Question No.

1 :

Which of the following is the earliest sign of dose related toxicity of carbamazepine?

a. Lethargy

b. Seizures

c. Diplopia

d. Headache

e. Loss of consciousness

Correct Answer & Detail

Correct Answer: c. Diplopia

Answer Detail:
The correct answer is c.

Diplopia is the earliest sign of dose-related toxicity of

carbamazepine.It is observed within 60 minutes after the
morning dose.

Plasma carbamazepine concentrations are not helpful in

determining the therapeutic target range in an individual.
Question No. 2 :

Which ONE of the following is the most common cause of diabetic ketoacidosis?

a. Acute infection

b. Acute pancreatitis

c. Missed insulin treatment

d. Undiagnosed insulin dependent diabetes mellitus

e. Drugs
Correct Answer & Detail

Correct Answer: a. Acute infection

Answer Detail:
The correct answer is a.

Diabetic ketoacidosis is characteristically associated with

type 1 diabetes. The common causes of diabetic
ketoacidosis include:

- Underlying or concomitant infection-40%

- Missed insulin treatment or noncompliance-25%.
- Newly diagnosed or previously unknown diabetes
mellitus-15%.
- Other causes make up to 20%.

The most common precipitating factor is infection, followed

by noncompliance with insulin therapy.
Question No. 3 :

Which of the following is most common type of esophageal malignancy?

a. Adenocarcinoma

b. Squamous cell carcinoma

c. Lymphoma

d. Metastatic lesions

e. Sarcoma
Correct Answer & Detail

Correct Answer: b. Squamous cell carcinoma

Answer Detail:
The correct answer is b.

Squamous cell carcinoma is the most common being 80-

85% of esophageal lesions.

Adenocarcinoma is the second most common malignant

lesion in esophagus being 5-10% at gastroesophageal
junction and is associated with Barrett's esophagus.

Lymphomas,metastatic lesions and sarcomas are very rare

causes of esophageal malignancies.
Question No. 4 :

10-months old female child is brought by her mother with constipation after
introducing cows milk.Mother has tried to give other fluids as well however it did not
help.

What should be the next step in the management?

a. Stop cows milk

b. Increase fluid content

c. Laxatives

d. Change it to formula milk

e. Refer to child specialist

Correct Answer & Detail

Correct Answer: a. Stop cows milk

Answer Detail:
The correct answer is a.

Milk allergy or lactose intolerance in minority of cases

present with constipation instead of diarrhoea.So in this
patient,stop cows milk and at the same time offer high fibre
diet with more liquids.It will usually cure the constipation.

The classic symptoms of milk intolerance are

diarrhoea,spitting up, or abdominal pain.

Many children with milk intolerance also wheeze,especially

when they get a cold.
They can also have the dry, sensitive skin of eczema and
their noses always seem to be running.
Ear infections are also more common than in other children.
Question No. 5 :

Which one of the following is a condition when breast feeding can be stopped?

a. Engorged breasts

b. Inverted nipples

c. Cracked nipples

d. Breast abscess

e. Mastitis
Correct Answer & Detail

Correct Answer: d. Breast abscess

Answer Detail:
In breast abscess, continue breast feeding from both
breasts. If breast feeding is not possible due to location of
the incision, milk should be expressed from the breast.
Breast feeding may be discontinued until abscess is
resolved.

Engorged breast occurs when milk supply comes on so

quickly that the breast become swollen, hard and tender.
The blood supply and other fluids accumulate in the breast
tissue. Breast feeding should be continued. Proper breast
feeding the baby on demand is key in managing this
condition.

Inverted nipple inverts into the breast instead of pointing

towards the baby when baby tries to suck from it. The best
approach is good preparation with prolonged breast contact
and feeding prior to milk coming in. Breast feeding should
be continued in mothers with inverted nipples.

Cracked nipples are usually caused by the baby clamping on

the end of the nipple rather than applying jaw behind the
nipple.Breast feeding should be continued. The best
approach is to rest the nipple for 1-2 feeds, express the milk
from the effected breast by hand and then feed the
expressed milk to the baby. Start feeding gradually with
short feeds.

Mastitis is cellulitis of the interlobular connective tissue of

the breast. It is mainly associated with cracked nipples or
poor milk drainage in lactating mother. The infecting
organism is Staphylococcus aureus. Breast feeding from the
affected side can be continued as infection is confined to the
interstitial breast tissue.
Question No. 6 :

A 25-year-old male comes with direct trauma to his left wrist.Which of the following
is first line investigation for suspected scaphoid fracture?

a. Plain X-ray

b. Un-enhanced MRI

c. Godolinium enhanced MRI

d. CT scan

e. Ultrasound

Correct Answer & Detail

Correct Answer: a. Plain X-ray

Answer Detail:
Plain X-ray film is still the first line investigation of choice for
suspected scaphoid fracture and may need to be repeated in
2 weeks time if fracture is not visible.

Four views are requested to minimize the possibility of

missing a finding.

If X-ray is negative and suspicion of scaphoid fracture is

high,consider an enhanced MRI.

Gadolinium enhanced MRI is excellent for detection of

avascular necrosis.

CT scan is required if orthopedic intervention is indicated.

CT scan shows exact fracture location,deformity as well as
union status.Ultrasound is no more used to diagnose
scaphoid fracture.
Question No. 7 :

A 25-year-old woman developed chicken pox at 14 weeks of gestation. Blood tests

show IgM for varicella as positive. What is the most appropriate management?

a. Antiviral therapy and pelvic ultrasound

b. Varicella zoster immunoglobulins

c. Repeat serology in one week

d. Give antibiotics

e. No action needed

Correct Answer & Detail

Correct Answer: a. Antiviral therapy and pelvic ultrasound

Answer Detail:
The correct answer is a.

This woman has developed chicken pox and is positive for

IgM antibodies which indicate acute infection. She should be
treated with antiviral therapy and a pelvic ultrasound to find
any congenital abnormality by 18 weeks of gestation.

Varicella zoster immunoglobulins (option b) are ineffective,

and should not be given, once clinical illness is established.
All other options are incorrect.
Question No. 8 :

A 41-year-old Aboriginal male with 10-year history of type ll Diabetes

Mellitus,suffered from acute myocardial infarction.He was treated in emergency
department of a local hospital.Three weeks latter,he started having fever and pleuritic
chest pain.Pericardial rub is audible on auscultation with no added sound.
ESR is 110.Chest X-ray showed bilateral mild pleural effusion. Echocardiography
showed inflammatory fluid around the heart.
What is best next step in management?

a. Heparin infusion

b. Aspirin

c. Pericardiocentesis

d. Pleurocentesis

e. Intravenous antibiotics

Correct Answer & Detail

Correct Answer: b. Aspirin

Answer Detail:
This patient has typical presentation of Dresslers
syndrome.This develops two to three weeks after acute
myocardial infarction or heart surgery.

Myocardial injury stimulates formation of auto-antibodies

against cardiac muscle.

Patient usually suffers from recurrent fever and chest pain

with pleural or pericardial rub.

Cardiac temponade is a potential complication.So

anticoagulants like heparin must be avoided.

Regular aspirin is the best treatment option at this stage.If

needed,steroids are another good option if patient is allergic
to aspirin.
Pleurocentesis and pericardiocentesis are not needed at this
stage.This condition is not caused by any micro-organism.So
intravenous antibiotics are not required.
Question No. 9 :

Which types of medullary carcinoma of the thyroid occurs most frequently in general
population?

a. Sporadic

b. Familial medullary thyroid carcinoma

c. MEN 2A

d. MEN 2B

e. None of the above

Correct Answer & Detail

Correct Answer: a. Sporadic

Answer Detail:
Sporadic medullary cancers are 80 % of all medullary
carcinomas.

Familial medullary thyroid carcinoma is 7 % of all medullary

cancers and has not association with other endocrine
tumors.

MEN2-A (multiple endocrine neoplasia) is found in 10 % of

the cases and it is associated with phaeochromocytoma and
hyperparathyroidism.
MEN 2-B is just 3% of all medullary tumours and is
associated with phaeochromocytoma,mucosal neuromas,and
marfanoid habitus.
Question No. 10 :

A 26-year-old woman with background history of difficult to treat bipolar disorder is

planning to conceive. She is on lithium and quetiapine for last 6 months and has been
stable. What is the best course of action?

a. Explain to the patient and continue lithium

b. Switch lithium to valproate

c. Switch lithium to lamotrigine

d. Give anti-psychotics

e. Stop all the medication during pregnancy

Correct Answer & Detail

Correct Answer: a. Explain to the patient and continue

lithium
Answer Detail:
This patient has history of treatment resistant bipolar
disorder. Discontinuation of lithium would put her at high
risk of deterioration.

In such situations, patient should be explained about

teratogenic risk of lithium and other mood stabilizers. If
patient decides to conceive, lithium should be continued in
her case as it is least teratogenic as compared to other
mood stabilizers.

The use of lithium within the first trimester has been

associated with an increased risk of Ebstein's anomaly, a
cardiac defect involving the downward displacement of the
tricuspid valve into the right ventricle.

The absolute risk for Ebsteins anomaly remains low,

approximately 1 in 1000 to 2000 compared with 1 in 20 000
in the general population.

For patients who are currently treated with valproate or

carbamazepine, it is suggest switching treatment to avoid
the teratogenic effects of these two antiepileptics.

The absolute risk of teratogenesis is much less with lithium

than that found with valproate, carbamazepine and
lamotrigine.

The management of a woman prescribed lithium during

pregnancy should involve a multidisciplinary approach with
liaison between the general practitioner, psychiatrist,
obstetrician and paediatrician.

According to Royal Australian and New Zealand College of

Psychiatrists guidelines, if use of a mood stabilizer is
essential, lithium is the safest option as compared to other
treatment options.
Question No. 11 :

A 42-year-old female presents with 2 week history of cough with yellow-brown

sputum, right sided pleuritic chest pain and fever. She had 2 episodes of blood-stained
sputum in last 24 hours. Chest X-ray was performed (click on the attachment).

What is the most likely diagnosis?

Question Attachments

a. Right lower lobe pneumonia

b. Right middle lobe pneumonia

c. Left middle lobe pneumonia

 d. Tuberculosis

e. Atypical pneumonia

Correct Answer & Detail

Correct Answer: b. Right middle lobe pneumonia

Answer Detail:
The correct answer is b.

This patient has history suggestive of pneumonia or lower

respiratory tract infection.

Chest X-ray shows dense consolidation associated with mild

volume loss in the right middle lobe.
Remainder of the right lung, left lung and both pleural
spaces are clear. Also moderate S-shaped thoracolumbar
scoliosis is noted.
Question No. 12 :

Common causes of unconsciousness include all of the following except?

a. Profound hypoxia

b. Severe hypercapnia

c. Hypocalcemia

d. Sedatives drugs

e. Cerebral hypoperfusion

Correct Answer & Detail

Correct Answer: c. Hypocalcemia
Answer Detail:
Common causes of loss of consciousness include profound
hypoxia,severe hypercapnia,sedatives or analgesic drugs
and cerebral hypo-perfusion.
Hypocalcemia is not associated with loss of consciousness.It
causes tetany and muscle twitching.
Question No. 13 :

Which of the following is not a contraindication to the use of salbutamol in preterm

premature rupture of membrane?

a. Non-insulin dependent diabetes mellitus

b. Maternal hyperthyroidism

c. Fetal cardiac disease

d. Maternal cardiac disease

e. Insulin dependent diabetes mellitus

Correct Answer & Detail

Correct Answer: a. Non-insulin dependent diabetes

mellitus
Answer Detail:
Intravenous salbutamol can be used as a second line
tocolytic in certain circumstances.

Salbutamol can be used in non-insulin dependent diabetes

mellitus.

Salbutamol is often associated with

hyperglycemia,hypokalemia,maternal
tachycardia,pulmonary oedema,hypotension and tremors.
Salbutamol is contraindicated in patients with history of
hyperthyroidism,fetal cardiac disease, maternal cardiac
disease and insulin dependent dependent diabetes mellitus.
Question No. 14 :

A 23-year-old woman presents with skipped heartbeats and on cardiac examination

she is found to have a midsystolic click followed by a late systolic
murmur.Echocardiography shows prolapse of the mitral valve.
Which of the following is correct about this condition?

a. Mitral valve prolapse is more common in men

b. Prophylaxis against bacterial endocarditis is never recommended

c. Mitral valve prolapse is present in up to 10% of the population

d. Risk of pulmonary embolism is high

e. Ventricular arrhythmias do not occur

Correct Answer & Detail

Correct Answer: c. Mitral valve prolapse is present in up to

10% of the population
Answer Detail:
Mitral valve prolapse can be diagnosed by auscultation and
echocardiogram in as much as 10% of the general
population.

Majority of the patients are asymptomatic while few may

complain of atypical chest pain,palpitation,shortness of
breath and weakness.

Mitral valve prolapse is more common in females.

Possible complications include supraventricular and
ventricular arrhythmias which may result in sudden death.
There is an increased risk of infective endocarditis.

Intra-atrial thrombus formation may occur and predispose

to cerebral and peripheral embolism.Because the clot
originates in the left atrium so pulmonary embolism does
not occur more frequently.
Question No. 15 :

A-54-year old male with history of COPD and gallstones is undergoing

cholecystectomy. He still smokes and manages without oxygen at home. What will be
your advice?

a. Abstain from smoking for 6 weeks before surgery

b. Abstain from smoking for one week before surgery

c. Discontinue smoking after surgery

d. Smoking has no effect on the surgery

e. None of the above

Correct Answer & Detail

Correct Answer: a. Abstain from smoking for 6 weeks

before surgery
Answer Detail:
COPD is an independent risk factor for major
cardiopulmonary complications in major surgical procedure.

Before surgery, patients with unstable COPD should receive

oral steroids, which do not compromise wound healing.
Patients with history of COPD are recommended to avoid
smoking for 6 weeks prior to the surgery.
Question No. 16 :

A 13-year-old girl comes to your clinic for an advice on contraception.She informs

you that she is in a relationship with her boyfriend and they are planning to go on a
trip out of the state.What is the best next step?

a. Immediately call her father and ask him to consent for his minor daughter

b. Give the prescription and educate about prevention of sexually transmitted infections

c. Make an appointment next week to see her and her boyfriend at your clinic

d. Contact the guardianship board and get a consent over phone

e. Advise her not to go out with her boyfriend

Correct Answer & Detail

Correct Answer: b. Give the prescription and educate

about prevention of sexually transmitted infections
Answer Detail:

In Australia,a medical practitioner is required to get consent from parents about

treating minor (less than 16 years).

However when writing a prescription of contraception,it is required to prevent

unwanted pregnancy and sexually transmitted infections by use of condoms.So the
best way of doing this is to give a prescription of contraceptives and educate her how
she can prevent unwanted pregnancy and sexually transmitted infections.

All other options are not correct in Australian health system.

Question No. 17 :

Which of the following statement is true regarding incidence of thrombosis and

bleeding in patients with myeloproliferative neoplasms?
 a. Myocardial infarctions occurs more commonly than strokes

b. Venous thromboses are more common than arterial thromboses

c. Bleeding is more frequent than thrombosis

d. Bleeding is typically mucocutaneous

e. Bleeding is never associated with thrombocytosis

Correct Answer & Detail

Correct Answer: d. Bleeding is typically mucocutaneous

Answer Detail:
Patients with myeloproliferative neoplasms
(thrombocytosis,leukaemia) are prone to bleeding which is
typically mucocutaneous.

Bleeding is usually less severe and less frequent than

thrombosis.

Arterial thromboses are more common than venous

thrombosis.

Strokes are more frequent followed by myocardial infarction

and peripheral arterial occlusion.
Question No. 18 :

Which of the following is the contraindication to surgical intervention in esophageal

malignant lesions?

a. Invasion of tracheobronchial tree

 b. Invasion of small blood vessels

c. Lesion more than 5cm

d. Odynophagia

e. Aspiration pneumonia

Correct Answer & Detail

Correct Answer: a. Invasion of tracheobronchial tree

Answer Detail:
Contraindications to surgical intervention in esophageal
malignancy include invasion of tracheobronchial tree or
great vessels and lesion more than 10 cm.

Invasion of small blood vessel is not a contraindication to

surgery however involvement of large vessels like aorta is
contraindication to surgery.

Odynophagia is pain on swallowing and it is not a

contraindication to operation in this situation.

Aspiration pneumonia is a possible complication of

esophageal lesions and dysphagia and is not a criteria to
decide for surgical intervention.
Question No. 19 :

A 56-year-old male with acute limb ischemia is on heparin infusion of

1130units/hour.Which one of the following method is used for monitoring?

a. Prothrombin time

b. Bleeding time

c. INR

d. Activated partial thromboplastin time

 e. Fibrinogen level

Correct Answer & Detail

Correct Answer: d. Activated partial thromboplastin time

Answer Detail:
The activated partial thromboplastin time (aPTT) is used to
assess the integrity of the intrinsic coagulation pathway
(prekallikrein, high molecular weight kininogen, factors XII,
XI, IX, VIII) and final common pathway (factors II, V, X,
and fibrinogen), and to monitor heparin therapy.
The goal of maintenance heparin therapy is to maintain the
aPTT in the range of 1.5 to 2.5 times the patient's aPTT
baseline value.

APTT is used to monitor heparin infusion rate 6-hourly

initially and when in therapeutic range (65-100 seconds)
every 24-hourly,while INR is used to monitor warfarin
therapy.

Bleeding time is normally between 1-9 minutes and if

prolonged may indicate blood vessel defects,platelet
aggregation defect and thrombocytopenia.

Prothrombin time normal range for someone who is not

taking a blood thinner medication is 11 - 13.5 seconds.

Prolonged PT means failure of clotting mechanism like

Vitamin K deficiency,factor VII deficiency,factor X deficiency
factor II(prothrombin)deficiency etc.
Question No. 20 :
Which one of the following of the following is not a feature of obstructive sleep
apnoea?

a. Daytime sleepiness

b. Sleep maintenance insomnia

c. Impaired vigilance

d. Hypertension

e. Narcolepsy

Correct Answer & Detail

Correct Answer: b. Sleep maintenance insomnia

Answer Detail:
Obstructive sleep apnoea causes following important
symptoms:

- Daytime sleepiness.
- Impaired vigilance.
- Decrease cognitive performance and driving.
- Depression.
- Disturbed sleep.
- Hypertension.
- Narcolepsy.

Patients with central sleep apnoea usually present with sleep

maintenance insomnia, which is relatively unusual in
obstructive sleep apnoea.

Recurrent central sleep apnoea is most commonly seen in

cardiac failure and stroke.
Question No. 21 :

A 21-year-old male is brought in the emergency department by ambulance.He is

cooperative on interaction and tell you that in his back of mind he is feeling as if he is
about to punch you.
He tells you that biomes-are physical things, neutrons are spiritual and electrons are
like 6 sense of man.
He is hearing voice of God which tells him to by burgers from a fast food shop and
distribute amongst the poor in the world.
What is the most appropriate course of action you would consider?

a. Do urinary drug screen

b. Call the security

c. Involuntary psychiatric admission

d. Give him 10mg haloperidol and wait to see if it works

e. Disagree with what patient says and refer the patient to GP

Correct Answer & Detail

Correct Answer: b. Call the security

Answer Detail:
This patient has expressed his thoughts to harm the
examining doctor,although apparently cooperative.

Immediately security should be called to prevent any further

violence which is highly predicted in this case.

Once security has been called, then do urine drug screen,

give haloperidol and call to psychiatry registrar for possible
admission as involuntary patient.

Sending the patient with GP follow up would be dangerous

as this patient has got psychotic symptoms with very bizarre
delusions, delusions of grandiosity and command
hallucinations and needs admission as involuntary treatment
under mental health act.
Question No. 22 :

Which of the following is the best measure of dehydration in an 8-year-old child

presenting with vomiting and diarrhoea?

a. Percentage loss of body weight

b. Frequency of diarrhea and vomiting

c. Degree of thirst

d. Capillary refill

e. Skin turger

Correct Answer & Detail

Correct Answer: a. Percentage loss of body weight

Answer Detail:
The correct answer is a.

Dehydration is still a cause of death during acute

gastroenteritis in children in developed countries.

The best measure of dehydration in all patients is the

percentage loss of body weight. If a child's recent pre-illness
weight is not available,information should be obtained from
the child health record.

Also urine output,frequency of diarrhoea and

vomiting,thirst,capillary refill and skin turgor potentially add
to the assessment of dehydration in a child.
The most useful signs for predicting more than 5%
dehydration in children are prolonged capillary refill time,
reduced skin turgor and deep respiration.

In adults, important clinical features of dehydration include

tachycardia, hypotension, reduced skin turgor and oliguria.
Question No. 23 :

What would be the most ominous sign in a child with croup?

a. Degree of stridor

b. Increase in temperature

c. Subcostal retraction and use of accessory muscles

d. Loudness of stridor

e. Low oxygen saturation

Correct Answer & Detail

Correct Answer: c. Subcostal retraction and use of

accessory muscles
Answer Detail:
The correct answer is c.

Croup (acute laryngotracheobronchitis) presents with a

coryzal prodrome, hoarseness (or husky voice in those old
enough to speak), inspiratory stridor, a harsh barking
'brassy' cough and variable airway obstruction due to
inflammatory oedema within the subglottis.

It is most common in 1 to 3 year old children and has

duration of 2 to 5 days. Parainfluenza viruses are the most
common cause of croup, and antibiotics are not indicated.
The severity of croup is defined in research studies by the
Westley score but key features are:

1- Mild airway obstruction: mild chest wall retractions and

tachycardia, but no stridor at rest.

2- Moderate airway obstruction: stridor at rest, chest wall

retractions, use of accessory respiratory muscles and
tachycardia.

3- Severe airway obstruction: persistent stridor at rest,

increasing fatigue, markedly decreased air entry, marked
tachycardia.
Restlessness, decreased level of consciousness, hypotonia,
cyanosis and pallor are signs of life-threatening airway
obstruction.

Increase in temperature, oxygen saturation and degree of

stridor are not reliable signs of assessing croup severity.
Oxygen desaturation, indicated by oximetry, is usually a late
and unreliable sign of severity. Occasionally, it may be
present in less severe croup.
Question No. 24 :

A 29-year-old lady at 32 weeks of gestation presents with regular uterine

contractions.Cardiotocography shows live fetus with regular accelerations.Blood
pressure is 200/120 mmHg. Liver function shows mildly raised serum alkaline
phosphatase.Sterile speculum examination shows foul smelling fluid leaking out of
vagina.

Which of the following is the next best step in this situation?

a. Suppression of labour is started by giving oral nifedipine with two further doses if
contractions still persist
 b. Intravenous salbutamol should be used as first line drug to stop uterine contractions

c. Both nifedipine and salbutamol are indicated in this patient

d. Further investigations are needed to find whether this patient needs tocolysis or not

e. Tocolysis is absolutely contraindicated in this patient

Correct Answer & Detail

Correct Answer: e. Tocolysis is absolutely contraindicated

in this patient
Answer Detail:
This patient has clinical presentation of preterm labour with
active uterine contractions.

She has high blood pressure and abnormal liver function

tests which is clue towards severe pre-eclampsia.

Tocolysis is contraindicated in pre-eclampsia and eclampsia.

After the rupture of membranes it is recommended not to

suppress uterine contractions with any medication.

Nifedipine and salbutamol in combination increase

cardiovascular side effects and should be avoided.
Question No. 25 :

A 32-year-old woman comes to your clinic for advice regarding screening. She has
history of gestational diabetes during pregnancy 2 years ago. Her blood sugar was
normal 6 months ago. Her grandfather died of myocardial infarction at the age of 80
years. Her sister has been diagnosed with diabetes mellitus at the age of 45.
What will you advise her?

a. Serum cholesterol every 5 years

 b. Fasting blood glucose every 3 years

c. Colonoscopy every year

d. Exercise tolerance test every year

e. FOBT every year

Correct Answer & Detail

Correct Answer: b. Fasting blood glucose every 3 years

Answer Detail:
Fasting blood glucose every 3 years, should be considered at
any age in following high risk groups.

1- All people with a history of previous cardiovascular

event including acute myocardial infarction and stroke.
2- All the women with a history of gestational diabetes
mellitus.
3- Women with polycystic ovary syndrome.
4- Those on antipsychotic drugs.
5- Those with impaired glucose tolerance test.

This woman fall in this high risk category and so does need
fasting blood glucose test once every 3 years to make early
diagnosis of diabetes mellitus.

A patient without any family history of colorectal cancer and

personal history of ulcerative colitis and colon cancer should
have FOBT at least every two years after the age of 50.

All adults aged 45 and over should have 5 yearly check of

serum cholesterol for screening of hypercholesterolemia.
Question No. 26 :

A mother brings her 8-month old male child with history of sudden bending of the
trunk and flexion of upper limbs.The child does not respond as he used to.

What is the most likely diagnosis?

a. Myoclonic seizure

b. Petit mal epilepsy

c. Infantile spasm

d. Habitual tics

e. Childhood epilespy

Correct Answer & Detail

Correct Answer: c. Infantile spasm

Answer Detail:
The correct answer is c.

Infantile spasms are a special form of epilepsy which occurs

during infancy.The spasms usually begin when the baby is
between 3-8 months of age.

In approximately 50% of cases, the cause of infantile

spasms is not known.

However, in the other 50% there are many different

conditions affecting the brain, such as birth malformation,
birth injury and meningitis, which can cause this type of
epilepsy.
Symptoms can vary from child to child, however there is
usually a sudden spasm or bending (flexion) of the body
either at the waist or neck.

A baby who is not yet sitting up may be lying quite

comfortably and will suddenly draw the legs up at the hips,
throw the arms out and lift the head. It is not uncommon for
the baby to cry out after a spasm and be rather irritable.

Children who can sit may bend at the waist and their head
can fall forward.Spasms usually occur in clusters. Each one
is brief, lasting only a few seconds.

All other options are incorrect in a child less than 12 months

of age.
Question No. 27 :

A 62-year old male is found to have painless hematuria and normal renal
function.Which of the following is the best investigation to reach the diagnosis?

a. Cystoscopy

b. Intravenous pyelography

c. Ultrasound

d. X-ray

e. CT scan

Correct Answer & Detail

Correct Answer: a. Cystoscopy

Answer Detail:
The correct answer is a.
Painless macroscopic hematuria is caused by following
clinical conditions:

1-Urinary tract malignancy.

2-Urinary calculi.
3-Urinary tract infection.
4-Benign prostatic hypertrophy.
5-Haemorrhagic cystitis.
6-Nephrological disease.
7-Bleeding diathesis/anticoagulation therapy.
8-Arteriovenous malformation/angiomyolipoma.

Macroscopic hematuria has a high diagnostic yield for

underlying malignancy, particularly in
appropriate age groups.In men aged more than 60 the
positive predictive value of macroscopic hematuria for
urological malignancy is 22.1 percent.

Given the high prevalence of malignancy, it is mandatory to

further evaluate patients with
suspected urological disease as the cause of macroscopic
hematuria.

If patient is less than 50 years of age,do CT scan of

abdomen and pelvis.All patients above 50 years require
cystoscopy.

Cystureterocopy is the gold standard for lower urinary tract

malignancies.Ultrasound is effective in the detection of
upper tract tumours.
Question No. 28 :
A 27-year-old lady known to be hemophilia A career,comes to discuss with you about
her plans to conceive.
She is concerned about the possibility of her baby being at risk because of her
hemophilia status.
Which of the following statement is true for a patient with hemophilia A and
pregnancy?

a. Genetic counselling is not required at this stage

b. Measure Factor 8 level now and at 39weeks of pregnancy

c. A majority of carriers of haemophilia A develop normal level of factor 8 as the pregnancy

progress and do not require replacement
d. Vacuum extraction is safely used if required during delivery of the baby

e. Caesarean section eliminate the risk of cranial haemorrhage in the neonate

Correct Answer & Detail

Correct Answer: c. A majority of carriers of haemophilia A

develop normal level of factor 8 as the pregnancy progress
and do not require replacement
Answer Detail:
The female patients with haemophilia A career state are at
risk of transmitting this trait to their male babies.

So genetic counselling is essentially required at this stage to

discuss various possibilities with the patient.

If this lady gets pregnant,then you should measure Factor 8

level at first antenatal visit and at 32 weeks of pregnancy.
A majority of carriers of haemophilia A develop normal level
of factor 8 as the pregnancy progress and do not require
replacement.
Vacuum extraction is contraindicated if required during
delivery of the baby.

Vaginal delivery is preferred over Cesarean section as

Cesarean section does not eliminate the risk of intracranial
haemorrhage in the neonate.
Question No. 29 :

A 72-year-old male presented with sudden onset of central chest pain.Chest X-ray is
normal. ECG has been performed (click on attachment). After examining the ECG,
what is the most likely diagnosis?

Question Attachments

a. Acute pulmonary embolism

b. Acute pneumothorax

c. Aortic dissection

d. Esophageal perforation

e. Acute myocardial infarction

Correct Answer & Detail

Correct Answer: e. Acute myocardial infarction

Answer Detail:
ECG of this patient with sudden onset of chest pain shows
ST segment elevation is lead II,III,AVF. So the most likely
diagnosis is acute inferior myocardial infarction often caused
by a lesion in right coronary artery or less commonly
circumflex coronary artery.
Acute pulmonary embolism is characterized by S1Q3T3
however this classic finding is often not present and most
patient with diagnosis of pulmonary embolism have normal
ECG.
A normal chest X-ray has ruled out the possibility of acute
pneumothorax in this patient.Also if aortic dissection is
present,it can show wide mediastinum on chest x-ray.
Symptoms of acute esophageal perforation include severe
sudden chest pain,dyspnoea,and patient may have history
of esophageal disease or acute intoxication with alcohol
associated with forceful vomiting.Also chest X-ray shows air
in mediastinum in cases of esophageal perforation.
Question No. 30 :

A 20-year-old female university student visited your GP clinic for advice. She has past
medical history of asthma and epilepsy. She has been seizure free, while on
lamotrigine for last 12 months. She is planning to start her first sexual relationship
and is keen to start combined oral contraceptive pills.

What is the most appropriate advice?

a. Combined oral contraceptive pills are contraindicated

b. Prescribe combined oral contraceptive pills and increase the dose of lamotrigine

c. Prescribe combined oral contraceptive pills and decrease the dose of lamotrigine

d. Cease lamotrigine and start on carbamazepine

e. Prescribe oral contraceptive pills and advise about safe sex

Correct Answer & Detail

Correct Answer: b. Prescribe combined oral contraceptive

pills and increase the dose of lamotrigine
Answer Detail:
The correct answer is b.

Combined oral contraceptive pills increase the metabolism of

lamotrigine through increased glucuronidation. It reduces
the lamotrigine level by 50% and it can lead to worsening of
seizure control.
So increase the dose of lamotrigine while commencing this
patient on combined oral contraceptive pills.
Question No. 31 :

A 28-year-old medical student, who has started his clinical postings, comes to you
because his colleagues noticed a yellowish, tinge to his sclera.
On examination he is normal except for the yellow sclera. Investigations showed
following picture:
Total bilirubin-elevated
Indirect bilirubin-elevated predominantly.

Which of the following is most likely diagnosis?

a. Gilberts syndrome

b. Haemolytic jaundice

c. Cancer of pancreas

d. Acute hepatitis

e. Cartenemia

Correct Answer & Detail

Correct Answer: a. Gilberts syndrome

Answer Detail:
The correct answer is a.

This patient has clinical features of Gilbert's syndrome. It is

an autosomal recessive disorder.
A presumptive diagnosis of Gilbert's syndrome is made
when a patient exhibits the following findings:

1-Repeated unconjugated hyperbilirubinaemia.

2-No evidence of haemolysis, with normal findings on
complete blood count, reticulocyte count, and blood smear.
3-Normal liver function tests except for the bilirubin.

Decreased uridine-diphosphoglucuronate
glucuronosyltransferase (UDPGT) activity leads to decreased
conjugation of unconjugated bilirubin.

In haemolytic jaundice, signs and symptoms of anemia

(fatigue, dizziness, dyspnoea, pallor, and tachycardia) are
commonly seen. Splenomegaly may be present in some
causes of haemolysis (hereditary spherocytosis).

Clinical features of pancreatic cancer include unexplained

upper abdominal pain, painless obstructive jaundice, weight
loss, and, in later stages, back pain.

In acute hepatitis, apart from hyperbilirubinemia, AST, ALT

and abnormalities of synthetic functions of liver may be
found.

Carotenemia is found in infants and toddlers whose diets

consist of large amounts of strained yellow vegetables,
particularly carrots.
Unlike jaundice, the sclera is not discoloured. In
carotenemia, the skin colour characteristically is more
yellow-orange rather than yellow and more noticeable over
the palms and soles.
Question No. 32 :

A 51-year old suicidal male was brought in by the the ambulance to the emergency
department with self-inflicted small lacerations in background of depression.
His wound has been washed and closed by you.While awaiting for psychiatry
assessment,he develops sudden severe central chest pain radiating to his jaw and left
arm.He is anxious,pale and sweating.
Immediate ECG was performed which showed acute ST-segment elevation in lead
II,III and AVF.Troponin is not elevated.He has no history of stroke,bleeding
disorders,active internal bleeding,brain tumour or recent surgery.

What is the most appropriate management?

a. Repeat troponin

b. Immediate reperfusion

c. Repeat ECG in 6 hours

d. Start beta-blocker

e. Await review by medical specialist

Correct Answer & Detail

Correct Answer: b. Immediate reperfusion

Answer Detail:
The correct answer is b.

This patient has typical clinical history of acute myocardial

infarction with acute ST-segment elevation (Inferior
STEMI).The best and most appropriate immediate treatment
for this patient is reperfusion therapy with fibrinolytics or
urgent percutaneous coronary intervention (PCI).

This patient has not contra-indication to reperfusion

therapy.So b is correct option here.

After myocardial damage, troponin is released in 2-4 hours

and persists for up to 7 days.So in this patients initial
troponin test is negative and it should not be the reason to
post-pone reperfusion therapy.
Repeat testing of troponin level is required to monitor the
extent of myocardial damage however is second on priority
in this emergency situation.

Serial ECGs are also required to monitor the effect of

reperfusion therapy and reversal of ST segment elevation.
Beta-blockers are considered once the patient has been be
thrombolysed and vitally stable.

Awaiting for medical specialist is not correct approach as

this is an emergency situation and can be managed by
emergency team very well.
This patient would require an inpatient coronary care unit
transfer for further management post-fibrinolytic therapy.

Fibrinolytic therapy is considered useful when patient

presents within 12 hours of the symptoms however
reperfusion therapy should be achieved as soon as possible
to minimize the myocardial damage. Thrombolytics available
in Australia include tissue plasminogen activators alteplase
(tPA) and reteplase.

Small lacerations are with washed and closed wounds are

not contra-indication to reperfusion therapy however
massive trauma or non-compressible vascular puncture is a
relative contra-indication to fibrinolytic therapy.
Question No. 33 :

A 20-year-old pregnant lady at 10 weeks of gestation presented with exposure to

rubella from a co-worker three days ago.She has never been vaccinated against
rubella.She doe not have any symptoms.

What will you do next?

a. Check serum IgA and IgG for rubella

b. Give intravenous immunoglobin

 c. Give MMR Vaccine

d. Give only rubella vaccine

e. Terminate the pregnancy

Correct Answer & Detail

Correct Answer: a. Check serum IgA and IgG for rubella

Answer Detail:
The correct answer is a.

All pregnant women with suspected rubella or exposure to

rubella should be serologically tested, irrespective of a
history of previous vaccination, clinical rubella or a previous
positive rubella antibody result.
So check serum IgA and IgG for rubella in this patient.

This is because the rash of rubella is not

diagnostic,asymptomatic infection can occur, and acute
rubella can be confirmed only by laboratory tests.So option
a is correct here.

Rubella infection during pregnancy is potentially teratogenic

with the risk of fetal infection greatest if maternal infection
occurs during the first trimester.

Fetal damage occurs in up to 90% cases of maternal rubella

infection in the first 8-10 weeks.

Risk of fetal damage declines to about 10-20 percent by 16

weeks. Fetal damage as a result of maternal rubella
infection is rare after 16 weeks gestation.
Vaccination against rubella is contraindicated during
pregnancy and the value of immunoglobulins is
controversial.

Therapeutic abortion is generally recommended after proven

infection during the first trimester.The doctor must counsel
the patient as to the risks associated with congenital rubella
syndrome.However patient may prefer to continue
pregnancy and you are expected to oblige their wishes.
Question No. 34 :

A 42-year-old female has history of chronic renal failure and gets dialysis 3 times a
week. She is good and decent with ward nurses. However, she speaks rudely with
dialysis nurse.

Which ONE of the following is the defense mechanism?

a. Acting out

b. Splitting

c. Regression

d. Denial

e. Repression

Correct Answer & Detail

Correct Answer: b. Splitting

Answer Detail:
The correct answer is b.

Splitting is a primitive defense. Negative and positive

impulses are split off and unintegrated, frequently projected
onto someone else. The defended individual segregates
experiences into all-good and all-bad categories, with no
room for ambiguity and ambivalence.

Splitting is the failure in a person's thinking to bring

together both positive and negative qualities of the self and
others into a cohesive, realistic whole.

Splitting is very common in people with borderline

personality disorder (BPD), and it leads people with BPD to
view others and themselves in all or nothing terms.

Topic review:

Acting out is the direct expression of an unconscious wish or

impulse in action, without conscious awareness of the
emotion that drives that expressive behavior.

Regression is the temporary reversion of the ego to an

earlier stage of development rather than handling
unacceptable impulses in a more adult way.

Denial is refusal to accept external reality because it is too

threatening; arguing against an anxiety-provoking stimulus
by stating it doesn't exist; resolution of emotional conflict
and reduction of anxiety by refusing to perceive or
consciously acknowledge the more unpleasant aspects of
external reality.

Repression is the psychological attempt by an individual to

repel one's own desires and impulses toward pleasurable
instincts by excluding the desire from one's consciousness
and holding or subduing it in the unconscious.
Question No. 35 :
A 40 year-old male presents with headaches,fever,photophobia and is found to have
stiff neck.You suspect meningitis however you think about other causes of neck
stiffness as well.Which of the following conditions does not cause neck stiffness?

a. Retropharyngeal abscess

b. Pneumonia

c. Tetanus

d. Botulism

e. Subarachnoid haemorrhage

Correct Answer & Detail

Correct Answer: d. Botulism

Answer Detail:
Neck stiffness is clinical feature of diseases causing
inflammation of meninges as well as spasm of neck
muscles.It is caused by all types of meningitis,subarachnoid
haemorrhage,tetanus, upper lobe pneumonia,tender
posterior cervical adenopathy,retropharyngeal abscess and
rheumatoid arthritis.
Botulism is caused by Clostridium botulinum which produces
botulinum toxin.This toxin blocks the release of acetylcholine
from cholinergic neurons resulting in loss of muscle
tone,contractility resulting in atrophy.This does not cause
neck stiffness.
Question No. 36 :

A 43-year-old obese lady had laparoscopic cholecystectomy about 6 months back.

Now she presents with abdominal pain and dyspepsia.
Laboratory investigations reveal elevation of aspartate aminotransferase,alkaline
phosphatase and alanine aminotransferase.Serum cholesterol is also elevated.

Which of the following is the investigation of choice?

 a. ERCP with biliary manometry

b. MRCP

c. Contrast CT abdomen and chest

d. Hepatobiliary ultrasound

e. Oral Cholecystogram

Correct Answer & Detail

Correct Answer: a. ERCP with biliary manometry

Answer Detail:
The correct answer is a.

This patient has clinical presentation suggestive of post-

cholecystectomy syndrome.The most common symptoms
include dyspepsia and non-specific abdominal symptoms
instead of true biliary colic.

Biliary duct inflammation secondary to trauma results in

narrowing of the duct.It can also be caused by a retained
bile duct stone,pancreatitis and gastroesophageal reflux.

Elevated liver enzymes suggest sphincter of Oddi

dysfunction.This dysfunction is best detected by biliary
manometry done during ERCP.

Manometry will show increased pressure in the biliary tract

when pain is reproduced.

A slowed hepatic hilum-duodenal transit time on a scan also

suggests sphincter of Oddi dysfunction.
Diagnosis of papillary stenosis is based on a clear-cut
history of recurrent episodes of biliary pain and abnormal
liver or pancreatic enzyme tests.
Question No. 37 :

A 49-year-old male,who is otherwise healthy,reports you to have tremors while he

goes to pick up the phone and dials numbers but when he looks at his hands while
resting,the tremors disappear.
On detailed history,he discloses that his father had similar problem.His examination is
unremarkable apart from the tremors.

What will be the appropriate drug therapy to help this patient?

a. Benzhexol

b. Propranolol

c. Reassure

d. Alcohol use in limited quantity

e. Primidone

Correct Answer & Detail

Correct Answer: b. Propranolol

Answer Detail:
The correct answer is b.

This is a case of essential tremors,a movement disorder with

unknown etiology but has a clear hereditary component.
Initially,it manifests by rapid shaking of the hands during
activity,latter it can affect the head,the voice, the arms
or,more rarely,the legs.It hinders ability to perform certain
tasks,such as writing, dressing or drinking.
Propranolol and primidone are two effective drugs for
essential but the former is preferred due less side effects.
Simple reassurance and limited alcohol use can be helpful to
improve essential tremors.It increases the risk of alcohol
abuse.

Benzhexol is used for the treatment of resting tremors of

Parkinson disease that stop during activity.
As coordination and other examination is normal and patient
is otherwise healthy so chance of cerebellar tremor or due to
any systemic disease is less likely.
Question No. 38 :

Which of the following mechanism is main cause of hyponatraemia in diabetic

ketoacidosis?

a. Sodium excretion in urine due to hyperosmolar diuresis

b. Intracellular sodium shift

c. Extracellular water shift due to hyperosmolarity

d. Increase in total body sodium

e. Unknown mechanism

Correct Answer & Detail

Correct Answer: c. Extracellular water shift due to

hyperosmolarity
Answer Detail:

High serum osmolarity drives water from intracellular to extracellular space causing
dilutional hyponatremia.
Sodium is also lost in the urine during the osmotic diuresis however it is not as
significant as the dilutional effect is.

Sodium shifts from intracellular space to extracellular in diabetic ketoacidosis and not
vice versa.

Total body sodium decreases in DKA due to osmotic diuresis.

Question No. 39 :

Which one of the following conditions is associated with an increased risk of coeliac
disease?

a. Alcoholic cirrhosis

b. Type II diabetes mellitus

c. Type 1 diabetes mellitus

d. Human immunodeficiency virus (HIV) infection

e. Essential hypertension

Correct Answer & Detail

Correct Answer: c. Type 1 diabetes mellitus

Answer Detail:
The correct answer is c.

There is increased risk (3-16%) of developing coeliac

disease amongst persons who have type I diabetes mellitus.

The prevalence of coeliac disease is 1.5 to 2 times as high

among women as among men.
Risk of developing coeliac disease is also increased if the
person has an affected first-degree relative (10 to 15
percent),hashimotos thyroiditis (5 percent) or other
autoimmune diseases (including autoimmune liver diseases,
Sjogrens syndrome, and IgA nephropathy),Downs
syndrome (5 percent),Turners syndrome (3 percent), and
IgA deficiency (9 percent).

Type II diabetes mellitus,alcoholic cirrhosis, essential

hypertension and HIV infection are not associated with
increased risk of developing coeliac disease.
Question No. 40 :

All of the following interventions are helpful in reducing risk of perinatal

transmission of HIV except?

a. Maternal antiretroviral treatment

b. Peripartum intravenous zidovudine

c. Consider elective caesarean section

d. Neonatal antiretroviral treatment

e. Breast feeding

Correct Answer & Detail

Correct Answer: e. Breast feeding

Answer Detail:
Interventions to prevent perinatal transmission of HIV
include:

- Maternal antiretroviral treatment.

- Peripartum intravenous zidovudine.
- Elective cesarean section.
- Neonatal antiretroviral treatment.
- Bottle feeding.

Breast feeding is contraindicated in mothers with history of

HIV as it increases chances of HIV transmission.
If there is no intervention done,perinatal HIV transmission
rate is 20-30% and with intervention transmission is less
than 2%.
Question No. 41 :

Which of the following is not an absolute contra-indication to fibrinolytic therapy in a

patient with ST segment elevation acute myocardial infarction?

a. Ischaemic stroke during previous 6-months

b. Haemorrhagic stroke in previous 10-years

c. Menstrual bleeding

d. Known bleeding disorder

e. Gastro-intestinal bleeding within last 4 weeks

Correct Answer & Detail

Correct Answer: c. Menstrual bleeding

Answer Detail:
The correct answer is c.

Absolute contraindications to fibrinolytic therapy in a patient

with ST segment elevation acute myocardial infarction
include:

1-Ischemic stroke within last 6-months.

2-Hemorrhagic stroke any time in the past.
3-Known bleeding disorder.
4-Gastro-intestinal bleeding within last month.
5-Known or suspected aortic dissection.
6-Recent major surgery in last 3-weeks.
7-Active internal bleeding excluding menstrual bleeding.

Menstrual bleeding is not a contraindication for fibrinolytic

therapy.
Question No. 42 :

A 30-year-old woman presented with nausea and vomiting during pregnancy. She has
past medical history of migraine.
What is the most appropriate management?

a. Paracetamol

b. Paracetamol and codein

c. Codein and metoclopramide

d. Codein and promethazine

e. Sumatriptan

Correct Answer & Detail

Correct Answer: c. Codein and metoclopramide

Answer Detail:
The correct response is c.

This patient has severe migraine and should be given

metoclopramide and codein.Metoclopramide is safe to use in
pregnancy, and may be added to paracetamol to increase its
effectiveness.
Opioid pain relievers such as codeine have not been
associated with an increase in birth defects or miscarriage.
Long term use of codein can lead to dependence in the
mother and withdrawal signs in the baby.

Paracetamol alone or with codein would not stop vomiting.

So option a and b both are incorrect.

Dihydroergotamine and the triptans should be avoided

throughout pregnancy.
Question No. 43 :

A 21-year-old female is diagnosed with acute appendicitis and is planned to undergo

laparoscopic appendectomy. All blood results are unremarkable.

What will you consider for antibiotic prophylaxis?

a. Intravenous Cephazolin and gentamicin

b. Oral ciprofloxacin

c. Doxycycline

d. Clindamycin

e. Intravenous metronidazole, and cephazolin or gentamicin

Correct Answer & Detail

Correct Answer: e. Intravenous metronidazole, and

cephazolin or gentamicin
Answer Detail:
The correct answer is e.
A single dose of antibiotic is usually sufficient as prophylaxis
for a surgical procedure involving manipulation of abdominal
viscera, but if the procedure is not completed within 3 hours
of initiating prophylaxis, a second dose should be given if a
short-acting antibiotic is used.

In practice, it is very difficult to establish prospectively that

any operation will be a clean procedure, as unexpected
pathology may be encountered or intraoperative
contamination may occur.

Meta-analysis of trials has shown that prophylaxis is

appropriate in all patients undergoing abdominal surgery.
Metronidazole plus either gentamicin or cephazolin is the
best choice prophylaxis for colorectal surgery and
appendectomy.
Question No. 44 :

A 42 year-old lady presented with abdominal pain, mild jaundice and fever. She was
admitted in the ward. Now she started having rigors and chills associated with nausea
and vomiting and is hypotensive.
What is the most likely diagnosis?

a. Septic shock

b. Acute cholangitis

c. Acute cholecystitis

d. Acute pancreatitis

e. Choledocholithiasis

Correct Answer & Detail

Correct Answer: b. Acute cholangitis

Answer Detail:
This patient has signs and symptoms consistent with
diagnosis of acute cholangitis. Fever is present in
approximately 90 percent of the cases. Abdominal pain and
jaundice occurs in about 70 percent of the cases. Patient can
get quickly septic and hypotensive with altered level of
consciousness.
Septic shock can result from acute cholangitis however that
is not the primary diagnosis here. So option a is incorrect
choice.
Acute cholecystitis characterized by right upper quadrant
pain, fever, and leukocytosis associated with gallbladder
inflammation that is usually related to gallstones.
Jaundice is not a feature of acute cholecystitis.If jaundice
occurs with acute cholecystitis it is then called acute
cholangitis.
In acute pancreatitis, the abdominal pain is typically
accompanied by nausea and vomiting, which may persist for
many hours. Patient becomes restless with agitation and
relief is noted on bending forward. Jaundice is absent in
acute pancreatitis.
Choledocholithiasis is the presence of gallstones within the
common bile duct. A patient with uncomplicated common
bile duct stones typically develops abdominal pain with mild
liver function abnormalities however he/she remains
afebrile.
The two major complications associated with
choledocholithiasis are acute cholangitis and acute
pancreatitis.
Question No. 45 :

A 62-year-old male presented with acute leg pain, paralysis and was found to have
acute limb ischemia. Vascular surgery was performed which restored the blood supply
by doing embolectomy within 3 hours. He is at risk of developing reperfusion injury.

All of the following are features of reperfusion injury except?

a. Hyperkalemia

b. Metabolic acidosis
 c. Myoglobinemia

d. Elevated creatinine kinase level

e. Hypokalemia

Correct Answer & Detail

Correct Answer: e. Hypokalemia

Answer Detail:
The correct answer is e.

Reperfusion injury can occur in patients with acute limb

ischemia when the blood supply is restored.

Features of reperfusion injury include:

- Acute renal failure

- Hyperkalemia.
- Myoglobinemia.
- Metabolic acidosis.
- Elevation in creatinine kinase level.

Hypokalemia is not the feature of reperfusion injury.

The extent of reperfusion injury depends on the duration

and location of the arterial blockage, the amount of
collateral flow, and the previous health of the involved limb.
Approximately one third of all deaths from occlusive arterial
disease are secondary to metabolic complications upon
revascularization.
Question No. 46 :

A 25-year-old woman is concerned about her risk of colorectal cancer. Her

grandfather was diagnosed with colorectal cancer at the age of 60, her father was
diagnosed with colorectal cancer at the age of 62 and her brother is diagnosed with
colorectal cancer at the age of 55. What will you advise her?

a. Bronchoscopy every 5 year from now

b. Mammography every 2 year after age of 35

c. Breast ultrasound every year

d. CT abdomen every 5 year

e. Colonoscopy every 2 year from now

Correct Answer & Detail

Correct Answer: e. Colonoscopy every 2 year from now

Answer Detail:
Currently in Australia, it is recommended to have 2-yearly
colonoscopy for people from age of 25-30 years if there is
family history of colorectal carcinoma:

- Three or more first or second degree relatives with

colorectal carcinoma at any age.
- Two or more first or second degree relatives diagnosed
with colorectal carcinoma before the age of 50 years.
- A family member where genetic studies identify a high
risk.

So this patient qualifies for 2-yearly colonoscopy as her 3

family members have colorectal carcinoma after the age of
50. So option e is correct.
All other options are incorrect.
Question No. 47 :
A 25-year old male, unemployed, presents to your office for a follow-up. History
revealed that he loves going out to nightclubs and having casual sex with multiple
partners. He had his first hepatitis B serology last week with the following results:
HBsAg- positive; HBsAb-negative, HBcAb(IgM)-positive, HBeAg-positive.

What is the most likely interpretation of his result?

a. An early hepatic cirrhosis

b. History of hepatitis B infection which resolved, resulting in life-long immunity

c. Past hepatitis B vaccination and is now immune

d. Hepatitis B carrier

e. Acute hepatitis B infection

Correct Answer & Detail

Correct Answer: e. Acute hepatitis B infection

Answer Detail:
The correct answer is e.

A positive HBsAg is indicative of an acute infection which

occurs about 1-6 months after exposure to the hepatitis B
virus.This acute infection is supported by the positive HBcAb
(IgM) which is only present in an acute infection.

If HBsAg persists after 6 months, it defines a carrier status.

HBeAg is positive which implies high infectivity in recent

infection.Following a Hep B vaccination would give a positive
HBsAb serology.In this case, patient needs education about
hepatitis B, safe sex and drug abuse.
Question No. 48 :
A 43-year-old male undergoes total thyroidectomy for papillary carcinoma of thyroid.
He developed hypoparathyroidism post-thyroidectomy.

Which of the following statement is correct regarding post-surgical

hypoparathyroidism?

a. Hypocalcaemia is always permanent

b. It decreases calcium and increases PTH

c. Hypocalcaemia is fatal if not treated promptly

d. Hypocalcaemia is very uncommon after total thyroidectomy

e. Vitamin D supplements are not required usually

Correct Answer & Detail

Correct Answer: c. Hypocalcaemia is fatal if not treated

promptly
Answer Detail:
The correct answer is c.

Hypocalcaemia is seen in patients who undergo total

thyroidectomy.Parathyroid glands are removed during the
surgical procedure. It results in primary hypoparathyroidism
causing low PTH and hypocalcaemia. So option b is
incorrect.

Permanent hypoparathyroidism develops in 1-2% of patients

after a total thyroidectomy.However transient
hypoparathyroidism and hypocalcemia is quite common. So
option a is incorrect.

Hypocalcaemia in patients after removal of parathyroid

glands is fatal if not treated promptly.
Hypocalcemia symptoms begin 12 to 24 h postoperatively
and may need treatment with oral or intravenous calcium.

Parathyroid function often returns, but persistent

hypocalcaemia requires treatment with vitamin D
preparations. So option e is incorrect.
Question No. 49 :

Which of the following is not an indication of urgent surgical intervention?

a. Localized peritonitis

b. Progressive distension of abdomen

c. Septicemia and abdominal findings

d. Massive bowel distention (colon > 12 cm)

e. Tender abdominal mass and hypotension

Correct Answer & Detail

Correct Answer: a. Localized peritonitis

Answer Detail:
Indications for urgent abdominal surgical interventions
include:

1-Diffuse peritonitis(localized peritonitis is not always an

indication).

2-Severe or increasing localized tenderness.

3-Progressive abdominal distension.

4-Tender mass with fever or hypotension (abscess).

5-Septicemia and abdominal findings.

7-Bleeding and abdominal findings.

8-Suspected bowel ischemia (acidosis,fever,tachycardia).

9-Massive bowel dilatation more than 12cm.

Localized peritonitis is not an indication for urgent surgical

intervention and can be managed conservatively.So option a
is correct response.
Question No. 50 :

In basic life support,what will be your next step if the patient is found unconscious
and is not breathing?

a. Open and clear,if necessary the airway and commence chest compressions

b. Open and clear if necessary the airway and give two rescue breaths

c. Check for a pulse for no longer than 10 seconds if no pulse give two rescue breaths

d. Attach difibrillator

e. Perform a precordial thumb then commence chest compressions

Correct Answer & Detail

Correct Answer: a. Open and clear,if necessary the airway

and commence chest compressions
Answer Detail:
If a patient is found unconscious with no breathing,first
thing to do is to make sure his/her airway is clear.Then
immediately start chest compressions.

In current basic life support guidelines practised in Australia

and UK,chest compressions take priority over breathing in a
sequence of ABCD.This is a change in new Australian
Resuscitation Council guidelines.

Even if unsure about signs of life,start immediate CPR as

delay in starting CPR is main determinant of the survival of
suddenly collapsed patient.