Question 1 Patients suffering from schizophrenia may experience both positive and negative symptoms.

All of the following are negative symptoms EXCEPT: a) b) c) d) e) Anhedonia Hallucinations Lack of motivation Emotional blunting Alogia

b) Hallucinations are abnormal perceptions, e.g. hearing voices speaking about the patient, and/or giving instructions to do certain things. They represent additional phenomena and, therefore, are classified as positive symptoms. Delusions (false ideas) is the other major group of positive symptoms. In contrast, each of the other options represents a loss or diminution of a mental function, e.g. anhedonia is a loss of capacity for pleasure. (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 Available: www.mja.com.au/public/issues/178_09_050503/lam10582_fm.html ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109485 ) Question 2 Martha was born at 35 weeks gestation. She required phototherapy for jaundice whilst in hospital. Martha is being breast-fed and is beginning to gain weight. She is now two months old. Regarding routine childhood vaccination which of the following statements is CORRECT? a) Vaccinations due to be given at two months of age should be postponed until Martha is at least 13 weeks old to allow for her prematurity. b) Martha's past history of jaundice is not a contraindication to oral polio vaccine. c) Vaccines for intramuscular injection should be given into the buttock in a premature baby. d) Breast-feeding is a contraindication to vaccination. e) It is not necessary to immunise Martha against hepatitis B.

b) A history of jaundice after birth is not a contraindication to any of the vaccines in the standard schedule. Vaccination should not be postponed because of prematurity. The fact that a child is breast-fed is not a contraindication to vaccination. Vaccines should never be given into the buttocks. The anterolateral thigh is the preferred site for vaccination in infants under 12 months of age. The deltoid region is the preferred site in older children (those who have commenced walking) and in adults. Martha would be due to receive vaccination against hepatitis B at the age of two months according to the

current standard vaccination schedule. (The Department of Health and Aged Services, Australia (2000), The Australian Immunisation Handbook, 7th ed, Australia, 39-42. ) * Question 3 Maud is a 70 year old who presents with acute peri-umbilical abdominal pain gradually increasing in intensity. She is vomiting profusely and develops watery diarrhoea with flecks of blood after an hour of pain. Examination of the abdomen reveals localised periumbilical tenderness with some rigidity. Rectal examination is normal. An irregular pulse is noted and an ECG is recorded (shown below).

The MOST LIKELY diagnosis is: a) b) c) d) e) Acute appendicitis Acute pancreatis Perforated peptic ulcer Biliary colic Mesenteric artery occlusion

e ) The clinical presentation is typical of mesenteric artery occlusion. This occurs most commonly in patients with atrial fibrillation leading to embolism. The ECG shows atrial fibrillation. Arteriography will show the vascular occlusion. (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=51716 Available: www.accessmedicine.com/content.aspx?aID=90793 ) * Question 4 A 15 year old male has sudden onset of severe pain in his right lower abdomen commencing 2 hours ago. He has vomited several times in the last hour. He is rolling on the bed, stating that the pain is going down into his groin. T 37.1 degrees Celcius, P 110min, BP 135/ 80. Abdomen - soft, no rebound. Tender right testicle. Your immediate management is: a) b) c) d) e) i/v fluids and antibiotics arrange urgent ultrasound examination i/v metoclopramide (maxolon) refer for emergency surgery arrange for intravenous pyelogram (IVP)

d) The sudden onset of severe pain in the lower abdomen, groin or scrotum, in a young male under 25 years, should be considered to be testicular torsion until proved otherwise. This is a surgical emergency, as infarction of the testis can occur quickly, and surgical exploration should be undertaken urgently. This patient has no fever, nor tenderness of the epididymis to indicate epididymo-orchitis. Antibiotic treatment will not help. Colour doppler ultrasound may show increased blood flow in infection and the absence of flow in advanced torsion. However, these are not reliable findings, and the investigation would waste valuable time. The vomiting is related to the pain, and would be alleviated by appropriate analgesia. Metoclopramide is not an immediate priority. The clinical picture is highly suggestive of testicular torsion rather than renal colic, thus IVP is not the appropriate immediate management. (Way LW, Doherty GM. (2003), Current Surgical Diagnosis and Treatment. 11th ed. Lange medical Publications, McGraw-Hill, p 1079-80 ) (Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed, Churchill Livingstone, Sydney, p 252 ) * Question 5 In a 3 year old child with signs and symptoms suggestive of bacterial meningitis, which of the following is the BEST initial management? a) b) c) d) e) Erythromycin IV Gentamicin IV Ceftriaxone IV Phenoxymethylpenicillin oral Amoxycillin oral

c) 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 ) Question 6 Atypical antipsychotic drugs (eg. olanzapine) have certain advantages compared to the typical antipsychotic drugs (eg. chlorpromazine) in the treatment of schizophrenia. All of the following are advantages of atypical drugs EXCEPT: a) b) c) d) Improved therapeutic effect on positive symptoms Improved therapeutic effect on negative symptoms Reduced potential for acute extrapyramidal symptoms Reduced potential for longer-term extrapyramidal symptoms

e) Improved therapeutic effect in some treatment-resistant patients

a) Both the typical and atypical antipsychotic drugs have a beneficial effect on positive symptoms in schizophrenia. However, they differ with regard to negative symptoms. Atypical antipsychotics are much better at combating these. The other options are true for the atypical drugs. (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 Available: www.mja.com.au/public/issues/178_09_050503/lam10582_fm.html ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109485 ) Question 7 Which of the following statements regarding undescended testes is CORRECT? a) b) c) d) e) The testes are undescended at birth in 40% of boys. Once the testis is palpable in the scrotum it will remain so. Descent is unlikely to occur after 1 year of age. Orchidopexy should be delayed until late childhood. The undescended testis is at reduced risk of malignancy.

c) 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 ) Question 8 An aspirate in an acutely painful, swollen knee shows the following: white cell count 4100/uL (< 2000/uL) red blood cells ++ no crystals no organisms cultured

What is your interpretation of these results? a) b) c) d) e) Inflammation is more likely Traumatic tap - cannot be interpreted Gonococcal arthritis Tuberculosis arthritis Viral arthritis

a) 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. (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 ) Question 9 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) Metastatic spread to pelvic lymph nodes occurs early d) Radionuclide bone scan is not a reliable method of detecting bony metastases e) Prostate cancers usually appear as hypoechoic nodules on transrectal ultrasound

b) 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 ) 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) b) c) d) e) Risperidone Olanzapine Quetiapine muisulpride Clozapine

b) 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 Available: www.mja.com.au/public/issues/178_09_050503/lam10582_fm.html ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109485 ) Question 11 Ara, 5 years old, presents with a painless limp. You suspect Perthes' disorder. Which of the following statements is CORRECT? a) b) c) d) Hip mobility is usually reduced, particularly adduction and external rotation Ultrasound is required to make a definitive diagnosis The white cell count and C reactive protein (CRP) are usually raised Progress is assessed with serial radiological examination Correct 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 )

(Way LW, Doherty GM. eds. (2003), Current Surgical Diagnosis and Treatment, 11th ed. Lange medical Books, McGraw-Hill, NY, p 1193-1194 ) Question 12 Significant protein-energy malnutrition is likely to lead to increased postoperative complications and prolonged recovery times. In assessing a patient's nutritional status, which ONE of the following findings would be of MOST concern? a) b) c) d) e) bony shoulder girdle sharply outlined weak grip strength an elevated white cell count in a patient with multiple trauma at the biceps skin fold, the dermis can be felt between finger and thumb recent weight loss of >5kg

b) Assessment of physiological function is of most importance, as weight loss without evidence of physiological abnormality is probably of no consequence. Physical weakness (as shown by weak grip strength), and poor respiratory muscle function increases the risk of post-operative pneumonia. When the bony shoulder girdle is sharply outlined, and tendons (eg of biceps and triceps) are readily palpable, the patient is likely to have lost more than 30% of total protein stores. Loss of body fat is often readily apparent on looking at the patient, and a biceps skinfold where the dermis can be felt between finger and thumb indicates that the body mass has less than 10% fat. Metabolic stress can occur from trauma, sepsis or ongoing inflammation. The trauma patient may well have near normal stores of protein and fat to call on in the short term. (Way LW, Doherty GM. eds. (2003), Current Surgical Diagnosis and Treatment, 11th ed. Lange medical Books, McGraw-Hill, NY, p 156-159 )(Merck Manual Available: www.merck.com/mrkshared/mmanual/section1/chapter2/2a.jsp Available: www.merck.com/mrkshared/mmanual/section1/chapter2/2c.jsp ) Question 13 In Australia, all of the following are risk factors for suicide, EXCEPT: a) b) c) d) Schizophrenia Family history of suicide Social disadvantage Female Correct e) Youth

Males, particularly young men and elderly single men, are at greater risk of suicide than women who generally have better social support structures than their male contemporaries.

(Guidelines for preventive activities in general practice. (2002) Updated 5th ed. Australian Family Physician, Special Issue, SI, 45 ) * Question 14 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 Incorrect. The correct answer is (c). c) 0.15ml of Adrenaline 1:1000 by deep intramuscular injection d) 0.15ml of Adrenaline 1:1000 by subcutaneous injection 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 ) Question 15 Which ONE of the following is a mass population screening test which has been demonstrated to reduce cancer mortality significantly? a) b) c) d) e) annual faecal occult blood testing in the over 50 age group annual colposcopy in sexually active women annual plasma CA125 in post menopausal women annual colonoscopy in siblings of patients with colon cancer 2 yearly mammography in women in the 35-45 age group Incorrect. The correct answer is (a).

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 high-risk 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 vol 30 no 6p,539 ) (Quinn, M. 'Screening for Ovarian cancer' Australian Family Physician vol 30 no6 p530 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=60590 ) All of the following groups are at higher risk than average of depression, EXCEPT: a) b) c) d) e) Women Postpartum women Young rural males Urban males Adolescents Incorrect. The correct answer is (d).

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 Available: www.accessmedicine.com/content.aspx?aID=109349 ) Question 17 14 month old Mark is brought in to see you. He has had high fever and a mild runny nose 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 618 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 ) (Merck Manual Available: www.merck.com/mrkshared/mmanual/tables/265tb8.jsp ) * Question 18 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) b) c) d) e) the patient is restless and confused Temperature 39.2 degrees Celsius pulse 130, sinus tachycardia urine output over past 4 hours of 120ml BP 80/45 mm Hg Correct

The above signs taken together suggest a picture of shock, probably septic 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. (Merck Manual Available: www.merck.com/mrkshared/CVMHighLight? file=/mrkshared/mmanual/section16/chapter204/204a.jsp%3Fregion %3Dmerckcom&word=shock&domain=www.merck.com#hl_anchor ) (Harrison's Online Available: www.accessmedicine.com/content.aspx? aID=86381&searchStr=septic+shock ) (Way LW, Doherty GM. eds. (2003), Current Surgical Diagnosis and Treatment, 11th ed. Lange medical Books, McGraw-Hill, NY, p 203-212 ) 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 Incorrect. The correct answer is (c). b) Uncontrolled diabetes c) Depression 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 ) * 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#searchTerm ) (Merck Manual Available: www.merck.com/mrkshared/mmanual/section19/chapter265/265a.jsp ) Question 21 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

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. This is not required for adults nor is it necessary for them to recommence a full vaccination schedule. 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 22 Which of the following conditions is the COMMONEST anxiety disorder encountered in general practice? a) Generalised anxiety disorder b) Phobic disorder c) Obsessive compulsive disorder Incorrect. The correct answer is (a). d) Panic disorder

e) Post-traumatic stress disorder

Generalised anxiety disorder is the commonest anxiety disorder seen in general practice. It has an insidious onset, usually having been present 5 to 10 years before diagnosis. It occurs more commonly in women and the frequency increases with age. (Generalised anxiety disorder (2002) Depression Awareness Journal, 11: 16-18 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109209 ) Question 23 Which of the following is NOT a diagnostic feature accompanying anxiety in generalised anxiety disorder (GAD)? a) b) c) d) e) Restlessness Fatigue Difficulty concentrating Muscle tension 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. (Generalised anxiety disorder (2002) Depression Awareness Journal, 11: 16-18 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109209 ) Question 24 Martin, aged 50 years, complains of insomnia for two weeks. He says this relates to anxiety about problems at work which surround the end of the financial year. While he is describing his problem, he is excited and agitated. On examination, his pulse rate is 75/min and BP 135/95 mm Hg. Which of the following behavioural therapies would be MOST helpful to Martin? a) Cognitive therapy b) Sleep restriction therapy c) Stimulus control therapy Incorrect. The correct answer is (d). d) Relaxation therapy e) Interpersonal therapy

The successful treatment of insomnia depends on both behavioural and pharmacological approaches. Relaxation therapy would be the most useful behavioural therapy for Martin, because he displays exaggerated arousal emotional, cognitive and physiological, shown by his mental approach when describing the problem and his physiological response in terms of pulse rate and BP. Progressive muscle relaxation aims to reduce somatic arousal and attention focussing techniques (e.g. on tranquil situations) to reduce cognitive and emotional arousal. (See reference for descriptions of other options, except interpersonal therapy which is not an accepted form of behavioural therapy.) (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 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 26 Insomnia is defined as inability to:

a) b) c) d)

Fall asleep Maintain sleep Sleep at normal times Obtain good quality sleep

Correct e) Obtain enough sleep

Insomnia is the commonest sleep disorder and is defined as poor quality sleep which often results in daytime symptoms, including fatigue, irritability, problems with concentration and memory, and feeling unwell. The other options describe features of various insomnia syndromes but do not define the overall problem. (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 Miriam, aged 67 years, presents with insomnia for two weeks. She has tried several over-the-counter medications but has not received any benefit. Further questioning reveals that she is feeling unusually worried about her health, is also irritable and restless and has generalised muscle tension. You have known Miriam for 5 years since you joined this practice. She has previously complained of 'arthritis' of the hips and knees, back pain and gastro-oesophageal reflux on various occasions. Which of the following drugs would be MOST suitable for long-term treatment Miriam. a) Amitriptyline b) Diazepam Incorrect. The correct answer is (c). c) Venlafaxine d) Oxazepam e) Fluoxetine

Miriam is suffering from generalised anxiety disorder (GAD). Fluoxetine and paroxetine are selective serotonin reuptake inhibitors (SSRI) which have not been shown to be effective in the treatment of GAD. Amitriptyline is a tricyclic antidepressant; diazepam and oxazepam are benzodiazepines. All three drugs can be used for treating anxiety, but have major disadvantages in terms of side affects and are unsuitable for long-term treatment of GAD. Venlafaxine is a serotonin and noradrenaline reuptake inhibitor (SNRI) which has been shown to be effective in the long-term treatment of GAD. However, it is important that patients also receive appropriate psychotheraphy, viz-cognitive behavioural therapy (CBT). (Murtagh, J. (2003), General Practice, Third edition, McGraw-Hill, Sydney, p 12511253 )

(Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109209 ) Question 28 The prevalence of insomnia in the Australian community is about: a) 10% Incorrect. The correct answer is (c). b) 20% c) 30% 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 co-existing disorder, such as depression or generalised anxiety, and often present with fatigue or daytime sleepiness rather than insomnia. (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 29 Which of the following is a cause of primary insomnia? a) Obstructive sleep apnoea b) Restless legs syndrome Incorrect. The correct answer is (c). c) Behavioural conditioning d) Sleep phase disorder e) Bereavement

In primary insomnia there is no pre-existing cause of sleep disorder as there is, for example, in obstructive sleep apnoea, restless legs syndrome, sleep phase disorder and bereavement. With behavioural conditioning or behaviours impairing sleep the patient has developed a habit of doing things immediately before bedtime which are not conducive to sleep, such as sitting in bed watching television. With the other options there is another established condition or situation which disrupts sleep. Hence insomnia is regarded as secondary in these cases. (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 30 Patients suffering from generalised anxiety disorder (GAD) often go undiagnosed for years because they: a) b) c) d) e) Deliberately conceal their anxiety Inadvertently play down their anxiety More often present with somatic complaints Are misdiagnosed as having depression 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 12511253 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=109209 ) 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+of+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) b) c) d) e) Tinea corporis Impetigo Pityriasis versicolor Psoriasis Dermatitis Incorrect. The correct answer is (a).

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%. (Robinson MJ, Robertson DM. (2003), Practical Paediatrics, 5th ed, Churchill Livingstone, Sydney, p 532-533 ) (Harrison's Online Available: www.accessmedicine.com/content.aspx?aID=65850&searchStr=leukemia %2c+lymphocytic%2c+acute#65850 )

* 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 Incorrect. The correct answer is (e). b) Tinea c) Contact dermatitis d) Eczema e) Scabies

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. 0.51.0cm "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 11441145 ) (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 (DPT) immunisation is recommended at 2, 4, 6 and 18 months of age. 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 ) * Question 36 The MOST appropriate treatment for first degree atrioventricular (AV) heart block is: a) b) c) d) e) An artificial pacemaker Isoprenaline hydrochloride (Isuprel) Atropine Digoxin Requires no treatment Correct

First degree AV block often does not require any treatment. Acute treatment of extreme bradycardia or second degree AV block (Mobitz type II) may require atropine or isoprenaline, but temporary pacing is the preferred treatment. Permanent pacing is recommended for distal block (Mobitz type 2) because of frequent early progression to third-degree atrioventricular block. Most patients with third degree (complete) AV block will require permanent cardiac pacing. Drugs such as digoxin may be the cause of an AV block and should be ceased or the dose reduced.

(Murtagh, J. (2003), General Practice, Third edition, McGraw-Hill, Sydney, p 789 ) (Harrison's Online Available: 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) b) c) d) Change to a progestagen only oral contraceptive Change to an oestrogen only oral contraceptive Reduce her alcohol intake 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) b) c) d) There is usually a history of past or present cigarette smoking There is usually a long history of atopic disease Attacks can be triggered by chemical and physical agents The asthma tends to be more chronic than episodic Incorrect. The correct answer is (b). e) The associated cough can be harsh, suffusing and non-productive

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) b) c) d) Hypertensive encephalopathy Richardson-Steele syndrome Alzheimer's disease 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+amnesia#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 Correct b) A BMI of 33 c) Associated diabetes d) Presence of osteoporosis e) A previous joint replacement

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 )