Download Student generated Short Answer Questions – 2008 - UQMBBS-2013

Student generated Short Answer Questions – 2008
SEMESTER 1
Abdominal Distension and Ascites: Short Answer Question (7 marks)
Students’ original questions
Q1
a) List 6 causes of abdominal distension. (3 marks)
Fat,
Fluid,
Foetus,
Tumour,
Flatus,
Faeces
b) Name the anatomical space fluid occupies in ascites? (1 mark)
Peritoneal
c) Please give 3 simplified mechanisms for the development of ascites,
NOT causes or pathologies. (3 marks)




sodium and water retention
hypoalbuminaemia
portal hypertension
lymph perculation/ overwhelmed removal of lymph.
Q2 Give three mechanisms that are involved in development of ascites and a pathological
cause for each. (1 mk for mechanism; 1 mk for cause: 6 total).
Eg. Mechanism: Decreased lymph removal leading to lymph percolation into peritoneal cavity
Cause: Physical obstruction of cisterna chyle.
Mechanism: Hypoalbuminaemia leading to decreased colloid pressure
Cause: Cirrhosis leading to decreased hepatic synthetic function.
Cause: Nephrotic syndrome/kidney failure leading to proteinuria.
Mechanism: Increased venous hydrostatic pressure in the hepatic portal system
Cause: Right heart failure leading to venous congestion
Cause: Cirrhosis leading to portal hypertension
Cause: Schistosomiasis leading to portal venous obstruction
Mechanism: Na+ and water retention as a result of renin-angiotensin system
activation
Cause: Left heart failure leading to renal hypoperfusion.
Cause: Fluid retention in peritoneal cavity leading to reduced plasma volume.
Q3 Give two clinical signs that you can elicit to differentiate ascites from other causes of
abdominal distention. (2 mks)
-fluid thrill (1 mark)
-shifting dullness (1 mark)
Anaphylaxis: Short Answer (13 marks)
Mary, aged 9, was with her parents when she developed an allergic reaction from a meal of
shellfish. She presents at the emergency department at 2:00pm and the triage nurse
documents the following history:
History of presenting complaint:
- Onset: shortness of breath immediately following a meal of shellfish at 1:30pm,
within ‘minutes’ she fainted and then regained consciousness once lying down.
PMH
- Insignificant, no history of asthma or allergies
Medications
- nil
Family History
- Father: hayfever and is allergic to peanuts.
Over the next four hours Mary develops further symptoms. Her breathing becomes more
laboured and by 5pm she has developed an audible wheeze. She also develops a diffuse itch
and urticaria
a) Mary experienced an early, sudden reaction which was followed, hours later, by
another wave of symptoms. Compare this late phase reaction to the early phase and
explain what has occurred. (4 marks)
Primary early response: 5-30 minutes
 Immediate degranulation and release of mediators e.g. histamine from IgE
sensitized mast cells (1/2 mark)
 Histamine → vasodilation & ↑ permeability of blood vessels (1/2 mark) →
peripheral hypovolemia → syncope (1/2 mark)
 Ach → smooth muscle contraction → bronchial spasm → shortness of breath (1/2
mark)
Late phase response: 2- 8 hours later
 release of newly formed mediators (1/2 mark)
 & recruitment of leucocytes (1/2 mark)
 Prostaglandins & leukotrienes → similar effects to Histamine & ACh
 oedema, mucus secretion, bronchospasm, epithelial damage
1 mark for coherent and logical comparison between the two phases.
b) Mary’s reaction can be described as a hypersensitivity reaction. Draw
lines to match the correct mechanism and example for each of the types of
hypersensitivity reaction. (4 marks) ½ mark per correct answer
Type of
Hypersensitivity
I
II
III
IV
Mechanism
Example
Production of IgG, IgM →
binds to antigen on target
cell or tissue →
phagocytosis or lysis of
target cell b activation of
complement; recruitment of
lymphocytes
Glomerulonephritis, serum
sickness, Arthus reaction
Activated T lymphocytes→
release cytokines and
macrophage activation, and
T cell-mediated cytotoxicity
Anaphylaxis, Allergies,
Bronchial spasm
Production of IgE antibody
→ immediate release of
vasoactive amines and
other mediators from mast
cells; recruitment of
inflammatory cells (latephase)
Goodpasture syndrome,
Autoimmune haemolytic
anaemia
Deposition of antigenantibody complexes →
complement activation →
recruitment of leukocytes →
release of enzymes and
other toxic mediators
Contact dermatitis,
Multiple sclerosis,
Transplant rejection
Answers 132, 213, 341, 424
c) During the emergency management of Mary you will check that her airway is clear, that
she is breathing and that she has a pulse. You will probably consider treating her with
adrenaline. What other actions should be performed in the emergency management of an
anaphylactic patient? (2 marks)
½ mark per correct answer
Establish venous access
Lie flat – return fluid from periphery
Intubate – to secure airway
Administer Oxygen
Administer glucose
Administer Corticosteroids: hydrocortisone
Administer IV fluid
Monitor BP
d) Adrenaline administration is important in the therapeutic response to
anaphylaxis. Complete the table below regarding the actions of adrenaline in the body that
are relevant to reversing the anaphylactic response.
(3 marks) ½ mark per correct answer
The following are effected
by the administration of
adrenaline:
What is the adrenoreceptor
involved in the response?
What is the effect on this
organ? How does this
reverse the anaphylactic
response?
Blood Vessels
Alpha 1 or alpha 2
(has effects on both)
Vasoconstriction increases
blood flow to vital organs
Bronchi
Beta 2
Bronchodilation improves
respiration
Mast Cells
Beta 2
Reduces release of
histamine reducing further
symptoms or reduces
severity of anaphylaxis
Arrhythmias: Short Answer Question (11 marks)
Initial presentation:
Mr Carthy, a 64 year old man with a history of long-standing hypertension and diabetes
mellitus type 2 presents c/o SOB and fatigue.
O/E:
HR 120 bpm
BP 100/70 mmHg
RR 24 bpm
Lead 2 ECG Trace
Questions:
1. (a) What is the ventricular rate of the ECG provided? (1 Mark).
120bpm.
(b) Is this a ventricular or supraventricular rhythm? (1 Mark).
Supraventricular.
Carotid sinus massage may be applied in the emergency room to better differentiate the
arrhythmia.
2. Explain how carotid sinus massage affects the ventricular
response? (2 Marks).
CSM increases vagal tone which slows conduction through the atrioventricular node and increases atrio-ventricular block.
Additional information:
Mr Carthy is diagnosed with atrial flutter, admitted to hospital and commenced on digitalis and
amiodarone. He feels better but has developed an irregularly irregular heart rate of 110 bpm.
Lead 2 ECG Trace
3. (a) What is the rational for treatment with these pharmacological agents? (2
Marks)
These agents slow the ventricular rate by increasing vagal tone and delaying
conduction through the AV node. This slows the ventricular rate, allowing adequate
time for ventricular filling.
(b) List 2 common side effects each for digoxin and amiodarone.
(2 Marks)
Digoxin: Anorexia, nausea, vomiting, diarrhoea, blurred vision.
Amiodarone: Benign corneal microdeposits, nausea, vomiting, skin pigmentation
(blue-grey), constipation, pulmonary alveolitis or fibrosis, hyper/hypothyroidism,
photosensitivity, transient elevation of hepatic transaminases, headache, dizziness,
fatigue, tremor, ataxia, sleep disturbances (nightmares or vivid dreams), taste
disturbances (metallic taste, loss of taste).
4.
(a) What is the rhythm now based on the ECG strip of Lead 2 provided above?
(1 Mark).
Atrial fibrillation
(b) What other therapy may be indicated and why? (2 Marks).
Patients with intermittent or persistent AF are at an increased risk of embolic stroke
due to the increased risk of mural thrombi formation. For this reason patients should
also receive anticoagulation.
Cardiovascular/Chest Pain: Short Answer Question (8 marks)
(a) Cardiovascular disease (CVD) is the leading cause of death and disability among Australians,
accounting for 21.9% of the total disability-adjusted life years lost in 1996. Cardiovascular events
including myocardial infarction (MI), transient ischaemic attacks (TIA) and stroke are preventable
and GPs are well placed to implement screening and prevention procedures that will reduce the
human and economic burden of these diseases.
Briefly define the 3 forms of prevention: Primary, Secondary and Tertiary / Continuing Care.
Also provide one example for each, with respect to Cardiovascular disease.
Prevention
type
Primary
Prevention
Secondary
Prevention
Tertiary
Prevention /
Continuing Care
Definition (1 mark each)
Example (1 mark each)
Prevention of diseases or
disorders in the general
population by encouraging
community-wide measures.
Primary prevention
maintains good health and
reduces the likelihood of
disease occurring.


Detection of the early stages
of disease before symptoms
occur and the prompt and
effective intervention to
prevent disease progression.

Prevention or minimisation
of complications or disability
associated with established
disease.













BP screening
blood cholesterol/triglyceride
screening
healthy diet low in fat
good level of physical activity
smoking cessation
weight reduction
adequate management of diabetes
Education
Health promotion
treatment of
hypercholesterolaemia/hyperlipida
emia with statins
treatment of hypertension
treatment/control of diabetes
mellitus
angioplasty/stenting
CABG (Coronary Artery Bypass
Grafting)
cardiac rehabilitation
treatment of CHF (esp with betablockers)
(b) Describe the mechanism of action of the ‘statins’ in the treatment of cardiovascular disease (2
marks)
Inhibit the actions of hydroxymethylglutaryl coenzyme A (HMG CoA) reductase used
in endogenous cholesterol synthesis → ↓ hepatocyte cholesterol concentrations → ↑
expression of hepatic LDL receptors → ↑ LDL uptake → ↓ plasma LDL
Also causes an ↑ in HDL and ↓ triglycerides (↓ synthesis of triglyceride rich
lipoproteins)
Other effects include:
 ↑ endothelial function (↑ [NO])
 possible anti-inflammatory effects
 ↓ thrombus formation
 possible antioxidant effects
 ↓ vascular smooth muscle growth
COPD SAQ
A 62 year old exotic dancer presents with worsening symptoms of COPD. You overhear a
colleague complaining that he shouldn’t have to spend so much time treating a man who has
“smoked himself half to death”.
a) Discuss how a doctor’s perceptions of self-induced disease may compromise quality
of care. Use the ideas of self-induced disease, responsibility, lifestyle, autonomy, and
transference to guide your answer. (5 marks)
The major ethical issue with assigning personal responsibility for health and illness is
finding an acceptable way to attribute and quantify causality. While it may be easy to
assign blame to a patient suffering from apparently self-induced illnesses, it is more
difficult to determine exactly how much a patient’s lifestyle has contributed to the
development of disease and exactly how responsible a person is for their actions, given
their culture, socioeconomic status, genetic heritage, education, and life experience.
Assigning absolute responsibility would deny the possible roles of genetic, environmental,
and social influences on health. However, to deny the influence of personal choice is a
deterministic view which completely discounts autonomy.
The compatibilist view is the compromise between these two extremes. When doctors
assign blame to patients with perceived self-induced disease, there is a risk of
transference, creating negative feelings toward the patient, which may compromise the
quality of care.
(1/2 mark for proper integration of each word and 1/2 mark for proper understanding of
each concept.)
**{According to Mal Parker, it would be good to:
 say a bit more on HOW negative feelings could compromise care.
 also consider expanding it a bit by saying that to the extent that responsibility is
attributed, up to the max of absolute responsibility, the possible functioning of the
other factors is diminished ….
 give an example of self-induced illness in order to demonstrate that you
understand the concept. The example from the case could be used.}
b) Discuss the concepts of negative sanctions and positive incentives in the context of
community resources and self-induced disease (5 marks)
A shortage of community resources increases the appeal of negative sanctions,
where you deny care or other benefits to patients who indulge in harmful behavior.
This is also problematic as it gives doctors the power to administer social justice. The
practice of denying certain procedures, particularly organ transplant, on the basis of
physiological criteria secondary to harmful behaviour, is somewhat more accepted.
Positive incentive programs, where patients gain benefits in recognition of healthy
lifestyles, are less ethically problematic and are aimed at reducing the burden of
disease by reducing disease prevalence rather than denying care.
Emphysema: Short Answer Question (10 marks)
Gary is a 54 year old male who presents with shortness of breath worsening over the past 6
months. He has a 40 pack-year history of smoking. You suspect he has emphysema.
(a) List one (1) sign found on clinical examination of the chest in a patient with
emphysema for each of: (1/2 mark for each box, max of 2 marks)
Hyperinflated chest/Barrel chest,
Inspection
use of accessory muscles,
intercostal/subcostal/supraclavicular recession (one of),
tachypnoea
decreased chest expansion,
Palpation
displaced apex beat,
(no marks if missing words decreased or displaced)
Hyper-resonant,
Percussion
decreased liver dullness
Crackles,
Auscultation
decreased breath sounds,
(b) Below is a vitalograph, as seen in a normal healthy person. Draw the tracing you
would expect to see from Gary. (2 marks)
[drew the graph myself, so there aren’t any copyright issues]
1 mark for decreased FVC
1 mark for decreased FEV1/FVC ratio
(c) Outline the process that leads to cor pulmonale in patients such as Gary. (3 marks)
Destruction of alveolar walls -> Loss of pulmonary vascular tissue and/or pulmonary
hypoxic vasoconstriction -> increased pulmonary vascular resistance -> pulmonary
HT -> increased afterload-> RV hypertrophy -> RV failure
(d) 10 years later Gary is diagnosed with small cell carcinoma. After being informed of
his prognosis, he refuses further treatment. What factors must be taken into
consideration while deciding if his refusal is valid. (3 marks)
Competent, informed, voluntary
(1/2 mark for listing, each and ½ mark for a brief explanation)
Eczema/Psoriasis: Short Answer Question (6.5 marks)
Tracey is an 18 month old child whom you diagnosed with eczema 3 months ago. Her parents
have been regularly bathing Tracey and applying a bland emollient 2-3 times a day since your
diagnosis.
(a) What are the common clinical findings in a toddler with eczema? (2 marks)
-
Asthma, allergic rhinitis, conjunctivitis (general atopy)
Involvement of antecubital and popliteal fossae, neck, face, wrists, ankles.
Lichenification (chronic skin thickening and increased skin markings)
Erythematous thickened plaques – may weep
Excoriations and scratch marks
Generally dry skin
Pruritis
Irritability
Growth retardation/failure to thrive
Despite Tracey’s parents’ dedication to the treatment regime, Tracey has not had the response to
treatment you would like and you consider prescribing a topical steroid cream in addition to the
emollient.
(b) Describe how steroids work in relation to eczema? (3 marks)
Atopic eczema is due to a disregulation of T-cell function (or something similar - 1
mark). Corticosteroids bind to glucocorticoid receptors in the cytoplasm and the
activated receptor moves into the nucleus which stimulates or inhibits protein
synthesis (1 mark). This reduces immune responses generally by reducing cytokine
and interleukin production (1/2 mark); production of phospholipase A2 is reduced
(thus reducing acute inflammation) (1/2 mark); and decreases release of histamine
from basophils (1/2 mark).
(c) List three (3) side effects of steroids (1 ½ marks. ½ mark each)
Osteoporosis
Adrenal suppression/atrophy
Increased susceptibility to infection
Psychosis/euphoria/depression
Decreased uptake and utilization of glucose OR abnormal carbohydrate metabolism
OR hyperglycaemia
Decreased protein synthesis and increased breakdown OR muscle wasting
Fat redistribution
Impaired wound healing
Impaired growth in children
Encephalitis: Short Answer (8 marks)
Susan, a 25 year old female presents to your surgery complaining of fever, headache and cold
sores. On examination you find she has papilloedema. During your examination, you observe a
clouding of consciousness and she begins to convulse. You send her immediately to the ED
1) Name 2 pathological processes that could account for her presentation
Infection,
Neoplasia,
Inflammation,
Ischaemia,
Obstruction
Diagnoses such as meningitis, encephalitis are NOT acceptable
2) List 3 Investigations that will aid in your immediate management and diagnosis of Susan, AND
JUSTIFY (no marks will be given for Ix only)
BSL  to rule out hypoglycaemia/hyperglycaemia
Head CT  to rule out space occupying lesion, subarachnoid haemorrhage, infarct
etc
Blood MCS  to rule out septic infection
LP  to check CSF for white cells, bacteria, inflammatory cells
FBC  to rule out infection
LFT  to rule our liver induced encephalopathy
NOT acceptable is
CT (no specific place), MRI, EEG – unsure whether or not to accept ECG, shows no
cardiac signs, but are routinely done.
Epigastric Pain: Short Answer Question (8 marks)
You are an intern sleeping in the emergency ward one night, when Bill, a 54 year old man, is
rushed in with severe epigastric pain and vomiting.
1 (4 marks)
List four (4) anatomical structures and an associated pathological process for each that give
rise to epigastric pain.
Structure
Example: myocardium
stomach
duodenum
pancreas
oesophagus
gallbladder
Aorta
musculoskeletal system
Skin
pericardium
Pathological process
Ischaemia/infarction
Ulceration/inflammation/infection/carcinoma/volvulus
Ulceration/inflammation/infection/obstruction/carcinoma
Inflammation/obstruction/infection/carcinoma
Perforation/ulceration/chemical irritation/distension
obstruction/infection/inflammation
Ruptured Dissection/aneurysm
Trauma/inflammation/fracture
Infection/inflammation/trauma
Inflammation
2 (2 marks)
Describe the mechanism of referred pain.
Good answer
 Pain arising from the visceral organ radiates to the dermatome level which receives
visceral afferent fibres from the organ concerned. (1)
 The brain maps somatic sensation more effectively than visceral sensation and the
irritation is interpreted as occurring in the skin rather than from the viscera. (1)
Poor answer (worth half marks)
 Pain arising from the internal organs is mapped better by the brain.
 Reason: too vague. Have not demonstrated complete understanding of the mechanism.
3 (2 marks)
Bill is in too much pain to talk. A quick examination shows absent bowel sounds, he looks
pale, sweaty and has a weak, thready pulse. He starts vomiting blood. You suspect peptic
ulcer perforation, and realising that this is a medical emergency, you begin to think about
immediate management.
Explain why treatment can be provided without consent in this case
o
o
o
o
Patient is unable to give consent (1/2)
The procedure is necessary, and not simply convenient (1/2)
The necessity must be to save the life of the person, or save a limb or function of
a part of the body that may cause long term harm to the patient. (1/2)
The patient is in grave danger, and treatment is urgent in terms or hours or days
(1/2)
Functional Bowel Disease: Short Answer Question
Ms Sraczka, a 36 year old single mother of 2 young children, presents with a 2 week history
of abdominal discomfort, feeling bloated & complains of some "loose bowel motions". She is
new to your practice as she has recently relocated from Tasmania. You suspect she may
have irritable bowel syndrome.
a) What are 3 broad differential diagnoses you should consider in this patient?





Lactose intolerance.
Infectious
Coeliac disease
Inflammatory bowel disease
Colorectal cancer related to familial polypoid syndrome – FAP / HNPCC
b) List 4 aspects of your management plan for a patient with irritable bowel syndrome.




Counselling and education regarding the disorder.
Restriction diets to identify triggers of symptoms
Keep a log book
Dietary advice eg high fibre diets





Identification of and dealing with stressors
Regular follow-ups
Regular hydration
Pharmacologic therapy eg Anti-spasmodic agents, Stool-bulking agents, Antidiarrhoeal agents, Anti-depressant drugs, Antiflatulence therapy, Chloride channel
activators.
Further investigations e.g. stool microscopy, colonoscopy
Gallstones: Short Answer Question (6 marks)
What are 3 common clinical presentations of gallstones? For each one, briefly explain their
pathogenesis and how they would present.
a) Bilary Colic- temporary obstruction of the cystic or common bile duct. Colicky pain
generally felt in the epigastrium.
b) Acute Cholecystitis- obstruction to gallbladder which induces blockage of
secretions, progressive dilation which may impact on vascular supply. Obstruction to
the bile secretions may also cause infection, and inflammation. Bilary colic pain is felt,
as well as a right upper quadrant localized pain due to parietal peritoneal
involvement. Fever.
c) Acute Cholangitis- a gallstone is lodged in the common bile duct. Generally
presents with a triad of fever, jaundice and bilary colic.
SAQ – Hypertension
Scenario- Mr Richard Cranium, a 66 year old patient of Anglo-Saxon descent, presents
requesting a ‘check up’ at your GP practice.
1.
What are the major cardiovascular risk factors? Indicate which of the risk factors are
modifiable and which are non-modifiable (3 marks)
Non-modifiable = (3 for 1.5 marks)
Age (>50),
sex (male),
family history
Modifiable = (3 for 1.5 marks)
Hyperlipidaemia (aetiology not primarily genetic),
hypertension,
diabetes mellitus,
smoking, obesity,
high fat diet,
physical inactivity.
Whilst seated, Mr Cranium’s BP: right arm = 145/95. No significant differences on left arm or
on standing.
2.
Do these measurements justify a clinical diagnosis of hypertension? Explain your
answer(4 marks)
No (0.5 mark). Epidemiologically, there is no specific cut-off at which blood pressure
begins to cause pathology of the vascular, cardiac and renal systems (0.5 marks).
Clinically, the diagnosis of HTN is made when there is seated systolic (>140) and/or
diastolic (>90) elevation (0.5 marks) on two or more visits (0.5 marks). These BP
measurements were chosen as points at which risk is significantly increased and
there are established benefits of treatment (1 mark).
There is the consideration of white coat hypertension as well, and taking more than
one BP measurement aims to reduce the influence of this syndrome.( 1 mark)
3.
Name the two aetiological classifications of hypertension and indicate which one is
more common. (1.5 marks)
Essential HTN (0.5) and secondary HTN (0.5 marks). Essential is more common (0.5
marks) (95% and 5% of HTN cases respectively).
4.
What are the two major neurohormonal systems that contribute to the maintenance of
MAP? Briefly describe the general mechanism of each(5 marks).
Autonomic nervous system(1 mark): The sympathetic nervous system maintains
vascular tone (vasoconstriction) and elevates heart rate (increased chronotrophism),
thereby maintaining TPR and CO respectively. The parasympathetic nervous system
decreases vascular tone and heart rate. (1.5 marks for mechanism)
Renin-Angiotensin system (1 mark): Activation increases MAP. Decreased renal
perfusion causes the macula densa of the juxtaglomerular apparatus to secrete renin.
Renin cleaves angiotensin I to angiotensin II (primarily in the lungs). Angiotensin II
acts as a potent vasoconstrictor which increases TPR and MAP. Angiotensin II also
activates the adrenal secretion of aldosterone, which causes renal sodium and water
retention.(1.5 marks for mechanism)
Lymphadenopathy: Short Answer Question (7 marks)
Part A
Mr X, an 74 year old retiree, presents to your GP clinic with a lump in his neck. You
know Mr X. well although he is often reluctant to keep up his regular visits and has
refused invasive diagnostic procedures and lifestyle advice on several instances in the
past. You suspect the swelling is within a lymph node.
a) Name 3 different anatomical structures (of different tissue types) in the neck and relevant
diagnosis (not pathological processes) for this structure.
Specific Anatomical Structure
example: Carotid Artery
Any lymph node (eg Cervical lymph node)
Thyroid gland
Thyroglossal duct
Salivary gland
Skin
Parathyroid gland
Any neck muscle (eg SCM)
Any neck nerve
Relevant Diagnosis
example: Carotid Aneurysm
-Malignant lymphadenopathy (metastaic or
secondary
-Infectious lymphadenopathy
-Lymphoma
Goitre
thyroglossal cyst
Stone or caliculi
Lipoma
Sebaceous cyst
Cystic hygroma
Malignancy
Pharyngeal pouch
Muscular spasm
Neurofibroma
b) What relevant questions should also be asked of Mr X. to test your hypothesis? (2 Marks)
smoking hx,
alcohol hx,
previous history of cancer,
fever, night sweats and weight loss
dentition,
recent URTI,
time course,
pain,
recent travel
Poor answers: age, gender, occupation, any questions relevant to signs found in a clinical exam
c) Describe prominent differences in clinical features between infectious and malignant
lymphadenopathy (1 Mark)
Infectious - tender, mobile, soft, regular border
Malignant - non tender, fixed, hard/rubbery, nodular border
Part B
To narrow down your long list of differentials, you would like to take a biopsy.
Describe the difference between material and obvious risk? (1 Mark)
Material Risks - Patient needs to be informed to the level that a reasonable person
(as patient) needs to make a reasonably informed decision OR to the level that the
doctor reasonably knows the patient needs. A risk that a reasonable person would
attach significance to.
Obvious Risks – don’t need to inform unless law requires it, or if patient requests
information, “obvious” different for a doctor if compared to a non-doctor
Myeloma: Short Answer Question (6 marks)
Bob is a 59 year old building contractor who presents with back pain following a minor fall. He
tells you he hasn’t felt well for a while now; his appetite is less than usual, he has a dry mouth
and has been unusually constipated. You take a thorough history and perform a physical
examination. By the end of your consultation, you are concerned that Bob may have multiple
myeloma.
Complete the following table by listing 3 investigations and one anticipated finding from each
investigation which would be consistent with a diagnosis of myeloma.
1 point is assigned for each investigation from the following list, and 1 point for the expected
finding. Students do not need to list every potential finding for the investigation: 1 acceptable
answer per investigation is sufficient.
Investigation (3 marks)
Serum protein electrophoresis
Anticipated Findings (3 marks)
Monoclonal or ‘M’ bands/spikes
(accept: immunoelectrophoresis)
Bone marrow aspirate
Skull X-ray
Spine X-ray
Urine electrophoresis
(accept: 24 hour urine collection
with electrophoresis)
FBC
Serum globulins
(accept: total protein)
ESR
Blood film
Serum urea nitrogen
Serum creatinine
Serum calcium
Serum uric acid
Alkaline phosphatase
MRI of spinal cord
Infiltration by plasma cells OR plasmacytosis
‘Pepper-pot’ or lytic bone lesions
Crush/wedge fractures
Lytic lesions
Diffuse osteopenia/osteoporosis
Bence Jones proteins
Free light chains
N or ↓ WBC
N or ↓ RBC or Hb
N or ↓ platelet count
Elevated
(accept: elevated IgG, IgM, IgA, IgE)
Elevated
Rouleaux formation
Normochromic normocytic anaemia
Elevated
Elevated
Elevated
Elevated
Usually normal
Cord or root compression (present in myeloma pain
syndromes)
Nausea and Vomiting: Short Answer Question (5 marks)
Mark 37, presents suddenly with diffuse abdominal pain, which he describes as
colicky, as well as persistent vomiting since dinner.
a) List 2 likely diagnoses and briefly describe their mechanisms for causing vomiting: (3
marks)
Mechanical obstruction
Hernia - herniation of loop of bowel → small intestinal obstruction → gastric outflow
interruption + reverse peristalsis → emesis
other possibilities include: Gastric outlet obstruction: peptic ulcer disease,
malignancy, gastric volvulus , Small intestine: adhesions, hernias, volvulus, Crohn's
disease, carcinomatosis
Dysmotility
Gastroparesis due to diabetes – decreased motility of stomach → decreased
emptying of stomach contents → contraction of stomach → vomiting
other possibilites include: medications, postviral, postvagotomy ; Small intestine:
scleroderma, amyloidosis, chronic intestinal pseudo-obstruction, familial
myoneuropathies
Peritoneal irritation
Appendicitis: inflammation → pain detected by sensory afferents → transmission to
higher cortical centres → action on the vomit centre → efferent fibres to somatic and
visceral receptors → vomit
Infections
Food poisoning: ingestion of preformed toxin from bacteria (eg Bacillus cereus,
Staphylococcus aureus, or Clostridium perfringens → toxin induces stimulation of
visceral afferents from stomach → send signal to chemoreceptor trigger zone →
efferent fibres to somatic and visceral receptors → vomit
Other possibilities include: Norwalk or rotavirus, Hepatitis A or B, Acute systemic
infections
Hepatobiliary and pancreatic disorders
Acute pancreatitis: inflammation → pain detected by sensory afferents →
transmission to higher cortical centres → action on the vomit centre → efferent fibres
to somatic and visceral receptors → vomit
Other possibilities include: Cholecystitis or cholelithiasis
Topical gastrointestinal irritants /Drugs
Alcohol ingestion → systemic emetogenic properties → travel in blood → acts on
chemoreceptor trigger zone → action on the vomit centre → efferent fibres to somatic
and visceral receptors → vomit
Other possibilties include: NSAIDs, chemotherapy, opioids
Miscellaneous
Myocardial infarction: severe crushing chest pain → sensory afferents transmit pain
to higher centres in cortex → action on the vomit centre → efferent fibres to somatic
and visceral receptors → vomit
Other possibilites include: hypercalcaemia, kidney stones, pyelonephritis, diabetic
ketoacidosis, uraemia, radiation therapy, adrenal crisis, parathyroid disease,
hypothyroidism, paraneoplastic syndrome
b) List 2 common antiemetics (1 mark)
 H1 receptor antagonists (e.g. cyclizine)
 Muscarinic antagonists (e.g. hyoscine)
 5-HT3 receptor antagonists (e.g. ondansetron)
 D2 receptor antagonists (e.g. metoclopramide)
c) Choose one of the drugs listed above (listed in part b) and briefly describe its main
mechanism of action (1 mark)
Hyoscine: Inhibits muscarinic receptors (in the vestibular nuclei) -> loss of stimulation
of chemoreceptor trigger zone -> decrease stimulation at vomiting centre (also
inhibits receptors directly in vomiting centre).
Cyclizine: Inhibits H1 receptor (in the vestibular nuclei) -> loss of stimulation of
chemoreceptor trigger zone -> decrease stimulation at vomiting centre; (alternative
response - also inhibits receptors at nucleus of solitary tract, which in turn inhibits
stimulation at vomiting centre)
Metoclopramide: Direct inhibition of D2 (dopamine) receptor in chemoreceptor trigger
zone -> decrease stimulation at vomiting centre
Ondansetron: Direct inhibition of 5-HT3 (serotonin) receptor in chemoreceptor trigger
zone -> decrease stimulation at vomiting centre; (also inhibits stimulation of visceral
afferents from stomach/pharynx which in turn inhibits stimulation in the CTZ).
Pass answer:
a) Lists 2 diagnoses without mechanism or poor mechanisms, eg
hernia – obstruction → vomiting
(1 mark for diagnosis and okay mechanism)
food poisoning → bacteria secretes toxin → vomiting (½ mark for diagnosis)
b) Does not list 2 antiemetics/ uses trade names, eg
maxolon (0 mark), ondansetron (½ mark)
c) Provides poor or nonspecific mechanism
maxolon acts on dopamine receptors in the brain and inhibits vomiting (½ mark acts on...
needs to say inhibits, etc)
Newborn: Cyanosis: Short Answer Question
PART A
Sally is diagnosed with Rubella by her GP. Routine blood tests show that she is also 7
weeks pregnant. Sally knows of the risks associated with Rubella and the effects on
the unborn baby. She wonders if she should terminate the pregnancy.
Briefly discuss the ethical arguments regarding termination of pregnancy.
Conservative:
The foetus is a potential person (1mark), thus has a right to life (1mark), and abortion
infringes upon this right.
Liberal:
A right to life requires an inherent interest (1mark), since a foetus has no concept of
continuing life it does not have an interest (1mark), and therefore no right to life.
PART B
Seven months later, Sally gives birth to a baby boy, Jo. The night registrar on the
medical ward is called to the maternity ward as she is distressed because Jo turned on
feeding.
(a)
[Picture of foetal circulation]
This is a diagram of a foetal heart.
Label (a)(ductus venosum)
Ductus Venosum (1 mark)
What is the function of (b) (foramen ovale)
Allows oxygenated blood from the placenta to bypass the non-functional
lungs in the foetus. (To get the 1mark, the student needs to mention the
oxygenated blood via the placenta, and that it allows for the bypass) (1 mark)
What does (c) become upon birth (ductus arteriosum)
Ligamentum arteriosum (1mark)
(b)
For each system listed, provide a pathological process for cyanosis in the
newborn
System
Pathological Process
(c)
Cardiovascular system
Right to left shunt (0.5 mark)  shunting of
deoxygenated blood away from the pulmonary
circulation (0.5 mark)  increased deoxyhaemoglobin
in the systemic circulation (0.5 mark)  cyanosis
Respiratory system
Decreased Ventilation/Diffusion (0.5 mark) 
Decreased Oxygenation of Haemoglobin (0.5 mark) 
Increased Deoxyhaemoglobin (0.5 mark)  Cyanosis
Haematological system
Genetic defect of haemoglobin (0.5 mark) 
decreased affinity for oxygen (0.5 mark)  increased
levels of deoxyhaemoglobin (0.5 mark)  cyanosis
The newborn is diagnosed with Tetralogy of Fallot.
List the four features of Tetralogy of Fallot
VSD (0.5 mark)
Overriding aorta (0.5 mark)
Right ventricular hypertrophy (0.5 mark)
Pulmonary Stenosis (0.5 mark)
SAQ
1. Maggie, a 53 year old lady presents with unilateral leg pain. You are highly suspicious of a
DVT. List 6 risk factors associated with DVT (3 marks).





Increasing age
History of venous thromboembolism/DVT/pulmonary embolism
Thrombophilia, specific examples also acceptable include:
o Protein C or S deficiency,
o Factor V leiden,
o antithrombin III deficiency,
o hyperhomocysteinaemia,
o antiphospholipid syndrome
Surgery
Stasis of blood flow, specific examples also acceptable include:
o travel,
o bed rest,
o immobilization,
o sedentary lifestyle,
o bone fractures,
o paralysis,
o leg ischemia or amputation.






Trauma
Hypercoagulopathy, specific examples also acceptable include:
o malignancy,
o smoking,
o exogenous oestrogen including oral contraceptive pill,
o pregnancy.
Inflammatory disease processes
Coronary artery disease
Intravenous catheters
Burns
2.What 2 findings specific for DVT might you elicit on physical examination that will assist in
confirming your suspicion? (2 marks)









Asymmetrical calf swelling
Asymmetrical thigh swelling
Superficial venous dilatation
Asymmetrical skin temperature
Tenderness
Redness
Homans’ sign
Mild fever
Pitting oedema
3. Assuming a high clinical probability of DVT, what is the most appropriate diagnostic
investigation and why? (2 marks)
Venous compression ultrasound.
Ultrasound and Doppler ultrasound are also acceptable answers.
Explanation:
 Two (2) marks awarded for an answer consistent with:
o A high specificity test is required to rule the diagnosis in.
o Ultrasound is a high specificity test.
 One mark awarded for venography because, although it is a high specificity
test, it is not an appropriate investigation due to cost and technical
requirements.
 D-dimer is not an acceptable answer because it has a low specificity and high
sensitivity and should therefore only be used in the setting of low clinical
suspicion.
SAQ
Joe B, a 53 yr old computer programmer, presents to A&E on a Saturday morning with a
productive cough, shortness of breath, and mild chest discomfort. You immediately notice his
slightly pale, sweaty appearance
History:
Joe has had the cough for 4 days, and this was preceded by a runny nose and sore throat.
The chest discomfort began shortly after the cough, and occurs with breathing. He has been
quite tired since the episode began, and had to take yesterday off work. He hasn’t been
traveling lately. The rest of his history is unremarkable, and Joe appears to be otherwise
healthy.
Question 1: (4.5 marks, ½ mark for each finding)
You include the following conditions in your differential diagnosis. What physical findings on a
chest examination would make you suspect each of the following:Condition
Lobar Pneumonia
(1.5 marks)
Pneumothorax
(1.5 marks)
Asthma
(1.5 marks)
Elements of Chest Examination
Dull to percussion
Bronchial breath sounds
Increased vocal resonance
Crackles
Reduced chest wall expansion on affected side
Reduced expansion on affected side
Hyper-resonant percussion note
Reduced or absent breath sounds
Reduced or absent vocal resonance
Mediastinal displacement away from lesion
Chest hyperinflation
Wheezing
Bilateral reduced chest wall expansion
Use of accessory muscles
Question 2: (3 Marks)
A chest radiograph is ordered. Opacity consistent with lobar pneumonia is seen in the region
of the right lower lobe. Briefly explain the pathophysiologic process occurring within the lungs
that accounts for this finding.
Proliferation of bacteria in the alveoli (1/2 mark) leads to a host inflammatory response
(1/2 mark) which results in:1. Capillary leak, (1/2 mark)
2. Exudation of protein-rich fluid (1/2 mark), and
3. Neutrophil proliferation and extravasation into the alveolar spaces (1/2 mark).
This combination of capillary leak, purulent exudation and fluid accumulation appears as
opacity on x-ray. (1/2 mark)
Question 3: (1.5 Mark total; 1/4 mark each)
It is decided that Joe does not need to be admitted to the hospital. List six factors that, when
present in a patient suspected to have pneumonia, would provide a strong basis for hospital
admission (eg. Coexisting illness, age >65 years etc)

Curb-65 Criteria and PSI (PORT) Criteria:
 Confusion or altered mental status,
 Urea >7mmol/L,
 RR ≥ 30/min,
 BP S ≤ 90 mmHg or D ≤ 60 mmHg,
 age ≥ 65 years
 Nursing Home Resident
 Coexisting Illness
 Temp <35 or >40 ,
 HR ≥ 125/min
 Arterial pH < 7.35,
 BUN > 30mg/dL,





Na+ < 130mmol/L,
BGL > 250mg/dL,
hematocrit < 30%,
PaO2 < 60mmHg,
pleural effusion
NB: Must state exact values to get the 1/4 mark. I.e can not say elevated urea, must say urea
>7mml/L etc.
PUO: Short Answer (10 marks)
Milly, 27, presents to her local GP with a 3 week history of fever.
a) List 4 important questions you would ask in the history (2 marks)









Red flag signs :
 weight loss
 night sweats
Travel history
 Recent travel to areas of endemic illness i.e. Africa, South east
Asia
 Travelling with ill travel companions
PMH
 PMH of autoimmune disease
 FHx of autoimmune diseases
 PMH of unexplained fever
Associated sx
 Rash
 Myalgia/arthralgia
Pattern of fever
 i.e. tertian/quaternary/saddleback
Medications
Sexual history
Occupational history
IV Drug use
b) List 3 broad causes of pyrexia (3 marks)
e.g. infectious




Connective tissue disease/autoimmune
Drug-induced
Neoplastic
Endocrine
c) Assuming an infectious cause describe the mechanism of fever in this patient. (5
marks)
Infectious agent -> release of monocytes/neutrophils (1) -> peripheral cytokine
release (IL-1, IL-6, TNF) (1) -> centrally released PGE2 acts on hypothalamic
thermoregulatory centre (1)-> elevated set point (1) -> peripheral response (shivering,
raised BMR, vasoconstriction) for heat conservation and production (1) -> fever
POOR ANSWER: Infection -> inflammatory response -> increased blood flow ->
fever
Short Answer Question
Jenny presents to your general practice with a chest infection, she has brought her daughter
Zoe (7 months) with her. You notice that her vaccination schedule is not up to date.
Question 1.
List 5 vaccinations that are given by six months of age (abbreviations accepted).






Hepatitis B (hepB)
Diphtheria, tetanus and acellular pertussis (DTPa) (pertussis without accellular
is accepted)
Haemophilus influenzae type b (Hib)
Inactivated poliomyelitis (IPV) (polio on its own is accepted)
Pneumococcal conjugate (7vPCV) (streptococcus pneumoniae or
pneumococcus accepted on their own)
Rotavirus
You talk to Jenny about getting Zoe's vaccinations up to date, however Jenny refuses as she
says she read an article on the net about the immediate side effects Zoe can have to the
vaccinations.
Question 2
List three (3) similarities and three (3) differences between refusal of childhood vaccination by
parent/s and refusal of childhood treatment by their parent/s.
Similarities
Sufficient information for decision-making
must be provided prior to both vaccination and
treatment.
Discussion of specific parental concerns or
specific concerns of the adult must occur.
A dismissive attitude to either the parent’s
approach/beliefs or the adult’s reluctance or
refusal will tend to reduce immunisation rates
or treatment acceptance respectively.
Differences
Refusal of immunisation of a child has
potential implications for the welfare of
others in the community, whose risk of
disease may be increased with decreased
immunisation rates.
Risk perception differs between the two kinds
of case, due to the relative absence of
experience of diseases which can be
vaccinated against (especially when
vaccination rates are high) compared with
most conditions affecting adults.
Assess competence of adult.
(Other adequate responses)
Refusal of vaccinations of children may lead
to financial penilisation if parents do not notify
a conscientious objection.
(other adequate responses)
Similarities
Any mention of the following concepts:
 Providing information or that the patient should be fully informed
 Discussing concerns of adults
 Dismissive or paternalism reduces immunisation rates
 Assess competence
Other acceptable answers
 Respecting autonomy of patient
Skin Cancer
1. Give one characteristic histological feature of the following skin cancer: SCC, BCC
and melanoma. (3 marks)
SCC: keratin whorls, keratin pearls or localized keratin accumulation (1
mark), BCC: palisade arrangement of nuclei at the periphery of proliferating
clusters of cells, picket fence arrangement of nuclei or darkly staining
basaloid cells (1 mark). Melanoma: nests of melanocytes, melanocytes
proliferating higher up in the epidermis (1 mark).
2. Give the three risk factors that associated with the development of skin cancer (1.5
marks)
Significant sun exposure in early life (0.5 mark), increasing age (0.5 mark),
family history of skin cancer (0.5 mark). (Other answers accepted - see poor
answer)
3. What is the main distinguishing feature between Breslow thickness and Clark level
with respect to their use in skin cancer staging? (2 marks)
Breslow thickness is the absolute level of penetration of neoplasm, measured
vertically in millimetres (1 mark). Clark level measures the depth of
penetration with respect to the anatomical location in the epidermis/dermis.
For example, dermal-papillary junction (1 mark).
Skin Cancer: Short Answer Question (18 marks)
You are a family GP in Gold Coast and one day, Tanya (19yo) walks in into your practice.
Tanya comes to see you concerning a suspicious looking mole on her shoulder. “I do have a
lot of moles but somehow this one looks bigger than before”, she says. You examine the
mole, and take the following photograph.
1. Name 4 features of this lesion that would raise your suspicion of it being a malignant melanoma.
(4 marks)
o It is asymmetrical
o Its border is irregular
o It shows colour variegation
o Its diameter is greater than >6mm
2. List 4 differential diagnoses of melanocytic nevi (2 marks)
Accept any of:
o
o
o
o
o
Melanoma
Seborrheic keratoses
Lentigines (accept both simple lentigo & solar lentigo)
Ephelides (accept ‘freckles’)
Haemangiomas
3. (a) List 5 possible routes by which a cancer can spread from its primary site to other areas of
the body. (5 marks)





Direct extension into surrounding tissue
Via the lymphatics (lymphatic spread)
Via the blood (venous or arterial; haematogenous spread)
Transcoelomic (seeding of body cavities)
In cerebrospinal fluid
(b) By which route does melanoma most often spread? (1 mark)

Via the lymphatics
Tanya’s case makes you think about the great number of Australians that die each year as
a result of skin cancer and you wonder how their deaths might have been prevented. (6
marks)
4. (a) Explain the difference between a primary prevention strategy and a secondary prevention
strategy.
Primary prevention strategies aim to reduce the incidence of a disease, i.e. prevent
disease occurrence. Secondary prevention strategies aim to reduce the prevalence
of a disease, i.e. by shortening the duration of a disease that has already developed.
(b) Give one example of a community-based primary prevention strategy and one example of a
community-based secondary prevention strategy that could be used to try to reduce skin cancer
mortality in Australia’s population.
A primary prevention strategy
Accept any reasonable answer, e.g. o Advising schools that they should make children wear hats when playing
outside
o Education campaigns advising people about correct sun safety.
A secondary prevention strategy:
Accept any reasonable answer, e.g. o Education campaigns advocating regular self-examination and professional
skin check ups
o Advising medical practitioners to conduct “opportunistic screening”, i.e. take
the opportunity to perform skin checks on patients when examining them for
something else
o A national screening program involving regular skin checks for all or for highrisk people
Spleen
(a) Wally L, aged 66, presents to your surgery with a 3-month history of fatigue, bleeding gums
and a ‘throat infection that won’t go away.’ Mr L also complains of abdominal discomfort,
pointing to the left upper quadrant. You notice that he looks rather pale.
One possible cause for Mr L’s abdominal discomfort is hypersplenism. Explain the normal
functions of the spleen and how such functions may have caused Mr L’s symptoms and signs
(2 marks)




(Normal function of the spleen: Removal/phagocytosis of old or abnormal erythrocytes/red
blood cells and leukocytes/white blood cells from circulation (1/2 mark) and
sequesters/stores/acts as a reservoir for platelets. (1/2 mark)
Overactive spleen can lead to excessive removal of erythrocytes  Anaemia (1/2 mark),
which may present with fatigue and pallor (1/2 mark).
Overactive spleen can lead to excessive removal of leukocytes  Increased susceptibility
to infections. (1/2 mark)
Overactive spleen may sequester more platelets  Thrombocytopenia  Increased risk
of bleeding, especially in the mucosa. (1/2 mark)
(b) List two (2) pathological processes that may cause hypersplenism (2 marks)
Congestion, obstruction, malignancy, infection, autoimmune reaction, storage
disease. (1/2 mark each, maximum 1 mark)
Travel Health: Short Answer Question (12 marks)
Maddox, a 22 year old male comes into your GP surgery. He has recently returned
from overseas & is complaining that he feels unwell.
a) What are four (4) key questions you would ask Maddox about his travel
history in order to develop an appropriate differential diagnosis? (2 marks)

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
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

Where did you travel?
When did you travel:– departure date– return date?
Did you travel in:– urban areas– rural areas?
What was the purpose of your travel:– tourism– visiting friends or relatives–
business– other?
What special activities did you undertake:– mountaineering– scuba diving– caving–
other?
What vaccinations did you receive?
Were you taking malaria prophylaxis?If so:– which drug did you take– when did you
start it– did you take it regularly as directed– are you still taking it?
Did you become ill while away?
Did anyone accompanying you become ill?
During the consultation, you find that Maddox’s symptoms include fever and lethargy.
You suspect he may have malaria.
b) Give four (4) other clinical features of malaria you would investigate (2 marks).


Confusion (cerebral malaria – fits and even coma)
hepatomegaly






splenomegaly
hepatoslenomegaly may be used instead of hepatomegaly/splenomegaly
jaundice
headache
any sign/symptom of anaemia (anaemia itself cannot be used as an answer)
myalgia
Maddox tells you that he did not take any prophylactic medications nor did he receive
any vaccinations due to his beliefs that they are a big scam by the big pharmaceutical
companies. He does not intend to have his children vaccinated either.
c) Explain as the GP how you would consider the following ethical principles (autonomy,
non-malificence, beneficence, justice) in relation to a parent choosing not to vaccinate their
child. (Maximum 8 marks)
Autonomy:




Autonomy – right to self-determination and non-interference - allowing one to make
their own decisions to refuse or consent to healthcare. (0.5 marks)
Doctors must respect the autonomy of their patients by avoiding paternalistic
behaviours (for example coercion) (0.5 marks), but must strive to improve autonomy
by ensuring their patients are fully informed (in this case, about the benefits of
vaccination)(0.5 marks)
Children are considered to have a lesser capacity to practice their autonomy
compared to an adult (0.5 marks). For this reason, a child’s parent or guardian is
able to consent to or refuse to vaccination, on behalf of the child, if it is done with the
child’s best interests in mind. (or, parents are commonly the substitute decision
makers who are responsible for their children’s healthcare) (0.5 marks)
Parents generally do not have the right to refuse a treatment that is immediately life
saving (0.5 marks). As a vaccine is not immediately life saving, the refusal of
vaccination for a child often falls within the rights of a parent authorizing their
autonomy. (0.5 marks)
Non-malifecence:



Non-malificence is the principal that dictates that above all, a doctor shall do no harm.
(0.5 marks)
In this case the doctor must consider the potential harms of administering the
vaccination (pain of injections) (0.5 marks) and the potential adverse effects of the
vaccination (0.5 marks). In the case of vaccinations these potential harms are low
(0.5 marks)
There is also a potential harm to the community if vaccination rates decline – there
will be a decrease in herd immunity and decreased protection for the wider
community (0.5 marks).
Beneficience:



Beneficience is the principle which drives doctors to do good to patients and to treat
with the patient’s best interests in mind (0.5 marks).
By immunizing children against preventable diseases, doctors are able to practice
beneficence by helping to prevent the burden of disease (1 mark)
By maintaining high vaccination rates, herd immunity is achieved thus benefiting the
wider community (0.5 marks)

In a highly immunized population, a parent may deem that their child can receive the
benefits of herd immunity without exposing their child to the potential adverse effects
of the vaccination program (0.5 marks)
Justice:




Justice is involved with the determination of rights and responsibilities and ensuring
that these are equally distributed amongst all members of society (0.5 marks)
Every individual in the community has a right to be protected from preventable
infectious disease, this can be achieved through maintaining high levels of childhood
vaccination (1 mark)
Vaccination is more cost effective than treating the acquired disease (good use of
public funds) (0.5 marks)
An unvaccinated child may be discriminated against in the context of their
education/societal opportunities (eg. denied daycare, removed from school during
outbreaks etc) (0.5 marks)
WBC Abnormalities SAQ
You are a haematologist at the RBWH and a patient, Bob G, is referred to you by his GP after
having a lymph node biopsied. The results show diffuse large B-cell lymphoma (stage 3). You
explain to him the diagnosis and prognosis. After the staging procedures are complete you
start Bob on CHOP-R therapy.
1. The staging demonstrates axillary and inguinal adenopathy. The bone marrow
biopsy/aspirate is negative and there are no other extranodal sites of involvement. Of
note, Bob presented without weight loss, night sweats or fever. What is the name of
the most common staging system used in patients with NHL? What stage would you
describe Bob’s lymphoma as being? (2 marks)
The Ann Arbor Staging System (1 mark)
Bob’s lymphoma is stage 3A (1 mark)
2. Explain the benefits of multi-drug treatment compared to single agent therapy (3
marks)
Using more than one drug increases the efficacy of treatment because the
patient experiences fewer side effects and more drug can be used/the ability of
the drug to kill cancer cells is better when used in combination.
An appropriate-level answer will mention and/or explain the concept of synergy – that
is, the word ‘synergy’ is not necessary but a demonstrated understanding of
decreased toxicity/lower drug doses for similar efficacy/complimentary mechanisms of
action is:
Drug regimens for cancer chemotherapy are designed to optimize the
antineoplastic effects of drug combinations (0.5 mark), while minimizing their
(systemic) toxicity (0.5 mark). The regimens often use drugs that work
synergistically, i.e. they have different toxic effects due to different
mechanisms of action, maximizing cytotoxic effects on tumour cells while
sparing host tissue(1 mark); thus multi-drug therapy can therefore be
successful with lower dose (1 mark).
3. CHOP-R includes the following drugs: cyclophosphamide, hydroxydoxorubicin,
vincristine, prednisone, and rituximab.
a. Give the mechanism of action for vincristine and indicate the cell cycle
phase where it acts. (2 marks)
Vincristine binds to tubulin (0.5mark) and blocks tubulin polymerization
(0.5mark). It acts on the M phase of the cell cycle (1 mark)
b. Name three adverse effects of prednisone in this patient (3 marks)
Cushingoid syndrome (telangiectasia, bufallo-hump, moon faces,
paper-like thin skin/bruising), hyperglycaemia, osteoporosis,
lymphopenia, cataracts, glaucoma, behavioural changes, hypertension.
(This list is not exhaustive – medically correct answers should all suffice)
– 1 mark for each good answer
SEMESTER 2
Dementia: Short Answer Question (9 marks)
Bill (73) and Joan (71) see you for a routine follow-up visit for Bill's blood pressure. Both have
been patients of yours for the past two years after selling their property and moving to
Brisbane from Roma due to declining health. Bill was diagnosed with Alzheimer's disease
shortly after seeing you for the first time and has been progressively deteriorating. Joan is frail
and suffers from rheumatoid arthritis and osteoporosis. Their closest family is their son, who
lives on the Gold Coast, 40 minutes from their unit. Today, both look a little more dishevelled
than usual and Joan is quite teary. She mentions that Bill has gone "walkabout" three
times this week and is now finding it difficult to dress himself. She mentions that she is having
difficulty helping him. Her arthritis makes her slow with zips and buttons and Bill gets angry
with her.
a) Using the table below, list and describe three features of Alzheimer's dementia and
describe at least two different ways in which the features would impact on Bill and on
Joan.
Feature
Impact on Bill
Impact on Joan
Example:
Depression (severe is rare
due to loss of insight)
Example:
Feelings of apathy,
or burdensomeness leading
to decreased self-esteem
and development
of/perpetuation of automatic
negative thoughts. Increased
risk of suicide during periods
of lucidity.
Frustration and annoyance at
self, sense of isolation.
Example:
Sense of guilt, frustration,
sadness, helplessness or
incompetence. Potentially
leading to a depressed mood
herself.
Memory loss - inability to
learn, retain and process new
information
Decline in language difficulty in naming and in
understanding what is being
said
Apraxia - Impaired ability to
carry out skilled motor tasks
Reduced ability to
communicate leading to
embarrassment, confusion,
anger and frustration. Failure
to understand directions,
instructions and requests
may result in dangerous
activities (failure to follow
safety directions, medication
dosage regimes).
Decreased independence,
reduced self esteem,
embarrassment and
frustration at not being able
to complete simple tasks
such as doing up zips,
buttons and shoelaces. Loss
of the ability to drive,
resulting in increasing social
isolation and withdrawal.
Increased need to supervise
and assist Bill, leading to
increased workload, stress
and decreased available time
for her own activities.
Difficulty communicating
effectively with her husband
may contribute to a sense of
isolation and altered feelings
toward him and subsequent
feelings of guilt. Frustration
with simple conversations
becoming repetitive and
tiring.
Required to assist with any
skilled motor tasks or will
have to do them herself,
increasing her daily
workload. Her own illnesses
may impair her ability to help
and external
assistance/devices may be
required adding costs and a
sense of helplessness,
dependence and
burdonsomeness.
Agnosia - Failure to
recognise objects
Depending on severity, may
result in confusion when
attempting simple activities
such as setting the table or
eating, or may lead to
potentially dangerous
situations with hot/sharp
items, small appliances and
tools, chemicals and
medications.
Progressive loss of executive
function
Inability to work or participate
in control of household
management tasks.
Continued attempts to do so
may result in unpaid bills, risk
of financial abuse,
inadvertent purchases.
Physical danger to himself or
others through wandering or
aggressive behaviour. May
result in further social
isolation. Delusional
episodes may be mistaken
for psychosis leading to
inappropriate medications.
Disinhibition may cause
behaviour that results in
community stigma and
further isolation or
victimisation.
Inability to relate to those
around him due to not being
aware of how his actions are
affecting them. May
contribute to loss of
friendships and long term
relationships without
understanding why, leading
to sadness, anger or
depression. He may refuse
treatment or medication
believing nothing is wrong
with him.
Feelings of apathy,
or burdensomeness leading
to decreased self-esteem
and development
of/perpetuation of automatic
negative thoughts, lethargy,
concentration problems and
lack of motivation. Increased
risk of suicide during periods
of lucidity.
Behavioural change agitation, aggression,
wandering, persecutory
delusions
Loss of insight
Depression (severe is rare
due to loss of insight)
Marking Guide:
May need to keep dangerous
items out of easy access
locations for fear that Bill will
accidentally harm himself or
others (‘child proofing’ the
house). May lead to anger,
frustration and arguments
over simple items Bill cannot
find or recognise, adding
more stress to their
relationship.
All responsibility for
household function lies with
her. This may be a new role
for her within the marriage.
She may also fall victim to
forms of financial or other
abuse.
Changes in Bill's personality
may lead to fear of physical
harm, sadness over the loss
of the previous relationship or
social embarrassment and
feelings of guilt. Wandering
episodes may lead to the
need to improve the security
of the house and yard or 24
hour observation, increasing
stress and workload.
Joan may take comments or
actions made by Bill
personally, yet still be fully
aware that they are due to
his inability to moderate his
behaviour. She may find it
difficult to get Bill to
cooperate with medical and
allied health staff or to
adhere to treatments,
increasing her stress and
anxiety.
Sense of guilt, frustration,
sadness, helplessness or
incompetence. Fear of
suicide of her husband. All
potentially leading to a
depressed mood herself.
A poor answer would be very factual and literal. The answers would be an extension of the
definition of the features and not an application of the definition to the biopsychosocial
aspects of Bill and Joan's lives. The student may not define the feature initially and use the
impact boxes to describe the feature, without actually describing the impact in terms of the
effect on Bill or Joan.
Feature
1 mark
Must show understanding of
the feature listed. This may
be through the description of
the feature, as in the sample
answer or by demonstrating
an obvious understanding of
the feature through its
impact. For example, apraxia
without further explanation
and an impact of inability to
remember... would only gain
½ a mark for the feature
because the feature listed is
technically correct, but the
student does not understand
what it is.
Impact on Bill
1 mark
Must describe at least two
ways in which the feature will
impact on the patient. Each is
worth ½ a mark.
Impact on Joan
1 mark
Must describe at least two
ways in which the feature will
impact on the carer. Each is
worth ½ a mark.
This should focus on aspects
of emotional, psychosocial,
practical or economic impact
(effect) on the patient. A
description of what the
feature is (eg. difficulty
performing skilled motor
tasks) only gains ½ a mark.
This should focus on aspects
of emotional, psychosocial,
practical or economic impact
on the carer. An extension of
a description of what the
feature is (eg. will have to
help in performing skilled
motor tasks) only gains ½ a
mark.
A good answer will place the
impact in the context of
Joan’s disease and social
support.
Depression
Mr Ben Zo, a 29 year old lawyer presents to you this morning saying that he is tired all the
time. He complains that he is having trouble concentrating at work and feels irritable. Despite
feeling tired during the day, he is finding it increasingly difficult to sleep at night and is
requesting “something to help him to sleep”. On further questioning, he denies any history of
traumatic life events, recent bereavements or changes to personal circumstances. You
believe Mr Ben Zoe is depressed.
(a) List four psychiatric diagnoses that you would consider for this patient (excluding
Major Depressive Disorder) (4 marks)
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
Bipolar disorder (depressive phase)
Substance abuse (alcohol, amphetamines, drug withdrawal)
Generalised anxiety disorder
Psychosis
Dysthymic disorder
Seasonal affective disorder
(b) You seek to identify if Mr Zo is at risk of suicide. List three (3) distinct risk factors that
you consider relevant in assessing his suicide risk that haven’t already been elicited
on history (3 marks)
3 marks for three responses. One mark for:


Suicidal ideation – thoughts, plans or intents
Previous suicide attempts

Feelings of hopelessness, helplessness and/or worthlessness
Half marks for (Note – this is the decision of the question checker from Mental Health)
 Family history of mental illness (eg mood disorder, suicide or substance
abuse)
 Access to means (eg drugs, firearms
 History of psychiatric illness (eg depression, bipolar disorder, alcoholism or
other substance abuse, schizophrenia, personality disorders…)
 Previous threats of suicide
 Social isolation or rural background
 Previous history of substance abuse
 Physical illness such as chronic pain, recent surgery and chronic or terminal
disease
No marks for:
 male gender,
 older age,
 recent bereavement,
 separation or divorce,
 recent retirement or loss of job
Doctor’s Health: Short Answer (4 marks)
The medical profession is often regarded as a particularly demanding and taxing lifestyle.
a)
Name 2 common problems that Doctor’s may be susceptible to due to the nature
of the profession.
Name 2 common problems that Doctor’s may be susceptible to due to the nature
of the profession.
 Alcohol and other substance abuse
 Depression
 Suicide
 Relationship difficulties
 Disenchantment with medicine leading to stress and burnout.
b)
List 2 barriers that may prevent Doctor’s seeking help regarding their problem.
List 2 barriers that may prevent Doctor’s seeking help regarding their problem.
 Stigma about psychiatric illness
 Lack of supervision
 Colleagues turn a blind eye “ there but for the grace of God go I”
 Misplaced loyalty esp. from student days
 Personality style eg the obsessional person sees admission of the need for
help as evidence of being intrinsically flawed
 Concerns about the confidentiality with which a colleague may treat
information they give them
 Pressure from self/ colleagues/ family to perform and achieve financially and
professionally
 Fear of being unable to continue to work and maintain lifestyle/service debts
 Knowledge about treatment limitations/ side-effects

Sense of omnipotence, unrealistic expectations of self
Drug Abuse SAQ
1. What are four diagnostic features of psychosis (2 marks)

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
Delusions
o Persecutory
o Of reference
o Grandiose
o (Paranoid – strictly speaking this is persecutory + grandiose)
o Autochthonous (Primary)
o Secondary
Formal thought disorder
Hallucinations (eg 3rd person auditory)
Thought alienation
o Insertion
o Withdrawal
o Stopping
o Broadcasting
Passivity phenomena
o Thought
o Will
o Action
2. List 2 pharmacological treatment agents used in psychosis, one side effect of each
and basic mechanisms of action of each (3 marks)
Typical Antipsychotics –
Side Effects
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
Dopaminergic
Extrapyramidal Side Effects
 (acute dystonias, akathsia, parkinsonism, tardive dyskinesia)
Endocrine side effects – increased prolactin levels
Anti-histamine
sedation,
antimuscarinic effects
dry mouth, blurred vision, urinary retention
postural hypotension,
weight gain
Jaundice
Agranulocytosis, Leucopenia
neuroleptic malignant syndrome (NMS)
Chlorpromazine only also causes photosensitivity
Prolongation of QTc interval (ECG effect)



Chlorpromazine
Thioridazine (?no longer available – taken off the market in UK)
Haloperidol
Examples
Mechanism Of Action
 Primary – antagonist at Dopamine D2,
 Secondary – antagonist at
o Dopamine - D1, D3
o Noradrenaline - alpha1
o Histamine - H1
o
o
Acetyle-choline - (muscarinic) M1
Serotonin (5-HT) - 5HT2. and probably others
Atypical Antipsychotics –
Not a uniform class. Much more variation between drugs…
Side Effects
 Extra-pyramidal side-effects
– much less common but do occur, probably more with
Risperidone, Amisulpride
– Dystonias
– dyskinesias
– akathisia, and other
 Weight Gain & metabolic syndrome
 esp. with olanzapine
 QTc prolongation
 Hypersalivation
 Esp. with Clozapine
 Agranulocytosis
 Esp. with Clozapine, requires monitoring as condition of
treatment
 Sedation
 More marked with quetiapine & Clozapine
 Less marked with the others
 Agitation sometimes with aripiprazole
Mechanism Of Action
 Mechanism of action not as well known and not the same between drugs.
 There is a theory that the newer drugs block 5-HT2A receptors & others
at the same time as they block DA receptors and that somehow this
serotonin-dopamine balance confers its characteristics.
 Also theory of “limbic-selectivity”

Aripiprazole is known to be dopamine D2/3 partial agonist.
Examples



Clozapine
Risperidone
Olanzapine
3. What are 4 of the criteria for drug dependence (2 marks)







Tolerance
Withdrawal symptoms
Difficulty controlling use, e.g. taken in larger amounts or for longer period
than intended or unsuccessful attempts to cut down
Strong desire or compulsion to use
Great deal of time getting, using, or recovering
Important activities given up or reduced
Continued use despite physical or psychological problems
4. List 4 risk factors for illicit drug use (2 marks)
o
o
o
Adolescence
Childhood physical sexual assault / poor quality family relationships
Early age of first use
o
o
o
o
o
o
o
o
o
o
o
o
o
Genetics
Knowledge
Lack of social bonding
Low socio-economic status
Male
Peer use / pressure
psychiatric conditions
Availability of drugs
financial means
lack of parental supervision
parental examples
physiologic vulnerability
Personality factors
 Anti-social behaviour
 Conduct disorder
 Impulse control problems
Epilepsy: Short Answer Question (10 marks)
Question:
Tara is a 20 year old female University student who comes to see you for a routine check up at
your GP clinic. You look up her history and note that Tara was diagnosed with Epilepsy when she
was sixteen (16) and is currently on Valproate. As you are talking to Tara you notice that she
seems quiet and subdued.
a) Discuss four (4) ways in which epilepsy can negatively impact on a Tara’s lifestyle



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




Stigma: Reinforces lack of self confidence and self esteem and therefore also anxiety
and depression states among epileptics. This leads to feelings of not fitting in
(especially children), difficulties in establishing friendships and other social contacts
and marginalization.
Relationships: Stigma and marginalization can result in difficulty establishing
relationships.
Loss of driver’s license: Almost always associated with some loss of freedom.
Simple things like going to work, visiting a doctor or going shopping may become very
difficult (especially in rural settings).
Employment: Certain occupations cannot be carried out by epileptics. The difficulty
in commuting to work may lead to loss of employment. Remember that employment
not only provides financial rewards but also a state of purpose. Therefore it is not
uncommon for the unemployed to question their self worth.
Sport & Leisure: Although encouraged, certain sports may require that a second
party be present (eg swimming).
Travel: Provisions for a supply of medication when travelling abroad must be made.
Travelling may raise further anxiety as to the consequences of a seizure while abroad.
Education: Some evidence suggests that epileptics collectively achieve at a lower
level than their peers. Biological factors such as memory disturbances play a
significant role as do other factors such as teacher/parental expectations,
misconceptions, high rate of absence from school, social isolation, and anxiety.
Housework: Activities such as climbing a ladder or using a power tool carry a higher
risk of injury.
Pregnancy: Seizures during pregnancy and side effects of medication (teratogenesis,
increased rate of babies born with birth defects, decreased effectiveness of OCP) are
all issues of concern to epileptic women of reproductive age.
b) An individual may cope with stigma in many ways. Following the example in the table list
three further ways an individual may cope with stigma, and explain these coping styles.
Coping style
Explanation
The patient may incorporate the stigma into their
Eg
Accept the stigma
identity and be open and positive about the stigma.
1
Correct the attribute to remove
stigma
2
Compensate
3
Find a secondary gain
Develop a new identity
Secrecy
Withdrawal
Through treatment and therapy the patient may be
able to remove the attribute causing the stigma
Finding ways to complete ordinary tasks despite
the condition and the stigma
Using the condition or the stigma associated with it
to access new areas and aspects of life
Finding a special, usually religious meaning behind
the stigmatised attribute, and embracing this as a
new identity
The patient may conceal the condition as far as
possible and may experience intense fear of others
discovering their condition
Withdrawal from normal social relationships and
becoming isolated due to excessive stigma from
the condition
Frequency/Urgency and Polyuria: Short Answer Question (6 marks)
Mr Hugh Rethra, a 67 year old man, presents to your general practice with urinary frequency
and urinary urgency. You perform a physical examination including a DRE. You diagnose
Benign Prostatic Hypertrophy
(a) What is the difference between urinary frequency and polyuria (specific volumes are not
required)? (1 mark)
Urinary frequency is urination a short intervals without increase in daily volume of
urinary output, whereas polyuria is the passage of a large volume of urine in a given
period.
(b) List four (4) differential diagnoses that may cause urinary frequency in this patient (2
marks)

Bladder infection (cystitis) *

Urethritis (infection of urethra)*

Infection of ureters*

Pyelonephritis (kidney infection)

*Or urinary tract infection

Bladder Neoplasm

Kidney neoplasm

Urinary tract neoplasm

Diabetes mellitus

Diabetes insipidus

Excess fluid intake

Diuretic use

Calculus of bladder#

Calculus of kidney#

Calculus ureter#

Calculus urethra#

# Or urinary tract calculi

Urethral stricture

Chemical irritation

Caffeine intake

Alcohol intake

Urethral stricture

Neurogenic bladder (poliomyelitis / parasympatholytic drugs / tabes dorsalis
multiple sclerosis / spinal cord lesion / diabetic neuropathy)

Psychogenic bladder

Anxiety

Urinary tract obstruction / Bladder outlet obstruction

External genital lesion

Pelvic mass

Extrinsic bladder compression

Upper motor neuron lesion

Detrusor instability

Prostate enlargement / obstruction e.g. prostatic cancer

Prostatitis

Nephritis

Hyperthyroidism

Hyperparathyroidism

Urinary tract clots

Anticholinergic drugs

Smooth muscle depressants

Haemorrhoid

Diverticulitis

Appendicitis
(c) Explain why Mr Smith is at increased risk of urinary tract infections. (1 mark)
BPH -> Urinary Tract Obstruction
Ascending
Reduced/absent voiding due to UTO
Bacterial growth and colonisation = infection
(d) A transurethral resection of the prostate is indicated. You are in the process of obtaining
consent. Briefly explain the two categories of material risk in QLD. (2 marks)
A risk is material if, in the circumstances of the particular case:
1. Proactive duty: a reasonable person in the patient’s position, if warned of
the risk, would be likely to attach significance to it. (1)
2. Reactive duty: the medical practitioner is or should reasonably be aware
that the particular patient, if warned of the risk, would be likely to attach
significance (1)
Parkinson’s Disease: Short Answer Question (8 marks)
Timmy Tremble, aged 63 years, presents to your GP practice, with an exacerbation of his
symptoms. He was previously diagnosed with Parkinson’s disease 5 years ago, and was
well-controlled on Levadopa until recently.
(a) List four classical features (signs / symptoms) of Parkinson’s disease. 2 marks
(pass: 1.5)




rigidity 0.5 marks
resting tremor (at 4-6 Hz) 0.5 marks
postural instability / gait disturbance 0.5 marks
akinesia / slowness or clumsiness in movements 0.5 marks [1]
(b) Describe the pathophysiology underlying Parkinson’s disease, specifically relating to
the basal ganglia and their influence on the motor pathways. You may wish to use a
diagram to aid in your explanation. 4 marks (pass: 2)




Idiopathic Parkinson’s disease is characterised by decreased dopamine
synthesis (0.5 marks) due to progressive degeneration of neurons in the pars
compacta of the substantia nigra (0.5 marks), resulting in a functional deficiency
of dopamine in the striatum of the basal ganglia (0.5 marks).
Under physiological conditions, dopamine stimulates the direct pathway (which
facilitates movement) through the basal ganglia, whilst inhibiting the indirect
pathway (which inhibits movement) (0.5 marks). The functional dopamine
deficiency leads to dysregulation of the basal ganglia via down regulation of the
direct pathway and up regulation of the indirect pathway (0.5 marks).
This leads to a decreased signal via the thalamus to the motor cortex (0.5
marks), resulting in decreased activation of the corticospinal tract (0.5 marks).
The overall result typically manifests as slowed responses and less spontaneous
movement (0.5 marks). [2,3]
A basic map of the basal ganglia and the pathways involved may assist in explaining the
underlying pathophysiology: e.g.
(c) Parkinson’s disease is a chronic illness. Describe four challenges faced by people
who have a chronic illness. 2 marks (pass: 1.5)









Gaining access to appropriate well coordinated services
Availability of after-hours care including home visits
Problems with transport and mobility
Communication problems
Financial disadvantage
Stigma / self-esteem issues
Management of co-morbidities or complications: depression, falls,
Relationship strains – carers, family and friends
Long-term management of medications e.g. adherence and side effects [5]
Headache Questions SAQ
A 35 year old female presents to a GP with increasing tiredness, a stiff neck and difficulty in
concentrating over the last 48 hours. Combined with this has been an increasing sensitivity to
bright light and loud sounds. She says she has experienced these symptoms in the past as
they usually precede a bad headache most often located to one side of her head which is
throbbing in nature and aggravated by physical activity.
a) Give three differential diagnoses for the presenting complaint


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




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




Cluster headache
Brain tumor
Temporal (giant cell) arteritis
Sinusitis
Subarachnoid hemorrhage
Pseudotumor cerebri
Transient ischemic attack
Tension headache
Venous thrombosis
Idiopathic intracranial hypertension (IIH)
Hypoxia
Hypoglycemia
Dialysis
Pheochromocytoma
Raeder's syndrome
Glaucoma
Hypnic headache
Dissection of the carotid or vertebral artery
Antiphospholipid antibody syndrome
Cerebral vasculitis
Moyamoya disease
CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and
leukoencephalopathy)
MELAS (mitochondrial encephalopathy, lactic acidosis, and strokelike episodes)
syndrome
b) Name three non-pharmacological treatments of this acute condition




Rest or sleep in a dark and quiet room
Relaxation techniques may be of benefit
Avoid triggers
Dark room









Warm or cold packs to head
Spinal manipulation
Rebreathing into paper bag
Relaxation techniques
Neck massage
Avoidance of triggers such as:
o alcohol
o hunger
o foods (eg chocolate, cheeses, MSG, nitrate-containing foods)
o irregular sleep patterns
o organic odours
o sustained exertion
o altered stress levels
o flashing lights/glares
managing environmental shifts such as:
o time zone changes
o high altitude
o barometric pressure changes
o weather changes
Avoid movement/activity (including reading and watching TV)
Rehydration with IV fluids if vomiting persistent
c) Name three pharmacological treatments of this acute condition







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
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



Paracetamol
NSAID
o Ibuprofen
o Naproxen
o Diclofenac
o ketoprfen
Metoclopramide
Domperidone
Sumatriptan
Naratriptan
Zolmitriptan.
Ergotamine
Dihydroergotamine
Aspirin
Opioids
Triptans
Narcotics
o Codeine
o Pethidine
Prochlorperazine
Kidney Failure: Short Answer Question
A 59 year old obese male with chronic renal failure is noted by the registrar to be in a
delirious state. This morning on ward rounds, he mentions that he wishes to make an
advance health directive (AHD) to cease dialysis, if his condition deteriorates further.
(a) Is he currently in a legal position to write an AHD? Select one of the following.
a)
yes
b)
no
Answer B
(b) Describe 2 of the advantages of AHDs: (2 marks)




They extend self-determination beyond competency
Avoids quality of life decisions having to be made by others
Help reduce anxiety of patients over end-of-life issues
Help reduce anxiety of health practitioners over end-of-life issues )
(c) List 2 circumstances in which an AHD may be overruled: (2 marks)




Terms are uncertain or contradictory.
Contrary to good medical practice.
Inappropriate because circumstances have changed.
Inappropriate because of advances in medical science. )
Meningitis: Short Answer Question (9 marks)
A 17 year old male presents to your general practice with headache, photophobia, neck stiffness
and a temperature of 39.2°C. You suspect bacterial meningitis.
a) Apart from meningitis, give two possible differential diagnoses (2 marks)
Malaria,
encephalitis,
septicaemia,
subarachnoid haemorrhage,
tetanus
b) Name three (3) organisms which commonly cause bacterial meningitis (3 marks)
Haemophilus influenza,
Neisseria meningitidis (or meningococcus),
Streptococcus pneumoniae (or streptococcus),
Listeria monocytogenes,
Escherichia coli,
Staphylococcus aureus,
Group B streptococcus
c) The diagnosis of bacterial meningitis caused by some organisms is notifiable under the public
health act of 2005. What public health measures are taken after diagnosis is made? (4 marks)




Notify public health
Contact tracing
Clearance (or chemoprophylaxis)
Vaccination if appropriate
Psychosis: Short Answer Question (8 marks)
Ms P, aged 22, presents to you in the E.D. one evening with an apparently minor laceration
on her left forearm. She has been brought in by a concerned friend, and is acting a little
strangely but you think this might just be anxiousness at being in the E.D., and annoyance at
the length of time she has been waiting to be seen. However, it crosses your mind that she
might need psychological assessment.
1. List 4 features of psychosis (2 marks, ½ mark each)
Disruption of the Form and Flow of Thought and Speech
Flight of ideas (disconnected ideas, incoherent speech, loose associations)
Pressured speech (rapid and unrelenting speech)
Thought blocking (speech halted for variable intervals)
Clanging (rhyming speech without meaningful content)
Echolalia (sing-song repetition of recently heard words or phrases)
Neologisms (idiosyncratic or newly coined words)
Alogia (paucity of speech, mutism)
Disruption of the Content of Thought and Perception
Delusions (false beliefs about reality that are not amenable to revision by
fact)
Persecutory delusions (others intend the person harm)
Delusions of grandeur (person is famous or all powerful)
Delusions of reference (events or others' actions are directed at the person)
Thought broadcasting (the person's thoughts can be sensed by others)
Thought insertion (others' thoughts are invading the person's mind)
Loss of insight (unawareness of the person's illness)
Hallucinations (typically auditory > visual in schizophrenia; visual > auditory in
organic psychoses)
Disruption of Emotions
Blunting of affect
Inappropriate affect
Labile affect
Disruption of behavior
Ritual behavior
Aggressiveness
Sexual inappropriateness
Posturing or grimacing
Mimicking
Withdrawal
2. Psychotic disorders may be functional (without known biologic cause) or organic
(resulting from medical or neurologic illness or cause).
List 2 features (signs or symptoms, but not investigation results)
(1 mark each) that might point to psychotic symptoms being the result of organic
disease.
For each of these listed features, describe how they point towards organic disease (1
mark for each)? (NB: Schizophrenia, depression, schizophreniform disorder, and
similar psychiatric conditions are not classed as organic illnesses for the purposes of
this question.) (4 marks)
Clues to the possible organic basis of psychosis include the following:
substantial memory loss, clouding of consciousness, absence of a family or
personal history of psychiatric illness, presence of a serious underlying
medical or neurologic condition, acute onset of symptoms, visual rather than
auditory hallucinations, and presence of myoclonus or asterixis. (Andreoli &
Carpenter’s Cecil Essentials of Medicine, 7th ed, p 1060)
Explanations could include:
 Memory loss is more common in patients with dementia, and is a common
feature of delirium (see Kumar & Clark, 6th ed, p 1309-10)
 Short term memory loss could be the result of intoxication or alcohol abuse
(Korsakoff's syndrome).


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


People with a family history of psychiatric conditions, are more likely to have the
condition themselves than those without a similar history. (e.g. for schizophrenia,
see Kumar & Clark, 6th ed, p 1307)
A serious known underlying medical condition would obviously make this a more
likely cause – delirium is common in hospital patients (see above ref & Harrison’s
17th p 1724)).
Acute onset can suggest delirium, particularly in hospital patients (see K&C ref)
Auditory hallucinations are a common symptom of schizophrenia, but visual
hallucinations are much more common in delirium.
myoclonus can be seen in association with pathology in cortical, subcortical, or
spinal cord regions, associated with hypoxic damage (especially following cardiac
arrest), encephalopathy, and neurodegenerative disorders. Reversible myoclonus
can be seen with metabolic disturbances (renal failure, electrolyte imbalance,
hypocalcemia), toxins, and many medications. (Harrison’s 17th, p2500).
Asterixis is an indication of hepatic encephalopathy. (Harrison’s 17th, p 1979).
Clouding of consciousness can be caused by diffuse metabolic processes (e.g.
organ failure) and focal, structural processes (e.g. stroke). (Harrison’s 17 th, p
1721).
Anything else that on the face of it makes sense.
3. Choose 2 features in Ms P’s history and explain how they might lead you to a
particular diagnosis. Each feature can contribute to a different diagnosis, or they can
both point to the same diagnosis. (2 marks)





She presents late at night which might point to alcohol or drugs being the cause
She has an obvious traumatic injury. There could be others, perhaps a head
injury, which could cause strange behaviour.
She might simply be anxious and tired, with the laceration being the only real
problem.
She might be depressed and the laceration is the result of self-harm, particularly
since it is her left arm.
Anything else that seems coherent
SAQ –Renal Failure
Dave the Wiggle is a long-term patient of your clinic with a progressively defining eGFR. It
has been under 60 for greater than 3 months, and his latest result indicates an eGFR of 40.
(a) Give two modifiable and two non-modifiable risk factors for this condition. (2 marks; 0.5
marks each)
modifiable risk factors:
 Hypertension
 Diabetes Mellitus
 Smoking
 Obesity
 Other answers:
o Excessive dietary protein,
o Hyperlipidemia,
o Abnormal calcium/phosphorus homeostasis
Non-modifiable risk factors:
 ’in age or advancing age
 Family history of kidney disease
 Race (ATSI, African)
 Other answers:
o Previous episode of acute renal failure;
o Structural abnormalities of urinary tract;
o
o
o
Autoimmune disease;
Genetics;
Intrinsic paucity in nephron number
(b) The kidney is involved in many functions of the body and some of these are listed in the
table below. What is the complication that results from a failure of this function in chronic
kidney failure? (0.5 marks each) Outline a mechanism for this effect (1 mark per mechanism).
An example is shown below.
Function of Kidney
Eg. Erythropoietin (EPO)
synthesis and release
Complication associated with
chronic renal failure
Anaemia
Vit D synthesis/activation
Osteomalacia
Acid/Base balance
Metabolic Acidosis
Mechanism
KF  dec EPO production
and release  dec red
blood production  overall
decreased RBC mass 
anaemia.
KF → decrease in 1,25dihydroxycholecalciferol →
decrease in activation of
vitamin D to active form →
decreased intestinal
absorption of calcium and
phosphate → decreased
mineralisation of bone
(osteomalacia)
KF → decreased excretion
of protons (H+, K+,
NH4+)(loss of buffering
systems) → increased
retention of H ions in the
blood → ↓pH → metabolic
acidosis