2006 FRACP Written Examination
Paper 2 – Clinical Applications
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A 35-year-old teacher is referred with chronic headaches, myalgias, restlessness, difficulty
concentrating and initial insomnia. She says that she worries most days that she might have a serious
illness. However, she has always been "a worrier" and she also worries constantly about the
performance of her students and about the security of her job. At times she uses alcohol to feel less
worried and to initiate sleep. There are no abnormal findings on physical examination or on
investigation and she can accept your reassurances that she is not seriously unwell. She has a bright
reactive affect. Which treatment approach for her complex symptoms is most likely to be helpful?
Temazepam at night.
Cognitive behavioural therapy.
A 62-year-old woman with rheumatoid arthritis for eight years presents for review. Her arthritis is well
controlled with 15mg of methotrexate weekly, folic acid supplements and ketoprofen sustained release
200mg daily, all of which she has been on for the past five years. She is overweight with a body mass
index of 35kg/m2 [18-26] and has mild, diet-treated type 2 diabetes mellitus. She is on no other
medications. You review her routine blood tests which are normal apart from her liver function tests
which have been progressively worsening over the past six months. The most recent test is shown
protein 88 g/L [63-82]
albumin 41 g/L [35-50]
bilirubin 8 μmol/L [<10]
alanine transaminase (ALT) 150 U/L [<52]
aspartate transaminase (AST) 120 U/L [<36]
alkaline phosphatase (ALP) 120 U/L [<126]
gamma glutamyltranspeptidase (GGT) 150 U/L [<43]
The most likely explanation for this woman's liver function test abnormalities is:
methotrexate induced hepatitis
A 56-year-old man is referred for assessment of resistant hypertension. Blood pressure readings at his
general practitioner’s surgery have been between 145 and 172 systolic and 86 and 98 diastolic
despite various combinations of up to two anti-hypertensive agents at a time. He has no other vascular
risk factors. He has no family history of hypertension. Examination does not reveal any clinical
findings suggesting a secondary cause of hypertension. He has normal creatinine and electrolytes. An
ECG and trans thoracic echocardiogram are normal
What is the most appropriate next investigation?
Aldosterone : renin ratio.
Magnetic resonance angiography of renal arteries
Ambulatory blood pressure recording.
Urine testing for drug compliance.
Which of the following is the most likely adverse effect of long-term inhaled corticosteroid use in an
A. Oral candidiasis.
C. Skin thinning.
A 24-year-old woman is on doxycycline 100 mg/day for moderately severe acne. She wants to
become pregnant. In terms of foetal outcome, at what stage of pregnancy (measured from last
menstrual period) is the risk to the foetus greatest from exposure to doxycycline?
B. 0-4 weeks.
C. 4-8 weeks.
D. 8-12 weeks.
E. 12-40 weeks.
A 21-year-old Filipino woman has been referred for investigation of anaemia. Her blood counts and
iron studies are as follows:
Haemoglobin 81 g/L [113-159]
Haematocrit 0.27 [0.32-0.42]
Red blood cells 4.58 x109/L [3.60-5.30]
White blood cells 4.60 x109/L [3.90-12.70]
Platelets 421 x109/L [150-396]
Mean corpuscular volume 59 fL [80-97]
Mean corpuscular haemoglobin 17.7 pg [28.0-34.0]
Mean corpuscular haemoglobin concentration 300 g/L [328-363]
Reticulocytes 142 x 109/L [8-104]
Serum ferritin 482 mcg/L [15-200]
HbA2 1.4% [1.6-3.5]
HbF 0.3% [0.2-1.0]
Which of the following is the most likely diagnosis?
A. alpha+-thalassaemia trait (a-/aa).
B. alpha0-thalassaemia trait (--/aa).
C. HbH disease (--/-a).
D. beta0-thalassaemia trait.
E. beta+-thalassaemia trait.
A 65-year-old woman, established on haemodialysis for nine months, is maintained on erythropoietin
4,000 units twice a week intravenously. Previously her haemoglobin (Hb) had remained steady in the
range of 105 – 115 gm/L. She now presents with a Hb of 89 gm/L on routine testing. There have
been no changes to her erythropoietin dose or other medications. Her mean corpuscular volume
(MCV) is 84 fL [78-98], her serum iron is 13 μmol/l [13-35], iron saturation is 18% [15-46], serum
ferritin is 630 μg/l [20-300] and her reticulocyte count is 30 x 109/L [12-100]. Which of the following is
the most likely cause for her erythropoietin resistance?
B. Pure red cell aplasia.
C. Vitamin B12 deficiency.
D. Iron deficiency.
A 25-year-old female presents with symmetrical small joint polyarthralgia associated with a
photosensitive facial rash, and low grade fever. Examination reveals small joint tenderness in the
hands without synovitis, and an erythematous, slightly scaly malar rash. The examination is otherwise
unremarkable, and urinalysis is normal. The following laboratory results are obtained.
C-reactive protein (CRP) 18 mg/L [0-11]
Antinuclear antibody (ANA) positive, titre: 1/2560; pattern: homogeneous
Anti-double stranded DNA (anti-dsDNA) 17 IU/mL [0-5]
Rheumatoid factor <20 IU/mL [0-20]
In addition to non-steroidal anti-inflammatory agents, which of the following is the most appropriate
next step in management?
B. Topical corticosteroids.
D. Oral corticosteroids.
A 45-year-old woman is admitted after being found unconscious. Her plasma glucose is 1.5 mmol/L.
The following results are obtained:
Plasma insulin 105 pmol/L [<80 fasting]
Plasma C-peptide 650 pmol/L [250-700]
CT (computed tomography) pancreas Normal
Which of the following best explains these findings?
A. Addison’s disease.
B. Insulin administration.
C. Alcohol ingestion.
E. Growth hormone deficiency
Which of the following drugs is least likely to cause a rise in serum potassium?
A patient with known cancer presents with increasing thirst. Initial biochemistry reveals normal
glucose, plasma sodium of 147 mmol/L [135-145], plasma osmolality of 300 [280-296], urinary sodium
of 31 and urinary osmolality of 77. These findings are most consistent with:
A. psychogenic polydipsia.
B. extrarenal fluid loss.
C. primary hyperaldosteronism.
D. diabetes insipidus.
E. SIADH (syndrome of inappropriate anti-diuretic hormone).
A 55-year-old man develops choreiform movements. He has no personal or family history to account
for these symptoms. DNA studies identify a pathognomonic expansion in IT15, the gene responsible
for Huntington disease. The figure below summarises the results of DNA studies of the IT15 repeat in
the patient and his immediate family. Samples were collected from the patient (lane 1), the patient’s
father (lane 2), the patient’s mother (lane 3), and the patient’s healthy sibling (lane 4). The range of
sizes of the IT15 repeat in the normal population is shown.
What is the best explanation for the patient’s lack of a family history of Huntington disease?
A 25-year-old male comes for assessment of fitness to dive. Which of the following is the strongest
contraindication to diving?
A. Mild bronchial hyperresponsiveness.
B. Previous spontaneous pneumothorax.
D. Coronary artery bypass grafting.
E. Upper respiratory tract infection.
A 66-year-old man presents with a history of slowing of most movements over the last six months, with
a bilateral resting tremor. On examination there is evidence of retropulsion. Examination of his eye
movements reveals impaired vertical saccades. He gives a history of frequent falls.
These features are most characteristic of which of the following?
A. Multiple systems atrophy.
B. Parkinson’s disease
C. Lewy body disease.
D. Progressive supranuclear palsy.
E. Corticobasal degeneration.
A 52-year-old woman presents with dry eyes which have progressively worsened over the past three
years. On examination her Schirmer test is 1mm in 5 minutes [5mm in 5 minutes] and she has
positive Rose Bengal staining of both corneas. Her erythrocyte sedimentation rate is 98 mm/hr
[<21mm/hr], antinuclear antibody is positive with a speckled pattern and a titre of 1:640 and Anti-Ro
and –La antibodies are detected.
The most appropriate initial treatment is:
B. low dose oral prednisolone.
D. hypomellose tear substitute.
E. prednisolone eye drops.
In which of the following conditions is treatment with gabapentin most effective?
A. Post-herpetic neuralgia.
C. Bipolar disorder.
D. Alcohol withdrawal.
E. Primary generalised epilepsy.
A 24-year-old man awakens with right shoulder/trapezius discomfort. The pain persists for two weeks,
and he is then aware of weakness of right shoulder movements. On examination he has a full range
of movement of his cervical spine without pain. He is unable to actively abduct his right arm past 45°,
and has Grade 0/5 power of right deltoid and infraspinatus. Upper extremity power is otherwise
normal, with normal biceps, triceps and brachioradialis reflexes. Sensory examination is normal. A
cervical magnetic resonance imaging (MRI) scan and right shoulder ultrasound are normal.
The most likely diagnosis is:
A. herpes zoster radiculopathy.
B. C5 radiculopathy.
C. rotator cuff injury.
D. inflammatory brachial plexopathy
E. suprascapular neuropathy.
A patient has the following abnormal findings:
sodium 130 mmol/L [134-145]
potassium 2.9 mmol/L [3.5-5.0]
phosphate 0.22 mmol/L [0.6-1.3]
magnesium 0.6 mmol/L [0.72-0.92]
creatinine 120 μmol/L [70-110]
ionised calcium 1.1 mmol/L [1.14 - 1.27]
glucose 5.1 mmol/L [4.1- 6.1]
Which of the following is the most likely cause?
A. Tumour lysis syndrome.
B. Diabetic ketoacidosis
D. Refeeding syndrome
E. Vitamin D deficiency
A test is used to screen for a target disorder.
The best definition of the specificity of the test is “the proportion of individuals:
A. with the target disorder who have a positive test result”.
B. without the target disorder who have a negative result”.
C. with a positive test result who have the target disorder”.
D. with a negative test result who do not have the target disorder”.
E. with or without the target disorder who have a correct result”.
A 38-year-old man lives in a boarding house for psychiatric patients. He has an established diagnosis
of schizophrenia. He has little in the way of occupation and regularly consumes up to 100g of alcohol
a day. Even though he has some persistent negative symptoms of schizophrenia, his positive
symptoms have been well controlled for several years on a low dose of risperidone that he tolerates
well. He presents now with a six month history of worsening depressed mood and intermittent suicidal
thinking. Which of the following is most likely to assist his mood?
A. Increasing the dose of risperidone
B. Initiating sertraline.
C. Enrolment in a social skills programme
D. Abstinence from alcohol.
E. Cognitive behavioural therapy.
A 90-year-old male resident of a nursing home has severe dementia. He is bedbound, mute, doubly
incontinent and requires full nursing care. He has a large pressure area over one buttock. He has had
two recent admissions to hospital with aspiration pneumonia and has been placed on thickened fluids
to try to prevent aspiration. He does not have any close family members. Now he does not co-operate
with feeding and when food is placed in his mouth he does not swallow it. In the absence of any advance directives, the most appropriate approach to the management of his hydration and nutrition
A. percutaneous endoscopic gastrostomy (PEG) tube feeding.
B. nasogastric tube feeding.
C. intravenous fluids.
D. overnight subcutaneous fluids.
E. mouth care.
A 25-year-old female presents with recurrent facial angioedema. The following laboratory results are
Complement C3 0.36 g/L [0.79-1.80]
Complement C4 0.06 g/L [0.13-0.48]
Total haemolytic complement (CH100) 210 CH100 units [390-1015]
Which of the following is the most likely explanation for these findings?
A. Hereditary C1 (complement 1) inhibitor deficiency
B. Delayed transfer of serum to laboratory.
C. C4 null allele.
D. Acquired C1 inhibitor deficiency
E. ACE-inhibitor therapy.
A 65-year-old male is referred with a three-year history of progressive breathlessness on exercise. He
has smoked 20 cigarettes per day for 45 years.
Spirometry is as follows:
FEV1 (forced expiratory volume in one second) 1.0 L [3.02 L]
FVC (forced vital capacity) 3.0 L [3.97 L]
Arterial blood gases on air are as follows:
pH = 7.40
PaO2 = 61 mm Hg
PaCO2 = 43 mm Hg.
Which of the following interventions is most likely to improve his survival?
A. Smoking cessation.
B. Inhaled corticosteroids
C. Inhaled long-acting beta-agonists.
D. Long term oxygen therapy
E. Inhaled long-acting anticholinergics.
A 65-year-old man developed Wegener’s granulomatosis eight years previously. At that time he had
upper and lower respiratory tract and renal involvement. He achieved remission with prednis(ol)one
and daily cyclophosphamide which was continued over 18 months. Seven months previously he
experienced a relapse with arthritis, sinusitis, an active renal sediment and a rise in serum creatinine
from 90 to 115 μmol/L. The relapse was treated successfully with prednis(ol)one and weekly
methotrexate. Prednis(ol)one was tapered and withdrawn. Currently, he feels well and examination is
Laboratory tests show normal blood count, erythrocyte sedimentation rate (ESR) 25 mm/hr [0-20], and
normal creatinine. Urine examination shows no protein, 10-100 red cells/high power field, and there
are no dysmorphic cells.
Which of the following is the next most appropriate course of action?
A. Renal biopsy
B. Replace methotrexate with cyclophosphamide
D. Serum antineutrophil cytoplasmic antibodies (ANCA) testing.
E. Reintroduce prednis(ol)one.
In therapy with immunosuppressive drugs (the relevant drugs are shown in brackets), knowledge of
which of the following genotypes is most likely to be useful in preventing serious adverse drug events?
A. Thiopurine methyltransferase (azathioprine).
B. CYP3A4 (cyclosporin).
C. Dihydrofolate reductase (methotrexate).
D. Type II glucocorticoid receptor (prednis(ol)one).
E. Plasma cholinesterase (cyclophosphamide).
A 28-year-old woman presents with episodes of colour change in her distal fingers when they are
exposed to the cold. The episodes occur most days and are characterised by white numb finger tips
which become blue and then red. She describes similar episodes that have occurred for many years.
She is otherwise well. Examination is unremarkable. Investigations show a positive anti-nuclear
antibody of a speckled pattern with a titre of 1:80. The most likely diagnosis is:
A. limited scleroderma.
B. diffuse scleroderma
C. primary Raynaud's phenomenon.
D. systemic lupus erythematosus
E. carcinoid syndrome.
A 45-year-old Australian-born woman with rheumatoid arthritis on long term prednisolone therapy
presents with a third nerve palsy, left sided cerebellar signs and altered consciousness. She has a
fever of 39°C and neck stiffness. Computed tomograp hy (CT) scan of the brain is normal. Lumbar
puncture reveals an opening pressure of 20 cm [< 20 cm], white cell count of 80 x 106/L (80%
lymphocytes), protein 0.6 g/L [< 0.45], glucose 3.5 mmol/L (blood glucose 4.0 mmol/L) and no red
cells. Gram stain reveals no organisms and culture is pending. The most appropriate initial treatment
A. observation, pending culture results.
B. aciclovir and ceftriaxone.
C. ceftriaxone and ampicillin.
D. isoniazid, rifampicin, ethambutol and pyrazinamide
E. vancomycin and penicillin
A 78-year-old woman has a history of hypertension on amlodipine, and has been found to have a
persistently elevated platelet count for several months. She presents to the emergency department
with abdominal pain. Her full blood examination and serum biochemistry are as follows:
haemoglobin 104 g/L [128-175]
white blood cell 70.40 x 109/L [3.90-12.70]
neutrophils 62.80 x 109/L [1.90-8.00]
lymphocytes 2.46 x 109/L [0.90-3.30]
monocytes 0.67 x 109/L [0.30-1.10]
eosinophils 4.43 x 109/L [0.00-0.50]
basophils 0.05 x 109/L [0.00-0.20]
platelets 3524 x 109/L [150-396]
mean corpuscular volume 74 fL [80-97]
sodium 142 mmol/L [136-145]
potassium 7.2 mmol/L [3.5-5.1]
bicarbonate 16 mmol/L [21-32]
chloride 112 mmol/L [98-107]
urea 13.2 mmol/L [2.0-8.5]
creatinine 0.13 mmol/L [0.04-0.08]
Which of the following is the most likely cause of her elevated serum potassium?
B. Renal tubular acidosis.
C. Chronic renal impairment.
D. Haemolytic anaemia.
E. Lactic acidosis
A 50-year-old male has chronic liver disease secondary to Hepatitis B infection. Previous endoscopy
has revealed large oesophageal varices. Blood results are:
Albumin 32 g/L [38-55]
Prothrombin Time 14 seconds [8-12]
Platelet count 70 x 109/L [150-450]
On routine review, his alpha fetoprotein is 300 ng/mL [0-15]. His abdominal computed tomography
(CT) scan is shown below.
The optimal treatment for this condition is:
A 49-year-old female presents with a five week history of symmetrical polyarthralgia. The following
laboratory results are obtained:
Antinuclear antibody (ANA) positive, titre: 1/80, pattern: speckled
Antibodies to extractable nuclear antigens (ENAs) negative
Anti-double stranded DNA antibody (anti-dsDNA) 7 IU/mL [0-5]
Anti-cyclic citrullinated peptide (anti-CCP) positive
Anti-filaggrin antibody positive
Rheumatoid factor (RF) < 20 [0-20]
Which of the following is the most likely diagnosis?
A. Rheumatoid arthritis.
B. Systemic lupus erythematosus.
C. Mixed connective tissue disease
D. Viral polyarthritis.
A 66-year-old alcoholic man collapses and is brought to the Emergency Department. He is found to
have fixed dilated pupils, and is somnolent with no upgaze. Reflexes are brisk with bilaterally upgoing
plantar responses. A cranial computed tomography (CT) scan performed after one hour is normal. An
electroencephalography (EEG) reveals intermittent generalised anterior predominant slowing, with
frontal intermittent rhythic delta activity (FIRDA) without focal of epileptiform features. Neurological
findings remain unchanged over a period of 24 hours. The most likely diagnosis is:
A. middle cerebral artery stroke with cerebral herniation ("coning").
B. bilateral middle cerebral artery stroke.
C. ponto-mesencephalic ("top of the basilar") stroke.
D. post-ictal encephalopathy.
E. Wernicke’s encephalopathy.
A 65-year-old man with a past history of diverticular disease presents with one week of fever and right
upper quadrant pain. He has never travelled overseas. His CT scan reveals a large fluid-filled lesion
as shown above. In addition to drainage of the abscess, what is the most appropriate initial empiric
A patient with lung cancer receives chemotherapy with carboplatin and etoposide. He is given
ondansetron and dexamethasone pre-chemotherapy and dexamethasone and metoclopramide postchemotherapy.
On day two post-chemotherapy he complains of stiffness around his shoulders and
feeling jittery and irritable. The drug most likely to be responsible for these symptoms is:
A 40-year-old human immunodeficiency virus type 1 (HIV-1) -infected patient receiving highly active
anti-retroviral therapy (HAART) smokes 25 cigarettes a day and has a serum cholesterol level of 6.0
mmol/L [2.5 – 5.2] and mild to moderate hypertension. Which of the following interventions is most
likely to reduce his cardiovascular risk?
A. Cessation of smoking
B. Combined aerobic and strength exercise programme.
C. Change of anti-retroviral therapy
D. Introduction of lipid-lowering agent.
E. Introduction of anti-hypertensive agent.
An 87-year-old man is admitted to hospital with a dense left hemiplegia and is totally bedbound and
immobile. Which of the following strategies is the most effective for reducing the risk of developing a
pressure ulcer in this patient?
A. Second-hourly turns
B. Assessment of pressure area risk by Norton Risk Assessment Score.
C. Nutritional supplementation.
D. Indwelling urethral catheterisation.
E. Pressure relieving mattress
A 55-year-old male smoker is referred to outpatients complaining of breathlessness. Which of the
following is the most effective intervention for him to achieve smoking abstinence?
A. Cognitive behavioural therapy.
C. Nicotine replacement therapy.
E. Medical advice to quit.
A 70-year-old woman has been on haemodialysis for 11 years. She complains of painful shoulders
and knees and wrists and cannot raise her arms beyond 90°. She has noted a gradual deterioration in
her arthralgias over a period of 12 months. A radiograph of her wrist is shown below. Which of the
following is most likely to explain her symptoms?
A 52-year-old female is sent home ten days after a left hemicolectomy. Her husband brings her back
to hospital 48 hours later with jaundice and confusion. She is anuric. She has ingested 14 grams of
paracetamol since discharge from hospital. Which of the following findings indicates the worst
prognosis without transplantation?
A. pH 7.28 [7.36-7.44].
B. Creatinine 220 μmol/L [50-90].
C. Bilirubin 53 μmol/L [0-18].
D. Glasgow coma score 8 .
E. Prothrombin time (PT) 160 secs [8-12].
A 26-year-old man presents with a swollen, painful left ankle and right wrist ten days after being
treated with doxycycline for chlamydial urethritis. Which of the following is the most appropriate for the
initial treatment of his joint symptoms?
In which of the following is radiotherapy least likely to be of clinical benefit to the patient?
A. Bleeding malignant gastric ulcer
B. Brain metastases with raised intracranial pressure.
C. Painful bone metastases from prostate cancer.
D. Intrahepatic metastases causing cholestasis.
E. Non small cell lung cancer causing bronchial obstruction.
A patient is at high risk for repeat radiographic contrast media reactions. Which of the following is
least likely to be effective?
A. Desensitisation with contrast media.
B. Change to use of non-ionic contrast media.
C. Premedication with oral diphenhydramine.
D. Premedication with oral prednis(ol)one.
E. Premedication with intramuscular adrenaline.
A 65-year-old woman presents to the hospital for the first time with vague symptoms of fatigue. The
following routine biochemistry is noted:
potassium 5.5 mmol/L [3.5-5.5]
urea 48 mmol/L [<6.5]
creatinine 1010 μmol/L [<120]
calcium 2.1 mmol/L [2.1-2.5]
phosphate 2.3 mmol/L [0.8-1.4]
She is hypertensive with a sitting blood pressure of 165/95 mmHg. There is no clinical oedema. Apart
from the fatigue she is asymptomatic, although some scratch marks are noted. She has 8.8cm
kidneys bilaterally on ultrasound, without obstruction. She has a past history of cholecystectomy and
What is the most appropriate next step in her management?
A. Urgent haemodialysis
B. Urgent peritoneal dialysis
C. Elective haemodialysis.
D. Elective peritoneal dialysis.
E. Urgent continuous venovenous haemodiafiltration.
In a 50-year-old man undergoing a computed tomography (CT) scan for investigation of abdominal
pain, which of the following is the most likely cause of an incidentally discovered 3cm adrenal mass
A. Adrenal metastasis.
B. Cortisol secreting adrenal adenoma
D. Non-functioning adrenal adenoma.
E. Adrenal carcinoma.
Of the following metastatic cancers, the one associated with the highest long term survival after
A. breast cancer with bone metastases.
B. ovarian cancer with malignant ascites.
C. germ cell cancer with lung metastases.
D. prostate cancer with bone metastases.
E. lung cancer with brain metastases.
A 65-year-old man collapses during a brisk walk, losing consciousness for 30 seconds. He had no
warning symptoms and he recovered rapidly. Six years earlier he suffered an uncomplicated
myocardial infarction without further chest pain and is taking aspirin, atenolol and simvastatin. On
examination he has an apex rate of 60, and blood pressure 118/84 mmHg. There is an ejection
systolic murmur and a left carotid bruit. ECG shows Q waves in the inferior leads with no acute
changes. Troponins are normal. Overnight monitoring shows sinus rhythm with ventricular ectopics
and runs of up to five beats of non-sustained ventricular tachycardia.
Which is the most appropriate investigation for the patient’s syncope?
A. Treadmill exercise ECG.
B. Transthoracic echocardiogram.
C. Carotid ultrasound.
D. Electrophysiologic study
E. Tilt table testing.
If the pre-test probability of a condition is known, which of the following is also needed to be able to
estimate the post-test probability?
D. likelihood ratio.
A 62-year-old man with type 2 diabetes and hypertension is on long term aspirin, quinapril, metoprolol
and insulin. He presents with two hours of central chest pain. A diagnosis of non-ST elevation
myocardial infarction is made. He proceeds to have coronary angiography which demonstrates diffuse
three-vessel coronary artery disease. He is discharged home with the introduction of a long acting
nitrate to await elective coronary artery surgery. He represents two weeks later with malaise and
abdominal pain. His serum creatinine has increased to 0.45mmol/L from a serum creatinine of
0.14mmol/L on his previous admission.
Which of the following is the most likely cause of the deterioration in renal function?
A. Aortic dissection.
B. Renovascular disease.
C. Angiotensin converting enzyme inhibitor nephropathy.
D. Cholesterol embolisation.
E. Contrast nephropathy.
A 63-year-old man presents with a six-month history of gradual onset of right hand weakness.
On examination there is wasting of the intrinsic muscles of the right hand. Power is normal proximally,
with weakness of right finger extensors, right finger abduction and adduction, and right flexor pollicis
longus (all Grade 3/5). There is milder weakness of right forearm pronation and right wrist extensors
(Grade 4/5). The right triceps and finger jerks are brisk relative to the left sided reflexes. The biceps
and brachioradialis reflexes are symmetrical. Sensory examination is normal. A cervical magnetic
resonance imaging (MRI) scan is normal.
The most likely diagnosis is:
A. multiple sclerosis.
B. motor neurone disease.
C. brachial plexopathy.
D. thoracic outlet syndrome.
E. mononeuritis multiplex.
A 25-year-old woman with no significant past medical history presents with weight gain, depression,
easy bruising and proximal muscle weakness. On examination she has a plethoric complexion,
central obesity with striae and a proximal myopathy. Investigations reveal low plasma concentrations
of cortisol and adrenocorticotrophic hormone (ACTH). Which of the following is the most likely
A. Cushing’s disease.
B. Pseudo-Cushing’s syndrome.
C. Factitious Cushing’s syndrome.
D. Ectopic ACTH syndrome.
E. Cortisol-producing adrenal adenoma.
An 82-year-old female has recent onset of high fevers and confusion. Her temperature is 38.2°C and
her urine is positive for leukocytes, erythrocytes and nitrites. A diagnosis of delirium secondary to
urinary tract infection is made and she is to be treated with a single dose of the aminoglycoside
antibiotic, gentamicin. What is the most important factor for calculating this single dose?
A. Body weight.
C. Glomerular filtration rate.
E. White cell count.
Several randomised controlled studies have compared anticoagulation with placebo in patients with
non-rheumatic atrial fibrillation. These trials suggest that the annual risk of stroke in untreated patients
with atrial fibrillation would be nearest to:
A 27-year-old woman presents with weight loss, tremor, palpitations and pain and tenderness over her
thyroid. The following results are obtained:
Free T4 75 pmol/L [10-24]
Free T3 25 pmol/L [2.5-6.5]
thyroid-stimulating hormone (TSH) <0.03 mIU/L [0.4-4.0]
erythrocyte sedimentation rate (ESR) 105 mm/hour [<10]
A thyroid scintiscan is awaited. In the meantime, in addition to beta blockers, which of the following is
the most appropriate first line treatment for her condition?
A “reasonably well” (normal performance status) patient with non-haemorrhagic cerebral metastases
from breast carcinoma presents with spontaneous lower limb venous thrombosis and pulmonary
embolism. Which of the following is the most appropriate long term management regime?
B. Inferior vena caval filter.
D. Graduated compression stockings.
A 64-year-old woman presents with a seven-day history of left upper quadrant pain. Her past medical
history includes type 2 diabetes, hypertension and smoking. The pain is over the left lower costal
margin, extending posteriorly. On examination there is a patchy area of sensory change in the left
The most likely diagnosis is:
A. diabetic monoradiculopathy.
B. degenerative radiculopathy.
C. thoracic meningioma.
D. thoracic demyelination.
E. herpes zoster
A 62-year-old man is admitted to hospital with fevers, malaise and myalgias six weeks after a
laparoscopic cholecystectomy. On examination he has a temperature of 39°C, splinter haemorrhages
and a loud pansystolic murmur. He has a past history of mitral valve prolapse which was diagnosed by
echocardiography. Enterococcus faecalis has been identified in three sets of blood cultures. The
isolate is highly sensitive to penicillin. He has no known allergies. The most appropriate therapy is:
B. vancomycin alone.
C. ampicillin alone.
D. ampicillin and gentamicin.
E. cephalothin and gentamicin.
An 81-year-old man presents to the emergency department after collapsing while running for a bus.
He has a history of hypertension treated with felodipine but no other major illnesses. He has noted
mild breathlessness on exertion, worsening over the past few years. Examination reveals blood
pressure is 125/90 mmHg. He has a soft systolic murmur but no signs of heart failure. His ECG is
shown below. Serum creatine kinase (CK) is 205 U/L [<180]. Troponin level is pending.
Which one of the following is the most appropriate initial management step?
Which of the following features of cystic fibrosis is most likely to be present in a 20-year-old male
D. Vitamin E deficiency
A 50-year-old man with a 60 pack year history of smoking presents with a two-month history of cough
and weight loss. His performance status is normal (ECOG (Eastern Cooperative Oncology Group) =
0). Investigations show him to have a T2N1M0 non-small cell carcinoma with a forced expiratory
volume in one second (FEV1) 80% predicted. Which of the following will provide the highest survival?
A. Surgical resection.
B. Radical radiotherapy.
C. Combined chemoradiation
D. Downstaging with chemotherapy and surgical resection
E. Surgical resection and adjuvant chemotherapy.
A patient is referred for investigation of diarrhoea and weight loss. The following results are obtained:
haemoglobin 100 g/L [130-180]
mean corpuscular volume (MCV) 72 fL [82-98]
anti-gliadin IgG 43 units [0-25]
anti-gliadin IgA 0 units [0-25]
IgA-endomysial antibody <5 [<5]
Which of the following is the next most appropriate test?
A. Serum IgA level.
B. Haemoglobin electrophoresis.
C. 3-day faecal fat.
D. Tissue transglutaminase antibodies.
E. Faecal microscopy and culture.
A 32-year-old male develops hemoptysis and fever two days after hospital admission with dyspnea.
The computed tomogram chest scans taken on admission, and after development of hemoptysis are
shown below. The most likely diagnosis is which of the following?
There is substantial genetically determined variation in the response to warfarin. In which of the
following is the most important variation that determines the necessary dose?
A. Affinity of vitamin K epoxide reductase for vitamin K.
B. Affinity of vitamin K epoxide reductase for warfarin.
C. Activity of Cytochrome P450 enzymes.
D. Baseline production of vitamin K dependent coagulation factors.
E. Activity of glutathione tranferase.
A 36-year-old male with a history of recent injecting drug use presents with a week of fevers and
sweats and excruciating lower thoracic back pain. Blood cultures grow Staphylococcus aureus. What
would be the most useful next investigation to establish a diagnosis?
A. CT (computed tomography) scan of thoracolumbar spine.
B. MRI (magnetic resonance imaging) scan of thoracolumbar spine.
C. Lumbar puncture.
D. Radionuclide bone scan.
E. Labelled white cell scan.
When considering the long-term outcome of renal transplantation, other than rejection, which of the
following has the greatest adverse effect on graft survival?
A. Diabetes in the recipient.
B. Donor age over 65 years.
C. Recipient age over 65 years.
D. Polycystic kidney disease in the recipient.
E. Post-transplant hypertension
A 60-year-old asymptomatic man has an ECG taken, as part of an insurance assessment, which
shows left bundle branch block. Physical examination is normal. Echocardiogram is normal aside from
delayed septal activation. The most appropriate next step is:
A. no action.
B. dipyridamole sestamibi scan.
C. exercise echocardiography
D. coronary angiography
E. biventricular pacemaker.
A 63-year-old man presents with aching legs, and an uncontrollable feeling that he needs to move his
legs when he goes to bed. The most likely diagnosis is:
A. periodic leg movements of sleep.
C. peripheral neuropathy.
D. nocturnal cramp syndrome.
E. restless legs syndrome.
A number of members of a family are affected with a rare syndrome of external ophthalmoplegia,
Parkinsonism, and early menopause. DNA studies identified multiple deletions of various sizes in
mitochondrial DNA in the affected people. The pedigree is shown below. What is the most likely mode
of inheritance of this syndrome?
A physician becomes ill with nausea and vomiting four hours after attending a pharmaceutical
company sponsored dinner. Which of the following is the most likely cause of this?
A. Clostridium difficile.
B. Staphylococcus aureus.
C. Escherichia coli.
D. Vibrio parahemolyticus.
E. Campylobacter jejuni.
A 57-year-old man with a long history of poorly controlled hypertension and smoking presents with
sudden onset of right-sided weakness. On examination, his speech is slurred but content and
comprehension are normal. There is a right facial weakness, with the right side of the soft palate
elevating poorly. He has a right hemiparesis, power grade 2-3/5, in a pyramidal distribution with
normal sensation to all modalities. Right-sided reflexes are enhanced with an extensor right plantar
The most likely cause of this stroke syndrome is left:
A. middle cerebral artery occlusion.
B. posterior inferior cerebellar artery occlusion.
C. hemispheric cortically based haemorrhage.
D. middle cerebral penetrating artery occlusion.
E. internal carotid artery occlusion.
A 21-year-old female presents with anaphylactic shock. Her blood pressure initially responds to a dose
of adrenaline however it falls again 30 minutes later. What would be the most important next
A. Subcutaneous adrenaline
B. Intramuscular adrenaline.
C. Intravenous fluid challenge.
D. Histamine 1 and 2 receptor antagonists.
E. Intravenous corticosteroid.
A 70-year-old female with a history of cognitive impairment has the computed tomography (CT) scan
of the brain shown below. This scan is most suggestive of which of the following diagnoses?
A 75-year-old woman is brought to a hospital emergency department by her son with whom she lives.
He describes a change in his mother’s mental state over the preceding week. She has been
wandering the house at night and has become uncharacteristically suspicious of her daughter-in-law,
accusing her of stealing her belongings. She also complained to her son that she had seen thieves in
her room at night. She has no prior psychiatric history.
The most likely diagnosis is:
A. late onset schizophrenia.
B. psychotic depression
E. temporal lobe epilepsy.
A 26-year-old man presents with a six month history of lower back and buttock pain with prolonged
stiffness in the morning. Physical examination reveals a Schober test of 4 cm on flexion [>5cm].
Which of the following tests is most likely to support a diagnosis of ankylosing spondylitis?
A. X-ray sacroiliac joints.
B. HLA B27 genotyping.
C. Erythrocyte sedimentation rate.
D. Rheumatoid factor.
E. Radionuclide bone scan.
A 47-year-old woman has coagulation studies performed as part of preoperative assessment prior to
elective hysterectomy for menorrhagia.
Prothrombin Time-International Normalised Ratio 1.0 [0.9-1.3]
Activated Partial Thromboplastin Time (APTT) patient 52.3 s [26-38]
Activated Partial Thromboplastin Time (APTT) control 30.0 s [26-38]
APTT correction (1:1 mix, Patient: Control) 49.6 s [26-38]
Thrombin Clotting Time 20 s [<24]
Fibrinogen 2.1 g/L [2.0-4.0]
Fibrinogen D-Dimer 0.50 [<0.35]
Which of the following is the most likely interpretation of these results?
A. Tranexamic acid therapy.
B. Disseminated intravascular coagulation.
C. Heparin exposure.
D. Von Willebrand disease.
E. Lupus anticoagulant.
A 26-year-old man is referred for assessment of proteinuria. He has a six-month history of recurrent
episodes of lower extremity petechial rash (shown above), arthralgia, Raynaud’s phenomenon and
fever. He has an eight-year history of intravenous drug use. Physical examination reveals
erythematous raised papules on both lower extremities and dependent oedema.
Serum creatinine 110 umol/L [< 120]
Albumin 28 gm/L [35-50]
C3 1.05 gm/L [0.80-1.50]
C4 <0.01 gm/L [0.16 – 0.55]
Antinuclear antibody negative
Antineutrophil cytoplasmic antibody (ANCA) negative
Midstream urine reveals 50 x 106 glomerular red blood cells per litre and proteinuria is quantitated at
5.5 gm/day [< 0.12].
A renal biopsy is performed. What is the most likely histological diagnosis on biopsy?
B. Idiopathic mesangiocapillary glomerulonephritis.
C. Cryoglobulinaemic glomerulonephritis.
D. Chronic post-infectious glomerulonephritis.
E. Henoch-Schonlein Purpura with IgA (immunoglobulin A) nephropathy.
In a woman with Graves disease, which of the following is associated with an increased relative risk of
developing Graves ophthalmopathy?
B. Young age.
C. High titre microsomal antibodies.
E. Previous thyroid surgery.
The ECG shown below is taken from a 25-year-old man after an episode of syncope. His mother died
suddenly at age 38; his younger sister has recently survived an out-of-hospital cardiac arrest. The
most appropriate management would be:
A 35-year-old man is admitted to hospital with a red and tender left thigh, three days after sustaining a
superficial abrasion to the area while surfing. He gives a history of fevers and chills and says that the
pain in the leg is now increasing. On examination he appears unwell, is hypotensive, tachycardic and
febrile to 40°C. The left thigh is erythematous, te nder to deep palpation with a 'boggy' feel over the
muscles. He is observed in the emergency department and the redness over the thigh progresses 2
cm in a two hour period. A computed tomography (CT) scan of the area shows inflammation of the
muscles and loss of fascial planes, but no abscess formation. Intravenous penicillin and clindamycin
are started. Which of the following additional interventions is most likely to result in survival and limb
A. Surgical exploration and debridement.
B. Intravenous hydrocortisone.
C. Intravenous immunoglobulin.
D. Hyperbaric oxygen therapy.
E. Intravenous activated protein C.
Different mutations in the DMD (Duchenne muscular dystrophy) gene cause three clinically distinct
syndromes in males. The table below lists the three conditions, the degree of skeletal muscle
weakness, and a number of different abnormal genotypes involving the DMD gene.
Which of the following represents the most likely relationship between the genotypes and phenotypes?
Option Duchenne muscular
Severe Moderate-mild Mild-nil
A in-frame deletion promoter deletion frameshift deletion
B frameshift deletion in-frame deletion promoter deletion
C frameshift deletion promoter deletion in-frame deletion
D promoter deletion frameshift deletion in-frame deletion
E promoter deletion in-frame deletion frameshift deletion
A. Option A.
B. Option B.
C. Option C.
D. Option D.
E. Option E.
The most appropriate clinical scenario for the use of non-steroidal anti-inflammatory agents for
management of cancer pain is which of the following?
A. Liver capsule pain in a patient with metastatic cancer.
B. Headache due to malignant meningitis.
C. Small bowel obstruction pain in a patient with ovarian cancer.
D. Bone pain due to metastatic lung cancer.
E. Neuropathic pain due to malignant nerve root infiltration.
Which of the following is the most appropriate indication for treatment with ursodeoxycholic acid?
A. Primary sclerosing cholangitis.
B. Massive choledocholithiasis.
C. Primary biliary cirrhosis.
D. Microlithiasis associated pancreatitis.
E. Cholecystolithiasis in a poor surgical candidate.
Which of the following clinical situations is the strongest contraindication to therapeutic anticoagulant
A. Infective endocarditis.
B. Intracranial bleeding in the last ten days.
C. Severe hypertension (Systolic Blood Presssure (BP) >200 mmHg).
D. Recent major trauma.
E. Moderate thrombocytopenia; platelet count 20-50 x 109/L.
Noninvasive positive pressure ventilation would be most appropriate for which of the following
A. Traumatic acute lung injury with hypoxia.
B. Post extubation respiratory failure with acute hypercapnia.
C. Cystic fibrosis with acute hypercapnia.
D. Acute cardiogenic pulmonary oedema with hypoxia.
E. Chronic obstructive pulmonary disease with acute hypercapnia.
A 64-year-old builder is referred for assessment of a chronic cough. There is no personal or family
history of asthma. He has smoked 20 cigarettes per day since the age of 18 years. There are no
symptoms to suggest gastro-oesophageal reflux or post-nasal drip. His practitioner had performed a
chest X-ray and thoracic computed tomography (CT) scan (shown above). The appearances of the
CT scan are most consistent with:
In a randomised trial 39,876 women aged over 45 years were assigned either aspirin 100mg on
alternate days or placebo, and were followed for 10 years for a first major cardiovascular event. The
results are shown in the figure below. Which statement best summarises the study results?
A. The probability that aspirin is better than placebo is 13%.
B. The absolute difference in events between aspirin and placebo is 2%.
C. The relative risk reduction with aspirin is 26%.
D. Regardless of treatment, 98% of women remained event-free over 10 years.
E. Regardless of treatment, the probability of an event over 10 years is 13%.
A previously well 25-year-old man is admitted unconscious following a suspected overdose. He
withdraws to pain and has dilated pupils that react sluggishly. His heart rate is 120/minute and he has
decreased bowel sounds. His ECG is shown above. The presentation is most consistent with
overdose of which of the following drugs?
A previously well 64-year-old man presents with symptoms of gastro-oesophageal reflux disease. He
is on no current medications. Gastroscopy demonstrates Barrett’s oesophagus with erosive
oesophagitis above the squamocolumnar junction. Random biopsies are reported as demonstrating
dysplastic epithelium with features of active inflammation. The most appropriate next step in
A. endoscopic ultrasound.
B. CT (computed tomography) chest/abdomen.
C. repeat biopsies after two months of treatment with proton pump inhibitors.
D. surgical resection.
E. surveillance endoscopy in one year.
Presymptomatic genetic testing ("predictive genetic testing") may be justifiable on various medical,
psychological, or economic grounds. Which one of the following disorders provides the best
justification for presymptomatic genetic testing on medical grounds?
Which of the following features in a patient with colon cancer is most suggestive of hereditary nonpolyposis
colon cancer (HNPCC)?
A. Right-sided lesion.
B. Microsatellite instability in the tumour tissue.
C. Multiple synchronous polyps.
D. Brother with colon cancer at age 55.
E. Uncle with a germline MLH1 mutation.
An 18-year-old woman presents with hirsutism. The following results are obtained:
Testosterone 4.5 nmol/L [<2.5]
Luteinising hormone (LH) 9 IU/L [2-15]
Follicle stimulating hormone (FSH) 4 IU/L [2-15]
Oestradiol 500 pmol/L [130-1500]
Dehydroepiandrosterone (DHEA) 10 umol/L [0.5-12]
17OH Progesterone 62 pmol/L [<6]
24 hour urinary free cortisol 280 nmol/24hours [100-300]
Adrenocorticotrophic hormone (ACTH) 3 pmol/L [1-5]
Which of the following is the most likely explanation for her hirsutism?
A. Polycystic ovarian syndrome.
B. Androgen secreting ovarian tumour.
C. Cushing’s syndrome.
D. Late onset congenital adrenal hyperplasia.
E. Adrenocortical carcinoma.
An 82-year-old man presents with difficulty walking due to osteoarthritis in his right hip. When
prescribing a cane as a walking aide for him, the most appropriate instruction regarding use of the
Hold the cane:
A. in the right hand and advance the cane with the right leg.
B. in the right hand and advance the cane with the left leg.
C. in the left hand and advance the cane with the right leg.
D. in the left hand and advance the cane with the left leg.
E. in the right hand and advance the cane after both feet have advanced.
A 65-year-old man with one hour of central chest pain returns to the same hospital where he had
percutaneous coronary intervention performed four weeks ago. He had stopped clopidogrel one week
earlier. He is hypotensive with 3mm ST elevation in antero-septal leads.
Which of the following is the most appropriate management?
A. Nitroglycerine infusion.
B. Bolus and infusion of a glycoprotein IIb/IIIa inhibitor.
C. Coronary angiography and revascularisation.
D. Intra-aortic balloon counter-pulsation.
An 81-year-old male has moderate dementia with mild behavioural disturbances, hypertension and
osteoporosis. He is living in a nursing home. His current medications are donepezil, olanzapine,
enalapril, vitamin D and calcium. A random fasting blood glucose is 11.5 mmol/L [<6 mmol/L]. The
next step in the management of this elevated blood glucose level should be:
A. referral of patient and carer to a dietitian.
B. commence short acting sulfonylurea.
C. commence metformin.
D. cease olanzapine.
E. cease donepezil.
Which of the following is the most appropriate standard with respect to informed consent?
A. Provision/discussion of all risks up to likelihood of 1:10000.
B. Provision of that information which the “average” person would want to know
C. Provision of information as set by recent relevant court proceedings.
D. Provision of adequate information, tailored to the patient’s specific circumstances.
E. Provision of information as per Society/College patient information publications.
A 23-year-old male has had his third episode of passing a renal calculus. Each episode has been
preceded by renal colic, twice on the left and once on the right. A calculus has been analysed in the
biochemistry laboratory and found to contain predominantly calcium oxalate. Typical calculi are shown
in the image below.
Which of the following is most likely to reduce his chance of further stones?
B. Avoiding oxalate rich foods (such as asparagus and rhubarb).
C. Drinking 3-4 litres of fluid per day.
D. Administration of oral citrate.
E. Use of a loop diuretic such as frusemide.
Which of the following is the strongest indication for thrombolysis in a patient with pulmonary
A. Pre-existing history of pulmonary hypertension.
B. Tachycardia (pulse >120/minute).
C. Hypotension (systolic blood pressure <90mmHg).
D. Right ventricular enlargement on echocardiogram.
E. Large area of embolism on ventilation perfusion lung scan.
An otherwise well 55-year-old female undergoes upper endoscopy for investigation of mild reflux
symptoms. An endoscopic image of the lower oesophagus is shown above. Biopsies demonstrate
intestinal metaplasia with high grade dysplasia and no inflammation. The most appropriate
Skin prick testing for specific IgE (immunoglobulin E) is most appropriate for investigation of which of
the following conditions?
A. Severe systemic reaction to gadolinium-based contrast medium.
B. Chronic urticaria.
C. Acute urticaria/angioedema following aspirin administration.
D. Large local reaction to bee sting.
E. Anaphylaxis following peanut ingestion.
A 76-year-old woman presents with a swollen, painful left knee. The knee has become increasingly
painful over two weeks and she is now unable to walk on it. She does not remember injuring the knee
and is otherwise well. On examination she is afebrile and has a large left knee effusion with reduced
range of movement. An X-ray of the knee is shown above. What is the most likely diagnosis?