1.

In a 3 year old child with signs and symptoms suggestive of bacterial meningitis, which of the following is the BEST initial management? a) Erythromycin IV b) Gentamicin IV c) Ceftriaxone IV Correct d) Phenoxymethylpenicillin oral e) Amoxycillin oral

If bacterial meningitis is suspected clinically it is vital to immediately administer an appropriate antibiotic prior to urgent transfer to hospital, as meningococcal meningitis may be rapidly fatal. The drug of choice would be benzylpenicillin 60mg/kg up to 3g IV or IM, or ceftriaxone 50mg/kg up to 2g IV in patients hypersensitive to penicillin or when further drug treatment may be delayed. (Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed, Churchill Livingstone, Sydney, p 378-379 )

2. Which of the following statements regarding undescended testes is CORRECT? a) The testes are undescended at birth in 40% of boys. b) Once the testis is palpable in the scrotum it will remain so. c) Descent is unlikely to occur after 1 year of age. Correct d) Orchidopexy should be delayed until late childhood. e) The undescended testis is at reduced risk of malignancy.

Testes which are undescended at birth may well descend into the scrotum during the first two weeks of life, however descent is unlikely to take place after the age of one year. 2% of boys born at full-term, and 20% of premature males, have undescended testes. A testis which was palpable in the scrotum in infancy may ascend and become impalpable due to failure of the spermatic cord to elongate at the same rate as body growth. Orchidopexy is best performed by 12-18 months of age as spermatogenesis in the undescended testis is impaired after the age of two years. The undescended testis is at 5-10 times greater risk of developing malignancy (seminoma). (Murtagh, J. (1997), General Practice, Third Edition McGraw-Hill, Sydney, Chap 102, p 1076-7 )

(Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed, Churchill Livingstone, Sydney, p 251-252 ) A 34 year old woman presents with an acutely painful swollen knee. Synovial fluid aspirate shows the following: WCC 4100/uL (NR < 2000/uL), 80% polymorphonuclear lymphocytes red blood cells ++ no crystals no organisms cultured

-What is your interpretation of these results? a) Inflammation is more likely Correct b) Gonococcal arthritis c) Viral arthritis d) Tuberculous arthritis e) Traumatic tap

Normal synovial fluid contains less than 2000 white blood cells per microlitre. Inflammation causes counts of 3000 or higher. Inflammation can also cause red blood cells to migrate into the joint fluid. Viral arthritis - usually symmetrical polyarthritis, predominantly lymphocytic effusion TB arthritis - chronic presentation with WCC >10,000/uL, 50% PMNLs, culture positive in 50% Gonococcal arthritis - WCC >10-20,000/uL (Ma, D.T.S., Carroll, G.J, Monoarthropathy Could this be infection?, Australian Family Physician, vol 27 (1/2) p 29-31 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=95832 )

Concerning prostate cancer, which ONE of the following is INCORRECT? a) The majority of carcinomas arise in the peripheral zone of the gland b) The prostate specific antigen (PSA) is elevated in all prostate cancers greater than 1.5 cm c) If metastasis occurs, pelvic lymph nodes are involved early Incorrect. The correct answer is (b). d) Radionuclide bone scan is a sensitive but not specific method of detecting bony metastases e) Prostate cancers usually appear as hypoechoic nodules on transrectal ultrasound

A normal PSA occurs in up to 20% of cancers, including tumours greater than 1.5 cm. Prostate cancer is the second most common cause of cancer deaths in men in Australia. The majority of prostate cancers- usually adenocarcinomas- arise in the peripheral zone of the gland, and metastasise early to pelvic lymph nodes. Bony metastases are also common. Bone scan is unreliable at detecting bony metastases when the prostate specific antigen (PSA) is <20ng/ml. The commonest pattern for prostate cancer on transrectal ultrasound is of hypoechoic nodules. This pattern may also be seen in prostatic hypertrophy or prostatitis. (Way LW, Doherty GM. eds. (2003), Current Surgical Diagnosis and Treatment, 11th ed. Lange medical Books, McGraw-Hill, NY, p 1066-1069 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=63040 )

Prostate-Specific Antigen Sections: Prostate Biopsy, Pathology, Prevention, Treatment of Benign Disease, Prostate Cancer Staging, Clinically Localized Disease, Radical Retropubic Prostatectomy (RRP) , Radiation Therapy, Rising PSA, Metastatic Disease: Noncastrate, Metastatic Disease: Castrate. Topics Discussed: androgen ablation; androgen antagonists; androgens; bone scan; brachytherapy; estrogen; finasteride; gonadotropin-releasing hormone; goserelin acetate; hematuria; hormonal therapy; ketoconazole; leuprolide acetate; metastatic prostate cancer; metastrongyloidea; orchiectomy; patient observation; prostate biopsy; prostate cancer; prostate disease; prostate-specific antigen; prostate-specific antigen test; prostatectomy, radical retropubic; prostatic intraepithelial neoplasia; quadramet; radiation therapy; testosterone; tnm prostate tumor staging; ultrasound, transrectal. Excerpt: "PSA is a kallikrein-like serine protease that causes liquefaction of seminal coagulum. It is produced by both nonmalignant and malignant epithelial cells. PSA is prostate specific, not prostate cancer specific, and increases may occur from prostatitis, nonmalignant enlargement of the gland (BPH), prostate cancer, and prostate biopsies. The level is not affected by the performance of a DRE. It circulates in the blood as an inactive complex with the protease inhibitors -1-antichymotrypsin and 2-macroglobulin and has an estimated half-life in the serum of 2 to 3 days. Levels should be undetectable if the prostate has been removed. PSA immunostaining is used to establish a prostate cancer diagnosis.A diagnosis of cancer is established by a TRUSguided needle biopsy. Direct visualization assures that all areas of gland are sampled. A minimum of six separate cores, three from the right and three from the left, are advised, as is a separate biopsy of the transition zone, if clinically indicated. Performance of a biopsy is not..."

Question 10 Which ONE of the following atypical antipsychotic drugs is optimal as first line therapy in managing the first episode of schizophrenia in a patient?

a) Risperidone b) Olanzapine Correct c) Quetiapine d) Amisulpride e) Clozapine

Olanzapine is the drug of choice for treatment of first episode schizophrenia, since it does not cause extrapyramidal symptoms at therapeutic doses, and is useful for combating affective symptoms, including depression. Its major disadvantage is weight gain. The other drugs listed carry a greater risk of extrapyramidal symptoms and other side effects. (Lambert TJ, Castle DJ (2003) Pharmacological approaches to management of schizophrenia. M J A, 178, Supplement: Comprehensive care for people living in the community, S57-S61

*Ara, 5 years old, presents with a painless limp. You suspect Perthes' disorder. Which of the following statements is CORRECT? a) Hip mobility is usually reduced, particularly adduction and external rotation Incorrect. The correct answer is (d). b) Ultrasound is required to make a definitive diagnosis c) The white cell count and C reactive protein (CRP) are usually raised d) Progress is assessed with serial radiological examination e) Osteotomy is the treatment of choice

Perthes' disorder is most common in 4-8 year olds. On examination hip mobility is reduced, particularly abduction in flexion. Xray confirms the diagnosis showing widening of the joint space, decalcification of the metaphysis and a dense slightly flattened femoral head. There is no need for testing white cell count or CRP as these are normal. In most cases the prognosis is excellent and the only requirement is to avoid prolonged walking or exercise. Progress is assessed by clinical examination and serial radiological examinations. Where there are severe changes containment of the femoral head is the treatment of choice and this usually requires a plaster cast or orthosis. Osteotomy of the pelvis or femur is only rarely required. (Murtagh, J. (2003), General Practice, Third Edition McGraw-Hill, Sydney, Chap 64, p 704-705 ) * Question 12 Susie is 16, and has had a lingering cough following an apparent viral bronchitis. Her doctor referred her for a chest X ray which has shown a mass in the antero-superior mediastinum. Which of the following is NOT a likely diagnosis?

a) teratoma Incorrect. The correct answer is (d). b) thymoma c) retrosternal thyroid d) bronchogenic cyst e) lymphadenopathy

Bronchogenic cysts are mostly found in the posterior mediastinum, and only rarely in the anterior mediastinum All of the others are likely diagnoses. Approximately half of all mediastinal masses are asymptomatic and discovered on a 'routine' X Ray. Lesions in young people, and lesions which produce symptoms are more likely to be malignant. (Tjandra J, Clunie G, Thomas R. (2001) 'Textbook of Surgery' Blackwell Science Asia, Melbourne p 625 ) *A 15kg child with a known food allergy to peanuts suddenly develops anaphylaxis. The RECOMMENDED immediate management is: a) 0.1ml of Adrenaline 1:1000 by deep intramuscular injection b) 0.1ml of Adrenaline 1:10,000 by deep subcutaneous injection c) 0.15ml of Adrenaline 1:1000 by deep intramuscular injection d) 0.15ml of Adrenaline 1:1000 by subcutaneous injection Incorrect. The correct answer is (c). e) 0.15ml of Adrenaline 1:10,000 by deep intramuscular injection

Adrenaline 1:1000. is recommended as it is readily available, and this concentration contains 1mg of adrenaline per ml. The recommended dose of 1:1000 adrenaline is 0.01mg/kg body weight by deep intramuscular injection, so a 15kg patient would require 0.01 X 15 = 0.15ml i.m. (Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed, Churchill Livingstone, Sydney, p 415-416 )

* Which ONE of the following is a mass population screening test which has been demonstrated to significantly reduce cancer mortality? a) annual faecal occult blood testing in the over 50 age group Correct b) annual colposcopy in sexually active women

c) annual plasma CA125 in post menopausal women d) annual colonoscopy in siblings of patients with colon cancer e) 2 yearly mammography in women in the 35-45 age group

There have been at least 3 randomised control screening trials conducted which show that faecal occult blood testing every 1-2 years in the over 50 year population reduces the mortality from colorectal cancer by around 20%. Colposcopy is a diagnostic, not a screening test. The appropriate screening test for cancer of the cervix in sexually active women is the Papanicolaou (Pap) smear. Plasma CA125 levels may be raised in asymptomatic women with ovarian cancer but there is not, as yet, any evidence for its benefit as a mass screening measure. Colonoscopy for siblings of patients with colorectal cancer may reduce their mortality, but this is 'selective' screening, by targeting a highrisk group. While mammography in the 50-70 age group has been shown to reduce mortality from breast cancer by around 30%, the benefit for women in the 40-50 age range is quite small, and there is little evidence for benefit in still younger women. (Semmens, J,Platell,C. 'Bowel Cancer' Australian Family Physician *All of the following groups are at higher risk than average of depression, EXCEPT: a) Women Incorrect. The correct answer is (d). b) Postpartum women c) Young rural males d) Urban males e) Adolescents

Men living in urban areas are not especially at risk of depression. However, young men living in rural areas are at greater risk because of social isolation. Women, particularly in the postpartum period, and adolescents are also more vulnerable to depression. (Guidelines for preventive activities in general practice. (2002) Updated 5th ed. Australian Family Physician, Special Issue, SI, 44 ) (Harrison's Online *Fourteen month old Mark has had a high fever and mild coryza for three days but has still been quite active. Mark's temperature has returned to normal today but he has now developed a red maculopapular rash on his trunk. The MOST LIKEY diagnosis is: a) Measles Incorrect. The correct answer is (e). b) Chicken pox c) Erythema infectiosum d) Rubella

e) Roseola infantum

Roseola infantum is a viral infection usually affecting children between the ages of 6-18 months. The patient typically develops high fever up to 40 degrees Celsius, but is otherwise not particularly unwell. There may be mild cervical lymphadenopathy and pharyngitis. After three days the temperature usually returns suddenly to normal and the patient develops a red macular or maculopapular non-desquamating rash which is truncal, usually sparing the face and limbs. The rash abates within two days. (Murtagh, J. (2003), General Practice, Third edition, McGraw-Hill, Sydney, Chap 81, p 907 ) (Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed, Churchill Livingstone, Sydney, p 362 ) *A 50 year old woman has had major abdominal surgery yesterday. You are called to see her urgently as she has symptoms of shock. Which ONE of the following examination findings is of MOST concern? a) the patient is restless and confused b) Temperature 39.2 degrees Celsius c) pulse 130, sinus tachycardia d) urine output over past 4 hours of 120ml e) BP 80/45 mm Hg Correct The above signs taken together describe a picture of shock. Hypotension (defined as systolic BP <90mm Hg, or >40mm Hg fall from baseline level) is a sinister development and requires urgent attention. It is often a LATE manifestation of circulatory failure. Thus it is the most alarming of these findings, and the one most indicative of the urgency of this situation.

*Simon aged 4 months is diagnosed with pertussis. What is the MOST APPROPRIATE management of Simon's parents to reduce their risk of infection? a) Immediate booster immunisations for pertussis b) A 10 day course of erythromycin Correct c) Commence a 3 dose pertussis revaccination schedule d) Arrange nasopharyngeal swabs e) Immediate immunisation with pertussis immunoglobulin

Fifty percent of babies with pertussis are infected by their parents. All household contacts of patients with pertussis should receive erythromycin for 10 days to prevent further spread of the disease. Cotrimoxazole is recommended for those intolerant of erythromycin. An initial or booster dose of pertussis vaccine should be considered for children aged up to 8 years. A booster vaccine is now available for adults and children > 8yrs who have had the initial course. It is recommended for children 15-17 yrs of age, parents planning their first pregnancy, adults working with young children or at 50 years of age. Babies under 2 months of age who have been exposed are best vaccinated early. Passive immunisation with pertussis immunoglobulin is not effective in the prevention of pertussis. Isolation is not required for household contacts. (NHMRC (2000). The Australian Immunisation Handbook. Seventh Edition. Australian Government Publishing Service ) (Sturmberg, J. P. (1999), Could it be whooping cough?, Australian Family Physician, vol 28, no 2, February, p129-31 ) (Merck Manual Available: www.merck.com/mrkshared/mmanual/section19/chapter265/265a.jsp ) * Question 20 Aidan, a 3 month old boy, presents with paroxysms of coughing associated with cyanosis, lethargy and poor feeding for several days. On examination, between episodes of coughing, he is afebrile and examination is normal. What is the NEXT step in management? a) Admission to hospital Correct b) Nasopharyngeal aspirate and review in 24 hours c) Immunisation at this visit with DTP and review in 24 hours d) Erythromycin syrup and review in 24 hours e) Trial of salbutamol by mask

The clinical picture suggests respiratory infection with Bordetella pertussis. The history of cyanosis associated with the coughing suggests the need for admission to hospital but, in addition, children under 6 months of age usually require admission for pertussis because of the risk of complications. Complications include respiratory arrest, bacterial pneumonia and encephalitis. Salbutamol has not been shown to be helpful in a child of this age and is of no benefit. Immunisation at a later date should be encouraged even if the child has had pertussis. Erythromycin is not curative but may reduce infectivity. (Sturmberg, J. P. (1999), Could it be whooping cough?, Australian Family Physician, vol 28, no 2, February, p129-31 ) (Murtagh, J. (2003), General Practice, Third edition, McGraw-Hill, Sydney, Chap 81, p 909-910 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=70757&searchStr=whooping+cough#searc

hTerm ) (Merck Manual Available: www.merck.com/mrkshared/mmanual/section19/chapter265/265a.jsp ) Question 19 Arthur is a 74 year old man who presents reluctantly because his wife feels 'he has not been himself since he came home and is not sleeping properly.' His appetite is poor and he has lost 6 kg in weight since discharge from hospital eight weeks ago following treatment for myocardial infarction. He has lost interest in his hobbies and is not taking his medications. He has been a type 2 diabetic for 12 years. On examination he shows signs of mild cardiac failure. The result of an HbA1C test is 10.5% (target <7%). Which ONE of the following is the MOST likely cause of Arthur's condition. a) Senile dementia b) Uncontrolled diabetes c) Depression Correct d) Silent reinfarction e) Chronic fatigue syndrome Arthur is showing several typical features of depression, viz insomnia, loss of interest in pleasurable activities, loss of appetite and loss of weight. Depression following myocardial infarction is well recognised and increases the risk of complications and death. Such patients are less likely to observe instructions regarding medications, making their situation worse. Arthur's diabetes is poorly controlled, as shown by the elevated HbA1C level but this is insufficient to explain his condition. The other options could contribute to the clinical picture shown by Arthur but are less likely to be the cause of his condition. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109349 ) (Merck Manual Available: www.merck.com/mrkshared/mmanual/tables/189tb1.jsp )

Which of the following is NOT a diagnostic feature accompanying anxiety in generalised anxiety disorder (GAD)?

a) Restlessness b) Fatigue c) Difficulty concentrating d) Muscle tension e) Loss of appetite Correct Loss of appetite is not a feature of GAD. The DSM-IV criteria include 3 or more of the following in addition to anxiety and worry: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.

Question 25 Doris is a 74 year old woman whose husband has died suddenly a week ago. She seeks your help in dealing with insomnia which has been troubling her since her husband's death. She has tried an over-the-counter preparation which she obtained at the local pharmacy but has not found it helpful. Which of the following drugs would you offer to prescribe for Doris? a) Temazepam Incorrect. The correct answer is (e). b) Zopiclone c) Zolpidem d) Amitriptyline e) Any of the above

There is a well defined role for short-term use of a hypnotic medication in a situation like sudden bereavement. None of the drugs listed stands out as the best hypnotic with few side effects. Temazepam is the most often prescribed hypnotic in Australia. However, benzodiazepines have generally fallen from favour because of their addictive properties if taken for more than several weeks. Zopiclone and zolpidem share some of the properties of benzodiazepines but have fewer adverse effects. Amitriptyline is a tricyclic antidepressant which is a useful hypnotic in lower doses than are used for depression. (Grunstein R (2002) Insomnia: diagnosis and management. Australian Family Physician, 31: 995-1000

Available:www.racgp.org.au/document.asp?id=9029 Available:www.racgp.org.au/afp/downloads/pdf/november2002/20021101grunstein.pdf Question 27 Mavis is an 83 year old widow who is brought to your consulting room by her daughter because she 'is not looking after herself properly.' Mavis appears unkempt and withdrawn and gives monosyllabic answers to your questions. The daughter says that she 'has been going downhill for a while,' ever since 'she began having problems with her memory.' Further discussion with the daughter reveals that Mavis is suffering from fatigue, anorexia and short-term memory loss, and is afraid to leave her house. She spends much of her day sleeping in front of the television set. Which of the following is the MOST LIKELY diagnosis? a) Alzheimer's dementia b) Vascular dementia c) Melancholia d) Psychotic depression Incorrect. The correct answer is (c). e) Bipolar disorder

Melancholia (previously called endogenous depression) is a severe form of 'biological' depression due to a primary abnormality of brain neurotransmitter metabolism, principally involving serotonin. Such severe depression can present as pseudodementia, mimicking Alzheimer's dementia. Psychotic depression is also a severe form of biological depression with the additional aspect of psychotic features. In bipolar disorder there are alternating episodes of depression and mania. Other possible diagnoses include medical disorders such as hypothyroidism. (Snowden J (2002) Severe depression in old age. Medicine Today, 3: 41-47 ) Question 28 The prevalence of insomnia in the Australian community is about: a) 10% b) 20% c) 30% Correct d) 40% e) 50%

The prevalence of insomnia in Australia is about 30%. The situation is similar in other industrialised nations. Male sufferers outnumber females by 1.3 to 1 in the 40+ years age group. Other factors which increase the prevalence of insomnia are old age,

unemployment and lower socio-economic status. The majority of patients have a coexisting disorder, such as depression or generalised anxiety, and often present with fatigue or daytime sleepiness rather than insomnia. Question 30 Patients suffering from generalised anxiety disorder (GAD) often go undiagnosed for years because they: a) Deliberately conceal their anxiety b) Inadvertently play down their anxiety c) More often present with somatic complaints d) Are misdiagnosed as having depression e) Tend to keep away from doctors Incorrect. The correct answer is (c).

Patients with GAD are frequently not diagnosed for years because they tend to present with associated somatic complaints, such as asthma, back pain, migraine, allergies, and gastrointestinal disorders and often consume a large amount of medical resources before the diagnosis is made. They are not deliberately concealing things from their doctors they simply do not appreciate the significance of their feelings. Patients with GAD may also have clinical depression which can further complicate the issue. (Murtagh, J. (2003), General Practice, Third edition, McGraw-Hill, Sydney, p 1251-1253 )

Question 31 All of the following are effective first line topical treatments for severe dandruff EXCEPT: a) Selenium sulphide b) Zinc pyrithione c) Betamethasone Correct d) Miconazole e) Ketoconazole

Dandruff, pityriasis capitis and seborrhoeic dermatitis are related conditions on a continuum of severity. Pityrosporidium ovale is a fungus which has been implicated in the development of these conditions. Eradication of the fungus has been shown to relieve the

symptoms of the condition. Selenium sulphide, zinc pyrithione, miconazole and ketoconazole are all first line treatments which can be used once weekly to daily depending on severity. Topical application of betamethasone lotion is effective but only considered if there has been little response to the first line treatments. (Fitzpatrick, T.B. Johnson, R.A. et al (Eds)(1993) Color Atlas and Synopsis of Clinical Dermatology 2nd ed p56 New York McGraw Hill ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=56775&searchStr=seborrheic+dermatitis+o f+scalp#56775 ) (Murtagh, J. (2003), General Practice, Third edition, McGraw-Hill, Sydney, p 1221 ) Question 32 Amy, a young girl, is worried about a rash on her face which has been there for a few weeks. It is mildly itchy and has slowly increased in size. On examination it is a circular lesion which looks scaly around the edges with the center appearing normal(see figure).

The MOST LIKELY diagnosis is: a) Tinea corporis Correct b) Impetigo c) Pityriasis versicolor d) Psoriasis e) Dermatitis

In children, tinea commonly involves the hair, face and body. Tinea corporis is recognised by its scaly, erythematous edge with clearing centre. Dermatitis and psoriasis can mimic tinea and where the clinical picture is uncertain a fungal scraping may confirm tinea.

Impetigo may present with blisters that leave a brown crust, or erosions with yellow crusts but without blistering. Pityriasis versicolor presents as well demarcated pale or tan-coloured macules usually on the upper trunk. (Fitzpatrick, T.B. Johnson, R.A. et al (Eds)(1993) Color Atlas and Synopsis of Clinical Dermatology 2nd ed p56 New York McGraw Hill ) (Murtagh J. (2003), General Practice. Third edition, McGraw-Hill, Sydney p 1165 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=77020&searchStr=tinea+corporis#77020 ) Question 33 After referral to a paediatric oncologist, Bronwyn is diagnosed as having acute lymphoblastic leukaemia (ALL). Both her parents are very distressed and visit you to find out more about this condition. Which of the following statements about acute lymphoblastic leukaemia is INCORRECT? a) 75% of children with ALL are cured Incorrect. The correct answer is (c). b) An initial intense course of treatment lasting approximately 4-6 weeks is required c) Intrathecal therapy is required only if the disease has spread to the spine d) Relapse rates are of the order of 30% e) Remission rates are of the order of 95%

Intrathecal therapy is now given to all children with ALL. Prior to blanket intrathecal therapy, up to 60% of children had a relapse due to CNS disease. The use of blanket CNS therapy has reduced the CNS relapse rate to less than 10%.

* Question 34 Mary is an attendant at a local accommodation centre and has an intensely itchy rash on her wrists and arms that has been present for the past few days (see figure).

She has recently bought a new watch and wonders if this is the cause of the problem. The MOST LIKELY diagnosis is: a) Papular urticaria b) Tinea c) Contact dermatitis d) Eczema e) Scabies Correct

Scabies is a skin infestation by the mite Sarcoptes scabei. It is generally spread by skin to skin contact such as in crowded areas, poverty, sexual contact and casual contact. The mite can live for 2 days outside the human body, so infection by contact with bed linen and other infected material is possible. Intense itch is characteristic of the condition - if it is not itchy, it is not scabies. Distinct erythemato-papular itchy nodules are due to an allergic reaction to the mite, its faeces and its larvae. 0.5-1.0cm "burrows" can often be found on the fingers and wrist. Contact dermatitis to her watch would produce a local contact dermatitis. (Fitzpatrick, T.B. Johnson, R.A. et al (Eds)(1993) Color Atlas and Synopsis of Clinical Dermatology 2nd ed p56 New York McGraw Hill ) (Murtagh, J. (2003), General Practice, Third edition, McGraw-Hill, Sydney, p 1144-1145 ) (Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed, Churchill Livingstone, Sydney, p 724-725 )

Question 35 Which of the following statements about routine immunisation is CORRECT? a) If more than 3 months elapses between triple antigen injections the series should be restarted to obtain adequate immunisation

b) The first triple antigen injection should always be half dose (1/2 cc) to reduce allergic reactions c) A convulsion following acellular pertussis triple antigen vaccine (DTPa) does not contraindicate its further use Correct d) Tetanus booster injections should be repeated every 3 years e) Measles vaccine should be given at 6 months of age to protect the child as soon as possible A convulsion, in the presence or absence of fever, occurring after DTPa vaccination, does not contraindicate completion of the course with DTPa-containing vaccine. The only adverse events which contraindicate further doses of pertussis containing vaccine are: encephalopathy within 7 days and an immediate severe allergic reaction.

It is now recommended that, after a full primary course of childhood vaccination, a single booster of tetanus toxoid is administered at age 50 years only (unless required sooner for managing a tetanus-prone wound). Measles, mumps and rubella immunisation is recommended at 12 months of age. Triple antigen immunisation is recommended at 2, 4, and 6 months of age with a booster at 15-17 years of age (Boostrix). The first dose should not be reduced. (NHMRC, (2000), The Australian Immunisation Handbook, 7th ed, Canberra, Australian Government Publishing Service, p177-8, 218 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=67428&searchStr=immunization+schedule #67428 ) http://www.accessmedicine.com/content.aspx?aID=79958 Question 37 Melissa, a 49 year old woman, presents with loss of libido which has been worsening over the past 12 months. She takes a combined oral contraceptive tablet, and a selective serotonin reuptake inhibitor (SSRI) for depression. She is a non smoker but drinks 1-2 glasses of wine a night. Which of the following advice would you offer Melissa to help her regain her libido? a) Change to a progestagen only oral contraceptive b) Change to an oestrogen only oral contraceptive c) Reduce her alcohol intake d) Change antidepressant medication Correct e) Undertake cognitive behavioural therapy

Various medications may cause loss of libido, including antidepressants like the SSRIs. The remedy is to change to a different class of antidepressant. Excess alcohol

consumption can have a deleterious effect on libido, however Melissa's intake is within recommended limits for adult females. Changing the oral contraceptive would be unlikely to help. Cognitive behavioural therapy would be the next step if suitable pharmacotherapy cannot be established. (Reddish, S. (2002), Loss of libido in menopausal women, Australian Family Physician, vol 31 Available: www.racgp.org.au/document.asp?id=6305 ) (Murtagh, J. (2003), General Practice, Third edition, Churchill Livingstone, Edinburgh, chap 106, p 1103-1109 ) Question 38 In assessing a patient for adult-onset asthma, which of the following is FALSE? a) There is usually a history of past or present cigarette smoking b) There is usually a long history of atopic disease c) Attacks can be triggered by chemical and physical agents d) The asthma tends to be more chronic than episodic e) The associated cough can be harsh, suffusing and non-productive Incorrect. The correct answer is (b).

Adult onset asthma is non-atopic, although patients can have attacks precipitated by aspirin, viruses, cold air and coughing itself. A history of smoking is nearly ubiquitous, but the connection to the development of adult-onset asthma is not yet understood. Patients tend not to have long spells of being 'puffer free', but regular inhaled steroids are very effective in controlling the condition. The cough can keep the patient awake all night, along with the rest of the family. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=83933 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=83951 )

Question 39

A 61 year old farmer with a history of hypertension presents with an amnesic episode of sudden onset. When assessed he is perplexed and bewildered, and repeatedly asks where he is and how he comes to be there. He has short term memory loss but knows his identity and is fully conscious. He recovers from his memory loss after 6 hours. Neurological examination is normal. His blood pressure is 165/96 sitting. The MOST LIKELY diagnosis is: a) Hypertensive encephalopathy b) Richardson-Steele syndrome c) Alzheimer's disease d) Transient global amnesia Correct e) Complex partial seizure

The most likely diagnosis is transient global amnesia. This is a syndrome in which a previously well person suddenly becomes confused and amnesic. The attacks are usually spontaneous. The patient appears bewildered and repeatedly asks questions about present and recent events. Orientation for person and sometimes place is preserved but recent memory is impaired and the patient cannot recall new information after a few minutes delay. Attacks usually last 24 to 48 hours. Recovery is complete and recurrence occurs in about 20% of patients. The cause is a mystery. Complex partial seizures are brief and the individual loses conscious contact with the environment. Post-ictal amnesia is common if the seizure becomes generalised. Richardson Steele Syndrome (or progressive supranuclear palsy) resembles Parkinson's disease in that there is a disturbance of balance and gait, with rigidity of the trunk and neck muscles. Alzheimer's disease is a progressive form of dementia which does not resolve. Hypertensive encephalopathy is an acute syndrome where severe hypertension is associated with headache, vomiting, convulsions, confusion, stupor and coma. (Harrison's Online Available:

www.accessmedicine.com/content.aspx?aID=53310&searchStr=transient+global+amnes ia#53310 ) Question 40 Which of the following factors would NOT be a poor prognostic indicator for joint replacement in hip osteoarthritis in a 65 year old man? a) Age b) A BMI of 33 c) Associated diabetes d) Presence of osteoporosis e) A previous joint replacement Incorrect. The correct answer is (a).

Poor prognostic indicators for joint replacement include: age less than 50 years, diabetes, obesity, high demand, poor bone quality, previous joint surgery and poor general health. Since Michael is 65 years old his age would not be a poor prognostic indicator. (Brewster, N. (1998), Joint replacement for arthritis, Australian Family Physician, vol.27, no1/2, Jan/Feb, 1998, p 21-27 ) (Murtagh, J. (2003), General Practice, Third edition, McGraw-Hill, Sydney, p 706 )