Presented by: Spot Quiz AKT Applied Knowledge Test Drs Christine Ahern, Peter Silberberg and Rob Trigger North Coast GP Training.

presented by:

Spot Quiz AKTApplied Knowledge Test

Drs Christine Ahern, Peter Silberberg and Rob Trigger

North Coast GP Training

With acknowledgement to

ACRRM, AMC & GP LOGIC

What’s coming up20 questions in 50 minutes

5 EMQs (Extended Matching Questions)

15 SBAs (Single Best Answer: “Multiple Choice”)

Practice exam to follow this afternoon...

EMQ Question 1:For the following patient with electrolyte disturbances, select

the MOST likely diagnosis:

Edith is 59 and has been your patient for some years. She has type II diabetes, hypertension and dyslipidaemia. Her BP, lipids and BSL’s are reasonably controlled on AvaproHct, AvandaMet and Lipitor. She has made some changes to her diet & has started walking regularly but continues to smoke despite your repeated warnings. Her recent bloods also show normal renal function but a sodium of 116. Her other electrolytes are normal but her anion gap is reduced. Looking back you can see that her sodium has been slowly dropping for the past several months. Having recalled her she says she is tired & her ‘usual’ daily cough is worse than previously…

EMQ Question 1 con’t:On physical examination she is not distressed & is afebrile Her BP and pulse are normal. She does not have any swelling but her weight has increased 4kgs compared to your last recording 6 months ago. Her skin turgor is normal as is the remainder of her physical examination. Follow-up investigations are listed below:

Thyroid function – normal; MSU – normal; serum osmolality is low but urine osmolality and sodium are high. CXR shows hyper expansion and a solitary round lesion in the right lung. What is the most likely diagnosis?

Question 1: Possible answersMDMA – induced hyponatremia

Medication effect

Meningitis

Multiple myeloma

Pneumonia

Primary hyperparathyroidism

Pulmonary abscess

Psychogenic polydipsia

Renal disease

Secondary hyperparathyroidism

SIADH

Spurious result

Tuberculosis

Acute or chronic renal insufficiency

Addison’s disease

Adrenal insufficiency

Central pontine myelinolysis

Delay in processing

Difficult collection

Familial hypercalcaemia

Hyperglycaemia

Hypoadrenalism

Hypothyroidism

Hyperglycaemia

Hyperlipidemia

Hyperproteinemia

Question 1: Answer & Discussion SIADH

EMQ Question 2:55 year old Peter Jones presents with the following skin  lesion on his leg. It arose following an insect bite a couple of years ago.

Upon examination the lesion had a firm fibrous consistency. When the skin over the lesion was squeezed a dimple formed, and there was tethering of the skin to the underlying fibrous tissue.

EMQ Question 2:

A. Acral lentiginous melanoma

B. Blue naevus

C. Compound naevus

D. Congenital naevus

E. Dysplastic naevus

F. Dermatofibroma

G. Ephelis

H. Haemangioma

I. Halo naevus

EMQ Question 2: Possible answers

J. Intradermal naevus

K. Junctional naevus

L. Lentigo maligna melanoma

M. Lentigines

N. Nodular melanoma

O. Pigmented BCC

P. Seborrhoeic keratosis

Q. Superficial spreading malignant melanoma

R. Talon noir

Question 2: Answer & DiscussionF. Dermatofibroma

EMQ Questions 3-5:N. Gastroenteritis

O. Inguinal hernia

P. Irritable bowel syndrome

Q. Mesenteric artery embolus

R. Mittelschmerz

S. Peptic ulcer disease

T. Pelvic inflammatory disease

U. Perforated peptic ulcer

V. Polycystic kidney disease

W. Ruptured Aortic aneurysm

X. Urinary tract infection

Y. Tuberous sclerosis

Z. Wilms’ tumour

A. Acute appendicitis

B. Acute pancreatitis

C. Adenomyosis

D. Bowel obstruction

E. Carcinoma of pancreas

F. Crohn’s disease

G. Constipation

H. Diffuse cystic dysplasia

I. Diverticulitis

J. Dysmenorrhoea

K. Ectopic pregnancy

L. Endometriosis

M. Gall bladder colic

EMQ Question 3:A 2-year-old female is seen in the emergency room because her mother noticed that her stomach was unusually distended and hard. While there, a small amount of blood is found in her diaper. An ultrasound reveals the presence of a large mass on one of her kidneys. What is the most probable diagnosis for this child?

Question 3: Answer & Discussion Wilm's tumour

EMQ Question 4:24 year old Tammy Sutton presents complaining of intermittent abdominal pain of about 18 months duration. It is felt around her umbilical area and comes in spasms relieved by the passage of diarrhoea. It is aggravated by certain foods and wearing tight clothes and relieved by hot drinks and a hot water bottle. It does not wake her from sleep and she has not lost any weight. There has been no blood or mucous. On examination all findings are normal.

Question 4: Answer & Discussion Irritable Bowel Syndrome

EMQ Question 5:Alfred Wayne is a 76-year-old man who presents to the surgery complaining of a sudden onset of abdominal pain. The pain started about 4 hours before presentation and has been persistent; it is present in the upper abdomen and is centered in the epigastrium. He describes the pain as deep and burning. There is no associated nausea or vomiting. He does not report any changes in his bowel habits and has not experienced any recent fevers. The review of systems is also negative for any recent unintended weight loss or trauma. The patient also reports having had "indigestion" in the past that caused pain similar to what he is currently experiencing, though much less in intensity. His past medical history is significant for coronary artery disease and hypertension.

EMQ Question 5 con’t:He takes two medications, both for his high blood pressure, but does not drink excessively and does not smoke.

On physical examination, the patient is pale and in obvious severe discomfort. His heart rate is 122 bpm, and his blood pressure is 110/65 mm Hg. He is breathing with rapid shallow breaths at a rate greater than 30 breaths/min. His temperature is 37.3ºC, and a pulse oximetry reading while the patient is breathing room air shows a saturation rate of 98%. The cardiovascular and respiratory findings are unremarkable. The patient has significant tenderness in the epigastric region, with a rigid abdomen. There is little to no tenderness to palpation in the lower quadrants; a reliable assessment of the upper quadrants is not possible because of the tenderness in the epigastric region.

EMQ Question 5 con’t:Hyperactive bowel sounds are heard on auscultation.

An electrocardiogram is performed and is noted to be unremarkable except for sinus tachycardia. Plain radiographs of the abdomen are performed (see X-rays).

Question 5: X-rays

Question 5: Answer & Discussion Perforated peptic ulcer

SBAs (MCQs) Questions 6-21:Question 6: A lipoma

A. is a premalignant condition.

B. is always subcutaneous.

C. often occurs in the scrotum.

D. cannot be tethered to the skin.

E. is usually lobulated.

Answer E

Question 7:Secretory otitis media:

A. is rare before the age of 5 years.

B. is most common in summer.

C. can be discounted as cause of learning problems at

school.

D. is not associated with otalgia.

E. frequently runs a fluctuating course.

Answer: E

Question 8:Essential hypertension in pregnancy is:

A. usually diagnosed in the third trimester.

B. usually asymptomatic.

C. common in women under 35 years of age.

D. usually associated with marked proteinuria.

E. uncommonly associated with a family history of hypertension.

Answer: B

Question 9:An infant develops jaundice 6 hours after birth. Which one of

the following is the most likely diagnosis?

A. Haemolytic disease of the newborn.

B. Umbilical sepsis.

C. Physiological jaundice.

D. Atresia of the bile ducts.

E. Neonatal hepatitis.

Answer: A

Question 10:Hepatomegaly in the newborn period is a feature of each of the following except:

A. galactosaemia.

B. breast milk jaundice.

C. neonatal hepatitis.

D. Rhesus haemolytic disease.

E. congestive cardiac failure.

Answer: B

Question 11:Untreated hypothyroidism in infants is associated with:

A. accelerated linear growth.

B. chromosomal abnormality.

C. eczema.

D. mental retardation.

E. diarrhoea.

Answer: D

Question 12:Which one of the following is least likely to be a complication

of chronic otitis media?

A. Cholesteatoma.

B. Decreased auditory acuity.

C. Meningitis.

D. Otosclerosis.

E. Thrombosis of the lateral venous sinus.

Answer: D

Question 13:In a patient who has suffered persistent asthma over several

weeks, the effect of the therapy is best indicated by:

A. relief of dyspnoea

B. absence of rhonchi

C. arterial blood gas analysis

D. tests of ventilatory function

E. exercise capacity

Answer: D

Question 14:The most common cause of blood-stained stool in an

otherwise normal infant is:

A. anal fissure

B. anal fistula

C. haemorrhoids

D. Meckel diverticulitis

E. intussusception

Answer: A

Question 15:A 5-year-old boy is diagnosed in the Emergency Department as having measles, the first symptoms having started 2 days previously. He has a 2-year-old sister, who has received the recommended immunisation schedule. Which one of the following is the most appropriate treatment?

A. Treat him symptomatically and send him home

B. Refer him to the infectious diseases hospital

C. Give him gamma globulin

D. Give gamma goblin to the sister

E. Reassure the mother that ‘he is over the worst of it’

Answer: A

Question 16:A 37 year old Aboriginal women who is gravida 4, para 3 spontaneous abortion 1, presents to you with a four day history of severe right iliac fossa pain. Her last menstrual period, which was a little heavier than normal, was three weeks ago. Her health record documents prescription of an oral contraceptive pill. Her temperature is 38°C, pulse 90 per minute, and blood pressure 120/170. Abdominal examination reveals tenderness to deep palpation in the right iliac fossa. There is no flank percussion tenderness.

Question 16 con’t:Which of the following is the most important FIRST diagnostic

test in this woman?

A. Abdominal ultrasound

B. Pregnancy test

C. Plain abdominal X-Ray

D. CT- abdomen and pelvis

E. Cervical swab

Answer: B

Question 17:Vera is a 65 year old pensioner who has been on low does oral corticosteroids for 5 years for polymyalgia rheumatica. She comes in with back pain and X-rays show a 40% crush fracture at T10. You arrange for her to have a bone densitometry when the mobile van visits your local town. The T score for her lower lumbar spine is 2-6 (normal >-1). Her pain is reasonably well controlled with ibuprofen.

Question 17 con’t:In addition to recommending calcium and vitamin D, which of

the following is the most appropriate at this time:

A. Ethynyl oestradiol

B. Calcipotriol

C. Alendronate sodium

D. Calcitonin

E. Raloxifene

Answer: C.

Question 18:17 year old Nathan has been brought into your surgery by his mother, who is concerned because having previous been very pleasant-natured, he has recently become irritable at home and is performing poorly as an apprentice mechanic. When you interview him without his mother present you discover he has been smoking ‘ice’ (crystal methamphetamine) on the weekends, and occasionally during the week.

Question 18 con’t:Which one of the following is the most effective intervention

Plan?

A. Educational visit to drug offenders in prison

B. Motivational interviewing and encouragement of peer group change

C. Replacement pharmacotherapy with methadone

D. In-patient detoxification and compulsory Narcotics Anonymous meetings

E. Take away Nathan’s car and driving privileges until he stops using ice

Answer: B.

Question 19:A 6 year old boy is brought into the emergency department of a country hospital by his parents. He had been found in a dam after having gone missing nearly an hour earlier. On admission he appears lifeless, with no discernable cardiac output. Rectal temperature is 32°C.

Question 19 con’t:Which one of the following best describes the most appropriate management:

A. Cardiopulmonary resuscitation and active rewarming in water 40-42°C

B. Pronounce him dead on arrival and arrange appropriate support for the family

C. Active rewarming using intravenous fluids and heat packs in groin and armpits

D. Transfer to tertiary centre for active rewarming using cardiopulmonary bypass

E. Active rewarming in water 40-42°C

Answer: A.

Question 20:Lucy is breast feeding her 5 month old son and presents with a fever and a sore, red area on her right breast. This is her third similar episode since delivery. You prescribe oral antibiotics.

Which one of the following is the best additional management?

A. Continue feeding, treat nipple cracks for candida

B. Wean baby quickly bromocriptine to dry milk supply

C. Cease feeding for 7 days and express both breasts

D. Continue feeding from L breast only. express R breast

E. Wean baby slowly within next month

Answer: A.

presented by:

Good Luck!

Drs Christine Ahern, Peter Silberberg and Rob Trigger

North Coast GP Training T: 02 6681 5711 or E: [email protected]