2008B_Paper 2 - Clinical Applications Adult Medicine

A 19-year-old female presents with short stature, neck webbing, wide spaced nipples and primary
amenorrhea. Which of the following is her most likely karyotype result?

A 31-year-old woman presents with an absence of menstrual periods since stopping the oral
contraceptive pill five months ago. She has the following investigations:
Weight 80.4 kg
Height 1.70 m
Body Mass Index 27.8 kg/m2
Prolactin 2566 mIU/L [60 – 550 mIU/L]
Luteinising hormone (LH) <1.0 IU/L [3.0 – 12.0 IU/L]
Follicle-stimulating hormone (FSH) <1.0 IU/L [2.0 – 10.0 IU/L]
Oestrogen 35 821 pmol/L [100 – 2400 pmol/L]
Testosterone 3.1 nmol/L [0.5 – 2.5 nmol/L]
Which of the following is the most likely explanation?

A 45-year-old male receives a kidney transplant from his brother. Ten days after the operation, the
transplant function appears to worsen, with serum creatinine rising from 140 μmol/L to 190 μmol/L
[60 - 120 μmol/L].
What is the most likely cause of the rise in creatinine?

An 82-year-old female complains of a decline in short-term memory, specifically difficulty remembering
some names and telephone numbers. She lives alone in her own home and has been independent in
all activities of daily living and instrumental activities of daily living, since the death of her husband
one year previously. Her mini-mental state examination (MMSE) score is 27 out of 30, with short-term
recall of only one out of three items.
The most likely diagnosis is:

A 65-year-old male has chest pain when he walks up hills. His pattern of angina has been unchanged
over the last five years. He is taking optimal medical therapy and follows a healthy lifestyle. He asks
about his prognosis with angioplasty and stenting.
Compared with optimal medical therapy, stenting would be most likely to reduce:

A woman with metastatic breast cancer and painful bone secondaries develops nausea and vomiting.
She is found to have a bowel obstruction and is admitted and made nil orally. She usually takes
MS Contin 70 mg bd, and 2 mls of morphine mixture 10 mg/ml for breakthrough pain, usually twice
each day. The bowel obstruction has not exacerbated her pain.
The best estimate of the equivalent parenteral four hourly dose of morphine is:

The renal clearance of drugs that are weak acids and weak bases is affected by changes in the
urine pH. The most accurate representation of how the pH changes renal clearance is:

A 25-year-old female with a history of allergic rhinitis and mild atopic dermatitis is currently pregnant
with her second child. Her two-year-old son has infantile eczema and peanut allergy confirmed on
skin prick testing. The patient requests advice about dietary interventions during this pregnancy to
reduce the risk of the second child developing peanut sensitisation.
Which of the following is the most appropriate advice?

Cardiovascular disease is the major cause of death in dialysis patients. Elevation of which of the
following clinical parameters carries the highest mortality risk?

A patient in the coronary care unit suffers a cardiac arrest due to ventricular fibrillation. The initial two
direct current (DC) shocks are unsuccessful. Cardiopulmonary resuscitation (CPR) is initiated. The
Advanced Cardiac Life Support Guidelines now recommend what rate of chest compressions, over
what period of time after the second defibrillation before re-examining cardiac rhythm?

In preventing the recurrence of rheumatic fever in young patients with rheumatic heart disease, which
is the most effective strategy?

Which one of the following most frequently causes hypoglycaemia in patients with diabetes?

A 65-year-old male is reviewed following surgical resection of non-small cell lung cancer. Pathology
reveals involvement of local hilar lymph nodes, in addition to the primary lung cancer. What is the
most appropriate further management?

A 50-year-old male has a two month history of frequent, small volume stools associated with cramps
and flatulence. This has occurred since returning from a holiday in South East Asia. The empiric
treatment most likely to be successful is:

A 52-year-old man with type 2 diabetes has been non-specifically unwell for a week. He underwent
resection of a craniopharyngioma nine months ago. He is maintained on replacement therapy with
desmopressin nasal spray, testosterone decanoate injections, oral hydrocortisone and thyroxine. He
presents to hospital with a reduced level of consciousness. Systolic blood pressure is 70 mmHg and
axillary temperature is 35oC. Investigations reveal the following results:
Serum sodium 136 mmol/L [136 – 148 mmol/L]
Serum potassium 5.2 mmol/L [3.6 - 5.5 mmol/L]
Serum bicarbonate 30 mmol/L [22 – 32 mmol/L]
Serum urea 8 mmol/L [3 - 8 mmol/L]
Serum creatinine 120 μmol/L [30 – 120 μmol/L]
Random glucose 18 mmol/L [3.5 - 7.8 mmol/L]
Free L-thyroxine 9.8 pmol/L [10.0 – 26.0 pmol/L]
What is the most likely cause of his acute presentation?

A 69-year-old lady presents with chest pain following a motor vehicle accident and is found on thoracic
computed tomography (CT) scan to have multiple sclerotic lesions involving ribs and thoracic
vertebrae. A technetium-99m-methylene diphosphonate (MDP) bone scan reveals multiple areas of
radiotracer uptake throughout the skeleton. Physical examination and mammography are normal.
Which of the following is most likely to give a diagnosis?

A 55-year-old woman with a history of bipolar disorder has been psychiatrically well for many years
and adherent to a prescribed dose of lithium 500 mg twice daily. She has normal renal function. She
presents to hospital at 10 a.m. with an exacerbation of her chronic obstructive pulmonary
disease (COPD). Her lithium level as measured in the Emergency Department is 1.4 mmol/L
[0.5 - 1.0 mmol/L].
The most appropriate initial action to take is to:

A 32-year-old man presents with a four day history of lower back pain and a two day history of
difficulty rising from a chair. These symptoms were preceded by a diarrhoeal illness which has now
resolved. On examination there is weakness of hip flexors bilaterally and he has trouble arising from a
squat. He has normal upper limb reflexes and absent lower limb reflexes. Bladder and bowel function
are normal.
The most appropriate next test in establishing a diagnosis would be:

A 70-year-old male presents with an irregular heart beat and the ECG confirms atrial fibrillation.
In terms of stroke prevention, which of the following is the strongest indication for recommending long
term oral anticoagulation in this patient?

A 68-year-old female presents with headache, nausea and vomiting. She is noted to have retinal
haemorrhages and papilloedema. Her blood pressure is 250/150 mmHg, creatinine 200 μmol/L
[50 - 120 μmol/L] and urea 28 mmol/L [<8.0 mmol/L]. The computed tomography (CT) scan of her
brain shows abnormalities in the parieto-occipital regions.
Which is the most appropriate initial treatment?

A 62-year-old non-smoking woman is admitted with a 24-hour history of fever, rigors, cough and
breathlessness. A left lower lobe pneumonia is diagnosed on chest X-ray and she is commenced on
intravenous ampicillin and oral clarithromycin. The next day she has improved clinically and
Streptococcus pneumoniae is isolated from blood cultures taken on admission. The isolate is found to
have a minimal inhibitory concentration (MIC) for penicillin of 0.125 mg/L (intermediate resistance).
Which of the following is the most appropriate antibiotic for ongoing management?

In a 70-year-old male with chronic obstructive pulmonary disease (COPD) which of the following
carries the greatest risk of death over the next 12 months?

A 24-year-old man is admitted to intensive care after being knocked off his bicycle by a car. He is
intubated and sedated. His family tell you he has had epilepsy with generalised seizures since
age 14. His only regular medication is phenytoin 300 mg daily and his last seizure was one year
previously. After resuscitation the results of his blood tests include the following:
Sodium (Na) 132 mmol/L [136 - 145 mmol/L]
Potassium (K) 4.6 mmol/L [3.5 - 5.0 mmol/L]
Creatinine 70 μmol/L [<110 μmol/L]
Albumin 24 g/L [36-45 g/L]
Haemoglobin (Hb) 96 g/L [130 - 175 g/L]
Total Phenytoin 6 mg/L [10 – 20 mg/L]
Free Phenytoin 1.5 mg/L [1 – 2 mg/L]
To treat his epilepsy, the best approach is to:

For which of the following presentations of inflammatory bowel disease is infliximab of most benefit?

A 72-year-old woman with type 2 diabetes presents with a chronic ulcer on the dorsum of her left foot.
She has not been hospitalised in the past two years. The ulcer has been present for six months and
has been treated with daily dressings. In the last 48 hours the surrounding skin has become inflamed,
she has developed general malaise and her glycaemic control has worsened. Bone is visible at the
base of the ulcer. There is no history of antibiotic allergy. What is the most appropriate empiric
treatment pending the result of a swab?

You are caring for a 55-year-old man on haemodialysis. He is on the transplant waiting list and asks
about his risk of developing cancer if he has a transplant. You note he is of Anglo-Saxon descent.
Which of the following cancers is he most likely to develop over the ensuing ten years
post-transplantation?

A 65-year-old Vietnam war veteran is described as having post-traumatic stress disorder (PTSD).
What is the most likely co-morbid psychiatric disorder?

An 81-year-old female has atrial fibrillation and osteoarthritis, treated with warfarin, digoxin and
paracetamol. She recently complained of depressive symptoms and was commenced on the selective
serotonin reuptake inhibitor, fluoxetine. Two weeks later she is brought to casualty with an extradural
haematoma and her international normalised ratio (INR) is 6.9.
The most likely mechanism by which fluoxetine contributed to the haemorrhage is by its effect on:

A sales representative brings you the following abstract in an advertising pamphlet:
‘Fifty consecutive patients with dilated cardiomyopathy in NYHA class II-IV with a left
ventricular ejection fraction (LVEF) of 35% or below were studied with full polysomnography
over one night. The mean Apnoea-Hypopnoea Index of beta-blocker free patients was 19.8+/-
14.2 versus 7.4+/-8.5 (p<0.05) and 8.7+/-8.1 (p<0.05) in patients treated with metoprolol or
carvedilol, respectively.’
The sales representative suggests that beta blockers should be used in heart failure patients with
sleep-disordered breathing, and that metoprolol is better than carvedilol in this situation.
Which is the strongest reason to disregard this advice?

The clinical presentation of motor neurone disease that is most likely to be associated with an
aggressive course and a short life expectancy is:

A 67-year-old man with longstanding rheumatoid arthritis treated with methotrexate, prednisolone and
celecoxib presents unwell with fatigue and anorexia. On examination his arthritis is quiescent but he
has two mouth ulcers. His full blood examination is shown below.
Haemoglobin (Hb) 102 g/L [115 – 150 g/L]
Mean corpuscular volume (MCV) 101.2 fL [80.0 – 96.0 fL]
Mean corpuscular haemoglobin (MCH) 29.1 pg [27.0 – 33.0 pg]
Mean corpuscular haemoglobin concentration (MCHC) 350 g/L [320 – 360 g/L]
White cell count (WCC) 1.4 x 109/L [4 – 11 x 109/L]
Neutrophils 0.5 x 109/L [2 – 5 x 109/L]
Platelets 90 x 109/L [150 – 400 x 109/L]
Erythrocyte sedimentation rate (ESR) 67 mm/hour [<22 mm/hour]
The most appropriate drug to administer is:

The concept that genetic counselling should be nondirective arises mostly from respect for which of
the following principles of medical ethics?

Which of the following factors is the strongest contraindication to the use of interferon in the treatment
of viral hepatitis?

Which of the following drugs is least likely to exacerbate urinary retention in an elderly man with
benign prostate hypertrophy?

A 60-year-old male presents with central weight gain, hypertension, and diabetes. He has a history of
asthma treated with inhaled corticosteroids. He drinks two standard drinks of alcohol/day. On
examination he has central obesity, thin skin, and proximal muscle weakness.
The following test results are obtained:
24 hour urinary free cortisol 1400 nmol/day [<400 nmol/day]
0900 plasma adrenocorticotrophic hormone (ACTH) 15 pmol/L [3 – 20 pmol/L]
Magnetic resonance imaging (MRI) pituitary normal
Which of the following is the most likely cause of this man’s presentation?

A 78-year-old male is admitted to hospital with a hemiplegic stroke. He is unable to mobilize or sit out
of bed. He is incontinent. He can swallow thickened fluids. The most effective method to reduce his
risk of pressure ulcers is:

A 48-year-old female presents to an Emergency Department complaining of acute breathlessness
following a four-hour car journey. Her breathlessness resolves in the Emergency Department.
Physical examination is normal, the SaO2 is 95% breathing room air and a chest X-ray and ECG are
normal. A sensitive d-dimer is negative.
What is the most appropriate management approach?

A previously healthy 67-year-old man presents with spontaneous muscle bleeds. Coagulation tests
reveal the following:
Activated partial thromboplastin time (APTT) 81 sec [26 - 38 sec]
APTT correction (immediate mix) 37 sec [26 - 38 sec]
APTT correction (2 hour incubation) 76 sec [26 - 38 sec]
Thrombin Clotting Time 12 sec [10 - 12 sec]
Fibrinogen 3.2 g/L [2.0 - 4.0 g/L]
Which of the following best accounts for the coagulation test results?

An observational study of over 70,000 patients examined gender differences in in-hospital mortality
after acute myocardial infarction. The crude hospital mortality rate was 14.8% for women and 6.1% for
men (odds ratio 2.65; 95% CI, 2.52 to 2.79). Most of this difference was due to imbalance in age; after
adjustment, the absolute difference in hospital mortality was only 1.95%. Further adjustment for
differences in comorbidity, body size and the use of percutaneous intervention left three-quarters of
the mortality difference ‘unexplained’.
What is the most likely reason for these findings?

The presence of which of the following is the best reason not to commence alendronate for a woman
with postmenopausal osteoporosis?

A 30-year-old female presents with a painful swollen left calf. Duplex study demonstrates a proximal
deep vein thrombus extending into the ileofemoral venous system. The following laboratory results
are obtained:
Prothrombin time (PT) 16 sec [11 – 18 sec]
Activated partial thromboplastin time (APTT) 43 sec [25 – 36 sec]
Dilute Russell Viper venom test Lupus anticoagulant detected
Anticardiolipin IgG negative
Anticardiolipin IgM negative
Anti-beta 2 glycoprotein 1 moderate positive
Treatment with anticoagulation with heparin followed by warfarin therapy is commenced. Repeat
testing at 12-weeks confirms a positive anti-beta 2 glycoprotein 1. What is the most appropriate
duration of anticoagulation?

A 35-year-old woman with type 1 diabetes since age 14 years is reviewed. She reports three
episodes of hypoglycaemia with levels <3.0 mmol/L during the night in the last month. There have
also been a number of hypoglycaemic episodes in the late morning. Recent results show:
Weight 55 kg
Fasting plasma glucose 12.3 mmol/L [4.0 – 6.0 mmol/L]
Hb A1c 6.9% [<6%]
Urine microalbumin:creatinine ratio 0.1 [<3.5]
Current insulin regimen:
Neutral Protamine Hagedorn (NPH) insulin 14 units before breakfast and 12 units before bed
Insulin aspart 4 - 6 units before breakfast and lunch and 8 - 10 units
before dinner
Which one of the following modifications to her insulin regimen would be most effective in optimising
her glycaemic control?

A 56-year-old man with a past history of bicuspid aortic valve develops bacteraemia with
Staphylococcus aureus and echocardiography shows a 1.0 cm vegetation on the aortic valve. He has
a known history of penicillin hypersensitivity – he reports a sudden onset of tongue and throat swelling
after receiving the drug when he was 20 years old.
What is the most appropriate intravenous antibiotic?

Compared with tamoxifen, aromatase inhibitors are more likely to be associated with an increased risk
of which of the following?

A 67-year-old diabetic female is referred for the first time. She has significant renal impairment with
the following results:
Serum creatinine 180 μmol/L [<110 μmol/L]
Estimated glomerular filtration rate (eGFR) 34 ml/min [90 – 150 ml/min].
Haemoglobin (Hb) 105 gm/L [115 - 135 gm/L]
Proteinuria 0.38 gm/day [<0.12 gm/day]
Blood pressure 150/90 mmHg
HbA1c 7.5%
Which of the following interventions is likely to have the greatest impact on slowing the progression of
her renal impairment?

In a 75-year-old woman presenting with a unilateral temporal headache, which of the following clinical
features is most specific for a diagnosis of temporal arteritis?

A previously well 30-year-old woman presents 24 hours after ingestion of around 50 tablets which
have not been identified. She initially had minimal symptoms for a few hours and then developed
severe vomiting and bloody diarrhoea. This has now settled but she is now hypotensive, tachycardic,
tachypnoeic, has a metabolic acidosis, poor urine output and raised liver transaminases (alanine
transaminase (ALT) 350 U/L [<35 U/L]).
The poisoning most consistent with this presentation is:

A 52-year-old man with no personal or family history of colon cancer, colonic polyps, or inflammatory
bowel disease underwent a colonoscopy for rectal bleeding that showed haemorrhoids and a 1.5 cm
pedunculated polyp at the hepatic flexure that was removed by means of a snare with cautery. The
polyp was a tubulovillous adenoma without high-grade dysplasia. What advice should be conveyed
about risks to close relatives?

A 25-year-old presents with acute pancreatitis. There is no significant past medical history
and minimal alcohol intake. Ultrasound demonstrates stones in the gall bladder. Which of the
following most strongly indicates the need for urgent endoscopic retrograde
cholangiopancreatography (ERCP)?

A patient with slowly advancing renal failure attends for a routine clinic visit. Laboratory results reveal
a serum creatinine of 650 μmol/L [<110 μmol/L] and an estimated glomerular filtration rate (eGFR)
of 11 ml/minute [90 – 150 ml/minute]. Despite this, the patient is working full time.
Which of the following is the strongest indicator of the need to commence dialysis in this patient?

A 60-year-old female with hypertension and epilepsy is referred to outpatients for management. She
smokes 20 cigarettes/day. What is the most appropriate intervention to achieve abstinence from
tobacco smoking?

A 59-year-old woman with chronic liver failure on the basis of longstanding alcohol abuse is admitted
with haematemesis. Her bleeding ceases spontaneously, her liver failure is stabilized with lactulose
and she is successfully withdrawn from alcohol with a tapering regime of benzodiazepines and
thiamine. She has a mild short term memory impairment which her family say is chronic. She
intermittently refuses lactulose, describing diarrhoea. Towards the end of her second week in hospital
she abruptly becomes abusive of staff, accusing all of neglecting her care, refuses a previously agreed
rehabilitation placement describing the rehabilitation facility as dangerous, refuses all her medications
describing them as “poison” and refuses venesection or other investigation.
The most likely psychiatric explanation for her new behaviour is:

The predominant cause of stroke after cardiac surgery is:

A 21-year-old male is referred for management of severe rhinosinusitis. He describes symptoms of
chronic nasal congestion, post-nasal drip and headache. Symptoms are acutely worse after aspirin
ingestion which also results in development of dyspnoea and wheeze. Examination reveals bilateral
nasal polyposis with nasal airway obstruction. Skin prick testing for common aeroallergens is
negative.
In addition to advising avoidance of aspirin and non-steroidal anti-inflammatory agents, which of the
following is the most appropriate first line of therapy for management of rhinosinusitis in this patient?

A 37-year-old male is found to have some persistently enlarged lymph nodes (<2 cm diameter) in the
left posterior triangle. A biopsy reveals follicular, Grade 1, B-cell non-Hodgkin lymphoma. Staging
procedures including computed tomography (CT) scan, positron emission tomography (PET) scan and
bone marrow biopsy confirm the disease is confined to a single lymph node region in the neck.
Which of the following management strategies is most appropriate?

A 27-year-old man presents with an 18 month history of low back pain and stiffness, a swollen left
knee and heel pain. Examination demonstrates reduced lumbar flexion and chest expansion. He is
HLA-B27 positive and has a C-reactive protein (CRP) of 25 mg/L [<8 mg/L].
In addition to physiotherapy what is the most appropriate initial pharmacological therapy?

Many medical journals require pre-registration of drug trials as a pre-requisite to considering
publication of trial results. Which is the most important reason for adopting this policy?

A 68-year-old man was admitted five days earlier for treatment of pneumonia. He has recovered
enough to contemplate discharge but over the course of the day he is noted to be newly disorientated,
is wandering and demanding to go home. Physical examination does not reveal any new signs. His
elderly wife visits in the afternoon and manages to settle him.
What is now the most appropriate course of action?

A 29-year-old woman is referred for evaluation after she was found to be heterozygous for
factor V Leiden mutation on screening. This screening was initiated when her great aunt sustained a
calf vein thrombosis following hip arthroplasty. She is currently 16-weeks pregnant and has no
personal history of venous thromboembolic disease.
Which of the following should be recommended for the remainder of her pregnancy?

An 81-year-old female has had surgery for early stage breast cancer (node negative) and the tumour
is ER+ (oestrogen receptor positive) and HER+ (herceptin receptor positive). She also has congestive
cardiac failure for which she takes frusemide and candesartan. Which of the following treatment
approaches would most improve her life expectancy?

A 35-year-old man with a longstanding history of attacks of acute gout is reviewed three months after
commencing allopurinol 100 mg daily. Which factor is most relevant in determining whether the dose
of the allopurinol should be increased on this visit?

A 57-year-old woman who had been previously well, presented with altered bowel habit and was
found to have a descending colon carcinoma. She subsequently had a left hemicolectomy.
Pathologically, there was no evidence of perforation, the adenocarcinoma was confined to the bowel
wall, but one of five nodes contained tumour.
What is the optimal treatment for her once she recovers from her surgery?

A 65-year-old man presents with a two week history of fever and arthralgia and is found to have a
serum creatinine of 750 μmol/L [<110 μmol/L]. Which of the following best supports a diagnosis of
crescentic glomerulonephritis?

A 67-year-old diabetic man with atrial fibrillation is taking warfarin for primary prophylaxis and is
scheduled for inguinal hernia repair. His echocardiogram shows no structural abnormality. His
international normalised ratio (INR) is 2.9. Which of the following preoperative anticoagulant
management strategies is most appropriate?

Which of the following agents is most likely to induce weight loss when used to treat type 2 diabetes
mellitus?

A 34-week pregnant patient presents to emergency with epigastric and right upper quadrant pain and
nausea. Blood pressure is 140/85 mmHg. Relevant blood work shows:
Aspartate transaminase (AST) 150 IU/L [15 – 45 IU/L]
Prothrombin Time 14 secs [11 – 15 secs]
Bilirubin 25 μmol/L [14 – 22 μmol/L]
Platelets 75 x 109/L [150 – 400 x 109/L]
Haemoglobin (Hb) 90 g/L [110 – 130 g/L]
Transabdominal ultrasound reveals sludge in the gall bladder.
The most appropriate management is:

A 46-year-old man with hypertension and previous end stage renal failure due to glomerulonephritis,
received a kidney transplant 15 years ago. His creatinine has been stable at 110-130 μmol/L
[60 - 120 μmol/L] for the last five years. During this time his immunosuppression has been unchanged
and consists of azathioprine 100 mg daily and prednisolone 5 mg daily.
His general practitioner is concerned about his reported mean corpuscular volume (MCV) of 106 fL
[80 – 96 fL]. Which of the following is the most likely cause?

Use of which of the following drug classes is most likely to lead to the onset of type 2 diabetes?

A 20-year-old female presents 48 hours after ingesting 16g of paracetamol. There are no signs of
hepatic encephalopathy. Blood tests on admission include alanine transaminase (ALT) of 8000 IU/L
[15 – 45 IU/L]. Treatment with N-acetyl cysteine is commenced. After 16 hours she has developed
mild abdominal tenderness and her international normalised ratio (INR) is 2.5.
In addition to liaising with a liver transplant unit, the most appropriate management is:

The most common reason for reduced oral intake in people with endstage dementia is:

Which of the following secondary causes of hyperlipidaemia is most likely to cause a predominant
increase in LDL-cholesterol?

A 27-year-old medical student presents with three episodes of fevers, headache, chills and rigors and
loose stools over the past week. She returned from an elective placement in Papua New Guinea
six weeks previously. She took doxycycline for malaria prophylaxis. Examination reveals a
fever of 40oC, but no other abnormal findings. Her chest X-ray is clear. The following test results
were obtained:
Haemoglobin (Hb) 115 g/L [115 – 135 g/L]
White cell count (WCC) within normal limits
Platelet count 120 x 109/L [150 – 400 x 109/L]
Thick and thin blood films no parasites detected
Liver function tests within normal limits
In addition to blood cultures, what is the most appropriate next step?

A 15-year-old male presents with acute onset of symptoms of upper airway obstruction. He has a
history of hereditary angioneurotic oedema. Which of the following is the most effective therapy?

A 54-year-old woman is receiving chemotherapy with oxaliplatin, 5 fluorouracil (5FU) and folinic acid
as adjuvant therapy for newly diagnosed node positive colon cancer. During the continuous infusion
of 5FU, she experiences retrosternal chest pain. She is not known to have a history of coronary artery
disease, and has not had chest pain previously. What is the most likely cause of her chest pain?

In the long-term management of asthma, which of the following is most effective in improving disease
outcomes?

A 70-year-old female has severe community acquired pneumonia. She has been oliguric over the
past three hours. She has the following hemodynamic parameters;
Heart rate 110/min [70 – 100/min]
Mean arterial pressure (MAP) 55 mmHg [70 – 100 mmHg]
Central venous pressure (CVP) 10 mmHg [4 – 10 mmHg]
Pulmonary artery occlusion pressure (PAOP) 14 mmHg [4 – 10 mmHg]
Cardiac output (CO) 5 L/min [4 – 7 L/min]
Cardiac index(CI) 2.7 L/min/m2 [2.5 – 4.2 L/min/m2]
In addition to fluid therapy, which of the following interventions is most likely to prevent her developing
acute renal failure?

A 58-year-old male presented with an acute inferior ST elevation myocardial infarction to a rural centre
and received thrombolysis. There was no resolution of ST elevation but he became pain free after
18 hours of chest pain. The patient had no further chest pain. A week later coronary angiography
was performed. This showed a proximal occlusion of the right coronary artery with no significant
disease elsewhere. Cardiac systolic function was only mildly impaired.
In addition to optimal medical therapy and risk factor modification, which of the following is the most
appropriate next step?

A 65-year-old man with a history of paroxysmal atrial tachycardia who has been treated with
amiodarone for five years presents with worsening palpitations. Thyroid function tests show the
following results:
FT4 45 pmol/L [10 – 24 pmol/L]
FT3 10.0 pmol/L [2.5 – 6.0 pmol/L]
Thyroid-stimulating hormone (TSH) <0.03 mIU/L [0.4 – 4.0 mIU/L]
He is commenced on carbimazole 10 mg tds but fails to improve and three weeks later his thyroid
function tests are as follows:
FT4 100 pmol/L
FT3 14 pmol/L
TSH <0.03 mIU/L
Which of the following is the most likely cause of this patient’s thyrotoxicosis?

A 43-year-old woman presents with a six month history of hypertension which has been difficult to
control. She is now taking three agents for her blood pressure control. She has a serum potassium
of 2.7 mmol/L [3.6 - 5.2 mmol/L] and you are concerned about primary hyperaldosteronism
(Conn’s syndrome).
Which of the following medications is most likely to interfere with the interpretation of an
aldosterone:renin ratio result?

A 22-year-old woman is brought to the Emergency Department after collapsing. She recalls feeling
“spaced out” and nauseated for 20-30 seconds prior to collapsing. Her friends state that she fell to the
floor and had some brief twitching movements of the face and limbs. She regained consciousness
quickly and was coherent by the time the ambulance arrived. This episode is most likely to be a:

A 20-year-old male with known human immunodeficiency virus (HIV) infection is admitted from the
community with a two day history of cough and sputum production. On examination he has a
temperature of 38oC and his chest X-ray shows patchy opacification of the right middle and lower
lobes.
The most likely organism responsible for his clinical features is:

A 54-year-old man with a previous history of gout presents with an acutely swollen painful left knee for
24 hours. On examination he is febrile (38.2oC) and has a large effusion of the left knee and limited
range of motion due to pain. Aspiration of the joint reveals:
White cell count 50,000 cells/ml
Microscopy No crystals
Gram stain negative
The best initial treatment is:

A 55-year-old male presents for antihypertensive medication. During the interview, you are told that
his 82-year-old father has recently been diagnosed with colon cancer. Which of the following is the
most appropriate colon cancer screening for this patient?

A 30-year-old woman has known Sjogren’s syndrome and a past history of a single renal calculus.
She presents with a metabolic acidosis, with hyperchloraemia. The plasma anion gap is normal.
There is no bicarbonate in the urine and the urine pH is 5.7. What is the most likely cause of her
presentation?

An 80-year-old man had two transient ischaemic attacks 18 months ago. These consisted of right
sided weakness and aphasia lasting 60 minutes with full recovery. A Doppler ultrasound examination
of the carotids reveals 80% stenosis at the bifurcation of the left carotid artery. The main reason not to
advise carotid endartectomy is:

A 42-year-old woman has recently had a mastectomy after being diagnosed with breast carcinoma.
Her paternal grandmother had ovarian carcinoma in her early fifties. She has a 32-year-old well sister.
Apart from advising her on appropriate adjuvant therapy, the next most important issue you should
also discuss with her is: