Yr 3 Formative EMQ

Medicine, Nursing & Health Sciences

YEAR 3 MBBS FORMATIVE EMQ TEST June 2007

INSTRUCTIONS TO CANDIDATES
1. CANDIDATES ARE REMINDED THAT THEY SHOULD HAVE NO BOOKS, NOTES, PAPER OR OTHER MATERIAL IN THEIR POSSESSION.
EXAM DURATION: 2 hours, 10 minutes (10 minutes reading time + 2 hours writing time)

There are 80 questions to be attempted. Each question has only one correct answer. You are advised to attempt each question. TWO EMQ ANSWER SHEETS are to be used for this paper. You MUST use BOTH SIDES of Answer Sheet 1 and clearly mark it as Test No. 1 You MUST use BOTH SIDES of Answer Sheet 2 and clearly mark it as Test No. 2 The candidate number in the bottom left section of Page 1 of the General Purpose Answer Sheet must be completed. Your number is your Monash student ID number. You should also complete your name in the top left hand section of the answer sheet and the subject and date details below that for identification purposes. Answer sheets must be completed by using black/blue pen or pencil. Any white out/erasure must be complete and without smudge.

Candidates must complete this section STUDENT ID ______________________________

STUDENTS MUST NOT REMOVE THIS PAPER FROM THE EXAM ROOM

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Yr 3 Formative EMQ

For the following clinical scenario, select the most likely cause of the patients splenomegaly that was found on examination. Options: A Acute lymphocytic leukaemia B C D E F G H I Acute myeloid leukaemia Amyloidosis Chronic lymphocytic leukaemia Chronic myeloid leukaemia Gauchers disease Infectious mononucleosis Infective endocarditis Hodgkins lymphoma

J K L M N O

Malaria Myelofibrosis Non-Hodgkins lymphoma Portal hypertension Thalassaemia Tuberculosis

Question: 1. A 21 year woman presents with a 3 week history of increasing tiredness associated with a sore throat and tender cervical lymph nodes. Atypical mononuclear cells were found in a peripheral blood sample, and she developed a fine rash after being given amoxycillin for her sore throat. Her spleen is palpable 1cm below the costal margin and is soft.

For the following scenario, select the most likely causative condition. Options: A Acropathy B C D E Hypertrophic pulmonary osteoarthropathy Osteoarthritis Osteomalacia Osteopetrosis

F G H I

Osteoporosis Pagets disease Psoriatic arthropathy Rickets

Question: 2. Mary is an 81 year old woman, who has been generally well and living on her own. She had a fall after tripping over her small dog. She is unable to stand up and on examining her, you note that her right leg is shorter than her left by 2 cm, and is in external rotation.

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Yr 3 Formative EMQ

For the following patient who presents with a skin lesion, select the most likely diagnosis. Options: A Basal cell carcinoma B C D E Glomus tumour Implantation dermoid cyst Keratoacanthoma Marjolins ulcer

F G H I J

Paronychia Pilonidal sinus Sebaceous cyst Sequestration dermoid cyst Squamous cell carcinoma

Question: 3. Bob Brown, aged 91, presents to you with a lesion on one side of his nose. The lesion has an overlying scab. The patient says he has had the lesion for many years and it occasionally bleeds. On examination you note a 2 x 3cm ulcer with raised edges. The edges appear white, however they have overlying telangiectasia.

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Yr 3 Formative EMQ

For each of the following patients who present with abdominal pain, select the single most appropriate INITIAL imaging investigation required. Options: A Abdominal x-ray B C D E F G H I J K L N O P Q R S T U V W X Carotid Doppler ultrasound Carotid arteriogram Chest x-ray Coronary arteriogram CT abdomen CT brain CT chest CT neck CT pulmonary angiogram Doppler venous ultrasound Echocardiogram MRI brain MRI chest MRI spine Nuclear bone scan Pulmonary arteriogram Thallium cardiac scan Thyroid nuclear scan Ultrasound abdomen (4) Ultrasound neck Ventilation perfusion (VQ) nuclear scan X-ray skeletal survey (6) (5)

Question: 4. A 44 year old previously well woman presents with acute postprandial right upper quadrant pain radiating to the right shoulder. Apart from right upper quadrant tenderness, examination is unremarkable. 5. A 59 year old man presents with severe central abdominal pain radiating through to his back. His BP is 90/70 and a tender, pulsatile central abdominal mass is palpable. 6. A 58 year old previously well man presents to a large metropolitan hospital with shortness of breath and sharp, substernal chest pain that is relived by sitting forward. Apart from tachycardia, his physical examination reveals a rub on auscultation. An electrocardiogram (ECG) shows concave upwards ST elevation in anterior, lateral and inferior chest leads.

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Yr 3 Formative EMQ

For the following patient who is admitted to hospital with severe left ventricular failure, choose the most likely diagnosis. Options: A Dilated cardiomyopathy B C D Ebsteins anomaly Infarction of papillary muscle Infective endocarditis

E F G H

Marantic endocarditis Rheumatic fever Noonans syndrome Syphilitic aortitis

Question: 7. A 20 year old man is admitted to hospital with severe left ventricular failure. On examination he has signs of aortic regurgitation and right sided pyramidal weakness. He has an intermittent pyrexia, anaemia and a raised neutrophil count.

Answer the question below using the most appropriate option from the following list. Options: A ACE inhibitors B C D E F Alpha blockers Beta Blockers Calcium channel blockers Thiazide diuretics Vasodilators

Question: 8. In a patient with chronic progressive renal impairment secondary to diabetic nephropathy, and no evidence of renal artery stenosis, which class of drug is the most appropriate initial therapy for hypertension?

For the following patient scenario, indicate the most likely diagnosis. Options: A Acute interstitial nephritis B C D E Acute tubular necrosis Adult polycystic kidney disease Analgesic nephropathy Crystal nephropathy

F G H I J

Hepato-renal syndrome Nephrotic syndrome Reflux nephropathy Renal tubular acidosis Sickle-cell nephropathy

Question: 9. A 25 year old meat-packer from Gippsland has been sent home by his supervisor due to swelling of his legs and tiredness. He is passing dark, frothy urine. On examination, there is oedema of his legs and genitalia. He has severe proteinuria (urinary albumin 6g/day) and the serum albumin is 27g/L (35 - 50g/L).

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Yr 3 Formative EMQ

For each of the following patients with gastrointestinal blood loss, select the most likely diagnosis. Options: A Acute diverticulitis B C D E F G Acute peptic ulcer Amoebic dysentery Anal fissure (10) AV malformation Carcinoma of the sigmoid colon Crohns disease

H I J K L M

Gastritis Haemorrhoids Mallory Weiss tear Meckels diverticulum Oesophageal varices (11) Ulcerative colitis

Question: 10. A 21 year old man presents to his local GP with bright per rectum bleeding. He notices blood streaking his stool and on the toilet paper. Defecation is painful and wiping his anus even more so. He has noticed no change in his weight and no change in his bowel habits. 11. A 74 year old alcoholic woman presents after having passed a large bright fresh haematemesis. On examination her abdomen is grossly distended with ascites and she has a caput medusa. She has multiple purpura and spider navei.

For the following clinical scenario, select the most likely site of this patients neurological lesion. Options: A Autonomic Neuropathy B C D E F G Brain stem lesion Cortical lesion Myopathy Peripheral neuropathy Spinal cord lesion Thalamic lesion

Question: 12. A 40 year old diabetic woman with renal failure presents with postural hypotension, nausea, vomiting and frequent diarrhoea with some loss of faecal continence. She is on no medications at present. On examination she is found to have a full bladder with a high post micturition residual volume.

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Yr 3 Formative EMQ

For each of the following patient scenarios, select the most appropriate pharmacological treatment. Options: A Clopidogrel B C D E DDAVP Dipyridamide Factor VIII (14) Factor IX

F G H I

Heparin Low molecular weight heparin Tissue plasminogen activator (13) Warfarin

Question: 13. A 45 year old man presents to the Emergency Department of a rural hospital with acute onset of crushing central chest pain, radiating down his left arm. An ECG reveals ST elevation in the anterior chest leads. 14. A 45 year old man has an x-linked disorder of coagulation which has resulted in multiple bleeding episodes, including bleeding into joints (haemarthroses). He receives a regular intravenous infusion of a drug to help prevent ongoing bleeding.

For the following patient who presents with a lump in the groin, select the most likely diagnosis. Options: A Femoral hernia B C D E Hydrocoele Inguinal hernia Sarcoma Seminoma

F G H I J

Spermatocoele Teratoma Torsion of the hydatid of Morgagni Torsion of the testis Varicocoele

Question: 15. John Best is a 32 year old man who complains of a swelling in his groin. On examination you find a swelling in the right scrotum. The testes can be felt separately from the swelling however it is impossible to get above the swelling.

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Yr 3 Formative EMQ

For the following patient scenario, select the most appropriate ethical expectation of the doctor in the Australian context. Options: A Develop a close relationship with the patient and his family. B C Ensure that the patient does not become depressed and give up hope. Protect and enhance the patients autonomy by offering him a full account of his diagnosis, which includes opportunity for treatment, and may include family consultation with his consent. Respect the cultural context from which the patient comes. Respect the wishes of the family.

D E

Question: 16. Mr Coutas is a 60 year old Greek man with limited English who presents with a four week history of lower back pain. His pain is constant but worsened by movement. He has been taking regular Panadol without any relief. A CT scan reveals the likelihood of cancer. As the unit resident you are approached by the son who requests a meeting between you and his family without his dads knowledge. Mr Coutas wife, daughter and son do not want him to be made aware of his diagnosis as they feel culturally it is inappropriate and that he would become very depressed.

For the following patient scenario, select the most appropriate diagnosis. Options: A Aspergillus B C D E Candida Cytomegalovirus Herpes simplex Mucormycosis

F G H I J

Mycobacterium avium intracellulare Mycobacterium tuberculosis Nocardia Staphylococcus sp Streptococcus sp

Question: 17. A 53 year old thin, homeless man presents to his community health service with a persistent cough and haemoptysis. A chest x-ray shows a cavitating lesion in the left lung apex.

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Yr 3 Formative EMQ

For the following scenario, select the most appropriate therapy for the patients condition. Options: A Long term suprapubic catheterisation B C D E F G Long term urethral catheterisation with prophylactic antibiotics Prazosin therapy Radical prostatectomy Regular review with serial PSA measurements Trans-urethral resection of the prostate Trimethoprim therapy

Question: 18. A physically active 75 year old man in otherwise good health presents with urinary symptoms (frequent nocturia, hesitancy and post micturition dribbling). He has an enlarged prostate on digital rectal examination, a serum creatinine of 200mol/L (<120mol/L), a serum PSA of 9ng/ml (< 6.5ng/ml), and a urinary tract ultrasound shows bilateral hydronephrosis.

For each of the following patient scenarios, identify the most likely site of injury as indicated by the characteristic motor and/or sensory deficits. Options: A Brown-Sequard Syndrome hemisection of the spinal cord (at T11) B C D E F G H I Cauda Equina lesion Common peroneal nerve injury Lateral cutaneous nerve of thigh injury Median nerve injury Radial nerve injury Syringomyelia C5-T2 Total transaction of spinal cord at T11 Ulnar nerve injury (20) (19)

Question: 19. Angela presents to her GP after having been hit by a hockey stick just below her right knee on the outside during the championship match. The stick had been lifted with full force and as the coach surveyed the bruise, she wondered if the fibula had been fractured. Afterwards, Angela noticed there was a patch of numbness on the dorsum of her right foot. 20. Peta, aged 25 years, presents to your clinic. She is currently pregnant and the baby is due in a month. She has noticed nocturnal tingling and pain in her right hand-especially at night. On examination, there is weakness of the thenar muscles and sensory loss in the index, middle and ring fingers.

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Yr 3 Formative EMQ

Below is a pathology report. From the options listed, select the most likely diagnosis. Options: A Anal fissure B C D Colorectal cancer Crohns disease Diverticulosis

E F G H

Haemorrhoids Infective diarrhoea Peptic ulcer disease Ulcerative colitis

Question: Pathology Report: 21. The lesion in the resected bowel demonstrated cobble stone appearance with the presence of fistulae and micro abscesses microscopically, transmural granulomas are seen with Langhans giant cells.

For the following patient with diabetes, select the most appropriate treatment. Options: A Combined rosiglitazone & metformin B C D E Combined sulphonylurea & metformin Commence insulin Commence metformin Intramuscular glucagons

F G H I

Intravenous dextrose Omit metformin Omit morning insulin dose Withhold oral hypoglycaemic agent

Question: 22. Bill Anderson is 70 years old and has type 2 diabetes. He is currently being treated with maximum doses of metformin. His blood sugar remains unacceptably high. He is taking frusemide and an angiotensin-converting enzyme inhibitor for heart failure.

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Yr 3 Formative EMQ

For the following patient who presents with gastrointestinal blood loss, select the most likely diagnosis. Options: A Acute diverticulitis B C D E F G Acute peptic ulcer Amoebic dysentery Anal fissure AV malformation Carcinoma of the sigmoid colon Crohns disease

H I J K L M

Gastritis Haemorrhoids Mallory Weiss tear Meckels diverticulum Oesophageal varices Ulcerative colitis

Question: 23. A 35 year old man presents to the Emergency Department after vomiting up a cup of bright red blood. He estimates he had consumed 15 glasses of beer that day, and had vomited vigorously several times in the past few hours. Only the last vomit had blood within it. On examination his blood pressure is 120/70 mmHg, his pulse rate is 80bpm. His haemoglobin is 140g/L (135 177g/L).

For the following patient scenario, indicate the diagnosis which you consider most likely. Options: A Bladder tumour B C D Glomerulonephritis Malignant hypertension Polycystic renal disease

E F G H

Pyelonephritis Renal calculi Renal trauma Urinary tract infection

Question: 24. A 22 year old woman presents to her GP with haematuria. She recently had an upper respiratory tract infection. Her urinalysis shows: dysmorphic red cell, red cell casts and proteinuria and no WBCs.

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Yr 3 Formative EMQ

For the following patient with a mediastinal mass, select the most likely diagnosis. Options: A Castlemans disease B C D E F Ganglioneuroma Germ cell tumour Hodgkins lymphoma Non-Hodgkins lymphoma Thymoma

Question: 25. An 18 year old female presents with a two month history of fatigue and night sweats. Her chest x-ray shows a mediastinal mass that on biopsy reveals Reed-Sternberg cells.

For the following patient scenario, choose the most likely organism which is causing the patients infective diarrhoea. Options: A Bacillus cereus B C D E Campylobacter jejuni Clostridium botulinum Clostridium difficile Clostridium perfringens

F G H I

Escherichia coli Salmonella enteritidis Shigella species Staphylococcus aureus

Question: 26. An 84 year old man was hospitalized for intravenous antibiotics for treatment of a severe episode of pneumonia. Two weeks later he developed watery diarrhoea.

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Yr 3 Formative EMQ

For the following patient scenario, select the most appropriate diagnosis. Options: A Ductal carcinoma in situ B C D Fibrocystic change Infiltrating duct carcinoma Lactating adenoma

E F G

Leukaemia Lipoma Metastatic melanoma

Question: 27. 60 year old female presents with a lump in her breast. The core biopsy performed shows glands of varying size, lacking a myoepithelial layer, lined by cells showing enlarged, hyperchromatic nuclei and prominent nucleoli.

For the following patient scenario, select the most likely single cause of the patients signs and symptoms. Options: A Asbestosis B C D E F Asthma Bronchogenic carcinoma Bronchopneumonia Idiopathic pulmonary hypertension

G H I J

Mitral valve stenosis Myocardial Infarction Pulmonary thromboembolism Sleep apnoea Type 1 hypersensitivity reaction

Chronic obstructive pulmonary disease K

Question: 28. A 76 year old woman is admitted via the Emergency Department with a fractured right femur and multiple soft tissue injuries following a motor vehicle accident. She is obese and smokes 25 cigarettes per day. She is on no regular medication. She undergoes open reduction and internal fixation of her fracture but is unable to mobilize for 5 days and requires narcotics for pain management. Six days post operatively, while straining to use her bowels, she develops sudden severe shortness of breath. Shortly thereafter she collapses, ceases breathing and has no cardiac output. Attempts at resuscitation are unsuccessful.

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Yr 3 Formative EMQ

For the following patient scenario, select the most likely diagnosis. Options: A Acute glandular fever syndrome B C D E F Community acquired sepsis Diffuse lympadenopathy Hepatitis B HIV seroconversion illness Measles

G H I J K

Meningitis syndrome Rubella Scarlet fever Syphilis Toxoplasmosis

Question: 29. John is a 29 year old man admitted to the infectious diseases unit of the hospital with a history of a flu like illness. His medical history and physical examination reveals a recent weight loss of 4.5 7kg, including diarrhoea for the past three weeks. He has had night sweats as well as enlarged glands in his neck and under his arms. He has a diffuse rash over his back. His temperature is 38.5C and he is complaining of chills and generalised tiredness and weakness. His lab results are as follows: Hb 107g/L (120 160g/L) WCC 3.2 x 109/L (3.5 11 x 109/L) Lymphocyte count 0.3 x 109/L (1.0 4.0 x 109/L) 9 Platelets 150 x 10 /L (150 400 x 109/L) 3 CD4 cell count 190 cells/mm (> 500 cells/mm3) HBsAg negative HIV ELISA test negative

Below is a list of antimicrobial agents. From this list choose the most effective therapy for the following patient scenario. Options: A Amoxycillin B C D E F Benzylpenicillin Ceftriaxone Clotrimazole Doxycycline Flucloxacillin

G H I J

Ketoconazole Metronidazole Roxithromycin Trimethoprim

Question: 30. A 21 year old female presents to the Emergency Dept with a 12 hour history of increasing headache and neck stiffness. She has no allergies. On examination you note that she is agitated, has a temperature of 38C, and is photophobic with a positive Kernigs sign. You also note that she has a petechial rash on her hands and feet.

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Yr 3 Formative EMQ

For the following patient scenario, indicate the site that is most likely site to be damaged resulting in the described disturbance of cardiac rhythm. Options: A Atrioventricular node B C D E F Bundle of His Cardiac muscle (myocardium) Left bundle branch Right bundle branch Sinoatrial node

Question: 31. You are evaluating Barbara, an elderly woman who has been bothered by dizziness and fatigue. Her blood pressure is normal and the resting pulse is 58bpm and irregular. An ECG shows that she has no P waves and an irregular rhythm.

For the following patient who presents with painful hands, choose the condition which most appropriately matches the physical description provided. Options: A Ankylosing spondylitis B C D E Crohns/ulcerative colitis, arthritis Osteoarthritis Reiters syndrome Rheumatoid arthritis

Question: 32. A 75 year old man presents to his GP with painful hands. On examination he is found to have Heberdens nodes at the distal interphalangeal and nodes at the proximal interphalangeal joints.

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Yr 3 Formative EMQ

For the following patient presenting with tiredness, select the matching term for the given characteristics or groups of conditions most likely causing her anaemia. Options: A B12 deficiency B C D E F G H I J Cold type haemolytic anaemia Drug induced haemolytic anaemia Folate deficiency G6PD deficiency Heredity elliptocytosis Heredity spherocytosis Iron deficiency anaemia Microangiopathic acquired haemolytic anaemia Post infective haemolytic anaemia

K L M N O

Pyruvate kinase deficiency Sideroblastic anaemia Thalassaemia Transfusion reaction Warm type haemolytic anaemia

Question: 33. A 78 year old woman presents to her GP complaining of tiredness. On examination, she is pale and she reveals that she is spending most of her pension on rent and utility bills, so for the past six months ONLY she has had a very poor diet, with no fresh vegetables. Her full blood examination reveals anaemia Hb 93g/L (115-160g/L), associated with an increased mean corpuscular volume (MCV) of 110 fl (78-98 fl).

For the following patient who presents with involuntary movement, select the most likely diagnosis. Options: A Asterixis B C D E Athetosis Cerebellar tremor Chorea Dystonia

F G H I J

Essential tremor Exaggerated physiological tremor Multiple sclerosis Parkinsons disease Wilsons disease

Question: 34. Jenny is a 37 year old woman who presents with an intention tremor, nystagmus and urinary incontinence.

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Yr 3 Formative EMQ

For the following patient scenario, indicate the most likely diagnosis. Options: A Apo-CII deficiency B C D E F G Familial combined hyperlipidaemia Familial hypertriglyceridaemia Heterozygous familial hypercholesterolaemia Lipoprotein lipase deficiency Secondary hyperlipidaemia Type III hyperlipoproteinaemia

Question: 35. Simon Westwood is a 45 year old motor mechanic who presents to his GP for an insurance medical. On taking his history you note that his father died of a heart attack at age 59. Physical examination reveals thickening of the Achilles and finger extensor tendons. A fasting lipid profile for Simon indicates the following results: Total cholesterol Triglycerides HDL cholesterol 7.7 mmol/L (2.9 5.5 mmol/L) 1.5 mmol/L (0.2 2.0 mmol/L) 1.8 mmol/L (1.0 2.9 mmol/L)

For the following patient scenario, choose the organism that is the most likely cause for her presentation. Options: A Acid-fast bacilli B C D E Gram negative cocci Gram negative rods Gram positive cocci Gram positive rods

Question: 36. Thu is a 32 year old woman who is a recent immigrant from South East Asia. She presents to the Emergency Department with a six week history of cough and wheeze. A chest x-ray shows patchy opacities in the upper zones, and a small pleural effusion. A Mantoux test is positive although she has not previously received a BCG vaccination. Her sputum is examined.

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Yr 3 Formative EMQ

For the following patient who presents with fever of unknown origin, select the most likely diagnosis Options: A Acute appendicitis B C D E F Cholecystitis Endocarditis Enterovirus infection Gastroenteritis Lymphoma

G H I

Malaria Pyelonephritis Viral haemorrhagic fever

Question: 37. A 40 year old man presents with a 3 day history of high fever, rigors, nausea and vomiting. He has recently returned from a business trip to India 10 days ago. He was fully immunized. His fever was 40C; he was sweating and shaking and his abdomen was tender. His WCC was 5.6 x 109/L (3.5 11 x 109/L).

For the following patient scenario, indicate the most likely cause of the patients presenting signs and symptoms. Options: A Left anterior cerebral artery stroke B C D E F G H Left middle cerebral artery stroke Left subcortical stroke Meningococcal meningitis Right anterior cerebral artery stroke Right middle cerebral artery stroke Right subcortical stroke Subarachnoid haemorrhage

Question: 38. Mrs. Jones is a right handed 65 year old lady with a previous history of anterior myocardial infarction. She presents with sudden onset of aphasia. She also has weakness of her right face and arm greater in proportion to right leg weakness. She has a right homonymous hemianopia.

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Yr 3 Formative EMQ

For the following scenario, select the most appropriate organism which will be seen on gram stain. Options: A Acid fast bacilli B C D E Gram negative cocci Gram negative rods Gram positive cocci Gram positive rods

Question: 39. In the sputum of a patient with community acquired pneumonia.

For the following patient scenario, select the most likely single cause of her signs and symptoms. Options: A Acute epiglottitis B C D E F Air embolism Aspiration pneumonitis Atelectasis Bronchial asthma Carcinoma of the lung

G H I J K L

Cardiac arrhythmia Congestive cardiac failure Cor pulmonale Pneumonia Pneumothorax Primary pulmonary hypertension

Question: 40. Lydia is a 35 year old previously healthy non-smoker. She presents with progressive exertional dyspnoea, fatigue and chest pain. On examination P2 is accentuated and a left parasternal heave is present. You organise a chest x-ray which shows normal lung fields with dilated pulmonary arteries.

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Yr 3 Formative EMQ

For the following patient scenario, select the most likely anatomical region responsible for the described disturbance in circulation (tachycardia and hypotension). Options: A Abdomen B C D E Chest Head Lower limb Mediastinum

F G H I

Pelvis Spinal cord Upper limb Vertebral column

Question: 41. A 26 year old man is involved in a high-speed car accident. He has been in the Emergency Dept for 15 minutes. His heart rate is 130bpm. His blood pressure is 78/50mmHg. His respiratory rate is 26 breaths/min and his oxygen saturation is 100% on room air. He is drowsy with a dilated left pupil. He has a bruise across his abdomen from the seat belt. There is no bleeding from his skin. His thighs are not swollen and he is able to move both his feet. His lateral cervical spine x-ray shows a possible undisplaced fracture of the spinous process of C7. His chest x-ray looks normal. His pelvic x-ray looks normal.

Answer the Question below using the most appropriate option. Options: A 1 B C D E F G H 2 3 4 5 6 7 8

I J K L M N O

9 10 11 12 13 14 15

Question: 42. What is the lowest possible Glasgow Coma Scale score that can be recorded?

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Yr 3 Formative EMQ

For the following patient scenario, select the most likely single diagnosis responsible for the described disturbance in breathing and circulation. Options: A Aspiration pneumonia B C D Cardiac contusion Left sided haemothorax Left sided pneumothorax

E F G H

Right sided haemothorax Right sided pneumothorax Tension pneumothorax Upper airway obstruction

Question: 43. Fred is a 60 year old man who is rushed to the Emergency Dept after being run over by a tractor. Fred was underneath the tractor trying to fix it when it started to move. The wheel of the tractor rolled over Freds chest. He is distressed because the left side of his chest is very painful and he feels like he cant breathe properly. His respiratory rate is 42 breaths/min. His oxygen saturation is 94% on supplemental oxygen. His heart rate is 120bpm. His blood pressure is 80/50mmHg. His neck veins are not distended. His trachea is midline. He has palpable rib fractures on the left. Breath sounds are quieter on the left side and the left side is dull to percussion.

For the following clinical scenario, select the most likely cause of this patients headache. Options: A Cervical spondylosis B C D Cluster headache Frontal sinusitis Meningitis

E F G H

Migraine Subarachnoid haemorrhage Temporal arteritis Tension headache

Question: 44. A 35 year old female presents to her GP with 1 2 episodes per month of unilateral pain in the temporofrontal region, radiating to the occipital region, often associated with a prodrome of nausea.

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Yr 3 Formative EMQ

For the following patient who presents with shortness of breath, select the most likely SINGLE cause of her signs and symptoms. Options: A Asbestosis B C D E Asthma Bronchogenic carcinoma Bronchopneumonia

F G H I

Idiopathic pulmonary hypertension Mitral Stenosis Pulmonary thromboembolus Sleep apnoea Type 1 hypersensitivity reaction Pericardial effusion

Chronic obstructive pulmonary J disease Congestive heart failure L

Question: 45. A 62 year old woman presents to her GP with shortness of breath on exertion which has been increasing in severity over several years. She has a past history of rheumatic fever as a child. She now complains of fatigue and has noticed increased swelling of her ankles. She wakes at night feeling short of breath and sleeps with three pillows. She gives no history of chest pain. She takes Digoxin each day (for atrial fibrillation) but is on no other regular medication. Examination reveals a weak apex beat, a gallop rhythm, basal crackles on auscultation of the lungs and there is pitting oedema of both ankles. Her pulse is irregular at 67bpm. Jugular venous pressure is raised to 4cm.

For the following patient presenting to you for a check-up, indicate the drug he is most likely to be taking and is associated with his pathology results. Options: A Atorvastatin B C D E F G H I J Adrenaline Alteplase Amitriptyline Antithrombin III Aspirin Bradykinin Fluoxetine Heparin Histamine

K L M N O P Q R S

Imipramine Lithium Moclobemide Prostacyclin Salbutamol Streptokinase Tranylcypromine Venlafaxine Warfarin

Question: 46. Michael, a 56 year old man presents to you, his local GP, for his regular well-man check up. He is overweight (BMI 28.3), and has mild hypertension, treated with a thiazide. On reviewing his results, the only significant findings are a total cholesterol of 7.8mmol/L (< 5.5mmol/L) and elevated concentrations of both AST and ALT. The transaminase concentrations were normal when you checked 6 months ago.
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Yr 3 Formative EMQ

For each of the following patient scenarios, select the most likely diagnosis. Options: A Acute cholecystitis B C D E F G Acute pancreatitis Appendicitis Gastritis Incarcerated inguinal hernia Obstructing renal cancer Pelvic inflammatory disease

H I J K L M N

Perforated duodenal ulcer Pyelonephritis Ruptured abdominal aortic aneurysm Sigmoid diverticulitis Sigmoid volvulus Small bowel obstruction Ureteric calculi

Question: 47. A 51 year old man presents with an episode of severe upper abdominal pain radiating to his back. The pain started about 6 hours ago and has gradually become more severe. He is restless and nauseated, with vague epigastric tenderness. Abdominal ultrasound shows evidence of biliary sludge, but the gall bladder is not thickened. His liver function is normal, WCC is mildly elevated and serum lipase is 1,200 (< 900).

For the following patient scenario, select the most appropriate option. Options: A Agitation B C D E F G Delusion Febrile Fluctuating symptoms Hypertension Lack of insight Poor short term memory

H I J K L M N

Raised white cell count Respiratory alkalosis Right basal consolidation Risk of self harm Sweaty Tactile hallucinations Visual hallucinations

Question: 48. Mr Reilly is a 57 year old car salesman, who presents with delirium after suffering a fractured femur. Which of the above options best distinguishes between delirium and dementia?

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Yr 3 Formative EMQ

For each of the following patient scenarios, indicate the diagnosis which you consider most likely. Options: A Acute osteoarthritis B C D Gout (49) Effusion caused by cardiac failure Haemarthrosis

E F G H

Rheumatoid arthritis Ross River Virus Septic arthritis Systemic lupus erythematosus (50)

Questions: 49. A 75 year old man is in hospital with left ventricular failure treated with diuretics. He develops spontaneous onset of pain in the left knee. On examination, his temperature is 37.2C and his knee is red, swollen, hot and tender with a positive patellar tap. Fluid from his swollen knee is aspirated and negatively birefringent crystals are identified under polarised light microscopy. 50. A 38 year old woman visiting from North Queensland presents acutely ill with complaints of cold fingers, joint pain, fever, weight loss, and a facial rash. Examination reveals a symmetrical inflammatory arthropathy, a rash over her face and neck, and lymphadenopathy. Investigations reveal thrombocytopenia, normal urine examination, and strongly positive anti nuclear antibodies (ANA).

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Yr 3 Formative EMQ

For the following post-operative patient scenario, select the most appropriate analgesic required. Options: A Fentanyl epidural B C D E Local anaesthetic injected directly into the site Morphine PCA Oral Indomethacin Oral Paracetamol

Question: 51. Mr Zhu is a 75 year old man who is day 1 post anterior resection of the rectum with formation of covering ileostomy. He had a DVT two months ago, so peri-operatively has been continued on a heparin infusion.

For the following patient scenario, select the most likely cardiac lesion. Options: A Aortic regurgitation B C D E Aortic stenosis Atrial septal defect Hypertrophic obstructive cardiomyopathy Mitral regurgitation

F G H I J

Mitral stenosis Pulmonary regurgitation Pulmonary stenosis Tricuspid regurgitation Ventricular septal defect

Question: 52. Mrs Milne is a 48 year old woman admitted for an elective abdominal hysterectomy. When taking an admission history, you note that she had rheumatic fever as a child and that she has recently had increasing lethargy, shortness of breath on exertion and a persisting overnight cough. On examination, you note a slow rising carotid pulse, a soft second heart sound followed by an ejection systolic murmur loudest at the left sternal edge in expiration and radiating to the neck.

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Yr 3 Formative EMQ

For the following patient presenting with abdominal pain, select the most likely diagnosis. Options: A Acute cholecystitis B C D E F G Acute pancreatitis Appendicitis Gastritis Incarcerated inguinal hernia Obstructing renal cancer Pelvic inflammatory disease

H I J K L M N

Perforated duodenal ulcer Pyelonephritis Ruptured abdominal aortic aneurysm Sigmoid diverticulitis Sigmoid volvulus Small bowel obstruction Ureteric calculi

Question: 53. A 45 year old woman presents to the Emergency Department with right upper quadrant pain which came on suddenly 2 hours ago and has been present constantly since that time. The pain radiates through to her back and to the right shoulder tip. It is associated with nausea, anorexia and vomiting. She has a temperature of 38.5C and is very tender in the right upper quadrant, especially when the RUQ is palpated during inspiration. Her white cell count is 20.0 x 109/L (4.0 11.0 X 109/L). Her liver function tests show a bilirubin of 25mol/L (2-17mol/L), GGT 75 U/L (5 65 U/L), ALP 140 U/L (30 - 120 U/L), ALT 150 U/L (< 56 U/L). Her lipase is 50i.u/L (50 300 i.u/L).

For the following patient scenario, select the most likely location for the pathology responsible for the gait disorder and associated clinical findings. Options: A Basal ganglion B C D E Cerebellum Left cerebral cortex Midbrain / brainstem Right cerebral cortex

Question: 54. A 65 year old male with a history of heavy alcohol use presents with difficulty walking. He has problems with finger nose testing and has dysdiadochokinesia.

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Yr 3 Formative EMQ

For the following patient who presents with headache, select the most appropriate INITIAL imaging investigation. Options: A Abdominal x-ray B C D E F G H I J K L Chest x-ray Carotid Doppler ultrasound Carotid arteriogram Coronary arteriogram CT abdomen CT brain CT chest CT neck CT pulmonary angiogram Doppler venous ultrasound Echocardiogram

M N O P Q R S T U V W X

ERCP MRI brain MRI chest MRI spine Nuclear bone scan Pulmonary arteriogram Skull x-ray Thallium cardiac scan Thyroid nuclear scan Ultrasound abdomen Ultrasound neck Ventilation/perfusion (VQ) nuclear scan

Question: 55. A 24 year old man presents with a headache after falling from a ladder at work. He subsequently had an epileptic seizure in the ambulance prior to arriving in the Emergency Department. Physical examination is unremarkable.

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Yr 3 Formative EMQ

For each of the following scenarios of chest pain, select the most likely diagnosis from the list. Options: A Acute myocardial infarction B C D E F Chest wall trauma Dissecting thoracic aneurysm (56) Exertional angina Gastro-oesophageal reflux Metastatic bone disease

G H I J

Pleurisy Pulmonary embolus Shingles Unstable angina (57)

Questions: 56. A 60 year old woman with known cardiovascular disease presents to the Emergency Department after experiencing severe central chest pain radiating to her back for about 1 hour. She is shocked (BP left arm 130/80mmHg; right arm 70/40mmHg), though there is no change in her ECG or cardiac enzymes. Chest x-ray shows a widened mediastinum. 57. A 58 year old man with a history of peptic ulcer five years previously is a smoker with a recent measured total cholesterol level of 6.5mmol/L (NR<5.5mmol/L). He is admitted to hospital following several weeks of increasingly severe episodes of dull central chest pain, usually brought on during his daily lunch break stroll to the sandwich shop. However, over recent days they have taken longer to settle and have occasionally come on whilst resting. He has not previously sought medical advice for his problem, but during the most recent episode, the pain began to spread down his left arm. He decided to visit the Emergency Department to see if his ulcer was playing up again.

For the following patient scenario, select the most likely distribution of bowel involvement. Options: A Appendix only B C D E F Diffuse involvement of duodenum and jejunum Diffuse involvement of rectum and colon Rectum only Segmental involvement of terminal ileum and ascending colon Sigmoid colon only

Question: 58. A 45 year old woman reports abdominal bloating and foul-smelling bowel actions, associated with tiredness. There is no history of abdominal pain. Investigations show a mild macrocytic anaemia and serology shows a high titre of anti-endomysial antibodies. Her symptoms improve markedly on a gluten-free diet.

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Yr 3 Formative EMQ

From the list of options select the most likely cause of the patients signs, symptoms and pathological findings. Options: A Autoimmune gastritis B C D E F Chemical gastritis Congenitally short oesophagus Gastric adenocarcinoma Gastric heterotopia Gastro-oesophageal reflux disease

G H

Helicobacter pylori gastritis Peptic ulcer disease

Question: 59. A 57 year old man presents with recurrent episodes of post prandial epigastric discomfort. Endoscopic examination of the oesophagus and stomach are performed and biopsies are taken. The histopathological findings detailed in the subsequent pathology report are as follows: Oesophagus, biopsy The sections show glandular mucosa composed of tall columnar epithelial cells with interspersed goblet cells containing alcian blue positive acid mucin. The lamina propria contains lymphocytes, plasma cells, neutrophils and eosinophils. There is no evidence of dysplasia or malignancy. Stomach, biopsy The sections show glandular mucosa with surface and pits lined by a single layer of tall columnar epithelial cells. The lamina propria contains mucus glands and a light infiltrate of inflammatory cells including scattered eosinophils and rare lymphocytes. Plasma cells, acute inflammatory cells or granulomas are not seen. There is no evidence of dysplasia or malignancy.

From the list of options select the most likely cause of the patients signs and symptoms. Options: A Asbestosis B C D E F Asthma Bronchogenic carcinoma Bronchopneumonia Chronic obstructive pulmonary disease Idiopathic pulmonary hypertension

G H I J

Mitral valve stenosis Pulmonary thromboembolus Sleep apnoea Type 1 hypersensitivity reaction

Question: 60. A 62 year old woman presents with shortness of breath on exertion which has been increasing in severity over several years. She now complains of fatigue and has noticed increased swelling of her ankles. She wakes at night feeling short of breath and sleeps with 3 pillows. She gives no history of chest pain. She takes Digoxin each day (for atrial fibrillation) and she takes amoxicillin when she attends for dental treatment but is on no other regular medication. Examination reveals basal crackles on auscultation of the lungs and there is pitting oedema of both ankles. She has an apical diastolic murmur. The pulse is irregular at 67bpm.

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Yr 3 Formative EMQ

For the following patient with cardiac failure, select the most likely diagnosis Options: A Alcoholism B C D E F Amyloidosis Aortic regurgitation Aortic stenosis Beri-beri Haemochromatosis

G H I J K

Ischaemic Heart Disease Mitral regurgitation Myocarditis Pericardial tamponade Restrictive pericarditis

Question: 61. A 68 year old man presents with 12 months of progressive shortness of breath on exertion and fatigue. He has a history of diabetes mellitus, hypercholesterolaemia and is a heavy smoker. He also complains of intermittent indigestion. His BP is 130/70; his ECG shows pathological anteroseptal Q waves and an echocardiogram shows a mildly dilated left ventricle with a reduced ejection fraction.

For the following patient with chronic renal failure select the electrolyte disturbance most likely to be involved. Options: A Hypercalcaemia B C D E F Hypocalcaemia Hyperchloraemia Hypochloraemia Hyperkalaemia Hypokalaemia

G H I

Hypomagnesaemia Hypernatraemia Hyponatraemia

Question: 62. A 45 year old man with end stage renal failure secondary to glomerulonephritis has a radionuclide scan, which shows four enlarged parathyroid glands. He is diagnosed with tertiary hyperparathyroidism.

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Yr 3 Formative EMQ

For the following patient with a mediastinal mass, select the most likely diagnosis Options: A Castlemans Disease B C D E F Ganglioneuroma Germ cell tumour Hodgkins lymphoma Non-Hodgkins lymphoma Thymoma

Question: 63. A 35 year old female presents with drooping eyelids, she fatigues quickly and has a mediastinal mass.

For the following patient with renal disease for which renal biopsy is performed, select the most likely diagnostic appearance. Options: (EM: Electron microscopy, IF: Immunofluorescence) A Basement membrane duplicated (EM) G B C D E F Effacement of foot process (EM) Glomerular crescents Glomerular linear deposits (IF) Glomerular nodules of hyaline material Interstitial inflammation H I J

Mesangial deposits of IgA (IF) Neutrophils in glomerulus Sclerosis of most glomeruli Thickened glomerular capillary walls

Question: 64. A 15 year old boy presents with a two day history of macroscopic haematuria. He reports a similar episode 2 months previously, which resolved spontaneously after 3 days.Dipstick urine analysis confirms haematuria and a trace of protein. Renal biopsy is performed.

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Yr 3 Formative EMQ

For each of the following clinical scenarios, select which structure is most likely to show the most obvious pathology. Options: A Bile canaliculi B C D E F Bile duct radical Central vein Common bile duct Hepatocyte (65) Kupfer macrophage

G H I J K

Portal tract Portal vein Perivascular cells Endothelial cells Perisinusoidal cells

Question: 65. A 65 year old diabetic has persistently mildly abnormal liver functions tests. An hepatic biopsy shows steatosis of what cell type?

From each of the following, select the most appropriate form of spread of tumour Options: A Direct B C D E F Haematogenous Intracranial Introsseus Lymphatic Transcoelomic

G H

Transorbital Transosseus

Question: 66. A 67 year old smoker presents with haemoptysis and dies. At autopsy a squamous cell carcinoma has eroded into his bronchial vein

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Yr 3 Formative EMQ

Which option, from the list below, is the most likely cause of the chest examination findings? Options: A Bronchiectasis B C D E Lung consolidation Pleural effusion Pneumothorax Pulmonary fibrosis

Question: 67. A 20 year old man with a history of cystic fibrosis presents with a history of productive yellow sputum and recurrent episodes of fever and tiredness. On examination you note finger clubbing, and course crackles over the base of both.

Answer the questions below using the most appropriate term from the list of options. Options: A Absolute risk reduction B C D E F G H I Attrition bias Blinding Concealment of allocation Confidence interval Detection bias Intention to treat Masking Number needed to treat

J K L M N O P Q R

Performance bias Precision P-value Random error Randomisation Relative risk Relative risk reduction Selection bias Validity

Question: 68. You are reading through the results and are drawn to type of analysis performed. Upon inspection you realise that participants were compared in groups to which they were randomised. What name is given to this type of analysis?

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Yr 3 Formative EMQ

Indicate the most likely set of arterial blood gases (taken Whilst breathing room air) for the following patient Interpretation of blood gases PH Normal range 7.35-7.45 Options: A. B. C. D. E. F. G. H. Question: 69. Judy, a 68 year old woman who is a Type 2 dependent diabetic, is brought to the Emergency Department with a 3 day history of increasing confusion. She has not been taking her insulin regularly for the last several weeks. In addition, she has been treated for a urinary tract infection, but has become increasingly dehydrated and oliguric. On examination she is dehydrated and confused with a respiratory rate of 20 breaths per minute. 7.10 7.10 7.30 7.35 7.40 7.50 7.50 7.50

PaCO2 35-45 mmHg 24 80 50 40 60 28 28 50

PaO2 Bicarbonate 80-100 mmHg 20-30 mmol/L 110 45 60 95 60 60 100 80 8 24 24 35 35 24 24 35

Saturation 95-98% 99% 75% 90% 99% 90% 90% 99% 95%

Please select a suitable answer from the options below for the following scenarios Options: A TSH decreased, free T4 decreased B C D E F TSH decreased, free T4 increased TSH decreased, free T4 normal TSH increased, free T4 decreased (70) TSH increased, free T4 increased TSH increased, free T4 normal

G H I

TSH normal, free T4 decreased TSH normal, free T4 increased TSH normal, free T4 normal (71)

Question: 70. A 60 year old woman is seen by her surgeon because she has an enlarged thyroid gland and symptoms of cold intolerance, constipation and lethargy. 71. An 18 year old man is seen by an Endocrinologist, because he has been noted to have an enlarged thyroid gland. Examination reveals a smooth, regular, moderately enlarged thyroid gland. He has no symptoms related to thyroid disease, has a normal pulse rate and normal reflexes.

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Yr 3 Formative EMQ

Please select a suitable answer from the following scenarios Options: A Overproduction of ACTH B C D E F Overproduction of FSH Overproduction of GH (72) Overproduction of LH Overproduction of Prolactin Overproduction of TSH

G H I J K L

Underproduction of ACTH (73) Underproduction of FSH Underproduction of GH Underproduction of LH Underproduction of Prolactin Underproduction of TSH

Question: 72. A 24-year-old male patient presents with a number of problems. These include hypoglycaemia, an increased salt appetite, weight loss and lethargy and abnormal pigmentation. On examination he is found to be hypotensive. After emergency treatment, diagnostic tests identify that his problem is primarily at the level of the pituitary gland. 73. A 33 year old woman, Mary, presents with a six month history of increasing sweating, weight gain and tingling and pain in her hands. She has an abnormal blood glucose tolerance test. A friend who has been overseas for six months, feels that Mary has a changed appearance, with coarser features of her face.

For the following patient scenario involving colorectal cancer, select the stage of the cancer, using the TNM system. Options:
A B C D Stage I Stage II Stage III Stage IV

Question:
74. Mr Jones is a 78 year old man who undergoes surgery for carcinoma of the colon. Prior to surgery a CT of the abdomen is performed. The CT scan is normal. At surgery a section of bowel is removed, along with adjacent nodes. Pathological investigation reveals a tumour extending through the muscularis propria, with involvement of one regional node.

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Yr 3 Formative EMQ

For the following patient scenario, identify the most appropriate oxygen delivery device that should be administered to the patient. Options:
A B C D E F Bag and mask ventilation device Continuous Positive Airways Pressure (CPAP) Nasal prongs Re-breather mask Simple face mask (Hudson mask) Venturi mask

Question:
75. Beryl is a 72 year old woman who is admitted to your ward/unit with a diagnosis of right lower lobe pneumonia. She has a history of chronic airways disease and her arterial blood gases are as follows: pH 7.25 (7.35 7.45) pCO2 70mmHg (35 45mmHg) pO2 50mmHg (80 100mmHg) SaO2 88% (96 100%)

For the following clinical scenario, select the most likely cause of this patients jaundice. Options:
A B C D E Alcoholic liver disease Carcinoma of the pancreas Choledocholithiasis Drug reaction Gilberts syndrome F G H I J Haemolysis Hepatitis A Hepatitis B Primary biliary cirrhosis Primary sclerosing cholangitis

Question:
76. A 61 year old woman is seen in Outpatients complaining of pruritus. She complains of feeling tired and lethargic and says her only enjoyment is drinking a glass of sherry every night. She has bilateral xanthomata and a soft ejection systolic murmur. Her liver function tests are bilirubin 80mol/L (< 17mol/L) ALT 32 U/L (5-56 U/L) alkaline phosphatase 440 U/L (30-120 U/L) albumin 31 g/L (35-45 g/L) Full blood examination shows a mild reduction in platelets.

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Yr 3 Formative EMQ

For the following patient scenario, select the most likely diagnosis. Options:
A B C D E De Quervains thyroiditis Follicular adenoma Graves disease Hashimotos thyroiditis Multinodular goitre F G H I J Primary hypothyroidism Riedels thyroiditis Secondary hyperthyroidism Simple goitre Thyroid carcinoma

Question:
77. A 37 year old mother of three and a part time pilates instructor presents with a six month history of menorrhagia and tiredness. Investigations show: FBE: Hb 110g/L (115 160g/L) WCC 7.1 x 109/L (4.0 11.0 x 109/L) Plts 225 x 109 (150 400 x 109) LFT, U+E+C, BSL within normal limits TFT:TSH 22.6 (0.5 5.6 mU/L) T4 31nmol/L (70 140nmol/L)

For the following clinical scenario, which artery is most likely to be the source of the patients problem. Options:
A B C D Axillary artery Brachial artery Common carotid artery Internal carotid artery E F G H Radial artery Subclavian artery Ulnar artery Vertebral artery

Question:
78. Svetlana is a 65 year old lady who complains of a sudden attack of loss of power in her right arm of 10 minutes duration which completely resolves and is not associated with any loss of consciousness.

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Yr 3 Formative EMQ

For each of the following patient scenarios, select the SINGLE MOST APPROPIATE treatment.

A B C D F G H I J K

Inhaled adrenaline Inhaled long acting anti-cholinergic by DPI once daily Inhaled long acting beta2-agonist twice daily (80) Inhaled short acting beta2-agonist as required (79) Intramuscular adrenaline Intravenous adrenaline Oral antihistamine Oral leukotriene receptor antagonist Oral prednisolone Oral theophylline

79. An 18 year old student has infrequent episodic asthma associated with exercise, usually when playing or training for basketball twice a week. Spirometry shows normal lung function. 80. A 35 year old secretary has recurrent symptoms of cough, wheeze and chest tightness associated with upper respiratory tract infections, change in weather and exposure to dust. She was commenced on fluticasone 250mcg 2 puffs twice a day by MDI with spacer 3 months ago, with some improvement, but still requires reliever medication twice a day, and is woken from her sleep once a week with chest tightness.

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