Question 1

Prolonged neurological sequelae in infants can occur if the mother has taken which of
the following in the third trimester?
a) Antipsychotics
a) Tricyclic antidepressants
b) Anticonvulsants
c) Benzodiazepines
Incorrect. The correct answer is (a).
d) Opioids

When given in high doses in late pregnancy, antipsychotic agents have caused
prolonged neurological disturbances in the newborn infant. Anticonvulsants are
associated with congenital defects rather than neurological sequelae.
Benzodiazepines can cause hypotonia, respiratory depression and hypothermia in the
newborn infant if used during labour in high doses. Withdrawal symptoms in
neonates have been reported with prolonged maternal use of tricyclic
antidepressants. Opioid analgesics may cause respiratory depression in the newborn
infant. Withdrawal symptoms in the newborn have been reported with prolonged use
of opioids.
(Therapeutic Guidelines
Available:
www.tg.com.au/etg_demo/tgc/plg/5a58359.htm#Antipsychotic )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=109485 )

* Question 2
A 21 year old man walks into your surgery with his head tilted sideways, his eyes
rolled up and his tongue sticking out. He speaks with difficulty but says that he has
been 'stuck' in this position since taking a new medicine a few hours ago 'for his
nerves'. You should administer:
a) Diazepam
b) Benztropine
Correct
c) Chlorpromazine
d) Phenytoin
e) Haloperidol

The presentation described is an acute dystonic reaction, which involves a spasmodic

torticollis, (where the head is pulled and held to the left or right by one or other
sternomastoid), upward drawn eyes and an open mouth (oromandibular dystonia). It
may occur (particularly in young men) within a few days of starting a neuroleptic
medication. Treatment is with the anticholinergic medication eg. Benztropine or
diphenhydramine. If the patient has a contraindication to anticholinergics then
diazepam may be helpful. The dystonias are a group of disorders involving prolonged
spasms of muscle contraction. Spasmodic torticollis is one type, as is trismus
(clenched jaw) and Blepharospasm (involuntary contraction of the orbicularis oculi).
In isolation, the dystonias are usually of unknown cause and treatment is difficult.
Dystonias as a reaction to medication are much more common in children, for
example, metoclopramide (an anti-emetic) results in an acute dystonic reaction in
1% of adults but 10% of children less than 10 years of age.
(The Merck Manual of Diagnosis and Treatment
Available:
http://www.merck.com/mrkshared/mmanual/tables/194tb2.jsp )
(eMedicine
Available:
www.emedicine.com/EMERG/topic157.htm )

Question 3
Mr Brown is 70 years old and suffers with severe pain in his back from osteoarthritis.
He also suffers with emphysema and has had prednisolone for exacerbations of this
disease. He is currently on warfarin for a cardiac arrhythmia and is also taking
lansoprazole as a maintenance dose after a duodenal ulcer was diagnosed 4 years
ago. Which of the following DOES NOT increase the risk of gastrointestinal side
effects from non-steroidal anti-inflammatory drugs (NSAIDs)?
a) Concurrent use of prednisolone
a) Previous duodenal ulcer
b) Concurrent use of anticoagulant
c) The fact that he is over 70 years of age
Incorrect. The correct answer is (e).
d) Male gender

Risk factors for gastro-intestinal side-effects of NSAIDs include age greater than 65
years, previous history of peptic ulcer and co-administration of prednisolone and
anti-coagulants. Male gender is not a risk factor.
(Rang HP, Dale MM, Ritter JM (1995) Pharmacology, Third ed. Churchill Livingstone,
Edinburgh, p 251-4)
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=96089&searchStr=antiinflammatory+agents%2c+non-steroidal#96089 )

Question 4
Coral is 55 years old. Her periods ceased 8 years ago. She now presents with vaginal
itch, discharge and soreness. The MOST LIKELY cause is:
a) Candida infection
b) Vaginal atrophy
Correct
c) Vaginal dermatoses
d) Gardnerella infection
e) None of the above

50% of women suffer symptoms of urogenital atrophy in the postmenopausal years.

Atrophy of the vaginal mucosa can lead to vaginal dryness, soreness, pruritus and
discharge.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 1008-17)
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section18/cha
pter236/236a.jsp%3Fregion%3Dmerckcom&word=vaginal&word=atrophy&domain=
www.merck.com#hl_anchor )
(Am Fam Physician 2000;61:3090-6
Available:
www.aafp.org/afp/20000515/3090.html )
(DeCherney A & Nathan L. Current Obstetric and Gynecologic Diagnosis and
Treatment, 9th Edition
Available:
www.accessmedicine.com/content.aspx?aID=307337&searchStr=atrophic+vaginitis
#307337 )
* Question 5
You are called to see a 78 year old woman with a three-week history of headaches
and depressive symptoms. She relates that 24 hours ago the vision in her right eye
suddenly dimmed. Today the visual acuity in the eye is limited to perception of hand
movements only, compared with 6/6 in the left eye. She is not known to be a
diabetic and her blood pressure is only minimally elevated. Which of the following
possible causes of her visual loss require IMMEDIATE investigation and treatment to
prevent blindness in the other eye?
a) Detached retina
b) Central retinal artery occlusion
Incorrect. The correct answer is (e).

c) Central vein occlusion

d) Acute glaucoma
e) Temporal arteritis

Temporal arteritis is an uncommon disease of the elderly and is characterised by the

classic complex of fever, anaemia, high ESR and headaches in an elderly person. It is
closely associated with polymyalgia rheumatica. Temporal arteritis is the most
common manifestation of a systemic vasculitis. Headache is the predominant
symptom and may be associated with a thickened or nodular artery. A serious
complication, as described in this lady, is ocular involvement - ischaemic optic
neuritis. Most patients have head or eye symptoms for months before objective eye
involvement. Acute glaucoma causes a red, painful eye, reduced vision and a fixed,
mid- dilated pupil which may be slightly ovoid. The pain may be severe and
associated with nausea and vomiting. Acute glaucoma may be preceded by blurred
vision or haloes around lights. It is a uniocular attack due to blockage of drainage of
aqueous fluid from the anterior chamber via the canal of Schlemm. Urgent treatment
with hyperosmotic agents is necessary to reduce the intraocular pressure.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=95244&searchStr=temporal+arteritis#
searchTerm )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section5/chapter50/50l.jsp#A005-050-0245 )

* Question 6
Which of the following is INCORRECT?
a) The incidence of haemochromatosis in Australia is 1:200
b) C282Y homozygotes account for more than 90% of haemochromatosis in
Australia
c) The majority of patients with one copy each of the C282Y and H63D mutation
never develop haemochromatosis
d) 90% of C282Y homozygotes develop symptoms of the disorder at some stage
in their lives
e) Carriers of one copy of the altered gene are generally healthy
Incorrect. The correct answer is (d).

Studies estimate that up to 50% of C282Y homozygotes will remain symptom free
throughout life.
(Newstead, J., Delatycki, M. and Aitken, M.A. (2002) Haemochromatosis and family
testing; What should a GP do? Australian Family Physician Vol. 31

Available:
www.racgp.org.au/document.asp?id=6568)
(Wojcik JP et al (2002). Natural history of homozygotes for hemochromatosis. Can J
Gastroenterol May; 16(5):297-302
Available PubMed Abstracts
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids
=12045778&dopt=Abstract )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=102502 )

Question 7
22 year old Melanie presents with a 2 day history of a vaginal discharge, urinary
frequency and dyspareunia. Which organism is the MOST LIKELY cause of this
presentation?
a) Gardnerella
b) HIV
c) Chlamydia trachomatis
Correct
d) Giardia lamblia
e) Hepatitis B

Chlamydia trachomatis is an intracellular bacterium. Genitourinary symptoms caused

by this organism include cervical discharge, cervical bleeding, menstrual change,
abdominal pain, fever, nausea, vomiting, urinary frequency and dysuria. Infection
rates are highest in the 15-25 year old age group. It is important to remember
Chlamydia may be initially asymptomatic especially in women and is the leading
cause of preventable infertility and ectopic pregnancy. Although it is important to
test for HIV, Melanie's symptoms are not consistent with a seroconversion type
illness. Hepatitis B also does not present with gynaecological symptoms. Gardnerella
is a simple vaginal infection with no clinical sequelae. Giardia is a single celled
organism which infects the small intestine.
(Heal C, Jones B, Veitch C et al (2002) Screening for Chlamydia in general practice.
AFP, 31
Available:
www.racgp.org.au/afp/downloads/pdf/august2002/20020801heal.pdf )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section13/cha
pter164/164c.jsp%3Fregion%3Dmerckcom&word=chlamydia&domain=www.merck.c
om#hl_anchor )

Question 8
The interossei of the hand are supplied by:
a) The radial nerve
b) The median nerve
c) The ulnar nerve
Correct
d) All of the above
e) None of the above

The nerve supply of the interossei of the hand is from the deep branch of the ulnar
nerve (spinal root C8-T1).
(Way LW, Doherty GM (2003) Current Surgical Diagnosis & Treatment, 11th Ed.
McGraw-Hill, Sydeny, p 1272)
(University of Arkansas for Medical Students
Available:
anatomy.uams.edu/anatomyhtml/hand_nerves2.html
Available:
anatomy.uams.edu/anatomyhtml/hand_muscles.html )

Question 9
A 55 year old woman presents with an itchy purple papular rash on her wrist. She is
not on any medications. This is MOST LIKELY to be:
a) Lichen Planus
Correct
b) Lichen Simplex Chronicus
c) Lichenoid eruption
d) Lichen Sclerosus
e) Lichenification

Lichen Planus is an epidermal inflammatory disorder of unknown cause characterised

by pruritic, violaceous, flat tipped papules mainly on the wrists and legs. Lichen
Simplex Chronicus is a thickening of the skin as a result of constant scratching, the
process of which is called lichenification. Lichen sclerosus is an unexplained vaginal
dystrophy characterised by itch and hypertrophy. A lichenoid eruption is most
typically due to a drug reaction. Lichen Sclerosis et Atrophicus is a condition of the
penis and vulva producing atrophy and tightening of the skin with increased risk of
the development of squamous cell carcinoma.

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=56794&searchStr=lichen+planus#5679
4)
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 1145)
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section10/cha
pter117/117d.jsp%3Fregion%3Dmerckcom&word=lichen&word=planus&domain=ww
w.merck.com#hl_anchor )

* Question 10
A 21 year old female patient presents with lower abdominal pain and tenderness at
14 weeks of gestation. Her temperature is 38.5 degrees Celsius. The most important
diagnosis to EXCLUDE is:
a) Pyelonephritis
b) Threatened abortion
c) Ectopic pregnancy
d) Degeneration of a uterine fibroid
e) Appendicitis
Correct

Appendicitis is the commonest surgical emergency and has its maximum incidence
between 20 and 30 years of age. In pregnancy it occurs mainly in the second
trimester. Pain is generally higher and more lateral than typical appendicitis. Ectopic
pregnancy occurs approximately one in every 100 clinically recognised pregnancies.
The classical triad of ectopic pregnancy includes amenorrhoea (65-80%), lower
abdominal pain (95+%) and abnormal vaginal bleeding (65-85%). Degeneration of a
uterine fibromyoma typically occurs in the second trimester of pregnancy and is due
to ischaemic necrosis. In threatened abortion there is vaginal bleeding. Pain is
usually not a significant feature unless the cervix is beginning to open. Pyelonephritis
can mimic acute appendicitis in pregnancy.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 326-7)
(Way LW, Doherty GM (2003) Current Surgical Diagnosis & Treatment, 11th Ed.
McGraw-Hill, Sydney, p 669)
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section18/cha
pter251/251p.jsp%3Fregion%3Dmerckcom&word=appendicitis&domain=www.merck
.com#hl_anchor )

* Question 11
A 42 year old man presents with a recurrent severe hemicranial nocturnal headache
which lasts for 60 minutes and occurs regularly every 3 weeks. The headache is
accompanied by a blocked nose and watering eye. The MOST LIKELY diagnosis is:
a) Chronic paroxysmal hemicrania
b) Migraine variant headache
c) Chronic sinusitis
d) Cluster headache
Correct
e) Trigeminal neuralgia

Cluster headache has a four-fold higher incidence in men than women. It is

characterised by constant unilateral orbital pain, with onset usually within 2-3 hours
of falling asleep. The pain is intense and steady with lacrimation, blocked nostril then
rhinorrhoea and sometimes miosis, ptosis, flush and oedema of the cheek, all lasting
approximately an hour or two. It tends to occur nightly for several weeks or a few
months, followed by complete freedom for months or even years. The response to
inhaled oxygen can be dramatic. Chronic paroxysmal hemicrania is similar to cluster
headache in presentation except that it is more common in women, attacks occur at
any time day or night lasting 2-25 minutes and it always responds to indomethacin.
Migraine variants include a range of presentations that are more common in children
and often go on to develop a more typical migraine presentation in adulthood.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 616-7)
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=51915 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section14/cha
pter168/168c.jsp%3Fregion%3Dmerckcom&word=cluster&word=headache&domain
=www.merck.com#hl_anchor )
(eMedicine Cluster Headache
Available:
www.emedicine.com/NEURO/topic70.htm )
(Chronic Paroxysmal Hemicrania
Available:
www.emedicine.com/NEURO/topic67.htm )

Question 12

An elderly patient with rheumatoid arthritis has been on prednisolone in a dose of

12.5 mg daily for 8 years. After a fall, she complains of severe pain over her lower
thoracic spine and is found to be very tender over T11 and T12. A radiograph shows
'cod-fish' vertebrae, with generalised radiolucency of bones and collapse of two
vertebral bodies. Examination of her serum is MOST LIKELY to show:
a) High calcium, low phosphate, raised alkaline phosphatase
Incorrect. The correct answer is (e).
b) Low calcium, high phosphate, normal alkaline phosphatase
c) Low calcium, low phosphate, raised alkaline phosphatase
d) Low calcium, normal phosphate, normal alkaline phosphatase
e) Normal calcium, normal phosphate, normal alkaline phosphatase

It is most likely the patient has steroid-induced osteoporosis. Plasma calcium,

phosphate and alkaline phosphatase are all normal in osteoporosis. If there are
multiple recent fractures, serum alkaline phosphatase may be elevated.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=101824 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section5/chap
ter57/57a.jsp%3Fregion%3Dmerckcom&word=osteoporosis&domain=www.merck.co
m#hl_anchor )

Question 13
Which of the following may be a good reason for stopping breast feeding:
a) Inverted nipples
b) Cracked nipples
c) Engorged breasts
d) Mastitis
e) Breast abscess
Correct

Frequent, unrestricted breast feeding day and night is a treatment for breast
engorgement. Improved breast drainage is important in mastitis and breastfeeding
should not be stopped. Breastfeeding can be continued in the presence of cracked
and inverted nipples. Temporary stoppage of breastfeeding on the affected side is
necessary while surgical drainage of a breast abscess is carried out.
(Common breast feeding problems. Medline Plus.

Available:
http://www.nlm.nih.gov/medlineplus/ency/article/002452.htm )
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 1052-5)
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section19/chapter256/256g.jsp#A019-2560223 )
(DeCherney A & Nathan L. Current Obstetric and Gynecologic Diagnosis and
Treatment, 9th Edition
Available:
www.accessmedicine.com/content.aspx?aID=312780&searchStr=breast+abscess#3
12780 )

Question 14
A 40 year old physician has had muscle twitching for one year. The twitching occurs
predominantly in the lower extremities. A neurological and general physical
examination is negative except for these twitchings. What is the MOST LIKELY
diagnosis?
a) Benign fasciculations
Correct
b) Hypoparathyroidism
c) Amyotrophic lateral sclerosis
d) Paramyoclonus multiplex
e) Dystrophia myotonica

Diseases of motor neurons or their proximal axons are often associated with
fasciculations, the spontaneous firing of an entire motor unit. Fasciculations occur at
times in most normal individuals, and unless weakness is present, are seldom of any
significance. Myoclonus is a descriptive term for very brief, involuntary, random
muscular contractions. Myoclonus may involve a single motor unit and simulate a
fasciculation, or it may involve groups of muscles that displace the limb. In
Dystrophia Myotonica there is intellectual impairment, amongst other associated
deficits, and the weakness starts with the face and extremities. Amyotrophic lateral
sclerosis (ALS) is characterised by a progressive loss of motor neurons, both upper
and lower motor neurons. The first evidence is an insidiously developing asymmetric
weakness. Hypoparathyroidism often presents with neurologic involvement manifesting as tetany - eg. Chvostek's sign.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=53044&searchStr=fasciculation#search
Term )

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/pubs/mmanual_home2/sec06/ch091/ch091b.htm )
(Answers.com
Available:
www.answers.com/topic/benign-fasciculation-syndrome )

Question 15
Which of the following is of LEAST value in assessing the level of active joint
inflammation ('disease activity') in rheumatoid arthritis?
a) Duration of morning stiffness
b) Presence of tiredness, malaise and weight loss
c) Degree of elevation of the erythrocyte sedimentation rate (E.S.R.)
d) Presence of rheumatoid factor in the blood
Correct
e) Strength of hand grip

Rheumatoid factor (RF) is useful in the diagnosis of rheumatoid arthritis and is of

prognostic significance; however fluctuations in RF titre have poor correlation with
disease activity. Constitutional symptoms such as tiredness, malaise, weight loss and
morning stiffness are good predictors of disease activity.
(Barraclough,D. (2001) Rheumatological symptoms-will investigation make a
difference? Australian Family Physician Vol 30
Available:
www.racgp.org.au/document.asp?id=921 )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=94458 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section5/chapter50/50a.jsp )

Question 16
In a couple trying to conceive, intercourse should take place:
a) As soon as there is a rise in basal temperature
b) 14 days after the onset of the next period
Incorrect. The correct answer is (c).
c) On alternate days prior to the basal temperature rise

d) On alternate days after the basal temperature rise

e) Daily after the basal temperature rise

Ovulation occurs on day 14 (plus or minus 2 days) before the onset of the next
menses. Basal body temperature rises around the time of ovulation and remains
elevated for at least 10 days. By the time the temperature rise is detected by the
patient, they are probably in the infertile phase of the menstrual cycle, so
intercourse should take place prior to the temperature rise. The purpose of having
intercourse on alternate days is to maximise the sperm count on each ejaculation.
(Goodmedicine - types of contraception, natural methods.
Available:
health.ninemsn.com.au/article.aspx?id=25563 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/pubs/mmanual/section18/chapter248/248a.htm )

* Question 17
Sudden onset of unilateral orbital pain, photophobia, lacrimation and blepharospasm
suggests a diagnosis of:
a) Open-angle glaucoma
b) Anterior uveitis
Correct
c) Temporal arteritis
d) Unilateral blepharitis
e) Vitreous haemorrhage

Anterior uveitis (acute iritis) presents with pain of acute onset, photophobia, blurred
vision, lacrimation, circumcorneal redness (ciliary congestion) and a small pupil
(initially from iris spasm). Talbot's test is positive: pain increases as the eyes
converge (and pupils constrict). The slit lamp reveals white precipitates on the back
of the cornea and anterior chamber pus (hypopyon). Open angle glaucoma is
painless and largely asymptomatic until there is visual field loss; temporal arteritis
causes pain in the temporal area, not in the orbit; blepharitis is inflammation of the
eyelids; vitreous haemorrhage can present with visual field loss depending on the
size of the haemorrhage and it is generally painless.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 569)
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=53539&searchStr=iritis#searchTerm )

(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/mrkshared/mmanual/tables/95tb1.jsp )

Question 18
A patient presents with acute gout but has a low serum uric acid. Which of the
following drugs can be responsible for a low serum uric acid?
a) Colchicine
b) Prednisolone
c) Indomethacin
d) Naproxyn
e) Salicylates
Correct

Up to 30% of patients with acute gout have a normal serum uric acid at
presentation. This may be due to precipitation into crystals in the synovium, an
effect of a drug the patient has taken for analgesia. Colchicine, steroids and NSAIDS
reduce inflammation in affected joints but have no effect on serum uric acid levels.
Salicylates eg aspirin at doses less than 2g/day increase serum uric acid levels, but
at doses above 4g/day reduce serum uric acid levels.
(Uric Acid Tests. Lab tests on line.
Available:
www.labtestsonline.org/understanding/analytes/uric_acid/test.html )
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 352-3)
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section5/chapter55/55a.jsp )

Question 19
The 'benign' jaundice that occasionally occurs in the third trimester of pregnancy is
most CLOSELY related to:
a) Decreased circulating amounts of albumin to bind bilirubin
b) A specific defect in glucuronide conjugation
c) An autoimmune process
d) High oestrogen and progesterone levels
Correct
e) The use of diuretics in the third trimester of pregnancy

In a small number of pregnant women, an intrahepatic cholestasis may appear. It

usually occurs in the third trimester of pregnancy and presents as jaundice and
pruritus. These patients probably have an increased susceptibility to the hepatic
effects of oestrogenic and progestational hormones.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=50706&searchStr=(jaundice)+AND+(pr
egnancy)#searchTerm )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section18/cha
pter251/251i.jsp%3Fregion%3Dmerckcom&word=(jaundice)&word=AND&word=(pre
gnancy)&domain=www.merck.com#hl_anchor )

Question 20
Accommodation of the eyes to NEAR objects is accompanied by:
a) Loss of binocular vision
b) Constriction of the pupils
Correct
c) Divergence of the visual axes
d) Decreased refractive (dioptric) power
e) Relaxation of the ciliary muscles

Normal pupillary responses consist of prompt, symmetric constriction (miosis) on

exposure to light or on attempted near convergence. Accommodation involves the
active changing of lens shape to focus near objects. Light detection by the retina is
passed to the brain via the optic nerve and pupil constriction is mediated by the third
cranial nerve (parasympathetic). The sympathetic nervous system is responsible for
pupil dilatation via the ciliary nerves.
(Moses RA. (1981) Adler's physiology of the eye. 7th Ed. Chapters 11 & 12. Mosby.
Available:
http://www.engin.brown.edu/courses/en122/arch/intraocular.html )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=53500&searchStr=Function+of+eye#s
earchTerm )

Question 21
The serum phosphate is MOST LIKELY to be low in which of the following disorders:

a) Osteoporosis
b) Osteomalacia
Correct
c) Multiple myeloma
d) Polymyalgia rheumatica
e) Paget's disease

Patients with osteomalacia almost always have hypophosphataemia. Serum

phosphate is normal in osteoporosis, Paget's disease and polymyalgia rheumatica
(PMR). Multiple myeloma may have a normal or slightly raised phosphate level.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=101230&searchStr=osteomalacia#101
230 )
(Ott, S. Osteoporosis and Bone Physiology. University of Washington CME Online
Course
Available:
courses.washington.edu/bonephys/hypercalU/opmal2.html )

Question 22
Which of the following is NOT TRUE regarding asymptomatic bacteriuria in pregnant
women?
a) The incidence is 3-7% of all pregnancies
b) Defined arbitrarily as greater than 100,000 bacteria/ml
c) One of the common organisms is Streptococcus Faecalis
d) Responds to a short course of oral antibiotics
e) Is a clinically unimportant phenomenon
Correct

Approximately 6% of women have asymptomatic bacteriuria in pregnancy, where

there are more than 100,000 bacteria per ml of urine in a mid-stream urine sample.
30% of patients with asymptomatic bacteriuria will subsequently develop acute
pyelonephritis. There is an association between pyelonephritis, low birth weight and
prematurity. Treatment is with an appropriate course of antibiotics. Recurrence can
occur in 35% of cases. The predominant organisms in subclinical or clinical urinary
tract infections in pregnancy are E. coli, Strep faecalis, Aerobacter, Klebsiella and
Proteus.
(Munro, R and Chambers, I. (2002) Laboratory Diagnosis of UTI. Common Sense
Pathology, Unit 5, October )

(Smaill F. Antibiotics for asymptomatic bacteriuria in pregnancy. The Cochrane

Database of Systematic Reviews 2001, Issue 2. Art. No.: CD000490. DOI:
10.1002/14651858.CD000490
Available:
www.cochrane.org/cochrane/revabstr/ab000490.htm )
(Tanago E & McAninch J. Smith's General Urology, 16th Edition
Available:
www.accessmedicine.com/content.aspx?aID=223891&searchStr=bacteriuria+in+pre
gnancy#223891 )
(DeCherney A & Nathan L. Current Obstetric and Gynecologic Diagnosis and
Treatment, 9th Edition
Available:
www.accessmedicine.com/content.aspx?aID=304582&searchStr=bacteriuria%2c+as
ymptomatic#304582 )

* Question 23
Which finding in this report of a cerebrospinal fluid (C.S.F.) examination is
INCONSISTENT with the other results?
a) Elevated protein
b) Normal chloride
c) Elevated glucose
Correct
d) No red cells
e) Gross excess of polymorphonuclear leucocytes

A lumbar puncture consistent with a diagnosis of pyogenic meningitis contains

excessive polymorphs, with protein at 1.5g/l (aseptic less than 1.5g/l) and glucose at
less than 2/3 the plasma level. There are no red cells unless it is a bloody tap (ie.
artefact due to rupture of blood vessel).
(Meningeal infections: CSF findings. Virtual Hospital
Available:
www.vh.org/adult/provider/pathology/CNSInfDisR2/Text/MInf.CSF.html )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/tables/165tb3.jsp )

Question 24
With regard to Tietze's syndrome, which of the following statements is INCORRECT?
Tietze's syndrome is:

a) Painful, tender swelling of one or more costochondral joints

Incorrect. The correct answer is (d).
b) The cause of up to 30% of chest pain presentations to emergency departments
c) Most commonly diagnosed before the age of 40 years
d) Sometimes associated with the development of rheumatoid arthritis later in life
e) Often associated with repeated minor chest trauma such as harsh coughing

The predominant feature of Tietze's syndrome (also called costochondritis) is that of

a painful costochondral junction with a palpable swelling. It often occurs in patients
with persistent cough and is aggravated by coughing or deep breathing. The 2nd
costochondral junction is most commonly affected. Women are more often affected
than men. The usual onset is before age 40 years. In the assessment of people
presenting with chest pain, 10-30% will have costochondritis, even in childhood.
Although many other conditions such as rheumatoid arthritis may present with
involvement of the costochondral joints, there is no evidence that Tietze's syndrome
will progress to any other illness. It usually follows a fluctuating course with eventual
resolution. Management might include analgesics, anti-inflammatory drugs, local
heat/ice, avoidance of triggers and local steroid injection.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 969-70)
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=96551&searchStr=chostochondritis#96
551 )
(eMedicine
Available:
www.emedicine.com/emerg/topic116.htm )

Question 25
A mother develops a fever of 38.2 degrees Celsius 3 days after the delivery of her
baby. Which of the following is the MOST LIKELY cause?
a) Endometritis
Correct
b) Dehydration
c) Breast engorgement
d) Deep venous thrombosis
e) Urinary tract infection (UTI)

Puerperal infection affects 2-8% of pregnant women and presents with a

temperature of greater than 38 degrees Celsius after the first 24 hours post-partum.
In up to 75% of cases the cause is genital tract infection, with endometritis most

common, especially in the context of a prolonged, complicated labour. Dehydration

and breast engorgement may cause a mild pyrexia up to 37.5 degrees. Thrombosis
may also cause a low-grade temperature initially although a septic pelvic
thrombophlebitis would present later with high fever. UTI occurs in 2-4% of postpartum women and usually presents with low grade fever unless there is
pyelonephritis.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 1056)
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/pubs/mmanual/section18/chapter254/254b.htm )
(DeCherney A & Nathan L. Current Obstetric and Gynecologic Diagnosis and
Treatment, 9th Edition
Available:
www.accessmedicine.com/content.aspx?aID=305988 )

Question 26
In which spinal cord segments are the motor neurones responsible for the knee-jerk
located?
a) L1,L2
b) L2,L3
c) L3,L4
Correct
d) L4,L5
e) L5,S1

The four muscles of the anterior thigh join to form a common tendon which inserts
into the patella. These muscles are supplied by the femoral nerve, spinal roots L3, 4.
The quadriceps tendon continues distal to the patella as the patellar tendon and it is
this tendon which is stretched in the knee-jerk. Stretching the muscle spindles
causes a reflex quadriceps contraction to limit the tendon stretch.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section14/cha
pter165/165c.jsp%3Fregion%3Dmerckcom&word=knee&word=jerk&domain=www.
merck.com#hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=103809&searchStr=reflexes#searchTer
m)
(University of Massachusetts Medical School

Available:
courses.umassmed.edu/mbb1/2003/sc/ReflexTable.cfm )

Question 27
Marion aged 56 years complains of constipation, tiredness, lethargy and lack of
energy. She looks puffy in the face, is faintly yellowish in colour and has a pulse of
56 beats/minute regular. Her full blood count shows her haemoglobin is 9.7 g/dl, she
has a macrocytosis, lymphocytosis and a raised erythrocyte sedimentation rate
(ESR). The MOST LIKELY diagnosis is:
a) Pernicious anaemia
b) Carcinoma of the bowel
c) Alcoholism with malnutrition
d) Hypothyroidism
Correct
e) Lymphocytic leukaemia

Both pernicious anaemia and primary autoimmune hypothyroidism can cause

lethargy, a yellow tinge to the skin, lymphocytosis and a macrocytic anaemia with a
raised ESR. They often occur simultaneously and are more common in females.
However constipation and bradycardia, with puffiness of the face (myxoedema) are
more indicative of hypothyroidism, making this the MOST likely diagnosis in this
case. One would expect a microcytic anaemia with carcinoma of the bowel due to
chronic occult bleeding and more signs of liver disease with alcoholism and
malnutrition. Lymphocytic leukemia may cause lethargy, lymphocytosis and
jaundice, but none of the other signs.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 221-2)
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=97981&searchStr=hypothyroidism )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section2/chapter8/8e.jsp )

Question 28
In which of the following conditions of the colon is malignant change MOST LIKELY to
occur?
a) Adenomatous polyp
b) Melanosis coli
c) Diverticulitis

d) Familial polyposis coli

Correct
e) Ulcerative colitis

Familial Intestinal Polyposis occurs in 1/8000 to 1/14000 people in western countries

and 50 percent have hundreds to thousands of polyps by age 16. 90% of affected
people will develop carcinoma of the colon by age 45. Between 10% and 20% of
adenomatous polyps show histological evidence of malignancy when removed. The
primary genetic defect occurs in the apoptosis gene p52. The lifetime risk of
malignant change in untreated ulcerative colitis is 12%. Melanosis coli is due to
laxative abuse and is not pre-malignant in itself. The association between carcinoma
of the colon and melanosis coli is probably due more to chronic constipation rather
than the staining of the bowel wall from laxatives. Diverticulitis is not associated with
malignant change.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section3/chap
ter34/34d.jsp%3Fregion%3Dmerckcom&word=polyposis&word=coli&domain=www.
merck.com#hl_anchor )
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=62641&searchStr=familial+adenomato
us+polyps#searchTerm )

Question 29
A 25 year old epileptic woman who had been in good health was admitted to hospital
in a comatose condition after the ingestion of 2.0 g of phenobarbitone. On
examination, most reflexes appeared to be intact and there was no depression of
respiration. Which of the following forms of therapy would be MOST appropriate?
a) Urgent peritoneal dialysis
b) Alkalinisation of urine
Correct
c) Prophylactic antibiotics
d) Administer analeptics
e) Give IV corticosteroids

Phenobarbitone is a long-acting barbiturate. Peak plasma levels occur within 2-4

hours. It exerts its effects through depression of the central nervous system. It is a
weak acid and is 50% protein bound. About 75% of the dose is metabolised and the
other 25% excreted unchanged by the kidneys. The half-life in over-dose is 80-120
hours. Initial management of barbiturate overdose requires prompt gastrointestinal
decontamination. Barbiturates are well absorbed by activated charcoal. For all
barbiturates, attention should be given to hemodynamic and respiratory support,

correction of temperature and electrolyte derangement, and monitoring for

pulmonary complications. Renal elimination of phenobarbitone is enhanced by
alkalinisation of urine to pH 8 and fluid administration with or without mannitol to
enhance diuresis.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/tables/307tb3d.jsp )
(Harrison's Online (see Table 377-4)
Available:
www.accessmedicine.com/content.aspx?aID=110193 )
(Habal, R. Toxicity, Barbiturate
Available:
www.emedicine.com/med/topic207.htm )

Question 30
A 32 year old man with ankylosing spondylitis presents to you for management of his
disease. Which of the following clinical features is he LEAST LIKELY to complain
about?
a) Sudden development of dull low back pain
b) Attacks of pain and photophobia in one eye
c) General malaise, fatigue and weight loss
d) Morning stiffness lasting a few hours
Incorrect. The correct answer is (a).
e) Bilateral hip and shoulder pain

The key features of ankylosing spondylitis are the insidious onset of back pain and
morning stiffness which improves with exercise, lasting for more than 3 months.
Back pain is the most common presenting symptom, and it occurs predominantly in
young adults. Approximately 25-35% have an arthritis in the hips and shoulders.
Some also have an asymmetric arthritis of other joints. Younger patients often
present with a peripheral enthesitis. Older patients may have more constitutional
symptoms such as fatigue. Up to 30% will have episodes of acute anterior uveitis
and many will have other extra-articular features.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 381-2)
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/mmanual/section5/chapter51/51a.jsp )
(Harrison's Online
Available:

www.accessmedicine.com/content.aspx?aID=94909&searchStr=ankylosing+spondyli
tis )

Question 31
In men less than 35 years of age the MOST COMMON causative organism in
epididymitis is:
a) Mumps virus
b) Escherichia coli
c) Chlamydia trachomatis
Correct
d) Neisseria gonorrhoeae
e) Streptococcus faecalis

The most common aetiology of epididymitis in males less than 35 years of age is
sexually transmitted diseases, and Chlamydia is much more common than the
gonococcus. E.coli can be a causative factor in urinary tract infections especially in
older men with urinary outflow obstruction (benign prostatic hypertrophy etc).
Mumps orchitis and epididymitis are now rare because of widespread vaccination.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 1066-7)
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section17/cha
pter219/219c.jsp%3Fregion%3Dmerckcom&word=epididymitis&domain=www.merck
.com#hl_anchor )

* Question 32
Jane is brought into the surgery after being struck in the eye with a tennis ball. On
examination you note blood in the anterior chamber of the eye. Which of the
following statements regarding her management is INCORRECT?
a) Aspirin and non-steroidal anti-inflammatories drugs (NSAIDs) are
contraindicated
b) The main treatment goal is prevention of secondary haemorrhage and
glaucoma
Incorrect. The correct answer is (c).
c) Topical mydriatics should be used to permit examination of the posterior
chamber
d) Tranexamic acid (Cyklokapron) may be used to stabilise clot formation and
prevent rebleeding
e) Urgent ophthalmological review is necessary to exclude other ocular damage

Management of hyphaema is directed at prevention of secondary haemorrhage

within the orbit which carries a high risk of severe glaucoma. Therefore strict bed
rest is essential with both eyes covered to reduce eye movements. Aspirin and
NSAIDs are contraindicated. Mydriatics would not be used due to the risk of causing
the iris to rebleed. An urgent ophthalmological assessment is essential. Ongoing
review will check for secondary bleeding (20% occur within 2-3 days), glaucoma and
corneal staining. Tranexamic acid may be used to stabilise the clot. Glaucoma may
develop months or years after the hyphaema has resolved.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 1377)
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/pubs/mmanual/section8/chapter91/91c.htm )
(AFP Online. Monolopolous, J. Emergency Primary Eye Care. 2002 Mar 31(3)
Available:
www.racgp.org.au/document.asp?id=5930 )
(Vaughan & Asbury's General Ophthalmology,16th Edition Riordan-Eva,P and
Whitcher JP
Available:
www.accessmedicine.com/content.aspx?aID=179421&searchStr=hyphema )

* Question 33
The MOST LIKELY venous source of fatal pulmonary embolism is:
a) Iliofemoral
Correct
b) Subclavian
c) Saphenous
d) Pelvic
e) Popliteal

Most pulmonary emboli arise from proximal deep vein thrombosis (deep veins of
lower limb, pelvis and inferior vena cava). Less frequently, thromboses of the upper
arm are the source. Saphenous vein thrombosis seldom results in clinically obvious
pulmonary embolism. Also, in order for the thrombus to cause fatality, it has to be
large enough to either cause obstruction in the right atrium or of the right ventricular
outflow tract. It therefore would have to originate in a large vein.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=85210 )
(The Merck Manual of Diagnosis and Treatment

Available:
www.merck.com/pubs/mmanual/section6/chapter72/72a.htm )
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 419)

Question 34
A patient with moderate to severe emphysema would demonstrate all of the
following physical signs EXCEPT:
a) Distant heart sounds
b) A prominent pulmonary second sound
c) A narrow intercostal angle
d) Prolonged expiration
Incorrect. The correct answer is (c).
e) Hyperresonance to pulmonary percussion

Pulmonary emphysema is one of the obstructive types of pulmonary diseases which

leads to progressive hyperinflation of the chest. As a result heart sounds become
distant, percussion becomes hyper-resonant and the intercostal angle enlarges as
the chest becomes more barrel shaped. Pulmonary hypertension leads to a louder
second (P2) heart sound. Prolonged expiration or a prolonged forced expiratory time
is an important sign in the obstructive airways group of diseases.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=84893 )
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/pubs/mmanual_home2/sec04/ch045/ch045a.htm )

Question 35
Mrs Leung, aged 68 years, has Type 2 diabetes for which she takes metformin
850mg tds and gliclazide 160mg bd. Her blood pressure is well controlled on
candesartan 16mg daily. She has no evidence of heart failure and is otherwise well.
Her HbA1c is now 9.2% (nondiabetic range <6%). Which of the following strategies
would NOT be an appropriate next step?
a) Commence isophane insulin 10 units before bed
b) Commence rosiglitazone 4mg daily
c) Refer for dietary and diabetes education to review lifestyle factors
d) Increase her dose of metformin to 1 gram tds
e) Increase her dose of gliclazide to 160mg tds

Correct

In an older Type 2 diabetic without microvascular complications, a higher HbA1c may

be satisfactory. However, once the level is greater than 9%, therapy must be
reviewed to improve control. It is always appropriate to review lifestyle factors. In
this case the gliclazide dose is already at the recommended maximum. There is room
to increase the metformin dose. However a more effective strategy is to add a
thiazolidinedione. Only rosiglitazone has a Pharmaceutical Benefit Scheme Authority
listing to be added to dual therapy with metformin and a sulphonylurea. It must be
monitored closely for possible elevated liver enzymes and heart failure but would be
expected to lower HbA1c by 1-2%. Since nearly all diabetics will eventually require
insulin therapy, the early introduction of a small dose of intermediate-acting insulin
before bed will often markedly improve control and ease anxiety about managing
injections.
(Wong J, Yue D. Starting insulin treatment in type 2 diabetes. Aust Prescr
2004;27:93-6
Available
www.australianprescriber.com/index.php?content=/magazines/vol27no4/93_96_diab
etes.htm# )

Question 36
In trigeminal neuralgia all of the following statements are true EXCEPT:
a) It is most common in middle-aged and elderly persons
b) Multiple sclerosis must be considered in younger people
c) There is an associated weakness in the muscles of mastication
d) The severe, lancinating pain may last for up to two minutes
e) It usually responds well to regular carbamazepine
Incorrect. The correct answer is (c).

Trigeminal neuralgia is characterised by stabs of intense pain in the distribution of

one or more divisions of the Trigeminal nerve, lasting 1-2 minutes (up to 15
minutes). It is usually unilateral (96%). Pain may be precipitated by touching a
trigger point on the face or by eating or talking. It is more common in women than
men and in those over 50 years. The cause is unknown. In younger patients multiple
sclerosis should be considered. If left untreated it can progress, with shorter and
shorter periods of remission. Carbamazepine is usually the first line of
pharmacological treatment. Surgical treatment may be necessary if it persists
despite a trial of other medications, but may cause permanent anaesthesia. The
motor division of the trigeminal nerve supplies the pterygoid and masseter muscles.
It is not usually affected by trigeminal neuralgia however surgical treatments of this
condition may result in weakness of mastication in 4% of cases.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 581-2)

(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=106249 )
(eMedicine
Available:
www.emedicine.com/med/topic2899.htm )

* Question 37
A 40 year old Vietnamese man who arrived in Darwin 6 weeks prior, presents with 5
days of headache, fever and malaise. What is the MOST LIKELY diagnosis?
a) Malaria
Correct
b) Typhoid fever
c) Dengue fever
d) Filariasis
e) Meningococcal meningitis

Malaria is endemic in South-east Asia and a clinical presentation such as this should
be regarded as malaria until proven otherwise. Its symptoms are usually nonspecific, with headache, fevers and malaise being the most common symptoms.
Typhoid fever has an incubation period of 7 to 21 days, with an average of 14 days.
Although headache and fever are common symptoms, one would expect other
symptoms such as abdominal pain and diarrhoea. Dengue fever has an incubation
period of only 5-8 days, followed by sudden headache, fevers and severe myalgias
("The Dandy Walker Syndrome"). A rash typically develops on the third to fifth day.
Filiariasis (due to Wucheria bancrofti) can present as a lymphangitis, with recurrent
fever and inflammation overlying the affected lymphatic vessel. Finally
meningococcal meningitis has a rapid clinical course and the patient would be
unlikely to present with such a long clinical history. Photophobia, neck stiffness and
altered conscious state could also be expected.
(The Merck Manual of Diagnosis and Treatment
Available:
www.merck.com/mrkshared/CVMHighLight?file=/mrkshared/mmanual/section13/cha
pter161/161b.jsp%3Fregion%3Dmerckcom&word=malaria&domain=www.merck.co
m#hl_anchor )
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 114-6)
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=77546&searchStr=clinical+features+of
+malaria#searchTerm )

Question 38
Peter presents with a painful left eye associated with a sudden loss of vision. Which
of the following conditions is NOT usually associated with pain in or around the eye?
a) Amaurosis fugax
Correct
b) Retrobulbar neuritis
c) Acute angle closure glaucoma
d) Temporal arteritis
e) Anterior uveitis

Amaurosis fugax is the painless temporary loss of vision in one eye associated with
an embolus temporarily lodging in a retinal arteriole.
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 1338)
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=53575&searchStr=amaurosis+fugax#5
3575 )

Question 39
A 62 year old housewife presents because of pain in her left cheek precipitated by
eating or touching her face just under the left eye. This pain lasts for 30 to 60
seconds. The patient is most likely to benefit from:
a) Dental attention
b) Penicillin
c) Blockade of the infraorbital nerve
d) Carbamazepine
Correct
e) Corticosteroids

Facial pain analysis requires a disparate approach. Neuralgias, particularly Trigeminal

neuralgia, are common causes and are more prevalent in women over 50 years.
Neuralgias are characterised by paroxysmal, fleeting, almost electric shock-like
episodes that are caused by demyelinating lesions of nerves that result in the
activation of a CNS pain-generating mechanism. The pain of Trigeminal neuralgia,
which can be in any branch of the Trigeminal nerve, usually lasts a minute or two. A
characteristic feature is the initiation of pain by stimuli applied to certain areas of the
face, lips, or tongue, or by movement of these parts. The adequate stimulus to
precipitate an attack is a tactile one and possibly a tickle, rather than a noxious or
thermal stimulus. Carbamazepine is the drug of choice for Trigeminal neuralgia.

Dental pain is common, with provocation by hot, cold or sweet foods being typical.
Pain with chewing itself may be due to Trigeminal neuralgia, temporomandibular
dysfunction or giant cell arteritis with jaw claudication.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=106249 )
(Murtagh J (2003) General Practice, Third Ed. McGraw-Hill, Sydney, p 581-2)

* Question 40
The most important muscle used for inspiration is:
a) External intercostals
b) Diaphragm
Correct
c) Scalenes
d) Rectus abdominis
e) Internal intercostals

In resting healthy individuals, contraction of the diaphragm is responsible for the

majority of inspiration. Clinically, it is important to remember that that the
diaphragm is innervated by the C3/4/5 spinal segments, (mostly C4/5) via the
phrenic nerves. Loss of function of this segment, either from trauma or metastatic
malignancy, will result in the loss of the function of the diaphragm and all intercostal
muscles. The patient will die of respiratory exhaustion in three days unless
respiration is supported. Unilateral phrenic nerve damage (i.e. bronchogenic
carcinoma), causes unilateral hemi diaphragmatic paralysis which can cause a 20%
loss of inspiratory effort. This is, remarkably, quite asymptomatic.
(Harrison's Online
Available:
www.accessmedicine.com/content.aspx?aID=83738 )
(Roberts F (2000) Respiratory physiology. Updates in Anaesthesia, Issue 12, p1-3
Available:
www.nda.ox.ac.uk/wfsa/html/u12/u1211_01.htm )