Download 2003

2003 FRACP Written Examination
Adult Medicine
Paper 2 – Clinical Applications
Format
Introduction
Paper 1 – Medical Sciences: 70 questions; time allowed: 2 hours
Paper 2 – Clinical Applications: 100 questions; time allowed: 3 hours
All questions are in the A-type multiple-choice format, that is, the single best answer of the five options given.
In the questions, values appearing within [
] refer to normal ranges.
When visual material has been turned on its side, an arrow on the page indicates the orientation of the visual
material.
Questions do not necessarily appear in the order in which they were first printed.
Answers
A table of answers is located at the end of each paper.
Scoring
A correct answer will score one mark and an incorrect answer zero. There is no negative marking in the
FRACP Written Examination.
Queries
Contact the Executive Officer, Examinations Section, Department of Training and Assessment via e-mail:
[email protected].
Please note that with changes in medical knowledge, some of the information may no longer be current.
Copyright © 2004 by The Royal Australasian College of Physicians
All Written Examination papers are copyright. They may not be reproduced in whole or part without written
permission from The Royal Australasian College of Physicians, 145 Macquarie Street, Sydney, Australia.
2
AM203
QUESTION 1
A 65-year-old woman presents with a one-week history of progressive dyspnoea. On admission, there are
signs of shock, a systolic murmur and an elevated jugular venous pressure. The ECG shows sinus
tachycardia but no other abnormality. An antero-posterior chest X-ray shows cardiomegaly. The serum
troponin I level is 0.5 mg/L [<0.1]. A computed tomography (CT) scan is shown below.
What is the most likely diagnosis?
A.
Pulmonary embolism.
B.
Right ventricular infarction.
C.
Pericardial tamponade.
D.
Myocarditis.
E.
Acute mitral regurgitation.
QUESTION 2
A 35-year-old mother with breast cancer reports that her aunt had developed breast cancer at 48 years of
age. She is keen to clarify the risk of her young daughter developing breast cancer. A blood sample from
the mother is submitted for mutation analysis of the BRCA1 and BRCA2 genes, but no mutation is found.
What impact does the mutation analysis have on the estimate of the daughter’s risk of developing breast
cancer?
A.
The maternal studies place the daughter at low risk of developing breast cancer.
B.
The maternal studies do not clarify the daughter’s risk.
C.
The maternal studies place the daughter at high risk of developing breast cancer.
D.
The daughter’s risk cannot be clarified without studies of her father’s BRCA1 and BRCA2 genes.
E.
The daughter’s risk cannot be clarified without studies of her own BRCA1 and BRCA2 genes.
Copyright © 2004 by The Royal Australasian College of Physicians
3
AM203
QUESTION 3
In assessment of cancer patients, the Karnofsky performance scale best correlates with:
A.
treatment dose.
B.
survival.
C.
analgesic requirement.
D.
rehabilitation needs.
E.
cancer volume.
QUESTION 4
An 85-year-old woman who fell in her home one week ago presents for follow-up examination.
At the time of her fall she experienced immediate pain in her buttocks and hips and was brought to the
emergency department, where all X-rays of the hips and pelvis were negative for fracture and she was sent
home.
A week later she continues to complain of severe pain and is unable to weight bear. On examination, she
has tenderness in the buttock area but a good range of motion in the hip joints.
What is the most likely cause of her pain?
A.
Sciatica.
B.
Lumbar stenosis.
C.
Ischial bursitis.
D.
Osteoarthritis of the hip.
E.
Pelvic fracture.
Copyright © 2004 by The Royal Australasian College of Physicians
4
AM203
QUESTION 5
A woman is brought to the emergency department having taken an overdose of an unknown amount of
paracetamol and alcohol. She was last seen at 12 a.m. (before the overdose) and is found at 5 a.m. The
paracetamol concentration is 1100 µmol/L at 6 a.m. (Australian Medicines Handbook (AMH) nomogram
below).
She took an overdose of paracetamol six months previously. At that time, she was given acetylcysteine and
developed generalised urticaria. She is on no other medication and does not drink alcohol regularly.
Paracetamol concentration
(µmol/L)
Treatment line
1400
High-risk treatment line *
1200
1000
800
600
400
200
0
1
1
4
8
12
16
Hours after ingestion
* refers to high-risk patients i.e. those with additional risk factors for toxicity
Which one of the following is the most appropriate treatment plan?
A.
Administration of activated charcoal.
B.
Administration of intravenous acetylcysteine.
C.
Administration of intravenous cimetidine.
D.
Haemoperfusion.
E.
Repeat paracetamol measurement at 8 a.m. and reassess.
QUESTION 6
Which one of the following events is least likely to occur in a person with diet-controlled type 2 (non-insulindependent) diabetes mellitus who is commenced on a thiazolidinedione (e.g. pioglitazone) as a sole agent?
A.
Increased body fat.
B.
Lowering of glycosylated haemoglobin (HbA1c).
C.
Hypoglycaemia.
D.
Increased high-density lipoprotein (HDL) concentration.
E.
Peripheral oedema.
Copyright © 2004 by The Royal Australasian College of Physicians
5
AM203
QUESTION 7
Which one of the following is the most common complication of endoscopic biliary sphincterotomy?
A.
Haemorrhage.
B.
Pancreatitis.
C.
Cholangitis.
D.
Perforation.
E.
Diarrhoea.
QUESTION 8
Which one of the following clinical features best differentiates inclusion body myositis from polymyositis?
A.
Quadriceps wasting.
B.
Deltoid wasting.
C.
Weakness of long finger flexors.
D.
Bilateral ptosis.
E.
Truncal weakness.
QUESTION 9
A 50-year-old man is receiving palliative care for advanced squamous cell carcinoma of the pharynx. He
experiences persistent pain, has become increasingly distressed by his loss of independence and mentions
thoughts of ending his life by suicide.
Which one of the following is likely to be the chief factor contributing to his suicidal ideation?
A.
Major depression.
B.
Unrelieved pain.
C.
Personality disorder.
D.
Normal grief reaction.
E.
Delirium.
Copyright © 2004 by The Royal Australasian College of Physicians
6
AM203
QUESTION 10
A 25-year-old man presents with recent onset of lethargy, fever, bruising and abdominal pain.
On examination, he is clinically anaemic and is noted to have scattered bruises, bilateral pleural effusions,
an abdominal mass and cervical and axillary lymphadenopathy.
Full blood examination shows:
haemoglobin
mean corpuscular volume (MCV)
white cell count
differential:
neutrophils
lymphocytes
monocytes
eosinophils
basophils
platelet count
76 g/L
100 fL
3.2 x 109/L
[128-175]
[80-97]
[3.9-12.7]
1.6 x 109/L
1.1 x 109/L
0.2 x 109/L
0.2 x 109/L
0.1 x 109/L
32 x 109/L
[1.9-8.0]
[0.9-3.3]
[0.3-1.1]
[0-0.5]
[0-0.1]
[150-396]
More than 90% of the nucleated cells in the bone marrow aspirate have the appearance shown below
(examples indicated by arrows).
Coagulation parameters are normal.
The most likely marrow karyotypic abnormality is:
A.
monosomy 7.
B.
t (9;22).
C.
5q minus.
D.
t (8;14).
E.
t (15;17).
Copyright © 2004 by The Royal Australasian College of Physicians
7
AM203
QUESTION 11
A 24-year-old woman presents with a four-week history of fever, weight loss, symmetric polyarthritis and a
non-specific rash on light exposed areas. The symptoms commenced during a backpacking holiday in
South-East Asia during which time she was taking daily doxycycline as malaria prophylaxis. Past history
includes a deep venous thrombosis of her left lower leg at the age of 19.
Serum biochemistry tests are normal. The full blood count shows mild anaemia and thrombocytopenia. The
fluorescent anti-nuclear antibody test (ANA) is positive. Antibodies to DNA are not detected.
The finding of autoantibodies to which one of the following would be most indicative of a diagnosis of
systemic lupus erythematosus?
A.
Phospholipids.
B.
Red blood cells.
C.
Lymphocytes.
D.
Extractable nuclear antigens (ENA).
E.
Platelets.
QUESTION 12
Which one of the following drugs is least effective in the treatment of Legionnaire’s disease?
A.
Rifampicin.
B.
Gentamicin.
C.
Erythromycin.
D.
Ciprofloxacin.
E.
Azithromycin.
QUESTION 13
An unconscious 50-year-old man is brought to the emergency department four hours after an intentional
overdose of approximately fifty 50 mg amitriptyline tablets. He has had a brief convulsion in the ambulance
on the way to hospital. An ECG shows a sinus tachycardia with widened QRS complexes of 0.13 seconds.
Monitoring shows runs (lasting up to five seconds) of a broad complex tachycardia.
He is intubated and transferred to intensive care.
The most important initial management is:
A.
amiodarone therapy.
B.
phenytoin therapy.
C.
bicarbonate therapy.
D.
lignocaine therapy.
E.
haemodialysis.
Copyright © 2004 by The Royal Australasian College of Physicians
8
AM203
QUESTION 14
A 45-year-old woman has intermittent right upper quadrant pain. This pain is associated with ingestion of
certain foods and periods of dehydration.
Her serum biochemistry results are:
creatinine
urea
electrolytes
0.08 mmol/L
4.0 mmol/L
normal
[0.06-0.11]
[4.0-8.0]
Her blood pressure is 130/85 mmHg.
Investigations have included an abdominal computed tomography (CT) scan, one view of which is shown
below.
Which one of the following is the most useful next investigation?
A.
Repeat CT scan in six months.
B.
Aspiration.
C.
Urinary cytology.
D.
Renal biopsy.
E.
Labelled red blood cell scan.
Copyright © 2004 by The Royal Australasian College of Physicians
9
AM203
QUESTION 15
A 19-year-old man, who is sexually active and admits to occasional recreational drug use, presents with a
three-day history of severe pain over the left sacroiliac area. Examination reveals a temperature of 38°C,
pulse rate of 80/minute and blood pressure of 120/80 mmHg. The only other findings are ridged nails and
pain on movement of the spine or when pressure is applied to the sacroiliac joints.
Investigations show:
white cell count
haemoglobin
platelet count
erythrocyte sedimentation rate (ESR)
C-reactive protein
12.5 x 109/L
normal
normal
50 mm/h
170 mg/L
[3.5-11.0]
[<10]
[<10]
X-rays of the spine and pelvis are normal. The bone scan is shown below.
The most likely diagnosis is:
A.
reactive arthritis following Chlamydia trachomatis infection.
B.
psoriatic arthritis.
C.
gonococcal arthritis.
D.
septic sacroiliitis.
E.
undifferentiated spondylarthropathy.
Copyright © 2004 by The Royal Australasian College of Physicians
10
AM203
QUESTION 16
A 66-year-old man presents with progressive exertional dyspnoea.
His anthropometric indices are:
height
weight
body mass index (BMI)
175 cm
98 kg
32 kg/m2
[18-25]
His lung function test results are:
forced expiratory volume in one second (FEV1)
forced vital capacity (FVC)
FEV1/FVC
total lung capacity (TLC)
residual volume (RV)
diffusing capacity for carbon monoxide
corrected for volume (KCO)
1.72 L
2.14 L
80%
4.12 L
1.98 L
(56% predicted)
(54% predicted)
(64% predicted)
(84% predicted)
4.9 mL/min/mmHg/L
(110% predicted)
What is the most likely cause of this man’s dyspnoea and lung function abnormalities?
A.
Obesity.
B.
Pulmonary fibrosis.
C.
Chronic obstructive pulmonary disease.
D.
Cardiac failure.
E.
Bilateral diaphragm paralysis.
QUESTION 17
A 28-year-old woman, who emigrated from Cambodia 10 years ago, presents to the emergency department
with a three-week history of increasing shortness of breath, orthopnoea, nocturnal dyspnoea and ankle
oedema. She is 25 weeks pregnant and has no significant past medical history.
The presence of pulmonary oedema is confirmed clinically and radiologically. She responds well to
intravenous frusemide but remains tachypnoeic with a heart rate of 120/minute in sinus rhythm. Her blood
pressure is 125/85 mmHg.
Echocardiography demonstrates mitral stenosis with an estimated valve area of 1.3 cm2 and a left atrial
diameter of 50 mm [<40 mm]. There are no other abnormalities.
What is the most appropriate next step in management?
A.
Balloon valvotomy.
B.
Surgical valvotomy.
C.
Digoxin therapy.
D.
Beta-blocker therapy.
E.
Angiotensin converting enzyme (ACE) inhibitor therapy.
Copyright © 2004 by The Royal Australasian College of Physicians
11
AM203
QUESTION 18
Hereditary non-polyposis colon cancer (HNPCC or Lynch syndrome) is associated with a number of extracolonic malignancies.
Which one of the following extra-colonic malignancies is most strongly associated with this diagnosis?
A.
Melanoma.
B.
Sarcoma.
C.
Leukaemia.
D.
Endometrial cancer.
E.
Renal cell cancer.
QUESTION 19
Which one of the following would be a relative contraindication to the use of raloxifene (a selective oestrogen
receptor modulator) in a perimenopausal woman?
A.
Severe hot flushes.
B.
Hypertension.
C.
Family history of breast cancer.
D.
Hypercholesterolaemia.
E.
Osteoporosis.
QUESTION 20
A 68-year-old woman with stage III ovarian cancer presents with a progressive cerebellar syndrome. Cranial
magnetic resonance imaging (MRI) demonstrates mild cerebellar atrophy and cerebrospinal fluid (CSF)
examination reveals 10 lymphocytes/high power field, normal protein and glucose concentrations and
negative cytology.
Which one of the following is the most appropriate next investigation?
A.
Anti-Purkinje cell antibodies (anti-Yo).
B.
Repeat cerebrospinal fluid studies.
C.
Electroencephalogram (EEG).
D.
Meningeal biopsy.
E.
Brain positron emission tomography (PET) scan.
Copyright © 2004 by The Royal Australasian College of Physicians
12
AM203
QUESTION 21
A 25-year-old woman complains of tiredness. She has no significant past medical history and denies any
medications. Apart from being thin, there are no abnormal findings on examination. Her blood pressure is
105/70 mmHg.
Results of investigations are listed below.
Serum biochemistry:
sodium
potassium
chloride
creatinine
138 mmol/L
2.3 mmol/L
85 mmol/L
0.10 mmol/L
[135-145]
[3.4-5.0]
[103-109]
[0.06-0.12]
7.50
95 mmHg
42 mmHg
39 mmol/L
[7.34-7.45]
[80-100]
[35-45]
[22-28]
Arterial blood gases:
pH
PaO2
PaCO2
bicarbonate
Urinary biochemistry:
sodium
potassium
chloride
30 mmol/L
42 mmol/L
13 mmol/L
The most likely explanation for these results is:
A.
occult diuretic use.
B.
occult laxative use.
C.
self-induced vomiting.
D.
primary hyperaldosteronism.
E.
Bartter’s syndrome.
QUESTION 22
A 43-year-old woman presents with intermittent exertional dyspnoea and nocturnal cough suggestive of
asthma. She is a lifelong non-smoker.
Which one of the following results is most specific for the diagnosis of asthma?
A.
Methacholine PC20 (provoking concentration producing a 20% fall in forced expiratory volume in 1
second (FEV1)) <16mg/mL.
B.
Fall in FEV1 of 15% with hypertonic saline challenge.
C.
FEV1/forced vital capacity (FVC) <80%.
D.
Increase in FEV1 of 10% after bronchodilator administration.
E.
Peripheral blood eosinophilia.
Copyright © 2004 by The Royal Australasian College of Physicians
13
AM203
QUESTION 23
A 42-year-old Asian man has chronic hepatitis B diagnosed four years previously. He presents with the
blood test results below. His alanine transaminase (ALT) levels have previously been normal and he has
been consistently hepatitis B surface antigen (HBsAg) positive and hepatitis B e antigen (HBeAg) negative.
He has not been taking any prescription or over-the-counter medications. He has not travelled
internationally for six years.
His current blood test results are as follows:
bilirubin
alanine transaminase (ALT)
aspartate transaminase (AST)
alkaline phosphatase (ALP)
gamma glutamyltranspeptidase (GGT)
albumin
HBsAg
HBeAg
hepatitis B virus (HBV) DNA
hepatitis C virus (HCV) antibody
ferritin
15 µmol/L
346 U/L
154 U/L
76 U/L
101 U/L
40 g/L
positive
negative
3.5 pg/mL
negative
450 µg/L
[3-21]
[5-40]
[5-40]
[30-115]
[<65]
[38-50]
[<0.5]
[25-200]
The most likely explanation for the current blood test results is:
A.
hepatitis D superinfection.
B.
pre-core mutant disease.
C.
hepatitis C co-infection.
D.
hepatitis E co-infection.
E.
haemochromatosis.
QUESTION 24
A 79-year-old man in a rehabilitation hospital is undergoing reconditioning therapy following surgical repair of
an abdominal aortic aneurysm one month previously. He develops chest pain and clear electrocardiographic
evidence of an acute anterior myocardial infarction. He has a past history of myocardial infarction with a left
ventricular ejection fraction (LVEF) of 40%. There is also a past history of peptic ulcer disease 10 years ago;
this has been successfully treated and there has been no recurrence of symptoms. His medications include
aspirin 325 mg/day, enalapril 10 mg/day and metoprolol 25 mg/day.
Which one of the following factors in this man's medical history is the strongest contraindication to
thrombolytic therapy for his acute myocardial infarction?
A.
Age.
B.
Aspirin therapy.
C.
Peptic ulcer disease.
D.
Previous myocardial infarction with reduced LVEF.
E.
Recent surgery.
Copyright © 2004 by The Royal Australasian College of Physicians
14
AM203
QUESTION 25
A 65-year-old woman presents with progressive lethargy and thoraco-lumbar pain.
Full blood examination shows:
haemoglobin
mean corpuscular volume (MCV)
white cell count
differential:
neutrophils
lymphocytes
monocytes
eosinophils
basophils
platelet count
102 g/L
102 fL
3.4 x 109/L
[113-159]
[80-97]
[3.9-12.7]
1.6 x 109/L
1.0 x 109/L
0.5 x 109/L
0.2 x 109/L
0.1 x 109/L
92 x 109/L
[1.9-8.0]
[0.9-3.3]
[0.3-1.1]
[0-0.5]
[0-0.1]
[150-396]
A chest X-ray shows diffuse osteopenia but is otherwise normal.
55% of nucleated cells in the bone marrow aspirate have the appearance shown below (examples indicated
by arrows).
The most likely diagnosis is:
A.
Burkitt’s lymphoma.
B.
amyloidosis.
C.
multiple myeloma.
D.
Waldenström’s macroglobulinaemia.
E.
metastatic carcinoma.
Copyright © 2004 by The Royal Australasian College of Physicians
15
AM203
QUESTION 26
A 38-year-old woman presents with a six-week history of increasing shortness of breath while playing tennis
and a two-week history of increasing muscle weakness. She reports mild symmetrical polyarthralgia of the
hands, wrists and knees for six months and Raynaud’s phenomenon during the recent winter. Examination
reveals proximal muscle weakness and a hyperkeratotic rash with fissuring on the palmar and lateral
surfaces of the fingers on both hands. Investigations reveal a serum creatine kinase (CK) level of 890 U/L
[16-139] and an interstitial pulmonary infiltrate on high resolution computed tomography (CT) scan of the
chest.
Autoantibody tests show the following results:
anti-nuclear antibody (ANA) test
anti-ENA (extractable nuclear antigens) antibodies
anti-DNA antibodies
titre 1:2560, speckled pattern
Jo-1 positive
negative
The most likely diagnosis is:
A.
dermatomyositis.
B.
progressive systemic sclerosis.
C.
polymyositis (anti-synthetase syndrome).
D.
systemic lupus erythematosus.
E.
Sjögren’s syndrome.
QUESTION 27
A 25-year-old man presents six weeks after a trip to central Africa with fever, chills and rigors. Stool
examination is positive for Entamoeba histolytica. An ultrasound reveals a 7.5 cm liver abscess.
The most appropriate next step in this patient’s management is:
A.
diagnostic aspirate of the liver abscess.
B.
percutaneous drainage of the liver abscess.
C.
metronidazole therapy.
D.
praziquantel therapy.
E.
quinine therapy.
QUESTION 28
Among the following anti-cancer agents, the one most likely to cause acute respiratory distress is:
A.
bleomycin.
B.
all-trans-retinoic acid.
C.
busulphan.
D.
gemcitabine.
E.
cyclophosphamide.
Copyright © 2004 by The Royal Australasian College of Physicians
16
AM203
QUESTION 29
A 55-year-old woman, diagnosed with hypertension at age 46, presents with increasing difficulty with blood
pressure control. She has no significant history of renal disease or childhood urinary tract infections. Her
two pregnancies were not complicated by increased blood pressure or proteinuria.
In the last 12 months, her anti-hypertensive regimen has included calcium channel blockade with nifedipine,
angiotensin II receptor blockade with irbesartan, diuretic treatment with a thiazide and peripheral
vasodilatation with prazosin.
Which one of the following is the most likely result of correction of the abnormality identified in the renal
angiogram shown above?
A.
Weight gain.
B.
No need for any anti-hypertensive medications.
C.
Further invasive procedures are unlikely to be required.
D.
Reduced risk of nephronal loss.
E.
Reduced risk of postural hypotension.
Copyright © 2004 by The Royal Australasian College of Physicians
17
AM203
QUESTION 30
A 20-year-old man presents following a generalised tonic-clonic seizure precipitated by alcohol excess and
sleep deprivation. He has an eight-year history of episodes of a brief loss of time without other symptoms.
Observers report that these episodes last 10 to 15 seconds during which he stares blankly and is
unresponsive to command. His left hand may stiffen and he may fiddle with his buttons using his right hand.
He will then look surprised and resume his conversation.
Cranial magnetic resonance imaging (MRI) (T1 weighted) is shown below.
The most likely diagnosis is:
A.
mesial temporal sclerosis.
B.
generalised epilepsy with absences.
C.
hippocampal tumour.
D.
callosal agenesis.
E.
temporal lobe neuronal migration abnormality.
Copyright © 2004 by The Royal Australasian College of Physicians
18
AM203
QUESTION 31
A 70-year-old man presents to the emergency department with prolonged chest pain which is relieved by
morphine and sublingual nitrates. He has a three-week history of frequent exertional and nocturnal chest
pain.
Three years ago he suffered an uncomplicated inferior myocardial infarction. Coronary angiography at that
time revealed a 30% proximal left anterior descending artery stenosis, a long 90% right coronary artery
stenosis and a 70% stenosis of the proximal circumflex artery. As he was asymptomatic at that time, he was
treated with aspirin, a beta-blocker and a hydroxy-methylglutaryl-coenzyme A (HMG CoA) reductase
inhibitor. He was also treated with an angiotensin converting enzyme (ACE) inhibitor for mild hypertension.
His current ECG shows Q waves in the inferior leads and 1 mm ST segment depression in leads V4-V6. A
chest X-ray shows pulmonary venous congestion.
Emergency staff have initiated heparin therapy and have continued his usual medications. On review two
hours later, he is asymptomatic, the ST changes have resolved and his serum troponin I level is 2.5 mg/L
[<0.1].
Which one of the following management strategies would be most appropriate for this patient?
Anti-Platelet
Therapy
Stress Test
Angiography and Revascularisation Strategy
A.
Clopidogrel
Yes
Only for recurrent pain or a positive stress test
B.
Clopidogrel
Not indicated
Angiography and proceed to coronary artery bypass graft
C.
Tirofiban
Not indicated
Proceed to coronary bypass surgery
D.
Tirofiban
Yes
E.
Tirofiban
Not indicated
Only for recurrent pain or a positive stress test
Angiography and proceed to coronary artery bypass graft
QUESTION 32
In a particular population, the risk of a healthy 70-year-old person developing dementia over the next five
years is 5%. 10% of the total population carry one or two ApoE4 alleles and have a threefold increased risk
of developing dementia during this interval.
What is the best estimate of the proportion of people developing dementia during this interval who do not
have one or two ApoE4 alleles?
A.
10%.
B.
30%.
C.
70%.
D.
90%.
E.
95%.
Copyright © 2004 by The Royal Australasian College of Physicians
19
AM203
QUESTION 33
The main effect of verapamil in altering the pharmacokinetics of digoxin is mediated by:
A.
decreasing renal blood flow.
B.
decreasing gastric emptying.
C.
decreasing hepatic blood flow.
D.
inhibiting cytochrome P450 enzymes.
E.
inhibiting P-glycoprotein.
QUESTION 34
A 30-year-old woman with longstanding type 1 (insulin-dependent) diabetes mellitus presents with severe
hypoglycaemia. She is known to have autonomic neuropathy resulting in gastroparesis. She is on a glutenfree diet for coeliac disease and thyroxine for hypothyroidism. Clinical examination is unremarkable apart
from the presence of lipohypertrophy.
Which one of the following features of her history or examination most significantly increases the risk of a
further severe hypoglycaemic episode in the next 24 hours?
A.
Thyroxine therapy.
B.
Gastroparesis.
C.
Lipohypertrophy.
D.
Coeliac disease.
E.
The current hypoglycaemic episode.
QUESTION 35
A 67-year-old man presents with a six-month history of increasing bilateral leg pain, exacerbated by walking
more than 100-150 m and often forcing him to stop and sit to relieve the pain. He has a long history of
hypertension and hyperlipidaemia and he suffered a myocardial infarction six months previously.
Examination reveals bruits over both carotids and the femoral arteries but all pedal pulses are readily
palpable. Ankle reflexes are absent. Proprioception is absent at the toes but sensation is otherwise intact.
Which one of the following investigations is most likely to establish the cause of this man’s leg pain?
A.
Arterial Doppler studies of the lower limbs.
B.
Nerve conduction studies of the lower limbs.
C.
Lower limb arteriography.
D.
A bone scan with SPECT (single photon emission computed tomography) of the lumbosacral spine.
E.
A computed tomography (CT) scan of the lumbar spine.
Copyright © 2004 by The Royal Australasian College of Physicians
20
AM203
QUESTION 36
A 24-year-old man develops acute severe tonsillitis with high fever (39.8oC). He is treated with erythromycin.
The next day he is noticed to be icteric. Abdominal examination is unremarkable.
Blood investigations show:
white cell count
normal differential
haemoglobin
platelet count
18.5 x109/L
[4.0-11.0]
145 g/L
395 x109/L
[120-160]
[150-400]
sodium
potassium
urea
creatinine
140 mmol/L
4.5 mmol/L
8.5 mmol/L
0.09 mmol/L
[135-150]
[3.5-5.0]
[3.6-9.3]
[0.06-0.12]
bilirubin
alkaline phosphatase (ALP)
gamma glutamyltranspeptidase (GGT)
aspartate transaminase (AST)
alanine transaminase (ALT)
albumin
78 µmol/L
46 U/L
55 U/L
35 U/L
32 U/L
40 g/L
[3-23]
[30-115]
[<65]
[5-40]
[5-40]
[40-52]
The most likely explanation for his jaundice is:
A.
haemolysis.
B.
Epstein-Barr virus.
C.
Gilbert’s syndrome.
D.
Wilson’s disease.
E.
erythromycin.
QUESTION 37
A hospitalised patient is seen with a stage III pressure ulcer (full thickness skin loss and necrosis of
subcutaneous tissue extending down to, but not through, underlying fascia) on the sacrum that measures 10
x 10 cm. There is extensive eschar adhering to the centre and to one side of the wound and a large amount
of purulent drainage is expressible from under the eschar. There is no surrounding skin erythema. The
patient is afebrile.
Which one of the following approaches would best control local infection?
A.
Debridement with saline irrigation and dry gauze dressing.
B.
Intravenous antibiotic therapy.
C.
Topical antibiotic therapy.
D.
Topical antiseptics.
E.
Occlusive calcium alginate dressing.
Copyright © 2004 by The Royal Australasian College of Physicians
21
AM203
QUESTION 38
Within two hours of vigorous exercise, a 20-year-old man presents with sudden onset of severe left lateral
lower chest pain, dyspnoea and anxiety.
Physical examination shows him to be febrile and anaemic and there is local tenderness over the left lateral
lower ribs.
Full blood examination shows:
haemoglobin
mean corpuscular volume (MCV)
white cell count
differential:
neutrophils
lymphocytes
monocytes
eosinophils
basophils
platelet count
reticulocyte count
75 g/L
81 fL
13.6 x 109/L
[128-175]
[80-97]
[3.9-12.7]
11.2 x 109/L
0.9 x 109/L
1.0 x 109/L
0.4 x 109/L
0.1 x 109/L
180 x 109/L
200 x 109/L
[1.9-8.0]
[0.9-3.3]
[0.3-1.1]
[0-0.5]
[0-0.1]
[150-396]
[9-116]
The blood film is shown below.
The most likely diagnosis is:
A.
thrombotic thrombocytopenic purpura.
B.
sickle crisis.
C.
Plasmodium falciparum malaria.
D.
autoimmune haemolysis.
E.
glucose-6-phosphate dehydrogenase deficiency.
Copyright © 2004 by The Royal Australasian College of Physicians
22
AM203
QUESTION 39
A 60-year-old man complains of recurrent episodes of watery diarrhoea four years after excision of an
abdominal tumour. Somatostatin receptor scintigraphy is performed and is shown below.
Which one of the following would be most effective in managing his symptoms?
A.
Interferon.
B.
Octreotide.
C.
Loperamide.
D.
Streptozotocin.
E.
Cholestyramine.
Copyright © 2004 by The Royal Australasian College of Physicians
23
AM203
QUESTION 40
A 35-year-old man who is receiving erythropoietin (EPO) therapy for anaemia associated with end stage
renal disease presents with lethargy. There is no obvious source of bleeding.
Blood investigations show:
haemoglobin
mean corpuscular volume (MCV)
reticulocyte count
65 g/L
109 fL
15 x 109/L
[110-160]
[83-97]
[50-100]
The most likely cause of his anaemia is:
A.
red cell aplasia.
B.
reduced iron stores.
C.
non-neutralising anti-EPO antibodies.
D.
aluminium toxicity.
E.
myelodysplasia.
QUESTION 41
A 40-year-old man presents with a six-month history of Raynaud’s phenomenon and recurrent leg ulcers.
Examination shows multiple small, palpable, purpuric skin lesions on both lower legs. Serum electrophoresis
and immunoelectrophoresis shows an immunoglobulin M (IgM) paraprotein of 2 g/L and moderate
cryoglobulins with a cryocrit of 10%.
The most appropriate next investigation is:
A.
anti-nuclear antibodies (ANA).
B.
hepatitis C serology.
C.
bone marrow biopsy.
D.
skin biopsy.
E.
rheumatoid factor.
QUESTION 42
An 82-year-old man is admitted with pneumonia and fever. Which one of the following is most suggestive of
the diagnosis of delirium?
A.
Inability to stay focused on questions being asked.
B.
Worsening behaviour at night.
C.
Angry outbursts and claims that the staff are trying to harm him.
D.
Mini-Mental Status Examination score of 18/30.
E.
Depressed affect.
Copyright © 2004 by The Royal Australasian College of Physicians
24
AM203
QUESTION 43
A 42-year-old man presents with a two-year history of increasing right facial numbness. He has a history of
intermittent unsteadiness, mild hearing loss and vertigo but has otherwise been well. Cranial magnetic
resonance imaging (MRI) (T1 weighted following gadolinium contrast) is shown below.
The most likely diagnosis is:
A.
multiple sclerosis.
B.
neurofibromatosis type 2.
C.
cerebellar haemangioblastoma.
D.
meningioma.
E.
pontine glioma.
QUESTION 44
A 56-year-old man with alcoholic cirrhosis has a long history of alcohol dependence. He is brought to
hospital after being disruptive at his home, where he lives alone. He has been accusing his neighbours of
“spying” on him. He is found to have been experiencing persistent auditory hallucinations for two months.
He has no previous history of these symptoms. He has continued his intake of over 300 g of alcohol/day.
The most likely cause of these hallucinations is:
A.
delirium tremens.
B.
alcohol-related hallucinosis.
C.
hepatic encephalopathy.
D.
Wernicke-Korsakoff syndrome.
E.
schizophrenia.
Copyright © 2004 by The Royal Australasian College of Physicians
25
AM203
QUESTION 45
A 63-year-old man is seen in follow-up after admission to hospital with an acute exacerbation of chronic
obstructive pulmonary disease (COPD). He has marked dyspnoea on exertion but remains independent in
activities of daily living. He gave up smoking 10 years ago and currently takes salbutamol and ipratropium
bromide via metered dose inhalers as needed.
Spirometry:
forced expiratory volume in one second (FEV1)
forced vital capacity (FVC)
0.7 L
2.9 L
(27% predicted)
(82% predicted)
In this man, which one of the following is the most likely benefit of treatment with inhaled corticosteroids?
A.
Improved survival.
B.
Decreased need for bronchodilator therapy.
C.
Slower decline in lung function.
D.
Reduced number of exacerbations.
E.
Improved exercise tolerance.
QUESTION 46
A 45-year-old asymptomatic man returns for follow-up. He was diagnosed 10 years ago with aortic
regurgitation due to a congenital bicuspid aortic valve. He has never had endocarditis.
Which one of the following echocardiographic profiles most strongly indicates the need for aortic valve
replacement?
LVEDD (mm)
[35-55]
FS
[0.30-0.40]
LA size (mm)
[<40]
A.
70
0.30
60
B.
75
0.40
40
C.
70
0.25
45
D.
65
0.45
50
E.
75
0.35
55
LVEDD
LVESD
FS
LA
Left ventricular end-diastolic diameter
Left ventricular end-systolic diameter
Fractional shortening = (LVEDD - LVESD) / LVEDD
Left atrial
Copyright © 2004 by The Royal Australasian College of Physicians
26
AM203
QUESTION 47
The carrier frequency for cystic fibrosis in the Caucasian population in Australia is approximately 4%. The
∆F508 mutation accounts for 75% of all mutations among carriers in this population.
A girl is diagnosed with cystic fibrosis. DNA studies identify one ∆F508 mutation but fail to identify a
mutation in the other allele. DNA studies of her unaffected brother are normal.
What is the risk of the brother being a carrier?
A.
<1%.
B.
4%.
C.
25%.
D.
50%.
E.
66%.
QUESTION 48
Addition of which one of the following drugs is most likely to increase the urinary excretion of lithium?
A.
Sodium bicarbonate.
B.
Amiloride.
C.
Frusemide.
D.
Chlorothiazide.
E.
Mannitol.
QUESTION 49
A previously well 53-year-old man is found to have a 3 cm right adrenal mass when undergoing a computed
tomography (CT) scan for suspected hepatobiliary disease. Physical examination is normal, apart from a
blood pressure of 150/90 mmHg.
The following laboratory test results are obtained:
serum sodium
serum potassium
serum creatinine
urinary catecholamines
urinary free cortisol
plasma adrenocorticotrophic hormone
plasma renin activity
140 mmol/L
3.8 mmol/L
0.10 mmol/L
0.3 µmol/24 h
380 nmol/24 h
<1 pmol/L
1.5 nmol/L/h
Which one of the following is the most likely cause of the adrenal mass?
A.
Adrenal carcinoma.
B.
Adrenal metastasis.
C.
Aldosterone-producing adenoma.
D.
Cortisol-producing adenoma.
E.
Non-functioning adrenal adenoma.
Copyright © 2004 by The Royal Australasian College of Physicians
[133-144]
[3.5-5.0]
[0.05-0.11]
[<0.6]
[100-400]
[1-15]
[0.4-2.3]
27
AM203
QUESTION 50
A 50-year-old man with alcohol-induced cirrhosis and portal hypertension presents with haematemesis. He
is found to have grade IV oesophageal varices. Bleeding is controlled by an infusion of octreotide and
endoscopic band ligation.
On discharge, which one of the following is least likely to be of benefit with respect to recurrent variceal
bleeding?
A.
Interval endoscopic band ligation.
B.
Interval endoscopic sclerotherapy.
C.
Oral beta-blocker therapy.
D.
Oral nitrate therapy.
E.
Oral proton pump inhibitor therapy.
QUESTION 51
A nursing home dietitian notifies you that an 85-year-old patient is gradually losing weight involuntarily. One
year ago she weighed 59 kg, six months ago 55 kg and this month 51 kg, a loss of approximately 7% over
six months and approximately 14% over one year. Current medical problems include osteoarthritis,
Parkinson's disease, probable Alzheimer's disease, congestive heart failure and chronic constipation. Her
medications include digoxin 0.25 mg/day, levodopa/carbidopa 250/25 mg four times/day and ibuprofen 400
mg four times/day.
What is the least likely cause of her weight loss?
A.
Gastrointestinal malignancy.
B.
Poorly fitting dentures.
C.
Anorexia due to medications.
D.
Depression.
E.
Inadequate feeding assistance.
QUESTION 52
A 47-year-old man with severe haemophilia A and a high titre factor VIII inhibitor is scheduled for hip
replacement surgery. The peri-operative replacement coagulation product of choice is:
A.
recombinant activated factor VII.
B.
recombinant factor VIII.
C.
recombinant factor IX.
D.
fresh frozen plasma.
E.
cryoprecipitate.
Copyright © 2004 by The Royal Australasian College of Physicians
28
AM203
QUESTION 53
A diagnosis of B cell lymphoma can often be confirmed by performing analysis of cell surface proteins by
flow cytometry. The expression of which one of the following surface proteins by the entire population of
lymphocytes in a suspension provides the best evidence for the presence of B cell lymphoma?
A.
CD19.
B.
CD20.
C.
CD22.
D.
Kappa light chain.
E.
Immunoglobulin M (IgM).
QUESTION 54
A 54-year-old man with methicillin-resistant Staphylococcus aureus (MRSA) sternal osteomyelitis is receiving
ongoing treatment with vancomycin. Shortly after administration of his vancomycin dose, he develops
diffuse erythema and hypotension.
The most likely cause is:
A.
hypersensitivity to vancomycin.
B.
rapid intravenous infusion of vancomycin.
C.
endotoxin release.
D.
impurities in the infused vancomycin preparation.
E.
bacterial contamination of the vancomycin preparation.
Copyright © 2004 by The Royal Australasian College of Physicians
29
AM203
QUESTION 55
The cytotoxic agent most commonly associated with the skin abnormality shown above is:
A.
doxorubicin.
B.
methotrexate.
C.
gemcitabine.
D.
capecitabine.
E.
irinotecan.
QUESTION 56
Tacrolimus administration after renal transplantation is least likely to cause which one of the following?
A.
Diabetes mellitus.
B.
Hypercholesterolaemia.
C.
Hypomagnesaemia.
D.
Seizures.
E.
Tremors.
Copyright © 2004 by The Royal Australasian College of Physicians
30
AM203
QUESTION 57
A 67-year-old woman presents with a two-week history of blurred vision and a constant bifrontotemporal
headache. Visual acuity is 6/9 bilaterally. Visual fields to confrontation reveal an arcuate scotoma defect in
both eyes. Colour vision is normal. The remainder of the neurological examination and the general
examination are normal.
Fundoscopy of the right eye is shown below.
The most likely diagnosis is:
A.
central retinal vein occlusion.
B.
anterior ischaemic optic neuropathy.
C.
papilloedema.
D.
venous stasis retinopathy.
E.
diabetic retinopathy.
QUESTION 58
Which one of the following drugs is most likely to cause a severe hypertensive reaction when used by a
patient taking a non-selective monoamine oxidase inhibitor?
A.
Adrenaline.
B.
Moclobemide.
C.
Orlistat (Xenical).
D.
Phenylephrine.
E.
Pethidine.
Copyright © 2004 by The Royal Australasian College of Physicians
31
AM203
QUESTION 59
A 67-year-old man with chronic obstructive pulmonary disease (COPD) has severe exertional dyspnoea and
is receiving maximal inhaled bronchodilator therapy. He no longer smokes.
Lung function tests are as follows:
forced expiratory volume in one second (FEV1)
forced vital capacity (FVC)
FEV1/FVC
total lung capacity (TLC)
residual volume (RV)
diffusing capacity for carbon monoxide (DLCO)
0.54 L
2.87 L
19%
7.96 L
5.09 L
6.1 mL/min/mmHg
(18% predicted)
(75% predicted)
(121% predicted)
(245% predicted)
(19% predicted)
Arterial blood gases on room air are as follows:
PaO2
PaCO2
pH
65 mmHg
52 mmHg
7.36
What is the most appropriate management to reduce this man’s exertional dyspnoea?
A.
Inhaled corticosteroids.
B.
Pulmonary rehabilitation program.
C.
Lung volume reduction surgery.
D.
Supplemental oxygen.
E.
Lung transplantation.
QUESTION 60
The major cause of death in patients more than six months following cardiac transplantation is:
A.
graft-versus-host reaction.
B.
opportunistic infection.
C.
rejection.
D.
malignancy.
E.
coronary artery disease.
Copyright © 2004 by The Royal Australasian College of Physicians
32
AM203
QUESTION 61
Approximately 10% of the Caucasian population have a mutation in the haemochromatosis gene (HFE).
Three men in a family (shown below) have been diagnosed with haemochromatosis.
What is the risk that the woman (indicated by the arrow in the pedigree below) has inherited the genetic
predisposition to develop this disorder?
Unaffected male
Unaffected female
Affected male
Affected female
A.
<1%.
B.
5%.
C.
10%.
D.
25%.
E.
50%.
QUESTION 62
A 65-year-old man, on treatment with allopurinol 300 mg daily for the control of hyperuricaemia and gout,
develops giant cell arteritis which is treated with prednis(ol)one. Reduction of the daily steroid dose below
25 mg results in recurrence of headache and scalp tenderness. He is commenced on azathioprine 50 mg
three times daily in an attempt to reduce his prednis(ol)one dose.
Which one of the following is the most likely consequence of this treatment?
A.
Exacerbation of gout.
B.
Azathioprine-related bone marrow depression.
C.
Allopurinol-related Stevens-Johnson syndrome.
D.
Azathioprine-related hepatotoxicity.
E.
Long-term requirement for prednis(ol)one >20 mg daily.
Copyright © 2004 by The Royal Australasian College of Physicians
33
AM203
QUESTION 63
Which one of the following medications is most likely to result in an increase in circulating insulin
concentrations?
A.
Metformin.
B.
Acarbose.
C.
Rosiglitazone.
D.
Repaglinide.
E.
Orlistat (Xenical).
QUESTION 64
A 75-year-old woman presents with a three-week history of episodic severe epigastric pain and vomiting.
The pain lasts for about three hours and radiates to the right upper quadrant and back. Apart from episodic
nausea, she is well between attacks of pain. Past medical history includes a cholecystectomy nine years
ago, peptic ulcer disease secondary to non-steroidal anti-inflammatory drugs three years ago and type 2
(non-insulin-dependent) diabetes mellitus diagnosed four years ago.
The most likely diagnosis is:
A.
choledocholithiasis.
B.
biliary dyskinesia.
C.
perforated peptic ulcer.
D.
reflux oesophagitis.
E.
pancreatitis.
Copyright © 2004 by The Royal Australasian College of Physicians
34
AM203
QUESTION 65
A 36-year-old man presents in a post-ictal state after an observed generalised seizure.
Full blood investigation shows:
haemoglobin
mean corpuscular volume (MCV)
white cell count
differential:
neutrophils
lymphocytes
monocytes
eosinophils
basophils
platelet count
90 g/L
106 fL
12.6 x 109/L
[128-175]
[80-97]
[3.9-12.7]
10.4 x 109/L
0.8 x 109/L
1.1 x 109/L
0.2 x 109/L
0.1 x 109/L
135 x 109/L
[1.9-8.0]
[0.9-3.3]
[0.3-1.1]
[0-0.5]
[0-0.1]
[150-396]
The blood film is shown below.
The most likely cause of the peripheral blood macrocytosis is:
A.
β-thalassaemia trait.
B.
myelodysplasia.
C.
alcoholic liver disease.
D.
hereditary spherocytosis.
E.
myelofibrosis.
Copyright © 2004 by The Royal Australasian College of Physicians
35
AM203
QUESTION 66
A 37-year-old man with known human immunodeficiency virus (HIV) infection for 10 years presents with
severe renal colic for which he has no prior history. Tests performed two weeks before have shown a normal
full blood count and biochemistry screen (including serum calcium), CD4 positive (CD4+) T cell count of 36
cells/mm3, and HIV RNA concentration (viral load) of 83,000 copies/mL. His medications include zidovudine
(AZT), lamivudine (3TC), indinavir, azithromycin and dapsone.
The most likely cause of his renal colic is:
A.
HIV-associated opportunistic infection.
B.
HIV-associated malignancy.
C.
HIV-associated hypercalciuria.
D.
adverse drug reaction.
E.
unrelated to HIV infection or therapy.
QUESTION 67
A 26-year-old male dairy farmer presents with a five-day history of malaise, myalgia, headache and fever.
His temperature is 39.3°C. He has mild neck stiffness.
Blood investigations show:
white cell count
differential:
neutrophils
lymphocytes
alkaline phosphatase (ALP)
alanine transaminase (ALT)
11.3 x 109/L
[3.5-10.5]
8.7 x 109/L
2.6 x 109/L
177 U/L
94 U/L
[2.0-7.5]
[0.9-4.3]
[31-110]
[6-45]
40 x 106/L
[<5]
28 x 106/L
12 x 106/L
[<2]
[<2]
Cerebrospinal fluid (CSF) analysis:
white cell count
differential:
neutrophils
lymphocytes
Urinalysis shows 1+ proteinuria.
He is given a single dose of ceftriaxone after the lumbar puncture. 24 hours later, he is feeling much better
and CSF culture is negative.
Therapy with which one of the following is now most appropriate?
A.
Ceftriaxone.
B.
Metronidazole.
C.
Benzylpenicillin.
D.
Doxycycline.
E.
Ciprofloxacin.
Copyright © 2004 by The Royal Australasian College of Physicians
36
AM203
QUESTION 68
Which one of the following confers the greatest risk for the development of fungal infection in a patient
undergoing chemotherapy?
A.
Prolonged granulocytopenia.
B.
Use of steroids.
C.
Long-term antibiotics.
D.
Central venous lines.
E.
Use of monoclonal antibodies.
QUESTION 69
A 53-year-old man undergoes an abdominal computed tomography (CT) scan (shown below) as part of an
evaluation for right upper quadrant pain. He is otherwise well with no significant past history.
There is a family history of stroke at a relatively young age (in the sixth decade).
Which one of the following is least likely to develop?
A.
Aortic dissection.
B.
Hepatic cysts.
C.
Periportal fibrosis.
D.
Polyuria.
E.
Renal failure.
Copyright © 2004 by The Royal Australasian College of Physicians
37
AM203
QUESTION 70
A 45-year-old woman presents with a two-month history of intermittent left visual blurring. The symptoms are
most prominent when playing squash, running on the beach or after a hot shower. At other times, her vision
is normal and there are no other neurological symptoms. She smokes 40 cigarettes/day and consumes on
average three standard drinks/day. Visual acuity is normal with full visual fields to confrontation. Pupillary
reflexes and fundoscopy are normal, as is the remainder of the neurological examination. General
examination is also normal. Cranial magnetic resonance imaging (MRI) is normal.
The most appropriate next investigation is:
A.
serum cryoglobulin level.
B.
orbital ultrasonography.
C.
fluorescein angiography.
D.
cranial magnetic resonance angiography.
E.
visual evoked potentials.
QUESTION 71
A 48-year-old woman with advanced metastatic breast cancer is receiving palliative care. She is receiving
morphine sulphate 120 mg/day, midazolam 20 mg/day and two weeks ago commenced dexamethasone 4
mg/day for the treatment of pain related to bone metastases. She has become increasingly agitated over a
two-day period, is disruptive at night and has begun to experience visual and auditory hallucinations. She
has become forgetful, uncooperative with staff and is refusing her treatments.
The most likely diagnosis is:
A.
cerebral metastases.
B.
delirium.
C.
steroid-induced psychosis.
D.
major depression.
E.
acute schizophrenia.
QUESTION 72
Which one of the following is the most common side-effect of the anti-dementia drug donepezil?
A.
Diarrhoea.
B.
Rash.
C.
Urinary frequency.
D.
Sedation.
E.
Angio-oedema.
Copyright © 2004 by The Royal Australasian College of Physicians
38
AM203
QUESTION 73
A man is admitted to hospital with a diagnosis of medullary thyroid carcinoma. He has a family history of
multiple endocrine neoplasia (MEN) type 2 and an inherited mutation in the RET proto-oncogene has been
identified.
A thyroidectomy is performed. Samples of normal and malignant tissue are compared for alterations in the
RET gene.
Which one of the following best describes the most likely genetic findings?
A.
Deletion of the mutant RET allele in malignant tissue.
B.
Deletion of the normal RET allele in malignant tissue.
C.
No difference between normal and malignant tissue.
D.
Amplification of the mutant RET allele in malignant tissue.
E.
Amplification of the normal RET allele in malignant tissue.
QUESTION 74
Which one of the following best summarises the effect of naltrexone in the management of opiate-dependent
individuals?
Naltrexone:
A.
prevents the euphoric effect of opiates.
B.
blocks withdrawal symptoms.
C.
produces unpleasant adverse effects when opiates are taken.
D.
reduces opiate craving.
E.
increases opiate tolerance.
QUESTION 75
A 45-year-old human immunodeficiency virus (HIV)-positive man presents with a two-month history of
numbness in both feet. Examination reveals bilateral loss of light touch to mid-calf, reduced vibration sense
at the ankle and absent ankle jerks. His CD4 positive (CD4+) T cell count is 250 cells/µL and HIV viral load
is 5000 copies/mL. His current anti-retroviral (ARV) drug therapy is stavudine (D4T), lamivudine (3TC) and
nevirapine.
The most likely diagnosis is:
A.
Guillain-Barré syndrome.
B.
HIV-induced neuropathy.
C.
cytomegalovirus (CMV) neuropathy.
D.
ARV-induced neuropathy.
E.
vitamin B12 deficiency.
Copyright © 2004 by The Royal Australasian College of Physicians
39
AM203
QUESTION 76
A 75-year-old woman with longstanding rheumatoid arthritis complains of neck pain. X-rays of her cervical
spine demonstrate the changes shown below.
Extension
View
Flexion
View
Which one of the following is most likely to accompany these changes?
A.
Sensory loss in the C2 dermatome.
B.
Horner’s syndrome.
C.
Wasting of the small muscles of the hands.
D.
Lower motor neurone changes in the upper limbs.
E.
Upper motor neurone changes in the lower limbs.
Copyright © 2004 by The Royal Australasian College of Physicians
40
AM203
QUESTION 77
A 50-year-old woman develops a dry cough and chest pain two days after a left total hip joint replacement.
She has swelling of the left leg and a few basal crepitations. A chest X-ray shows bibasal collapse. Doppler
ultrasonography of her legs does not demonstrate a clot.
The next most appropriate investigation is:
A.
D-dimer assay.
B.
ventilation-perfusion [V/Q] scanning.
C.
pulmonary angiography.
D.
computed tomographic (CT) pulmonary angiography.
E.
venography.
QUESTION 78
The severity of pulmonary hypertension can be determined using continuous wave Doppler measurements
of the velocity of tricuspid regurgitation. This method uses the Bernoulli equation which states that UP = 4v2
(where UP = instantaneous pressure gradient and v = velocity across the valve). There is tricuspid
regurgitation with a peak velocity of 4 metres/second and a mean velocity of 3.5 metres/second.
Assuming right atrial pressure is 5 mmHg, the best estimate of the peak right ventricular systolic pressure (±
2 mmHg) is:
A.
50 mmHg.
B.
55 mmHg.
C.
60 mmHg.
D.
65 mmHg.
E.
70 mmHg.
Copyright © 2004 by The Royal Australasian College of Physicians
41
AM203
QUESTION 79
The arrow points to sternal notch marker
The above thyroid technetium scintiscan is least consistent with thyrotoxicosis due to which one of the
following clinical conditions?
A.
Subacute thyroiditis.
B.
Thyroxine therapy.
C.
Amiodarone therapy.
D.
Graves’ disease.
E.
Postpartum thyroiditis.
QUESTION 80
For pre-operative staging of oesophageal cancer, which one of the following provides the most accurate
information on the T stage?
A.
Endoscopy.
B.
Computed tomography (CT) scanning.
C.
Magnetic resonance imaging (MRI).
D.
Endoscopic ultrasonography (EUS).
E.
Positron emission tomography (PET) scanning.
Copyright © 2004 by The Royal Australasian College of Physicians
42
AM203
QUESTION 81
A 74-year-old man who had a stroke one week previously is reported by his caregiver to be drooling
intermittently, coughing at mealtimes, requiring a prolonged period of time to eat and failing to finish more
than half of his food. The patient's recent stroke was his second in one year and there is clinical evidence
that both cerebral hemispheres are now involved.
What is the most appropriate investigation for this problem?
A.
Barium swallow.
B.
Oesophageal manometry.
C.
Ultrasound evaluation of swallowing.
D.
Gastroscopy (upper gastrointestinal endoscopy).
E.
Video fluoroscopy evaluation of swallowing.
QUESTION 82
A 69-year-old woman presents with severe pancytopenia and peripheral blood macrocytosis associated with
a low serum vitamin B12 level.
Which one of the following investigation results most strongly supports a diagnosis of pernicious anaemia?
A.
Positive anti-parietal cell antibody.
B.
Positive intrinsic factor antibody.
C.
Elevated fasting plasma homocysteine level.
D.
Elevated fasting serum gastrin level.
E.
Reduced red cell folate level.
QUESTION 83
A 24-year-old pregnant woman reports at her first antenatal visit that her sister gave birth to a child with
congenital heart block (CHB). Testing for which one of the following would be most useful in assessing the
risk of CHB in this pregnancy?
A.
Fluorescent anti-nuclear antibodies (ANA).
B.
Anti-DNA antibodies.
C.
Antibodies to extractable nuclear antigens (ENA).
D.
Anti-cardiolipin antibodies.
E.
Lupus anticoagulant.
Copyright © 2004 by The Royal Australasian College of Physicians
43
AM203
QUESTION 84
Ascaris lumbricoides is a common worm infestation in the developing world. Which one of the following
syndromes would be most characteristic of this infection?
A.
Eosinophilic meningitis.
B.
Cholangitis.
C.
Painless rectal bleeding.
D.
Migratory rash.
E.
Perianal itch.
QUESTION 85
A 42-year-old woman presents with pain and bleeding on defecation. On investigation she is found to have
squamous cell carcinoma of the anus.
The most appropriate management of her problem is:
A.
radiotherapy followed by surgery.
B.
concurrent chemoradiotherapy.
C.
abdominoperineal resection.
D.
brachytherapy.
E.
chemotherapy.
QUESTION 86
Unawareness of hypoglycaemia is predominantly due to failure of secretion of which one of the following
hormones?
A.
Glucagon.
B.
Adrenaline.
C.
Cortisol.
D.
Growth hormone.
E.
Somatostatin.
Copyright © 2004 by The Royal Australasian College of Physicians
44
AM203
QUESTION 87
A 23-year-old woman weighing 54 kg presents with a history of systemic lupus erythematosus. Her
problems began at 16 years of age with a systemic illness including arthritis, skin rashes and petechial
haemorrhages. She periodically develops macroscopic haematuria and has a significantly elevated urinary
protein excretion rate. Her renal biopsy shows interstitial scarring, basement membrane thickening and 65%
of glomeruli with inflammatory crescents.
Blood investigations show:
serum creatinine
serum urea
serum potassium
serum anti-DNA antibodies
serum complement component 3 (C3) concentration
serum complement component 4 (C4) concentration
0.50 mmol/L
33.5 mmol/L
5.8 mmol/L
>50 U/mL
1.20 mmol/L
0.06 mmol/L
[0.06-0.11]
[4.0-8.0]
[3.5-5.0]
[0-5]
[0.55-1.20]
[0.12-0.35]
Anti-cardiolipin antibodies are detected in moderate titre.
The feature most strongly suggestive of the need for aggressive immunomodulatory treatment (e.g.
alkylating agents) is:
A.
DNA concentration.
B.
presence of crescents in glomeruli.
C.
presence of anti-cardiolipin antibodies.
D.
presence of low C3 and C4 concentrations.
E.
presence of interstitial scarring.
QUESTION 88
In a patient with acute ischaemic stroke, which one of the following treatments is the most appropriate early
intervention?
A.
Aspirin.
B.
Streptokinase.
C.
Low molecular weight heparin.
D.
Unfractionated heparin.
E.
Warfarin.
Copyright © 2004 by The Royal Australasian College of Physicians
45
AM203
QUESTION 89
A 45 year-old man with a family history of ischaemic heart disease is diagnosed with hypertension and
hypercholesterolaemia. He is started on aspirin 150 mg daily, atorvastatin 20 mg nocte and atenolol 50 mg
daily. Eight weeks later, he is reviewed and complains of some lethargy and itching. His blood pressure is
120/70 mmHg. He is noted to be icteric. There are no other findings on physical examination.
Blood investigations show:
white cell count
normal differential
haemoglobin
platelet count
prothrombin time-international
normalised ratio (PT-INR)
bilirubin
alanine transaminase (ALT)
aspartate transaminase (AST)
alkaline phosphatase (ALP)
gamma glutamyltranspeptidase (GGT)
albumin
sodium
potassium
urea
creatinine
hepatitis B surface antigen
hepatitis C antibody
ferritin
anti-nuclear antibody
anti-mitochondrial antibody
anti-smooth-muscle antibody
5.6 x 109/L
[4.0-9.0]
142 g/L
468 x 109/L
[130-175]
[150-450]
1.0
103 µmol/L
610 U/L
358 U/L
540 U/L
746 U/L
40 g/L
145 mmol/L
4.5 mmol/L
3.8 mmol/L
0.10 mmol/L
negative
negative
356 µg/L
negative
negative
negative
[0.9-1.1]
[3-21]
[5-40]
[5-40]
[30-115]
[<65]
[38-50]
[139-145]
[3.8-4.8]
[2.5-5.6]
[0.06-0.11]
[25-200]
An abdominal ultrasound shows non-dilated bile ducts. The gall bladder is normal with no calculi. A liver
biopsy is performed and two representative sections are shown over.
The most likely explanation for the abnormal liver function test results is:
A.
atenolol.
B.
atorvastatin.
C.
non-alcoholic steatohepatitis (NASH).
D.
autoimmune hepatitis.
E.
primary biliary cirrhosis.
Copyright © 2004 by The Royal Australasian College of Physicians
46
QUESTION 89 CONTINUED
Copyright © 2004 by The Royal Australasian College of Physicians
AM203
47
AM203
QUESTION 90
A 50-year-old woman presents with sudden onset of profound deafness in the left ear. Examination
indicates that nerve deafness is more likely than a conduction problem. Other findings include right inferomedial scleritis, bilateral osteoarthritic fingers, blood-stained nasal discharge and obesity.
Which one of the following investigations is most likely to lead to the correct diagnosis?
A.
Magnetic resonance imaging (MRI) of the brain.
B.
Anti-double-stranded-DNA antibodies assay.
C.
Anti-neutrophil cytoplasmic antibody (ANCA) assay.
D.
Lumbar puncture.
E.
Urinary drug screen.
QUESTION 91
A 43-year-old man is referred for investigation of snoring and witnessed apnoeas. A diagnostic sleep study
shows an apnoea-hypopnoea index of 14 events/hour. Therapy with nasal continuous positive airway
pressure (CPAP) is recommended.
Which one of the following best predicts compliance with CPAP in this man?
A.
Presence of cardiovascular comorbidity.
B.
Arousal index of >15/hour on the sleep study.
C.
Daytime sleepiness.
D.
Obesity.
E.
Significant oxygen desaturation (minimum overnight haemoglobin-oxygen saturation as measured by
pulse oximetry (SpO2) <85%) on sleep study.
QUESTION 92
Which one of the following drugs would be most likely to have a clinically significant interaction with St John’s
Wort (Hypericum perforatum)?
A.
Digoxin.
B.
Cimetidine.
C.
Cyclosporin.
D.
Metformin.
E.
Desipramine.
Copyright © 2004 by The Royal Australasian College of Physicians
48
AM203
QUESTION 93
A 24-year-old woman, who has recently arrived in Australia from Vietnam, presents for evaluation of
abnormal menstrual bleeding. There are no abnormalities on examination.
Results of investigations are listed below.
Full blood count:
haemoglobin
red cell count
mean corpuscular volume (MCV)
mean corpuscular haemoglobin (MCH)
mean corpuscular haemoglobin concentration (MCHC)
white cell count
differential
platelet count
113 g/L
5.2 x 1012/L
71 fL
22.0 pg
310 g/L
6.6 x 109/L
normal
212 x 109/L
[120-155]
[4.1-5.2]
[80-95]
[27.0-32.5]
[325-360]
[3.5-9.5]
[130-330]
Blood film shows red cell microcytosis and hypochromasia but is otherwise normal.
Haemoglobin (Hb) electrophoresis (cellulose acetate, pH 8.6):
HbA2
HbF
No abnormal bands
2.7%
0.4%
HbH preparation:
[1.8-3.5]
[0-2.0]
HbH inclusions present
Serum biochemistry:
iron
transferrin
ferritin
8 µmol/L
3.2 g/L
15 µg/L
The most likely diagnosis is:
A.
homozygous alpha+ thalassaemia (−α/−α).
B.
early iron deficiency.
C.
congenital sideroblastic anaemia.
D.
sickle cell anaemia.
E.
heterozygous beta thalassaemia.
Copyright © 2004 by The Royal Australasian College of Physicians
[7-32]
[2.1-3.6]
[7-280]
49
AM203
QUESTION 94
A 10-year-old boy suffers an acute anaphylactic reaction following ingestion of peanuts. His skin test to
peanut is strongly positive and he develops diffuse urticaria 10 minutes after the skin test is applied.
In addition to education in the use of a self-injecting adrenaline kit, the most appropriate management is:
A.
peanut desensitisation.
B.
daily antihistamines until his allergy declines with age.
C.
lifelong avoidance of peanuts.
D.
leukotriene inhibitor therapy.
E.
provision of antihistamines for future attacks.
QUESTION 95
A 30-year-old man is admitted to hospital with a three-day history of headache and fever. In the six hours
preceding admission, he has become confused and drowsy and is observed to have focal twitching of the
right arm. His temperature is 39.2oC. He is unable to answer questions coherently or follow commands. He
has mild neck stiffness. A computed tomography (CT) scan of the brain is normal.
Cerebrospinal fluid (CSF) analysis is as follows:
white cell count
differential:
lymphocytes
neutrophils
protein
glucose
90 x 106/L
[<5]
80 x 106/L
10 x 106/L
0.80 g/L
3.2 mmol/L
[<2]
[<2]
[0.15-0.40]
[2.5-4.5]
Herpes simplex encephalitis is suspected and he is started on intravenous aciclovir.
Which one of the following is the most appropriate next investigation to confirm the diagnosis?
A.
Cerebral magnetic resonance imaging (MRI).
B.
Electroencephalography (EEG).
C.
Cerebral positron emission tomography (PET) scanning.
D.
Brain biopsy.
E.
Polymerase chain reaction (PCR) assay for viral DNA.
Copyright © 2004 by The Royal Australasian College of Physicians
50
AM203
QUESTION 96
Which one of the following is most predictive of complicated grief following the death of a close relative?
A.
Distress of bereaved at the time of death.
B.
History of prior conflict with the deceased.
C.
Death due to cancer.
D.
The fact that the bereaved lives alone.
E.
Older age of the bereaved.
QUESTION 97
A 63-year-old man is brought to the emergency department by his family with a one-hour history of
continuing abnormal behaviour following an argument with his wife. His speech is fluent and his
comprehension is normal. He has no recollection of the argument or the events leading up to his
presentation. He continually requires reassurance regarding the current situation and has difficulty
remembering the advice given. His long-term memory is intact. Neurological examination is otherwise
normal. A cranial computed tomography (CT) scan is normal.
The most likely diagnosis is:
A.
conversion disorder.
B.
transient global amnesia.
C.
temporal lobe epileptic event.
D.
thalamic stroke.
E.
basilar artery thrombosis.
QUESTION 98
A 46-year-old engineer has symptoms meeting the criteria for chronic fatigue syndrome. These symptoms
have resulted in his inability to work for six months.
Which one of the following offers the best chance of an improvement in symptomatology sufficient to allow a
return to work?
A.
Low-dose corticosteroids.
B.
Prolonged rest.
C.
Dietary supplements.
D.
Cognitive behaviour therapy.
E.
Immunotherapy.
Copyright © 2004 by The Royal Australasian College of Physicians
51
AM203
QUESTION 99
A 60-year-old woman has been on continuous combined hormone replacement therapy since menopause.
She complains of mental slowing, weight gain, insomnia, and headaches in the last six months. Her general
practitioner has commenced her on nortriptyline one month ago without improvement in symptoms.
The following results are obtained:
serum prolactin
serum luteinising hormone
serum follicle-stimulating hormone (FSH)
serum thyroid-stimulating hormone (TSH)
free thyroxine (free T4)
1900 mIU/L
0.3 IU/L
0.5 IU/L
2.1 mIU/L
8 pmol/L
[30-450]
[premenopausal: 0.4-9.0]
[premenopausal: 1.0-9.0]
[0.4-4.0]
[10-23]
The best explanation for these results is:
A.
nortriptyline therapy.
B.
depression.
C.
prolactin-secreting pituitary microadenoma.
D.
non-functioning pituitary macroadenoma.
E.
hormone replacement therapy.
QUESTION 100
A 42-year-old man with acute myeloid leukaemia undergoes allogeneic stem cell transplantation from a
human leucocyte antigen (HLA)-matched sibling. He is progressing well for the first 10 days, but then
complains of abdominal pain and leg swelling.
He is noted to have marked ascites, moderate peripheral oedema and jaundice.
Liver function tests are as follows:
bilirubin
alkaline phosphatase (ALP)
gamma glutamyltranspeptidase (GGT)
aspartate transaminase (AST)
alanine transaminase (ALT)
albumin
123 µmol/L
440 U/L
680 U/L
1254 U/L
1356 U/L
30 g/L
[3-23]
[30-115]
[<65]
[5-40]
[5-40]
[40-52]
An abdominal ultrasound confirms large volume ascites with an enlarged liver (span 18 cm). The spleen is
normal in size.
The most likely explanation for his condition is:
A.
graft-versus-host disease.
B.
cytomegalovirus hepatitis.
C.
hepatosplenic candidiasis.
D.
portal vein thrombosis.
E.
veno-occlusive disease.
Copyright © 2004 by The Royal Australasian College of Physicians
52
AM203
2003 FRACP Written Examination
Adult Medicine
Paper 2 - Clinical Applications
Answers
1.
C
34.
E
67.
D
2.
B
35.
E
68.
A
3.
B
36.
C
69.
C
4.
E
37.
A
70.
E
5.
B
38.
B
71.
B
6.
C
39.
B
72.
A
7.
B
40.
A
73.
C
8.
C
41.
B
74.
A
9.
A
42.
A
75.
D
10.
D
43.
B
76.
E
11.
D
44.
B
77.
D
12.
B
45.
D
78.
E
13.
C
46.
C
79.
D
14.
A
47.
D
80.
D
15.
D
48.
A
81.
E
16.
E
49.
D
82.
B
17.
D
50.
E
83.
C
18.
D
51.
A
84.
B
19.
A
52.
A
85.
B
20.
A
53.
D
86.
B
21.
C
54.
B
87.
B
22.
B
55.
D
88.
A
23.
B
56.
B
89.
B
24.
E
57.
C
90.
C
25.
C
58.
D
91.
C
26.
C
59.
B
92.
C
27.
C
60.
E
93.
A
28.
B
61.
B
94.
C
29.
D
62.
B
95.
E
30.
A
63.
D
96.
B
31.
E
64.
A
97.
B
32.
C
65.
C
98.
D
33.
E
66.
D
99.
D
100.
E
Copyright © 2004 by The Royal Australasian College of Physicians