au aE es the SeAustralian Medical Counc. Handbook of Multiple Choice Questions - TABLE OF CONTENTS Foreword SOC BSCS B ERR TCT ES SSCS SSE C HRP HHERHEC SEES SOCCER PERETCHETC ERS [PRR RRR RRR RRR RRR RRR RRR RRR RE ES ote tee o & iii Gordon G Page Preface ........... Bo aaa eae itd Rey taal apurdraaid. aves agald oait PART re eee iv Richard R Doherty and Richard Smallwood Contributors ......... Sgullesuieubounaiureal Wate ceduiseiueeseeiva sets iid hele Bole BF Editorial Committee Additional Contributors and Reviewers AMC Secretariat Acknowledgements SCPC EPEC SSS SHSESHESHESBFETCTHERECEES SPCC SCHESFPTSSTHPTEB ETRE Ss 2G G88 88 o Se eee tee e eft e xii Introduction SSSR FHF CSCC e SSeS TECHS REPHTEF BRB eee Ste eease eee tte eeeeeeesrerees eeeeee Set tttiatethetboatoan Xiv Vernon C Marshall. Section 1 - The AMC MCQ Examination process — Example MCQ 1.1 to 1.22 GN COMMENHMATIES ...........ceeseceseceeerseees ebesuewenieusvescianere gaxieseesaseotesemmvasnaseeds petsaaeey Lal Assessment Methodologies in Medicine — Peter G Devitt and Neil A Spike .......eseseeeeeeeererereeenenes 1.2 Structure and Standard of the AMC Examination: Examination Blueprint and Mix of Questions — Vernon C Marshall, Peter G Devitt, and Neil S Paget 0.0... ceecceceeseeseeeeneeeeeeeeeeeeeene 6 3 Analysis, Revision and Review of Questions — Vernon C Marshall and Neil S Paget: eae fe Audie Bree @ arsecan dhadiea menketecmacnonteecasbtes Jevmevensutaesee) 1.4 Patnweiys ‘0 Meclea Reuse in ‘Australia - lan B BRK. saninalhigiis biti GRE aa BO Section 2 - Trial Examination .................. iy eo siphes peer ptt tacts 45 Self-test Multidisciplinary MCQ Examination MCQ 2.001 -— 2.150 .. Seat Halal ges acteteaudeaad dias lexaiaelpriceuvacuunastuiasoemse oo tesmadoaveaens se OL MCQ Trial Egimniation ‘Commentanes 2. 001 - 2. 150. sednacchhastnnetenntnatiansttiihaainin air EE POn ae Section 3 SERPS REO S PFS STS HOSTS ETTORE Tee ee eee S PSSST STC PCPS TSS SCTE SEES SEEGER EES oo8 203 Annotated MCGQ in five patient group (PG) categories Questions MCQ 3.001 — 3.411 ................006 er tral Allasio ca LS seseceesseeee 204-375 Adult Health and Aged Care (PGI-AH) MCQ 3.001-3.228 Medicine and oe 200 Medicine/Surgery/Gynaecology Gynaecology 28 .. cat icoipiet bcrsceusccuss anol | Child and Adolescent Health (PG2-CH) MCQ 3.229-3.298 POeCiOtriCs 70 oe ce seteteeeeeteeeserees DI Z-3I6 Maternal Health (PG3-MAH} MCQ@ 3:299-3.326 Obstetrics 28 .........csecseterseseresrseranserterens BOF OAF Mental Health (PG4—-MEH) MCQ 3.327-3.378 Psychidtry 52.0000... ccsceeseneeenseeteseeeeeees 048-365 Population and Community Health and MCQ 3.379-3.411 Population and Community Ethics (PGS-PCH) BOTH 3S. cs eencnneccenenitnnendttanasi lid elas as OOOmOre Commentaries MCG 3.001 — SiAV 0 avcsisccccscccdicccvencsscccsccssesscsasececcveravevessescessacosndanes 376-637 Adult Health and Aged Care (PG1—AH) MCQ 3.001-3.228 Medicine and Surgery 200 Medicine/Surgery/Gynaecology GYNOeCOlGY 28s Giiicawnsne cl P84 Child and Adolescent Health (PG2-CH) MCQ@ 3.229-3.298 POeCIATICS 70.........:cccesseeeererssereeesrerere DOO-O/ | Maternal Health (PG3-MAH) MCG 3.299-3.326 Obstetrics 28.00... ccseseeeueenersteereeee 7 2-983 Mental Health (PG4—-MEH) MCQ 3527-8378 Psychiatry 52..... 2c janie cnn 84-619 Population and Community Health and MCQ 3.379-3.411 Population and Community Ethics (PG5-PCH) HOGA SS secre nansinnnanninnOZO OarWE UEUFELe utes cL Section 4—Alleword.. atm idle aie haa 638s 4.] Glossary and Abbreviations:2™ |e. Weement Weneke Oren ee 639 4.2 NONMTIGL VONWES o.csssssescctasasisge hale REM MEMOS AS T 4.3 EDONVINS seistcesia wiseets O49 F 4.4 Guidelines fok Further Multidiseipiinary Reading: “Peter Devitt, Richard ‘Doneny, Frank Homes \ Barry McGrath, Vernon Marshall, Kichu Nair, Neil Paget, Roger Pepperell, Jeffery Prebble, C Graeme Smith, Neil Spike, Ross Sweet, Peter Vine and Bryan Yeo .. iiisenia Seas a NEG i! 4.5 Goals and oe of Medical Education — Mission Statement, Due aicha BRS A EI -ssspansased ccesnncesvaraveimnrcsvavacessiuenitesusies oe MAUR tata a ot clesertireecidl ueliccsccccssrchccen cc, BS r 4.6 Reference Units -— SI Units .. der nunceslnnnnanes Son seasseraunenisuaied-eni tei euiphesennsvus nsnnuunvuarzemec vetted acetone ae? | 47 Question Interpretation .......0... di das) anenlesenanannsca:tindessieps Oto 4.8 ltem Classifications — FuNetiCN aia preeaae Systems/Regions/Subspecialities .. socndedaseslveartnasaaeiauas OPO 4.9 Anthology Clinical Presentation List AMC Anthology of Medical Conditions .. ve eaeuekOD 4.10 Annotated MCQ Scenario Topics, Classifications, Anthology References ane Fswar coe. coments a Tie: Section 5 — Epilogue ............ccccssseeseees WéduiesSieakbaan sawapates camexadibnkguliaciasrotes Siiesiehs 739 Introduction to the AMC's online trial examination MSS Pe i sl CN oe se ofa oe fark Rote oess donee ete ee cee NSS et Aeon Sea I ae a aAustralian Medical Council Handbook of Multiple Choice Questions FOREWORD This Handbook of Multiple Choice Questions is the fourth in a series of publications that has been produced by the Australian Medical Council (AMC) to assist International Medical Graduates (IMGs) prepare for the AMC examinations. The AMC and the authors of this and earlier documents deserve considerable recognition for their insight, Commitment and expertise in supporting IMGs’ entry into the Australian medical system, and for doing so in a manner which assures the Australian public about their competence. The introduction to this book lists The many clinicians who have contributed to its develooment. They are among the most respected doctors in Australia. These same clinicians devote many days each year to the develooment and review of materials for the AMC examinations and most have been doing so for many years. Their commitment to the AMC and its examinations underscores the respect they have and priority they assign to the AMC and its role and, more importantly, the quality of the assessment materials comprising the AMC examinations. The examinations of the AMC are developed to assess competence at the level of a graduate from an Australian medical school, and assess competence relative to the requirements of safe, effective medical practice and health care in Australia. Effective this year, IMGs seeking general registration through the Standard Pathway must pass the AMC's multiple choice question (MCQ) examination as a precondition to working in Australia. This latest publication serves IMGs well as an introduction and orientation to this examination. It has been over a decade since the AMC produced its first publication in this series. The first publication, like this current publication, addressed the needs of IMGs in their preparation for the AMC MCQ@ examination. A comparison of the first and fourth booklets identifies a remarkable evolution of the MCQ examination; from an emphasis on the assessment of an IMG's knowledge base to one of testing their ability to make key clinical decisions underlying safe and effective clinical practice. This evolution is based on the recognition that, while possessing knowledge remains a cornerstone of clinical competence, the ability to apply that knowledge in the context of clinical problems is the real test of clinical competence, and that knowing alone is Q necessary but not sufficient condition to being clinically competent. The skill of applying knowledge to clinical problems, like all skills, is developed through a process of deliberate practice accompanied by feedback. This Handbook of Multiple Choice Questions provides the IMG with an opportunity to practice this skill in the context of the types of questions they will encounter on the AMC MC@ examination and, as needed, to obtain up-to-date and detailed feedback (and knowledge acquisition) to guide its development. The commentaries accompanying each question provide excellent discussions of the rationale for the best response to the question, and for why the other responses are not the best response (e.g. not as likely, not the first step to be taken, not as important). In essence, this publication can be a key resource to IMGs preparing for the AMC MCQ examination and, in addition, is an excellent self-assessment and learning resource for Australian senior medical students and prevocational trainees. Gordon G. Page, PhD Consultant to the Australian Medical Council Emeritus Professor of Medical Education University of British Columbia Vancouver Canadaa Py e Me el ralian Medical Council Medical Council . lbook of Multiple Choice Questions REFACE 1e Board of Examiners of the Australian Medical Council (AMC) is primarily concerned ith ensuring that International Medical Graduates awarded the AMC certificate ill have the right balance of knowledge, skills, judgement and other professional tributes to allow them to work effectively in Australia. The MCQ examination is the st step in the process by which doctors trained outside the Australasian system an demonstrate knowledge and skills comparable to those of a new Australasian ‘aduate. In setting this examination, the AMC's Board of Examiners maintains an 2m bank and develops new test items which focus on important steps in delivery F medical care in an Australian setting. Items selected for examinations cover a ide range of topics and clinical tasks, which take into account factors such as the atterns of illness in the Australian community and health priorities, which largely etermine how health care is delivered. pursuing the objectives of the MCQ examination, we have been particularly mindful f the need to move away from traditional testing strategies in MCQ examinations. s a result, items used in the MCQ examination are increasingly focused on the pplication of medical knowledge to a clinical problem rather than simply the recall f technical information. It has become apparent that this presents a considerable hallenge to many candidates who may not have had to confront such examinations | the past. Ye AMC's Handbook of Multiple Choice Questions should assist candidates prepare 9 the AMC's MCQ examination with more confidence. The book offers a series f carefully chosen insights into the content and style of current AMC MCQ items: 1ey are arranged in the same patient groups and clinical tasks which make up the lueprint of the MCQ examination, and reflect the strong move towards application of Nowledge. Each of the items has been chosen to emphasise a learning point and the em commentaries provide additional guidance to candidates. Candidates should >cognise, however, that the book’s content is not an exhaustive collection and that 1e items in the book are only examples and are not part of the item bank from which \eir examination questions will be drawn; but the book MCQ items exemplify themes nd principles of diagnosis, investigation and management common to current AMC ank questions. 1e book's authors include members of the Board, other senior examiners and a range f contributing clinicians who have been part of the AMC’s item development team. part from drafting the items and their commentaries, the authors have scrutinised ioth content and construction of items in a multidisciplinary editorial panel. We are onfident that this process has produced a volume that candidates will find helpful in 1eir preparation for the AMC examination. ichard R Doherty ~hair, Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners, \ustralian Medical Council ichard Smallwood resident, Australian Medical Council CO EDITC Vernc Edito Emer Cons Senic Past Exar Pete ASSO: Senic Senic Mery of th Clink Rich Profe Con Cen Seni Cha Exar Clini Frar Clin Seni Mer of Tt Clin Ban Pro} Che sen Me of Tt Clir ——Australian Medical Council Handbook of Multiple Choice Questions CONTRIBUTORS EDITORIAL COMMITTEE Vernon C Marshall MBBS, FRACS, FACS Editor-in-Chief, Australian Medical Council Emeritus Professor of Surgery, Monash University Consultant Surgeon, Monash Medical Centre Senior Examiner in Surgery for the Australian Medical Council Past Chairman — Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Peter G Devitt MBBS, MS, FRACS Associate Professor of Surgery, University of Adelaide Senior Visiting Surgeon, Royal Adelaide Hospital Senior Examiner in Surgery for the Australian Medical Council Member-—Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Clinical Discipline head — Adult Health and Aged Care (Surgery) Richard R Doherty MBBS, DObstRCOG, FRACP Professor of Paediatrics, Monash University Consultant Paediatrician and Head, Paediatric Infectious Diseases, Monash Medical Centre Senior Examiner in Paediatrics for the Australian Medical Council Chairman — Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Clinical Discipline head — Child and Adolescent Health Frank P Hume MBBS, FRACP, MRC Psych Clinical Lecturer, School of Psychiatry, University of New South Wales Senior Examiner in Psychiatry for the Australian Medical Council Member-—Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Clinical Discipline head — Mental Health Barry P McGrath MBBS, MD, FRACP Professor of Medicine, Monash University Chair — Confederation of Postgraduate Medical Education Councils of Australia Senior Examiner in Medicine for the Australian Medical Council Member—Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Clinical Discipline head — Adult Health and Aged Care (Medicine)Ausiralian Medical Council Handbook of Multiple Choice Questions Balakrishnan R Nair AM, MBBS, FRACP, FRCP Clinical Professor of Medicine and Associate Dean of Continuing Professional Development, School of Medical Practice and Population Health, University of Newcastle Director, Continuing Medical Education and Professional Development, Hunter New England Health, Newcastle Senior Examiner in Medicine for the Australian Medical Council Member — Board of Examiners and Clinical Panel of Examiners of the Australian Medical Council Neil S Paget MA, MAdmin, DipEd, MACE Honorary Professor of Medicine, Monash University Technical Advisor on Assessment for the Australian Medical Council Member-—Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Roger J Pepperell MBBS, MD, MGO, FRACP, FRCOG, FRANZCOG, FACOG (Hon) Emeritus Professor of Obstetrics and Gynaecology, University of Melbourne Consultant Obstetrician and Gynaecologist, Royal Women’s Hospital, Melbourne Senior Examiner in Obstetrics and Gynaecology for the Australian Medical Council Past Chairman — Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners Chairman — Clinical Panel of Examiners of the Australian Medical Council Clinical Discipline head — Maternal Health and Gynaecology Jeffrey Prebble OAM, MBBS, FRACP Associate Professor of Paediatrics, University of Queensland Consultant Paediatrician in Toowoomba, Queensland Examiner in Paediatrics for the Australian Medical Council Member — MCQ Panel of Examiners of the Australian Medical Council Graeme C Smith MBBS, MD, DPM, FRANZCP Emeritus Professor, School of Psychology, Psychiatry and Psychological Medicine, Monash University Honorary Psychiatrist, Southern Health, Victoria Senior Examiner in Psychiatry for the Australian Medical Council Member — Clinical Panel of Examiners of the Australian Medical Council Neil A Spike MBBS, FRACGP Associate Professor and Head, Department of General Practice, Monash University Director of Education, School of Primary Health Care, Monash University Senior Examiner in General Practice for the Australian Medical Council Member -— Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Clinical Discipline head — Population and Community Health and EthicsAustralian Medical Council Handbook of Multiple Choice Questions Ross Sweet AM, MBBS, FRCOG, FRANZCOG, FACLM Former Senior Clinical Lecturer in Obstetrics and Gynaecology, University of Adelaide Former Medical Chief, Women’s and Babies’ Division, Women's and Children’s Hospital, Adelaide Senior Examiner in Obstetrics and Gynaecology for the Australian Medical Council Member — MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Peter J Vine MBBS, FRACP Adjunct Associate Professor, School of Community Health, Charles Sturt University, Albury NSW Senior Lecturer and Head of Campus, University of New South Wales Rural Clinical School, Albury Wodonga Campus Formerly Senior Lecturer (Part-time) Monash University Department of Paediatrics Senior Examiner in Paediatrics for the Australian Medical Council Member-—Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Bryan W Yeo MBBS, FRACS, FRCS Associate Professor of Surgery, University of New South Wales Senior Visiting Surgeon, Prince of Wales Hospital, Sydney Senior Examiner in Surgery for the Australian Medical Council Member-—Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council ADDITIONAL CONTRIBUTORS AND REVIEWERS E. Jonn Anstee MBBS, FRACS Consultant Plastic and Reconstructive Surgeon Former Head, Department of Plastic Surgery, Alfred Hospital, Melbourne Senior Lecturer, Monash University Department of Surgery John Barnard DEd, PhD, EdD Adjunct Professor, Department of Medical Education, University of sydney Executive Director, EPEC Pty Ltd Psychometrician for the Australian Medical Council Christen Barras MBBS Stroke Imaging Fellow, Department of Neuroscience, Royal Melbourne Hospital, Parkville Melissa Barrett MBBS, FRANZCP Site Coordinator of Training, Prince of Wales Hospital, SydneyAustralian Medical Council Handbook of Multiple Choice Questions Kerry Breen AM, MBBS, MD, FRACP Associate Professor of Medicine, University of Melbourne Past President, Medical Practitioners Board of Victoria Past President, Australian Medical Council Past Chairman, Australian Health Ethics Committee (NHMRC) Wendy Brown MBBS, PhD, FRACS Clinical Associate Professor, Department of Surgery, Monash University, Alfred Hospital Anthony J Buzzard MBBS, FRACS, FRCS, FACS Associate Professor, Department of Surgery, Monash University, Alfred Hospital Senior Examiner in Surgery for the Australian Medical Council Member - Board of Examiners and MCQ Panel of Examiners of the Australian Medical Council Arthur Lindesay Clark AM, MBBS, MD, FRACP Professor Emeritus of Paediatrics, Monash University Honorary Consultant Paediatrician, Southern Area, Victoria Past Chairman — Board of Examiners and MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Richard N de Steiger MBBS, FRACS, FAOrthA Consultant Orthopaedic Surgeon, Director, Department of Orthopaedic Training and Research, The Eoworth Centre, Richmond, Victoria JEK Galbraith OBE, MBBS, MD, FRACS, FRCS, FRACO, FACS, FACTM Honorary Consultant Ophthalmologist, Royal Melbourne Hospital Examiner in Surgery for the Australian Medical Council Reuben D Glass MBBS, FRACP, DipEd Former Senior Lecturer in Paediatrics, Monash University Consultant Women’s and Children’s Program, Southern Health Senior Examiner in Paediatrics for the Australian Medical Council Member-—Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Richard W Harper MBBS, FRACP, FACC Consultant and Interventional cardiologist Emeritus Professor/Director of Cardiology, Monash Medical Centre and Monash UniversityAustralian Medical Council Handbook of Multiple Choice Questions Phillioa J Hay MBChB, MD, DPhil, FRANZCP Foundation Professor of Mental Health, School of Medicine, University of Western Sydney Senior Examiner in Psychiatry for the Australian Medical Council Member — Board of Examiners and Clinical Panel of Examiners of the Australian Medical Council Catherine Hickie MBBS, FRANZCP Director of Clinical Training, Bloomfield Hospital, Orange Conjoint Senior Lecturer, School of Psychiatry, University of NSW Manish Jain MBBS, MD, FRANZCR Consultant Radiologist, Monash Radiology Michael R Kidd AM, MBBS, MD, FRACGP, DipRACOG, DCCH Past President, Royal Australian College of General Practitioners Professor of General Practice, The University of Sydney Senior Examiner in General Practice for the Australian Medical Council Member-—Board of Examiners, MCQ Panel of Examiners and Clinical Panel of Examiners of the Australian Medical Council Christian A Lampel MBBS (Lond.), DA, D Obs.RCOG, FACGP General Practitioner, Moe Medical Centre, Moe, Victoria Honorary Lecturer, Monash University Reginald SA Lord AM, MBBS, MD, FRACS, FRCS Emeritus Professor of Surgery, University of New South Wales Professor of Surgery, University of Western Sydney Senior Examiner in Surgery for the Australian Medical Council Member — Clinical Panel of Examiners of the Australian Medical Council Guy Ludbrook MBBS, PhD, FANZCA Professor of Anaesthesia, The University of Adelaide and Royal Adelaide Hospital Prashanth Mayur MBBS, FRANZCP Director, Mood Disorders Unit, Cumberland Hospital, Sydney Ronald McCoy MBBS General Practitioner, Senior Medical Educator, gplearning, Royal Australian College of General Practitioners Adjunct Lecturer, Central Clinical School, University of Sydney lan McCrossin MBBS, FACNSM Consultant Dermatologist, Department of Dermatology, Liverpool Hospital, SyaneyAusiralian Medical Council Handbook of Multiple Choice Questions lan Munt MBBS, FRANZCP Staff Specialist, Townsville Child & Youth Mental Health Service, Townsville Health Service Disirict, Townsville Hospital, Townsville Member — Clinical Panel of Examiners of the Australian Medical Council Michael Oldmeadow MBBS, FRACP senior Lecturer, Monash University Department of Medicine Consultant Physician, Professorial General Medical Unit, The Alfred Hospital, Melbourne senior Examiner in Medicine for the Australian Medical Council Member — MCQ Panel of Examiners and Clinical Panel] of Examiners of the Australian Medical Council Andrew Perry MBBS Emergency Medicine Registrar, Royal Adelaide Hospital Clinical Associate Lecturer, University of Adelaide Laurence Simpson MBBS, MD, FRACS, FCCP Consultant Thoracic Surgeon Deputy President, Committee of Convocation, University of Melbourne Member, Faculty Board, and Lecturer, Faculty of Medicine, Dentistry and Health sciences, University of Melbourne Medical Educator, Royal Australian College of General Practitioners senior Examiner in Surgery, Australian Medical Council Neil Vallance MBBS, FRACS Consultant Otolaryngologist senior Otolaryngologist, Monash Medical Centre and Southern Health, Melbourne Jane Vernon-Roberts MBBS, MPH, GradDipPsychotherapy, FACPPsychMed Head of Clinical Studies, The University of Adelaide Clinical Studies Advisor, The Royal Adelaide Hospital senior Visiting Medical Practitioner, Department of Endocrinology, Royal Adelaide Hospital senior Examiner in General Practice for the Australian Medical Council Member — Clinical Panel of Examiners of the Australian Medical Council Belinda Yeo BA, MBBS Medical Registrar, St. Vincent's Hospital, Sydney David Yeo BMedSc, MBBS, MS, FRACS Surgical Registrar, Royal Prince Alfred Hospital, sydneyarte ae Pe gen Bea en = erik ete lise Res ite __ Handbook of Multiple Choice Questions _ AMC SECRETARIAT ‘Dr. Heather G Alexander BSc , DipNutrDiet , MAppSc (Research), PhD Director, AMC Assessment Services, Australian Medical Council Susan A Buick Project Manager, AMC Examination Development Assistant to the Editor-in-Chief Editorial Committee, Australian Medical Council lan B Frank Chief Executive Officer, Australian Medical Council Martin J Jagodzki Publications Co-ordinator, Australian Medical Council Matthew W Haggan Publications Clerk, Australian Medical CouncilAusiralian Medical Council Handbook of Multiple Choice Questions ACKNOWLEDGEMENTS This selection of MCQ with annotated commentaries extends the Australian Medical Council publication series, which now comprises: a first volume of annotated MCQ: the | AMC Anthology of Medical Conditions (outlining broad aspects of a curriculum based on clinical presentations); the AMC Handbook of Clinical Assessment (containing over 150 annotated clinical case scenarios used in the AMC Part 2 Clinical Examination, outlining standards expected from candidates); and this volume of AMC Annotated | Multiple Choice Questions (Australian Medical Council Handbook of Multiple Choice. Questions), containing a selection of almost 600 MCQ@Q and commentaries from the AMC Part 1 MCQ assessment. The aims of this selection of MCQ remain as before - to acquaint candidates presenting for assessment with details and standards of the AMC Part 1 MCQ assessment and to provide self-testing and educative material across the spectrum of clinical medicine. To meet these aims the AMC has again drawn upon the expertise of a multidisciplinary group of senior examiners and clinical teachers fo provide clinical MCQ and commentaries. The Editorial Committee comprises multi skilled coninbutors to ensure that: continuing trends in medical education and MCQ design and construction are observed and followed; questions testing recall of core Knowledge include clinical application of such knowledge to solve relevant and important clinical problems: the mix of questions supplied gives an appropriately comprehensive overview of the medical syllabus; clinical questions have evidence-based backing wherever possible: both principles and practice of clinical medicine and applied basic clinical sciences are included; and fond prejudices and outworn shibboleths have been largely replaced © by updated consensus reviews of clinical practice. Content and standards have been given additional perspectives by valuable contributions and reviews from additional AMC general and specialist examiners and consultants, and from trainees in major clinical disciplines. As coordinating editor | am most grateful to all contributors and to the core discipline heads for their dedicated efforts. The AMC secretariat continues to evolve and to provide an expert and comprehensive service. Susan Buick has taken on formidable additional responsibilities as overall AMC MCQ@ assessment coordinator and editorial advisor, but her vigour and enthusiasm remain pivotal to the editorial enterprises. The helpful advice of Heather Alexander has been appreciated. Martin Jagodzki has brought invaluable expert professional skills to his role as Publications Coordinator for the AMC; and Matthew Haggan, as Publications Clerk, has also been innovative in formatting and exemplary in attention to detail. Both have coped cheerfully with continuing revisions, reordering and rewriting, and have skillfully co-ordinated publishing activities and examination activities in liaison with Megan Lovett. lan Frank, Chief Executive Officer AMC, has advised and liaised with the Editorial Committee on changes in government regulations; and has provided a chapter on current pathways to medical registration in Australia. As in previous publications, many questions and commentaries contain visual material comprising clinical illustrations, ECGs and imaging results. Peter Devitt, Bryan Yeo and other specialist contributors have generously provided examples from their clinical files. Consent has been obtained for alll illustrations of patients. Additional privacy hasAustralian Medical Council Handbook of Multiple Choice Questions been provided by electronic monitoring and masking of features where required to maintain confidentiality. We are grateful to Ronald McCoy for meticulous attention in proofreading. We are extremely grateful to Gordon Page, who has been advisor to AMC activities and mentor to many of us over many years, for providing a foreword. The editorial committee hopes that AMC candidates and local clinical students will benefit from this MCQ publication while preparing for their written and clinical assessments. Vernon C Marshall, Editor-in-ChiefAustralian Medical Council _ Handbook of Multiple Choice Questions INTRODUCTION ‘Confidence, like art, never comes from having all the answers; it comes from being open fo all the questions.’ — Earl Gary Stevens Clinical competence is a prerequisite of the practising medical doctor. Competence can be considered in terms of *... knowledge, abilities, skills and attitudes displayed in the context of a carefully chosen set of realistic professional tasks which are of an appropriate level of generality.’ Not surprisingly, given the complexity and breadth of clinical competency, many instruments have been developed to assess it. One commonly used assessment instrument is the multiple choice question (MCQ). The Australian Medical Council (AMC) uses MCQ as one component of its assessment for international medical graduates (IMG) who wish to register for clinical practice in Australia. Assessment also includes a clinical assessment, to be taken after the MCQ examination has been passed. While MCQ have several different formats, the AMC uses the one-of-five single best answer (type A) format. It is widely acknowledged that MCQ have limitations in what can most readily be assessed. To maximise the validity, reliability and educational impact of their MCQ, AMC writing groups produce questions, most of which contain clinical scenarios requiring test-takers to analyse, synthesise and evaluate the information provided and, through their selected response, demonstrate an understanding of the specific underlying principles in the question. With this style of question, test-takers may find that all of the answer options are feasible, but they are required to make a judgement, based on the information provided, as to which one of the five options is the ‘most likely diagnosis’, the ‘most appropriate tes?, the ‘first step in managemen?, the ‘most appropriate treatment, or the ‘most appropriate response’ for a specific scenario. In some contexts, MCQ assessments have simply been used to determine what the test-taker knows and does not know in recall of core knowledge (‘Which one of the following is the most common malignancy in Australian women?’ ‘Which one of the following is the most common cause of dementia in people over the age of 65 in Australia?’). Additional educational purposes for such knowledge-recall assessments should be considered; and are pursued further in this collection of MCQ from the AMC multidisciplinary question bank (‘Can candidates accurately identify and solve cinical presentations and problems which exemplify important malignancies or mood alsorders seen in the Australian population 2"). Questions predominantly involving recall of knowledge are, accordingly, being progressively replaced in AMC assessments by MCQ concentrating on problem- solving skills in real-life clinical situations. Any assessment also provides an opportunity to give feedback to the test-taker, which is an important component of the education process and will improve learning by the test-taker. Following this educational principle, this MCQ book produced by AMC has been designed to provide feedback on each question and identify not only the correct response, but more importantly by annotated commentaries to provide the reasoning behind the correct and incorrect responses to highlight the learning points for each question. The Australian Medical Council Handbook of Multiple Choice Questions begins with Section 1 — an introductory series of chapters outlining: the standards to which the examination is set; details of the AMC examination blueprint; MCQ classification and mix of questions; scoring details; and methods of analysis, review and revision of MCQ. These are set against a discussion of assessment methods in general, with particular reference to MCQ assessment, and with more than 20 illustrative MCQ examples and commentaries.Australian Medical Council Handbook of Multiple Choice Questions The introductory section is followed by Section 2 - a self-test multidisciplinary randomised MCQ@ paper of 150 questions covering the same clinical disciplines, patient groups and proportional mix of questions as applies in the AMC Part 1 MCQ examination. Many questions are critical to the safety of, or clinical outcome or threat to life for, the patient, and are based on common important conditions. Commentaries for each of the 150 questions follow the paper, giving feedback on correct and incorrect responses and the reasons thereto, to aid candidates in identifying their strengths and weaknesses across disciplines. It is hoped that readers will be able, after completing Section 1 and the test MCQ paper, to identify any weaknesses and gaps in knowledge, skills and professional approaches, and to utilise the next section for formative self-education. Section 3 contains a further compendium of over 400 additional MCQ and commentaries, arranged in five patient population groups: Adult Health and Aged care, including Women’s Health/Gynaecology; Childhood and Adolescent Health; Maternal Health; Mental Health; and Population and Community Health and Ethics. Each of the five population groups has its MCQ and commentaries arranged sequentially through a matrix of specialty systems and regions, to facilitate revisions of individual specialty disciplines and patient groups. The book thus provides a total of almost 600 MCQ and explanatory commentaries across a broad curriculum. Commentaries are designed to outline consensus good clinical practice, based wherever possible on evidence-based guidelines, as elaborated in the suggestions for further reading. Specific references are provided, where deemed helpful, for some of the scenarios. Section 4 — an Afterword — outlines: a glossary and list of abbreviations and normal values; a listing of multinational eponyms used in the book with a brief account of their origins; guidelines for further reading; the AMC mission statement of goals and objectives of medical education, as used by the AMC in its assessment of Australian and New Zealand medical schools; reference units listing for SI and related units; guides to question interpretation; and the matrices used for item classification. The Epilogue of Section 5 describes the optional electronic MCQ component, whereby candidates can self-evaluate with an interactive computer-linked mini-examination of 50 MCQ selected from the book, in the format of the AMC part 1 MCQ assessment. This supplement also provides access to further computer-linked self-test assessments under examination conditions, providing questions which are revised at intervals, with links to this book and the AMC Anthology of Clinical Conditions. The Editorial Committee anticipates that candidates enrolled for the AMC Part | MCQ@ examination will find this book valuable in their preparation. The book should additionally be a useful resource for practitioners at various levels to review their clinical knowledge across a range of disciplines and patient groups. Medical students from Australian universities and clinical schools should also find this book a valuable revision tool towards the completion of their medical courses. Vernon C Marshall, Editor-in-Chief 1 Hager P, Gonczi A. What is competence? Medical Teacher 1996 18(1}:15-18.a wah - - 2 2 MW J “ins - en ‘ Ths To ear ee cee Re mL ER acer a" aa - z ene eee ee eal Lom et See cee aT Ee PES Riis meet Se Palas ete See orbs a eer ese d Tepe ea er re ee Eke fon tee crane seh . oe ee ey =, 3 rites: . So ¢ YEEEs cacnmaae . ‘ eA * we Sas toe oy a a Liste st a ae a a a aes Srey ea ao ae een Cheteas: eS BSNS I Sw, ELF arrows + Stn lon T io mina Vernon C Marshall, Peter G Devitt and Neil S Paget Austral icine Med ion In ies in t 2 = Analysis, Revision and Review of Questions Vernon C Marshall and Neil S Paget 2 Cp) ne S O i a, & S E = E Eel S = a me os - Structure and Standard of the AMC Exai Pathways to Medical Registrat Assessment Methodolog Peter G Devitt and Neil A Spike SECTION 1 lan B Frank 12 ls 1.4 1.1Australian Medical Council Handbook of Multiple Choice Questions 1.1 ASSESSMENT METHODOLOGIES IN MEDICINE The process of assessment and examination is an integral part of any educational system. Assessment has a number of different aims. These include diagnostic, formative and summative processes. A diagnostic assessment is one that is applied at the commencement of an educational process to gauge the cognitive level, proficiency or attitudes of those about to be taught. A formative assessment is one that is produced for the benefit of those in the learning process to enable them to learn, to find out for themselves what they do and do not know and, most importantly, to obtain feedback on their abilities, knowledge or other skills which are being developed. Formative assessments are designed specifically to provide feedback to learners about progress towards specific objectives. Formative assessments are not designed or used for ranking or grading. A summative assessment is set by the education body to measure what has been learnt, understood and can be applied. It is typically a high stakes process with rewards and penalties. Summative assessments can act as barriers to be negotiated successfully before proceeding to some form of certification, with passers separated from failures. Passers can additionally be ranked and graded. Many medical schools focus on the summative process and have a final examination at the end of their training programs. There is debate on the value of such ‘barrier’ processes and whether continuous assessment could be more effective in terms of the function of the assessment process, whether this be to stimulate learning or to provide an account of what has been learnt and to what standard. Assessment material can be provided in many different forms using different media. This book exemplifies a formative assessment process in which material is provided for education and self-testing, with feedback provided. Within medicine, several different domains are relevant to the optimal education of a doctor. These include clinical competence, communication skills, professional behaviour and knowledge/cognitive ability. These are to some degree artificial groupings, but do tend fo reflect the different assessment methodologies used. Written examinations focus on knowledge, its acquisition and its use in the Understanding, analysis and evaluation of data and problems. The skills and proficiency of history- taking, physical examination, diagnosis, investigation, treatment and communication are assessed in various forms of clinical examination, of which the objective structured clinical examination (OSCE) is, perhaps, the most popular. The assessment of technical skills and professional behaviour tends to be devolved to mentors involved in vocational training and education of the trainee. This section discusses the assessment methodologies for successive levels of a pyramid of clinical competence, a structure whose base (the largest component of the pyramid) is a foundation of knowledge.’ Knowledge itself, and the ability to retain and recall this knowledge, is relatively easy to measure. More importantly, students should be able to display understanding and analysis, assimilation, synthesis and evaluation of data and material based on this knowledge. The challenge is to use assessments which measure all of these competency skills. Written tests of knowledge and its application comprise either some form of free-text response (e.g. an essay) or a structured system (e.g. multiple choice tests). Both have their advantages and disadvantages. Within any assessment process. a number of criteria should be met.Australian Medical Council Handbook of Multiple Choice Questions Validity The validity of a test is determined by its ability to sample appropriately from the full soectrum of the course it is being used to examine. Content validity refers to the structure of the examination as a whole, as well as its individual items. Face validity indicates that the test appears to measure what is intended. Construct validity implies that the test structure, item types, and scoring procedures are appropriate to the skills of the population being assessed. Assuming a limited time for the examination process, an essay assessment (for example) can examine in depth and can measure several different cognitive and expressive skills. But essays evoke limited sampling, whereas multiple-choice processes, although tending to focus on knowledge recall, can do so across a much wider range. Reliability Reliability refers to consistency and precision of the assessment method. A reliable test is reproducible on subsequent occasions and will produce similar results on repeat testing in similar cohorts of examinees. Inter-rater reliability refers to the consistency of ratings of the same performance by multiple assessors — a clear asset of the multiple choice question (MCQ). Fidelity The fidelity or authenticity of any test is the closeness of that test to the real situation. At one end of the reality-linked spectrum is the cost and expertise that goes into the development of high fidelity scenarios to assess airline pilots’ ability to act in crisis situations. At the more mundane end is the MCQ written assessment to test knowledge recall and its clinical application. Discrimination This is the ability of a test to measure accurately the performance levels of the cohort being tested. In a discriminating task, such as an individual MCG, the top candidates are expected to perform well and the weak candidates less well. A test with poor discrimination will see many of the weak candidates outperform the ones at the top of the range. Educational impact This is the ability of the test instrument's structure and content to stimulate and to have a positive influence on further learning. Other criteria also need considering — these include objectivity, statistical application and cognitive level, and which items constitute essential or core components of cognisance. An objective assessment should have little inter-observer or intra-observer variability. The assessment should set an appropriate pass level for the cohort being tested; and the degree of difficulty of the test should be measurable. Assessment processes will vary in their need and ability to measure different cognitive levels — from recall of core knowledge up to weighing and evaluating complex clinical material. The description and ranking of cognitive skills can be illustrated, as in Figure 1, by a pyramid sitting on a firm base of knowledge and ascending through understanding, analysis and application of that knowledge, to synthesis and evaluation. Testing of the basal level is relatively easy and, by design or fault, is often the main focus ofAustralian Medical Council Handbook of Multiole Choice Questions Figure 1. Assessment of cognitive ability and professional skills and attitudes (adapted from Miller GE 1990) Performance in practice (in vivo) e.g. MiniCEX, supervised apprenticeship Clinical competence (in vitro) e.g. OSCE, OSLER, SP-based tests SC, LC Clinical context-based tests e.g. MCQ, essay, viva, SAQ, MEQ, SC, LC Factual knowledge test e.g. MCQ, essay, viva, SAQ, MEQ MiniCEX Mini-Clinical Evaluation Exercise SP Standardised Patient MEQ Modified Essay Question SAQ OSCE OSLER SC LC Progressive Professional Authenticity Short Answer Question Objective Structured Clinical Examination Objective Structured Long Examination Record Short Clinical Examination Long Clinical Case many examination processes. Constructing an examination tool which measures the Upper cognitive skills is much more difficult: often requests to ‘argue’, ‘weigh up’ or ‘evaluate’ are also either answered or measured in terms of recall of knowledge.? The MCQ has several different formats. In its simplest form, the multiple true/false response MCQ@ (type J) can be a solid measure of recalled knowledge. Similarly, the one-from-five version (type A) is often used specifically to test recall. This may be particularly the case when the question is worded to include the negative (‘not': or except’). These negative questions can also be confusing when interspersed with questions seeking a positive response. They have therefore been progressively archived and removed from the active AMC MCQ bank. When the MCQ one-from-five format is used to measure higher cognitive functions, the process becomes more complex in terms of the content and structure of the stem. The content may contain data to analyse, or a clinical scenario to weigh up. The question will have a fuller structure, specifically designed to require weighing of the options — many or all resoonses may be partially correct, but only one is the mosi correct or most appropriate option for the specific scenario. Difficulties with this approach become evident when shades of opinion are used and ranked; and when experts differ among themselves as to what is ‘most likely or ‘the best' or ‘most common’. The examiners’ task is to ensure that correct responses embody consensus best practice, backed wherever possible by evidence-based studies. The MCQis also subject to cueing (giving inadvertent pointers to the correct response) and a cohort will tend to score higher in this style of test when compared with the same material delivered in an open-ended format.4 Testing the highest levels of cognitive function is usually beyond the ability of an MCQ and is probably better tested in some form of free text response — either the essay or a modified essay question (MEQ). The downside of these latter types of test is theirAustralian Medical Council Handbook of Multiple Choice Questions limited role in formative assessment and the more subjective nature of the marking. The essay thus tends to be less reliabie and its content validity is limited. The multiple choice question (MCQ) While no practitioner can function without a solid core basis of knowledge, If Is important to assess the ability of the practitioner to use this knowledge. Can the individual understand what has been learnt? Can the material be assimilated, assessed and analysed? Can it be synthesised, weighed and evaluated? These are the higher cognitive skills and the challenge for the educationalist is to find appropriate means to measure them accurately and reliably. The MCQ is a popular examination format, though it can be misused or misapplied. In part this is due to poor construction, and in part due to an inappropriate focus on recall of knowledge rather than testing powers of reasoning. To test the powers of reasoning and problem-solving, an MCQ stem is required that provides a block of information or data that can be analysed, synthesised or evaluated; and options provided that cater for these. Another hallmark of the good quality MCQ is its capacity to enable the candidate to deduce the correct answer from the stem alone, without reference to the options. This is offen called the ‘cover test’: the candidate should be able to construct an answer from the stem alone if the options are covered over, which should correspond to the correct option. A good MCQ paper will have appropriate validity in terms of its ability to sample widely across the core content of the syllabus. Its reliability will be related to the use of well- tested questions of appropriate degrees of difficulty and statistical power to enable each question, and the total examination, to discriminate between the upper and lower echelons of each cohort. In this way the examination will be reproducible across different cohorts. The fidelity of the examination will be balanced between a smaller percentage of questions, measuring important or core aspects of recall knowledge, and the bulk which match clinical realities and test the ability of candidates to apply their skills of reasoning and problem solving. Guessing the answer in a one-from-five type of MCQ will lead to a 20% correct choice by random selection. Thus it makes little sense to have a question where the degree of difficulty means that even with deliberate choice less than 20% of candidates will select the correct answer. Such a question will be a poor discriminator of the top cohort of candidates. Cueing may lead to higher scoring in MCQs in comparison with similar question material being provided in open-ended or long-menu formats.** These latter questions may be suitable for computer-based examinations, where the user may have access to over 500 possible responses. The following chapters in this section outline the evolution of the AMC MCQ examination and its place in the current AMC assessment process. Peter G Devitt and Neil A Spike 1. Cognitive, cognition, cognisance {from Latin cognosere ‘getting to know') — The process of acquiring knowledge through thought, experience and use of the senses. Oxford English Dictionary. 2. Miller, GE. The assessment of clinical skills/competence/performance. Academic Medicine (supplement) 1990;65:563-70. 3. Jozefowicz RF et al. The quality of in-house medical school examinations. Academic Medicine 2002:77:154-41. 4. $chuwirth LWT, van der Vieuten CPM, Donkers HHLM. A closer look at effects in multiple-choice questions. Medical Education 1996; 30:44-49. 5. Veloski JJ, Rabinowitz HK, Robeson MR, Young PR. Patients don't present with five choices: an alternative to multiple-choice tests in assessing physicians’ competence. Academic Medicine 1999;74:539-46. 6. $chuwirth LWT, van der Vieuten CPM, Stoffers HE, Peperkamp AG. Computerized long-menu questions as an alternative to open-ended questions in computerized assessment. Medical Education 1996:30:50-5.Australian Medical Council Handbook of Multiple Choice Questions 1.2. STRUCTURE AND STANDARD OF THE AMC EXAMINATION The AMC assessment for general registration comprises two examination Stages: a multiple choice question (MCQ) paper and a clinical examination. The combined assessment is designed as a comprehensive andintegrated test of medical knowledge and clinical competence. The two stages (MCQ and clinical examination) must be taken and passed sequentially. There are no limits to the number of attempts at each stage, nor on the time limits for their completion. Stage 1 - The MCQ Examination The MCQ examination presently consists of two papers, each of three-and-a-half hours duration. Each paper contains a multidisciplinary mix of Type A format questions (one correct response from five). Of these questions, 80% are previously used questions which are scored to provide the candidate's mark: another 20% of questions are new pilot questions being tested for future use, but not counted in a candidate's mark. Until mid-2009 the papers have comprised a fixed total of 300 questions, with 240 being scored and 60 being pilots for future use. The examination is now computer-integrated and performed by computer. In the future the multidisciplinary assessment will be fully Computer-adaptive, with an appropriate number and range of MCQ to ensure statistical relia bility and validity. Examples of AMC MCQ Structure MCQs incorporate a stem, a lead-in question and five optional responses, one of which is the correct response. The stem is an introductory statement (usually within a clinical context) which presents the problem. The stem may pose a test of factual recall of core knowledge, or more usually, provides a clinical scenario incorporating data to be assimilated, understood and analysed. The provision of a clinical problem within the stem usually implies that the question aims to measure higher order cognitive and problem-solving skills. The lead-in question indicates the relationship between the stem and the options, clarifying the questions posed for examinees, so that usually the examinee can pose an answer before looking at the options. Options that are incorrect are called distractors. Aims of the MCQ Examination The MCQ examination aims to encompass the first stage of a multidisciplinary integrated assessment covering a range of conditions and topics across broad disciplines of medicine, surgery, psychiatry, obstetrics/gynaecology, paediatrics, general and community practice and public health, including subspecialties of each ciscipline, assessed at graduating degree level. The questions aim to test applied medical knowledge illustrating principles and practice of medicine in the above fields. Most involve clinically based scenarios. Application of basic clinicalsciences of anatomy, physiology, biochemistry, pathology and pharmacology to important clinical topics is included as part of core knowledge to be tested. Wherever possible, correct responses will comply with evidence-based medicine principles.Australian Medical Council Handbook of Multiple Choice Questions Questions may consist solely of written material or may incorporate radiographs or scans (ultrasound, computed tomography [CT], magnetic resonance imaging [MRI], nuclear medicine imaging, etc.), colour photographs or brief video clips, electrocardiograms (ECGs), and line drawings. The format and performance of the examination is now fully computer-based, allowing the examination to be taken at secure Australian-based and overseas venues. Most of the MCQs are chosen to reflect common clinical conditions in the Australian community. A smaller number are used to test knowledge and understanding concerning less common conditions which illustrate important principles. Similarly, the majority of questions aim to test basic or essential core medical knowledge and its clinical application. Aspects of clinical skills and attitudes can also be assessed, including counselling and consulting skills, but these aspects are additionally and more fully assessed in the subsequent clinical examination. Questions are designed to test the candidate's knowledge and ability to exercise discrimination, judgement and reasoning in distinguishing between the correct diagnosis and plausible alternatives. Many questions are structured to require analysis, interoretation and evaluation in their completion. Several similar-themed questions can be based around various aspects of one clinical scenario to involve sequential aspects of history-taking, physical examination, diagnosis and differential diagnosis, investigations, and management and outcomes. The following five questions illustrate this, giving examples of similar theme questions with the same or similar stem and with a sequence of varying lead-ins.Australian Medical Council Handbook of Multiple Choice Questions Example MCQ 1.1 — DIARRHOEA AFTER A COURSE OF AMOXYCILLIN — DIAGNOSIS A 65-year-old woman in a nursing home had a course of amoxycillin for seven days for an upper respiratory infection. She developed severe watery and mucoid diarrhoea after two days of treatment and these symptoms persist along with cramping abdominal pain associated with frequent urgent call to stool, fever and nausea with intermittent vomiting. Which one of the following is the most likely diagnosis? A. Ischaemic colitis. B. Necrotising enterocolitis. C. Pseudomembranous colitis. D. Ulcerative colitis. E. Shigellosis. Example MCQ 1.2 —- DIARRHOEA AFTER A COURSE OF AMOXYCILLIN — CAUSATIVE ORGANISM A 65-year-old woman had a course of amoxycillin for seven days for an upper respiratory infection. She developed severe watery diarrhoea after two days of treatment and these symptoms persist along with cramping abdominal pain associated with urgent call to stool, fever and nausea with intermittent vomiting. Which one of the following gut organisms is most likely to be responsible for her symptoms? A. Salmonella typhi. B. Shigella flexneri. C. Clostridium difficile. D. Entamoeba coli. E. Vibrio cholera. Example MCQ 1.3 - DIARRHOEA AFTER A COURSE OF AMOXYCILLIN — TREATMENT A 65-year-old woman had a course of amoxycillin for seven days for an upper respiratory infection. She developed severe watery diarrhoea after two days of treatment and these symptoms persist along with cramping abdominal pain associated with urgent call to stool, fever and nausea with intermittent vomiting. In addition to cessation of amoxycillin, which one of the following is the most appropriate initial treatment2 . Monitor progress without further antibiotics. Commence metronidazole. . Commence vancomycin. . Commence chloramphenicol. Commence ciprafloxacin. Eh SD (Ch): aeAusiralian Medical Council Handbook of Multiple Choice Questions Example MCQ 1.4 — SKIN LESIONS ON THE BACK AND TRUNK OF A 5-YEAR-OLD —- DIAGNOSIS A five-year-old presents with a rash on his back and trunk over one week, as shown. His general health is excellent and the remainder of his examination is normal. Which one of the following Is the most likely diagnosis? . Impetigo. Varicella. . Herpes simplex. . Molluscum contagiosum. Papilloma virus. Te @) ee Example MCQ 1.5 — SKIN LESIONS ON THE BACK AND TRUNK OF A 5-YEAR-OLD — TREATMENT A five-year-old presents with a rash on his back and trunk over one week as shown. His general health is excellent and the remainder of his examination is normal. Which one of the following is the most appropriate next step in his care? . Swab a lesion for virus culture. Apply aciclovir ointment. . Reassure and await resolution. . Apply diathermy to each lesion. Surgically debride. MBG) 2Australian Medical Council | Handbook of Multinle Choice Questions | Commentary MCQ 1.1 | Her symptoms suggest a diagnosis of pseudomembranous colitis, an important colonic infection acquired almost exclusively as a complication of antibiotic use and disruption of the normal colonic flora (C is correct). All antibiotics can be associated with the syndrome — amoxycillin, clindamycin and cephalosporins in particular. | None of the other types of colitis (ischaemic colitis, necrotising enterocolitis, ulcerative colitis or shigellosis) would fit the clinical setting so well. ischaemic colitis occurs in elderly patients affecting the splenic flexure and descending colon which lie in a junctional watershed of arterial supply. The cause may be arterial thromboembolism from a cardiac focus, but ischaemic colitis can complicate severe hypotension, systemic sepsis and hypercoagulable states. Patients present with acute left-sided abdominal pain and rectal bleeding. Necrotising enterocolitis occurs in neonates subjected to serious stresses of pre- maturity, hyaline membrane disease, or congenital heart disease, presenting with diarrhoea, distension and abdominal bleeding and intestinal oneumatosis on X-ray. The condition can also be a complication in neutropenic patients after chemotherapy with cytotoxic drugs in children or adults, presenting with fever and bloody diarrhoea and right lower abdominal tenderness. Diagnosis is aided by bowel walll thickening identified on CT or MRI imaging. Ulcerative colitis invariably involves the rectum and presents with bloody diarrhoea and passage of mucus, offen with the first episode occuring in young adults. shigellosis (bacillary dysentery) occurs in epidemic form in areas of population overcrowding and poor sanitation, with diarrhoea of varying severity from mild to fulminant. Commentary MCQ 1.2 Pseudomembranous colitis is due to infection with an anaerobic, Gram-positive, spore-forming bacillus, Clostridium diifficile, which colonises the lower intestinal tract, . sparing the ileum, producing confluent pseudomembranes containing necrotic epithelium, fibrin and mucus (C is correct). The condition is particularly prone to occur in hospitals and chronic nursing home care facilities, where resistant C. difficile spores may contaminate the environment. The organism elaborates enterotoxins and cytotoxins in susceptible individuals. None of the other organisms would be as likely as a cause — Entamoeba coli is a non-pathogenic component of normal bowel flora, and the specific infections of typhoid, cholera, and shigellosis are much less likely in this scenario. Commentary MCQ 1.3 Although resolution of C. difficile pseudomembranous colitis occurs in a proportion of cases, MOST Cases require specific treatment for persisting symptoms. Metronidazole is the preferred antimicrobial as treatment and is the most effective and least expensive of available agents. Metronidazole is best given orally in a course of at least six days (B is correct). Vancomycin is also effective but, because of the risk of inducing vancomycin resistance in bowel organisms (e.g. vancomycin-resistant enterococci), is avoided in all but the most difficult cases.Australian Medical Council Handbook of Multiple Choice Questions Ciprofloxacin is more appropriate for ‘travellers’ diarrhoea, Salmonella enteritis, and shigellosis. Chloramphenicol has a broad spectrum of activity, but use is limited by its toxicity. Other treatment guidelines are to maintain hydration, avoid opiates and anti- peristaltic agents which may mask symptoms, and attendance to faecal-oral and hand hygiene. Commentary MCQ 1.4 The lesions seen in this child show the typical appearance of molluscum contagiosum, vesicular papules with central umbilication, which are caused by a pox virus (D is correct). These lesions may be single but usually are multiple and more extensive and may persist for months. The child is not systemically Unwell and the lesions may appear on any part of the body. Resolution without any intervention usually occurs within one year. The lesions may be quite resistant to treatment with physical agents, although cryotherapy has been used with varying success. Impetigo has a different appearance, with confluence of some lesions and pustular crusting of the lesions with surrounding erythema indicative of bacterial infection, usually associated with Staphylococcus aureus. While varicella has lesions with a similar aopearance, the spots appear in crops, with initial crops crusting while others are still appearing. The child Usually is mildly unwell and the lesions are often quite extensive over most of the body, including the mucous membranes. Herpes simplex lesions are usually discrete or in groups of blisters which are painful. Depending on the position of the body, they may last several days and the child may have systemic upset with fever and irritability. Lesions commonly occur in the mouth and may cause the child to refuse food and fluids. The lesions may last 7-10 days. Papilloma viruses can cause a variety of clinical presentations, the most common being simple warts, offen seen on the hands and extensor surfaces of the elbows and knees. These may last for months. The clinical features —- aqopearance, associated pain and cropping, or parts of body involved — are the differentiating features of these lesions. Commentary MCQ 1.5 The lesions are characteristic of molluscum contagiosum. Molluscum contagiosum is Ga virus infection skin lesion found commonly in young children. The lesions tend to soread along the skin and to areas of skin contact (for example chest wall to upper arm) in the so-called ‘kissing’ lesions. The natural history of molluscum lesions is well known; lesions appear in crops and eventually resolve soontaneously without scarring. The agent of molluscum is a small DNA virus which Is resistant to currently available antiviral agents. The lesions, however, can take months or years to resolve. Aciclovir is ineffective while diathermy or expression of the central plug or chemical irritation will result in resolution but leave a residual scar. Spontaneous resolution of alllesions often follows accidentalirritation and inflammation of an individual lesion. This suggests that the development of an immune reaction is one determinant of resolution. Reassure and await resolution is the best management (C is correct). Surgical debridement is not required.Ausiralian Medical Council Handbook of Multiple Choice Questions Mix of Questions The mix of questions for the MCQ component is required to be broadly representative of the syllabus appropriate to the undifferentiated final year graduate. Questions are distributed over the broad range of subjects, functions and systems by which all questions are classified. These classifications are detailed in Section 4.8 near the end of the book. All questions are analysed and reviewed for validity, reliability, fidelity, educational impact and discrimination, with revision when appropriate (see Section Vea). Standard of the AMC MCQ Examination The standard of the AMC examination is formally defined as the level of attainment of medical knowledge, clinical skills and attitudes corresponding to that of newly qualified graduates of Australian medical schools who are about to commence intern training (postgraduate year 1 [PGY1]). * The goals and objectives forming the basis of medical education in Australia, as determined by the Australian Medical Council for the accreditation of medical schools, are expressed in terms of objectives relating to: * medical knowledge and understanding, and clinical application ¢ — clinical skills competency and performance ° attitudes as they affect professional behaviour. These objectives are outlined more fully in Section 4.5. In Australian university undergraduate assessments these objectives are assessed in a variety of ways, including MCQ, clinical and continuous assessments. The AMC assessment comprises MCQ and clinical examinations designed and conducted so as to be as closely comparable as possible with the content and standards of Australian University assessments. The format of each component has shown continuous evolution, in accordance with modern developments in education and assessment, and is constantly being monitored and reviewed with sophisticated statistical analysis and trialling at Australian clinical schools. Further MCQ examples with feedback commentaries follow.Australian Medical Council Handbook of Multiple Choice Questions Example MCQ 1.6 — ACUTE PROGRESSIVE WEAKNESS OF EXTREMITIES IN A 32-YEAR- OLD MAN A 32-year-old man has a four-day history of progressive weakness in his extremities. He has been healthy except for an upper respiratory tract infection ten days ago. His temperature is 37.8°C, BP is 130/80mmHg, pulse is 94/min, and respirations are 42/min and shallow. He has symmetric weakness of both sides of the face and the proximal and distal muscles of the extremities. Sensation is intact. No deep tendon reflexes can be elicited; the plantar responses are flexor. Which one of the following is the most likely diagnosis? A. Acute disseminated encephalomyelitis. B. Guillain-Barre syndrome. C. Myasthenia gravis. D. Poliomyelitis. E. Polymyositis. Example MCQ 1 7 - RISKS OF STRANGULATION OF VARIOUS HERNIAS Ischaemic strangulation is an important complication associated with hernias. Which one of the following types of hernia is most often associated with strangulation of its contents? . Indirect inguinal hernia. Direct inguinal hernia. . Femoral hernia. . Paraumbilical hernia. Oesophaged hiatus hernia. POS Oe aan Example MCQ 1.8 - A PAINFUL GROIN LUMP IN A 55-YEAR-OLD A 55-year-old woman presents with a history of noting a painful and tender groin lump for 24 hours. On examination she has a firm tender lump in the left groin as illustrated. No cough impulse is discernible. Vital signs are pulse 100/min, BP 160/100mmHg, and temperature 37.8°C. Which one of the following is the most likely diagnosis¢ . Strangulated inguinal hernia. Strangulated femoral hernia. . Psoas abscess. . Primary lymphoma. Metastatic neoplasm. ES Gye eaeAUSsiralian Medical Council Handbook of Multiole Choice Questions Commentary MCQ 1.6 Guillain and Barré, French neurologists working together during the 1914-1918 war described a syndrome in French soldiers of an ascending acute symmetrical lower motor neuron paralysis, commencing distally and spreading proximally, which may involve the bulbar brain stem region, as here (B is correct). It is believed to be viral in origin and can follow a prodromal u pper respiratory tract infection (URTI). Usually self- limiting, patients often recover completely. None of the conditions fits the clinical picture as well as Guillain-Barré syndrome. Myasthenia gravis is characterised by abnormal fatigable weakness of muscle. Muscle strength rapidly weakens with Use, and worsening symptoms (e.g. ptosis, diplopia) towards the day’s end are characteristic. The condition is a complement/antibody mediated autoimmune blockade of acetylcholine receptors. Poliomyelitis is now uncommon in developed countries following widespread use of oral vaccines (Sabin) against the virus. The disease is characterised by lower motor neuron paralysis affecting, particularly, anterior horn motor neurons with accompanying lymphocytic meningitis. Respiratory failure occurs in fatal cases from Paralysis of intercostal muscles and involvement of respiratory motor nuclei. Polymyositis is a diffuse immunologically mediated connective tissue disorder, more common in women, causing inflammatory change in muscles. Muscle weakness is usually of insidious onset causing difficulty climbing stairs or rising from a chair. A similar syndrome of myositis can occur with a variety of malignancies. Acute disseminated encephalomyelitis presents as a_ disseminated acute demyelinating disease with headache, fever, confusion and meningitis associated with multifocal brain and spinal cord signs and flaccid paralysis. The condition can be difficult to differentiate from multiple sclerosis, but is usually self-limiting. MCQ can focus on specific diseases or conditions with questioning about their clinical features, prevalence and ouicomes (questioning from the fop down }. Such questions (e.g. MCQ 1.7) often are testing recall of core knowledge; and this publication contains a number of such questions seeking to assess core knowledge recall. Commentary MCQ 1.7 Awareness of the relative risks of strangulation of various hernias is important in predicting outcomes and guiding management. The risk of strangulation is related to both the diameter and rigidity of the neck of the hernia and the tortuosity of the track. The obliquely tortuous track and narrow rigid neck of a femoral hernia make it the most likely to strangulation of the hernias listed (C is correct). In most instances of symptomatic groin hernias, whether femoral or inguinal, surgical repair would be recommended to relieve symptoms; in only a minority of patients with gross medical comorbidity would treatment be expectant without surgery. Hernial trusses are outmoded and potentially hazardous in treatment of groin hernias. If a femoral hernia can be confidently diagnosed Clinically, the indications for surgery become even more compelling because of the real risk of strangulation. A directinguinal hernia usually hasa more wide-mouthedsac than the obliquesacofan indirect inguinal hernia, making the latter the more concerning of the two mostAustralian Medical Council Handbook of Multiple Choice Questions common types of inguinal hernia. Neither of these inguinal hernias is as much at risk as a femoral hernia. In paraumbilical hernias in adults, most again will be advised to proceed to surgery when symptomatic. With wide-mouthed hernias associated with significant medical comorbidity, use of an abdominal corset may be preferred. Sliding oesophageal hiatus hernias do not strangulate. Strangulation of paraoesophageal hiatus hernias can occur but is uncommon. These sorts of questions (from the top down) may find more application in viva voce assessments for prizes or for retesting borderline candidates. In contrast, MCQ can preferably focus on presenting clinical scenarios derived from real life, requiring problem-solving skills to identify the causative process or disease and its differentiation from other causes (Questioning ‘from the botiom up’). The majority of questions in this book are of this latter type (e.g. MCQ 1.8). Commentary MCQ 1.8 A firm tender non-reducible lump in the inner upper part of the femoral triangle as illustrated here, overlies the saphenous opening, just below and lateral to the pubic tubercle, which marks the site of exit from the femoral canal, medial to the femoral vein. Such a swelling will be either: ¢ astrangulated and obstructed femoral hernia (which now exhibits the classic signs of strangulation, being tense, tender, with no cough impulse, and irreducible) © alymph node swelling of the femoral lymph node group, which drain the lower limb, perineum, vulva or anal canal (in males, penis and scrotum replace vulva as primary foci). The most likely of these diagnoses in an adult female (and the most important to diagnose quickly) is a strangulated femoral hernia (B is correct). Femoral hernias are more common in women than men, and their oblique course (via femoral septum to femoral canal, then through the cribriform fascia at the apex of the canal into subcutaneous fat) makes them more prone fo strangulation of their contents than a strangulated inguinal hernia, which emerges from the superficial inguinal ring just above and medial to the pubic tubercle. lf the ischaemic contents are intestine, bowel obstruction with cramping abdominal colicky pain, abdominal distension, constipation and vomiting may be associated features, and should help cue the diagnosis. If the contents are omentum, such additional clues are absent, and systemic manifestations are confined to fever and general toxaemia. The major differential diagnosis is of a femoral lymph node swelling, which may be secondary to an infective or neoplastic primary focus, or may be a primary lymphoma. Differentiation requires meticulous examination of potential primary sites, which may be occult — not forgetting regions such as between the toes, in the anal canal, beneath the foreskin, and in the vulva. Lymphoma assessment requires examination of all other lymph node areas as well as checking for liver and splenic enlargement.