PSYCHIATRY
1.A lady with a previous divorce now comes to you with a seductive behaviour
a. Narcistic
b. Histrionic
c. Borderline
2.In Australia bush fire are common either accidentally or some people lighting fire deliberately.
Which is true regarding pyromaniacs?
a. Done for notoriety or publicity
b. To hide their acts
c. As they like to play with fire
d. Set fire and get panic attacks
e. For satisfaction
3.Depersonalization may occur in
a. Schizophrenia
b. Ecstatic religious experience
c. Depression
d. Post traumatic disorder
e. All of the above
4.A middle aged lady present to you with nausea dyspepsia abdominal distention. She had a past
history of going to many doctors and being treated for many disorders. she has been treated by a
rheumatologist for aches and pains, cardiologist for her palpitations and gave her propanolol
without improvement , a neurologist for her epilepsy. On examination you find a tense anxious
woman in spite of her daily dose of benzodiazepine. There are scar from appendectomy and
hysterectomy operations. What is the most appropriate diagnosis?
a. Munchausen syndrome
b. Conversion disorder
c. Hypochondriasis
d. factitious disorder,
e. Neurotic anxiety
5.Many psychopharmacologic substance are lipophilic the advantage is
a. better absorbed with meals
b. promptly binds with free fatty acids
c. more resistant to be metabolized by thae liver
d. the pass rapidly to the brain and to the blood
e. a drug which has a long life and needs to be given once a day daily
6. Lithium:
a. loses it effectiveness over the time
b. is non addictive
c. works better in women than men
d. interaction with NSAIDS
7. morbid jealousy
a. alcoholism
b. schizophrenia
c. depression
d. obsessive compulsive
e. mania
8. A 40 yr old male school teacher who has recently separated from his wife was; prescribed
imipramine 25 mg for his depression. He had a road accident in which he hurt his child. He was
admitted to hospital for taking an overdose of imipramine with alcohol. He does not give consent to
go for psychiatric counselling or to be admitted hospital for further treatment. Your next step in the
management of this patient is:
a. Ask him to go to alcoholics anonymous
b. Increase the dose of Amitriptyline to 125 mg and send him home
c. Change to another drug
d. Retain him in the hospital against his using he Mental health act
e. Contact his wife and try to persuade her to return to him
f. Alcohol counselling
9.A 46 year old widow consults you for advice on management of insomnia, indifferent appetite;
recent weight loss of 5 kg., headaches and tearfulness. 4 weeks ago her only son died after
subarachnoid haemorrhage. Since then she had experienced auditory hallucination, of her son's
voice calling out her name and had felt his presence in their living room. Your initial management
of this woman would involve:
a. Grief counselling and a brief course of benzodiazepine
b. Grief counselling and a brief course of TCA
c. Grief counselling and a brief course of phenothiazine’s
d. Referral to psychiatrist
e. Referral for hospitalisation and treatment
10.Depersonalization may occur in:
a. schizophrenia
b. ecstatic religious experience
c. depression
d post traumatic disorder
e.A11 of the above
11. A 36 yr old engineer is due to give an speech soon and is reluctant to be exposed to people. At
the same time, he does not want to sign cheques or write anything in public. He also thinks his,
boas is controlling what he is doing although he knows that there is no motive for that because he
is a very good worker. He realizes there is no reason to act this way, Lately he has been avoiding to
go to the canteen with his mates and takes alcohol to cope with the situation. What he is suffering
from?
a. Social phobia
b. agoraphobia
d. antisocial personality disorder
e. panic disorder
f. paranoid disorder
12. Deinstitutionalisation means:
a. Transferring a patient from a psychiatric hospital to a community based facility.-
b . Put him in prison hospital
c. discharge the patient to a nursing home
d. Put patient in a psychiatric hospital
e. psychiatric patients are not permitted to vote
13.Lithium:
a. loses its effectiveness over the time
b. Is non-addictive
c. works better in women than men
d. Interaction with NSAIDS causes increase in lithium levels
e. Lithium toxicity
14.Cognitive therapy has good results in:
a. depression
b- chronic pain
c. social phobia
d. bulimia
e. all of the above
15. Many psychopharmacologic substance are lipophilic. The advantage is:
a. better absorbed with meals
b. promptly bind to free fatty acids
c. more resistant to be metabolised by the liver they pass rapidly to the blood and to the brain
e. a drug has a long life and needs to be given once a day only
16. Psychiatric treatment in women is more commonly found in:
a. first trimester of pregnancy
b. second trimester
c. third trimester
d. puerperium
e.6 weeks after the first control
17.Regarding depression, what is true?
a. onset in winter, disappear in summer
b. -onset in autumn, disappear in summer
c. onset in summer; disappear in winter
d. onset in summer, disappear in autumn
e. onset in spring, disappear in winter
18. Despite obvious to the contrary, a 16 w old female with anorexia nervosa, thinks she is
overweight. This is an example of :
a. delusion
b. obsession
c. over valued idea
d. rumination
e. hallucination
19. A 35 year old female secretary, unmarried, complains of feeling of mass or lump on her neck:
a. psychological (Globus Hystericus)
b. inflamed tonsils
c. lingual thyroid
d. hyperthyroidism
e. goitre
20.In generalized anxiety disorder, what Will develop in the next follow :
a. Schizophrenia
b. bipolar manic depression.
depressive illness
mania
phobia.
21. Using the WHO criteria, what is the most common symptoms of schizophrenia?
a. Flat affect
b. Auditory Hallucination
c. Visual hallucination
d. Lack of insight
e. Suicidal ideation
22. Exposure to stimuli and response prevention is the treatment of
a. Obsessive-compulsive disorder
b. Agoraphobia
c. Depression
d. Bipolar manic depression
e. Schizophrenia
23.Morbid jealousy, associated with:
a. alcoholism
b. schizophrenia
c. depression
d. obsessive compulsive
e. mania
24.WOF may be treated with ECT
a. puerperal depression
b. catatonic schizophrenia
c. mania
d. acute schizophrenia
e. all of the above
25.A 1 yr old child of normal intelligence becomes withdrawn and shows deterioration in his school
work. What is most likely:
a. schizophrenia
b. response to stress *in the family
c. normal variance of adolescence
d. Migraine
26. Anorexia nervosa is characterized by all of the following except.
1. 90% of those affected are females
2. raised FSH is pathognomonic
3. not eating or recognizing hunger
27. Fluoxetine is a new antidepressant unrelated to TC.A but with similar pharmacologic action.
What is its mechanism of action?
a. inhibits uptake of dopamine
b. inhibits uptake of norepephrine
c. inhibits uptake of serotonin
d. inhibit uptake of epinephrine
28.Apatient maintained on lithium carbonate was given an NSAIDS and developed then Most likely
explanation for this :
- lithium toxicity
- toxicity to NSAIDs
29. In married couple, the most likely cause of inhibited sexual excitement is?
a. fear of pregnancy
b. marital discord
c. empty nest syndrome
d. organic disorder
30.A Malaysian university student who is working as a waiter, whose girlfriend went home to attend
her father's funeral became irritable, restless and unable to sleep. He complains that his
companions are talking behind his back and plotting against him what is your diagnosis?
a. reactive psychosis
b. grief reaction
c. onset schizophrenia
d. suspicious cannabis
e. panic psychosis
31. A 45 yr old salesman comes to you with complaints of difficulty of getting to sleep, waking up
with nightmares & loss of weight. What is your diagnosis'?
- anxiety
- depression
32. The most common cause of vaginismus :
-- Phobia
- schizophrenia
33. In borderline personality. What is correct?
a. antisocial with difficulty in establishing a relationship
b. histrionic personality
c. social withdrawal
d. identification problem –
e. tendency to self harm
34. What is correct of obsessive rumination?
a. compulsive hand washing
b. repetitive, persistent sexual fantasy c.
35. A 35 yr old man maintained on lithium was admitted for an infection. HIV test taken and done
without his consent turned up positive. What is correct in this case?
a. stop lithium and start AZT
b. Tell the patient he has AIDS and extract a history of his sexual contacts/partners
c. It is unlawful to do the test without consent and pre treatment counselling
d. Inform the staff of the patient condition
36. A 65 yr old Greek lady living in Australia since 34 yrs ago has been living alone. She now
seems to answer voices and does strange things. The most likely
a. paranoid delusions
b. migrant psychosis
c. Capgras syndrome
d. Paraphilia
e. Frigoli
37. A 23 yr old male unemployed is complaining about his nose. He says that he can't get a good
job because of his nose. He also said he can't get a girl friend , and is demanding about a reduction
of his nose. The doctors an opinion is that the nose looks normal. What is your management?
a. refer to p1'astic surgeon
b. refer to psychiatry
d. try a short course of...
e. explain him very gently that his nose looks normal and try to find out what social causes and
difficulties about his work.
38. What is delusion?
a. False Belief
b. False thought
c. Sexual Fantasy
39. Most appropriate re :post partum psychosis is:-
a. family counselling
b. ask mother to stop breastfeeding
c. admit to hospital
d. psychiatric treatment to the mother
e. treat and send home
40. A 85 YO old man with progressive loss of memory for recent events, unable to do any
calculations is disoriented for time, WOF is correct?
1. frontal lobe tumour
2. Alzheimer’s
3. Multi infarct Dementia
4. Due to old age
41. A young girl with running nose; diarrhoea. sweating; lacrimation, and abdominal pain. WOF is
the cause'?
a. heroin withdrawal
b. cocaine
c. LSD
d. marijuana
e. amphetamine
42. Endogenous depression. WOF is true?
a. Early morning waking
b. Difficulty in initial sleep
c. Dreams with content involving death patient
d. Somnolence in the early part of day
e. None of Above
43. Basis of Dopamine theory of Scz:
a. Phenothiazine can cause Parkinson like syndrome
b. Amphetamine can cause schizophrenia
c. Anticholinergic drug can cause delirium.
c. Tricyclic Antidepressants have anticholinergic effects.
d. Imipramine helps in obsessive neurosis.
44 Acute alcoholic hallucination can be differentiated from delirium tremens by the fact that:
A. It occurs following ingestion of small amount of ethanol whereas DT is a withdrawal syndrome.
c. Unilateral tinnitus is pathognomic of alcohol hallucination.
d. Unilateral auditory hallucination is path gnomic of alcoholic, hallucination.
e. The sensorial remain clear despite the presence of terrifying auditory hallucination.
f. The hallucination of alcoholic is visual and unpleasant.
45. WOF is characteristic of schizophrenia'?
a auditory hallucination
b. Depersonalisation
d. antisocial behaviour
e. flight of ideas
f. all of the above
46 A 70 yr old male taking Aldomet for hypertension for the last 10 Years starts to isolate himself
and is suffering from deafness: He feels that people are speaking about him. What is most likely
diagnosis:
a. Symptoms of Aldomet
b. reaction to deafness
c. atherosclerotic dementia
d. senile dementia
e. senile paraphrenia
MEDICINE
1. In dislocation of shoulder, which nerve is liable to be injured?
a. Radial
b. Axillary
c. Musculocutaneous
d. Ulnar
e. Brachial plexus
2. Which of the following is likely to damage an artery?
a. Anterior Dislocation shoulder
b. Posterior dislocation shoulder
c. Anterior dislocation hip
d. Posterior dislocation hip
e. Posterior dislocation knee
3. In Colles Fracture, the distal segment is displaced:
a. Backwards and ulnarwards
b. Backwards and radially
c. Forwards and ulnarwards
d. Forwards and radially
e. Minimally displaced
4. An 18-month-old is brought to you by the mother for breast enlargement. Tanner 3. No pubic
hair or axillary hair is seen. No other abnormality is seen. What is your diagnosis?
a. Precocious puberty
b. Idiopathic thelarche
c. Congenital adrenal hyperplasia
d. Breast tumour
e. Mastitis
5. A 21-year-old child is brought to you for having loose motions for 3 days. The stool contains
undigested food material. No vomiting. Thriving well. What is he suffering from?
a. Cystic fibrosis
b. Coeliac disease
c. Gastroenteritis
d. Toddlers diarrhoea
e. IBS
6. A large man presents with big face broad hands thick and oily skin and hoarse voice. What is the
initial investigation of choice?
a. GTT + GH
b. Insulin challenge test + GH
c. GH+ cortisol
d. GH
e. GTT
7. Regarding heparin induced thrombocytopenia, what is true?
a. Purpura
b. Joint bleeding
c. Ecchymosis
d. Thrombosis
e. Hematuria
8. Regarding ADHD, what is correct?
a. Age 5-7 years
b. Reading difficulties
c. Social withdrawal
d. Females affected more than Males
e. Prevalence is 15%
9. All the following can cause dysphagia except:
a. Oesophageal cancer
b. Achalasia
c. Oesophageal varices
d. Barrett’s oesophagus
e. Hiatus hernia
10.A 6 week old is brought to you for not having passed motion for last 4 days. He has been
feeding well, and is gaining weight. Otherwise well and active. What is the most probable
explanation?
a. Hirsprung’s disease
b. Normal variant
c. Hypothyroidism
d. Acquired constipation
e. Foreign body
11. A man returns after a trip to India. Now has 3 days diarrhoea with blood in stools. Looks run
out and dehydrated. Noted to have fever. What is most correct?
a. Giardia infection
b. Amoebiasis
c. E. coli gastroenteritis
d. Viral diarrhoea
e. Cholera
12. In a 40 years old lady, all the following may be the cause of menorrhagia except:
a. Hormonal response to uterus
b. Subserous fibroid
c. Intermural fibroid
d. Adenomyosis
e. Endometriosis
13. 3 month old comes with unilateral eye discharge. What is the most possible cause:
a. Chlamydia infection
b. Gonococcus
c. Ophthalmia neonatorum
d. Blocked nasolacrimal duct
e. Normal variant
*14. A 6-month-old presents with SOB. There was a birthday party at home yesterday. On
examination, child is wheezing. What is most initial investigation?
a. Sweat test
b. Bronchogram
c. CXR
d. Inspiratory and Expiratory Rontogram
e. PEFR measurement
15. A mother brings her 3-year-old baby girl with unilateral nasal discharge off and on for last 3
months. Secretion is foul smelling and at times copious. Baby is uncooperative. What is the initial
investigation of choice?
a. CXR
b. indirect laryngoscopy
c. Examination under GA
16. A 6-year-old girl wakes up at night c/o sever pain in her calves. Mother rubs her calves and she
feel fine, goes to sleep. This has been happening for a number of days now. At daytime she is
active and playing. All of the following are true except:
a. Ca and CK will be abnormal
b. No investigations are needed
c. Family Hx will be positive
d. Reassurance is the treatment.
17. Which vaccination should not be given to a child who is under remission on chemotherapy for
CLL?
a. Polio
b. MMR
c. HiB
d. DPT
18.Solitary mobile carcinoma breast lump. No axillary lymphadenopathy. Which of the following is a
prognostic marker?
a. Age > 45
b. Neu2 / HER oncogene status
c. Oestrogen level
19. All can occur with chronic limb ischemia except:
a. Great Toe gangrene
b. Pallor
c. Ulcer on medial side of leg above malleolus
d. Rest pain
e. Intermittent claudication
*22. 40 year old with acute painful testis:*
a. Varicocele
b. Hydrocele
c. Epididymoorchitis
d. Torsion
e. Tumour
23. WOF is true regarding a 2cm kidney stone in the pelvis seen in KUB examination.:
a. Expectant treatment is right
b. It is a urate stone
c. Lithotripsy
d. Open surgery
24. Patient can’t dorsiflex or evert his foot. What is wrong?
a. L4
b. L5
c. Tibial nerve
d. Peroneal nerve
e. Sciatic nerve
25. Body dysmorphia is seen in AOF except:
a. Anorexia nervosa
b. Acromegaly
c. Non dominant parietal lobe lesion
d. Dominant parietal lobe lesion
e. Narcissistic personality disorder
26. 6 year old child comes to you with up rolling if eyes, neck stiffness, protruded tongue, rigid
body and face tilted to one side. Had vomiting and was being treated by the GP. What is the cause?
a. Huntington’s chorea
b. Epilepsy
c. Reaction to metoclopramide
d. Gastritis
27. Lung cancer associated with non-smokers:
a. Sq. cell Ca.
b. Adenocarcinoma
c. Small cell Ca.
d. Oat cell Ca.
e. Large cell Ca.
28. All of the following cause gynecomastia except :
a. spironolactone
b. cimetidine
c. digoxin
d. alpha methyldopa
e. labetolol
29.A young female presents with 24 hour h/o sore throat. Later she develops proteinuria and some
hematuria. What is the most probable cause?
a. Glomerulonephritis
b. IgA Nephropathy
c. Nephrotic syndrome
d. HTN
30.What is the most important step in psychotherapy?
a. Detailed history
b. Isolation
c. History from friends and relatives.
d. Developing relationship
e. Investigations
31. When do we use Psychodynamic Psychotherapy?
a. Obsessive Compulsive Disorder
b. Bipolar Disorder
c. Schizophrenia
d. Depression
e. Anorexia Nervosa
32. You are asked to examine a person. He is cut off from the world since he was teen. Lives alone
and wants to be alone. No friends. Family wants to support but he refuses to get any help. He
doesn’t have any thought disorder or perceptional symptoms, but his affect is blunt. What would be
the most probable diagnosis?
a. Chronic schizophrenia
b. Major depression
c. Narcissistic Personality
d. Bipolar disorder
33.Regarding Billing’s method of contraception, AOF are true except:
a. Cervical mucus has to be palpated
b. Unsafe sex, if it becomes more
c. Safe sex after 2-3 days of becoming more
d. Since it considers the cervical mucus, it is same contraception in regular, irregular and
lactational menstrual periods.
34.Regarding Levonorgestral containing IUCD, AOF are true except:
a. Light periods
b. Amenorrhoea
c. Decreased risk of cervical carcinoma
d. Decreased risk of sexually transmitted diseases
e. Decreased risk of ectopic pregnancy
35.Spleenectomy in spherocytosis will do all the following except:
a. Normalize anaemia
b. Normalize spherocytosis
36. An 8-year-old child presents to the ED with bilateral tonsillitis with greyish white exudates. He
has cervical lymphadenopathy, fever and hepatosplenomegaly. What is the probable cause?
a. EBV
b. CMV
c. Diphtheria
d. Bacterial
37. A young child with 2-week h/o dry cough with whop, and some times vomits. What is true
about this patient?
a. Will have cough for the next 4 weeks
b. Amoxicillin should be started
c. D & T vaccine should be given immediately
38. A patient with pyloric stenosis, vomiting for 4 days now presents to ED with mother. He is dull
lethargic, skin turgor is lost, and BP is 90/50. What is the most initial choice of fluid in this patient?
a. Normal saline
b. Hartman’s solution
c. Ringer’s lactate solution
d. Dextrose 5% and Normal saline
39.Regarding diffuse fibrosing alveolitis what is true?
a. Decreased FEV1 / FEV
b. Decreased TLC
c. Decreased Expansion
d. Decreased O2 tension
e. Hypercarbia
40.Psychiatric side effect of corticosteroids?
Withdrawal causes delirium
41. A patient is suffering from cyclical mastalgia. Routine treatment fails. What is your next
management?
a. NSAID
b. Bromocriptine
c. Danazol
d. Progesterone
e. Lasix
42.Regarding CPR, WOF statement is most correct?
a. Adrenaline should be given every 10 minutes
b. Bicarbonate is mandatory
c. ECM only pumps ½ of the cardiac output in one stroke
d. ECG is necessary before cardio-version.
43. Patient with grandiose character. Doesn’t care about others. Feels himself to be unique:
a. Histrionic personality
b. Schizoid
c. Narsistic
d. Delusional
e. Borderline
44.Picture of CT Scan showing two white spots just lateral to the midline. A patient 59 year old
presents with sudden onset of left hand weakness. What could be the possible cause?
a. SDH
b. SAH
c. Intra cerebral haemorrhage
d. Cerebral infarct
45. WOF has the least risk of having congenital malformation at birth.
a. Chromosomal abnormality AD, AR, Sex linked recessive
b. Rubella at 18 weeks
46. What is the most likely cause of post coital bleeding?
a. Endometrial Carcinoma
b. Vaginal candidiasis
c. Cervical polyp
d. Fibroid
47. Regarding thyroid cancer, all are true except:
a. Enlarged thyroid
b. Solitary nodule
c. Hot nodule
d. Change in voice
e. Tracheal compression
48. Patient presents with fever, tachycardia (Pulse 110/mt), Tremors, and palpable & tender
thyroid. On investigation, there is no radioactive iodine uptake. What is the possible treatment?
a. Carbimazole
b. I131
c. Beta-Blocker + Paracetamol
d. Thyroxine
49. A women has bilateral suppurative inflammatory lesion on the axilla and groin. What is true?
a. Actinomycosis
b. Fungal infection – Mycosis Fungoides
c. Suppurative Hidradenitis
d. Multiple lymphadenopathy with abscess
e. Pilonidal sinus
50. An old man who was operated for aortic aneurysm 3 weeks ago, presents to the ED with
irregular pulse, restlessness, abdominal distension and not having passed flatus and motions for
last 2 days. WOF is the most possible cause?
a. Rupture of suture site
b. Mesenteric artery embolism
c. Urinary retention
d. Diverticulosis
51 Why do we do an ultra sound in a patient with sign symptoms of biliary disease?
a. To visualize stones in the GB or CBD
b. To visualize pancreatic cancer
c. To see the dilation of bile tree
d. To locate the hepatic cancer
e. To visualize the GB pathology
52. A seventy-year lady who is alcoholic and smokes > 20 cigarettes a day, presents to you with
tiredness and fatigue. She also complains of weakness in limbs. Her Hb was 98, MCV 110, and
platelets were decreased. What is the most possible cause?
a. AoCD
b. IDA
c. Alcoholism
d. Pernicious Anaemia
e. Auto immune Haemolytic Anaemia
53. A young female on oral contraceptive misses one tablet while in the mid cycle. Had coitus the
same day, and takes the ‘missed’ tablet 12 hours later. Then continues with rest of her tablets. She
has spotting on the third day of coitus. What will be your advice?
a. Continue with the OCP.
b. Change to different contraceptive drug.
54. AOF are the features of basal ganglion except:
a. Ataxia
b. Tremor
c. Bradykinesia
d. Chorea
e. Rigidity
55.Most common cause of bowel obstruction in Australia assuming that he as not undergone any
abdominal surgery, is:
a. Volvulus
b. Intersuseption
c. Groin hernia
d. Internal hernia
e. Tumours
56. A patient presents with wasting of small muscles of hand with thenar sparing. What is the most
probable diagnosis?
a. Ulnar N
b. Median N
c. Axillary N
d. Musculocutaneous N
57. Picture on Page 206 of AMC. Picture of scalp showing white scaly lesion.
a. Psoriasis
b. Alopecia Areata
c. Pediculosis
d. Tinea Capitis
58. A young couple wants to adopt abstinence as contraception. Assuming the female is having a
regular monthly cycle of 28 days, you would advice them to avoid sex on AOF days except:
a. Day 4 – 17
b. Day 8 – 17
c. Day 10 – 19
d. Day 12 – 19
e. Day 17 - 21
59. Most common cause of cholecystitis in Australia
a. Gall stone at out flow
b. Gall stone in CBD
c. Pancreatitis
d. Tumour
e. Hepatitis
60.WOF is expected to happen after splenectomy for spherocytosis?
a. RBC life span improves
b. Leukopenia
c. Reduction in anaemia
d. Reduction of spherocytes
e. Reduction in fragility of RBCs.
61.What is the cause of majority of HbsAg patients in Chinese population?
a. Blood product
b. IVDU
c. Child birth
d. Sexual spread
e. Haemophilia
62. A 60 years old female patient of RA takes 5mg of Prednisolone tabs BD for last 10 years. Now
she comes to you complaining sudden onset of pain and swelling of her right knee, which is warm
and tender. Your management would be:
a. Increase dose of NSAID
b. Decrease dose of NSAID
c. IV Antibiotics & hospitalisation
d. Knee X Ray for unrecognised trauma
e. Knee aspiration for cytology.
63. A 12 year old is having pain in his hip. His mother noticed a limp. He is afebrile, and the
general examination is normal. What is the most probable cause of his symptoms?
a. Slipped upper femoral epiphysis
b. Perthes disease
c. Non specific synovitis
d. Osteomyelitis
64. Photo of viral wart on the eyelid of a young female.
a. Wart
b. Molluscum contagiosum
c. Herpes simplex
d. Skin tag
65. AOF cause gynecomastia, except:
a. Spironolactone
b. Digoxin
c. Methyldopa
d. Labetolol
66. A 41 week primi comes to you complaining of no fetal movements for last 24 hrs. FHS is
140/mt, CTG is normal, and rest of the examination is normal. You send her home. Next day she
rings you stating that there is again no fetal movement for the last 24 hrs. What will be you next
step of management?
a. Tell her that all her examinations are fine, & she should not worry
b. Ask her to wait for another 24 hrs.
c. Admit labour ward and induce labour.
d. Immediate LSCS
67. Picture of supracondylar fracture (AMC Book): A young girl fall on her out stretched hand. What
will be your management?
a. Neurological study to check the Median Nerve involvement
b. Fasciotomy
c. # Reduction and assessment of circulation
d. Back slab and review in 24 hours
68. Many people attended a dinner party on a week end. 10% had diarrhoea. Most of them
recovered spontaneously, but few needed hospitalisation for severe dehydration. What is the most
probable cause?
a. Giardia
b. Salmonella
c. Clostridium
d. Shigella
69.Complication of # of epiphyseal plate
a. Retardation of longitudinal growth
b. Joint stiffness
c. Malunion
d. Non-union
e. Avascular necrosis
70.4 day old full term baby normal at birth. Suddenly collapse at cot. O/E baby is peripherally
cyanosed , no pulse and respiratory distress. Diagnosis?
a. Pulmonary Hypertension
b. Fallot’s Tetralogy
c. PDA
d. CHD
e. Lt Heart hyperplasia.
f. Transposition of great vessels
MEDICINE, SURGERY , OBSTETRICS AND PSYCHIATRY
1. An elderly woman can read the newspaper, but has halos in bright sunlight.
A. Cataract
B. Glaucoma
C. Presbyopia
D. Macular Degeneration
2. Which of the following drugs decrease renin:
A. Beta Blockers
B. ACE Inhibitors
C. Spironolactone
D. Hydralazine
E. Centrally acting antihypertensives.
3. Newborn with respiratory distress , faint breath sounds on the left and with a scaphoid abdomen
A. Meconium aspiration syndrome
B. Situs inversus
C. Diaphragmatic hernia
4. Which nerve gives the sensation of taste to the anterior 2/3rd of tongue.
A. Trigeminal nerve
B. Facial nerve
C. Hypoglossal nerve
D. Glossopharyngeal nerve
5. A Patient who underwent a cholecystectomy, now comes with jaundice .what is the investigation
of choice.
A. Oral cholecystogram
B. CT scan
C. Ultrasound
D. Sr. Creatinine
E. Upper GI Studies
6. Regarding pseudobulbar palsy AOF is true …except
A. Wasting and fasciculation of tongue
B. Jaw jerk decreased
C. Loss of sphincter control
D. Gag reflex present
7. Regarding ACE Inhibitors, which is not true :
A. Used in the treatment of heart failure
B. Used as first line in the treatment of Hypertension
C. Used in Diabetics
D. Cannot be used in the treatment of Aortic stenosis.
8. Regarding CRF and Calcium metabolism
A. Ca is decreased
B. Ca is increased
C. There is no relation between CRF and Ca
D. Causes Osteomalacia.
9. Most significant complication of massive blood transfusion. ( *)
A. Pulmonary oedema
B. Change in acid base balance
C. DIC and coagulation defect
D. Increased CVP
10. Regarding CRF and Potassium all of the following reduce potassium except (treatment of
hyperkalemia) *
A. Calcium Carbonate
B. Glucose and Insulin
C. Dialysis
D. Resonium
E. Sodium Bicarbonate
11. 55year old patient with dysphagia for solids with a previous history of reflux
A. Carcinoma oesophagus
B. Stricture
C. Scleroderma
D. Achalasia \
E. Raynaud’s syndrome
12. An infant came with pneumonia , X ray showed consolidation of a lobe with round
translucencies and a small pleural effusion. What is the treatment of choice?
A. Crystalline penicillin
B. Flucloxicillin
C. Amoxicillin / clavulanic acid
D. Tetracycline
13. A new born was peripherally cyanosed and crying lustily ..the axillary temperature recorded
was 37.2degrees what would be the next step( *)
A. Take an x ray
B. reassure
C. oxygen
D. urine culture
14. 34 year old lady on phenytoin wants to take OCP’S what can be prescribed
A. Microgynon 30
B. Microgynon 50
C. Triphasic
D. Oetradiol patches
E. Progesterone only pill
15. 6 months old boy brought by his mother with a temperature of 38.9degrees with bilateral
wheezing .his resp. rate was 36/min .other members in the family had a h/o similar illness. There
is family h/o asthma. What is the diagnosis?
A. Asthma
B. Foreign body
C. Bronchiolitis
D. Pneumonia
16. 16 weeks p
regnant lady came for a check up ,for the diagnosis of foetal anencephaly all are true except
A. increased alpha feto protein
B. increased beta HCG
C. nuchal thickness
D. decreased alpha fetoprotein
17. Regarding tubal pregnancy most suggestive is (*)
A. –ve beta HCG
B. ultrasound showing empty uterus
C. ultrasound showing tubal mass
D. CT scan
18. 10 weeks old child with persistent unilateral eye discharge responding to antibiotics but
recurring
A. nasolacrimal duct obstruction
B. gonococcus
C. Chlamydia
19. unilateral foul smelling ,bloodstained discharge from nose
A. foreign body
B. nasal polyps
C. Atopy
D. Rhinitis
20. 10 year old came to your surgery with scrotal pain .on examination both testis are in the
scrotum , next management :
A. do an ultrasound
B. arrange surgery
C. write some analgesic and send him home
D. do nothing it will go away
E. tell his mother to review back again when the pain recurs
21. 19 year old girl had a binge of drinking the previous night with lower abdominal tenderness and
all investigations and testis are normal (*)
A. treat as gastroenteritis
B. tell her it is due to alcohol
C. not sure of diagnosis ;come back for review
D. Give analgesic and antiemetic and send her home.
22. Reversal of non depolarising skeletal muscle blockade
A. Pyridostigmine
B. Neostigmine
C. Atropine
D. Benzhexol
23. differentiation between schizophrenia and shcizophreniform disorders is by (*)
A. affective symptoms
B. duration of symptoms
C. lack of insight
D. female and male ratio
24. A lady with a previous divorce now comes to you with a seductive behaviour
A. Narcicistic
B. Histrionic
C. Borderline
25. In Australia bush fires are common either accidentally or due to some people lighting fire
deliberately, which is true regarding pyromaniacs.
A. Done for notoriety and publicity
B. To hide their acts
C. As they like to play with fire
D. Set fire and get panic attacks
E. For satisfaction.
26. People living near airport have(*)
A. Explosive personality
B. Insomnia
C. Agitated
D. Depression
27. Regarding panic attacks all are true except (*)
A. 20% have had at least one attack in their lifetime.
B. With out agoraphobia it is equal in male and female
C. Always avoid precipitating factors
D. Usually occurs in the twenties
28. Regarding treatment of chronic duodenal ulcer
A. eradication of H pylori
B. H2 blockers
C. PPI
D. Selective vagotomy
29. 4 year old boy with fever and malaise , lymphocyte count –normal, platelets decreased ,Hb
decreased
A. ALL
B. Infectious mononucleosis
C. Hodgkin’s disease
30. Pregnant lady with Group B strep infection, what is true.
A. Penicillin to be given as prophylaxis
B. Bolus dose of penicillin before labour
C. Take a swab and if B strep present then treat.
31. Regarding MI , maximum deaths occur in (*)
A. with in 1st 2 hrs
B. 2 to 12hrs
C. 12 to 24hrs
D. 2 to 7days
E. after discharge
32. A case of stable angina with chest pain. On examination enzymes, ECG are normal but as you
were examining him he belches and says he feels better - what would you do (*)
A. Admit to coronary care Unit and do ECG monitoring.
B. send him home with appointment to cardiologist
C. refer to gastroenterologist
D. if enzymes normal then probably no cardiac
33. With regard to primary health care all are true except(*)
A. 1/3rd of population come to a GP with psychiatric symptoms.
B. Most patients are psychotic
C. Only few are referred to psychiatrists
D. Alcoholics and drug abuse frequently overlooked by GP’s
34. A patient with known Parkinson’s disease for 2 yrs on long term treatment now comes with
tongue protruding out. What would you do ?
A. Decrease levodopa +carbidopa
B. Increase levodopa + carbidopa
C. Stop levodopa +carbidopa
D. Treat with chlorpromazine
35. In a case of twin pregnancy all are true except
A. asymmetrical growth retardation
B. anaemia in pregnancy
C. premature labour
D. acute polyhydramnios
E. 2nd twin foetal malformation.
36. 60 yr old female with diarrhoea and profuse mucous discharge .what could be the cause
A. Cron’s disease
B. ulcerative colitis
C. villous adenoma
D. rectal Ca
E. acute mesenteric ischaemia
37. How do you differentiate between anorectal and colorectal cause of bleeding(*)
A. Blood mixed with stools
B. Fresh bright bleeding
C. Mucoid discharge
D. Pain during defecation
38. most common cause of severe chest pain in pericarditis
A. viral pericarditis
B. tuberculosis
C. Mycoplasma
D. Uraemia
E. MI
39. all of the following are causes of supraclavicular mass except (*)
A. stomach Ca
B. cervical rib
C. breast Ca
D. subclavian thrombosis
E. subclavian artery aneurysm
40. which of the following has worst prognosis
A. advanced breast Ca
B. choriocarcinoma
C. Hodgkin’s lymphoma
D. Non-Hodgkin lymphoma
E. Prostate carcinoma
41. Which of the following does not metastasise to brain
A. Malignant melanoma
B. Prostatic Ca
C. Lung Ca
D. Breast Ca
42. 40 yr old lady with a 2 cm palpable breast lump on the right side .What is the next step.(*)
A. FNAC
B. Ultrasound
C. Lumpectomy
D. Mammography
E. Radical mastectomy
43. A lady with a palpable breast lump, FNAC showed few malignant cells regarding conservative
surgery what is true? (*)
A. Assess for oestrogen receptors
B. Bone marrow biopsy
C. Axillary lymph node sampling
D. Mammography
44. A lady with a breast cancer on left side operated 2yrs ago now detects a small lump on the
right side .how do you explain the lump
A. Cancer arising de novo
B. Fibroadenoma
C. Metastasis from the previous one
45. facial nerve palsy can be associated with all of the following except
A. chronic parotitis
B. Ca parotid
C. Acoustic neuroma
D. # base of the skull
46. A middle aged woman with deafness and loss of corneal reflex but with no tinnitus
A. vestibular neuronitis
B. Meniere’s disease
C. Acoustic neuroma
D. Multiple sclerosis
47. Ptosis ,dysphagia ,ataxia ,on the same side and spinothalamic loss on the opposite side:
A. vertebral artery occlusion
B. basilar artery occlusion
C. MS – midbrain
D. Posterior communicating artery syndrome (PICA)
48. 22yr old lady with diplopia. On closing the right eye ,the medial side of the image is lost ( i.e
diplopia on looking laterally ) what is the diagnosis
A. left 6th nerve palsy
B. left 3rd nerve palsy
C. right 6th nerve palsy
D. posterior cranial fossa tumour
49. Regarding a patient with hepatoma , which of the following is least likely
A. Hepatitis B
B. Hepatitis C
C. Hemochromatosis
D. CMV
E. Alcoholic cirrhosis
50. In which of the following cell mediated immunity is lost first followed by loss of humoral
immunity (*)
A. CLL
B. HIV
C. RA
51. which of the following is not a carcinogen (*)
A. EBV
B. CMV
C. Hep C
D. HIV
52. Picture of a lesion at the lateral angle of the eye what is the treatment ( it’s a BCC) :
A. Surgical removal
B. Excision and radiation
C. Cryotherapy
D. Chemotherapy
E. Local steroids
53. Picture of swelling at the outer angle of the eye .it is described as being hard and present since
birth:
A. Osteoma
B. Sebaceous cyst
C. Lipoma
54. picture of a large swelling on the back near the left scapula
A. lipoma
B. sebaceous cyst
C. 2ndary breast
55. Picture of the face with a non itchy rash like lesion on the cheeks, forehead.
A. SLE
B. Seborrheic dermatitis
C. Acne rosacea
D. Dermatomyositis
56. post operative specimen ( testicle with epididymis )
A. TB
B. Epididymoorchitis
C. Teratoma
D. Torsion of testis
E. seminoma
57. A chest x ray of a child showing consolidation > neutrophils increased. What could be the cause
A. Klebsiella pneumonia
B. Group B streptococcus
C. Staphylococcus
D. Mycoplasma pneumonia
58. A lesion (looks like an ulcer) diagnosis?
A. Amelanotic melanoma
B. Implantation dermoid
C. Basal cell carcinoma
59. ECG- patient is a diabetic and he is dyspnoeic .diagnosis(*)
A. Inferior wall MI
B. Anterior wall MI
C. Pericarditis
D. WPW syndrome
E. Pulmonary embolism
60. ECG patient has palpitations, otherwise normal (*)
A. Atrial fibrillation
B. Atrial flutter with variable block
C. WPW syndrome with accelerated beats
61. ECG patient comes with sweating , palpitations
A. Ventricular ectopic
B. Ventricular tachycardia
C. Atrial fibrillation
D. RBBB
62. How do you treat WPW in a patient with a previous history of collapse?
A. Beta blockers
B. Cardioversion
C. Radiofrequency ablation abnormal tract
D. Surgical ablation
D. Long term verapamil
63. 40 yr old man with SVT 160/min ..Patient not arousable , Treatment is
A. cardioversion
B. adenosine
C. procainamide
D. verapamil
E. take an ECG
64. A child with heart rate of 220/min otherwise normal , how do you manage
A. cold stimulus
B. Valsalva
C. Verapamil
D. DC shock
65. All of the following are side effects of depot medroxyprogesterone , except(*)
A. Amenorrhoea
B. Weight gain
C. Depression
D. Used with oestrogen causes stratification and cornification of vagina
E. hypotension
66. 20yr old man came with pain referring from groin to loin to tip of penis brought a sample of
urine mixed with blood and asks for a shot of pethidine to relieve his pain. What is the next step
A. give him an injection of pethidine to relieve his pain
B. KUB
C. Ultrasound abdomen
D. Examine fresh urine sample
67. 12yr old boy with bee sting with wheeze ,with swollen lips ,tachycardia , restless, immediate
treatment(*)
A. adrenaline IM
B. hydrocortisone IV
C. oxygen
D. antihistamine
E. give NSAID and send him home
68. Young man with tachycardia, BP 90/70,Pulse 140 difficulty in breathing (*)
A. start two IV line to Hartmann
B. wide bore needle
C. tube drainage
69. RTA respiratory distress mediastinal shift to opposite side with emphysema in the neck .what is
the diagnosis
A. Tension pneumothorax
B. Hemothorax
C. Cardiac tamponade
D. Bronchial tear
70. Newborn male with normal genitalia , which is true
A. 47xxy
B. 46xy with androgen insensitivity
C. mother treatment with cyproterone from 8 weeks
71. 16yr old girl came with her mother with no menstrual , breast development is normal
(testicular feminisation)
A. 45xo
B. 46xy
C. Turner syndrome
72. After MVA a patient is dyspnoeic BP 100/70, HR 110/min, Breath sounds decreased on left side,
heart sounds normal, JVP raised, next step in management (*)
A. IV fluids
B. Wide bore thoracostomy
C. Tube thoracostomy
73. A patient with excruciating chest pain and a diastolic murmur .what does the X-ray show (*)
A. widening of mediastinum
B. increased left ventricular size
C. trachea shifted to left
74. A child with fever malaise, sore throat …white papillae on the tongue and later a sandpapery
rash...what is the diagnosis
A. measles
B. rubella
C. scarlet fever
75. A child with fever of 3 days duration and a rash develops when fever subsides
A. Rubella
B. Roseola
C. Erythema multiforme
76. An unconscious man (a known COPD case) was brought to the emergency, on examination
there was a bruise on the parietal area and needle mark in the cubital fossa. His ABG was as
follows (PH: 7.26, PCO2: 60, PO2: 50) His previous ABG showed (PH: 7.35, PCO2: 30, PO2: 60)
.what is the diagnosis? (*)
A. Narcotic
B. Subdural haemorrhage
C. Subarachnoid haemorrhage
77. 16 weeks pregnant woman with proteinuria 3 +, hematuria, and hypertension (*)
A. PIH
B. Pre-existing renal disease
C. Essential hypertension
D. Pregnancy will continue until term
78. Which of the following is familial
A. papillary carcinoma
B. medullary carcinoma
C. follicular Ca
D. anaplastic
E. secondary Ca of thyroid
79. A patient with HIV and cough (respiratory symptoms) has a Mantoux 5mm +ve , what is the
next step
A. INH prophylaxis
B. Zidovudine
C. Interferon
80. Patient with HIV +ve status ..what is true (*)
A. Life long infectivity
B. He has AIDS
C. Can transmit through saliva
D. He should avoid sexual intercourse
81. Tremor can be present in all of the following except
A. hyperthyroidism
B. hypothyroidism
C. benign essential tremor
D. Parkinsonism
E. chronic liver disease
82. A lady with tremor on lifting the phone and disappears when she looks at her hand with mild
rigidity of the hand but no cogwheel rigidity. What is the treatment?
A. Propranolol
B. Benzhexol
C. Levodopa
83. Complication of # of epiphyseal plate
A. retardation of longitudinal growth
B. joint stiffness
C. malunion
D. non-union
E. avascular necrosis
84. which of the following does not have any interaction
A. warfarin & Isosorbitrate
B. verapamil & metoprolol
C. erythromycin & terfenadine
D. digoxin & amiodarone
85. 12yr old child weight 90th percentile with a limp
A. Perthes’s disease
B. slipped capital femoral epiphyses
C. tibial synovitis
86. 13yr old child which would be the appropriate bone age for a normal adult height
A. 9yr old
B. 13yr old
C. 18yr old
87. Regarding mammography, what is true?
A. It is painless
B. Can diagnose breast Ca earlier than self-examination
C. More diagnostic for 70yr old
D. Definitive diagnosis of Ca breast
88. 10 days old boy with vomiting, serum potassium is 7.7; serum Na is 118.what is the diagnosis.
A. Pyloric stenosis
B. congenital adrenal hyperplasia
C. SIADH
D. Posterior cranial fossa tumour
89. A young boy has fever and limp. There is tenderness at one point in the tibia; all movements
are full except flexion which is restricted to 30degrees. what is the diagnosis?
A. Septic arthritis
B. Osteomyelitis
C. Perthes disease
90. 6 hours after difficult catheterisation, a patient developed fever with chills
A. suppurative urethritis
B. gram negative septicaemia (bacteremia)
C. haemorrhage
91. Regarding hemochromatosis , diagnostic investigation is
A. Sr. ferritin
B. Transferrin
C. Sr .Iron
D. Liver biopsy
92. In Australia the common cause of iron deficiency is
A. Nutritional deficiency
B. Malabsorption
C. Diarrhoea
93. most common cause of bleeding P/R in children
A. fistula in ano
B. fissure in ano
C. haemorrhoid
94. Patient with depression is treated with antidepressants; following a course of treatment she
now wants to stop the drug .What do you advice?
A. Follow up every week
B. Follow up every month
C. Admission to hospital
95. Child with abdominal mass and with metastasis to skull
A. neuroblastoma
B. Willm’s tumour
C. retinoblastoma
96. A child babbles , sits for sometime unsupported ,stands with support and holds an object by
the palm .what is the age (*)
A. 5 months
B. 7 months
C. 1year
D. 18 mon.
97. A patient with dysthymia for 2years ..treatment is (*)
A. SSRI + SSRI+ benzodiazepine
B. SSRI cognitive + behaviour therapy
C. SSRI
D. Antipsychotics +SSRI
98. A young patient vomits 1Litre of blood and has 2 times malaena. what is next appropriate step
A. Gastroscopy
B. Immediate surgery
C. Barium meal
99. old lady with knee swelling and has weekly positive birefringent crystals ,the crystals contain
A. calcium pyrophosphate dihydrate
B. calcium hydroxyapatite
C. urate
100. A patient is worried about the (sexual dysfunction and depression) side effects of sertraline.
What would be the advice regarding the same to the patient?
A. It is only side effect of antidepressant
B. both these side effects are not related to sertraline
101. Young man after a RTA was found unconscious only responds to painful stimuli and eye cold
stimuli what is the GCS score
A. GCS >3
B. 3 to 6
C. 6 to 9
102. child with fever and blisters in the palm and sole and mouth ,there is lymphadenopathy
A. Coxsackie’s
B. Kawasaki
C. Herpes
103. All of the following are scaly lesions except
A. Keratoacanthoma
B. Squamous cell Ca
C. Pityriasis rosea
D. Psoriasis
104. Rash similar to syphilis except
A. Infectious mononucleosis
B. Atopic eczema
C. Discoid eczema
D. Tinea corporis
105. Pregnant lady with carpel tunnel syndrome .what is true?
A. Surgical intervention is rarely needed
B. Splinting in hyperextension
C. Surgical correction
106. what is typical feature of carpal tunnel syndrome
A. severe pain awakening the patient at night
B. pain in the ring and little finger
C. paresthesia restricted to median nerve
D. history of myxedema
107. 3rd day blues what is correct? (*)
A. Occurs at least in 50% after delivery
B. More common following “C “section
C. Always lead to psychosis
D. Results in more premature malformed children
108. regarding child abuse
A. more common in deformed ,premature and LBW children
B. toddlers are more commonly affected
C. majority patients would have a psychiatric disorder
D. other children in the family wont get affected
109. confidentiality can be broken in which of the following situations
A. child abuse
B. when the police comes to ask
C. insurance matters
110. all are hepatotoxic except
A. paracetamol
B. OCP’S
C. Halothane
D. INH
111. carcinomatous change can occur in all except
A. Sjogren’s syndrome
B. thyrotoxicosis
C. coeliac disease
112. 2yr old child with chronic respiratory infection, what would you do?
A. Sweat chloride test
B. X ray chest
C. Barium meal
113. Child with chronic cough and rectal prolapse, diagnosis?
A. Congenital megacolon
B. Cystic fibrosis
C. Whooping cough
114. 6 weeks old child on breast feeding with 4 days constipation and thriving well diagnosis? (*)
A. Hirschsprung’s disease
B. normal variant
C. hypothyroidism
D. acquired constipation
115. Which of the following is not associated with brain metastasis?
A. Small cell Ca
B. Breast Ca
C. Renal Ca
D. Lung Ca
116. An elderly patient ,known case of Ca rectum , on morphine has chronic constipation and was
treated with lactulose but was not responding .what is the next step
A. Arrange a surgical consultation
B. Enema
C. P/R examination
D. Modify diet
117. All of the following are associated with Raynaud’s except
A. RA
B. SLE
C. Scleroderma
D. Dermatomyositis
E. Ankylosing spondylitis
118. cause of diarrhoea in an old bed ridden patient
A. faecal impaction
B. Carcinoma
C. Constipation
119. Haemolytic anaemia all are true except
A. Increased urobilinogen
B. Icterus and clear urine
C. MCV decreased
120. A child ingested washing powder half an hour ago next management(*)
A. Admit to hospital and possible endoscopy
B. Charcoal
C. Sent him home
D. Syrup of ipecacuanha
E. Observe
121. Mother of an 18 month child was concerned as it was not babbling .audiological assessment
was done when he was 10 months old .what is the next step
A. Arrange audiometry
B. Repeat hearing test
C. Reassure the mother
122. 71/2 yr old girl attained menarche; her mother noticed the breast growth and axillary hair
growth 6 months ago.
A. premature puberty
B. undiagnosed congenital adrenal hyperplasia
C. turner syndrome
123. In a young female patient what is the most common cause of subarachnoid haemorrhage?
A. Ruptured aneurysms
B. Av malformations
C. Mycotic aneurysms
D. trauma
124. A neonate few hours after birth developed cyanosis which was not responding to oxygen. NO
murmer is there. Diagnosis? (*)
A. Transposition of great vessels
B. Tetralogy of fallot’s
C. VSD
D. ASD
125. Lung Carcinoma seen in non smokers
A. Adenocarcinoma
B. Squamous cell carcinoma
C. Small cell ca.
D. Basal cell ca.
126. A child has facial movements and it is increased on watching TV (question on tics). They are
present even during examination.
A. Myoclonic epilepsy
B. Tics
C. Partial complex epilepsy
D. Panic attack
127. In TNM staging which has a better prognosis
A. T1 N0 M0
B. T1 N1 M0
C. T1 NI MI
128. 60 yr old female patient had repeated bilateral thrombophlebitis and DVT cause
A. pancreatic Cancer
B. ovarian cancer
C. protein c deficiency
129. Most common cause of central cyanosis
A. Left to right shunt
B. Right to left shunt
C. CO poisoning
130. Regarding immunology what is correct?
A. Ig G associated with atopic eczema
B. Delayed hypersensitivity is T cell mediated
131. Why is it difficult to differentiate beta HCG and LH
A. FSH high
B. LH high
C. Prolactin high
D. Progesterone low
132. Young hypertensive male with proteinuria, hematuria and upper respiratory infection for 2
days .Diagnosis?
A. Ig A nephropathy
B. Glomerulonephritis
C. Nephrotic syndrome
D. Acute pyelonephritis
E. Membrane nephropathy
133. All of these can cause gynecomastia except
A. Spironolactone
B. Cimetidine
C. Labetolol
D. Digoxin
E. methyldopa
134. which of the following is least likely associated with primary hypothyroidism
A. 72y/o with multinodular goitre
B. 28 y/o with menorrhagia
C. 9y/o with retarded bone age
D. 16y/o with anovulatory cycles
135. which of the following is incorrect :
A. alcohol reduces triglycerides
B. olive oil decreases HDL
C. increased LDL/HDL ratio is good
D. Taking 300 gms of fish daily does not reduce cholesterol
136. Point prevalence in schizophrenia means the
A. Current cases at that time
B. Cases in one year
C. The total number of cases
137. Regarding Diabetes mellitus what is true? (*)
A. At least take 100gms of carbohydrate everyday to prevent ketonuria.
B. If one parent has diabetes there is 1:8 chance of getting affected.
C. You can’t give insulin until level comes to normal.
138. Regarding diabetic foot ,all are true ,except (*)
A. 50% mortality following amputation
B. If the pulse is present patient is unlikely to have it.
C. To have diabetic foot controlling glucose level can help
139. Regarding 80% carotid artery stenosis. What is true? (*)
A. The incidence of stroke will be halved
B. 40% stroke with out treatment
C. 50% incidence of stroke after endarterectomy
D. 40% death will occur within 30days
140. Spiral # of humerus which nerve damaged
A. Radial
B. Ulnar
C. Median
D. Volkmann’s ischemia contracture
141. 50 yr old patient wakes up at night due to pain in the calf which is relieved by walking. What
is the cause?
A. Ischemic pain
B. Raynaud’s phenomenon
C. Muscular cramps
D. DVT
E. Intermittent claudication
142. A patient with pain in the calf worsened by elevation of feet
A. Ischemia
B. Nocturnal cramps
C. DVT
143. Which of the following feature is unlikely to be due to arterial ischemia
A. Pain along the buttock and thigh after exertion
B. Weakness of the buttock and thigh
C. Shooting pain from buttock and thigh
D. Leg paralysis
144. Most common feature of rectal carcinoma
A. Tenesmus
B. Bleeding
C. Incomplete defecation
D. rectal prolapse
145. A patient after MVA sustained a pelvic # and has blood in the external meatus ,initial
investigation of choice is (*)
A. Urethrogram
B. CT scan
C. Cystoscopy
D. Catherisation
E. IVU
146. Regarding uncomplicated haemorrhoids all are true except
A. Pain
B. Pruritus
C. Bleeding
D. Prolapse
E. Mucus discharge
147. Regarding PMS what is true?
A. 5% have very severe symptoms
B. 40% have PMS
C. all patients with PMS always have dysmenorrhoea
148. Patient mechanic with penetrating hand injury. What is true? (*)
A. Drainage should be done from extensor surface
B. It indicates that there is extension of the palmar abscess into extensor aspect
C. The swelling is due to oedema
D. It indicates the involvement of extensor tendons
149. Apathetic and dull are the negative symptoms of schizophrenia. Which is the other negative
symptom (*)
A. Catatonia
B. Blunted affect
C. Cataplexy
150. A patient who is aware about his own problems during treatment .what is it ? (*)
A. Instinct
B. Insight
C. Pseudo altruism
D. Intellectualisation
151. In chronic liver failure (obstructive jaundice) what’s true
A. Vitamin K absorption is reduced
B. Prothrombin cannot be converted to thrombin
C. Chronic hepatitis
152. In hemochromatosis after venesection all are true except
A. Skin pigmentation becomes normal
B. Cardiac siderosis is reversible
C. Hepatoma can be cured
153. In hemochromatosis
A. size of the liver is decreased following treatment
154. A patient with perforated peptic ulcer all are correct except
A. Patient remembers exactly the moment of rupture
B. Back pain
C. Vomiting
D. Board like rigidity
E. Guarding
155. Concerning cluster headache all are correct except
A. vomiting
B. treat with methysergide
C. occurs after 3-4 hrs of falling asleep
D. occurs at the same time of the day
156. A young man with throat infection in child hood and was treated with penicillin ..He now
comes with a fear of developing a rash due to penicillin as he was influenced by his friends words.
What does he have?
A. Induced delusion
B. Hypochondriasis
157. young man with needle marks and pin point pupils ,gag reflexes are normal ,no extensor
plantar reflexes(*)
A. opiate ingestion
B. temporoparietal #
158. A young man with left sucking wound in the chest .After initial airway resuscitation and
circulation management what is the next step(*) C.
A. Debridement and closure
B. Pressure bandage
C. IV fluids
159. Which infection is least likely during childbirth?
A. Syphilis
B. Gonorrhoea
C. Streptococcal
D. HIV
E. Herpes
160. Appropriate Estimation of the foetal gestational age is by (*)
A. Transvaginal ultrasound at 8 weeks
B. Bimanual examinations at 8 weeks
C. Ultrasound at 18 weeks
D. Transvaginal ultrasound at 18 weeks
161. Regarding OCP what is the absolute contraindication?
A. Focal migrainous hemiplegia
B. Hypertension
C. Diabetes
162. Regarding OCP what is correct? (*)
A. All the progesterone’s except cyproterone have derived from testosterone
B. Derive from oestrogen
C. Derive from progesterone
163. Young man with severe joint pain and profuse bleeding from venipuncture site. Diagnosis? (*)
A. DIC
B. Thrombophlebitis
C. Clotting defect
164. All are true regarding DIC except (*)
A. Fibrin decreased
B. FDP decreased
C. PTT increased
165. intermittent claudication commonest site
A. profunda femoris
B. superficial femoral artery
C. posterior tibial artery
D. bifurcation of abdominal aorta
E. external iliac artery
166. Which defence mechanism is mature?
A. Denial
B. Projection
C. Introjection
D. Humour
167. Undescended testis is most commonly associated with (*)
A. Torsion of testis
B. Spermatogenesis will be perfect if the operation is done before 3 years
C. Development delay of the child
D. Acute epididymitis
E. Hernia
168. G3P0 pregnant lady came to you at 16 weeks pregnancy .She had two spontaneous abortions
at 17 and 18 weeks in the previous pregnancies .how do you treat?
A. Chromosomal analysis
B. Cervical stitch
C. Complete bed rest
169. Regarding Mullerian agenesis all of the following is true except
A. Short vagina
B. Normal breast development
C. X linked recessive
170. What would be the most likely cause for bloody discharge from the nipple in a 50 year old
lady?
A. Intraductal papilloma
B. Intraductal carcinoma
C. Paget’s disease
D. Fibrocystic disease
171. The relative marker in Hepatocellular carcinoma is
A. PSA
B. CA125
C. CEA
D. CA153
E. AFP
172. Treatment of seminoma stage 2 with metastasis to the para-aortic lymph nodes
A. Radio therapy to testis and nodes
B. Surgery and radiation to Para aortic nodes
C. Chemotherapy
D. Surgery
173. 70 year old woman with vaginal prolapse with ring pessary what is the complication (*)
A. atrophic vaginitis
B. cervical carcinoma
C. decubitus ulcer
D. carcinoma of vagina
174. After splenectomy you expect all of the following except (*)
A. Life long increased risk of infection
B. Transient increased platelets to predispose to thrombosis
C. Persistent decrease of RBC life span
D. Decrease in anaemia
175. Diabetic mother after prolonged labour delivered a jittery baby which responds to oxygen
..what is the diagnosis
A. Hyperglycaemia
B. Hypoglycaemia
C. Meconium aspiration
D. Hyperbilirubinemia
176. Splenectomy is most beneficial in which of the following
A. Haemophilia
B. Chronic ITP
C. Myelofibrosis
177. A middle aged man unable to fall asleep has night mares and remembers his daily activities
diagnosis?
A. Anxiety disorder
B. Depression
C. OCD
D. Insomnia
178. Alcoholism is associated with all of the following except
A. Substance abuse (benzodiazepine)
B. Depression
C. OCD
179. Proteinuria is seen in all of the following except
A. congenital nephritis
B. RPGN
C. UTI
D. RA
E. Horseshoe kidney
180. Tourette syndrome ; all are correct except
A. Motor and vocal tics are seen
B. 2 or more bouts per day
C. the person is not distressed with vocal tics
D. coprolalia is less than 10%
E. onset always less than 18 years of age
181. A 35 year old lady has a grey greenish vaginal discharge, microscopy shows clue cells, and
she responded well to metronidazole .diagnosis (*)
A. Chlamydia
B. Bacterial vaginosis
C. Trichomoniasis
D. Moniliasis
182. Regarding stammering which is correct
A. spontaneous resolution at 16years
B. resolution after 2 year.
C. No resolution in life
D. Operative measure
183. Still birth after a normal delivery. all of the following tests are done except
A. Kleihaur test
B. Chromosomal analysis
C. Foetal parts
D. Maternal antibodies
E. Foetal post-mortem
184. Polyhydramnios all are true except
A. Rh incompatibility
B. Oesophageal atresia
C. bladder neck obstruction
D. Anencephaly
185. Polyhydramnios see in all except
A. Diabetes
B. Multiple pregnancy
C. Cardiac anomalies
D. Hydrops fetalis
186. Child with greyish tonsillar exudate and atypical lymphocytes
A. Infectious mononucleosis
B. CMV
C. ALL
187. Urge incontinence all are true except (*)
A. Colposuspension
B. Taping the vagina
C. Pelvic exercise
D. Weighted vaginal cones
188. (Regarding Rubella and pregnancy) a kindergarten teacher 6 weeks pregnant had one of her
student with rubella .all are true except
A. immunoglobulins
B. IgG is increased initially then IgM
C. Antibody measure and repeat SRH after 10 days
D. If mother infected early then child can have microcephaly, seizures and cataracts
189. A patient with pyloric stenosis vomiting a lot and vomitus contains undigested food material
taken 2 days back. What is the initial management?
A. Normal saline
B. Hartmann’s
C. Ringer lactate
190. daily requirement of potassium
A. 50mmol
B. 1gm
C. 30mmol
191. In pyloric stenosis vomiting is
A. Intermittent
B. Occurs 1hour after food
C. 2 days after food
192. A man with abdominal pain x ray showed multiple fluid levels .what is the management
A. 2 litres RL
B. 2 litres Hartmann’s before surgery
C. 2 litres Hartmann’s after surgery
D. 2 litres Hartmann’s after surgery
193. regarding antibiotic prophylaxis what is true
A. single dose is sufficient when compared to multidose
B. urologic surgery needs a culture for the specific antibiotic
194. 4 year old child constipated ,rectum empty and sphincter tone lax ,mass at the apex of
rectum
A. Hirschsprung’s
B. acquired megacolon
C. hypothyroidism
195. hypercalcemia seen in all except
A. hyperparathyroidism
B. pancreatitis
C. RTA
196. 3 year old girl with periorbital oedema ,protein 3+, all are true except
A. prednisolone will impr
answers..psychiatry
1...b
2...e
The diagnostic criteria for pyromania are:
deliberate and purposeful firesetting on more than one occasion;
tension or emotional arousal before the act;
intense interest, curiosity or fascination about fire (which can include fire equipment and the
consequences of fire);
pleasure, gratification or relief when setting or witnessing fires and their aftermath;
the firesetting is not done for another motive such as financial gain, anger or revenge, to gain
recognition or to relieve boredom, and is not done in response to a delusion or hallucination or due
to impaired judgment (such as through intoxication); and
the firesetting is not better accounted for by conduct disorder, antisocial personality disorder or a
manic episode.
3...c
4...a
5...d
6...b
7...b
8...d
9...a
10...c
11...f
12...a
13...b
14...e
15...e
16...e 6 weeks post partum
17...b...not sure ,this is what happens in seasonal dysthymic disorder
18...a Delusion
A delusion is commonly defined as a fixed false belief and is used in everyday language to describe
a belief that is either false, fanciful or derived from deception.
19...
20...e
21...d
22...a
23...b...also in alcoholism and cocaine addiction
24...e
25...b
26...b
27...c
28...developed what
29...a????
32....fear is a common cause
33...a
35...c
37...b
38...a
39...d
41...a
43...a
44...a
45...a
46...b
MEDICINE
1...b....in ant.dislocations
3...c
4...c
5...d
6...a
7...d
8...a
9...c
10...b
11...c
12...b
13...d
14...d
15...c
16...b
17...b
18...c
19...c
22...c
23...c
24...d
26...c
27...e...
28...e
29...a
30...d
31...e....not sure
32...b.......not sure
34...d
35...b
36...c
37...a
38...d
39...c
41...c
43...c
44...c
46...c
47...c
48...c
49...c
50...b
51...c
52...d...????
53...advice to stop taking pills from the this pack that will initiate bleeding and start another .
54...a
55...c
56...a
57...d
58...c
59...a???
60...c
61...???
62...e
63...a
65...d
66...c ....its 41 weeks!
67...c..b/c volkmann contractures r common in this injury
68...b
69...a though all epiphyseal # dont cause growth retardation..it depends on severity of injury,
invovement of growth plate
70...e....if it is "hypoplasia
MEDICINE, SURGERY , OBSTETRICS AND PSYCHIATRY
1...b
2...a
3...c
4...b
5...c...US ?????
6...all r false except d
7...d...afterload reducers r not used in AS.
8...d
9...b
10...a
11...a
12...c caused in this age group by S. pnemoniae, H.influenzae and staphlococcus.
13...b...excessive crying causes cyanosis
14...b
15...c????
16...c
17...c???
18...a
19...a
20...b...b/c the most common cause of scrotal pain in infants and children is torsion f testes
22...b ...
23...b
24...b
25...c
26...b
28...d????
30...b
31...a
32...c ????? anyone??
33...b
34...c
35...e
37...b
38...e
39...d
40...a
41...b
42...a
43...c
44...a
45...a
46...d ...c can also be true b/c sometimes acoustic neuroma patients dont complain of tinnitis.
47...D
PICA =posterior inf cerebellar artery .
Lateral medullary syndrome (also called Wallenberg's syndrome and posterior inferior cerebellar
artery syndrome) is a disease in which the patient has difficulty with swallowing or speaking or
both owing to one or more patches of dead tissue (known as an infarct) caused by interrupted
blood supply to parts of the brain.
This syndrome is characterized by sensory deficits affecting the trunk and extremities on the
opposite side of the infarct and sensory and motor deficits affecting the face and cranial nerves on
the same side with the infarct. Other clinical symptoms and findings are ataxia, facial pain, vertigo,
nystagmus, Horner's syndrome, diplopia and dysphagia. The cause of this syndrome is usually the
occlusion of the posterior inferior cerebellar artery (PICA) at its origin.
The affected persons have difficulty in swallowing (dysphagia) resulting from involvement of the
nucleus ambiguus, and slurred speech (dysphonia, dysarthria). Damage to the spinal trigeminal
nucleus causes absence of pain on the ipsilateral side of the face, as well as an absent corneal
reflex.
The spinothalamic tract is damaged, resulting in loss of pain and temperature sensation to the
opposite side of the body. The damage to the cerebellum or the inferior cerebellar peduncle can
cause ataxia.
48...c
49..d
50...b
51...b
52...a
54...a
57...d???
62...c
63...a
65...e
66...d
67...O2 then adrenaline
69...a
74...c
75...b
76...a
77...b
78...b
79...a
80...a
81...b
82...a
83...a
84...a
86...b
87...b
88...b
89...b
90...b
Wednesday 4 November 2009
Tuesday 6 October 2009
HIV AND "SKIN"
Fungal/yeast
1 Candida (oral or oesophageal)
2 Tinea infections (corporis,
cruris, pedis, interdigitale etc)
3 Pityriasis versicolor
4 Seborrhoeic dermatitis
(especially when severe or
recalcitrant)
5 Pityrosporum folliculitis
Viral
1 Herpes zoster
2 Herpes simplex
3 Viral wart infections
4 Molluscum contagiosum
Bacterial
5 Staphylococcus aureusimpetigo,
chronic folliculitis
Mycobacterial
6 M tuberculosis
Infestations
7 Scabies (especially Norwegian
scabies)
Other
1 Psoriasis
2 Kaposi’s sarcoma
3 Acne
All of these skin conditions can
occur without HIV, but consider
HIV particularly if they are
recalcitrant, recurrent or atypical.
1 Candida (oral or oesophageal)
2 Tinea infections (corporis,
cruris, pedis, interdigitale etc)
3 Pityriasis versicolor
4 Seborrhoeic dermatitis
(especially when severe or
recalcitrant)
5 Pityrosporum folliculitis
Viral
1 Herpes zoster
2 Herpes simplex
3 Viral wart infections
4 Molluscum contagiosum
Bacterial
5 Staphylococcus aureusimpetigo,
chronic folliculitis
Mycobacterial
6 M tuberculosis
Infestations
7 Scabies (especially Norwegian
scabies)
Other
1 Psoriasis
2 Kaposi’s sarcoma
3 Acne
All of these skin conditions can
occur without HIV, but consider
HIV particularly if they are
recalcitrant, recurrent or atypical.
HIV Presentation
Acute HIV-related conditions that may present in the emergency
department
1. Community acquired bacterial pneumonia. People with HIV, regardless of their level of
immunosuppression, are more at risk of bacterial pneumonia. They have similar signs
and symptoms to the non-HIV-infected population, eg fever, cough, dyspnoea,
increased respiratory rate and sputum production.
2. TB presents with malaise, weight loss, night sweats, fever, cough, sputum production
(may be blood-stained), and lymphadenopathy.
3. Pneumocystis pneumonia (PCP) presents with exertional dyspnoea, fever, dry cough,
normal auscultation. X-ray typically shows perihilar shadowing (ground glass haze),
but may be normal.
4. Cryptococcal meningitis. This presents with headache, with or without classical signs
of meningism. Occasionally rapid progression occurs, and the patient may present in
coma.
5. Cerebral toxoplasmosis. This may present with headache, fever, lethargy and
confusion, progressing to fits and coma.
department
1. Community acquired bacterial pneumonia. People with HIV, regardless of their level of
immunosuppression, are more at risk of bacterial pneumonia. They have similar signs
and symptoms to the non-HIV-infected population, eg fever, cough, dyspnoea,
increased respiratory rate and sputum production.
2. TB presents with malaise, weight loss, night sweats, fever, cough, sputum production
(may be blood-stained), and lymphadenopathy.
3. Pneumocystis pneumonia (PCP) presents with exertional dyspnoea, fever, dry cough,
normal auscultation. X-ray typically shows perihilar shadowing (ground glass haze),
but may be normal.
4. Cryptococcal meningitis. This presents with headache, with or without classical signs
of meningism. Occasionally rapid progression occurs, and the patient may present in
coma.
5. Cerebral toxoplasmosis. This may present with headache, fever, lethargy and
confusion, progressing to fits and coma.
Thursday 24 September 2009
EPILEPSY MANAGEMENT-AUSTRALIA
Treatment of status epilepticus in hospital.
1.Immediate measures Secure airway
Give oxygen
Assess cardiac and respiratory function
Secure iv access
Give lorazepam 4 mg iv or diazepam
10 mg iv
Repeat after 10 mins if no response
2.In hospital
Take blood for electrolytes, LFT, calcium,
glucose, clotting, AED levels and storage
for later analysis
Measure blood gases
Establish aetiology
Give thiamine or 50% glucose solution if
indicated
Within 30 minutes In patients with established epilepsy:
give usual AED orally, NG or iv
3.In patients with new-onset epilepsy or if
seizures continue:
fosphenytoin (18 mg/kg phenytoin
equivalent), up to 150 mg/min with ECG
monitoring or phenytoin 18mg/kg,
50 mg/min with ECG or phenobarbital
15 mg/kg iv, 100 mg/min
Longer than ITU may be necessary
minutes Anaesthetise with EEG monitoring
Midazolam, phenobarbital, propofol, or
thiopentone most commonly used
Non-convulsive status Augment or reinstate usual AEDs
Consider lorazepam or diazepam iv
1.Immediate measures Secure airway
Give oxygen
Assess cardiac and respiratory function
Secure iv access
Give lorazepam 4 mg iv or diazepam
10 mg iv
Repeat after 10 mins if no response
2.In hospital
Take blood for electrolytes, LFT, calcium,
glucose, clotting, AED levels and storage
for later analysis
Measure blood gases
Establish aetiology
Give thiamine or 50% glucose solution if
indicated
Within 30 minutes In patients with established epilepsy:
give usual AED orally, NG or iv
3.In patients with new-onset epilepsy or if
seizures continue:
fosphenytoin (18 mg/kg phenytoin
equivalent), up to 150 mg/min with ECG
monitoring or phenytoin 18mg/kg,
50 mg/min with ECG or phenobarbital
15 mg/kg iv, 100 mg/min
Longer than ITU may be necessary
minutes Anaesthetise with EEG monitoring
Midazolam, phenobarbital, propofol, or
thiopentone most commonly used
Non-convulsive status Augment or reinstate usual AEDs
Consider lorazepam or diazepam iv
PNEUMONIA INFECTIOUS AGENTS
1.Haemophilus influenza -Smokers, COPD
2.Mycoplasma --------Young, otherwise healthy patients
3.Legionella --------Epidemic infection in older smokers, particularly when located near infected water sources, such as air-conditioning systems
4.Pneumocystis jiroveci (formerly carinii) pneumonia HIV-positive persons with <200 CD4 cells not on prophylaxis.
5.Coxiella burnetti (Q-fever) Exposure to animals, particularly at the time they are giving birth
6.Klebsiella Alcoholics
7.Staphylococcus aureus Following viral syndromes or viral bronchitis, especially influenza
8.Coccidioidomycosis Exposure to the deserts of the American Southwest, particularly Arizona
9.Chlamydia psittaci Exposure to birds
10.Histoplasma capsulatum Exposure to bat or bird droppings, spelunking (recreational cave exploration)
11.Bordetella pertussis Cough with whoop and post-tussive vomiting
12.Francisella tularensis Hunters, or exposure to rabbits
SARS, Avian injluenza Travel to Southeast Asia
13.Bacillus anthracis, Yersinia pestis, and Francisella tularensis Bioterrorism
2.Mycoplasma --------Young, otherwise healthy patients
3.Legionella --------Epidemic infection in older smokers, particularly when located near infected water sources, such as air-conditioning systems
4.Pneumocystis jiroveci (formerly carinii) pneumonia HIV-positive persons with <200 CD4 cells not on prophylaxis.
5.Coxiella burnetti (Q-fever) Exposure to animals, particularly at the time they are giving birth
6.Klebsiella Alcoholics
7.Staphylococcus aureus Following viral syndromes or viral bronchitis, especially influenza
8.Coccidioidomycosis Exposure to the deserts of the American Southwest, particularly Arizona
9.Chlamydia psittaci Exposure to birds
10.Histoplasma capsulatum Exposure to bat or bird droppings, spelunking (recreational cave exploration)
11.Bordetella pertussis Cough with whoop and post-tussive vomiting
12.Francisella tularensis Hunters, or exposure to rabbits
SARS, Avian injluenza Travel to Southeast Asia
13.Bacillus anthracis, Yersinia pestis, and Francisella tularensis Bioterrorism
Sunday 16 August 2009
ANDROGEN DEFICIENCY IN MALE
Symptoms and signs suggestive of
androgen deficiency in men
• Incomplete sexual development, eunuchoidism,
aspermia
• Reduced sexual desire (libido) and activity
• Decreased spontaneous erections
• Breast discomfort, gynecomastia
• Loss of body (axillary and pubic) hair, reduced shaving
• Very small or shrinking testes (especially < 5 mL)
• Inability to father children, low or zero sperm counts
• Height loss, low-trauma fracture, low bone mineral
density
• Reduced muscle bulk and strength
• Hot flushes, sweats
androgen deficiency in men
• Incomplete sexual development, eunuchoidism,
aspermia
• Reduced sexual desire (libido) and activity
• Decreased spontaneous erections
• Breast discomfort, gynecomastia
• Loss of body (axillary and pubic) hair, reduced shaving
• Very small or shrinking testes (especially < 5 mL)
• Inability to father children, low or zero sperm counts
• Height loss, low-trauma fracture, low bone mineral
density
• Reduced muscle bulk and strength
• Hot flushes, sweats
Wednesday 12 August 2009
AUTOSOMAL DOMINENT CONDITIONS
Autosomal dominant inheritance is seen in:
Achondroplasia, Acute intermittent porphyria, Adult polycystic kidney disease, Ehlers-Danlos syndrome, Familial adenomatous polyposis, Gilbert's syndrome, Hereditary sensory and motor neuropathy, Hereditary spherocytosis, Huntington's disease, Hyperlipidaemia type II, Malignant hyperthermia, Marfan's syndrome, Myotonia congenita, Myotonic dystrophy, Neurofibromatosis, Osteogenesis imperfecta type 1, Noonan's syndrome, Polyposis coli, Rotor syndrome, Retinoblastoma, Tuberose sclerosis, Von Hippel-Lindau disease, von Willebrand's disease
Achondroplasia, Acute intermittent porphyria, Adult polycystic kidney disease, Ehlers-Danlos syndrome, Familial adenomatous polyposis, Gilbert's syndrome, Hereditary sensory and motor neuropathy, Hereditary spherocytosis, Huntington's disease, Hyperlipidaemia type II, Malignant hyperthermia, Marfan's syndrome, Myotonia congenita, Myotonic dystrophy, Neurofibromatosis, Osteogenesis imperfecta type 1, Noonan's syndrome, Polyposis coli, Rotor syndrome, Retinoblastoma, Tuberose sclerosis, Von Hippel-Lindau disease, von Willebrand's disease
Saturday 6 June 2009
ISOTRETINOIN IN ACNE
Features of oral isotretinoin treatment
• For patients with severe acne
• For patients unresponsive to conventional therapy
• For acne patients experiencing psychological distress
• Extremely effective, as it targets all causes of acne
• Duration of treatment and daily dose are individualised
• Low starting dose is used that may be gradually increased, as
tolerated
• Side effects are usually manageable
• Warn of mood changes and the potential risk of depression
• Warn about contraception and teratogenicity
• For patients with severe acne
• For patients unresponsive to conventional therapy
• For acne patients experiencing psychological distress
• Extremely effective, as it targets all causes of acne
• Duration of treatment and daily dose are individualised
• Low starting dose is used that may be gradually increased, as
tolerated
• Side effects are usually manageable
• Warn of mood changes and the potential risk of depression
• Warn about contraception and teratogenicity
ISOTRETINOIN IN ACNE
Features of oral isotretinoin treatment
• For patients with severe acne
• For patients unresponsive to conventional therapy
• For acne patients experiencing psychological distress
• Extremely effective, as it targets all causes of acne
• Duration of treatment and daily dose are individualised
• Low starting dose is used that may be gradually increased, as
tolerated
• Side effects are usually manageable
• Warn of mood changes and the potential risk of depression
• Warn about contraception and teratogenicity
• For patients with severe acne
• For patients unresponsive to conventional therapy
• For acne patients experiencing psychological distress
• Extremely effective, as it targets all causes of acne
• Duration of treatment and daily dose are individualised
• Low starting dose is used that may be gradually increased, as
tolerated
• Side effects are usually manageable
• Warn of mood changes and the potential risk of depression
• Warn about contraception and teratogenicity
ACNE TREATMENT
Tips for antibiotic
therapy
• Do not use topical and
oral antibiotics at the
same time
• Use oral antibiotics for a
6-12-week course
• If a longer course of oral
antibiotics is required, use
benzoyl peroxide for a
week between courses
• Warn of side effects of
antibiotic therapy,
particularly
photosensitivity with
doxycycline
therapy
• Do not use topical and
oral antibiotics at the
same time
• Use oral antibiotics for a
6-12-week course
• If a longer course of oral
antibiotics is required, use
benzoyl peroxide for a
week between courses
• Warn of side effects of
antibiotic therapy,
particularly
photosensitivity with
doxycycline
ACNE MANAGEMENT
IMPORTANT POINTS HISTORY AND EXAMINATION
History
• How long have you had
pimples for?
• Are there any triggers?
• Is there a family history?
• What treatments have you
had? How long did you
follow each treatment?
• What was the most
effective treatment? Why
did you stop it?
• How do you feel about
your skin? Does it stop
you from doing anything?
Examination
• Assess the severity and
whether there is any
scarring.
• Determine any
psychological impact.
History
• How long have you had
pimples for?
• Are there any triggers?
• Is there a family history?
• What treatments have you
had? How long did you
follow each treatment?
• What was the most
effective treatment? Why
did you stop it?
• How do you feel about
your skin? Does it stop
you from doing anything?
Examination
• Assess the severity and
whether there is any
scarring.
• Determine any
psychological impact.
Saturday 30 May 2009
Lethal In Low Doses
Box 1: Nine ingestants that can be
lethal in toddlers in low doses
• Calcium channel blockers
• Camphor
• Imidazolines (eg, clonidine)
• Cyclic antidepressants
• Lomotil
• Opiates
• Salicylates
• Sulphonylureas
• Toxic alcohols
Note: Not in order of lethality
lethal in toddlers in low doses
• Calcium channel blockers
• Camphor
• Imidazolines (eg, clonidine)
• Cyclic antidepressants
• Lomotil
• Opiates
• Salicylates
• Sulphonylureas
• Toxic alcohols
Note: Not in order of lethality
Friday 1 May 2009
Preventing Recurrent DVT
A patient with successfully treated
DVT remains at increased risk of
DVT or PE for life and will need prophylaxis
at times. Prophylaxis (with,
for example, enoxaparin 40mg daily)
should begin 12 hours before elective
surgery.
In orthopaedic surgery, it should
be continued at this dose for three
weeks after discharge from hospital2.
Early remobilisation and compression
stockings should be used routinely
for all surgery. Intra-operative
calf compression machines are often
used in prolonged elective surgery.
High-risk medical patients (eg,
those likely to be inpatients for more
than five days) should receive routine
prophylaxis whether or not they
have had a prior DVT.
Seek advice if the patient has renal
impairment because LMW heparins
accumulate quickly in patients with
moderate to severe renal failure.
All women with previous DVT or
artificial heart valves should receive
daily heparin prophylaxis during
pregnancy. Haematological review is
recommended in those with diagnosed
thrombophilia (deficiency of
anti-thrombin III, protein C or S,
mutations of factor V or prothrombin
genes), as more intense prophylaxis
may be needed in some.
Patients with a past history of
DVT who are planning air travel for
more than four hours should be
given recommendations in writing:
• Self-inject 40mg enoxaparin before
each separate flight (not including
refuelling stops)
• Ask for a seat with good leg room
• Accept every non-alcoholic
beverage offered
• Minimise alcohol consumption
• Perform in-seat exercises recommended
by the airline.
National guidelines do not recommend
frequent walking around the
cabin because of the risk of turbulence.
Aspirin does more harm than
good in air travellers.
References
Current Diagnosis of Venous Thromboembolism
in Primary Care: A Clinical Practice Guideline,
American Academy of Family Physicians and
the American College of Physicians.
Annals of Internal Medicine: p57- 62: Vol 5:
No 1: January/February 2007
1. Palareti G., Cosmi B., Legnani C., et al. DDimer
Testing to Determine the Duration of
Anticoagulation Therapy. N Engl J Med 2006;
355:1780-1789, Oct 26, 2006.
DVT remains at increased risk of
DVT or PE for life and will need prophylaxis
at times. Prophylaxis (with,
for example, enoxaparin 40mg daily)
should begin 12 hours before elective
surgery.
In orthopaedic surgery, it should
be continued at this dose for three
weeks after discharge from hospital2.
Early remobilisation and compression
stockings should be used routinely
for all surgery. Intra-operative
calf compression machines are often
used in prolonged elective surgery.
High-risk medical patients (eg,
those likely to be inpatients for more
than five days) should receive routine
prophylaxis whether or not they
have had a prior DVT.
Seek advice if the patient has renal
impairment because LMW heparins
accumulate quickly in patients with
moderate to severe renal failure.
All women with previous DVT or
artificial heart valves should receive
daily heparin prophylaxis during
pregnancy. Haematological review is
recommended in those with diagnosed
thrombophilia (deficiency of
anti-thrombin III, protein C or S,
mutations of factor V or prothrombin
genes), as more intense prophylaxis
may be needed in some.
Patients with a past history of
DVT who are planning air travel for
more than four hours should be
given recommendations in writing:
• Self-inject 40mg enoxaparin before
each separate flight (not including
refuelling stops)
• Ask for a seat with good leg room
• Accept every non-alcoholic
beverage offered
• Minimise alcohol consumption
• Perform in-seat exercises recommended
by the airline.
National guidelines do not recommend
frequent walking around the
cabin because of the risk of turbulence.
Aspirin does more harm than
good in air travellers.
References
Current Diagnosis of Venous Thromboembolism
in Primary Care: A Clinical Practice Guideline,
American Academy of Family Physicians and
the American College of Physicians.
Annals of Internal Medicine: p57- 62: Vol 5:
No 1: January/February 2007
1. Palareti G., Cosmi B., Legnani C., et al. DDimer
Testing to Determine the Duration of
Anticoagulation Therapy. N Engl J Med 2006;
355:1780-1789, Oct 26, 2006.
Preventing Recurrent DVT
A patient with successfully treated
DVT remains at increased risk of
DVT or PE for life and will need prophylaxis
at times. Prophylaxis (with,
for example, enoxaparin 40mg daily)
should begin 12 hours before elective
surgery.
In orthopaedic surgery, it should
be continued at this dose for three
weeks after discharge from hospital2.
Early remobilisation and compression
stockings should be used routinely
for all surgery. Intra-operative
calf compression machines are often
used in prolonged elective surgery.
High-risk medical patients (eg,
those likely to be inpatients for more
than five days) should receive routine
prophylaxis whether or not they
have had a prior DVT.
Seek advice if the patient has renal
impairment because LMW heparins
accumulate quickly in patients with
moderate to severe renal failure.
All women with previous DVT or
artificial heart valves should receive
daily heparin prophylaxis during
pregnancy. Haematological review is
recommended in those with diagnosed
thrombophilia (deficiency of
anti-thrombin III, protein C or S,
mutations of factor V or prothrombin
genes), as more intense prophylaxis
may be needed in some.
Patients with a past history of
DVT who are planning air travel for
more than four hours should be
given recommendations in writing:
• Self-inject 40mg enoxaparin before
each separate flight (not including
refuelling stops)
• Ask for a seat with good leg room
• Accept every non-alcoholic
beverage offered
• Minimise alcohol consumption
• Perform in-seat exercises recommended
by the airline.
National guidelines do not recommend
frequent walking around the
cabin because of the risk of turbulence.
Aspirin does more harm than
good in air travellers.
References
Current Diagnosis of Venous Thromboembolism
in Primary Care: A Clinical Practice Guideline,
American Academy of Family Physicians and
the American College of Physicians.
Annals of Internal Medicine: p57- 62: Vol 5:
No 1: January/February 2007
1. Palareti G., Cosmi B., Legnani C., et al. DDimer
Testing to Determine the Duration of
Anticoagulation Therapy. N Engl J Med 2006;
355:1780-1789, Oct 26, 2006.
2. TGA-approved product information for
DVT remains at increased risk of
DVT or PE for life and will need prophylaxis
at times. Prophylaxis (with,
for example, enoxaparin 40mg daily)
should begin 12 hours before elective
surgery.
In orthopaedic surgery, it should
be continued at this dose for three
weeks after discharge from hospital2.
Early remobilisation and compression
stockings should be used routinely
for all surgery. Intra-operative
calf compression machines are often
used in prolonged elective surgery.
High-risk medical patients (eg,
those likely to be inpatients for more
than five days) should receive routine
prophylaxis whether or not they
have had a prior DVT.
Seek advice if the patient has renal
impairment because LMW heparins
accumulate quickly in patients with
moderate to severe renal failure.
All women with previous DVT or
artificial heart valves should receive
daily heparin prophylaxis during
pregnancy. Haematological review is
recommended in those with diagnosed
thrombophilia (deficiency of
anti-thrombin III, protein C or S,
mutations of factor V or prothrombin
genes), as more intense prophylaxis
may be needed in some.
Patients with a past history of
DVT who are planning air travel for
more than four hours should be
given recommendations in writing:
• Self-inject 40mg enoxaparin before
each separate flight (not including
refuelling stops)
• Ask for a seat with good leg room
• Accept every non-alcoholic
beverage offered
• Minimise alcohol consumption
• Perform in-seat exercises recommended
by the airline.
National guidelines do not recommend
frequent walking around the
cabin because of the risk of turbulence.
Aspirin does more harm than
good in air travellers.
References
Current Diagnosis of Venous Thromboembolism
in Primary Care: A Clinical Practice Guideline,
American Academy of Family Physicians and
the American College of Physicians.
Annals of Internal Medicine: p57- 62: Vol 5:
No 1: January/February 2007
1. Palareti G., Cosmi B., Legnani C., et al. DDimer
Testing to Determine the Duration of
Anticoagulation Therapy. N Engl J Med 2006;
355:1780-1789, Oct 26, 2006.
2. TGA-approved product information for
DVT FACTS
1. The surgical or sick medical
patient is the classic high-risk
person for DVT.
2.High clinical suspicion and a
positive D-dimer mandate further
investigation.
3.If suspicion is high, treatment for
DVT or PE should be started as
soon as the diagnosis is
suspected, not delayed for
confirmatory imaging studies.
Many DVTs are unprovoked,
especially in males.
4.Testing INR too often wastes
resources and leaves you making
frequent dose changes to ‘chase
your tail’.
5.Electing to continue warfarin for
12 months delays recurrence of
VTE but does not eliminate it.
patient is the classic high-risk
person for DVT.
2.High clinical suspicion and a
positive D-dimer mandate further
investigation.
3.If suspicion is high, treatment for
DVT or PE should be started as
soon as the diagnosis is
suspected, not delayed for
confirmatory imaging studies.
Many DVTs are unprovoked,
especially in males.
4.Testing INR too often wastes
resources and leaves you making
frequent dose changes to ‘chase
your tail’.
5.Electing to continue warfarin for
12 months delays recurrence of
VTE but does not eliminate it.
Friday 17 April 2009
INVESTIGATIONS OF INFECTIVE SYMPTOMS IN PREGNANCY
Clinical presentation Possible diagnosis Investigations
Maculopapular rash Rubella IgM and IgG*
Parvovirus IgM and IgG*
Enterovirus Throat or faecal culture
Vesicular rash Varicella Rash IgM and IgG* if uncertain
Enterovirus Throat or faecal culture
Flu-like symptoms CMV IgM and IgG*
(fever, myalgia, malaise, LFTs, FBC
+/- lymphadenopathy) Toxoplasmosis IgM and IgG*
Listeriosis Blood and faecal culture
Other viral infections Serology or culture as required
*In parallel with previous
antenatal serum and 2-4 weeks later if required
Maculopapular rash Rubella IgM and IgG*
Parvovirus IgM and IgG*
Enterovirus Throat or faecal culture
Vesicular rash Varicella Rash IgM and IgG* if uncertain
Enterovirus Throat or faecal culture
Flu-like symptoms CMV IgM and IgG*
(fever, myalgia, malaise, LFTs, FBC
+/- lymphadenopathy) Toxoplasmosis IgM and IgG*
Listeriosis Blood and faecal culture
Other viral infections Serology or culture as required
*In parallel with previous
antenatal serum and 2-4 weeks later if required
PREPREGNANCY COUNSELLING.
GPs should encourage couples who are planning
to conceive to have counselling and
testing before conception.
Tests for infection should include:
• rubella IgG
• syphilis serology – TPHA or RPR
• hepatitis B serology – hepatitis B
surface antigen
• hepatitis C serology – hepatitis C antibody
• HIV
• varicella – IgG
• CMV IgG (in high-risk patients)
Women who have negative rubella serology
should be offered MMR vaccine and
retested for rubella seroconversion eight
weeks later. About 5% will need revaccination.
A very small number of women will
remain rubella seronegative despite two successive
MMR vaccinations.
It is unlikely that further vaccination will
lead to seroconversion. In these cases it is
best to counsel the woman to avoid rubella
contact in her subsequent pregnancy.
Women found negative to varicella IgG
should be offered varicella vaccine with two
doses, eight weeks apart. Pregnancy should
be delayed until eight weeks after vaccination
for rubella or varicella.
In those at high risk of CMV infection
(carers of young children), CMV IgG should
also be measured.
Seronegative women should be counselled
to practise thorough hygiene when in
contact with secretions of newborn infants
and toddlers.
A pre-pregnancy session will also allow
the GP to provide nutritional advice and
instructions on ways to minimise risks of
infection with toxoplasmosis, listeria and
other infections.
to conceive to have counselling and
testing before conception.
Tests for infection should include:
• rubella IgG
• syphilis serology – TPHA or RPR
• hepatitis B serology – hepatitis B
surface antigen
• hepatitis C serology – hepatitis C antibody
• HIV
• varicella – IgG
• CMV IgG (in high-risk patients)
Women who have negative rubella serology
should be offered MMR vaccine and
retested for rubella seroconversion eight
weeks later. About 5% will need revaccination.
A very small number of women will
remain rubella seronegative despite two successive
MMR vaccinations.
It is unlikely that further vaccination will
lead to seroconversion. In these cases it is
best to counsel the woman to avoid rubella
contact in her subsequent pregnancy.
Women found negative to varicella IgG
should be offered varicella vaccine with two
doses, eight weeks apart. Pregnancy should
be delayed until eight weeks after vaccination
for rubella or varicella.
In those at high risk of CMV infection
(carers of young children), CMV IgG should
also be measured.
Seronegative women should be counselled
to practise thorough hygiene when in
contact with secretions of newborn infants
and toddlers.
A pre-pregnancy session will also allow
the GP to provide nutritional advice and
instructions on ways to minimise risks of
infection with toxoplasmosis, listeria and
other infections.
Monday 13 April 2009
SIGNS OF A PERFORATED EYE
■ an irregular or peaked pupil
■ a shallow anterior chamber
compared to the other eye
■ absent or diminished red
reflex
■ a boggy haemorrhagic
swelling over the sclera
■ uveal tissue, which is dark,
lying external to the globe
Note: not all these signs need
be present.
■ a shallow anterior chamber
compared to the other eye
■ absent or diminished red
reflex
■ a boggy haemorrhagic
swelling over the sclera
■ uveal tissue, which is dark,
lying external to the globe
Note: not all these signs need
be present.
EYE EXAMINATIO TOOLS
■ a vision chart
■ a light source with a cobalt
blue filter
■ a means of magnification such
as loupes (or a pair of +3.0
“chemist’s glasses”)
■ amethocaine drops to
anaesthetise the ocular surface
■ fluorescein drops to stain any
epithelial defects
■ cycloplegic drops to dilate the
pupil
■ an ophthalmoscope to visualise
the red reflex and/or posterior
segment of the eye
■ cotton buds to wipe up any
secretions and help evert the
upper lid.
■ a light source with a cobalt
blue filter
■ a means of magnification such
as loupes (or a pair of +3.0
“chemist’s glasses”)
■ amethocaine drops to
anaesthetise the ocular surface
■ fluorescein drops to stain any
epithelial defects
■ cycloplegic drops to dilate the
pupil
■ an ophthalmoscope to visualise
the red reflex and/or posterior
segment of the eye
■ cotton buds to wipe up any
secretions and help evert the
upper lid.
Sunday 5 April 2009
Diagnosis of metabolic Syndrome
The size of the waistline is the key
to selecting patients to investigate.
People who are genetically predisposed
and who take in an excessive
amount of calories are most
likely to develop this condition.
The lean man with a pot belly, a
shape seen commonly in general
practice, could be considered the
most toxic shape of all.
Objective assessment of known
risk factors (cholesterol, fasting
lipids, blood glucose level, blood
pressure, smoking, obesity and
sedentariness) is also necessary.
Risk factors for metabolic syndrome
often cluster together and have
a multiplicative rather than an additive
effect. In women, it is the level
of fasting triglycerides, rather than
cholesterol, that predicts subsequent
cardiovascular disease and death.
Waist target parameters have
tightened over time and vary according
to genetic polymorphism (see
table below).
If BMI is >30kg/m2, central
obesity can be assumed and waist
circumference does not need to be
measured. Abnormal blood glucose
should be investigated with a
glucose tolerance test.
About a third of patients with diabetes
will be picked up by the
glucose tolerance test compared with
just focusing on the fasting glucose.
Obesity and central adiposity
seem to co-segregate, not only with
cardiovascular and diabetes risk, but
also with an increased risk of certain
types of malignancy, such as breast
and endometrial cancer.
to selecting patients to investigate.
People who are genetically predisposed
and who take in an excessive
amount of calories are most
likely to develop this condition.
The lean man with a pot belly, a
shape seen commonly in general
practice, could be considered the
most toxic shape of all.
Objective assessment of known
risk factors (cholesterol, fasting
lipids, blood glucose level, blood
pressure, smoking, obesity and
sedentariness) is also necessary.
Risk factors for metabolic syndrome
often cluster together and have
a multiplicative rather than an additive
effect. In women, it is the level
of fasting triglycerides, rather than
cholesterol, that predicts subsequent
cardiovascular disease and death.
Waist target parameters have
tightened over time and vary according
to genetic polymorphism (see
table below).
If BMI is >30kg/m2, central
obesity can be assumed and waist
circumference does not need to be
measured. Abnormal blood glucose
should be investigated with a
glucose tolerance test.
About a third of patients with diabetes
will be picked up by the
glucose tolerance test compared with
just focusing on the fasting glucose.
Obesity and central adiposity
seem to co-segregate, not only with
cardiovascular and diabetes risk, but
also with an increased risk of certain
types of malignancy, such as breast
and endometrial cancer.
METABOLIC SYNDROME
the International
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised
fasting plasma glucose
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised
fasting plasma glucose
METABOLIC SYNDROME
the International
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised
fasting plasma glucose
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised
fasting plasma glucose
METABOLIC SYNDROME
the International
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised fasting plasma glucose
Diabetes Federation published a consensus
worldwide definition of metabolic syndrome.
It is defined as central obesity in
concurrence with any two of the following
factors: raised triglycerides, reduced HDL
cholesterol, raised blood pressure or raised fasting plasma glucose
Friday 3 April 2009
CASE STUDY
CASE ONE
A mother brings her six-year-old
son to your emergency department.
He was practising his “Power
Ranger” moves in the family’s
split-level living room and leapt
from the upper to the lower level,
landing heavily on his feet. He
complains of neck pain but no
other symptoms.
What features are present on
inspection?
He has a torticollis, and is in some
degree of pain.
What immobilisation is
indicated?
This child would not fit into a collar.
Forcing the issue would create further
pain and distress and may exacerbate
an injury. He should be allowed to
adopt a position of comfort, with
padded support if necessary, and
given simple analgesia as required.
What imaging is indicated?
X-rays are indicated as an initial investigation,
but should be interpreted
with care, with recognition that in
this age-group plain X-rays are
known to be poorly sensitive.
What is the injury?
X-rays showed an anterior subluxation
of C2 on C3. In this particular
case, injury was missed on two presentations,
as the treating doctor interpreted
the X-rays as normal and
assumed a “muscular strain”. Relying
on negative X-rays in this age
group is a classical error – the
history and examination (inspection)
give the diagnosis.
Neck pain after play mishap
X-rays are indicated for the boy but
should be interpreted with care.
A mother brings her six-year-old
son to your emergency department.
He was practising his “Power
Ranger” moves in the family’s
split-level living room and leapt
from the upper to the lower level,
landing heavily on his feet. He
complains of neck pain but no
other symptoms.
What features are present on
inspection?
He has a torticollis, and is in some
degree of pain.
What immobilisation is
indicated?
This child would not fit into a collar.
Forcing the issue would create further
pain and distress and may exacerbate
an injury. He should be allowed to
adopt a position of comfort, with
padded support if necessary, and
given simple analgesia as required.
What imaging is indicated?
X-rays are indicated as an initial investigation,
but should be interpreted
with care, with recognition that in
this age-group plain X-rays are
known to be poorly sensitive.
What is the injury?
X-rays showed an anterior subluxation
of C2 on C3. In this particular
case, injury was missed on two presentations,
as the treating doctor interpreted
the X-rays as normal and
assumed a “muscular strain”. Relying
on negative X-rays in this age
group is a classical error – the
history and examination (inspection)
give the diagnosis.
Neck pain after play mishap
X-rays are indicated for the boy but
should be interpreted with care.
CERVICAL SPINE CLEARING
1. The awake, alert patient, with no other
significant injuries.
Bony and ligamentous
injury to the cervical spine and its supporting
structures is intrinsically painful and also
causes pain because of secondary muscle
spasm. Patients in this category can tell you
where it hurts, and are able to respond adequately
to examination.
If these features are present, the neck can
be cleared clinically:
■ No midline cervical tenderness
■ No focal neurological deficit
■ Normal alertness
■ No intoxication
■ No painful distracting injury
■ 50% or greater active range of movement
in all planes.
If any of the first five features are present,
standard plain three-view X-rays are indicated.
These three views should include a
lateral view (to include all seven cervical
vertebrae and enough of the first dorsal vertebra
to demonstrate alignment), an anterior-
posterior projection, and an openmouth
odontoid view.
2. The mentally obtunded patient.
Thisgroup is the most difficult to assess accurately.
They may be affected by intoxicants,
head injury, hypoxia, shock or pain, or by a
combination of these factors. They need careful
clinical assessment and imaging, and are
at high risk of having a spinal injury and it
may be masked.
X-rays are often of sub-standard quality
in this group for several reasons, including
poor co-operation leading to difficulty visualising
C7-T1 junction and difficulty
getting the open mouth “peg view”. Plain
X-rays of good quality, which include the
C7/T1 junction and the odontoid peg/C1/occipital
junctions, are needed to clear the neck
for most patients and swimmer’s views
and/or obliques may be needed.
Those patients with a significant head
injury, requiring CT scanning of the brain,
should also have CT scanning of the craniocervical
junction and often the rest of the
neck as well. Patients with other significant
injuries, whether spinal, chest, abdomen or
pelvic, often require CT scanning, and clearance
of the cervical spine using CT should
be done then.
3. The patient who clearly has a spinal
injury.
This is the easiest group for decisionmaking!
They may have evidence of a spinal
cord injury, or displaced fracture on plain
X-rays, or other myelopathic or radiculopathic
symptoms or signs that will require
specialist consultation. They need transfer
for detailed imaging such as CT and/or MRI,
as well as treatment.
4. The patient with other injuries requiring
transfer to a higher-level facility. Plain Xrays
should be performed and the need for
continued immobilisation discussed with
the referral centre.
significant injuries.
Bony and ligamentous
injury to the cervical spine and its supporting
structures is intrinsically painful and also
causes pain because of secondary muscle
spasm. Patients in this category can tell you
where it hurts, and are able to respond adequately
to examination.
If these features are present, the neck can
be cleared clinically:
■ No midline cervical tenderness
■ No focal neurological deficit
■ Normal alertness
■ No intoxication
■ No painful distracting injury
■ 50% or greater active range of movement
in all planes.
If any of the first five features are present,
standard plain three-view X-rays are indicated.
These three views should include a
lateral view (to include all seven cervical
vertebrae and enough of the first dorsal vertebra
to demonstrate alignment), an anterior-
posterior projection, and an openmouth
odontoid view.
2. The mentally obtunded patient.
Thisgroup is the most difficult to assess accurately.
They may be affected by intoxicants,
head injury, hypoxia, shock or pain, or by a
combination of these factors. They need careful
clinical assessment and imaging, and are
at high risk of having a spinal injury and it
may be masked.
X-rays are often of sub-standard quality
in this group for several reasons, including
poor co-operation leading to difficulty visualising
C7-T1 junction and difficulty
getting the open mouth “peg view”. Plain
X-rays of good quality, which include the
C7/T1 junction and the odontoid peg/C1/occipital
junctions, are needed to clear the neck
for most patients and swimmer’s views
and/or obliques may be needed.
Those patients with a significant head
injury, requiring CT scanning of the brain,
should also have CT scanning of the craniocervical
junction and often the rest of the
neck as well. Patients with other significant
injuries, whether spinal, chest, abdomen or
pelvic, often require CT scanning, and clearance
of the cervical spine using CT should
be done then.
3. The patient who clearly has a spinal
injury.
This is the easiest group for decisionmaking!
They may have evidence of a spinal
cord injury, or displaced fracture on plain
X-rays, or other myelopathic or radiculopathic
symptoms or signs that will require
specialist consultation. They need transfer
for detailed imaging such as CT and/or MRI,
as well as treatment.
4. The patient with other injuries requiring
transfer to a higher-level facility. Plain Xrays
should be performed and the need for
continued immobilisation discussed with
the referral centre.
Thursday 2 April 2009
Non-ulcer dyspepsia
Functional or non-ulcer dyspepsia is defined as at least three
months of dyspepsia in which no definite biochemical or
structural cause can be found to explain symptoms. There
is no confirmatory test and the diagnosis can only be made
after exclusion of the aforementioned structural causes.
A diagnosis of non-NSAID, non-H pylori ulcer should
only be entertained after:
■ exclusion of surreptitious NSAID use
■ careful exclusion of H pylori infection by several
biopsies
■ use of more than one H pylori diagnostic test
■ exclusion of confounders that would alter the sensitivity
of these tests, such as concurrent proton pump inhibitor
(PPI) use, recent antibiotic therapy or gastrointestinal
bleed.
Management involves 4-8 weeks of PPI therapy.
Although rare, exclusion of gastric carcinoma and other
upper gastrointestinal malignancies is important in those
with “alarm symptoms”, which the American Gastroenterological
Association guidelines summarise as:
■ age older than 55 years with new-onset dyspepsia
■ family history of upper gastrointestinal cancer
■ unintended weight loss
■ gastrointestinal bleeding
■ progressive dysphagia
■ odynophagia
■ unexplained iron-deficiency anemia
■ persistent vomiting
■ palpable lymphadenopathy
■ jaundice.
However, the presence of alarm symptoms has been
found to have poor predictive value for malignancy – rather
they alert the practitioner to the need for early endoscopy
to avoid the risk of missing a neoplastic process.
Functional dyspepsia can be difficult to manage. There
is evidence showing a small benefit with H pylori eradication
and PPI therapy. Although impaired gastric emptying
is noted in 25-40% of patients with functional dyspepsia,
there is inadequate evidence for the efficacy of
prokinetic therapy.
Despite its similarities to irritable bowel syndrome in
pathophysiology, there is also inadequate evidence to support
routine use of anti-depressants and psychological
therapies, although these should be considered as alternatives
for refractory patients. Counselling and reassurance
is essential.
Functional or non-ulcer dyspepsia is defined as at least three
months of dyspepsia in which no definite biochemical or
structural cause can be found to explain symptoms. There
is no confirmatory test and the diagnosis can only be made
after exclusion of the aforementioned structural causes.
A diagnosis of non-NSAID, non-H pylori ulcer should
only be entertained after:
■ exclusion of surreptitious NSAID use
■ careful exclusion of H pylori infection by several
biopsies
■ use of more than one H pylori diagnostic test
■ exclusion of confounders that would alter the sensitivity
of these tests, such as concurrent proton pump inhibitor
(PPI) use, recent antibiotic therapy or gastrointestinal
bleed.
Management involves 4-8 weeks of PPI therapy.
Although rare, exclusion of gastric carcinoma and other
upper gastrointestinal malignancies is important in those
with “alarm symptoms”, which the American Gastroenterological
Association guidelines summarise as:
■ age older than 55 years with new-onset dyspepsia
■ family history of upper gastrointestinal cancer
■ unintended weight loss
■ gastrointestinal bleeding
■ progressive dysphagia
■ odynophagia
■ unexplained iron-deficiency anemia
■ persistent vomiting
■ palpable lymphadenopathy
■ jaundice.
However, the presence of alarm symptoms has been
found to have poor predictive value for malignancy – rather
they alert the practitioner to the need for early endoscopy
to avoid the risk of missing a neoplastic process.
Functional dyspepsia can be difficult to manage. There
is evidence showing a small benefit with H pylori eradication
and PPI therapy. Although impaired gastric emptying
is noted in 25-40% of patients with functional dyspepsia,
there is inadequate evidence for the efficacy of
prokinetic therapy.
Despite its similarities to irritable bowel syndrome in
pathophysiology, there is also inadequate evidence to support
routine use of anti-depressants and psychological
therapies, although these should be considered as alternatives
for refractory patients. Counselling and reassurance
is essential.
Monday 30 March 2009
EPIGASTRIC PAIN
peptic ulcer disease
(5-15%)
■ gastro-oesophageal reflux
disease (5-15%)
■ gastric or oesophageal
cancer (<2%)
■ gallstones/biliary pain
■ chronic pancreatitis/
pancreatic cancer
■ coeliac disease
■ lactose intolerance
■ medications – digoxin,
theophylline, erythromycin,
potassium supplements,
corticosteroids and NSAIDs
■ infiltrative diseases of
the stomach – eosinophillic
gastritis, Crohn’s disease,
sarcoidosis
■ metabolic causes –
hypothyroidism,
hypercalcaemia,
hyperkaelemia, heavy
metals
■ hepatoma and
steatohepatitis
■ intestinal angina
■ abdominal wall pain
■ Zollinger-Ellison syndrome
■ diabetic radiculopathy
Functional dyspepsia
(up to 60%)
■ caffeine, alcohol and
smoking can exacerbate
symptoms
(5-15%)
■ gastro-oesophageal reflux
disease (5-15%)
■ gastric or oesophageal
cancer (<2%)
■ gallstones/biliary pain
■ chronic pancreatitis/
pancreatic cancer
■ coeliac disease
■ lactose intolerance
■ medications – digoxin,
theophylline, erythromycin,
potassium supplements,
corticosteroids and NSAIDs
■ infiltrative diseases of
the stomach – eosinophillic
gastritis, Crohn’s disease,
sarcoidosis
■ metabolic causes –
hypothyroidism,
hypercalcaemia,
hyperkaelemia, heavy
metals
■ hepatoma and
steatohepatitis
■ intestinal angina
■ abdominal wall pain
■ Zollinger-Ellison syndrome
■ diabetic radiculopathy
Functional dyspepsia
(up to 60%)
■ caffeine, alcohol and
smoking can exacerbate
symptoms
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