2016 EMQ

Question 1

30yoM, rigors, SOB, R-side chest pain worse on inspiration

Answer 1

pneumonia

Question 2

what oral med after treatment for DVT post 5-hr flight?

A. Alteplase
B. Aspirin
C. Atorvastatin
D. Heparin
E. Warfarin
F. Clopidogrel

Answer 2

warfarin (anticoagulant)

Question 3

A. Start Insulin Glargine
B. Metformin
C. Cease metformin and reassess
D. Increase Metformin Dose
E. Start Insulin post prandil
F. Gliptin
G. Glicadize

1. pt on 2g SR metformin and high dose glipizide, hba1c 9.5
2. T2DM F on metformin w/ recent eGFR drop to 29%
3. 60yo F on metformin 2g daily and 30IU glargine nocte; fasting BG 5.8mmpl and hba1c 8.1%

Answer 3

1. introduse insulin glargine
2. stop metformin and reassess
3. introduce postprandial insluin

Question 4

3yo M presented w. fever, bleeding gum and weight loss. Recurrent chest infections in the past.
O/E: pale, cervical lymphadenopathy and mild hepatosplenomegaly. Blood smears show blasts

what is the diagnosis and why

Answer 4

ALL
- most common in children
-hepatosplenomegaly
-cervical lymphadenopathy
-majority blasts on blood smear

Question 5

What are normal hba1c and normal fasting BG?

Answer 5

normal hba1c <5.7%; 5.7-6.4% prediabetic and diabetes diagnosed >6.5%

nromal fasting BG 3.9-5.6mmol/L

Question 6

A. Duchenne MD
B. Cerebral Palsy
C. Normal variant
D. Osteomyelitis
E. Juvenile idiopathic arthritis
F. Perthes disease
G. Slipped capital femoral epiphysis
H. Non-accidental injury/fracture

what is the diagnosis and why?

1. previously active 8yo, limping past 2 week and complaints of R knee pain over >2 weeks; no memory of trauma
2. 7yo M, fever and sore R hip. O/E R thigh swollen nd red
3. 4yo child initially developed normally and began walking. Later developed difficulty walking up stairs. Symmetrical waddling gait. O/E: neuro intact but noticed thick calves.
4. 22 month old, not walking. When crawls tends to drag legs along. When you stand her up she stands on her toes.

what is the diagnosis and why?

Answer 6

1. JIA (50% monoarticular, commonly knee, usually sore especially in the morning, stiffness, fever, swollen LN and rash)

I think more likely to be JIA than Perthes (stiffness and reduced ROM in hip)

2. osteomyelitis: swollen dn red over the skin but has fever so not just cellulitis
3. pseudo- hypertrophy of calves= Duchenne
4. delayed gross motor development, stands on toes= cerebral palsy

Question 7

A. CXR & AXR
B. CT
C. Laparotomy
D. Diagnostic Laparoscopy
E. Gastroscopy
F. Colonoscopy
G. Abdominal Ultrasound
H. No investigations required

1. 14yo M, increasing central and R sided abdo pain. O/E: 38 C temp, hard abdo w/ rebound tenderness and guarding, elevated WCC
2. 40yo F, intermittent RUQ pain, exacerbated after eating

Answer 7

1. diagnostic laparoscopy
2. abdo USS

Question 8

78 y/o M 24 hours post surgical repair of fractured neck of femur starts seeing spiders on his bed
sheets with associated fluctuation in consciousness and agitation. His wife reports that he is taking a
Tri-cyclic Antidepressant and that he drinks roughly 10 beers a night.

what is the most likely diagnosis and why?

Answer 8

delerium

• post-surgical delerium is common- due to infection or pain medications
• especially visual hallucinations
  -usually takes tricyclics and ETOH
• no previous schizophrenia or hx of psychosis

Question 9

A. Salmonella typhi
B. Hookworm
C. C. diff
D. Novovirus
E. Trichuris trichuria
F. enterotoxic E.coli
G. Staphylococcus aureus enterotoxin
H. Giardia intestinalis
I. Shigella

what is diagnosis and why

1. 40yo M, occasional diarrhoea, abdo pain and mild anaemia, liked to walk around barefoot. Aboriginal, remote community
2. med student travelling and drinking unfiltered and untreated tank water for 4/52. 6 loose bowel motions daily 5 weeks, noticed floaty stool (pale, foul-smelling floating)

Answer 9

1. hookworm (walking barefoot= itchy, anaemia and diarrhoea, aboriginal
2. giardia (foul-smelling, floaty and pale stools and unfiltered H2O)

Question 10

A. Acute suppurative otitis media
B. Glue ear (bilateral)
C. Serous otitis media
D. Traumatic ruptured tympanic membrane
E. Otitis externa
F. Presbycusis

1. girl URTI 2/52 oreviosult, feeling of fullness in ears and pain
2. 21yoM, diving trip in maldives, R ear pain, d/c and sensation of blocked ear

Answer 10

1. serous OM
2. ruptured tympanic membrane

Question 11

55yo F, periods stopped 4 years ago, irregular spotting

Answer 11

endometrial cancer

Question 12

A. acute gastroenteritis
B. coeliac disease
C. colorectal carcinoma
D. faecal impaction
E. inflammatory bowel disease
F. irritable bowel
G. sphincter disruption
H. spinal cord lesion
I. systemic neuropathology

What is the most likely underlying condition in the following cases with “bowel changes”

1. 83yo F, constant diarrhoea, incontinence pad day and night, constipated prior to this
2. 23yo F, 3year hs of intermittent abdo pain, bloating and flatulence, colonoscopy of upper endoscopy= normal, anti-tissue tranglutaminase Abs negative

Answer 12

1. faecal impaction
2. IBS

Question 13

A. Medication
B. Double dose of folic acid and iron
C. Frequent small meals
D. Mylanta
E. Increase protein in diet

42 yo woman, 10/40, some nausea and vomiting associated with pregnancy. Doesn’t want to take
any medications.

Answer 13

small frequent meals

Question 14

A. Aortic stenosis
B. Pulmonary stenosis
C. Coarctation of aorta
D. Tetralogy of fallot
E. Transposition of great vessels
F. ASD
G. PDA

1. 4yo M, well comes to GP w/ Mo. O/E: well, not cyanotic, auscultation has soft ejection systolic murmur in pulmonary area. Low splitting of heart sounds.
2. 8yo F, systolic murmur radiating to carotids

what and why

Answer 14

1. ASD which would cause shunt L to R
2. radiating to carotids and systolic murmur= coarctation of aorta

Question 15

A. BPH
B. Prostate cancer
C. Urethral stricture
D. UTI
E. Pyelonephritis
F. Prostatitis
G. STI

1. 32 yo M, increasing hesitancy over last few months. Never feels as thought he empties his bladder. Experienced some dysuria and frequency after overseas trip.
2. 70yo M, PSA 5 (normal <4), enlarged prostate

Answer 15

1. urethral stricture
2. BPH

Question 16

A. Bone marrow suppression
B. Folate deficiency
C. Iron deficiency
D. B12 deficiency
E. Increased red cell destruction

what is the most likely cause or type of anaemia?

1. 20yo F, hx of abdo bloating and loose, bulky stools
2. 45 F heavy periods
3. 24yo M, laparoscopy for suspected appendicitis. thickened segment of fat wrapping terminal ileum.
4. child- Pugh B cirrhosis hep c+ve

Answer 16

1. folate deficiency
2. Fe deficiency
3. B12 deficiency (malabsorption)
4. Destruction of RBCs (haemolytic anaemia)

Question 17

A. FBC
B. ECG
C. Spirometry
D. Stress ECG
E. Serum troponin
F. Sleep Study
G. echocardiogram

1. 75yo fatigue, increasing SOBOE >6months, well controlled T2DM and HTN. Sleeps on one pillor, no swelling of ankles.
2. tried truck driver, 100kg 160cm tall, fatigue, restless sleep, separate bed from wife, nocturia, HTN, night sweats- what is the 1st appropriate Ix?

Answer 17

1. Stress ECG
2. sleep study

Question 18

32yo M, ED w/ large amounts of bright red blood in stools, increasing fatigue over last few weeks. Bleeding gums and pain in back and ribs. O/E: patechaie everywhere

Answer 18

AML

(adult) acute myeloid leukemia

Question 19

what medication would cause this and why?
A. Metoclopramide
B. Diltiazem
C. Bisoprolol
D. Thiazide diuretic

1. shuffling gait after starting new med.
2. peripheral oedema after new HTN med

Answer 19

1. metoclopramide
   - it is a dopamine receptor antagonist which is used as an antiemetic
   -other: prochlorperazine
   -causes tardive dyskinesia
2. diltiazem= Ca channel blocker (non-dihydropyridine)
   - CCBs cause peripheral oedema
   -however more common w/ dihydropyridine: amlodipine, nifedipine
   -less common with verapamil and diltiazem (non-dihydro…)

Question 20

pt presents w/ palpable rubbery mass in the posterior triangle, and generalized cervical lymphadenopathy. Reed-Sternberg cells

Answer 20

Hodgkin’s

Question 21

A. Diabetes
B. Hypertension
C. Phaeochromocytoma
D. Conn’s syndrome
E. Renal artery stenosis
F. acute tubular necrosis

1. 35yo M to GP, recent onset severe headaches and palpitations. 2 years ago: thyroidectomy for medullary thyroid cancer. Note glucosuria and HTN.
   what is the most likely cause of his sx.s?
2. 72yo M, surgical ward repair of AAA rupture. BP recorded 60 MAP. AAA repaired but ongoing renal impairment.

Answer 21

1. phaeochromocytoma
2. acute tubular necrosis

Question 22

what is tardive dyskinesia and what medications can cause it?

Answer 22

medication-induced hyperkinetic disorder
- oro-bucco-lingual and facial dyskinesia
- limb, trunk and respi
-dystonia: sustained or repetitive muscle contractions
-akathisia: motor restlessness
-tics, tremor

caused by: dopamine receptor antagonists
- first-gen antipsychotics e.g. haloperidol
-2nd gen antipsychotics e.g. risperidone, aripiprazole, olanzapine, CLOZAPINE
- antiemetics: metoclopramide, prochlorperazine

Question 23

a. Dexamethasone
b. Ondansetron
c. Metoclopromide
d. Olanzapine
e. Haloperidol
f. Benzotropine
g. Clomazepine
h. Cyclizine
i. domperidone

72yo M, lung small cell carcinoma. Has CT scan confirming brain met.s and cerebral odema. Which med to manage nausea and vomiting? why?

Answer 23

Dexamethasone

• ondansetron is frequently used to relieve chemo- induced nausea HOWEVER,
  this patient has cerebral odema and dexamethasone (corticosteroid) will help reduce cerebral oedema and have anti-inflammatory effects as well as relieving nausea

Question 24

A. Acquired renal cystic disease
B. Acute tubular necrosis
C. Acute interstitial nephritis
D. Diabetic nephropathy
E. Polycystic kidney disease
F. Renal artery stenosis
G. Reflux nephropathy
H. ANCA - glomerulonephritis
I. Nephrotic syndrome
J. Other glomerulonephritis

1. 45yo M, abdo pain, HTN 180/110 w/ anaemia Hb 120 and raised creatinine. Na and K normal. +++ blood and trace protein on urinalysis. Renal USS: calculus in L ureter and enlarged kidney w/ multiple bilateral cysts of 5mm-2cm diameter. Most likely cause of underlying kidney dx?
2. 20 yo F, PHx severe UTI requiring hospitalisation/ 160/90 Cr raised and electrolytes NAD. Small and oddly shaped kidneys. Most likely underlying cause? WHY

Answer 24

1. PKD
2. reflux nephropathy (or VUR= vesicoureteral reflux)
   - flow backward from bladder into ureters and kidneys. Can cause recurrent infections and inflammation damage and scarring of renal parenchyma CKD and renal impairment.
   - recurrent severe UTI
   -HTN
   -raised Cr
   -small and oddly shaped kidneys

Question 25

A. Ross river virus B. Metapneumavirus C. Adenovirus D. Enterovirus E. Rhinovirus F. Influenza G. EBV H. Measles I. Rubella J. Parainfluenza 1. 4yo M, returns to tasmania after living in NT for 2 years. SOB, clear nasal d/c >1/52. Worsened >24hrs nor fever, fatigue, cough and SOB. Generalised rash over body and small white lesions over reddened pharynx and buccal mucosa. why 2. 11-month-old 2 day hx URTI. Loss of appetite, super clingy to Mo, alert. Mild tachypenoa and tachycardia w/ reduced SpO2. Mild increased WOB, generalized widespread wheeze and crackles 3. 3yo F, unwell then inspiratory stridor and barking cough

Answer 25

1. Koplik spots= white spots on mucosa= measles (rubeola virus) 2. respiratory syncytial virus (RSV) 3. Parainfluenza= croup

Question 26

young child 7-day hx fever, bilateral conjunctivitis, red palms and red mucosa, strawberry tongue

Answer 26

kawasaki dx

Question 27

4yo M, skin lesions 2-4mm, pruritic

Answer 27

molluscum contagiosum

Question 28

A. ECT B. SSRI C. Benztropine D. Flupenthixol decanoate E. Sodium valproate F. Clozapine 1. Patient with schizophrenia who is unable to take his oral medications daily when discharged from hospital and why 2. Patient whose eyes start rolling back after dose of one of his psychotropic medications was increased. Whats med and why

Answer 28

1. Flupenthixol decanoate - antipsychotic; depression and schizophrenia -depot injection 2. benztropine (to reverse) as this is describing an oculogyric crisis= dystonic reaction invlosing extraocular muscles, usually upwards deviation of eyes

Question 29

A. PID B. Acute appendicitis C. Acute cholecystitis D. Pyelonephritis E. Renal colic F. Ectopic pregnancy G. Mittelschmerz H.infective endo 1. F dysuria, flank pain, new sexual partner 2. 37M, intermittent severe L flank pain w/ hx of chron's dx, urinalysis small amount of blood and leukocytes, no nitrates 3. 60M, treated osteomyelitis of tibia on surg ward. PMhx of copd and IV drug use. Spiking fevers and pansystolic murmur

Answer 29

1. pyelonephritis 2. renal colic 3. infective endocarditis

Question 30

. 60 y.o. M presents with R hemiparesis, on B/G of HTN, previous CABG. On CT brain there is a wedge area of pallor Options - cerebral infarct - intracerebral haemorrhage -tumour

Answer 30

cerebral infarct

Question 31

A. Carbon monoxide B. Methane C. Glycerol D. Organic solvents E. Organophosphates F. Lead G. Isopropyl H. Glyphosate 1. 45F, selling tickets for a farm festival in a newly constructed iron shed. She is feeling cold so decides to light a fire w/ firewood. Later that day she presents to her GP w/ nausea, vomiting, dizziness and headache. She has increased RR and HR but no cyanosis. 2. middle-aged M accidentally dropped a barrel of unknown chemicals on the floor and spilled some on himself. There was no H2O tap around so he decided to just wipe it on his pants. Hrs later, he experienced teary eyes, blurred vision, constant drooling, sweating, and SOB. Pupils constricted in ED.

Answer 31

1. carbon monoxide 2. organophosphates

Question 32

22yo female had frequency dysuria and frequency, denied of any sexual activity before. Causative organisms

Answer 32

e coli

Question 33

A. Placental abruption B. Placental praevia C. Vasa praevia D. Vaginal carcinoma E. Cervical carcinoma F. Endometrial carcinoma G. Threatened abortion H. Gestational trophoblastic disease I. Ectopic J. Dysfunctional uterine bleeding 1. fetal HR 80bpm, dark red PV bleeding and constant abdo pain. G4P3, 32/40 2. 30yo F, G2P1 at 28/40 w/ painless bright red PV bleeding. Fetal HR 140 3. 32yo 3rd pregnancy, 12/40 PV spotting. Palpation: correct size for gestation. O/E: closed OS w/ some spots of bloods from it. On USS: fuzzy signal w/ machine working properly. 4. G8P6T2 45F, PV bleeding, not seen dr in 9 years. Refises pelvic exam. 5. F on OCP; post-coital bleeding >6/52. Been on OCP for 6 years w/ similar post-coital bleeding but less severe and no other issues.

Answer 33

1. placental abruption 2. placenta previa 3. GTD 4. cervical cancer 5. cervical ectropion

Question 34

F, PID and yellow d/c, normal swab

Answer 34

chlamydia

Question 35

A. Acute glaucoma B. Iritis C. Endophthalmitis D. Foreign body in eye E. Scleritis F. Brain trauma of some sort 1. red painful eye, hypopyon (pus in anterior chamber), recent eye surgery 2. 60F, acute painful eye and seeing through mist w/ halos of light. Similar less severe episodes in the past. Also wears contact lenses. Exam: L pupil dilated and unreactive to light. R NAD

Answer 35

1. endopthalmitis 2. acute glaucoma

Question 36

A. WIlson’s disease B. Alpha-1 antitrypsin deficiency C. Viral hepatitis D. Alcoholic hepatitis E. Fatty liver disease F. Haemochromatosis G. Autoimmune hepatitis 1. M, Gp noticed he looked darker than usual, RUQ pain, arthralgia, HFE gene identified on C282Y 2. 48M, increasing SOB, deranged LFTs, no biliary tree changes on US

Answer 36

1. haemochromatosis 2. a1- antitrypsin deficiency

Question 37

GCS

Answer 37

Eye-opening - 4 spontaneous - 3 to speech - 2 to pain - 1 none Verbal response Oriented: 5 Confused: 4 Inappropriate words: 3 Incomprehensible sounds: 2 None: 1 Motor response Obeys commands: 6 Localizes pain: 5 Withdrawal from pain: 4 Abnormal flexion (decorticate): 3 Abnormal extension (decerebrate): 2 None: 1