HM Medical Clinic

 

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Clinical MCQs Assessment – Sample Questions
The fol owing 20 clinical MCQs are representative of the style and format of MCQs that candidates
wil receive as part of the AACP Stage 2 Clinical MCQ Assessment.
The answers and explanatory notes are provided at the end of this document.
SQ1. Which ONE of the following patients has the HIGHEST calculated creatinine clearance? a) A 65‐year‐old, 65kg man with a creatinine of 100micromol/L b) An 85‐year‐old, 65kg woman with a creatinine of 100micromol/L c) A 75‐year‐old, 55kg woman with a creatinine of 100micromol/L d) An 85‐year‐old, 55kg man with a creatinine of 100micromol/L SQ2. Of the following statements regarding urinary incontinence, which ONE is the LEAST a) Patients with urge incontinence often experience a sudden urge to void fol owed by an involuntary loss of urine b) Selective alpha blockers such as prazosin may be used with caution in males to treat overflow incontinence, but may worsen stress incontinence in females c) Patients with overflow incontinence often have a high post‐void bladder volume due to poor detrusor activity or outlet obstruction d) Anticholinergic agents such as oxybutynin may be used with caution to treat urge incontinence, but may worsen overflow incontinence in males e) Patients with functional incontinence often involuntarily leak urine when sneezing, coughing or during exertion SQ3. According to the 2006 Asthma Management Handbook, which ONE of the following statements regarding asthma is the LEAST appropriate? a) Asthma is a chronic inflammatory disorder of the airways typical y characterised by recurrent episodes of wheezing, breathlessness, chest tightness, and coughing b) Symptoms of asthma tend to be more severe at night or in the early morning c) There are numerous potential triggers for symptoms of asthma, such as allergens, viral respiratory infections, and irritants such as tobacco smoke d) Long‐term, poorly control ed asthma is unlikely to result in permanent structural changes in e) The symptoms of asthma are usual y associated with airflow obstruction that is often reversible, either spontaneously or with medical treatment SQ4. The efficacy of which ONE of the following medications is MOST likely to be attenuated in a patient with a creatinine clearance of approximately 20mL/min? a) Nitrofurantoin SQ5. You perform a medication review for a 65 year old nursing home resident. His medical history includes advanced Parkinson's disease with associated depression and constipation. His current a) cabergoline 2mg daily b) docusate and senna 50/8mg twice daily c) levodopa/carbidopa 100/25mg every four hours d) selegiline 5mg daily e) sertraline 50mg daily Nursing staff report that he is reasonably well managed, except for daily nausea which is causing him significant distress. Which ONE of the following medications is MOST appropriate to treat this man's nausea? a) Metoclopramide b) Prochlorperazine SQ6. Which ONE of the following drugs is LEAST likely to improve a patient's prognosis following a myocardial infarction? SQ7. Which ONE of the following is NOT a potential indication for dexamethasone? a) Treatment of cerebral oedema associated with metastatic brain tumours b) Management of nausea and vomiting associated with chemotherapy c) Adjuvant for pain relief d) Treatment for anaemia of chronic disease e) Appetite stimulant in palliative care SQ8. Which ONE of the following conditions is LEAST likely to increase the risk of lactic acidosis in a patient taking metformin? a) Heart failure c) Renal failure d) Respiratory failure e) Rheumatoid arthritis SQ9. Which ONE of the following medications is MOST likely to cause or exacerbate dry eyes? a) Bromocriptine c) Levodopa with carbidopa SQ10. Which ONE of the following medications is MOST likely to cause or aggravate overflow incontinence in males due to benign prostatic hypertrophy? SQ11. A 92 year old woman has a history of severe dementia (Mini Mental State Examination score was 10/30 6 months ago and 9/30 last month), TIAs, anxiety and has had a bilateral cataract extraction and lens implantation. Her medications are as fol ows: a) Paracetamol 1g m b) Galantamine 8mg each m c) Pantoprazole 40mg d d) Calcium carbonate 600mg daily e) Metoclopramide 10mg tds prn She has significant upper gastrointestinal symptoms, with persistent nausea. She is using metoclopramide on average twice daily, in addition to her regular proton pump inhibitor, and her nausea continues to be a problem. Of the fol owing treatment strategies, which ONE would be the MOST appropriate at this stage? a) Change her metoclopramide to a regular three times daily dose schedule b) Increase the pantoprazole dose to 40mg twice daily c) Review the need for the galantamine, as it may be contributing to the GI symptoms d) Check the serum calcium as hypercalcaemia from her calcium supplements is the most likely e) Cease the metoclopramide and commence a 5HT3 antagonist such as dolasetron SQ12. According to the Therapeutic Guidelines, which ONE of the following antibiotic regimens is the LEAST appropriate to treat chronic prostatitis? a) Amoxycil in+clavulanate 500+125 mg orally, 12‐hourly for 2 weeks b) Norfloxacin 400 mg orally, 12‐hourly for 4 weeks c) Ciprofloxacin 500 mg orally, 12‐hourly for 4 weeks d) Trimethoprim 300 mg orally, daily for 4 weeks e) Doxycycline 100 mg orally, 12‐hourly for 2 to 4 weeks SQ13. Which ONE of the following electrolyte levels is MOST likely to be disturbed in a patient diagnosed with the syndrome of inappropriate antidiuretic hormone secretion (SIADH)? SQ14. Which ONE of the following medications is LEAST likely to be used in the prevention or treatment of peripheral neuropathy? a) Hydroxocobalamin SQ15. A 64‐year‐old woman with persistent asthma is referred for a HMR. Her asthma has been stable for the past six months on her current regimen of high‐dose inhaled fluticasone, regular salmeterol and as‐needed salbutamol. She uses her reliever approximately once every 1 to 2 weeks. Of the fol owing recommendations, which ONE would be the MOST appropriate for this patient's therapy at this time? a) Continue all her medications at their current doses b) Cease both the fluticasone and the salmeterol c) Cease the salbutamol and fluticasone and use salmeterol regularly and when‐required d) Continue the salmeterol at current dose and reduce the dose of fluticasone e) Cease the salmeterol and reduce the dose of fluticasone SQ16. According to the Palliative Care Therapeutic Guidelines, which ONE of the following agents is the LEAST appropriate to manage nausea and vomiting in palliative care? b) Metoclopramide d) Prochlorperazine e) Dexamethasone SQ17. You perform a HMR for a 69‐year‐old woman who is suffering from persistent fatigue. Her weight is stable, she is sleeping well, and her mood is good. Her medical history is notable for hypothyroidism, diabetes mellitus, recently diagnosed glaucoma, and osteoporosis. Her current medications are a) alendronate 70mg weekly b) glibenclamide 5mg twice daily c) thyroxine 100mcg daily d) timolol 0.5% eye drops twice daily e) latanoprost 0.005% eye drops daily Her blood pressure is 108/62 mmHg, pulse rate is 58/min. Laboratory studies include a recent HbA1c of 6.9%, and a serum thyroid‐stimulating hormone level of 3.4 mU/mL (reference range 0.4 ‐ 4.0 mU/mL). Renal function and liver chemistry tests are normal. Of the fol owing medications, which ONE is the MOST likely cause for this patient's fatigue? b) Glibenclamide SQ18. You perform a medication review for an 81 year old nursing home resident. His past medical history includes systolic heart failure, ischaemic heart disease, mild aortic stenosis and diabetes. His current medications are: • atorvastatin 20mg daily • bisoprolol 2.5mg daily • digoxin 125mcg daily • gliclazide 80mg twice daily • glyceryl trinitrate patch 10mg/24hr daily Pathology results from one month ago were as fol ows: • sodium 141 mmol/L (135‐145 mmol/L) • potassium 4.2 mmol/L (3.5‐5.0 mmol/L) • urea 8.5 mmol/L (2.2‐7.7 mmol/L) • creatinine 132micromol/L (50‐120 micromol/L) His blood pressure the morning of the review was 150/95 (HR 91 bpm), and his notes show that these readings have been around this level for some time. Which ONE of the following recommendations is the LEAST appropriate for this patient at this time? a) Add low dose hydrochlorothiazide to his therapy b) Increase the dose of bisoprolol c) Add ramipril to his therapy d) Add diltiazem to his therapy e) Add an antiplatelet agent to his therapy SQ19. The National Prescribing Service reviewed the role of antipsychotics in managing behavioural and psychological symptoms of dementia (BPSD) in 2007. Which ONE of the following behavioural and psychological symptoms of dementia is MOST likely to respond to antipsychotic therapy? b) Hallucinations e) Cognitive defects SQ20. You review an 84‐year‐old female nursing home patient as nursing staff have noticed she has become increasingly confused. Current laboratory tests are shown below: • Sodium 124mmol/L (135 ‐ 145 mmol/L) • Potassium 3.6mmol/L (3.5 ‐ 5.0 mmol/L) • Creatinine 85micromol/L (50 ‐ 100 micromol/L) Her current medications are: • Paroxetine 20mg each morning • Ramipril 5mg each morning • Frusemide 40mg each morning • Spironolactone 25mg daily • Temazepam 10mg each night • Paracetamol 500mg ‐ 1g 4 hourly prn Of the fol owing management or investigation strategies, which ONE is the MOST appropriate next step in this case? a) A serum osmolarity test should be conducted to establish whether she has SIADH b) Her frusemide dose should be reduced as it is the most likely cause of the hyponatraemia c) The paroxetine should be ceased as it is the most likely cause of the hyponatraemia d) Her current fluid volume status should be evaluated e) She should have comprehensive biochemical tests conducted to determine levels of calcium, magnesium, phosphate, alkaline phosphatase This patient's creatinine clearance is approximately 60mL/min <Cockroft Gault equation> Reference:
AMH 2011 p xv
Patients with stress incontinence often involuntarily leak urine when sneezing, coughing or during excertion‐ functional incontinence results from an inability to get to the toilet in time eg immobility or psychological disturbance. Reference: AMH Drug Choice Companion Aged Care Third Edition
Explanatory notes: Urge incontinence is associated with a sudden urge to void. Alpha blockers may be used for overflow incontinence in men but may worsen stress incontinence in Overflow incontinence may result from poor detrusor activity or obstruction of the urethra. Anticholinergics may be used to treat urge incontinence in women but may worsen overflow incontinence in men. The inflammatory process can cause permanent changes in the airways. Long‐term changes include increased smooth muscle, increase in bronchial blood vessels, thickening of col agen layers and loss of normal distensibility of the airway. Reference: 2006 Asthma Management Handbook p15
Explanatory notes: Asthma is an inflammatory airways disease characterised by wheeze and cough that may be worse at night or in the early morning. These symptoms are associated with airways obstruction that is usual y reversible. Triggers for asthma are many and varied depending upon the patient. Nitrofurantoin is excreted through the kidneys, it is recommended that nitrofurantoin not be given to patients with a creatinine clearance of less than 40 to 60 mL per minute [0.67 to 1.00 mL per second]; nitrofurantoin loses its effectiveness in patients with renal function impairment, and toxic effects are increased. Reference: AusDI
Explanatory notes: Whilst the excretion of allopurinol, gentamicin, trimethoprim and digoxin relies upon the kidney, these drugs are not less effective in renal impairment. Domperidone is the preferred agent to treat nausea and vomiting in patients with Parkinson's disease. References: AMH 2011 Chapter 12 Gastrointestinal Drugs, Antiemetics; eMIMS
Explanatory notes: Metoclopramide and prochlorperazine may worsen the symptoms of Parkinson's disease. Ondansetron is reserved for chemotherapy, radiotherapy or surgery‐related nausea and vomiting, or when other anti‐emetics are inappropriate. Promethazine is sedating and anticholinergic‐ another option is more appropriate. Verapamil has limited evidence for reduction of mortality after MI and should only be used where beta blockers are contraindicated. Beta‐blockers, ACE inhibitors, aspirin and statins have all been demonstrated to improve prognosis following MI. References: AMH 2011 > Chapter 6
Cardiovascular drugs > Drugs for angina and acute coronary syndromes > ST segment elevation MI;
eTG Cardiovascular 2008
Explanatory notes: Beta‐blockers reduce myocardial oxygen demand by lowering heart rate, BP and cardiac filling pressure. They reduce cardiovascular morbidity and mortality. Atenolol, metoprolol and propranolol are marketed for this indication. Antiplatelet drugs such as aspirin reduce mortality and risk of re‐infarction and stroke. ACE inhibitors limit progression of heart failure and reduce mortality and risk of reinfarction in all Statin therapy has been shown to reduce premature death, myocardial infarction and other adverse outcomes such as stroke and revascularisation post MI. Statin therapy should be continued, or initiated during the hospital admission, no matter what the underlying cholesterol level. Dexamethasone is not indicated in managing ACD (although it may be used for autoimmune hamolytic anaemia) References: Aus DI; AMH 2011; eTG Pal iative Care 2010
Explanatory notes: Dexamethasone may be used for cerebral oedema, chemotherapy‐induced nausea and vomiting, pain relief and as an appetite stimulant in palliative care. It is not used in treating anaemia of chronic Risk factors for lactic acidosis in patients taking metformin are those where patients have reduced tissue perfusion or impaired metformin excretion. Rheumatoid arthritis causes neither of these, hence is least likely to be associated with lactic acidosis. References: AMH 2011 Chapter 10 Drugs
for Diabetes, Metformin; eTG Endocrinology 2009
Explanatory notes: Risk factors for lactic acidosis in patients taking metformin are those where patients have reduced tissue perfusion or impaired metformin excretion. Rheumatoid arthritis causes neither of these, hence is least likely to be associated with lactic acidosis. Benztropine commonly causes dry eyes. References: AMH 2011 Chapter 16 Neurological Drugs,
Drugs for Parkinsonism, Anticholinergics; eMIMS
Explanatory notes: Bromocriptine, levodopa with carbidopa, selegiline and entacapone rarely cause dry eyes. Verapamil may cause or aggravate overflow incontinence via reduction in detrusor activity. Reference: AMH Drug Choice Companion Aged Care Third Edition 2010 > Genitourinary topics >
Urinary incontinence > Medications which may cause or aggravate urinary incontinence
Explanatory notes: Ramipril aggravates stress, not overflow, incontinence. Prazosin generally improves overflow incontinence in men with BPH. Neither candesartan nor metoprolol are strongly associated with aggravating overflow incontinence Galantamine offers modest efficacy in patients with mild to moderate dementia, and its use should be reviewed regularly. In this patient, efficacy is doubtful, and there are significant gastrointestinal adverse effects which may be improved of the drug is ceased. References: eTG Psychotropic 2008;
AMH 2011 Chapter 16 Neurological Drugs, Drugs for Alzheimer's Disease
This is an appropriate regimen for acute UTI in males, not prostatits References: eTG Antibiotic 2010; AMH 2011 Chapter 13 Genitourinary Drugs, Drugs for benign
prostatic hyperplasia and prostatitis
The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is characterised by disruption in sodium levels PSA Clinical Case Studies Lab data. Atorvastatin is not associated with preventing or treating peripheral neuropathy. References: AMH
2011; eTG Neurology 2011
In a patient taking high‐dose inhaled corticosteroids as part of therapy for persistent asthma whose disease is stable, reducing the dose of corticosteroids should be considered to prevent therapy‐ related side effects. Reference: Asthma Management Handbook 2006
Explanatory notes: Ceasing both the fluticasone and the salmeterol may cause her to lose her good asthma control; salmeterol is not suitable for when‐required use; ceasing salmeterol would not be recommended as it currently reduces her dose of inhaled steroid. Benztropine is not commonly used to manage nausea and vomiting in palliative care. Reference: eTG
Pal iative Care 2010
Explanatory notes: Haloperidol, metoclopramide, prochlorperazine and dexamethasone are all used to manage nausea and vomiting in palliative care. Her pulse and BP suggest that she is excessively beta‐blocked, most likely due to systemic absorption Explanatory notes: Alendronate, glibenclamide and latanoprost do not usually cause fatigue; her TFTs do not support This patient is already taking bisoprolol and digoxin, and the addition of diltiazem may cause significant bradycardia. Additionally, digoxin levels may be significantly increased by diltiazem. It is more appropriate to address the hypertension with one of the other options presented. Reference:
AMH 2011 Chapter 6 Cardiovascular drugs
Explanatory notes: Low dose thiazides are considered to be first line therapy for most patients with hypertension, and would be a reasonable choice in this man. Despite his degree of renal impairment, a low dose thiazide would likely be effective as (in low doses for hypertension) they lower BP mostly by a vasodilator effect. (AMH 2009) Increasing the dose of bisoprolol would offer additional hypertension control as well as improve his heart failure prognosis. (AMH 2009) Ramipril has been shown to improve symptoms, reduce mortality and risk of hospitalisation in heart failure patients. Introduction of this agent, with monitoring of creatinine and potassium is an appropriate recommendation. (AMH 2009) Antiplatelet therapy in ischaemic heart disease reduces the incidence of ischaemia at rest and the risk of myocardial infarction or death. Additionally, all diabetic patients over the age of 50 have a cardiovascular risk equivalent to a nondiabetic person with known coronary artery disease, so an antiplatelet agent is a desirable addition to his therapy. (AMH 2009) Aggression, agitation and psychotic symptoms (e.g. delusions or hal ucinations) respond best to antipsychotic therapy. References: AMH Drug Choice Companion Aged Care Third Edition 2010;
NPS PPR 37; eTG Psychotropic 2008
Explanatory notes: Symptoms unlikely to respond to antipsychotic therapy include wandering, withdrawal, cognitive defects, touching, shouting, insomnia, pacing and incontinence. References: AMH Drug Choice
Companion Aged Care Third Edition 2010; NPS PPR 37; eTG Psychotropic 2008
The first step in the evaluation of all cases of hyponatraemia is evaluation of volume status. Dilutional hyponatraemia is by far the most common cause of hyponatraemia in patients prone to oedema. The use of frusemide and other heart failure medications in this patient indicate that hypervolaemic hyponatraemia is a possibility. Reference: Hughes, J. et al. Use of Laboratory Test
Data: Process Guide and Reference for Pharmacists > Ch. 2 Sodium >Hyponatraemia

Source: https://www.aacp.com.au/accreditation/accreditation-assessment/?fdlfile=MwD0AGOwLGZjLmOxMJR4MQAyMGqzLJMzZQZjMGOuAQEvZmZ0AJAwAmIxBQNlZJSvMzMvMzV4AQLmBQtjZGp4BTSxZJSwZGSxL2H5ZTHmMGt2BJIxBJDlAQDjLwLmL2AzA2Z3MTH5Lwp0ZGqxZwuwZmuvMTLmBGL2A2EzLwNlZmR=