2006b_Paper 2 – Clinical Applications

A 35-year-old teacher is referred with chronic headaches, myalgias, restlessness, difficulty concentrating and initial insomnia. She says that she worries most days that she might have a serious illness. However, she has always been "a worrier" and she also worries constantly about the performance of her students and about the security of her job. At times she uses alcohol to feel less worried and to initiate sleep. There are no abnormal findings on physical examination or on investigation and she can accept your reassurances that she is not seriously unwell. She has a bright reactive affect. Which treatment approach for her complex symptoms is most likely to be helpful?

A 62-year-old woman with rheumatoid arthritis for eight years presents for review. Her arthritis is well controlled with 15mg of methotrexate weekly, folic acid supplements and ketoprofen sustained release 200mg daily, all of which she has been on for the past five years. She is overweight with a body mass index of 35kg/m2 [18-26] and has mild, diet-treated type 2 diabetes mellitus. She is on no other medications. You review her routine blood tests which are normal apart from her liver function tests which have been progressively worsening over the past six months. The most recent test is shown below. protein 88 g/L [63-82] albumin 41 g/L [35-50] bilirubin 8 μmol/L [<10] alanine transaminase (ALT) 150 U/L [<52] aspartate transaminase (AST) 120 U/L [<36] alkaline phosphatase (ALP) 120 U/L [<126] gamma glutamyltranspeptidase (GGT) 150 U/L [<43] The most likely explanation for this woman's liver function test abnormalities is:

A 56-year-old man is referred for assessment of resistant hypertension. Blood pressure readings at his general practitioner’s surgery have been between 145 and 172 systolic and 86 and 98 diastolic despite various combinations of up to two anti-hypertensive agents at a time. He has no other vascular risk factors. He has no family history of hypertension. Examination does not reveal any clinical findings suggesting a secondary cause of hypertension. He has normal creatinine and electrolytes. An ECG and trans thoracic echocardiogram are normal What is the most appropriate next investigation?

Which of the following is the most likely adverse effect of long-term inhaled corticosteroid use in an adult asthmatic?

A 24-year-old woman is on doxycycline 100 mg/day for moderately severe acne. She wants to become pregnant. In terms of foetal outcome, at what stage of pregnancy (measured from last menstrual period) is the risk to the foetus greatest from exposure to doxycycline?

A 21-year-old Filipino woman has been referred for investigation of anaemia. Her blood counts and iron studies are as follows: Haemoglobin 81 g/L [113-159] Haematocrit 0.27 [0.32-0.42] Red blood cells 4.58 x109/L [3.60-5.30] White blood cells 4.60 x109/L [3.90-12.70] Platelets 421 x109/L [150-396] Mean corpuscular volume 59 fL [80-97] Mean corpuscular haemoglobin 17.7 pg [28.0-34.0] Mean corpuscular haemoglobin concentration 300 g/L [328-363] Reticulocytes 142 x 109/L [8-104] Serum ferritin 482 mcg/L [15-200] HbA2 1.4% [1.6-3.5] HbF 0.3% [0.2-1.0] Which of the following is the most likely diagnosis?

A 65-year-old woman, established on haemodialysis for nine months, is maintained on erythropoietin 4,000 units twice a week intravenously. Previously her haemoglobin (Hb) had remained steady in the range of 105 – 115 gm/L. She now presents with a Hb of 89 gm/L on routine testing. There have been no changes to her erythropoietin dose or other medications. Her mean corpuscular volume (MCV) is 84 fL [78-98], her serum iron is 13 μmol/l [13-35], iron saturation is 18% [15-46], serum ferritin is 630 μg/l [20-300] and her reticulocyte count is 30 x 109/L [12-100]. Which of the following is the most likely cause for her erythropoietin resistance?

A 25-year-old female presents with symmetrical small joint polyarthralgia associated with a photosensitive facial rash, and low grade fever. Examination reveals small joint tenderness in the hands without synovitis, and an erythematous, slightly scaly malar rash. The examination is otherwise unremarkable, and urinalysis is normal. The following laboratory results are obtained. C-reactive protein (CRP) 18 mg/L [0-11] Antinuclear antibody (ANA) positive, titre: 1/2560; pattern: homogeneous Anti-double stranded DNA (anti-dsDNA) 17 IU/mL [0-5] Rheumatoid factor <20 IU/mL [0-20] In addition to non-steroidal anti-inflammatory agents, which of the following is the most appropriate next step in management?

A 45-year-old woman is admitted after being found unconscious. Her plasma glucose is 1.5 mmol/L. The following results are obtained: Plasma insulin 105 pmol/L [<80 fasting] Plasma C-peptide 650 pmol/L [250-700] CT (computed tomography) pancreas Normal Which of the following best explains these findings?

Which of the following drugs is least likely to cause a rise in serum potassium?

A patient with known cancer presents with increasing thirst. Initial biochemistry reveals normal glucose, plasma sodium of 147 mmol/L [135-145], plasma osmolality of 300 [280-296], urinary sodium of 31 and urinary osmolality of 77. These findings are most consistent with:

A 55-year-old man develops choreiform movements. He has no personal or family history to account for these symptoms. DNA studies identify a pathognomonic expansion in IT15, the gene responsible for Huntington disease. The figure below summarises the results of DNA studies of the IT15 repeat in the patient and his immediate family. Samples were collected from the patient (lane 1), the patient’s father (lane 2), the patient’s mother (lane 3), and the patient’s healthy sibling (lane 4). The range of sizes of the IT15 repeat in the normal population is shown. What is the best explanation for the patient’s lack of a family history of Huntington disease?

A 25-year-old male comes for assessment of fitness to dive. Which of the following is the strongest contraindication to diving?

A 66-year-old man presents with a history of slowing of most movements over the last six months, with a bilateral resting tremor. On examination there is evidence of retropulsion. Examination of his eye movements reveals impaired vertical saccades. He gives a history of frequent falls. These features are most characteristic of which of the following?

A 52-year-old woman presents with dry eyes which have progressively worsened over the past three years. On examination her Schirmer test is 1mm in 5 minutes [5mm in 5 minutes] and she has positive Rose Bengal staining of both corneas. Her erythrocyte sedimentation rate is 98 mm/hr [<21mm/hr], antinuclear antibody is positive with a speckled pattern and a titre of 1:640 and Anti-Ro and –La antibodies are detected. The most appropriate initial treatment is:

In which of the following conditions is treatment with gabapentin most effective?

A 24-year-old man awakens with right shoulder/trapezius discomfort. The pain persists for two weeks, and he is then aware of weakness of right shoulder movements. On examination he has a full range of movement of his cervical spine without pain. He is unable to actively abduct his right arm past 45°, and has Grade 0/5 power of right deltoid and infraspinatus. Upper extremity power is otherwise normal, with normal biceps, triceps and brachioradialis reflexes. Sensory examination is normal. A cervical magnetic resonance imaging (MRI) scan and right shoulder ultrasound are normal. The most likely diagnosis is:

A patient has the following abnormal findings: sodium 130 mmol/L [134-145] potassium 2.9 mmol/L [3.5-5.0] phosphate 0.22 mmol/L [0.6-1.3] magnesium 0.6 mmol/L [0.72-0.92] creatinine 120 μmol/L [70-110] ionised calcium 1.1 mmol/L [1.14 - 1.27] glucose 5.1 mmol/L [4.1- 6.1] Which of the following is the most likely cause?

A test is used to screen for a target disorder. The best definition of the specificity of the test is “the proportion of individuals:

A 38-year-old man lives in a boarding house for psychiatric patients. He has an established diagnosis of schizophrenia. He has little in the way of occupation and regularly consumes up to 100g of alcohol a day. Even though he has some persistent negative symptoms of schizophrenia, his positive symptoms have been well controlled for several years on a low dose of risperidone that he tolerates well. He presents now with a six month history of worsening depressed mood and intermittent suicidal thinking. Which of the following is most likely to assist his mood?

A 90-year-old male resident of a nursing home has severe dementia. He is bedbound, mute, doubly incontinent and requires full nursing care. He has a large pressure area over one buttock. He has had two recent admissions to hospital with aspiration pneumonia and has been placed on thickened fluids to try to prevent aspiration. He does not have any close family members. Now he does not co-operate with feeding and when food is placed in his mouth he does not swallow it. In the absence of any advance directives, the most appropriate approach to the management of his hydration and nutrition is:

A 25-year-old female presents with recurrent facial angioedema. The following laboratory results are obtained: Complement C3 0.36 g/L [0.79-1.80] Complement C4 0.06 g/L [0.13-0.48] Total haemolytic complement (CH100) 210 CH100 units [390-1015] Which of the following is the most likely explanation for these findings?

A 65-year-old male is referred with a three-year history of progressive breathlessness on exercise. He has smoked 20 cigarettes per day for 45 years. Spirometry is as follows: FEV1 (forced expiratory volume in one second) 1.0 L [3.02 L] FVC (forced vital capacity) 3.0 L [3.97 L] Arterial blood gases on air are as follows: pH = 7.40 PaO2 = 61 mm Hg PaCO2 = 43 mm Hg. Which of the following interventions is most likely to improve his survival?

A 65-year-old man developed Wegener’s granulomatosis eight years previously. At that time he had upper and lower respiratory tract and renal involvement. He achieved remission with prednis(ol)one and daily cyclophosphamide which was continued over 18 months. Seven months previously he experienced a relapse with arthritis, sinusitis, an active renal sediment and a rise in serum creatinine from 90 to 115 μmol/L. The relapse was treated successfully with prednis(ol)one and weekly methotrexate. Prednis(ol)one was tapered and withdrawn. Currently, he feels well and examination is normal. Laboratory tests show normal blood count, erythrocyte sedimentation rate (ESR) 25 mm/hr [0-20], and normal creatinine. Urine examination shows no protein, 10-100 red cells/high power field, and there are no dysmorphic cells. Which of the following is the next most appropriate course of action?

In therapy with immunosuppressive drugs (the relevant drugs are shown in brackets), knowledge of which of the following genotypes is most likely to be useful in preventing serious adverse drug events?

A 28-year-old woman presents with episodes of colour change in her distal fingers when they are exposed to the cold. The episodes occur most days and are characterised by white numb finger tips which become blue and then red. She describes similar episodes that have occurred for many years. She is otherwise well. Examination is unremarkable. Investigations show a positive anti-nuclear antibody of a speckled pattern with a titre of 1:80. The most likely diagnosis is:

A 45-year-old Australian-born woman with rheumatoid arthritis on long term prednisolone therapy presents with a third nerve palsy, left sided cerebellar signs and altered consciousness. She has a fever of 39°C and neck stiffness. Computed tomograp hy (CT) scan of the brain is normal. Lumbar puncture reveals an opening pressure of 20 cm [< 20 cm], white cell count of 80 x 106/L (80% lymphocytes), protein 0.6 g/L [< 0.45], glucose 3.5 mmol/L (blood glucose 4.0 mmol/L) and no red cells. Gram stain reveals no organisms and culture is pending. The most appropriate initial treatment is:

A 78-year-old woman has a history of hypertension on amlodipine, and has been found to have a persistently elevated platelet count for several months. She presents to the emergency department with abdominal pain. Her full blood examination and serum biochemistry are as follows: haemoglobin 104 g/L [128-175] white blood cell 70.40 x 109/L [3.90-12.70] neutrophils 62.80 x 109/L [1.90-8.00] lymphocytes 2.46 x 109/L [0.90-3.30] monocytes 0.67 x 109/L [0.30-1.10] eosinophils 4.43 x 109/L [0.00-0.50] basophils 0.05 x 109/L [0.00-0.20] platelets 3524 x 109/L [150-396] mean corpuscular volume 74 fL [80-97] sodium 142 mmol/L [136-145] potassium 7.2 mmol/L [3.5-5.1] bicarbonate 16 mmol/L [21-32] chloride 112 mmol/L [98-107] urea 13.2 mmol/L [2.0-8.5] creatinine 0.13 mmol/L [0.04-0.08] Which of the following is the most likely cause of her elevated serum potassium?

A 50-year-old male has chronic liver disease secondary to Hepatitis B infection. Previous endoscopy has revealed large oesophageal varices. Blood results are: Albumin 32 g/L [38-55] Prothrombin Time 14 seconds [8-12] Platelet count 70 x 109/L [150-450] On routine review, his alpha fetoprotein is 300 ng/mL [0-15]. His abdominal computed tomography (CT) scan is shown below. The optimal treatment for this condition is:

A 25-year-old person has the karyotype shown below. What is the most likely phenotype of the external genitalia at this age?

A 49-year-old female presents with a five week history of symmetrical polyarthralgia. The following laboratory results are obtained: Antinuclear antibody (ANA) positive, titre: 1/80, pattern: speckled Antibodies to extractable nuclear antigens (ENAs) negative Anti-double stranded DNA antibody (anti-dsDNA) 7 IU/mL [0-5] Anti-cyclic citrullinated peptide (anti-CCP) positive Anti-filaggrin antibody positive Rheumatoid factor (RF) < 20 [0-20] Which of the following is the most likely diagnosis?

A 66-year-old alcoholic man collapses and is brought to the Emergency Department. He is found to have fixed dilated pupils, and is somnolent with no upgaze. Reflexes are brisk with bilaterally upgoing plantar responses. A cranial computed tomography (CT) scan performed after one hour is normal. An electroencephalography (EEG) reveals intermittent generalised anterior predominant slowing, with frontal intermittent rhythic delta activity (FIRDA) without focal of epileptiform features. Neurological findings remain unchanged over a period of 24 hours. The most likely diagnosis is:

A 65-year-old man with a past history of diverticular disease presents with one week of fever and right upper quadrant pain. He has never travelled overseas. His CT scan reveals a large fluid-filled lesion as shown above. In addition to drainage of the abscess, what is the most appropriate initial empiric antibiotic treatment?

A patient with lung cancer receives chemotherapy with carboplatin and etoposide. He is given ondansetron and dexamethasone pre-chemotherapy and dexamethasone and metoclopramide postchemotherapy. On day two post-chemotherapy he complains of stiffness around his shoulders and feeling jittery and irritable. The drug most likely to be responsible for these symptoms is:

A 40-year-old human immunodeficiency virus type 1 (HIV-1) -infected patient receiving highly active anti-retroviral therapy (HAART) smokes 25 cigarettes a day and has a serum cholesterol level of 6.0 mmol/L [2.5 – 5.2] and mild to moderate hypertension. Which of the following interventions is most likely to reduce his cardiovascular risk?

An 87-year-old man is admitted to hospital with a dense left hemiplegia and is totally bedbound and immobile. Which of the following strategies is the most effective for reducing the risk of developing a pressure ulcer in this patient?

A 55-year-old male smoker is referred to outpatients complaining of breathlessness. Which of the following is the most effective intervention for him to achieve smoking abstinence?

A 70-year-old woman has been on haemodialysis for 11 years. She complains of painful shoulders and knees and wrists and cannot raise her arms beyond 90°. She has noted a gradual deterioration in her arthralgias over a period of 12 months. A radiograph of her wrist is shown below. Which of the following is most likely to explain her symptoms?

A 52-year-old female is sent home ten days after a left hemicolectomy. Her husband brings her back to hospital 48 hours later with jaundice and confusion. She is anuric. She has ingested 14 grams of paracetamol since discharge from hospital. Which of the following findings indicates the worst prognosis without transplantation?

A 26-year-old man presents with a swollen, painful left ankle and right wrist ten days after being treated with doxycycline for chlamydial urethritis. Which of the following is the most appropriate for the initial treatment of his joint symptoms?

In which of the following is radiotherapy least likely to be of clinical benefit to the patient?

A patient is at high risk for repeat radiographic contrast media reactions. Which of the following is least likely to be effective?

A 65-year-old woman presents to the hospital for the first time with vague symptoms of fatigue. The following routine biochemistry is noted: potassium 5.5 mmol/L [3.5-5.5] urea 48 mmol/L [<6.5] creatinine 1010 μmol/L [<120] calcium 2.1 mmol/L [2.1-2.5] phosphate 2.3 mmol/L [0.8-1.4] She is hypertensive with a sitting blood pressure of 165/95 mmHg. There is no clinical oedema. Apart from the fatigue she is asymptomatic, although some scratch marks are noted. She has 8.8cm kidneys bilaterally on ultrasound, without obstruction. She has a past history of cholecystectomy and perforated appendix. What is the most appropriate next step in her management?

In a 50-year-old man undergoing a computed tomography (CT) scan for investigation of abdominal pain, which of the following is the most likely cause of an incidentally discovered 3cm adrenal mass lesion?

Of the following metastatic cancers, the one associated with the highest long term survival after treatment is:

A 65-year-old man collapses during a brisk walk, losing consciousness for 30 seconds. He had no warning symptoms and he recovered rapidly. Six years earlier he suffered an uncomplicated myocardial infarction without further chest pain and is taking aspirin, atenolol and simvastatin. On examination he has an apex rate of 60, and blood pressure 118/84 mmHg. There is an ejection systolic murmur and a left carotid bruit. ECG shows Q waves in the inferior leads with no acute changes. Troponins are normal. Overnight monitoring shows sinus rhythm with ventricular ectopics and runs of up to five beats of non-sustained ventricular tachycardia. Which is the most appropriate investigation for the patient’s syncope?

If the pre-test probability of a condition is known, which of the following is also needed to be able to estimate the post-test probability?

A 62-year-old man with type 2 diabetes and hypertension is on long term aspirin, quinapril, metoprolol and insulin. He presents with two hours of central chest pain. A diagnosis of non-ST elevation myocardial infarction is made. He proceeds to have coronary angiography which demonstrates diffuse three-vessel coronary artery disease. He is discharged home with the introduction of a long acting nitrate to await elective coronary artery surgery. He represents two weeks later with malaise and abdominal pain. His serum creatinine has increased to 0.45mmol/L from a serum creatinine of 0.14mmol/L on his previous admission. Which of the following is the most likely cause of the deterioration in renal function?

A 63-year-old man presents with a six-month history of gradual onset of right hand weakness. On examination there is wasting of the intrinsic muscles of the right hand. Power is normal proximally, with weakness of right finger extensors, right finger abduction and adduction, and right flexor pollicis longus (all Grade 3/5). There is milder weakness of right forearm pronation and right wrist extensors (Grade 4/5). The right triceps and finger jerks are brisk relative to the left sided reflexes. The biceps and brachioradialis reflexes are symmetrical. Sensory examination is normal. A cervical magnetic resonance imaging (MRI) scan is normal. The most likely diagnosis is:

A 25-year-old woman with no significant past medical history presents with weight gain, depression, easy bruising and proximal muscle weakness. On examination she has a plethoric complexion, central obesity with striae and a proximal myopathy. Investigations reveal low plasma concentrations of cortisol and adrenocorticotrophic hormone (ACTH). Which of the following is the most likely diagnosis?

An 82-year-old female has recent onset of high fevers and confusion. Her temperature is 38.2°C and her urine is positive for leukocytes, erythrocytes and nitrites. A diagnosis of delirium secondary to urinary tract infection is made and she is to be treated with a single dose of the aminoglycoside antibiotic, gentamicin. What is the most important factor for calculating this single dose?

Several randomised controlled studies have compared anticoagulation with placebo in patients with non-rheumatic atrial fibrillation. These trials suggest that the annual risk of stroke in untreated patients with atrial fibrillation would be nearest to:

A 27-year-old woman presents with weight loss, tremor, palpitations and pain and tenderness over her thyroid. The following results are obtained: Free T4 75 pmol/L [10-24] Free T3 25 pmol/L [2.5-6.5] thyroid-stimulating hormone (TSH) <0.03 mIU/L [0.4-4.0] erythrocyte sedimentation rate (ESR) 105 mm/hour [<10] A thyroid scintiscan is awaited. In the meantime, in addition to beta blockers, which of the following is the most appropriate first line treatment for her condition?

A “reasonably well” (normal performance status) patient with non-haemorrhagic cerebral metastases from breast carcinoma presents with spontaneous lower limb venous thrombosis and pulmonary embolism. Which of the following is the most appropriate long term management regime?

A 64-year-old woman presents with a seven-day history of left upper quadrant pain. Her past medical history includes type 2 diabetes, hypertension and smoking. The pain is over the left lower costal margin, extending posteriorly. On examination there is a patchy area of sensory change in the left T7/8 dermatome. The most likely diagnosis is:

A 62-year-old man is admitted to hospital with fevers, malaise and myalgias six weeks after a laparoscopic cholecystectomy. On examination he has a temperature of 39°C, splinter haemorrhages and a loud pansystolic murmur. He has a past history of mitral valve prolapse which was diagnosed by echocardiography. Enterococcus faecalis has been identified in three sets of blood cultures. The isolate is highly sensitive to penicillin. He has no known allergies. The most appropriate therapy is:

An 81-year-old man presents to the emergency department after collapsing while running for a bus. He has a history of hypertension treated with felodipine but no other major illnesses. He has noted mild breathlessness on exertion, worsening over the past few years. Examination reveals blood pressure is 125/90 mmHg. He has a soft systolic murmur but no signs of heart failure. His ECG is shown below. Serum creatine kinase (CK) is 205 U/L [<180]. Troponin level is pending. Which one of the following is the most appropriate initial management step?

Which of the following features of cystic fibrosis is most likely to be present in a 20-year-old male patient?

A 50-year-old man with a 60 pack year history of smoking presents with a two-month history of cough and weight loss. His performance status is normal (ECOG (Eastern Cooperative Oncology Group) = 0). Investigations show him to have a T2N1M0 non-small cell carcinoma with a forced expiratory volume in one second (FEV1) 80% predicted. Which of the following will provide the highest survival?

A patient is referred for investigation of diarrhoea and weight loss. The following results are obtained: haemoglobin 100 g/L [130-180] mean corpuscular volume (MCV) 72 fL [82-98] anti-gliadin IgG 43 units [0-25] anti-gliadin IgA 0 units [0-25] IgA-endomysial antibody <5 [<5] Which of the following is the next most appropriate test?

A 32-year-old male develops hemoptysis and fever two days after hospital admission with dyspnea. The computed tomogram chest scans taken on admission, and after development of hemoptysis are shown below. The most likely diagnosis is which of the following?

There is substantial genetically determined variation in the response to warfarin. In which of the following is the most important variation that determines the necessary dose?

A 36-year-old male with a history of recent injecting drug use presents with a week of fevers and sweats and excruciating lower thoracic back pain. Blood cultures grow Staphylococcus aureus. What would be the most useful next investigation to establish a diagnosis?

When considering the long-term outcome of renal transplantation, other than rejection, which of the following has the greatest adverse effect on graft survival?

A 60-year-old asymptomatic man has an ECG taken, as part of an insurance assessment, which shows left bundle branch block. Physical examination is normal. Echocardiogram is normal aside from delayed septal activation. The most appropriate next step is:

A 63-year-old man presents with aching legs, and an uncontrollable feeling that he needs to move his legs when he goes to bed. The most likely diagnosis is:

A number of members of a family are affected with a rare syndrome of external ophthalmoplegia, Parkinsonism, and early menopause. DNA studies identified multiple deletions of various sizes in mitochondrial DNA in the affected people. The pedigree is shown below. What is the most likely mode of inheritance of this syndrome?

A physician becomes ill with nausea and vomiting four hours after attending a pharmaceutical company sponsored dinner. Which of the following is the most likely cause of this?

A 57-year-old man with a long history of poorly controlled hypertension and smoking presents with sudden onset of right-sided weakness. On examination, his speech is slurred but content and comprehension are normal. There is a right facial weakness, with the right side of the soft palate elevating poorly. He has a right hemiparesis, power grade 2-3/5, in a pyramidal distribution with normal sensation to all modalities. Right-sided reflexes are enhanced with an extensor right plantar response. The most likely cause of this stroke syndrome is left:

A 21-year-old female presents with anaphylactic shock. Her blood pressure initially responds to a dose of adrenaline however it falls again 30 minutes later. What would be the most important next intervention?

A 70-year-old female with a history of cognitive impairment has the computed tomography (CT) scan of the brain shown below. This scan is most suggestive of which of the following diagnoses?

A 75-year-old woman is brought to a hospital emergency department by her son with whom she lives. He describes a change in his mother’s mental state over the preceding week. She has been wandering the house at night and has become uncharacteristically suspicious of her daughter-in-law, accusing her of stealing her belongings. She also complained to her son that she had seen thieves in her room at night. She has no prior psychiatric history. The most likely diagnosis is:

A 26-year-old man presents with a six month history of lower back and buttock pain with prolonged stiffness in the morning. Physical examination reveals a Schober test of 4 cm on flexion [>5cm]. Which of the following tests is most likely to support a diagnosis of ankylosing spondylitis?

A 47-year-old woman has coagulation studies performed as part of preoperative assessment prior to elective hysterectomy for menorrhagia. Prothrombin Time-International Normalised Ratio 1.0 [0.9-1.3] Activated Partial Thromboplastin Time (APTT) patient 52.3 s [26-38] Activated Partial Thromboplastin Time (APTT) control 30.0 s [26-38] APTT correction (1:1 mix, Patient: Control) 49.6 s [26-38] Thrombin Clotting Time 20 s [<24] Fibrinogen 2.1 g/L [2.0-4.0] Fibrinogen D-Dimer 0.50 [<0.35] Which of the following is the most likely interpretation of these results?

A 26-year-old man is referred for assessment of proteinuria. He has a six-month history of recurrent episodes of lower extremity petechial rash (shown above), arthralgia, Raynaud’s phenomenon and fever. He has an eight-year history of intravenous drug use. Physical examination reveals erythematous raised papules on both lower extremities and dependent oedema. Investigations reveal: Serum creatinine 110 umol/L [< 120] Albumin 28 gm/L [35-50] C3 1.05 gm/L [0.80-1.50] C4 <0.01 gm/L [0.16 – 0.55] Antinuclear antibody negative Antineutrophil cytoplasmic antibody (ANCA) negative Midstream urine reveals 50 x 106 glomerular red blood cells per litre and proteinuria is quantitated at 5.5 gm/day [< 0.12]. A renal biopsy is performed. What is the most likely histological diagnosis on biopsy?

In a woman with Graves disease, which of the following is associated with an increased relative risk of developing Graves ophthalmopathy?

The ECG shown below is taken from a 25-year-old man after an episode of syncope. His mother died suddenly at age 38; his younger sister has recently survived an out-of-hospital cardiac arrest. The most appropriate management would be:

A 35-year-old man is admitted to hospital with a red and tender left thigh, three days after sustaining a superficial abrasion to the area while surfing. He gives a history of fevers and chills and says that the pain in the leg is now increasing. On examination he appears unwell, is hypotensive, tachycardic and febrile to 40°C. The left thigh is erythematous, te nder to deep palpation with a 'boggy' feel over the muscles. He is observed in the emergency department and the redness over the thigh progresses 2 cm in a two hour period. A computed tomography (CT) scan of the area shows inflammation of the muscles and loss of fascial planes, but no abscess formation. Intravenous penicillin and clindamycin are started. Which of the following additional interventions is most likely to result in survival and limb preservation?

Different mutations in the DMD (Duchenne muscular dystrophy) gene cause three clinically distinct syndromes in males. The table below lists the three conditions, the degree of skeletal muscle weakness, and a number of different abnormal genotypes involving the DMD gene. Which of the following represents the most likely relationship between the genotypes and phenotypes? Option Duchenne muscular dystrophy Becker muscular dystrophy X-linked cardiomyopathy Skeletal muscle weakness Severe Moderate-mild Mild-nil A in-frame deletion promoter deletion frameshift deletion B frameshift deletion in-frame deletion promoter deletion C frameshift deletion promoter deletion in-frame deletion D promoter deletion frameshift deletion in-frame deletion E promoter deletion in-frame deletion frameshift deletion

The most appropriate clinical scenario for the use of non-steroidal anti-inflammatory agents for management of cancer pain is which of the following?

Which of the following is the most appropriate indication for treatment with ursodeoxycholic acid?

Which of the following clinical situations is the strongest contraindication to therapeutic anticoagulant therapy?

Noninvasive positive pressure ventilation would be most appropriate for which of the following patients?

A 64-year-old builder is referred for assessment of a chronic cough. There is no personal or family history of asthma. He has smoked 20 cigarettes per day since the age of 18 years. There are no symptoms to suggest gastro-oesophageal reflux or post-nasal drip. His practitioner had performed a chest X-ray and thoracic computed tomography (CT) scan (shown above). The appearances of the CT scan are most consistent with:

In a randomised trial 39,876 women aged over 45 years were assigned either aspirin 100mg on alternate days or placebo, and were followed for 10 years for a first major cardiovascular event. The results are shown in the figure below. Which statement best summarises the study results?

A previously well 25-year-old man is admitted unconscious following a suspected overdose. He withdraws to pain and has dilated pupils that react sluggishly. His heart rate is 120/minute and he has decreased bowel sounds. His ECG is shown above. The presentation is most consistent with overdose of which of the following drugs?

A previously well 64-year-old man presents with symptoms of gastro-oesophageal reflux disease. He is on no current medications. Gastroscopy demonstrates Barrett’s oesophagus with erosive oesophagitis above the squamocolumnar junction. Random biopsies are reported as demonstrating dysplastic epithelium with features of active inflammation. The most appropriate next step in management is:

Presymptomatic genetic testing ("predictive genetic testing") may be justifiable on various medical, psychological, or economic grounds. Which one of the following disorders provides the best justification for presymptomatic genetic testing on medical grounds?

Which of the following features in a patient with colon cancer is most suggestive of hereditary nonpolyposis colon cancer (HNPCC)?

An 18-year-old woman presents with hirsutism. The following results are obtained: Testosterone 4.5 nmol/L [<2.5] Luteinising hormone (LH) 9 IU/L [2-15] Follicle stimulating hormone (FSH) 4 IU/L [2-15] Oestradiol 500 pmol/L [130-1500] Dehydroepiandrosterone (DHEA) 10 umol/L [0.5-12] 17OH Progesterone 62 pmol/L [<6] 24 hour urinary free cortisol 280 nmol/24hours [100-300] Adrenocorticotrophic hormone (ACTH) 3 pmol/L [1-5] Which of the following is the most likely explanation for her hirsutism?

An 82-year-old man presents with difficulty walking due to osteoarthritis in his right hip. When prescribing a cane as a walking aide for him, the most appropriate instruction regarding use of the cane is: Hold the cane:

A 65-year-old man with one hour of central chest pain returns to the same hospital where he had percutaneous coronary intervention performed four weeks ago. He had stopped clopidogrel one week earlier. He is hypotensive with 3mm ST elevation in antero-septal leads. Which of the following is the most appropriate management?

An 81-year-old male has moderate dementia with mild behavioural disturbances, hypertension and osteoporosis. He is living in a nursing home. His current medications are donepezil, olanzapine, enalapril, vitamin D and calcium. A random fasting blood glucose is 11.5 mmol/L [<6 mmol/L]. The next step in the management of this elevated blood glucose level should be:

Which of the following is the most appropriate standard with respect to informed consent?

A 23-year-old male has had his third episode of passing a renal calculus. Each episode has been preceded by renal colic, twice on the left and once on the right. A calculus has been analysed in the biochemistry laboratory and found to contain predominantly calcium oxalate. Typical calculi are shown in the image below. Which of the following is most likely to reduce his chance of further stones?

Which of the following is the strongest indication for thrombolysis in a patient with pulmonary embolism?

An otherwise well 55-year-old female undergoes upper endoscopy for investigation of mild reflux symptoms. An endoscopic image of the lower oesophagus is shown above. Biopsies demonstrate intestinal metaplasia with high grade dysplasia and no inflammation. The most appropriate management is:

Skin prick testing for specific IgE (immunoglobulin E) is most appropriate for investigation of which of the following conditions?

A 76-year-old woman presents with a swollen, painful left knee. The knee has become increasingly painful over two weeks and she is now unable to walk on it. She does not remember injuring the knee and is otherwise well. On examination she is afebrile and has a large left knee effusion with reduced range of movement. An X-ray of the knee is shown above. What is the most likely diagnosis?

Which one of the following conditions is most likely to develop in a patient with panic disorder?