Trial MCQ Paper 2

Answer: D) Antinuclear Antibody (ANA) test

For suspected systemic lupus erythematosus (SLE), the recommended initial investigation is to perform an Antinuclear Antibody (ANA) test. A positive ANA test would prompt further testing, including anti-double-stranded DNA (dsDNA) and extractable nuclear antigen (ENA) antibodies, to confirm the diagnosis and assess disease activity in SLE.

Answer: B) Antiphospholipid Syndrome

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by recurrent venous or arterial thrombosis and pregnancy complications, such as recurrent miscarriages. Elevated levels of ani-phospholipid antibodies (anticardiolipin antibodies, beta 2 Glycoprotein 1 antibodies  and lupus anticoagulant) are common findings in APS. The presence of these antibodies, along with clinical manifestations like joint pain and skin rashes, supports the diagnosis of antiphospholipid syndrome.

Answer: D) Smoking cessation aggravates ulcerative colitis and improves Crohn’s disease

Smoking is an important environmental factor in inflammatory bowel disease (IBD), having different effects in ulcerative colitis (UC) and Crohn’s disease (CD). Smoking is found to be protective against ulcerative colitis and, after onset of the disease, might improve its course, decreasing the need for colectomy. However, smoking increases the risk of developing Crohn’s disease and worsens its course, increasing the need for steroids, immunosuppressants and re-operations. Smoking cessation aggravates ulcerative colitis and improves Crohn’s disease.

Answer: B) Prescribe amoxycillin

The presence of an opaque and bulging tympanic membrane with visible fluid is suggestive of acute otitis media. With that presence of fever and vomiting is an indication to start amoxycillin.

Answer: A) Coeliac disease can be diagnosed clinically without the need for additional tests.

The diagnosis of Coeliac disease depends on showing the characteristic intestinal changes and improvement on the Gluten Free Diet.

Characteristic intestinal changes includes raised intraepithelial lymphocytes (>25 per 100 enterocytes), crypt hyperplasia and villous atrophy.

Answer: E) It does not eliminate the need for regular cervical cancer screening tests

The HPV vaccine does not protect against all types of HPV known to cause cervical cancer, so regular screening tests are still required for those who have been vaccinated.

Answer: A) Initiate intravenous antibiotics and arrange for urgent ophthalmology consultation

The patient's presentation with severe eye pain, proptosis, restricted extraocular movements, and systemic symptoms is concerning for orbital cellulitis, which is a serious infection requiring urgent management. The most appropriate next step is to initiate intravenous antibiotics (3rd generation Cephalosporins) and arrange for urgent ophthalmology consultation to prevent potential vision-threatening complications.

Answer: C) It is recommended to take Praziquantel to treat acute schistosomiasis

It is important not to treat acute schistosomiasis with praziquantel, as this is likely to cause a worsening of symptoms, which may even become life threatening.

Answer: D) Administer a 7 day course of oral metronidazole 400mg BD

The patient's clinical presentation, characterized by a malodorous discharge, fishy odor, and clue cells on microscopic examination, is consistent with bacterial vaginosis (BV). The most appropriate next step in managing this patient is to administer a course of oral metronidazole (400mg BD for 7 days), as it is the first-line treatment for bacterial vaginosis. This helps restore the balance of vaginal flora and alleviate symptoms.

Answer: D) Median Nerve Injury

The patient's presentation with inability to move the thumb and first two fingers, and a characteristic claw-like hand with inability to form an "OK" sign (Pincer Grasp) is indicative of median nerve injury. Supracondylar fractures of the humerus, particularly in pediatric patients, can result in injury to the median nerve. Early recognition and appropriate management are essential to prevent long-term complications.

Answer: D) Mammary Duct Ectasia

The patient's presentation with nipple inversion, occasional tenderness, greenish discharge, and erythematous changes in the surrounding areola is suggestive of mammary duct ectasia. This condition involves dilation and inflammation of the subareolar ducts, which can result in nipple inversion and discharge. Although the symptoms may resemble more concerning conditions, mammary duct ectasia is typically benign. Management often involves conservative measures, and in some cases, anti-inflammatory treatments may be considered.

Answer: E) Paget Disease of the Breast

The patient's presentation with persistent eczematous changes, crusting of the nipple, occasional tingling, and burning sensations is indicative of Paget Disease of the Breast. This rare form of breast cancer involves the nipple and areola and is often associated with an underlying breast malignancy.

Answer: C) Perianal Streptococcal Dermatitis

The patient's presentation with perianal discomfort, itching, pain during bowel movements, erythema, and superficial excoriation around the perianal area is suggestive of perianal streptococcal dermatitis. This condition is commonly seen in children and is associated with group A beta-hemolytic streptococcal infection, often following a sore throat. Unlike other causes of perianal itching, perianal streptococcal dermatitis typically lacks vesicles or ulcers.

Answer: C) When the pain is not controlled with simple analgesia

Antivenom should be considered in all cases of Redback envenomation where simple analgesia (eg. ice and paracetamol) is not sufficient to alleviate symptoms. Presence of systemic symptoms such as vomiting, severe headache, abdominal pain is also an indication for antivenom.

Answer: B) The frequency of breast cancer screening is once in every 5 years

Screening is offered every 2 years for individuals with no additional risk. If a first degree relative is diagnosed with breast cancer before the age of 50 years, annual mammograms are recommended.

Answer: A) Infectious Mononucleosis

Infectious Mononucleosis, often caused by the Epstein-Barr virus (EBV), presents with triad of fever, sore throat and generalized lymphadenopathy. Clinical examination may reveal pharyngeal erythema, enlarged tonsils with exudate, and splenomegaly in some cases.

Answer: C) Vitamin D deficiency

Severe vitamin D deficiency can lead to derangements in calcium, phosphate, and parathyroid hormone (PTH) levels. In this scenario, low levels of vitamin D impair the absorption of calcium and phosphate in the intestines, resulting in hypocalcemia and hypophosphatemia. The parathyroid glands respond by increasing PTH secretion in an attempt to restore normal calcium levels, contributing to secondary hyperparathyroidism. This can lead to bone resorption and the clinical manifestations of bone pain and weakness.

Answer: C) Start antiviral therapy with Valaciclovir

Valaciclovir is the recommended first-line treatment for genital herpes in Australia and Acyclovir can be used alternatively. Management of a first episode of genital herpes should be immediate and not wait until the results of HSV NAAT tests and contact tracing is not recommended.

Answer: C) Take alendronate first thing in the morning on an empty stomach with a full glass of water.

Alendronate is a bisphosphonate that should be taken on an empty stomach, typically first thing in the morning, with a full glass of plain water. Food, beverages, and other medications can interfere with the absorption of alendronate, so it is essential to take it separately from these. Additionally, patients are advised to remain upright for at least 30 minutes after taking alendronate to minimize the risk of esophageal irritation and optimize absorption.

Answer: D) Kawasaki Disease

Kawasaki Disease is an acute febrile illness primarily affecting young children. It is characterized by fever persisting for more than five days and at least four of the following clinical features ; Conjunctival injection, Erythema of oral and/or pharyngeal mucosa, Erythema and oedema of hands and feet, Polymorphous skin rash and Cervical lymphadenopathy.

Answer: C) Levonorgestrel is a progestin-only emergency contraceptive pill, while Ulipristal acetate is a selective progesterone receptor modulator.

Both are available over the counter in Australia. Levonorgestrel is effective within 72 hours of unprotected sex while Ulipristal acetate is effective up to 120 hours and is also more effective than Levonorgestrel in preventing unwanted pregnancies. Any female in childbearing age can have both these drugs and there is no age requirements to use either of them.

Aanswer: A) IM GLucagon 1mg stat

To correct hypoglycemia in an unconscious patient, IV or IM routes should be used. If IV access is not available at the time of presentation the recommendation is to use IM Glucagon 1mg stat.

Answer: B) Perform endometrial biopsy

Postmenopausal bleeding is a concerning symptom that requires further evaluation as 10% will have endometrial carcinoma. The most appropriate next step in managing this patient is to perform an endometrial biopsy to assess the endometrial lining. Normal endometrial thickness (4-8mm) on USS doesn't exclude endometrial cancer.

Answer: C) Control with carbimazole and then administer radioactive iodine.

In recurrent Grave's disease, the preferred treatment is carbimazole followed by radioactive iodine. Surgery is not indicated as there is no gland enlargement causing symptoms and can damage the surrounding structures including recurrent laryngeal nerve.