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Part B
In this part of the test, there are six short extracts relating to the work of health professionals.
For questions 1 to 6, choose the answer (A , B or C ) which you think fits best according to the
text.

Write your answers on the separate Answer Sheet.

____________________________________________________________________________

1. From which of the following sign can it be understood that the cast is too firm?

A. Inflammation of the arm

B. Change in colour of the hand
C. Bleeding at the fracture site

Cast and Splint- Take-Home Instructions:

The patient should be instructed not to remove the splint and to return for checkups
at 24 hours and 2 weeks. X-rays to verify alignment are optional . When showering,
the patient should cover the affected arm with a plastic bag, which can be secured
at the top with rubber bands or tape. The patient should also be given written
instructions about cast and splint care, along with advice to return to the office or go
to a hospital emergency department if signs of neurovascular compromise are
noted. Swelling or paresthesias of the hand, bluish discoloration of the fingers, or
increasing pain at the fx site may indicate an overly tight cast, which requires
splitting or reapplication. While the fiberglass material is generally water-resistant, a
shower or bath taken without protecting the cast will soak the padding. This can
lead to maceration of the skin under the cast and subsequent local infection, so
patients should avoid getting the cast wet.

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 2. Which of these is a certain side-effect of cyclophosphamide according to the passage?

A. Foetus is adversely affected

B. Production of ova and sperms declines
C. Nursing baby is seriously harmed

Cyclophosphamide:

Cyclophosphamide is a prescription medicine used alone, or in combination with other

medications to treat several types of cancer including lymphoma, leukemia, ovarian, and
breast cancer. It has also been used to treat "minimal change" nephrotic syndrome, a
kidney disease, when other treatments have failed.

Pregnancy should be avoided during cyclophosphamide treatment. Cyclophosphamide has

been shown to be harmful to the unborn baby when taken by pregnant women. Tell your
doctor if you are pregnant or plan to become pregnant while receiving cyclophosphamide. If
you become pregnant during your treatments, tell your doctor right away.
This medication may also affect fertility in both men and women, by reducing sperm and
egg production.

Cyclophosphamide is excreted in breast milk. Because of the potential for serious harm to
the nursing baby, do not take cyclophosphamide without talking to your doctor if you are
breastfeeding.

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3. What course of action should be followed if a significant airway risk is identified?

A) Anaesthesia must be deferred till the required tools and staff are available
B) Sedation should should be administered with utmost caution by an expert
C) Anaesthesia should be given after the airway risk is minimized

Significant airway risk

When procedural sedation or anaesthesia is planned the sedationist / anaesthetist must

formally assess the patient’s airway and document this in the patient’s health care record
prior to commencing procedural sedation / anaesthesia. If this assessment indicates a
significant airway risk then an anaesthetist must be present before sedation is given.

When a significant airway risk is identified the procedural sedation / anaesthesia must not
commence until all required special equipment needed is present and functional, and
procedural team members needed are present.

Functioning and clean suction equipment must always be immediately available when
procedural sedation / anaesthesia is given.

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4. Which of the following steps could reduce the risk of entrapment at the beds?

A. Lowering the height of the foot controls

B. Identifying the alternative sources of power
C. Inadvertent activation of controls during cleaning

Entrapment risk at profiling beds:

EPBs may present a risk of trapping or crushing, particularly if they have foot pedal
controls which raise and lower the bed. A small number of fatal accidents have
occurred where foot controls were activated accidentally. There is also potential for
entrapment on other parts of the mechanism during transit, cleaning and maintenance.

Organisations using EPBs should consider the risk of entrapment, taking account of
patient vulnerability, moving and handling operations, and the relationship to other
equipment. Potential control measures could include leaving the mattress platform
in its lowest position when the patient is unattended and disabling the foot controls
(temporarily or permanently), which may be possible without affecting other functions.

Measures should prevent inadvertent activation during cleaning and maintenance. This
may require trained staff deactivating the controls and recognising whether the beds
are fitted with battery back-up (so disconnection from mains power alone may not be
sufficient). Manufacturers’ instructions for maintenance should be followed and further
advice sought where necessary.

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5. Long-term use of proton pump inhibitors may increase the risk of

A. Some respiratory problems

B. Some gastric cancers
C. Some cardiovascular issues

 Proton pump inhibitors rank among the top 10 prescribed classes of drugs
and are commonly used to treat acid reflux, indigestion, and peptic ulcers.
Although generally assumed to be safe, recent studies have shown that they
have numerous side effects.
 Long-term use of PPIs may mask gastric cancers or other serious gastric
problems and physicians should be aware of this effect.
 PPI use has also been associated with the development of microscopic
colitis.
 There is also evidence that PPI use alters the composition of the bacterial
populations inhabiting the gut.
 Associations have been shown between PPI use and an increased risk of
pneumonia,
 Associations of PPI use and cardiovascular events have also been widely
studied but clear conclusions have not been made as these relative risks are
confounded by other factors
 High dose and/or long-term use of PPIs carries a possible increased risk of
bone fractures.

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6. What is the most appropriate action when a treatment has no prospect of positive
results?

A. Balance must be achieved between burden and benefit

B. The patient should be transferred to another doctor
C. Family should be counseled

"Futile" Treatments

In the circumstance that no evidence shows that a specific treatment desired by the
patient will provide any medical benefit, the physician is not ethically obliged to
provide such treatment The physician need not provide an effort at resuscitation that
cannot conceivably restore circulation and breathing, but he or she should help the
family to understand and accept this reality. The more common and much more
difficult circumstance occurs when treatment offers some small prospect of benefit
at a great burden of suffering, but the patient or family nevertheless desires it. If the
physician and patient (or appropriate surrogate) cannot agree on how to proceed,
there is no easy, automatic solution. Consultation with learned colleagues or an
ethics consultation may be helpful in ascertaining what interventions have a
reasonable balance of burden and benefit. Timely transfer of care to another
clinician who is willing to pursue the patient's preference may resolve the problem.

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 Part C
In this part of the test, there are two texts about different aspects of health care. For questions 1
to 8, choose the answer ( A , B , C or D ) which you think fits best according to the text.

Write your answers on the separate Answer Sheet.

Text 1:

Anxiety in Children
Studies have found a preponderance of anxiety disorders in girls during childhood and
adolescence (Lewinsohn et al., 1998; Mackinaw-Koons & Vasey, 2000). By age 6, twice as
many girls as boys have experienced symptoms of anxiety, and this discrepancy persists
through childhood, adolescence, and young adulthood (Roza et al., 2003)The fact that girls are
more likely than boys to report anxiety may contribute to this variation, although how much is
not known (Wren et al., 2007). For adolescents with anxiety, the differences be- tween genders
cannot be accounted for solely by variations in psychosocial factors such as stress, self-
perceived social competence, or emotional reliance. This suggests that female vulnerability to
anxiety may be related more to genetic influences than to varying social roles and experiences
(Lewinsohn et al., 1998).

One study of gender role orientation in boys and girls with anxiety disorders found that self-
reported masculinity was related to lower overall levels of fearfulness and fewer specific fears of
failure and criticism, medical fears, and fears of the unknown (Ginsburg & Silverman, 2000). In
contrast, no relation was found between self- reported femininity and fearfulness. This suggests
that gender role orientation, especially masculinity, may play a role in the development and
persistence of fearfulness in children.

The experience of anxiety is pervasive across cul- tures. Although cross-cultural research into
anxiety disorders in children is limited, specific fears in children have been studied and
documented in virtually every culture. Developmental fears (e.g., a fear of loud noises or of
separation from the primary caregiver) occur in children of all cultures at about the same age.
The details may vary from culture to culture, but the number of fears in children tends to be
highly similar across cultures, as does the presence of gender differences in pattern and
content. Nevertheless, the expression, developmental course, and interpretation of symptoms of
anxiety are affected by culture (Ingman, Ollendick, & Akande, 1999). For example, Native
Hawaiian adolescents display rates of OCD that are twice as high as other ethnic groups
(Guerrero et al., 2003). When attempting to explain such differences, it is important to keep in
mind that genetic and/or environmental risk factors may play a role.

Cultural differences in traditions, beliefs, and prac- tices about children can affect the
occurrence of anxi ety and related symptoms, and how they are perceived by others and
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experienced by the child (Wang & Ollen- dick, 2001). For example, James, a 16-year-old
Chinese American boy had been to multiple doctors throughout his life for treatment for stomach
cramps, nausea, and hot flushes in the morning before going to school and also in anticipation
of social interactions. James had a social phobia but both he and his family felt his problem was
physical and wanted to focus only on his physi- cal symptoms in therapy and not subjective
feelings of anxiety.

Increased levels of fear in children are found in cul- tures that favor inhibition, compliance, and
obedience (Ollendick et al., 1996). Chinese cultural values such as human malleability and self-
cultivation may heighten levels of general distress and specific fears (Dong, Yang, & Ollendick,
1994). In addition, Chinese adolescents report higher levels of social anxiety than American
youth, including anxiety about humiliation and rejection and public performance fears (Yao et
al., 2007). This is likely related to their collectivistic versus individualistic value orientation.
Children in Thailand have also been found to display more symptoms of anxiety, such as
shyness and somatic complaints, than children in the United States (Weisz, Weiss, Suwanlert, &
Chaiyasit, 2003). Perhaps the most accurate way to analyze cultural differences in anxiety is
using Weisz and colleagues’ (2003, p. 384) behaviour lens principle, which states that child
psychopathology reflects a mix of actual child behaviour and the lens through which it is viewed
by others in a child’s culture.

Over the years, numerous theories and causes have been proposed to explain the origins of
fear and anxiety in children, including brain disease, mental strain, parenting practices,
conditioning, and instinct (Treffers & Silverman, 2001). The recent study of fear and anxiety in
children dates back to Freud’s (1909/1953) classic account of the case of Little Hans; Watson
and Rayner’s (1920) conditioning of a fear in Little Albert; and Bowlby’s (1973) monumental
works on early attachment and loss. Although each early theory has been debated since it was
introduced, all have had a lasting impact on how we think about anxiety in children.

Exposing youngsters to the situations, objects, and occasions that produce their anxiety is the
main line of attack in treating fears and anxieties. The most effective procedures for treating
specific phobias involve participant modelling and reinforced practice.
Cognitive–behavioural treatment (CBT) teaches children to understand how their thinking
contributes to anxiety, how to change maladaptive thoughts to decrease their symptoms, and
how to cope with their fears and anxieties other than by escape and avoidance. Medications
such as SSRIs are effective in treating children with OCD. However, findings for the
effectiveness of medications used to treat other anxiety disorders have been inconsistent.
Family interventions for anxiety disorders may result in more dramatic and lasting effects than
focusing only on the child.

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Text 1: Questions 7 to 14

7. What can be understood about the anxiety in females?

A. It is not seen in the girls below 6 years

B. It is mostly independent of age
C. It cannot be attributed to Psychosocial factors
D. It is twice as severe as it is in males

8. According to the first paragraph, which researcher suggests that there may not indeed
be any difference between males and females in the incidence of anxiety disorders?

A. Lewinsohn
B. Vasey
C. Roza
D. Wren

9. In the second paragraph, the study by Ginsberg and Silverman reports that

A. in general, boys are fearless, while girls are fearful.

B. those who claim to be male tend be less fearful.
C. masculinity may play a role in the development and persistence of fearfulness in
children
D. there is a strong association between self-reported femininity and fearfulness.

10. According to the paragraph 3, which aspect of anxiety in children could differ across
cultures?

A. what is made out of the symptoms

B. how many anxieties occur
C. at which age developmental anxieties occur
D. what differences there are between genders

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11. In the paragraph 4, the author cites James's case as an example to reinforce that

A. children often suffer from social phobia.

B. children's medical problems are frequently misinterpreted by doctors
C. families usually want to conceal their children's psychological problems.
D. cultural variations can often change the way children's issues are interpreted.

12. As per the fifth paragraph, American youth report lower levels of social anxiety than their
Chinese counterparts probably because

A. they have individualistic value orientation.

B. they have collectivistic value orientation.
C. differences between their value systems
D. wider influence of mass media in America

13. What does the author tell about early theories on children's anxiety?

A. they were all put forward during the same decade

B. they have all had a lasting impact on anxiety in children
C. all of them were controversial
D. most of them were proposed by Freud

14. In the final paragraph, what is touted by the writer as the main line of offence in treating
anxiety and fear in children is

A. facing the cause of the fear.

B. cognitive behaviour therapy.
C. medications.
D. family interventions.

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Text 2:
Is Your Medicine What You Think It Is?
The sudden hospitalization of dozens of children in Paraguay for severe breathing problems in
2013 led to an alarming discovery: an entire shipment of poor-quality medicine for treating colds
was contaminated with levomethorphan, an extremely potent and potentially lethal opioid. World
Health Organization (WHO) global surveillance that began that same year revealed that the
active pharmaceutical ingredient had originated in Belize and had already caused 50 deaths in
Jamaica. Such stories are still not rare. The WHO issued a report last November revealing that
roughly one in ten medical products sold in low- and middle-income countries is of poor quality.
Michael Deats, team leader for the WHO’s surveillance efforts, shares his views from the front
line of the fight against poor-quality medicines. The struggle involves the global health and
medical community, including businesses and regulators along the fast-growing supply chain,
and the patients they serve. The force is bolstered by USP, an organization that sets
international standards for quality medicine.

Many believed the problem was restricted to branded, expensive products from major
pharmaceutical companies, but that’s definitely not the case. Generics and branded, expensive
and less-expensive, are all affected by this issue. If there’s a market, if there’s unmet demand
for medicines, somebody will step into the vacuum.

However, this problem is being overlooked in wealthy countries. It’s a global issue and
everyone’s affected. Irrespective of economic profiles, all countries are vulnerable in different
ways. In high-income countries, we often see falsified medicines penetrating online pharmacies
and informal supply chains. In low- and middle-income countries, problems result from weak
systems and technical capacity, porous borders, governance issues, and access difficulties. We
get reports every day.

Indeed, managing risk along the medicine’s journey to the patient and ensuring drug quality and
safety is a challenge. It’s impossible to be able to look at everything if you’ve got 10,000 drug
outlets in a major city, and a regulatory agency that may have 30 people. And if you’ve got
20,000 medicines registered in your country, you’re not going to be sampling all of those. You
need information as to what products are most at risk, which regions and geographic locations
are most at risk, and what part of the supply chain is most at risk, and then focus your
resources. If you’re not looking after the last mile to the patient, that’s where bad stuff is going to
get into the chain. We’ve been working hand in hand with USP [recently officially recognized by
the WHO as a standard-setter and trusted expert on quality medicines], which has proved to be
a good collaborative alliance to prevent harm, safeguard health advances and reduce costs.

But how do you take on corruption, limit the black market and encourage reliable reporting? If a
country wants to tackle this issue, there’s got to be political will from the top. You’ve also got to
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create an environment where there’s clear water between the regulator and the regulated.
When regulators are transparent, it’s very clear what action they will take when certain things
happen, and that any sanctions are used proportionally if they are required.
In some countries, medicines are as good as money. You can put steps in place to secure the
supply chain and make sure you haven’t got expired medicines hanging around, which will
surely be taken and distributed on the market. Corruption is incredibly tough to deal with.
Healthcare professionals report the most serious cases, and their information is the most
reliable. But they also report the fewest cases. You hear, ‘I’m scared,’ or ‘I want to keep my job’.
We need to deal with that. The WHO’s report highlights lax legal penalties, including a case
where selling fake antimalarials in sub-Saharan Africa resulted only in fines and suspended
sentences.

Although having a nice piece of legislation on the books is all very well, you’ve got to have a
criminal justice system capable of dealing with that case. If you’re taking an antimalarial that’s
made of potato starch, it’s not going to poison you, but neither is it going to treat your malaria.
The courts are used for cases where you can see damage to an individual. We’re now seeing a
lot of awareness training among prosecutors, barristers, lawyers, judges, police, and Customs
officers to demonstrate that this is doing severe damage and needs to be prioritized.

The more we encourage transparency and openness, the better is the picture we get. Too
often, it’s only after a long time or after a bad outcome from a patient that a healthcare worker
will request examination of the medicine, and realize that there’s no active ingredient in it. We
need to accelerate that process through education and awareness, simpler reporting systems,
smartphone applications for healthcare workers, and try to remove some of the barriers.

Also, international standards can strengthen the forces resisting bad medicine. Medicines,
especially some of the molecules, are subject to degradation though they may have left the
manufacturing site meeting the standards. Unfortunately, by the time it reaches the country in
which it’s going to be dispensed, it’s degraded. It is critical that we have those pharmacopeial
standards in place so we can test and be sure. Clear, precise, and accurate standards across
the board are welcomed by regulatory agencies. When a country is struggling with an issue, and
they can pick up a recognized international standard, it can help them get out of trouble. It’s a
lifeline if you’ve got good standards.

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Questions: 15-22

15. The author cites the Paraguay incident to

A. illustrate adverse effects of impure drugs.

B. suggest that Paraguayean authorities are not strict in checking quality of
medicines.
C. prove Belize mostly produces contaminated medicines.
D. to reinforce that levomethorphan causes respiratory problems.

16. What does the word vacuum imply in the second paragraph?

A. Lack of air
B. Lack of supply
C. Lack of demand
D. Lack of emptiness

17. In the paragraph 3, which of the following is Not mentioned as the reason for the
problem of substandard medicines in less developed countries?

A. Poor administrative systems

B. Technical capacity
C. Weak borders
D. Access difficulties

18. What point does the writer make in the fourth paragraph?

A. The number of registered drugs is increasing rapidly

B. Poor-quality medicines reach patients mostly through through last part of the
supply chain
C. Regulatory staff and drug outlets are highly disproportionate
D. Absolute surveillance over medicines is impracticable

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19. In the fifth paragraph, how does the author propose reliable reporting be encouraged?

A. By imposing harsh legal penalties

B. By having stable political systems
C. By making those who report feel secure
D. By creating transparency between the regulators and the regulated

20. What does the word this refer to in the sixth paragraph?

A. medicine acting as a poison

B. medicine remaining ineffective
C. falsified anti-malarial drug
D. lack of efficient criminal justice system

21. According to the seventh paragraph, in most cases a healthcare expert requests
examination of medicine after a long time because

A. they do not have the right qualification

B. they wait for a bad outcome from the patient
C. smartphones applications for simpler reporting are not available
D. they have too many obstacles

22. What point does the author infer about medicines in the final paragraph?

A. They may undergo transformation between production and consumption

B. They mostly get degraded before they reach patients
C. They are resisted by international standards
D. They often act as a lifeline

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