Division of Medicine

Clinical Education Centre

Bld 63, Level 4

Missenden Road, Camperdown

FRACP

EXAMINATION REVISION

Paper B

9^thFebruary 2002

MOCK EXAMINATION

Held in the Library

FRACP PART B

1) A 19-year-old male college student is evaluated for shortness of breath that occurs when he plays basketball or jogs. He has no other symptoms and does not smoke cigarettes. Physical examination complete blood count, and radiograph of the chest are normal. Which of the following is most likely to be helpful in confirming the suspected diagnosis?

(A) Arterial blood studies before and after exercise

(B) Spirometry before and after exercise

(D) Determination of lung volumes and diffusing capacity

(E) Measurement of venous blood lactate before and after exercise

2) A 19-year old man comes to the emergency department because of urethral discharge. Gram stain shows numerous neutrophils, some of which contain gram-negative intracellular diplococci. Ceftriaxone 250mg intramuscularly, is administered. Five days later, the patient comes to your office because discharge has persisted.

Which of the following is the most likely cause of this discharge?

(A) Chlamydia trachomatis

(B) Ureaplasma urealyticum

(D) Re-infection with Neisseria gonorrhoeae

(E) Urethral stricture

3) A 65-year-old man who has just moved to your city is referred to you by his previous physician for management of recently diagnosed congestive heart failure. The patient has a history of poorly controlled hypertension. Three months ago progressive shortness of breath, increased fatigue, and two-pillow orthopnea developed. One month ago he consulted his physician about these symptoms, and he brought his records from that visit to you:

This patient is 178 cm (70 in) tall and weighs 86 kg (190 lb); body mass index

is 27. Pulse rate is 100-112 per minute, and rhythm is regular; blood pressure

is 150/90 mm Hg. The neck veins are 3 cm above the sternal angle with the

patient at a 45-degree angle. There are bibasilar moist crackles that do not

clear on coughing. The heart is enlarged; a ventricular gallop is present, but

there are no murmurs. There is 2+ ankle adema. The remainder of the physical examination is normal. Routine laboratory studies are normal except

for a blood urea 8.1mmol/ l nitrogen and a serum creatinine of 133 Mmol/l .

Electrocardiogram shows left ventricular hypertrophy. Radiograph of the chest shows an enlarged heart and calcified aorta.

Blood urea nitrogen 15 mmol/l

Serum creatinine 150 Mmol/l

Serum sodium 135 mEq/L

Serum potassium 3.5 mEq/L

Serum digoxin 1.8 ng/mL {therapeutic: 1.0-2.0}

Which of the following should you do now?

(A) Reassure the patient and schedule a return appointment in one month

(B) Increase digoxin to 0.25 mg daily alternating with 0.375 mg daily

(D) Add captopril, 12.5 mg three times daily, to the current regimen

________________________________________________________________________________

4) A 74-year-old woman, who was treated for breast cancer six years ago, is brought to the emergency room because of severe weakness and obtundation. According to her family she has had increasing weakness, obtundation, polyuria, urinary incontinence, and poor oral intake for one week. One month ago, computed tomography of the head revealed multiple intracerebral lesions. The patient was given radiation therapy to the brain lesions, and she has been taking dexamethasone, 12 mg orally daily for 2 weeks.

Physical examination on admission shows an acutely ill woman who is obtunded and disoriented. Temperature is 36.6 C (97.8 F). Pulse rate is 100 per minute and regular. Respirations are 28 per Blood pressure is 110/60 mm Hg supine and 90/50 mm Hg sitting. Tissue turgor is poor. The neck is supple. The lungs are clear. There is no heart murmur or ventricular gallop. There is lower abdominal tenderness, especially in the suprapubic area. Diffuse muscle weakness is noted. No lateralizing neurologic signs or abnormal reflexes are noted.

Laboratory studies:

Leukocyte count 19,500/cu mm; 90% neutrophils,

8% lymphocytes, 2% monocytes

Plasma glucose 48 mmol / l

Blood urea nitrogen 16 mmol / l

Serum creatinine 177 mmol/ l

Serum calcium 2.2 mmol/ l

Serum electrolytes:

Sodium 130 mEq/L

Potassium 5.0 mEq/L

Chloride 96 mEq/L

Bicarbonate 24 mEq/L

Urinalysis Glucose 4+, protein 2+; 30-40 WBCs,

5-6 RBCs/hpf; moderate bacteria

Cultures of blood and urine are requested.

Which of the following should you administer during the next four hours?

(A) 0.45% saline containing 10 units of regular insulin/L at 600 mL/hr

(B) 0.9% saline containing 10 units of regular insulin/L at 600 mL/hr

(D) 5% dextrose and 0.45% normal saline containing 10 units of regular insulin/L at 600 mL/hr

(E) Ringer’s lactate solution containing 10 units of regular insulin/L at 600 mL/hr

5) Among workers aged 18 through 25, abuse of which of the following substances is implicated most frequently as the cause of occupational accidents and injuries?

(A) Alcohol

(B) Cocaine (including crack)

(D) Benzodiazepines

(E) Opiates

6) A 76-year-old woman is evaluated because of a history of “currant jelly” stool on three separate occasions in the past three years. She reports having had “many tests,” including barium enemas, sigmoidoscopies, and esophagogastroduedenoscopies, which failed to define the cause of the bleeding. One year ago she required two units of blood to raise her hematocrit from 24% to 30%. She has been taking iron, 300 mg orally twice daily, since then.

The patient has hypertension, coronary artery disease, and heart failure treated with digoxin, enalapril, furosemide, and metoprolol. She does not have chest pain or dyspnea.

The patient is 157 cm (62 in) tall and weighs 79 kg (174 lb); body mass index is 32. Temperature in C (97.7 F). Pulse rate is 88 per minute, and respirations are 14 per minute. Blood pressure is 120/ 70 Hg supine and 118/82 mm Hg standing. The conjunctivae are pale. A ventricular gallop and a grade 3 systolic ejection murmur are heard. There are bruits over both femoral arteris. Rectal examination reveals dark brown stool that is positive for occult blood. Other findings of physical examination is normal.

Barium enema shows a few diverticular scattered throughout the descending and transverse colon Colonoscopy shows angiodysplasia of the cecum; no bleeding site is seen. Technetium (^99mTc) red cell scan of the colon is negative. Hemoglobin is 10.5g/dL; hematocrit is 30%.

Which of the following would be most appropriate at this time?

(A) Continued observation

(B) Repeat barium enema

(D) Right hemicolectomy

(E) Mesenteric angiography

7) A 75-year-old woman who is a neighbour of yours calls and asks you to stop by on your way home because for three days she has had markedly increasing fatigue and has been unable to get around denies cough, chest or abdominal pain, nausea, vomiting, sweating, or fever. You order a home laboratory service to obtain a complete blood count, plasma glucose, blood urea nitrogen, and serum electrolytes and agree to see her in the evening.

The patient is known in the neighbourhood as being somewhat reclusive. She has no family except for a daughter to whom she has not spoken in 20 years.

On physical examination at her home she is pale and appears significantly fatigues and mildly short breath. Temperature is 37.0 C (98.6 F); pulse rate is 92 per minute and regular in a sitting position 105 per minute standing; standing up is difficult for her because of arthritis. Blood pressure is 125/60 Hg sitting and 105/50 mm Hg standing. Examination of the chest reveals crackles at both lung bases, no area of dullness. There is an intermittent ventricular gallop. The abdomen soft, with no masses or ternderness. There are marked joint deformities of both kness but no redness Edema (1-2+) is noted in the lower extremities. Neurologic examination, including a mental status examination, is entirely normal except for some decrease in recent memory.

Laboratory studies (obtained this morning):

Hematocrit 40%

Leukocyte count 9500/cu mm; 80% segmented neutrophils,

7% band forms, 13% lymphocytes

Plasma glucose 4.3 mmol / l

Blood urea nitrogen 6.1 mmol / l

Serum creatinine 106 Mmol/l

Serum electrolytes :

Sodium 135 mEq/L

Potassium 4.0 mEq/L

Chloride 104 mEq/L

Bicarbonate 24 mEq/L

Although you advise the patient to be admitted to the hospital, she adamantly refuses and asks you to call her daughter.

Which of the following is the best plan of action at this time?

(A) Initiate proceedings to have her declared incompetent

(B) Ask her to find a different physician

(D) Order furosemide, 20 mg orally, and visit her again the next day

(E) Call the daughter and ask her to encourage her mother to be hospitalised.

8) You are asked to see a 17-year-old male student who was admitted to the hospital because of painful swollen right knee. The patient’s mother informs you that he has had large bruises after minor injuries al his life. Six months ago he bled for about ten days after biting his tongue; he was admitted to the hospital and given three blood transfusions. The patient has no siblings. The mother tells you the brother required a transfusion following tonsillectomy and bled for two weeks following a dental extraction. Her sister’s son has large bruises after minor injuries and has been found to have “some kind of hemophilia.” The patient took acetaminophen about two hours ago because of pain in the knee; he received no other medication.

Which of the following test results would be expected?

Partial

Bleeding time thromboplastin time Prothrombin time Thrombin time

(A) Abnormal Normal Abnormal Normal

(B) Normal Abnormal Normal Normal

(D) Normal Normal Abnormal Abnormal

(E) Normal Abnormal Abnormal Abnormal

9) Which of the following is most useful in the evaluation of a patient suspected of having occupational asthma?

(A) Skin testing with common airborne allergens to determine the patient’s atopic status

(B) Methacholine challenge test to determine the presence of bronchial

hyperreactivity

Inhaled allergens

(D) Serial measurements of ventilatory function performed before, during, and after work

(E) Documentation of a known sensitizing agent at the patient’s workplace

10) A previously healthy 75-year-old woman is brought to your office by he son, who noted that his mother has had a poor appetite, lost at least 4.5 kg (10 lb), and been withdrawn for three months. The patient has not had cough or fever, but she tires easily and has been constipated.

The patient appears very subdued, but she responds to questions. Temperature is 37.1 C (98.8 F) rate is 96 per minute, and rhythm is irregularly irregular. Blood pressure is 150/90 mm Hg in both arms. The eyelids droop. Examination of the fundi reveals grade II hypertensive changes. Estimated central venous pressure of 8 cm H₂O; the neck is otherwise normal. Examination of the heart and lungs reveals a grade 2/6 systolic murmur at the axilla and crackles at both lung bases. The abdomen is normal. She subdued but oriented, and generalised weakness that is most marked in the hip flexors is noted; neurologic examination is otherwise normal.

Laboratory findings include the following: hematocrit of 38%, leukocyte count of 7300/cu mm, and urea nitrogen of 3.2 mmol/ l

Which of the following would be most useful in establishing the diagnosis?

(A) Edrophonium chloride (Tension) test

(B) 50% glucose, intravenously

(D) Intravenous methylprednisolone

________________________________________________________________________________

11) A 24-year-old man is evaluated for facial pain and fever lasting four days. Symptoms began with upper respiratory tract infection accompanied by purulent nasal discharge; he then began to have over the right cheek and fever to 38.4 C (101.1 F).

Physical examination reveals purulent nasal discharge and tenderness over the right maxilla. C T Scan confirm right maxillary sinusitis.

Which of the following is the most cost-effective antibiotic treatment for this patient?

(A) Amoxicillin-clavulanate

(B) Penicillin

(D) Cefaclor

(E) Trimethoprim-sulfamethoxazole

12) A healthy 71-year-old man describes visual loss in his right eye. Flashes of light and a curtain of lateral vision began when he awoke eight hours ago. These symptoms have persisted.

Which of the following is the most likely explanation?

(A) Retinal vein occlusion

(B) Retinal detachment

(D) Ocular migraine

(E) Occipital lobe seizure

13) A 29-year-old woman has had type 1 diabetes mellitus for 16 years and has been your patient for years. During the past three years blood pressure has increased from 110/70 to 135/86 mm Hg; no orthostatic changes have been noted. The patient’s hemoglobin A_1C level has ranged from 8% to 9% {4.0-6.1}.

Today blood pressure is 130/84 mm Hg. The patient routinely monitors her blood glucose level and reports that recently it has fluctuated more than usual, ranging from 60 to 210 mg/dL. She also has nausea after eating and has required less food than usual to satisfy her appetite.

Laboratory studies:

Blood urea 6 mmol / l

Nitrogen 106 Mmol/ l

Serum electrolytes

Sodium 136 mEq/L

otassium 4.2 mEq/L

Chloride 98 mEq/L

Bicarbonate 24 mEq/L

Hemoglobin A_1C 6%

Urinalysis Protein 1+

Which of the following is the most likely cause of this patient’s symptoms?

(A) Adrenal insufficiency

(B) Incipient renal failure

(D) Delayed gastric emptying

(E) Inaccurate insulin administration

14) A 50 year old businessman underwent a vagotomy and antrectomy for duodenal ulcer disease 25 years previously. Since that time, he has experienced four episodes of gastrointestinal haemorrhage from recurrent stomal ulceration. Fasting serum gastrin (whilst on no therapy) is 390 pmol/L (normal <60).

The most appropriate next investigation is:

(A) Assessment of gastric acid secretion

(B) CT abdomen

(D) Endoscopic ultrasonagraphy

(E) A secretin stimulation test

15) A 24 yr old woman presents complaining of embarrassing excessive hair on her face and limbs which was first noticed in high school but dismissed by her GP as being due to adolescent ‘hormone problems’. She also has irregular periods and found it difficult to lose weight.

On examination: Hirsuit, normal voice, no clitoromegaly, otherwise normal feminization, euthyroid, not cushingoid, BP 140/87. BMI 30 kg/M2 and WHR 1.0.

Investigations: Total serum testosterone within normal range for women, DHEAS normal, PRL normal, 170H Progesterone normal. LH/FSH ratio 1.5.

(A) The LH/FSH ratio has a greater than 96% sensitivity in diagnosing polycyctic ovarian disorder

(B) Weight loss should be the first treatment option as this has been shown to decrease free testosterone and increase SHBG levels in patients with hirsuitism due to PCOS

(D) The absence of ovarian cysts on ultrasound would have excluded a diagnosis of PCOS

(E) Her SHBG is likely to be increased marginally

16) A young mother presents with a chronic loose motions and is found to have a painless thyroid nodule. She has suffered from recurrent renal calculi in the past and her mother died of thyroid cancer.

(A) If she is found to have a mutation of the RET proto-oncogene, she has a 60% chance of developing a medullary carcinoma of the thyroid

(B) Her child should be genetically tested regardless of symptoms and signs, after the age of 6 but before teenage

(D) If she is positive for the mutation, FNABx is not indicated and she should undergo hemithyroidectomy and lymph node clearance on the left side of the nodule

(E) She has 9% chance of also having a phaeochromocytoma.

17) A young teenager presents with pleuritic chest pain, dyspnoea, leukocytosis and a lower lobe infiltrate on CXR. He has the blood film shown. The most likely diagnosis is:

(A) Pneumococcal pneumonia

(B) Acute chest syndrome

(D) Fat embolism

18) A 60 yr old presents to casualty with a 4hr history of dizziness, nausea and vomiting, falling to the left. He says his right side feels numb. On examination he has impaired pain and temperature sensation on the face, limbs and trunk on the right and impaired light touch, vibration and position sense greater in the leg than the arm on the right. His wife also comments that his eyes appear “uneven”. He is most likely to have a lesion in,

(A) The left superior cerebellar artery

(B) The left posterior inferior cerebellar artery

(D) The right superior cerebellar artery

(E) The left posterior cerebral artery

19) A 30 year old man is involved in a car crash and admitted to ICU after evacuation of a subdural haematoma and open femoral fracture in theatre. He makes a slow recovery and upon regaining consciousness 3 weeks later he remarks that his shoulders feel “numb”. On examination he is afebrile, there is a loss of pain and temperature sensation over the shoulders and upper arms, however no loss of vibration and position sense. There is some associated muscle wasting over the shoulder right side greater than left. This is probably due to;

(A) Anterior Spinal cord syndrome secondary to hypotension peri-operatively

(B) Epidural abscess secondary to open wound

(D) Unnoted Brown-Sequard syndrome

(E) Acute transerve myelitis

20) A young lady presents to your surgery complaining of an enlarged R pupil. On examination, she is found to have no response to direct or consensual light but a slow response to accommodation. In addition to this she is most likely to have;

(A) Absent reflexes

(B) No response to pilocarpine (0. 1-0.5%)

(D) Hyperintense signal in the midbrain on T2 weighted MRI

(E) VDRL positive

21) A 42 year old female with a past history of recurrent spontaneous abortions is admitted for an elective hysterectomy. Pre-operatively, she is found to have a prolonged activated partial thromboplastin time (APTT) of 50 seconds. A mixing test of 1:1 patient and normal plasma also gives a prolonged APTT. The prothrombin and thrombin clotting times are normal.

Which one of the following statements is incorrect?

(A) Kaolin clotting time may be helpful in identifying the cause of the prolonged APTT

(B) There is a high risk of surgical bleeding and the operation should be cancelled

(D) If she developed DVT post-operatively, it would be possible to monitor heparin therapy by laboratory tests

(E) The test for anticardiolipin antibody is likely to be positive

22) A 55 year old man was admitted for an elective cardiothoracic procedure in 1989. Two crossmatch compatible and fully screened units of blood were transfused from his 2 children as dedicated donors. Ten days later he developed fevers, erythematous desquamative skin rash, bloody diarrhoea, liver function abnormalities and a severe pancytopenia.

Which of the following statements is / are correct?

(A) This probably represented a delayed transfusion reaction due to an undetected antibody.

(B) This problem was more common with random donated units of blood than with dedicated blood from family members

(D) The illness was consistent with graft-versus-host disease

(E) The use of a white cell filter would have prevented the occurrence of this syndrome

23) With regard to herpes simplex encephalitis in adults, which of the following statement is incorrect ?

(A) It will usually present as a focal neurological process

(B) Most patients have either a history of ‘cold sores’ or herpetic skin lesions present on examination

(C) About one half of patients initially presumed to have herpes simplex encephalitis will have an alternative diagnosis or no diagnosis made on brain biopsy

(D) Viral antibody detection in the CSF is a sensitive test for herpes simplex encephalitis early in the course of the illness

(E) Renal impairment is a recognised complication of intravenous acyclovir

24) A 36 year old Chinese man presented with intermittent painful swollen achilles tendons. He had a history of episodes of transient painful arthritis of his knees lasting 1-2 days during which he could not stand. There was no other relevant past or family history. On examination he had enlarged non tender achilles tendons and nodules over his metocarpophalangeal joints in the extensor tendons. Spinal movements were normal.

Which of the following statements is/are correct?

(A) He is most likely to be HLA B27 positive

(B) This presentation is consistent with familial hypercholesterolaemia

(D) An elevated uric acid would confirm the diagnosis of gout

(E) X-ray of his pelvis is likely to show sacroiliitis

25) A 45 year old man with insulin dependent diabetes since the age of 12 years presented with a 12 month history of a painful restricted left shoulder. His shoulder movements were limited in all directions with no evidence of weakness or rotator cuff tendinitis. He gave a past history of a right carpal tunnel syndrome which responded to surgical decompression. He gave a history of triggering of the fingers of both hands with increasing limitation of finger movement. Examination demonstrated skin thickening over the fingers but not the remainder of the body. He had bilateral Dupytren’s contractures.

Which of the following statements is incorrect?

(A) He has scleroderma

(B) He has diabetic cheirarthropathy

(D) Good control of his diabetes may improve his condition

(E) This condition is not associated with abnormal nailfold capillaroscopy

26) A female aged 17 years presents with constipation and the barium enema picture is shown below. Which of the following statements is incorrect?

(A) Intermittent faecal soiling is to be expected

(B) Constipation probably dates to childhood

(D) The rectum may return to normal size with laxative treatement

(E) Colonic resection is unnecessary

27) A professional man aged 54 years with a body mass index of 32 is found to have a mildly enlarged liver. His alcohol consumption is 40g daily. The following laboratory tests were obtained:

serum bilirubin 27 umol/l

serum albumin 41 g/l

serum globulins 28 g/l

AST 60 u/l

ALT 60 u/l

SAP 130 u/l

GGT 330 u/l

Serum iron 24 umol/l

TIBC 51 umol/l

Ferritin 1200 ug/l

Which of the following statements is correct?

(A) The patient probably has haemochromatosis

(B) Mallory’s hyaline found on liver biopsy would indicate alcoholic liver disease

(D) The elevation of GGT is helpful in the differential diagnosis of this patient’s problems

(E) Liver biopsy is most likely to show fatty infiltration

28) A previously well male aged 27 years presents with fatigue and breathlessness over a period of 10 days. Clinically he is found to be mildly jaundiced, pale and to have splenomegaly palpable 4cm below the left costal margin. Full blood count reveals haemoglobin 8.5 gm/dl, white cell count 12.5 x 10⁹ per litre with mild neutrophilia and platelet count 350 x 10⁹ per litre. The Direct Coombs test is negative. Blood film shows large numbers of spherocytes, but no other abnormalities. Bone marrow biopsy shows marked reduction in erythroid precursors with relatively normal myeloid and megakaryocytic elements. Further questions reveals there is a family history of anaemia and a maternal uncle had had a therapeutic splenectomy.

Which of the following statements is incorrect?

(A) The patient is probably suffers from G6PD deficiency

(B) The likely diagnosis is hereditary spherocytosis

(D) Heinz body preparation will be negative

(E) B₁₉ parvovirus infection may be implicated in the sudden development of anaemia

29) A nulliparous woman aged 23 years has tonic-clonic epilepsy. She is well controlled on sodium valproate and seeks advice relating to her disorder and medication in relation to preganancy.

Which of the following statements is correct?

(A) As she is well controlled it is unlikely that there will be any alteration in the seizure frequency during her pregnancy

(B) Drug requirements may decrease in the third trimester

(D) Breast feeding should be avoided while taking sodium valproate

(E) There is an increased risk of foetal malformation independent of drug therapy

30) A man aged 50 years presents with visual scintillations in the left eye and is found to have unilateral left papilloedema. He has no other neurological abnormality. Which of the following statement is correct?

(A) The unilateral nature of the papilloedema excludes raised intracranial pressure (ICP)

(B) A loss of peripheral visual field in the left eye would support a diagnosis of ischaemic papillitis

(C) In the absence of any systematic disease, a normal CT scan of the orbit and anterior cranial fossa supports a diagnosis of ischaemic papillitis

(D) In ischaemic papillitis, the risk of involvement of the other eye over 5 years is less than 5%

(E) High dose steroids reverse the changes of ischaemic papillitis

· * * * * *

ANSWERS PART B

1. B

2. A

3. D

4. B

5. A

6. A

7. D

8. B

9. D

10. B

11. E

12. B

13. D

14. E

15. B

16. C

17. B

18. B

19. A

20. B

21. B

22. D

23. B

24. B

25. A

26. C

27. E

28. A

29. E

30. C