practice fellowship examination december 2014 …€¦ · · 2015-01-20practice fellowship...

PRACTICE FELLOWSHIP EXAMINATION

DECEMBER 2014

WRITTEN EXAMINATION

SELECT CHOICE QUESTIONS

EXAMINATION TIME. 360 MINUTES

DIRECTIONS TO CANDIDATES

1. Your name and examination number must appear on both the front cover and answer sheet of

the examination paper.

2. You should attempt all questions.

3. Choose a single most correct response to each question.

4. Only one item is correct.

5. Any question or item not attempted will be scored as incorrect.

6. Correct items will receive ONE mark; incorrect items will receive NO mark.

7. Do not write on answer sheet other than as per instructions.

THE QUESTION BOOK MUST BE RETURNED AT THE COMPLETION OF THIS SECTION OF THE EXAMINATION.

1) A previously well 34 year-‐old woman presents with acute onset of sweating, palpitations and tremor following a viral illness. Examination reveals a very tender thyroid gland. The most likely diagnosis is

a) Hashimoto’s thyroiditis b) Post-‐partum thyroiditis c) Subacute thyroiditis d) Grave’s disease

2) A 6 year-‐old boy is brought to the ED with signs and symptoms suggestive of an upper respiratory tract infection. Which of the following treatments is most likely to reduce his symptoms?

a) Vitamin C b) Echinacea c) Nasal decongestant d) Zinc

3) A 42 year-‐old man presents with left-‐sided facial weakness. Which of the following clinical features is LEAST consistent with a diagnosis of Bell’s palsy?

a) Ear pain b) A perception of sensory changes on the involved side of the face c) Abnormally acute hearing d) Intact forehead movement on the affected side

4) A 62 year-‐old woman presents with pancreatitis. Which of the following clinical and biochemical scoring systems is most useful for predicting outcome while the patient is in the ED?

a) APACHE II score b) Ranson’s score c) Glasgow score d) Serum CRP at presentation

5) Which of the following is most likely to be present in an infant with osteomyelitis?

a) Prominent localised swelling b) Elevated white cell count in peripheral blood c) Elevated ESR d) Fever

6) A 29 year old woman presents to the ED with abdominal pains. Examination reveals a gravid uterus with intermittent contractions. What is the most accurate method for determining gestational age?

a) Height of the uterine fundus from the pubic symphysis b) Ultrasound in the first trimester c) Last normal menstrual period d) Bedside ED ultrasound in the third trimester

7) During non-‐invasive ventilation for acute pulmonary oedema, which of the following findings is most likely to be seen with BiPap over CPAP?

a) Reduced work of breathing b) Increased risk of myocardial infarction c) Reduced rate of intubation d) Reduced mortality

8) A 67 year old man presents with weakness and lethargy. He is found to be hypercalcaemic (Serum Ca2+ 2.84 mmol/L and serum albumin 36 g/L). The most likely underlying cause is

a) Hyperparathyroidism b) Malignancy c) Thiazide diuretic use d) Renal failure

9) Activated charcoal binds poorly to a) Carbamazepine b) Theophylline c) Lithium d) Phenobarbitone

10) The most common presenting symptom of systemic lupus erythematosus is a) Malar rash b) Pericarditis c) Arthralgias d) Renal disease

11) The most common cause of complete heart block is a) Anterior myocardial infarction

b) Inferior myocardial infarction c) Myocardial fibrosis d) Electrolyte abnormalities, particularly hypokalaemia

12) A 64 year-‐old woman presents to the ED with recurrent episodes of severe right-‐sided pain in her teeth, lips and gums. A full neurological examination is unremarkable. The most appropriate next step is to

a) Arrange a CT brain b) Prescribe diazepam c) Prescribe carbamazepine d) Prescribe paracetamol and oxycodone

13) The most common unexpected adverse incident during an interhospital transfer is a) Worsening haemodynamic status b) Problems with vascular access c) Worsening oxygen saturation d) Equipment problems

14) A 14 year-‐old boy presents via ambulance a few hours ingesting a “tea” made from a plant in his

backyard. He is agitated, tachycardic, picking at objects in the air, and has dry mucous membranes. This presentation is most likely to be due to ingestion of

a) Foxglove b) Oleander c) Angel’s trumpet d) Castor bean plant

15) An 84 year-‐old man is diagnosed with acute lower limb ischaemia. Which of the following treatment options is most appropriate?

a) Limb elevation b) Withhold analgesia to help determine response to therapy c) Clopidogrel loading dose of 600mg d) Heparin infusion

16) The most common anatomic site of hypertensive intracranial haemorrhage is the a) Thalamus b) Pons c) Putamen d) Cerebellum

17) Regarding the microbiology of pneumonia,

a) Haemophilus influenzae is a common cause of mild pneumonia in young adults b) Mycoplasma pneumoniae infection is rare in the elderly c) Legionella pneumophilia is more likely to cause mild disease than severe pneumonia d) Anaerobic organisms are commonly seen in nursing home patients with aspiration

pneumonia

18) Regarding the assessment of a child with suspected supracondylar fracture of the proximal humerus,

a) The most common mechanism is a fall on the outstretched hand b) Ulnar nerve injuries are common c) Injury to the anterior interosseous nerve results in sensory deficits in the thumb and

index finger d) Absence of a radial pulse is common and most frequently due to transient arterial spasm

19) Which type of renal calculus is most likely to cause end stage renal failure?

a) Calcium oxalate b) Struvite c) Uric acid d) Cysteine

20) An 18 year-‐old man presents with a needlestick injury to his foot while walking on St Kilda beach. He has brought the needle to the ED. Which of the following actions is recommended?

a) Test the needle and offer prophylaxis based on the test results b) Two drug antiretroviral post-‐exposure prophylaxis for HIV c) HBIG and hepatitis B vaccination if not previously vaccinated d) Interferon-‐α or ribavirin to reduce risk of hepatitis C transmission

21) The factor that contributes the most to the cost variance in the ED is a) Patient disposition from the ED b) Diagnostic category c) Increasing age d) Treatment time in the ED

22) The most common organism responsible for malignant otitis externa is a) Pseudomonas aeruginosa b) Proteus species c) Enterobacteriaceae d) Staphylococcus aureus

23) Regarding the assessment of a patient with suspected mental illness a) Direct referrals from triage nurses to psychiatric clinicians is associated with an

increased risk of adverse outcome b) Visual hallucinations are more common in psychiatric illness than in organic illness c) Psychiatric patients have a higher incidence of physical illness than the general

population d) Illusions, misinterpretations and impaired concentration are often seen in psychiatric

illness

24) A 66 year-‐old man is comatose after being resuscitated from an out of hospital cardiac arrest.

Which of the following situations is NOT a relative contraindication to therapeutic hypothermia? a) Pre-‐existing coagulopathy b) Severe cardiogenic shock c) Administration of thrombolytic therapy d) Uncontrolled bleeding

25) A 24 year-‐old man presents with a painful left ear after an assault at a nightclub. You diagnose a perichondral haematoma. Which of the following steps is most appropriate?

a) Needle aspiration b) Incise skin to drain and leave open c) Incise skin to drain and re-‐suture d) Oral antibiotics to cover Staphylococcus and Pseudomonas.

26) A 42 year-‐old man with a history of severe, brittle asthma presents to the ED with a fracture-‐dislocation of his ankle. Which of the following analgesics is most appropriate initial treatment?

a) Tramadol b) Morphine c) Fentanyl d) Oxycodone

27) In the setting of maternal trauma, which of the following situations indicates an emergency caesarean section?

a) 36-‐week gestation and haemodynamic instability prior to initial fluid resuscitation b) 30-‐week gestation with a persistently abnormal CTG trace c) 34-‐week gestation with uterine tenderness and absent foetal heart tones d) 36-‐week gestation with significant feto-‐maternal haemorrhage on Kleihauer-‐Betke test

and normal CTG

28) Which of the following coexisting illnesses has the greatest effect on determining pneumonia severity using the pneumonia severity index (PSI)?

a) Chronic obstructive pulmonary disease b) Liver disease c) Chronic renal failure d) Congestive cardiac failure

29) When fractured, which of the following carpal bones, is LEAST likely to undergo avascular

necrosis? a) Scaphoid b) Lunate c) Triquetrum d) Capitate

30) Regarding the management of a patient with an anterior dislocation of their shoulder, a) The scapular rotation technique involves rotating the inferior tip of the scapula laterally. b) Procedural sedation is more likely to result in successful reduction than intra-‐articular

local anaesthetic c) The scapular rotation technique should be performed with the patient supine d) Kocher’s manoeuvre is no longer recommended

31) The maximum recommended safe volume of 1% lignocaine for local infiltration in a 50kg woman is

a) 12 mL b) 15 mL c) 18 mL d) 21 mL

32) A two year-‐old boy is brought to the ED by his mother after eating unidentified mushrooms that were growing in the backyard. The ingestion occurred one hour ago and he is currently asymptomatic. The most appropriate action is to

a) Discharge home with advice to return if gastrointestinal symptoms occur b) Administer oral activated charcoal c) Attempt to identify the mushroom prior to deciding upon therapy d) Admit for observation and serial liver function tests

33) Which of the following treatments is NOT useful for severe high altitude cerebral oedema?

a) Acetazolamide b) Dexamethasone c) Oxygen therapy d) Controlled descent

34) Which of the following NSAIDs is likely to have the lowest rate of gastrointestinal side effects?

a) Naprosyn 250mg tds b) Indomethacin 25mg tds c) Ibuprofen 400 mg tds d) Diclofenac 25mg tds

35) Regarding spinal injuries, a) Hyperextension is the principal mechanism of injury to the thoracic spine b) The majority of thoracic spine injuries are unstable c) Lap-‐only type seatbelts are associated with Chance fractures of the lumbar spine d) Pars interarticularis fractures of the thoracolumbar spine are considered unstable

36) Which of the following wounds is most likely to benefit from the administration of prophylactic antibiotics?

a) Deep partial thickness burns b) Plantar puncture wound c) Dog bite to the face d) Clenched fist injury

37) The most common adverse effect from antipsychotic agents is a) Dystonia b) Akathisia c) Parkinsonism d) Orthostatic hypotension

38) Which of the following therapies is most likely to be of benefit in the management of a child with heat stroke?

a) Oral rehydration solution b) Paracetamol or ibuprofen c) Diazepam or chlorpromazine d) Dantrolene

39) Which of the following fungal skin infections should initially be treated with oral therapy?

a) Tinea corporis b) Tinea cruris c) Tinea pedis d) Tinea capitis

40) You are evaluating a 24 year-‐old female for possible meningitis, and are planning to perform a lumbar puncture. Which of the following is most likely to reduce the risk of her developing a post-‐lumbar puncture headache?

a) Performing the lumbar puncture with the patient lying on her side rather than sitting up. b) Orienting the bevel of the needle parallel to the long axis of the spine c) Administering intravenous fluids during and after the procedure d) Performing an epidural blood patch

41) Which of the following imaging series will result in the highest dose of radiation? a) CT facial bones b) CT head c) CT cervical spine d) Bone scan (Tc-‐99m)

42) In a disaster with mass casualties a) The first wave of casualties to arrive in ED are the most critically injured b) CPR is rarely indicated at the scene c) The disaster medical response is primarily an ED issue d) There is a role for medical personnel in the Bronze/Hot zone of an incident

43) In regard to aeromedical retrieval, which is FALSE a) Rotary wing craft would be preferred for transport over a distance of 150km b) Fixed wing craft have greater speed and space c) Most rotary wing craft can be pressurised to some degree as required d) Fixed wing craft have less vibration, noise and temperature impact on patients

44) Which viral infection is a risk factor for the development of secondary diabetes mellitus? a) Cytomegalovirus b) Epstein-‐Barr virus c) Hepatitis B virus d) Human immunodeficiency virus

45) Following rapid ascent from a dive, a 25 year old man develops marked lower limb weakness and is unable to stand. What FiO2 of oxygen should be administered to him by the first aid officer on the dive boat?

a) 21% (air) b) 30% c) 50% d) 100%

46) A patient with lung cancer presents 6 days after chemotherapy with fever (39) and rigors. Which of the following is true?

a) Mortality rate, without prompt IV antibiotics is greater than 60% b) A clear infection source is usually detected on physical examination c) Risk of severe sepsis is directly related to rapidity of onset of neutropenia d) Neutropenia is defined as a neutrophil count of less than 2 x 109

47) In relation to the physical signs in cardiac tamponade, which of the following is TRUE?

a) Pulsus Paradoxus is a decrease in systolic blood pressure of more than 10mmHg with expiration

b) The jugular vein Y-‐descent is increased due to loss of diastolic filling of the ventricles c) Becks triad consists of tachycardia, increased JVP & diminished heart sounds. d) Kussmaul sign is a paradoxical increase in venous distention and pressure during

inspiration

48) A 57 year old woman presents with vertigo, hearing loss and postural instability. Examination findings include horizontal nystagmus and positive (abnormal) head impulse test. What is the most likely cause?

a) Vestibular neuritis b) BPPV c) Labyrinthitis d) Cerebellar infarct

49) A 26 year old patient man is brought to ED after a suspected snake bite to left ankle. Pressure immobilisation bandaging is in place. Which of the following is the strongest indication for anti-‐venom administration?

a) SVDK on blood is positive for brown snake venom b) SVDK on urine is positive for brown snake venom c) SVDK on wound swab is positive for brown snake venom d) Severe, non-‐specific symptoms (headache, nausea, vomiting and abdominal pain)

50) A 37 year old woman is brought to ED after she was witnessed to swallow 4 packets of rat poison each containing 50g of brodifacoum ( a long-‐acting anticoagulant). There is no suspicion of ingestion of other substances. She is asymptomatic and examination is unremarkable. INR is normal. She is no longer suicidal and is suitable for outpatient management of her mental health issues. Which of the following if indicated? a) 10mg oral Vitamin K, discharge, repeat INR at 48 hours b) 10mg oral vitamin K and admission for serial INR testing c) 50g activated charcoal and admission for serial INR testing d) 50g activated charcoal, 10mg vitamin K and admission for serial INR testing

51) Which drug is contraindicated in the treatment of theophylline related seizures? a) Diazepam b) Phenobarbitone c) Chloral hydrate d) Phenytoin

52) Following aspiring overdose the initial acid base derangement is usually a) Respiratory acidosis b) Metabolic acidosis c) Respiratory alkalosis d) Metabolic alkalosis

53) In Australia what is the safe observation and investigation period after which a patient can be discharged if there are no signs of envenomation post snake bite?

a) 4 hours b) 6 hours c) 8 hours d) 12 hours

54) Regarding suicide a) It is becoming less frequent as more sophisticated mental health care is becoming

available b) Men are 10 times more likely to complete suicide than women c) Suicide is very rare in elderly patients d) Approximately 10% of patient who complete suicide are seen in an Emergency

Department in the month preceding their death

EMQ 1

Theme: Cardiology Options A HOCM B ASD C PDA D VSD E LVF F Coarctation of the Aorta G Aortic dissection H Mitral stenosis I Aortic stenosis J Eisenmengers syndrome K Aortic incompetence L Mitral incompetence Lead in: For each of the following patients select the most likely diagnosis based on the given examination findings. Stems: 55). A 40 year old man with a sharp rising jerky pulse, prominent a wave on JVP, ejection systolic murmur at the left sternal edge and pansystolic murmur at the apex. The murmur increases with isotonic exercise and decreases with isometric exercise and decreases with isometric exercise. 56). A 40 year old man with small volume slow upstroke pulse, ejection systolic murmur, 4th heart sound, reversed splitting of second heart sound and bibasal inspiratory crackles. 57). 50 year old man with hypotension, sinus tachycardia, collapsing pulse, distended neck veins, diastolic murmur, third heart sound and altered conscious state. 58). A 24 year old man with clubbing, central cyanosis, right ventricular heave and palpable S2, early diastolic murmur, loud P2, 4th heart sound.

EMQ 2 Theme ECGs Options A Acute Pericarditis B Wellen’s Syndrome C Anterior STEMI D Brugada syndrome E De Winter Syndrome F Atrial flutter G Arrythmogenic right ventricular cardiomyopathy H Ventricular tachycardia I Hypertrophic obstructive cardiomyopathy J Trifascicular block K Wolf Parkinson White syndrome L Romano Ward syndrome Lead in: For each patient presenting with syncope an ECG has been taken on arrival. Select the most likely diagnosis from the options provided. 59). A 30 year old female presents following a collapse at work.

EMQ 2 continued. 60). A 30 year old man presents following a collapse playing basketball. He felt light headed and experienced palpitations prior to the collapse.

61). A 55 year old female presents following two recent episodes of syncope. She reports occasional palpitations.

EMQ 2 continued 62). A 61 year old man with palpitations and light-‐headedness preceding a brief episode of loss of consciousness.

EMQ 3 Theme – Oncology Options A Pancreatic carcinoma B Gastric carcinoma C Caecal carcinoma D Breast cancer E Ovarian cancer F Malignant melanoma G Multiple myeloma H Non Hodgkins lymphoma Lead in For each of the following patients select the most likely diagnosis. Stems 63). A 60 year old woman with abdominal bloating, fatigue, weight gain, urinary frequency and constipation. 64). A 55 year old woman with weight loss, jaundice, pale stool and dark urine. 65). A 65 year old man with weight loss, abdominal distension, night sweats, fatigue and itching. 66). A 78 year old man with dyspnoea, fatigue, pallor and constipation. 67). A 70 year old man with dyspnoea, fatigue, pallor and indigestion.

EMQ 4 Theme: Investigations in Abdominal Pain Options: A Abdominal CT scan B Abdominal Ultrasound C Abdominal x-‐ray D Blood gases E Chest x-‐ray F ECG G Full blood examination H Glucose I Lipase J Liver function tests K No investigations L Urea and Electrolytes Lead in: Select the most useful investigation to be performed in the assessment of abdominal pain to make the diagnosis. Stems: 68). A 72 year old man presents to the Emergency Department with 3 to 4 hours of increasing abdomina pain. On examination he has an irregular heart rate of 120/minute, BP 80/40, and he has generalised guarding and rebound. 69). A 50 year old man has noted a few days of left loin pain. At times, he has noted discomfort in his left lower quadrant. At triage his pulse is 90/minute, temperature is 37.0 oC and BP is 130/80. Urinalysis at triage is negative. There is marked tenderness in his left ilac fossa with localised guarding. 70). A 6 year old girl has been complaining to her parents of lower abdominal pain and is brought to the Emergency Department. On examination her pulse rate is 130/minute, respiratory rate is 35 breaths/minute and she has a BP of 90/40. She has no focal features on examination of her abdomen.

EMQ 5 Theme: Spinal cord lesions Options: A L1/2 B L2/3 C L3/4 D L4/5 E L5/S1 F S1/S2 G S2/S3 Lead in: For each patient with spinal cord pathology, select the most likely level of the lesion. Stem: 71). A 30 year old man presents to the Emergency Department with a right foot drop following a back injury while lifting heavy boxes at work. On examination weakness of the right knee flexion is also noted. 72). An elderly woman presents to the Emergency Department with worsening back pain and increasing difficulty walking. On examination she has grade 3/5 power in left hip flexion and decreased sensation (all modalities) over her quadriceps. 73). A 60 year old man with metastatic lung cancer presents with a few days of increasing difficulty walking. Over the last 24 hours he has become faecally incontinent.

EMQ 6

Theme: Paediatric respiratory Options: A Croup B Acute Asthma C Bronchiolitits D Acute Epiglottitis E Inhaled Foreign Body F Anaphylaxis G Whooping Cough Lead in: For the following children presenting with respiratory symptoms, select the most likely diagnosis. Stems: 74). An 11 month old boy if referred to the Emergency Department with 3 days of persistent cough, preceded by 1 week of rhinorrhoea, conjunctivitis and low-‐grade fever. He is usually healthy, but is unvaccinated. On examination: • Not unwell • No stridor • Temperature 375 oC • O2 sats 98% on room air Frequent bouts of severe coughing, followed by gagging. Chest clear on auscultation. 75). An 18 month old girl presents with acute respiratory distress and stridor. She was perfectly well just before this episode, playing with her 4 year old brother in the toy room. On examination: • Distressed • Marked stridor • Temperature 37 oC • O2 sats 95% on room air Chest examination: no abnormalities other than transmitted upper airway sounds. No rash.

76). A 6 month old boy is brought to the Emergency Department by her parents one evening. They report poor feeding and apparent breathing difficulties. He had coryza and fever in the preceding 2 days. On examination: • Moderated unwell • Temperature 38 oC • O2 sats 94% on room air Bilateral chest hyperinflation, subcostal recession and scattered expiratory wheezes. 77). A 14 month old boy is referred to the Emergency Department by his GP one evening with fever

and cough. The child had coryza, irritability and malaise in the preceding 3 days. On examination:

• Well looking, happy child • Stridor evident when crying • Temperature 375 oC • O2 sats 98% on room air

Barking cough. Clear chest with good bilateral breath sounds. 78). A 20 month old boy is brought in by ambulance one afternoon. He suffered actue respiratory distress while having lunch at a nearby restaurant. His parents state he was perfectly well before that. On examination:

• In distress, vomiting • Stridor evident at rest • Temperature 375 oC • O2 sats 95% on room air

Diffuse erythematous, blanching rash. Lip swelling. Reduced bilateral breath sounds, some wheezes also heard. 79). An 18 month old boy is brought in by ambulance one evening, with respiratory distress. The child is unvaccinated. Other details of history are unclear. On examination:

• Unwell, toxic looking. Sitting forward, drooling • Stridor evident at rest • Temperature 395 oC • O2 sats 92% on room air

Marked work of breathing with subcostal recession. Reduced breath sounds bilaterally, with transmitted stridor.

EMQ 7 Theme: Spinal pathology Options: A Cauda Equina syndrome B Transverse Myelitis C Central Cord syndrome D Anterior Spinal Artery syndrome E Doral Column syndrome F Brown-‐Sequard syndrome G Neurogenic shock H Transverse spinal cord syndrome (below T1) Lead in: For the following patient presenting with a history of trauma and neurological symptoms, select the most likely diagnosis. Stems: 80). A 25 year old construction worker fell >4 metres onto a concrete surface. He has an acute injury to his lumbar spine. He complains of back pain and inability to move his legs. On examination:

• Temperature 37 oC • GCS 15 • HR 110 /minute, sinus rhythm • BP 120/80 mmHg

Total flaccid paralysis and anaesthesia of both lower limbs. Sensory level around inguinal regions bilaterally. Insensate below this level, except in perianal area. 81). A 79 year old man tripped and fell forward at home, hitting his head against a table edge. He has neck pain, and is placed in a hard cervical collar. On examination:


Quadriparesis, more marked in both upper limbs than lower limbs. Reduced sensation all four limbs, worse in upper limbs. Variable reflexes.

EMQ 7 continued 82). A 30 year old woman fell off a horse, injuring her cervical spine. She is placed in a hard cervical collar. On examination


Quadriplegia. Completely insensate below level of clavicles. Warm, dry skin. 83). A 35 year old woman presents with 7 days of mid to lower back pain, with progressive bilateral leg weakness (without pain) and urinary incontinence. She suffered a syncopal episode 10 days ago when she had a viral infection, and twisted her back as she collapsed. One examination


Bilateral lower limb paraparesis and reduced sensation, including perineal / perianal region. Symmetrical lower limb hyporeflexia. No abnormalities of the spine; no abnormalities above the waist. 84). A 40 year old man was involved in a high-‐speed motorcycle accident. His only injuries are fractures to L1 and L2 vertebrae. On examination


Bilateral lower limb paraparesis including perineal / perianal region. Symmetrical lower limb hyporeflexia. Reduced pain and temperature sensation to both lower limbs, but proprioception and vibration sense preserved. No abnormalities above waist. 85). A 30 year old man was allegedly stabbed in the back at a nightclub. He sustained a penetrated wound to his lower thoracic area. Other injuries include a right-‐sided pneumothorax, which was appropriately treated.


Right lower limb paresis, with areflexia. Sensation in same limb is preserved, except for proprioception. Markedly reduced sensation, but normal power and reflexes in left lower limb.

EMQ 8 Theme: Haematemesis Options: A Duodenal ulcer B Vascular malformation C Mallory-‐Weiss tear D Oesophageal varices E Gastric carcinoma F Crohn’s disease G Oesophageal carcinoma H Haemophilia I Gastric ulcer J Oesophagitis K Meckel’s diverticulum Lead in: Each of the following patients present to the emergency department with haematemesis. For each select the most appropriate diagnosis from the list above. Stems: 86). A 57 year old man with a past medical history of alcoholic liver disease and ascites. 87). A 62 year old lady presents with haematemesis and severe constant abdominal pain. She has a long history of indigestion and has lost 10kg in the last month. 88). A 34 year old man with a history of back pain, arthritis, diarrhoea and weight loss. 89). A 35 year old has haematemesis after an episode of severe coughing. On examination he appears intoxicated but there are no signs of chronic liver disease. 90). A 41 year old lady presents with haematemesis. She has a history of epigastric pain that usually occurs at night. The pain is relieved by Mylanta and is worse when she is hungry.

EMQ 9 Theme: Causes of pneumonia Options: A Streptococcus pneumonia B Staphylococcus aureus C Legionella pneumophilia D Pseudomonas aeruginosa E Mycoplasma pneumonia F Klebsiella pneumonia G Chlamydia pneumoniae H Mycobacterium tuberculosis I Escherichia coli Lead in: The following are characteristics of which form of bacterial pneumonia? Stems: 91). Fever, chills, headache, malaise, dry cough, dyspnoea, anorexia, diarrhoea, nausea and vomiting. 92). Sudden onset of fever, rigors, pleuritic chest pain, cough productive of rust-‐coloured sputum. 93). Sudden onset of rigors, dyspnoea, chest pain and bloody sputum particularly in alcoholics or nursing home patients with upper lobe changes on CXR and abscess formation. 94). Gradual onset of cough, fever, dyspnoea especially after a viral illness with patchy multilobular changes on CXR.

EMQ 10 Theme: PR bleeding in children Options: A Anal fissure B Hirschsprung’s disease C Haemorrhoids D Crohn’s disease E Ulcerative colitis F Juvenile polyps G Haemolytic-‐uraemic syndrome H Intussuception I Eosinophilic colitis J Meckel’s diverticulum Lead in: For each of the following children presenting to the emergency department, select the most likely diagnosis. Stems: 95). A 16 month old boy who’s parents state has been passing dark red stools. The parents state that he does not appear to have had any abdominal. On examination the child is pale.

• Temperature 36.5 oC • HR 140 /minute • BP 90/40 mmHg

96). A 4 year old girl presents with abdominal pain and bloody diarrhoea. She is pale and lethargic. You notice petechiae where the blood pressure cuff was. On examination:

• Temperature 37.8 oC • HR 140 /min • BP 90/50 mmHg

97). A 7 week old baby boy presents with scanty streaks of fresh blood mixed with normal-‐coloured loose stool. On examination:

• Temperature 36.8 oC • HR 140 /min • BP 75/40 mmHg

EMQ 10 continued 98). A 7 year old girl presents with streaks of blood on the outside of the stool and drops of blood in the toilet. The child is well with no history of abdominal pain or rectal pain. On examination

• Temperature 36.7 oC • HR 80 /min • BP 100/70 mHg

99). A 14 year old boy presents with a 2 week history of abdominal pain and severe watery diarrhoea, with occasional bright red blood mixed with stools. He complains of poor sleep and has about 20 motions per day. On examination there he has a soft abdomen with diffuse tenderness. You note perianal skin tags.

• Temperature 37 oC • HR 70 /min • BP 110/70 mmHg

EMQ 11 Theme: Toxicology Options: A Lithium B Aspirin C Ethanol D Benzodiazepine E Tricyclic antidepressant F Beta blocker G Paracetamol H Methanol I Amphetamine J Digoxin Lead-‐in: For each of the clinical scenarios described below select the most likely drug taken in overdose from the list above. Stems: 100). A 22 year old male admitted to the Emergency Department complaining of deafness and tinnitus. On examination he is diaphoretic:

• Temperature 38.9 oC • GCS 15 • HR 120 /min • BP 100/60 mmHg

101). A 32 year old female brought in by ambulance found collapsed at home. On examination he has dilated pupils:

• Temperature 37.7 oC • GCS 9 (E2, V3, M4) • HR 130 /minute • BP 90/65 mmHg

EMQ 11 continued 102). A 72 year old man presents with drowsiness and confusion. On examination:

• Temperature 36.8 oC • GCS 13 (E3, V5, M5) • HR 48 /minute • BP 98/68 mmHg

His ECG shows a first degree heart block and widening of the QRS. EMQ 11 continued 103). An 82 year old woman presents with nausea, vomiting and diarrhoea. She is also complaining of blurring of vision and flashes of light. On examination:

• Temperature 37 oC • GCS 14 (E4, V4, M6) • HR 50 /minute, irregularly irregular • BP 120/80 mmHg

104). A 30 year old female with long-‐standing psychiatric illness presents with polyuria, diarrhoea, vomiting and coarse tremor. On examination she is agitated:

• Temperature 37 oC • GCS 15 • HR 100 /minute • BP 110/70 mmHg

EMQ 12 Theme: Electrolyte imbalance Options: A Primary hyperparathyroidism B Addison’s disease C Hyperthyroidism D Small cell carcinoma E Cushing’s disease F Diabetes mellitus G Diabetes insipidus H Pyloric stenosis I Psychogenic polydipsia J Multiple myeloma K Vitamin D deficiency Lead in: For each of the combinations of biochemical abnormalities outlined below, select the most likely diagnosis from the list above. Stems: 105). Hyponatraemia, hyperkalaemia, hypoglycaemia and increased urea. 106). Hyponatraemia, hypokalaemia and metabolic alkalosis 107). Hypernatraemia, hypokalaemia and hyperglycaemia. 108). Hypoalbuminaemia, hypercalcaemia and hyperuricaemia. 109). Hypercalcaemia, hypophosphataemia and increased alkaline phosphatase.

EMQ 13 Theme: Red eye Options: A Episcleritis B Herpetic corneal ulcer C Open-‐angle glaucoma D Acute closed-‐angle glaucoma E Scleritis F Subconjunctival haemorrhage G Allergic conjunctivitis H Viral conjunctivitis I Bacterial conjunctivitis J Anterior uveitis K Pterygium Lead in: In each of the following patients presenting with red eyes, select the most appropriate diagnosis. Stems: 110). A 3 year old child woke up with purulent bilateral eye discharge and discomfort. His vision is normal. On examination both conjunctivae are inflamed. 111). A 6 year girl with whooping cough presents with sudden-‐onset of painless red left eye. 112). A 60 year old man presents with acute severe pain in his left eye with impaired vision and haloes around light. He has vomited twice. 113). A 45 year old lady presents with severe, constant, boring pain in her eye that radiates to the face and periorbital region. The pain is worse on eye movement. She also complains of photophobia and epiphoria. 114). A 31 year old lady presents with a 2 day history of photophobia, reduced visual acuity and severe pain in her right eye. Her pain resolves on administration of topical anaesthetic.

EMQ 14 Theme: Dermatology Options: A Idiopathic thrombocytonpaenic purpura B Henoch-‐Schonlein purpura C Thombotic thrombocytopaemic purpura D Haemolytic uraemic syndrome E Vasculitis F Toxic Epidermal Necrolysis G Staphylococcal scaled skin syndrome H Eczema herpeticum I Dermatitis herpetiformis J Toxic shock syndrome K Kawasaki disease L Erythema multiforme M Stevens Johnson syndrome Lead in: For each patient with rash select the most likely diagnosis from the options provided. Stems: 115). A 35 year old pregnant female presents unwell with confusion, pallor and petechiae On examination

• HR 110 /minute regular • BP 110/60 mmHg • RR 20 /minute • Temperature 37.8 oC

Laboratory results include: • Hb 90 • WCC 12 • Platelets 20 • Na+ 140 mmol/L (135-‐145) • K+ 3.7 mmol/L (3.2-‐4.3) • Cl-‐ 100 mmol/L (99-‐109) • Creat 150 umol/L (45-‐85)

116). A 60 year old man presents with a gradual onset of cutaneous blistering involving approximately 5% of the body surface area. Target lesions are evident, including on palms and soles. Oral and genital ulcers are present. On examination

• HR 110 /minute regular • BP 110/60 mmHg • RR 20 /minute • O2 saturations 100% on room air • Temperature 36.8 oC

117). A 10 year old boy presents with widespread petechiae and easy bruising. He has recently had a viral upper respiratory tract infection, but is otherwise well. On examination

• HR 110 /minute regular • RR 20 /minute • O2 saturations 100% on room air • Temperature 36.8 oC

118). A 4 year old girl presents with a tender scarlatiniform, erythematous rash. Several blisters are present and Nikolsky sign is positive. On examination

• HR 130 /minute regular • RR 24 /minute • O2 saturations 100% on room air • Temperature 38 oC

119). A 20 year old man presents unwell with a diffuse erythematous rash. He had nasal packing for epistaxis removed two days prior. On examination:

• HR 140 /minute regular • BP 90/60 mmHg • RR 30 /minute • O2 saturations 100% on room air • Temperature 38.5 oC

120). A 5 month old infant presents unwell with extensive vesicles on a background of healing atopic dermatitis. Lymphadenopathy is evident. On examination:

• HR 170 /minute regular • BP 75/50 mmHg • RR 50 /minute • Temperature 38 oC

practice fellowship examination december 2014 …€¦ · · 2015-01-20practice fellowship...

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