Part 2

Question 1

A 70-year-old woman presents with sudden severe headache “worst ever”. CT brain normal. Next step?
A. Discharge
B. Lumbar puncture
C. MRI in 1 week
D. Start aspirin
E. Observe

Answer 1

Answer: B
Suspected subarachnoid haemorrhage.
If CT negative → LP for xanthochromia.

Question 2

A 30-year-old IV drug user presents with fever and new murmur. Most common organism?
A. Streptococcus viridans
B. Staphylococcus aureus
C. Enterococcus
D. Pseudomonas
E. Candida

Answer 2

Answer: B
IVDU → right-sided infective endocarditis → S. aureus

Question 3

A patient presents with acute monoarthritis of first MTP joint. Best initial treatment?
A. Allopurinol
B. Prednisolone
C. NSAID (e.g. indomethacin)
D. Methotrexate
E. Colchicine long-term

Answer 3

Answer: C
Acute gout → NSAID first-line.
Allopurinol NOT started during acute attack.

Question 4

A child presents with barking cough and inspiratory stridor. Most appropriate treatment?
A. Amoxicillin
B. Nebulised salbutamol
C. Oral dexamethasone
D. Intubation immediately
E. Adrenaline IM

Answer 4

Answer: C
Croup → dexamethasone.
Nebulised adrenaline if severe.

Question 5

A 45-year-old obese woman presents with RUQ pain after fatty meal. Most likely diagnosis?
A. Acute hepatitis
B. Pancreatitis
C. Cholelithiasis
D. Peptic ulcer
E. Appendicitis

Answer 5

Answer: C
Biliary colic classic after fatty meal.

Question 6

A patient on warfarin presents with INR 8 and no bleeding. Management?
A. Stop warfarin only
B. Vitamin K orally
C. FFP
D. PCC
E. Continue warfarin

Answer 6

Answer: B
INR >5 without bleeding → hold warfarin + give oral vitamin K.

Question 7

A 62-year-old smoker presents with painless haematuria. Most likely diagnosis?
A. UTI
B. Renal stone
C. Bladder cancer
D. Glomerulonephritis
E. Prostatitis

Answer 7

Answer: C
Painless haematuria in smoker = bladder cancer until proven otherwise.

Question 8

Which vaccine is contraindicated in pregnancy?
A. Influenza (inactivated)
B. Tdap
C. MMR
D. Pertussis
E. COVID mRNA

Answer 8

Answer: C
MMR = live vaccine → contraindicated.

Question 9

Which electrolyte abnormality is typical in Addison disease?
A. Hypernatraemia + hypokalaemia
B. Hyponatraemia + hyperkalaemia
C. Hypercalcaemia
D. Metabolic alkalosis
E. Hyperglycaemia

Answer 9

Answer: B
Primary adrenal insufficiency:
• Low cortisol
• Low aldosterone
• Hyponatraemia
• Hyperkalaemia

Question 10

A 40-year-old man presents with resting tremor, rigidity, and bradykinesia. First-line treatment?
A. Haloperidol
B. Levodopa/carbidopa
C. Propranolol
D. Diazepam
E. Fluoxetine

Answer 10

Answer: B
Parkinson disease.
Levodopa + carbidopa reduces peripheral metabolism.

Question 11

A 67-year-old man with atrial fibrillation presents with sudden right-sided weakness and aphasia. CT brain shows no haemorrhage. Symptoms started 2 hours ago. Most appropriate management?
A. Aspirin immediately
B. IV alteplase
C. Heparin infusion
D. Clopidogrel
E. Observe

Answer 11

✅ Answer: B – IV alteplase
AMC Substantiation:
This is acute ischaemic stroke within 4.5-hour window.
Key criteria:
Focal neurological deficit
CT excludes haemorrhage
Within thrombolysis window
Management per Australian Stroke Guidelines:
If <4.5 hours → IV alteplase (tPA)
BP must be <185/110 before thrombolysis
Consider mechanical thrombectomy if large vessel occlusion (within 6–24h depending on criteria)
Why others are wrong:
Aspirin → given AFTER thrombolysis or if outside window
Heparin → NOT routine in acute stroke
Clopidogrel → secondary prevention
Observe → unacceptable
Pharmacology: Alteplase
Mechanism: Converts plasminogen → plasmin → fibrin breakdown.
Major risks:
Intracranial haemorrhage
Angioedema (↑ risk if on ACE inhibitors)
Contraindications:
Recent surgery
Active bleeding
Severe uncontrolled HTN
Previous intracranial haemorrhage
AMC Trap:
Never give aspirin BEFORE thrombolysis.

Question 12

A 25-year-old woman presents with fever, flank pain and dysuria. Urine positive for nitrites and leukocytes. She is not pregnant. Most appropriate treatment?
A. Nitrofurantoin
B. Trimethoprim
C. Oral cephalexin
D. IV ceftriaxone
E. No antibiotics

Answer 12

✅ Answer: D – IV ceftriaxone
AMC Substantiation:
This is acute pyelonephritis, not simple cystitis.
Red flags:
Fever
Flank pain
Systemic features
Australian guidelines:
Uncomplicated cystitis → oral therapy
Pyelonephritis → IV ceftriaxone initially
Pharmacology:
Ceftriaxone:
3rd-gen cephalosporin
Covers E. coli, Klebsiella
Adverse effects:
Biliary sludging
Allergy (cross-reactivity with penicillin ~1%)
Counselling:
Complete full course
Return if worsening
AMC Trap:
Nitrofurantoin does NOT treat pyelonephritis (poor renal tissue penetration).

Question 13

A 70-year-old man presents with progressive proximal muscle weakness and heliotrope rash. Most likely diagnosis?
A. Polymyalgia rheumatica
B. Dermatomyositis
C. Myasthenia gravis
D. Motor neurone disease
E. Inclusion body myositis

Answer 13

✅ Answer: B – Dermatomyositis
AMC Substantiation:
Classic:
Proximal weakness
Heliotrope rash
Gottron papules
Association:
Strong malignancy link (especially ovarian, lung)
Investigations:
CK elevated
ANA positive
Muscle biopsy diagnostic
Management (Australian practice):
First-line:
High-dose prednisolone
Add:
Methotrexate or azathioprine if steroid-dependent
Pharmacology:
Prednisolone:
MOA → anti-inflammatory via glucocorticoid receptor.
Adverse effects:
Osteoporosis
Diabetes
Weight gain
Infection risk
Counselling:
Calcium + vitamin D
Consider bisphosphonate
AMC Trap:
Polymyalgia rheumatica = pain + stiffness WITHOUT true weakness.

Question 14

A 60-year-old man with history of alcohol use presents with haematemesis. Most likely source?
A. Mallory-Weiss tear
B. Peptic ulcer
C. Oesophageal varices
D. Gastritis
E. Boerhaave syndrome

Answer 14

✅ Answer: C – Oesophageal varices
AMC Substantiation:
Alcohol → cirrhosis → portal hypertension → varices.
Massive painless haematemesis classic.
Management (Australian emergency protocol):
ABC
IV fluids
IV octreotide
IV ceftriaxone (prophylaxis)
Urgent endoscopic band ligation
Pharmacology:
Octreotide:
Somatostatin analogue
Reduces portal pressure
Ceftriaxone:
Prevents SBP
AMC Exam Pearl:
Always give antibiotics in variceal bleed.

Question 15

A 30-year-old man presents with painful red eye and photophobia. Pupil constricted. Most likely diagnosis?
A. Conjunctivitis
B. Acute angle-closure glaucoma
C. Anterior uveitis
D. Corneal abrasion
E. Scleritis

Answer 15

✅ Answer: C – Anterior uveitis
Substantiation:
Features:
Pain
Photophobia
Constricted pupil
Ciliary flush
Associated with:
HLA-B27
Ankylosing spondylitis
Management:
Urgent ophthalmology
Topical steroids
Cycloplegics
AMC Trap:
Angle-closure glaucoma = mid-dilated fixed pupil.

Question 16

A patient presents with sudden onset dyspnoea and unilateral absent breath sounds. Hypotensive and distended neck veins. Most likely diagnosis?
A. Massive PE
B. Tension pneumothorax
C. MI
D. Cardiac tamponade
E. Asthma

Answer 16

✅ Answer: B – Tension pneumothorax
Classic Triad:
Hypotension
Tracheal deviation
Absent breath sounds
Management:
Immediate needle decompression (do NOT wait for imaging).

Question 17

Which drug is safest for hypertension in pregnancy?
A. ACE inhibitor
B. Losartan
C. Labetalol
D. Amlodipine
E. Spironolactone

Answer 17

✅ Answer: C – Labetalol
Pregnancy HTN first-line:
Labetalol
Methyldopa
Nifedipine
ACEi/ARB contraindicated (renal agenesis risk)

Question 18

A 5-year-old child presents with palpable purpura on legs and abdominal pain. Diagnosis?
A. ITP
B. HSP
C. SLE
D. Meningococcaemia
E. TTP

Answer 18

✅ Answer: B – Henoch-Schönlein Purpura
Classic tetrad:
Palpable purpura
Arthralgia
Abdominal pain
Renal involvement

Question 19

A 55-year-old obese woman presents with fasting glucose 8 mmol/L on two occasions. First-line treatment?
A. Insulin
B. Metformin
C. Sulfonylurea
D. SGLT2 inhibitor
E. DPP-4 inhibitor

Answer 19

✅ Answer: B – Metformin
MOA:
↓ hepatic gluconeogenesis
↑ insulin sensitivity
Adverse:
GI upset
Lactic acidosis (rare)
Contraindicated:
eGFR <30
AMC Pearl:
Always lifestyle + metformin first.

Question 20

A patient presents with confusion and glucose 2.5 mmol/L. On insulin therapy. Immediate management?
A. Oral sugar
B. IV dextrose
C. Glucagon IM
D. Insulin
E. Observe

Answer 20

✅ Answer: B – IV dextrose
If unconscious → IV glucose.
If conscious → oral sugar.

Question 21

72-year-old woman presents with acute onset left calf pain and pallor. The leg is cold with absent distal pulses. Most likely diagnosis?
A. DVT
B. Cellulitis
C. Acute limb ischaemia
D. Compartment syndrome
E. Peripheral neuropathy

Answer 21

✅ Answer: C – Acute limb ischaemia
🔎 AMC Substantiation
This is the classic 6 P’s of acute limb ischaemia:
• Pain
• Pallor
• Pulselessness
• Paraesthesia
• Paralysis
• Poikilothermia (cold limb)
Sudden onset strongly suggests arterial embolism, often from atrial fibrillation.
🚨 Emergency Management (Australian vascular protocol)
Immediate IV heparin bolus (unless contraindicated)
Urgent vascular surgery referral
Imaging (CT angiography) ONLY if limb viable and does not delay intervention
Revascularisation (embolectomy or thrombolysis)
Time-sensitive: irreversible damage after ~6 hours.
💊 Pharmacology – Heparin
MOA: Potentiates antithrombin III → inhibits factor Xa and IIa.
Adverse effects:
Bleeding
HIT (heparin-induced thrombocytopenia)
Osteoporosis (long-term)
Interaction:
↑ bleeding risk with antiplatelets/NSAIDs
AMC Trap:
DVT = swollen warm limb with preserved pulses.
Absent pulses = arterial problem.

Question 22

A 28-year-old woman presents with palpitations, anxiety, tremor and heat intolerance. TSH suppressed, free T4 elevated. She wants pregnancy soon. Best treatment?
A. Radioactive iodine
B. Carbimazole
C. Propylthiouracil
D. Thyroidectomy immediately
E. Beta-blocker only

Answer 22

✅ Answer: C – Propylthiouracil (PTU)
🔎 AMC Substantiation
This is Graves disease in a woman planning pregnancy.
Australian endocrine principles:
• First trimester → PTU preferred
• After first trimester → switch to carbimazole
Reason:
Carbimazole associated with congenital anomalies (aplasia cutis).
💊 Pharmacology Comparison
Carbimazole
Inhibits thyroid peroxidase
Adverse: agranulocytosis, rash, cholestasis
PTU
Blocks TPO + peripheral T4→T3 conversion
Adverse: severe hepatotoxicity (black box warning)
Counselling:
Report sore throat (agranulocytosis)
Regular TFT monitoring
AMC Pearl:
Radioactive iodine is contraindicated in pregnancy and breastfeeding.

Question 23

A 65-year-old man presents with painless jaundice, weight loss and palpable gallbladder. Most likely diagnosis?
A. Gallstones
B. Acute hepatitis
C. Pancreatic head carcinoma
D. Cholangiocarcinoma
E. Cirrhosis

Answer 23

✅ Answer: C – Pancreatic head carcinoma
🔎 AMC Substantiation
Classic Courvoisier sign:
Painless jaundice + palpable gallbladder → malignant obstruction.
Mechanism:
Tumour obstructs common bile duct gradually → gallbladder distends.
Gallstones usually cause painful obstruction and fibrotic gallbladder.
📋 Investigation Pathway (Australian practice)
LFTs → cholestatic pattern (↑ ALP, ↑ bilirubin)
Abdominal ultrasound
CT pancreas (staging)
CA 19-9 (supportive, not diagnostic)
Management:
• Resectable → Whipple procedure
• Unresectable → biliary stenting + palliative chemo
AMC Red Flag:
Weight loss + painless jaundice = cancer until proven otherwise.

Question 24

A 35-year-old woman presents with fatigue, weight gain, dry skin and bradycardia. TSH elevated, free T4 low. First-line treatment?
A. Carbimazole
B. Liothyronine
C. Levothyroxine
D. Iodine
E. No treatment

Answer 24

✅ Answer: C – Levothyroxine
🔎 AMC Substantiation
Primary hypothyroidism.
Treatment principles:
• Start low dose in elderly or cardiac patients
• Recheck TSH in 6 weeks
• Adjust dose gradually
Target:
TSH within reference range (or lower half in younger adults).
💊 Pharmacology – Levothyroxine
Synthetic T4 → converted to T3.
Adverse effects (over-replacement):
Palpitations
Osteoporosis
Atrial fibrillation
Interactions:
Iron and calcium reduce absorption
Take on empty stomach
Pregnancy:
Dose often needs ↑ 30–50%.
AMC Trap:
Never treat subclinical hypothyroidism unless TSH >10 or symptomatic.

Question 25

A 50-year-old man presents with severe epigastric pain radiating to the back. Lipase markedly elevated. Most likely diagnosis? A. Perforated ulcer B. Acute pancreatitis C. Cholecystitis D. MI E. Mesenteric ischaemia

Answer 25

✅ Answer: B – Acute pancreatitis 🔎 AMC Substantiation Diagnostic criteria (need 2 of 3): • Typical pain (epigastric, radiates to back) • Lipase >3× normal • Imaging consistent Common causes (Australia): • Gallstones • Alcohol 🚨 Management (Therapeutic Guidelines) Aggressive IV fluids (Hartmann’s preferred) Analgesia (opioids acceptable) NBM initially Early enteral feeding once stable ERCP if gallstone obstruction Severity Assessment: Use BISAP or APACHE II. Complications: • Necrosis • Pseudocyst • ARDS • Hypocalcaemia AMC Trap: Amylase less specific than lipase.

Question 26

A 23-year-old woman presents with lower abdominal pain, fever and purulent vaginal discharge. Cervical motion tenderness is present. Most likely diagnosis? A. Ectopic pregnancy B. Ovarian torsion C. Pelvic inflammatory disease D. Endometriosis E. Appendicitis

Answer 26

✅ Answer: C – Pelvic inflammatory disease (PID) 🔎 AMC Substantiation Classic triad: Lower abdominal pain Cervical motion tenderness Adnexal tenderness Often due to Chlamydia trachomatis or Neisseria gonorrhoeae. 🚨 Key Exam Red Flags Rule out pregnancy (β-hCG first) Risk of infertility, ectopic pregnancy Tubo-ovarian abscess if severe 🇦🇺 Australian Treatment (Therapeutic Guidelines) Empirical outpatient regimen: Ceftriaxone IM single dose Doxycycline 14 days Metronidazole 14 days Hospitalise if: Severe illness Pregnancy Abscess Failed oral therapy 💊 Pharmacology Essentials Doxycycline MOA: 30S ribosomal inhibition Adverse: photosensitivity, oesophagitis Contraindicated in pregnancy Metronidazole Covers anaerobes Disulfiram-like reaction with alcohol AMC Trap: Always treat sexual partners.

Question 27

A 60-year-old smoker presents with haematuria without pain. Most likely diagnosis? A. UTI B. Renal stone C. Bladder carcinoma D. Glomerulonephritis E. Prostatitis

Answer 27

✅ Answer: C – Bladder carcinoma 🔎 AMC Substantiation Painless haematuria in older smoker = urothelial carcinoma until proven otherwise. Major risk factors: Smoking (strongest) Aromatic amines Cyclophosphamide 📋 Investigation Pathway (Australia) Urine cytology CT urogram Cystoscopy (diagnostic gold standard) Management: TURBT for non-muscle invasive Intravesical BCG Radical cystectomy if invasive 💊 BCG Intravesical Therapy MOA: Local immune activation against tumour cells. Adverse: Cystitis symptoms Rare systemic BCG infection AMC Red Flag: Never assume UTI without dysuria.

Question 28

A 45-year-old man presents with crushing chest pain radiating to left arm. ECG shows ST elevation in leads II, III, aVF. Diagnosis? A. NSTEMI B. Stable angina C. Inferior STEMI D. Pericarditis E. PE

Answer 28

✅ Answer: C – Inferior STEMI 🔎 AMC Substantiation Leads II, III, aVF → inferior wall → right coronary artery. 🚨 Immediate Management (Australian ACS pathway) Aspirin 300 mg P2Y12 inhibitor (ticagrelor preferred) Anticoagulation (heparin) Urgent PCI (goal <90 min) If PCI unavailable → thrombolysis within 12 hours. 💊 Pharmacology Essentials Aspirin Irreversible COX-1 inhibition GI bleeding risk Ticagrelor Reversible P2Y12 inhibitor Dyspnoea side effect Avoid strong CYP3A4 inhibitors Heparin Monitor for HIT AMC Pearl: Inferior MI may cause bradycardia (SA/AV node supply).