ICA Formative SBA QUESTION COPY - University of · PDF fileICA Formative SBA QUESTION COPY . 83/02 Semester 1 Page 2 CASE 1 ... Timed urine albumin excretion rate D) Serum creatinine

83/02 Semester 1 Page 1

THE UNIVERSITY OF SYDNEY PAPER 2 FACULTY OF MEDICINE UNIVERSITY OF SYDNEY MEDICAL PROGRAM YEAR 3

21 JUNE 2002

ICA Formative

SBA

QUESTION COPY


CASE 1

Mr Terry Wyatt is a 55 year old man who presents with sudden onset of severe abdominal and left shoulder tip pain. On examination his pulse rate is 120 per minute, systolic blood pressure 100 mmHg with a postural drop of 20 mmHg, hands are cold and sweaty and there is board-like rigidity on abdominal examination. His initial WCC is *18.5 x 109/L (Normal Range (NR): 4.0-11.0 x 109/L). 1. Which one of the following gives the clue to the most likely diagnosis?

A) Elevated WCC B) Shoulder tip pain C) Postural hypotension D) Board-like abdominal rigidity

2. What is the most likely diagnosis?

A) Perforated peptic ulcer B) Acute mesenteric ischaemia C) Perforated acute appendicitis D) Acute haemorrhagic pancreatitis

3. What is the most appropriate initial management?

A) Immediate laparotomy B) Subcutaneous pethidine C) Intravenous concentrated albumin D) Rapid infusion of intravenous normal saline

4. Which is the most likely postoperative complication occurring on day 10 following laparotomy for an acute abdomen?

A) Atelectasis B) Wound haematoma C) Deep vein thrombosis D) Myocardial infarction

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CASE 2

Melissa Ryan, a 29 year old woman, initially presented 6 months ago with diplopia. The diplopia resolved over the subsequent month. At a routine check-up, a pale right optic disc was noted on ophthalmoscopy. 5. To explain the pale disc the most likely site of pathology is:

A) Left optic nerve B) Right optic nerve C) Left optic radiation D) Left dorsal lateral geniculate nucleus of the thalamus

Three months later, when Melissa was away on holidays, she consulted another doctor as she was finding it difficult to control her bladder. She had urgency and was often incontinent. Her symptoms improved somewhat after a course of antibiotics. She had also noticed some tingling feelings in her arms and legs. 6. The most likely cause of these symptoms is:

A) Urinary tract infection B) Connective tissue disorder C) Epstein-Barr virus infection D) Lesions in motor and sensory tracts in the spinal cord

Melissa has recently read about a famous Australian athlete who developed multiple sclerosis. She asks if she too has this disease and how it can be further investigated. 7. The most useful investigation is:

A) Brain MRI B) HLA typing C) Lumbar puncture D) Visual evoked potentials

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CASE 3

Damien Lowe, a 27 year old man who has a history of intravenous drug use, presents with a one week history of fever and malaise, with bilateral small areas of patchy opacification on CXR. He has normal oxygenation on room air at rest and a cough productive of small amounts of sputum. His fundi appear normal, but he has an ejection systolic murmur and his urinalysis shows 1+ protein. Physical examination reveals no organomegaly, skin rashes, nor any nailbed abnormalities, and is otherwise normal. 8. Which of the following clinical data would most reliably exclude bacterial endocarditis?

A) Sputum growing S. pneumoniae B) Evidence of ventilation-perfusion mismatch on a lung scan C) Three negative blood cultures, taken over 24 hours, prior to commencing antibiotics D) Trans-oesophageal echocardiogram showing no evidence of vegetations on the heart

valves ********************************************************************************** CASE 4

Raymond Jacobs is a 29 year old man who has had type 1 diabetes mellitus since the age of 12. He injects insulin 4 times daily. He has been unwell for 24 hours with fever, nausea and anorexia. He telephones his general practitioner for advice regarding his diabetes management. 9. Which is the best advice regarding his treatment during this illness?

A) He should start broad-spectrum antibiotic therapy B) He should omit insulin until he is able to resume eating normally C) He should drink fluids containing sugar and continue to administer insulin D) His home blood glucose monitor is likely to be inaccurate in the presence of fever

Twelve hours later Mr Jacobs is brought to the hospital Emergency Department with drowsiness, confusion and rapid breathing. His temperature is 38.7ºC. His blood glucose concentration is *48 mmol/L (NR: 3.0-7.7 mmol/L). Blood oxygen saturation is 98% on room air. 10. Which is the most likely cause of his altered mental state?

A) Bacterial meningitis B) Diabetic ketoacidosis C) Hyperosmolar non-ketotic diabetic coma D) Pneumonia and impaired cerebral oxygenation


11. He is admitted to hospital. What is the most appropriate method of management of his diabetes at this stage?

A) Bolus doses of intravenous insulin B) His usual subcutaneous insulin doses C) Continuous intravenous insulin infusion D) Subcutaneous insulin with doses adjusted according to blood glucose concentration using a

“sliding scale” 12. During his hospital admission you perform investigations for diabetes complications. Which is the best screening test for early diabetic nephropathy?

A) Renal ultrasound B) Creatinine clearance rate C) Timed urine albumin excretion rate D) Serum creatinine and urea concentrations

13. Which one of the following interventions has been shown to reduce the progress of diabetic nephropathy?

A) β-blockers B) ACE inhibitors C) Thiazide diuretics D) Dietary protein restriction

14. What changes would you expect to see on fundoscopy in early diabetic retinopathy?

A) Papilloedema B) Retinal detachment C) Arterio-venous nipping D) Dot and blot haemorrhages

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CASE 5

Melanie Chan is a 33 year old woman who presents with diarrhoea for the last week. Although she has had some irregularity of bowel habit associated with variably situated crampy abdominal pain for several years, her current bout of stool looseness is more prolonged and worse than usual. 15. Which one of the following findings is most supportive of a diagnosis of infective diarrhoea rather than irritable bowel syndrome?

A) Mucus in the stool B) Urgency of defaecation C) Abdominal tenderness on examination D) Red and white blood cells on stool microscopy

********************************************************************************** CASE 6

Charles Robinson is a 56 year old otherwise healthy man who has a 6 month history of burning epigastric pain that often occurs post-prandially. He had not been previously investigated. He has failed to respond to over-the-counter ranitidine. He has had no history of dysphagia, bleeding, vomiting or weight loss. There is no relevant family history. Physical examination is unremarkable. 16. Which one of the following is the most appropriate next step?

A) CT scan of the abdomen B) Upper gastrointestinal endoscopy C) Empiric omeprazole for one month D) Test for H. pylori by serology and treat the infection if positive

********************************************************************************** CASE 7

Neil Crossley is a 59 year old man who presents with very pale, bulky, offensive stools that are difficult to flush away. The three day faecal fat reveals the passage of *20 grams of fat per day (NR < 7 grams per day). The serum folate and B12 levels are normal. A serum amylase is normal. A small bowel biopsy obtained at upper gastrointestinal endoscopy is within normal limits. 17. The most likely underlying diagnosis of the steatorrhoea is:

A) Coeliac disease B) Chronic pancreatitis C) Small bowel bacterial overgrowth D) Crohns disease of the terminal ileum

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CASE 8

Sridhar Prasad is a 73 year old man who presents with increased rigidity and generalised slowing over the preceeding 12 months. He takes no regular medications. Clinical examination of Mr Prasad reveals findings consistent with idiopathic Parkinson’s disease. 18. Which one of the following clinical features supports the diagnosis of Parkinson’s disease?

A) Weakness of his left upper limb B) Supranuclear vertical gaze palsy C) Limb rigidity greater than truncal rigidity D) Choreiform movements of his left upper limb

19. Which one of the following neurotransmitter abnormalities is characteristically associated with idiopathic Parkinson’s disease at postmortem?

A) Dopamine depletion in the basal ganglia B) Increased dopamine in the motor cortex C) Acetylcholine depletion in the basal ganglia D) Increased acetylcholine in the motor cortex

********************************************************************************** CASE 9

Barry Parsons, a 58 year old man, presents with cough and blood stained sputum for one month, and on chest X-ray has multiple nodular infiltrates. He has a long history of sinusitis, but recently has had increased purulent blood-stained nasal discharge. He has microscopic haematuria and his serum creatinine is *0.14 mmol/L (NR: 0.06 - 0.12 mmol/L). 20. Which one of the following investigations is most appropriate to determine the cause of the renal disease?

A) Cystoscopy B) Renal biopsy C) Renal ultrasound D) Intravenous pyelogram

21. Which one of the following blood tests is most likely to reveal the specific diagnosis?

A) Anti-double stranded DNA antibodies B) Angiotensin converting enzyme (ACE) C) Anti-neutrophil cytoplasmic antibodies (ANCA) D) Anti-glomerular basement membrane antibodies (AGBM)


Mr Parsons' blood count reveals the following: Indices Results Normal Range Haemoglobin *98 g/L 130 - 180 g/L White Cell Count (WCC) *14.6 x 109/L 4.0 - 11.0 x 109/L Neutrophil *12.0 x 109/L 2.0 - 7.5 x 109/L Lymphocyte 2.4 x 109/L 1.5 - 4.0 x 109/L Platelet count *600 x 109/L 150 - 400 x 109/L 22. Mr Parsons' raised WCC is most likely due to which of the following?

A) Chest infection B) Leukamoid reaction C) Urinary tract infection D) Systemic inflammation

********************************************************************************** CASE 10

Shirley Harris, a 63 year old woman, presents to your surgery with a 4 x 3 cm lymph node in the left supraclaviclular fossa. She feels tired but has no other symptoms. On examination she has generalised lymphadenopathy. Her blood count is as follows: Indices Results Reference Range WCC *66.0 x109/L 4.0 - 11.0 x109/L PMN 2.5 x109/L 2.0 - 7.5 x109/L Lymph *60 x109/L 1.5 - 4.0 x109/L Hb *95 g/L 115 - 165 g/L MCV *75 fl 80 - 100 fL Platelets 326 x109/L 150 - 400 x109/L Film small (mature) lymphocytosis and smudge cells, microcytocis, hypochromia, pencil cells 23. On examination you would expect to find:

A) Petechiae B) Splenomegaly C) A heart murmur D) Nail fold infarcts

24. The most likely cause of her anaemia is:

A) Haemolysis B) Iron deficiency C) Myelodysplasia D) Bone marrow failure


25. The most likely cause of her lymphocytosis is:

A) Large cell lymphoma B) Acute lymphoblastic leukaemia C) Chronic lymphocytic leukaemia D) Glandular fever (EBV infection)

26. Which one of the following statements about the treatment of chronic lymphocytic leukaemia is correct?

A) Treatment is usually of curative intent B) May be best managed with watchful waiting C) Radiotherapy is the primary treatment modality D) Treatment needs to be commenced promptly on diagnosis

27. The progression of acute lymphoblastic leukaemia is:

A) Slowly progressive if not treated B) Characterised by spontaneous flares and remissions C) Incurable but chemotherapy will produce long remissions D) Often associated with bone marrow “failure” at presentation

28. Which one of the following statements is correct about blood product support in the treatment of acute leukaemia?

A) Platelet transfusions are used only to treat bleeding B) Recombinant Factor VIII may be used to treat bleeding episodes C) Red cell transfusions are indicated if the haemoglobin is <12 g/L (NR: 115-165 g/L) D) Platelet transfusions are usually used prophylactically in the presence of severe

thrombocytopaenia (e.g. <10 x109/L, NR: 150-400 x109/L) **********************************************************************************


CASE 11

Mr James Clerk is a fit 35 year old man who presented to his general practitioner with the sudden onset of rotatory vertigo associated with nausea and vomiting. The episode started without warning 2 weeks previously and has persisted with each day lessening in intensity. He is only mildly unsteady now. There has been no change in his hearing and there are no other accompanying symptoms. 29. The most likely cause of his symptoms is:

A) Viral labyrinthitis B) Meniere's disease C) Cerebellar stroke D) Middle ear infection

Clinical examination shows a well man, with jerk nystagmus fast phase to the left, mildly unsteady Romberg's test and gait, normal ear drums and clinical test of hearing within normal limits. There are no other abnormal clinical signs. Mr Clerk's balance continues to improve with return to normal activities in a further week. 30. The best continuing treatment for his condition is:

A) Observation B) Low dose aspirin C) Vestibular suppressants D) Vestibular rehabilitation

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CASE 12

Janelle Isaacs, a 32 year old woman, presents to her local doctor complaining of a 2 day history of diarrhoea and associated weakness and lethargy. Her past history includes both laxative and diuretic abuse. Clinically she is dehydrated with a blood pressure of 100/60 mmHg and a 10 mmHg postural drop. Serum biochemical studies demonstrate the following results: Indices Results Normal range Sodium *133 mmol/L 135 - 145 mmol/L Potassium *2.6 mmol/L 3.5 - 5.0 mmol/L Urea 5.6 mmol/L 3.0 - 8.0 mmol/L Creatinine 0.07 mmol/L 0.06 - 0.12 mmol/L 31. Which one of the following would suggest that diuretic abuse is likely to be contributing to her hypokalaemia?

A) A high urinary sodium excretion B) A high urinary potassium excretion C) An elevation in plasma aldosterone D) The presence of metabolic alkalosis

********************************************************************************** CASE 13

Waveney Peters is a 25 year old woman with some right leg varicose veins since the birth of her first child a year ago. She has had sudden onset of a tender swelling in the right groin. On examination, there is a 3 cm tender swelling just below and lateral to the pubic tubercle. There is no cough impulse and the swelling does not reduce when she lies down. 32. What is the most likely diagnosis?

A) Femoral hernia B) Trochanteric bursitis C) Indirect inguinal hernia D) Superficial thrombophlebitis

33. What is the most appropriate next step?

A) Needle aspiration B) Surgical exploration C) Intravenous cephalosporin D) CT scan of abdomen and groin

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CASE 14

Marion Hegarty, a 64 year old woman, is seen in the Emergency Department with a history of 2 episodes of right-sided weakness in the last 24 hours. They first involved her arm and leg and resolved over 10 minutes. The second episode was more prolonged lasting 20 minutes and associated with word finding difficulty. She has a previous history of hypertension treated with Perindopril 4 mg daily and diet controlled diabetes. She currently smokes 10 cigarettes per day. Her neurologic examination is normal. She has bilateral carotid bruits. CT head scan is normal. Carotid duplex study demonstrates bilateral carotid stenosis greater than 70%. 34. What is the most effective treatment to prevent her having a stroke?

A) Low dose aspirin B) Left carotid endarterectomy C) Anticoagulation with heparin D) Bilateral carotid endarterectomy

35. Which one of the following has NOT been shown to be effective long term prophylaxis for prevention of further cerebrovascular episodes in this situation?

A) Clopidogrel B) Low dose aspirin C) Low dose warfarin D) Dipyridamole plus low dose aspirin

36. Which risk factor is the LEAST important on a population basis in the development of cerebrovascular disease?

A) Hypertension B) Homocystinuria C) Cigarette smoking D) Hypercholesterolaemia

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CASE 15

Karen Friedman, a 45 year old woman, develops an acutely painful left knee over a period of 2 days. She has insulin dependent diabetes. There is no history of trauma. On examination she is unwell, febrile at 38.5ºC and has a warm tender knee with a moderate effusion and limited range of motion due to pain. No other joints are involved. 37. The most important diagnostic test is:

A) X-ray of knee B) Serum uric acid C) Rheumatoid factor D) Synovial fluid aspirate

38. The most likely diagnosis is:

A) Gout B) Pseudogout C) Septic arthritis D) Rheumatoid arthritis

39. Her serum uric acid is *0.44 mmol/L (NR < 0.42 mmol/L). What is the significance of a raised serum uric acid in Ms Friedman?

A) Confirms the diagnosis of gout B) Can be related to renal impairment C) Confirms the diagnosis of pseudogout D) Indicates the need for treatment with allopurinol

40. Her ESR is raised at *80 mm/hr (NR: 3-15 mm/hr). What is the correct interpretation of this result?

A) Makes acute gout highly unlikely B) Confirms the diagnosis of septic arthritis C) Excludes the diagnosis of rheumatoid arthritis D) Not helpful in differentiating between the diagnoses

41. If septic arthritis is proven, what is the most likely organism?

A) Salmonella typhi B) Staphylococcus aureus C) Klebsiella pneumoniae D) Streptococcal pneumoniae

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CASE 16

Jane Beldham is a 55 year old woman who presents to you, her general practitioner, requesting information about screening for breast cancer. 42. Which one of the following statements is correct regarding breast screening for women over the age of 50 in Australia?

A) Breast self-examination is considered adequate B) Annual measure of tumour markers is adequate C) Mammography should be performed every 2 years D) Mammography should be performed every 5 years

She asks you at what age she is most at risk. 43. In which age group is a woman at greatest risk of breast cancer?

A) 60-70 years B) 50-60 years C) 40-50 years D) 30-40 years

********************************************************************************** CASE 17

Simon Handel is a 25 year old man who sustains a clean, fairly superficial, 3 cm long laceration to his left forearm on a piece of broken glass. 44. Which one of the following statements about management is correct?

A) Prophylactic antibiotics are required B) Thorough cleansing with saline is the decontamination method of choice C) Immediate tetanus prophylaxis is required as this is a tetanus prone wound D) X-ray is required even if the whole length and depth of the wound can be visualised

45. Which one of the following statements about wound closure is correct?

A) The suture material of choice is silk B) Sutures on the forearm should be removed at 3 to 5 days C) Histoacryl (tissue glue) is a possible alternative to suturing for this wound D) A continuous subcuticular absorbable suture should be employed for the best cosmetic

result


********************************************************************************** CASE 18

Sandra Habib is a 40 year old woman who has had hypertension over the last 3 years which has been difficult to control. She describes episodes of headache and tremulousness and also occasional flushing. A diagnosis of phaeochromocytoma is considered. 46. Which is the best strategy for confirming the diagnosis?

A) Adrenal gland fine needle aspiration B) CT scan of the abdomen with contrast C) Spot urinary catecholamines and metanephrines D) 24 hour urinary collection for catecholamines and metanephrines

********************************************************************************** CASE 19

Simon Talbot is 20 years old and has been rapidly gaining weight over the last 2 years, particularly around the abdomen. His legs and arms are quite thin and he complains that they are weak and it is hard for him to go up stairs. He has developed a very round and red face. His urinary free cortisol is high. 47. The most appropriate next diagnostic step is:

A) Short synacthen test B) Serum FSH and TSH C) MRI scan of the pituitary D) Dexamethasone suppression test

********************************************************************************** CASE 20

Lydia Pappas is an elderly patient being nursed following a stroke. An indwelling urinary catheter has been in place to assist her management. During the previous month, urine specimens have grown organisms on 3 occasions and antibiotics have been given on each occasion based on the reported susceptibilities. She now has a low grade temperature (37.8ºC) but is otherwise stable. Another catheter specimen is collected and the laboratory reports the presence of pyuria together with Pseudomonas aeruginosa at >108 orgs/L. The organism is sensitive to aminoglycosides, quinolones and the anti-pseudomonal beta-lactams. 48. The most appropriate treatment is:

A) Gentamicin B) Norfloxacin C) Ceftazidime D) Urinary catheter change


********************************************************************************** CASE 21

Cecily Prentice is a 70 year old woman recovering from pneumonia after undergoing a hip replacement operation. She was not producing sputum and a blood culture was negative. She has been treated with 2 different antibiotics for 7 days and there is progressive but slow improvement in her respiratory function. Her temperature however remains elevated in the range 37.5˚C to 38˚C. She is not known to be immunosuppressed. A sputum sample is now growing normal oral flora and profuse Candida albicans. 49. Which is the most likely explanation for this result?

A) HIV infection B) Pneumonia caused by Candida albicans C) Candida albicans infection in the hip with spread to the respiratory tract D) Colonisation of the upper respiratory tract by Candida albicans secondary to antibiotics

********************************************************************************** CASE 22

Amy Gao, a 25 year old woman with asthma, is needing to use her salbutamol inhaler 3 or 4 times each day. Every couple of days she wakes in the early hours of the morning with wheeze. She is using beclomethasone 1000 micrograms bd. Her best peak flow reading is 500 l/min but she has not reached this for some months. Currently she has readings between 440 and 450 l/min. 50. What would be the most appropriate adjustment to her treatment?

A) Add oral theophylline B) Add a leukotriene antagonist C) Add a long acting beta agonist D) Increase the dose of inhaled steroid

********************************************************************************** CASE 23

Mrs Joanna Youtzas is a 54 year old woman who presents for a routine “check-up” and is found to have a blood pressure of 155/90 mmHg. Examination reveals she is moderately overweight (BMI 30 kg/m2), in sinus rhythm with a heart rate of 80 beats per minute and has an audible fourth heart sound. 51. Which one of the following additional findings is most specific in support of a diagnosis of significant and long-standing hypertension?

A) Corneal arcus B) Ankle oedema C) Silver wiring on fundoscopy


D) Elevated fasting blood glucose 52. Which one of the following clinical features is NOT relevant to the possible causation of hypertension in this patient?

A) A history of snoring B) The detection of a carotid bruit C) The detection of an abdominal bruit D) A history of regular alcohol consumption

Mrs Youtzas is commenced on a thiazide diuretic, as a first line agent, and her blood pressure after 6 weeks remains elevated at 150/90. She is also found to have moderate hypercholesterolaemia (total cholesterol of *6.5 mmol/L, NR < 5.5 mmol/L), mild hypertriglyceridaemia (*2.5 mmol/L, NR <2.0 mmol/L) and mildly elevated fasting glucose (*7.4 mmol/L, NR: 3.0 - 5.4 mmol/L). 53. Which one of the following management options will provide the most therapeutic benefit?

A) Stop the thiazide and commence a betablocker B) Continue the thiazide and add an ACE inhibitor C) Stop the thiazide and commence an ACE inhibitor D) Continue the thiazide and add a centrally acting vasodilator

54. Which one of the following is correct regarding risk factor control in this patient?

A) Advice to achieve weight loss and increase regular exercise is not beneficial B) Weight loss may improve blood pressure, hyperlipidaemia and blood glucose control C) The presence of hyperglycaemia and hyperlipidaemia reduces the significance of

hypertension as a risk factor D) Rigorous control of blood glucose will obviate the need to reduce blood pressure and

plasma cholesterol and triglycerides 55. The elevation of Mrs Youtzas’ blood pressure is likely to be associated with which one of the following pathophysiological changes?

A) Dilatation of the peripheral arterioles B) Overall increase in glomerular filtration rate C) Reduction of the wall thickness in retinal arterioles D) Increased haemodynamic injury to the vascular intima in large arteries

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CASE 24

Michael Moore is a 20 year old man who comes to the Emergency Department because of painless haematuria, loin pain and a sore throat. He has had 3 similar episodes over the past 2 years. 56. Which is the most likely diagnosis?

A) Renal stone B) Acute pyelonephritis C) Nephrotic syndrome D) IgA glomerulonephritis

********************************************************************************** CASE 25

Adrian Crawford is a 23 year old man with a history of heroin abuse who has been found after being unconscious for 36 hours. He awakens and complains of severe pain in his lower leg muscles. 57. Which one of the following is the most likely diagnosis?

A) Fracture of tibia B) Knee septic arthritis C) Deep venous thrombosis D) Compression injury of muscle

58. Which one of the following would be most useful in confirming the diagnosis?

A) Venogram B) Full blood count C) Lower limb X-ray D) Serum creatine kinase

59. Which one of the following would be the most appropriate management?

A) Surgical fasciotomy B) Intravenous heparin C) Elevate and rest leg D) Split plaster and dressing

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CASE 26

Wayne Hughes presents to the Emergency Department following an alleged assault in which a glass shattered on his face. He complains of blurred vision, headache and pain on the right side of his face. 60. The most important initial assessment is:

A) Fundoscopy B) Visual acuity test C) Neurological assessment D) Cranial nerve assessment

After ophthalmological assessment has been performed, the right conjunctiva is noted to be swollen, the eyeball is soft and there is a small hyphema. Visual acuity is 6/36 (right), 6/6 (left). 61. The most likely diagnosis is:

A) Ruptured globe B) Orbital foreign body C) Traumatic optic neuropathy D) Blowout fracture of the orbit

********************************************************************************** CASE 27

George Cini is a 71 year old man who presents with a history of sudden visual loss. This occurred whilst watching television and there were no preceeding symptoms. He is obese and has hypertension which is well controlled. On examination, he appears not to be able to see to the left side with either eye. 62. The most likely diagnosis is:

A) Optic neuritis B) Retrochiasmal stroke C) Retinal vascular embolus D) Ischaemic optic neuropathy

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CASE 28

Xiufu Zhang, a 23 year old woman, presents to her general practitioner with mild dyspnoea on exertion which she noticed on a recent bush walking holiday. On a recent visit to the Blood Bank where she had been an annual donor for 4 years, she was rejected because of a low haemoglobin level. A blood count revealed: Indices Results Reference Range Haemoglobin *90 g/L 115 - 165 g/L MCV *65.3 fL 80 - 100 fL MCH *20.7 pg 27 - 32 pg MCHC 317 g/L 300 - 350 g/L White Cells 4.7 x 109/L 4.0 - 11.0 x 109/L Platelets *426 x 109/L 150 - 400 x 109/L Blood Film: Poikilocytosis +, Hypochromia++ 63. What is the most likely cause of her anaemia?

A) Malabsorption B) Blood donation C) Dietary iron deficiency D) Gastrointestinal malignancy

64. Which of the following is the most appropriate management of this patient?

A) Oral iron therapy B) The patient should not be a blood donor in future C) Cease blood donation and allow anaemia to resolve D) Intramuscular iron therapy followed by oral iron therapy for 3 months

65. Which one of the following conditions may also manifest as microcytic hypochromic anaemia?

A) Acute blood loss B) Thalassaemia trait C) Chronic liver disease D) Haemolytic anaemia

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CASE 29

Mr Ronald Steele is a 62 year old man who presents with sudden onset of left leg pain. The pain occurred 10 days after an episode of chest pain which lasted for an hour and for which he did not seek medical attention. On examination, there are no pulses palpable below the left femoral. 66. Which of the following physical signs indicates more severe and prolonged limb ischaemia?

A) Pain B) Pallor C) Parasthesia and paresis D) Prolonged capillary return

67. What is the most likely diagnosis?

A) Embolus from left atrium B) Embolus from left ventricle C) Embolus from aortic plaque D) Superficial femoral artery thrombosis

68. What is the most appropriate immediate management?

A) Thrombolytic therapy B) Low molecular weight heparin C) Femoral embolectomy under local anaesthesia D) Peripheral angiography to determine the site of obstruction

********************************************************************************** CASE 30

Fred Zammit is a 75 year old man who presents with a 3 month history of weight loss (about 10 kg) and increasing low back pain. The pain keeps him awake at night and is no longer controlled with Panadeine Forte (paracetamol 500 mg and codeine 30 mg per tablet). 69. In this clinical setting which one of the following statements is correct?

A) This presentation is suggestive of vertebral cancer B) This presentation is suggestive of a herniated intervertebral disc C) The weight loss is no more than would be expected with severe pain D) He should be reassured that the natural history of acute low back pain is favourable

END OF SBA PAPER

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ICA Formative SBA QUESTION COPY - University of · PDF fileICA Formative SBA QUESTION COPY . 83/02 Semester 1 Page 2 CASE 1 ... Timed urine albumin excretion rate D) Serum creatinine