would most likely be seen?
    A. A heavy eosinophilic infiltrate
    B. Fibrinoid necrosis with a neutrophilic infiltration
    C. Focal fragmentation of elastic elements
    D. Obliterative endarteritis of the vasa vasorum
    E. Ring-like calcification of the vessel media
    Answer
    --------------------------------------------------------------------------------

    41>A 16-year-old girl is brought to emergency room by her parents for
    severe right foot pain. The patient states that the pain started 1
    day prior to presentation. She cannot recall any recent trauma,
    and denies any past medical or surgical problem. She is active
    and walks at least 1 hour daily in the nearby forest. She goes
    to high school and is doing very well. She gets along well with
    her parents except that they insist she should eat more, as her
    weight has dropped from 130 to 105 pounds over the past year.
    Which of the following is the most likely diagnosis?
    A. Conversion disorder
    B. Depression with somatic manifestation
    C. Injured medial ankle tendon
    D. Metatarsal stress fracture
    E. Tick bite
    Answer
    --------------------------------------------------------------------------------

    42>A newborn has a heart rate of 130/min, irregular respirations, and
    active muscle movements with good tone. He coughs and grimaces in
    response to stimulation; he is pink in color, except for his hands
    and feet, which are slightly bluish. This neonate's APGAR score is
    A. 6
    B. 7
    C. 8
    D. 9
    E. 10

    43>Which of the following amino acids would most likely be found on the
    surface of a protein molecule?
    A. Alanine
    B. Arginine
    C. Isoleucine
    D. Leucine
    E. Phenylalanine
    F. Tryptophan
    Answer
    --------------------------------------------------------------------------------

    44>A 46-year-old man sustains a spider bite on his upper eyelid, and an
    infection develops. The physician is very concerned about spread of
    the infection to the dural venous sinuses of the brain via emissary
    veins. With which of the following dural venous sinuses does the
    superior ophthalmic vein directly communicate?
    A. Cavernous sinus
    B. Occipital sinus
    C. Sigmoid sinus
    D. Superior petrosal sinus
    E. Straight sinus
    Answer
    --------------------------------------------------------------------------------

    45>A 10-week-old apparently healthy infant is laid down for a nap. The
    mother sits in a rocking chair nearby reading. At one point, she
    hears the baby make a single small cry, but she keeps reading because
    the baby quiets quickly. Later, she gets up to check on the child,
    whom she finds dead.Careful autopsy would be most likely to reveal
    which of the following cardiac findings?
    A. Endocarditis
    B. Failure of development of the endocardial cushion
    C. Large interventricular septal defect
    D. Mitral valve stenosis
    E. Right ventricular hypertrophy
    Answer
    --------------------------------------------------------------------------------

    46>A 40-year-old HIV-positive man with a CD4 cell count of 25/mm3
    complains of progressive memory loss, confusion, and incontinence.
    MRI reveals moderate brain atrophy. The patient subsequently dies
    of disseminated aspergillosis. Autopsy confirms the presence of
    moderate cerebral atrophy. Histologically, there are multifocal
    lymphohistiocytic infiltrates with numerous microglial nodules
    and scattered multinucleated giant cells. Which of the following
    conditions was most likely responsible for this patient's neurologic
    symptoms?
    A. Aspergillosis
    B. CMV encephalitis
    C. HIV encephalitis
    D. Mycobacterial infection
    E. Vacuolar myelopathy
    Answer
    --------------------------------------------------------------------------------

    47> The pedigree above illustrates the mode of inheritance for which of
    the following diseases?
    A. Glucose-6-phosphate dehydrogenase deficiency
    B. Leber's hereditary optic neuropathy
    C. Neurofibromatosis
    D. Sickle cell anemia
    E. Tay Sachs disease
    Answer
    --------------------------------------------------------------------------------

    48>A 45-year-old man develops a large meningioma that compresses the brain.
    A head CT scan demonstrates a subfalcine herniation. This herniation
    would most likely damage which of the following structures?
    A. Cerebellar tonsils
    B. Cingulate gyrus
    C. Medial temporal lobe
    D. Medulla
    E. Midbrain
    Answer
    --------------------------------------------------------------------------------

    49>A middle-aged patient develops a gelatinous, well-circumscribed mass
    in her right cerebral hemisphere. Biopsy of the mass reveals neoplastic
    cells with a "fried egg" morphology. Which of the following tumors does
    this patient most likely have?
    A. Choroid plexus papilloma
    B. Ependymoma
    C. Glioblastoma multiforme
    D. Oligodendroglioma
    E. Pilocytic astrocytoma
    Answer
    --------------------------------------------------------------------------------

    50>A patient develops an excruciatingly painful infection of the anterior
    half of the external ear canal. Which of the following nerves transmits
    this impulse?
    A. Auricular branch of the vagus
    B. Auriculotemporal nerve
    C. Greater auricular nerve
    D. Lesser occipital nerve
    E. Vestibulocochlear nerve
    Answer
    --------------------------------------------------------------------------------

    Answers
    --------------------------------------------------------------------------------
    1>The correct answer is A. An exudate results from leakage of protein-rich fluid from the plasma into the interstitium. It is usually the result of increased vascular permeability caused by inflammation. Exudates also contain numerous acute or chronic inflammatory cells, depending on the inciting event. Of the above choices, only bacterial pleuritis would produce an exudate. If pleuritis is caused by pyogenic organisms, the exudate is purulent (neutrophil-rich). If pleural inflammation is due to mycobacterial infection or neoplastic infiltration, the resulting exudate will contain chronic inflammatory cells.
    In contrast, a transudate contains less protein and few inflammatory cells. There are two main mechanisms of transudate formation: 1) decreased oncotic pressure, such as that which occurs in cirrhosis of the liver, nephrotic syndrome, and protein-losing enteropathy (choices B, D, and E); and 2) increased hydrostatic pressure, which may result from congestive heart failure (choice C).
    --------------------------------------------------------------------------------
    2>The correct answer is B. Myxopapillary ependymoma is a variant of ependymoma, a tumor arising from ependymal cells. Histologically, myxopapillary ependymoma contains a myxoid (mucus-rich) intercellular matrix, in which spindly neoplastic ependymal cells are arranged in a fascicular and papillary pattern (hence its designation). It is a benign tumor that almost always occurs in the distal segment of the spinal cord, ie, the conus medullaris. Once excised, the patient is cured.
    The cerebellum (choice A) is the favorite site for pilocytic astrocytomas, medulloblastomas, and hemangioblastomas, but not ependymomas.
    In general, classic ependymomas occur in close proximity to the ventricular cavities, specifically, the 4th ventricle (choice C) in children and the lateral ventricles (choice D) in adults. The myxopapillary variant does not occur in either location.
    A midbrain location (choice E) would be truly exceptional for any type of ependymoma.
    --------------------------------------------------------------------------------
    3>The correct answer is B. The disease is beta thalassemia major, which is a severe hemolytic anemia characterized by a failure to produce the beta chains of hemoglobin (some HbF, the fetal form of hemoglobin, is produced). The excess alpha chains are insoluble, leading to intra- and extravascular hemolysis. These patients require large numbers of transfusions, and iron overload with resulting secondary hemochromatosis can contribute to eventual cardiac failure. The heart is also damaged by the chronic high output state needed to compensate for the anemia.
    Calcium (choice A) deposition is seen in damaged tissues and states with high serum calcium, such as hyperparathyroidism.
    Magnesium (choice C), potassium (choice D), and sodium (choice E) are highly soluble and do not usually precipitate in tissues.
    --------------------------------------------------------------------------------
    4>The correct answer is A. The test described is the Ames test, which measures damage to DNA and correlates well with carcinogenicity in vitro. It is relatively inexpensive to perform, compared to other tests of carcinogenicity, and is frequently used as a screening test for potential carcinogens.
    The nitroblue tetrazolium test (choice B) is used to examine the ability of neutrophils to undergo a respiratory burst, and is used in the diagnosis of hereditary immunodeficiencies.
    The Watson-Schwartz test (choice C) detects porphobilinogen in urine, and is used in the The correct answer is C. Any tumor "filling the 4th ventricle" blocks the circulation of cerebrospinal fluid (CSF). This blockage leads to increased intracranial pressure, which manifests with nausea, vomiting, headache, nuchal rigidity, and mental status changes. If surgery is not performed promptly, cerebellar tonsillar herniation and rapid death will ensue. In children, medulloblastoma and ependymoma are the most frequent neoplasms presenting in this manner.
    There is no evidence in this case suggesting that acute hemorrhage into the 4th ventricular cavity (choice A) has occurred, nor is medulloblastoma typically associated with this complication. CNS tumors that frequently bleed are metastases from melanoma, renal cell carcinoma, and choriocarcinoma.
    Alterations in medullary function (choice B) lead to cardiorespiratory instability and may be caused by direct tumor compression or infiltration of the medulla, neither of which is supported by MRI findings in this case.
    Infiltration of the cerebellar vermis (choice D) is certainly seen in many cases of medulloblastoma, a tumor that arises from this midline cerebellar structure. However, this would lead to truncal ataxia and gait instability, not symptoms of increased intracranial pressure.
    Medulloblastoma characteristically spreads to the subarachnoid space (choice E), from which the neoplasm may metastasize to distant sites such as spinal cord. Plaques of medulloblastoma are often found on the cerebellar surface, creating a characteristic sugar coating, but this would not cause any significant blockage of CSF circulation.
    The correct answer is C. Any tumor "filling the 4th ventricle" blocks the circulation of cerebrospinal fluid (CSF). This blockage leads to increased intracranial pressure, which manifests with nausea, vomiting, headache, nuchal rigidity, and mental status changes. If surgery is not performed promptly, cerebellar tonsillar herniation and rapid death will ensue. In children, medulloblastoma and ependymoma are the most frequent neoplasms presenting in this manner.
    There is no evidence in this case suggesting that acute hemorrhage into the 4th ventricular cavity (choice A) has occurred, nor is medulloblastoma typically associated with this complication. CNS tumors that frequently bleed are metastases from melanoma, renal cell carcinoma, and choriocarcinoma.
    Alterations in medullary function (choice B) lead to cardiorespiratory instability and may be caused by direct tumor compression or infiltration of the medulla, neither of which is supported by MRI findings in this case.
    Infiltration of the cerebellar vermis (choice D) is certainly seen in many cases of medulloblastoma, a tumor that arises from this midline cerebellar structure. However, this would lead to truncal ataxia and gait instability, not symptoms of increased intracranial pressure.
    Medulloblastoma characteristically spreads to the subarachnoid space (choice E), from which the neoplasm may metastasize to distant sites such as spinal cord. Plaques of medulloblastoma are often found on the cerebellar surface, creating a characteristic sugar coating, but this would not cause any significant blockage of CSF circulation.
    diagnosis of porphyrias.
    The Widal test (choice D) is used to diagnose typhoid fever.
    The Woellner enzyme test (choice E) detects heterophil antibodies in patients with Epstein-Barr virus infection, such as infectious mononucleosis.
    --------------------------------------------------------------------------------
    5>The correct answer is A. A good way to remember what goes through the superior orbital fissure is that everything that innervates the eye, other than the optic nerve, passes through this fissure. This includes the oculomotor nerve (CN III), the trochlear nerve (CN IV), the ophthalmic nerve (V1), and the abducens nerve (CN VI).
    The facial nerve (CN VII; choice B) passes through the internal auditory meatus.
    The mandibular nerve (V3; choice C) passes through the foramen ovale.
    The maxillary nerve (V2; choice D) passes through the foramen rotundum.
    The middle meningeal artery (choice E) passes through the foramen spinosum.
    The ophthalmic artery (choice F) passes through the optic canal.
    The optic nerve (choice G) passes through the optic canal.
    --------------------------------------------------------------------------------
    6>The correct answer is B. Cranial nerve IX is the glossopharyngeal nerve, which has a nucleus in the medulla and is necessary for the gag reflex. The gag reflex is elicited by touching either side of the posterior pharynx with a tongue blade, producing bilateral elevation of the palate and bilateral contraction of the pharyngeal muscles. The afferent of this reflex arc consists of the ipsilateral glossopharyngeal nerve, while the vagus nerve, bilaterally, supplies the efferent limb. While the glossopharyngeal nerve may seem to be one of the less important cranial nerves, you should remember to test for its function, as a loss of gag reflex can lead to the patient's death secondary to an aspiration pneumonia. This form of pneumonia can be difficult to treat, as it commonly is due to a mixed flora, which may include a variety of anaerobes.
    Cranial nerve VII (choice A) is the facial nerve, which supplies motor function to the face, but does not supply the oropharynx.
    Cranial nerve XII (choice C) is the hypoglossal nerve, which supplies the tongue. It is not involved in the gag reflex.
    Cranial nerve XI (choice D) is the spinal accessory nerve, which supplies the trapezius and sternocleidomastoid.
    Cranial nerve VIII (choice E) is the vestibulocochlear nerve, responsible for hearing and equilibrium.
    --------------------------------------------------------------------------------
    7>The correct answer is D. The rule of thumb is that the plasma concentration will reach 50% in one half-life, 75% in two half-lives, 87.5% in three half-lives, etc., so that the difference between the current drug level and 100% halves with each half-life. In this instance, it takes two half-lives to reach 75%. The half-live of this drug is 6 hours, so two half-lives is 12 hours.
    --------------------------------------------------------------------------------
    8>The correct answer is E. Herpes simplex can cause a necrotizing, hemorrhagic acute encephalitis that may rapidly produce death. The encephalitis characteristically involves the lower portions of the cerebral cortex, notably the temporal lobes and the base of the frontal lobes, possibly because the infection spreads from the oropharynx.
    --------------------------------------------------------------------------------
    9>The correct answer is D. The genetic condition is Marfan syndrome, which is characterized by skeletal, ocular, and cardiovascular abnormalities. Typically, Marfan patients are tall with very long legs and tapering fingers. Laxity of joints is present, so that the thumb can be extended back to the wrist. Chest and spinal column deformities may be present as well. The most frequent cardiovascular anomalies are incompetence of the aortic valve, aortic dissection, and mitral valve prolapse ("floppy valve"). The latter may give rise to mitral regurgitation with the typical auscultatory phenomenon of a systolic click followed by a murmur. The most characteristic ocular change is ectopia lentis, i.e., dislocation of the lens. Most deaths are due to rupture of aortic dissections. The gene mutated in Marfan syndrome encodes fibrillin, a 350-kD protein that serves as scaffolding for the deposition of elastin and formation of elastic fibers. Elastin (choice C) is a 70-kD protein that constitutes the central core of elastic fibers. Abundant elastin is found in the walls of large arteries, uterus, skin, and ligaments. Although elastic fibers are disrupted by mutations of the fibrillin gene, the structure of elastin protein is intact in Marfan syndrome.
    Collagen (choice A) is affected in a different set of genetic diseases, including Ehlers-Danlos syndromes and osteogenesis imperfecta.
    Dystrophin (choice B) is a large transmembrane protein whose function is essential in maintaining the structural integrity of striated muscle fibers. Mutations of the dystrophin gene, located on X chromosome, are responsible for muscular dystrophy.
    Mutations of the gene for myosin b-chain (choice E) account for more than one third of cases of hypertrophic cardiomyopathy, a condition characterized by hypertrophy of the left ventricle. Hypertrophic cardiomyopathy is not associated with mitral valve prolapse.
    --------------------------------------------------------------------------------
    10>The correct answer is D. The disease is poliomyelitis, which is caused by the poliovirus, a picorna virus. The virus is spread via the fecal-oral route and can then cause paralysis by infecting the alpha-motor neurons of the anterior horn of the spinal cord. Early symptoms include malaise, headache, fever, nausea, abdominal pain, and sore throat.
    Bacterial and fungal infections can be spread by dirt contact with an open wound (choice A).
    AIDS is an example of a disease spread by injection (choice B) or exchange of body fluids.
    Malaria is an example of a disease spread by mosquitoes (choice C).
    Tetanus is the classic example of disease spread by a puncture wound of the foot (choice E).

    11>The correct answer is A. This is a typical presentation of an abdominal aortic aneurysm, which is almost always due to severe atherosclerosis. The foci of calcification described occur within the atherosclerotic plaques, and indicate severe atherosclerotic disease.
    Congenital weakness of vessels (choice B) can produce berry aneurysms, especially in cerebral vessels in the circle of Willis.
    Cystic medial necrosis (choice C) can produce dissecting aneurysms, especially in Marfan's syndrome.
    Syphilitic aneurysms (choice D) typically involve the aortic root as it leaves the heart.
    Vasculitis (choice E) can produce aneurysms in small arteries.
    --------------------------------------------------------------------------------
    12>The correct answer is A. This scenario is classic for "dependent" personality. Look for reliance on others, subordination of own needs, and fear of abandonment. Note that in real life, patients may show symptoms of more than one personality disorder.
    Histrionic personality disorder (choice B) is characterized by theatricality, suggestibility, a strong desire for attention, and shallowness.
    Obsessive-compulsive personality disorder (choice C), also called anancastic personality disorder, is characterized by obsessions, perfectionism, rigidity, and self-doubt.
    Paranoid personality disorder (choice D) is characterized by suspiciousness, oversensitivity, querulousness, and an unforgiving character.
    Schizoid personality disorder (choice E) is characterized by emotional coldness, solitude, and social insensitivity.
    --------------------------------------------------------------------------------
    13>The correct answer is A. The point of this question is that sometimes the obvious explanation is the correct one. Occlusion of the central retinal artery rapidly causes irreversible blindness with loss of the inner retinal layers. (The photoreceptor rod and cone cells are maintained by the pigment epithelium.) The site of occlusion is typically just posterior to the cribriform plate. A garden-variety atheroma or embolism is overwhelmingly the most common cause of central retinal artery occlusion.
    Despite all of the teaching about the risk of blindness in temporal arteritis (choice B), this disorder causes only 10% of central retinal artery occlusions.
    Hypertension (choice C) is more apt to cause bleeding than thrombosis.
    Polycythemia vera (choice D) could (rarely) cause occlusion because of increased blood viscosity and a tendency for thrombosis.
    Tumor (choice E) might also cause retinal artery thrombosis, but this would be far rarer than atheroma.
    --------------------------------------------------------------------------------
    14>B
    --------------------------------------------------------------------------------
    15>C
    --------------------------------------------------------------------------------
    16>The correct answer is A. The facial nerve and the vestibulocochlear nerve emerge from the brain stem at the cerebellopontine angle. These are the two nerves which will be initially affected by a tumor in this region.
    The glossopharyngeal nerve and vagus nerve (choices B and E) emerge from the brain stem at the post-olivary sulcus. This is caudal to the cerebellopontine angle.
    The optic nerve (choice C) exits from the optic chiasm on the ventral surface of the diencephalon. This is rostral to the cerebellopontine angle.
    The trigeminal nerve (choice D) emerges from the brain stem at the anterolateral surface of the pons. This is rostral and ventral to the cerebellopontine angle.
    --------------------------------------------------------------------------------

    17>The correct answer is B. This patient has gout, characterized by painful joints due to the precipitation of uric acid crystals caused by excessive production of uric acid (a minority of cases are associated with underexcretion of uric acid). Kidney disease is also seen due to accumulation of uric acid in the tubules. The disease mostly affects males, and is frequently treated with allopurinol, an inhibitor of xanthine oxidase. Xanthine oxidase catalyzes the sequential oxidation of hypoxanthine to xanthine to uric acid.
    A defect in urea synthesis (choice A) would result in the accumulation of ammonia.
    Phenylketonuria is a disease in which tyrosine cannot be produced from phenylalanine (choice C). It is characterized by a musty body odor and mental retardation.
    Defective topoisomerases (choice D) would affect DNA unwinding, and therefore replication.
    Leukotrienes (choice E) are potent constrictors of smooth muscle and would more likely lead to bronchoconstriction.
    --------------------------------------------------------------------------------
    18>The correct answer is C. Any tumor "filling the 4th ventricle" blocks the circulation of cerebrospinal fluid (CSF). This blockage leads to increased intracranial pressure, which manifests with nausea, vomiting, headache, nuchal rigidity, and mental status changes. If surgery is not performed promptly, cerebellar tonsillar herniation and rapid death will ensue. In children, medulloblastoma and ependymoma are the most frequent neoplasms presenting in this manner.
    There is no evidence in this case suggesting that acute hemorrhage into the 4th ventricular cavity (choice A) has occurred, nor is medulloblastoma typically associated with this complication. CNS tumors that frequently bleed are metastases from melanoma, renal cell carcinoma, and choriocarcinoma.
    Alterations in medullary function (choice B) lead to cardiorespiratory instability and may be caused by direct tumor compression or infiltration of the medulla, neither of which is supported by MRI findings in this case.
    Infiltration of the cerebellar vermis (choice D) is certainly seen in many cases of medulloblastoma, a tumor that arises from this midline cerebellar structure. However, this would lead to truncal ataxia and gait instability, not symptoms of increased intracranial pressure.
    Medulloblastoma characteristically spreads to the subarachnoid space (choice E), from which the neoplasm may metastasize to distant sites such as spinal cord. Plaques of medulloblastoma are often found on the cerebellar surface, creating a characteristic sugar coating, but this would not cause any significant blockage of CSF circulation.
    --------------------------------------------------------------------------------
    19The correct answer is E. Maternal diabetes is best known for causing large but immature-for-age babies. There is also a specific association between maternal diabetes and transposition of the great vessels. In transposition of the great vessels, the aorta takes off from the anterior part of the right ventricle and the pulmonary trunk takes off from the posterior part of the left ventricle. This produces a complete separation of the systemic and pulmonary circulations. Without surgical correction, most affected infants die within the first months of life, although a patent ductus arteriosus, patent foramen ovale, or ventricular septal defect may allow enough mixing of blood to temporarily sustain life.
    In atrial septal defect (choice A) blood can pass from one atrium to the other.
    Associate coarctation of the aorta (choice B) with Turner syndrome.
    Eisenmenger's syndrome (choice C) is a shift from a left-to-right shunt to a right-to-left shunt secondary to developing pulmonary hypertension.
    Tetralogy of Fallot (choice D) consists of a ventricular septal defect, an overriding aorta, pulmonic stenosis, and right ventricular hypertrophy. It is the most common cause of early cyanosis.
    --------------------------------------------------------------------------------
    20The correct answer is A. This is an example of displacement. In this defense mechanism, there is a transfer of emotion from a person, object, or situation with which it is appropriately associated to another that causes less distress. Displacement is common and often destructive to other individuals, such as when a man is fired from his job and subsequently beats his wife or children. In the medical setting, the hospital staff is a frequent target of displacement when family members react to their own feelings of guilt about someone's death.
    Projection (choice B) occurs when someone attributes his or her own thoughts to a different person.
    Reaction formation (choice C) is the unconscious adoption of behavior opposite to one's true feelings.
    Regression (choice D) is the adoption of behavior more appropriate to a younger age.
    Repression (choice E) is the deeply subconscious blocking of memories or emotions.
    --------------------------------------------------------------------------------
    21The correct answer is B. This item tests your knowledge of neurocutaneous syndromes, a group of hereditary conditions characterized by concomitant neoplastic or hamartomatous lesions predominantly affecting the skin and nervous system. Subependymal giant cell astrocytoma is a peculiar astrocytic tumor that grows from the walls of the lateral ventricles. It is pathognomonic of tuberous sclerosis, which is caused by mutations of TS1 or TS2 genes. Tuberous sclerosis manifests with multiple hamartomatous lesions in the skin, CNS, and visceral organs. Cortical tubers are malformed (hamartomatous) nodules of the cortex, probably resulting from faulty cortical development. Other lesions include shagreen patches and ash-leaf spots on the skin, cardiac myomas, and renal angiomyolipomas.
    Café-au-lait spots (choice A) are found in both types of neurofibromatosis. Lisch nodules (choice D) are small pigmented nodular lesions of hamartomatous nature that are present in the iris of patients with neurofibromatosis type 1. Schwannomas of the 8th cranial nerve (choice E), especially when bilateral, are typically associated with neurofibromatosis type 2.
    Hemangioblastoma (choice C) is a vascular tumor of unknown histologic origin that frequently develops in the cerebellum of patients with von Hippel-Lindau syndrome. Renal cell carcinomas are also common in this disease. Von Hippel-Lindau syndrome is caused by autosomal dominant mutations of the VHL gene, a tumor suppressor gene. You may recall that mutations of VHL gene are also found in the majority of sporadic renal cell carcinomas
    --------------------------------------------------------------------------------22The correct answer is A. This is a typical presentation of an abdominal aortic aneurysm, which is almost always due to severe atherosclerosis. The foci of calcification described occur within the atherosclerotic plaques, and indicate severe atherosclerotic disease.
    Congenital weakness of vessels (choice B) can produce berry aneurysms.
    Cystic medial necrosis (choice C) can produce dissecting aneurysms (e.g., in Marfan's syndrome).
    Syphilitic aneurysms (choice D) typically involve the aortic root as it leaves the heart.
    Vasculitis (choice E) can produce aneurysms in small arteries.
    --------------------------------------------------------------------------------
    23The correct answer is C. The physician should obtain an emergency order of detention, regardless of her threats of a lawsuit. The woman clearly still has suicidal intent, demonstrated by her expressed verbalizations, and is therefore a danger to herself.
    Choices A, B, and D clearly place her in a position where she can carry out her plans to terminate her life.
    Sedating her (choice E) is the second best choice since it will prevent her from taking her life; however, sedation does not give therapists the opportunity to address the underlying motivations for her suicidal ideation.
    --------------------------------------------------------------------------------
    24The correct answer is B. Blocking antibody is generally an IgG antibody against the allergen. It is induced in the allergic patient by administering small amounts of allergen over a period of time. When the person is again exposed to the allergen, the IgG reacts with the allergen before it can reach the IgE-coated mast cell.
    Antihistamines (choice A) would block histamine receptors but would not react with the allergen before it could reach the IgE-coated mast cell.
    Cromolyn sodium (choice C) is a drug that stabilizes mast cell membranes, thus inhibiting degranulation, but would have no effect on allergen binding to IgE on mast cells.
    Epinephrine (choice D) is the mainstay of therapy in severe cases of immediate hypersensitivity (anaphylaxis). It increases intracellular cyclic AMP, thus decreasing mast cell degranulation, and causes smooth muscle dilation in the airways. Epinephrine would have no effect on the binding of the allergen to IgE on mast cells.
    Cyclic AMP is degraded in cells by the enzyme phosphodiesterase. Theophylline (choice E) inhibits this enzyme, thereby increasing mast cell cyclic AMP levels and making degranulation less likely without affecting the binding of the allergen to IgE on mast cells.
    --------------------------------------------------------------------------------
    25The correct answer is E. At this level, the lateral portion of the dorsal columns (funiculus) is comprised of the fasciculus cuneatus. Axons carrying tactile, proprioceptive, and vibratory information from the ipsilateral arm enter the spinal cord via the dorsal root, ascend the cord in the fasciculus cuneatus, and synapse in the nucleus cuneatus of the caudal medulla. Secondary neurons from this nucleus give rise to internal arcuate fibers, which decussate and ascend to the thalamus (ventral posterolateral nucleus, VPL) as the medial lemniscus. Tertiary neurons from the VPL project to the ipsilateral somatosensory cortex. Therefore, damage to the fasciculus cuneatus would result in a deficit in tactile, proprioceptive, and vibratory sense in the ipsilateral arm, because the fibers that carry this information do not cross until they reach the medulla.
    Fine motor control of the fingers (choice A) would be carried principally by the ipsilateral lateral corticospinal tract in the lateral funiculus of the cord.
    Motor control of the contralateral foot (choice B) is carried by the ipsilateral corticospinal tract in the lateral funiculus of the cord.
    Hemianhidrosis (lack of sweating) over half of the face (choice C) could be produced by interruption of sympathetic innervation to the face. The hypothalamospinal tract projects from the hypothalamus to the intermediolateral cell column at levels T-1 to T-2. It descends in the lateral funiculus of the cord. Interruption of this tract results in Horner's syndrome (miosis, ptosis, hemianhidrosis).
    Proprioception from the ipsilateral leg (choice D) is carried by the fasciculus gracilis in the medial part of the dorsal columns.
    --------------------------------------------------------------------------------
    26The correct answer is A. While it is hard to develop a deficiency in oil-soluble vitamins (A, D, E, K) because the liver stores these substances, deficiency states can be seen in chronic malnutrition (specifically chronic fat deprivation) and chronic malabsorption. Vitamin A is necessary for formation of retinal pigments (deficiency can cause night blindness) and for appropriate differentiation of epithelial tissues (including hair follicles, mucous membranes, skin, bone, and adrenal cortex).
    Vitamin C (choice B), which is water soluble rather than oil soluble, is necessary for collagen synthesis.
    Vitamin D (choice C) is important in calcium absorption and metabolism.
    Vitamin E (choice D) is a lipid antioxidant that is important in the stabilization of cell membranes.
    Vitamin K (choice E) is necessary for normal blood coagulation.
    --------------------------------------------------------------------------------
    27The correct answer is C. The most likely diagnosis is an intracranial meningioma. Meningiomas are slow-growing, benign tumors comprising 15% of intracranial tumors; they are most common in the elderly. They originate from either dura mater or arachnoid and are sharply demarcated from brain tissue. Meningiomas often incite an osteoblastic reaction in the overlying cranial bones. Microscopically, the meningioma cells have a tendency to encircle one another, forming whorls and psammoma bodies. Clinically, they present as mass lesions; seizures may occur. The superior parasagittal surface of the frontal lobes is a favorite site of origin. This can often produce leg weakness, since the leg motor fibers that pass down through the internal capsule originate in parasagittal cortical regions. Treatment of meningiomas is usually surgical.
    Arachnoid cysts (choice A) are formed by splitting of the arachnoid membrane; most arachnoid cysts arise near the Sylvian fissure. They may present with mass effect, but would be unlikely to produce seizures, prominent focal signs, or reactive hyperostosis.
    Glioblastoma multiforme (choice B) is an aggressive malignant astrocytoma that would likely have killed the patient long before 5 years had elapsed.
    Metastatic breast cancer (choice D) would generally look different microscopically (the whorling cell pattern is characteristic of meningioma). It would be unlikely for metastatic cancer to cause a reaction in the overlying bone, or to be present long enough to cause symptoms for 5 years.
    Oligodendrogliomas (choice E) are glial tumors that could produce the described clinical picture, but usually do not cause hyperostosis of the calvarium or exhibit the characteristic whorling cell pattern microscopically
    --------------------------------------------------------------------------------
    28The correct answer is D. The two most common causes of aortic dissection are hypertension and atherosclerosis. An important distinction between the two is that hypertensive dissections generally originate in the ascending aorta, at an intimal surface free of atherosclerosis.
    Dissection secondary to atherosclerosis is typically the consequence of a ruptured aortic aneurysm, which originates in the abdominal aorta at the iliac bifurcation. Dissections due to both hypertension and atherosclerosis generally course through the wall within the media (choice B). They both can involve the entire length of the aorta, and may rupture anywhere along its course (choices A and C). Well recognized sequelae of dissections include rupture through the adventitia, compromise of major arterial branches or the aortic valve, cardiac tamponade, and rapid exsanguination (choice E).
    --------------------------------------------------------------------------------
    29The correct answer is D. Although rare now because of advances in treatment, syphilitic aortitis and aneurysm are still seen, especially in underserved populations. This complication generally occurs 10 to 40 years after initial infection. The vasa vasorum of the aorta undergoes obliterative endarteritis, leading to atrophy of the muscularis and elastic tissues of the aorta and dilatation. Linear calcifications are often seen in the ascending aorta by x-ray. The intimal wrinkling or "tree barking" is also a common feature. Syphilitic aneurysm can be associated with respiratory distress, cough, congestive heart failure and rarely, rupture.
    Atherosclerosis (choice A) is the most common cause of aortic aneurysms. These are most often located in the abdominal aorta, distal to the renal arteries. Intimal wrinkling and linear calcifications are not seen.
    Hypertension (choice B) is usually responsible for dissecting aneurysms located within 10 cm of the aortic valve. Patients present with sudden chest pain, which is usually severe and tearing in nature. The chronic hypertension causes a cystic medial necrosis, allowing the separation of vessel layers.
    Marfan's syndrome, an autosomal dominant connective tissue disorder (choice C) is also associated with dissecting aneurysms, usually of the ascending aorta. The patients are often very tall with arachnodactyly and ligamentous laxity. Their life-span is generally shortened. This patient's description and age are not consistent with this diagnosis.
    Takayasu's arter itis (choice E) is a syndrome characterized by ocular disturbances and weak pulses in the arms. It occurs most frequently in young females. It is considered a giant cell arteritis, and does not cause aneurysms.
    --------------------------------------------------------------------------------
    30The correct answer is E. The disease is progressive supranuclear palsy, a degenerative disorder characterized by ophthalmoplegia, pseudobulbar palsy, axial dystonia, and bradykinesia. The presentation described in the question is typical. The pathologic changes consist of widespread neuronal loss and gliosis in subcortical sites with sparing of the cerebral and cerebellar cortices.
    Pigmented neurons in the substantia nigra (pars compacta) and locus ceruleus (choice A) selectively degenerate in Parkinson's disease.
    In Alzheimer's disease, there is diffuse cortical atrophy (choice B), especially over the association cortex of frontal, temporal, and parietal lobes, with relative sparing of primary sensory and motor areas.
    Selective frontal and temporal lobe atrophy (choice C) is characteristic of Pick's disease.
    The caudate nucleus and putamen undergo severe atrophy (choice D) in Huntington's disease. Cortical atrophy occurs to a lesser extent.
    --------------------------------------------------------------------------------
    31The correct answer is B. Collagen formation begins with transcription of mRNA from appropriate DNA genes in the nucleus. While still within the nucleus, the mRNA is spliced. It is then transported through the cytoplasm to the ribosomes on the rough endoplasmic reticulum. Individual chains are translated on the ribosomes, with the ends feeding into the endoplasmic reticulum lumen. Within the lumen, glycosylation of the individual chains occurs. The material then moves toward the Golgi bodies (whose lumens are connected to the endoplasmic reticulum) where the triple helices of procollagen form. The procollagen is then secreted into the extracellular space, where cleavage of pro-peptides and cross- linking of different triple helices occurs, maturing the collagen.
    The extracellular space (choice A) is the site of procollagen cleavage and cross- linking.
    The nucleus (choice C) is the site of mRNA transcription and splicing.
    The rough endoplasmic reticulum (choice D) is the site of chain translation and glycosylation.
    The smooth endoplasmic reticulum (choice E) does not participate in collagen synthesis
    --------------------------------------------------------------------------------
    32The correct answer is A. The uncus, which is the medial protrusion of the parahippocampal gyrus, is an external structure seen on the ventral surface of the temporal lobe. The amygdala is a collection of nuclei that lies directly beneath the uncus.
    The caudate nucleus (choice B) is a deep nuclear structure that lies lateral to the lateral ventricles.
    The claustrum (choice C) is a thin and elongated nucleus that lies just medial to the insular cortex.
    The hippocampus (choice D) is a nuclear structure that lies in the interior of the parahippocampal gyrus.
    The putamen (choice E) is a nuclear structure that resides lateral to the caudate, and medial to the claustrum.
    The thalamus (choice F) is a deep nuclear structure, caudal to the caudate nucleus.
    --------------------------------------------------------------------------------
    33The correct answer is A. A third heart sound (S3) is a low-pitched sound occurring at the termination of rapid filling. In patients over 40 years of age, the appearance of a third heart sound strongly suggests congestive heart failure. It also occurs in patients with atrioventricular valve incompetence and can be a normal finding in some young athletes.
    A fourth heart sound (S4; choice B) can be a normal finding in some older patients who do not have congestive heart failure.
    Ascites (choice C) can also occur in patients with renal, hepatic, or local conditions not associated with cardiac factors.
    Both orthopnea (choice D) and pulmonary rales (choice E) often occur secondary to heart failure, however, they both are associated with noncardiac disorders as well.
    --------------------------------------------------------------------------------
    34The correct answer is A. Several immunodeficiency disorders have X-linked genetics, including Bruton's agammaglobulinemia, Wiskott-Aldrich syndrome, and some cases of severe combined immunodeficiency diseases. Bruton's agammaglobulinemia is characterized by recurrent respiratory infections caused by pyogenic organisms.
    Common variable immunodeficiency (choice B) is a relatively common, but probably heterogeneous, group of acquired and familial diseases. It is distinct from X-linked (Bruton's) agammaglobulinemia.
    DiGeorge syndrome (choice C) is due to a developmental malformation of the third and fourth pharyngeal pouches leading to failure of the thymus, and sometimes the parathyroids, to develop. Defective cellular immunity and abnormalities of calcium metabolism are typical.
    Hereditary angioedema (choice D) is a usually recessive genetic disease caused by deficiency of C1 esterase inhibitor.
    Isolated IgA deficiency (choice E) can be acquired or genetic, but is not usually X-linked.
    --------------------------------------------------------------------------------
  27. Atiq

    Atiq Guest

    MOST children aged 11 months can
    (A) walk independently.
    (B) build a tower of four cubes.
    (C) point to a named part of the body.
    (D) feed themselves with a spoon.
    (E) pick up a raisin between thumb and finger.


    A delusion is an EXAMPLE of
    (A) formal thought disorder.
    (B) blunted affect.
    (C) a false belief.
    (D) auditory hallucinations.
    (E) passivity experiences.


    A 2-year-old boy presented to your surgery with the onset of the skin rash, depicted in the accompanying photograph over the previous 3 to 4 h. He has a temperature of 38.8 degrees C. Which one of the following responses would be the MOST APPROPRIATE?
    (A) Send him home and tell his parents to give him paracetamol to control the fever.
    (B) Send to hospital immediately.
    (C) Give penicillin and send home.
    (D) Give a broad spectrum antibiotic and send home.
    (E) Give a single large dose of parenteral penicillin and send immediately to hospital.


    Papillary carcinoma of the thyroid gland
    (A) is a slow growing tumour which is influenced by thyroid stimulating hormone secretion.
    (B) is multifocal and spreads mainly by the blood to bone.
    (C) is sometimes associated with phaeochromocytoma and skin lesions.
    (D) produces calcitonin and the syndrome of malignant hypocalcaemia.
    (E) is extremely radiosensitive and should be treated by irradiation of the thyroid gland.
  28. Guest

    Guest Guest

    This is so intelligent, putting all those questions on web site., visible to everyone.
    I am sure this is the last time that this question will be in the AMC exam.
    Do you think they (AMC) are so stupid ?
  29. Please , do not sent me more e-mails regarding AMC questions.
    The AMC Questions has been sold.
    I have no copies.
    Good bye,
  30. Guest

    Guest Guest

    It is not Stupid that whoever contributes MCQs in the webs
    I think U are SOOOOOOO Clever to Know that AMC is NOT STUPID
    Only U are TOOOOO SELFISH & Kept all those questions by yourself
    If U have already passed - U are the Luckiest person with decomposed intestine

    And the guy who could make PROFIT with these questions-- keep that money safely
    If money comes easily-- U will lose easily
    Good Luck !
  31. A.Y

    A.Y Guest

    I said it we all know that those questions were shared between candidates secretly. But now they are all on the WEB, everyone can see them including AMC so EXPECT NOT TO SEE ANY OF THOSE QUESTIONS IN THIS FORM ON EXAM AGAIN.

    If you have a different opinion you might be from the AMC.
  32. anne123

    anne123 Guest

    I am not from AMC, I am the same candidate as you.

    My opinion is that AMC are doing a good job by changing all questions for every exam and introducing a new ones.
    Well done AMC team!

    I sat an exam after finishing recalls form all exams 2000-2006. I couln't pass, coz during real exam many recalls were change in very clever way that it is not easy to notice it. Also they gave many new ones.
    If only 15-20% recalls on real exam and you know all answers but don't have strong knowledge you will fail.

    Study with topics not only with recalls. Topics are always the same. Know them by heart.

    Happy study!
  33. Guest7

    Guest7 Guest

    Thanks for the advice. I am preparing now for the examination. I have not found any job yet here in Queensland so I have all the time to study. Can you please help me to find a copy of those recalls?

    To anyone: I have been here in Queensland for two months already. Can you please advice me on how and where to find a GP job? I have 8 years of GP experience and have passed the IELTS already. I am preparing for the AMC examination but I would like to work as well to keep me through the daily expenses. Thank you.
  34. A.Y

    A.Y Guest


    Anne123,

    As a result of this questions available publicly on the web site, the AMC started to change a topics/scenarios.
    In one of the previous exam it was a case of Ross fever ( never appeared before ).
    So forget now scenario dizzines & vertigo ( lateral medullary syndrome), patient who writting a letter for DOH ( schizophrenia ) etc etc.
    They not going to put those scenarios again, believe me.

    If you want to get exam papers go to the Westmead library or Western Sydney University library, join the study group, show your commitment and you will get questions & pass exam.
    By the way some candidates paid a lot of money for the Bridging courses which helped them to pass AMC exam.

    So I don't think that putting exam papers publicly on web site is good idea.
    By the way why someone who put significant effort should give a papers to lazy slack who lives overseas.
    What did that person do for the rest of candidates here in Australia ?
    I drove a taxi night shifts for the 6 years before passing an exam.
    What do you want ? To pass it without any effort.
    You slack bastard. GO AWAY.

    AY
  35. A.Y

    A.Y Guest

    Doesn't matter that we are all Indians or Pakistani or whatever.
    All of us here in Australia had a tought life, we helped each other , but we all contributed to previous exam papers.
  36. A.Y

    A.Y Guest

    You will see that the passing the AMC will become difficult again
    ( almost impossible I would say) as it was in mid 1990.

    I can't believ that people are so stupid. You know the ADTOA web site

    http://www.adtoa.org/

    is fully contriolled by Goverment/AMC.
    If you want to share questions that is all right, sent it through E-mail or exchange them with other candidates in library. It should be kept as our secret. Not for whole world to see it.

    STUPID. I have no other words for people who sharing it.
    I didn't pass Clinical yet, but I guess I can chuck all papers to the rubbish bin. Useless.

    Don't ber surprise if you see questions like plaque,Reflex Sympathetic Dystrophy Syndrome, Reye Syndrome, Pendred Syndrome, Perilymphatic Fistula (Vestibular Balance Disorders), Takayasu Disease, BSE (Mad Cow Disease), Amyotrophic Lateral Sclerosis, Legionnaire Disease and Pontiac Feveretc.

    You should be prepared, they tyalking about high medical standards here.
    I guess that you got my message .
  37. Guest

    Guest Guest

    Hi

    Don't get SOOO ANGRY - Man
    No good for you and for others
    I would sympathize your sufferings in OZ

    So- don't go for any further- Don't be trying too much !
    Go back to your OWN place & Relax
    By the way--after you have passed part-1 - U shouldn't discourage to the Candidates who are hunting for greener Grass
    Everybody has realized how AMC Exam goes
    some MCQs could help them a bit
    After you have passed you shouldn't criticize the people who had contributed in Good ways

    Good Luck in your Part 2
  38. faran

    faran Guest

    sharing q on web is not bad if every one is participating but if only 2 are doing it and rest are enjoying show then its good to keep to ur emails .but i beleive everyone has different circumstances and every dr whether who lives overseas or here is real hard worker. we dont just see an answer and accept as it is . we all study from books and then confirm it .its good to share becasue otherwise only those who can go to libraries can have access .what about other people ?and bye the way who said that people in libbraries are friendly and give u stufff. they are selective and they can refuse on ur face as well .so forum people who are doing it openly are quite better than them .take care bye
  39. sug

    sug Guest

    You bloody right man. This is a free show for people around a world. I am happy to share my questions and experience with other candidates. People usually met each other in the exam first, then in the library. It is a two way interaction.f you want good set of questions you have to show you commitment. Many of us spent hours and hours studing for this exam, a now some people expecting to get all those questions served to them over the net. .
  40. Guest92

    Guest92 Guest

    It is like a fairy tale about a cricket and ant. The ant worked a hard throught the year, harvested a food, etc while a cricket enjoyed a music.
    When winter came.....
    You know a rest.... I guess


    ANT :D
  41. Guest

    Guest Guest

    There is no such thing like a free lunch.

    :lol:
  42. Guest

    Guest Guest

    Plenty Here

    Go to salvation army & eat
  43. Meherun

    Meherun Guest



    I think that AY was right. As you can see from the following link ( article the Australian Medical Council WILL CHANGE A MCQ FORMAT FROM JANUARY NEXT YEAR - 2007.Also some off-shore venue are cancelled - jULY 2007.
    Now you will get 300 question ( previously 250) and you have to answer 80 mastery questions ( previosly 80).
    I should say that sharing a questions publicly on the web is not good idea at all.But if you want to see pass rate to be ~ 30% as it was in 1990 - then GOOD LUCK>

    Keep posting them, som AMC can get them as well.



    Read this article :

    The AMC and Medical Council of Canada [MCC] are presently working on a joint project for the administration of Off-shore examinations. The first step in this project is the 7 th November 2006 examination to be held in a number of Off-shore locations, and three centres within Australia.

    Commencing in 2007, with the Off-shore examinations, the AMC/MCC joint project examination will be comprised of 300 MCQ items, of which 240 will be allocated as scored items, and 60 items will be pilot items [not scored towards a candidate’s overall result]. In order for the AMC examination process to be in line with the joint AMC/MCC examination it is expected the AMC will implement a number of changes in all MCQ examinations. It is anticipated the format and content of the examination will remain unchanged, however the number of MCQ items is expected to increase to 300 items, with an increase in the time undertaken for the examination to 3 ½ hours for Part 1 [morning session] and 3 ½ hours for Part 2 [afternoon session].

    Proposed items commencing 2007
    240 items [of which 80 are mastery items]
    60 Pilot Items
    http://www.amc.org.au/

    TOTAL 300 items

    It is planned that the breakdown of items across all disciplines will remain in the same proportion as the present AMC MCQ examination and the pass standard [cut score and mastery score] will remain the same – a score of 250 overall and a score of 300 in mastery on the AMC scale is required in order to attain the pass standard.

    The AMC advises all candidates to check the AMC website for confirmation of these changes, the anticipated date of the final decisions is not expected until mid-December 2006. The AMC has posted this information in order for candidates to be aware that changes are imminent. Please do not telephone or email the AMC for further information on these changes, as no further details are available until mid-December 2006.

    IAN FRANK

    CHIEF EXECUTIVE OFFICER 4 th October 2006.




    http://www.amc.org.au/
  44. Meherun

    Meherun Guest



    I think that AY was right. As you can see from the following link ( article the Australian Medical Council WILL CHANGE A MCQ FORMAT FROM JANUARY NEXT YEAR - 2007.Also some off-shore venue are cancelled - jULY 2007.
    Now you will get 300 question ( previously 250) and you have to answer 80 mastery questions ( previosly 60).
    I should say that sharing a questions publicly on the web is not good idea at all.But if you want to see pass rate to be ~ 30% as it was in 1990 - then GOOD LUCK>

    Keep posting them, som AMC can get them as well.



    Read this article :

    The AMC and Medical Council of Canada [MCC] are presently working on a joint project for the administration of Off-shore examinations. The first step in this project is the 7 th November 2006 examination to be held in a number of Off-shore locations, and three centres within Australia.

    Commencing in 2007, with the Off-shore examinations, the AMC/MCC joint project examination will be comprised of 300 MCQ items, of which 240 will be allocated as scored items, and 60 items will be pilot items [not scored towards a candidate’s overall result]. In order for the AMC examination process to be in line with the joint AMC/MCC examination it is expected the AMC will implement a number of changes in all MCQ examinations. It is anticipated the format and content of the examination will remain unchanged, however the number of MCQ items is expected to increase to 300 items, with an increase in the time undertaken for the examination to 3 ½ hours for Part 1 [morning session] and 3 ½ hours for Part 2 [afternoon session].

    Proposed items commencing 2007
    240 items [of which 80 are mastery items]
    60 Pilot Items
    http://www.amc.org.au/

    TOTAL 300 items

    It is planned that the breakdown of items across all disciplines will remain in the same proportion as the present AMC MCQ examination and the pass standard [cut score and mastery score] will remain the same – a score of 250 overall and a score of 300 in mastery on the AMC scale is required in order to attain the pass standard.

    The AMC advises all candidates to check the AMC website for confirmation of these changes, the anticipated date of the final decisions is not expected until mid-December 2006. The AMC has posted this information in order for candidates to be aware that changes are imminent. Please do not telephone or email the AMC for further information on these changes, as no further details are available until mid-December 2006.

    IAN FRANK

    CHIEF EXECUTIVE OFFICER 4 th October 2006.




    http://www.amc.org.au/
  45. Guest

    Guest Guest

    How many mastery questions we have to pass now ?
    Previously pass was a 40 out of 60 mastery qs.
    Does it mean that now we have to pass a 60 /80 mastery questions ?
    This is ridiculous. You have to do a 75% to pass !
    Something is fishy here guys.....
Thread Status:
Not open for further replies.

Share This Page