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1.

A 65yo man presents with painless hematuria, IVU is normal, prostate is mildly
enlarged with mild frequency. What is the most appropriate next step?
a. US Abdomen
b. Flexible cystoscopy
c. MRI
d. Nuclear imaging
e. PSA
Q. 1. What is the key?
Q. 2. Points in favour of the key.
Ans. 1. The key is B. Flexible cystoscopy.
Ans. 2. Painless hematuria in an elderly (here 65 years old man) indicates carcinoma
bladder for which flexible cystoscopy is done.
An elderly gentleman complaining of painless hematuria : always exclude bladder cancer
The most important and definite Investigation for bladder cancer is a cystoscopy+ Biopsy.
Initially : Urine microscopy but it does not rule out CA.
Other causes of painless hematuria are rhabdomyolysis , coagulation disorder , prostate cancer , hemolytic
anemia , renal tumor , and polycystic kidney disease
you can exclude those by absence of :
1- History of crush injury for rhabdomyolysis
2- No bleeding from other orifices for coagulation disorder
3- No symptoms of prostatism for Prostate Cancer
4- No signs of anemia
5- No tenderness in loin or masses (renal tumor)
6- No hypertension (in polycystic kidney)
although other investigations like Mid urine sample , IVU , may show UTI , other findings like filling defects ,
etc.. they dont help with diagnosis and prognosis

Diagnosis : Bladder CA. (1 in 10,000)


Most common : Transistional cell CA. 3x in MEN of 50+ age.
Inc factors :
Smoking, schistosomiasis, rubber dye industries, White ppl, recurrent infections.
Symptoms :
Painless hematuria (on and off)
Pain in lower abdomen

Treatment :
TUR with 1 chemotherapy within 24 hours. If needed, BCG is used for next chemo
cycles.
2. A 74yo smoker presented to his GP with cough and SOB. Exam revealed
pigmentation of the oral mucosa and also over the palms and soles. Tests show that he
is diabetic and hypokalemic. What is the most probable dx?
a. Pseudocushing syndrome
b. Conns disease
c. Ectopic ACTH
d. Cushings disease
e. Hypothyroidism
Q. 1. What is the likely key?
Q. 2. Please explain the key.

Ans. 1. The key is C. Ectopic ACTH.


Ans. 2. The patient is smoker and probably developed small cell lung cancer which is
working as a tumour producing ectopic ACTH resulting in pigmentation. Resultant raised
cortisol is leading to diabetes and hypokalemia.
the features can be explained by increased levels of ACTH and adrenocortical hormones. So the question is
: ectopic or pituitary ACTH excess? It seems to be from an ectopic source since the patient is smoker and
has SOB and cough ( Lung tumor whether small cell CA bronchus or carcinoid tumor- both may

secrete ectopic ACTH ) . Furthermore , Cushing's disease is often the result of pituitary
ACTH-secreting adenoma that also causes pressure symptoms like headache and
visual disturbances which are absent in this case.
Ectopic ACTH increase the secretion of aldosterone from adrenal gland and aldosteronism causes
hypernatraemia and hypokalaemia.
Cortisol is a form of stress hormone. So it induces glycogenolysis causing increase in blood glucose.
No pigmentation in conn
Conns must have hypertension n not necessarily hypokalemia but it presents with signs of hypokalemia like
weakness quadriparsis cramps.
Why not Cushings?
SCLC is a direct cause of ectopic ACTH (statement is clear cut - Smoker). Further ectopic acth can
lead to cushings at later stages but its major cause is use of steroids and pituitary adenoma while
ectopic acth is down the list. And if cushings happen, the major indicative symptoms are stria, moon
face, easily fractured bones, plethora.

Diagnosis : Small Cell Lung CA causing ectopic ACTH.


Main reason : SMOKING for years. At Least 20 so age goes up to 50 to 60. Male.
Symptoms :
Persistent cough, hemoptysis, chest n shoulder pains, SOB, clubbing. +/- pleural effusion,
pneumonia, pins and needles in arm n shoulder sensation.
Invs :
Initial : CXR. Shows shadowing
Confirmatory : CT chest THEN Biopsy thru bronchoscope or transthoracic needle biopsy. Depends
on the location.
Pleural Tap can be done if pleural effusion.
Treatment :
Surgery, radio and chemo.
Prognosis : Good if early diagnosed. Bad if late.

3. A 44yo woman has lost weight over 12 months. She has also noticed episodes where
her heart beats rapidly and strongly. She has a regular pulse rate of 90bpm. Her ECG
shows sinus rhythm. What is the most appropriate inv to be done?
a. Thyroid antibodies
b. TFT
c. ECG
d. Echocardiogram
e. Plasma glucose
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What is the significance of episodes of rapid strong heart beat?
Ans. 1. The key is B. TFT.
Ans. 2. Thyrotoxicosis [weight loss over 12 months, episodes of rapid strong heart beet
(thyrotoxicosis induced paroxysmal atrial fibrillation) points towards the diagnosis of
thyrotoxicosis].

Ans. 3. Episodes of rapid strong heart beat indicates thyrotoxicosis induced paroxysmal
atrial fibrillation.

Diagnosis : Hyperthyroidism/thyrotoxicosis.
Gender : more in females. 20 to 50 age.
Most common : Graves'
Symptoms :
Irritable, always on the go, losing weight despite increase appetite, palpitations, heat
intolerance, sweating, Diarrhea, SOB, itch, very light periods, increase risk of AF
and osteoporosis.
Meds that cause it : Amiodarone and lithium.
Invs : TFTS. Low TSh and high T4.
Treatment :
1. Carbimazole for 12 to 18 months.
Pregnancy - Propylthiouracil
2. Radioiodine. Should not be pregnant and conceive for at least 6 months. Father at
least 4 months.
3. Surgery
4. Beta blockers (propranolol, atenolol)
Follow up every year is very imp.
4. 79yo anorexic male complains of thirst and fatigue. He has symptoms of frequency,
urgency
and terminal dribbling. His urea and creatinine levels are high. His serum calcium is 1.9
and he is anemic. His BP is 165/95 mmHg. What is the most probable dx?
a. BPH
b. Prostate carcinoma

c. Chronic pyelonephritis
d. Benign nephrosclerosis
Explanation of Question no. 4:
First to say in this case (almost all features goes in favour of prostatic carcinoma like- frequency,
urgency and terminal dribbling are features of prostatism; Age, anorexia and anaemia favours
carcinoma prostate diagnosis and it would be accurate presentation if it was hypercalcaemia. But
given calcium level is of hypocalcaemic level and it is the main cause of discrepancy of this
question). Renal failure can be an association of malignant disease and can cause high
BP. Thirst is a feature of hypercalcaemia (here may be erroneously calcium level is given in
hypocalcaemic level ; probably a bad recall). Prostate biopsy is the confirmatory diagnosis and
others like PSA is suggestive. This is what I could pointed out. If there is any better explanation
please place it to correct the answer- any one please.

Calcium

2.1-2.6 mmol/l

I think this patient has CKD secondary to prostate CA which leads to hypocalcemia
due to vit D def.
Osteoblastic metastases Occasional patients with widespread osteoblastic metastases, particularly those
with breast or prostate cancer, have hypocalcemia.
Diagnosis : Prostate Cancer
Most common CA in men of uk. 1 in 8 men. After 65.
Risk factors: Fatty diet, exposure to cadmium, ageing n family history.
Symptoms :
Poor stream, hesitancy, dribbling, frequency, urgency, poor emptying.
Invs :
Examine. PSA levels.
Confirmatory test : Biopsy.
Grading : Gleason Score.
4 or less - well differentiated. 10 yr risk of local progression 25%
5 - 7 - moderately differentiated. 50% risk
Over 7 - poorly differentiated. 75% risk
Risk assessment PSA levels.
Low - <10 and gleason score 6 or below
Intermediate - psa 10 to 20 or gleason score 7
High - psa >20 or gleason 8 to 10.
Staging : MRI preferred over CT.
Treatment : Surgery. Radical prostatectomy. S/E impotence, incontinence of urine.
Radiotherapy. External and internal (brachytherapy)
HRT to stop TESTOSTERONE.
Medicines - LHRH. Goserelin, leuprorelin, triptorelin (act on pitutary) and Flutamide, cyproterone
(anti androgenic)
Prognosis : variable. Depends on the stage.
Complications :
UTi, AKI, CKD, sexual dysfunction, metastasis.
Note : Prostate CA has increased risk with HYPERCALCEMIA. Not hypo. So the statement seems to
be wrong. Even BPH has nothing to do with Ca levels.
Benign nephrosclerosis is due to long standing HTN. No link to prostate found.

5. A 64yo man has recently suffered from a MI and is on aspirin, atorvastatin and ramipril. He has
been having trouble sleeping and has been losing weight for the past 4 months. He doesnt feel
like doing anything he used to enjoy and has stopped socializing. He says he gets tired easily and
cant concentrate on anything. What is the most appropriate tx?
a. Lofepramine
b. Dosulepin
c. Citalopram
d. Fluoxetine
e. Phenelzine
Ans. The key is C. Citalopram. [Citalopram is the antidepressant of choice in IHD]
Citalopram is associated with dose-dependent QT interval prolongation and is contraindicated in patients with known QT interval prolongation or congenital long QT
syndrome.
Sertraline can also be used in patients with IHD for depression. sertraline is considered the
drug of choice post-MI
1. Depression with obesity=fluoxetine (It helps without weight loss)
2. Depression with sexual dysfunction=mirtazapine
3. Post stroke depression use nortriptyline (TCA)
4. Depression with obsessive compulsive disorder=clomipramine (TCA)
5. Depression with ischemic heart disease=SSRI e. g citalopram

6. A 67yo man after a stroke, presents with left sided ptosis and constricted pupil. He also has
loss
of pain and temp on the right side of his body and left side of his face. Which part of the brain is
most likely affected?
a. Frontal cortex
b. Cerebellum
c. Pons
d. Medulla
e. Parietal cortex
Q. 1. What is the key?
Q. 2. What is the name of this condition?
Ans. 1. The key is D. Medulla.
Ans. 2. The name of the condition is Lateral medullary syndrome [ipsilateral Horner syndrome
and contralateral loss of pain and temperature sense]
Lateral medullary syndrome, also known as Wallenberg's syndrome, occurs following occlusion of the
posterior inferior cerebellar artery
Cerebellar features
ataxia
nystagmus
Brainstem features

ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. Horner's


contralateral: limb sensory loss

Lateral medullary or Wallenberg's syndrome:

Usually from occlusion of the vertebral artery.


Occasionally from occlusion of the posterior inferior cerebellar artery.
Involvement of the vestibular system causes nausea, vomiting and vertigo.
Ipsilateral features:
o Ataxia from cerebellar involvement.
o Horner's syndrome from damage to descending sympathetic
fibres.

o
o
o
o
o
o
o

Reduced corneal reflex from descending spinal tract damage.


Nystagmus.
Hypacusis.
Dysarthria.
Dysphagia.
Paralysis of palate, pharynx, and vocal cord.
Loss of taste in the posterior third of the tongue.
Contralateral findings:
o Loss of pain and temperature sensation in the trunk and limbs
(anterior spinothalamic tract).
o Tachycardia and dyspnoea (cranial nerve X).
o Palatal myoclonus (involuntary jerking of the soft palate,
pharyngeal muscles and diaphragm).

7. A 60yo man presents with dysphagia and pain on swallowing both solids and liquids. A barium
meal shows gross dilatation of the esophagus with a smooth narrowing at the lower end of the
esophagus. What is the SINGLE most likely cause of dysphagia?
a. Achalasia
b. Myasthenia gravis
c. Esophageal carcinoma
d. Esophageal web
e. Systemic sclerosis
Ans. The key is A. Achalasia.
Achalasia typically presents in middle-age and is equally common in men and women
Investigations
manometry: excessive lower oesophageal sphincter tone which doesn't relax on swallowing considered most important diagnostic test
barium swallow shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance. This

is in contrast to the rat's tail appearance of carcinoma of the oesophagus

CXR: wide mediastinum, fluid level


Gold standard - Manometry

Treatment

intra-sphincteric injection of botulinum toxin


Heller cardiomyotomy for fit young patients.
balloon dilation for old unwell patients.

Complications : Aspiration pneumonia, perforation, GERD, Oesophagus CA.

Dysphagia
The table below gives characteristic exam question features for conditions causing
dysphagia:

Dysphagia may be associated with weight loss, anorexia or


vomiting during eating
Oesophageal
cancer

Oesophagitis

Past history may include Barrett's oesophagus, GORD,


excessive smoking or alcohol use

May be history of heartburn


Odynophagia but no weight loss and systemically well

Oesophageal
candidiasis

There may be a history of HIV or other risk factors such as steroid


inhaler use

Achalasia

Dysphagia of both liquids and solids from the start


Heartburn
Regurgitation of food - may lead to cough, aspiration pneumonia etc

Pharyngeal
pouch

More common in older men


Represents a posteromedial herniation between thyropharyngeus
and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that
gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and
chronic cough. Halitosis may occasionally be seen

Systemic
sclerosis

Other features of CREST syndrome may be present, namely


Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility,
Sclerodactyly, Telangiectasia

As well as oesophageal dysmotility the lower oesophageal sphincter


(LES) pressure is decreased. This contrasts to achalasia where the
LES pressure is increased

Myasthenia
gravis

Other symptoms may include extraocular muscle weakness or ptosis

Dysphagia with liquids as well as solids

Globus hystericus

May be history of anxiety


Symptoms are often intermittent and relieved by swallowing
Usually painless - the presence of pain should warrant further
investigation for organic causes

8. A man undergoes a pneumonectomy. After surgery, invs show hyponatremia. What could be
the
cause of the biochemical change?
a. Removal of hormonally active tumor
b. Excess dextrose
c. Excess colloid
d. Excessive K+
e. Hemodilution
Ans. The key is A. Removal of hormonically active tumour.
Small cell lung carcinoma produces acth like peptide which stimulates aldosterone secretion causing
hypernatremia. Removal of that will lead to hyponatremia.
OHCM 170...Lung tumors may secrete both ACTH and ADH. If it was an ACTH secreting tumor then it's
removal may cause hyponatremia. As ACTH helps in absorption of Na and water by releasing Aldosterone
from adrenal gland. On the other hand if it was an SIADH secreting tumor then opposite would happen.

9. A pregnant lady came with pain in her calf muscle with local rise in temp to the antenatal clinic.
What tx should be started?
a. Aspirin
b. LMWH
c. Paracetamol
d. Cocodamol
e. Aspirin and heparin
Ans. The key is B. LMWH.
During pregnancy :
Start LMWH and continue throughout pregnancy. Stop the injections 24 hours before labour and
then restart them 4 hours post op. Warfarin is Contraindicated in pregnancy.
If NO pregnancy :
the protocol is different.
- LMWH stat
- Start Warfarin within 24 hours
- Monitor INR and withdraw LMWH when value is 2.0
- Depending on provoked or non provoked, give Warfarin for 3 and 6 months respectively and then
stop.
- IVC filter is used when anticoagulants fail
- Compression stockings to all patients to prevent 'Post-phlebitic limb changes'

Wells' diagnostic algorithm[1]


Score one point for each of the following:
Active cancer (treatment ongoing or within the previous six months, or
palliative).
Paralysis, paresis or recent plaster immobilisation of the legs.
Recently bedridden for three days or more, or major surgery within the
previous 12 weeks, requiring general or regional anaesthesia.
Localised tenderness along the distribution of the deep venous system
(such as the back of the calf).
Entire leg is swollen.
Calf swelling by more than 3 cm compared with the asymptomatic leg
(measured 10 cm below the tibial tuberosity).
Pitting oedema confined to the symptomatic leg.
Collateral superficial veins (non-varicose).
Previously documented DVT.
Subtract two points if an alternative cause is considered at least as likely as DVT.
The risk of DVT is likely if the score is two or more, and unlikely if the score is one or
less.
invs :
initial - Duplex USG
Gold standard - invasive venography

10. A 53yo female presents with an acute painful hot knee joint. She is a known case of
RA. On
examination, the knee is red, tender and swollen. The hamstring muscles are in spasm.
Her
temp is 38.5C and BP is 120/80mmHg. What is the SINGLE best next inv?
a. Joint aspiration for cytology and culture and sensitivity
b. Joint aspiration for positive birefrengent crystals
c. Joint aspiration for negative birefrengent crystals
d. Blood culture
e. Serum uric acid
Q. 1. What is the likely key here?
Q. 2. Is there any link in septic arthritis and rheumatoid arthritis?

Q. 3. What is the likely organism in this age group?


Q. 4. What is the likely organism in younger age group?
Ans. 1. A. Joint aspiration for cytology and culture and sensitivity.
Ans. 2. Any chronically arthritic joint is predisposed to infection.
Moreover chronic use of steroid in Rh. arthritis is one of the important
predisposing factor.
Ans. 3. Staphylococcus
Ans. 4. Neisseria gonorrhoeae

RA always involves bilateral symmetrical joints with morning stiffness. The patient presented with
new complaint which is monoarticular, swollen n hot. It's clearly Septic arthritis n u do joint
aspiration. Chronic use of steroids is one of the important predisposing factors.

Diagnosis : Septic Arthritis due to persistent Rheumatoid Arthritis.


The classic picture is a single swollen joint with pain on active or passive movement.
It is more common in patients with prior joint damage, as in gout, rheumatoid arthritis
and systemic connective tissue disorders.
Fever and rigors. Chest wall pains.

Treatment :
Flucloxacillin and for MRSA - Vancomycin.
Penicillin with Gentamicin is being used as well.
11. An 80yo man presented with pain in his lower back and hip. He also complains of
waking up in
the night to go to the washroom and has urgency as well as dribbling. What is the most
likely dx?
a. BPH
b. Prostatitis
c. UTI
d. Prostate carcinoma
e. Bladder carcinoma
Q. 1. What is the likely key?
Q. 2. What are the points in favour of your diagnosis?
Q. 3. What are the investigations?
Q. 4. What are the treatment options for carcinoma prostate?

DISCUSSED IN MCQ 4.
Ans. 1. D. Prostate carcinoma.
Ans. 2. Age, nocturia, urgency and dribbling points towards prostate pathology. Pain of
lower back and hip points towards bony metastases from prostate cancer.
Ans. 3. Blood test for PSA; Prostate biopsy; MRI [if initial biopsy is negative, to decide
repeat biopsy]. Source NICE.
Ans. 4. Treatment options: 1. Active treatment [i) radical prostatectomy ii) radical
radiotherapy iii) hormone therapy iv) brachytherapy v) pelvic radiotherapy vi)
orchidectomy]
2. Active surveillance
3. Watchful waiting
4. Palliative care [Source: NICE].

12. An 18yo female has periorbital blisters. Some of them are crusted, others secreting
pinkish fluid. What is the most likely dx?
a. Shingles
b. Chicken pox
c. Varicella
d. Rubella
e. Measles
Q.1. What is the likely key?
Q. 2. Which nerve is involved here?
Q. 3. Is this disease unilateral or bilateral?

Ans. 1. A. Shingles
Ans. 2. Ophthalmic division of trigeminal nerve.
Ans. 3. Typically shingles is unilateral.
Short note everywhere. Mcq covers it up.
Treatment :
Refer to ophthalmologist. Ocular lubricants, cool compressors, topical steroids,
Botulinum toxin injection if neurotrophic ulcers form.
13. A 29yo lady who is a bank manager is referred by the GP to the medical OPC due to
a long hx of tiredness and pain in the joints. An autoimmune screen result showed
smooth muscle
antibodies positive. What is the most appropriate next inv?
a. ECG
b. TFT
c. LFT
d. Serum glucose
e. Jejunal biopsy
Q. 1. What is the likely key?
Q. 2. What is the diagnosis?
Q. 3. What is the definitive investigation?
Q. 4. What is the treatment?
Ans. 1. C. LFT
Ans. 2. Autoimmune hepatitis.
Ans. 3. Definitive investigation is liver biopsy
Ans. 4. Steroid [start with high dose prednisolone]. Azathioprine is commonly added with
steroid to reduce its dose as steroid has more side effects than azathioprine.
Diagnosis : Autoimmune hepatitis.
Symptoms :
Tiredness, fatigue, mild pruritus, amenorrhea, pleuritis, abdominal discomfort,
Oedema, Skin rashes, acne, weight loss. Nausea is prominent.
Signs :
Hepatomegaly, splenomegaly, spider angiomata, ascites, encephalopathy,
jaundice in 50%
The autoantibodies present include antinuclear antibody (ANA), anti-smooth
muscle antibody (ASMA), anti-liver-kidney microsomal-1 (anti-LKM-1) antibody,
antibodies against soluble liver antigen (anti-SLA), antimitochondrial antibody
(AMA) and antiphospholipid antibodies.
Invs :
1. Autoantibodies. Typical is ASMA.
2. Ig G is raised. (Can lead to hyperviscosity syndrome)
3. LFTs. ALT and AST are raised. ALP maybe normal.
4. USG abdomen.
5. Liver biopsy - Confirmatory.
Treatment :
Steroids.

Budesonide + Azathioprine
Prednisolone + Azathioprine
+/- methotrexate, Anti TNF alpha drugs
Liver transplant.
14. A 5yo with recurrent chest pain, finger clubbing with offensive stool. Choose the
single most
likely inv?
a. Endomysial/Alpha gliadin antibody
b. Sweat test
c. Barium meal
d. ECG
e. Glucose tolerance test
Q. 1. What is the likely key?
Q. 2. What is the diagnosis?
Q. 3. What is the mode of inheritance?
Ans. 1. B.
Ans. 2. Cystic fibrosis
Ans.3. Autosomal recessive.
DIAGNOSIS : Cystic FIbrosis. Mutation of CFTR on chromosome 7.
It cause dehydration. Hence, bronchiectasis, bowel obstruction and bacterial
growth,

Signs

Finger clubbing.
Cough with purulent sputum.
Crackles.
Wheezes (mainly in the upper lobes).

INVS :
Sweat Test. Chloride concentration > 60. Sinus X ray or CT scan - Opacities of
sinuses.
Lung function tests, LFTs, Sputum microbiology.

17. A man with suspected active TB wants to be treated at home. What should be done
to prevent
the spread of disease?
a. Immediate start of the tx with Anti-TB drugs
b. All family members should be immediately vaccinated with BCG vaccine
c. Patient should be isolated in a negative pressure chamber in his house
d. Universal prevention application protocol
Ans. d. Universal prevention application protocol.
This protocol isnt available anywhere on the internet. Everybody is suggesting D on the
basis of exclusion.

18. A 7yo child is brought to the ED with a 1 day hx of being listless. On examination, the
child is
drowsy with an extensive non-blanching rash. What advice would you give the parents?
a. All family members need antibiotic therapy
b. Only the mother should be given rifampicin prophylaxis
c. All family members need isolation
d. All family members should be given rifampicin prophylaxis
Q. 1. What is the likely key?
Q. 2 What is the probable diagnosis?
Q. 3. What is the diagnostic investigation?
Q. 4. What is the initial management?
Ans. 1. D. All family member should be given rifampicin prophylaxis
Ans. 2. Meningococcal disease.
Ans. 3. Blood or CCF PCR
Ans. 4. Prehospital management: Benzyl penicillin or cefotaxime.
DIAGNOSIS : Meningococcal infection. It can be meningococcal Septicemia which
is without Meningitis, or can be Meningococcal Meningitis. This Mcq doesnt have
meningitis signs so we will stick to M.Septicemia.
Caused by N.Meningitidis
Signs and Symptoms :
Most common and important - Non - blanching rash
Fever, headache
May have : Stiff neck, back rigidity, bulging fontanelle (in infants), photophobia.
Altered mental state, unconsciousness, toxic/moribund state, Kernig's sign (pain and
resistance on passive knee extension with hips fully flexed) and Brudziski's sign
(hips flex on bending the head forward)
Pre-Hospital Management :
Call 999 and give Benzyl penicillin or Cefotaxime

INVESTIGATIONS :
Blood cultures.
FBC (WCC), CRP, U&Es, renal function tests, LFTs.
Blood test for polymerase chain reaction (PCR): perform whole blood realtime PCR testing - (EDTA sample) - for N. meningitidis to confirm a
diagnosis of meningococcal disease
Investigations for disseminated intravascular coagulation: prothrombin
time is elevated, activated partial thromboplastin time (aPTT) is elevated,
platelet count is reduced and the fibrinogen level is low.
Lumbar puncture - once the patient is stable
Aspirate from other sterile sites suspected of being infected (eg, joints) for
microscopy, culture and PCR.
TREATMENT :

Choice of antibiotics in hospital :


o Ceftriaxone is usually given to those over 3 months
o Cefotaxime and amoxicillin are usually given to those under 3
months.

Vancomycin is given in addition, to those who have recently


travelled outside the UK or have had prolonged or multiple
exposure to antibiotics.
CHEMOPROPHYLAXIS :
To close contacts of cases, irrespective of vaccination status - for example,
those who have had prolonged close contact with the case in a household-type
setting during the seven days before onset of illness
Ciprofloxacin and rifampicin are both recommended by Public Health England
(PHE) but ciprofloxacin is the preferred choice for most individuals.
Ciprofloxacin can be used in all ages and in pregnancy; it is easily available in
a single dose and does not interfere with oral contraceptives (but is contraindicated if there has been previous sensitivity):
o Adults and children aged >12 years - 500 mg orally stat.
o Children aged 5-12 years - 250 mg orally stat.
o Children aged <5 years - 30 mg/kg up to a maximum of 125 mg orally
stat.
Rifampicin is no longer the drug of choice as, although it is licensed for
chemoprophylaxis, it has several disadvantages including important drug
interactions

19. A 47yo man has a temp of 39C and is delirious. He has developed blisters mainly on
his trunk,
which appeared a few hours ago. He is well and not on any medications. He last
travelled 5
months ago to Italy. Which of the following is the most likely dx?
a. Shingles
b. Chicken pox
c. Pemphigoid
d. Bullous pemphigus
Q 1. What is the likely key?
Q. 2. Why delirium in this patient?
Q. Is his travel history has any link to the development of this disease?
Ans. 1. B. Chicken pox
Ans. 2. Adults more commonly develop a more generalized brain inflammation
("encephalitis") whose symptoms may include delirium and seizures.
Ans. 3. Incubation period of chicken-pox is 10-21 days. So this travel history is not
significant.
DIAGNOSIS : Chicken POX.
Why not Shingles?
Shingles is painful, while mcq does not mention it.
Shingles have dermatomal distribution while chickenpox is mainly peripheral and
truncal in distribution.
Chicken pox has 10 - 21 days incubation period, and so does shingles, so this 5
months thing is wrongly stated.
The patient is delirious - suggesting ENCEPHALITIS which is the main
complication of C.pox.
INVS :

Scraping the blisters and the skin and checking it with immunohistochemical
and PCR.
CXR and LP for its complications. (Pneumonia and Encephalitis)

Management
Chickenpox in an otherwise healthy individual

Simple advice regarding adequate fluid intake, minimising scratching if


possible and that the first 1-2 days they are most infectious.
Symptomatic treatment - eg, analgesia and antipyretics such as
paracetamol. There is a possible association with non-steroidal antiinflammatory drugs (NSAIDs) and risk of necrotising soft tissue infections.
Pruritus can be helped by sedating antihistamines and emollients.
Calamine lotion is no longer recommended, as when it dries it ceases to
be effective. Secondary infection may require antibiotics.
Aciclovir should be considered if the patient presents within 24 hours
Anyone with encephalitis - should be admitted to hospital.

20. A 64yo pt has been having freq episodes of secretory diarrhea, which is extremely
watery, with large amts of mucus. A dx of villous adenoma was made after endoscopy.
What electrolyte
abnormality is most likely in this pt?
a. Hyperkalemia
b. Hypernatremia
c. Hyponatremia
d. Hypokalemia
e. Hypercalcemia
Q. 1. What is the likely key?
Q. 2. Why this occurs?
Ans. 1. D
Ans. 2. There is active potassium secretion causing high fecal potassium concentration
leading to this hypokalaemia in secretory diarrhea. There is also reduced potassium
absorption in diarrhea.
Electrolyte loss in diarrhoea (Na, K, Mg, Cl). But potassium loss is more marked especially in severe,
chronic and when associated with mucous loss. Villous adenomas secrete protein n potassium rich mucus
so hypoalbuminemia n hypokalemia

Hypokalaemia is usually defined as a serum concentration of potassium <3.5 mmol/L.


It can be classified as follows:

Mild - 3.1 - 3.5 mmol/L


Moderate - 2.5 - 3.0 mmol/L
Severe - <2.5 mmol/L

Typical ECG findings when potassium is <3.0 mmol/L:

Flat T waves
ST depression
Prominent U waves

NB: the QT interval may appear prolonged, but this is usually a pseudo-prolongation
as the flattened T waves merge into the U waves.
MAIN CAUSES OF HYPOKALEMIA.
KIDNEY causes :

Thiazide or loop diuretics (the most common cause)


Renal tubular acidosis
Hypomagnesaemia
Hyperaldosteronism - eg, Conn's syndrome, renal artery stenosis, Cushing's disease
Tubulo-interstitial renal disease due to Sjgren's syndrome or systemic lupus
erythematosus
Excess liquorice ingestion
Activation of the renin-angiotensin system - eg, Bartter's syndrome or Gitelman's
syndrome

Via the GI tract:

Diarrhoea
Vomiting (bicarbonate diuresis)
Intestinal fistulae
Villous adenoma
Pyloric stenosis
Laxative abuse
Bowel preparation with oral sodium phosphate solution

Via the skin:

Burns
Increased sweating - eg, exercising in a hot climate
Increased loss in sweat - eg, cystic fibrosis

21. A pt with an acute gout attack came to the ED. What drug should be given to relieve
symptoms?
a. NSAIDs
b. Allopurinol
c. Ibuprofen
Q. 1. What is the key?
Q. 2. What is the acute management of gout?
Ans. 1. A
Ans. 2. Oral NSAIDs commenced immediately and continue for 1 2 weeks; Colchicine
can be effective alternative but is slower to work than NSAIDs. Intra articular
corticosteroids are highly effective in acute gouty monoarthritis.

DIAGNOSIS : GOUT
Cause : Interleukin - 1

Risk factors

Male sex, Meat, Seafood, Alcohol (10 or more grams per day), Diuretics,
Obesity, Hypertension, Coronary heart disease, Diabetes mellitus, Chronic
renal failure, High triglycerides

Pharmacological therapeutic options include:

Non-steroidal anti-inflammatory drugs (NSAIDs)


Colchicine
Corticosteroids

NOTE : This MCQ has NSAIDS and Ibuprofen in options which is from the same
group
but the preferred NSAIDS are : Diclofenac, naproxen and indomethacin.
Colchicine is particularly appropriate when NSAIDs are poorly tolerated, in patients
with heart failure and in those who are on anticoagulants.
30-35 mg of prednisolone reported a low incidence of side-effects
Allopurinol should never be started during an acute attack. Wait for 1-2
weeks after the attack resolves.
Co-prescribe colchicine or a low dose non-steroidal anti-inflammatory drug
(NSAID) to prevent an attack of gout whilst initiating therapy, and continue
until after hyperuricaemia has settled (usually a total of three months).
If an acute attack develops during treatment, maintain the dose of allopurinol
but add colchicine or NSAIDs.

22. A pt was lying down on the operating table in a position with his arms hanging down
for 3 hours. Soon after he woke up, he complains of numbness and weakness in that
hand and has limited wrist movement/wrist drop and sensory loss over dorsum of that
hand, weakness of extension of the fingers and loss of sensation at the web of the
thumb. What structure is likely to be damaged?
a. Radial nerve
b. Median nerve
c. Ulnar nerve
d. Axillary nerve
e. Suprascapular nerve
ANS is A. Radial Nerve.
Radial nerve, in spiral grove on humerus is pressed and damaged. It is also called saturday night
palsy.

23. A pt who was previously on 120mg slow release oral morphine has had his dose
increased to

200mg. He is still in significant pain. He complains of drowsiness and constipation. What


is the
next step in the management?
a. Increase slow release morphine dose
b. Fentanyl patch
c. Replace morphine with oral hydromorphone
d. Replace morphine with oxycodone
e. Subcutaneous morphine
Q. 1. What is the likely key? D - Replace morphine with oxycodone.
Q. 2. Why not other options? X

Morphine Start with oral solution 510mg/4h PO with an equal breakthrough dose as
often as required. A double dose at bedtime can enable a good nights sleep. Patient
needs will vary greatly and there is no maximum dose; aim to control symptoms with
minimum side-effects. If not effective, increase doses in 3050% increments
(5mg10mg20mg30mg45mg). Change to modified release preparations (eg MST
Continus 12h) once daily needs are known by totalling 24h use and dividing by 2.
Prescribe 1/6th of the total daily dose as oral solution for breakthrough pain. Side
effects (common) are drowsiness, nausea/vomiting, constipation and dry mouth.
Hallucinations and myoclonic jerks are signs of toxicity and should prompt dose review.
If the oral route is unavailable try morphine/diamorphine IV/SC. If difficulty tolerating
morphine/diamorphine, try oxycodone PO/IV/SC/PR, starting at an equivalent dose. It is
as effective as morphine and is a useful 2nd-line opioid with a different range of receptor
activity. There are also fentanyl transdermal patches which should usually be started
under
specialist supervision (after opioid dose requirements have been established). Remove
after 72h, and place a new patch at a different site. 45mg oral morphine/24h is
approximately equivalent to a 12mcg/h fentanyl patch.

24. A 40yo woman notices increasing lower abdominal distention with little/no pain. On
examination, a lobulated cystic mass is felt and it seems to be arising from the pelvis.
What is
the most appropriate inv?
a. CA 125
b. CA 153
c. CA 199
d. CEA
e. AFP
Q. 1. What is the likely key?
Q. 2. What is the likely diagnosis?
Ans. 1. A
Ans. 2. Ovarian ca. X
DIAGNOSIS : Ovarian CA
Age - 60 to 80 women
SYMPTOMS :

Early symptoms are often vague, such as abdominal discomfort,


abdominal distension or bloating, urinary frequency or dyspepsia.
Constitutional symptoms include fatigue, weight loss, anorexia and
depression.
It most commonly presents with a pelvic or abdominal mass that may be
associated with pain. Abdominal, pelvic or back pain is usually a late sign
It may cause abnormal uterine bleeding.
Often associated with ascites. One third of patients with ascites also have
a pleural effusion.

INVESTIGATIONS :

CA-125 test.
If this is reported as raised (35 IU/mL or greater) arrange pelvic and
abdominal ultrasound scans.
CT is the investigation of choice in the UK

Treatment :
The standard comprehensive surgical staging approach consists of a total abdominal
hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO)
The standard regime is paclitaxel and carboplatin given intravenously every three
weeks for six cycles.
Radiotherapy.
PRGNOSIS :

Stage I: 92%
Stage II: 55%
Stage III: 21.9%
Stage IV: 5.6%

25. A resident of a nursing home presented with rashes in his finger webs and also on
his abdomen, with complaints of itching which is severe at night. He was dx with
scabies. What the best tx for
his condition?
a. 0.5% permethrin
b. Doxycycline
c. 5% permethrin
d. Reassure
e. Acyclovir
Q. 1. What is the likely key?
Q. 2. Will you consider any other treatment beside this?
Ans. 1. C

Ans. 2. Scabies outbreaks in nursing homes and cases of crusted scabies may require
combination therapy consisting of topical application of permethrin and 2 oral doses of
ivermectin at 200 mcg/kg (administered 1 wk apart). X
DIAGNOSIS : SCABIES

signs and symptoms develop after 3-4 weeks. Symptoms reappear within 1-3
days if the person is re-infested due to prior sensitisation.
The most common presenting symptom is widespread itching. This is usually
worse at night and when the person is warm. A history of several family
members all suffering with itch is strongly suggestive of scabies. Scratching
predisposes to secondary bacterial infection.
Lesions may be papules, vesicles, pustules, and nodules. Erythematous papular
or vesicular lesions are usually seen in the sites of the burrows. The more
widespread, symmetrical, itchy, papular eruption is not in the areas of burrows or
obvious mite activity. This is most commonly seen around the axillae, the periareolar region of the breasts in women, and the abdomen, buttocks, and thighs.
The 'wake' sign is specific for scabies, can be seen with the naked eye and
points towards the location of the mite.
Hyperkeratotic crusted lesions called as Crusted Norwegian Scabies

INVS :
Ink Burrow Test.
Diagnosis can be confirmed by taking a skin scraping from an affected area.
TREATMENT :
First line : Permethrin 5%
2nd line : malathion 0.5% aqueous liquid

26. A 34yo alcoholic is found passed out in front of a local pub. The ambulance crew
informs you
that he was sweating when they found him and there were cans of cider lying empty
around
him. What is the initial stage of inv?
a. Capillary blood sugar
b. CT head
c. MRI head
d. ABG
e. MCV
key: A
Hypoglycemia: blood glucose <3.0 mmol/L
alcohol exerts hypoglycemic effects through inhibiting both gluconeogenesis and glycogenolysis , especially
when the drinker already has starvation or adrenocortical insufficiency.
Here we need to find the causes of passed out..first thing first.glucose for hypo...ABG can help to find
acidosis which is likely to find in alcohol poisoning..MCV it will b increased in alcoholic but we are more likely
to look for anaemia in this as there may b H&M which could lead pt to pass out..CT head for SDH.

Risk factors

Tight glycaemic control.


Malabsorption.
Injection into lipohypertrophy sites.
Alcohol.
Insulin prescription error (notable in hospitalised patients).
Long duration of diabetes.
Renal dialysis.
Drug interactions between hypoglycaemic agents - eg, quinine, selective serotonin reuptake
inhibitors (SSRIs).
Impaired renal function.
Lack of anti-insulin hormone function - eg, Addison's disease, hypothyroidism.

Initially

Glucose 10-20 g is given by mouth, either in liquid form or as granulated sugar (two
teaspoons) or sugar lumps
Repeat capillary blood glucose after 10-15 minutes; if the patient is still hypoglycaemic then
the above can be repeated (probably up to 1-3 times).

If hypoglycaemia causes unconsciousness, or the patient is unco-operative

75-80 ml 20% glucose or 150-160 ml of 10% glucose (the volume will be determined by the
clinical scenario).
25 ml of 50% glucose concentration is viscous, making it more irritant and more difficult to
administer, and is rarely used now.

Once the patient regains consciousness, oral glucose should be administered, as above.

If the patient is at home, or intravenous (IV) access cannot be rapidly


established

Glucagon 1 mg should be given by intramuscular (IM), or subcutaneous (SC) injection.


This dose is used in insulin-induced hypoglycaemia (by SC, IM, or IV injection), in adults and
in children over 8 years (or body weight over 25 kg). NB: 1 unit of glucagon = 1 mg of
glucagon.

The patient must be admitted to hospital if hypoglycaemia is caused by an oral antidiabetic


drug, because the hypoglycaemic effects of these drugs may persist for 12-24 hours and
ongoing glucose infusion or other therapies such as octreotide (see under 'Hypoglycaemia
which causes unconsciousness or fitting is an emergency', below) may be required.

Glucagon
Glucagon can have variable absorption, as it is given SC or IM. It has a relatively slow onset of action and
relies on glycogen stores. Therefore, it may not be effective in cachectic patients, those with liver disease,
and in young children. It is contra-indicated in insulinoma and phaeochromocytoma. It also causes
more insulin to be released and creates the potential for secondary rebound hypoglycaemia.

27. A young boy fell on his outstretched hand and has presented with pain around the
elbow. He
has absent radial pulse on the affected hand. What is the most likely dx?
a. Dislocated elbow

b. Angulated supracondylar fx
c. Undisplaced fx of radial head
d. Posterior dislocation of shoulder
Q. 1. What is the key?
Q. 2. What is the cause of absent radial pulse?
Q. 3. What is the immediate management?
Ans. 1. b.
Ans. 2. Damage or occlusion of the brachial artery is the cause of absent radial pulse.
Ans. 3. Open reduction to fix the occluded artery.
This scenario is classic for supracondylar fx,the distal humerus is displaced posteriorly causes vascular and
nerve injuries which if not addressed properly leads to volkmann contracture
posterior dislocation can compromise vascular supply but falling on outstretched hand causes it unlikely.
Other causes of pulseless radial artery except the two above ?
congenital absence,embolization, cervical rib, thoracic outlet syndrome
falling on an outstretched hands can lead to different type of fractures , like frac of clavicle , radius ,
supracondylar etc. but here it says that radial pulse is not felt ,which is a dreaded complication of
supracondylar frac

Mechanism of injury in elbow fractures and dislocation

Radial head and neck


fractures

Fall on to an outstretched hand

Olecranon fractures

Elderly - indirect trauma by pull of triceps and


brachioradialis
Children - direct blow to elbow

Fractures of the coronoid


process

Fall on to an extended elbow as for elbow dislocation

Fractures of the distal


humerus

Fall on to an extended outstretched hand

Intercondylar fractures

Direct or indirect blow to elbow

Condylar fractures

Direct blow to a flexed elbow

Capitellum fracture

Fall on to an outstretched hand, or direct trauma

Elbow dislocation

Fall on to an extended elbow


Common in sport in the young

28. A 65yo woman presented with transient arm and leg weakness as well as a sudden
loss of vision in the left eye. Her symptoms resolved within the next couple of hours.
What is the most
appropriate next inv?
a. CT brain
b. Echo
c. Doppler USG
d. Arteriography
e. 24h ECG
Q. 1. What is the key?
Q. 2. What is the likely diagnosis?
Q. 3. What will be seen on dopplar USG?
Q. 4. What is the management?
Ans. 1. The key is c.
Ans. 2. TIA
Ans. 3. Carotid artery narrowing
Ans. 4. Aspirin 300 mg daily for 2 weeks then aspirin 75mg daily and modified released
dipiridamol 200mg 12 hourly.
unilateral blindness is typical sign for carotid stenosis

The duration is no more than 24 hours in tia

The most common source of emboli is the carotids, usually at the bifurcation.
People who have had a suspected TIA who need brain imaging (ie the vascular territory or
pathology is uncertain) should undergo diffusion-weighted MRI except where contra-indicated, in
which case CT should be used.
People who have a suspected TIA at high risk of stroke (eg, an ABCD2 score of 4 or above - see
below) in whom vascular territory or pathology is uncertain should undergo urgent brain imaging
(preferably diffusion-weighted MRI).
People with a suspected TIA at low risk of stroke (eg, an ABCD2 score of less than 4) in whom
vascular territory or pathology is uncertain should undergo brain imaging within one week of onset
of symptoms (preferably diffusion-weighted MRI).

Driving
Group 1 (car or motorcycle)

Must not drive for one month.


No need to notify DVLA after a single TIA.
Multiple TIAs over a short period: require three months free from further attacks before
resuming driving and DVLA should be notified.

Group 2 (lorry or bus)

Licence refused or revoked for one year following a stroke or TIA.

Assessment of the risk of stroke


An ABCD2 score of more than 4 suggests high risk of an early stroke.

Scoring System for Risk of Stroke after TIA (ABCD2 Score)

Age

Age >60

Blood pressure

BP>140 systolic and/or >90 diastolic

Clinical features

Unilateral weakness

Speech disturbance without weakness

Other

>60 minutes

10-59 minutes

<10 minutes

Duration of symptoms

Diabetes

Presence of diabetes

RCP recommendations
Patients with suspected TIA who are at high risk of stroke (eg, an ABCD2 score of 4 or above)
should receive:
o Aspirin or clopidogrel (each as a 300 mg loading dose and then 75 mg daily)
and a statin started immediately.
o NB: clopidogrel is not licensed for the management of TIA and therefore the
National Institute for Health and Care Excellence (NICE) and the British
National Formulary (BNF) recommend aspirin plus modified-release
dipyridamole.
o Specialist assessment and investigation within 24 hours of onset of symptoms.
People with crescendo TIA (two or more TIAs in a week), atrial fibrillation or those on
anticoagulants should be treated as being at high risk of stroke even if they may have an
ABCD2 score of 3 or below.
Patients with suspected TIA who are at low risk of stroke (eg, an ABCD2 score of 3 or below)
should receive:
o Aspirin or clopidogrel (each as a 300 mg loading dose and then 75 mg daily)
and a statin.
o NB: clopidogrel is not licensed for the management of TIA and therefore NICE
and the BNF recommend aspirin plus modified-release dipyridamole.
Patients with TIA in atrial fibrillation should be anticoagulated in the TIA clinic once intracranial
bleeding has been excluded and if there are no other contra-indications.

29. A man complains of loss of sensation in his little and ring finger. Which nerve is most
likely to be involved?
a. Median nerve
b. Ulnar nerve
c. Radial nerve
d. Long thoracic nerve
e. Axillary nerve
Ans. b.

30. A young man complains of double vision on seeing to the right. Which nerve is most
likely to be involved?
a. Left abducens
b. Right abducens
c. Left trochlear
d. Right trochlear
e. Right oculomotor
Ans. b.

31. A 45yo man keeps having intrusive thoughts about having dirt under the bed. He
cant keep
himself from thinking about these thoughts. If he tries to resist, he starts having
palpitations.
What is the most likely dx?
a. OC personality
b. OCD
c. Schizophrenia
d. Panic disorder
e. Phobia
Q. 1. What is the key?
Q. 2. What is the managemment?
Ans. 1. b.
Ans. 2. CBT 1st line. SSRIs.
intrusive thoughts and anxiety when trying to fight them mean OCD.

32. A 33yo man presents with an itchy scaly annular rash on his thigh after a walk in the
park. Which of the following drugs will treat his condition?
a. Erythromycin

b. Doxycycline
c. Penicillin
d. Amoxicillin
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. b.
Ans. 2. Lyme disease.
Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks
Features

early: erythema chronicum migrans + systemic features (fever, arthralgia)


CVS: heart block, myocarditis
neuro: cranial nerve palsies, meningitis

Investigation
serology: antibodies to Borrelia burgdorferi
Management
doxycycline if early disease. Amoxicillin is an alternative if doxycycline is contraindicated (e.g.
pregnancy)
ceftriaxone if disseminated disease
Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia
after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)

33. A pt with cerebral mets has polyuria and polydipsia. What part of the brain would be
affected?
a. Cerebral cortex
b. Cerebellum
c. Diencephalon
d. Pons
e. Medulla
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. c.
Ans. 2. Cranial diabetes insipidus.
diencephalon contains hypothalamus centre for thirst.
Other causes of polyuria and thirst.

Psychogenic or primary polydipsia (PP).


Diabetes mellitus.
Other osmotic diureses - eg, hypercalcaemia.
Diuretic abuse.

Investigation
high plasma osmolality, low urine osmolality
water deprivation test

34. A 32yo man presented with painless hematuria. He is hypertensive but the rest of
the exam is
unremarkable. What is the most likely dx?
a. Polycystic kidneys
b. Ca bladder
c. Ca prostate
d. TTP
e. HUS
Q. 1. What is the key?
Q. 2. What are the points to justify your answer?
Q. What is the investigation of choice?
Ans. 1. A.
Ans. 2. Painless haematuria at an younger age with hypertension.
Ans. 3. Renal ultrasound.

autosomal dominant
Gross haematuria following trauma is a classic presenting feature of ADPKD,Advise
against participating in contact sports which risk abdominal trauma
polycystic kidneys can produce excess erythropoietin and hence raise Hb
Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-II receptor
antagonists are the preferred choice

35. A 45yo female complains of pain in the inner side of her right thigh. She was dx with
benign
ovarian mass on the right. Which nerve is responsible for this pain?
a. Femoral nerve
b. Obturator nerve
c. Iliohypogastric nerve
d. Ovarian branch of splanchic nerve
e. Pudendal nerve
Ans. B. [The Obturator nerve is responsible for the sensory innervation of the skin of the
medial aspect of the thigh].

36. A 37yo lady strongly believes that a famous politician has been sending her flowers
every day
and is in love with her. However, this is not the case. What is the most likely dx?
a. Erotomania
b. Pyromania
c. Kleptomania
d. Trichotillomania
e. Grandiosity
Ans. 1. A. [Erotomania is a type of delusion in which the affected person believes that
another person, usually a stranger, high-status or famous person, is in love with them].
Pyromania fail to resist impulses to deliberately start fires, in order to relieve tension or
for instant gratification.
Kleptomania is the inability to refrain from the urge to steal items.
Trichotillomania compulsive urge to pull out one's hair, leading to noticeable hair loss
and balding.
Grandiosity refers to an unrealistic sense of superiority.
37. A 3yo child has been brought with facial lacerations. On examination he has some
cuts over his right cheek and under the eye. The GCS on initial evaluation is 15. What is
the appropriate next inv?
a. Skull XR
b. Facial XR
c. CT scan
d. MRI
e. Observation
Ans. b.
If u have cuts over ur cheek..there is high chance that there can be a fracture of a facial bone..hence by
observing u dont want to wait for a hematoma to form then go for a facial xr Skull xray isnt of any value as
the gcs is 15!

38. A 73yo woman has lymphadenopathy and splenomegaly. She feels well but has had
recurrent
chest infections recently. Choose the single most likely blood film findings?
a. Atypical lymphocytes
b. Excess of mature lymphocytes
c. Plasma cells
d. Multiple immature granulocytes with blast cells
e. Numerous blast cells
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. Points in favour of your answer?
Ans. 1. B.
Ans. 2. CLL
Ans. 3. Age of patient (usually above 50 yrs), lymphadenopathy and splenomegaly,
appearance of lymphocytes (mature lymphocytes but functionally not normal).
Repeated chest infection points towards abnormal function of lymphocytes against
infection.

It's CLL because in CML the risk age is 40-60 years, and in CBC there should be increased myeloid
cells(which is absent in options). If I exclude these factors, then the possible DX would be CLL and film
finding is B.
1. Acute lymphoblastic leukemia- abnormal immature lymphocytes, (can be immature B or T lymphocytes)
called lymphoblasts. 2. Chronic lymphocytic leuaemia- Excess of mature lymphocytes. 3. Acute myeloid
leukaemia- blast cells (abnormal immature white cells) derived from myeloid stem cells. 4. Chronic myeloid
leukaemia- near normal granulocytes developed from abnormal stem cells (these are mature cells).
Also age is a factor ALL in any age but common in child, AML- age over 50, CLL common over age 60,
CML- in adults and commoner with increasing age.

39. A lady presents with itching around the breast and greenish foul smelling discharge
from the
nipple. She had a similar episode before. What is the most likely dx?
a. Duct papilloma
b. Duct ectasia
c. Breast abscess
d. Periductal mastitis
e. Mammary duct fistula
Q. 1. What is the key?
Q. 2. What other options (breast conditions) frequently come in plab mcq?
Ans. 1. Key is b.
Ans. 2. 1. Breast ca 2. Duct papilloma and intraductal papilloma (both are same thing) 3.
Mammary duct fistula 4. Breast abscess. X

Mammary duct
ectasia

Dilatation of the large breast ducts


Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as 'plasma cell
mastitis'

Duct papilloma

Local areas of epithelial proliferation in large mammary duct


May present with blood stained discharge

Breast abscessMore common in lactating women Red, hot tender swelling purulent discharge.
Periductal mastitis occurs when the ducts under the nipple become inflamed and infected. It's a benign
condition (not cancer), which can affect women of all ages but is more common in younger women.
Symptoms include: the breast becoming tender and hot to the touch. the skin may appear reddened.
Mammary duct fistulaThis is a communication between the skin and a major subareolar breast
duct.
It may occur following incision and drainage of a non-lactating abscess, spontaneous discharge
of a periareolar mass or following biopsy of a periductal inflammatory mass.
Treatment is by excision under antibiotic cover.

40. A young male whose sclera was noted to be yellow by his colleagues has a hx of
taking OTC
drugs for some pain. Tests showed raised bilirubin, ALT and AST normal. The
provocation test
with IV nicotinic acid is positive and produces further rise in the serum bilirubin levels.
What is
the most likely dx?
a. Acute hepatitis
b. Drug hypersensitivity
c. Gilberts syndrome
d. Acute pancreatitis
Q. 1. Does nicotinic acid provocation test can differentiate between CLD and Gilberts?
Q. 1. What is the key?
Q. 2. What are the points in favour of your diagnosis?
Ans. 1. C.
Ans. 2. Only bilirubin is increased but not the liver enzymes. Also positive nicotinic acid
provocation test is in its favour. X
Normal AST and ALT rules out any possible insult to the liver.
drug hypersensitivity will not give positive nicotinic acid provocation test.

autosomal recessive condition of defective bilirubin conjugation due to a deficiency of


UDP glucuronyl transferase
unconjugated hyperbilirubinemia (i.e. not in urine)
diagnosed around puberty, and aggravated by intercurrent illness, stress, fasting or
after administration of certain drugs

Investigation and management


investigation: rise in bilirubin following prolonged fasting or IV nicotinic acid
no treatment required

*********************
41. A 24yo biker has been rescued after being trapped under rocks for almost 12h. He
complains of reddish brown urine. His creatinine is 350umol/L and his urea is 15mmol/L.
What is the most
imp step in the management of this patient?
a. Dialysis
b. IV NS
c. IV dextrose
d. IV KCl
e. Pain relief
Q. 1. What is the key?
Q. 2. What is the likely diagnosis?
Ans. 1. Key is B.
Ans. 2. Rhabdomyolysis. X

Crush syndrome is characterised by:

Hypovolaemic shock
Hyperkalaemia

Metabolic acidosis .
Acute kidney injury.
Disseminated intravascular coagulation (DIC).
ECG may show changes secondary to hyperkalaemia.

In the adult, a saline infusion of 1,500 ml/hour should be initiated during extrication. Early,
vigorous hydration (10 litres/day) helps preserve renal function.
42. A 74yo man who has been a smoker since he was 20 has recently been dx with
SCLC. What
serum electrolyte picture will confirm the presence of SIADH?
a. High serum Na, low serum osmolarity, high urine osmolarity
b. Low serum Na, low serum osmolarity, high urine osmolarity
c. Low serum Na, high serum osmolarity, high urine osmolarity
d. High serum Na, low serum osmolarity, low urine osmolarity
e. High serum Na, high serum osmolarity, low urine osmolarity
Ans. b.
SIADH means excess ADH so water retention which will lead to dilutional hyponatremia and decrease in
serum osmolarity and sebsequent increase in urine osmolarity

Management: treat the cause and restrict fluid.


if severe: salt+- loop diuretics
vaptans can be used.
43. A man brought into the ED after being stabbed in the chest. Chest is bilaterally clear
with
muffled heart sounds. BP is 60/nil. Pulse is 120bpm. JVP raised. What is the most likely
dx?
a. Pulmonary embolism
b. Cardiac tamponade
c. Pericardial effusion
d. Hemothorax
e. Pneumothorax
Ans. b.
Beck's triad : low bp , muffled HS, raised jvp .. Cardiac tamponade

Features
dyspnoea
raised JVP, with an absent Y descent - this is due to the limited right ventricular filling
tachycardia
hypotension
muffled heart sounds
pulsus paradoxus
Kussmaul's sign (much debate about this)
ECG: electrical alternans

44. A 50yo pt is admitted for elective herniorraphy. Which of the following options will
lead to a
postponement of the operation?
a. SBP 110mmHg
b. MI 2 months ago
c. Hgb 12g/dl
d. Pain around hernia
e. Abdominal distention
Key is B. After MI elective surgery should not be done before 6 months post MI.
Criteria for postponing elective surgery. ...Hb <10 ,

Plt count <50000


Systolic BP... <90
Uncontrolled HTN, DM , asthma
MI within 3 months

45. A 32yo woman of 39wks gestation attends the antenatal day unit feeling very unwell
with
sudden onset of epigastric pain associated with nausea and vomiting. Her temp is
36.7C. Exam:
she is found to have RUQ tenderness. Her blood results show mild anemia, low
platelets,
elevated liver enzymes and hemolysis. What is the most likely dx?
a. Acute fatty liver of pregnancy
b. Acute pyelonephritis
c. Cholecystitis
d. HELLP syndrome
e. Acute hepatitis
Q. 1. What is the key?
Q. 2. What is the main treatment
Ans. 1. D.
Ans. 2. The main treatment is to deliver the baby as soon as possible [as early as after
34 weeks if multisystem disease is present].
HELLP syndrome is a group of symptoms that occurs in pregnant women who have preeclampsia or eclampsia and who also show signs of liver damage and abnormalities in blood
clotting.
H aemolysis
EL (elevated liver) enzymes
LP (low platelet) count

46. A woman comes with an ulcerated lesion 3 cm in the labia majorum. What is
the lymphatic drainage of this area?
a. External iliac
b. Superficial inguinal LN
c. Para-aortic
d. Iliac
e. Aortic
Ans. Key is B. Superficial inguinal LN.

47. A man post-cholecystectomy presented with jaundice, fever and dark urine. What is
the most
diagnostic inv?
a. ERCP
b. USG Abdomen
c. CT Scan
d. MRCP
e. MRI

Q. 1. What is the key?


Q. 2. What is the likely diagnosis?
Ans. 1. A. ERCP
Ans. 2. Cholangitis. Post cholescytectomy syndrome?
investigation of choice in post cholecystectomy syndrome is ercp

Charcot's triad of right upper quadrant (RUQ) pain, fever and jaundice
Management
intravenous antibiotics
endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to
relieve any obstruction

ERCP contraindications:

Acute pancreatitis (unless persistently raised or worsening bilirubin suggests


ongoing obstruction)
Previous pancreatoduodenectomy
Coagulation disorder if sphincterotomy planned
Recent myocardial infarction
Inadequate surgical back-up
History of contrast dye anaphylaxis
Poor health condition for surgery
Severe cardiopulmonary disease

48. A 79yo stumbled and sustained a minor head injury 2 weeks ago. He has become
increasingly
confused, drowsy and unsteady. He has a GCS of 13. He takes warfarin for Afib. What is
the most likely dx?
a. Extradural hemorrhage
b. Cerebellar hemorrhage
c. Epidural hemorrhage
d. Subdural hemorrhage
e. Subarachnoid hemorrhage
Q. 1. What is the key?
Q. 2. What is the management?
Ans. 1. D.
Ans. 2. 1 line: Evacuation by burr hole craniostomy. 2 line: Craniotomy if the clot is
organized.
st

nd

The gradual onset of symptoms supports the dx


Subdural hematoma as old shrunken /alcoholic brains are prone to develop tear in the veins which bleed
slowly and eventually the hematoma gets big enough to show the symptoms
Also in this case the patient is on warfarin

Type of injury

Extradural
(epidural)
haematoma

Notes

Often results from acceleration-deceleration trauma or a blow to the


side of the head. The majority of epidural haematomas occur in the
temporal region where skull fractures cause a rupture of the middle
meningeal artery.
Features

Subdural
haematoma

features of raised intracranial pressure


some patients may exhibit a lucid interval

Bleeding into the outermost meningeal layer. Most commonly occur


around the frontal and parietal lobes.
Risk factors include old age, alcoholism and anticoagulation.

Slower onset of symptoms than a epidural haematoma.

Subarachnoid
haemorrhage

Usually occurs spontaneously in the context of a ruptured cerebral


aneurysm but may be seen in association with other injuries when a
patient has sustained a traumatic brain injury
worst headache.

49. A 25yo female complains of intermittent pain in her fingers. She describes episodes
of
numbness and burning of the fingers. She wears gloves whenever she leaves the
house. What is
the most probable dx?
a. Kawasaki disease
b. Takayasu arteritis
c. Buergers disease
d. Embolism
e. Raynauds phenomenon
Ans is e.
wearing glove is the catch phrase
Takayasu;pulseless disease, will present with other symptoms like unequal pulses,diziness,weakness
fr buergers hx of smoking...age usually more then 40.buerger's disease should present with smoking hx of
an aged male.

Management
first-line: calcium channel blockers e.g. nifedipine
IV prostacyclin infusions: effects may last several weeks/months

50. A 22yo lady has been unwell for some time. She came to the hospital with
complaints of fever
and painful vesicles in her left hear. What is the most probable dx?
a. Acne
b. Herpes zoster
c. Chicken pox
d. Insect bite
e. Cellulitis
Q. 1. What is the key?
Q. 2. What is the specific name of the condition?

Ans. 1. Herpes Zoster


Ans. 2. Herpes zoster oticus/Ramsay hunt syndrome.
Ramsey hunt syndrome
Painful vesicles in her left ear
Features
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear

other features include vertigo and tinnitus

Management
oral aciclovir and corticosteroids are usually given

51. A 5yo girl had earache and some yellowish foul smelling discharge, perforation at the
attic and
conductive hearing loss. She has no past hx of any ear infections. What is the most
appropriate
dx?
a. Acute OM
b. OM with effusion
c. Acquired cholesteatoma
d. Congenital cholesteatoma
e. Otitis externa
Q. 1. What is the key?
Q.2. What are the points in favour of your diagnosis?
Ans. 1. The key is c. Acquired cholesteatoma.
Ans. 2. Ans. 1. The key is c. Acquired cholesteatoma.
Ans. 2. acquired cholesteatomas develop as a result of chronic middle ear infection and are
usually associated with perforation of the tympanic membrane at the attic (mass is seen in attic
with perforation at pars flaccida- in contrast to medial to tympanic membrane which is in
congenital). Clinical presentation usually consists of conductive hearing loss, often with purulent
discharge from the ear
In congenital
mass medial to the tympanic membrane
normal tympanic membrane
no previous history of ear discharge, perforation or ear surgery.

52. A female with T1DM would like to know about an deficiency of vitamins in pregnancy
that can
be harmful. A deficiency of which vitamin can lead to teratogenic effects in the child?
a. Folic acid
b. Vit B12
c. Thiamine
d. Riboflavin
e. Pyridoxine
Ans. A. Folic acid.

Diet: To prevent neural tube defects (NTD) and cleft lip, all should have folate rich foods
+ folic acid 0.4mg daily >1 month pre-conception till 13wks (5mg/day if past NTD, on anti
epileptics, obese (BMI 30), HIV+ve on co-trimoxazole prophylaxis, diabetic or sickle cell
disease.

Smoking: decreases ovulations, causes abnormal sperm production ( less penetrating


capacity),
rates of miscarriage (2), and is associated with preterm labour and lighter-for-dates
babies placenta praevia and abruption. Reduced reading ability in smokers children up
to 11yrs old shows that long term effects are important.
Alcohol consumption: High levels of consumption are known to cause the fetal alcohol
syndrome. Mild drinking eg 12U/wk has not been shown to adversely affect the fetus.
Especially harmful in weeks 3-8.Miscarriage rates are higher among drinkers of alcohol

53. A 23yo woman has been having pain at the base of her thumb, the pain is
reproduced when
lifting her 3 month old baby or changing diapers and also with forceful abduction of the
thumb
against resistance. What is the likely cause?
a. Avascular necrosis of scaphoid
b. Trigger finger.
c. De Quervains tenosynovitis
Q. 1. What is the key?
Q. 2. How will you diagnose the case?
Ans. 1. The key is c. De Quervains tenosinovitis.
Ans. 2. Can be diagnosed by Finkelsteins test:
The physician grasps the thumb and the hand is ulnar deviated sharply. If sharp pain
occurs along the distal radius (top of forearm, about an inch below the wrist), de
Quervain's syndrome is likely.
De Quervain's tenosynovitis is a common condition in which the sheath containing the
extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects
females aged 30 - 50 years old
Features
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein's test: with the thumb is flexed across the palm of the hand, pain is
reproduced by movement of the wrist into flexion and ulnar deviation
Management
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required

54. A 6m child presents with fever and cough. His mother has rushed him to the ED
asking for help. Exam: temp=39C and the child is feeding poorly. Dx?
a. Bronchiolitis
b. Asthma
c. Bronchitis
Q. 1. What is the key?
Q.2. What is the management?
Ans. 1. A. Bronchiolitis.
Ans. 2. Management: 1. Oxygen inhalation 2. Nasogastric feeding. DONT USE: i)
bronchodilator ii) steroid iii) antibiotics routinely. [OHCS, page-160]
Acute bronchiolitis is the big lung infection in infants
Symptoms: coryza precedes cough, low fever, tachypnoea, wheeze, inspiratory
crackles, apnoea, intercostal recession cyanosis.
Cause: Winter respiratory syncytial virus. Others: Mycoplasma, parainfluenza,
adenoviruses. Those <6 months old are most at risk.
Signs prompting admission: Poor feeding, >50 breaths/min, apnoea, dehydration, rib
recession, patient or parental exhaustion
Tests: If severe: CXR (hyperinflation); blood gases/SpO2; FBC.
Treatment: O2 (stop when SpO2 92%); nasogastric feeds. 5% need ventilating
(mortality 1%; 33% if symptomatic congenital heart disease). Dont use bronchiodilators
and steroids routinely

55. A 75yo man collapsed while walking in his garden. He recovered fully within 30 mins
with BP
110/80 mmHg and regular pulse of 70bpm. He has a systolic murmur on examination.
His
activities have been reduced lately which he attributes to old age. What is the definitive
diagnostic inv that will assist you with his condition?
a. ECG
b. Echo
c. 24h ECG monitoring
d. 24h BP monitoring
e. Prv CIN
Q. 1. What is the key?
Q. 2. What are the possible causes of this syncope?
Ans. 1. B. Echo.
Ans. 2. i) Aortic stenosis more likely in elderly. ii) hypertrophic cardiomyopathy less
likely in this age as presentation may present in an earlier age.

Aortic stenosis (AS)


Causes: Senile calcification is the commonest. Others: congenital (bicuspid valve,
Williams syndrome, rheumatic heart disease.
Presentation: Think of AS in any elderly person with chest pain, exertional dyspnoea or
syncope. The classic triad includes angina, syncope, and heart failure (usually after age
60). Also: dyspnoea; dizziness; faints; systemic emboli if infective endocarditis; sudden
death.

Signs: Slow rising pulse with narrow pulse pressure (feel for diminished and delayed
carotid upstrokeparvus et tardus); heaving, non-displaced apex beat; LV heave; aortic
thrill; ejection systolic murmur (heard at the base, left sternal edge and the aortic area,
radiates to the carotids).
There may be an ejection click (pliable valve) or an S4 (said to occur more often with
bicuspid valves, but not in all populations).
Tests: ECG: P-mitrale, LVH with strain pattern; LBBB or complete AV block (calcified
ring). CXR: LVH; calcified aortic valve post-stenotic dilatation of ascending aorta.
Echo: diagnostic.
Doppler echo can estimate the gradient across valves
Cardiac catheter can assess: valve gradient; LV function; coronary artery disease
Management: If symptomatic, prognosis is poor without surgery.
If moderate-to-severe and treated medically, mortality can be as high as 50% at 2yrs,
therefore prompt valve replacement is usually recommended.
In asymptomatic patients with severe AS and a deteriorating ECG, valve replacement is
also recommended. If the patient is not medically fit for surgery, percutaneous
valvuloplasty/replacement (TAVI = transcatheter aortic valve implantation) may be
attempted.
56. A 35yo man with a hx of schizophrenia is brought to the ER by his friends due to
drowsiness. On examination he is generally rigid. A dx of neuroleptic malignant
syndrome except:
a. Renal failure
b. Pyrexia
c. Elevated creatinine kinase
d. Usually occurs after prolonged tx
e. Tachycardia
Ans. Key is D. Usually after prolonged tx. It usually occurs within 10 days of starting
treatment. renal failure is the wrong answer as neuroleptic syndrome can lead to renal
failure so we have to give IV fluids to prevent it.
Cause: antipsychotics or dopamenergic drugs (levodopa)
Management: STOP the drug causing it. IV fluids, Dantrolene, Bromocriptine
57. A 33yo drug addict wants to quit. She says she is ready to stop the drug abuse. She
is supported by her friends and family. What drug tx would you give her?
a. Benzodiazepines
b. Diazipoxide
c. Lithium
d. Methadone
e. Disulfiram
Q.1. What is the key.
Q.2. What drugs should you use in i) tobacco abuse and in ii) alcohol abuse?
Ans. 1. Key is d. Methadone. (used in opiate abuse). Nalexone is the antidote.
Ans. 2. i) tobacco abuse: a) bupropion ii) alcohol: a) acamprosate decreases craving b)
disulfirum is a deterrent.

58. A 16m child presents with drooling, sore throat and loss of voice. He has fever with a
temp of

38.2C. What is your next step towards management?


a. Direct pharynoscopy
b. Call ENT surgeon
c. Call anesthesiologist
d. IV fuilds
e. Start antibiotics
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. What is the urgent management?
Ans. 1.Key is C. Call anesthesiologist.
Ans. 2. Diagnosis is Acute epiglottitis.
Ans. 3. In given case urgent intubation is needed to secure airway to prevent blockage
of respiration.
Differential: croup. Croup has barking cough which is worse at night and there is no
drooling of saliva NO COUGH IN EPIGLOTITTIS. Croup caused by parainfluenza while
epiglottitis is caused by H.influenze
Acute epiglottitis is rarer than croup but mortality is high: 1% if respiratory distress. Its
an emergency as respiratory arrest can occur.
Presentation: Often, history is short, septicaemia is rapid, and cough is absent. Also:
sore throat (100%), fever (88%), dyspnoea (78%), voice change (75%), dysphagia
(76%), tender anterior neck cellulitis (27%), hoarseness (21%), pharyngitis (20%),
anterior neck nodes (9%), drooling (head for ward tongue out), prefers to sit, refusal to
swallow,
Cause: Haemophilus (vaccination has reduced prevalence); Strep pyogenes.
Investigation: Fibre-optic laryngoscopy remains the 'gold standard' for diagnosing
epiglottitis
Management: Take to ITU; dont examine throat (causes resp. arrest). Give O2 by
mast, Give nebulized adrenaline, IV dexamethasone, antibiotics, antipyretics until the
anesthetist arrives. Definitive management is intubation

59. A 62yo woman complains of unsteadiness when walking. On examination she has
pyramidal
weakness of her left lower limb and reduced pain and temp sensation on right leg and
right side
of trunk up to the umbilicus. Joint position sense is impaired at her left great toe but is
normal
elsewhere. She has a definite left extensor plantar response and the right plantar
response is
equivocal. Where is the lesion?
a. Left cervical cord
b. Midline mid-thoracic cord
c. Right mid-thoracic cord
d. Left mid-thoracic cord

e. Left lumbo-sacral plexus


Q. 1. What is the key?
Q. 2. What is the name of this condition?
Ans. 1. The key is d. Left mid-thoracic cord.
Ans. 2. Brown-sequard syndrome.

Pain & temperature: carried by lateral spinothalamic tract dicussate to the opposite side
within the spinal cord. Vibration, proprioception: carried by the medial lemniscal
system decussate at the junction of pons and medulla. Upper motor neurons in
pyramidal tract also decussate close to medulla. So from this we know that the lesion is
on the left side. And since the symptoms are below the umbillicus it rules out a cervical
lesion. Lesion of lumbo sacral plexus will impair the whole of the lower limb. So the
correct answer is D.
Brown Sequard syndrome:
A lesion in one half of the spinal cord (due to hemisection or unilateral cord lesion)
Presentation: Ipsilateral UMN weakness below the lesion (severed corticospinal tract,
causing spastic paraparesis, brisk reflexes, extensor plantars) Ipsilateral loss of
proprioception and vibration (dorsal column severed) Contralateral loss of pain and
temperature sensation (severed spinothalamic tract which has crossed over
Causes: Bullet, stab, dart, kick, tumour, disc hernia, cervical spondylosis, MS,
neuroschistosomiasis, myelitis, septic emboli (eg meningococcal).
Imaging: MRI
60. A 26yo man present to ED with increasing SOB on left side and chest pain. He has
been a heavy smoker for the past 4 years. He doesnt have any past med hx. What is
the likely dx?
a. Pulmonary embolism
b. MI
c. Asthma
d. Pleural effusion
e. Pneumothorax
Q. 1. What is the key?
Q. 2. What are the points in favour of your diagnosis?
Q. 3. What is the cause of the disease in this case?
Ans. 1. The key is e. Pneumothorax.
Ans. 2. Increased shortness of breath and chest pain with no past medical history.
Ans. 3. Heavy smoking. Tobacco is a risk factor for spontaneous pneumothorax.

Pneumothorax
Causes Often spontaneous (especially in young thin men) due to rupture of a subpleural
bulla.
Other causes: asthma; COPD; TB; pneumonia; lung abscess; carcinoma; cystic fibrosis;
lung fibrosis; sarcoidosis; connective tissue disorders (Marfans sy., EhlersDanlos sy.),
trauma; iatrogenic (subclavian CVP line insertion, pleural aspiration/ biopsy,
transbronchial biopsy, liver biopsy, +ve pressure ventilation).
Symptoms: There may be no symptoms (especially if fit, young and small pneumothorax)
or there may be sudden onset of dyspnoea and/or pleuritic chest pain. Patients with

asthma or COPD may present with a sudden deterioration. Mechanically ventilated


patients may present with hypoxia or an increase in ventilation pressures.
Signs: Reduced expansion, hyper-resonance to percussion and diminished breath sounds
on the affected side. With a tension pneumothorax, the trachea will be deviated away
from the affected side

Management:

61. A pt with hepatocellular ca has raised levels of ferritin. What is the most probable
cause?
a. Hemochromatosis
b. A1 antitrypsin def

c. Cystic fibrosis
Ans. Haemochromatosis.
Haemochromatosis... Autosomal recessive.
SYMPTOMS bronzing of skin, DM, hepatomegly, arthropathy. Can also cause infertility,
arrhythmias, neurological symptoms. Liver fibrosis, cirrhosis & HCC.
INVESTIGATIONS: Serum ferritin then genetic testing for HFE mutations.
TREATMENT: phlebotomy OR liver transplant
62. A woman has electric pains in her face that start with the jaw and move upwards.
Her corneal
reflexes are normal. What is the most likely dx?
a. Atypical face pain
b. Trigeminal neuralgia
c. Tempero-mandibular joint dysfunction
d. GCA
e. Herpes zoster
Q. 1. What is the key?
Q. 2. What are the options mentioned are possible causes of absent corneal reflex?
Ans. 1. Key is b. Trigeminal neuralgia.
Ans. 2. Possible options are 1. Trigeminal neuralgia 2. Herpes zoster ophthalmicus
Trigerminal Neuralgia...Facial pains. PRESENTATION: The episodes are sporadic and
sudden and often like 'electric shocks', lasting from a few seconds to several minutes.
Pain is unilateral, brief, stabbing, recurrent in the distribution of CN5. Can be provoked
by light touch to the face, eating, cold winds, or vibrations typically occurs after shaving,
brushing teeth.
Cause is a compression of CN5.
No Investigations
TREATMENT: Carbamezapine is the first line. Rhizotomy (surgery) may also be done
63. A 32yo man presented with slow progressive dysphagia. There is past hx of retrosternal
discomfort and he has been treated with prokinetics and H2 blockers. What is the
probably dx?
a. Foreign body
b. Plummer vinson syndrome
c. Pharyngeal pouch
d. Peptic stricture
e. Esophageal Ca
Q. 1. What is the key?
Q. 2. What is the underlying cause of this stricture?
Ans. 1. The key is D. Peptic stricture.
Ans. 2. The underlying cause is Gastro-oesophageal reflux.

Points not in favor of CA: Age (32yrs), no anemia, anorexia, lethargy etc mentioned.

Peptic Stricture
PRESENTATION: heartburn, dysphagia, impaction of food, weight loss, and chest pain.
There can be progressive dysphagia, weight loss & anemia.
CAUSES: History of GERD, corrosive intake, drugs like NSAIDs
INVESTIGATIONS: Endoscopy (risk of perforation) Barium swallow
TREATMENT: Benign: endoscopic baloon dilation. Malignant: oesophagectomy
64. A 56yo man comes with hx of right sided weakness & left sided visual loss. Where is
the
occlusion?
a. Ant meningeal artery
b. Mid meningeal artery
c. Mid cerebral artery
d. Carotid artery
e. Ant cerebral artery
f. Ant communicating artery
Q. 1. What is the key?
Q. 2. How will you differentiate between middle cerebral artery occlusion from anterior
cerebral artery occlusion?
Ans. 1. The key is d. Carotid artery.
Ans. 2.
i)
Middle cerebral artery occlusion: paralysis or weakness of contralateral
face and arm (faciobracheal). Sensory loss of the contralateral face and arm.
ii)
Anterior cerebral artery occlusion: paralysis or weakness of the
contralateral foot and leg. Sensory loss at the contralateral foot and leg.
Carotid Artery occlusion:
PRESENTATION: Patients may present with TIAs or CVEs.
Typical symptoms are contralateral weakness or sensory disturbance, ipsilateral
blindness, and (if the dominant hemisphere is involved) dysphasia, aphasia or speech
apraxia.
Carotid bruit may or may not be present
INVESTIGATIONS: For diagnosis: CAROTID ANGIOGRAPHY GOLD STANDARD. MR
angio and angio CT can also be used.
Echo colour Doppler ultrasonography is the screening method of choice
TREATMENT: Medical: Antiplatelets, Anti HTN, Statins
Surgery: Carotid endartarectomy. Symptomatic patients with greater than 50% stenosis
and healthy, asymptomatic patients with greater than 60% stenosis warrant
consideration for carotid endarterectomy.
65. A young college student is found in his dorm unconscious. He has tachyarrhythmia
and high
fever. He also seems to be bleeding from his nose, which on examination shows a
perforated
nasal septum. What is the most likely dx?
a. Marijuana OD
b. Cocaine OD
c. Heroin OD
d. Alcohol OD
e. CO poisoning

Q. 1. What is the key?


Q. 2. What are the points that favours the diagnosis in given question?
Q. 3. What are other important findings?
Ans. 1. Key is B. Cocaine overdose.
Ans. 2. Points in favour: i) Tachyrhythmia ii) High fever iii) perforated nasal septum iv)
unconsciousness
Ans. 3. Other findings: i) Psychiatric: anxiety, paranoia ii) Tachypnoea iii) Increased
energy and talking rapidly iv) Dilated pupils. Also: [rhabdomyolysis, metabolic acidosis,
convulsion].
COCAINE may be snored, taken via IV or smoked.
PRESENTATION: occasional use produces euphoria, increased alertness and feelings
of self-confidence and competence
frequent repeated use causes tachycardia, twitching, insomnia and anxiety
ADDICTION: can result in perforated nasal septum, psych problems.
The patient may present in anxiety, paranoia, they may ask for help.
MANAGEMENT: CBT, self help groups. Benzodiazepines are first line drugs, anti
depressents like SSRIs but donot use with cocaine (causes SSRI syndrome). Beta
blockers for anxiety

66. A 56yo pt whose pain was relieved by oral Morphine, now presents with
progressively
worsening pain relieved by increasing the dose of oral morphine. However, the pt
complains
that the increased morphine makes him drowsy and his is unable to carry out his daily
activities.
What is the next step in his management?
a. Oral oxycodone
b. Oral tramadol
c. PCA
d. IV Fentanyl
e. Diamorphine
Ans. Key is oral oxycodon.
If there are intolerable side effects to morphine go for oral oxycodone
Pain ladder: NSAIDs, Mild opioids, strong opioids.
Once on one step of the ladder do not go back.
NSAIDs are good for bone pain.
Morphine Start with oral solution 510mg/4h PO with an equal breakthrough dose
as often as required. A double dose at bedtime can enable a good nights sleep. Patient
needs will vary greatly and there is no maximum dose; aim to control symptoms
with minimum side-effects. If not effective, increase doses in 3050% increments
(5mg10mg20mg30mg45mg). Change to modified release preparations (eg
MST Continus 12h) once daily needs are known by totalling 24h use and dividing by
2. Prescribe 1/6th of the total daily dose as oral solution for breakthrough pain. Sideeff
ects (common) are drowsiness, nausea/vomiting, constipation and dry mouth.
Hallucinations and myoclonic jerks are signs of toxicity and should prompt dose review.
If the oral route is unavailable try morphine/diamorphine IV/SC (see BOX for

conversions). If difficulty tolerating morphine/diamorphine, try oxycodone


PO/IV/SC/
PR, starting at an equivalent dose. It is as effective as morphine and is a useful 2ndline
opioid with a different range of receptor activity. 61 OxyNorm is the oral liquid form.
There are also fentanyl transdermal patches which should usually be started under
specialist supervision (after opioid dose requirements have been established). Remove
after 72h, and place a new patch at a different site. 45mg oral morphine/24h
is approximately equivalent to a 12mcg/h fentanyl patch.
67. A 30yo man presents with a 5cm neck mass anterior to the sternocleido-mastoid
muscle on the left side in its upper third. He states that the swelling has been treated
with antibiotics for
infection in the past. Whats the most likely cause?
a. Branchial cyst
b. Parotitis
c. Pharyngeal pouch
d. Thyroglossal cyst
e. Thyroid swelling
Q. 1. What is the key?
Q. 2. Justify your answer.
Ans. 1. The key is A. Branchial cyst.
Ans. 2. i) Branchial cyst is anterior triangular lump. [parotid is also anterior triangular
lump but it regresses with appropriate treatment]. ii) pharyngeal pouch is posterior
triangular lump. iii) Thyroglossal is midline lump. iv) thyroid swelling moves with
swallowing.
Branchial cysts emerge under the anterior border of sternocleidomastoid where the
upper third meets the middle third (age <20yrs).
CAUSE: Due to non-disappearance of the cervical sinus (where 2nd branchial arch
grows down over 3rd and 4th)
TREAT by excision
If lump in the supero-posterior area of the anterior triangle, is it a parotid tumour
68. An 18yo man is rushed into the ER by his friends who left him immediately before
they could be interviewed by staff. He is semiconscious, RR=8/min, BP=120/70mmHg,
pulse=60bpm. He is
noted to have needle track marks on his arms and his pupils are small. What is the
single best
initial tx?
a. Insulin
b. Naloxone
c. Methadone
d. Gastric lavage
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of the diagnosis?
Ans.1. The key is B. Naloxone.
Ans. 2. The diagnosis is opiate overdose.

Ans. 3. Points in favour are: i) reduced consciousness ii) RR 8/min (12<) iii) hypotension
(here lower normal) iv) miosis v) needle track marks on his arms.
Opioid overdose presents with the usual Adverse effects of opioids. This is a typical
presentation. Treatment IS WITH NALOXONE IV/IM/SC
OPIOID WITHDRAWAL SYMPTOMS:
Sweating. Watering eyes. Rhinorrhoea Yawning Feeling hot and cold. Anorexia
and abdominal cramps. Nausea, vomiting and diarrhoea. Tremor. Insomnia,
restlessness, anxiety and irritability. Generalised aches and pains. Tachycardia,
hypertension. Goose flesh (goosebumps). Dilated pupils. Increased bowel
sounds. Coughing.
COMPLICATIONS: Skin infection at injection sites (can be severe; necrotising
fasciitis can occur). Septicaemia. Infective endocarditis. HIV infection. Hepatitis
A, B and C infection. Tuberculosis infection.
TREATMENT: Methadone or buprenorphine. Stabilize the patient on either of the two.
Naltrexone can be used once the patient is detoxified.

69. A 30yo man and wife present to the reproductive endocrine clinic because of
infertility. The man is tall, has bilateral gynecomastia. Examination of the testes reveals
bilateral small, firm testes.
Which of the following inv is most helpful in dx?
a. CT of pituitary
b. Chromosomal analysis
c. Measure of serum gonadotropins
d. Measure of serum testosterone
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of your diagnosis?
Ans. 1. The key is B. Chromosomal analysis.
Ans. 2. The diagnosis is Klinefelters syndrome. (xxy)
Ans. 3. The points in favour are: i) Infertility ii) Tall stature iii) Bilateral gynaecomastia iv)
Bilateral small firm testes.
Klinefelters syndrome: (47,XXY, 48,XXYY polysomy or a mosaic 47,XXY/46,XY)
Turners is XO with NO Barr body.
PRESENTATION: Infertility & small testis (most common & most imp) gynecomastia,
lack of secondary sexual characteristics, tall and slender and learning disablities
(delayed speech, behavioral problems)
Investigations: Before birth via amniocentesis or CVS.
Later serum testosterone is low. FSH & LH are high (FSH>LH)
Chromosome karyotyping gives the deifinitive diagnosis
TREATMENT: 1. Testosterone replacement. 2.Intracytoplasmic injection of sperm. 3.
Surgery for gynecomastia
70. An 18yo female just received her A-Level results and she didnt get into the
university of her
choice. She was brought into the ED after ingestion of 24 paracetamol tablets. Exam:
confused

and tired. Initial management has been done. Inv after 24h: normal CBC, ABG = pH7.1,
PT=17s,
Bilirubin=4umol/L, creatinine=83umol/L. What is the next step in management?
a. Observation for another 24h
b. Refer to psychologist
c. Give N-Acetylcysteine
d. Discharge with psychiatry referral
e. Liver transplantation
Q. 1. What is the key?
Q. 2. What are the indications of this management?
Ans. 1. The key is E. Liver transplantation.
Ans. 2. King's College Hospital criteria for liver transplantation in paracetamol-induced acute liver failure.
arterial pH <7.3 or arterial lactate >3.0 mmol/L after adequate fluid resuscitation, OR
if all three of the following occur in a 24-hour period:
Creatinine >300 mol/L.
PT >100 seconds (INR >6.5).
Grade III/IV encephalopathy.

PARACETAMOL POISONING: >150mg/kg or 12g total


PRESENTATION: Hepatic damage shown by deranged LFTs occurs after 24hrs.
Patients may develop encaph, hypoglycemia, ARF
INVESTIGATIONS: Paracetamol levels: 4hrs post ingestion, if time is >4hr or staggered
overdose
Any alcohol taken (acute alcohol ingestion will inhibit liver enzymes and may reduce the
production of the toxin NAPQI, whereas chronic alcoholism may increase it)

MANAGEMENT:
If presentation is within the first 4 hours give activated charcoal
All patients who have a timed plasma paracetamol level plotted on or above the
line drawn between 100 mg/L at 4 hours and 15 mg/L at 15 hours after ingestion,
should receive acetylcysteine.
If time unknown (even in staggered dose) give N-Acetyl cysteine without delay
NAC most effective in the first 8 hrs.
NAC can be given during pregnancy
Beware if the patient is on any P450 enzyme inducer medicines as they increase
the toxicity
Refer to ICU if there is fulminant liver failure - those treated with N-acetylcysteine
(NAC) to the medical team and all para-suicides to the psychiatric team.
71. A 75yo alcoholic presents with a mass up to umbilicus, urinary dribbling,
incontinence, and
clothes smelling of ammonia. What is the next step in management?
a. Urethral catheter
b. Suprapubic catheter
c. Antibiotics
d. Condom catheter
e. Nephrostomy
Q. 1. What is the key?
Q. 2. What is the cause of this retention?
Ans. 1. The key is A. Urethral catheter.
Ans. 2. Alcohol consumption (it is rather a less common cause of urinary retention).

ACUTE URINARY RETENTION

Causes of urinary retention

In men - BPH, meatal stenosis, paraphimosis, penile constricting bands,


phimosis, prostate cancer.
In women - prolapse (cystocele, rectocele, uterine), pelvic mass (gynaecological
malignancy, uterine fibroid, ovarian cyst), retroverted gravid uterus.
In both - bladder calculi, bladder cancer, faecal impaction, gastrointestinal or
retroperitoneal malignancy, urethral strictures, foreign bodies, stones.
Infectious and inflammatory:
In men - balanitis, prostatitis and prostatic abscess.
In women - acute vulvovaginitis, vaginal lichen planus and lichen sclerosis,
vaginal pemphigus.
In both - bilharzia, cystitis, herpes simplex virus (particularly primary infection),
peri-urethral abscess, varicella-zoster virus.
Drug-related:
Up to 10% AUR episodes are thought to be attributable to drugs. Those known to
increase risk include:
Anticholinergics (eg, antipsychotic drugs, antidepressant agents, anticholinergic
respiratory agents). Opioids and anaesthetics. Alpha-adrenoceptor agonists.
Benzodiazepines. NSAIDs Detrusor relaxants. Calcium-channel blockers
Antihistamines. Alcohol.
Neurological:
More often causing chronic retention but may cause AUR:
Autonomic or peripheral nerve (eg, autonomic neuropathy, diabetes mellitus,
Guillain-Barr syndrome, pernicious anaemia, poliomyelitis, radical pelvic
surgery, spinal cord trauma, tabes dorsalis).
Brain (eg, cardiovascular disease (CVD), MS, neoplasm, normal pressure
hydrocephalus, Parkinson's disease).
Spinal cord (eg, invertebral disc disease, meningomyelocele, MS, spina bifida
occulta, spinal cord haematoma or abscess, spinal cord trauma, spinal stenosis,
spinovascular disease, transverse myelitis, tumours, cauda equina).
Other:
In men - penile trauma, fracture, or laceration.
In women - postpartum complications (increased risk with instrumental delivery,
prolonged labour and Caesarean section), urethral sphincter dysfunction
(Fowler's syndrome).
In both - pelvic trauma, iatrogenic, psychogenic.
[2]

MANAGEMENT: Foleys catheter first line. If contraindicated or failed refer to urology or


try suprapubic catheterization
COMPLICATIONS: UTIs, Renal failure, Post retention diureses and hematuria
72. In CRF, main cause of Vit D deficiency is the failure of:
a. Vit D absorption in intestines
b. 25 alpha hydroxylation of Vit D
c. Excess Vit D loss in urine

d. 1 alpha hydroxylation of Vit D


e. Availability of Vit D precursors
Ans. The key is D. 1 alpha hydroxylation of Vit D [kidney] [25 alpha hydroxilation of Vit
D- liver].
VITAMIN D: FUNCTION: Absorption of calcium and phosphorus from GIT
SOURCES: Oily fish, fortified food, skin synthesized VitD using sunlight
Deficiency causes Rickets in children and ostomalacia in adults
Causes of Deficiency: Increased demand in pregnancy, breast feeding, Malabsorptive
diseases like Crohns, coeliac, pancreatic insufficiency, CKD, Liver diseases
Treatment: Take vit D supplements in the form of calciferol. Tablets or injections.
Injections can be effective for upto 6 months.
All pregnant and breastfeeding women should take a daily supplement containing 10
micrograms of vitamin D
All children aged 6months to 6years should take daily vitD supplements in the form of
drops
73. Pt with puffiness of face and rash showing cotton wool spots on fundoscopy. Whats
the dx?
a. Macular degeneration
b. Hypertensive retinopathy
c. Diabetic background
d. Proliferative diabetic retinopathy
e. SLE
Q. 1. What is the key?
Q. 2. Why there is puffyness of face?
Q. 3. Why there is cotton wool spots on fundoscopy? What is the most common ocular
manifestation of SLE?
Ans. 1. The key is SLE.
Ans. 2. Puffiness is due to lupus nephritis.
Ans. 3. SLE, can involve the retina. The classic lesion of SLE is a white fluffy appearing
lesion within the retina known as a cotton wool spot. The most common ocular
manifestation in SLE is Keratoconjunctivits sicca.
SLE. Female male 5:1. More common in asians, afro caribbeans
Cause: HLA DR-2 DR-3 association, Environmental factors like UV rays, EBV and drugs
(chlorpromazine, methyldopa, hydralazine, isoniazid, d-penicillamine and minocycline)
Presentation: SLE is a remitting and relapsing illness
Raynauds phenomenon
Arthritis: Early morning stiffness, non erosive, no swelling peripheral, symmetrical
Photosensivity: malar rash. Precipitated by sunlight, sparing the nasolabial fold.
Erythematous, raised & pruritic
Discoid lupus eryhtamatosus: well damarcated with scaling, on sun exposed areas
Mouth ulcers
Pulmonary: pleurisy, fibrosing alveolitis
Renal: Nephritis is often asymptomatic. Glomerulonephritis is common in lupus pts
Neuro: depression and anxiety are common. There may be seizures, meningitis,
psychosis
Vasculitis

Criteria for diagnosis: if any 4 of these 11 are present not necessarily at the same
time.
Malar rash.
Discoid lupus.
Photosensitivity.
Oral or nasopharyngeal ulcers.
Non-erosive arthritis involving two or more peripheral joints.
Pleuritis or pericarditis.
Renal involvement with persistent proteinuria or cellular casts.
Seizures or psychosis.
Haematological disorder: haemolytic anaemia or leukopenia or lymphopenia or
thrombocytopenia.
Immunological disorder: anti-DNA antibody or anti-Sm or antiphospholipid
antibodies.
A positive antinuclear antibody.
Investigations: FBC: Anemia, thrombocytopenia may be seen.
ESR IS RAISED BUT CRP IS USUALLY NORMAL
Antibodies: ANA: screening test but not diagnostic, 95% sensitive. Anti DNA: diagnostic
and show disease activity. High specificity. Anti-Sm is the most specific antibody but
30-40% sensitive. Anti-SSA (Ro) or Anti-SSB (La) are present in 15% of patients
Anti-RNP may indicate mixed connective tissue disease with overlap SLE, scleroderma,
and myositis
Anti-histone: drug-induced lupus ANA antibodies are often this type
anticardiolipin antibodies and lupus anticoagulant should be checked in lupus patients,
as they are associated with APLS.
Complement C3 and C4 levels are reduced
TREATMENT: Avoid sun exposure
NSAIDs for musculoskeletal pains
Steroids: Effective but can be harmful for CVS, osteoporosis. High-dose
prednisolone is reserved for life-threatening SLE
Hydroxychloroquine remains first-line treatment for patients with mild SLE,
especially for those with arthralgia, skin rashes, alopecia, and oral or genital
ulceration
Cyclophosphamide is reserved for treatment of life-threatening disease,
particularly lupus nephritis, vasculitis and cerebral disease
Mycophenolate mofetil is as effective as cyclophosphamide in inducing
remission in lupus nephritis Mycophenolate mofetil is more effective than
azathioprine in maintenance therapy for preventing relapse
Azathioprine is used as a steroid-sparing agent. As an alternative to
cyclophosphamide, azathioprine is much safer but probably less effective
Intravenous immunoglobulins are increasingly being used in the treatment of
resistant lupus and also have a role in patients who have concomitant infection
and active lupus, for whom immunosuppression treatment is often
inappropriate.
Belimumab is licensed as adjunctive therapy in patients with active,
autoantibody-positive SLE with a high degree of disease activity despite
standard therapy
Fertility is normal and pregnancy is safe in mild or stable lupus
COCP should be used with caution

74. A 35yo man presents with progressive breathlessness. He gave a hx of


polyarthralgia with
painful lesions on the shin. CXR: bilateral hilar lymphadenopathy. Whats the most likely
dx?
a. Bronchial asthma
b. Cystic fibrosis
c. Sarcoidosis
d. Bronchiectasis
e. Pneumonia
Q. 1. What is the key?
Q.2 . What is the specific name of this condition? What is the triad?
Ans. 1. The key is C. Sarcoidosis.
Ans. 2. Lofgren syndrome. The triad is i) Erythema nodosum ii) Bilateral hilar
lymphadenopathy iii) Arthralgia.
Sarcoidosis:
Presentation: Lungs are in involved in more than 90% cases of sarcoidosis. There is
interstitial lung disease. The painful skin lesion is erythema nodosum. Also look for
Lupus pernio (chronic raised hardened, often purple lesion) may be seen on the face.
Lofgren syndrome is often a part of sarcoidosis. The triad is i) Erythema nodosum
ii) Bilateral hilar lymphadenopathy iii) Arthralgia
Sarcoidosis is a multisystem disease and can involve any system/organ
Tests: ESR is often raised. Serum ACE enzyme levels are raised in 60% of times
Plain CXR may show bilateral hilar or paratracheal lymphadenopathy. High resolution
CT should be done. There will be restricitve pattern of disease on pulmonary function
tests.
Transbronchial biopsy can demonstrate the presence of non-caseating granulomata,
giving a more accurate diagnosis
Bronchioalveolar lavage may also be done
75. A child presents with clean wound, but he has never been immunized as his parents
were
worried about it. There is no contraindication to immunization, what is the best
management?
a. Full course of DTP
b. 1 single injection DT
c. 1 single injection DTP
d. Only Ig
e. Antibiotic
Ans. The key is A. Full course of DTP.

Vaccination is at 2,3,4 months of age for children under 10 yrs of age. If a dose is missed
just give the next dose and no need to repeat the previous doses and just complete the 3
doses.
For >10 yrs it is same with an interval of at least 1 month between doses.
BOOSTERS: Age <10 yr should receive boosters 3 years after completing the 3 doses it
is DPT. 2nd booster is 10yrs after the 1st booster.
Age >10 yrs receive boosters 5yrs after completing the initial 3 doses. 2nd booster is
10yrs after the 1st booster.
Where there is no reliable history of previous immunisation, it should be assumed that
they are unimmunised, and the full UK recommendations should be followed

76. A 65yo HTN man presents with lower abdominal pain and back pain. An expansive
abdominal mass is palpated lateral and superior to the umbilicus. What is the single
most discriminating inv?
a. Laparascopy
b. KUB XR
c. Pelvic US
d. Rectal exam
e. Abdominal US
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points given here in favour of your diagnosis?
Ans. 1. The key is E. Abdominal US.
Ans. 2. The diagnosis is Abdominal aortic aneurism.
Ans. 3. Points in favour of AAA are i) hypertension ii) abdominal pain iii) back pain iv)
expansile abdominal mass lateral and superior to the umbilicus.
RISK Factors include : Family Hx , tobacco smoking is an important factor.
Male sex.
Increasing age.
Hypertension.
Chronic obstructive pulmonary disease.
Hyperlipidaemia
UNRUPTURED AAA is commonly asymptomatic and is an accidental finding.
Ruptured AAA may present with:
Pain in the abdomen, back or loin - the pain may be sudden and severe.
Syncope, shock or collapse:

The degree of shock varies according to the site of rupture and whether it is contained eg, rupture into the peritoneal cavity is usually dramatic, with death before reaching
hospital; whereas rupture into the retroperitoneal space may be contained initially by a
temporary seal forming.
Ultrasound is simple and cheap; it can assess the aorta to an accuracy of 3 mm. It is
used for initial assessment and follow-up.
SCANS :
CT Scan provides more anatomical details - eg, it can show the visceral arteries, mural
thrombus, the 'crescent sign' (blood within the thrombus, which may predict imminent
rupture) and para-aortic inflammation. CT with contrast can show rupture of the
aneurysm.
MRI angiography may be used.
If size exceeds 5.5cm, we go for surgery.
77. A 55yo man has had severe pain in the right hypochondrium for 24h. The pain
comes in waves and is accompanied by nausea. Nothing seems to relieve the pain. He
feels hot and sweaty but has normal temp. What is the most appropriate next inv:
A.US Abdomen
b. ERCP
c. MRCP
d. Serum amylase
e. UGI endoscopy
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of your diagnosis?
Ans. 1. The key is A. US abdomen.
Ans. 2. The diagnosis is biliary colic.

Ans. 3. Points in favour- i) severe right hypochondrial pain. ii) colicky nature of the pain
(comes in waves) iii) nausea iv) absence of fever iv) absence of jaundice.
Biliary colic :
The pain starts suddenly in the epigastrium or right upper quadrant (RUQ) and may
radiate round to the back in the interscapular region.
Contrary to its name, it often does not fluctuate but persists from 15 minutes up to 24
hours, subsiding spontaneously or with analgesics.
Nausea or vomiting often accompanies the pain, which is visceral in origin and occurs as
a result of distension of the gallbladder due to an obstruction or to the passage of a
stone through the cystic duct.
Differential diagnosis include reflux, peptic ulcers, irritable bowel syndrome, relapsing
pancreatitis and tumours - eg, stomach, pancreas, colon or gallbladder. Two or more of
these conditions may overlap, so the diagnosis may not be easy.
ULTRASOUND is the best way to demonstrate stones, being 90-95% sensitive.

78. A 67yo man has deteriorating vision in his left eye. He has longstanding
COPD and is on multiple drug therapy. What single medication is likely to
cause this visual deterioration?
a. B2 agonist
b. Corticosteroid
c. Diuretic
d. Theophylline
Q. 1. What is the key?
Q. 2. What is the cause of deteriorating vision?
Ans. 1. The key is B. Corticosteroid.

Ans. 2. Prolonged corticostiroids [also topical i.e. eye drop] can cause
cataract.
79. A woman who returned from abroad after 3 weeks of holiday complains of severe
diarrhea of 3 weeks. She also developed IDA and folic acid def. What condition best
describes her situation?
a. Jejunal villous atrophy
b. Chronic diarrhea secretions
c. Malabsorption
d. Increased catabolism
e. Increased secretions of acid
Q. 1. What is the key?
Q. 2. What are the points in favour?
Q. 3. What are the signs of deficiency may be present?
Ans. 1. The key is C. Malabsorption.
Ans. 2. Diarrhoea, IDA and folic acid deficiency.

Ans. 3.

Iron-deficiency anaemia.

Folate deficiency or vitamin B12 deficiency.

Bleeding, resulting from low vitamin K.

Oedema, which occurs in protein/calorie malnutrition.

Tropical sprue is seen in residents of, and visitors to, tropical areas and it tends to begin
with an acute episode of diarrhoea, fever and malaise before settling into a more chronic
presentation of steatorrhea, malabsorption, nutritional deficiency, anorexia, malaise and
weight loss. Folate deficiency is a significant part of the clinical picture.
80. A 35yo male is bitterly annoyed with people around him. He thinks that people are
putting ideas into his head. What is the single most likely dx?

a. Thought block
b. Thought insertion
c. Thought broadcasting
d. Thought withdrawal
e. Reference
Q. 1. What is the key?
Q. 2. In which disease you will find this feature?
Ans. 1. The key is B. Thought insertion.
Ans. 2. It is seen in schizophrenia.
Symptoms called disorders of thought possession may also occur in schizophrenia.
These include:
Thought insertion. This is when someone believes that the thoughts in their mind are not
their own and that they are being put there by someone else

.Thought withdrawal. This is when someone believes that thoughts are being removed
from their mind by an outside agency.
Thought broadcasting. This is when someone believes that their thoughts are being read
or heard by others.
Thought blocking. This is when there is a sudden interruption of the train of thought
before it is completed, leaving a blank. The person suddenly stops talking and cannot
recall what he or she has been saying.

81. A 10yo girl presents with hoarseness of the voice. She is a known case of bronchial
asthma and has been on oral steroids for a while. What is the most likely cause of
hoarseness?
a. Laryngeal candidiasis
b. Infective tonsillitis

c. Laryngeal edema
d. Allergic drug reaction
e. Ludwigs angina
Hoarseness may be a feature of laryngeal obstruction - so can be a warning of
impending airway obstruction.

This may occur in:

Infections - acute epiglottitis, diphtheria, croup, laryngeal abscess, laryngitis


Inflammation/oedema - airway burns, anaphylaxis, physical trauma, angio-oedema,
hereditary angio-oedema.
Vocal cord immobility - laryngeal nerve palsy (depending on the position of the cords) or
cricoarytenoid joint disease.
Immuno compromised states lead to fungal infections. These include HIV, Diabetes etc.
Patients taking long term steriods (inhalar or oral), antibiotics n those having vitb12 and
folic acid deficiecy are at a risk of having oral thrush.
Q. 1. What is the key?
Q. 2. What is the reason for this condition?
Ans. 1. The key is A. Laryngeal candidiasis.
Ans. 2. Steroids predisposes to fungal infection.
82. A lady with breast cancer has undergone axillary LN clearance. She develops arm
swelling after being stung by a bee. What is the most likely mechanism responsible for
the swelling?
a. Lymphedema
b. Cellulitis
c. Hypersensitivity reaction
d. DVT

e. Fluid retention
Q. 1. What is the key?
Q. 2. What is the reason for this condition?
Ans. 1. The key is A. Lymphoedema.
Ans. 2. Reason is compromised lymphatic drainage of arm due to axillary LN clearance.
83. A 34yo pt presents with 50% partial thickness burns. What should be the most
appropriate management?
a. IV fluids calculated from the time of hospital arrival
b. IV fluids calculated from the time of burn
c. No IVF
d. IV dextrose stat
e. Burns ointment
Q. 1. What is the key?
Q. 2. How the calculation of fluid is made?
Ans. 1. The key is B. IV fluids calculated from the time of burn.
Ans. 2. Resuscitation fluids required in the first 24 hours from the time of injury.
For adults: 3 ml (in partial thickness burn) of Hartmanns solution/kg body
weight/% total
Body surface area.
Half of this calculated volume is given in the first 8 hours and the other half is given over
the following 16 hours.

84. A 54yo man has recently been dx with moderate depression. He has hx of MI and is
suffering from insomnia. What is the drug of choice for him?
a. Citalopram
b. Lofepramine

c. ECT
d. Haloperidol
e. Diazepam
Ans. Key is A. Citalopram. [Citalopram is the antidepressant of choice post MI].
85. A man presented with cellulitis and swelling. He was started on flucloxacillin. What
other medication do you want to add?
a. Vancomycin
b. Penicillin
c. Metronidazole
d. Ceftriaxone
e. Amoxicillin
Q. 1. What is the key?
Q. 2. Is it justified to add this drug? If justified please mention why?
Ans. 1. The key is B. Penicillin.
Ans. 2. Custom and practice has traditionally combined the use of benzylpenicillin and
flucloxacillin in the management of hospitalised patients with cellulitis. In most cases this
is not seen as practical or necessary. Flucloxacillin covers both beta-haemolytic
streptococci and penicillinase-resistant staphylococci.
But for exam purpose, treatment of cellulitis = Benzylpenicillin + Flucloxacillin.
Drug of choice for cellulitis is flucloxacillin. IT Is sufficient alone. If needed to add
something, add penicilin ,, or add doxycycline if exposed to salt water,,, add
erythromycin if there is penicillin allergy, or add ciprofloxacin if exposed to fresh water.
86. A 24yo college student presents with nausea, vomiting, headache, neck stiffness
and a fever of 38.4C. What is the most appropriate empirical antibiotic to be started?
a. Ceftriaxone
b. Penicillin

c. Gentamicin
d. Tazobactam
e. Meropenem
Ans. The key is A. Ceftriaxone. [In OHCM-Cefotaxime <55yrs and Cefotaxime +
Ampicillin if age >55yrs].

One should start benzyl penicillin before admission. After admission, ideally cefotaxime
should be given as per new guidelines. But, as there was no option of cefotaxime, we
would go for ceftriaxone (also 3rd gen cephalosporin)
87. A man with prosthetic heart valve underwent hemicolectomy and after some days
complains of left hypochondriac pain, fever and has a systolic murmur. What is the next
inv to ascertain the cause of HF?
a. CT
b. Blood culture
c. ECG
d. MRI
e. Radioactive thyroid scan
Infective Endocarditis
Risk factors:
Cardiac conditions considered to increase a patient's risk of developing infective
endocarditis:
Valvular heart disease with stenosis or regurgitation. Valve replacement.
Structural congenital heart disease, including surgically corrected or palliated structural
conditions, but excluding: Isolated atrial septal defect. Fully repaired ventricular septal
defect. Fully repaired patent ductus arteriosus. Closure devices that are judged to be
endothelialized.

Investigations
Nonspecific signs of infection - eg, elevated CRP or ESR, leukocytosis, anaemia and
microscopic haematuria.
CXR: as part of the initial assessment.
Electrocardiogram is useful to detect the 10% of patients who will develop conduction
defects.
Blood cultures:
Should be taken prior to starting treatment in all cases. Meticulous aseptic technique is
required.
Echocardiography
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. Why have you made this diagnosis?
Q. 4. What are the important risk factors for this condition?
Ans. 1. The key is B. Blood culture.
Ans. 2. The diagnosis is infective endocarditis.
Ans. 3. Fever + new murmur = endocarditis until proven otherwise.
Ans. 4. Important risk factors: dermatitis, IV injections, renal failure, organ
transplantation, DM, post operative wound. Risk factors for abnormal valves: aortic or
mitral valve disease, tricuspid valve in IV drug users, prosthetic valves.

88. A 45yo man with posterior gastric ulcer presented with severe excruciating pain
which subsided after conservative treatment. 10 days later he developed swinging
pyrexia. US shows a collection in the peritoneum. What will be the most likely location of
the collection?
a. Hepatorenal pouch

b. Left paracolic gutter


c. Subphrenic
d. Pelvic cavity
e. Lesser sac

Ans. The key is E. Lesser sac.


89. A 23yo lady was prescribed with azithromycin 1gm for her chlamydial pelvic
infection. She has got a new boyfriend for the last 2 months. She has recently started
contraception to avoid conception. Which of the following contraception method will be
affected by azithromycin?
a. Barrier
b. IUCD
c. POP
d. COCP
Ans. None of them! Before it was thought that hepatic enzyme inhibitor drugs may affect
COCP but later it was established that actually there is no such significant effect. Only
drugs like rifampicin and rifambuin can cause this. No other antibiotic alters COCP
levels. Moreover, POP is not affected by any antibiotic other than rifampicin. Barrier
method has nothing to do with any antibiotic as its a mechanical method. IUCD has no
proved interaction with antibiotics.

90. An 11yo boy is being checked by the diabetic specialist nurse. His HbA1c was high
and he has been skipping meals recently. He has been unhappy at school. Which single
member of the clinical team would you refer him to next?
a. GP
b. Pediatrician

c. Dietician
d. Clinical psychologist
Ans. The key is D. Clinical psychologist. [Unhappy at school, skipping meals these are
psychological issue. He needs psychological counseling].
There was a discussion on plab forum that the answer should be pediatrician , but here
the problem is psychological. Had he missed any medication, he would have had to see
pediatrician.
91. A 35yo man who has served in the army presents with lack of interest in enjoyable
activities and feeling low. He doesnt feel like reading the news or watching movies as he
believes there is
violence everywhere. What is the most appropriate first line therapy?
a. Citalopram
b. Lofepramine
c. CBT
d. Chlordiazepoxide
e. Desensitization
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What is the first line treatment?
Q. 4. Here why 1 line treatment is not considered?
st

Ans. 1. The key is C. CBT


Ans. 2. The diagnosis is depressive illness.
Ans. 3. In depressive illness 1 line therapy is SSRI
st

Ans. 4. In this patient abnormal thinking of presence of violence everywhere is the


trigger for his depression and in this situation CBT gives the best result.

[It is not post traumatic stress disorder as constant vivid flashbacks of the experience
which is the main feature of PTSD is absent here. In the given scenario depression has
a trigger of abnormal thought process that there is violence everywhere! So cognitive
behavioural therapy is the best treatment here (though in typical depression drug of
first choice is SSRI- according to samson note)].
(personally not sure about this one as pt has all the features of ptsd except the flashbacks.
Though, the answer would still be cbt )
92. A man has reducible bulge below the pubic tubercle, and on occlusion of the deep
inguinal ring, cough impulse is present. What is the most likely dx?
a. Direct inguinal
b. Indirect inguinal
c. Femoral
d. Spigelian
e. Lumbar
Q. 1. What is the key?
Q. 2. What are the points in favour of your answer?
Ans. 1. The key is C. Femoral hernia.
Ans. 2. It is just below the pubic tubercle that is just below the inguinal ligament.
Note: this question is a very bad recall as hernia below pubic tubercle is femoral and
cough impulse felt in occluded deep ring is seen in inguinal hernia. In femoral hernia
positive cough impulse is found in femoral ring.
Features of femoral hernia:
Below and lateral to the pubic tubercle
More common in women, particularly multiparous ones

High risk of obstruction and strangulation


Surgical repair is required
Other hernias :

Types of abdominal wall hernias:

Type of hernia

Details

Inguinal hernia

Inguinal hernias account for 75% of abdominal wall hernias.


Around 95% of patients are male; men have around a 25%
lifetime risk of developing an inguinal hernia.

Above and medial to pubic tubercle

Strangulation is rare

Femoral hernia

Below and lateral to the pubic tubercle

More common in women, particularly multiparous ones

High risk of obstruction and strangulation

Surgical repair is required

Umbilical
hernia

Symmetrical bulge under the umbilicus

Paraumbilical
hernia

Asymmetrical bulge - half the sac is covered by skin of the


abdomen directly above or below the umbilicus

Epigastric
hernia

Lump in the midline between umbilicus and the xiphisternum

Most common in men aged 20-30 years

Incisional
hernia

May occur in up to 10% of abdominal operations

Spigelian
hernia

Also known as lateral ventral hernia

Rare and seen in older patients

A hernia through the spigelian fascia (the aponeurotic layer


between the rectus abdominis muscle medially and the semilunar
line laterally)

Obturator
hernia

A hernia which passes through the obturator foramen. More


common in females and typical presents with bowel obstruction

Richter hernia

A rare type of hernia where only the antimesenteric border of the


bowel herniates through the fascial defect

93. A 48yo woman is admitted to ED with a productive cough and moderate fever. She
has often central chest pain and regurgitation of undigested food most times but doesnt
suffer from acid reflux. These symptoms have been present for the last 3.5 months
which affects both food and drink. A CXR shows an air-fluid level behind a normal sized
heart. What is the most likely dx?
a. Pharyngeal pouch
b. Hiatus hernia

c. Bulbar palsy
d. Achalasia
e. TB
Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is D. Achalasia.
Ans. 2. Points in favour: Aspiration pneumonia due to retained food and fluid in
oesophagus. Regurgitation of undigested food without acid reflux. Dysphagia for both
food and drink. Air-fluid level behind heart.
Why it is not hiatus hernia? Ans. Differentiating point:-i) In hiatus hernia usually you will
get associated GORD [particularly in sliding hernia which is the most common (99%).
However in rolling hernia there may be no reflux]. ii) In hiatus hernia x-ray chest may
demonstrate a retrocardiac gas-filled structure rather than a air-fluid level iii) Also in
hiatus hernia there may be nausea or vomiting.
Why it is not pharyngeal pouch? Ans. In pharyngeal pouch there will be halitosis.
Achlasia has been discussed before in detail.

94. A 64yo man has been waking up in the middle of the night to go to the bathroom. He
also had difficulty in initiating micturition and complains of dribbling. A dx of BPH was
made after a transrectal US guided biopsy and the pt was prepared for a TURP. What
electrolyte abnormality is highly likely due to this surgery?
a. Hypokalemia
b. Hypocalcemia
c. Hyperkalemia
d. Hyponatremia
e. Hypernatremia

Q. 1. What is the key?


Q. 2. Why this happens?
Ans. 1. The key is D. Hyponatremia.
Ans. 2. Absorption of fluid used for bladder irrigation to flush out blood clots and IV fluids
all may lead to hypervolaemia and dilutional hyponatremia.
95. A 56yo lady has developed severe right sided headache which worsens whenever
she comes to bright light since the last 4 days. She feels nauseated, but doesnt vomit.
What is the most likely
dx?
a. SAH
b. Brain tumor
c. Migraine
d. Cluster headache
e. Subdural headache
Q. 1. What is the key?
Q. 2. What is the type of the given case?
Q. 3. What are the points in favour of mentioned type?
Ans. 1. The key is C. Migraine.
Ans. 2. It is migraine without aura. There is presence of trigger (bright light)
Ans. 3. Criteria of migraine without aura: 5 headaches lasting 4-72 hours +
nausea/vomiting (or photo/phono-phobia) + any 2 of: i) unilateral ii) pulsating iii) worsen
by routine activity [OHCM, 9 edition, page-462].
th

It should be noted that as a general rule 5-HT receptor agonists are used in the acute
treatment of migraine whilst 5-HT receptor antagonists are used in prophylaxis. NICE
produced guidelines in 2012 on the management of headache, including migraines.

Acute treatment

first-line: offer combination therapy with an oral triptan and an NSAID, or an oral
triptan and paracetamol
for young people aged 12-17 years consider a nasal triptan in preference to an
oral triptan
if the above measures are not effective or not tolerated offer a non-oral
preparation of metoclopramide* or prochlorperazine and consider adding a nonoral NSAID or triptan

Prophylaxis

prophylaxis should be given if patients are experiencing 2 or more attacks per


month. Modern treatment is effective in about 60% of patients.
NICE advise either topiramate or propranolol 'according to the person's
preference, comorbidities and risk of adverse events'. Propranolol should be
used in preference to topiramate in women of child bearing age as it may be
teratogenic and it can reduce the effectiveness of hormonal contraceptives
if these measures fail NICE recommend 'a course of up to 10 sessions of
acupuncture over 5-8 weeks' or gabapentin
NICE recommend: 'Advise people with migraine that riboflavin (400 mg once a
day) may be effective in reducing migraine frequency and intensity for some
people'
for women with predictable menstrual migraine treatment NICE recommend
either frovatriptan (2.5 mg twice a day) or zolmitriptan (2.5 mg twice or three
times a day) as a type of 'mini-prophylaxis'
pizotifen is no longer recommend. Adverse effects such as weight gain &
drowsiness are common

*caution should be exercised with young patients as acute dystonic reactions may
develop

96. A 35yo man presented with hematuria, abdominal swelling and has a BP of 190/140.
What is the most diagnostic inv?
a. Cystoscopy
b. USG

c. CT
d. Renal biopsy
e. Urine analysis
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What will be the USG findings to establish diagnosis in given case?
Ans. 1. The key is B. USG.
Ans. 2. The diagnosis is ADPKD.
Ans. 3. In given case patients age is 35. So the USG diagnostic criteria is: Age 18 39
yrs>3 unilateral or, bilateral cysts (here bilateral means if 1 + 1 it is enough).
Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited
cause of kidney disease, affecting 1 in 1,000 Caucasians. Two disease loci have been
identified, PKD1 and PKD2, which code for polycystin-1 and polycystin-2 respectively

ADPKD type 1

ADPKD type 2

85% of cases

15% of cases

Chromosome 16

Chromosome 4

Presents with renal failure earlier

The screening investigation for relatives is abdominal ultrasound:

Ultrasound diagnostic criteria (in patients with positive family history)

two cysts, unilateral or bilateral, if aged < 30 years


two cysts in both kidneys if aged 30-59 years

four cysts in both kidneys if aged > 60 years


97. A young man is brought to the ED after a RTA. His GCS on initial evaluation is 6.

What is the most appropriate next step?


a. CT
b. MRI
c. IV fluids
d. Skull XR
e. Secure airway
Ans. The key is E. Secure airway.
In a case of Road Traffic Accident. or any trauma, management starts with A- airway
(includes cervical immobility), B- (breathing), C (circulation) , D (disability) . ETT
SHOULD BE CONSIDERED IN ALL PATIENTS WITH GCS BELOW 8.
98. A 65yo man presented with frank hematuria. He has no other urinary symptoms.
What is the most appropriate next step that will lead to the dx?
a. IVU
b. US Abdomen
c. Cystoscopy
d. Mid-stream urine for culture
e. Transrectal US
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the reasons for this diagnosis?
Q. 4. If there is painless haematuria in young (say 25-30yrs) what diagnosis will come
first?
Ans.1. Key is C. Cystoscopy.
Ans. 2. Bladder cancer.

Ans. 3. Age 65, asymptomatic haematuria.


Ans. 4. ADPKD [at the beginning there is very few or no symptoms]

Bladder CA has already been discussed in mcq # 1.


99. A 30yo woman had a gradual decrease of visual acuity since the last 3 years. Now
she has a disability due to very low vision. Whats the dx?
a. Glaucoma
b. Cataract
c. Macular degeneration
d. Retinitis pigmentosa
e. Keratitis
Q. 1. What is the key?
Q. 2. Why it is not the other given D/D s?
Ans. 1. The key is D. Retinitis pigmentosa.
Ans. 2. i) It is not angle closure glaucoma as angle closure glaucoma occurs usually
after the age of 50; In open angle glaucoma visual loss is not evenly gradual rather
occurs a bit suddenly at its later part. It is not cataract as cataract occurs usually in
elderly. In macular degeneration near blindness does not occur rather causes inability to
identify face or cannot read small prints; otherwise peripheral vision is not that
depressed. In keratitis will be pain, redness, photophobia and vision is ok.
Retinitis pigmentosa primarily affects the peripheral retina resulting in funnel vision
Features

night blindness is often the initial sign


funnel vision (the preferred term for tunnel vision)
fundoscopy: black bone spicule-shaped pigmentation in the peripheral retina,
mottling of the retinal pigment epithelium
Associated diseases

Refsum disease: cerebellar ataxia, peripheral neuropathy, deafness, ichthyosis


Usher syndrome

abetalipoproteinemia
Lawrence-Moon-Biedl syndrome
Kearns-Sayre syndrome
Alport's syndrome

100. A 27yo lady has had an uncomplicated pregnancy so far. She came to the hospital
2h ago after her water broke. The midwife is looking at her now. She has regular
contractions. P.V exam revealed 2cm dilated cervix. Vital signs are normal. What stage
of labour is she in?

a. Second stage

b. First stage

c. Latent stage

d. Third stage

e. Active phase

Ans. The key is B. First stage starts with softening of cervix with start of opening of

cervix and ends when cervix is fully dilated (i.e. 10 cm dilated). [There is nothing named
latent stage but latent phase which is up to 4cm dilatation. So, the preferred option is
first stage here].
Stages of Labour

First stage
The first stage begins with regular contractions (when the fetal presenting part has
descended into the true pelvis), or on admission to hospital with obvious signs of labour.
The first stage ends when the cervix is fully dilated (10 cm).
First stage can be divided into:

Latent or quiet phase: Contractions are not particularly painful and at 5- to 10-minute
intervals. Contractions become stronger with shorter intervals, although the cervix is still
dilating relatively slowly, with membranes possibly breaking later in this phase.

Active phase:Starts with the cervix 3-4 cm dilated and is associated with more rapid
dilatation normally at 0.5-1.0 cm/hour. Once the cervix is dilated to 9 cm, towards the
end of the active phase, contractions may be more painful and women may want to
push. Pushing is undesirable at this stage; there is the need to establish by vaginal
examination whether the cervix is fully dilated. During this time the fetal head descends
into the maternal pelvis and the fetal neck flexes.

While the length of established first stage of labour varies between women, first labours
last on average 8 hours (unlikely 18 hours). Second and subsequent labours last on
average 5 hours (unlikely 12 hours). However if the first stage does not appear to be
progressing, the cause needs to be determined.

Second stage:
This starts when the cervix is fully dilated and ends with the birth of the baby:

Contractions are stronger, occur at 2- to 5-minute intervals and last 60-90 seconds.
The fetal head descends deeply into the pelvis and rotates anteriorly so that the back of
the fetal head is behind the mother's symphysis pubis (98% of cases).
The second stage is said to be active once the baby is visible and the woman usually
also wants to assist what have become expulsive contractions by pushing.
The fetal head becomes more visible with each contraction until a large part of the head
can be seen.
The head is now born with first the forehead, then the nose, mouth and chin.
The head rotates to allow the shoulders to be born next, followed by the trunk and legs.
After this, the baby should start to breathe and to cry loudly.

Third stage:

This stage starts with the birth of the baby and ends with the delivery of the placenta and
membranes:

Separation of the placenta occurs immediately after birth due to forceful uterine
contractions along with retraction of the uterus, thus greatly reducing the size of the
placental bed.
It normally takes up to 5 minutes, but can take longer.
Haemorrhaging is prevented by the contraction of uterine muscle fibres closing off the
blood vessels that were supplying the placenta.
Without active management, after 10-20 minutes, separation is shown by a gush of
blood, prominence of the fundus in the abdomen and apparent lengthening of the
umbilical cord.
101. A 2yo boy fell off his tricycle and hurt his arm. He got up to start crying, but before
there was
any sound, he went pale, unconscious and rigid. He recovered after 1-2 mins but
remained pale.
After an hour he was back to normal. His mother says she was afraid he was going to
die, and
that he had a similar episode 3 months prior after falling down some steps. What single
inv is
indicated?
a. CT head
b. EEG
c. CBC
d. None
e. Skeletal survey
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. The key is D. None.
Ans. 2. Diagnosis is breath holding spell.
102. A 29yo woman had just delivered a still born vaginally, following a major placental
abruption.
Choose the single most likely predisposing factor for developing PPH in this lady?
a. Retained product
b. DIC
c. Fibroid uterus
d. Uterine infection
e. Large placental site

Q. 1. What is the key?


Q. 2. What are the causes of this condition here?
Ans. 1. The key is B. DIC.
Ans. 2. Pregnancy itself is a risk factor for DIC. Placental abruption is a more common
cause of DIC.
Other causes of pregnancy related DIC are: eclampsia, retention of a dead fetus,
amniotic fluid embolism, retained placenta or bacterial sepsis.
103. A 28yo woman has delivered with rotational forceps after an 8h labor and 3h
second stage.
Choose the single most likely predisposing factor for PPH for this pt?
a. Atonic uterus
b. Cervical/vaginal trauma
c. Retained product
d. Preterm labor
e. Uterine infection
Ans. The key is B. Cervical/vaginal trauma. [complication of forceps delivery].
Primary PPH is the loss of greater than 500mL (defi nitions vary) in the first
24h after delivery

Causes: uterine atony (90%), genital tract trauma (7%), clotting disorders (3%)
Risks: Antenatal Previous PPH or retained placenta BMI>35kg/m2 Maternal
Hb<8.5g/dl at onset of labour Antepartum haemorrhage Multiparity 4+ Maternal age
35y+ Uterine malformation or fibroids A large placental site (twins, severe rhesus
disease, large baby) Low placenta, Overdistended uterus (polyhydramnios, twins)
Extravasated blood in the myometrium (abruption).
In labour Prolonged labour (1st, 2nd or 3rd stage) Induction or oxytocin use
Precipitant labour Operative birth or caesarean section. Book mothers with risk factors
for obstetric unit delivery.
Treatment: Give oxytocin 5U slowly IV for atonic uterus.
Attach oxygen, Give IV fluids, maintain systolic >100mmHg, Transfuse blood.
Is the placenta delivered? If it is, is it complete? If not, explore the uterus. If the
placenta is complete, put the patient in the lithotomy position with adequate analgesia and
good lighting. Check for and repair trauma.
If the placenta has not been delivered but has separated, attempt to deliver it by
controlled cord traction after rubbing up a uterine contraction. If this fails, ask an
experienced obstetrician to remove it under general anaesthesia.Beware renal shut down.
104. A 50yo man has had anterior resection of the rectum for carcinoma. He expressed
concerns
about control of post-op pain in discussions with the anaesthetist before surgery. What is
the
best management strategy?
a. Oral diclofenac
b. Oral codeine
c. IM morphine
d. IM dihydrocodeine
e. Ondansetron oral
Ans. The key is C. IM morphine. [Post operative pain is severe pain which needs strong
opioid analgesics].

Oral route will not be suitable for this patient as he is having a major abdominal surgery
so most probably he will be NPO post operatively. Dihydrocodeine is useful for mild to
moderate pain but since its a major surgery and the patient is himself worried about the
pain good analgesia should be maintained. Ondensetron is an anti emetic not an
analgesic. So the most suitable option here is IM Morphine as it is a strong analgesic
most suitable for severe pain.
105. A 73yo male presents with enlarged cervical nodes. He has had recurrent infections
over the last year. His conjunctiva is pale. Choose the single cell type you will find on the
blood film.
a. Granulocyte without blast cells
b. Myelofibroblasts
c. Plasma cells
d. Mature lymphocytes
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of your diagnosis?
Ans. 1. The key is D. Mature lymphocytes.
Ans. 2. The diagnosis is CLL.
Ans. 3. It is CLL because of his age (73 yrs). Other supportive features are cervical
lymphadenpathy, recurrent infections (mature but functionally defective lymphocytes),
and pale conjunctiva (anaemia).
It is a typical presentation of CLL with reurrent infections, symmetrical lymphadenopathy,
anemia. There can also be hepatosplenomegaly and thrombocytopenia leading to
patechae
On blood film there will be B cell lymphocytosis often with smudge cells. There are
mature but functionally impaired lymphocytes as they escape apoptosis. In bone marrow
there is lymphocytic replacement of bone marrow cells. Mainstay of treatment is
chemotherapy.
106. A 45yo lady has 10m hx of SOB. She is found to have irregularly irregular pulse
and loud P2 with fixed splitting and ejection systolic murmur in left 2nd ICS. What is the
probable dx?
a. TOF
b. ASD
c. VSD
d. PDA
e. CoA
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. The key is B. Atrial septal defect.
Ans. 2. Diagnosis is ASD with atrial fibrillation. [i) atrial fibrillation = irregularly irregular
pulse. ii) ASD = SOB, fixed splitting with loud P2, ESM in pulmonary area]. This pictures
are of atrial septal defect itself though similar findings we get in pulmonary hypertension.
One should not misdiagnose SOB, ESM in pulmonary area and loud P2 as pulmonary
hypertension in the given case.

Fixed splitting is the clincher in this question.


VSD: Pansystolic murmur
PDA: machinery murmur

ASD is acyanotic condition. Ostium seccundum is the most common cause. There is left
to right shunting of blood leading to dyspnoea/heart failure eg at age 4060. There may
be pulmonary hypertension, cyanosis, arrhythmia, haemoptysis, and chest pain.
SIGNS: AF; raised JVP; wide, fixed split S2; pulmonary ejection systolic murmur
If an embolus from DVT of lower limb passes to the brain and causes ischemia it can
only pass from vein to artery through ASD.
INVESTIGATIONS: Echo is diagnositic
Tx: In children closure by surgery before 10yrs of age, In adults transcatheter closure is
now more common than surgery
107. A 5m baby present with recurrent vomiting. Mother noticed some of the vomitus is
blood
stained. Choose the single most likely inv?
a. Upper GI endoscopy
b. Barium meal
c. US
d. Colonoscopy
e. CT abdomen
Ans. The key is A. upper GI endoscopy.
Haematemesis (unless swallowed blood - eg, following a nosebleed or ingested blood
from a cracked nipple in some breast-fed infants) may suggest an important and
potentially serious bleed from the oesophagus, stomach or upper gut.
Projectile vomiting, non bilious: Pyloric stenosis
Bilious vomiting: Call for senior help, consider duodenal obstruction.
108. A 76yo is treated with HTN. He suffers from pain and redness at the MTP joint of
his right big toe. Which of the following anti-HTN cause this symptoms?
a. Losartan
b. Bendroflumethiazide
c. Ramipril
d. Bisoprolol
e. Verapamil
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What is the cause of the disease?
Ans. 1. The key is B. Bendroflumethiazide
Ans. 2. Diagnosis is acute gout.
Ans. 3. Thiazide diuretics may cause hyperuricemia and thus precipitate acute gout.
Thiazide diuretics are contraindicated in gout!
In gout mostly large joints are involved like ankle, knee, foot. But small joints of hands
can also be involved.
It is caused by deposition of monosodium urate crystals in and near joints, precipitated,
for example, by trauma, surgery, starvation, infection or diuretics.
CAUSES: Hereditary, dietary purines, alcohol excess, diuretics, leukaemia, cytotoxics
(tumour lysis).

INVESTIGATIONS: Polarized light microscopy of synovial fluid: negatively birefringent


crystals (while those of pseudogout are positively birefringenent).... Serum urate may or
may not be raised. Punched out erosions on X Ray in advanced disease.
TREATMENT: ACUTE: NSAIDs (indomethacin), colchicine if NSAIDs are contra
indicated like peptic ulcer, heart disease. In renal failure both are problematic so use
steroids.
CHRONIC: Start if >1 attack in 12 months, tophi or renal stones. Use allopurinol. Aim is
plasma urate <0.3mmol/L
In acute attack allopurinol is CI as it exacerbates the attack, wait until 3 weeks after
acute attack to start allopurinol. But once on allopurinol no need to stop it during acute
attacks.
Febuxostat and probenicid are alternatives.
109. A 33yo male involved in a street fight presents with bruises and deformity in the
upper part of
his leg. XR shows fx of the neck of fibula. What is the single most associated nerve
injury?
a. Sciatic nerve
b. Gluteal nerve
c. Musculocutaneous nerve
d. Lateral peroneal nerve
e. Tibial nerve
f. Femoral nerve
Ans. is D. Lateral peroneal nerve. [Lateral peroneal nerve is other name of superficial
peroneal nerve].
110. A 35yo man presents with hx of dyspepsia. H.Pylori antibodies are negative. No
improvement is seen after 1m of tx. What is the next step?
a. Urea breath test
b. Gastroscopy
c. CT
d. MRI
Q. 1. What is the key?
Q. 2. What may be the D/D here?
Q. 3. At this age what are the indications of this procedure?
Ans. 1. Gastroscopy.
Ans. 2. Not responding to treatment D/D is: i) Zollinger Elison syndrome ii) Ca stomach
Ans. 3. Indications of gastroscopy in a 35 yo man (man of age <50yrs): i) Acute
symptoms with H/O previous episode (PUD) ii) Alarm features [weight loss, anaemia,
vomiting, hematemesis and melaena, dysphagia, palpable abdominal mass], fear of
cancer, evidence of organic disease.

Urgent specialist referral - two-week rule


If the patient has dyspepsia at any age with any of the following alarm symptoms:
Chronic GI bleeding.
Progressive unintentional weight loss.
Progressive dysphagia.
Persistent vomiting.
Iron-deficiency anaemia.
Epigastric mass.

[13]

Suspicious barium meal.


NB: patients aged 55 years or older with unexplained and persistent recent-onset
dyspepsia should be referred urgently for endoscopy

If age less than 55 and no alarm signs, try life style modifications and simple antacids. If
no improvement then do H.pylori testing (antibodies). If it is positive do eradication and
review in 4 weeks.
If resolved, no further action required.
If symptoms are not resolved, do urea breath test.
If it is positive, again eradication for H.pylori
If it is negative, do upper GI endoscopy
If the initial H.pylori testing was negative give PPIs or H2 blockers for 4 weeks and
review if symptoms resolve no action needed if they dont resolve do upper GI
endoscopy.
111. A 15yo male has bilateral ankle edema. His BP=110/70mmHg and urinalysis
shows protein++++.
What is the most likely dx?
a. HUS
b. IgA nephropathy
c. Membranous GN
d. Minimal change GN
e. Nephrotic syndrome
Q. 1. What is the key?
Q. 2. What are the points in favour of your diagnosis?
Q. 3. What is the treatment?
Ans. 1. The key is D. Minimal change disease.
Ans. 2. Points in favour: i) Age 15 ii) Ankle oedema iii) Normotension iv) Heavy
proteinuria.
Ans. 3. Treatment of choice is steroid (prednisolone). Failure of steroid or frequent
relapse (>3) cyclophosphamide.
Most common cause of nephrotic in children is minimal change disease. There will be
hypoalbuminemia and peripheral edema too. Electron microscopy shows effacement of
podocyte foot processes.. MCD has albumin selective proteinuria. Treatment is with
steroids.
IgA nephropathy is nephritic and will also show HTN and microscopic hematuria and
follows upper resp tract infection.
Membranous GN also presents as nephrotic but age and since MCD is most common
we choose MCD.
Nephrotic syndrome itself is not a diagnosis.
112. A 28yo man has developed a red, raised rash on trunk after playing football. His
PMH shows he had childhood asthma. The rash is becoming increasingly itchy. What is
the most appropriate tx?
a. Oral chlorpheneraime
b. Oral amoxicillin
c. IM adrenaline
d. Nebulized salbutamol
e. Histamine
Q. What is the key?

Q. 2. What is the diagnosis?


Ans. 1. The key is A. Oral chlorpheneramine.
Ans. 2. Diagnosis is Atopy (allergy).
Since it is an allergic reaction only 2 options are suitable. A & C. IM adrenaline is used in
anaphylactic shock which can occur due to allergy. But this is just a mild allergic reaction
here so anti histamine (chlorpheneramine) is adequate.
Anaphylaxis presents with:
Sudden onset and rapid progression of symptoms.
Life-threatening airway and/or breathing and/or circulation problems
Patient will be mostly in shock.
Mostly commonly caused by certain foods like peanuts, pulses, fish, eggs. Also by
venom (bee,wasps) and drugs like antibiotics.
Treatment:ABCDE, Oxygen, IM Adrenaline. <6yrs0.15ml, 6-12yrs 0.3ml, >12 yrs 0.5ml
1:1000
113. A 72yo man has been advised to have antibiotic prophylaxis for some years now
before dental tx. He has never experienced chest pain. Three weeks ago, he noticed
breathlessness on exertion and for one week he had orthopnea. His pulse is normal.
What is the most probable dx?
a. Aortic regurgitation
b. Ischemic mitral regurgitation
c. Mitral valve prolapse
d. Pulmonary stenosis
e. Mitral valve stenosis
Ans. The kay is E. Mitral valve stenosis.
The patient has mitral stenosis or Aortic regurgitation. he is given prophylaxis for
infective endocarditis. According to OHCM, such prophylaxis has no benefit and should
not be given.
RISK FACTORS for IE: aortic or mitral valve disease; tricuspid valves in IV drug users;
coarctation; patent ductus arteriosus; VSD; prosthetic valves
Mitral Stenosis: Presentation: dyspnoea; fatigue; palpitations; chest pain; systemic
emboli; haemoptysis; chronic bronchitis-like picture
CAUSES: Rheumatic, congenital, mucopolysaccharidoses, endocardial fibroelastosis,
malignant carcinoid, prosthetic valve.
SIGNS: Malar flush on cheeks (due to cardiac output); low-volume pulse; AF common;
tapping, non-displaced, apex beat (palpable S1). On auscultation: loud S1; opening snap
(pliable valve); rumbling mid-diastolic murmur (heard best in expiration, with patient on
left side
ECG shows P-mitrale ECHO is diagnostic. CXR: left atrial enlargement (double
shadow in right cardiac silhouette)
TREATMENT: balloon valvuloplasty (if pliable, non-calcified valve), open mitral
valvotomy
or valve replacement.
Complications: Pulmonary hypertension, emboli, pressure from large LA on local
structures, eg hoarseness (recurrent laryngeal nerve), dysphagia (oesophagus),
bronchial obstruction; infective endocarditis

AORTIC REGUGITATION: CAUSES Acute: Infective endocarditis, ascending aortic


dissection,
chest trauma.
SYMPTOMS: Exertional dyspnoea, orthopnoea, and paroxysmal nocturnal dyspnoea.
palpitations, angina, syncope, CCF
Signs: Collapsing (water-hammer) pulse (p40); wide pulse pressure; displaced,
hyperdynamic apex beat; high-pitched early diastolic murmur (heard best in expiration,
with patient sitting forward).
The diagnosis here is mitral stenosis because of the normal pulse. I think the
information in the question is too deficient for such a disease and diagnosis!

FEVER + NEW MURMUR IS ENDOCARDITIS UNTIL PROVEN OTHERWISE


114. A 37yo woman presents with fatigue. Exam: angular stomatitis, no koilonychea.
Choose the single cell type you will find on the blood film.
a. Macrocytes
b. Microcytes
c. Granulocytes wthout blast cells
d. Blast cells
Q. 1. What is the key?
Q. 2. What is the cause here?
Q. 3. What are the points in favour of mentioned cause?
Ans. 1. The given key is A. Macrocytes.
Ans. 2. The cause here is VIT. B12 or folate deficiency.
Ans. 3. Points in favour of Vit. B12 or folate deficiency: i) fatigue (anaemia) ii) angular
stomatitis (can be seen in Vit. B12 or folate deficiency) iii) absence of koilonychea is
against IDA.
SIGNS in ANEMIA:
Koilocychia (spoon shaped nails) iron deificiency anemia
atrophic glossitis in iron def.
post cricoid webs (plummer vinson syndrome)
Angular stomatitis (cheilosis) in both vit B12 and iron def.
glossitis (beefy-red sore tongue) Vit. B12 def.
115. A 4yo boy with a febrile convulsion lasting eight minutes has been given IV
lorazepam to control them. What is the single most likely serious side effect?
a. Amnesia
b. Anaphylactic shock
c. Apnea
d. Bronchospasm
e. Cardiac arrhythmia
Ans. The key is C. Apnoea.
Due to respiratory depression caused by benzodiazepines. They can also cause
amnesia but it wont be in acute setting.
116. A 4wk girl has been dx of having breast milk jaundice. She is otherwise well. What
is the single most appropriate management?
a. Continue breastfeeding

b. Exchange transfusion
c. Increase fluid intake
d. Phototherapy
e. Stop breastfeeding
Q. 1. What is the key?
Q. 2. What is breast milk jaundice?
Q. 3. What type of hyperbilirubinemia occurs in breast milk jaundice?
Q. 4. What is the cause of this jaundice?
Ans. 1. The key is A. Continue breast feeding.
Ans. 2. If jaundice lasts past the first week of life in a breastfed baby who is otherwise
healthy, the condition may be called "breast milk jaundice."
Ans. 3. Unconjugated hyperbilirubinaemia.
Ans. 4. Cause of breast milk jaundice: factors in a mother's milk that help a baby absorb

bilirubin from the intestine.


Hyperbilirubinaemia (<200mol/L) after 24h is usually physiological
Visible jaundice within 24h of birth is always abnormal. Causes: Sepsis or Rhesus
haemolytic disease: +ve direct Coombs test.
Prolonged jaundice (not fading after 14 days) Causes: breastfeeding; sepsis, (UTI &
TORCH, hypothyroidism; cystic fibrosis; biliary atresia if conjugated and pale stools.
If the jaundice is between 1-14 days no intervention is needed unless it is severe in which
case phototherapy or exchange transfusion is done.
117. A 12yo girl when playing in the garden accidentally stepped on a hive and was
bitten several
times. She has numerous wheals on her body and complains of severe itching. What is
the single
most appropriate management?
a. Oral antihistamine
b. IV antihistamine
c. IM adrenaline
d. Oral ciprofloxacin
e. Reassurance
Ans. The given key is C. IM adrenaline which is a wrong key. The correct answer is A.
Oral antihistamine.
Followings are the indications of adrenaline in anaphylaxis:
1. Horseness of voice
2. Wheeze
3. Shortness of breath
4. Shock
5. Stridor
6. Swelling of the tongue and cheek
7. Facial swelling

Consider anaphylaxis when there is compatible history of rapid-onset severe allergictype reaction with respiratory difficulty and/or hypotension, especially if there are skin
changes present and the treatment of anaphylaxis is IM adrenaline not anti histamine
Adrenaline can be repeated after 5mins.

And since she is bitten by bee several times it a risk factor for anaphylaxis.
118. A term baby born to a 30yo woman of blood group A-ve develops severe jaundice
within the
first 24h of birth. What is the most likely dx?
a. Hereditary spherocytosis
b. G6PD
c. ABO incompatibility
d. Rh incompatibility
e. Physiological jaundice
Ans. The key is D. Rh incompatibility.
As mentioned in the Q116 neonatal jaundice within 24hrs of birth could be either
because of sepsis or Rh incompatibility.
Mother is always Rh- and the baby is Rh +. Fetal antigen crosses the placenta and the
mother produces the antibodies against the antigen. Which cross the placenta in
subsequent pregnancies as a result of secondary response (greater in magnitude) and
cause hemolysis of the fetal blood.
ABO incompatibility: (mother O; baby A or B, or mother A and baby B, or vice
versa) DCT +ve in 4%; indirect Coombs +ve in 8%. Maternal IgG anti-A or antiB haemolysin is always present
119. A 4yo girl is found to have bounding pulse and continuous machinery murmur.
What is the most probable dx?
a. TOF
b. ASD
c. VSD
d. PDA
e. CoA
Ans. The key is D. PDA.

Machinery murmur is the clincher for PDA.


VSD has a pansystolic murmur
ASD ejection systolic and fixed splitting
PDA PRESENTATION: Usually asymptomatic. Acyanotic disease. A large-shunt PDA
may cause lower respiratory tract infection as well as feeding difficulties and poor growth
during infancy, with failure to thrive because of heart failure.
ECHO IS DIAGNOSTIC
MANAGEMENT: Indomethacin can be used but not useful in term infants. Closure is
indicated if the patient is symptomatic at any stage of life or if asymptomatic but with
great left heart load.
Surgery is used where non surgical method can not be used. In asymptomatic infant we
wait till 1 yr for spontaneous closure of PDA if that does not occur it can be closed by
surgery at any time.
In preterms indomethacin or ibuprofen may be used.
Most common complication is infective endocarditis.

120. A 12yo child with episodes of sudden bluish discoloration and brief loss of
consciousness. Exam: clubbing, central cyanosis, systolic thrill with systolic ejection
murmur in 2nd left ICS. What is the most probable dx?
a. TOF
b. ASD
c. VSD
d. PDA
e. CoA
Ans. The key A. TOF.
ASD, VSD, PDA are all acyanotic congenital heart diseases. TOFF is the most common
cyanotic congenital heart disease that survives to adulthood.
Typical features:
1 Ventricular septal defect (VSD)
2 Pulmonary stenosis (most imp feature)
3 Right ventricular hypertrophy
4 The aorta overriding the VSD
During a hypoxic spell, the child becomes restless and agitated and may cry
inconsolably. Toddlers may squat, which is typical of TOF. Clubbing, difficulty of feeding,
failure to thrive all are features.
Chest Xray Shows BOOT SHAPED HEART. Echo is also done.
In acute stage give O2, place the child in knee chest position, give morphine. Surgery is
required within 1st yr of life otherwise mortality is 95%.
121. An 8yo child who is tall for his age and has a refractory error for which he wears
glasses has
presented with severe crushing chest pain. What is the most likely dx?
a. Fragile X syndrome
b. Prader-willi syndrome
c. DiGeorge syndrome
d. Marfans syndrome
Q. 1. What is the key?
Q. 2. What is the cause of this severe crushing chest pain?
Q. 3. What are the most common cardiac abnormalitis found in this disease?
Ans. 1. The key is D. Marfans syndrome.
Ans. 2. Cause of severe crushing chest pain may be aortic dissection.
Ans. 3. Most common cardiac abnormalities in Marfans syndrome are: dilatation of the
aorta and mitral regurgitation.
Marfans syndrome diagnosis:
Major criteria (diagnostic if >2): Lens dislocation (ectopia lentis) aortic dissection or
dilatation; dural ectasia; skeletal features: arachnodactyly (long spidery fingers),
armspan > height, pectus deformity, scoliosis, pes planus. Minor signs: Mitral valve
prolapse, high-arched palate, joint hypermobility. Diagnosis is clinical.
DANGER IS AORTIC DISSECTION. Surgery is done when aorta >5cm
Can also cause pneumothorax.
122. A 4yo child presents with pain of spontaneous onset in his knee of 2 days duration.
He has
developed mild fever in the 2nd day. He can walk but has a limp. Exam: painful restriction
in the

right hip. What is the most probable dx?


a. Osteosarcoma
b. Septic arthritis
c. TB arthritis
d. Exostosis
e. Osteomyelitis
Q. 1. What is the key?
Q. 2. What are the points in favour of your diagnosis?
Ans. Given key is E. Osteomyelitis which is a wrong key. The correct answer is B. Septic
arthritis.
Ans. Points in favour of diagnosis: i) Pain in joints (knee and hip) ii) Fever iii) Painful
restricted movement of joint.
Not sure about the correct answer here. But i think osteomyelitis.
Osteomyelitis mostly has a primary source of infection via which the infection spreads to
bone.
PRESENTATION: Pain of gradual onset over the course of a few dayswith
tenderness,
warmth, and erythema at the affected part; unwillingness to move. Vertebrae and distal
femur mostly affected.
Diagnosis: FBC, ESR, CRP, blood culture. Bone biopsy and culture is gold standard.
Staph aureus (MR the most common organism found.)
Treatment Drain abscesses and remove sequestra by open surgery. Antibiotics:
vancomycin 1g/12h and cefotaxime 1g/12h IVI until the organism and its sensitivities are
known. Fusidic acid or clindamycin can also be used.
Septic Arthritis: Exclude septic arthritis in any acutely inflamed joint, as it can destroy a
joint
in under 24h. Knee & hip joint are most commonly involved.
Risk factors for septic arthritis include:
Increasing age
Diabetes mellitus
Rheumatoid arthritis
Joint surgery
Hip or knee prosthesis
Skin infection in combination with joint prosthesis
Infection with HIV
Diagnosis: Urgent joint aspiration for synovial fluid microscopy and culture is
the key investigation. The joint is usually swollen, warm, tender and exquisitely painful
on movement.
Flucloxacillin or clindamycin as empirical treatment.
123. A man with anterior resection and end to end anastomosis done complains of
severe pain in the chest and abdominal distension. What is the most appropriate inv
likely to review the cause this deterioration?
a. XR abdomen
b. Exploratory laparoscopy
c. CT
d. US
e. Laparotomy
Ans. The key is E. Laparotomy. [diagnostic and therapeutic].

124. Pt with hx of alcoholism, ataxic gait, hallucinations and loss of memory. He is given
acamprosate. What other drug can you give with this?
a. Chlordiazepoxide
b. Thiamine
c. Diazepam
d. Disulfiram
e. Haloperidol
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of diagnosis?
Ans. 1. The key is B. Thiamine.
Ans. 2. The diagnosis is Wernickes encephalopathy.
Ans. 3. Points in favour of diagnosis: i) history of alcoholism ii) ataxic gait iii)
hallucination iv) memory loss.
Thiamine (vitamin B1) deficiency with a classical triad of 1 confusion 2 ataxia (widebased gait) and 3 ophthalmoplegia (nystagmus, lateral rectus or conjugate gaze
palsies). Always
consider this diagnosis in alcoholics: it may also present with memory disturbance.
TREATMENT: early treatment is essential to prevent progression to the irreversible
Korsakoff syndrome. Alcoholics can present with hypoglycemia so make sure you give
thiamine BEFORE glucose as glucose can precipitate wernickes encaph.
125. A 35yo male builder presented with sudden onset of severe abdominal pain. He
was previously fit and well other than taking ibuprofen for a long term knee injury. On
examination he is in severe pain, pulse=110bpm, BP=110/70mmHg and has a rigid
abdomen. What is the most likely dx?
a. Biliary peritonitis
b. Ischemic colon
c. Pancreatic necrosis
d. Perforated diverticulum
e. Perforated peptic ulcer
Ans. The key is E. Perforated peptic ulcer. [NSAIDs induced perforation].

Peritonitis (Perforation of peptic ulcer/duodenal ulcer, diverticulum, appendix,


bowel, or gallbladder) Signs: prostration, shock, lying still, +ve cough test tenderness (
rebound/percussion pain), board-like abdominal rigidity, guarding and no bowel sounds.
Erect CXR may show gas under the diaphragm.
NB: acute pancreatitis causes these signs, but does not require a laparotomy
so dont be caught out and always check serum amylase
126. A woman 5 days post-op for bilateral salphingo-oopherectomy and abdominal
hysterectomy has developed abdominal pain and vomiting a/w abdominal distension and
cant pass gas. No bowel sounds heard, although well hydrated. What is the most
appropriate next step?
a. XR abdomen
b. Exploratory laparoscopy
c. CT
d. USG
e. Barium enema

Q. 1. What is the key?


Q. 2. What is the diagnosis?
Q. 3. What are the causes of it?
Q. 4. What is the management?
Ans. 1. The key is A. X-ray abdomen.
Ans. 2. The diagnosis is paralytic ileus.
Ans. 3. Causes of paralytic ileus: i) electrolyte imbalance ii) gastroenteritis iii)
appendicitis iv) pancreatitis v) surgical complications and vi) certain drugs.
Ans. 4. Management of paralytic ileus: i) nil by mouth ii) nasogastric suction to alleviate
the distension and remove the obstruction.
Bowel sounds are absent in paralytic ileus But bowel sounds are exaggerated in
mechanical obstruction.

Ileus and incomplete small bowel obstruction can be conservatively managed while
strangulation large bowel obstruction requires surgery.
CT can confirm the level of obstruction.
127. A 30yo man complains of hoarseness of voice. Exam: unilateral immobile vocal
cord. What is the most probable dx?
a. Graves disease
b. Hematoma
c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Tracheomalacia
Ans. The key is C. unilateral recurrent laryngeal nerve injury.
Causes: 30% are cancers (larynx in ~40%; thyroid, oesophagus, hypopharynx,
bronchus, or malignant node). 25% are iatrogenic, ie after parathyroidectomy. Other
causes: CNS disease (polio; syringomyelia); TB; aortic aneurysm;
Symptoms: Symptoms of vocal cord paralysis are:
Hoarseness with breathy voice with a weak cough.
Repeated coughing/aspiration (weak sphincter + supraglottic sensation).
Exertional dyspnoea (glottis is too narrow to allow much air flow).
Nerve damaged with injury of superior thyroid artery: External laryngeal nerve
Nerve damaged with injury to inferior thyroid artery: Recurrent laryngeal nerve

128. A 38yo woman has delivered after an induced labor which lasted 26h. choose the
single most likely predisposing factor for postpartum hemorrhage?
a. Atonic uterus
b. Cervical/vaginal trauma
c. Rupture uterus
d. Fibroid uterus
e. Age of mother
Ans. The key is A. Atonic uterus.
Primary PPH is the loss of greater than 500mL (definitions vary) in the first 24h after
delivery

Causes: uterine atony (90%), genital tract trauma (7%), clotting disorders (3%)

Risks: Antenatal Previous PPH or retained placenta BMI>35kg/m2 Maternal


Hb<8.5g/dl at onset of labour Antepartum haemorrhage Multiparity 4+ Maternal age
35y+ Uterine malformation or fibroids A large placental site (twins, severe rhesus
disease, large baby) Low placenta, Overdistended uterus (polyhydramnios, twins)
Extravasated blood in the myometrium (abruption).
In labour Prolonged labour (1st, 2nd or 3rd stage) Induction or oxytocin use
Precipitant labour Operative birth or caesarean section. Book mothers with risk factors
for obstetric unit delivery.
Treatment: Give oxytocin 5U slowly IV for atonic uterus.
Attach oxygen, Give IV fluids, maintain systolic >100mmHg, Transfuse blood.
Is the placenta delivered? If it is, is it complete? If not, explore the uterus. If the
placenta is complete, put the patient in the lithotomy position with adequate analgesia and
good lighting. Check for and repair trauma.
If the placenta has not been delivered but has separated, attempt to deliver it by
controlled cord traction after rubbing up a uterine contraction. If this fails, ask an
experienced obstetrician to remove it under general anaesthesia.Beware renal shut down.
129. A 32yo woman in tears describing constant irritability with her 2 small children and
inability to relax. She describes herself as easily startled with poor sleep and disturbed
nightmares following a house fire a year ago, while the family slept. What is the single
best tx?
a. Rassurance
b. Relaxation therapy
c. Quetiapine
d. Lofepramine
e. Fluoxetine
Q. 1. What is the key
Q. 2. What is the diagnosis?
Q. 3. What are the points in favour of your diagnosis?
Ans. 1 The key is E. Fluoxetine. The key is probably a wrong key. Likely correct key is B.
Relaxation therapy
Ans. 2. The diagnosis is post traumatic stress disorder.
Ans. 3. Points in favour of PTSD: i) H/O stressor (house fire a year ago) ii) Nightmares of
the stressor iii) Hyper arousal (very anxious and inability to relax (leading to irritability) iv)
associated depression (poor sleep, tearful).
Note: Fluoxetin and peroxetin are the drugs of choice in PTSD. CBT is the nonpharmacological treatment.
PTSD:
Symptoms: Fearful; horrified; dazed Helpless; numb, detached Emotional
responsiveness
Intrusive thoughts Derealization Depersonalization Dissociative amnesia Reliving
of events Avoidance of stimuli Hypervigilance Lack of Concentration Restlessness
Autonomic arousal: pulse; BP; sweating Headaches; abdo pains
Signs: Suspect this if symptoms become chronic, with these
signs (may be delayed years): difficulty modulating arousal; isolated-avoidant modes of
living; alcohol abuse; numb to emotions and relationships; survivor guilt; depression;
altered world
view in which fate is seen as untamable, capricious or absurd, and life can yield no
meaning

or pleasure.
Treatment: Watchful waiting for mild cases.
For severe cases: CBT or eye movement desensitization and reprocessing is done.
Drug treatment is not recommended but in case it is needed prescribe mirtazapine or
paroxetine.
So i agree in this question it is PTSD and B should be the answer.
130. A 22yo woman with longstanding constipation has severe ano-rectal pain on
defecation. Rectal exam: impossible due to pain and spasm. What is the most probable
dx?
a. Anal hematoma
b. Anal fissure
c. Anal abscess
d. Protalgia fugax
e. Hemorrhoids
Ans. The key is B. Anal fissure.

Anal fissures: Acute If less than 6weeks, >6wks chronic.


Causes: Most are due to hard faeces. Spasm may constrict the inferior rectal artery,
causing ischaemia, making healing difficult and perpetuating the problem.
History of constipation almost always present. Examination is almost impossible due to
severe pain.
Treatment: Acute: Increase fluid intake, fiber diet. Bulk forming laxatives are first line.
Topical anesthetics are used. Lactulose can be tried.
Chronic: Topical GTN is the first line and mainstay of treatment. If ineffective for
>8wks surgical referral for use of botulinum toxin.
131. A 20yo student attends the OPD with complaint of breathlessness on and off,
cough and sputum. His sleep is disturbed and skin is very dry in flexural areas of the
body. Exam: tachypnea, hyperresonant percussion and wheezing on auscultation. What
is the most likely dx?
a. Extrinsic allergic alveolitis
b. Asthma
c. Wegeners granulomatosis
d. COPD
e. Cystic fibrosis
Q. What is the key?
Q. What are the diagnostic criteria?
Ans. The key is B. Asthma.
Ans. 2. Diagnostic criteria of asthma: i) Airway hyper-responsiveness to certain stimuli ii)
Recurrent variable airflow limitation usually reversible iii) presents as wheezing,
breathlessness, chest tightness and cough.
ASTHMA.
Symptoms: Dyspnea, wheeze, cough (with or without sputum), chest tightness (4 most
important) particularly if symptoms are worse at night or early morning and in response
to certain triggers like cold, exercise, allergens. Symptoms exacerbated by use of

NSAIDs and Beta blockers. Mostly there is history of allergy (atopy) as in this question
there is history of dry skin. Try to find the precipitating factor.
Signs Tachypnoea; audible wheeze; hyperinflated chest; hyperresonant percussion
note; reduced air entry ; widespread, polyphonic wheeze.

Management: CHRONIC (LONG TERM)

132. A pt with thought disorder washes hands 6x each time he uses the toilet. What is
the best
management?
a. Psychodynamic therapy
b. CBT
c. Antipsychotics
d. Refer to dermatology
e. Reassure
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. The key is B. CBT.
Ans. 2. The diagnosis is obsessive compulsive disorder.
OCD:
Compulsions are senseless, repeated rituals. Obsessions are stereotyped, purposeless
words, ideas, or phrases that come into the mind.
Repetitive behavior and an urge to do it.
Treatment: CBT is first line. Clomipramine (start with 25mg/day PO) or SSRIs (eg
fluoxetine)
133. A 25yo woman presented to her GP on a routine check up. Upon vaginal exam, she
was fine except for finding of cervical ectropion which was painless but mild contact
bleeding on touch. What is the next management?
a. Endometrial ablation
b. Cervical smear
c. Colposcopy
d. Antibiotics
e. Vaginal US
f. Pack with gauze and leave to dry
Q. 1. What is the key?
Q. 2. Points in favour of key.
Ans. 1. The key is D. Antibiotics. WRONG KEY!
Ans. 2. Points in favour of antibiotic: Ectropion and contact bleeding can occur in
infection. In the given case swab is taken to establish or rule out infection. As this is not
in options then the best response is antibiotics. If improves with antibiotics then repeat
smear in 6 months.
There is a red ring around the os because the endocervical epithelium has extended its
territory over the paler epithelium of the ectocervix. Ectropions extend temporarily under
hormonal influence during puberty, with the combined Pill, and during pregnancy. As
columnar epithelium is soft and glandular, ectropion is prone to bleeding, to excess
mucus production, and to infection. Treatment: Once a normal cervical smear has
been confirmed, it is actively managed only if there are symptoms. After stopping any
oestrogen-containing contraceptive, treatment options are controversial but include
diathermy, cryotherapy, surgery with laser treatment and microwave therapy.
SO THE CORRECT ANSWER IS B.
134. A 32yo had a normal vaginal delivery 10 days ago. Her uterus has involuted
normally. Choose the single most likely predisposing factor for PPH?

a. Retained product
b. DIC
c. Uterine infection
d. Von Willebrand disease
e. Primary PPH
Q. 1. What is the key?
Q. 2. What type of PPH it would be?
Ans. 1. The key is C. uterine infection.
Ans. 2. Secondary PPH
Loss of >500ml blood in the first 24hrs after delivery is PRIMARY PPH.
Secondary PPH: This is excessive blood loss from the genital tract after 24h from
delivery. It usually occurs between 5 and 12 days and is due to infections (most common
cause) (endometritis) or retained placenta.
Look for history of extended labour, difficult third stage, ragged placenta, PPH.
Symptoms: Abdominal pain. Offensive smelling lochia. Abnormal vaginal bleeding PPH. Abnormal vaginal discharge. Dyspareunia. Dysuria.

Signs: are those of sepsis. Tachycardia, fever, rigors, suprapubic tenderness.


Treatment: For endometritis: IV antibiotics if there are signs of severe sepsis. If less
systemically unwell, oral treatment may be sufficient. Piperacilin and tazobectum may be
used.
If RPOC are suspected, elective curettage with antibiotic cover may be required. Surgical
measures should be undertaken if there is excessive or continuing bleeding, irrespective
of ultrasound findings
135. A 37yo man slipped while he was walking home and fell on his out stretched hand.
He complains of pain in the right arm. XR showed fx of the head of radius. What is the
single most associated
nerve injury?
a. Radial nerve
b. Musculocutaneous nerve
c. Median nerve
d. Ulnar nerve
Q. 1. What is the key?
Q. 2. What is the root value?
Ans. 1. The key is A. Radial nerve.
Ans. 2. Root value of radial nerve: C5,6,7,8 and T1.

136. A butcher stabbed accidently his groin. He bled so much that the towel was soaked
in blood and BP=80/50mmHg, pulse=130bpm. What % of circulatory blood did he lose?
a. <15%
b. 15-30%
c. 30-40%
d. 40-50%
e. >50%
Q. 1. What is the key?
Q. 2. What is the classification of blood loss according to vital sign?
Ans. 1. The key is C. 30-40%
Ans. 2. Hypovolemic shock Classification:
1. Class 1 up to 15% of blood volume lost: pulse <100; systolic BP normal; pulse
pressure normal; Respiratory rate 14-20; urine output greater than 30 ml/hour.
2. Class 2 15%-30% blood volume lost: pulse 100-120; systolic blood pressure
normal; pulse pressure decreased; respiratory rate 20-30; urine output 20-30 ml/hour.
3. Class 3 30%-40% blood volume lost: pulse 120-140; systolic BP decreased; pulse
pressure decreased, respiratory rate 30-40; urine output 5-15 ml/hr
4. Class 4, blood loss of greater than 40%: pulse rate >140; systolic BP decreased;
pulse pressure decreased respiratory rate >35; urine output negligible.

137. A 67yo man presents with palpitations. ECG shows an irregular rhythm and
HR=140bpm. He is otherwise stable, BP=124/80 mmHg. What is the most appropriate
management?
a. Bisoprolol
b. ACEi
c. Ramipril
d. Digoxin
Ans. The key is A. Bisoprolol.
The patient has Atrial fibrillation. Irregularly irregular pulse and tachycardia.
Agents used to control rate in patients with atrial fibrillation
beta-blockers
calcium channel blockers
digoxin (not considered first-line anymore as they are less effective at controlling
the heart rate during exercise. However, they are the preferred choice if the
patient has coexistent heart failure)
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide,
propafenone, quinidine
TREATMENT CHOICE:

In the given question since the patient is above the age of 65 so rate control is
done! For which either a beta blocker or calcium channel blocker is used!
138. A 78yo man is depressed after his wifes death. He has been neglecting himself.
His son found him in a miserable state when he went to visit. The son cant deal with his
father. What is the appropriate management?
a. Voluntary admission to psychiatry ward
b. Hand over to social worker
c. Request son to move in with father
d. Send pt to care home
Ans. The key is A. Voluntary admission to psychiatry ward.
139. An old alcoholic presents with cough, fever, bilateral cavitating consolidation. What
is the most probable cause?
a. Gram +ve diplococcic
b. Coagulase +ve cocci
c. Gram ve cocci
d. AFB
e. Coagulase ve cocci
Q. 1. What is the key?
Q. 2. What is the organism?
Ans. 1. The key is B. Coagulase +ve cocci.
Ans. 2. Name of organism is Staphylococcus aureus.

Legionella: hotel stay, foreign travel, flu like symptoms, hyponatremia, pleural effusion.
TEST: urinary antigen. CXR shows bi-basal consolidation

Mycoplasma Pneumonae: Rash (erythema multiforme), unusual symptoms (abd pain, dry
cough), long duration of symptoms, hyponatremia, Diagnosis by serology. CXR: reticularnodular shadowing or patchy consolidation


Staphylococcal pneumonia may complicate influenza infection and is seen most
frequently in the elderly and in intravenous drug users or patients with underlying disease. Shows
bilateral cavitations.

Pneumonia associated with COPD: H.influenze (more likely) or P.aeruginosa

P.aeruginosa: Common in bronchiectasis or CF. Also causes hospital acquired infection.

Klebsiella pneumoniae is classically in alcoholics

Strept pneumonia: Associated with herpes labialis. commoner in the elderly,


alcoholics, post-splenectomy, immunosuppressed and patients with chronic heart failure
or pre-existing lung disease

Pneumocystis pneumonia (PCP) causes pneumonia in the immunosuppressed


(eg HIV). CXR may be normal or show bilateral perihilar interstitial shadowing.
Diagnosis: visualization of the organism in induced sputum, bronchoalveolar lavage, or
in a lung biopsy specimen

SO i think it is either klebsiella (gram - rod) or streptococcus as these are the ones
common in alcoholics but bilateral cavitations do point in favor of staphylococcus.
140. A 67yo man had successful thrombolysis for an inf MI 1 month ago and was
discharged after 5 days. He is now re admitted with pulmonary edema. What is the most
probable dx?
a. Aortic regurgitation
b. Ischemic mitral regurgitation
c. Mitral valve prolapse
d. Pulmonary stenosis
e. Rheumatic mitral valve stenosis
Ans. The key is B. Ischaemic mitral regurgitation. [ Causes of Ischaemic mitral regurgitation: left
ventricular remodeling and dysfunction, annular dilation/dysfunction, and mechanical dyssynchrony].

Complications OF MI:
Cardiac arrest
Unstable angina
Bradycardias or heart block
cardiogenic shock
Tachyarrhythmias:
Consider implantable cardiac defibrillator
Right ventricular failure (RVF)/infarction
Pericarditis
DVT & PE:
Systemic embolism:
Cardiac tamponade
Mitral regurgitation
Ventricular septal defect
Late malignant ventricular arrhythmias
Dresslers syndrome
Left ventricular aneurysm
Mitral regurgitation: May be mild (minor papillary muscle dysfunction) or severe
(chordal or papillary muscle rupture or ischaemia). Presentation: Pulmonary oedema.
Treat LVF and consider valve replacement.

141. A 60yo lady who had stroke 3 years ago now reports having increased dyspnea on
exertion and atrial fibrillation. CXR: straight left border on the cardiac silhouette. What is
the most probable
dx?
a. Aortic regurgitation
b. Ischemic mitral regurgitation
c. Mitral valve prolapse
d. Pulmonary stenosis
e. Rheumatic mitral valve stenosis
Q. 1. What is the key?
Q. 2. What are the points in favour of your answer?
Ans. 1. The key is E. Rheumatic mitral valve stenosis.
Mitral Stenosis: Presentation: dyspnoea; fatigue; palpitations; chest pain; systemic
emboli; haemoptysis; chronic bronchitis-like picture
CAUSES: Rheumatic, congenital, mucopolysaccharidoses, endocardial fibroelastosis,
malignant carcinoid (rare), prosthetic valve.
SIGNS: Malar flush on cheeks (due to inc cardiac output); low-volume pulse; AF
common;
tapping, non-displaced, apex beat (palpable S1). On auscultation: loud S1; opening
snap (pliable valve); rumbling mid-diastolic murmur (heard best in expiration,
with patient on left side
ECG show P-mitrale ECHO is diagnostic. CXR: left atrial enlargement
(double shadow in right cardiac silhouette)
TREATMENT: balloon valvuloplasty (if pliable, non-calcified valve), open mitral
valvotomy
or valve replacement.
Complications: Pulmonary hypertension, emboli, pressure from large LA on local
structures, eg hoarseness (recurrent laryngeal nerve), dysphagia (oesophagus),
bronchial obstruction; infective endocarditis
Ans. 2. Points in favour: i) Dyspnoea on exertion ii) Straight left border of the cardiac
silhouette. Iii) Atrial fibrillation is a common association.
142. A 60yo diabetic complains of pain in thigh and gluteal region on walking up the
stairs for the last 6 months. She is a heavy smoker and has ischemic heart disease.
What is the most appropriate dx?
a. Thromboangitis Obliterans
b. Sciatica
c. DVT
d. Atherosclerosis
e. Embolus
Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is D. Atherosclerosis.
Ans. 2. i) It is not sciatica as sciatica pain is worse when sitting. There may be
weekness, numbness, difficulty moving the leg or foot. A constant pain on one side of
the rear. A shooting pain that makes it difficult to stand up. ii) It is not DVT as no
swelling, warmth or redness of skin are there iii) It is not thromboangitis obliterans as
pulses are ok, no colour change or reduced hair growth, no ulceration or gangrene iv) no
embolism as no pain (rest pain), no numbness, no redness or itching or rash, no
ulceration of skin.

This patient has intermittent claudication due to atherosclerosis,

Symptoms Cramping pain is felt in the calf, thigh, or buttock after walking for a given
distance (the claudication distance) and relieved by rest. Ulceration, gangrene, and foot
pain at resteg burning pain at night relieved by hanging legs over side of bedare the
cardinal features of critical ischaemia.
Fontaine classification for peripheral arterial disease: 1. Asymptomatic 2. Intermittent
claudication 3.Ischaemic rest pain 4. Ulceration/gangrene (critical ischaemia)
Signs: Absent femoral, popliteal or foot pulses; cold, white leg(s); atrophic skin;
punched out ulcers (often painful); postural/dependent colour change; a vascular
(Buergers) angle of <20 and capillary filling time >15s are found in severe ischaemia
Imaging: Colour duplex USS is 1st line (non-invasive and readily available). If
considering
intervention then MR/CT angiography
MANAGEMENT: Stop smoking, exercise, treat HTN, antiplatelet (clopidogrel). Advise
exercise until maximum tolerable pain.
Vasoactive drugs may be used. If PAD is advancing consider:
Percutaneous transluminal angioplasty (PTA) is used for disease limited to a single
arterial segment.
Surgical reconstruction: arterial bypass
Amputation. If all fail. Knee should be saved if possible.
143. A 3yo child who looks wasted on examination has a hx of diarrhea on and off. The
mother
describes the stool as bulky, frothy and difficult to flush. What is the single inv most likely
to
lead to dx?
a. Sweat chloride test
b. Anti-endomysial antibodies
c. LFT
d. US abdomen
e. TFT
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. The key is B. Anti-endomysial antibody
Ans. 2. The diagnosis is celiac disease.
Coeliac Disease: Suspect this in all those with diarrhoea + weight loss or anaemia (esp.
if iron or B12). It is a T-cell-mediated autoimmune disease of the small bowel in which
prolamin
(alcohol-soluble proteins in wheat, barley, rye oats) intolerance causes villous atrophy
and malabsorption (including of bile acids)

Investigations: FBC, Dec feritin, dec vit.B12


Antibodies: alpha -gliadin, transglutaminase and anti-endomysial 95% specific. Duodenal
biopsy shows subtotal villous atrophy.

Treatment Lifelong gluten-free diet


144. A 45yo woman has had severe epigastric and right hypochondrial pain for a few
hours. She has a normal CBC, serum ALP is raised, normal transaminase. 3 months
ago she had a
cholecystectomy done. What is the most appropriate inv?
a. US abdomen
b. ERCP
c. MRCP
d. CT abdomen
e. Upper GI endoscopy
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. The key is B. ERCP.
Ans. 2. Diagnosis is choledocolithiasis.
Right upper quadrant pain think of gall stones. And since the LFTs here show
obstructive picture ALP increased with normal transaminases the obstruction is most
probably in the biliary tract CBD.
ERCP: Endoscopic retrograde cholangiopancreatography (ERCP)
Indications: No longer routinely used for diagnosis, it still has a significant therapeutic
role: sphincterotomy for common bile duct stones; stenting of benign or malignant
strictures and obtaining brushings to diagnose the nature of a stricture.
MRCP: MRCP (magnetic resonance cholangiopancreatography) gives detail of the
biliary system and the pancreatic duct. MRCP has excellent sensitivity and specificity for
diagnosing common bile duct stoneswhen these are >6mm both are 99% (although
accuracy is lower for stones <6mmand is the imaging modality of choice.
But here since we need to remove the stones as well so we use ERCP.
145. A 53yo woman presented with pain in the eye, blurry vision and clumsiness for 3
months. She has a hx of difficulty in swallowing and weakness in her right upper limb 2y
ago. What is the inv of choice?
a. CSF analysis
b. EEG
c. EMG
d. MRI brain
e. Visual evoked response test
Q. What is the key?
Q. What is the diagnosis?
Ans. 1. The key is D. MRI brain.
Ans. 2. Diagnosis is multiple sclerosis.

Multiple sclerosis: Discrete plaques of demyelination occur at multiple CNS sites. Early
exposure to sunlight/vit. D is important, and vit. D status relates to prevention of MS,
PRESENTATION: Usually monosymptomatic: unilateral optic neuritis (pain on
eye

movement and rapid central vision); numbness or tingling in the limbs; leg
weakness; brainstem or cerebellar symptoms (eg diplopia, ataxia). The disease
has a relapsing - remitting course.

INVESTIGATIONS: This is clinical, as no test is pathognomonic. MRI is sensitive


but not specific for plaque detection.
CSF: Oligoclonal bands of IgG on electrophoresis suggest CNS inflammation but
does not confirm MS.. Delayed visual, auditory, and somatosensory evoked
potentials.
MANAGEMENT: Stress free life. Give vit. D to achieve serum 25(OH)D levels of
50nmol/L
Methylprednisolone shortens relapse doesnt alter overall prognosis.
Beta interferon reduces replaces by 30% but does not reduce overall disability
Monoclonal antibodies: Alemtuzumab and natalizumab reduce relapses by 68%.
Glatiramer in secondary progressive
Azathioprine in relapsing-remiting
Palliation: Spasticity: Baclofen, diazepam, dantrolene or tizanidine.
Tremor: Botulinum toxin
Urgency/frequency: If post-micturition residual urine >100mL, teach intermittent selfcatheterization; if <100mL, try tolterodine
146. A 55yo male presents with malaise and tiredness. Exam: spleen approaching RIF,
no
lymphadenopathy. Choose the single cell type?
a. Helmet shaped cell
b. Sickle cell
c. Granulocyte without blast cells
d. Blast cells
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the diagnostic features?

diagnosis is CML.
Ans. 1. The key is C. Granulocyte without blast cells.
Ans. 2. The diagnosis is CML.
Ans. 3. Diagnostic features are i) increased number of mature granulocytes ii) huge
splenomegaly.
Causes of Splenomegaly: If massive, think of: chronic myeloid leukaemia,
myelofibrosis, malaria (or leishmaniasis)

Splenomegaly with fever Infection (malaria, SBE/IE hepatitis, EBV,TB, CMV,


HIV)
With lymphadenopathy Glandular fever, leukemia/lymphoma, Sjogrens syndrome
With purpura Septicemia, typhus, DIC, amyloid, meningococcemia
CML: It is a myeloproliferative disorder, common ge of occurence is 40-60 years.
Philadelphia chromosome (Ph) Present in >80% of those with CML t(9:22)
Symptoms Mostly chronic and insidious: weightloss, tiredness, fever, sweats.
There
may be features of gout (due to purine breakdown), bleeding (platelet
dysfunction),
and abdominal discomfort (splenic enlargement). ~30% are detected by chance.
Signs Splenomegaly (>75%)often massive. Hepatomegaly, anaemia, bruising (fi
g 2).
Tests WBC increased (often >100109/L) with whole spectrum of myeloid cells,
ie increased neutrophils, myelocytes, basophils, eosinophils. Hb dec or normal,
platelets variable. Urate increased B12increased. Bone marrow hypercellular.
Treatment: is by chemotherapy or stem cell transplantation.
147. A 6yo pt comes with easy bruising in different places when she falls. CBC:
WBC=25, Hgb=10.9, Plt=45. Her paul brunnel test +ve. What is the most likely dx?
a. Glandular fever
b. ITP
c. Trauma
d. NAI
e. Septicemia
Q. 1. What is the key?
Q. 2. What are the lab. Values that suggests the diagnosis here?
Ans. 1. The key is A. Glandular fever.
Ans. 2. Suggestive lab. Values: WBC=25 (leucocytosis), Hgb=10.9 (usually patient is not
anaemic), Plt=45 (thrombocytopenia-leading to easy bruising), Positive paul bunnel test.

INFECTIOUS MONONUCLEOSIS
Caused by EBV, spread by saliva or droplets. EBV also causes certain cancers
(Hogdkins, burkitts and nasopharyngeal CA)
Symptoms: Sore throat, inc T, anorexia, malaise, lymphadenopathy (esp.
posterior
triangle of neck), palatal petechiae, splenomegaly, fatigue/mood
Blood film Lymphocytosis and atypical lymphocytes (large, irregular nuclei)

Heterophil antibody test (Monospot, Paul Bunnell) 90% show heterophil


antibodies by 3wks, disappearing after ~3 months PCR may also be done.
Treatment: None usually needed.Avoid contact sports for 8 weeks. Avoid
alcohol. Steroid or acyvlovir may be given but there is not much benefit.
Never give ampicillin or amoxicillin for sore throats as they often cause a severe
rash in those with acute EBV infection
148. A 41yo woman who has completed her family, has suffered from extremely heavy
periods for many years. No medical tx has worked. She admits that she would rather
avoid open surgery.
After discussion, you collectively decide on a procedure that wouldnt require open
surgery or
GA. Select the most appropriate management for this case.
a. Endometrial ablation
b. Hysterectomy
c. Fibroid resection
d. Myomectomy
e. Uterine artery embolization
Ans. The key is uterine artery embolization.
Treating menorrhagia Drugs Progesterone-containing IUCDs, eg Mirena
should be considered 1st line treatment for those wanting contraception.
effective for bleeding and also reduce the size of fibroid uterus.
2nd line recommended drugs are antifibrinolytics, antiprostaglandins or the
Pill. Antifibrinolytics Taken during bleeding these reduce loss (by 49%)eg
tranexamic acid CI: thromboembolic disease
Antiprostaglandins eg mefenamic acid 500mg/8h PO pc (CI: peptic ulceration) taken
during
days of bleeding particularly help if there is also dysmenorrhoea. COCP can also be
used if they are not contraindicated..
3rd line recommendation is progestogens IM or norethisterone
Rarely gonadotrophin (LHRH) releasing hormones are used
Surgery Endometrial resection is suitable for women who have completed
their families and who have <10wk size uterus and fibroids <3cm. Contraception will be
required. For women wishing to retain fertility who have fibroids >3cm consider uterine
artery embolization or myomectomy
Women not wishing to retain fertility, with a uterus >10wk size and fibroids >3cm may
benefit from hysterectomy, vaginal hysterectomy being the preferred route.
149. A girl with hx of allergies visited a friends farm. She got stridor, wheeze and
erythematous rash. What is the most appropriate tx?
a. 0.25ml IM adrenaline
b. 0.25ml PO adrenaline
c. 0.25ml IM adrenaline
d. IV chlorphearamine
Ans. The key is A. 0.25 ml IM adrenaline [Presence of stridor and wheeze are
suggestive of anaphilaxis and treatment option is adrenaline].
Consider anaphylaxis when there is compatible history of rapid-onset severe allergictype reaction with respiratory difficulty and/or hypotension, especially if there are skin
changes present and the treatment of anaphylaxis is IM adrenaline not anti histamine

Treatment:ABCDE, Oxygen, IM Adrenaline. <6yrs0.15ml, 6-12yrs 0.3ml, >12 yrs 0.5ml


1:1000
Since the age of the girl is not mentioned here and options A & C are the same so A or
C could be the answers supposing the girl was 6-12 yrs of age.
150. A 5yo boy is referred to the hospital and seen with his father who is worried that he
has been listless. He is not sure why his GP suggested he should come to the ED and is
keen to get some tablets and go home. Exam: tired and irritable, swelling around eyes.
Renal biopsy: remarkable
for podocyte fusion on EM. What is the most probable dx?
a. NAI
b. Myelodysplastic disease
c. HSP
d. Membranous GN
e. Minimal change GN
Ans. The key is E. Minimal change glomerulonephritis. [Podocyte fusion on electron
microscopy]
Most common cause of nephrotic in children is minimal change disease. There will be
hypoalbuminemia and peripheral edema too. Electron microscopy shows effacement of
podocyte foot processes.. MCD has albumin selective proteinuria. Treatment is with
steroids.
151. A 6yo boy is brought to the hospital for a 3rd episode of sore throat in 1 month. He is
found
bleeding from gums and nose and has pale conjunctiva. Whats the single cell type?
a. Clumped platelets
b. Microcytes
c. Granulocyte without blast cells
d. Blast cells
e. Mature lymphocytes
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. 3. What are the points that favour diagnosis?
Ans. 1. The key is D. Blast cells.
Ans. 2. The diagnosis is ALL
Ans. 3. Points in favour: i) Age-6yrs ii) recurrent infection (sorethroat) due to neutrpenia
and abnormal lymphoblasts which cannot protect from infection iii) thrombocytopenia
causing gum and nose bleeding. Iii) anaemia (pale conjunctiva) due to reduced red cell
production from marrow occupation by blast cells. [Here debate came why it is not
aplastic anaemia? There is no risk factor mentioned for this patient for aplastic anaemia.
There may be congenital aplastic anaemia but again it would present earlier in life. So it
goes more with leukaemia but it cannot be confirmed unless we do bone marrow
aspiration.]
ALL: This is a malignancy of lymphoid cells, affecting B or T lymphocyte cell lines,
arresting
maturation and promoting uncontrolled proliferation of immature blast
cells, with marrow failure and tissue infiltration.

Causes: Genetic susceptibility, environmental factors (ionizing radiations) Downs


syndrome.
Commonest cancer of childhood.

Signs and symptoms:


Marrow failure: Anaemia (Hb), infection (WCC), and bleeding (platelets).
Infiltration: Hepatosplenomegaly, lymphadenopathysuperficial or mediastinal,
orchidomegaly, CNS involvementeg cranial nerve palsies, meningism.
INVESTIGATIONS: Characteristic blast cells on blood film and bone marrow
CXR and CT scan to look for mediastinal and abdominal lymphadenopathy.
Lumbar puncture should be performed to look for CNS involvement.
TREATMENT: Blood transfusions, prophylactic antibiotics, IV antibiotics in case of
infection. Main stay of treatment is chemotherapy.
Prognosis Cure rates for children are 7090%; for adults only 40%
152. A 23yo man has been stabbed in the back and has SOB. The trachea is not
deviated, he has engorged neck veins and absent breath sounds on the right. What is
the most appropriate dx?
a. Tension pneumothorax
b. Cardiac tamponade
c. Simple pneumothorax
d. Hemothorax
e. Pleural effusion
Q. 1. What is the key?
Q. 2. What are the point in favour of your answer?
Ans. 1. The key is A. Tension pneumothorax.
Ans. 2. Points in favour: i) Stab wound in the back ii) SOB iii) Engorged neck vein iv)
Absent breath sound.
153. A 44yo pt comes with right hemiparesis. Exam: left sided ptosis and left dilated
pupil. Where is the lesion?
a. Cerebral infarct
b. Cerebellar infarct
c. Medulla oblongata
d. Pons
e. Midbrain
Q. 1. What is the key?
Q. 2. What is the name of this condition?
Ans. 1. The key is E. Midbrain.
Ans. 2. Weber syndrome [presence of ipsilateral oculomotor nerve palsy and
contralateral hemiparesis or hemiplagia].
Ptosis + miosis = horners syndrome
CN3 nucleus lies in the midbrain.
Fore brain: CN 1,2
Mid brain: CN 3,4
Pons: CN 5,6,7,8
Medulla: CN 9,10,12

Ptosis + mydriasis= oculomotor nerve palsy.

Webers syndrome (superior alternating hemiplegia) Ipsilateral oculomotor


nerve palsy with contralateral hemiplegia, due to infarction of one-half of the midbrain,

after occlusion of the paramedian branches of the basilar or posterior cerebral


arteries
154. A 50yo man has a stab wound to his left anterior chest at the level of the 4th ICS. He
has a BP 80mmHg, pulse=130bpm. His neck veins are dilated and his heart sounds are
faint. His trachea is central. What is the most appropriate dx?
a. Cardiac tamponade
b. Diaphragmatic rupture
c. Fractured ribs
d. Tension pneumothorax
e. Traumatic rupture of aorta
Q. 1. What is the Key?
Q. What are the points in favour of your answer?
Ans. 1. The key is Cardiac tamponade.
Ans. 2. Points in favour: i) Systolic BP 80 mmHg ii) Pulse 130 bpm iii) Engorged neck
vein iv) Faint heart sounds v) Trachea is central.
Essence:Pericardial fluid collects intrapericardial pressure rises heart cannot
fill pumping stops.
Causes: Trauma, lung/breast cancer, pericarditis, myocardial infarct, bacteria, eg TB.
Signs: Falling BP, a rising JVP, and muffled heart sounds (Becks triad); JVP on
inspiration
(Kussmauls sign); pulsus paradoxus (pulse fades on inspiration) (also in severe
asthma). Echocardiography may be diagnostic. CXR: globular heart; left heart border
convex or straight; right cardiophrenic angle <90. ECG: electrical alternans
Management: Prompt pericardiocentesis. While waiting give O2, IV fluids, monitor ECG.
155. A 15yo boy has a soft painless swelling in the left scrotum, blue in color and can be
compressed. What is the most appropriate next step?
a. Analgesia
b. Antibiotic
c. Biopsy
d. Immediate surgery
e. Reassurance
Q. 1. What is the key?
Q.2. What is the name of this condition?
Ans. 1. The key is E. Reassurance.
Ans. 2. Name of the condition is Varicocele.
Testicular lump = cancer until proved otherwise.
Acute, tender enlargement of testis = torsion until proved otherwise
Diagnosing scrotal masses
Cannot get above inguinoscrotal hernia or hydrocele extending proximally
Separate and cystic epididymal cyst
Separate and solid epididymitis/varicocele
Testicular and cystic hydrocele
Testicular and solidtumour, haematocele, granuloma, orchitis, gumma. USS may help.
Varicocele Dilated veins of pampiniform plexus. Left side more commonly affected.
Often visible as distended scrotal blood vessels that feel like a bag of worms.
Patient may complain of dull ache. Associated with subfertility, but repair (via surgery

or embolization) seems to have little effect on subsequent pregnancy rates.


156. A 12yo pt presents with copious diarrhea. Exam: urine output=low, mucous
membrane=dry, skin turgor=low. What is the most appropriate initial management?
a. Antibiotic
b. Antimotility
c. Anti-emetic
d. Fluid replacement
e. Reassurance
Q. 1. What is the key?
Q. 2. What is the diagnosis and why?
Ans. 1. The key is D. Fluid replacement.
Ans. 2. Diagnosis is severe dehydration. Points in favour: i) low urine output ii) dry
mucous membrane and iii) low skin turgor.
Gastroenteritis Rotavirus is the most common cause of gastroenteritis in infants and
children.
Norovirus (most common cause in adults)
ASSESSMENT OF DEHYDRATION:
Mild dehydration: Decreased urine output.
5% dehydration: Dry mucous membranes; decreased urine output.
10% dehydration: The above + sunken fontanele, inc pulse; hoarse cry; dec skin turgor.
>10%: The above, but worse, with: shock, drowsiness, and hypotension.
MANAGEMENT
Mild: Treated at home by oral rehydrating therapy.
Moderate: Oral fluids, via NG or IV fluids can be used. Rapid rehydration involves 4
hours of
10mL/kg/h 0.9% NaCl then maintenance after if needed. Monitor U & Es
Severe: If not in shock oral or NG route can be used. If in shock. 0.9% saline 20mL/kg
IVI bolus, while calculations are performed. Continuously monitor pulse, BP, ECG.
Continue with boluses until the signs of shock ease.
Then give the daily requirement + fluid deficit
157. A 60yo smoker presents with cramp-like pain in the calves relieved by rest and nonhealing ulcers. Exam: cold extremities with lack of hair around the ankles, absent distal
pulses. What is the
most probable dx?
a. Intermittent claudication
b. Chronic ischemia of the limbs
c. Buergers disease
d. DVT
e. DM
Q. 1. What is the key?
Q. 2. Points that support your diagnosis.
Ans. 1. The key is B. Chronic ischaemia of the limb.
Ans. 2. Intermittent claudication is a symptom not diagnosis. It is not buergers disease
as buerger occur in more younger heavy smoker (before the age of 50yrs) mostly limited

to the extremities, It is not DVT as dvt pain or tenderness is not of an intermittent


claudication pattern. Again in DM there is no intermittent claudication.
158. An otherwise healthy 13yo boy presents with recurrent episodes of facial and
tongue swelling and abdominal pain. His father has had similar episodes. What is the
most likely dx?
a. C1 esterase deficiency
b. HIV
c. Mumps
d. Sarcoidosis
e. Sjogrens syndrome
Q. 1. What is the key?
Q. 2. What is the name of this condition?
Q. 3. Why it is not acquired?
Ans. 1. The key is A. C1 esterase inhibitor deficiency.
Ans. 2. Hereditary angioedema.
Ans. 3. Acquired angioedema usually manifest after the age of 40 yrs.
The oedema is triggered by increased permeability of the blood vessels.The net result is
episodes of massive local oedema, ie angio-oedema. (In angio-oedema, the swelling is
subcutaneous or submucosal rather than epidermal, so urticaria is absent.) It can mimic
anaphylaxis.
Type I has low levels of C1-INH (C1 esterase inhibitor) (the majority of cases).
Type II has impaired function of C1-INH.

Clinical features
Recurrent episodes of angio-oedema and/or abdominal pain - may involve: Laryngeal
oedema - can be fatal:

Pointers to a diagnosis of HAE are:


Family history.
Recurrent episodes of non-urticarial swelling lasting >24 hours, and
unresponsive to antihistamines.
Laryngeal oedema.

Recurrent, unexplained abdominal pain and vomiting.


Symptoms starting in childhood and worsening in adolescence.
The recommended initial tests are:
Serum complement factor 4 (C4) level.
C1 inhibitor (C1-INH) antigenic protein level.
C1-INH function (if available).
Management involves:
Emergency treatment of attacks
Patient education and awareness; may need own supply of emergency
treatment.
Good links with A&E departments.
Prophylaxis:
o Short-term cover for procedures - eg, dental treatment.
o Long-term prophylactic drugs if required.
o Avoidance of triggers.
Testing of family members is recommended owing to the potential seriousness of
an attack.
Drugs:
Plasma-derived C1-INH, A bradykinin receptor inhibitor, Antifibrinolytic drugs - eg,
tranexamic acid, Attenuated androgens - eg, danazol.

159. A 25yo had an LSCS 24h ago for fetal distress. She now complains of intermittent
vaginal
bleeding. Observations: O2 sat=98% in air, BP=124/82mmHg, pulse=84bpm,
temp=37.8C. The
midwife tells you that she had a retained placenta, which required manual removal in the
OT.
Choose the most appropriate C-Section complication in this case?
a. Retained POC
b. Aspiration pneumonitis
c. Endometritis
d. Uterine rupture
e. DIC
Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is C. Endometritis.
Ans. 2. More handling of tissue like manual removal of placenta, intermittent vaginal
bleeding and raised temperature points toward infective process like endometritis.
This is secondary PPH.
Secondary PPH: This is excessive blood loss from the genital tract after 24h from
delivery. It usually occurs between 5 and 12 days and is due to infections (most common
cause) (endometritis) or retained placenta.
Look for history of extended labour, difficult third stage, ragged placenta, PPH.
Symptoms: Abdominal pain. Offensive smelling lochia. Abnormal vaginal bleeding PPH. Abnormal vaginal discharge. Dyspareunia. Dysuria.

Signs: are those of sepsis. Tachycardia, fever, rigors, suprapubic tenderness.


Treatment: For endometritis: IV antibiotics if there are signs of severe sepsis. If less
systemically unwell, oral treatment may be sufficient. Piperacilin and tazobectum may be
used.
If RPOC are suspected, elective curettage with antibiotic cover may be required. Surgical
measures should be undertaken if there is excessive or continuing bleeding, irrespective
of ultrasound findings
160. A 30yo woman has brief episodes of severe shooting pain in the rectum. Rectal
examination and flexible sigmoidoscopy are normal. What is the most probable dx?
a. Anal hematoma
b. Anal fissure
c. Rectal carcinoma
d. Proctalgia fugax
e. Piles
Ans. is D. Proctagia fugax [normal rectal examination and flexible sigmoidoscopy
excludes other options].

Shooting pain mostly neuropathic pain.

Proctalgia fugax Idiopathic (could be because of spasm of muscles) , intense, brief,


stabbing/crampy rectal pain,often worse at night. Very short lived pain. The mainstay of
treatment is reassurance. Inhaled salbutamol or topical GTN (0.20.4%) or topical
diltiazem (2%) may help.
161. A 78yo male, DM and HTN, had a fall and since then is unable to walk. He presents
with
deformity and tenderness over the right hip area. XR=fx of femur neck. What is the
single most
associated nerve injury?
a. Sciatic nerve
b. Gluteal nerve
c. Lateral peroneal nerve
d. Tibial nerve
e. Femoral nerve
Ans. The key is A. Sciatic nerve.
Fractures of the femoral neck are far more common in the elderly but fractures of the
femoral shaft and supracondylar fractures most often occur in adolescents and young
adults. Hip fracture is the most common reason for admission to an orthopaedic trauma
ward. Intertrochanteric fractures affect the base of the femoral neck, May disrupt the
blood supply to the femoral head, leading to avascular necrosis.

Posterior dislocation of the hip

This is caused by major force to a flexed knee and hip - eg, when knees strike
the dashboard in a road traffic accident.
Posterior dislocations account for the majority of hip dislocations.
The affected leg is shortened and internally rotated with flexion and adduction at
the hip. This appearance may not occur if there is also a femoral shaft fracture.
Diagnosis is usually obvious on AP X-ray
Treatment: ABC, Pain management, reduction under GA. Allis technique

Complications
These include:
Sciatic nerve injury: pain in the distribution of the sciatic nerve, loss of sensation
in the posterior leg and foot and loss of dorsiflexion (peroneal branch) or plantar
flexion (tibial branch) of the foot.
Vascular injury: not as frequent as with anterior dislocations.
Avascular necrosis of the femoral head: risk increases the longer the hip is
dislocated.
Secondary osteoarthritis.
[1]

Anterior dislocation of the hip

This is much less common.


It causes pain in the hip and inability to walk or adduct the leg.
The leg is externally rotated, abducted, and extended at the hip.

Complications

These include damage to the femoral nerve, artery and vein:


Injury to the femoral nerve may occur, resulting in paralysis and numbness in the
femoral nerve distribution.
Injury to the femoral artery may produce arterial insufficiency in the leg

162. A 20yo man has a head on collision in a car. On presentation his is breathless, has
chest pain and fx of 5-7th rib. CXR confirms this. What is the most appropriate initial
action in this pt?
a. Antibiotics
b. Analgesia
c. O2 by mask
d. Physiotherapy
e. Refer to surgeon
Ans. The key is C. O2 by mask. [There was debate in this forum that pain relief should
be given first which will automatically relieve breathing problem. But others told O2 first].
O2 first is the correct answer!
[http://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=22&contentid
=flailchest]
ABCDE always comes first.
163. A 28yo man with complains of headache and nose bleeds also has pain in the
lower limbs on
exertion. Exam: radio-femoral delay, cold legs with weak pulse and mild systolic murmur
with
normal S1S2. What is the most probable dx?
a. TOF
b. ASD
c. VSD
d. PDA
e. CoA
Ans. The key is coarctation of aorta. [headache and nosebleeds - >hypertension, pain in
lower limb on exertion -> as reduced blood supply to leg due to coarctation, radiofemoral delay, cold legs with week pulse, mid-systolic murmur are all features of
coarctation of aorta].
Radio femoral delay is a clincher for coarctation of aorta.
Coarctation of the aorta Congenital narrowing of the descending aorta. More common
in boys.
Associations: Bicuspid aortic valve; Turners syndrome. Signs: Radiofemoral delay
(femoral pulse later than radial); weak femoral pulse; BP; scapular bruit; systolic
murmur (best heard over the left scapula).
Complications: Heart failure; infective endocarditis. Coarctation of the aorta is
associated with berry aneurysms which if ruptured cause Sub arachnoid hemorrhage.
Tests: CT or MRI-aortogram, CXR shows rib notching.
Cardiac catheterisation
To confirm the diagnosis when this is not clear at ultrasound.

To determine the gradient across the coarctation (with a gradient in excess of 20


mm Hg considered to be significant).
To assess other abnormalities and the overall haemodynamic picture when
considering therapeutic options in more detail.
Therapeutically using balloon angioplasty with or without stent implantation.

Treatment: Surgery or balloon dilatation stenting.


164. A 23yo male has a tonic clonic seizure whilst at college. His GCS is 12,
BP=120/77mmHg,
HR=99bpm. What is the most appropriate inv for his condition?
a. CT
b. MRI
c. Serum blood glucose
d. Serum drug levels
Ans. The key is C. Serum blood glucose [it is also possible that he may have taken drug,
even though first we have to do serum glucose as its presence can be very easily
managed and it needs urgent management to save life. If it is excluded then we can look
for other causes which may be not fatal in short time as hypoglycaemia].
This case will be treated as status epilepticus. Normally status occurs in a patient with
known epilepsy but here no such history is given. Even in a person who presents with
his first seizure we need to look for hypoglycemia first before going onto later tests.
Status epilepticus:
This means seizures lasting for >30min, or repeated seizures without intervening
consciousness.
Also consider eclampsia in mind if the patient is female and the abdomen is
distended.
Investigations
Bedside glucose, the following tests can be done once treatment has started: lab
glucose,
ABG, U&E, Ca2+, FBC, ECG.
Consider anticonvulsant levels, toxicology screen, LP, culture blood and urine, EEG,
CT, carbon monoxide level. Pulse oximetry, cardiac monitor.
Treatment: Try to control seizure in less than 20mins as there could be permanent
brain damage.
1. IV lorazepam:0.1mg/kg. Repeat if no response in 10mins. Be careful about respiratory
depression. If there is no IV access give PR Diazepam.
2.Buccal midazolam: Alternative oral route. squirt half the volume between the lower
gum and the cheek on each side.
3.Phenytoin infusion: 1520mg/kg IVI (roughly 1g if 60kg, and 1 . 5g if 80kg; max 2g.
2nd line! Dont use if bradycardic or hypotensiv. ECG monitoring is recommended.
Diazepam infusion: eg 100mg in 500mL of 5% dextrose. It is most unusual for seizures
to remain unresponsive following this. If they do, allow the idea to pass through your
mind that they could be pseudoseizures, particularly if there are odd features (pelvic
thrusts; resisting attempts to open lids and your attempts to do passive movements;
arms and legs flailing around).

4. Dexamethasone: 10mg IV if vasculitis/cerebral oedema (tumour) possible.


5. General anaesthesia: For refractory status: get anaesthetist/ICU involved early

165. A 20yo man complains of recent onset of itching which followed a viral infection.
There are
numerous wheals of all sizes on his skin particularly after he has scratched it. These can
last up
to an hour. What is the most probable dx?
a. Uremia
b. Urticaria
c. Psychogenic itching
d. Atopic eczema
e. Primary biliary cirrhosis
Ans. The key is B. Urticaria.
Urticaria Signs: wheals, rapid onset after taking drug association with angio-oedema
/anaphylaxis. It can result from both immunological and non-immunological mechanisms.
Causes: Drugs:morphine & codeine cause direct mast cell degranulation; penicillins &
cefalosporins trigger IgE responses; NSAIDs; ACEi.

Clinical diagnosis. No investigations required.


Management:
Find the cause and avoid/treat it.
Antihistamines:
Non-sedating H1 antihistamines are the mainstay of treatment
In pregnancy chlorphenamine is often the first choice of antihistamine.

166. A 75yo lady who had mitral valve replacement 13 yrs ago has developed recurrent
breathlessness. Her husband has noticed prominent pulsation in her neck. She
complains of

abdominal pain and ankle swelling. What is the most probable dx?
a. Aortic regurgitation
b. Mitral regurgitation
c. Mitral stenosis
d. Tricuspid regurgitation
e. Pulmonary stenosis
Ans. The key is D. Tricuspid regurgitation. [Points in favour: i) recurrent breathlessness
if the cause is LV dysfunction, ii) prominent pulsation in the neck giant v waves, iii)
abdominal pain pain in liver on exertion, ankle swelling; These are features of tricuspid
regurgitation. Reference:- OHCM, 9 edition, page- 142]
th

Pulmonary stenosis is mostly congenital. But it can be caused by rheumatic fever and in
this case the patient could have developed rheumatic fever given his history of valve
replacement. But there is no mention of abdominal pain in pulmonary stenosis so i guess
thats the differentiating point here.
Aortic regurgitation, mitral stenosis and regurgitation donot involve abdominal pain and
ankle swelling. And the JVP will not be raised.
Tricuspid regurgitation
Causes: Functional (RV dilatation; eg due to pulmonary hypertension induced by LV
failure); rheumatic fever; infective endocarditis (IV drug abuser); carcinoid syndrome;
congenital (eg ASD, AV canal, Ebsteins anomaly, ie downward displacement of the
tricuspid valve drugs (eg ergot derived dopamine agonists,fenfluramine).
Symptoms: Fatigue; hepatic pain on exertion; ascites; oedema and also dyspnoea and
orthopnoea if the cause is LV dysfunction.
Signs: Giant v waves and prominent y descent in JVP, RV heave; pansystolic murmur,
heard best at lower sternal edge in inspiration; pulsatile hepatomegaly; jaundice; ascites.
Management: Treat underlying cause. Drugs: diuretics, digoxin, ACE-i. Valve
replacement (~10% 30-day mortality).
.
167. A 45yo T1DM had an annual check up. Ophthalmoscopy showed dot and blot
hemorrhage + hard exudate and multiple cotton wool spots. What is the next step in
management?
a. Reassurance and annual screening only
b. Urgent referral to ophthalmologist
c. Laser therapy
d. Non-urgent referral to ophthalmologist
e. Nothing can be done
Ans. The key is D. Non-urgent referral to ophthalmologist. [It is pre-proliferative
retinopathy so non-urgent referral; If proliferative (with neovascularization) urgent
referral].
Diabetic retinopathy Blindness is preventable. Annual retinal screening mandatory
for all patients not already under ophthalmology care. Pre-symptomatic screening
enables laser photocoagulation to be used, aimed to stop production of angiogenic
factors from the ischaemic retina. Indications: maculopathy or proliferative retinopathy.
Background retinopathy: Microaneurysms (dots), haemorrhages (blots) and
hard exudates (lipid deposits). Refer if near the macula, eg for intravitreal triamcinolone.
Pre-proliferative retinopathy: Cotton-wool spots (eg infarcts), haemorrhages,
venous beading. These are signs of retinal ischaemia. Non urgent Refer to a specialist.

Proliferative retinopathy: New vessels form. Needs urgent referral.


Maculopathy: (hard to see in early stages). Suspect if acuity. Prompt laser, intra vitreal
steroids or anti-angiogenic agents may be needed in macular oedema.
168. A 2m baby who has ambiguous genitalia presents to the ED with vomiting. Labs:
Na+=125mmol/L, K+=6mmol/L. What is the most likely dx?
a. Fragile X syndrome
b. Turners syndrome
c. Noonan syndrome
d. Congenital adrenal hyperplasia
Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is D. Congenital adrenal hyperplasia
Ans. 2. Points in favour: i) ambiguous genitalia ii) salt wasting manifested as
hyponatremia and hyperkalemia (In mild forms of salt-wasting adrenal hyperplasia, salt
wasting may not become apparent until an illness stresses the child). [here
hyperkalaemia inspite of vomiting is indicating the disease].
Congenital adrenal hyperplasia (From secretion of androgenic hormones deficiency of
21-hydroxylase, 11-hydroxylase, or 3--hydroxysteroid dehydrogenase).
Cortisol is inadequately produced, and the consequent rise in ACTH leads to adrenal
hyperplasia and overproduction of androgenic cortisol precursors. CAH is a leading
cause of male pseudohermaphroditism.
Signs: Vomiting, dehydration, and ambiguous genitalia. Girls may be masculinized.
Boys may seem normal at birth, but have precocious puberty, or ambiguous genitalia
(androgens in 17-hydroxylase deficiency), or incomplete masculinization (hypospadias
with cryptorchidism
from 3-hydroxysteroid dehydrogenase). Hyponatraemia and hyperkalaemia are
common. Plasma 17-hydroxyprogesterone Increased in 90%; Increased urinary 17ketosteroids (not in 17-hydroxylase deficit).
Management of adrenocortical crisi: Urgent treatment is needed
0.9% saline IVI (35g Na+/day), glucose, fludrocortisone and hydrocortisone in neonate
IV stat then maintanance dose.
CAH can lead to addisons disease later in life due to delayed onset.
169. A 40yo man collapsed at home and died. The GPs report says he suffered from
T2DM and
BMI=35. What is the most likely cause of death?
a. Myocardial Infarction
b. Diabetes mellitus
c. Heart failure
d. Pulmonary embolism
e. Renal failure
Q. 1. What is the key?
Q. 2. Why the patients death was unnoticed?
Ans. 1. The key is A. MI.
Ans. 2. In diabetics MI become painless when the patient develop autonomic neuropathy
(till there is no autonomic neuropathy diabetic patients will feel MI pain). In this case the
disease was unnoticed as it was a painless attack.
It is one of the complications of Diabetes.
Vascular disease Chief cause of death. MI is 4-fold commoner in DM and is more
likely to be silent. Stroke is twice as common. Women are at high risk.

Address other risk factorsdiet, smoking, hypertension. Suggest a statin (eg simvastatin
40mg
nocte) for all, even if no overt IHD, vascular disease or microalbuminuria. Fibrates
are useful for triglycerides and reduced HDL. Aspirin 75mg reduces vascular events
(if past stroke or MI) and is good as statin co-therapy (safe to use in diabetic retinopathy;
use in primary prevention is disappointing, at least at 100 mg/day.
170. A 38yo pt presented with tingling, numbness, paraesthesia, resp stridor and
involuntary spasm of the upper extremities. She has undergone surgery for thyroid
carcinoma a week ago. What is the most likely dx?
a. Thyroid storm
b. Hyperparathyroidism
c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Hypocalcemia
Q. 1. What is the key?
Q. 2. What is the cause of this condition?
Q. 3. Why there is respiratory stridor?
Ans. 1. The key is E. Hypocalcaemia.
Ans. 2. Hypocalcaemia may be due to accidental parathyroid gland removal during
thyroidectomy.
Ans. 3. Laryngospasm is a feature in hypocalcaemia which may cause stridor.
Thyroid storm causes thyrotoxicosis (inc heart rate, palpitations, weight loss, tremors,
heat intolerance etc) hyperparathyroidism causes hypercalcemia (bone pains, kidney
stones, confusion, psychosis), nerve injuries only explain the stridor.
Causes of hypocalcemia:

Treatment

Mild symptoms: give calcium 5mmol/6h PO, with daily plasma Ca2+ levels.
In chronic kidney disease:May require alfacalcidol
Severe symptoms: give 10mL of 10% calcium gluconate (2.25mmol) IV over 30min,
and repeat as necessary. If due to respiratory alkalosis, correct the alkalosis
171. A 50yo chronic smoker came to OPD with complaint of chronic productive cough,
SOB and
wheeze. Labs: CBC=increase in PCV. CXR >6ribs seen above the diaphragm in
midclavicular line. ABG=pO2 decreased. What is the most likely dx?
a. Interstitial lung disease
b. Wegeners granulomatosis
c. Ca bronchi
d. COPD
e. Amyloidosis
Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is D. COPD.
Ans. 2. Points in favour: i) Age 50 yrs ii) Chronic smoker iii) Chronic productive cough,
SOB and Wheeze iv) Raised PCV secondary to chronic hypoxaemia v) Low set
diaphragm and widened horizontal ribs vi) Hypoxaemia on ABG.

COPD:
COPD is a common progressive disorder characterized by airway obstruction (FEV1
<80% predicted; FEV1/FVC <0.7. It includes emphysema and chronic bronchitis.
COPD is favoured by: Age of onset >35yrs Smoking (passive or active) or pollution
related Chronic dyspnoea Sputum production Minimal diurnal or day-to-day FEV1
variation.
Chronic bronchitis is defIned clinically as cough, sputum production on most days for 3
months of 2 successive yrs. Symptoms improve if they stop smoking.
Emphysema is defined histologically as enlarged air spaces distal to terminal bronchioles,
with destruction of alveolar walls.
Pink puffers have inc alveolar ventilation, a near normal PaO2 and a normal or low
PaCO2. They are breathless but are not cyanosed. They may progress to type 1
respiratory failure.
Blue bloaters have decreased alveolar ventilation, with a low PaO2 and a high PaCO2.
They are cyanosed but not breathless and may go on to develop cor pulmonale. Their
respiratory centres
are relatively insensitive to CO2 and they rely on hypoxic drive to maintain respiratory
effort
Symptoms Cough; sputum; dyspnoea; wheeze.
Signs Tachypnoea; use of accessory muscles of respiration; hyperinflation; cricosternal
distance (<3cm); decreased chest expansion; resonant or hyperresonant percussion note;
quiet breath sounds (eg over bullae); wheeze; cyanosis; cor pulmonale.
Complications Acute exacerbations infection; polycythaemia; respiratory failure; cor
pulmonale (oedema; raised JVP); pneumothorax (ruptured bullae); lung carcinoma.

Tests FBC: Raised PCV. CXR: Hyperinflation (>6 anterior ribs seen above diaphragm in
midclavicular line); flat hemidiaphragms; large central pulmonary arteries; peripheral
vascular markings; bullae. ECG: Right atrial and ventricular hypertrophy (cor
pulmonale).
ABG: Reduced PaO2 hypercapnia. Lung function: obstructive + air trapping (FEV1
<80% of predicted. FEV1 : FVC ratio <70%
TREATMENT OF CHRONIC STABLE PATIENTS.

172. A 44yo pt has sudden onset of breathlessness and stridor few minutes after
extubation for

thyroidectomy. The pat had longstanding goiter for which he had the surgery. What is
the most
likely dx?
a. Thyroid storm
b. Hematoma
c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Tracheomalacia
Ans. The key is tracheomalacia.
173. A 15yo boy presents with generalized edema. His urinalysis reveals protein +++,
eGFR =110. What is the most likely dx?
a. IgA nephropathy
b. Membranous nephropathy
c. Minimal change disease
d. PSGN
e. Lupus nephritis
Ans. The key is C. Minimal change disease. [Points in favour: i) Age 15 yrs ii)
Generalized oedema iii) Protein in urine +++ vi) Normal eGFR of 110 (Normal range- 90
to 120 mL/min)].
Most common cause of nephrotic syndrome in children is minimal change disease.
There will be hypoalbuminemia and peripheral edema too. Electron microscopy shows
effacement of podocyte foot processes.. MCD has albumin selective proteinuria.
Treatment is with steroids.
174. A 72yo man is receiving chemotherapy for SCLC. He has his 4th tx 8 days ago. He
has a cough with some green sputum but feels well. Temp=37.6C. Chest exam = few
coarse crepitations in the right base. HR=92bpm. CBC: Hgb=12.5g/dL, WBC=1.1,
Neutrophils=0.6, Plt=89. Sputum, urine and blood culture sent to microbiology. What is
the most appropriate management?
a. Broad spectrum antibiotics IV
b. Broad spectrum antibiotics PO
c. GCSF
d. Postpone tx until bacteriology results available
e. Reassure and send home
Q. 1. What is the key?
Q. 2. What is the Diagnosis?
Q. 3. What is the treatment of low WBC count?
Ans. 1. The key is A. Broad spectrum antibiotics IV
Ans. 2. The diagnosis is lower respiratory tract infection.
Ans. 3. GCSF subcutaneously. [it is the treatment of chemotherapy induced leucopenia]
Use of antibiotics in neutropenia:
Treat any known infection promptly.
If T >38C or T >37.5C on 2 occasions, >1h apart, or the patient is toxic, assume
septicaemia and start blind combination therapyeg piperacillintazobactam(+
vancomycin,if Gram +ve organisms suspected or isolated, eg Hickman line sepsis).
Check local preferences. Continue until afebrile for 72h or 5d course, and until
neutrophils >0.5109/L. If fever persists despite antibiotics, think of CMV, fungi (eg
Candida; Aspergillus) and central line infection.

Consider treatment for Pneumocystis eg co-trimoxazole, ie trimethoprim


20mg/kg + sulfamethoxazole 100mg/kg/day PO/IV in 2 daily doses). Remember TB.
Avoid IM injections as they can lead to hematomas.
In this question the neutrophil count is 0.6 and temp is 37.6. So we should still start Iv
antibiotics as they are dangerously close the ranges given in the text above.
Granulocytes colony stimulating factors are used to produce neutrophils and is used in
preventing sepsis but the patient here is almost in sepsis! GCSF are mostly used in
myeloproliferative disorders.
175. A 25yo woman with T1DM has delivered a baby weighing 4.5kg. Her uterus is well
contracted. Choose the single most likely predisposing factor for PPH from the options?
a. Atonic uterus
b. Cervical/vaginal trauma
c. Retained POC
d. Large placental site
e. Rupture uterus
Q. 1. What is the key?
Q. Reason for your answer.
Ans. 1. The key is B. Cervical/vaginal trauma
Ans. 2. The baby is a big baby. If patients uterus was not well contracted we would fear
of atonic uterus! But as uterus is well contracted it is not atonic uterus. Rather most likely
cause is trauma dring delivery of this big baby.
Primary PPH is the loss of greater than 500mL (definitions vary) in the first 24h after
delivery

Causes: uterine atony (90%), genital tract trauma (7%), clotting disorders(3%)
Risks: Antenatal Previous PPH or retained placenta BMI>35kg/m2 Maternal
Hb<8.5g/dl at onset of labour Antepartum haemorrhage Multiparity 4+ Maternal age
35y+ Uterine malformation or fibroids A large placental site (twins, severe rhesus
disease, large baby) Low placenta, Overdistended uterus (polyhydramnios, twins)
Extravasated blood in the myometrium (abruption).
In labour Prolonged labour (1st, 2nd or 3rd stage) Induction or oxytocin use
Precipitant labour Operative birth or caesarean section. Book mothers with risk factors
for obstetric unit delivery.
Treatment: Give oxytocin 5U slowly IV for atonic uterus.
Attach oxygen, Give IV fluids, maintain systolic >100mmHg, Transfuse blood.
Is the placenta delivered? If it is, is it complete? If not, explore the uterus. If the
placenta is complete, put the patient in the lithotomy position with adequate analgesia and
good lighting. Check for and repair trauma.
If the placenta has not been delivered but has separated, attempt to deliver it by
controlled cord traction after rubbing up a uterine contraction. If this fails, ask an
experienced obstetrician to remove it under general anaesthesia.Beware renal shut down.
176. A 23yo lady presents with headache. Exam: photophobia and generalized rash that
doesnt
blanch on pressure. What must be done immediately?
a. IV benzylpenicillin

b. Isolate pt
c. Gown and mask
d. Blood culture
Ans. The key is A. IV benzylpenicillin.
When to act: Headache, pyrexia, neck stiffness, altered mental state: if any 2 co-exist
and not yet in hospital, give benzylpenicillin 1.2g IM/IV before admitting.
Organisms: Meningococcus or pneumococcus. Less commonly Haemophilus
influenzae;
Listeria monocytogenes. CMV, cryptococcus or TB if immunocompromised eg HIV +ve
organ transplant, malignancy.
Features
Early: Headache, leg pains, cold hands and feet, abnormal skin colour.
Later:
Meningism: neck stiffness, photophobia, Kernigs sign (pain + resistance on passive
knee extension with hip fully flexed).
Decreased Conscious level , coma.
Seizures (~20%) focal CNS signs (~20%) opisthotonus
Petechial rash (non-blanching ; may only be 1 or 2 spots, or none).
Signs of galloping sepsis: slow capillary refill; DIC; dec BP. inc T and pulse: inc or
normal.
Management:
Start antibiotics immediately.
<55yrs: cefotaxime 2g/6h slow IV.
>55yrs: cefotaxime as above + ampicillin 2g IV/4h (for Listeria).
Prophylaxis: (discuss with public health/ID) Household contacts in droplet range. Give
rifampin or ciprofloxacin.
If in this question there was an option for IV cefotaxime that would have been the correct
answer since here the patient has presented in the hospital. Benzylpenicilline is given
before admission or before taking the patient to the hospital
177. A 4yo baby has generalized tonic-clonic seizure and fever of 39C. his mother
informs you that this has happened 3-4x before. What is the most likely dx?
a. Febrile convulsion
b. Absence seizures
c. Epilepsy
d. Partial complex seizure
Ans: The key is C. Epilepsy! Probably wrong key! Epilepsy doesnt occur with fever!
Likely correct key is A. Febrile convulsion.
FEBRILE CONVULSION is a single tonicclonic, symmetrical generalized seizure
lasting <20min, occurring as T rises rapidly in a febrile illnesstypically in a normally
developing child (5yrs old).
Think of meningo-encephalitis, CNS lesion, epilepsy, trauma, hypoglycemia, dec
Ca2+, or dec Mg2+ if: Focal CNS signs or CNS abnormality Previous history of
epilepsy The seizure lasts >15min There is >1 attack in 24h.

Examination: Find any infection; if any neck stiffness consider meningitis. :


Management: Put in recovery position; if fit is lasting >5min: lorazepam IV, buccal
midazolam or diazepam PR. Tepid sponging if hot; paracetamol syrup
Labs: Consider FBC, U&E, Ca2+, glucose, MSU, CXR, ENT swabs.
Avoid LP in the postictal period. If you suspect meningitis, then treat now.
Parental education: Allay fear (a child is not dying during a fit). For the 30% having
recurrences, teach carers to use buccal midazolam or rectal diazepam 0.5mg/ kg
Further prevention: Diazepam PR during fevers has a role; other anticonvulsants are
never needed. Explain that all fevers (eg vaccination-associated) should prompt oral
antipyretics.
Prognosis: In typical febrile convulsions there is no progress to epilepsy in 97%.
178. A middle aged Asian presents with episodes of fever with rigors and chills for last
1y. Blood film: ring form plasmodium with schaffners dots in RBCs. What is the drug to
eradicate this infection?
a. Doxycycline
b. Mefloquine
c. Proguanil
d. Quinine
e. Artesonate
Q. 1. What is the key?
Q. 2. What does Shuffners dot in RBC indicate?
Ans. 1. The key is B. Mefloquine.
Ans. 2. Shuffners dot indicates, it is plasmodium ovale or plasmodium vivax infestation.
MALARIA:
Plasmodium vivax and ovale: cyclical fever every 48 hours.
P.malariae: Cyclical fever every 72 hours. Can cause glomerulonephritis. Rarely fatal.
P. falciparum: fevr 36-48hrs cyclical. Fulminant disease.
Presentation: 3 phases:
1 Shivering (1h): I feel so cold.
2 Hot stage (26h): T 41C, flushed, dry skin; nausea/vomiting; headache.
3 Sweats (~3h) as T falls
Also malaise, fatigue, anorexia, myalgias...
Signs: Anaemia, jaundice, and hepatosplenomegaly. No rash or lymphadenopathy
Protective factors: G6PD lack; sickle- cell trait; melanesian ovalocytosis;
Complications: Hemolytic anemia can occur.
5 grim signs: 1 dec Consciousness/coma (cerebral malaria) 2 Convulsions 3 Coexisting
chronic illness 4 Acidosis (eg esp bad if HCO3 <15mmol/L) 5 Renal failure
Diagnosis: Serial thin & thick blood films.
P. vivax ring forms partly hidden by Schuffners dots. P. malariae: ring and band forms
P. falciparum: sausage-like gametocytes in RBC ghosts.
Treatment: If the patient has taken prophylaxis, dont use the same drug for treatment.
If species unknown or mixed infection, treat as P. falciparum. Nearly all P. falciparum is
resistant to chloroquine and in many areas also to Fansidar (pyrimethamine +
sulfadoxine).
Chloroquine is 1st choice for benign malarias in most parts of the world. Never rely on
chloroquine if used singly for prophylaxis.
Treating uncomplicated P. ovale, P. vivax, & P. malariae: Chloroquine base: 10mg/
kg, then 5mg/kg at 6h, 24h and 48h. In resistant cases, try Malarone (atovaquone and
proguanil) ,quinine, or Riamet. Primaquine dose in P. vivax: 500g/kg (max.30mg)

daily for 14d; P. ovale: 250g/kg (max. 15mg) daily for 14dgiven after chloroquine to
treat liver stage and prevent relapse. Screen for G6PD deficiency first. CI: pregnancy. P.
malariae does not need primaquine.
Treating uncomplicated P.falciparum malaria:
Artemether-lumefantrineif >35kg: 4 tabs stat, then 4 tablets at 8, 24, 36, 48 and 60h.
Artesunate-amodiaquine; if a fixed combination pill is available.
Dihydroartemisinin-naphthoquine Dihydroartemisinin piperaquine. Atovaquoneproguanil. can be used.
In pregnancy: Artemisinins are OK in children and pregnancy from 13 weeks;
(use quinine + clindamycin in 1st trimester).
In addition give symptomatic treatment for fever, blood transfusion if required.

Prophylaxis:
If little/no chloroquine resistance: Proguanil 200mg/24h+chloroquine base 300mg/wk.
If chloroquine-resistant P. falciparum: Mefloquine 250mg/wk (18d before to 4wks after
trip) or doxycycline 100mg/d (1d before to 4wks after) or atovaquone 250mg + proguanil
100mg (Malarone) 1 tab/d (1d before travel to 7d after).

179. A 35yo woman had an uneventful lap chole 18h ago. She has a pulse=108bpm,
temp 37.8C. There are signs of reduced air entry at the right base but the CXR doesnt
show an obvious abnormality. What is the most appropriate management strategy?
a. Cefuroxime PO
b. Ceftriaxone IV
c. Chlorpheniramine PO
d. Chest physiotherapy
e. Reassure
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. The key is D. Chest physiotherapy.
Ans. 2. Atelactasis.
Best visible on CT scan and not on chest xray. Mostly occurs as a complication of
anaesthesia.
Arrange physiotherapy and antibiotics.

180. A 20yo pop star singer complains of inability to raise the pitch of her voice. She
attributes this to the thyroid surgery she underwent a few months back. What is the most
likely dx?
a. Thyroid storm
b. Bilateral recurrent laryngeal nerve injury
c. Unilateral recurrent laryngeal nerve injury
d. External laryngeal nerve injury
e. Thyroid cyst
Ans. The key is D. External laryngeal nerve injury.

Complications of thyroid surgery:


1. Bleeding, which may cause tracheal compression.
2. Recurrent laryngeal nerve injury:
Innervates all of the intrinsic muscles of the larynx, except the cricothyroid muscle.
Patients with unilateral vocal fold paralysis present with postoperative hoarseness.
Presentation is often subacute and voice changes may not present for days or
weeks. Unilateral paralysis may resolve spontaneously.
Bilateral vocal fold paralysis may occur following a total thyroidectomy and usually
presents immediately after extubation. Both vocal folds remain in the paramedian
position, causing partial airway obstruction.
Superior (external) laryngeal nerve injury:
o The external branch provides motor function to the cricothyroid muscle.
o Trauma to the nerve results in an inability to lengthen a vocal fold and
thus to create a higher-pitched sound.
o The external branch is probably the most commonly injured nerve in thyroid
surgery.
o Most patients do not notice any change but the problem may be careerending for a professional singer.
Hypoparathyroidism: the resulting hypocalcaemia may be permanent but is
usually transient. The cause of transient hypocalcaemia postoperatively is not
clearly understood.
Thyrotoxic storm: is an unusual complication of surgery but is potentially lethal.
Infection: occurs in 1-2% of all cases. Peri-operative antibiotics are not
recommended for thyroid surgery.
Hypothyroidism.
Damage to the sympathetic trunk may occur but is rare.
181. A 28yo woman at 39wk gestation is in labor. She develops abdominal pain and
HR=125bpm, BP=100/42mmHg, temp=37.2C and saturation=99%. Exam: lower
abdomen is exquisitely tender. CTG=prv normal, now showing reduced variability and
late deceleration develops with slow recovery. She has had 1 prv LSCS for a breech
baby. Choose the most appropriate CS
complication for this lady?
a. Endometritis
b. UTI
c. Urinary tract injury
d. Pleurisy
e. Uterine rupture
Ans. The key is E. Uterine rupture.
Uterine rupture: Its an obstetrical emergency
Causes: ~70% of UK ruptures are due to dehiscence of caesarean section scars.
Other risk factors: Obstructed labour in the multiparous, especially if oxytocin is used
Previous
cervical surgery High forceps delivery Internal version Breech extraction. Rupture is
usually during the third trimester or in labour.

Vaginal birth after caesarean (trial of scar): Vaginal birth will be successful in 72
76%. Endometritis, need for blood transfusion, uterine rupture and perinatal death are
commoner than repeated elective C section.
Signs and symptoms Rupture is usually in labour. In a few (usually a caesarean scar
dehiscence) rupture precedes labour. Pain is variable, some only having slight pain and
tenderness over the uterus. In others pain is severe.
Vaginal bleeding is variable and may be slight (bleeding is intraperitoneal). Unexplained
maternal tachycardia, sudden maternal shock, cessation of contractions, disappearance
of the presenting part from the pelvis, and fetal distress are other presentations.
Postpartum indicators of rupture: continuous PPH with a well-contracted uterus; if
bleeding continues postpartum after cervical repair; and whenever shock is present.
Management If suspected in labour, perform laparotomy, deliver the baby by caesarean
section, and explore the uterus. If rupture is small Repair or if vagina or cervix are
involved in the tear hysterectomy may be needed.
182. An 8m infant presented with FTT and constipation. Exam: large tongue and fam hx
of prolonged neonatal jaundice. What is the most likely dx?
a. Downs syndrome
b. Fragile X syndrome
c. Praderwilli syndrome
d. DiGeorge syndrome
e. Congenital hypothyroidism
Q. 1. What is the key?
Q. 2. What are the points in favour?

Congenital Hypothyroidism: Thyroid hormone is necessary for growth and


neurological development.
Signs: May be none at birthor prolonged neonatal jaundice, widely opened posterior
fontanelle, poor feeding, hypotonia, and dry skin are common. Inactivity, sleepiness,
slow feeding, little crying, and constipation may occur. Look for coarse dry hair, a flat
nasal
bridge, a protruding tongue, hypotonia, umbilical hernia, slowly relaxing reflxes, pulse,
and poor growth and mental development if it has not been picked up. Other later signs:
dec IQ, delayed puberty (occasionally precocious), short stature, delayed dentition.
Universal neonatal screening: Cord blood or filter paper spots (at ~7 days, from heel
prick) allow early diagnosis (theGuthrie card).
Tests: Decreased T4, Increased TSH (but undetectable in secondary hypothyroidism),
Decreased I131 uptake, dec Hb. Bone age is less than chronological age. As it is unwise
to X-ray the whole skeleton, the left wrist and hand are most commonly used.
Treatment: Levothyroxine (LT4): Start neonates with ~15g/kg/day; adjust by 5g/kg
every 2
weeks to a typical dose of 2050g/day. Avoid high TSH levels.

Ans.1. The key is E. Congenital hypothyroidism.


Ans. 2. Points in favour:i) FTT ii) constipation iii) macroglossia iv) prolonged neonatal
jaundice.
183. A 3m infant has presented with recurrent infections. He has abnormal facies and
CXR shows absent thymic shadow. What is the most likely dx?
a. Downs syndrome
b. Fragile X syndrome
c. DiGeorge syndrome
d. Marfans syndrome
Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is C. DiGeorge syndrome.
Ans. 2. Points in favour: i) Early age of onset ii) abnormal facies iii) absent thymic
shadow on Chest X-ray iii) history of recurrent infection [in newborne can be recognized
by convulsions from hypocalcaemia due to malfunctioning parathyroid glands and low
level of parathyroid hormones].

DiGeorges syndrome A deletion of chromosome 22q11.2 causes absent thymus,


fits, small parathyroids ( decreased Ca2+), anaemia, lymphopenia, dec growth hormone,
dec T-cell-immunity. It is related to velo-cardiofacial syndrome: characteristic
face, multiple anomalies, eg cleft palate, heart defects, cognitive defects
Management:
Cardiac defects are the usual focus of clinical management.
Hypocalcaemia should be screened for by checking calcium levels three-monthly in infancy
and then annually. Low calcium and high phosphate levels should prompt further testing of
parathyroid hormone and vitamin D levels.
All patients should have baseline immunological testing and annual blood count
Cleft palates may be submucous. In particular, they should be sought if feeding difficulties
are encountered in the neonatal period.
Gastro-oesophageal reflux needs to be managed appropriately with feed thickeners and antireflux medication. Nasogastric tube feeding and occasionally gastrostomy may be needed to
deal with feeding issues.

184. A 30yo man presents with deep penetrating knife wound. He said he had TT when
he left school. What will you do for him now?
a. Human Ig only
b. Human Ig and TT
c. Full course of tetanus vaccine only
d. Human Ig and full course of tetanus vaccine
e. Antibiotic
Ans. The key is B. Human Ig and TT.

185. A 32yo previously healthy woman has developed pain and swelling of both knees
and ankles with nodular rash over her shins. As part of the inv a CXR has been
performed. What is the single
most likely CXR appearance?
a. Apical granuloma
b. Bilateral hilar lymphadenopathy
c. Lobar consolidation
d. Pleural effusion
e. Reticular shadowing in the bases
Q. 1. What is the key?
Q. 2. What is the name of this condition? What are the points in favour?
Ans. 1. The key is B. bilateral hilar lymphadenopathy.
Ans. 2. The name is Lofgrens syndrome. It is the triad of i) erythema nodosum ii)
bilateral hilar lymphadenopathy and iii) arthralgia.
Apical granuloma: apical granuloma modified granulation tissue containing elements of
chronic inflammation located adjacent to the root apex of a toothwith infected necrotic pulp.
Lobar consolidation: pneumonia

Sarcoidosis:
Presentation: Lungs are in involved in more than 90% cases of sarcoidosis. There is
interstitial lung disease. The painful skin lesion is erythema nodosum. Also look for
Lupus pernio (chronic raised hardened, often purple lesion) may be seen on the face.
Lofgren syndrome is often a part of sarcoidosis. The triad is i) Erythema nodosum
ii) Bilateral hilar lymphadenopathy iii) Arthralgia
Sarcoidosis is a multisystem disease and can involve any system/organ
Tests: ESR is often raised. Serum ACE enzyme levels are raised in 60% of times
Plain CXR may show bilateral hilar or paratracheal lymphadenopathy. High resolution
CT should be done. There will be restricitve pattern of disease on pulmonary function
tests.

Transbronchial biopsy can demonstrate the presence of non-caseating granulomata,


giving a more accurate diagnosis
Bronchioalveolar lavage may also be done
186. A neonates CXR shows double bubble sign. Exam: low set ears, flat occiput. What
is the most likely dx?
a. Downs syndrome
b. Fragile X syndrome
c. Turners syndrome
d. DiGeorge syndrome
Q. 1. What is the key?
Q. 2. What double bubble sign indicate?
Ans. 1. The key is A. Downs syndrome.
Ans. 2. Double bubble sign indicate duodenal atresia.
Downs syndrome:
Causes:
Non-disjunction of chromosome >88%
Mosaicism <8%
The robertsonian translocation trisomy 21 is the cause in 4% of Downs syndrome
Presentation:
simian palmar crease, hypotonia, flat face/round head, protruding tongue, broad hands,
upward slanted palpebral fissures and epicanthic folds, speckled irises (Brushfield
spots); mental and growth retardation; pelvic dysplasia, cardiac malformations, short,
broad hands, hypoplasia of middle phalanx of (incurving) 5th finger, intestinal atresia and
high arched palate.
.

Associated problems: Duodenal atresia; VSD; patent ductus; AVSD (foramen primum
defects, and, later, a low IQ and a small stature.
Pr enatal diagnosis:
The combined test: combines nuchal translucency (NT) + free -human chorionic
gonadotrophin (HCG) + pregnancy associated plasma protein (PrAP-A or PAPP-A) + the
womans age. Used between 10 weeks 3 days and 13 weeks 6 days. It achieves detection
rates of 95% of all aneuploides, 86% trisomy-21, and 100% of trisomy-18 and trisomy-13
The quadruple test combines maternal -fetoprotein (AFP) + unconjugated estriol + free
HCG or total HCG + inhibin-A + the womans age in the 2nd trimester. Use between 15
weeks + 0 days and 20 weeks + 0 days so useful for women presenting in the 2nd
trimester
The integrated test: It involves NT + PrAP-A in the 1st trimester + the quadruple test in
the 2nd trimester. Do not use 2nd trimester tests for triplets
187. A 19yo boy complains of itching on the site of insect bite. What is the single most
appropriate management?
a. Penicillin oral

b. Doxycycline oral
c. Oral antihistamine
d. Oral ciprofloxacin
e. Reassurance
Ans. The key is C. Oral antihistamine.
This is a case of simple physical utricaria follwing an insect bite which causes itching.
For which oral antihistamine is most suitable.
188. A man presents with scrotal swelling, the swelling is cystic and is non-tender. It is
located in the upper pole of the posterior part of the testis. What is the most likely dx?
a. Epididymal cyst
b. Testicular ca
c. Hydrocele
d. Teratoma
e. Testicular torsion
Ans. The key is A. Epididymal cyst. [the location of upper pole of the posterior part of
testis is the common site for epididymal pathology].
Diagnosing scrotal masses
Cannot get above inguinoscrotal hernia or hydrocele extending proximally
Separate and cystic epididymal cyst
Separate and solid epididymitis/varicocele
Testicular and cystic hydrocele
Testicular and solidtumour, haematocele, granuloma, orchitis, gumma. USS may help.
Epididymal cysts usually develop in adulthood and contain clear or milky
(spermatocele)
fluid. They lie above and behind the testis. Remove if symptomatic
189. A young footballer has collapsed during a game. During initial evaluation:
RR=14/min,
pulse=88bpm, BP=110/70mmHg. He seems to be sweating and muttering some
incomprehensible words. What is the most imp next step?
a. CT
b. MRI
c. Blood sugar
d. Body temp
e. IV fluids
Ans. The key is C. Blood sugar.
The collapse could be because of hypoglycemia. So we should BSR of the patient first
before taking him for CT scan or any other investigation as it is easy and fast and could
give us a cause of collapse that is quickly reversible.
Even in managing a patient with COMA or seizures. after ABC first thing to do is to
check BSR.
The patient here most probably had an attack of SYNCOPE. If in the question there was
an option for ECG then that would have been the right answer.
Syncope:
Causes:

Neurally mediated syncope (NMS) - also called reflex syncope of which vasovagal is the
most important cause of syncope.
Orthostatic hypotension
Cardiac arrythmias
Structural cardiac or cardiopulmonary disease
Substance abuse
Psychogenic
Presentation:
In some forms of syncope there may be a prodromal period with lightheadedness, nausea, sweating, weakness or visual disturbances, but loss of
consciousness often occurs without warning.
Syncope is usually brief, with complete loss of consciousness in reflex syncope
not lasting more than 20 seconds (but may occasionally be up to several
minutes). Recovery from syncope is usually associated with almost immediate
restoration of appropriate behaviour and orientation, but there may be marked
fatigue. Retrograde amnesia may occur, especially in older individuals.
Investigations: The initial evaluation of a patient presenting with transient loss of
consciousness consists of careful history, physical examination, including orthostatic blood
pressure measurements, and an ECG. Further investigations :

FBC: acute anaemia will cause syncope, but patients adapt in cases of chronic anaemia.
Fasting blood glucose (hypoglycaemia).
Management: Reassure and if an underlying cause is found treat it.
190. A 45yo waitress complains of pelvic pain which worsens pre-menstrually and on
standing and walking. She also complains of post-coital ache. Select the most likely
cause leading to her
symptoms?
a. PID
b. Endometritiosis
c. Pelvic congestion syndrome
d. Adenomyosis
e. Premature ovarian failure
Ans. The key is C. Pelvic congestion syndrome.
PID mostly presents with pelvic pain, fever, spasm of lower abdominal muscles and
cervicitis with profuse, purulent, or bloody vaginal discharge. Heavy menstrual loss
suggests endometritis.
Endometriosis can present as given in this question but it will have menstrual
abnormalities too and the pain will not be related to any specific activity.

Pelvic Congestion Syndrome:


Condition is characterised by the presence of dilated pelvic veins associated with stasis

Aetiology
Considered that ovarian dysfunction is responsible for the excessive production of local
oestrogen, causing dilatation and stasis in the pelvic veins, which leads to pelvic pain
Presentation:
women with this condition commonly complain of a dull, aching pain, exacerbated by
activities that increase intra-abdominal pressure; the pain is relieved by lying down.
other clinical features may also be deep dyspareunia, congestive dysmenorrhoea and
post-coital ache condition usually occurs in the reproductive age group, with a mean age
of 33 years.
Examination may reveal tenderness that is maximal over the ovaries. Vaginal and
cervical examination may reveal an apparent blue colouration due to congestion of the
pelvic veins. The patient may also have varicose veins of the legs
Investigations for endometriosis and pelvic inflammatory disease must be instigated
Venography is still considered the definitive radiological investigation for women with
pelvic congestion syndrome
Radiological features: dilated uterine and ovarian veins with reduced venous clearance
of contrast medium
Management
Medical treatment options include:
Medroxyprogesterone acetate (MPA) suppresses ovarian function and therefore reduces
pelvic congestion and pain, however benefit was not sustained after discontinuing
treatment (1)
Gonadorelin analogues goserelin 3.6 mg per month given for 6 months provided an
alleviation of symptoms, an improvement in sexual functioning and a reduction of anxiety
and depressive states in women with pelvic congestion
Other possible treatment options include:
Bilateral ovarian vein ligation
Hysterectomy plus bilateral salpingo-oophrectomy (with post-operative hormone
replacement therapy)
191. A 37yo female had a fall with outstretched hand, presented with dinner fork
deformity and
tenderness over the right arm. What is the single most associated nerve injury?
a. Axillary nerve
b. Radial nerve
c. Musculocutaneous nerve
d. Median nerve
e. Ulnar nerve
Ans. The key is D. Median nerve. [Median nerve is the nerve injured in Colles fracture].
Distal radial fractures Colles type Fracture: (common in osteoporotic post-menopausal
women who fall on an outstretched hand).
There is dorsal angulation and displacement producing a dinner-fork wrist deformity
(the fingers are the prongs). Avulsion of the ulna styloid process may also occur.

Treatment:
For reduction, Biers block method (= IV regional anaesthesia) is best.
Complications: Median nerve symptoms (should resolve after good reduction); ruptured
tendons
(esp. extensor pollicis longus); malunion & nonunion.
192. A mother comes with her 15m child. Which of the following will bother you?
a. Shies away from strangers
b. Can walk but not run
c. Vocabulary consists of only 2 meaningless words
d. She cant make a sentence
e. None
Q. 1. What is the key?
Q. 2. How many words is told clearly by a 15 month old child?
Ans. 1. The key is C. Vocabulary consists of only 2 meaningless words.
Ans. 2. At 15 months the child can clearly say 5 words and his first meaningful clear
word he says at 12 months.

Developmental Milestones.

193. A 35yo lady who has been using IUCD for one year now complains of pelvic pain
and heavy
painful periods. Select the most likely cause leading to her symptoms?
a. PID
b. Endometriosis
c. Adenomyosis
d. Fibroids
e. Asherman syndrome
Q. 1. What is the key?
Q. 2. What points favour your diagnosis?
Ans. 1. The key is A. PID.

Ans. 2. The given picture may have D/D of PID or fibroid. As IUCD is a risk factor for
PID, it is the most likely diagnosis of given picture.

Fibroids are not related to IUCD. Also in fibroids there will be findings on examination
such as mass in lower abdomen.

194. The dx cells of Hodgkin disease are:


a. T-cells
b. R-S cells
c. B-cells
d. Macrophages
e. Auer rods
Ans. The key is B. R-S cells. [Diagnostic cell in Hodgkins disease is Reed-Sternberg
cells].
Hodgkins lymphoma: Lymphomas are disorders caused by malignant proliferations of
lymphocytes. These accumulate in the lymph nodes causing lymphadenopathy.In
Hodgkins lymphoma,characteristic cells with mirror-image nuclei are found, called
ReedSternberg cells
Cause: 2 peaks of incidence: young adults and elderly. EBV has a role in causing it.
Symptoms Often presents with enlarged, painless, non-tender, rubbery superficial
lymph nodes, typically cervical (6070%), also axillary or inguinal nodes. Nodes may
become matted. 25% have constitutional symptoms.
Mediastinal lymph node involvement can cause features due to mass effect, eg
bronchial or SVC obstruction or direct extension, eg causing pleural effusions.
Signs Lymph node enlargement. Also, cachexia, anaemia, spleno- or hepatomegaly.
Types:

Tests Tissue diagnosis: Lymph node excision biopsy if possible. Inc ESR or dec Hb
show worse prognosis.
Staging is by Ann-Arbor system.
Treatment: Depends on chemotherapy and radiotherapy.
195. A 16yo girl is admitted after taking a paracetamol OD 4 h ago. She has consumed
large amounts of alcohol. Her plasma paracetamol conc is just below the conc that
would suggest tx. What should be the tx option for her?
a. Refer to psychiatry ward
b. Refer to medical ward
c. N-acetylcystine
d. Serum plasma paracetamol
e. No further investigation
Ans. The key is A. Refer to psychiatry ward.
Chronic alcohol consumption is an inducer of P-450 enzyme system while acute alcohol
consumption is inhibitor. Since this lady has consumed large amounts of alcohol recently
(acute) the risk of fatal effects of paracetamol poisoning will be reduced. And all such
patients should be referred to the psych ward.
PARACETAMOL POISONING: >150mg/kg or 12 total
PRESENTATION: Hepatic damage shown by deranged LFTs occurs after 24hrs.
Patients may develop encaph, hypoglycemia, ARF

INVESTIGATIONS: Paracetamol levels: 4hrs post ingestion, if time is >4hr or staggered


overdose
Any alcohol taken (acute alcohol ingestion will inhibit liver enzymes and may reduce the
production of the toxin NAPQI, whereas chronic alcoholism may increase it)

MANAGEMENT:
If presentation is within the first hour give activated charcoal
All patients who have a timed plasma paracetamol level plotted on or above the
line drawn between 100 mg/L at 4 hours and 15 mg/L at 15 hours after ingestion,
should receive acetylcysteine.
If time unknown (even in staggered dose) give N-Acetyl cysteine without delay
NAC most effective in the first 8 hrs.
NAC can be given during pregnancy
Beware if the patient is on any P450 enzyme inducer medicines as they increase
the toxicity
Refer to ICU if there is fulminant liver failure - those treated with N-acetylcysteine
(NAC) to the medical team and all para-suicides to the psychiatric team.

196. A 64yo woman has been on HRT for 9yrs. She had regular withdrawal bleeds until
3 yrs ago and since then has been taking a no bleed prep. Recently she noticed a brown
vaginal discharge.
Choose the single most appropriate initial inv?
a. Cervical smear
b. High vaginal swab
c. TFT
d. Transvaginal US
Q. 1. What is the key?
Q. 2. Why this test will be done?
Ans. 1. The key is D. Transvaginal US.
Ans. 2. To determine the endometrial thickness!
In a postmenopausal woman with vaginal bleeding, the risk of cancer is approximately 7.3% if her
endometrium is thick (> 5 mm) and < 0.07% if her endometrium is thin ( 5 mm).
In postmenopausal women without vaginal bleeding, the risk of cancer is approximately 6.7% if the
endometrium is thick (> 11 mm) and 0.002% if the endometrium is thin ( 11 mm).

Investigate postmenopausal vaginal bleeding promptly as the cause may be


endometrial cancer.
Endometrial Carcinoma:
Most are adenocarcinomas, and are related to excessive exposure to oestrogen unopposed
by progesterone.
Risk Factors: Obesity Unopposed oestrogen Functioning ovarian tumour Family
History of breast, ovary, or colon cancer Nulliparity Late menopause Diabetes
mellitus Tamoxifen, tibolone Pelvic irradiation Polycystic ovaries.

Presentation This is usually as postmenopausal bleeding (PMB). It is initially scanty and


occasional ( watery discharge). Then bleeding gets heavy and frequent. Premenopausal
women may have intermenstrual bleeding, but 30% have only menorrhagia.
Diagnosis: TVUS scan is an appropriate first-line procedure to identify which women with
PMB are at higher risk of endometrial cancer. Endometrial thickness of >5mm warrants
biopsy. The definitive diagnosis is made by uterine sampling or curettage. All parts of

the uterine cavity must be sampled; send all material for histology. Hysteroscopy enables
visualization of abnormal endometrium to improve accuracy of sampling.
Staging The tumour is
Stage I in the body of the uterus only.
Stage II in the body and cervix only.
Stage. III advancing beyond the uterus, but not beyond the pelvis.
Stage: IV extending outside the pelvis (eg to bowel and bladder).
Treatment: Stages I and II may be cured by total hysterectomy with bilateral salpingooophorectomy and/or radiotherapy if unfit for surgery. In advanced diseases consider
radiotherapy and/or high dose progesterone which shrinks the tumor.

197. A

young girl complains of episodic headaches preceded by fortification spectra.


Each episode
last for 2-3 days. During headache pt prefers quiet, dark room. What is the tx of choice
for acute
stage?
a. Paracetamol
b. Aspirin
c. Sumatriptan
d. Gabapentin
e. Cafergot
Ans. The key is B. Aspirin. [OHCM, 9 Eition, page-462 where NSAIDS like ketoprophen
or dispersible aspirin 900 mg/6 hr are recommended as treatment in acute stage].
th

Migraine:
Symptoms Classically: Visual or other aura lasting 1530min followed within 1h by
unilateral, throbbing headache. Or: Isolated aura without headache; Episodic severe
headaches without aura, often premenstrual, usually unilateral, with nausea, vomiting
photophobia/phonophobia (common migraine). There may be allodyniaall stimuli
produce pain: I cant brush my hair, wear earrings or glasses, or shave, its so painful.
Signs: None.
Aura: Visual: chaotic cascading, distorting, melting and jumbling of lines, dots, or
zigzags, scotomata or hemianopia; Somatosensory: paresthesia spreading from fingers
to face; Motor: dysarthria and ataxia (basilar migraine), ophthalmoplegia, or
hemiparesis; Speech: (8% of auras) dysphasia or paraphasia, eg phoneme
substitution.

Criteria for diagnosis if no aura 5 headaches lasting 472h + nausea/vomiting (or


photo/phonophobia) + any 2 of: Unilateral Pulsating Impairs (or worsened by)
routine activity.
Partial triggers Seen in 50%: CHOCOLATE or: Chocolate, Hangovers, Orgasms,
Cheese, Oral contraceptives, Lie-ins, Alcohol, Tumult, or Exercise.
Treatment:
Acute:

Step one: simple analgesic with or without anti-emetic In patients who have tried step
1 and didnt respond and in patients with moderate-to-severe migraine, move to step
three.

Use early in the attack to avoid gastric stasis.


Use soluble aspirin 600-900 mg (not in children) or ibuprofen 400-600 mg.
Use prochlorperazine 3 mg buccal tablet if there is nausea and vomiting.

Step two: rectal analgesia and rectal anti-emetic.


Step three: specific anti-migraine drugs Triptans (5HT1-receptor agonists) or
ergotamine (the use of ergotamine is limited by absorption problems and side-effects
such as nausea, vomiting and abdominal pain
Triptans are Contra indicated if IHD, coronary spasm, uncontrolled BP, recent lithium,
SSRIS,
or ergot use.
Prevention Remove triggers; ensure analgesic rebound headache is not complicating
matters. Drugs eg if frequency equal or >2 a month or not responding to drugs
1st-line: Propranolol, amitriptyline (SE: drowsiness, dry mouth, vision), topiramate (SE:
memory) or Ca2+ channel blockers.
2nd-line: Valproate, pizotifen (effective, but unacceptable weight gain in some),
gabapentin, pregabalin, ACE-i, NSAIDS

198. A 60yo pt recovering from a surgery for toxic goiter is found to be hypotensive,
cyanosed in the the RR. Exam: tense neck. There is blood oozing from the drain. What
is the most likely dx?
a. Thyroid storm
b. Reactionary hemorrhage
c. Secondary hemorrhage
d. Primary hemorrhage
e. Tracheomalacia
Ans. The key is B. Reactionary haemorrhage. [in the recovery room, cyanosis,
hypotension, tense neck, oozing of blood from drain; all these goes in favour of
reactionary haemorrhage].
Primary Haemorrhage: Haemorrhage occurring at the time of Injury/Trauma/Surgery
Reactionary Haemorrhage:
Trauma/Surgery

Haemorrhage

occurring

within

first

24

hrs

following

The causes Reactionary Haemorrhage:


1)
2)
3)
4)

Slipping away of Ligatures


Dislodgement of Clots
Cessation of Reflex vasospasm
Normalization of Blood Pressure

Secondary Haemorrhage: Haemorrhage occurring after 7 -14 days after Trauma/Surgery.


The attributed cause is infection and sloughing away of the blood vessels.
The symptoms tell us that the patient is in hypovolemic shock one of the causes of which is
haemorrhage and Since here the patient is still in the recovery room this type of haemorrhage is
reactionary.
199. A 33yo man is hit by a car. He loses consciousness but is found to be fine by the
paramedics.
When awaiting doctors review in the ED he suddenly becomes comatose. What is the
most likely
dx?
a. SAH
b. Subdural hemorrhage
c. Intracerebral hemorrhage
d. Extradural hemorrhage
Ans. The key is D. Extradural haemorrhage. [Age 33 (younger age), considerable head
trauma, and lucid interval (present in bothe extradural and subdural) are the points in
favour].
Lucid interval can occur both ins Subdural and extra dural haemorrhage. The difference
is that the presentation of the lucid interval (that is the gain of consciousness and the
LOC) in extra dural occurs within hours or 1-2 days while in subdural it can take days to
weeks upto 9 months.
Epidural (extradural) haemorrhage:
Suspect this if, after head injury, conscious level falls or is slow to improve, or
there is a lucid interval. Extradural bleeds are often due to a fractured temporal or
parietal bone causing laceration of the middle meningeal artery and vein, typically
after trauma to a temple just lateral to the eye. Any tear in a dural venous sinus will
also result in an extradural bleed. Blood accumulates between bone and dura.
Presentation: Increasingly severe headache, vomiting, confusion, and fits follow,
hemiparesis with brisk reflexes and an upgoing plantar. If bleeding continues, the
ipsilateral pupil dilates, coma deepens, bilateral limb weakness develops, and breathing
becomes deep and irregular (brainstem compression). Death follows a period of coma
and is due to respiratory arrest. Bradycardia and raised blood pressure are late signs.
Tests CT scan shows a haematoma (often biconvex/lens-shaped; the blood forms a
more rounded shape compared with the sickle-shaped subdural haematoma. Skull X-ray
may be normal or show fracture lines crossing the course of the middle meningeal

vessels. Skull fracture after trauma greatly increases risk of an extradural haemorrhage
and should lead to prompt CT. Lumbar puncture is contraindicated.
Management Stabilize and transfer urgently for clot evacuation ligation of the bleeding
vessel. Care of the airway in an unconscious patient and measures to decrease ICP
often
require intubation and ventilation (+ mannitol IVI
Prognosis Excellent if diagnosis and operation early. Poor if coma, pupil abnormalities,
or decerebrate rigidity are present pre-op.

200. A 77yo male presents with hx of enuresis and change in behavior. Exam: waddling
gait. What is the most likely dx?
a. Subdural hemorrhage
b. Brain tumor
c. Normal pressure hydrocephalus
d. Psychotic depression
Ans. The key is C. Normal pressure hydrocephalus. [age (usually occurs in 60s or 70s),
loss of bladder control (enuresis), waddling gait and behavior change are all features of
normal pressure hydrocephalus].
Normal Pressure Hydrocephalus:
describes the condition of ventricular dilatation in the absence of raised CSF pressure on
lumbar puncture, characterised by a triad of gait abnormality, urinary (usually)
incontinence and dementia.
Cause: Idiopathic or it may be secondary to:
Subarachnoid haemorrhage. Meningitis. Head injury. Central nervous system (CNS)
tumour.
Symptoms: The (gradually progressive) classic triad of symptoms is:

Gait disturbance - this is due to distortion of the corona radiata by the dilated
ventricles. Movements are slow, broad-based and shuffling. The clinical
impression is thus one of Parkinson's disease, except that rigidity and tremor
are less marked and there is no response to carbidopa/levodopa. Gait
disturbance is referred to as gait apraxia.
Sphincter disturbance - this is also due to involvement of the sacral nerve
supply. Urinary incontinence is predominant although bowel incontinence
can also occur.
Dementia - this is due to distortion of the periventricular limbic system. The
prominent features are memory loss, inattention, inertia and bradyphrenia
(slowness of thought). The dementia progresses less rapidly than that seen
with Alzheimer's disease.

Signs

Pyramidal tract signs may be present.


Reflexes may be brisk.

Papilloedema is absent (but there has been found to be an association with


glaucoma, so glaucomatous optic disc changes may be noticed).

Investigations
Neuroimaging - MRI or CT scanning may show ventricular enlargement out
of proportion to sulcal atrophy and periventricular lucency.
CSF: Large-volume lumbar puncture (spinal or CSF tap test) - CSF pressure
will be normal, or intermittently raised.
Intraventricular monitoring
Management:
Medical treatment of NPH includes acetazolamide and repeated lumbar puncture.
Surgical:
The mainstay of treatment is surgical insertion of a CSF shunt. This could be to the
peritoneum, the right atrium or, more recently, via external lumbar drainage.

201. A 29yo teacher is involved in a tragic RTA. After that incident, he has been
suffering from
nightmares and avoided driving on the motorway. He has been dx with PTSD. What is
the most
appropriate management?
a. CBT
b. Diazepam
c. Citalopram
d. Dosalepin
e. Olanzepin
Ans. The key is A. CBT.
PTSD:
Symptoms: Fearful; horrified; dazed Helpless; numb, detached Emotional
responsiveness
Intrusive thoughts Derealization Depersonalization Dissociative amnesia Reliving
of events Avoidance of stimuli Hypervigilance Lack of Concentration Restlessness
Autonomic arousal: pulse; BP; sweating Headaches; abdo pains
Signs: Suspect this if symptoms become chronic, with these
signs (may be delayed years): difficulty modulating arousal; isolated-avoidant modes of
living; alcohol abuse; numb to emotions and relationships; survivor guilt; depression;
altered world
view in which fate is seen as untamable, capricious or absurd, and life can yield no
meaning
or pleasure.
Treatment: Watchful waiting for mild cases.

For severe cases: CBT or eye movement desensitization and reprocesing is done. Drug
treatment is not recommended but in case it is needed prescribe mirtazepine or
paroxetine.

202. A 5yo child presents with fever. He looks pale. His parents say he always feels
tired. On exam: orchidomegaly & splenomegaly. Labs: WBC=1.7, Hgb=7.1, Plt=44. What
is the dx?
a. ALL
b. CLL
c. AML
d. CML
e. Hodgkins
Ans. The key is A. ALL. [normally in ALL CBC shows raised WBC, low RBC and low
platelet; but it is also possible to all cell lines to be depressed, as is the presented case].
ALL: This is a malignancy of lymphoid cells, affecting B or T lymphocyte cell lines,
arresting
maturation and promoting uncontrolled proliferation of immature blast
cells, with marrow failure and tissue infiltration.
Causes: Genetic susceptibility, environmental factors (ionizing radiations) Downs
syndrome.
Commonest cancer of childhood.

Signs and symptoms:


Marrow failure: Anaemia (Hb), infection (WCC), and bleeding (platelets).
Infiltration: Hepatosplenomegaly, lymphadenopathysuperficial or mediastinal,
orchidomegaly, CNS involvementeg cranial nerve palsies, meningism.
INVESTIGATIONS: Characteristic blast cells on blood film and bone marrow
CXR and CT scan to look for mediastinal and abdominal lymphadenopathy.
Lumbar puncture should be performed to look for CNS involvement.
TREATMENT: Blood transfusions, prophylactic antibiotics, IV antibiotics in case of
infection. Main stay of treatment is chemotherapy.
Prognosis Cure rates for children are 7090%; for adults only 40%
203. A 6wk child is brought in with vomiting, constipation and decreased serum K+.
What is the dx?
a. Pyloric stenosis
b. Duodenal atresia
c. Hirschsprung disease
d. Achalasia cardia
e. Tracheo-esophageal fistula
Ans. The key is A. Pyloric stenosis. [why not duodenal atresia? Pyloric stenosis is much
more commoner than duodenal atresia; in duodenal atresia the vomitus should contain
bile, which is not the case in pyloric stenosis].

Pyloric stenosis
Symptoms: Presents at 38 weeks)
with vomiting which occurs after feeds and becomes projectile (eg vomiting over
far end of cot). Pyloric stenosis is distinguished from other causes of vomiting by
the following:

The vomit does not contain bile, as the obstruction is so high.


No diarrhoea: constipation is likely (occasionally starvation stools).
Even though the patient is ill: he is alert, anxious, and always hungryand
possibly malnourished, dehydrated.
The vomiting is extremely large volume and within minutes of a feed.
Try to palpate the olive-sized pyloric mass
There may be severe water & NaCl deficit. The picture is of hypochloraemic,
hypokalaemic
metabolic alkalosis
Imaging: Ultrasound detects early, hard-to-feel pyloric tumours, but is only
needed if examination is ve. Barium studies are never needed.
Management: Correct electrolyte disturbances. Before surgery (Ramstedts
pyloromyotomy/ endoscopic surgery) pass a wide-bore nasogastric tube.
204. A 17 yo girl had an episode of seizure. Contraction of muscles started from around
the
interphalangeal joints, which spread to the muscles of wrist and elbow. Choose possible
type of
seizure?
a. Grand mal
b. Tonic clonic
c. Myoclonic
d. Absent
Ans. The key is C. Myoclonic. [seizers associated with contraction of specific muscle
group is seen in myoclonic seizers].
Types of seizures:

Primary generalized seizures Simultaneous onset of electrical discharge


throughout cortex, with no localizing features referable to only one hemisphere.
Absence seizures: Brief (10s) pauses, They do not fall but may pause in what they
are doing. Their face often looks pale with a blank expression. They may look dazed, the
eyes stare and the eyelids may flutter a little. Sometimes their head may fall down a little, or
their arms may shake once or twice. Each seizure usually starts and finishes abruptly. The
person is not aware of the absence and resumes what they were doing.

Tonicclonic seizures: Loss of consciousness. Limbs stiffen (tonic), then jerk


(clonic). May have one without the other. Post-ictal confusion and drowsiness.
Myoclonic seizures: Sudden jerk of a limb, face or trunk. The patient may be
thrown suddenly to the ground, or have a violently disobedient limb: one patient
described it as my flying-saucer epilepsy, as crockery which happened to be in
the hand would take off .
Atonic (akinetic) seizures: Sudden loss of muscle tone causing a fall, no LOC.
Infantile spasms/West syndrome: Peak age: 5 months. Clusters of head nodding
(Salaam attack) and arm jerks, every 330sec. IQ decrease in ~70%. EEG is
characteristic (hypsarrythmia).
205. 46yo man, known case of chronic GN presents to OPD. He feels well. BP =
140/90mmHg. Urine dipstick: protein ++, blood ++ and serum creatinine=106mmol/L.
Which medication can prevent the progression of this dx?
a. ACEi
b. Diuretics
c. Cytotoxic meds
d. Longterm antibiotics

e. Steroids
Ans. The key is A. ACEI. [renal impairment is delayed by ACEI].
206. A 23 yo girl presented with perioral paresthesia and carpopedal spasm 20 mins
after a huge argument with her boyfriend. What is the next step for this pt?
a. SSRI
b. Diazepam
c. Rebreath into a paper bag
d. Propranolol
e. Alprazolam
Q. 1. What is the key?
Q. 2. What is the likely diagnosis?
Ans. 1. The key is C. Rebreathin in paper bag. [hyperventilation causes CO2 washout and
respiratory alkalosis. If you continue breathing and rebreathing in paper bag it will allow CO2
concentration to rise in paper bag and as you rebreath this again and again you will regain some
washed out CO2 and thus relief to this alkalosis].
Ans. 2. The girl may have anxiety disorder when it precipitates leads to hyperventilation
syndrome.

Anxiety:
Symptoms: Tension, agitation; feelings of impending doom, trembling; a sense
of collapse; insomnia; poor concentration; goose flesh; butterflies in the
stomach; hyperventilation (so tinnitus, tetany, tingling, chest pains); headaches;
sweating; palpitations; poor appetite; nausea;
lump in the throat unrelated to swallowing (globus hystericus); difficulty in
getting to sleep; excessive concern about self and bodily functions; repetitive
thoughts and activities
Childrens symptoms: Thumb-sucking; nail-biting; bed-wetting; foodfads.
Causes Genetic predisposition; stress (work, noise, hostile home), events (losing
or gaining a spouse or job; moving house). Others: Faulty learning or secondary
gain (a husband forced to stay at home with agoraphobic wife).
Treatment:
Symptom control: Listening is a good way to reduce anxiety. Explain that
headaches are not from a tumour, and that palpitations are harmless. Regular
(non-obsessive!) exercise: Beneficial effects appear to equal meditation or
relaxation.
Meditation: Intensive but time-limited group stress reduction intervention based
on mindfulness meditation can have long-term beneficial effects.
Cognitivebehavioural therapy and relaxation appear to be the best specific
measures with 5060% recovering over 6 months.
Behavioural therapy employs graded exposure to anxiety-provoking stimuli.
Drugs augment psychotherapy: 1 Benzodiazepines (eg diazepam) 2 SSRI eg
paroxetine in social anxiety). 3 Azapirones (buspirone, 5HT1A partial agonist;
ess addictive/sedating than diazepam, and few withdrawal issues). 4 Old-style
antihistamines (eg hydroxyzine).
5. Beta blockers.6 Others: pregabalin and venlafaxine.
Progressive relaxation training: Teach deep breathing using the diaphragm,
and tensing and relaxation of muscle groups, eg starting with toes and working
up the body. Practice is essential.
Hypnosis

207. A 25 yo woman has been feeling anxious and nervous for the last few
months. She also
complains of palpitations and tremors. Her symptoms last for a few minutes and
are very hard
to control. She tells you that taking alcohol initially helped her relieve her
symptoms but now
this effect is wearing off and she has her symptoms even after drinking alcohol.
What is the dx?
a. Panic disorder
b. Depression
c. OCD
d. Alcohol addiction
e. GAD
Ans. The key is A. Panic disorder.
Panic Attack:
This condition often co-exists with agoraphobia - the avoidance of exposed situations for
fear of panic or inability to escape

Panic attacks must be associated with >1 month's duration of subsequent,


persisting anxiety about recurrence of the attacks, the consequences of the
attacks, or significant behavioural changes associated with them.
A panic attack is defined as a discrete episode of intense subjective fear, where
at least four of the characteristic symptoms, listed below, arise rapidly and peak
within 10 minutes of the onset of the attack:

Attacks usually last at least 10 minutes but their duration is variable.

The symptoms must not arise as a result of alcohol or substance misuse,

medical conditions or other psychiatric disorders, in order to satisfy the


diagnostic criteria.
Panic disorder manifests as the sudden, spontaneous and unanticipated
occurrence of panic attacks, with variable frequency, from several in a day to just
a few per year:

Palpitations, pounding heart or accelerated heart rate.

Sweating.

Trembling or shaking.

Dry mouth.

Feeling short of breath, or a sensation of smothering.

Feeling of choking.

Chest pain or discomfort.

Nausea or abdominal distress.

Feeling dizzy, unsteady, light-headed or faint.

Derealisation or depersonalisation (feeling detached from oneself).

Fear of losing control or 'going crazy'.

Fear of dying.

Numbness or tingling sensations.

Chills or hot flushes.

Signs: No specific signs


Investigations: Just to rule out any physical illness.
Management: Involve the family, find and avoid any triggers. Find out if the symptoms
are because of alcohol use and treat that.
CBT is the first line.

Drugs: Offer an SSRI licensed for this indication first-line unless contra-

indicated.

Consider imipramine or clomipramine if there is no improvement after 12

weeks and further medication is indicated


If there has been an improvement after 12 weeks, continue for 6 months after the
optimum dose has been reached
At the end of treatment, withdraw the SSRI gradually,
Step 3
Reassess the condition and consider alternative treatments.

Step 4
If two interventions have been offered without benefit, consider referral to
specialist mental health services.

208. A 2yo child is very naughty. His teacher complains that he is easily distracted. His
parents say that he cant do a particular task for a long time. He sometimes hurts himself
and breaks many things. This causes many troubles at home. What is the dx?
a. ASD

b. Dyslexia
c. ADHD
d. Antisocial personality disorder
e. Oppositional defiant
Ans. The key is C. ADHD (Attention deficit hyperreactive disorder).

Attention deficit & hyperactivity disorder (ADHD)


is the most common neurobehavioral disorder of childhood. It has prevalence of
35% in Western nations ADHD is commoner in learning-disabled children, and if
prenatal cannabis exposure. The core diagnostic criteria are: impulsivity,
inattention and hyperactivity. Not all those with ADD are hyperactive. There is no
diagnostic test
Most parents first note hyperactivity at the toddler stage, Family association is
often present. These children are at increased risk of self harm and suicide.
Management:
1st line treatment for pre-school children and school age children with
moderate ADHD/moderate impairment is parent training/education
programmes. Older children may benefit from cognitive behavioural therapy.
Drugs may be useful in school age children if non-drug treatments fail (eg
methylphenidate atomoxetine:
Severe ADHD in school age children methylphenidate and atomoxetine are
1st line
treatments so ensure referral
209. A 79 yo lady who is otherwise well recently started abdominal pain. She is afebrile
and
complains that she passed air bubbles during urination. A urethral catheter showed fecal
leakage in the urinary bag. What is the likely pathology?
a. Diuretics
b. CD
c. Rectosigmoid tumor
d. Large bowel perforation
e. UC
Ans. The key is B. CD. [debate came that Crohns disease cannot occur in 79 yrs but
this is not the case! Crohns disease can occur at any age, but is most frequently
diagnosed in people ages 15 - 35. About 10% of patients are children under age 18.
[http://www.nytimes.com/health/guides/disease/crohns-disease/risk-factors.html]. So
I think it can occur in this age also and the features support the diagnosis of CD.

NEXT PAGE!

210. A 2 month child with diarrhea and vomiting for 6 days is brought in looking lethargic.
What is the appropriate initial inv?
a. BUE
b. Random blood sugar
c. CBC
d. CXR
e. AXR
Ans. The key is A. BUE.
Diarrhea makes the child dehydrated and loss of electrolytes occur. Which are making
the the lethargic so we need to check blood Urea and electrolyes and correct the
electrolyte imbalance.
211. A 72 yo man fell while shopping and hurt his knee. His vitals are fine. He speaks in
a low voice
and is very slow to give answers. What is the most probable dx?
a. Alzheimers
b. Vascular demetia
c. TIA
d. Pseudo-dementia
e. Picks dementia
Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is A. Alzheimers.
Ans. 2. Points in favour: i) age 72 yrs ii) fall iii) loss or slowness of speech.
why not vascular? in vascular: i) confusion ii) disorientation iii)loss of vision
why not pseudodementia? in pseudo i) onset is short and abrupt ii associated
depression
why not picks i) dementia and aphasia
Why not TIA? In TIA complete resolution of symptom!! But here symptoms are
persistent.

Alzheimers Disease:
This is the leading cause of dementia.
Onset may be from 40yrs (earlier in Downs syndrome, in which AD is inevitable).
Presentation: Suspect Alzheimers in adults with enduring, progressive and
global cognitive impairment (unlike other dementias which may affect certain
domains but not others): visuo-spatial skill (gets lost), memory, verbal abilities
and executive function (planning) are all affected
and there is anosognosiaa lack of insight into the problems engendered by the
disease, eg
missed appointments, misunderstood conversations or plots of films, and
mishandling of money and clerical work. Later there may be irritability; mood
disturbance (depression or euphoria); behavioural change (eg aggression,
wandering, disinhibition); psychosis (hallucinations or delusions); agnosia (may
not recognize self in the mirror). There is no standard natural history. Cognitive
impairment is progressive, but non-cognitive symptoms may come and go over

months. Towards the end, often but not invariably, patients become sedentary,
taking little interest in anything.
Associations: environmental and genetic factors both play a role. Accumulation
of beta-amyloid
peptide, neurofibrillary tangles, increased numbers of amyloid plaques, and loss of the
neurotransmitter acetylcholinethe hippocampus, amygdala, temporal neocortex and
subcortical nuclei (eg nucleus basalis of Meynert) are most vulnerable. Vascular effects
are also important95% of AD patients show evidence of vascular dementia

Risk factors 1st-degree relative with AD; Downs syndrome; homozygosity for
apolipoprotein
e (ApoE) e4 allele;are some of the risk factors
Treatment:
Refer to a specialist memory service.
Acetylcholinesterase inhibitors
Donepezil
Rivastigmine. Patches are also available.
Galantamine
212. A 47 yo man met with a RTA. He has multiple injuries. Pelvic fx is confirmed. He
has not passed urine in the last 4 hrs. What is the next appropriate management for this
pt?
a. Urethral catheter
b. Suprapubic catheter
c. IV fluids
d. IV furosemide
e. Insulin
Q. 1. What is the key?
Q. 2. What is the reason of this management?
Ans. 1. The key is B. Suprapubic catheter.
Ans. 2. In pelvic fracture there is chance of urethral rupture and hence displacement of
urethral catheter.

Indications of urethral catheterization:


Indications Relieve urinary retention, Monitor urine output in critically ill
patients, Collect uncontaminated urine for diagnosis.
It is contraindicated in urethral injury (eg pelvic fracture) and acute
prostatitis.
Suprapubic catheterization: Sterile technique required. Absolutely
contraindicated unless there is a large bladder palpable or visible on ultrasound,
because of the risk of bowel perforation. Be wary, particularly if there is a history
of abdominal or pelvic surgery. Suprapubic catheter insertion is high risk and you
should be trained before attempting it, speak to the urologists first!
213. A 49 yo pt presents with right hypochondriac pain. Inv show a big gallstone. What is
the most appropriate management?
a. Lap Cholecystectomy
b. Reassure
c. Low fat diet
d. Ursodeoxycholic acid
e. Emergency laparotomy
Q. 1. What is the key?

Q. 2. Points in favour?
Ans. 1. The key is A. Lap Cholecystectomy.
Ans. 2. i) as symptomatic only reassurence is not appropriate ii) as big ursodyoxycholic
acid is less effective iii) less invasive is preferred so laparoscopic rather than
laparotomy.

Gall Stones:
Pigment stones: (<10%) Small, friable, and irregular. Causes: haemolysis.
Cholesterol stones: Large, often solitary. Causes: age, obesity (Admirands
triangle: inc risk of stone if dec lecithin, dec bile salts, inc cholesterol).
Mixed stones: Faceted (calcium salts, pigment, and cholesterol).
Gallstone prevalence: 8% of those over 40yrs. 90% remain asymptomatic.
Risk factors for stones becoming symptomatic: smoking; parity.
Acute cholecystitis follows stone or sludge impaction in the neck of the
gallbladder, which may cause continuous epigastric or RUQ pain (referred to the
right shoulder, vomiting, fever, local peritonism, or a GB mass. If the stone
moves to the common bile duct (CBD), obstructive jaundice and cholangitis
may occur
Tests: WCC,
Ultrasound Is the best way to demonstrate stones, being 90-95% sensitive.

it shows a thick-walled, shrunken GB (also seen in chronic disease)


Treatment:
NBM, pain relief, IVI, and antibiotics eg cefuroxime 1.5g/8h IV.
Laparoscopic cholecystectomy is the treatment of choice for all patients fit
for GA.
Open surgery is required if there is GB perforation.
Cholecystostomy is also the preferred treatment for acalculous cholecystitis
214. In a man who is neglected and alcohol dependent, which high suicidal risk, which
factor can
increase this risk further?
a. Alcohol dependence
b. SSRI
c. Smoking
d. Agoraphobia
e. Court involvement
Ans. The key is A. Alcohol dependence. This is considered a wrong key by previous
plabbers and suggested correct key is B. SSRI.

Since the patient is already alcohol dependent so that cannot FURTHER increase the
risk. The correct answer here will be SSRI.
215. A 71 yo man presents with coarse tremor. He is on some meds. Which one can be
the reason for the tremor?
a. Lithium
b. Diazepam
c. Fluoxetine
d. Imipramine
e. Haloperidol
Ans. The key is A. Lithium. [lithium is associated with tremor].

Lithium:
Indications for use:
Acute manic or hypomanic episodes
Prophylaxis for bipolar disease. Significantly reduces suicidal risks.
Prophylaxis for recurrent depression & schizoaffective disorder.
Augments the effect of anti depressants.
Cluster headache prophylaxis.
Control of intentional self harm or suicidal behavior.
Contra-indications:
Cardiac disease
Significant renal impairment
Addison's disease and patients with low body sodium levels
Untreated hypothyroidism
Avoid in first trimester of pregnancy. Can be used in 2nd and 3rd trimesters if necessary.
Avoid during breast feeding.
During treatment: Check lithium levels (12 hours post dose) at least every three months
Common side-effects can usually be reduced or eliminated by lowering the lithium dose or
changing the dosage schedule:

Abdominal pain
Nausea
Metallic taste in the mouth (usually wears off)
Fine tremor
Thirst, polyuria, impaired urinary concentration - avoid fluid restriction
Weight gain and oedema

216. A young woman complains of diarrhea, abdominal cramps and mouth ulcers. AXR
shows
distended transverse colon with goblet cell depletion on rectal biopsy. What is the most
probable dx?
a. CD
b. UC
c. Bowel Ca
d. Bowel obstruction
e. IBS
Q. 1. What is the key?
Q. 2. What are points in favour?
Ans. 1. The key is B. UC.
Ans. 2. In UC there is goblet cell depletion and less mucous production in contrast with
CD where there may be goblet cell hyperplasia and mucous secretion is not reduced.
Refer to the explanation of Question No. 209.
217. After eating a cookie at a garden party, a child began to cough and went blue. The
mother also noticed that there were swollen patches on the skin. What is the dx?
a. Allergic reaction

b. Aspiration of food
c. Cyanotic heart disease
d. Trachea-esophageal fistula
e. Achalasia cardia
Ans. The key is A. Allergic reaction.
This here is anaphylaxis as there are noticable skin changes present.
Urticaria Signs: wheals, rapid onset after taking drug association with angio-oedema
/anaphylaxis. It can result from both immunological and non-immunological mechanisms.
Causes: Drugs:morphine & codeine cause direct mast cell degranulation; penicillins &
cefalosporins trigger IgE responses; NSAIDs; ACEi.

Clinical diagnosis. No investigations required.


Management:
Find the cause and avoid/treat it.
Antihistamines:
Non-sedating H1 antihistamines are the mainstay of treatment
In pregnancy chlorphenamine is often the first choice of antihistamine.

Consider anaphylaxis when there is compatible history of rapid-onset severe allergictype reaction with respiratory difficulty and/or hypotension, especially if there are skin
changes present and the treatment of anaphylaxis is IM adrenaline not anti histamine
Treatment:ABCDE, Oxygen, IM Adrenaline. <6yrs0.15ml, 6-12yrs 0.3ml, >12 yrs 0.5ml
1:1000
218. A 70 yo man presents with balance difficulties, vomiting and nausea. Which of the
following is the best inv?
a. MRI cerebellum

b. CT cerebellum
c. Skull XR
d. LP
e. Blood culture
Ans. The key is A. MRI cerebellum. [posterior fossa lesion MRI is preferred].
219. A 2 yo pt presents with colicky pain which radiates from loin to groin. He complains
of similar episodes in the past. Inv has been done and 7mm stone was found in the
ureter. What is the most appropriate management?
a. Percutaneous nephrolithotomy
b. Open surgery
c. Ureterscopy or laser
d. Conservative tx
e. ESWL
Q. 1. What is the key?
Q. 2. What treatments are recommended for different sized stones?
Ans. 1. The key is E. ESWL.
Ans. 2. Stones < 5mm: pass spontaneously, Increase fluid intake.
Stones 5mm-7mm /pain not resolving: medical expulsive therapy---> Nifedipine or Tamsulosin(and/or
prednisolone).
Stones 7mm-2cm: ESWL or Ureteroscopy using dormia basket.
Stones > 2cm/large/multiple/complex: Percutaneous nephrolithotomy.

Renal Stones (nephrolithiasis): Consist of crystal aggregates. Site: 1 Pelviureteric


junction 2 Pelvic brim 3 Vesicoureteric junction.
Types Calcium oxalate (75%) Magnesium ammonium phosphate (struvite/triple
phosphate; 15%) Also: urate (5%), hydroxyapatite (5%), brushite, cystine (1%), mixed
Presentation: Asymptomatic or: 1 Renal colic: excruciating ureteric spasms loin to
groin (or genitals/inner thigh), with nausea/vomiting. Often cannot lie still (differentiates
from peritonitis). Renal obstruction felt in the loin (like intercostal nerve irritation pain;
the latter is not colicky, and is worsened by specific movements/pressure on a trigger
spot). Obstruction of mid-ureter may mimic appendicitis/diverticulitis. Obstruction of
lower ureter
may lead to symptoms of bladder irritability and pain in scrotum, penile tip, or labia
majora. Obstruction in bladder or urethra causes pelvic pain, dysuria, strangury
(desire but inability to void) interrupted flow. UTI can co-exist (risk if voiding
impaired); pyelonephritis (fever, rigors, loin pain, nausea, vomiting), pyonephrosis
(infected hydronephrosis) 3 Haematuria 4 Proteinuria 5 Sterile pyuria 6 Anuria
Tests: BLIs, Mid stream urine, Urine C&S, urinary pH. Urine dipstick: Usually +ve for
.blood (90%).
Imaging: Spiral non-contrast CT is superior to and has largely replaced IVU for
imaging stones (99% visible). 80% of stones are visible on KUB XR
Management: Initially: Analgesia, eg diclofenac + IV fluids if unable to tolerate PO;
antibiotics (eg cefuroxime 1.5g/8h IV, or gentamicin) if infection.
Stones <5mm in lower ureter: ~9095% pass spontaneously. Increase fluid intake.
Stones >5mm/pain not resolving: Medical expulsive therapy: nifedipine 10mg/8h PO or
alpha-blockers (tamsulosin 0.4mg/d 227) promote expulsion and reduce analgesia

requirements:Most pass within 48h. If not, try extracorporeal shockwave lithotripsy


(ESWL) (if <1cm), or ureteroscopy using a basket.
Percutaneous nephrolithotomy (PCNL): keyhole surgery to remove stones, when large,
multiple, or complex. Open surgery is rare.
Indications for urgent intervention (delay kills glomeruli): Presence of infection
and obstructiona percutaneous nephrostomy or ureteric stent may be needed to relieve
obstruction ; urosepsis; intractable pain or vomiting; impending ARF; obstruction in a
solitary kidney; bilateral obstructing stones.

220. A

footballer has been struck in the groin by a kick and a presents with severe pain
and mild
swelling in the scrotum. What is the most appropriate next step?
a. USG
b. Doppler
c. Exploratory surgery
d. IV fluids
e. Antibiotics
Ans. The key is C. Exploratory surgery. [To exclude torsion].
Testicular Torsion: It is the twisting of the testes and it impairs the blood flow to the
testes.
If in any doubt, surgery is required. If suspected refer immediately to urology.
Symptoms: Sudden onset of pain in one testis, which makes walking uncomfortable.
Pain in the abdomen, nausea, and vomiting are common.
Signs: Inflammation of one testisit is very tender, hot, and swollen. The testis may lie
high and transversely. Torsion may occur at any age but is most common at 1130yrs.
With intermittent torsion the pain may have passed on presentation, but if it was severe,
and the lie is horizontal, prophylactic fi xing may be wise.
: The main differential is epididymo-orchitis but with this the patient tends to be older,
there may be symptoms of urinary infection, and more gradual onset of pain.
Tests: Doppler USS may demonstrate lack of blood flow to testis, as may isotope
scanning. Only perform if diagnosis equivocaldo not delay surgical exploration.
Treatment: Ask consent for possible orchidectomy + bilateral fixation (orchidopexy) At
surgery expose and untwist the testis. If its colour looks good, return it to the scrotum
and fix both testes to the scrotum.
221. A 47 yo ex-soldier suffers from low mood and anxiety. He cant forget the images
he faces
before and has always had flashbacks. He is not able to watch the news because there
are
usually some reports about war. What is he suffering from?
a. Depression

b. PTSD
c. Panic attack
d. Agoraphobia
e. GAD
Ans. The key is B. PTSD. [repeated flashbacks and tendency to avoid the thoughts of
stressor is diagnostic of PTSD].
PTSD:
Symptoms: Fearful; horrified; dazed Helpless; numb, detached Emotional
responsiveness
Intrusive thoughts Derealization Depersonalization Dissociative amnesia Reliving
of events Avoidance of stimuli Hypervigilance Lack of Concentration Restlessness
Autonomic arousal: pulse; BP; sweating Headaches; abdo pains
Signs: Suspect this if symptoms become chronic, with these
signs (may be delayed years): difficulty modulating arousal; isolated-avoidant modes of
living; alcohol abuse; numb to emotions and relationships; survivor guilt; depression;
altered world
view in which fate is seen as untamable, capricious or absurd, and life can yield no
meaning
or pleasure.
Treatment: Watchful waiting for mild cases.
For severe cases: CBT or eye movement desensitization and reprocesing is done. Drug
treatment is not recommended but in case it is needed prescribe mirtazepine or
paroxetine.

222. A 36 yo woman has recently spent a lot of money on buying clothes. She goes out
almost every night with her friends. She believes that she knows better than her friends,
so she should
choose the restaurant for eating out. She gave hx of having low mood at 12 yo. Whats
the dx?
a. Mania
b. Depression
c. Bipolar affective disorder
d. Borderline personality disorder
e. Dysthymia
Ans. The key is C. Bipolar affective disorder. [Initial depressive episode (may be before
a long) followed by mania is bipolar affective disorder].
Signs of mania: Mood: Irritability (80%), euphoria (71%), lability (69%).
Cognition: Grandiosity (78%); flight of ideas/racing thoughts (71%); distractibility/ poor
concentration (71%); confusion (25%), many conflicting lines of thought urgently racing
in contrary directions; lack of insight. Behaviour: Rapid speech (98%), hyperactivity
(87%), reduced sleep (81%), hypersexuality (57%), extravagance (55%). Psychotic
symptoms: Delusions (48%), hallucinations (15%). Less severe states are termed
hypomania. If depression alternates
with mania, the term bipolar affective disorder is used (esp. if there is a
history of this). During mood swings, risk of suicide is high. Cyclical mood
swings without the more florid features (as above) are termed cyclothymia

Causes Infections, hyperthyroidism; SLE; thrombotic thromocytopenic purpura; stroke;


water dysregulation/hyponatremia;. Drugs: Amphetamines, cocaine, antidepressants
(esp. venlafaxine), captopril, steroids, procyclidine, L-dopa, baclofen.
Bipolar disorder: (Age at onset: <25.) In a 1st attack Ask about: Infections, drug use,
and past or family history of psychiatric disorders. Do: CT of the head, EEG, and screen
for drugs/toxins.
Treating acute mania for acute moderate/severe mania: olanzapine 10mg PO(SE:
weight gain; inc glucose), or valproate semisodium, eg 250mg/8h PO
Prophylaxis Those who have bipolar affective disorder after successful treatment of the
manic or depressive episode should have a mood stabilizer for longer-term control. If
compliance is good, and U&E, ECG, and T4 normal, give lithium carbonate.

223. A 28 yo female presents with a 3m hx of diarrhea. She complains of abdominal


discomfort and passing stool 20x/day. Exam=febrile. Barium enema shows cobblestone
mucosa. What is the
most likely dx?
a. Ameoba
b. Colon Ca
c. GE
d. CD
e. UC
Ans. The key is D. CD. [Hx of diarrhea, abdominal discomfort, and patient being febrile
indicate gut inflammation and cobblestone appearance on barium enema is suggestive
of CD].
Refer to the explanation of Q.NO 209

224. A child is brought in with high grade fever, runny nose and bark-like cough. He is
also drooling. What is the most appropriate tx for this child?
a. Corticosteroids
b. Paracetamol
c. Adrenaline nebulizer
d. IV antibiotics
e. Intubation under GA
Ans. The key is E. Intubation under GA. [high fever, bark-like cough, drooling in a child
suggest epiglottitis where urgent intubation is needed to avoid respiratory blockage from
epiglottitis].
It is a very tricky question. Symptoms of both croup and acute epiglottitis are mixed here!
A confirm diagnosis cannot be made.
In favour of croup: runny nose and barking cough.
In favour of acute epiglottitis: high grade fever, drooling.
Perhaps in the original exam question more information was provided which couldnot be
recalled here in the question which would have helped in the diagnosis.
Laryngotracheobronchitis/croup: is the leading cause of stridor with a barking cough.
More common than epiglottitis.

Cause: 95% are viral, eg parainfluenza (ribavirin can help, eg in immunodeficiency).


Bacteria (klebsiella; diphtheria) & fungi are rare.
Presentation: If there is cough and no drooling, croup is almost always the
diagnosis.
Initially presents with symptoms of URTI. Hoarsness and barking cough develop in a couple
of days worse at night and mild to moderate fever. Stridor is also present. Respiratory
distress with marked tachypnoea and intercostal recession may be noted. Drowsiness,
lethargy, and cyanosis despite increasing respiratory distress should be considered as red
flags for impending respiratory failure.
Management: Usually self-limiting; treat at home ( antibiotics). Admit (eg to ITU) if
severe. In children, CXR may show steeple sign of a tapering trachea. Give antibiotics,
humidified O2, + nebulized adrenaline (5mL 1:1000, may buy time in severe disease
needing ventilating), and dexamethasone 150g/kg PO stat or budesonide 2mg
nebulized.
Acute epiglottitis is rarer than croup but mortality is high: 1% if respiratory distress. Its
an emergency as respiratory arrest can occur.
Presentation: Often, history is short, septicaemia is rapid, and cough is absent. Also:
sore throat (100%), fever (88%), dyspnoea (78%), voice change (75%), dysphagia
(76%), tender anterior neck cellulitis (27%), hoarseness (21%), pharyngitis (20%),
anterior neck nodes (9%), drooling (head for ward tongue out), prefers to sit, refusal to
swallow,
Cause: Haemophilus (vaccination has reduced prevalence); Strep pyogenes.
Investigation: Fibre-optic laryngoscopy remains the 'gold standard' for diagnosing
epiglottitis
Management: Take to ITU; dont examine throat (causes resp. arrest). Give O2 by
mast, Give nebulized adrenaline, IV dexamethasone, antibiotics, antipyretics until the
anesthetist arrives. Definitive management is intubation

225. A 78yo lady on warfarin for atrial fibrillation lives in a care home. She presents with
hx of
progressive confusion for three days. She was also noticed to have bruises on her arms.
INR = 7. What is the most probable dx?
a. Alzheimers
b. Delirium
c. Subdural hemorrhage
d. Vascular dementia
e. Picks dementia
Ans. The key is C. Subdural haemorrhage. [Age 78 yrs, living in a care home where
unnoticed trivial injury is possible (like fall), warfarin and high INR is potential risk factor
of subdural haemorrhage suggested by bruises on arms also].
Subdural Haemorrhage: Consider this very treatable condition in all whose conscious
level fluctuates, and also in those having an evolving stroke, especially if on
anticoagulants.
Causes: Bleeding is from bridging veins between cortex and venous sinuses (vulnerable
to deceleration injury), resulting in accumulating haematoma between dura and

arachnoid. Most subdurals are from trauma but the trauma is often forgotten as it was so
minor or so long ago (up to 9 months). Elderly are particularly susceptible. Other risk
factors: falls (epileptics, alcoholics); anticoagulation
Symptoms Fluctuating level of consciousness (seen in 35%) insidious physical or
intellectual slowing, sleepiness, headache, personality change, and unsteadiness.
Signs: Raised ICP; seizures. Localizing neurological symptoms (eg unequal pupils,
hemiparesis) occur late and often long after the injury
Imaging: CT/MRI shows clot midline shift (but beware bilateral isodense clots). Look
for crescent-shaped collection of blood over 1 hemisphere. The sickleshape different
iates subdural blood from extradural haemorrhage.
Treatment Irrigation/evacuation, eg via burr twist drill and burr hole craniostomy, can be
considered 1st-line; craniotomy is 2nd-line if the clot has organized. Address causes of
the trauma (eg falls due cataract or arrhythmia; abuse).

226. A 28 yo drug user presents to the ED with collapse and anuria. His serum K+ =
7.5mmol/L. CXR = early pulmonary edema. What is the next appropriate management?
a. Urgent hemodialysis
b. IV calcium gluconate
c. IV insulin + dextrose
d. Furosemide
e. IV NS 0.9%
Ans. The key is B. IV calcium gluconate. [To correct hyperkalemia to prevent cardiac
arrhythmia].
Hyperkaelemia: A plasma potassium >6.5mmol/L is an emergency and needs urgent
treatment
The worry is of myocardial hyperexcitability leading to ventricular fibrillation and cardiac
arrest.
Concerning signs and symptoms fast irregular pulse, chest pain, weakness,
palpitations, and light-headedness.
ECG: tall tented T waves, small P waves, a wide QRS complex (eventually becoming
sinusoidal), and ventricular fibrillation
Artefactual results: If the patient is well, and has none of the above findings, repeat
the test urgently as it may be artefactual
Causes: Oliguric renal failure K+-sparing diuretics Rhabdomyolysis Metabolic
acidosis(DM)
Excess K+ therapy Addisons disease Massive blood transfusion Burns Drugs, eg
ACE-i, suxamethonium Artefactual result
Management:
Stabilisation of the cardiac membrane
intravenous calcium gluconate

Short-term shift in potassium from extracellular to intracellular fluid compartment


combined insulin/dextrose infusion
nebulised salbutamol
Removal of potassium from the body
calcium resonium (orally or enema)
loop diuretics
dialysis

227. A 32 yo woman suffers an episode of severe occipital headache with vomiting and
loss of
consciousness. She is brought to the hospital where she is found to be conscious and
completely alert. Exam: normal pulse & BP. No abnormal neurological signs. What is the
next step in management?
a. Admission for observation
b. CT brain
c. MRI head
d. Reassurance and discharge
e. XR skull
Ans. The key is B. CT brain. [basilar migraine can cause severe headache and LOC. But
there occurs no neurological deficit and recovering from unconsciousness becomes
completely alert. But to diagnose basilar migraine there should at least history of two
migraine attacks with aura. As here diagnostic criteria of basilar migraine is not fulfilled
we can not discharge the patient without neuroimaging like CT or MRI].
228. A 25 yo woman was brought to the ED by her boyfriend. She has many superficial
lacerations on her forearm. She is so distressed and constantly says her boyfriend is
going to end the relationship. She denies trying to end her life. What is the most likely
dx?
a. Acute psychosis
b. Severe depression
c. Psychotic depression
d. Borderline personality disorder
e. Schizophrenia
Ans. The key is D. Borderline personality disorder. [ Borderline personality disorder: Act
impulsively and develop intense but short-lived emotional attachment to others. They are usually
attention seekers but not suicidal].
Borderline Personality Disorder: There is unstable affect regulation, poor impulse control, and
poor interpersonal relationships/self-image, eg with repeated self-injury, suicidality, and a difficult
life-course trajectory
Associations: ADHD;2 learning difficulties. Genetics and adverse childhood events (eg abuse)
are predispositions. Intervene (and refer) early with specific management plan, addressing work,
Dialectical behaviour therapy, inpatient hospital programmes, and drugs can reduce depression,
anxiety, and impulsive aggression. Eventually, supportive interpersonal dyads are achievable

229. A young woman was brought to the hospital. On exam she has low temperature and

tremor.
She says when she closes her eyes, she can see colors. What drug has been used?
a. Amphetamines
b. LSD
c. Cocaine
d. Heroine
e. Ecstasy
Ans. The key is B. LSD.
LSD stands for its chemical name, lysergic acid diethylamide. It is also commonly called
acid. Other terms include blotter, tripper, flash, stars, rainbows.
What are the harmful effects? It can make you frightened and confused. Sometimes you
can get "flashbacks" when you relive the same experience again. People can be more likely
to self-harm when they have a bad trip.

230. A lady comes in severe liver disease and hematemesis. Her INR is >10. What
should she be given?
a. FFP
b. Steroids
c. Whole blood
d. IV fluids
e. Vit K
Ans. The key is A. FFP.

IN any major bleeding irrespective of INR prothrombin complex concentrate (or FFP) is
given and vit.K is also given! But vit.K takes time to act FFP is a better options.
Situation

Major bleeding

Management

Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP*

INR > 8.0

Stop warfarin

Minor bleeding

Give intravenous vitamin K 1-3mg


Repeat dose of vitamin K if INR still too high after 24 hours
Restart warfarin when INR < 5.0

INR > 8.0

Stop warfarin

No bleeding

Give vitamin K 1-5mg by mouth, using the intravenous preparation orally


Repeat dose of vitamin K if INR still too high after 24 hours
Restart when INR < 5.0

INR 5.0-8.0

Stop warfarin

Minor bleeding

Give intravenous vitamin K 1-3mg


Restart when INR < 5.0

INR 5.0-8.0

Withhold 1 or 2 doses of warfarin

No bleeding

Reduce subsequent maintenance dose

231. After eating a cookie at a garden party, a child began to cough and went blue. The
mother also noticed that there were swollen patches on the skin. What is the initial
management?
a. OTC antihistamine
b. Oxygen
c. Bronchodilators
d. Epinephrine IM
e. Nebulized epinephrine
Ans. The key is D. Epinephrine IM [anaphylaxis with partially blocked airway].
Already explained in previous questions.

232. A 63 yo female is noted to have left pupil unresponsive to light and is dilated. What
is the most probably dx?
a. Pontine hemorrhage
b. Subdural hemorrhage
c. Cerebellar hemorrhage
d. Extradural hemorrhage
e. Subarachnoid hemorrhage
Ans. The key is D. Extradural hemorrhage. It is a wrong key. In a 63 year old extradural
hemorrhage is extremely unlikely. As no clinical picture is described in question except 3rd nerve
palsy E. SAH is more logical answer!
Sub Arachnoid Haemorrhage
Spontaneous bleeding into the subarachnoid space is often catastrophic
Causes: Rupture of saccular aneurysms (80%); arteriovenous malform ations (AVM; 15%). No
cause

is found in <15%.
Risk factors: Smoking, alcohol misuse, inc BP, bleeding disorders, mycotic aneurysm (SBE),
perhaps post-menopausal oestrogen >45yrs old).
Berry aneurysms Common sites: junction of posterior communicating with the internal carotid or
of the anterior communicating with the anterior cerebral artery or bifurcation of the middle
cerebral artery. Some are hereditary. Associations: Polycystic kidneys, coarctation of the aorta,
EhlersDanlos syndrome
Symptoms Sudden (usually, but not always, within seconds) devastating typically occipital
headacheI thought Id been kicked in the head. Vomiting, collapse, seizures and coma often
follow. Coma/drowsiness may last for days.
Signs Neck stiffness, Kernigs sign (takes 6h to develop), retinal, subhyaloid and vitreous bleeds
(=Tersons syndrome; it carries a worse prognosis) Focal neurology at presentation may suggest
site of aneurysm (eg pupil changes indicating a IIIrd nerve palsy with a posterior communicating
artery aneurysm) or intracerebral haematoma. Later deficits suggest complications
Tests CT detects >90% of SAH within the 1st 48h. LP if CT ve and no contraindication >12h
after headache onset. CSF in SAH is uniformly bloody early on, and becomes xanthochromic
(yellow) after several hours due to breakdown products of Hb (bilirubin). Finding xanthochromia
confirms SAH
Management Refer all proven SAH to neurosurgery immediately.
Re-examine CNS often; chart BP, pupils and GCS. Repeat CT if deteriorating.
Maintain cerebral perfusion by keeping well hydrated, and aim for SBP >160mmHg. Treat BP
only if very severe.
Nimodipine is a Ca2+ antagonist that reduces vasospasm and consequent morbidity from
cerebral ischaemia.
Endovascular coiling is preferred to surgical clipping where possible. Do catheter
or CT angiography to identify single vs multiple aneurysms before intervening.
Intracranial stents and balloon remodelling enable treating wide-necked aneurysms.
Complications Rebleeding is the commonest cause of death, and occurs in 20%,
often in the 1st few days. Cerebral ischaemia due to vasospasm may cause a permanent
CNS deficit, and is the commonest cause of morbidity. Hydrocephalus, due to blockage
of arachnoid granulations, requires a ventricular or lumbar drain. Hyponatraemia
is common but should not be managed with fluid restriction. Seek expert help

233. A 28yo business exec presents at the GP asking for some help because she has
been arguing with her boyfriend frequently. She is worried about her weight, and she
thinks she may be fat. She has been on a diet and lost 7 kgs in the last 2 months on
purpose. She is eating less. She used to do a lot of exercise. Now she says shes feeling
down, has some insomnia and feels tired and without energy. She has not showed up at
work. She is worried because recently she got a loan to buy a luxury car. She cant be
fired. She complains about her low mood. She thinks this is weird because she used to
be extremely productive. She used to work showing an excellent performance at the
office. She even received compliments from her boss. How, she says her boyfriend is
angry because her apartment is a chaos. Usually she spends a lot of time cleaning it,
even upto 3 AM. She liked it to be perfect, but not its a mess. On exam: BMI=23, no
other signs. What is the most probably dx?
a. Anorexia nervosa
b. Bipolar disease

c. Binge eating disorder


d. Hyperthyroidism
e. Schizophrenia
Ans. The key is B. Bipolar disease.
Bipolar Disease:
It is characterised by episodes of mania (or hypomania) and depression. Either one can
occur first and one may be more dominant than the other but all cases of mania
eventually develop depression.
During the manic phase the following may be present:

Grandiose ideas.
Pressure of speech.
Excessive amounts of energy.
Racing thoughts and flight of ideas.
Overactivity.
Needing little sleep or an altered sleep pattern.
Easily distracted - starting many activities and leaving them unfinished.
Bright clothes or unkempt.
Increased appetite.
Sexual disinhibition.
Recklessness with money.

Depressive phase:
In the depressive phase, patients experience low mood with reduced energy. Patients
have no joy in daily activities and have negative thoughts. They lack facial expressions
and have poor eye contact and may be tearful and unkempt. Low mood is worse in the
mornings and is disproportionate to the circumstances. There may be feelings of
despair, low self-esteem and guilt for which there may be no clear reason. There may be
weight loss, reduced appetite, altered sleep pattern with early morning wakening and
loss of libido.
Diagnosis:
ICD-10 requires at least two episodes in which a person's mood and activity levels are
significantly disturbed (one of which must be mania or hypomania)
Three of the following symptoms confirm mania:

Grandiosity/inflated self-esteem.
Decreased need for sleep.
Pressured speech.
Flight of ideas (rapidly racing thoughts and frequent changing of their train of
thought).
Distractibility.
Psychomotor agitation.
Excessive involvement in pleasurable activities without thought for
consequences (eg, spending spree resulting in excessive debts).

There may also be psychotic symptoms - eg, delusions and hallucinations. The manic
episode is mixed if there are associated depressive symptoms
Management: The following are non-pharmacological methods:

Education regarding diagnosis, treatment and side-effects.


Good communication.
Self-help groups.
Support groups.
Self-monitoring of symptoms, side-effects and triggers.
Coping strategies.
Psychological therapy.
Encouragement of engagement in calming activities.
Telephone support.

Psychological therapies have been shown to be beneficial - eg, cognitive behavioural


therapy which helps to identify triggers and how to avoid them.
Pharmacological treatment: For manic attack treatment is same as for mania
If the pt is on antipsychotics and still develops an attack of mania the dose should be
increased. Drugs commonly used are haloperidol, olanzapine, quetiapine and
risperidone. If one antipsychotic is ineffective it is worth changing to a different one.
If ineffective consider adding lithium, if contra indicated add valproate.
Treatment of an acute depressive episode
A risk assessment of suicidal ideation should be made. If it is considered that
compulsory hospital admission would be in the patient's interest, the Mental Health Act
or Common Law may need to be invoked

Patients with moderate-to-severe depression should be offered fluoxetine


combined with olanzapine or quetiapine on its own.
If there is no response, lamotrigine on its own can be tried.
If patients are already taking lithium, the level should be checked and the
dose increased as necessary. If this fails, fluoxetine combined with
olanzapine or quetiapine can be added.,

During an acute mixed episode antidepressants should be avoided and the aim should
be to try to stabilise patients on anti-manic medication.

234. A woman brought her husband saying she wants the thing on his forehead
removed. The
husband is refusing tx saying it improves his thinking. What is the next most appropriate
next

step?
a. Assess his mental capacity to refuse tx
b. Remove lesion
c. Refer to ED
d. Mini-mental state exam
e. Refuse surgery and send pt back
Ans. The key is A. Assess his mental capacity to refuse treatment.
235. A 37 yo man who has many convictions and has been imprisoned many times has
a hx of many unsuccessful relationships. He has 2 boys but doesnt contact them. What
is the most probable
dx?
a. Borderline personality disorder
b. Schizophrenia
c. Avoidant personality disorder
d. Histrionic personality disorder
e. Antisocial behavior disorder
Ans. The key is E. Antisocial behavior disorder.
Antisocial behavior
Features include:

Unstable interpersonal relationships.


Disregard for the consequences of their behaviour.
A failure to learn from experience.
Egocentricity.
A disregard for the feelings of others.
A wide range of interpersonal and social disturbance.
Comorbid depression and anxiety.
Comorbid alcohol and drug misuse

Diagnostic criteria:
People with antisocial personality disorder have a pervasive pattern of disregard for and
violation of the rights of others and the rules of society. A history of conduct disorder before
the age of 15 is a requirement for a diagnosis of antisocial personality disorder (in the DSMIV criteria) and includes the following features:

Repeated breaches of the law. They may well have recurrent criminal
convictions.
Frequent lying and deception, even when there is no obvious gain.
Physical aggression.
Reckless disregard for safety of self or others.
Utter irresponsibility in work and family environments.
Lack of remorse.

Tests: Toxicology screen and HIV screening should be done

Management: All patients diagnosied in primary setting should be referred to specialist


centers.
No drug has UK marketing authorisation specifically for the treatment of antisocial
personality disorder. However, antidepressants and antipsychotics are often used to treat
some of the associated problems and symptoms.
Psychotherapy is at the core of care for personality disorders generally. Cognitive
behavioural therapy and group therapy are perhaps the most widely used and available
forms of psychotherapy

Complications:
Suicide
Substance abuse
Accidental injury
Depression
Homicide

236. A 60 yo man has a pathological rib fx. He also complains of recurrent infection.
BMA is done. Labs: Ca2+ = 3.9mmol/L and ALP = 127u/L. what type of cell would be
found in abdundance in
the marrow smear?
a. Plasma cell
b. Myeloid cell
c. Bence-jones protein
d. Megakaryocytes
e. Reticulocytes
Q. 1. What is the key.
Q. 2. What is the diagnosis?
Q. What are the points in favour of diagnosis?
Ans. 1. The key is A. Plasma cell.
Ans. 2. The diagnosis of multiple myeloma.
Ans. 3. Points in favour: i) age 60 yrs ii) pathological rib fracture (from metastases) iii)
recurrent infection (due to B cell dysfunction (manifested as hypogammaglobulinemia),
numerical and functional abnormalities of T cells, and dysfunction of natural killer cells),
iv) raised calcium level.
Multiple Myeloma: PCDs are due to an abnormal proliferation of a single clone of
plasma or lymphoplasmacytic cells leading to secretion of immunoglobulin occuring as
monoclonal bands or paraprotein in urine or serum electrophoresis.
IgG in ~ ; IgA in ~ ; A very few are IgM or IgD. Other Ig levels are low
(immunoparesis, causing susceptibility to infection). In ~ , urine contains Bence Jones
proteins.
Symptoms:
Osteolytic bone lesions causing backache, pathological fractures (eg long bones
or ribs) and vertebral collapse. Hypercalcaemia may be symptomatic.

Anaemia, neutropenia, or thrombocytopenia may result from marrow infiltration


by plasma cells, leading to symptoms of anaemia, infection and bleeding.
Recurrent bacterial infections due to immunoparesis, and also because of neutropenia
due to the disease and from chemotherapy.
Renal impairment due to light chain deposition.
Diagnostic criteria:
1 Monoclonal protein band in serum or urine electrophoresis.
2 Plasma cells on marrow biopsy
3 Evidence of end-organ damagefrom myeloma:
Hypercalcaemia Renal insufficiency Anaemia
4 Bone lesions: a skeletal survey afterdiagnosis detects bone disease: Xraysof chest; all
of spine; skull; pelvis.
Tests: Rouleaux formation, persistently inc ESR or Polycythemia Vera, inc urea and
creatinine, inc Ca2+ (in ~40%), alk phos usually normal unless healing fracture.
Screening test: Serum and urine electrophoresis. Beta2-microglobulin (as a prognostic
test).
Imaging: X-rays: lytic punched-out lesions, eg pepper-pot skull, vertebral collapse,
fractures or osteoporosis.
CT or MRI may be useful to detect lesions not seen on XR.
Treatment: Symptomatic. For bones give bisphosphonates. For anemia transfusion or
erythropoietin. Keep hydrated to prevent renal failure, dialysis may be needed. Treat
infections.
Chemotherapy: If unsuitable for intensive , melphalan + prednisolone is used.
Complications: Hypercalcemia, Renal injury, cord compression, hyperviscosity.
237. A child presents with blue marks on the sclera, short stature and heart murmur.
What is the dx?
a. Osteogenesis imperfect
b. Hypopituitarism
c. VSD
d. Achondrogenesis
e. Dwarfism
Ans. The key is A. Osteogenesis imperfecta.

Osteogenesis imperfecta:
is an inherited disorder of type I collagen that
results in fragile, low density bones
Types:
I The mildest and most common form. It is autosomal dominant. Associated with blue
sclerae (due to increased corneal translucency) and 50% have hearing loss. Fractures
typically occur before puberty. There is a normal life expectancy.
II Lethal perinatal form with many fractures and dwarfism; it is recessive.
III Severe formoccurs in about 20%. Recessive. Fractures at birth + progressive spinal
and limb deformity, with resultant short stature; blue or white sclera;Life expectancy is
decreased.
IV Moderate form, autosomal dominant. Fragile bones, white sclerae after infancy.

Radiographs: Many fractures, osteoporotic bones with thin cortex, and bowing
deformity of long bones.
Histology: Immature unorganized bone with abnormal cortex.
Treatment: Prevent injury. Physio, rehab and occupational therapy are key.
Bisphosphonates can be used.
238. A 5month child cant speak but makes sounds. She can hold things with palm, not
fingers. Cant sit independently but can hold her head and sit when propped up against
pillows. Hows the
childs development?
a. Normal
b. Delayed speech
c. Delayed sitting
d. Delayed motor development
Ans. The key is A. normal

239. A 27 yo woman has hit her neck in an RTA without complains of tingling or motor
loss. What is the next most appropriate inv?
a. MRI
b. XR
c. CT cervical
d. Diagonal XR
Ans. The key is B. X-ray. [As there is no neurological deficit we can exclude any fracture
by x-ray first].[Diagonal x ray means ,oblique view of cervical spine. By this view we can assess facet
joint arthopathy. This doesn't related to RTA].

240. A young female who has many superficial lacerations was brought into the ED by
her boyfriend for superficially lashing her upper arm. She is adamant and screaming that
she is not suicidal but scared her boyfriend wants to leave her. What is the dx?
a. Acute psychosis
b. Severe depression
c. Obsessive

d. Bipolar
e. Borderline personality
f. Schizophrenia
Ans. The key is acute psychosis.
241. A 22yo woman was brought by her boyfriend with multiple superficial lacerations.
There are
scars of old cuts on her forearms. She is distressed because he wants to end the
relationship.
She denies suicide. What is the most likely dx?
a. Acute psychosis
b. Borderline personality disorder
c. Severe depression
d. Schizoid personality
e. Psychotic depression
Ans. The key is B. Borderline personality disorder.
242. A 31yo single man lives with his mother. He usually drives to work. He always
thinks when the traffic lights change, his mother is calling him, so he drives back home.
What is the dx?
a. OCD
b. GAD
c. Schizophrenia
d. Bipolar
e. Cyclothymia
Ans. The key is C. Schizophrenia. [ delusion of reference - he thinks that the changing traffic lights
are giving message to him].

Schizophrenia is the most common form of psychosis. It is a lifelong, condition, which can
take on either a chronic form or a form with relapsing and remitting episodes of acute illness.
Multiple factors are involved in schizophrenia - eg, genetic, environmental and social.
Risk factors include= family history, intrauterine and perinatal complications,Intrauterine
infection, particularly viral, Abnormal early cognitive/neuromuscular development etc.
Features=
The hallmark symptoms of a psychotic illness are: Delusions,Hallucinations (auditory
hallucination like two or more voices discussing the patient in the third person,thought
echo,voices commenting on the patient's behaviour), Thought disorder (thought
insertion,thought withdrawal, thought broadcasting), Lack of insight.
These first Rank or positive symptoms of schizophrenia are absent in other psychotic
disorders.

Schizophrenia
NICE published guidelines on the management of schizophrenia in 2009.
Key points:
oral atypical antipsychotics are first-line
Examples of atypical antipsychotics
clozapine, olanzapine,risperidone,quetiapine,amisulpride

adverse effects:
weight gain
clozapine is associated with agranulocytosis

cognitive behavioural therapy should be offered to all patients


close attention should be paid to cardiovascular risk-factor modification due to the
high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic
medication and high smoking rates).

243. A 56yo woman is known case of pernicious anemia. She refuses to take
hydroxycobalamin IM as she is needle shy. She asks for oral medication. Why will oral
meds be not effective?
a. Intrinsic factor def
b. Malabsorption
c. Irritated gastric mucosa
d. Lack of gastric acidity
Ans. The key is A. Intrinsic factor def.
Pernicious Anemia: This is caused by an autoimmune atrophic gastritis, leading to
achlorhydria and lack of gastric intrinsic factor secretion.
Associations Other autoimmune diseases: thyroid disease (~25%), vitiligo, Addisons
disease, hypoparathyroidism. Carcinoma of stomach is ~3-fold more common in
pernicious anaemia
Investigations: Hb (30110g/L) Raised MCV Decreased WCC and platelets if
severe Decreased Serum B12 Reticulocytes reduced or normal as production
impaired Hypersegmented polymorphs Megaloblasts in the marrow
Specific tests: 1.Parietal cell antibodies: found in 90% with PA, 2 Intrinsic factor (IF)
antibodies:
specific for pernicious anaemia, but lower sensitivity.
Treatment Treat the cause if possible. If a low B12 is due to malabsorption, injections
are required. Replenish stores with hydroxocobalamin (B12) 1mg IM alternate days, for
2wks Maintenance: 1mg IM every 3 months for life.
If the cause is dietary, then oral B12 can be given after the initial acute course.
244. An 11m baby had an apnea event. The parents are worried that if something like
this happens in the future, how they are to deal. Advise them about infant CPR.
a. Index and middle finger compression
b. Compression with palm of one hand
c. Compression with palm of two hands
d. Compression with rescue breaths 30:2
e. Compression with rescue breaths 15:2
Ans. The key is A. Index and middle finger compression.
How to give chest compressions: Compress lower half of sternum to of the
chests depth; use the heel of one hand (or, in babies, with both your thumbs,
with your hands encircling the thorax) If >8yrs, the adult 2-handed method is
OK. For an infant, 2 fingers are sufficient, in the middle of a line joining the nipples.
How to give the rescue breaths to a child: Ensure head tilt and chin lift.

Pinch the soft part of his nose. Open his mouth a little, but maintain chin up.
Take a breath, and place your lips around his mouth (good seal). Blow steadily
into his mouth over 11.5sec

245. A teacher brings in a child who says she fell down after hitting a table. On probing
further, you
decide that it was most probably an absence seizure. What led you to this dx?
a. The child had not eaten since morning
b. The child suddenly went blank and there was up-rolling of eyes
c. The child started moving his fingers uncontrollably before he fell
d. The childs body became rigid and then started to jerk
Ans. The key is B. The child suddenly went blank and there was up-rolling of eyes.
Types of seizures:

Primary generalized seizures Simultaneous onset of electrical discharge


throughout cortex, with no localizing features referable to only one hemisphere.
Absence seizures: Brief (10s) pauses,They do not fall but may pause in what they
are doing. Their face often looks pale with a blank expression. They may look dazed, the
eyes stare and the eyelids may flutter a little. Sometimes their head may fall down a little, or
their arms may shake once or twice. Each seizure usually starts and finishes abruptly. The
person is not aware of the absence and resumes what they were doing..

Tonicclonic seizures: Loss of consciousness. Limbs stiffen (tonic), then jerk


(clonic). May have one without the other. Post-ictal confusion and drowsiness.
Myoclonic seizures: Sudden jerk of a limb, face or trunk. The patient may be
thrown suddenly to the ground, or have a violently disobedient limb: one patient
described it as my flying-saucer epilepsy, as crockery which happened to be in
the hand would take off .
Atonic (akinetic) seizures: Sudden loss of muscle tone causing a fall, no LOC.
Infantile spasms/West syndrome: Peak age: 5 months. Clusters of head nodding
(Salaam attack) and arm jerks, every 330sec. IQ decrease in ~70%. EEG is
characteristic (hypsarrythmia)

246. A man has discharge from his left ear after a fight. Where is the discharge coming
from?
a. CSF
b. Inner ear
c. Outer ear
d. Brain
Ans. The key is A. CSF. [probable fracture base of skull]
Ear Discharge & Their Source:
External ear: Inflammation, ie otitis externa produces a scanty watery discharge, as
there are no mucinous glands Blood can result from trauma to the canal. Liquid wax
can sometimes leak out.
Middle ear: Mucous discharges are almost always due to middle ear
disease.Serosanguinous discharge suggests a granular mucosa of chronic otitis media.
An offensive discharge suggests cholesteatoma.
CSF otorrhoea: CSF leaks may follow trauma: suspect if you see a halo sign on filter
paper, or its glucose is increased , or Beta2 (tau) transferrin is present.
.
247. A 40 yo manic depressive is noted to have high serum levels of lithium and
profound
hypokalemia. His GP had started him on anti-HTNs. Choose the single most likely
cause?
a. Verapamil
b. Amiodarone
c. Ranitidine
d. Lithium
e. Thiazide
Ans. The key is E. Thiazide. [Thiazide was prescribed for Hpt and when lithium was
prescribed its level increased due to thiazide and thiazide also caused hypokalemia
resulting the given picture].
Thiazide Diuretics Side Effects:
A possible increase in blood sugar level.
A possible increase in the level of uric acid. So contra indicated in gout.
It can cause a low blood level of potassium, sodium, and magnesium, and a high
level of calcium. These effects may cause weakness, confusion, and rarely,
abnormal heart rhythms to develop.
Other problems, such as:
o Upset stomach.
o Dizziness on standing (due to too low blood pressure).
o Erection problems (impotence) - often reversible on stopping
treatment.
o Skin sensitivity to sunlight.

248. A 74yo man presents with weakness in his arm and leg from which he recovered
within a few days and short term memory loss. He has an extensor plantar response. He
has similar episodes 2 years ago and became unable to identify objects and to make
proper judgment. What is the most appropriate dx?

a. Alcoholic dementia
b. Picks dementia
c. Huntingtons disease
d. Alzheimers disease
e. Vascular dementia
Ans. The key is E. Vascular dementia. [hemiparesis, memory impairment, extensor
plantar reflex, inability to identify objects, poor judgment are features of vascular
dementia].
Vascular dementia: ~25% of all dementias. It represents the cumulative effects of many
small strokes, thus sudden onset and stepwise deterioration is characteristic
Look for evidence of vascular pathology (BP, past strokes, focal CNS signs).
Diagnosis:

Presence of dementia - cognitive decline from higher level of functioning. This


can be demonstrated as memory loss plus impairment in two or more different
cognitive domains . This should be established by clinical examination and
neuropsychological testing. Deficits should be severe enough to interfere with
activities of daily living - not secondary effects of the cerebrovascular event
alone.
Cerebrovascular disease, defined by the presence of signs on neurological
examination and/or by brain imaging.
A relationship between the above two disorders inferred by:
o Onset of dementia within three months following a recognised
stroke.
o An abrupt deterioration in cognitive functions.
o Fluctuating, stepwise progression of cognitive deficits.

Management: Like other dementias the treatment is symptomatic, addressing the


individual's main problems and supporting the carers. Detecting and addressing
cardiovascular risk factors is also very important to try to slow progression

249. A nurse comes to you saying that she has recently developed the habit of washing
her hands after every 15-20 mins. She is unable to conc on her work and takes longer
than before to finish tasks as she must constantly was her hands. What is the most
appropriate management?
a. CBT
b. SSRI
c. ECT
d. Antipsychotics
e. Desensitization
Q. 1. What is the key?
Q. 2. What is the diagnosis?
Ans. 1. The key is A. CBT.
Ans. 2. The diagnosis is OCD.
Compulsions are senseless, repeated rituals. Obsessions are stereotyped, purposeless
words, ideas, or phrases that come into the mind.

Repetitive behavior and an urge to do it.


Treatment: CBT is first line. Clomipramine (start with 25mg/day PO) or SSRIs (eg
fluoxetine)
250. A 61yo man underwent a surgery in which ileal resection had been done. He
complains of
fatigue, headache, and heart racing. Labs: MCV=108fL, Hgb=8.9g/dL. What is the most
likely dx?
a. Vit B12 def
b. Iron def
c. Folate def
d. Hemolytic anemia
e. Anemia of chronic disease
Q. 1. What is the key?
Q. 2. What are the points in favour?
Ans. 1. The key is Vit. B12 deficiency.
Ans. 2. Vit B12 is absorbed mostly in ileum. Megaloblastic anaemia.
Sites of minerals and nutrients absorption:

250. A 61yo man underwent a surgery in which ileal resection had been done. He
complains of
fatigue, headache, and heart racing. Labs: MCV=108fL, Hgb=8.9g/dL. What is the most
likely dx?

a. Vit B12 def


b. Iron def
c. Folate def
d. Hemolytic anemia
e. Anemia of chronic disease
Key : A (Vit B12 def)
Points in favour : typical symptoms of fatigue, headache and palpitations along
with favourable age group. Most important clues lie in Ileal resection (vit b12
absorption occurs in terminal ileum) and secondly increased MCV(showing
macrocytosis).
From symptoms and low HB here we know straight away that the diagnosis here is
some kind of anemia. Next most important thing to look for in anemia questions is the
MCV.Normal MCV is between 76-96 fl.
Microcytic (low MCV) = IDA , Thalassemia , Sideroblastic anemias , Anemia of chronic
disease.
Normocytic (normal MCV) = Acute blood loss , Anemia of chronic disease, bone
marrow failure , Renal failure , hypothyroidism (or increased mcv), haemolysis (or
increased mcv), pregnancy.
Macrocytic (high MCV) = Vit B12 deficiency , Folate deficiency , Alcohol excess or
Liver disease, Myelodysplastic syndromes, Marrow infiltration, hypothyroidism, antifolate
drugs.
Next we look for the cause of the anemia in the question which quite obviously in this
question is the ileal resection. Vitamin B12 is absorbed in the terminal ileum once it is
attached to the intrinsic factor secreted by the parietal cells in the stomach. Intrinsic
factor is deficient in an an autoimmune disease called Pernicious anemia. Other causes
of Vit B12 deficiency include gastrectomy, gastric resection , atrophic gastritis , long term
H.pylori infection, inadequate intake of vit B 12 (vegan diet), malabsorption, Crohns
disease, chronic tropical sprue, DRUGS ( eg, colchicine, neomycin, metformin,
anticonvulsants, long term use of PPIs and H2 receptor blockers).
Ruling out = Except Folate def. other options are easy to rule out. IDA is microcytic
and there is no history of any chronic disease for answer to be D. There is no
evidence of haemolysis in the question like jaundice, retic count and raises LDH etc.
Folate deficiency anemia is mostly due to decreased intake or is pregnancy induced
and has nothing to do with ileum resection.
Topic = Vitamin B12 deficiency and Pernicious anemia
EPI = occurs in all races, peake age is 60, more common in those with blue eyes, early
greying, a positive family history and blood group A. The condition has a female:male ratio of
1.6:1.0.
Presentation = fatigue and lethargy, dyspnoea, faintness, palpitations and headache.
Vitamin B12 deficiency may present with unexplained neurological symptoms - eg,
paraesthesia, numbness, cognitive changes or visual disturbance.
Findings on examination may include pallor, heart failure (if anaemia is severe), lemon tinge
to the skin, glossitis and oral ulceration. Neuropsychiatric features may include irritability,
depression, psychosis and dementia. Neurological features may include subacute combined
degeneration of the spinal cord and peripheral neuropathy.
Investigations = FBC, Blood film , Biochemistry (including serum vit B12 levels
and serum Folate levels),Schilling test and Bone marrow aspiration.

Treatment = For patients with no neurological involvement, treatment is with six injections
of hydroxocobalamin, 1 mg in 1 mL at intervals of between 2-4 days. Subsequently, 1 mg is
usually given at intervals of three months. No NICE guidelines available. Monitory with Vit
B12 levels is not recommended so taper according to severity of symptoms.
For patients with neurological involvement, referral to a haematologist is recommended.
Initial treatment is with hydroxocobalamin 1 mg on alternate days until there is no further
improvement, after which 1 mg should be given every two months for life.
Care should be taken not to give folic acid instead of VitB12 as this may result in
fulminant neurological defcit.
251. A 7yo is brought by his mother who says that he was well at birth but has been
suffering from
repeated chest and GI infections since then. She also says that he is not growing well for
this age.
What is the likely condition of this child?
a. CF
b. SCID
c. Primary Tcell immunodeficiency
d. Primary Bcell immunodeficiency
e. Malabsorption
Key = A (Cystic fibrosis)
Points in favour = recurrent chest and GI infections and child not growing well.

Epidemiology
CF is the most common inherited disease in white populations.[3]
Prevalence is 1 in 2,500 newborn infants, with calculated carrier frequency of 1 in
25.[4] Just over 10,000 people were recorded as having CF in the 2013 UK CF
Registry.[5]
The only risk factor is a family history of the condition.

Pathogenesis
The abnormality in the CFTR gene explains the pathology of CF.

High sodium sweat


Primary secretion of sweat duct is normal but CFTR does not absorb chloride ions,
which remain in the lumen and prevent sodium absorption.

Pancreatic insufficiency
Production of pancreatic enzymes is normal but defects in ion transport produce relative
dehydration of pancreatic secretions, causing their stagnation in the pancreatic ducts.

Biliary disease
Defective ion transfer across the bile duct causes reduced movement of water in the
lumen so that bile becomes concentrated, causing plugging and local damage.

Gastrointestinal disease
Low-volume secretions of increased viscosity, changes in fluid movement across both
the small and large intestine and dehydrated biliary and pancreatic secretions cause
intraluminal water deficiency.

Respiratory disease
Dehydration of the airway surfaces reduces mucociliary clearance and favours bacterial
colonisation, local bacterial defences are impaired by local salt concentrations and
bacterial adherence is increased by changes in cell surface glycoproteins.
Increased bacterial colonisation and reduced clearance produce inflammatory lung
damage due to an exuberant neutrophilic response involving mediators such as IL8 and
neutrophil elastase.

Presentation

As normal digestive function is possible with <5% pancreatic function, CF can


present at any age.
The most common presentation is with respiratory problems - usually recurrent
lower respiratory tract infection (LRTI) with chronic sputum production.
However, immunoreactive trypsinogen (IRT) is now measured on a dried blood spot
obtained on the Guthrie card at day six of life. Samples with abnormally raised IRT levels
will undergo CFTR mutation screening. This was introduced in 2007. This therefore
means that clinical presentation of CF will become rarer. However, screening failures do
sometimes occur. Presentation of CF varies with age.
Presentation and diagnosis
Antenatal

Amniocentesis/chorionic villus sampling (CVS).


Ultrasound demonstration of bowel
perforation/hyperechogenic bowel (4% cases
due to CF).

Perinatal

Screening.
Bowel obstruction with meconium ileus (bowel
atresia).
Haemorrhagic disease of the newborn.
Prolonged jaundice.

Infancy and childhood

Recurrent respiratory infections.


Diarrhoea.
Failure to thrive (thriving does not exclude
diagnosis).
Rectal prolapse.
Nasal polyps (in children, nearly always due to
CF).
Acute pancreatitis.
Portal hypertension and variceal haemorrhage.
Pseudo-Bartter's syndrome, electrolyte
abnormality.
Hypoproteinaemia and oedema.

Adolescence/adulthood

Screening.
Recurrent respiratory infections.
Atypical asthma.
Bronchiectasis.
Male infertility with congenital bilateral absence
of the vas deferens.
Heat exhaustion/electrolyte disturbance.
Portal hypertension and variceal haemorrhage.

Signs
These may include:
Finger clubbing.
Cough with purulent sputum.
Crackles.
Wheezes (mainly in the upper lobes).
Forced expiratory volume in one second (FEV1) showing obstruction.
Babies diagnosed with CF will usually have no signs or symptoms.

Investigations

Sweat testing confirms the diagnosis and is 98% sensitive. Chloride


concentration >60 mmol/L with sodium concentration lower than that of chloride
on two separate occasions.
Molecular genetic testing for CFTR gene.
Sinus X-ray or CT scan - opacification of the sinuses is present in almost all
patients with CF.
CXR or CT of thorax.
Lung function testing - spirometry is unreliable before 6 years.
Sputum microbiology - common pathogens include Haemophilus
influenzae,Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia
cepacia, Escherichia coli and Klebsiella pneumoniae.
Various blood tests including FBC, U&Es, fasting glucose, LFTs and vitamin A, D
and E levels are usually performed.
Semen analysis if appropriate.

Management is done by multi disciplinary team and is problem specific as the


disease has such a wide spectrum of abnormalities including multiple systems.
252. A 3yo child has a high temp for 4 days and he had not seen a doctor. Then mother
notices rashes
on buccal mucosa and some around the mouth. What is the most appropriate dx?
a. Measles
b. Roseola infectiosum
c. Rubella
d. Chicken pox
e. Impetigo
253. A 70yo lady presents with fever for 3d and confusion. There is no significant PMH.
What is the

most probable dx?


a. Delirium
b. Hypoglycemia
c. Alzheimers
d. DKA
Key = A (Delirium)
Points in favour = Old age with acute confusion accompanied by fever for 3
days(causing factor). The fact that there is no other significant PMH.
Acute/sub-acute confusion in an older patient should be considered delirium until proven
otherwise. Almost possibly any underlying medical condition can be the etiology but
most common are infections, drugs and alcohol withdrawal. Differential may include
dementia, Bipolar disorder, depression and functional psychosis.
Depression has its specific set of symptoms such as low mood, sadness, loss of
interest etc and although delirium can present with these features as well along with
confusion, for the dx to be depression the symptoms must be at least 2 weeks long and
cause significant impairment.
Bipolar disorder, Dementia and Schizophrenia all have a chronic history with specific
symptoms for each one of them.
Ruling out = DKA is not common in elderly and there is no history of DM.
While hypoglycemia can present with acute confusion but not for 3 days for
it to be hypoglycemia we need more symptoms and an earlier duration of onset.
Alzheimer's has to have a chronic history of dementia and can not present with acute
confusion only without any PMH.
Dx = Delirium
ICD-10 definition : An etiologically nonspecific organic cerebral syndrome characterized
by concurrent disturbances of consciousness and attention, perception, thinking,
memory, psychomotor behaviour, emotion, and the sleep-wake schedule. The duration
is variable and the degree of severity ranges from mild to very severe.
EPI = There is increase in incidence with age reaching to 13.6% in those over 85 years.
The prevalence is high in those with malignancy and HIV and in patients with preexisting cognitive impairment.
Presentation : The diagnosis of delirium is clinical. The following features may be
present:
Usually acute or subacute presentation.
Fluctuating course.
Consciousness is clouded/impaired cognition/disorientation.
Poor concentration.
Memory deficits - predominantly poor short-term memory.
Abnormalities of sleep-wake cycle, including sleeping in the day.
Abnormalities of perception - eg, hallucinations or illusions.
Agitation.
Emotional lability.
Psychotic ideas are common but of short duration and of simple content.
Neurological signs - eg, unsteady gait and tremor.

There are no specific investigations and we can order possibly the whole battery of tests
to find the underlying cause.
Management comprises of supportive and environmental measure along with medical
therapy consisting of antipsychotics such as haloperidol and olanzapine. Then comes
the management post-discharge.
Delirium resulting from alcohol discharge is called Delirium tremens and can be
treated with benzodiazepines such as diazepam and chlordiazepoxide.

254. An obese mother suffers from OSAS. Which of the following inv is best for her?
a. ABG
b. Overnight pulse-oximetry
c. Polysomnography
d. EEG
Key = C (Polysomnography)
Points in favour = It is the gold standard investigation for OSAS
In PSG various physiological recordings are taken whilst the patient is asleep overnight.
It cosists of at least an EEG, two elctro-oculograms to measure eye movement and an
electromyogram on the chin to monitor muscle movement.
Overnight pulse-oximetry is a cheaper and more readily available method of diagnosing
OSAS but PSG remains to the best one possible.
ABGs are done to rule out daytime hypoxia or hypercapnia in patients presenting with
symptoms of heart failure. EEG alone is of no diagnostic help.
Dx = Obstructive Sleep Apnea Syndrome
EPI = Incidence is increasing as the incidence of obesity is increasing. Highly prevalent
in patients with type 2 DM and related metabolic conditions.
Risk factors include:
Obesity (strongest risk factor).
Male gender.
Middle age (55-59 in men, 60-64 in women).
Smoking.
Sedative drugs.
Excess alcohol consumption.
Family history
Possibly genetic tendency related to jaw morphology.
Obese children - they have a higher prevalence and severity of OSAS.
Presentation : The following may be suggestive OSAS

Impaired concentration.
Snoring.
Unrefreshing sleep.
Choking episodes during sleep.
Witnessed apnoeas.
Restless sleep.

Irritability/personality change.
Nocturia.
Decreased libido.
Excessive daytime sleepiness.

Along with obesity, increased neck circumference and certain craniofacial or pharyngeal
abnormalities may be notes in examination.
Treatment : CPAP remains to be the treatment of choice along with some behaviour
modification which include sleeping posture, smoking and alcohol cessation and weight
loss. Oral appliances such as mandibular advance splits can also be used for mild to
moderate OSAS.
Surgery is considered only for patients for whom CPAP and oral appliances have failed.
255. A 28yo business man came to the sexual clinic. He was worried that he has HIV
infection. 3 HIV
tests were done and all the results are negative. After a few months, he comes back
again and
claims that he has HIV. What is the dx?
a. Somatization
b. Hypochondriac
c. Mancheusens
d. OCD
e. Schizophrenia
Key = B (Hypochondriasis)
Points in favour = Belief/delusion of having a serious/life threatening disease
which persists after being ruled out by investigations.
Somatoform disorders consists of a group psychiatric illnesses in which patients either
feel or make up signs and symptoms without existence of an organic disease. It includes
the following disorders :
Somatization disorder : Characterised by occurrence of chronic multiple somatic
symptoms for which there is no physical cause.
Hypochondriasis : Patients have a strong fear or belief that they have a serious often
fatal disease that persists despite appropriate medical reassurance. (like in this case).
Body dysmorphic disorder : A preoccupation with bodily shape or appearance with
belief that one is disfigured in some way.
Dissociative (conversion) disorder : Characterised by loss or distortion of neurological
function not fully explained by organic disease. Previously known as Hysteria.
Somatoform Pain disorder: Severe, persistent pain which cannot be explained by
medical condition.
Munchausens syndrome : Severe chronic form of factitious disorder usually older
males who travel widely sometimes in several hospitals in one day. They are convincing
enough to persuade doctors to undertake investigations but no underlying condition is
found. Previous similar hospital visits can be traced.
This cannot be Schizophrenia because of absence of specific symptom featuring in
schizophrenia.

Management : Cognitive behavioural therapy is the main course in management.


Antipsychotics may help but main line of treatment remains to be reassurance and CBT.
256. A 6wk child presents with progressive cyanosis, poor feeding, tachypnea over the
first 2 wks of
life and holosystolic murmur. What is the most appropriate condition?
a. ASD
b. VSD
c. Tricuspid atresia
d. PDA
e. TOF
257. A 29yo woman who was dx to have migraine presents with severe onset of occipital
headache.
She lost her consciousness. CT=normal. Neurological exam=normal. What is the most
appropriate management?
a. Repeat CT
b. MRI
c. LP
d. XR
e. No inv required
Key = E (no investigation required)
Points in favour = occipital headache is common in migraine. Normal CT and
neuro exam means there is no need for any further investigations.
Loss of consciousness in patients with migraine is an alarming sign and should prompt
for imaging straight away. A normal CT and no focal neurological deficit on examination
reassure that there is no new pathology. The young age of the patient gives us a clue as
well. So there is no need of any intervention in this scenario.
Dx = Migraine
Classification = Migraine with aura, Migraine without aura and Chronic migraine
EPI = Common in women than men (vice versa in children)
First attack often in childhood with over 80% having their first attack before the
age of 30. If onset is at age over 50 other pathology should be sought.
Family history is usually positive.
Severity decreases with advancing age.
Presentation : Typically the headaches last between 4 and 72 hours and have at least
two of the following features:
Unilateral.
Pulsating.
Moderate or severe intensity of pain.
Aggravated by, or resulting in the avoidance of, routine physical activity.
In addition, there is at least one of:
Nausea and vomiting during migraine attacks. These are common symptoms that
affect at least 60% of patients suffering from migraines.
Photophobia and phonophobia, which are also very common.
Aura is highly variable in nature (visual,sensory etc) but tends to be consistent for an
individual. Headache starts maximum within one hour of an aura.

Investigations : Diagnosis is purely clinical. Investigations are only done to rule out
secondary causes of headache or when alarming symptoms like loss of consciousness,
seizure. memory loss etc present.
Treatment : Acute attack = Step one = Simple analgesics with or without anti emetics
Step two = Anal analgesics and anal anti emetics
Step three = Triptans or ergotamine ( Patients having
moderate to severe migraine should be moved directly to step 3 ).
Prophylaxis = The NICE guidelines and CKS suggests the following indications for
prophylaxis :
Frequent attacks are two or more attacks per month that produce disability
lasting for three days or more.
Medication overuse is a risk when medication is used on more than two days per
week on a regular basis. Overuse needs to be addressed before further
treatment can begin.
Prophylaxis should be used when standard analgesia and triptans are either
contra-indicated or ineffective.
Beta blockers, amitriptyline, sodium valproate and Botulinum toxin A all can be
used as drugs for prophylaxis. Identifying and refraining from triggering factor (if
any) can also be used to avoid attacks such as stress, dietary factors like
cheese,chocolate,alcohol etc.

258. A 19yo man has been happier and more positive than usual, with more energy than
he has ever
felt before for no particular reason. He has been getting more work done at the office
today and
has been socializing with his friends as usual. What is the most likely dx?
a. Atypical depression
b. Marked depression
c. Bipolar syndrome
d. Psychosis
e. Hypomania
Key = E
Points in favour = There is elevation of mood and energy, increase in activity but
not to severity of Mania and there is no evidence of delusions or hallucinations.
Hypomania is a milder form of mania. There is elevation of mood and energy , increase
in activity and socializing, inability to concentrate and flight of ideas but without
hallucinations or delusions.
Mania on the other hand has more severe symptoms like pressured speech, grandiosity,
increase in sexual activity, insomnia, flight of ideas, psychomotor agitation along with
hallucinations and delusions.
For the dx of Bipolar disorder there needs to be a documented episode of depression
along with mania (bipolar 1) or hypomania (bipolar 2).
Depression has opposite symptoms of mania like low mood and energy , low activity and
interest etc.

Manic episodes can be treated by atypical antipsychotics like olanzapine and


risperidone.
Lithium is used but it has slower onset of action. Lorazepam can be used to
sedate and decrease agitation. Carbamazepine is sometimes used as first line
treatment.
259. A 35yo female attempts suicide 10x. There is no hx of psychiatric problems and all
neurological
exams are normal. What is the best tx?
a. Problem focused tx
b. CBT
c. Antipsychotic
d. Antidepressant
e. ECT
260. A 57yo man presents with weight loss, tiredness, fever and abdominal discomfort.
Exam: spleen
palpable up to the umbilicus. Labs: WBC=127, Hgb=8.7, Plt=138. What is the most likely
dx?
a. CML
b. AML
c. CLL
d. AML
e. Polycythemia
Key = A (CML)
Points in favour = Splenomegaly and raised WBC along with typical signs and
symptoms.
261. A baby born at 34 weeks with a heart murmur is kept in the incubator for almost 4
weeks. There
is no murmur at discharge. What is the likely cause of this murmur?
a. PDA
b. TOF
c. Aneurysm of sinus of Valsalva
d. Aorto-pulmonary septal defect
e. AVM
Key = A (PDA)
Points in favour = PDA can be found in pre mature babies which closes after birth.
The ductus arteriosus is, in developmental terms, a remnant of the sixth aortic arch and
connects the pulmonary artery to the proximal descending aorta just after the left
subclavian artery origin. It is a normal structure in fetal life.
In utero the lungs are not expanded. Gas exchange occurs at the placenta and only
about 10% of the circulation passes through the lungs. The ductus arteriosus connects
the pulmonary artery to the aorta to shunt most of the blood away from the lungs. After
delivery it closes and the blood passes through the opened lungs. Failure of the ductus
arteriosus to close can lead to overloading of the lungs. The shunt is left to right unless
pulmonary hypertension occurs and pulmonary pressure exceeds systemic pressure.

After birth the ductus closes functionally in 12-18 hours and anatomically in 2-3 weeks. If
it remains open beyond three months of life in preterm infants and beyond one year of
life in full-term infants it is termed as persistent patency of ductus arteriosus because the
incidence of spontaneous closure beyond these time limits is very low.
Murmurs in all other cases will persist.
PDA:
History : Patients with a small PDA are usually asymptomatic.A large-shunt PDA may
cause lower respiratory tract infection as well as feeding difficulties and poor growth
during infancy, with failure to thrive because of heart failure.
Examination :
If the pulmonary circulation is markedly overloaded there will be tachycardia,
tachypnoea and a wide pulse pressure.
The precordium is hyperactive and a systolic thrill may be present at the upper
left sternal border.
The first heart sound is normal but the second is often obscured by the murmur.
A grade 1 to 4/6 continuous ('machinery') murmur is best audible at the left
infraclavicular area or upper left sternal border.
In the case of a large PDA shunt, a diastolic mitral rumble may be heard because
of the high flow rate across the mitral valve.
Patients with a small PDA do not have the above-mentioned findings.
Peripheral pulses are bounding as the run-off into the pulmonary circulation
drops the diastolic pressure and causes a wide pulse pressure.
Investigations : ECG, CXR and Echocardiography
Management : Indometacin is ineffective in term infants with PDA and should not be
used. Medical management is limited to use of decongestive measures such as diuretics
in those with features of heart failure.
PDA closure is indicated for any symptomatic infant, child or adult (with exclusion
of those with fixed high pulmonary vascular resistance). Closure is also indicated
in asymptomatic patients with left heart volume load. This can be done either by
surgery or interventional techniques at any age.[4]
Surgical closure is reserved for patients in whom a non-surgical closure
technique is not considered applicable. In infants with heart failure or pulmonary
hypertension, surgery is performed on an urgent basis. The standard surgical
procedure is ligation and division of the ductus through left posterolateral
thoracotomy without cardiopulmonary bypass.[3]
In asymptomatic well infants current practice is to wait until 1 year of age, with
regular echocardiographic evaluation to check for spontaneous closure of the
PDA. If the duct is still patent at 1 year of age it can be closed usually by
occlusion at cardiac catheterisation (endovascular occlusion). National Institute
for Health and Care Excellence (NICE) guidance has been produced and
considers that current evidence on the safety and efficacy of endovascular
occlusion of PDA appears to support the use of this procedure.[5] The procedure
should be performed in units where there are arrangements for cardiac surgical
support in the event of complications. The choice of device depends largely on
the size of PDA. Coils are suitable for closing of small- to medium-sized PDAs
while larger PDAs require other devices such as the Amplatzer patent ductus
arteriosus device.

Serious complications of transcatheter closure of PDA are rare and include


device embolisation, femoral artery or vein thrombosis related to vascular access
and infection.[4]
Whilst the ductus arteriosus is patent then the risk of endocarditis should be
considered (there is no increased risk of endocarditis once repair is complete).
Routine antibiotic prophylaxs is not indicated but during invasive procedures (eg,
urinary or gastrointestinal procedures) involving areas of sepsis, suitable
antibiotics should be given promptly (to cover all the likely organisms, including
any known to cause endocarditis).[6]

262. A 6yo girl who has previously been well presented with a hx of tonic-clonic seizures
lasting
4mins. Her mother brought he to the hospital ad she appeaed ell. She is afeile
ad didt
lose consciousness during the episode of seizure. She has no neurologic deficit. What is
the most
appropriate inv for her?
a. ABG
b. Serum electrolytes
c. ECG
d. Blood glucose
263. A 60yo woman was found by her son. She was confused and had urinary
incontinence. She has
recovered fully after 6h with no neurological complaints. What is the most likely dx?
a. Stroke
b. Vestibular insufficiency
c. TIA
d. Intracranial hemorrhage
Key = C (TIA)
Points in favour = Complete recovery in less than 24 hours
A transient ischaemic attack (TIA) is a temporary inadequacy of the circulation in part of
the brain (a cerebral or retinal deficit) that gives a clinical picture similar to a stroke
except that it is transient and reversible. Hence, TIA is a retrospective diagnosis. The
duration is no more than 24 hours and a deficit that lasts longer than 24 hours is defined
as a stroke. The majority of TIAs last for less than 30 minutes.

Management
Secondary prevention (see below) includes the use of antiplatelet therapy,
antihypertensive, and lipid-modifying treatments, the management of atrial fibrillation if
present and the management of any other underlying or risk factors, including diabetes.

Driving[4]

Group 1 (car or motorcycle)


Must not drive for one month.
No need to notify DVLA after a single TIA.
Multiple TIAs over a short period: require three months free from further attacks
before resuming driving and DVLA should be notified.
Group 2 (lorry or bus)
Licence refused or revoked for one year following a stroke or TIA.

Assessment of the risk of stroke


An ABCD2 score of more than 4 suggests high risk of an early stroke.[5][6]

Scoring System for Risk of Stroke after TIA (ABCD2 Score)

Age

Age >60

Blood pressure

BP>140 systolic and/or >90 diastolic

Clinical features

Unilateral weakness

Speech disturbance without weakness

Other

>60 minutes

10-59 minutes

<10 minutes

Duration of symptoms

Diabetes

Presence of diabetes

RCP recommendations[1]

All patients with a TIA should be seen by a specialist in neurovascular disease


(eg, in a specialist neurovascular clinic or an acute stroke unit).
People with a suspected TIA should be assessed as soon as possible for their
risk of subsequent stroke by using a validated scoring system such as ABCD2
(as above).
Patients with suspected TIA who are at high risk of stroke (eg, an ABCD2 score
of 4 or above) should receive:
o Aspirin or clopidogrel (each as a 300 mg loading dose and then 75 mg
daily) and a statin started immediately.
o NB: clopidogrel is not licensed for the management of TIA and therefore
the National Institute for Health and Care Excellence (NICE) and the
British National Formulary (BNF) recommend aspirin plus modifiedrelease dipyridamole.[7]
o Specialist assessment and investigation within 24 hours of onset of
symptoms.
o Measures for secondary cardiovascular prevention introduced as soon as
the diagnosis is confirmed, including discussion of individual risk factors.
People with crescendo TIA (two or more TIAs in a week), atrial fibrillation or
those on anticoagulants should be treated as being at high risk of stroke even if
they may have an ABCD2 score of 3 or below.
Patients with suspected TIA who are at low risk of stroke (eg, an ABCD2 score of
3 or below) should receive:
o Aspirin or clopidogrel (each as a 300 mg loading dose and then 75 mg
daily) and a statin.
o NB: clopidogrel is not licensed for the management of TIA and therefore
NICE and the BNF recommend aspirin plus modified-release
dipyridamole.[7]
o Specialist assessment and investigations as soon as possible, but
definitely within one week of onset of symptoms.
o Measures for secondary prevention introduced as soon as the diagnosis
is confirmed, including discussion of individual risk factors.
People who have had a TIA but present late (more than one week after their last
symptom has resolved) should be treated as though they are at a lower risk of
stroke.
Patients with TIA in atrial fibrillation should be anticoagulated in the TIA clinic
once intracranial bleeding has been excluded and if there are no other contraindications.
If the patient is in atrial fibrillation, management of that condition is required. In persistent
atrial fibrillation there is benefit from anticoagulation but there is no evidence of any such
benefit in the absence of atrial fibrillation.
All people with TIA, who after specialist assessment are considered candidates for
carotid endarterectomy, should have carotid imaging conducted urgently to facilitate

carotid surgery, which should be undertaken within seven days of the onset of
symptoms.

264. A 34yo woman presents 3 weeks after childbirth. She has had very low mood and
has been
suffering from lack of sleep. She also has thought of harming her little baby. What is the
most
appropriate management for this pt?
a. ECT
b. CBT
c. IV haloperidol
d. Paroxethine
e. Amitryptiline
Key = A (ECT)
Points in favour = This is postpartum psychosis since the onset is more than 2
weeks after delivery. There is evidence of depression and psychosis so ECT
should be done.
265. A 65yo woman presents with headache. She also complains of dizziness and
tinnitus. He has
recently realized she has visual problems. There is hx of burning sensation in fingers
and toes.
On exam: splenomegaly, itchy after hot bath. Labs: RBC=87, Hgb=31.9, Plt=796. What
is the dx?
a. CML
b. CLL
c. Polycythemia vera
d. Myelofibrosis
e. NHL
Key = C (Polycythemia vera)
Points in favour = Headache, burning finger along with visual problems. High hb
266. A 29yo male brought to ED in conscious state. There is no significant past hx.
Which of the
following should be done as the initial inv?
a. CT
b. Blood glucose
c. ABG
d. MRI
e. CBC
Key = B (blood glucose)
Points in favour = Always check for hypoglycemia in unconscious patient first
especially young patients with no significant past history.
Assessing BSR levels is much easier and less invasive than other tests and
quicker to rule out.

Diagnostic criteria

The World Health Organization reclassified chronic myeloproliferative diseases as


myeloproliferative neoplasms in 2008.[4] The criteria for the diagnosis of PRV requires
two major criteria and one minor criterion, or the first major criterion and two minor
criteria.
Major criteria:
o Haemoglobin of more than 18.5 g/dL in men, 16.5 g/dL in women, or
elevated red cell mass greater than 25% above mean normal predicted
value.
o Presence of JAK2 617V F mutation or other functionally similar mutations,
such as the exon 12 mutation of JAK2.
Minor criteria
o Bone marrow biopsy showing hypercellularity with prominent erythroid,
granulocytic, and megakaryocytic proliferation.
o Serum erythropoietin level below normal range.
o Endogenous erythroid colony formation in vitro.
Other confirmatory findings no longer required for diagnosis include:
o Oxygen saturation with arterial blood gas greater than 92%.
o Splenomegaly.
o Thrombocytosis (>400,000 platelets/mm3).
o Leukocytosis (>12,000/mm3).
o Leukocyte alkaline phosphatase (>100 units in the absence of fever or
infection).

Investigation

Initial blood tests:


o FBC in PCV will show not only elevated Hb and packed cell volume but
WCC and platelets will be elevated too. In secondary polycythaemia only
red blood cells are raised.
o Ferritin is often low in primary polycythaemia because of increased
demand for iron. In secondary causes it is usually normal..
Radiology:
o Radioisotopes can be used to measure circulating volumes. Red cells can
be labelled with 51Cr and albumin with 131I. This is expensive, needs
skill and is not widely available.
o CT, MRI or ultrasound scanning of the abdomen may show enlargement
of the spleen as is often found in PRV. It should also check for
abnormalities of the renal system.
Bone marrow and aspirate:
o Tend to be hypercellular in PRV.
o In the plethoric phase, the blood smear shows normal erythrocytes,
variable neutrophilia with myelocytes, metamyelocytes, and varying
degrees of immaturity, basophilia, and increased platelet counts.
o In the spent phase, the blood smear shows abundant teardrop cells,
leukocytosis, and thrombocytosis.
o Generally the findings are not specific to PRV. The bone marrow can be
normal in PRV.
Serum erythropoietin levels are often low in PRV. This can differentiate
secondary erythrocytosis and pseudoerythrocytosis from PRV, but there is
overlap in the levels found and it cannot reliably differentiate.

Cytogenetic studies. Karyotyping can detect fewer than 30% of patients with
PRV. An abnormal test is useful, but a normal test does not exclude PRV.
Clonal assays (using glucose-6-phosphate dehydrogenase (G6PD) markers) are
not generally available for clinical use. Even if it were available it is only of use in
female patients.
Research markers include the thrombopoietin receptor MPL expression and the
PRV1 mRNA in granulocytes.[5]

JAK2 testing
With the development of new techniques for detecting the Janus kinase 2 (JAK2) V617F
mutation this may become a clinically useful marker for PRV. It has been recommended
as a diagnostic marker.[6][5]
JAK2-positive polycythaemia vera is diagnosed if:[2]
The JAK2 mutation is identified; and
The haematocrit is more than 0.48 in women or more than 0.52 in men, or the
red cell mass is 25% higher than normal.
JAK2-negative polycythaemia vera is diagnosed if:[2]
The JAK2 mutation is not identified; and
The haematocrit is more than 0.56 in women or more than 0.60 in men, or the
red cell mass is 25% higher than normal; and
There is no identifiable secondary cause for polycythaemia; and either
o There is palpable splenomegaly or the presence of an acquired genetic
abnormality in the haematopoietic stem cells or both; or
o Any two of the following clinical features are identified: an abnormally
increased platelet count, an abnormally increased neutrophil count,
radiological evidence of splenomegaly, and abnormally low serum
erythropoietin.

Management
The main concern with the management of the disease is the prevention of thrombosis,
which is the main cause of morbidity and mortality. Fibrotic and leukaemic disease also
raises mortality and morbidity.
Intermittent long-term phlebotomy to maintain the haematocrit below 45% (lower
target level may be appropriate for women). Phlebotomy may cause progressive
and sometimes severe thrombocytosis and iron deficiency. Splenomegaly and
pruritus may persist despite control of the haematocrit by phlebotomy.[7]
Low-dose aspirin produces a small reduction in thrombotic events, including
myocardial infarction and stroke, whilst not increasing the risk of
haemorrhage.[8][9]
If it is not possible to control thrombotic events with phlebotomy alone then
myelosuppression must be considered. However, this is not without risk and
increases the risk of leukaemic transformation. Risks and benefits have to be
balanced.
Chemotherapy options include:[2]
o For people younger than 40 years of age: first-line is interferon; secondline is hydroxycarbamide or anagrelide.
o For people 40-75 years of age: first-line is hydroxycarbamide; second-line
is interferon or anagrelide.

For people older than 75 years of age: first-line is hydroxycarbamide;


second-line is radioactive phosphorus or busulfan.
Pruritus can be quite disabling:
o Taking baths or showers at lower temperatures and patting the skin dry,
to avoid rubbing, may help.
o Antihistamines, including H2 receptor antagonists (H2RAs), are useful in
refractory cases.
o Selective serotonin reuptake inhibitors (SSRIs) - eg, paroxetine or
fluoxetine.
Elevated uric acid may require allopurinol.
It may be necessary to consider splenectomy when there is painful splenomegaly
or there are repeated episodes of splenic infarction.

267. A 45yo woman comes with red, swollen and exudating ulcer on the nipple and
areola of right
breast with palpable lump under the ulcer. What do you think is nthis skin condition?
a. Inflammatory cells releasing cytokines
b. Infiltration of the lymphatics by the carcinomatous cells
c. Infiltration of the malignant skin cells to the breast tissue
Key = B
Points in favour = This is a case of CA breast in which infiltration of the
lymphatics cause the ulceration.
268. A 20yo young lady comes to the GP for advice regarding cervical ca. she is worried
as her mother
past away because of this. She would like to know what is the best method of
contraception in
her case?
a. POP
b. Barrier method
c. IUCD
d. COCP
e. IUS
Key = B (barrier method)
Points in favour = barrier method can help prevent catching HPV infection which
is the main etiology behind CA cervix. Other methods may provide with better
contraception but are not good means of preventing hpv infections.
269. A 66yo man, an hour after hemicolectomy has an urine output of 40ml. However,
an hour after
that, no urine seemed to be draining from the catheter. What is the most appropriate
next step?
a. IV fluids
b. Blood transfusion
c. Dialysis
d. IV furosemide
e. Check catheter
Key = E
Points in favour = Always check catheter for any obstruction or other abnormality
before iv fluids.

270. A 24yo pt presented with anaphylactic shock. What would be the dose of
adrenaline?
a. 0.5ml of 1:1000
b. 0.5ml of 1:10000
c. 1ml of 1:500
d. 5ml of 1:1000
e. 0.05ml of 1:100
Key = A
271. A 44yo woman complains of heavy bleeding per vagina. Transvaginal US was done
and normal.
Which of the following would be the most appropriate inv for her?
a. Hysterectomy
b. Endometrial biopsy
c. CBC
d. High vaginal swab
e. Coagulation profile
Key = E (coagulation profile)
Points in favour = After normal vaginal US coagulation profile should be done to
rule out systemic causes of heavy bleeding first. Endometrial biopsy will be
needed if ultrasound shows some endometrial abnormality. Before considering
steps like hysterectomy, systemic causes of bleeding must be ruled out by
checking coagulation profile.
CBC and high vaginal swab will not help much in finding the cause of bleeding.
272. A 60yo woman presented to OPD with dysphagia. No hx of weight loss of
heartburn. No change
in bowel habits. While doing endoscopy there is some difficulty passing through the LES,
but no
other abnormality is noted. What is the single most useful inv?
a. CXR
b. MRI
c. Esophageal biopsy
d. Esophageal manometry
e. Abdominal XR
Key = D
Points in favour = This can be a case of achalasia or esophageal spasms. In both
cases manometry is the gold standard investigation. Another investigation which
could have been done before manometry and even endoscopy is The Barium
Swallow.
Remaining inx given in the question will not help is in the diagnosis.
Achalasia is primarily a disorder of motility of the lower oesophageal or cardiac
sphincter. The smooth muscle layer of the oesophagus has impaired peristalsis and
failure of the sphincter to relax causes a functional stenosis or functional oesophageal
stricture. Most cases have no known underlying cause, but a small proportion occurs
secondary to other conditions - eg, oesophageal cancer.
It tends to present in adult life and is very rare to present in children.

Presentation

The most common presenting feature is dysphagia. This affects solids more than
soft food or liquids.
Regurgitation may occur in 80-90% and some patients learn to induce it to
relieve pain.
Chest pain occurs in 25-50%. It occurs after eating and is described as
retrosternal. It is more prevalent in early disease.
Heartburn is common and may be aggravated by treatment.
Loss of weight suggests malignancy (may co-exist).
Nocturnal cough and even inhalation of refluxed contents is a feature of later
disease.
Examination is unlikely to be revealing although loss of weight may be noted.
Rarely, there may be signs of an inhalation pneumonia.

Treatment : Calcium channel blockers and nitrates can be used.


Pneumatic dilatation or endoscopic botulinum toxin injection can be
used as well.
Heller myotomy remains to be best treatment of choice in patients who are
fit for surgery.
273. A 24yo woman presents with deep dyspareunia and severe pain in every cycle.
What is the
initial inv?
a. Laparoscopy
b. Pelvic US
c. Hysteroscopy
d. Vaginal Swab
Key = B (Pelvis ultrasound)
Points in favour = To rule out cervical abnormalities, endometriosis. ovarian cysts
etc.
274. A 38yo woman, 10d postpartum presents to the GP with hx of passing blood clots
per vagina
since yesterday. Exam: BP=90/40mmhg, pulse=110bpm, temp=38C, uterus tender on
palpation
and fundus 2cm above umbilicus, blood clots +++. Choose the single most likely dx/
a. Abruption of placenta 2nd to pre-eclampsia
b. Concealed hemorrhage
c. Primary PPH
d. Secondary PPH
e. Retained placenta
f. Scabies
275. A 32yo female with 3 prv 1st trimester miscarriages is dx with antiphospholipid
syndrome.
Anticardiolipin
antibodies +ve. She is now 18wks pregnant. What would be the most appropriate
management?
a. Aspirin
b. Aspirin & warfarin
c. Aspirin & heparin
d. Heparin only

e. Warfarin only
Key = C
Points in favour = More than 3 prev miscarriages due to APLS - LMWH plus aspirin
throughout pregnancy is indicated.
Antiphospholipid syndrome (APS) is an autoimmune disorder characterised by arterial
and venous thrombosis, adverse pregnancy outcomes (for mother and fetus), and raised
levels of antiphospholipid (aPL) antibodies.

Presentation:
APS has varied clinical features and a range of autoantibodies. Virtually any system can
be affected, including:[1][4][5]
Peripheral artery thrombosis, deep venous thrombosis.
Cerebrovascular disease, sinus thrombosis.
Pregnancy loss: loss at any gestation - recurrent miscarriage or prematurity can
be seen in APS.
Pre-eclampsia, intrauterine growth restriction (IUGR).
Pulmonary embolism, pulmonary hypertension.
Livedo reticularis (persistent violaceous, red or blue pattern of the skin of the
trunk, arms or legs; it does not disappear on warming and may consist of regular
broken or unbroken circles), purpura, skin ulceration.
Thrombocytopenia, haemolytic anaemia.
Libman-Sacks endocarditis and cardiac valve disease:
o Usually mitral valve disease or aortic valve disease and usually
regurgitation with or without stenosis.
o Mild mitral regurgitation is very common and is often found with no other
pathology. There may also be vegetations on the heart and valves.
Myocardial infarction.
Retinal thrombosis.
Nephropathy: vascular lesions of the kidneys may result in chronic kidney
disease.
Adrenal infarction.
Avascular necrosis of bone.

Investigations
Young adults (50 years old) with ischaemic stroke and women with recurrent
pregnancy loss (3 pregnancy losses) before 10 weeks of gestation should be screened
for aPL antibodies.[3]
Levels of aCL, anti-beta2 GPI or lupus anticoagulant (LA) on two occasions at
least 12 weeks apart.
FBC; thrombocytopenia, haemolytic anaemia.
Clotting screen.
CT scanning or MRI of the brain (cerebrovascular accident), chest (pulmonary
embolism) or abdomen (Budd-Chiari syndrome).
Doppler ultrasound studies are recommended for possible detection of deep vein
thrombosis.

Two-dimensional echocardiography may demonstrate asymptomatic valve


thickening, vegetations or valvular insufficiency.

Management in Pregnancy :
APS in pregnancy may affect both mother and fetus throughout the entire
pregnancy and is associated with high morbidity. Clinical complications are
variable and include recurrent miscarriage, stillbirth, IUGR and pre-eclampsia.
For women with APS with recurrent (3) pregnancy loss, antenatal
administration of low molecular weight heparin combined with low-dose
aspirin is recommended throughout pregnancy. Treatment should begin as
soon as pregnancy is confirmed.
For women with APS and a history of pre-eclampsia or IUGR, low-dose
aspirin is recommended.
Women wit aPL antibodies should be considered for postpartum
thromboprophylaxis.
276. A 23yo presents with vomiting, nausea and dizziness. She says her menstrual
period has been
delayed 4 weeks as she was stressed recently. There are no symptoms present. What is
the next
appropriate management?
a. Refer to OP psychiatry
b. Refer to OP ENT
c. CT brain
d. Dipstick for B-hCG
Key = D
Points in favour = Test for pregnancy first in case of amenorrhea
e. MRI brain
277. A 16yo girl came to the sexual clinic. She complains of painful and heavy bleeding.
She says she
doest a egula le. What is the ost appropriate management?
a. Mini pill
b. Combined pill
c. IUS
d. Anti-prostoglandins
e. Anti-fibrinolytics
278. A 36yo man walks into a bank and demands money claiming he owns the bank. On
being denied,
he goes to the police station to report this. What kind of delusions is he suffering from?
a. Delusion of reference
b. Delusion of control
c. Delusion of guilt
d. Delusion of persecution
e. Delusion of grandeur
Key = E
Points in favour = Delusion of grandeur is defined as delusion of exaggerated self
worth. Hence the answer.
279. Which method of contraception can cause the risk of ectopic pregnancy?

a. COCP
b. IUCD
c. Mirena
d. POP
Key = B (IUCD)
280. A woman has pernicious anemia. She has been prescribed parenteral vitamin B12
tx but she is
needle phobic. Why is oral tx not preferred for this pt?
a. IM B12 is absorbed more
b. Intrinsic factor deficiency affects oral B12 utilization
c. IM B12 acts faster
d. IM B12 needs lower dosage
e. Pernicious anemia has swallowing difficulties
Key = B
Points in favour = There is def of intrinsic factor dt autoimmune causes in
pernicious anemia. VitB12 can not be absorbed without binding to intrinsic
factor.Refer to the explanation of answer to question number 250.
281. An old man comes to the doctor complaining that a part of this body is rotten and
he wants it
removed. What is the most likely dx?
a. Guilt
b. Hypochondriasis
. Muhauses
d. Nihilism
e. Capras syndrome
282. A 31yo woman who is 32weeks pregnant attends the antenatal clinic. Labs:
Hgb=10.7, MCV=91.
What is the most appropriate management for this pt?
a. Folate supplement
b. Ferrous sulphate 200mg/d PO
c. Iron dextran
d. No tx req
Key = D (no tx required)
Explanation : This is dilutional anemia hence no treatment required.
283. A 47yo man who is a chronic alcoholic with established liver damage, has been
brought to the
hospital after an episode of heavy drinking. His is not able to walk straight and is
complaining of
double vision and is shouting obscenities and expletives. What is the most likely dx?
a. Korsakoff psychosis
b. Delirium tremens
c. Wernickes encephalopathy
d. Tourettes syndrome
e. Alcohol dependence
Key = C (Wernickes encephalopathy)
Points in favour = Chronic alcoholic - thiamine deficiency - double vision, unable
to walk.

In case of delirium tremens , there is history of alcohol consumption around 42-72 hours
back. There are symptoms like hallucination, confusion and severe agitation and
sometimes seizures as well.
There is history of vocal or neurological tics for it to be tourettes syndrome.
Korsakoffs syndrome is a late complication of untreated Wernickes. They are both
together known as wernicke-korsakoff syndrome.
Wernicke-korsakoff syndrome:- Wernicke-Korsakoff syndrome (WKS) is a spectrum
of disease resulting from thiamine deficiency, usually related to alcohol abuse.
Presentation :
Vision changes:
o Double vision
o Eye movement abnormalities
o Eyelid drooping
Loss of muscle co-ordination:
o Unsteady, unco-ordinated walking
Loss of memory, which can be profound.
Inability to form new memories.
Hallucinations.
Examination of the nervous system may show polyneuropathy.
Reflexes may be decreased (or of abnormal intensity), or abnormal reflexes may
be present.
Gait and co-ordination are abnormal on testing.
Muscles may be weak and may show atrophy.
Eyes show abnormalities of movement - nystagmus, bilateral lateral rectus palsy
and conjugate gaze palsy.
Blood pressure and body temperature may be low.
Pulse may be rapid.
The person may appear cachectic.
Confabulation
Memory loss
Retrograde amnesia

Encephalopathy
At least two of the four following criteria should be present to diagnose
encephalopathy:[7]
Dietary deficiencies.
Oculomotor abnormalities.
Cerebellar dysfunction.
Either an altered mental state or mild memory impairment.
Treatment :
Thiamine orally (IM or IV may be used in secondary care) plus vitamin B complex
or multivitamins, which should be given indefinitely. Treatment with thiamine is
often started under specialist care, although when deficiency is suspected, it
should be started in primary care.
Offer oral thiamine to harmful or dependent drinkers if either of the following
applies:[9]

They are malnourished (or have a poor diet); prescribe oral thiamine 50
mg per day (as a single dose) for as long as malnutrition may be present.
o They have decompensated liver disease.
A Cochrane review found there was insufficient evidence from randomised
controlled clinical trials to guide clinicians in the dose, frequency, route or
duration of thiamine treatment of WKS due to alcohol abuse.[10] However, more
recent work states that the route of administration and dose depend on the
severity of dependence and overall physical health of the patient.[11]
Although potentially serious allergic adverse reactions may (rarely) occur during,
or shortly after, parenteral administration, the Commission on Human Medicines
has recommended that:[12]
o This should not preclude the use of parenteral thiamine in patients where
this route of administration is required, particularly in patients at risk of
WKS where treatment with thiamine is essential.
o IV administration should be by infusion over 30 minutes.
o Facilities for treating anaphylaxis (including resuscitation facilities) should
be available when parenteral thiamine is administered.

284. A 32yo woman of 39wks gestation attends the antenatal day unit feeling very
unwell with
sudden onset of epigastric pain a/w nausea and vomiting. Temp 36.7C. Exam: RUQ
tenderness.
Bloods: mild anemia, low plts, elevated LFT and hemolysis. What is the most likely dx?
a. Acute fatty liver of pregnancy
b. Acute pyelonephritis
c. Cholecystitis
d. HELLP syndrome
e. Acute hepatitis
Key = D (HELLP syndrome)
Points in favour = hemolysis, elevated LFTs and low platelets

Presentation

HELLP syndrome is a serious form of pre-eclampsia and patients may present at


any time in the last half of pregnancy.
One third of women with HELLP syndrome present shortly after delivery.
Symptoms of HELLP syndrome are usually nonspecific.
Initially, women may report nonspecific symptoms including malaise, fatigue,
right upper quadrant or epigastric pain, nausea, vomiting, or flu-like symptoms.
Hepatomegaly can occur.
Some women may have easy bruising/purpura.
On examination, oedema, hypertension and proteinuria are present.
Tenderness over the liver can occur.

Investigations

There needs to be a high index of clinical suspicion in order to avoid diagnostic


delay and improve outcome.
Haemolysis with fragmented red cells on the blood film
Raised LDH >600 IU/L with a raised bilirubin.
Liver enzymes are raised with an AST or ALT level of >70 IU/L.
Levels of AST or ALT >150 IU/L are associated with increased maternal
morbidity and mortality.

Management

The main treatment is to deliver the baby as soon as possible, even if premature,
since liver function in the mother gets worse very quickly.
Problems with the liver can be harmful to both mother and child.
Definitive treatment of HELLP syndrome requires delivery of the fetus and is
advised after 34 weeks of gestation if multisystem disease is present.
There is no clear evidence of any effect of giving corticosteroids on clinical
outcomes for women with HELLP syndrome.[2]
Transfusion of red cells, platelets, fresh frozen plasma and cryoprecipitate or
fibrinogen concentrate are required as indicated clinically and by blood and
coagulation tests.
Postpartum HELLP syndrome may be treated with steroids and plasma
exchange.
If the fetus is less than 34 weeks of gestation and delivery can be deferred,
corticosteroids should be given.
Blood pressure control is very important.
Women with severe liver damage may need liver transplantation.

285. A 57yo woman presents with dysuria, frequency and urinary incontinence. She
complains of
dyspareunia. Urine culture has been done and is sterile. What is the most appropriate
step?
a. Oral antibiotics
b. Topical antibiotics
c. Topical estrogen
d. Oral estrogen
e. Oral antibiotics and topical estrogen
Key = C (topical estrogen)
Explanation = The problem here is vaginal dryness for which the age and
symptoms are a good clue. Topical estrogen or HRT can be given to treat vaginal
dryness, vaginal discharge and recurrent UTIs in post menopausal women.
286. A pt came to the ED with severe lower abdominal pain. Vitals: BP=125/85mmHg,
Temp=38.9C.
Exam: abdomen rigid, very uncomfortable during par vaginal. She gave a past hx of PID
3 years
ago which was successfully treated with antibiotics. What is the appropriate inv?
a. US
b. Abdomen XR
c. CT
d. High vaginal
e. Endocervical swab

287. A pregnant woman with longterm hx of osteoarthritis came to the antenatal clinic
with
complaints of restricted joint movement and severe pain in her affected joints. What is
the
choice of drug?
a. Paracetamol
b. Steroid
c. NSAID
d. Paracetamol+dihydrocoiene
e. Pethadine
Key = A (paracetamol)
Explanation = Safest drug in pregnancy is paracetamol among the choices given
288. A 24yo 18wk pregnant lady presents with pain in her lower abdomen for the last
24h. She had
painless vaginal bleeding. Exam: abdomen is tender, os is closed. What is the most
probable dx?
a. Threatened miscarriage
b. Inevitable miscarriage
c. Incomplete miscarriage
d. Missed miscarriage
e. Spontaneous miscarriage
Key = A
Points in favour = painless vaginal bleeding , tender abdomen , os closed
Classification of miscarriage is as follows:
Threatened miscarriage: mild symptoms of bleeding. Usually little or no pain.
The cervical os is closed.
Inevitable miscarriage: usually presents with heavy bleeding with clots and
pain. The cervical os is open. The pregnancy will not continue and will proceed to
incomplete or complete miscarriage.
Incomplete miscarriage: this occurs when the products of conception are
partially expelled. Many incomplete miscarriages can be unrecognised missed
miscarriages.
Missed miscarriage: the fetus is dead but retained. The uterus is small for
dates. A pregnancy test can remain positive for several days. It presents with a
history of threatened miscarriage and persistent, dirty brown discharge. Early
pregnancy symptoms may have decreased or gone.
Habitual or recurrent miscarriage : three or more consecutive miscarriages.
. A o hild plaig i the gade had a lea ut. She didt hae a
aiatios. Also, thee is
no contraindication to vaccinations. Parents were worried about the vaccine side effects.
What
will you give?
a. Clean the wound and dress it
b. Give TT only
c. Give DPT only
d. Give DPT and tetanus Ig
e. Give complete DPT vaccine course
290. A 32yo female who has had 3 prv miscarriages in the 1st trimester now comes with
vaginal

bleeding at 8wks. US reveals a viable fetus. What would be the most appropriate
definitive
management?
a. Admit
b. Aspirin
c. Bed rest 2 weeks
d. Cervical cerclage
e. No tx
Key = B (Aspirin)
Explanation = This is a case of APS probably as evident by 3 prev miscarriages
and vaginal bleeding now. Aspirin should be advised throughout the pregnancy
(along with LMWH).
291. A 6yo girl started wetting herself up to 6x/day. What is the most appropriate tx?
a. Sleep alarms
b. Desmopressin
c. Reassure
d. Behavior training
e. Imipramine
Key = A (sleep alarms)
Explanation = Alarm training is a first line treatment for nocturnal enuresis in
children and is the most effective long term strategy. Desmopressin can be used
in children above the age of 7 but is indicated in case of rapid control or when
alarms are inappropriate and is usually used second line to alarm training.
Imipramine is another option approved for 6 year olds but is reserved for resistant
cases only because of its side effects. Behavior therapy is often considered
inferior to these other confirmed methods of treatment.
Reassurance is for children under the age of 5.
292. A 27yo 34wk pregnant lady presents with headache, epigastric pain and vomiting.
Exam:
pulse=115, BP=145/95mmHg, proteinuria ++. She complains of visual disturbance. What
is the
best medication for the tx of the BP?
a. 4g MgSO4 in 100ml 0.9%NS in 5mins
b. 2g MgSO4 IV bolus
c. 5mg hydralazine IV
d. Methyldopa 500mg/8h PO
e. No tx
Key = C
Explanation = This is a case of severe pre-eclampsia as evident by pregnancy of
more than 20 weeks, sustained bp of more than 140/90 mmhg and headache,
epigastric pain and visual disturbances. Treatment of choice for Bp control in
severe pre-eclampsia and eclampsia is IV hydralazine or labetalol or nifedipine
orally.
MgSO4 is for control of fits not bp.

Management of severe pre-eclampsia[1]

Delivery of the fetus and placenta is the only cure. However, preterm delivery may
adversely affect neonatal outcome, with complications resulting from prematurity and low
birth weight.
Blood pressure:
o Antihypertensive treatment should be started in women with a systolic
blood pressure over 160 mm Hg or a diastolic blood pressure over 110
mm Hg. In women with other markers of potentially severe disease,
treatment can be considered at lower degrees of hypertension.
o Labetalol (given orally or intravenously), oral nifedipine or intravenous
hydralazine are usually given for the acute management of severe
hypertension.
o Atenolol, angiotensin-converting enzyme (ACE) inhibitors, angiotensin-II
receptor antagonists and diuretics should be avoided.
o Antihypertensive medication should be continued after delivery, as
dictated by the blood pressure. It may be necessary to maintain treatment
for up to three months, although most women can have treatment
stopped before this.
Prevention of seizures:
Magnesium sulfate should be considered when there is concern about the risk of
eclampsia.
In women with less severe disease, the decision is less clear and will depend on
individual case assessment.
Control of seizures:
o Magnesium sulfate is the therapy of choice to control seizures. A loading
dose of 4 g is given by infusion pump over 5-10 minutes, followed by a
further infusion of 1 g/hour maintained for 24 hours after the last seizure.
o Recurrent seizures should be treated with either a further bolus of 2 g
magnesium sulfate or an increase in the infusion rate to 1.5 g or 2.0
g/hour.
Fluid balance:
o Fluid restriction is advisable to reduce the risk of fluid overload in the
intrapartum and postpartum periods. Total fluids should usually be limited
to 80 ml/hour or 1 ml/kg/hour.
Delivery:
o The decision to deliver should be made once the woman is stable and
with appropriate senior personnel present.
o If the fetus is less than 34 weeks of gestation and delivery can be
deferred, corticosteroids should be given, although after 24 hours the
benefits of conservative management should be reassessed.
o Conservative management at very early gestations may improve the
perinatal outcome but must be carefully balanced with maternal wellbeing.
o The mode of delivery should be determined after considering the
presentation of the fetus and the fetal condition, together with the
likelihood of success ofinduction of labour after assessment of the
cervix.[5]
o The third stage should be managed with 5 units of intramuscular/slow
intravenous Syntocinon. Ergometrine and Syntometrine should not be
given for prevention of haemorrhage, as this can further increase the
blood pressure.
o Prophylaxis against thromboembolism should be considered.

Management of eclampsia

Resuscitation:
o The patient should be placed in the left lateral position and the airway
secured.
o Oxygen should be administered.
Treatment and prophylaxis of seizures:
o Magnesium sulfate is the anticonvulsant drug of choice.
o Intubation may become necessary in women with repeated seizures in
order to protect the airway and ensure adequate oxygenation.
Treatment of hypertension:
o Reduction of severe hypertension (blood pressure >160/110 mm Hg or
mean arterial pressure >125 mm Hg) is essential to reduce the risk of
cerebrovascular accident. Treatment may also reduce the risk of further
seizures.
o Intravenous hydralazine or labetalol are the two most commonly used
drugs. Both may precipitate fetal distress and therefore continuous fetal
heart rate monitoring is necessary.
Fluid therapy:
o Close monitoring of fluid intake and urine output is mandatory.
o Pre-loading the circulation with 400-500 ml colloid prior to regional
anaesthesia or vasodilatation with hydralazine may reduce the risk of
hypotension and fetal distress.
Delivery:
o The definitive treatment of eclampsia is delivery. Attempts to prolong
pregnancy in order to improve fetal maturity are unlikely to be of value.
o However, it is unsafe to deliver the baby of an unstable mother even if
there is fetal distress. Once seizures are controlled, severe hypertension
treated and hypoxia corrected, delivery can be expedited.
o Vaginal delivery should be considered but Caesarean section is likely to
be required in primigravidae, well before term and with an unfavourable
cervix.
o After delivery, high-dependency care should be continued for a minimum
of 24 hours.
All patients need careful follow-up and a formal postnatal review to establish if there is
chronic hypertension, proteinuria or liver damage.

Complications

Eclampsia is usually part of a multisystem disorder. Associated complications


include haemolysis, HELLP syndrome (3%), disseminated intravascular
coagulation (3%), renal failure (4%) and adult respiratory distress syndrome
(3%).
Pre-eclampsia can progress to eclampsia with epileptic fits and sometimes other
neurological symptoms, including focal motor deficits and cortical blindness.
Cerebrovascular haemorrhage is a complicating factor in 1-2%.

293. A 24yo lady who is 37wk pregnant was brought to the ED. Her husband says a few
hours ago she
complained of headache, visual disturbance and abdominal pain. On arrival at the ED
she has a

fit. What is the next appropriate management for this pt?


a. 4g MgSO4 in 100ml 0.9%NS in 5mins
b. 2g MgSO4 IV bolus
c. 2g MgSO4 in 500ml NS in 1h
d. 4g MgSO4 IV bolus
e. 10mg diazepam in 500ml 0.9%NS in 1h
Key = A
Explained in the previous question.
. What is the pathologial hage i Baets esophagitis?
a. Squamous to columnar epithelium
b. Columnar to squamous epithelium
c. Dysplasia
d. Metaplasia
e. Hyperplasia
Key = A (squamous to columnar)
295. A 34yo male presents with hx of headache presents with ataxia, nystagmus and
vertigo. Where
is the site of the lesion?
a. Auditory canal
b. 8th CN
c. Cerebellum
d. Cerebral hemisphere
e. Brain stem
Key = Cerebellum
Points in favour = ataxia, nystagmus and vertigo
296. A 24yo girl comes to the woman sexual clinic and seeks advice for contraception.
She is on
sodium valproate.
a. She at use COCP
b. She can use COCP with extra precaution
c. She can use COCP if anticonvulsant is changed to carbamezapin.
d. She can use COCP with estrogen 50ug and progesterone higher dose
e. She can use COCP
Key = E
Points in favour = Women using anticonvulsants that do not induce live liver
enzyme cytochrome - P450 can use OCPs without any restriction.
Anticonvulsants not inducing liver enzymes = gabapentin, levetiracetam, valproate and
vigabatrin.
Anticonvulsants inducing liver enzymes = phenytoin, carbamazepine, barbiturates,
primidone, topiramate and oxcarbazepine. May use depot medroxyprogesterone acetate,
copper intrauterine contraceptive devices, the levonorgestrel-releasing intrauterine system,
barrier methods and natural family planning methods.
297. A 27yo lady came to the ED 10 days ago with fever, suprapubic tenderness and
vaginal discharge.
PID was dx. She has been on the antibiotics for the last 10days. She presents again with
lower
abdominal pain. Temp=39.5C. what is the most appropriate next management?
a. Vaginal swab
b. Endocervical swab

c. US
d. Abdominal XR
e. Laparoscopy
298. An 18yo man complains of fatigue and dyspnea, he has left parasternal heave and
systolic thrill
with a harsh pan-systolic murmur at left parasternal edge. What is the most probable dx?
a. TOF
b. ASD
c. VSD
d. PDA
e. TGA
Key = C (VSD)
Points in favour = Age , Left parasternal heave, pan systolic murmur at left
parasternal edge.
Transposition of great arteries presents in the infants and not that late in life.
TOF may be left undiagnosed this late but patients present with severe cyanosis and
other typical features of TOF.
ASD has a soft systolic ejection murmur in the pulmonic area and diastolic rumble at left
sternal border.
VSD :-

Epidemiology[3]

VSDs are the most common congenital heart defect in children, occurring in 50%
of all children with congenital heart disease and in 20% as an isolated lesion.
The incidence of VSDs has increased significantly with advances in imaging and
screening of infants and ranges from 1.56 to 53.2 per 1,000 live births. The ease
with which small muscular VSDs can now be detected has contributed to this
increase in incidence.
In the adult population VSDs are the most common congenital heart defect,
excluding bicuspid aortic valve.

Presentation
How haemodynamically significant a VSD is depends on its size, pressure in the
individual ventricles and pulmonary vascular resistance.[3] The presence of a VSD may
not be obvious at birth because of nearly equal pressures in both the ventricles with little
or no shunting of blood. As the pulmonary vascular resistance drops, the pressure
difference between the two ventricles increases and the shunt becomes significant
allowing the defect to become clinically apparent. An exception to this rule is Down's
syndrome where the pulmonary vascular resistance may not fall and the VSD may not
become clinically apparent, first presenting with pulmonary hypertension. All babies with
Down's syndrome should therefore be screened for congenital heart disease no later
than 6 weeks of age.[8]
The clinical presentation varies with the severity of the lesion:
With a small VSD, the infant or child is asymptomatic with normal feeding and
weight gain and the lesion may be detected when a murmur is heard at a routine
examination.

With a moderate-to-large VSD, although the babies are well at birth, symptoms
generally appear by 5 to 6 weeks of age. The main symptom is exercise
intolerance and since the only exercise babies do is feeding, the first impact is on
feeding. Feeding tends to slow down and is often associated with tachypnoea
and increased respiratory effort. Babies are able to feed less, and weight gain
and growth are soon affected. Poor weight gain is a good indicator of heart
failure in a baby. Recurrent respiratory infections may also occur.
With very large VSDs the features are similar but more severe. If appropriate
management is not carried out promptly in infants with large VSDs excessive
pulmonary blood flow may lead to increase in pulmonary vascular resistance and
pulmonary hypertension. These babies may develop a right to left shunt with
cyanosis or Eisenmenger's syndrome.

Physical signs
Again, these depend on the severity of the lesion with, one exception, the loudness of
the murmur. Murmurs are caused by turbulence of blood flow. There may be more
turbulence with a small hole than with a large defect. The loudness of the murmur gives
no indication of the size of the lesion. Even the adage 'the louder the sound, the smaller
the lesion' is untrue.
With a small VSD the infant is well developed and pink. The precordial impulse
may be greater than usual but is usually normal. If it can be heard, the
physiological splitting of the second sound is normal but there is a harsh systolic
murmur that is best heard at the left sternal edge, which may obliterate the
second sound. The murmur tends to be throughout systole but, if the defect is in
the muscular portion, it may be shorter as the hole is closed as the muscle
contracts.
With a moderate or large VSD there is enhanced apical pulsation as well as a
parasternal heave. A grade 2 to 5/6 systolic murmur is audible at the lower left
sternal border. It may be pansystolic or early systolic. A prominent third sound
with a short early mid-diastolic rumble is audible at the apex with a moderate-tolarge shunt (because of increased flow through the mitral valve during diastole).
S2 is loud and single in patients with pulmonary hypertension.
Large defects with no shunts or those with Eisenmenger physiology and right-toleft shunt may have no murmur.
Investigations = ECG, CXR, ECHOCARDIOGRAPHY and Cardiac catheterization.

Management[10]
Medical management

Management in the infant and child depends on symptoms, with small


asymptomatic defects needing no medical management, and unlikely to need
any intervention.
First-line treatment for moderate or large defects affecting feeding and growth is
with diuretics for heart failure and high-energy feeds to improve calorie intake.
Angiotensin-converting enzyme inhibitors are used to reduce afterload which
promotes direct systemic flow from the left ventricle, thus reducing the shunt.
Digoxin can also be given for its inotropic effect.

Any patient needing significant medical management should be referred for


surgical assessment.

Surgical management

Surgical repair is required if there is uncontrolled heart failure, including poor


growth. Even very small babies may be considered for surgery.
Infundibular defects may be considered for closure even if they are asymptomatic
because of their location.
Development of aortic valve prolapse and aortic regurgitation in perimembranous
VSDs may be an indication for surgical closure.
Most defects are closed nowdays by directly placing a patch from the right
ventricular side, usually with the surgeon working through the tricuspid valve.
Patients with large muscular VSDs which are difficult to see or those with multiple
holes (Swiss cheese septum) presenting as neonates or infants need initial
palliation in the form of pulmonary artery banding followed many months later by
corrective surgery and removal of the pulmonary artery band.

Catheter closure

Advances in catheter techniques and devices mean that many muscular and
perimembranous VSDs can now be closed percutaneously. This is in the setting
of normal atrioventricular and ventriculoarterial connections and absence of any
atrioventricular or arterial valve override.
Transcatheter techniques are useful because they avoid cardiopulmonary
bypass. There are, however, recognised complications for device closure of
perimembranous VSDs, including complete heart block needing permanent
pacemaker.[11]
The National Institute for Health and Care Excellence (NICE) has provided
detailed guidance on indications, efficacy and complications of the procedure.[12]
It is safer to close muscular VSDs using a device but muscular VSDs which are
haemodynamically significant are likely to be seen in only young infants, making
catheterisation difficult and challenging. Hybrid procedures increasingly being
used involve insertion of the device in the operation theatre after surgical
exposure of the defect.[13]

299. A young girl presenting with fever, headache, vomiting, neck stiffness and
photophobia. She has
no rashes. What is the most appropriate test to confirm dx?
a. Blood culture
b. Blood glucose
c. LP
d. CXR
e. CT
Key = C
Points in favour = This is suspected meningitis. Do Lp to confirm.

300. A 65yo HTN man wakes up in the morning with slurred speech, weakness of the
left half of his
body and drooling. Which part of the brain is affected?
a. Left parietal lobe
b. Right internal capsule
c. Right midbrain
d. Left frontal lobe
Key = B

351. A 35yo lady presents with painful ulcers on her vulva, what is the appropriate inv
which will lead to the dx?
a. Anti-HSV antibodies
b. Dark ground microscopy of the ulcer
c. Treponema palladium antibody test
d. Rapid plasma regain test
e. VDRL
Dx genital herpes
Ans. key A. Anti-HSV antibodies. [Genital Herpes may be asymptomatic or may remain
dormant for months or even years. When symptoms occur soon after a person is
infected, they tend to be severe. They may start as multiple small blisters that eventually
break open and produce raw, painful sores that scab and heal over within a few weeks.
The blisters and sores may be accompanied by flu-like symptoms with fever and swollen
lymph nodes.
treatment : There are three major drugs commonly used to treat genital herpes
symptoms: acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir(Valtrex). These are
all taken in PO. Severe cases may be treated with the intravenous (IV) drug acyclovir].
options B C D & E are tests for syphilis which presents with single painless ulcer
(canchre)
352. A 53yo man presents with a longstanding hx of a 1cm lesion on his arm. It has
started
bleeding on touch. What is the most likely dx?
a. Basal cell carcinoma
b. Kaposis sarcoma
c. Malignant melanoma
d. Squamous cell carcinoma
e. Kerathoacanthoma
Ans. D Squamous cell carcinoma. [SSCs Arises in squamous cells. SCCs may occur on all
areas of the body including the mucous membranes and genitals, but are most common in areas frequently
exposed to the sun, such as the rim of the ear, lower lip, face, balding scalp, neck, hands, arms and legs.

SCCs often look like scaly red patches, open sores, elevated growths with a central
depression, or warts; they may crust or bleed.
investigation: tissue sample (biopsy) will be examined under a microscope to arrive at
a diagnosis.

prognosis : Squamous cell carcinomas detected at an early stage and removed


promptly are almost always curable and cause minimal damage].
basal cell carcinoma is usually on face with inverted margins
malignant melanoma is on sun exposed parts and is dark (black colored) ulcer
353. A

47yo man with hx of IHD complains of chest pain with SOB on exertion over the
past few days. ECG normal, Echo= increased EF and decreased septal wall thickness.
What is the most likely dx?
a. Dilated CM
b. Constrictive pericarditis
c. Amyloidosis
d. Subacute endocarditis
Ans. The key is A. Dilated CM.
points in fav: sob, palpitation, dec septal wall thinning
treatment : beta blocker, acei, diuretics
Constrictive pericarditis doesnt fits because it starts with urti has pain on lying flat which
is relieved by leaning forward
ecg shows wide spread st elevation
Amyloid deposition in the heart can cause both diastolic and systolic heart failure.
EKG changes may be present, showing low voltage and conduction abnormalities
like atrioventricular block or sinus node dysfunction. On echocardiography the
heart shows restrictive filling pattern, with normal to mildly reduced ejec fraction
354. An elderly pt who is known to have DM presents to the hospital with drowsiness,
tremors and confusion. What inv should be done to help in further management?
a. Blood sugar
b. ECG
c. Standing and lying BP
d. Fasting blood sugar
e. CT
Ans. The key is A. Blood sugar.since he is known diabetic he may have gotten
hypoglycemic d/t his meds
355. A 28yo pregnant woman with polyhydramnios and SOB comes for an anomaly scan
at 31 wks. US= absence of gastric bubble. What is the most likely dx?
a. Duodenal atresia
b. Esophageal atresia
c. Gastrochiasis
d. Exomphalos
e. Diaphragmatic hernia
Ans. The key is B. Oesophageal atresia.
This condition is visible, after about 26 weeks, on an ultrasound. On antenatal
USG, the finding of an absent or small stomach in the setting of polyhydramnios
used to be considered suspicious of esophageal atresia. However, these findings
have a low positive predictive value. The upper neck pouch sign is another sign

that helps in the antenatal diagnosis of esophageal atresia and it may be detected
soon after birth as the affected infant will be unable to swallow its own saliva.
Also, the newborn can present with gastric distention, cough, apnea, tachypnea,
and cyanosis. In many types of esophageal atresia, a feeding tube will not pass
through the esophagus.
356. A 1m boy has been brought to the ED, conscious but with cool peripheries and has
HR=222bpm. He has been irritable and feeding poorly for 24h. CXR=borderline enlarged
heart with clear lung fields. ECG=regular narrow complex tachycardia, with difficulty
identifying p wave. What is the single most appropriate immediate tx?
a. Administer fluid bolus
b. Administer oxygen
c. Oral beta-blockers
d. Synchronized DC cardio-version
e. Unilateral carotid sinus massage

The key is D. Synchrnized DC cardioversion.


reason: As the patient is in probable hemodynamic instability (suggested by cool
peripheries) so we should go for DC cardioversion.
diagnosis SVT.
357. A 7yo child presented with chronic cough and is also found to be jaundiced on
examination.
What is the most likely dx?
a. Congenital diaphragmatic hernia
b. Congenital cystic adenematoid malformation
c. Bronchiolitis
d. RDS
e. Alpha 1 antitrypsin deficiency

The key is E. Alpha 1 antitrypsin deficiency.


REASON. Unexplained liver disease with respiratory symptoms are very suggestive of
AATD.
liver disease occurs because of the accumulation AAT in it
where as d/t inability to be transported out of liver AATD causes emphysema hence the
resp problems
358. A 35yo construction worker is dx with indirect inguinal hernia. Which statement
below best
describes it?
a. Passes through the superficial inguinal ring only
b. Lies above and lateral to the pubic tubercle
c. Does not pass through the superficial inguinal ring
d. Passes through the deep inguinal ring
Ans. The key is D. Passess through the deep inguinal ring.
direct hernia passes directly through the posterior wall of inguinal canal whereas indirect
can only do so via deep ring

359. A woman has numerous painful ulcers on her vulva. What is the cause?
a. Chlamydia
b. Trichomonas
c. Gardenella
d. HSV
e. EBV
Ans. The key is D. HSV. reason has been explained in q 351
360. A 72 yo man has been on warfarin for 2yrs because of past TIA and stroke. What is
the most important complication that we should be careful with?
a. Headache
b. Osteoporosis
c. Ear infection
d. Limb ischemia
e. Diarrhea
Ans. key is wrong
right key is A Headache, as there are chances of SAH or generally ICH
361. A 55yo man has been admitted for elective herniorraphy. Which among the
following can be the reason to delay his surgery?
a. Controlled asthma
b. Controlled atrial fib
c. DVT 2yrs ago
d. Diastolic BP 90mmHg
e. MI 2 months ago
Ans. E SAFER TO DO SURGERY AFTER 6 MONTHS
362. A 65yo known case of liver ca and metastasis presents with gastric reflux and
bloatedness. On bone exam there is osteoporosis. He also has basal consolidation in
the left lung. What is the next appropriate step?
a. PPI IV
b. Alendronate
c. IV antibiotics
d. Analgesic
e. PPI PO
IN THIS case reflux is the cause of recurrent pneumonia so both C AND E can be
right but to chose single one E is more appropriate
363. A 66yo man has the following ECG. What is the most appropriate next step in
management?
a. Metoprolol
b. Digoxin
c. Carotid sinus massage
d. Adenosine
e. Amiodarone.
Ans. A beta blocker for A FIB

364. A 22yo sexually active male came with 2d hx of fever with pain in scrotal area.
Exam: scrotal skin is red and tender. What is the most appropriate dx?
a. Torsion of testis
b. Orchitis
c. Inguinal hernia
d. Epididymo-orchitis
D Epididymo-orchitis.
In orchitis there should be fever, elevation of testes reduces pain (positive prehn sign), In
torsion testis lies at a higher level. In torsion urinalysis negative but in orchitis it is
positive. Orchitis usually occurs in sexually active man. X
365. A man on warfarin posted for hemicolectomy. As the pt is about to undergo surgery.
What
option is the best for him?
a. Continue with warfarin
b. Continue with warfarin and add heparin
c. Stop warfarin and add aspirin
d. Stop warfarin and add heparin
e. Stop warfarin
D Stop warfarin and add heparin
5 DAYS BEFORE SURGERY WARFARIN MUST BE REPLACED BY HEPARIN,
366. A 65yo known alcoholic is brought into hospital with confusion, aggressiveness and
ophthalmoplegia. He is treated with diazepoxide. What other drug would you like to
prescribe?
a. Antibiotics
b. Glucose
c. IV fluids
d. Disulfiram
e. Vit B complex
E Vitamin B complex. [confusion and ophthalmoplegia points towards the diagnosis of
Wernickes encephalopathy].
which occurs d/t thiamine def.
367. A 32yo woman has severe right sided abdominal pain radiating into the groin which
has lasted for 3h. She is writhering in pain. She has no abdominal signs. What is the
most likely cause of her abdominal pain?
a. Appendicitis
b. Ruptured ectopic pregnancy
c. Salpingitis
d. Ureteric colic
e. Strangulated hernia
D Ureteric colic.
It indicate stone at lower ureter. [i) Pain from upper ureteral stones tends to radiate to the flank and
lumbar areas. ii) Midureteral calculi cause pain that radiates anteriorly and caudally. This midureteral pain in

particular can easily mimic appendicitis on the right or acute diverticulitis on the left. iii) Distal ureteral stones
cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female.

368. A 39yo coal miner who smokes, drinks and has a fam hx of bladder cancer is
suffering from BPH. The most important risk factor for his bladder carcinoma is?
a. Fam hx
b. Smoking
c. Exposure to coal mine
d. BPH

B smoking.
. Risk factors of bladder cancer:
i) Smoking ii) Exposure to chemicals used in dye industry iii) Whites are more likely to
develop bladder cancer iv) Risk increases with age v) More common in men vi) Chronic
bladder irritation and infections (urinary infections, kidney and bladder stones, bladder
catheter left in place a long time.) vii) Personal history of bladder or other urothelial
cancer viii) Family history ix) Chemotherapy or radiotherapy x) Pioglitazone for more
than one year and certain herb xi) Arsenic in drinking water xii) Low fluid consumption.
369. A 34yo woman is referred to the endocrine clinic with a hx of thyrotoxicosis. At her
1st
appointment she is found to have a smooth goiter, lid lag and bilateral exophthalmos
with puffy
eyelids and conjunctival injection. She wants to discuss the tx of her thyroid prb as she is
keen to become pregnant. What is the most likely tx you would advise?
a. 18m of carbimazole alone
b. 18m of PTU alone
c. A combo od anti-thyroid drug and thyroxine
d. Radioactive iodine
e. Thyroidectomy

B 18m of PTU alone.


Other drug option i.e Carbamazepine is teratogenic [can cause i) spina bifida
ii)cardiovascular malformations ETC . PTU is on the other hand relatively safe in
pregnancy.
370. A child living with this stepfather is brought by the mother with multiple bruises,
fever and
fractures. What do you suspect?
a. NAI
b. Malnutrition
c. Thrombocytopenia
d. HIV
Ans. The key is A. NAI. [H/O living with stepfather, multiple bruises, fever and fractures
are suggestive of NAI]. OTHER possible points can include hx not matching with
bruises, wounds which are a day or two older at the time of presentation.

371. A young man who was held by the police was punched while in custody. He is now
cyanosed and unresponsive. What is the 1st thing you would do?
a. IV fluids
b. Clear airway
c. Turn pt and put in recovery position
d. Give 100% oxygen
e. Intubate and ventilate
B. Clear airway. [ABC protocol].
372. A HTN male loses vision in his left eye. The eye shows hand movement and a light
shined in the eye is seen as a faint light. Fundus exam: flame shaped hemorrhages. The
right eye is normal. What is the cause of this pts unilateral blindness?
a. HTN retinopathy
b. CRA thrombosis
c. CRV thrombosis
d. Background retinopathy
e. Retinal detachment
key is wrong.
right ans is C ( unilateral blindness with flame shaped hemorrhages are
characteristic of CRVO). Flame shaped hemorrhages are seen in HTN and diabetic
retinopathy too but they will cause bilateral damage.
373. A mentally retarded child puts a green pea in his ear while eating. The carer
confirms this.
Otoscopy shows a green colored object in the ear canal. What is the most appropriate
single
best approach to remove this object?
a. By magnet
b. Syringing
c. Under GA
d. By hook
e. By instilling olive oil
C UNDER GA
[Pea is not a magnetic material and hence it cannot be removed by magnet, it will
swell up if syringing is attempted, as hook placement is likely with risk of pushing
the pea deeper it is not also suitable in a mentally retarded child, and olive oil is
not of help in case of pea. So to avoid injury it is better to remove under GA
374. A pt presents with longstanding gastric reflux, dysphagia and chest pain. On barium
enema, dilation of esophagus with tapering end is noted. He was found with Barretts
esophagus. He had progressive dysphagia to solids and then liquids. What is the single
most appropriate dx?
a. Achalasia
b. Esophageal spasm
c. GERD
d. Barretts esophagus
e. Esophageal carcinoma

E Oesophageal carcinoma. [there is dilatation in oesophagus which is seen both in


achalasia and carcinoma. Dysphagia to solid initaially is very much suggestive of
carcinoma and also barretts change is a clue to carcinoma]
Progressive dysphagia with h/o barrett esophagus are the key indicators
375. A 48yo lady presents with itching, excoriations, redness, bloody discharge and
ulceration around her nipple. What is the most likely dx?
a. Pagets disease of the breast
b. Fibrocystic dysplasia
c. Breast abscess
d. Duct papilloma
e. Eczema
A Pagets disease of the breast.
TYPICAL manifestation of pagets disease
eczema like rash involving nipple and areola with straw or bloody discharge. Eczema is
bilateral.
Also nipple turns inward in advances stages pt complaints of burning sensation at the
site of lesion
DX mammography and biopsy
TX surgery + chemo or radio may be needed
376. Pt with widespread ovarian carcinoma has bowel obstruction and severe colic for
2h and was normal in between severe pain for a few hours. What is the most appropriate
management?
a. PCA (morphine)
b. Spasmolytics
c. Palliative colostomy
d. Oral morphine
e. Laxatives
C. Palliative colostomy.
Cancer or chemotherapy induced obstructions are unlikely to respond to conservative
management [NBM, IV fluid, nasogastric suction] and hence only analgesia will not
relieve it. So in such cases we have to go for palliative colostomy.
377. A 70yo man admits to asbestos exposure 20yrs ago and has attempted to quit
smoking. He has noted weight loss and hoarseness of voice. Choose the single most
likely type of cancer a.w risk
factors present.
a. Basal cell carcinoma
b. Bronchial carcinoma
c. Esophageal carcinoma
d. Nasopharyngeal carcinoma
e. Oral carcinoma

B. Bronchial carcinoma. [Asbestos exposure is a risk factor for lung cancer


and also has a synergistic effect with cigarette smoke].

#. Conditions related to asbestos exposure: i) Pleural plaques (after a latent period of


20-40 yrs) ii) Pleural thickening iii) Asbestosis (latent period is typically 15-30 yrs) iv)
Mesothelioma (prognosis is very poor) v) Lung cancer.
378. A 32yo woman had progressive decrease in vision over 3yrs. She is no dx as
almost blind. What would be the mechanism?
a. Cataract
b. Glaucoma
c. Retinopathy
d. Uveitis
e. Keratitis

B. Glaucoma.
. Cataract is unlikely at this age. Nothing in the history suggests retinopathy. Uveitis and
iritis doesnt have such degree of vision loss and iritis and anterior uveitis have pain,
redness and photophobia. Open angle glaucoma is likely cause.
379. A child during operation and immediately after showed glycosuria, but later his
urine sugar was normal. Choose the most probable dx.
a. Pre-diabetic state
b. Normal finding
c. Low renal tubular threshold
d. DM
B Normal finding.
Stress during operation can cause transient hyperglycemia causing glycosuria
secondary to stress induced rise of cortisol which becomes normal after some time.
380. A pt presented with hx of swelling in the region of the sub-mandibular region, which
became
more prominent and painful on chewing. He also gave hx of sour taste in the mouth, the
area is
tender on palpation. Choose the most probable dx?
a. Chronic recurrent sialadenitis
b. Adenolymphoma
c. Mikuliczs disease
d. Adenoid cystic carcinoma
e. Sub-mandibular abscess
A Chronic recurrent sialadenitis. [pain, swelling, more pain on chewing, tenderness, and
submandibular region suggests diagnosis of submandibular chronic recurrent
sialadenitis, usually secondary to sialolithiasis or stricture].
381. ECG of an 80yo pt of ICH shows saw-tooth like waves, QRS complex of 80ms
duration,
ventricular rate=150/min and regular R-R interval. What is the most porbable dx?
a. Atrial fib
b. Atrial flutter
c. SVT
d. Mobitz type1 second degree heart block
e. Sinus tachycardia

B Atrial flutter. [Saw-tooth like waves, normal QRS comples of 80 ms (normal range 70100 ms), ventricular rate of 150/min and regular R-R interval is diagnostic of atrial
flutter].
FOR AFIB THERE WD BE IRREGULARARLY IRREGULAR RHYTHM
382. A 50 yo woman who was treated for breast cancer 3 yrs ago now presents with
increase thirst and confusion. She has become drowsy now. What is the most likely
metabolic abnormality?
a. Hypercalcemia
b. Hyperkalemia
c. Hypoglycemia
d. Hyperglycemia
e. Hypercalcemia.
E HYPERCALCEMIA
Ans. 2. Increased thirst, confusion, drowsiness these are features of hypercalcemia. Any
solid organ tumour can produce hypercalcemia. Here treated Ca breast is the probable
cause of hypercalcemia.
383. A 29yo woman presents to her GP with a hx of weight loss, heat intolerance, poor
conc and
palpitations. Which of the following is most likely to be a/w dx of thyroiditis a/w viral
infection?
a. Bilateral exophthalmos
b. Diffuse, smooth goiter
c. Reduced uptake on thyroid isotope scan
d. Positive thyroid peroxidase antibodies
e. Pretibial myxedema
C. Reduced uptake on thyroid isotope scan.
DX De Quervains or subacute thyroiditis.
. Viral or subacute thyroiditis: diagnostic criteria: i) Features of hyperthyroidism present.
ii) Pain thyroid, not mentioned. iii) Investigations: high esr (60-100) not mentioned,
Reduced uptake of radioactive iodine by the gland.
384. A lady, post-colostomy closure after 4 days comes with fluctuating small swelling in
the stoma.
What is the management option for her?
a. Local exploration
b. Exploratory laparotomy
c. Open laparotomy
d. Reassure
A Local exploration.
THERE MUST BE SOME LOCAL WOUND PROBLEM
385. A 65yo female pt was given tamoxifen, which of the following side effect caused by
it will
concern you?
a. Fluid retention
b. Vaginal bleeding
c. Loss of apetite
d. Headache and dizziness
e.
B Vaginal bleeding.

. Tamoxifen can promote development of endometrial carcinoma. So vaginal bleeding


will be of concern for us.
386. A 39yo man with acute renal failure presents with palpitations. His ECG shows tall
tented T
waves and wide QRS complex. What is the next best step?
a. Dialysis
b. IV calcium chloride
c. IV insulin w/ dextrose
d. Calcium resonium
e. Nebulized salbutamol

B. IV calcium chloride (both IV calcium gluconate or IV calcium chloride can be used)


when there is ECG changes.
DX The ECG changes are suggestive of Hyperkalemia.
At potassium level of >5.5mEq/L occurs tall tented T waves and at potassium level
>7mEq/L occurs wide QRS complex with bizarre QRS morphology.
387. A 54yo pt 7 days after a total hip replacement presents with acute onset
breathlessness and
raised JVP. Which of the following inv will be most helpful in leading to a dx?
a. CXR
b. CTPA
c. V/Q scan
d. D-Dimer
e. Doppler US of legs

The key is B. CTPA.


The patient has a +ve two level PE Wells score (if it was negative we should do DDimer) and there is no renal impairment or history suggestive of allergy to contrast
media (if these present we should have go for VQ scan) the investigation of choice is
PTCA. NICE guideline.
388. A 7yo girl has been treated with penicillin after sore throat, fever and cough. Then
she
develops skin rash and itching. What is the most probable dx?
a. Erythema nodosum
b. Erythema multiforme
c. SJS
d. Erythema marginatum
e. Erythema gangernosum

. The key is B. Erythema multiforme.


Common drugs causing erythma multiforme are: antibiotics (including, sulphonamides,
penicillin), anticonvulsants (phenytoin,barbiturates), aspirin, antituberculoids, and allopurinol.
CLOSELY related option is SJS which would have muco cutaneous rash but in here we hav only
cutaneous rash.

Nodosum is in diseases like Tb, sarcoidosis, IBD


Marginatum is the rash of acute rheumatic fever

389. A 60yo man presented with a lump in the left supraclavicular region. His appetite is
decreased and he has lost 5kg recently. What is the most probably dx?
a. Thyroid carcinoma
b. Stomach carcinoma
c. Bronchial carcinoma
d. Mesothelioma
e. Laryngeal carcinoma
The key is B. Stomach carcinoma. [Mentioned lump in the left supraclavicular region is
Vershows gland, has long been regarded as strongly indicative of the presence of cancer in the
abdomen, specifically gastric cancer].
390. A 64yo man has presented to the ED with a stroke. CT shows no hemorrhage.
ECG shows atrial fib. He has been thrombolysed and hes awaiting discharge. What
prophylactic regimen is best for him?
a. Warfarin
b. Heparin
c. Aspirin
d. Statins
e. Beta blockers
The key is A. Warfarin. [Atrial fibrillation: post stroke- following a stroke or TIA warfarin
should be given as the anticoagulant of choice. NICE guideline].
391. A 54yo man after a CVA presents with ataxia, intention tremors and slurred speech.
Which part of the brain has been affected by the stroke?
a. Inner ear
b. Brain stem
c. Diencephalon
d. Cerebrum
e. Cerebellum
The key is E. Cerebellum.
i) Ataxia ii) slurred speech or dysarthria iii) dysdiadochokinesia iv) intention tremor v)
nystagmus. are the signs of cerebellar defect
392. A 57yo man with blood group A complains of symptoms of vomiting, tiredness,
weight loss and palpitations. Exam: hepatomegaly, ascites, palpable left supraclavicular
mass. What is the most likely dx?
a. Gastric carcinoma
b. Colorectal carcinoma
c. Peptic ulcer disease
d. Atrophic gastritis
e. Krukenberg tumor
Ans. The key is A. Gastric carcinoma. [i) blood group A is associated with gastric cancer
ii) vomiting, tiredness, weight loss are general features of gastric cancer iii) palpitation
from anemia of cancer iv) hepatomegaly and ascites are late features of gastric cancer.

v) palpable left supraclavicular mass- is Vershows gland, has long been regarded as
strongly indicative of gastric cancer].
393. A 21yo girl looking unkempt, agitated, malnourished and nervous came to the
hospital asking
for painkillers for her abdominal pain. She is sweating, shivering and complains of joint
pain.
What can be the substance misuse here?
a. Alcohol
b. Heroin
c. Cocaine
d. LSD
e. Ecstasy
The key is B. Heroin. [agitation, nervousness, abdominal cramp, sweating, shivering and
piloerection, arthralgia these are features of heroin withdrawal].
Also asking for painkillers. Probably looking for morphine.

394. A child presents with increasing jaundice and pale stools. Choose the most
appropriate test?
a. US abdomen
b. Sweat test
c. TFT
d. LFT
e. Endomyseal antibodies
The key is A. US abdomen. [This is a picture suggestive of obstructive jaundice. LFT can
give clue like much raised bilirubin, AST and ALT not that high and raised alkaline
phosphatase but still USG is diagnostic in case of obstructive jaundice].
395. A 32yo man presents with hearing loss. AC>BC in the right ear after Rinne test. He
also
complains of tinnitus, vertigo and numbness on same half of his face. What is the most
appropriate inv for his condition?
a. Audiometry
b. CT
c. MRI
d. Tympanometry
e. Webers test
The key is C. MRI. [features are suggestive of acoustic neuroma, so MRI is the preferred
option]. it involves basically 8th nerve but 6 7 9 and 10th nerves are also involved with it
396. A 56 yo lady with lung cancer presents with urinary retention, postural hypotension,
diminished reflexes and sluggish pupillary reaction. What is the most likely explanation
for her symptoms?
a. Paraneoplastic syndrome
b. Progression of lung cancer
c. Brain metastasis
d. Hyponatremia
e. Spinal cord compression
The key is A. Paraneoplastic syndrome.

s/s are of autonomic neuropathy which occurs in paraneoplastic syndrome


397. An old woman having decreased vision cant see properly at night. She has
changed her glasses quite a few times but to no effect. She has normal pupil and
cornea. What is the most likely dx?
a. Cataract
b. Glaucoma
c. Retinal detachment
d. Iritis
e. GCA
key is wrong
correct key is A cataract
old age and progressive weakness supports Cataract
Not glaucoma...as pupil would be mid dilated and sluggish reaction and in acute attack corneal
edema
Not RD...as pupil would be yellowish in color and there would be RAPD in massive RD and vision
would be dropped in day and night
Not iritis..as pupil would be constricted and cornea would have precipitation on its back (keratic
precipitate)
Not GCA(giant cell arteritis) as vision on it is suddenly dropped to HM up to LP and vision dropped
day and night

398. A pt comes with sudden loss of vision. On fundoscopy the optic disc is normal.
What is the
underlying pathology?
a. Iritis
b. Glaucoma
c. Vitreous chamber
d. Retinal detachment

Ans. 1. The Key is D. Retinal detachment.


#Causes of sudden painless loss of vision:
1.
2.
3.
4.
5.
6.

Retinal detachment
Vitreous haemorrhage
Retinal vein occlusion
Retinal artery occlusion
Optic neuritis
Cerebrovascular accident

remember retinal detachment has vision loss as if curtain is coming down


399. A child was woken up from sleep with severe pain in the testis. Exam: tenderness
on palpation and only one testis was normal in size and position. What would be your
next step?
a. Analgesia
b. Antibiotics
c. Refer urgently to a surgeon
d. Reassurance
e. Discharge with analgesics

Ans. The key is A. Analgesia. [According to some US sites it is analgesia but no UK site
support this!!! So for Plab exam the more acceptable option is C. Refer urgently to a
surgeon].
IN TORSION THE SOONER THE SURGICAL INTERVENTION DONE, THE BETTER
THE RESULTS ARE
400. A child suffering from asthma presents with Temp 39C, drooling saliva on to the
mothers lap,
and taking oxygen by mask. What sign will indicate that he is deteriorating?
a. Intercostal recession
b. Diffuse wheeze
c. Drowsiness
The key is A. Intercostal recession. [ here intercostals recession and drowsiness both
answers are correct. Hope in exam there will be one correct option]. but to chose
among them, better go with A
401. A 12yo boy presents with painful swollen knew after a sudden fall. Which bursa is
most likely tobe affected?
a. Semimembranous bursa
b. Prepatellar bursa
c. Pretibial bursa
d. Suprapatetaller bursa
. The key is B. Prepatellar bursa. [A fall onto the knee can damage the prepatellar bursa. This
usually causes bleeding into the bursa sac causing swollen painful knee. Prepatellar bursitis that is caused
by an injury will usually go away on its own. The body will absorb the blood in the bursa over several weeks,
and the bursa should return to normal. If swelling in the bursa is causing a slow recovery, a needle may be
inserted to drain the blood and speed up the process. There is a slight risk of infection in putting a needle
into the bursa].
402. A

61yo man has been referred to the OPD with frequent episodes of breathlessness
and chest pain a/w palpitations. He has a regular pulse rate=60bpm. ECG=sinus rhythm.
What is the
most appropriate inv to be done?
a. Cardiac enzymes
b. CXR
c. ECG
d. Echo
e. 24h ECG
The key is E. 24h ECG.
Indications of 24 h ambulatory holter monitoring:

To evaluate chest pain not reproduced with exercise testing

To evaluate other signs and symptoms that may be heart-related, such as fatigue,
shortness of breath, dizziness, or fainting

To identify arrhythmias or palpitations

To assess risk for future heart-related events in certain conditions, such as idiopathic
hypertrophic cardiomyopathy, post-heart attack with weakness of the left side of the
heart, or Wolff-Parkinson-White syndrome

To assess the function of an implanted pacemaker

To determine the effectiveness of therapy for complex arrhythmias

403. A woman dx with Ca Breast presents now with urinary freq. which part of the brain
is the
metastasis spread to?
a. Brain stem
b. Pons
c. Medulla
d. Diencephalon
e. Cerebral cortex
The key is D. Diencephalon. [diencephalon is made up of four distinct components: i) the
thalamus ii) the subthalamus iii) the hypothalamus and iv) the epithalamus. Among these
the hypothalamus has crucial role in causing urinary frequency].
404. A man is very depressed and miserable after his wifes death. He sees no point in
living now that his wife is not around and apologises for his existence. He refuses any
help offered. His son has brought him to the ED. The son can.t deal with the father any
more. What is the most
appropriate next step?
a. Voluntary admission to psychiatry ward
b. Compulsory admission under MHA
c. Refer to social services
d. Alternate housing
e. ECT
Ans. The key is B. Compulsory admission under MHA. [This patient is refusing any help
offered! And his son cannot deal with him anymore! In this situation voluntary admission
to psychiatry ward is not possible and the option of choice is compulsory admission
under MHA].
405. A 31yo man has epistaxis 10 days following polypectomy. What is the most likely
dx?
a. Nasal infection
b. Coagulation disorder
c. Carcinoma
The key is A. Nasal infection.
HEMORRHAGE AFTER 7 TO 14 DAYS IS SECONDARY HEMORRHAGE [Infection is
one of the most important cause of secondary hemorrhage].
406. A woman had an MI. She was breathless and is put on oxygen mask and GTN, her
chest
pain has improved. Her HR=40bpm. ECG shows ST elevation in leads I, II, III. What is
your next step?

a. LMWH
b. Streptokinase
c. Angiography
d. Continue current management
e. None

Ans. The key is B. Streptokinase


algorithm for st elevation MI
angioplasty/thrombolysis
b blocker
acei
clopidogrel
407. A 67yo male presents with polyuria and nocturia. His BMI=33, urine culture =
negative for
nitrates. What is the next dx inv?
a. PSA
b. Urea, creat and electrolytes
c. MSU culture and sensitivity
d. Acid fast urine test
e. Blood sugar
The key is E. Blood sugar. [Age at presentation and class1 obesity favours the diagnosis
of type2 DM].
since culture is -ve for nitrates, so uti is ruled out
408. A pt from Africa comes with nodular patch on the shin which is reddish brown. What
is the
most probable dx?
a. Lupus vulgaris
b. Erythema nodosum
c. Pyoderma gangrenosum
d. Erythema marginatum
e. Solar keratosis
The key is B. Erythema nodosum. [Causes of erythema nodosum: MOST COMMON
CAUSES- i) streptococcal infection ii) sarcoidosis. Other causes- tuberculosis,
mycoplasma pneumonia, infectious mononucleosis, drugs- sulfa related drug, OCP,
oestrogen; Behcets disease, CD, UC; lymphoma, leukemia and some others].
#Nodes are mostly on anterior aspect of shin
409. A 29yo lady came to the ED with complaints of palpitations that have been there for
the past 4 days and also feeling warmer than usual. Exam: HR=154bpm, irregular
rhythm. What is the tx for her condition?
a. Amiadarone
b. Beta blockers
c. Adenosine
d. Verapamil
e. Flecainide

The key is B. Beta blockers [the probable arrhythymia is AF secondary to


thyrotoxicosis(heat intolerance). So to rapid control the symptoms of thyrotoxicosis Beta
blocker should be used].
410. A T2DM is undergoing a gastric surgery. What is the most appropriate pre-op
management?
a. Start him in IV insulin and glucose and K+ just before surgery
b. Stop his oral hypoglycemic on the day of the procesure
c. Continue regular oral hypoglycemic
d. Stop oral hypoglycemic the prv night and start IV insulin with glucose and K+ before
surgery
e. Change to short acting oral hypoglycemic
The key is D. Stop oral hypoglycemic the prv night and start IV insulin with glucose and
K+ before surgery.
411. A 19yo boy is brought by his mother with complaint of lack of interest and no social
interactions. He has no friends, he doesnt talk much, his only interest is in collecting
cars/vehicles having around 2000 toy cars. What is the most appropriate dx?
a. Borderline personality disorder
b. Depression
c. Schizoaffective disorder
d. Autistic spectrum disorder
The key is D. Autistic spectrum disorder.
Autism spectrum disorders affect three different areas of a child's life:
Social interaction
Communication -- both verbal and nonverbal
Behaviors and interests
In some children, a loss of language is the major impairment. In others, unusual
behaviors (like spending hours lining up toys) seem to be the dominant factors.
412. A 45yo man who is diabetic and HTN but poorly compliant has chronic SOB,
develops severe SOB and chest pain. Pain is sharp, increased by breathing and
relieved by sitting forward. What is the single most appropriate dx?
a. MI
b. Pericarditis
c. Lung cancer
d. Good pastures syndrome
e. Progressive massive fibrosis
The key is B. Pericarditis. [Nature of pain i.e. sharp pain increased by breathing and
relieved by sitting forward is suggestive of pericarditis].
Nature of pericardial pain: the most common symptom is sharp, stabbing chest pain
behind the sternum or in the left side of your chest. However, some people with acute
pericarditis describe their chest pain as dull, achy or pressure-like instead, and of
varying intensity.

The pain of acute pericarditis may radiate to your left shoulder and neck. It often
intensifies when you cough, lie down or inhale deeply. Sitting up and leaning forward can
often ease the pain.
Ecg widespread st elevation
Tx: ansaid

413. A 6m boy has been brought to ED following an apneic episode at home. He is now
completely well but his parents are anxious as his cousin died of SIDS at a similar age.
The parents ask for guidance on BLS for a baby of his age. What is the single most
recommended technique for cardiac compressions?
a. All fingers of both hands
b. All fingers of one hand
c. Heel of one hand
d. Heel of both hand
e. Index and middle fingertips of one hand
The key is E. Index and middle fingertips of one hand.
414. A 70yo man had a right hemicolectomy for cecal carcinoma 6days ago. He now has
abdominal distension and recurrent vomiting. He has not opened his bowels since
surgery. There are no bowel sounds. WBC=9, Temp=37.3C. What is the single most
appropriate next management?
a. Antibiotic therapy IV
b. Glycerine suppository
c. Laparotomy
d. NG tube suction and IV fluids
e. TPN

1.
2.
3.
4.

1.
2.

The key is D. NG tube suction and IV fluids. [The patient has developed paralytic ileus
which should be treated conservatively].
s/s of paralytic ileus
diffuse abd pain
constipation
abd distension
nausea vomitis may contain bile
INV : abd x ray errect+ serum electrolytes
TX : conservative
npo
ng +iv fluids
215. A 60yo man with a 4y hx of thirst, urinary freq and weight loss presents with a deep
painless
ulcer on the heel. What is the most appropriate inv?
a. Arteriography
b. Venography
c. Blood sugar
d. Biopsy for malignant melanoma
e. Biopsy for pyoderma
The key is C. Blood sugar. [The patient probably developed diabetic foot].
the next step wd be doppler scan to assess the vascular status
416. A 16yo boy presents with rash on his buttocks and extensor surface following a
sore throat.
What is the most probable dx?
a. Measles
b. Bullous-pemphigoid
c. Rubella

d. ITP
e. HSP
it's a wrong key
right ans is E
# In HSP rash typically found in buttocks, legs and feets and may also appear on the
arms, face and trunk.
in ITP it mostly occurs in lower legs. #HSP usually follow a sore throat and ITP follow
viral infection like flue or URTI.
# HSP is a vasculitis while ITP is deficiency of platelets from more destruction in spleen
which is immune mediated].
417. A 34yo man with a white patch on the margin of the mid-third of the tongue. Which
is the single most appropriate LN involved?
a. External iliac LN
b. Pre-aortic LN
c. Aortic LN
d. Inguinal LN
e. Iliac LN
f. Submental LN
g. Submandibular LN
h. Deep cervical LN
The key is G. Submandibular LN.
418. A 50yo lady presents to ED with sudden severe chest pain radiating to both
shoulder and
accompanying SOB. Exam: cold peripheries and paraparesis. What is the single most
appropriate
dx?
a. MI
b. Aortic dissection
c. Pulmonary embolism
d. Good pastures syndrome
e. Motor neuron disease
The key is B. Aortic dissection. [Usual management for type A dissection is surgery and
for type B is conservative].
Dissecting aortic aneurysm. pt history of chest pain & interscapular back pain indicate dissecting aneurysm
in the descending thoracic aorta can causes interference with the blood supply to the anterior spinal artery
and causes the infarction of the ant aspect of the spinal artery that is anterior spinal artery syndrome and
paraparesis. Treatment- Type A: Immediately IV labetalol for control of HTN to reduces the extension of
dissection then for surgical Mx but Type-B for only conservative Mx.

STANFORD CLASSIFICATION
1. TYPE A : INVOLVING ASCENDING AORTA
2. TYPE B: DOES NOT INVOLVE ASCENDING AORTA
419. A 54yo myopic develops flashes of light and then sudden loss of vision. That is the
single most appropriate tx?
a. Panretinal photocoagulation
b. Peripheral iridectomy
c. Scleral buckling

d. Spectacles
e. Surgical extraction of lens
The key is C. Scleral buckling.
DX: RETINAL DETACHMENT
420. A 40yo chronic alcoholic who lives alone, brought in the ED having been found
confused at
home after a fall. He complains of a headache and gradually worsening confusion. What
is the
most likely dx?
a. Head injury
b. Hypoglycemia
c. Extradural hematoma
d. Subdural hematoma
e. Delirium
The key is D. Subdural hematoma. [subdural hematoma may be acute or chronic. In
chronic symptoms may not be apparent for several days or weeks. Symptoms of
subdural hematomas are: fluctuating level of consciousness, insidious physical or
intellectual slowing, sleepiness, headache, personality change and unsteadiness.
TX: SURGERY e.g. via barr twist drill and burr hole craniostomy 1 line. Craniotomy if
the clot organized 2 line].
MOST COMMON IN OLD PEOPLE AND DRUNKS WITH H/O FREQUENT FALLS
st

nd

421. A 54yo man with alcohol dependence has tremor and sweating 3days into a hosp
admission for a fx femur. He is apprehensive and fearful. What is the single most
appropriate tx?
a. Acamprossate
b. Chlordiazepoxide
c. Lorazepam
d. Lofexidine
e. Procyclidine
Ans. The key is B. Chlordiazepoxide. [This is a case of alcohol withdrawal syndrome.
Chlordiazepoxide when used in alcohol withdrawal it is important not to drink alcohol
while taking Chlordiazepoxide.
Chlordiazepoxide should only be used at the lowest possible dose and for a maximum of
up to four weeks. This will reduce the risks of developing tolerance, dependence and
withdrawal].
422. A 5yo child complains of sore throat and earache. He is pyrexial. Exam: tonsils
enlarged and
hyperemic, exudes pus when pressed upon. What is the single most relevant dx?
a. IM
b. Acute follicular tonsillitis
c. Scarlet fever
d. Agranulocytosis
e. Acute OM
Ans. The key is B. Acute follicular tonsillitis. [Tonsillitis is usually caused by a viral
infection or, less commonly, a bacterial infection. The given case is a bacterial

tonsillitis (probably caused by group A streptococcus). There are four main signs
that tonsillitis is caused by a bacterial infection rather than a viral infection. They are:
a high temperature
white pus-filled spots on the tonsils
no cough
swollen and tender lymph nodes (glands).
423. A man with a fam hx of panic disorder is brought to the hosp with palpitations,
tremors,
sweating and muscles tightness on 3 occasions in the last 6 wks. He doesnt complain of
headache and his BP is WNL. What is the single most appropriate long-term tx for him?
a. Diazepam
b. Olanzapine
c. Haloperidol
d. Fluoxetine
e. Alprazolam
Ans. The key is D. Fluoxetine. [Recommended treatment for panic disorder is i) CBT ii)
Medication (SSRIs or TCA). NICE recommends a total of seven to 14 hours of CBT to
be completed within a four month period. Treatment will usually involve having a weekly
one to two hour session. When drug is prescribed usually a SSRI is preferred.
Antidepressants can take two to four weeks before becoming effective].
424. A 28yo man presents with rapid pounding in the chest. He is completely conscious
throughout. The ECG was taken (SVT). What is the 1st med to be used to manage this
condition?
a. Amiodarone
b. Adenosine
c. Lidocaine
d. Verapamil
e. Metoprolol
Ans. The key is B. Adenosine. [Management of SVT: i) vagal manoeuvres (carotid sinus
message, valsalva manoeuvre) transiently increase AV-block, and unmask the
underlying atrial rhythm. If unsuccessful then the first medicine used in SVT is
adenosine, which causes transient AV block and works by i) transiently slowing
ventricles to show the underlying atrial rhythm ii) cardioverting a junctional tachycardia to
sinus rhythm. OHCM].
425. A 56yo woman who is depressed after her husband died of cancer 3m ago was
given
amitryptaline. Her sleep has improved and she now wants to stop medication but she
still
speaks about her husband. How would you manage her?
a. CBT
b. Continue amitryptaline
c. Psychoanalysis
d. Bereavement counselling
e. Antipsychotic

Ans. The key is B. Continue amitriptyline. [depression is important feature of


bereavement. Patient may pass sleepless nights. As this patients sleep has improved it
indicate he has good response to antidepressant and as he still speaks about her
husband there is chance to deterioration of her depression if antidepressant is stopped.
For depressive episodes antidepressants should be continued for at least 6-9 months
351. A 35yo lady presents with painful ulcers on her vulva, what is the appropriate inv
which will lead to the dx?
a. Anti-HSV antibodies
b. Dark ground microscopy of the ulcer
c. Treponema palladium antibody test
d. Rapid plasma regain test
e. VDRL
Dx genital herpes
Ans. key A. Anti-HSV antibodies. [Genital Herpes may be asymptomatic or may remain
dormant for months or even years. When symptoms occur soon after a person is
infected, they tend to be severe. They may start as multiple small blisters that eventually
break open and produce raw, painful sores that scab and heal over within a few weeks.
The blisters and sores may be accompanied by flu-like symptoms with fever and swollen
lymph nodes.
treatment : There are three major drugs commonly used to treat genital herpes
symptoms: acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir(Valtrex). These are
all taken in PO. Severe cases may be treated with the intravenous (IV) drug acyclovir].
options B C D & E are tests for syphilis which presents with single painless ulcer
(canchre)
352. A 53yo man presents with a longstanding hx of a 1cm lesion on his arm. It has
started
bleeding on touch. What is the most likely dx?
a. Basal cell carcinoma
b. Kaposis sarcoma
c. Malignant melanoma
d. Squamous cell carcinoma
e. Kerathoacanthoma
Ans. D Squamous cell carcinoma. [SSCs Arises in squamous cells. SCCs may occur on all
areas of the body including the mucous membranes and genitals, but are most common in areas frequently
exposed to the sun, such as the rim of the ear, lower lip, face, balding scalp, neck, hands, arms and legs.

SCCs often look like scaly red patches, open sores, elevated growths with a central
depression, or warts; they may crust or bleed.
investigation: tissue sample (biopsy) will be examined under a microscope to arrive at
a diagnosis.
prognosis : Squamous cell carcinomas detected at an early stage and removed
promptly are almost always curable and cause minimal damage].
basal cell carcinoma is usually on face with inverted margins
malignant melanoma is on sun exposed parts and is dark (black colored) ulcer
353. A 47yo man with hx of IHD complains of chest pain with SOB on exertion

over the
past few days. ECG normal, Echo= increased EF and decreased septal wall thickness.
What is the most likely dx?
a. Dilated CM
b. Constrictive pericarditis
c. Amyloidosis

d. Subacute endocarditis
Ans. The key is A. Dilated CM.
points in fav: sob, palpitation, dec septal wall thinning
treatment : beta blocker, acei, diuretics
Constrictive pericarditis doesnt fits because it starts with urti has pain on lying flat which
is relieved by leaning forward
ecg shows wide spread st elevation
Amyloid deposition in the heart can cause both diastolic and systolic heart failure.
EKG changes may be present, showing low voltage and conduction abnormalities
like atrioventricular block or sinus node dysfunction. On echocardiography the
heart shows restrictive filling pattern, with normal to mildly reduced ejec fraction
354. An elderly pt who is known to have DM presents to the hospital with drowsiness,
tremors and confusion. What inv should be done to help in further management?
a. Blood sugar
b. ECG
c. Standing and lying BP
d. Fasting blood sugar
e. CT
Ans. The key is A. Blood sugar.since he is known diabetic he may have gotten
hypoglycemic d/t his meds
355. A 28yo pregnant woman with polyhydramnios and SOB comes for an anomaly scan
at 31 wks. US= absence of gastric bubble. What is the most likely dx?
a. Duodenal atresia
b. Esophageal atresia
c. Gastrochiasis
d. Exomphalos
e. Diaphragmatic hernia
Ans. The key is B. Oesophageal atresia.
This condition is visible, after about 26 weeks, on an ultrasound. On antenatal
USG, the finding of an absent or small stomach in the setting of polyhydramnios
used to be considered suspicious of esophageal atresia. However, these findings
have a low positive predictive value. The upper neck pouch sign is another sign
that helps in the antenatal diagnosis of esophageal atresia and it may be detected
soon after birth as the affected infant will be unable to swallow its own saliva.
Also, the newborn can present with gastric distention, cough, apnea, tachypnea,
and cyanosis. In many types of esophageal atresia, a feeding tube will not pass
through the esophagus.
356. A 1m boy has been brought to the ED, conscious but with cool peripheries and has
HR=222bpm. He has been irritable and feeding poorly for 24h. CXR=borderline enlarged
heart with clear lung fields. ECG=regular narrow complex tachycardia, with difficulty
identifying p wave. What is the single most appropriate immediate tx?
a. Administer fluid bolus

b. Administer oxygen
c. Oral beta-blockers
d. Synchronized DC cardio-version
e. Unilateral carotid sinus massage

The key is D. Synchrnized DC cardioversion.


reason: As the patient is in probable hemodynamic instability (suggested by cool
peripheries) so we should go for DC cardioversion.
diagnosis SVT.
357. A 7yo child presented with chronic cough and is also found to be jaundiced on
examination.
What is the most likely dx?
a. Congenital diaphragmatic hernia
b. Congenital cystic adenematoid malformation
c. Bronchiolitis
d. RDS
e. Alpha 1 antitrypsin deficiency

The key is E. Alpha 1 antitrypsin deficiency.


REASON. Unexplained liver disease with respiratory symptoms are very suggestive of
AATD.
liver disease occurs because of the accumulation AAT in it
where as d/t inability to be transported out of liver AATD causes emphysema hence the
resp problems
358. A 35yo construction worker is dx with indirect inguinal hernia. Which statement
below best
describes it?
a. Passes through the superficial inguinal ring only
b. Lies above and lateral to the pubic tubercle
c. Does not pass through the superficial inguinal ring
d. Passes through the deep inguinal ring
Ans. The key is D. Passess through the deep inguinal ring.
direct hernia passes forectly through the posterior wall of inguinal canal whereas indirect
can only do so via deep ring
359. A woman has numerous painful ulcers on her vulva. What is the cause?
a. Chlamydia
b. Trichomonas
c. Gardenella
d. HSV
e. EBV
Ans. The key is D. HSV. reason has been explained in q 351

360. A 72 yo man has been on warfarin for 2yrs because of past TIA and stroke. What is
the most important complication that we should be careful with?
a. Headache
b. Osteoporosis
c. Ear infection
d. Limb ischemia
e. Diarrhea
Ans. key is wrong
right key is A Headache, as there are chances of SAH or generally ICH
361. A 55yo man has been admitted for elective herniorraphy. Which among the
following can be the reason to delay his surgery?
a. Controlled asthma
b. Controlled atrial fib
c. DVT 2yrs ago
d. Diastolic BP 90mmHg
e. MI 2 months ago
Ans. E SAFER TO DO SURGERY AFTER 6 MONTHS
362. A 65yo known case of liver ca and metastasis presents with gastric reflux and
bloatedness. On bone exam there is osteoporosis. He also has basal consolidation in
the left lung. What is the next appropriate step?
a. PPI IV
b. Alendronate
c. IV antibiotics
d. Analgesic
e. PPI PO
IN THIS case reflux is the cause of recurrent pneumonia so both C AND E can be
right but to chose single one E is more appropriate
363. A 66yo man has the following ECG. What is the most appropriate next step in
management?
a. Metoprolol
b. Digoxin
c. Carotid sinus massage
d. Adenosine
e. Amiodarone.
Ans. A beta blocker for A FIB
364. A 22yo sexually active male came with 2d hx of fever with pain in scrotal area.
Exam: scrotal skin is red and tender. What is the most appropriate dx?
a. Torsion of testis
b. Orchitis
c. Inguinal hernia
d. Epididymo-orchitis
D Epididymo-orchitis.

In orchitis there should be fever, elevation of testes reduces pain (positive prehn sign), In
torsion testis lies at a higher level. In torsion urinalysis negative but in orchitis it is
positive. Orchitis usually occurs in sexually active man. X
365. A man on warfarin posted for hemicolectomy. As the pt is about to undergo surgery.
What
option is the best for him?
a. Continue with warfarin
b. Continue with warfarin and add heparin
c. Stop warfarin and add aspirin
d. Stop warfarin and add heparin
e. Stop warfarin
D Stop warfarin and add heparin
5 DAYS BEFORE SURGERY WARFARIN MUST BE REPLACED BY HEPARIN,
366. A 65yo known alcoholic is brought into hospital with confusion, aggressiveness and
ophthalmoplegia. He is treated with diazepoxide. What other drug would you like to
prescribe?
a. Antibiotics
b. Glucose
c. IV fluids
d. Disulfiram
e. Vit B complex
E Vitamin B complex. [confusion and ophthalmoplegia points towards the diagnosis of
Wernickes encephalopathy].
which occurs d/t thiamine def.
367. A 32yo woman has severe right sided abdominal pain radiating into the groin which
has lasted for 3h. She is writhering in pain. She has no abdominal signs. What is the
most likely cause of her abdominal pain?
a. Appendicitis
b. Ruptured ectopic pregnancy
c. Salpingitis
d. Ureteric colic
e. Strangulated hernia
D Ureteric colic.
It indicate stone at lower ureter. [i) Pain from upper ureteral stones tends to radiate to the flank and
lumbar areas. ii) Midureteral calculi cause pain that radiates anteriorly and caudally. This midureteral pain in
particular can easily mimic appendicitis on the right or acute diverticulitis on the left. iii) Distal ureteral stones
cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female.

368. A 39yo coal miner who smokes, drinks and has a fam hx of bladder cancer is
suffering from BPH. The most important risk factor for his bladder carcinoma is?
a. Fam hx
b. Smoking
c. Exposure to coal mine
d. BPH

B smoking.
. Risk factors of bladder cancer:
i) Smoking ii) Exposure to chemicals used in dye industry iii) Whites are more likely to
develop bladder cancer iv) Risk increases with age v) More common in men vi) Chronic
bladder irritation and infections (urinary infections, kidney and bladder stones, bladder
catheter left in place a long time.) vii) Personal history of bladder or other urothelial
cancer viii) Family history ix) Chemotherapy or radiotherapy x) Pioglitazone for more
than one year and certain herb xi) Arsenic in drinking water xii) Low fluid consumption.
369. A 34yo woman is referred to the endocrine clinic with a hx of thyrotoxicosis. At her
1st
appointment she is found to have a smooth goiter, lid lag and bilateral exophthalmos
with puffy
eyelids and conjunctival injection. She wants to discuss the tx of her thyroid prb as she is
keen to become pregnant. What is the most likely tx you would advise?
a. 18m of carbimazole alone
b. 18m of PTU alone
c. A combo od anti-thyroid drug and thyroxine
d. Radioactive iodine
e. Thyroidectomy

B 18m of PTU alone.


Other drug option i.e Carbamazepine is teratogenic [can cause i) spina bifida
ii)cardiovascular malformations ETC . PTU is on the other hand relatively safe in
pregnancy.
370. A child living with this stepfather is brought by the mother with multiple bruises,
fever and
fractures. What do you suspect?
a. NAI
b. Malnutrition
c. Thrombocytopenia
d. HIV
Ans. The key is A. NAI. [H/O living with stepfather, multiple bruises, fever and fractures
are suggestive of NAI]. OTHER possible points can include hx not matching with
bruises, wounds which are a day or two older at the time of presentation.
371. A young man who was held by the police was punched while in custody. He is now
cyanosed and unresponsive. What is the 1st thing you would do?
a. IV fluids
b. Clear airway
c. Turn pt and put in recovery position
d. Give 100% oxygen
e. Intubate and ventilate
B. Clear airway. [ABC protocol].

372. A HTN male loses vision in his left eye. The eye shows hand movement and a light
shined in the eye is seen as a faint light. Fundus exam: flame shaped hemorrhages. The
right eye is normal. What is the cause of this pts unilateral blindness?
a. HTN retinopathy
b. CRA thrombosis
c. CRV thrombosis
d. Background retinopathy
e. Retinal detachment
key is wrong
right ans is C ( unilateral blindness with flameshaped hemorrhages are
characteristic of CRVO)
373. A mentally retarded child puts a green pea in his ear while eating. The carer
confirms this.
Otoscopy shows a green colored object in the ear canal. What is the most appropriate
single
best approach to remove this object?
a. By magnet
b. Syringing
c. Under GA
d. By hook
e. By instilling olive oil
C UNDER GA
since child is retard, if he wasnt then the ans would be D
olive oil is for insects
374. A pt presents with longstanding gastric reflux, dysphagia and chest pain. On barium
enema, dilation of esophagus with tapering end is noted. He was found with Barretts
esophagus. He had progressive dysphagia to solids and then liquids. What is the single
most appropriate dx?
a. Achalasia
b. Esophageal spasm
c. GERD
d. Barretts esophagus
e. Esophageal carcinoma
E Oesophageal carcinoma. [there is dilatation in oesophagus which is seen both in
achalasia and carcinoma. Dysphagia to solid initaially is very much suggestive of
carcinoma and also barretts change is a clue to carcinoma]
Progressive dysphagia with h/o barrett esophagus are the key indicators
375. A 48yo lady presents with itching, excoriations, redness, bloody discharge and
ulceration around her nipple. What is the most likely dx?
a. Pagets disease of the breast
b. Fibrocystic dysplasia
c. Breast abscess
d. Duct papilloma
e. Eczema

A Pagets disease of the breast.


TYPICAL manifestation of pagets disease
eczema like rash involving nipple and areola with straw or bloody discharge
Also nipple turns inward in advances stages pt complaints of burning sensation at the
site of lesion
DX mammography and biopsy
TX surgery + chemo or radio may be needed
376. Pt with widespread ovarian carcinoma has bowel obstruction and severe colic for
2h and was normal in between severe pain for a few hours. What is the most appropriate
management?
a. PCA (morphine)
b. Spasmolytics
c. Palliative colostomy
d. Oral morphine
e. Laxatives
C. Palliative colostomy.
Cancer or chemotherapy induced obstructions are unlikely to respond to conservative
management [NBM, IV fluid, nasogastric suction] and hence only analgesia will not
relieve it. So in such cases we have to go for palliative colostomy.
377. A 70yo man admits to asbestos exposure 20yrs ago and has attempted to quit
smoking. He has noted weight loss and hoarseness of voice. Choose the single most
likely type of cancer a.w risk
factors present.
a. Basal cell carcinoma
b. Bronchial carcinoma
c. Esophageal carcinoma
d. Nasopharyngeal carcinoma
e. Oral carcinoma

B. Bronchial carcinoma. [Asbestos exposure is a risk factor for lung cancer


and also has a synergistic effect with cigarette smoke].
#. Conditions related to asbestos exposure: i) Pleural plaques (after a latent period of
20-40 yrs) ii) Pleural thickening iii) Asbestosis (latent period is typically 15-30 yrs) iv)
Mesothelioma (prognosis is very poor) v) Lung cancer.
378. A 32yo woman had progressive decrease in vision over 3yrs. She is no dx as
almost blind. What would be the mechanism?
a. Cataract
b. Glaucoma
c. Retinopathy
d. Uveitis
e. Keratitis

B. Glaucoma.

. Cataract is unlikely at this age. Nothing in the history suggests retinopathy. Uveitis and
iritis doesnt have such degree of vision loss and iritis and anterior uveitis have pain,
redness and photophobia. Open angle glaucoma is likely cause.
379. A child during operation and immediately after showed glycosuria, but later his
urine sugar was normal. Choose the most probable dx.
a. Pre-diabetic state
b. Normal finding
c. Low renal tubular threshold
d. DM
B Normal finding.
Stress during operation can cause transient hyperglycemia causing glycosuria
secondary to stress induced rise of cortisole which becomes normal after some time.
380. A pt presented with hx of swelling in the region of the sub-mandibular region, which
became
more prominent and painful on chewing. He also gave hx of sour taste in the mouth, the
area is
tender on palpation. Choose the most probable dx?
a. Chronic recurrent sialadenitis
b. Adenolymphoma
c. Mikuliczs disease
d. Adenoid cystic carcinoma
e. Sub-mandibular abscess
A Chronic recurrent sialadenitis. [pain, swelling, more pain on chewing, tenderness, and
submandibular region suggests diagnosis of submandibular chronic recurrent
sialadenitis, usually secondary to sialolithiasis or stricture].
381. ECG of an 80yo pt of ICH shows saw-tooth like waves, QRS complex of 80ms
duration,
ventricular rate=150/min and regular R-R interval. What is the most porbable dx?
a. Atrial fib
b. Atrial flutter
c. SVT
d. Mobitz type1 second degree heart block
e. Sinus tachycardia
B Atrial flutter. [Saw-tooth like waves, normal QRS comples of 80 ms (normal range 70100 ms), ventricular rate of 150/min and regular R-R interval is diagnostic of atrial
flutter].
FOR AFIB THERE WD BE IRREGULARARLY IRREGULAR RHYTHM
382. A 50 yo woman who was treated for breast cancer 3 yrs ago now presents with
increase thirst and confusion. She has become drowsy now. What is the most likely
metabolic abnormality?
a. Hypercalcemia
b. Hyperkalemia
c. Hypoglycemia
d. Hyperglycemia
e. Hypercalcemia.
E HYPERCALCEMIA

Ans. 2. Increased thirst, confusion, drowsiness these are features of hypercalcemia. Any
solid organ tumour can produce hypercalcemia. Here treated Ca breast is the probable
cause of hypercalcemia.
383. A 29yo woman presents to her GP with a hx of weight loss, heat intolerance, poor
conc and
palpitations. Which of the following is most likely to be a/w dx of thyroiditis a/w viral
infection?
a. Bilateral exophthalmos
b. Diffuse, smooth goiter
c. Reduced uptake on thyroid isotope scan
d. Positive thyroid peroxidase antibodies
e. Pretibial myxedema
C. Reduced uptake on thyroid isotope scan.
DX De Quervains or subacute thyroiditis.
. Viral or subacute thyroiditis: diagnostic criteria: i) Features of hyperthyroidism present.
ii) Pain thyroid, not mentioned. iii) Investigations: high esr (60-100) not mentioned,
Reduced uptake of radioactive iodine by the gland.
384. A lady, post-colostomy closure after 4days comes with fluctuating small swelling in
the stoma.
What is the management option for her?
a. Local exploration
b. Exploratory laparotomy
c. Open laparotomy
d. Reassure
A Local exploration.
THERE MUST BE SOME LOCAL WOUND PROBLEM
385. A 65yo female pt was given tamoxifen, which of the following side effect caused by
it will
concern you?
a. Fluid retention
b. Vaginal bleeding
c. Loss of apetite
d. Headache and dizziness
e.
B Vaginal bleeding.
. Tamoxifen can promote development of endometrial carcinoma. So vaginal bleeding
will be of concern for us.
386. A 39yo man with acute renal failure presents with palpitations. His ECG shows tall
tented T
waves and wide QRS complex. What is the next best step?
a. Dialysis
b. IV calcium chloride
c. IV insulin w/ dextrose
d. Calcium resonium
e. Nebulized salbutamol

B. IV calcium chloride (both IV calcium gluconate or IV calcium chloride can be used)


when there is ECG changes.
DX The ECG changes are suggestive of Hyperkalemia.
At potassium level of >5.5mEq/L occurs tall tented T waves and at potassium level
>7mEq/L occurs wide QRS complex with bizarre QRS morphology.
387. A 54yo pt 7 days after a total hip replacement presents with acute onset
breathlessness and
raised JVP. Which of the following inv will be most helpful in leading to a dx?
a. CXR
b. CTPA
c. V/Q scan
d. D-Dimer
e. Doppler US of legs

The key is B. CTPA.


The patient has a +ve two level PE Wells score (if it was negative we should do DDimer) and there is no renal impairment or history suggestive of allergy to contrast
media (if these present we should have go for VQ scan) the investigation of choice is
PTCA. NICE guideline.
388. A 7yo girl has been treated with penicillin after sore throat, fever and cough. Then
she
develops skin rash and itching. What is the most probable dx?
a. Erythema nodosum
b. Erythema multiforme
c. SJS
d. Erythema marginatum
e. Erythema gangernosum

. The key is B. Erythema multiforme.


Common drugs causing erythma multiforme are: antibiotics (including, sulphonamides,
penicillin), anticonvulsants (phenytoin,barbiturates), aspirin, antituberculoids, and allopurinol.
CLOSELY related option is SJS which would have muco cutaneous rash but in here we hav only
cutaneous rash

389. A 60yo man presented with a lump in the left supraclavicular region. His appetite is
decreased and he has lost 5kg recently. What is the most probably dx?
a. Thyroid carcinoma
b. Stomach carcinoma
c. Bronchial carcinoma
d. Mesothelioma
e. Laryngeal carcinoma
The key is B. Stomach carcinoma. [Mentioned lump in the left supraclavicular region is
Vershows gland, has long been regarded as strongly indicative of the presence of cancer in the
abdomen, specifically gastric cancer].

390. A 64yo man has presented to the ED with a stroke. CT shows no hemorrhage.
ECG shows atrial fib. He has been thrombolysed and hes awaiting discharge. What
prophylactic regimen is best for him?
a. Warfarin
b. Heparin
c. Aspirin
d. Statins
e. Beta blockers
The key is A. Warfarine. [Atrial fibrillation: post stroke- following a stroke or TIA warfarine
should be given as the anticoagulant of choice. NICE guideline].
391. A 54yo man after a CVA presents with ataxia, intention tremors and slurred speech.
Which part of the brain has been affected by the stroke?
a. Inner ear
b. Brain stem
c. Diencephalon
d. Cerebrum
e. Cerebellum
The key is E. Cerebellum.
i) Ataxia ii) slurred speech or dysarthria iii) dysdiodokokinesis iv) intention tremor v)
nystagmus. are the signs of cerebellar defect
292. A 57yo man with blood group A complains of symptoms of vomiting, tiredness,
weight loss and palpitations. Exam: hepatomegaly, ascites, palpable left supraclavicular
mass. What is the most likely dx?
a. Gastric carcinoma
b. Colorectal carcinoma
c. Peptic ulcer disease
d. Atrophic gastritic
e. Krukenburg tumor
Ans. The key is A. Gastric carcinoma. [i) blood group A is associated with gastric cancer
ii) vomiting, tiredness, weight loss are general features of gastric cancer iii) palpitation
from anemia of cancer iv) hepatomegaly and ascites are late features of gastric cancer.
v) palpable left supraclavicular mass- is Vershows gland, has long been regarded as
strongly indicative of gastric cancer].
293. A 21yo girl looking unkempt, agitated, malnourished and nervous came to the
hospital asking
for painkillers for her abdominal pain. She is sweating, shivering and complains of joint
pain.
What can be the substance misuse here?
a. Alcohol
b. Heroin
c. Cocaine
d. LSD
e. Ecstasy

The key is B. Heroin. [agitation, nervousness, abdominal cramp, sweating, shivering and
piloerection, arthralgia these are features of heroin withdrawal].
394. A child presents with increasing jaundice and pale stools. Choose the most
appropriate test?
a. US abdomen
b. Sweat test
c. TFT
d. LFT
e. Endomyseal antibodies
The key is A. US abdomen. [This is a picture suggestive of obstructive jaundice. LFT can
give clue like much raised bilirubin, AST and ALT not that high and raised alkaline
phosphatase but still USG is diagnostic in case of obstructive jaundice].
395. A 32yo man presents with hearing loss. AC>BC in the right ear after Rhine test. He
also
complains of tinnitus, vertigo and numbness on same half of his face. What is the most
appropriate inv for his condition?
a. Audiometry
b. CT
c. MRI
d. Tympanometry
e. Webers test
The key is C. MRI. [features are suggestive of acaustic neuroma, so MRI is the preferred
option]. it involves basically 8th nerve but 6 7 9 and 10th nerves are also involved with it
396. A 56 yo lady with lung cancer presents with urinary retention, postural hypotension,
diminished reflexes and sluggish pupillary reaction. What is the most likely explanation
for her symptoms?
a. Paraneoplastic syndrome
b. Progression of lung cancer
c. Brain metastasis
d. Hyponatremia
e. Spinal cord compression
The key is A. Paraneoplastic syndrome.
s/s are of autonomic neuropathy which occurs in paraneoplastic syndrome
397. An old woman having decreased vision cant see properly at night. She has
changed her glasses quite a few times but to no effect. She has normal pupil and
cornea. What is the most likely dx?
a. Cataract
b. Glaucoma
c. Retinal detachment
d. Iritis
e. GCA
key is wrong
correct key is A cataract

old age and progressive weakness supports Cataract


398. A pt comes with sudden loss of vision. On fundoscopy the optic disc is normal.
What is the
underlying pathology?
a. Iritis
b. Glaucoma
c. Vitreous chamber
d. Retinal detachment

Ans. 1. The Key is D. Retinal detachment.


#Causes of sudden painless loss of vision:
1.
2.
3.
4.
5.
6.

Retinal detachment
Vitreous haemorrhage
Retinal vein occlusion
Retinal artery occlusion
Optic neuritis
Cerebrovascular accident

remember retinal detachment has vision loss as if curtain is coming down


399. A child was woken up from sleep with severe pain in the testis. Exam: tenderness
on palpation and only one testis was normal in size and position. What would be your
next step?
a. Analgesia
b. Antibiotics
c. Refer urgently to a surgeon
d. Reassurance
e. Discharge with analgesics
Ans. The key is A. Analgesia. [According to some US sites it is analgesia but no UK site
support this!!! So for Plab exam the more acceptable option is C. Refer urgently to a
surgeon].
IN TORSION THE SOONER THE SURGICAL INTERVENTION DONE, THE BETTER
THE RESULTS ARE
400. A child suffering from asthma presents with Temp 39C, drooling saliva on to the
mothers lap,
and taking oxygen by mask. What sign will indicate that he is deteriorating?
a. Intercostal recession
b. Diffuse wheeze
drooling means the age is less than 3, so drowsiness is ruled out because of the age of the baby
c. Drowsiness
The key is A. Intercostal recession. [ here intercostals recession and drowsiness both
answers are correct. Hope in exam there will be one correct option]. but to chose
among them, better go with A
401. A 12yo boy presents with painful swollen knew after a sudden fall. Which bursa is
most likely tobe affected?
a. Semimembranous bursa
b. Prepatellar bursa

c. Pretibial bursa
d. Suprapatetaller bursa
. The key is B. Prepatellar bursa. [A fall onto the knee can damage the prepatellar bursa. This
usually causes bleeding into the bursa sac causing swellen painful knee. Prepatellar bursitis that is caused
by an injury will usually go away on its own. The body will absorb the blood in the bursa over several weeks,
and the bursa should return to normal. If swelling in the bursa is causing a slow recovery, a needle may be
inserted to drain the blood and speed up the process. There is a slight risk of infection in putting a needle
into the bursa].
402. A

61yo man has been referred to the OPD with frequent episodes of breathlessness
and chest pain a/w palpitations. He has a regular pulse rate=60bpm. ECG=sinus rhythm.
What is the
most appropriate inv to be done?
a. Cardiac enzymes
b. CXR
c. ECG
d. Echo
e. 24h ECG
The key is E. 24h ECG.
Indications of 24 h ambulatory holter monitoring:

To evaluate chest pain not reproduced with exercise testing

To evaluate other signs and symptoms that may be heart-related, such as fatigue,
shortness of breath, dizziness, or fainting

To identify arrhythmias or palpitations

To assess risk for future heart-related events in certain conditions, such as idiopathic
hypertrophic cardiomyopathy, post-heart attack with weakness of the left side of the
heart, or Wolff-Parkinson-White syndrome

To assess the function of an implanted pacemaker

To determine the effectiveness of therapy for complex arrhythmias

403. A woman dx with Ca Breast presents now with urinary freq. which part of the brain
is the
metastasis spread to?
a. Brain stem
b. Pons
c. Medulla
d. Diencephalon
e. Cerebral cortex
The key is D. Diencephalon. [diencephalon is made up of four distinct components: i) the
thalamus ii) the subthalamus iii) the hypothalamus and iv) the epithalamus. Among these
the hypothalamus has crucial role in causing urinary frequency].

404. A man is very depressed and miserable after his wifes death. He sees no point in
living now that his wife is not around and apologises for his existence. He refuses any
help offered. His son has brought him to the ED. The son can.t deal with the father any
more. What is the most
appropriate next step?
a. Voluntary admission to psychiatry ward
b. Compulsory admission under MHA
c. Refer to social services
d. Alternate housing
e. ECT
Ans. The key is B. Compulsory admission under MHA. [This patient is refusing any help
offered! And his son cannot deal with him anymore! In this situation voluntary admission
to psychiatry ward is not possible and the option of choice is compulsory admission
under MHA].
405. A 31yo man has epistaxis 10 days following polypectomy. What is the most likely
dx?
a. Nasal infection
b. Coagulation disorder
c. Carcinoma
The key is A. Nasal infection.
HEMORRHAGE AFTER 5 TO 7 DAYS IS SECONDARY HEMORRHAGE [Infection is
one of the most important cause of secondary hemorrhage].
406. A woman had an MI. She was breathless and is put on oxygen mask and GTN, her
chest
pain has improved. Her HR=40bpm. ECG shows ST elevation in leads I, II, III. What is
your next step?
a. LMWH
b. Streptokinase
c. Angiography
d. Continue current management
e. None

Ans. The key is B. Streptokinase


algorithm for st elevation MI
angioplasty/thrombolysis
b blocker
acei
clopidogrel
407. A 67yo male presents with polyuria and nocturia. His BMI=33, urine culture =
negative for
nitrates. What is the next dx inv?
a. PSA
b. Urea, creat and electrolytes
c. MSU culture and sensitivity
d. Acid fast urine test
e. Blood sugar

The key is E. Blood sugar. [Age at presentation and class1 obesity favours the diagnosis
of type2 DM].
since culture is -ve for nitrates, so uti is ruled out
408. A pt from Africa comes with nodular patch on the shin which is reddish brown. What
is the
most probable dx?
a. Lupus vulgaris
b. Erythema nodosum
c. Pyoderma gangrenosum
d. Erythema marginatum
e. Solar keratosis
The key is B. Erythema nodosum. [Causes of erythema nodosum: MOST COMMON
CAUSES- i) streptococcal infection ii) sarcoidosis. Other causes- tuberculosis,
mycoplasma pneumonia, infectious mononucleosis, drugs- sulfa related drug, OCP,
oestrogen; Behcets disease, CD, UC; lymphoma, leukemia and some others].
#Nodes are mostly on anterior aspect of shin
409. A 29yo lady came to the ED with complaints of palpitations that have been there for
the past 4 days and also feeling warmer than usual. Exam: HR=154bpm, irregular
rhythm. What is the tx for her condition?
a. Amiadarone
b. Beta blockers
c. Adenosine
d. Verapamil
e. Flecainide
The key is B. Beta blockers [the probable arrhythymia is AF secondary to
thyrotoxicosis(heat intolerance). So to rapid control the symptoms of thyrotoxicosis Beta
blocker should be used].
410. A T2DM is undergoing a gastric surgery. What is the most appropriate pre-op
management?
a. Start him in IV insulin and glucose and K+ just before surgery
b. Stop his oral hypoglycemic on the day of the procesure
c. Continue regular oral hypoglycemic
d. Stop oral hypoglycemic the prv night and start IV insulin with glucose and K+ before
surgery
e. Change to short acting oral hypoglycemic
The key is D. Stop oral hypoglycemic the prv night and start IV insulin with glucose and
K+ before surgery.
411. A 19yo boy is brought by his mother with complaint of lack of interest and no social
interactions. He has no friends, he doesnt talk much, his only interest is in collecting
cars/vehicles having around 2000 toy cars. What is the most appropriate dx?
a. Borderline personality disorder
b. Depression
c. Schizoaffective disorder

d. Autistic spectrum disorder


The key is D. Autistic spectrum disorder.
Autism spectrum disorders affect three different areas of a child's life:
Social interaction
Communication -- both verbal and nonverbal
Behaviors and interests
In some children, a loss of language is the major impairment. In others, unusual
behaviors (like spending hours lining up toys) seem to be the dominant factors.
412. A 45yo man who is diabetic and HTN but poorly compliant has chronic SOB,
develops severe SOB and chest pain. Pain is sharp, increased by breathing and
relieved by sitting forward. What is the single most appropriate dx?
a. MI
b. Pericarditis
c. Lung cancer
d. Good pastures syndrome
e. Progressive massive fibrosis
The key is B. Pericarditis. [Nature of pain i.e. sharp pain increased by breathing and
relieved by sitting forward is suggestive of pericarditis].
Nature of pericardial pain: the most common symptom is sharp, stabbing chest pain
behind the sternum or in the left side of your chest. However, some people with acute
pericarditis describe their chest pain as dull, achy or pressure-like instead, and of
varying intensity.

The pain of acute pericarditis may radiate to your left shoulder and neck. It often
intensifies when you cough, lie down or inhale deeply. Sitting up and leaning forward can
often ease the pain.
Ecg widespread st elevation
Tx: ansaid
413. A 6m boy has been brought to ED following an apneic episode at home. He is now
completely well but his parents are anxious as his cousin died of SIDS at a similar age.
The parents ask for guidance on BLS for a baby of his age. What is the single most
recommended technique for cardiac compressions?
a. All fingers of both hands
b. All fingers of one hand
c. Heel of one hand
d. Heel of both hand
e. Index and middle fingertips of one hand
The key is E. Index and middle fingertips of one hand.
414. A 70yo man had a right hemicolectomy for ceacal carcinoma 6days ago. He now
has abdominal distension and recurrent vomiting. He has not opened his bowels since
surgery. There are no bowel sounds. WBC=9, Temp=37.3C. What is the single most
appropriate next management?
a. Antibiotic therapy IV
b. Glycerine suppository
c. Laparotomy
d. NG tube suction and IV fluids
e. TPN

1.
2.
3.
4.

1.
2.

The key is D. NG tube suction and IV fluids. [The patient has developed paralytic ileus
which should be treated conservatively].
s/s of paralytic ileus
diffuse abd pain
constipation
abd distension
nausea vomitis may contain bile
INV : abd x ray errect+ serum electrolytes
TX : conservative
npo
ng +iv fluids
215. A 60yo man with a 4y hx of thirst, urinary freq and weight loss presents with a deep
painless
ulcer on the heel. What is the most appropriate inv?
a. Ateriography
b. Venography
c. Blood sugar
d. Biopsy for malignant melanoma
e. Biopsy for pyoderma
The key is C. Blood sugar. [The patient probably developed diabetic foot].
the next step wd be doppler scan to assess the vascular status
416. A 16yo boy presents with rash on his buttocks and extensor surface following a
sore throat.
What is the most probable dx?
a. Measles
b. Bullous-pemphigoig
c. Rubella
d. ITP
e. HSP
its a wrong key
right ans is E
# In HSP rash typically found in buttocks, legs and feets and may also appear on the
arms, face and trunk.
in ITP it mostly occurs in lower legs. #HSP usually follow a sorethroat and ITP follow
viral infection like flue or URTI.
# HSP is a vasculitis while ITP is deficiency of platelets from more destruction in spleen
which is immune mediated].
417. A 34yo man with a white patch on the margin of the mid-third of the tongue. Which
is the single most appropriate LN involved?
a. External iliac LN
b. Pre-aortic LN
c. Aortic LN
d. Inguinal LN
e. Iliac LN
f. Submental LN

g. Submandibular LN
h. Deep cervical LN
The key is G. Submandibular LN.
418. A 50yo lady presents to ED with sudden severe chest pain radiating to both
shoulder and
accompanying SOB. Exam: cold peripheries and paraparesis. What is the single most
appropriate
dx?
a. MI
b. Aortic dissection
c. Pulmonary embolism
d. Good pastures syndrome
e. Motor neuron disease
The key is B. Aortic dissection. [Usual management for type A dissection is surgery and
for type B is conservative].
STANFORD CLASSIFICATION
1. TYPE A : INVOLVING ASCENDING AORTA
2. TYPE B: DOESNOT INVOLVE ASCENDING AORTA
419. A 54yo myopic develops flashes of light and then sudden loss of vision. That is the
single most appropriate tx?
a. Pan retinal photo coagulation
b. Peripheral iridectomy
c. Scleral buckling
d. Spectacles
e. Surgical extraction of lens
The key is C. Scleral buckling.
DX: RETINAL DETACHMENT
420. A 40yo chronic alcoholic who lives alone, brought in the ED having been found
confused at
home after a fall. He complains of a headache and gradually worsening confusion. What
is the
most likely dx?
a. Head injury
b. Hypoglycemia
c. Extradural hematoma
d. Subdural hematoma
e. Delirium
The key is D. Subdural hematoma. [subdural hematoma may be acute or chronic. In
chronic symptoms may not be apparent for several days or weeks. Symptoms of
subdural hematomas are: fluctuating level of consciousness, insidious physical or
intellectual slowing, sleepiness, headache, personality change and unsteadiness.
TX: SURGERY e.g. via barr twist drill and barr hole craniostomy 1 line. Craniotomy if
the clot organized 2 line].
MOST COMMON IN OLD PEOPLE AND DRUNKS WITH H/O FREQUENT FALLS
st

nd

421. A 54yo man with alcohol dependence has tremor and sweating 3days into a hosp
admission for a fx femur. He is apprehensive and fearful. What is the single most
appropriate tx?
a. Acamprossate
b. Chlordiazepoxide
c. Lorazepam
d. Lofexidine
e. Procyclidine
Ans. The key is B. Chlordiazepoxide. [This is a case of alcohol withdrawal syndrome.
Chlordiazepoxide when used in alcohol withdrawal it is important not to drink alcohol
while taking Chlordiazepoxide.
Chlordiazepoxide should only be used at the lowest possible dose and for a maximum of
up to four weeks. This will reduce the risks of developing tolerance, dependence and
withdrawal].
422. A 5yo child complains of sore throat and earache. He is pyrexial. Exam: tonsils
enlarged and
hyperemic, exudes pus when pressed upon. What is the single most relevant dx?
a. IM
b. Acute follicular tonsillitis
c. Scarlet fever
d. Agranulocytosis
e. Acute OM

Ans. The key is B. Acute follicular tonsillitis. [Tonsillitis is usually caused by a viral
infection or, less commonly, a bacterial infection. The given case is a bacterial
tonsillitis (probably caused by group A streptococcus). There are four main signs
that tonsillitis is caused by a bacterial infection rather than a viral infection. They are:
a high temperature
white pus-filled spots on the tonsils
no cough
swollen and tender lymph nodes (glands).
423. A man with a fam hx of panic disorder is brought to the hosp with palpitations,
tremors,
sweating and muscles tightness on 3 occasions in the last 6 wks. He doesnt complain of
headache and his BP is WNL. What is the single most appropriate long-term tx for him?
a. Diazepam
b. Olanzapine
c. Haloperidol
d. Fluoxetine
e. Alprazolam
Ans. The key is D. Fluoxetine. [Recommended treatment for panic disorder is i) CBT ii)
Medication (SSRIs or TCA). NICE recommends a total of seven to 14 hours of CBT to
be completed within a four month period. Treatment will usually involve having a weekly
one to two hour session. When drug is prescribed usually a SSRI is preferred.
Antidepressants can take two to four weeks before becoming effective].

424. A 28yo man presents with rapid pounding in the chest. He is completely conscious
throughout. The ECG was taken (SVT). What is the 1st med to be used to manage this
condition?
a. Amiodarone
b. Adenosine
c. Lidocaine
d. Verapamil
e. Metoprolol
Ans. The key is B. Adenosine. [Management of SVT: i) vagal manoeuvres (carotid sinus
message, valsalva manoeuvre) transiently increase AV-block, and unmask the
underlying atrial rhythm. If unsuccessful then the first medicine used in SVT is
adenosine, which causes transient AV block and works by i) transiently slowing
ventricles to show the underlying atrial rhythm ii) cardioverting a junctional tachycardia to
sinus rhythm. OHCM].
425. A 56yo woman who is depressed after her husband died of cancer 3m ago was
given
amitryptaline. Her sleep has improved and she now wants to stop medication but she
still
speaks about her husband. How would you manage her?
a. CBT
b. Continue amitryptaline
c. Psychoanalysis
d. Bereavement counselling
e. Antipsychotic
Ans. The key is B. Continue amitriptyline. [depression is important feature of
bereavement. Patient may pass sleepless nights. As this patients sleep has improved it
indicate he has good response to antidepressant and as he still speaks about her
husband there is chance to deterioration of her depression if antidepressant is stopped.
For depressive episodes antidepressants should be continued for at least 6-9 months

426. A 64yo man presents with a hx of left sided hemiparesis and slurred
speech. He was absolutely fine 6h after the episode. What is the most
appropriate prophylactic regimen?
a. Aspirin 300mg for 2 weeks followed by aspirin 75mg
b. Aspirin 300mg for 2 weeks followed by aspirin 75mg and dipyridamole
200mg
c. Clopidogrel 75mg
d. Dipyridamole 200mg
e. Aspirin 300mg for 2 weeks
KEY- B
Dx- TIA.
What is TIA?

Inadequate circulation in part of the brain, gives a picture similar to stroke


but duration < 24 hours.
Common in old age. Men > women. ^ in black race.
Important risk factors- HTN, smoking, DM, Hyperlipidemia, Heart
disease. Management is by: Antiplatelets, anti HTN, lipid modifying ttt, AF
ttt and any risk factors like DM.
Treatment: Aspirin + dypiridamole (each as 300mg loading then 75mg
daily) + statin. [NICE guidelines]
427. A 63yo lady with a BMI=32 comes to the ED with complaints of
pigmentation on her legs. Exam: dilated veins could be seen on the lateral
side of her ankle. Which of the following is involved?
a. Short saphenous vein
b. Long saphenous vein
c. Deep venous system
d. Popliteal veins
e. Saphano-femoral junction
KEY- A
Short saphenous vein- lateral side
Long saphenous vein- medial side
*Long saphenous vein is the vessel of choice used for autotransplantation in
coronary artery bypass. It is also a common site for varicose vein formation.

428. A 55yo man presents with hx of weight loss and tenesmus. He is dx


with rectal carcinoma. Which risk factors help to develop rectal carcinoma
except following?
a. Smoking
b. Family hx
c. Polyp
d. Prv carcinoma
e. High fat diet
f.
High fibre diet
KEY- F
All options except High fiber diet are risk factors for developing rectal
carcinoma.
*Other risk factors for Rectal Carcinoma are:
-IBD
-Nulliparity and early menopause
-Diet rich in meat and fat, poor in folate and Calcium
-Sedentary lifestyle, obesity, smoking and high alcohol intake.
-Diabetes
-Radiation and asbestos exposure

429. A pt presents with a painful, sticky red eye with a congested


conjunctiva. What is the most suitable tx?
a. Antibiotic PO
b. Antihistamine PO
c. Antibiotic drops
d. Steroid drops
e. IBS
KEY- C
Dx- Bacterial Conjunctivitis.
Painful eye, usually bilateral. Smearing of vision on waking up.
Mild photophobia. If severe, indicates corneal involvement or adenoviral
conjunctivitis.
Thick yellowish-white mucopurulent discharge. Visual acuity is normal
Symptoms- Red eye, difficult to open in the morning, glued together by
discharge. Presence of follicles on the conjunctiva- More likely viral
conjunctivitis.

Treatment:
Topical broad spectrum antibiotics. Drug of choice is chloramphenicol
drops. If pregnant, intolerant to chloramphenicol or history of aplastic
anemia or blood dyscrasia, use fusidic acid.
430. A 45yo woman complains of pain in her hands precipitated by
exposure to the cold weather. She is breathlessness on walking. When she is
eating, she can feel food suddenly sticking to the gullet. It seems to be in the

middle of the esophagus but she cant localize exactly where it sticks. It is
usually relieved with a drink of water. Choose the single most likely cause
of dysphagia from the options?
a. Esophageal carcinoma
b. Systemic sclerosis
c. SLE
d. Pharyngeal carcinoma
e. Globus hystericus
KEY-B
We can rule out option A and D simply because she presents with systemic
complaints, and these two will cause only local signs.
*Globus hystericus is when a patient feels like they have a lump in their
throat, when infact they dont. Examination is completely normal.
*This leaves SLE and systemic sclerosis. In SLE, there is the condition
mentioned in this question (Raynauds phenomenon) but NO DYSPHAGIA.
->Systemic sclerosis (SS) is classified into 2 types- Limited cutaneous SS
(70%) and Diffuse cutaneous SS (30%) according to extent of skin
involvement.
-Limited SS formerly called CREST syndrome
Calcinosis
Raynauds phenomenon- cardinal sign, early and very common presentation.
Esophageal dysmotility
Sclerodactyly
Telangiectasia
431. A 3yo child brought to the ED with a swelling over the left arm. XR
shows multiple callus formation in the ribs. Exam: bruises on child's back.
What is the most appropriate next step?
a. Check child protection register
b. Coagulation profile
c. Skeletal survey
d. Serum calcium
e. DEXA scan
KEY- C
Dx- This is a case of Non accidental injury (NAI) i.e. child abuse.
*The clinchers are the multiple calluses in the ribs and the bruises on the
childs back, denoting repeated trauma. The injuries are often multiple,
frequent or of different ages. Abusers almost always go to the ED and not

their family GP since the chances of meeting the same ER doctor twice is
less, hence the chance of someone detecting the abuse is less.
*Initial investigations include FBC, clotting screen, skeletal survey (X-ray
series to detect any other injuries), brain imaging and retinal exam if there is
head injury, and sexual health test. Next, check child protection register.
*Other options:
-Checking child protection register is not done until confirmation or
suspicion is made (not initial step).
-Serum calcium has no benefit here (serum sodium is sometimes checked if
Salt poisoning is suspected)
-DEXA scan has no role here since it is used for diagnosis and follow up of
osteoporosis.
432. A 35yo woman has had bruising and petechiae for a week. She has
also had recent menorrhagia but is otherwise well. Blood: Hgb=11.1,
WBC=6.3, Plt=14. What is the single most likely dx?
a. Acute leukemia
b. Aplastic anemia
c. HIV infection
d. ITP
e. SLE
KEY- D
*Patient only presents with petechiae and menorrhagia, but is othwerwise
well. Hence all other options are unlikely. Also aplastic anaemia will result
in pancytopenia, but WBCs and Hb is normal here.
*What is ITP? Immune thrombocytopenic purpura.
-Autoimmune, destruction or decreased reduction of platelets. Hence
decreased platelets.
-Classified into primary (isolated) or secondary (in association with other
disease).
>Secondary ITP causes:
_Autoimmune disorders (Antiphospholipid AB syndrome, SLE)
_Viral ( CMV, VZ, HepC, HIV)<-- Most common in children at around 6
years.
_H.pylori
_Drugs
>Presentation:Petichae, epistaxis, hematuria or menorrhagia. Rarely intracranial bleeds.
>Investigations:

FBC, peripheral blood smear. Screen for HIV, HepC and other underlying
cause.
>Treatment:
-Only if symptomatic.
-Avoid NSAIDs and aspirin.
-First line tt is Prednisolone for 3 weeks, then taper off, IVIG and give IV
anti-D in Rh +ve and non-splenectomised people.
-Second line Splenectomy. Complications- infection, bleeding, thrombosis,
relapse.
-Refractory ITP- Romiplostim and Eltrombopag (thrombopoetin receptor
agonists)
433. A 30yo man complains of episodes of hearing music and sometimes
threatening voices within a couple of hours of heavy drinking. What is the
most likely dx?
a. Delirium tremens
b. Wernickes encephalopathy
c. Korsakoffs psychosis
d. Alcohol hallucinosis
e. Temporal lobe dysfunction
KEY- D
*Alcohol withdrawal presents in the following stages:
-Minor withdrawal symptoms- [Appear 6-12 hours after alcohol has
stopped.] Insomnia, tremors, mild anxiety, mild agitation or restlessness,
nausea, vomiting, headache, excessive sweating, palpitations, anorexia,
depression and craving.
-Alcohol hallucinosis- Visual, auditory or tactile hallucinations that can
occur either during acute intoxication or withdrawal. During withdrawal,
they [occur 12-24 hours after alcohol has stopped.]
-Withdrawal seizures are generalized tonic-clonic seizures that [appear 2448 hours after alcohol has stopped.]
-Delirium tremens appears [48-72 hours after alcohol has stopped]. Altered
mental status in the form of confusion, delusions, severe agitation and
hallucinations. Seizures can occur. Examination might reveal stigmata of
chronic alcoholic liver disease.
>Investigation: FBC, LFTs, clotting, ABG to look for metabolic acidosis,
Glucose, blood alcohol levels, U&E, creatinine, amylase, CPK and blood

culture. CXR to check for aspiration pneumonia. CT scan if seizures or


evidence of head trauma. ECG-arrhythmia.
>Management of alcohol withdrawal-ABC
-Treat hypoglycemia
-Sedation: Benzodiazepine (chlordiazepoxide). Alternative- diazepam.
-Carbamezapine or Mg if history of withdrawal seizures.
-IV Thiamine to prevent or treat Wernickes encephalopathy that might lead
to korsakoff syndrome.
*Wernickes encephalopathy- Triad of ataxia, ophthalmoplegia and mental
confusion). If left untreated, leads to Korsakoffs syndrome (Wernickes
plus confabulation, antero or retrograde amnesia and telescoping of events)
>Investigations: FBC (^MCV), LFTs, Glucose, U&E (^Na, ^Ca,
^Uricaemia), ABG (^Carbia and Hypoxia), Serum thiamine (low).
434. A pt had TIA which he recovered from. He has a hx of stroke and
exam shows HR in sinus rhythm. He is already on aspirin 75mg and antiHTN drugs. What other action should be taken?
a. Add clopidogrel only
b. Increase dose of aspirin to 300mg
c. Add warfarin
d. Add clopidogrel and statin
e. Add statin only
KEY- D
TIA Prophylaxis: Aspirin, clopidogrel and statin.
TIA ttt: Aspirin and dypiridamole.
435. A 40yo woman suddenly collapsed and died. At the post-mortem
autopsy, it was found that there a bleed from a berry aneurysm from the
circle of Willis. In which space did the bleeding occur?
a. Subarachnoid
b. Subdural
c. Extradural
d. Subparietal
e. Brain ventricles
KEY- A.
Berry (or saccular) aneurysms are found in the circle of willis which is found
in the subarachnoid space. They are the most common form of cerebral
aneurysms. They present with sudden severe headache and gold standard for
diagnosis is CT. Gold standard for treatment is surgical clipping, done after

restoration of respiration and reduction of ICP. Berry aneurysms are often


associated with APCKD.

436. A schizophrenic pt hears people only when he is about to fall asleep.


What is the most likely dx?
a. Hypnopompic hallucinations
b. Hyponogogic hallucinations
c. Hippocampal hallucinations
d. Delirious hallucinations
e. Auditory hallucinations
KEY- B
Hypnopompic hallucinations- While waking up.
Hyponogogic hallucinations- While falling asleep.
Hippocampal hallucination- Photographic, animated or film-like clarity of
people, animals, faces, flowers, insects etc.
Auditory hallucinations- hearing voices that arent present.
437. A pt who came from India presents with cough, fever and enlarged
cervical LN. Exam: caseating granulomata found in LN. What is the most
appropriate dx?
a. Lymphoma
b. TB adenitis

c. Thyroid carcinoma
d. Goiter
e. Thyroid cyst
KEY- B
Points in favour- Traveling to India, cough, LN and caseating granulomata,
which is unique for TB.
438. A 44yo man comes with hx of early morning headaches and
vomiting. CT brain shows ring enhancing lesions. What is the single most
appropriate option?
a. CMV
b. Streptococcus
c. Toxoplasmosis
d. NHL
e. Pneumocystis jerovii
KEY- C
*Causes of ring enhancing lesions on CT brain:
-Brain abscess
-Primary or secondary tumour
-CNS lymphoma
-CNS toxoplasmosis
-Nocardia infection.
>Out of the options, toxoplasmosis is the right answer, and it is commonly
found in HIV patients. TREATMENT with pyrimethamine/sulfadiazine and
folinic acid. OR clindamycin if intolerant FOR 4-6 WEEKS.
If immunocompromised, PROPHYLAXIS with
Trimethoprim+sulfamethoxazole.
439. A 72yo man is found to be not breathing in the CCU with the
following rhythm. What is the most likely dx?
a. SVT
b. VT
c. VF
d. Atrial fib
e. Atrial flutter
KEY- C
VFib- Chaotic depolarisation of ventricles. Atrial rate 60-100. Ventricular
rate 400-600. Irregular. Ttt by immediate defibrillation

VTach- Sequence of 3 or more ventricular beats. Atrial rate 60-100.


Ventricular rate 110-250. Regular. Can progress to VFib and cardiac arrest.
Ttt if pulse present, cardioversion. If pulseless, defibrillation.
440. A 65yo man with difficulty in swallowing presents with an
aspiration pneumonia. He has a bovine cough and fasciculating tongue.
Sometimes as he swallows food it comes back through his nose. Choose the
single most likely cause of dysphagia from the given option?
a. Bulbar palsy
b. Esophageal carcinoma
c. Pharyngeal pouch
d. Pseudobulbar palsy
e. Systemic sclerosis
KEY- A
Bulbar palsy - Relates to medulla. Affection of lower cranial nerves (VIIXII). Dysphagia, dysphonia, dysarthria, tremulous lips, FASICULATIONS.
Pseudobulbar palsy - Affection of corticobulbar tracts. Dysphagia,
dysphonia. Donald duck speech, unable to protrude tongue. NO
FASICULATIONS
441. A 16yo teenager was brought to the ED after being stabbed on the
upper right side of his back. Erect CXR revealed homogenous opacity on the
lower right lung, trachea was centrally placed. What is the most probable
explanation for the XR findings?
a. Pneumothorax
b. Hemothorax
c. Pneumonia
d. Tension pneumothorax
e. Empyema
KEY- B
Sharp stabbing wound- Hemothorax. Clincher- homogenous opacity; not
seen with pneumothorax. Also since trachea is not displaced from the centre,
it is simple, not tension hemothorax.
Treatment- Chest drain insertion in the 5th intercostal space, mid-axillary
line.
For tension hemo/pneumothorax, needle thoracostomy insertion in the 2nd
intercostal space, mid-clavicular line.
442. A 55yo woman complains of retrosternal chest pain and dysphagia
which is intermittent and unpredictable. The food suddenly sticks in the

middle of the chest, but she can clear it with a drink of water and then finish
the meal without any further problem. A barium meal shows a corkscrew
esophagus. What is the single most likely dysphagia?
a. Esophageal candidiasis
b. Esophageal carcinoma
c. Esophageal spasm
d. Pharyngeal pouch
e. Plummer-vinson syndrome
KEY- C.
**Esophageal spasm- Oesophageal motility disorder. Dysphagia,
regurgitation and chest pain. corkscrew oesophagus on Barium swallow Xray. Ttt- Nitroglycerin, CCB, PPI. Botulinum toxin, balloon dilatation.

**Plummer vinson syndrome- triad of iron deficiency, esophegeal webs and


dysphagia. Premalignant - squamous cell carcinoma of oesophegus. Also
presents with cheilitis, koilonychia, glossitis and splenomegaly. Patient
complains of burning sensation in tongue and oral mucosa. Ttt is iron
supplementation and endoscopic dilation for webs
**Oesophageal candidiasis- Immunocompromised like HIV or renal
transplant. Odynophagia, with oral thrush. maybe weight loss. Ttt

fluconazole for atleast 21 days or atleast 14 days after disappearance of


symptoms.
**Oesophageal carcinoma- Dysphagia to colod foods then later to liquids.
Weight loss, hoarseness of voice(if involving the recurrent laryngeal nerve),
hematemesis, hemoptysis, nausea and vomiting.
Risk factors- smoking and unhealthy diet.
Diagnosis- Endoscopy and biopsy.
Treatment- Surgery, radio and chemotherapy depending on stage.
**Pharyngeal pouch (Zenckers diverticulum)- Common above 70. M:F is
5:1.
Presentation: Dysphagia, regurgitation, aspiration, chronic cough and weight
loss.Neck lump that gurgles on palpation. Halitosis from food decaying in
the pouch. Investigation: Barium swallow shows residual contrast pool
within the pouch. Aspiration from the pouch might cause inhalation
pneumonia. Ttt cricopharyngeal myotomy.
443. A 38yo female presents with sudden loss of vision but fundoscopy is
normal. She a similar episode about 1 y ago which resolved completely
within 3m. Exam: mild weakness of right upper limb and exaggerated
reflexes. What is the single most appropriate tx?
a. Pan retinal photo coagulation
b. Pilocarpine eye drops
c. Corticosteroids
d. Peripheral iridectomy
e. Surgical extraction of lens
KEY- C
> This is a case of optic neuritis caused by Multiple sclerosis. Steroids are
the answer here. They are given during acute symptomatic attacks of MS.
During relapse or remission, disease modifying agents like interferons are
given.
> Pan retinal photocoagulation is done for diabetic retinopathy where parts
on the retina are burned in order to reduce the Oxygen demand.
Lens extraction is done mainly for cataract to remove the opacified lens that
disturbs the vision
> Peripheral iridectomy is done by making a hole in the iris for open angle
glaucoma in order to provide an alternative drainage for the fluid
accumulating inside the eye, thus decreasing the IOP.

> Pilocarpine is a parasympathomimetic given for open angle glaucoma in


order to contract the ciliary muscles and to open the trabecular meshwork,
allowing increased outflow of the aqueous humour
>Surgical extraction of the lens is done for cataract where the opacified lens
that disturbs the vision is removed

444. A 15yo boy presents with a limp and pain in the knee. Exam: leg is
externally rotated and 2cm shorter. There is limitation of flexion, abduction
and medial rotation. As the hip is flexed external rotation is increased.
Choose the most likely dx?
a. Juvenile rheumatoid arthritis
b. Osgood-schlatter disease
c. Reactive arthritis
d. Slipped femoral epiphysis
e. Transient synovitis of the hip
KEY- D
> Slipped femoral epiphysis- Fracture through the growth plate (physis),
which results in slippage of the overlying end of the femur (epiphysis).
Symptoms include gradual, progressive onset of thigh or knee pain with a
painful limp. Hip motion will be limited, particularly internal rotation.
> Osgood Schlatter disease- Inflammation of the patellar ligament at the
tibial tuberosity. Painful lump just below the knee, often seen in young
adolescents. Risk factors- overuse (especially in sports involving running,
jumping and quick changes of direction) & adolescent growth spurts.
> Reactive arthritis or Reiter's syndrome- Autoimmune reaction to an
infection somewhere else in the body. Triad- arthritis, uveitis,
urethritis\cervicitis
445. A 64yo woman has difficulty moving her right shoulder on
recovering from surgery of the posterior triangle of her neck. What is the
single most appropriate option?
a. Accessory nerve
b. Glossopharyngeal nerve
c. Hypoglossal nerve
d. Vagus nerve
e. Vestibule-cochlear nerve
KEY- A

446. A 37yo man with an ulcer on the medial malleolus. Which of the
following LN is involved?
a.
b.
c.
d.
e.
f.
g.
h.

External iliac LN
Pre-aortic LN
Aortic LN
Inguinal LN
Iliac LN
Submental LN
Submandibular LN
Deep cervical LN

447. A pt presents with weight loss of 5kgs despite good appetite. He also
complains of palpitations, sweating and diarrhea. He has a lump in front of
his neck which moves on swallowing. What is the most appropriate dx?

a. Lymphoma
b. TB adenitis
c. Thyroid Ca
d. Goiter
e. Thyroid cyst
KEY- D
Typical symptoms of hyperthyroidism- Weight loss, palpitations, sweating,
diarrhoea. Goiter lump moves with swallowing.
Thyroglossal cyst moves upwards on tongue protrusion
Thyroid cancer usually presents as a painless, hard and FIXED thyroid mass
enlarging rapidly over a period of a few weeks.
448. A 76yo woman has become tired and confused following an
influenza like illness. She is also breathless with signs of consolidation of
the left lung base. What is the most likely dx?
a. Drug toxicity
b. Delirium tremens
c. Infection toxicity
d. Hypoglycemia
e. Electrolyte imbalance
KEY- C
Infection toxicity is also called Toxic shock syndrome. It is the case here
because of the history of preceding flu-like illness which points towards
toxins (enterotoxin type B) from Staphylococcus aureus]. There is also
consolidation of the lung which is most probably due to the Staph
pneumonia.
Delirium tremens is due to alcohol withdrawal and it usually occurs at
around day 3 of cessation of alcohol intake.
No other choice fits this scenario.
449. A young pt is complaining of vertigo whenever she moves sideways
on the bed while lying supine. What would be the most appropriate next
step?
a. Head roll test
b. Reassure
c. Advice on posture
d. Carotid Doppler
e. CT
KEY- A

Dx? Benign Paroxysmal Positional Vertigo (BPPV)- Most common cause of


vertigo. Vertigo triggered by change in head position. Might be
accompanied by nausea and nystagmus. Less commonly, vomiting and
syncope.
Diagnosis: Dix-Hallpike and Head roll test.
Management: Epley and Semont Maneuver.
450. A 32yo man has OCD. What is the best tx?
a. CBT
b. SSRI
c. TCA
d. MAO inhibitors
e. Reassure
KEY- A
OCD is treated initially with individual CBT (Cognitive Behavioural
therapy) plus exposure and response prevention. If symptoms become severe
or do not improve, SSRIs like fluoxetine or Citalopram etc are introduced.
Recent studies have shown that there is no superiority of one over the other
(CBT over SSRIs), but CBT remains the initial management plan, This
question is quite deficient, and the original key is B. SSRI, but Im sure in
the exam, it will be more detailed; but this is how OCD is managed.
Reference: Patient.co.uk. Link- http://patient.info/doctor/obsessivecompulsive-disorder-pro
451. A 65yo woman says she died 3m ago and is very distressed that
nobody has buried her. When she is outdoors, she hears people say that she
is evil and needs to be punished. What is the most likely explanation for her
symptoms?
a. Schizophrenia
b. Mania
c. Psychotic depression
d. Hysteria
e. Toxic confusional state
KEY- C
Psychotic depression consists of a major depressive episode plus psychotic
symptoms like hallucinations or delusions (in this case nihilistic delusions).
Toxic confusional state can be eliminated since there is no history of
infection.
452. A 50yo woman presents following a fall. She reports pain and
weakness in her hands for several months , stiff legs, swallowing difficulties,

and has bilateral wasting of the small muscles of her hands. Reflexes in the
upper limbs are absent. Tongue fasciculations are present and both legs
show increased tone, pyramidal weakness and hyper-reflexia with extensor
plantars. Pain and temp sensation are impaired in the upper limbs. What is
the most likely dx?
a. MS
b. MND
c. Syringobulbia
d. Syringomyelia
e. Myasthenia gravis
KEY- C
In MS, there are characteristic relapse and remission which is absent here.
MND is purely motor, there is no sensory deficit; In myasthenia gravis there
is muscular weakness without atrophy.
Syringomyelia is a condition in which there is fluid-filled tubular cyst
(syrinx) within the central, usually cervical, spinal cord. The syrinx can
elongate, enlarge and expand into the grey and white matter and, as it does
so, it compresses the nervous tissue of the corticospinal and spinothalamic
tracts and the anterior horn cells. This leads to various neurological
symptoms and signs, including pain, paralysis, stiffness and weakness in the
back, shoulders and extremities. It may also cause loss of extreme
temperature sensation, particularly in the hands, and a cape-like loss of pain
and temperature sensation along the back and arms.
** If the syrinx extends into the brainstem, syringobulbia results. This may
affect one or more cranial nerves, resulting in facial palsies. Sensory and
motor nerve pathways may be affected by interruption and/or compression
of nerves.
453. Which of the following formulas is used for calculating fluids for burn
pts?
a. 4 x weight(lbs) x area of burn = ml of fluids
b. 4 x weight(kgs) x area of burn = L of fluids
c. 4 x weight(kgs) x area of burn = ml of fluids
d. 4 x weight(lbs) x area of burn = L of fluids
e. 4.5 x weight(kgs) x area of burn = dL of fluids
KEY- C
>Burns are injuries caused by thermal, chemical, electrical or radiation
energy.

Start with ABCs. Establish the time of the injury- from the time the injury
happened, not from the time the patient presents. Give strong analgesia. Rule
out Non accidental injury. Avoid hypothermia.
>Fluid Requirements = Body area burned(%) x Wt (kg) x 4mL. This is
called Parkland formula. Give 1/2 of total requirements in 1st 8 hours, then
give 2nd half over next 16 hours. Area of body burn is calculated by addition
of percentage of burn in each area, by rule of 9s:
9% head and neck, 9% each upper limb, 18% each lower limb, 18% front of
trunk, 18% back of trunk, 1% Palmar surface of the hand, including fingers,
1% Perineum

454. A 65yo male presents with dyspnea and palpitations. Exam:


pulse=170bpm, BP=120/80mmHg. Carotid massage has been done as first
instance. What is the next step of the management?
a. Adenosine
b. Amilodipine
c. DC cardioversion
d. Lidocaine
e. Beta blocker
KEY- A
Likely diagnosis SVT. Initially, vagal manoeuvres, if fails iv adenosine.
Vagal manoeuvres (carotid sinus massage, Valsalva manoeuvre)
transiently increase AV block, and may unmask an underlying atrial rhythm.
If unsuccessful, give adenosine, which causes transient AV block.
455. A 48yo farmer presented with fever, malaise, cough and SOB.
Exam: tachypnea, coarse end-inspiratory crackles and wheeze throughout,
cyanosis. Also complaint severe weight loss. His CXR shows fluffy nodular
shadowing and there is PMN leukocytosis. What is the single most
appropriate dx?
a. Ankylosing spondylitis
b. Churg-strauss syndrome
c. Cryptogenic organizing
d. Extrinsic allergic alveolitis
e. Progressive massive fibrosis
KEY- D
Dx- Farmers lung/ Hypersensitivity penumonitis/ Extrinsic allergic
penumonitis.
It is diffuse granulomatous inflammation of the lung in patients who are
allergic to organic antigens present in dust particles. On chest X-ray, diffuse
nodular opacities are seen.
456. A 35yo lady is admitted with pyrexia, weight loss, diarrhea and her
skin is lemon yellow in color. CBC = high MCV. What is the most probably
dx?
a. Aplastic anemia
b. Pernicious anemia
c. Leukemia
d. ITP
e. Lymphoma
KEY- B

Clincher- High MCV. It may be graves with pernicious anemia. Lemon


yellow pallor occurs in pernicious anemia. Hyperthyroidism may cause
persistently raised body temperature
457. A 72yo woman who had a repair of strangulated femoral hernia 2
days ago becomes noisy, aggressive and confused. She is febrile, CBC
normal apart from raised MCV. What is the most likely dx?
a. Electrolyte imbalance
b. Delirium tremens
c. Wernickes encephalopathy
d. Infection toxicity
e. Hypoglycemia
KEY- B
Delirium tremens occurs after alcohol withdrawal, usually 3 to 4 days after
cessation of alcohol. Altered mental status in the form of confusion,
delusions, severe agitation and hallucinations. Seizures can occur.
Examination might reveal stigmata of chronic alcoholic liver disease.
Alcohol also typically raises MCV.
Wernickes encephalopathy- Triad of ataxia, ophthalmoplegia and mental
confusion). If left untreated, leads to Korsakoffs syndrome (Wernickes
plus confabulation, antero or retrograde amnesia and telescoping of events)
Electrolyte imbalance may cause confusion but not aggressiveness.
Infection toxicity will cause high fever, low BP, rash etc which is absent
here.
Hypoglycemia can occur with alcohol intake but it does not present this way.
It presents with sweating, pallor, shakiness etc.
458. An old lady had UTI and was treated with antibiotics. She then
developed diarrhea. What is the single most likely tx?
a. Co-amoxiclav
b. Piperacillin + tazobactam
c. Ceftriaxone
d. Vancomycin
KEY- D
This is a case of pseudomembraneous colitis. It is caused by Clostridium
difficile. It occurs after use of antibiotics. Treated with Vancomycin or
Metronidazole.
459. A 56yo man has symptoms of sleep apnea and daytime headaches
and somnolence. Spirometry shows a decreased tidal volume and vital
capacity. What is the single most appropriate dx?

a. Ankylosing spondylitis
b. Churg-strauss syndrome
c. Good pasture syndrome
d. Motor neuron disease
e. Progressive massive fibrosis
f.
Spinal cord compression
KEY- D
Involvement of respiratory muscles in Motor Neuron Disease is associated
with poor respiration causing sleep apnoea.
460. A 55yo man presents with mild headache. He has changed his
spectacles thrice in 1 yr. there is mild cupping present in the disc and sickle
shaped scotoma present in both eyes. What is the single most appropriate tx?
a. Pan retinal photo coagulation
b. Pilocarpine eye drops
c. Corticosteroids
d. Scleral buckling
e. Analgesics alone
KEY- B
> Sickle-shaped scotoma or siedel sign is often seen in glaucoma. That along
with the fact that he keeps changing his spectacles denotes that this is a case
of progressive open angle glaucoma. It can also present with nausea,
vomiting, headache and ocular pain. Treated with Carbonic anhydrase
inhibitors like acetazolamide, Miotic agents (parasympathomimetics) such
as pilocarpine, Alpha2-adrenergic agonists like brimonidine, or
Prostaglandin analogs like latanoprost.
> Pan retinal photocoagulation is done for diabetic retinopathy where parts
on the retina are burned in order to reduce the Oxygen demand.
> Scleral buckling is done for retinal detachment to put the retina back in
place.
461. A 55yo woman was found collapsed at home, paramedics revived
her but in the ambulance she had a cardiac arrest and couldnt be saved. The
paramedics report tells that the woman was immobile lately due to hip pain
and that they found ulcers on the medial side of ankle. She had DM and was
on anti-diabetics. What is the cause of her death?
a. Acute MI
b. DKA
c. Pulmonary embolism
d. Acute pericarditis

e. Cardiac tamponade
KEY- C
This is a case of collapse due to PE following DVT caused by the patients
immobilization due to hip pain.
Cardiac tamponade- Triad of hypotension, distended engorged neck veins,
and muffled JVP.
Pericarditis- Chest pain worse with inspiration and lying down, relieved by
lying forward.
No history supporting DKA or MI.
462. An 18yo previously well student is in his 1 year at uni. He has been
brought to the ED in an agitated, deluded and disoriented state. What is the
most probable reason for his condition?
a. Drug toxicity
b. Delirium tremens
c. Infection toxicity
d. Electrolyte imbalance
e. Head injury
KEY- A
Clinchers are teenage, and 1st year of university, where students tend to
experiment with drugs.
Infection toxicity can be ruled out due to lack of any signs of infection like
fever. Lack of history of trauma rules out head injury, and delirium tremens
is due to alcohol withdrawal.
st

463. A young adult presents to the ED after a motorcycle crash. The pt


has bruises around the left orbital area. GCS=13, examination notes
alcoholic breath. Shortly afterwards, his GCS drops to 7. What is the single
most important initial assessment test?
a. MRI brain
b. CT brain
c. CXR
d. CT angio brain
e. Head XR
KEY- B
This is a typical case of Epidural hematoma. It is usually due to trauma, and
has a period of lucidity before collapse. Due to the sudden drop in GCS, CT
brain should be immediately done.
464. A 30yo female attends OPD with a fever and dry cough. She says
that she had headache, myalgia and joint pain like one week ago. Exam:

pulse=100bpm, temp=37.5C. CXR: bilateral patchy consolidation. What is


the single most likely causative organism?
a. Pneumococcal pneumonia
b. Legionella
c. Mycoplasma
d. Klebsiella
e. Chlamydia pneumonia
KEY- C
> Mycoplasma pneumonia- Atypical pneumonia. Slow onset, dry cough,
pleuritic pain, myalgia, arthralgia, malaise.
> Legionella- history of travel and stay in hotel- atypical symptoms plus GI
manifestations.
> Klebsiella- commonly associated with alcohol.
465. A 46yo man is being investigated for indigestion. Jejunal biopsy
shows deposition of macrophages containing PAS (Periodic acid-schiff) +ve
granules. What is the most likely dx?
a. Bacterial overgrowth
b. Celiac disease
c. Tropical sprue
d. Whipples disease
e. Small bowel lymphoma
KEY- D
Periodic acid-schiff positive granules containing macrophages in jejunal
biopsy is diagnostic of whipples disease.
Coeliac disease is gluten sensitivity.
466. A 32yo woman of 38wks gestation complains of feeling unwell with
fever, rigors and abdominal pains. The pain was initially located in the
abdomen and was a/w urinary freq and dysuria. The pain has now become
more generalized specifically radiating to the right loin. She says that she
has felt occasional uterine tightening. CTG is reassuring. Select the most
likely dx?
a. Acute fatty liver of pregnancy
b. Acute pyelonephritis
c. Round ligament stretching
d. Cholecystitis
e. UTI
KEY- B
This is a case of UTI followed by ascending infection leading to
pyelonephritis. Fever, rigors and abdominal pain are typical symptoms.

467. A 32yo pt presents with cervical lymphadenopathy and


splenomegaly. What is the single most appropriate option?
a. Hemophilus
b. Streptococcus
c. Toxoplasmosis
d. NHL
e. Pneumocystis jerovcii
KEY- D
Non Hodgkins lymphoma is the only option here that will have both
lymphadenopathy and splenomegaly (although splenomegaly is not a
common presentation). Pneumocystis jerovici and Toxoplasmosis are
common in HIV patients.
468. A 62yo man who was admitted for surgery 3days ago suddenly
becomes confused. His attn span is reduced. He is restless and physically
aggressive and picks at his bed sheets. What single aspect of the pts hx
recovered in his notes is most likely to aid in making the dx?
a. Alcohol consumption
b. Head trauma
c. Hx of anxiety
d. Prescribed med
e. Obvious cognitive impairment
KEY- A
This is a typical case of Delirium tremens. It appears [48-72 hours after
alcohol has stopped]. Altered mental status in the form of confusion,
delusions, severe agitation and hallucinations. We should ask alcohol
history. Examination might reveal stigmata of chronic alcoholic liver
disease.
469. A 10yo girl presents with pallor and features of renal failure. She
has hematuria as well as proteinuria. The serum urea and creat are elevated.
These symptoms started after an episode of bloody diarrhea 4 days ago.
What is the most probable dx?
a. TTP
b. HUS
c. ITP
d. HSP
e. ARF
KEY- B

Haemolytic Uraemic Syndrome (HUS) is a triad of Haemolytic anaemia,


thrombocytopaenia and Renal failure. It is said to be caused most commonly
by E.coli O:157H7 which binds to endothelial receptors in the GIT, Renal
and central nervous system. Symptoms [ abdominal pain, pallor due to
anaemia, hematuria and proteinuria, features of renal failure likenausea/vomiting, swelling of face, hand, feet or entire body etc. and elevated
urea and creatinine etc.] start around two weeks after an episode of bloody
diarrhea. The diarrheoa is charactised to get bloody after 1-3 days. This
scenario is typical for HUS. It is also known to be precipitated by strept
pneumonia and some drugs like cyclosporin and tacrolimus.
470. A 40yo woman has had intermittent tension, dizziness and anxiety
for 4 months. Each episode usually resolves after a few hours. She said she
takes alcohol to make her calm. She is in a loving relationship and has no
probs at work or home. What is the next step in her management?
a. Collateral info
b. CT brain
c. CBC
d. LFT
e. TFT
KEY- A Collateral info. Likely diagnosis is panic disorder. Collateral info
from family, friends & other peers should be asked to find out the cause for
her anxiety.
471. A 45yo IV drug abuser is brought into the ED with complaint of
fever, shivering, malaise, SOB and productive cough. Exam: temp=39C,
pulse=110bpm, BP=100/70mmHg. Inv: CXR=bilateral cavitating
bronchopneumonia. What is the single most likely causative organism?
a. Mycoplasma
b. Staphylococcus
c. Chlamydia pneumonia
d. Pseudomonas
e. PCP
KEY- B
Staphylococcus and PCP are common in IV drug abusers. Both are also
recognized cause of cavitating pneumonia. This case is with productive
cough which goes more with staphylococcus as PCP is not productive, but is
rather associated with dry cough.
Mycoplasma pneumonia- Atypical pneumonia. Slow onset, dry cough,
pleuritic pain, myalgia, arthralgia, malaise.

472. A 71yo woman looks disheveled, unkempt and sad with poor eye
contact. She has recently lost her husband. Which of the following describes
her condition?
a. Anxiety
b. Hallucination
c. Mania
d. High mood
e. Low mood
KEY- E
Dx- Depression. Disheveled and unkempt because she doesnt take care of
herself, plus the loss of her husband, points towards depression.
473. A 62yo male comes to the GP complaining of double vision while
climbing downstairs. Which of the following nerve is most likely involved?
a. Abducens nerve
b. Trochlear nerve
c. Oculomotor nerve
d. Optic nerve
e. Trigeminal nerve
KEY- B
This is a lesion in the Trochlear nerve affecting the Superior oblique muscle.
All extrinsic muscles of the eye are supplied by the Oculomotor nerve
except the Lateral rectus by the Abducens nerve and the Superior oblique by
the trochlear (mnemonic LAST).
Oculomotor nerve affection causes palsy of inferior rectus, medial rectus and
superior rectus manifesting as double vision in multiple gaze. But trochlear
involving superior oblique only causes diplopia in downgaze only.

474. L1 level, what is the most appropriate landmark?


a. Mcburneys point
b. Stellate ganglion
c. Deep inguinal ring
d. Termination of the spinal cord
e. Transpyloric plane

KEY- E

475. A 32yo woman presents to the ED with headache and vomiting. She
was decorating her ceiling that morning when the headache began, felt
mainly occipital with neck pain. Some 2hs later she felt nauseated, vomited
and was unable to walk. She also noticed that her voice had altered. She
takes no reg meds and has no significant PMH. Exam: acuity, field and fundi
are normal. She has upbeat nystagmus in all directions of gaze with normal
facial muscles and tongue movements. Her uvulas deviated to the right and
her speech is slurred. Limb exam: left arm past-pointing and
dysdiadochokinesia with reduced pin prick sensation in her right arm and
leg. Although power is normal, she cant walk as she feels too unsteady.
Where is the most likely site of lesion?
a. Right medial medulla
b. Left medial pons
c. Left cerebellar hemisphere
d. Right lateral medulla
e. Left lateral medulla
KEY- E
Lateral medullary syndrome affects:
-Contralateral spinothalamic tract (loss of pain and temperature on the
opposite side of the body)
-Ipsilateral Sympathetic tract- Horners syndrome.
-Ipsilateral Spinal trigeminal nucleus (loss of pain,temperature and corneal
reflex on same side of the face)
-Nucleus ambigous- Dysphagia and Dysarthria
-Inferior cerebellar peduncle- Ataxia
Ipsilateral Cranial nerves- IX, X and XI (dysphagia, loss of gag reflex, palate
paralysis)
Cause- Occlusion of PICA (posterior inferior cerebellar artery)
Medial medullary syndrome affects:
Contralateral corticospinal tract/pyramids- weakness of arms and legs
opposite side.
Contralateral Medial lemniscus/dorsal column- loss of proprioception and
vibration.
Ipsilateral hypoglossal nerve- weakness of tongue on the same side.
[Hypoglossal nerve affection manifests as protrusion of the tongue to the
side of the weakness while at rest, it deviates to the contralateral side)
Cause- Occlusion of Anterior spinal artery.
476. A 28yo female presents with 1 wk hx of jaundice and 2d hx of
altered sleep pattern and moods. She was dx with hypothyroidism for which

she is receiving thyroxine. TFT showed increased TSH. PT=70s. What is the
most probable dx?
a. Acute on chronic liver failure
b. Hyper-acute liver failure
c. Autoimmune hepatitis
d. Acute liver failure
e. Drug induced hepatitis
KEY- C
Autoimmune hepatitis may present as acute hepatitis, chronic hepatitis, or
well-established cirrhosis. Autoimmune hepatitis rarely presents as
fulminant hepatic failure. One third may present as acute hepatitis marked
by fever, hepatic tenderness and jaundice. Non specific features are
anorexia, weight loss and behavioural change (here altered sleep pattern and
moods). There may be coagulopathy (here PT=70s.) leading to epistaxis,
gum bleeding etc. Presence of other autoimmune disease like
hypothyroidism supports the diagnosis of autoimmune hepatitis.
477. A 55yo man has a chronic cough and sputum, night sweats and
weight loss. What is the single most likely causative organism?
a. Coagulase +ve cocci in sputum
b. Gram -ve diplococci in sputum
c. Gram +ve diplococci in sputum
d. Pneumocystis carinii in sputum
e. Sputum staining for mycobacterium tuberculosis
KEY- E
Classic features of TB- Chronic cough and sputum, night sweats and weight
loss. Organism is Acid fast bacilli mycobacterium tuberculosis.
478. A 20yo pregnant 32wks by date presents to the antenatal clinic with
hx of painless vaginal bleeding after intercourse. Exam: P/A soft and
relaxed, uterus=dates, CTG=reactive. Choose the single most likely dx?
a. Abruption of placenta 2 to pre-eclampsia
b. Antepartum hemorrhage
c. Placenta previa
d. Preterm labor
e. Placenta percreta
KEY- C
Clincher- painless bleeding, typical presentation of placenta previa. Uterus is
soft and relaxed and theres no pain, so we rule out placental abruption.
nd

479. A 30yo man presents to the ED with difficulty breathing. He has


returned from India. Exam: throat reveals grey membranes on the tonsils and
uvula. He has mild pyrexia. What is the single most relevant dx?
a. Diphtheria
b. IM
c. Acute follicular tonsillitis
d. Scarlet fever
e. Agranulocytosis
KEY- A
Clinchers- History of travel to India, and greyish membrane.
Infectious mononucleosis will typically present in a teenager, with enlarged
cervical lymphadenopathy and fever.
Acute follicular tonsillitis as the name suggests, will have follicles on the
tonsils.
Scarlet fever presents with rash and strawberry tongue
480. A 23yo man comes to the ED with a hx of drug misuse. He
recognizes that he has a prb and is willing to see a psychiatrist. Which of the
following terms best describes this situation?
a. Judgement
b. Thought insertion
c. Thought block
d. Mood
e. Insight
KEY- E
Insight is the patient's awareness and understanding of the origins and
meaning of his attitudes, feelings, and behavior and of his disturbing
symptoms, basically, he is aware that he has a problem.
481. A pt with hodgkins lymphoma who is under tx develops high fever.
His blood results show WBC <2800 and has a chest infection. Choose the
most likely tx?
a. Co-amoxiclav
b. Piperacillin+tazobactam
c. Erythromycin
d. Piperacillin+Co-amoxiclav
e. Penicillin+tazobactam
KEY- B

This patient with Hodgkins lymphoma has a severe infection and his WBC
count is very low, so he needs to be covered with broad spectrum antibiotics,
hence piperacillin and tazobactam.
482. A 25yo woman presents with urinary freq, dysuria and fever. Urine
microscopy shows 20-50 RBC and 10-20 WBC in each field. What is the
most probable dx?
a. Schistosmiasis
b. Kidney trauma
c. Ureteric calculus
d. Bladder calculi
e. Cystitis
KEY- E
Clincher- WBCs.
These are typical Symptoms of UTI- fever, frequency, dysuria. Urine
microscopy here (hematuria and presence of WBCs) indicate cystitis.
Schistosomiasis can present with hematuria and fever but also with
additional symptoms like diarrhea, abdominal pain, hepatosplenomegaly,
cough and history of travel would likely be given.
Kidney trauma can present with hematuria, but not dysuria, frequency and
fever.
Calculi can present with severe lower abdominal and back pain, difficult
urination, frequency, fever, dysuria and haematuria. The pain, that comes in
waves, may also be associated with nausea, vomiting and chills. WBCs
though, will not be present.
483. A 65yo presents with dyspareunia after sex. She in menopause. She
complains of bleeding after sex. What is the most probably dx?
a. Cervical ca
b. Endometrial ca
c. Ovarian ca
d. Breast ca
e. Vaginal ca
KEY- B
RULE- Postmenopausal bleeding, be it post coital or not, is Endometrial
cancer unless proven otherwise.
Clinchers- Post menopausal, and age 65.
Cervical cancer is common in women aged 25-34 years, while 90% of
women with endometrial cancer are over 50 years of age. [Sourcepatient.co.uk]

484. A 45yo man underwent an emergency splenectomy following a fall


from his bicycle. He smokes 5 cigarettes/day. Post-op, despite mobile, he
develops swinging pyrexia and a swollen painful left calf. His CXR shows
lung atelectasis and abdominal US demonstrates a small subphrenic
collection. What is the single most likely risk factor for DVT in this pt?
a. Immobility
b. Intraperitoneal hemorrhage
c. Smoking
d. Splenectomy
e. Sub-phrenic collection
KEY- D
Since it is stated that patient is mobile. option A can be eliminated. Option B
and E are not known to predispose to Thromboembolism. This leaves C and
D, and splenectomy is a stronger link to DVT due to it being:
1. A recent major surgery(within 12 weeks), which is a big risk factor
for DVT.
2. The surgery itself- Vascular events after splenectomy are likely
multifactorial, probably resulting from some combination of
hypercoagulability, platelet activation, disturbance and activation of
the endothelium, and altered lipid profiles. The spleen's primary
phagocytic function is to remove infectious organisms, other insoluble
cellular debris, and senescent or abnormal red cells and platelets. This
filtration function results from the blood moving slowly through the
splenic sinusoids in the red pulp lined with macrophages actively
ingesting that which does not easily pass around them. Absence of this
extremely sensitive filter may permit particulate matter and damaged
cells to persist in the bloodstream, therefore perturbing and activating
the vascular endothelium leading to a shift in vascular homeostasis
toward enhanced coagulation.
485. A 6m baby had LOC after which he had jerky movement of hands
and feet. What is the most probable dx?
a. Infantile spasm
b. Absence
c. Partial simple seizure
d. Atonic seizure
e. Partial complex
KEY- E
> Generalised- Entire body is involved.
> Focal/Partial- Not the entire body is involved.

> Complex- Loss of consciousness.


> Simple- No loss of consciousness.
> Absence seizures- The person has a brief loss of consciousness (an
absence) for a few seconds. They do not fall but may pause in what they are
doing. Their face often looks pale with a blank expression. They may look
dazed, the eyes stare and the eyelids may flutter a little. Sometimes their
head may fall down a little, or their arms may shake once or twice. Each
seizure usually starts and finishes abruptly. The person is not aware of the
absence and resumes what they were doing.
> Infantile spasm (West Syndrome) occurs in the first year of life (3-8
months) and is not associated with LOC. Its nature is more generalized
rather than the focal nature described here. Infantile spasm can also be called
salaam spasms, because the appearance of the seizures is like a bowing
forwards or backwards movement.
486. A 24yo primigravida who is 30wk pregnant presents to the labor
ward with a hx of constant abdominal pain for the last few hours. She also
gives a hx of having lost a cupful of fresh blood per vagina before the pain
started. Abdominal exam: irritable uterus, CTG=reactive. Choose the single
most likely dx?
a. Abruption of placenta 2 to pre-eclampsia
b. Antepartum hemorrhage
c. Placenta previa
d. Vasa previa
e. Revealed hemorrhage
KEY- B
Presentation indicates abruption of the placenta, but not confirmed yet.
Generally bleeding during this time is given a general diagnosis of
antepartum haemorrhage. There is no history or features suggestive of of
hypertension or pre-eclampsia so A is not the choice. Abruption can be
either concealed or revealed abruption.
Placenta praevia is painless bleeding.
487. A 62yo lady presents with right sided headache and loss of vision.
What is the single most inv?
a. ESR
b. BUE
c. CT head
d. XR orbit
e. IOP
KEY- A
nd

> This is most probably Giant cell arteritis/Temporal arteritis. It is common


in females and elderly people and should always be considered in cases of
new-onset headache in patients 50 years of age or older. Initial investigation
is ESR which will be raised (>40mm/hr), and confirmatory diagnosis is
temporal artery biopsy. Patient should be started on steroids immediately if
GCA is suspected, even if diagnosis is not confirmed, as delay in treatment
might lead to blindness due to occlusion of the ophthalmic artery.
> IOP (Intraocular pressure) is used to investigate glaucoma.
488. A 24yo man asks his GP for a sick note from work. He says that
feels down, is lethargic and has stopped enjoying playing the piccolo (his
main hobby). He was admitted to the psychiatry ward last year following an
episode of overspending, promiscuity and distractibility. What is the most
probable dx?
a. Psychosis
b. Cyclothymia
c. Bipolar affective disorder
d. Seasonal affective disorder
KEY- C
> Features of Mania (overspending, promiscuity and distractibility) plus
Depression (low mood, lethargy and anhedonia) denote Bipolar Disorder.
> Cyclothymia is a mild form of Bipolar disorder [Mild depression without
somatic symptoms + Hypomania] that often goes unnoticed.
489. A 42yo female who is obese comes with severe upper abdominal
pain with a temp=37.8C. She has 5 children. What is the most probable dx?
a. Ectopic pregnancy
b. Ovarian torsion
c. Hepatitis
d. Biliary colic
e. Cholecystitis
KEY- E
> This is cholecystitis, or non-alcoholic steatohepatitis. The 5 Fs of
cholecystitis are- Fat
Female
Fare
Forty
Fertile.
> Ovarian torsion and ectopic pregnancy will have lower abdominal pain.

490. A child has just recovered from meningitis. What inv will you do
before discharge?
a. CT scan
b. EEG
c. Blood culture
d. Repeat LP
e. Hearing test
KEY- E
** Patient is already recovering from meningitis, so none of options A, B, C
or D are indicated.
** Since hearing loss is the most common complication of meningitis,
people recovering from the condition will usually have a hearing test. The
test should be carried out before you're discharged, or within 4 weeks of
being well enough to have the test. Children and young people should
discuss the results of their hearing test with a paediatrician between 4 and 6
weeks after being discharged from hospital. In cases where hearing is
severely affected, cochlear implants may be needed. [NICE Guidelines and
NHS].
> Complications of Meningitis:
*Immediate: septic shock, DIC, coma with loss of protective airway
reflexes, cerebral oedema and raised ICP, septic arthritis, pericardial
effusion and haemolytic anaemia (H. influenzae).
Subdural effusions: reported in 40% of children aged 1-18 months with
bacterial meningitis.
Syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Seizures
*Delayed: decreased hearing, or deafness; other cranial nerve dysfunction,
multiple seizures, focal paralysis, subdural effusions, hydrocephalus,
intellectual deficits, ataxia, blindness, Waterhouse-Friderichsen syndrome
and peripheral gangrene.
491. A primiparous woman with no prv infection with herpes zoster is
18wk pregnant. She had recent contact with a young 21yo pt having
widespread chicken pox. What is the most suitable management for the
pregnant lady?
a. Acyclovir PO
b. Acyclovir IV +IVIG
c. Acyclovir IV
d. Reassure
e. IVIG

KEY- E
*If the pregnant woman is not immune to VZV and she has had a significant
exposure, she should be offered varicella-zoster immunoglobulin (VZIG) as
soon as possible. VZIG is effective when given up to 10 days after contact
(in the case of continuous exposures, this is defined as 10 days from the
appearance of the rash in the index case).
*If she had no previous infection and develops a rash (got infected) and
comes within 24 hour of development of rash- acyclovir is given. [MRCOG
Guideline].
492. A 40yo woman presents to the GP with low mood. Of note, she has
an increased appetite and has gone up 2 dress sizes. She also complains that
she cant get out of bed until the afternoon. What is the most likely dx?
a. Pseudo depression
b. Moderate depression
c. Severe depression
d. Dysthymia
e. Atypical depression
KEY- E
Atypical depression is a subtype of major depression or dysthymic disorder
that involves several specific symptoms, including increased appetite or
weight gain, hypersomnia, marked fatigue or weakness, moods that are
strongly reactive to environmental circumstances, and feeling extremely
sensitive to rejection, or feeling of being weighed down, paralyzed, or
"leaden.
493. An 8yo boy is clinically obese. As a baby he was floppy and
difficult to feed. He now has learning difficulties and is constantly eating
despite measures by his parents to hide food out of reach. What is the most
probable dx?
a. Cushings syndrome
b. Congenital hypothyroidism
c. Prader Willi syndrome
d. Lawrence moon biedel syndrome
e. Downs syndrome
KEY- C
Prader Willi syndrome- congenital disorder caused by defect in gene on
chromosome 15. Characterized by hypotonia at birth, feeding difficulties,
poor growth and delayed development. At the beginning of childhood, they
present with obsessive eating and obesity, learning difficulties, behavioural

problems and compulsive behavior such as picking on skin. Distinctive


facial features like triangular mouth, unusually fair skin and light-coloured
hair, almond shaped eyes and short forehead.
494. A 20yo lady is suffering from fever and loss of appetite. She has
been dx with toxoplasmosis. What is the tx?
a. Pyrimethamine
b. Pyrimethamine + sulfadiazine
c. Clindamycin
d. Spiramycin
e. Trimethoprim + sulfamethoxazole
KEY- B
Toxoplasmosis:
TREATMENT with pyrimethamine/sulfadiazine and folinic acid. OR
clindamycin if intolerant FOR 4-6 WEEKS.
If immunocompromised, PROPHYLAXIS with
Trimethoprim+sulfamethoxazole.
495. A 68yo woman has a sudden onset of pain and loss of hearing in her
left ear and unsteadiness when walking. There are small lesions visible on
her palate and left external auditory meatus. What is the single most likely
dx?
a. Acute mastoiditis
b. Cholesteatoma
c. Herpes zoster infection
d. Oropharyngeal malignancy
e. OM with infusion
KEY- C
Clincher- lesions which are probably vesicles.
Herpes zoster oticus (Ramsay Hunt syndrome) occurs when latent varicella
zoster virus reactivates in the geniculate ganglion of the 7th cranial nerve.
Symptoms: Painful vesicular rash on the auditory canal on drum, pinna,
tongue, palate or iris with ipsilateral facial palsy, loss of taste, vertigo,
tinnitus, deafness, dry mouth and eyes. OHCM 9th edition, page 505.
496. A 45yo woman has been dx with Giant Cell A and is being treated
with steroids. What is the other drug that can be added to this?
a. ACEi
b. Beta blockers
c. Aspirin

d. Interferons
e. IVIG
KEY- C
For GCA, along with Steroids, 3 other medications are required:
1). Low-dose aspirin: Start aspirin 75 mg daily unless there are contraindications - eg, active peptic ulceration or a bleeding disorder. Low-dose
aspirin has been shown to decrease the rate of visual loss and strokes in
patients with GCA.
2). Start gastroprotection with a proton pump inhibitor in view of added risk
of peptic ulceration with high-dose steroids and aspirin.
3). Start Osteoporosis prophylaxis with bisphosphonates since patient in on
long-term steroid treatment.
497. A 17yo man has acute pain and earache on the right side of his face.
Temp=38.4C and has extensive pre-auricular swelling on the right, tender on
palpation bilaterally. What is the single most likely dx?
a. Acute mastoiditis
b. Acute otitis externa
c. Acute OM
d. Mumps
e. OM with effusion
KEY- D
> Mumps- Prodromal malaise, fever, painful parotid swelling, becoming
bilateral in 70%. OHCS 9th edition, page 142.
> Otitis externa typically presents after swimming, and involves only the
external ear. Treated with topical antibiotic drops (aminoglycosides) and
acetic acid 2% ear drops.
> Otitis media will involve the tympanic membrane and the pain will be in
the ear, not pre-auricular. Treated with analgesics and antipyretics for adults,
and antibiotics for children.
498. An ECG of an elderly lady who collapsed in the ED shows rapid
ventricular rate of 220 bpm, QRS=140ms. What is the most probable dx?
a. Atrial fibrillation
b. VT
c. SVT
d. Mobitz type1 2 degree heart block
e. Sinus tachycardia
KEY- B
nd

VTach- Sequence of 3 or more ventricular beats. Atrial rate 60-100.


Ventricular rate 110-250. Wide QRS complex (>120ms). Regular. Can
progress to VFib and cardiac arrest. Ttt- if pulse present, cardioversion. If
pulseless, defibrillation.
SVT and AFib will have narrow QRS complexes.

499. A pt presents with purple papular lesions on his face and upper trunk
measuring 1-2 cm across. They arent painful or itchy. What is the single
most likely dx?
a. Kaposis sarcoma
b. Hairy leukoplakia
c. Cryptosporidium
d. CMV infection
e. Cryptococcal infection
KEY- A
Kaposis sarcoma is a spindle-cell tumour derived from capillary endothelial
cells or from fibrous tissue, caused by human herpes virus. It presents as non
painful purple papules ( to 1 cm) or plaques on skin and mucosa (any
organ). It is not itchy, and it metastasizes to nodes. Associated with AIDS
infection. OHCM 9th edition, page 716.
500. A 6yo boy is clinically obese, his BMI >95 centile. He has no other
medical prbs, examination is unremarkable. His mother says that she has
tried everything to help him lose weight. What is the most probable dx?
a. Cushings syndrome
b. Congenital hypothyroidism
c. Downs syndrome
d. Lawrence moon biedel syndrome
e. Primary obesity
KEY- E
Features support primary childhood obesity. No other associated signs or
symptoms except obesity. Its not cushing (No moon face, pigmentation,
hyperglycaemia) etc. Its not congenital hypothyroidism, (No weight loss
despite increased appetite), not Down syndrome (No features of Down) or
Lawrence moon biedel syndromes (No learning difficulties).
th

501. A 20yo boy is brought by his parents suspecting that he has taken some drug. He is
agitated,
irritated and cant sleep. Exam: perforated nasal septum. Which of the following is the
most
likely to be responsible for his symptoms?
a. Heroine
b. Cocaine
c. Ecstasy/MDMA/amphetamine
d. Alcohol

e. Opioids
B. Cocaine
perforated nasal septum
Heroine: pinpoint pupils, dec consciousness, bradycardia, resp depression, hypoxia.
antidote: naloxone
Ecstasy/MDMA/amphetamine: agitation, anxiety, confusion, ataxia, tachycardia,
hypertension, hyponatraemia, hyperthermia, rhabdomyolysis
Mechanism of action
cocaine blocks the uptake of dopamine, noradrenaline and serotonin
The use of cocaine is associated with a wide variety of adverse effects:
Cardiovascular effects
myocardial infarction
both tachycardia and bradycardia may occur
hypertension
QRS widening and QT prolongation
aortic dissection
Neurological effects
seizures
mydriasis
hypertonia
hyperreflexia
Psychiatric effects
agitation
psychosis
hallucinations
Others

hyperthermia
metabolic acidosis
rhabdomyolysis

Management of cocaine toxicity


in general benzodiazipines are generally first-line for most cocaine related problems
chest pain: benzodiazipines + glyceryl trinitrate. If myocardial infarction develops then primary
percutaneous coronary intervention
hypertension: benzodiazipines + sodium nitroprusside
the use of beta-blockers in cocaine-induced cardiovascular problems is a controversial issue. The
American Heart Association issued a statement in 2008 warning against the use of beta-blockers
(due to the risk of unopposed alpha-mediated coronary vasospasm) but many cardiologists since
have questioned whether this is valid. If a reasonable alternative is given in an exam it is

probably wise to choose it.

502. For a pt presenting with Parkinsons disease which of the following drugs is most
useful in the management of the tremor?

a. Apomorphine
b. Cabergoline
c. Selegiline
d. Amantadine
e. Benzhexol
e. Benzhexol
Antimuscarinics
block cholinergic receptors
now used more to treat drug-induced parkinsonism rather than idiopathic Parkinson's
disease
help tremor and rigidity
e.g. procyclidine, benzotropine, trihexyphenidyl (benzhexol)
503. A 26yo woman has become aware of increasing right sided hearing deficiency
since her recent pregnancy. Her eardrums are normal. Her hearing tests show: BCnormal. Weber test lateralizes to the right ear. What is the single most likely dx?
a. Encephalopathy
b. Functional hearing loss
c. Tympano-sclerosis
d. Otosclerosis
e. Sensorineural deafness
key is D. Otosclerosis. [There are no features of encephalopathy. As Weber test is lateralized it is unlikely to
be functional hearing loss. In tympanosclerosis ear drum becomes chalky white. So as the ear drum is
normal it is not tympanosclerosis. Weber test is lateralized to right and deafness is also on the right. So it not
sensorineural deafness but conductive deafness which makes otosclerosis as the most likely diagnosis.
Rinne's test
air conduction (AC) is normally better than bone conduction (BC)
if BC > AC then conductive deafness
Weber's test
in unilateral sensorineural deafness, sound is localised to the unaffected side
in unilateral conductive deafness, sound is localised to the affected side

504. A 58yo T1DM on anti-HTN therapy for 13yrs developed central chest pain for 45
mins while
driving a/w cold sweating and dyspnea. What is the single most appropriate dx?
a. MI
b. Pericarditis
c. Pulmonary embolism
d. Costochondritis
e. Pneumothorax
a. MI

characteristic central or epigastric chest pain radiating to the arms, shoulders, neck, or jaw.
The pain is described as substernal pressure, squeezing, aching, burning, or even sharp pain.
Radiation to the left arm or neck is common.
Chest pain may be associated with sweating, nausea, vomiting, dyspnoea, fatigue, and/or
palpitations.

Pericarditis chest pain: may be pleuritic. Is often relieved by sitting forwards


Pulmonary embolism pleuritic chest pain, dyspnoea and haemoptysis
Costochondritis Chest wall pain with a history of repeated minor trauma or unaccustomed activity
(eg, painting, moving furniture) is common

505. A man was brought to the ED from a shopping mall after collapsing there. He is
conscious and answering questions now. His ECG shows irregular rhythm. Your choice
of inv:
a. CT
b. MRI
c. 24h ECG
d. Echo
d. Echo
The man had a syncopial attack ..the most valvular cause for it is aortic stenosis which needs an
Echo to diagnose it or if there is any other valvular lesion or ventricular dysfunction
go for echo just to exclude any structural abnormalities.
holter- ecg is already said to be irregular. we already know that there is an rhythm problem so no
use to holter.
If in history something indicated towards TIA or stroke then CT or MRI would be considered.

506. A 10yo boy is clinically obese and the shortest in his class. He had a renal
transplant last year and his mother is worried that he is being bullied. What is the most
probable dx?
a. Cushings syndrome
b. Congenital hypothyroidism
c. Pseudocushings syndrome
d. Lawrence moon biedel syndrome
e. Downs syndrome
a. Cushings syndrome
he's on steroids post-renal transplant, Oral steroids is the chief cause of Cushing's syndrome (OHCM, 8th,
page 124).
Laurance-moon synd. Night blindness due to retinitis pigmentosa, polydactyly are important features
(OHCS/8th/648). With no emphasis on more common features, Oral-steroid induced (post renal transplant)
Cushing makes more sense.
Congenital hypothyroidism Feeding difficulties, Somnolence, Lethargy, Low frequency of crying,
Constipation
Downs syndrome he is clinically obese not conganital case,down syndrome has cardaic problem and
characteristic facial feature and mentalyy retarded so it cant be option,these features are same for lawrence
moon but ptnt are mentally retarded whereas kid is studying in normal school rather than special one
Pseudocushings syndromeit is mainly an idiopathic condition.Some frequently occurring illnesses can
induce a phenotype that largely overlaps with Cushing syndrome and is accompanied by hypercorticolism

507. A 45yo man had cancer of head of pancreas which has been removed. He has a hx
of
longstanding heartburn. He now comes with rigid abdomen which is tender, temp 37.5C,
BP=90/70mmHg, pulse=120bpm. What is the next step of the inv?
a. CT abdomen

b. XR abdomen
c. MRI abdomen
d. US abdomen
e. Endoscopy
b. XR abdomen
Long standing Heart burn - peptic ulcer disease resulting into hollow viscous perforation leading to
gas under diaphragm in x-ray abdomen!
where are all those sign of acute pancreatitis in this case except hypotension and tachycardia which can
occur with perotinitis.suppose its pancreatitis ,do u think cT is nxt step after presentation? Nxt step must be
serum amylase and lipase and cT is most accurate.

Laparoscopy has become a routine procedure in the management of acute


abdominal disease

508. A 50yo man presents to the ED with acute back pain radiating down to his legs.
Pain which is usually relieved by lying down and exacerbated by long walks and prolong
sitting. What inv
would be the best option?
a. MRI
b. CT spine
c. XR spine
d. Dual energy XR abruptiometry
e. Serum paraprotein electrophoresis
a. MRI
Diagnosis most likely Prolapsed Intervertebral Disc. Sudden onset acute back pain radiating down the leg,
and it is relieved on lying down and exacerbated by prolonged walks and on coughing and moving the back.
Investigation done is MR Spine to look for prolapsed disc and nerve root compression.
Never think of CT in case of spinal cord compression
mri... better for visualisin soft tissue.. ct better if bony detail is desired.. this is lumbar degenerative disc
disease most likely due to a herniated nucleus pulposus at l4/5 or l5/s1

Lumbosacral disc herniation: (patient.co.uk)


If there is nerve entrapment in the lumbosacral spine, this leads to symptoms of
sciatica which include:
o Unilateral leg pain that radiates below the knee to the foot/toes.
o The leg pain being more severe than the back pain.
o Numbness, paraesthesia, weakness and/or loss of tendon reflexes,
which may be present and are found in the same distribution and
only in one nerve root distribution.
o A positive straight leg raising test (there is greater leg pain and/or
more nerve compression symptoms on raising the leg).
o Pain which is usually relieved by lying down and exacerbated by
long walks and prolonged sitting.
o MRI is very sensitive in showing disc herniations

Management
Simple analgesics as first line
Pain due to a herniated lumbosacral disc may settle within six weeks. If it does not, or there

are red flag signs such as the possibility of cauda equina syndrome, referral to an
orthopaedic or neurosurgeon should be considered.

509. What is the most appropriate antibiotic to treat uncomplicated chlamydial infection
in a 21yo
female who isnt pregnant?
a. Erythromycin
b. Ciprofloxacin
c. Metronidazole
d. Cefixime
e. Doxycycline
e. Doxycycline
Chlamydia is the most prevalent sexually transmitted infection in the UK.
Management
doxycycline (7 day course) or azithromycin (single dose). The 2009 SIGN guidelines
suggest azithromycin should be used first-line due to potentially poor compliance
with a 7 day course of doxycycline
if pregnant then erythromycin or amoxicillin may be used.
Potential complications

epididymitis
pelvic inflammatory disease
endometritis
increased incidence of ectopic pregnancies
infertility
reactive arthritis
perihepatitis (Fitz-Hugh-Curtis syndrome)

510. A 45yo manual worker presented with a 2h hx of chest pain radiating to his left arm.
His ECG is normal. What is the single most appropriate inv?
a. Cardiac enzymes
b. CXR
c. CT
d. ECG
e. V/Q scan
a. Cardiac enzymes
to rule out NSTEMI.

Non-ST-elevation ACS (NSTE-ACS): patients present with acute chest pain but without
persistent ST-segment elevation. The ECG shows persistent or transient ST-segment
depression or T-wave inversion, flat T waves, pseudo-normalisation of T waves, or no ECG
changes at presentation.
Management:
All patients should receive
aspirin 300mg
nitrates or morphine to relieve chest pain if required

Antithrombin treatment. Fondaparinux should be offered to patients who are not at a high risk of bleeding
and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a
patients creatinine is > 265 mol/l unfractionated heparin should be given.

Clopidogrel 300mg should be given to all patients and continued for 12 months.

Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban) should be given to


patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month
mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital
admission.

Coronary angiography should be considered within 96 hours of first admission to hospital to patients who
have a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in patients
who are clinically unstable.

511. A 26yo woman had bipolar disorder for 10yrs and is on Lithium for it. She is
symptom free for
the past 4 years. She is now planning her pregnancy and wants to know whether she
should
continue taking lithium. What is the single most appropriate advice?
a. Continue lithium at the same dose and stop when pregnancy is confirmed
b. Continue lithium during pregnancy and stop when breast feeding
c. Reduce lithium dosage but continue throughout pregnancy
d. Reduce lithium gradually and stop when pregnancy is confirmed
e. Switch to sodium valproate
d. Reduce lithium gradually and stop when pregnancy is confirmed
symptom free for last 4 years. Lithium is teratogenic.
Adverse effects

nausea/vomiting, diarrhoea
fine tremor
polyuria (secondary to nephrogenic diabetes insipidus)
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain

Monitoring of patients on lithium therapy


inadequate monitoring of patients taking lithium is common - NICE and the National Patient Safety
Agency (NPSA) have issued guidance to try and address this. As a result it is often an exam hot
topic
lithium blood level should 'normally' be checked every 3 months. Levels should be taken 12 hours
post-dose
thyroid and renal function should be checked every 6 months
Pregnancy: avoid in first the trimester (teratogenic). Only use in the second and third trimester if
considered essential, ie a severe risk to the patient, and monitor levels closely, as dose
requirements may alter.
Breast-feeding: avoid, as present in milk, and there is risk of toxicity in an infant. Bottle-feeding is
advisable.

Withdrawal
Abrupt withdrawal (both because of poor compliance or rapid change in dose) can precipitate
relapse. Withdraw lithium slowly over several weeks, watching for relapse.

512. A pt presents with dysphagia and pain on swallowing. He has sore mouth and
soreness in the corners of the mouth. What is the single most likely dx/
a. Kaposis sarcoma
b. Molluscum contagiosum
c. CMV infection
d. Candida infection
e. Toxoplasma abscess
d. Candida infection
Pain on swallowing is classic for candida.
Kaposi's sarcoma
caused by HHV-8 (human herpes virus 8)
presents as purple papules or plaques on the skin or mucosa (e.g. gastrointestinal and respiratory
tract)
skin lesions may later ulcerate
respiratory involvement may cause massive haemoptysis and pleural effusion
radiotherapy + resection
Molluscum contagiosum
The majority of cases occur in children (often in children with atopic eczema), with the maximum incidence
in preschool children aged 14 years.characteristic pinkish or pearly white papules with a central umbilication,
which are up to 5 mm in diameter. Lesions appear in clusters in areas anywhere on the body (except the
palms of the hands and the soles of the feet).

CMV infection
Infection is worldwide and usually asymptomatic . The most common disease manifestation is
gastrointestinal disease. CMV pneumonia is the most serious complication, but has become less common
with prevention strategies for at-risk patients. Rare manifestations include retinitis and encephalitis.

ToxoplasmaThis is asymptomatic in most cases.Toxoplasmic chorioretinitis.Toxoplasmic


encephalitis.Pneumonitis.Multiorgan involvement with respiratory failure and shock.

513. A 30yo lady has epistaxis for 30mins. Her Hgb is normal, MCV normal, WBC
normal,
PT/APTT/Bleeding time are normal. Where is the defect?
a. Plts
b. Coagulation factor
c. Sepsis
d. Anatomical
e. RBC
d. Anatomical
All labs normal.

Trauma to the nose (the most common cause) - especially nose picking!
Insertion of foreign bodies and excessive nose blowing may also be seen as
trauma. The latter is likely to occur with a cold when the nasal mucosa is
congested. Sinusitis causes nasal congestion.
Disorders of platelet function - thrombocytopenia and other causes of abnormal
platelets, including splenomegaly and leukaemia. Waldenstrm's
macroglobulinaemia may present with nosebleeds. Idiopathic thrombocytopenic
purpura (ITP) can occur in children and young adults.
Drugs - aspirin and anticoagulants.
Disorders of platelets are more likely to be a problem than clotting factor deficiency.
Abnormalities of blood vessels in the elderly arteriosclerotic vessels prolong
bleeding. Hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber syndrome)
causes recurrent epistaxis from nasal telangiectases.
Malignancy of the nose may present with bleeding - juvenile angiofibroma is a
highly vascular benign tumour that typically presents in adolescent males.
Cocaine use - if the septum looks sloughed or atrophic ask about use of cocaine.
Other conditions - Wegener's granulomatosis and pyogenic granuloma can present
as an epistaxis.

514. Midpoint between the suprasternal notch and pubic symphysis. What is the single
most
appropriate landmark?
a. Fundus of the gallbladder
b. Mcburneys point
c. Stellate ganglion
d. Deep inguinal ring
e. Transpyloric plane
e. Transpyloric plane
An upper transverse, the transpyloric, halfway between the jugular notch and the upper border of the
symphysis pubis; this indicates the margin of the transpyloric plane, which in most cases cuts through the
pylorus, the tips of the ninth costal cartilages and the lower border of the first lumbar vertebra;

Fundus located at the tip of the 9 costal cartilage


th

Mcburneys point one-third of the distance from the anterior superior iliac spine to the umbilicus

Stellate ganglion located at the level of C7 (7th cervical vertebrae), anterior to the transverse process
of C7, superior to the neck of the first rib, and just below the subclavian artery

Deep inguinal ring immediately above the midpoint of the inguinal ligament (midway
between the anterior superior iliac spine and the pubic tubercle)

Structures crossed
The transpyloric plane is clinically notable because it passes through several important
abdominal structures. These include:
lumbar vertebra 1 and hence passes just before the end of the spinal cord in
adults.
the fundus of the gallbladder
the end of the spinal cord
the Neck of pancreas

the origin of the superior mesenteric artery from the abdominal aorta and
termination of the superior mesenteric vein at the hepatic portal vein
the left and right colic flexure
hilum of the kidney on the left
hilum of the kidney on the right
the root of the transverse mesocolon
duodenojejunal flexure
the 1st part of the duodenum
the upper part of conus medullaris
the spleen
the pylorus of the stomach which will lie at this level approximately 5 cm to the
right of the midline.
cisterna chyli (which drains into the thoracic duct)

515. Tip of the 9th costal cartilage. What is the single most appropriate landmark?
a. Fundus of the gallbladder
b. Deep inguinal ring
c. Termination of the spinal cord
d. Transpyloric plane
e. Vena cava opening in the diaphragm
a. Fundus of the gallbladder
spinal cord around the L1/L2 vertebral level, forming a structure known as the conus medullaris.

Apertures through the diaphragm


1. Vena caval hiatus (vena caval foramen)
at the level of T8 and transmits the IVC and occasionally the phrenic nerve.
2. Esophageal hiatus
at the level of T10 and transmits the esophagus and vagus nerves.
3. Aortic hiatus
at the level of T12 and transmits the aorta, thoracic duct, azygos vein, an
occasionally greater splanchnic nerve.

516. A child complains of RIF pain and diarrhea. On colonoscopy, granular transmural
ulcers are seen near the ileo-cecal junction. What should be the management?
a. Sulfasalazine
b. Oaracetamol
c. Ibuprofen
d. Metronidazole
a. Sulfasalazine
Crohns disease-transmural ulcers

metronidazole is often used for isolated peri anal disease


Remission
glucocorticoids (oral, topical or intravenous) are generally used to induce remission.
5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as
effective

stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help
ulcerative colitis)
Maintenance
azathioprine or mercaptopurine is used first-line to maintain remission
methotrexate is used second-line
517. A 60yo woman presents with acute onset of bone and back pain following a rough
journey in a car. Exam: tenderness at mid-thoracic vertebra with spasm, she feels better
once she bends
forward. What is the single most probable dx?
a. Osteoporotic fx verterbra
b. Myofacial pain
c. Whiplash injury
d. MI
e. Pancreatitis
b. Myofacial pain
Myofascial pain syndrome typically occurs after a muscle has been contracted
repetitively.
Only myofascial pain/muscle sprain relieves on change of position.
Whiplash is only for cervical vertebrae
osteoporotic fx has dull pain and persistent or even worse on movement.
After repeated contraction of a muscle there occur spasm of the muscle and often the
pain may felt in some other part (referred pain). Here rough journey and associated
spasm is clincher. In vertebral fracture you will find neurological features which is absent
here.
Spinal Stenosis pain also Relieved by sitting down, leaning forwards and crouching
down

518. A 70yo woman presents with recurrent episodes of parotid swelling. She complains
of difficulty in talking and speaking and her eyes feel gritty on waking in the morning.
What is the single most likely dx?
a. C1 esterase deficiency
b. Crohns disease
c. Mumps
d. Sarcoidosis
e. Sjogrens syndrome
e. Sjogrens syndrome
main symptoms of xerophthalmia (dry eyes), xerostomia (dry mouth) and enlargement of the
parotid glands.
Difficulty eating dry food, typically cracker biscuits.
Difficulty with dentures.
Complaint of the tongue sticking to the roof of the mouth.
Speaking for long periods of time causes hoarseness.
Oral candidiasis and angular cheilitis.
Dry eyes tend to cause a gritty sensation. There is a predisposition to blepharitis and the
eyes may be sticky in the morning.

There may be recurrent parotitis, usually bilateral. Glands are usually enlarged
but this is not often the presenting feature.
Dryness of the mucosa of the trachea and bronchi may present as a dry cough.
Dryness of the pharynx and oesophagus may cause difficulty in swallowing, and
lack of saliva and secretions may predispose to gastro-oesophageal reflux.
There can be dry skin and vaginal dryness causing dyspareunia
Disease of the pancreas can lead to malabsorption and even acute pancreatitis
or chronic pancreatitis but a more likely cause of elevated serum amylase is
parotitis.
Fatigue is a common feature.
About 20% have Raynaud's phenomenon.

Associated diseases
There may be a number of associated autoimmune conditions, such as the variant of
scleroderma: calcinosis, Raynaud's phenomenon, (o)esophageal motility disorder,
sclerodactyly and telangiectasia (CREST). There may be joint pain, swelling and fatigue
rrecurrent miscarriage with antiphospholipid syndrome.

Investigations

Rheumatoid factor
Antinuclear antibodies
Schirmer test

519. A 39yo woman has not had her period for 10months. She feels well but is anxious
as her mother had an early menopause. Choose the single most appropriate initial inv?
a. Serum estradiol conc.
b. Serum FSH/LH
c. Serum progesterone conc.
d. None
e. Transvaginal US
b. Serum FSH/LH
Premature Menopause (ovarian faililure)shoud be ruled out.So FSH and LH(very high)
Premature Ovarian Failure (menopause before 40 years of age).

climacteric symptoms: hot flushes, night sweats


infertility
secondary amenorrhoea
raised FSH, LH levels
serum estradiol reflects primarily the activity of the ovaries. useful in the detection of
baseline estrogen in women with amenorrhea or menstrual dysfunction, and to detect the
state of hypoestrogenicity and menopause.
Serum progesterone: indicates if failure to ovulate
7 days prior to expected next period
520. A 50yo man with DM suddenly develops persistent crushing central chest pain
radiating to the neck. What is the single most appropriate dx?
a. Angina
b. Costochondritis (tietzs disease)

c. Dissecting aneurysm
d. MI
e. Pulmonary embolism
c. Dissecting aneurysm
Pain can radiate to back (classically described in questions) or to the neck as well. MI is an important
differential but usually MI in diabetics is silent one.
Angina does not radiate, costochondritis mostly have localised pain
In aortic dissection, pain is abrupt in onset and maximal at the time of onset. In contrast, the pain associated
with acute myocardial infarction starts slowly and gains in intensity with time. It is usually more oppressive
and dull.
Although tearing is the classical description, the pain is described as sharp more often than tearing, ripping,
or stabbing.

Investigations
Often the first problem is to distinguish aortic dissection from myocardial infarction. Both conditions may
exist if the dissection involves the coronary ostium. For this reason, the electrocardiogram (ECG) is very
important.

Best: MRI
521. A 22yo man has rushed into the ED asking for help. He describes recurrent
episodes of
fearfulness, palpitations, faintness, hyperventilation, dryness of the mouth with peri-oral
tingling and cramping of the hands. His symptoms last 5-10 mins and have worsened
since their
onset 3months ago. He is worried he may be having a heart attack. An ECG shows
sinus
tachycardia. What is the single most appropriate immediate intervention?
a. High flow oxygen
b. IV sedation
c. Rebreathe into a paper bag
d. Refer for anxiety management course
e. Refer for urgent cardiology opinion
c. Rebreathe into a paper bag

Characteristic symptoms experienced during


panic attacks
Panic disorder manifests as the sudden, spontaneous and unanticipated occurrence of panic
attacks, with variable frequency, from several in a day to just a few per year:
Palpitations, pounding heart or accelerated heart rate.
Sweating.
Trembling or shaking.
Dry mouth.
Feeling short of breath, or a sensation of smothering.
Feeling of choking.
Chest pain or discomfort.
Nausea or abdominal distress.

Feeling dizzy, unsteady, light-headed or faint.


Derealisation or depersonalisation (feeling detached from oneself).
Fear of losing control or 'going crazy'.
Fear of dying.
Numbness or tingling sensations.
Chills or hot flushes.

522. An 8yo boy has longstanding asthma. He has admitted with a severe episode and
is tired and drowsy. He has not improved on oxygen, inhaled B2 agonist and IV
hydrocortisone. CXR shows bilateral hyperinflation. He is too breathless to use a
peakflow meter and is O2 sat <90%. What is the single most appropriate inv?
a. CBG
b. CXR
c. CT chest
d. Pulse oximetry
e. Spirometry
a. CBG
cbg=capillary blood gas, abg= arterial blood gas any one can be used.
ABG to assess the severity to guide oxygen therapy and to decide if intubation is needed or not.

Clinical assessment of the severity of an acute asthma attack in those aged over 2
years
Acute severe
Unable to complete sentences in one breath.
Unable to feed or talk.
Pulse >125 in those aged over 5 years or
>140 in 2- to 5-year-olds.
Respiratory rate >30 in those aged over 5
and >40 in 2- to 5-year-olds.

Life-threatening
Silent chest.
Cyanosis.
Poor respiratory
effort.
Hypotension.
Exhaustion.
Confusion.
Coma.

523. A man was operated for colorectal ca. His pain is relieved with morphine 60mg bd
PO but now he cant swallow medications. What will be the next regimen of analgesic
administration?
a. Oxycodone
b. Fentanyl patch
c. Morphine 60mg IV/d
d. Morphine 240mg IV/d
b. Fentanyl patch

A regular 4-hourly starting dose for opioid-naive patients is usually 5-10 mg


morphine.
Once pain relief is at a satisfactory and stable level, sustained-release
preparations can be substituted to allow od or bd dosing
Any breakthrough pain not associated with unusual activity should be treated
with morphine elixir or ordinary tablets at 1/6 total daily dose.
the breakthrough dose of morphine is one-sixth the daily dose of morphine
When increasing the dose of opioids the next dose should be increased by 3050%.
If vomiting, dysphagia or increasing weakness prevent patients from taking oral
morphine then usual practice is to convert to a subcutaneous infusion of opioid
via a device such as a syringe driver.( in whom oral opioids are not suitable and
analgesic requirements are unstable) Injection site should be changed every 2-3
days.
An alternative to both oral morphine and subcutaneous diamorphine in patients with
stable pain is transdermal fentanyl or buprenorphine patches. (in whom oral opioids
are not suitable and analgesic requirements are stable) They can be useful in
ambulatory patients where the following exist:
-Problems with the oral route.
-Intractable constipation or subacute obstruction.
-Morphine intolerance.
Consider if agitated confusion is due to opioid toxicity rather than uncontrolled pain
before giving further opioids. Consider switching to an alternative strong opioid.
Alternatives include hydromorphone, methadone and oxycodone
Consider changing the route of administration - eg where gastrointestinal absorption
is poor, consider switching to skin patches.
opioids should be used with caution in patients with chronic kidney disease.
Alfentanil, buprenorphine and fentanyl are preferred

Oral to oral route conversions[2]

Converting

Converting to:

Divide 24-hour dose of current opioid by figure


below to calculate initial 24-hour dose of new opioid

from:
(new opioid)
(current
opioid)

oral codeine

oral morphine

Divide by 10

oraltramadol

oral morphine

Divide by 5

oral morphine

oral oxycodone

Divide by 2

oral morphine

oralhydromorphone

Divide by 7.5

524. Just above the mid-inguinal point. What is the single most appropriate landmark?
a. Femoral artery pulse felt
b. Mcburneys point
c. Stellate ganglion
d. Deep inguinal ring
e. Transpyloric plane
d. Deep inguinal ring

525. 5th ICS in the ant axillary line. What is the single most appropriate landmark?
a. Apex beat
b. Chest drain insertion
c. Stellate ganglion
d. Transpyloric plane
e. Vena cava opening into the diaphragm
b. Chest drain insertion
Surface anatomy of Apex beat is left 5th ICS midclavicular line.

526. A 34yo man with MS has taken an OD of 100 tablets of paracetamol with intent to
end his life. He has been brought to the ED for tx but is refusing all intervention.
a. Assessment
b. Evaluate pts capacity to refuse tx
c. Establish if pt has a prv mental illness
b. Evaluate pts capacity to refuse tx

Urgent treatment

Consent not needed when urgent treatment is required:

To save the patient's life.


To prevent a serious deterioration in the patient's condition, so long as the
treatment is not irreversible.
To alleviate serious suffering so long as the treatment is neither irreversible nor
hazardous.
To prevent the patient from behaving violently or being a danger to self or others
so long as the treatment is neither irreversible nor hazardous, and represents
the minimum interference necessary.

527. A 23yo woman with painless vaginal bleeding at 36wks pregnancy otherwise
seems to be
normal. What should be done next?
a. Vaginal US
b. Abdominal US
c. Vaginal exam
d. Reassurance
b. Abdominal US
to assess fetal being and check placenta previa
vaginal US is more accurate but not initial when bleeding.
No PV until no PP
Placenta previa
Painless bleeding starting after the 28th week (although spotting may occur earlier) is usually
the main sign.

Acute bleeding
Admit the patient to hospital.
DO NOT PERFORM A VAGINAL EXAMINATION, as this may start torrential bleeding in the
presence of placenta praevia.

Blood loss is assessed and cross-matched for possible transfusion.


Resuscitation if indicated; the mother is the priority and should be stabilised prior
to any assessment of the fetus.
Appropriate surgical intervention may be required:
o In severe bleeding the baby is delivered urgently whatever its
gestational age.
o Hysterectomy should also be considered in severe cases.
If immediate delivery is not likely, maternal steroids may be indicated in order to
promote fetal lung development and reduce the risk of respiratory distress
syndrome and intraventricular haemorrhage.

528. A 29yo lady admitted with hx of repeated UTI now developed hematuria with loin
pain. What is the most probable dx?
a. Acute pyelonephritis
b. Chronic pyelonephritis
c. UTI
d. Bladder stone
a. Acute pyelonephritis

Presentation
Onset is usually rapid with symptoms appearing over a day or two. There is unilateral or
bilateral loin pain, suprapubic or back pain. Fever is variable but can be high enough to
produce rigors. Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur.
There may or may not be accompanying lower urinary tract symptoms with frequency,
dysuria, gross haematuria or hesitancy. Gross haematuria occurs in 30-40% of young
women. The patient looks ill and there is commonly pain on firm palpation of one or both
kidneys and moderate suprapubic tenderness without guarding.
Investigation of choice:
Contrast-enhanced helical/spiral CT (CECT) scan is the best investigation in adults
In children, the choice is between ultrasound and CT scanning. CT is more sensitive but
the exposure to radiation may make ultrasound a safer option.
Treatment: ciprofloxacin for seven to ten days

529. A 45yo chronic smoker attends the OPD with complaints of persistent cough and
copious
amount of purulent sputum. He had hx of measles in the past. Exam: finger clubbing and
inspiratory crepitations on auscultation. What is the single most likely dx/
a. Interstitial lung disease
b. Bronchiectasis
c. Asthma
d. COPD
e. Sarcoidosis
b. Bronchiectasis
Bronchiectasis -(clubbing is not present in pure COPD)
Plus all the signs and symptoms are characteristic of bronchiectasis.
- Copious and purulent sputum
- Finger clubbing
- Post infective occurrence (as can be noted with pertussis, measles, recurrent childhood bronchiolitis etc)
That being said, he probably has underlying COPD owing to the history of chronic smoking, which makes
him susceptible to repeated viral infections of the respiratory tract and consequently bronchiectasis.
If COPD ever presents with finger clubbing, we investigate for underlying bronchogenic Ca or
bronchiectasis.

Interstitial lung disease The most common symptom of all forms of interstitial lung disease is
shortness of breath. dry nonproductive cough.
Asthma wheeze, breathlessness, chest tightness and cough, particularly if:
symptoms worse at night and in the early morning
symptoms in response to exercise, allergen exposure and cold air

symptoms after taking aspirin or beta blockers

COPD patients over 35 years of age who are smokers or ex-smokers and have symptoms such as
exertional breathlessness, chronic cough or regular sputum production.

Bronchiectasis
Bronchiectasis describes a permanent dilatation of the airways secondary to
chronic infection or inflammation.
Post-infection - eg, childhood respiratory viral infections (measles, pertussis,
influenza, respiratory syncytial virus), tuberculosis, bacterial pneumonia. Infection
is the most common cause.
persistent daily expectoration of large volumes of purulent sputum.
dyspnoea, chest pain and haemoptysis. Bronchiectasis may progress to
respiratory failure and cor pulmonale.
Coarse crackles are the most common finding
The gold standard for diagnosis is HRCT of the chest.
first-line treatment is amoxicillin 500 mg three times a day or clarithromycin 500
mg twice daily
All children and all adults up to the age of 40, presenting with bronchiectasis,
should have investigations for cystic fibrosis.

530. A 68yo man has had malaise for 5 days and fever for 2 days. He has cough and
there is dullness to percussion at the left lung base. What is the single most appropriate
inv?
a. Bronchoscopy
b. CXR
c. CT
d. MRI
e. V/Q scan
b. CXR
If a person is sufficiently sick to require hospitalization, a chest radiograph is
recommended.
A CT scan can give additional information in indeterminate cases.

Pneumonia
Presentation
Symptoms: cough, purulent sputum which may be blood-stained or rustcoloured, breathlessness, fever, malaise.
Diagnosis is unlikely if there are no focal chest signs and heart rate, respiratory
rate and temperature are normal.
The elderly may present with mainly systemic complaints of malaise, fatigue,
anorexia and myalgia.
Signs: tachypnoea, bronchial breathing, crepitations, pleural rub, dullness with
percussion.
CURB-65 criteria of severe pneumonia
Confusion (abbreviated mental test score <= 8/10)
Urea > 7 mmol/L
Respiratory rate >= 30 / min
BP: systolic <= 90 or diastolic <= 60 mmHg
age >= 65 years

Management
low or moderate severity CAP: oral amoxicillin. A macrolide should be added for
patients admitted to hospital
high severity CAP: intravenous co-amoxiclav + clarithromycin OR cefuroxime +
clarithromycin OR cefotaxime + clarithromycin

531. A 5yo child was admitted with hx of feeling tired and lethargic all the time, bleeding
gums and
sore throat since the last 3months. Exam: hepatosplenomegaly. What is the most
probable dx?
a. ALL
b. AML
c. CML
d. CLL
e. Lymphoma
a. ALL
Acute lymphoblastic leukaemia (ALL) is the most common type in children, primarily
affecting 2 to 8 year-olds.
Approximately 2/3s of AML patients are over 60.
hepatosplenomegaly in both. lymphadenopathy in ALL.
AML presents with bleeding gums, but bleeding tendency in ALL too. ALL also has gum
hypertrophy.
ALL
Symptoms
Fatigue, dizziness and palpitations
bone and joint pain
Recurrent and severe infections (oral, throat, skin, perianal infections commonly)
Fever
Left upper quadrant fullness and early satiety due to splenomegaly (10-20%)
Haemorrhagic or thrombotic complications due to thrombocytopenia or
disseminated intravascular coagulopathy (DIC) - for example, menorrhagia,
frequent nosebleeds, spontaneous bruising
Signs
Pallor
Tachycardia and a flow murmur
Nonspecific signs of infection
Petechiae,purpura or ecchymoses
hepatosplenomegaly
Lymphadenopathy
Gum hypertrophy
Cranial nerve palsy (especially III, IV, VI and VIII) in mature B-cell ALL

532. A 65yo man presents with back pain. Exam: splenomegaly and anemia. Blood:
WBC=22,
Hgb=10.9, Plt=100, ESR=25. He has been found to have Philadelphia chromosome.
What is the
single most likely dx?
a. ALL
b. AML
c. CML
d. CLL
e. Lymphoma
c. CML
CML is characterised by a consistent cytogenetic abnormality - a reciprocal translocation
between the long arms of chromosomes 22 and 9, t(9;22). The result is a shortened
chromosome 22, known as the Ph chromosome.

Symptoms

Fatigue.
Night sweats.
Weight loss.
Abdominal fullness or abdominal distension.
Left upper quadrant pain due to splenic infarction.

Signs

Splenomegaly - the most common physical finding


Hepatomegaly.
Enlarged lymph nodes are also a possibility.
Anaemia
Easy bruising.
Fever.
Gout due to rapid cell turnover.
Hyperviscosity syndrome due to leukocytosis - visual disturbance (fundoscopy
may show papilloedema, venous obstruction and retinal haemorrhages),
priapism,cerebrovascular accident (CVA), confusion.

FBC:
o
o

Leukocytosis is common.
Differential shows granulocytes at all stages of development and
increased numbers of eosinophils and basophils.
o Platelets may be elevated, decreased or normal levels.
o A mild-to-moderate, usually normochromic and normocytic, anaemia
is common.
Peripheral blood smear - all stages of maturation seen; often resembles a bone
marrow aspiration.

533. A 24yo woman has 8wk amenorrhea, right sided pelvic pain and vaginal bleeding.
She is
apyrexial. Peritonism is elicited in the RIF. Vaginal exam reveals right sided cervical
excitation.
What is the most probable dx?
a. Ectopic pregnancy
b. Salpingitis
c. Endometriosis
d. Ovarian torsion
e. Ovarian tumor
a. Ectopic pregnancy
amenorrea, pelvic pain n vaginal bleeding clinical triad of ectopic pregnancy
cervical excitation is sign in ectopic pregnancy and PID
cervical motion tenderness which is when bilateral we suspect PID n when unilateral ectopic most likely
since the pt is apyrexial this rules out PID

The most common symptoms are


Abdominal pain.
Pelvic pain.
Amenorrhoea or missed period.

Examination

There may be some tenderness in the suprapubic region.


Peritonism and signs of an acute abdomen may occur.
Women with a positive pregnancy test and any of the following need to be
referred immediately to hospital:
o Pain and abdominal tenderness.
o Pelvic tenderness.
o Cervical motion tenderness.
Vaginal bleeding (with or without clots).
The most accurate method to detect a tubal pregnancy is transvaginal ultrasound.
Human chorionic gonadotrophin (hCG) levels are performed in women with pregnancy of
unknown location who are clinically stable.

534. A 64 yo woman has been treated for breast cancer with tamoxifen. What other drug
should be added to her tx regime?
a. Bisphosphonates
b. Calcium
c. Vit D
d. Calcitonin
e. Phosphate binders
a. Bisphosphonates
bisphosphonates reduce the risk of bone metastasis in cancers and is normally taken as adjuvant therapy in
many types of tumours including breast cancer

Plus it prevents bone resorption


breast cancer can easily metastasise to bones and that in turn will lead to bone lysis so maybe thats why we
need bisphosphonates.
since the patient has been treated with TAMOXIFEN , we conclude the fact that she has a metastatic
disease.
According to BNF , the use of BISPHOSPHONATE in patients with metastatic breast cancer may reduce
pain and prevent skeletal complications of bone metastases.
The other choices like calcitonin and VIT D are of little value in postmenopausal women with metastases.

Bisphosphonates
Bisphosphonates decrease demineralisation in bone. They inhibit osteoclasts.
Clinical uses
prevention and treatment of osteoporosis
hypercalcaemia
Paget's disease
pain from bone metatases
Adverse effects
oesophagitis, oesophageal ulcers
osteonecrosis of the jaw
increased risk of atypical stress fractures of the proximal femoral shaft.
535. A 6yo woman with regular menses and her 28yo partner comes to the GP surgery
complaining of primary infertility for 2yrs. What would be the single best investigation to
see whether she is ovulating or not?
a. Basal body temp estimation
b. Cervical smear
c. Day2 LH and FSH
d. Day21 progesterone
e. Endometrial biopsy
d. Day21 progesterone
To check for whether it is ovulatiry or anovulatiry cycles. Progesterone level inceases and peaks 5 to six
days post ovulation. Which is 21 day progesterone levels

Infertility affects around 1 in 7 couples. Around 84% of couples who have regular sex will
conceive within 1 year, and 92% within 2 years
Causes
male factor 30%
unexplained 20%
ovulation failure 20%
tubal damage 15%

other causes 15%

Basic investigations
semen analysis
serum progesterone 7 days prior to expected next period (day 21 of 28 day
cycle)
indicates ovulation.
Interpretation of serum progestogen
Level

Interpretation

< 16 nmol/l

Repeat, if consistently low refer to specialist

16 - 30 nmol/l

Repeat

> 30 nmol/l

Indicates ovulation

Key counselling points


folic acid
aim for BMI 20-25
advise regular sexual intercourse every 2 to 3 days
smoking/drinking advice

536. A 10yo boy who takes regular high dose inhaled steroids for his longstanding
asthma has been advised to use bronchodilators to control his acute attacks. His parents
are unsure when should he use his bronchodilator. What is the single most appropriate
inv?
a. CXR
b. None
c. Peak flow rate diary
d. Pulse oximetry
e. Spirometry
c. Peak flow rate diary
spirometry is to make the diagnosis while Peak flow rate is for monitoring
PEF decides the severity of asthma attack..so when PEF will decreas during day he could take
bronchodilato
A peak flow diary is a useful way for you to write down and record your peak flow scores on a regular basis.
A peak flow is a measurement of how much air you can blow out of your lungs in a set amount of time. Peak
flow scores help you to see when your asthma is getting better of worse.

537. A woman presented with blurred vision and intermittent clumsiness for 3m.
Reflexes are brisk in her arm and optic disc is pale. What is the single most appropriate
test to confirm dx?
a. CSF analysis
b. CT
c. MRI
d. EEG
e. EMG
c. MRI
multiple sclerosis, investigation of choice is gadolinium enhanced mri.

Multiple sclerosis: features

3 times more common in women


most commonly diagnosed in people aged 20-40 years

Patient's with multiple sclerosis (MS) may present with non-specific features, for
example around 75% of patients have significant lethargy.
Visual

optic neuritis: common presenting feature


optic atrophy
Uhthoff's phenomenon: worsening of vision following rise in body temperature
internuclear ophthalmoplegia

Sensory
pins/needles
numbness
trigeminal neuralgia
Lhermitte's syndrome: paraesthesiae in limbs on neck flexion
Motor

spastic weakness: most commonly seen in the legs

Cerebellar
ataxia: more often seen during an acute relapse than as a presenting symptom
tremor
Others

urinary incontinence
sexual dysfunction
intellectual deterioration

538. A 63yo man presents after having a seizure. Exam: alert, orientated, inattention on
the left side and hyperreflexia of the arm. What is the most probable dx?

a. Cerebral tumor
b. Pituitary adenoma
c. Cerebellar abscess
d. Huntingtons chorea
e. Parkinsonism
a. Cerebral tumor
Inattention or neglect is a feature of parietal lobe lesion. If lesion is on right side there will be left sided
inattention. That is patient is unaware of his left side and he when shaves do it only to right half of face,
during eating eats only from the right half of plate and can not drive as he only aware of his right side and
totally unaware of left side of the road
nothing else fit thats the best expl.. pituitary will give bitemporal vision loss cerebellar signs are nystagmus
ataxia etc. Chorea is repeated movements.. its focal ant lobe lesion.
Seizure n hyperflexia (exaggerated reflexes) are indicators of space occupied lesion (SOL)
Because the pt has got upper motor neuron signs.
Its not pitutry because no signs of optic n compression and its not bilateral.
Its not cerebellar dis other wise he should have ataxia, pass pointing rombergism.
Its not chorea cuz no symptoms of chorea.
Not parkinson because no hypokinesia, tremor
seizure causing neuro deficit in elderly... first D/D should b cerebral tumour unless specified otherwise..

539. A 40yo man with a 25y hx of smoking presents with progressive hoarseness of
voice, difficulty swallowing and episodes of hemoptysis. He mentioned that he used to
be a regular cannabis user. What is the single most likely dx?
a. Nasopharyngeal cancer
b. Pharyngeal carcinoma
c. Sinus squamous cell carcinoma
d. Squamous cell laryngeal cancer
e. Hypopharyngeal tumor
d. Squamous cell laryngeal cancer
Hoarseness of voice is localizing the problem to the larynx

The symptoms of cancer of the pharynx differ according to the type:


Oropharynx: common symptoms are a persistent sore throat, a lump in the
mouth or throat, pain in the ear.
Hypopharynx: problems with swallowing and ear pain are common symptoms
and hoarseness is not uncommon.
Nasopharynx: most likely to cause a lump in the neck but may also cause nasal
obstruction, deafness and postnasal discharge.

Laryngeal Cancer

Smoking is the main avoidable risk factor for laryngeal cancer


Chronic hoarseness is the most common early symptom.
urgent CXR to decide where to refer
Flexible laryngoscopy is the best way to inspect the larynx
staging include CT and/or MRI scans.

540. A 30yo lady complains of intermittent diarrhea, chronic abdominal and pelvic pain
and
tenesmus. Sometimes she notices blood in her stool. Select the most likely cause
leading to her
symptoms?

a. Inflammatory bowel disease


b. Diverticulosis
c. Irritable bowel disease
d. Adenomyosis
e. UTI
a. Inflammatory bowel disease
classic features.

Diverticulosis is defined as the presence of diverticula which are asymptomatic.


The diagnosis of IBS should be considered if the patient has had the following for
at least 6 months:
abdominal pain, and/or
bloating, and/or
change in bowel habit
Adenomyosis is the invasion of the myometrium by endometrial tissue.
Extrauterine endometrial tissue causes inflammation, pain and the formation of
adhesions. Clinically its significance is as a cause of chronic pelvic pain,
dyspareunia and female infertility.

541. A 50yo lady with weak limbs when examined was found to have burn marks on
finger tips,
wasted and weak hands with diminished reflexes. She also has weak spastic legs and
dissociated
sensory loss. What is the dx?
a. MS
b. Syringomyelia
c. MND
d. Guillian-barre
e. Freidriechs ataxia
b. Syringomyelia
weakness and wasting of muscle, diminished or loss of tendon reflex, loss of pain and temperature sense,
experience of pain on touching skin, there are burn marks on finger due to loss of temperature sense, these
all points towards syringomyelia
MS- causes UMNL with brisk reflex not causes dissociated sensory loss. most common cause of dissociated
sensory loss - syringomyelia,& Brown-sequard syndrome.
motor+sensory-syringomyelia
motor+tongue-syringobulbia
motor only MND
Friedreich's ataxia is a progressive neurodegenerative disorder, typically with onset before 20 years of age.
Signs and symptoms include progressive ataxia, ascending weakness and ascending loss of vibration and
joint position senses, pes cavus, scoliosis, cardiomyopathy, and cardiac arrhythmias.
If the syrinx extends into the brainstem, syringobulbia results. This may affect one or more cranial nerves,
resulting in facial palsies.
Syringomyelia is more common in men

Sensory features
Pain and temperature sensation are lost due to spinothalamic tract damage.

Classically, the sensation loss is experienced in a shawl-like distribution over the


arms, shoulders and upper body.
Dysaesthesia (pain experienced when the skin is touched) is common.
Light touch, vibration and position senses in the feet are affected as the syrinx
enlarges into the dorsal columns.
Painless ulcers on the hands.
Motor features
These begin to occur as the syrinx extends and damages the lower motor
neurons of the anterior horn cells.
Muscle wasting and weakness begins in the hands and then affects the forearms
and shoulders.
Tendon reflexes are lost.
Claw hand may be present.
There may be respiratory muscle involvement.
Autonomic features
Bladder, bowel and sexual dysfunction can occur.
Horner's syndrome may be present.

Investigations

MRI is now primarily used for diagnosis


CT scanning is better at showing abnormalities of bony spinal canal, whilst MRI
scanning is better at showing soft tissue.
Plain X-rays may show a widened cervical canal.
Lumbar puncture is best avoided because of risk of herniation.

542. A 23yo woman is being followed up 6wks after a surgical procedure to evacuate the
uterus
following a miscarriage. The histology has shown changes consistent with a hydatidiform
mole.
What is the single most appropriate inv in this case?
a. Abdominal US
b. Maternal karyotype
c. Paternal blood group
d. Serum B-HCG
e. Transvaginal US
d. Serum B-HCG
Complete hydatidiform mole
Occurs when an empty egg is fertilized by a single sperm that then duplicates its own
DNA, hence the all 46 chromosomes are of paternal origin
Features
bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates
very high serum levels of human chorionic gonadotropin (hCG)

hypertension and hyperthyroidism* may be seen

Management
urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12
months
Around 2-3% go on to develop choriocarcinoma
In a partial mole a normal haploid egg may be fertilized by two sperms, or by one sperm
with duplication of the paternal chromosomes. Therefore the DNA is both maternal and
paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen
*hCG can mimic thyroid-stimulating hormone (TSH)

543. A 67yo man with hx of weight loss complains of hoarseness of voice. CT reveals
opacity in the right upper mediastinum. He denied any hx of difficulty breathing. What is
the single most
appropriate inv?
a. Laryngoscopy
b. Bronchoscopy
c. LN biopsy
d. Bronchoalveolar lavage
e. Barium swallow
c. LN biopsy
Hoarseness + weight loss.. suspicion of malignancy.

hoarseness due to Malignancy


Laryngeal cancer - smoking is major risk factor.
Other neck or chest tumours - eg, lung cancer, lymphoma, thyroid cancer.
Hoarseness persisting for >3 weeks requires investigation to exclude malignancy:
Carcinomas of larynx and lung must be considered, so CXR and/or laryngoscopy
are indicated.
National Institute for Health and Care Excellence (NICE) guidance on suspected
cancer states that for patients with hoarseness persisting for >3 weeks,
particularly smokers aged 50 years and heavy drinkers:
o Arrange urgent CXR.
o Refer patients with positive findings urgently to a team specialising in the
management of lung cancer.
o Refer patients with a negative finding urgently to a team specialising in
head and neck cancer.

544. A 52yo man whose voice became hoarse following thyroid surgery 1 wk ago shows
no
improvement. Which anatomical site is most likely affected?

a. Bilateral recurrent laryngeal nerve


b. Unilateral recurrent laryngeal nerve
c. Unilateral external laryngeal nerve
d. Bilateral external laryngeal nerve
e. Vocal cords
b. Unilateral recurrent laryngeal nerve
bilateral injury of the RLN leads to aphonia.
In unilateral damage, the patient voice is still preserved but it's harsh ( hoarse ) due to unilateral paralysis of
the vocal cords.
Direct injury to the vocal cords is unlikely in thyroid procedures since the larynx isn't opened.
The external laryngeal nerves are more frequently damaged than the RLN , but they cause only minor
changes in voice quality ( pitch changes).
Bilateral rln palsy will cause emergency airway obstruction and stridor
Vocal cord inj should be transient and improving
External laryngeal inj doesnt cause hoarseness
B due to close relation of the inferior thyroid artery to the recurrent laryngeal nerve the clamping of artery
during surgery might accidentally injured the nerve causing hoarseness of voice if bilaterally affected the
nerve it will most likely causing acute respiratory distress

545. A 73yo male presents with a 12m hx of falls. His relatives have also noticed rather
strange
behavior of late and more recently he has had episodes of enuresis. Exam:
disorientation to
time and place, broad-based, clumsy gait. What is the most probable dx?
a. Dementia
b. Pituitary adenoma
c. CVD
d. Syringomyelia
e. Normal pressure hydrocephalus
e. Normal pressure hydrocephalus
clincher: Gait, dementia and enuresis
the wet, wobbly and wacky grandpa
It is a reversible cause of dementia. Seen in elderly patients. Secondary to reduced CSF absorption at the
arachnoid villi.
Classical triad of features:1. Urinary incontinence
2. Dementia
3. Bradyphrenia
4. Gait abnormality
Imaging:
Hydrocephalus with an enlarged 4th ventricle
Management:
Ventriculoperitoneal shunting
one in which person talks vulgar things---> frontotemporal dementia
One in which dementia fluctuates---> lewy body dementia
One asso with parslysis---> vascular dementia
One with stepwise deterioration---> Alzheimer's disease

546. A 75yo nursing home resident complains of headache, confusion and impaired
vision for 4days. She has multiple bruises on her head. What is the most likely cause of
confusion in this pt/
a. Alcohol intoxication

b. Infection
c. Subdural hematoma
d. Hypoglycemia
e. Hyponatremia
c. Subdural hematoma
multiple bruises on her head
Subdural
haematoma

Bleeding into the outermost meningeal layer. Most commonly


occur around the frontal and parietal lobes.
Risk factors include old age, alcoholism and anticoagulation.
Slower onset of symptoms than a epidural haematoma.

547. A 50yo woman returned by air to the UK from Australia. 3days later she presented
with sharp chest pain and breathlessness. Her CXR and ECG are normal. What is the
single most
appropriate inv?
a. Bronchoscopy
b. Cardiac enzymes
c. CT
d. MRI
e. Pulse oximetry
f. V/Q scan
g. CTPA
g. CTPA
Long flight and sharp chest pain along with breathlessness points towards PE
As per NICE guidelines the most appropriate investigation is CTPA if ur suspecting PE. V/Q scan is
preferred in only few situation like pregnancy, Ckd patients, or ctpa n/a. U have to do wells scoring of the
patient and if its > 4, u straight away do CTpa .. Dont even wait for d dimer. Definitely CTPA in this case

medical student textbook triad of pleuritic chest pain, dyspnoea and haemoptysis.
computed tomographic pulmonary angiography (CTPA) is now the recommended gold
standard
Management:
Low molecular weight heparin (LMWH) or fondaparinux should be given initially after a
PE is diagnosed.An exception to this is for patients with a massive PE where
thrombolysis is being considered. In such a situation unfractionated heparin should be
used.
a vitamin K antagonist (i.e. warfarin) should be given within 24 hours of the
diagnosis
the LMWH or fondaparinux should be continued for at least 5 days or until the
international normalised ratio (INR) is 2.0 or above for at least 24 hours,
whichever is longer, i.e. LMWH or fondaparinux is given at the same time as
warfarin until the INR is in the therapeutic range
warfarin should be continued for at least 3 months.

NICE advise extending warfarin beyond 3 months for patients with


unprovokedPE.
for patients with active cancer NICE recommend using LMWH for 6 months

Thrombolysis
thrombolysis is now recommended as the first-line treatment for massive PE
where there is circulatory failure (e.g. hypotension). Other invasive approaches
should be considered where appropriate facilities exist

548. A tall thin young man has sudden pain in the chest and becomes breathless while
crying. What is the single most appropriate inv?
a. Cardiac enzymes
b. CXR
c. CT
d. ECG
e. V/Q scan
b. CXR
spontaneous pneumothorax .most often in young thin male ..due to rupture of bullous emphysema
patient may have marfans syndrome or alpha-1 antitrypsin deficiency

Secondary pneumothorax
Recommendations include:
if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is
short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm. If
aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should
be inserted. All patients should be admitted for at least 24 hours
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving
oxygen and admitting for 24 hours
549. A 21yo woman has had several sudden onset episodes of palpitations, sweating,
nausea and
overwhelming fear. On one occasion she was woken from sleep and feared she was
going insane. There is no prv psychiatric disorder. What is the most probable dx?
a. Pheochromocytoma
b. Panic disorder
c. GAD
d. Phobia
e. Acute stress disorder
b. Panic disorder
panic attack is MORE likely... it can be pheochromocytoma but "overwhelming fear" makes panic
attack look more fitting... It cant be phobia, because the attacks are just random without any known
trigger

Pheochromocytoma pressure symptoms

Treatment in primary care


NICE recommend either cognitive behavioural therapy or drug treatment
SSRIs are first-line. If contraindicated or no response after 12 weeks then
imipramine or clomipramine should be offered
550. A 55yo woman with a persistent cough and hx of smoking develops left sided chest
pain
exacerbated by deep breathing with fever and localized crackles. What is the single
most
appropriate dx?
a. Dissecting aneurysm
b. Pericarditis
c. Pneumonia
d. Pneumothorax
e. Pulmonary embolism
c. Pneumonia
dissec aneurysm will have a sharp pain radiating to the back.
pericarditis has similiar features , but i dont see a cardiac cause.
pneumothorax is seen in smokers , as a complication to COPD , but it wont have fever and above features. (
reduced air entry is seen in it, with hyper resonance on percussin ).
pulm embloism also seems unlikely , should have travel history .
looks like pneumonia then - pain on inspiration ( pleural pain ), fever , cough, and crackles !

Klebsiella pneumoniae is classically in alcoholics


Streptococcus pneumoniae (pneumococcus) is the most common cause of communityacquired pneumonia
Characteristic features of pneumococcal pneumonia
rapid onset
high fever
pleuritic chest pain
herpes labialis
Management
CURB-65 criteria of severe pneumonia
Confusion (abbreviated mental test score <= 8/10)
Urea > 7 mmol/L
Respiratory rate >= 30 / min
BP: systolic <= 90 or diastolic <= 60 mmHg
age >= 65 years
Patients with 3 or more (out of 5) of the above criteria are regarded as having a severe
pneumonia
The British Thoracic Society published guidelines in 2009:

low or moderate severity CAP: oral amoxicillin. A macrolide should be added for
patients admitted to hospital
high severity CAP: intravenous co-amoxiclav + clarithromycin OR cefuroxime +
clarithromycin OR cefotaxime + clarithromycin

551. A 40yo woman complains of dysphagia for both solids and liquids. She sometimes
suffers from
severe retrosternal chest pain. Barium swallow reveals a dilated esophagus which
tapers to a
fine distal end. What is the best management strategy?
a. Reassurance
b. Antispasmodics
c. Dilatation of the LES
d. Endoscopic diverticulectomy
e. Barium swallow
c. Dilatation of the LES
Achalasia typically presents in middle-age and is equally common in men and women
Investigations
manometry: excessive LOS tone which doesn't relax on swallowing - considered most

important diagnostic test

barium swallow shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance. This

is in contrast to the rat's tail appearance of carcinoma of the oesophagus

CXR: wide mediastinum, fluid level


Gold standard - Manometery

Treatment

intra-sphincteric injection of botulinum toxin


Heller cardiomyotomy for fit young patients.
balloon dilation for old unwell patients.

Complications : Aspiration pneumonia, perforation, GERD, Oesophagus CA.

552. A 38yo female G4 at 32wks of pregnancy presented with thick white marks on the
inside of her mouth for 3wks. Her mouth including her tongue appeared inflamed on
examination. She
smokes 20 cigarettes/day despite advice to quit. She attends her ANC regularly. What is
the
most probable dx?
a. Lichen planus
b. Aphthous ulcer
c. Smoking
d. Candidiasis
e. Leukoplakia
d. Candidiasis
pregnancy is one of the risk factors, as well as smoking.
Oral fluconazole 50 mg/day for 7 days.

Prevention of oral candidiasis

Patients taking oral/inhaled steroids - good inhaler technique, spacer device,


rinse mouth with water after use.
Denture wearers - thorough cleaning of dentures, leave them out at night, ensure
they fit correctly.
Smoking cessation.

Lichen planus is a flat topped violaceous skin lesion not associated with smoking.
Classically, white slightly raised lesions with a trabecular, lacy appearance on the inside
of the cheeks.Can be precipitated by trauma (Kbner's phenomenon).Topical steroids
are considered to be the first-line treatment for oral lichen planus. Topical
immunomodulators (eg, imiquimod) may be useful as second-line treatment in severe
oral lichen planus.
Aphthous ulcer clearly defined, painful, shallow rounded ulcers not associated with
systemic disease. They are not infective.
Leukoplakia This is a white patch adhering to oral mucosa that cannot be removed by
rubbing. It is usually a diagnosis of exclusion.

553. A 69yo woman has had a stroke. Her left upper and lower limbs are paralyzed and
she is having difficulty in speaking. Which anatomical site is most likely affected?
a. Hippocampus
b. Cerebellum
c. Internal capsule
d. Thalamus
e. Brain stem
c. Internal capsule
Internal capsule. Its lacunar infarct. Internal capsule has both corticospinal and corticobulbar fibers. Infarct
results in hemiparesis/ hemiplegia with dysphagia/ dysarthria
Right middle cerebral artery territory is affected that irrigates internal capsule structure and broca area too
by exclusion method for me:
A would've caused memory deficit.
B some typical signs.
D sensory loss ipsilat.
E at least 2 cranial nerves involved

554. A 72yo man brought to the ED with onset of paraplegia following a trivial fall. He
was treated for prostatic malignancy in the past. What is the single most probable dx?
a. Pagets disease
b. Osteoporotic fx of vertebre
c. Secondary
d. Multiple myeloma
e. Spondylosis
c. Secondary
Bones weakened from metastatic cancer may break (fracture). The fracture can happen with a fall or injury,
but a weak bone can also break during everyday activities. These fractures often cause sudden, severe
pain. The pain may keep you from moving much at all. In some cases, a fracture is the first sign of bone
metastasis.
The most common sites of fractures are the long bones of the arms and legs and the bones of the spine.
Sudden pain in the middle of the back, for example, is a common symptom of a bone in the spine breaking
and collapsing from cancer.
c.a prostate led to vertebral mets(most common bone secondary in c.a prostate),that lead to fracture on
trivial injury and paraplegia due to spinal cord compression

Multiple myeloma can present with a wide variety of symptoms including


hypercalcaemia, anaemia, renal impairment and bone pain.

Spondylosis inflammatory back pain and enthesitis (inflammation at the site of bone
insertion of ligaments and tendons) or arthritis with radiological findings.
Pagets disease most common complaints are bone pain and/or deformity.pathological
fractures elevated serum alkaline phosphatase or characteristic abnormality on X-ray.
555. A 14yo girl has developed an itchy, scaly patch on her scalp. She had a similar
patch that cleared spontaneously 2yrs ago. Her aunt has a similar undiagnosed rash on
the extensor aspects of her elbows and knees. What is the single most likely dx?
a. Eczema
b. Fungal infection
c. Impetigo
d. Lichen planus
e. Psoriasis
e. Psoriasis
HINT: Someone with psoriasis may have other family members with the same problem. Psoriasis is a skin
condition that tends to flare up from time to time
Psoriasis. Rash Always on extensors.

Eczema on flexors.
onset below age 2 years, flexural involvement, generally dry skin, other atopic disease
Impetigo 'golden', crusted skin lesions typically found around the mouth, very
contagious
Lichen planus itchy, papular rash most common on the palms, soles, genitalia and
flexor surfaces of arms, 'white-lace' pattern on the surface (Wickham's striae)

Psoriasis
presents with red, scaly patches on the skin although it is now recognised that patients
with psoriasis are at increased risk of arthritis and cardiovascular disease.
plaque psoriasis: the most common sub-type resulting in the typical well demarcated
red, scaly patches affecting the extensor surfaces, sacrum and scalp
flexural psoriasis: in contrast to plaque psoriasis the skin is smooth
guttate psoriasis: transient psoriatic rash frequently triggered by a streptococcal
infection. Multiple red, teardrop lesions appear on the body
pustular psoriasis: commonly occurs on the palms and soles
Management of chronic plaque psoriasis
regular emollients may help to reduce scale loss and reduce pruritus
first-line: NICE recommend a potent corticosteroid applied once daily plus vitamin
D analogue applied once daily (applied separately, one in the morning and the
other in the evening) for up to 4 weeks as initial treatment
second-line: if no improvement after 8 weeks then offer a vitamin D analogue
twice daily
third-line: if no improvement after 8-12 weeks then offer either: a potent
corticosteroid applied twice daily for up to 4 weeks or a coal tar preparation
applied once or twice daily
short-acting dithranol can also be used

556. A pt after transurethral prostatic biopsy. What electrolyte imbalance can he


develop?
a. Hyperkalemia
b. Hyponatremia
c. Hypocalcemia
d. Hypernatremia
e. Hypercalcemia
b. Hyponatremia
Transurethral Resection of the Prostate (TURP) Syndrome is a rare but potentially lifethreatening complication of a transurethral resection of the prostate procedure. It occurs as a
consequence of the absorption into the prostatic venous sinuses of the fluids used to irrigate
the bladder during the operation. Symptoms and signs are varied and unpredictable, and
result from fluid overload and disturbed electrolyte balance and hyponatraemia. Treatment is
largely supportive and relies on removal of the underlying cause, and organ and
physiological support. Preoperative prevention strategies are extremely important.

557. A 28yo woman has been admitted at 38wks gestation. Her BP=190/120mmHg and
proteinuria +++. Immediately following admission she has a grand-mal seizure. What is
the single most
appropriate initial management?
a. Diazepam IV
b. Fetal CTG
c. Hydralazine IV
d. Immediate delivery
e. Magnesium sulphate IV
e. Magnesium sulphate IV
Eclampsia is defined as the occurrence of one or more convulsions superimposed on
pre-eclampsia.

Management of eclampsia

Resuscitation
Treatment and prophylaxis of seizures:
o Magnesium sulfate is the anticonvulsant drug of choice.
o Intubation may become necessary in women with repeated seizures
Treatment of hypertension:
o Reduction of severe hypertension (blood pressure >160/110 mm Hg
or mean arterial pressure >125 mm Hg) is essential to reduce the
risk of cerebrovascular accident. Treatment may also reduce the
risk of further seizures.

Intravenous hydralazine or labetalol are the two most commonly


used drugs. Both may precipitate fetal distress and therefore
continuous fetal heart rate monitoring is necessary.
Fluid therapy:
o Close monitoring of fluid intake and urine output is mandatory.
Delivery:
o The definitive treatment of eclampsia is delivery.
o However, it is unsafe to deliver the baby of an unstable mother even
if there is fetal distress. Once seizures are controlled, severe
hypertension treated and hypoxia corrected, delivery can be
expedited.
o Vaginal delivery should be considered but Caesarean section is
likely to be required in primigravidae, well before term and with an
unfavourable cervix.
o After delivery, high-dependency care should be continued for a
minimum of 24 hours

558. A 27yo woman had pre-eclampsia and was delivered by C-section. She is now
complaining of RUQ pain different from wound pain. What inv will you do immediately?
a. Coagulation profile
b. LFT
c. Liver US
d. MRCP
e. None
b. LFT
HELLP syndrome

Presentation

HELLP syndrome is a serious form of pre-eclampsia and patients may present at


any time in the last half of pregnancy.
One third of women with HELLP syndrome present shortly after delivery.
Initially, women may report nonspecific symptoms including malaise, fatigue,
right upper quadrant or epigastric pain, nausea, vomiting, or flu-like symptoms.
Hepatomegaly can occur.
Some women may have easy bruising/purpura.
On examination, oedema, hypertension and proteinuria are present.
Tenderness over the liver can occur.

Investigations

There needs to be a high index of clinical suspicion in order to avoid diagnostic


delay and improve outcome.
Haemolysis with fragmented red cells on the blood film
Raised LDH >600 IU/L with a raised bilirubin.
Liver enzymes are raised with an AST or ALT level of >70 IU/L.

Definitive treatment of HELLP syndrome requires delivery of the fetus and is advised
after 34 weeks of gestation if multisystem disease is present.

559. A 10yo girl has been referred for assessment of hearing as she is finding difficulty
in hearing her teacher in the class. Her hearing tests show: BC normal, symmetrical AC
threshold reduced
bilaterally, weber test shows no lateralization. What is the single most likely dx?
a. Chronic perforation of tympanic membrane
b. Chronic secretory OM with effusion
c. Congenital sensorineural deficit
d. Otosclerosis
e. Presbycusis
b. Chronic secretory OM with effusion
B/L conductive deafness
glue ear/ OM e effusion
Bc normal means no sn deafness .. there is conductive deafness .. otosclerosis has cd but it usually appears
in 3rd decade of life n associated with tinnitus .. perforation on both sides is uncommon .. so we're left with
csom with effusion which is most common cause of cd in school going age
Glue Ear/ otitis media with effusion: recurrent ear infections, poor speech development, and failing
performances at school, typically in children between the ages of 2 and decreasing with advancement of
age.. .Causes conductive hearing loss.
The clincher also is 'child finding difficulty in hearing in classroom/turning up the volume of Tv'

Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and
mastoid cavity. Clinical features are recurrent otorrhoea through a tympanic perforation, with
conductive hearing loss of varying severity.

CSOM presents with a chronically draining ear (>2 weeks), with a possible
history of recurrent AOM, traumatic perforation, or insertion of grommets.
The otorrhea should occur without otalgia or fever.
Fever, vertigo and otalgia should prompt urgent referral to exclude intratemporal
or intracranial complications.
Hearing loss is common in the affected ear

Treatment options include:


grommet insertion - to allow air to pass through into the middle ear and hence do
the job normally done by the Eustachian tube. The majority stop functioning after
about 10 months
adenoidectomy
560. A thin 18yo girl has bilateral parotid swelling with thickened calluses on the dorsum
of her hand. What is the single most likely dx?
a. Bulimia nervosa
b. C1 esterase deficiency
c. Crohns disease
d. Mumps
e. Sarcoidosis
a. Bulimia nervosa
Clincher for a is calluses over dorsum; (chronic inducing vomiting) ,parotid swelling

Thickened calluses at back of hand (Russel's sign -tooth mark on finger for induced vomiting) +parotid
enlargment Bulimia

C1 esterase deficiency autosomal dominant condition associated with low plasma


levels of the C1 inhibitor (C1-INH) protein. attacks may be proceeded by painful macular
rash
painless, non-pruritic swelling of subcutaneous/submucosal tissues
may affect upper airways, skin or abdominal organs (can occasionally present as
abdominal pain due to visceral oedema)
Mumps can be asymptomatic.fever, headache, malaise, myalgia and anorexia, can
precede parotitis.Parotitis is usually bilateral although it can be unilateral.
Sarcoidosis
acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever,
polyarthralgia
insidious: dyspnoea, non-productive cough, malaise, weight loss
skin: lupus pernio(chronic raised hardened, often purple lesion)
hypercalcaemia
Heerfordt's syndrome (inflammation of submaxillary/parotid glands with uveitis
and facial nerve palsy) may accompany constitutional presentation.

Bulimia nervosa
Presentation

The history often dates back to adolescence.


o Regular binge eating.
o Attempts to counteract the binges - eg, vomiting, using laxatives,
diuretics, dietary restriction and excessive exercise.
o Preoccupation with weight, body shape, and body image.
o low self-esteem, and self-harm.
o Periods may be irregular.
Physical examination is usually normal and is mainly aimed at excluding
medical complications such as dehydration or dysrhythmias (induced by
hypokalaemia).
o Examination must include height and weight (and calculation of the BMI)
and blood pressure.
o Salivary glands (especially the parotid) may be swollen.
o There may be oedema if there has been laxative or diuretic abuse.
o Russell's sign may be present (calluses form on the back of the hand,
caused by repeated abrasion against teeth during inducement of
vomiting).

561. A 48yo presents with severe chest pain since the last 40mins. In the ED he is given
oxygen, GTN, morphine. ECG=ST elevation. Bloods=increased troponin levels. What is
the next step of
management?
a. Beta blockers
b. Percutaneous angiography
c. Anticoagulant & heparin
d. Clopidogrel
e. Aspirin

b. Percutaneous angiography
Technically speaking trops are raised which means 2-3 hours have passed. PCI is indicated within 120
mins.
It should be E
PCI is more appropriate as the clinch is the time 40 mins that's why i went for B.
I would go for B
In case of ST elevation MI.. mx include aspirin at first usually given by GP or paramedic then morphine with
metoclopramide. GTN not used routinely except in case of HTN or severe LVF. Next step is PCI if available
within 120mins of hospital contact. If not available .fibrinolysis done if no CI and later proceed for PCI.
As here time frame of 4o mins mentioned..i guess its PCI..B
Its B. ST elevation MI means that the thrombus clot has already been stabilized and occluded the
vessel...that is why we give t-PA (thrombolytic) in ST elevation MI only... aim is to break down the thrombus,
not stop it from forming...aspirin only stops it from forming it doesn't break it down... smile emoticon also
raised troponin levels mean that the patient has a previous infarct at most 10 days before (since it raised in
only 40 minutes, not 4 hours), having previous infarct means has 2 or 3 vessel disease and not 1 vessel
disease, he is high risk patient and should have angioplasty as soon as possible...answer is B, angiography
is done right before angioplasty

Acute Myocardial Infarction

Pre-hospital management
first line management is MONA (Morphine, O2, Nitrates and Aspirin)
Sublingual glyceryl trinitrate and intravenous morphine + metoclopramide should be
given to help relieve the symptoms.
Aspirin 300mg should be given to all patients (unless contraindicated)
Pre-hospital thrombolysis is indicated if the time from the initial call to arrival at hospital
is likely to be over 30 minutes.

Primary percutaneous coronary intervention (PCI)


Door (or diagnosis) to treatment time should be less than 90 minutes, or less than 60
minutes if the hospital is PCI ready and symptoms started within 120 minutes
If they cannot be transferred to a larger hospital for PCI within 120 minutes then
fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed
to show resolution of the ST elevation then they would then require transfer for PCI.
PCI should be considered if there is an ST elevation acute coronary syndrome, if
symptoms started up to 12 hours previously

562. A 34yo female presents with a foul smelling discharge. What set of organisms are
we looking for to be treated here?
a. Chlamydia, gonorrhea
b. Chlamydia, gardenella
c. Chlamydia, gonorrhea, gardenella
d. Gonorrhea, gardenella
e. Gardenella only
e. Gardenella only

Chlamydia is usually asymptomatic (no odour) and generally goes with gonorrhea. BV will give the grey fishsmelling discharge
Bacterial vaginosis and Trichomonas vaginalis give foul smelling discharge. In BV its grey white fishy and in
TV it can be greenish frothy fihy alongwith vulvovginitis i-e strawberry cervix. The discharge of Chlamydia
and Gonorrhea is not foul smelling but gives dysuria.

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms


such as Gardnerella vaginalis.
Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
Management
oral metronidazole for 5-7 days

563. A 6wk formula fed baby boy is found at the child health surveillance to be deeply
jaundiced. His weight gain is poor and his stools are pale. What is the most likely dx?
a. Galactosemia
b. Biliary atresia
c. G6PD deficiency
d. Rh incompatibility
e. Congenital viral infection
b. Biliary atresia
pale stools , dark urine- biliary atresia
pale stools, straw urine - galactosemia
galactosemia presents with vomitting,diarrhea,failure to thrive and jaundice...progressive n deep jaundice is
biliary atresia

Biliary atresia presents shortly after birth, with persistent jaundice, pale stools and dark
urine. All term infants who remain jaundiced after 14 days (and preterm infants after 21
days) should be investigated.
Galactosemia There is often feeding difficulty, with vomiting and failure to gain weight,
with poor growth in the first few weeks of life.
G6PD deficiency
neonatal jaundice is often seen
intravascular haemolysis
gallstones are common
splenomegaly may be present
Heinz bodies on blood films

564. A 45yo man with colon cancer now develops increased thirst, increased frequency
in urination and weight loss. His fasting blood glucose=9mmol/L. what is the most
appropriate management?
a. Oral hypoglycemic
b. Insulin long acting
c. Short acting insulin before meal
d. IV insulin
e. Subcutaneous insulin
a. Oral hypoglycemic
colon cancer is assoc with hyperinsulinemia or insulin resistance..so oral hypoglycemics preferred
because oral hypoglycemic (metformin) has anticancerogenic effect.
A.. first line treatment dont get confused by colon cancer..
Metformin is the first drug of choice for the management of type 2 diabetes. It has two main antidiabetic
mechanisms of action, both of which have also been implicated as anticarcinogenic mechanisms. Firstly,
metformin inhibits hepatic glucose production through an LKB1/AMP-activated protein kinasemediated
mechanism which has been shown to adversely affect the survival of cancer cell lines. Secondly, metformin
improves insulin sensitivity in peripheral tissues reducing hyperinsulinemia. Insulin resistance and
hyperinsulinemia have been associated with increased risk of several types of neoplasm and specifically
with colorectal cancer.

565. A 34yo man from Zimbabwe is admitted with abdominal pain to the ED. An AXR
reveals bladder calcification. What is the most likely cause?
a. Schistosoma mansoni
b. Sarcoidosis
c. Leishmaniasis
d. TB
e. Schistosoma haematobium
e. Schistosoma haematobium
Schistosoma Hematobium (Bilhaarziasis). CA urinary bladder and vesicolithiasis are the two main concern
here

S. haematobium causes urinary schistosomiasis, and is the most prevalent and


widespread species in Africa and the Middle East.
Schistosomiasis is associated with anaemia, chronic pain, diarrhoea, exercise intolerance,
and malnutrition.
The first sign may be swimmer's itch
Fever.
Hepatosplenomegaly.
Right upper quadrant pain or tenderness.
Urticaria may be seen occasionally.
Lymphadenopathy.
Praziquantel is the drug of choice
Oxamniquine is the only alternative
Complications:
renal stones
increased risk of squamous cell carcinoma of bladder that has been noticed
especially in Egypt. It is possible that the infestation and the carcinogens in
tobacco smoke have a synergistic effect.

Hydronephrosis
renal failure may occur
iron-deficiency anaemia
Portal hypertension

566. A 6yo came with full thickness burn. He is crying continuously. What is the next
step of
management?
a. Refer to burn unit
b. IV fluid stat
c. Antibiotic
d. Analgesia
e. Dressing
d. Analgesia
In NHS,, making comfortable to patient is vital. Here question ask for initial management, hence analgesia is
the most here then after treat accordingly, either refer to burn unit or give if fluids using parklands.
D. Then iv fluids then refer to burn unit.

Referral to secondary care


all deep dermal and full-thickness burns.
superficial dermal burns of more than 10% TBSA in adults, or more than 5%
TBSA in children
superficial dermal burns involving the face, hands, feet, perineum, genitalia, or
any flexure, or circumferential burns of the limbs, torso, or neck
any inhalation injury
any electrical or chemical burn injury
suspicion of non-accidental injury
Management of burns
initial first aid as above
review referral criteria to ensure can be managed in primary care
superficial epidermal: symptomatic relief - analgesia, emollients etc
superficial dermal: cleanse wound, leave blister intact, non-adherent dressing,
avoid topical creams, review in 24 hours
567. A 78yo nursing home resident is revived due to the development of an intensely
itchy rash.
Exam: white linear lesions are seen on the wrists and elbows and red papules are
present on the
penis. What is the most appropriate management?
a. Topical permethrin
b. Referral to GUM clinic
c. Topical betnovate
d. Topical ketoconazole
e. Topical selenium sulfide hyoscine
a. Topical permethrin

Red papule on penis typical with wrist and elbow lesion goes with Scabies, topical permethrin once wk and
repeat if symptoms remain.

white linear lesions


Features
widespread pruritus
linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist
Nodules may develop. These occur particularly at the elbows, anterior axillary folds,
penis, and scrotum.
in infants the face and scalp may also be affected
secondary features are seen due to scratching: excoriation, infection
Management
permethrin 5% is first-line
malathion 0.5% is second-line
give appropriate guidance on use
pruritus persists for up to 4-6 weeks post eradication

568. A 4yo has earache and fever. Has taken paracetamol several times. Now its
noticed that he
increases the TV volume. His preschool hearing test shows symmetric loss of 40db.
What is the
most likely dx?
a. OM with effusion
b. Otitis externa
c. Cholesteatoma
d. CSOM
e. Tonsillitis
a. OM with effusion
see Q. 559
569. A pt presents with gradual onset of headache, neck stiffness, photophobia and
fluctuating LOC. CSF shows lymphocytosis but no organism on gram stain. CT brain is
normal. What is the single most likely dx?
a. Hairy leukoplakia
b. TB
c. CMV infection
d. Candida infection
e. Cryptococcal infection
b. TB
TB as there is lymphocytosis and no organism on gram staining Zn staining or AFB can detect
mycobacterium TB

Viral meningitis may be clinically indistinguishable from bacterial meningitis but features
may be more mild and complications (eg, focal neurological deficits) less frequent. Any
person presenting with suspected meningitis should therefore be managed as having
bacterial meningitis until proved otherwise.

classic triad of fever, neck stiffness and a change in mental status was present in only
44% of adults presenting with community-acquired acute bacterial meningitis. However,
95% had at least two of the four symptoms of headache, fever, neck stiffness and
altered mental status.
Most patients with viral meningitis present with subacute neurological symptoms
developing over 1-7 days. Chronic symptoms lasting longer than one week suggest
meningitis caused by some viruses as well as TB, syphilis or fungi.

Bacterial

Viral

Tuberculous

Appearance

Cloudy

Clear/cloudy

Slight cloudy, fibrin


web

Glucose

Low (< 1/2 plasma)

60-80% of plasma
glucose*

Low (< 1/2 plasma)

Protein

High (> 1 g/l)

Normal/raised

High (> 1 g/l)

White cells

10 - 5,000
polymorphs/mm

15 - 1,000
lymphocytes/mm

10 - 1,000
lymphocytes/mm

570. An 18m boy has been brought to the ED because he has been refusing to move his
left arm and crying more than usual for the past 24h. He has recently been looked after
by his mothers new bf while she attended college. Assessment shows multiple bruises
and a fx of the left humerus
which is put in plaster. What is the single most appropriate next step?
a. Admit under care of pediatrician
b. Discharge with painkillers
c. Follow up in fx clinic
d. Follow up in pediatric OPD
e. Follow up with GP
a. Admit under care of pediatrician
Non accidental injury
The most common manifestation of abuse is bruising
An estimated 15-25 % of pediatric burns are the result of abuse.
Fractures are the second most common manifestation of child abuse after soft tissue
injuries.
Any fracture in a young child should be concerning, especially if the child is not
ambulating.
Abusive head trauma, also known as shaken baby syndrome, is the most common
cause of child abuse death, usually occurring during the first year of life.

571. A 74yo female presents with headache and neck stiffness to the ED. Following a
LP the pt was started on IV ceftriaxone. CSF culture = listeria monocytogenes. What is
the appropriate tx?
a. Add IV amoxicillin
b. Change to IV amoxicillin + gentamicin
c. Add IV ciprofloxacin
d. Add IV co-amoxiclav
e. Continue IV ceftriaxone as mono-therapy
b. Change to IV amoxicillin + gentamicin
Meningitis caused by meningococci
Intravenous ceftriaxone for at least seven days is usually used..
Prevention of secondary case of meningococcal meningitis is usually with
rifampicin or ciprofloxacin.
Meningitis caused by pneumococci
Vancomycin and a third-generation cephalosporin (either cefotaxime or ceftriaxone)
Benzylpenicillin may be given if the organism is penicillin-sensitive but penicillin
resistance is becoming an increasing problem.
Meningitis caused by H. influenzae type b
Children aged 3 months and older and young people - intravenous ceftriaxone for
10 days.
Meningitis caused by group B streptococci
This mainly occurs in babies between the ages of 7-90 days. Intravenous
cefotaxime for at least 14 days should be given.
Meningitis caused by listeriosis
For children under the age of 3 months, intravenous amoxicillin or ampicillin for
21 days in total, plus gentamicin for at least the first seven days.

572. A pt presents with fever, dry cough and breathlessness. He is tachypneic but chest
is clear.
Oxygen saturation is normal at rest but drops on exercise. What is the single most likely
dx?
a. CMV infection
b. Candida infection
c. Pneumocystis carinii infection
d. Cryptococcal infection
e. Toxoplasma abscess
c. Pneumocystis carinii infection
This kind of history about oxygen desaturation on exercise is typical for PCP. Dry cough along with that
supports that.
patient is immunocompromised. Mostly in HIV patients we see that pt becomes breathless after a walk or
exercise. Also fever with dry cough is there. Most likely pathogen is PCP.
CMV affects retina n brain
Toxoplasmosis..brain
Candida. .mouth and esophagus
Cryptococcus..meningitis

Whilst the organism Pneumocystis carinii is now referred to as Pneumocystis jiroveci,


the term Pneumocystis carinii pneumonia (PCP) is still in common use

PCP is the most common opportunistic infection in AIDS


all patients with a CD4 count < 200/mm should receive PCP prophylaxis
Features:
dyspnoea
dry cough
fever
very few chest signs
Pneumothorax is a common complication of PCP.
Extrapulmonary manifestations are rare (1-2% of cases), may cause
hepatosplenomegaly
lymphadenopathy
choroid lesions
Investigation
CXR: typically shows bilateral interstitial pulmonary infiltrates but can present with other
x-ray findings e.g. lobar consolidation. May be normal
exercise-induced desaturation
sputum often fails to show PCP, bronchoalveolar lavage (BAL) often needed to
demonstrate PCP (silver stain shows characteristic cysts)
Management
co-trimoxazole
IV pentamidine in severe cases
steroids if hypoxic (if pO2 < 9.3kPa then steroids reduce risk of respiratory failure by
50% and death by a third)

573. A 14yo boy fell and hit his head in the playground school. He didnt lose
consciousness. He has
swelling and tenderness of the right cheek with a subconjuctival hemorrhage on his right
eye.
What is the most appropriate initial inv?
a. CT brain
b. EEG
c. MRI
d. Skull XR
e. Facial XR
e. Facial XR
there's no indication of CT scan here- he is conscious and has not vomited

The difference between Skull and facial x ray is view. Skull PA view is done in prone
position for seeing Skull bones. Facial is simply reverse i.e AP view done in supine
position and gives more clear view of facial bones. Suspected injury to facial bones is a

CONTRAINDICATION for PA view as patient cannot be asked to lie down in prone


position/ or to lean forward with face down.
A facial or sinus X-ray may be done to:
Find problems of the sinuses of the face and nose, such as sinusitisor abnormal
growths (polyps or tumors).
Find fractures of the facial bones and nose.
Check the bones around the eye (orbital cavity).
Check the sinuses before surgery.
Check for metal objects around the eyes before a magnetic resonance imaging
(MRI) test.
Look for the cause of pain in the face.
574. A 15m child is due for his MMR vaccine. There is a fam hx of egg allergy. He is
febrile with acute OM. What is the single most appropriate action?
a. Defer immunization for 2wks
b. Dont give vaccine
c. Give half dose of vaccine
d. Give paracetamol with future doses of the same vaccine
e. Proceed with standard immunization schedule
a. Defer immunization for 2wks
egg allergy is not contraindication for MMR ...therefore if pt is febrile then wait for the next two weeks until he
is afebrile and give the normal dose of immunization

Children in the UK receive two doses of the Measles, Mumps and Rubella (MMR)
vaccine before entry to primary school. This currently occurs at 12-15 months and 3-4
years as part of the routine immunisation schedule
Contraindications to MMR
severe immunosuppression
Acute illness
allergy to neomycin
children who have received another live vaccine by injection within 4 weeks
pregnancy should be avoided for at least 1 month following vaccination
immunoglobulin therapy within the past 3 months (there may be no immune
response to the measles vaccine if antibodies are present)
Adverse effects
malaise, fever and rash may occur after the first dose of MMR. This typically
occurs after 5-10 days and lasts around 2-3 days
Note that the following are NOT contra-indications:
Family history of any adverse reactions following immunisation.
Previous history of infection with pertussis, measles, rubella or mumps.
Contact with an infectious disease.
Asthma, eczema, hay fever or rhinitis.
Treatment with antibiotics or locally acting (eg, topical or inhaled) steroids.
The child's mother being pregnant.
The child being breast-fed.
History of jaundice after birth.
Being over the age recommended in the immunisation schedule.

'Replacement' corticosteroids.
Allergy to eggs
Neurological conditions are not a contra-indication although, if the condition is
poorly controlled (eg, epilepsy), immunisation should be deferred.
MMR should ideally be given at the same time as other live vaccines, such as
BCG. However, if live vaccines cannot be administered simultaneously, a fourweek interval is recommended.

575. A 33yo lady with Hodgkins lymphoma presents with temp=40C, left sided
abdominal pain and lymphadenitis. Blood was taken for test. What will you do next?
a. Wait for blood test
b. Start broad spectrum IV antibiotics
c. Oral antibiotics
d. CBC
e. Monitor pyrexia
b. Start broad spectrum IV antibiotics
the patient has an immune compromising disease ,you cant wait until you get lab results or give oral
antibiotics, you shuld give systemic antibiotic to treat any possible infectons
Chemotherapy causes imunosuppresion so increased chance of infections,as in this case temp 40,and
lymphadenitis so broad spectrum antibiotics

576. A 40yo man with marked weight loss over the preceding 6m has bilateral white,
vertically
corrugated lesion on the lateral surfaces of the tongue. What is the single most likely dx?
a. C1 esterase deficiency
b. Crohns disease
c. HIV disease
d. Sarcoidosis
e. Sjogrens syndrome
c. HIV disease

'Hairy' leukoplakia
This is associated with Epstein-Barr virus (EBV) and occurs mostly in people with HIV,
both immunocompromised and immunocompetent.
The natural history of hairy leukoplakia is variable. Lesions may frequently appear and
disappear spontaneously. Hairy leukoplakia is often asymptomatic and many patients
are unaware of its presence. Some patients with hairy leukoplakia do experience
symptoms including mild pain, dysaesthesia, alteration of taste and the psychological
impact of its unsightly cosmetic appearance.
Systemic antiviral therapy, which usually achieves resolution of the lesion within
1-2 weeks of therapy.
Topical therapy with podophyllin resin 25% solution, which usually achieves
resolution after 1-2 treatment applications.
Topical therapy with retinoic acid (tretinoin), which has been reported to resolve
hairy leukoplakia.
Ablative therapy, which can also be considered for small hairy leukoplakia
lesions. Cryotherapy has been reported as successful but is not widely used.

577. A 3m baby was miserable and cried for 2h following his 1st routine immunization
with DTP, HiB and meningitis. What is the single most appropriate action?
a. Defer immunization for 2wks
b. Dont give vaccine
c. Give half dose of vaccine
d. Give paracetamol with future doses of the same vaccine
e. Proceed with standard immunization schedule
e. Proceed with standard immunization schedule
General contraindications to immunisation
confirmed anaphylactic reaction to a previous dose of a vaccine containing the
same antigens
confirmed anaphylactic reaction to another component contained in the relevant
vaccine (e.g. egg protein)
Situations where vaccines should be delayed
febrile illness/intercurrent infection
Contraindications to live vaccines
pregnancy
immunosuppression
Specific vaccines
DTP: vaccination should be deferred in children with an evolving or unstable
neurological condition
Not contraindications to immunisation
asthma or eczema
history of seizures (if associated with fever then advice should be given regarding
antipyretics)
breastfed child
previous history of natural pertussis, measles, mumps or rubella infection
history of neonatal jaundice
family history of autism
neurological conditions such as Down's or cerebral palsy
low birth weight or prematurity
patients on replacement steroids e.g. (CAH)
578. A 65yo man with HTN develops gingival hyperplasia. What is the single most likely
dx?
a. ACEi
b. Beta blockers
c. Crohns disease
d. Nifedipine
e. Sarcoidosis
d. Nifedipine

Side effect of CCB


also due to cyclosporin, phenytoin, AML.

579. A 65yo woman is undergoing coronary angiography. What measure will protect her
kidneys
from contrast?
a. Furosemide
b. Dextrose
c. 0.45% saline
d. 0.9% saline
d. 0.9% saline
post contrast nephropathy due to contrast induced or cholesterol embolisation.
adequately hydrated pt prior to procedure reduces the complications.

580. An 83yo woman who is a resident in a nursing home is admitted to hospital with a
4d hx of
diarrhea. She has had no weight loss or change in appetite. She has been on analgesics
for 3wks
for her back pain. She is in obvious discomfort. On rectal exam: fecal impaction. What is
the
single most appropriate immediate management?
a. Codeine phosphate for pain relief
b. High fiber diet
c. Oral laxative
d. Phosphate enema
e. Urinary catheterization
d. Phosphate enema
Codiene
Laxative
Fiber will increase gut motility
Where as
Phosphate enema will act locally
Helpful in clearing
Fecal impaction too

Bulk producers:
Increase faecal mass, which stimulates peristalsis.
They must be taken with plenty of fluid
Contra-indications: difficulty in swallowing; intestinal obstruction; colonic atony;
faecal impaction.
Stool softeners:
Side-effects can include: anal seepage, lipoid pneumonia, malabsorption of fatsoluble vitamins
Stimulants:
Increase intestinal motility and should not be used in intestinal obstruction.
Prolonged use should be avoided, as it may cause colonic atony and
hypokalaemia (but there are no good, long-term follow-up studies).
Osmotic agents:

Retain fluid in the bowel.


Enemas and suppositories - useful additional treatment.

581. A 26yo woman being treated for a carcinoma of the bronchus with steroids presents
with
vomiting, abdominal pain and sudden falls in the morning. What is the most specific
cause for
her symptoms?
a. Steroid side effects
b. Postural hypotension
c. Adrenal insufficiency
d. Conns disease
e. Cushings disease
c. Adrenal insufficiency
Streoids causing suppression of acth. In turn causing mineralcorticoid deficiency so adrenal insufficiency
high dose sterods suppresss adrenals...cause hyponatraemia..hypotension..hypoglycaemia..hyperkalaemia
Exogenous steroids can suppress the pituitary adrenal axis leading to adrenal insufficiency. Symptoms
include weakness, anorexia, dizzy,
Faints,nausea,vomiting,abd pain
Steroid does not cause vomit or falls so A can be excluded.
Postural hypotension does not cause abd. Pain so B excluded .
Conn's syndrome is hyperaldosteronism which would cause hypernatremia and hypokalemia and
hypertension.
So D excluded
Cushing causes hypertension so E Excluded
C is the right answer cuz adrenal insufficiency due to prolonged steroid intake would cause addison
syndrome which is hyponatremia hypotension abdominal pain .

582. A 78yo woman presents with unilateral headache and pain on chewing.
ESR=70mm/hr. She is on oral steroids. What is the appropriate additional tx?
a. Bisphosphonates
b. HRT
c. ACEi
d. IFN
e. IV steroids
a. Bisphosphonates
She getting treated for temporal arteritis, therefore steroid will cause osteoporosis. So additional therapy is A
It appears GCA. We first do ESR and start steroids. If symptoms are not resolved then we up the dose of
steroids.
Additional treatment would be bisphosphonate to reduce risk of osteoporosis.

Bisphosphonates
Bisphosphonates decrease demineralisation in bone. They inhibit osteoclasts.
Clinical uses
prevention and treatment of osteoporosis
hypercalcaemia

Paget's disease
pain from bone metatases

Adverse effects
oesophagitis, oesophageal ulcers
osteonecrosis of the jaw
increased risk of atypical stress fractures of the proximal femoral shaft.
583. A 30yo man is suffering from fever, rash and photophobia. Doctors are suspecting
he is suffering from meningitis. Which is the best medication for this condition?
a. Ampicilling
b. Cefotaxime
c. Tetracycline
d. Acyclovir
e. Dexamethasone
b. Cefotaxime
Initial 'blind' therapy
Children 3 months and older and young people should be given intravenous
ceftriaxone as empirical treatment before identification of the causative
organism. If calcium-containing infusions are required at the same time,
cefotaxime is preferable.
584. A 15yo girl was admitted with anemia, chest infection and thrombocytopenia. She
was treated and her symptoms had regressed. She was brought again with fever and
the same symptoms a few days later. She also seems to have features of meningitis.
What is the most likely dx?
a. AML
b. ALL
c. Aplastic anemia
d. CML
e. CLL
b. ALL
Young, anemia, thrombocytopenia, recurrent infectionswith/without cns involvement and testicular swelling...
always go for All..if not treated completed can appear again...in aplastic anemia the cell count of all cell
types is low with a mention of some predisposing factor..like drugs, radiation or a dry tap of bone marrow.
Patients with ALL frequently have meningeal leukaemia at the time of relapse (50-75% at one year in
the absence of CNS prophylaxis) and a few have meningeal disease at diagnosis (<10%).

ALL
Symptoms
Fatigue, dizziness and palpitations
bone and joint pain
Recurrent and severe infections (oral, throat, skin, perianal infections commonly)
Fever
Left upper quadrant fullness and early satiety due to splenomegaly (10-20%)

Haemorrhagic or thrombotic complications due to thrombocytopenia or


disseminated intravascular coagulopathy (DIC) - for example, menorrhagia,
frequent nosebleeds, spontaneous bruising

Signs

Pallor
Tachycardia and a flow murmur
Nonspecific signs of infection
Petechiae,purpura or ecchymoses
hepatosplenomegaly
Lymphadenopathy
Gum hypertrophy
Cranial nerve palsy (especially III, IV, VI and VIII) in mature B-cell ALL

585. A pt was admitted to the ED after a head injury. When examined on arrival his
GCS=15 and then at night his GCS deteriorated to 12. What investigation should be
done?
a. CT head
b. XR skull
c. IV mannitol
d. Drill a burr hole
e. Shift to OR
a. CT head

In patients with normal or near-normal GCS and who are alert

Haemodynamic status - pulse rate, blood pressure, fluid status.


Neurological assessment - full history and examination, make notes of pupil size
and reaction to light.
Look for other possible injuries and any other relevant examination.

In patients with reduced GCS

Resuscitate but make a quick assessment of GCS and pupils. The priority is to
get the patient to hospital and CT scanned within the first hour after injury.

Selection of adults for CT scan

CT scan of the brain within one hour (with a written radiology report within one
hour of the scan being undertaken):
Glasgow Coma Scale (GCS) <13 when first assessed or GCS <15 two
hours after injury
Suspected open or depressed skull fracture
Signs of base of skull fracture*
Post-traumatic seizure
Focal neurological deficit
>1 episode of vomiting
All patients with a coagulopathy or on oral anticoagulants should have a CT
brain scan within eight hours of the injury, provided there are no other identified
risk factors, as listed above.

586. A 4yo boy who prv had normal hearing, has a mild earache relieved by
paracetamol. He has
been noticed to turn up the vol on the TV. He has bilateral dull tympanic membranes. His
preschool hearing test shows symmetrical loss of 40dB. What is the single most likely
dx?
a. Acute otitis externa
b. Acute OM
c. Ear wax
d. Foreign body
e. OM with effusion
e. OM with effusion
Glue Ear/ otitis media with effusion: recurrent ear infections, poor speech development, and failing
performances at school, typically in children between the ages of 2 and decreasing with advancement of
age.. .Causes conductive hearing loss.
The clincher also is 'child finding difficulty in hearing in classroom/turning up the volume of Tv'

Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and
mastoid cavity. Clinical features are recurrent otorrhoea through a tympanic perforation, with
conductive hearing loss of varying severity.

CSOM presents with a chronically draining ear (>2 weeks), with a possible
history of recurrent AOM, traumatic perforation, or insertion of grommets.
The otorrhea should occur without otalgia or fever.
Fever, vertigo and otalgia should prompt urgent referral to exclude intratemporal
or intracranial complications.
Hearing loss is common in the affected ear

Treatment options include:


grommet insertion - to allow air to pass through into the middle ear and hence do
the job normally done by the Eustachian tube. The majority stop functioning after
about 10 months
adenoidectomy

587. An 18yo man presents to his GP with thirst and polyuria. Some 6m ago he had a
significant head injury as the result of a RTA. He is referred to the local endocrine clinic.
Which of the following results would be the most useful in confirming the dx of diabetes
insipidus after a water
deprivation test (without additional desmopressin)?
a. Plasma sodium of 126mmol/l
b. Plasma sodium of 150mmol/l
c. Plasma osmolality of 335mosmol/kg and urine osmolality of 700mosmol/kg
d. Plasma osmolality of 280mosmol/kg and urine osmolality of 700mosmol/kg
e. Plasma osmolality of 335mosmol/kg and urine osmolality of 200mosmol/kg
e. Plasma osmolality of 335mosmol/kg and urine osmolality of 200mosmol/kg
normal osmolality of plasma is somewhere around 285 to 295. Since water is being lost plasma will
be more concentrated hence osmolality more than 300. Urines normal osmolality is more than 600.
Since urine is dilute osmolality is much lower..so E is correct
In DI: urine osmolarity is low while plasma osmolarity is high.
In contrast, in SIADH, urine osmolarity is high while plasma osmolarity is low.

Classification of causes of diabetes insipidus on basis of water


deprivation and DDAVP response
Urine osmolality after
fluid deprivation
(mOsm/kg)

Urine osmolality after


DDAVP (mOsm/kg)

Likely diagnosis

<300

>800

CDI

<300

<300

NDI

>800

>800

Primary/psychogenic
polydipsia

<300

>800

Partial CDI or NDI or PP or


diuretic abuse

588. A 75yo man has left-sided earache and discomfort when he swallows. There is
ulceration at the back of his tongue and he has a palpable non-tender cervical mass.
What is the single most likely dx?
a. Acute mastoiditis
b. Dental abscess
c. Herpes zoster infection
d. Oropharyngeal malignancy
e. Tonsillitis
d. Oropharyngeal malignancy
Nontender lymphadenopathy usu suggests neoplasia.And she has ulcer near to the root of the tongue.out of
the given option closest diagnosis seems to be orppharyngeal Carcinoma which is option D.

The symptoms of cancer of the pharynx differ according to the type:


Oropharynx: common symptoms are a persistent sore throat, a lump in the
mouth or throat, pain in the ear.
Hypopharynx: problems with swallowing and ear pain are common symptoms
and hoarseness is not uncommon.
Nasopharynx: most likely to cause a lump in the neck but may also cause nasal
obstruction, deafness and postnasal discharge.
589. A 42yo man has been tired and sleepy for the last few weeks in the morning. His
work has starte getting affected as he feels sleepy in the meetings. His BMI=36. What is
the single most likely dx?
a. Idiopathic hypersomnia
b. Narcolepsy
c. Chest hyperventilation syndrome
d. OSAS
e. REM-related sleep disorder
d. OSAS
Obstructive sleep apnea syndrome

Risk factors include:


Obesity (strongest risk factor).
Male gender.
Middle age (55-59 in men, 60-64 in women).
Smoking.
Sedative drugs.
Excess alcohol consumption.
All patients with OSA causing excessive daytime or awake time sleepiness need to
cease driving until satisfactory control of symptoms has been attained.
Narcolepsy tetrad of classic symptoms: excessive daytime sleepiness (EDS), cataplexy,
hypnagogic hallucinations and sleep paralysis.
590. A 35yo pregnant woman has been having tingling and numbness of her thumb,
index and
middle fingers for a while. She has been treated with local steroids but it hasnt helped
her
much and now she has planned to undergo a surgical procedure. Which of the following
structures will be incised?
a. Flexor digitorum profundus
b. Transverse carpel ligament
c. Palmar aponeurosis
d. Extensor retinaculum
b. Transverse carpel ligament
carpal tunnel syndrome
in pregnancy, if carpal tunnel syndrome occurs: you first go for topical steroids.. then splint.. and then
surgery: and you incise the transverse carpal lig.

carpal tunnel, an anatomical compartment bounded by the bones of the carpus and the
flexor retinaculum.

CTS is characterised by tingling, numbness, or pain in the distribution of the median nerve
(the thumb, index, and middle fingers, and medial half the ring finger on the palmar aspect)
that is often worse at night and causes wakening.

Positive Phalen's test: flexing the wrist for 60 seconds causes pain or
paraesthesia in the median nerve distribution.
Positive Tinel's sign: tapping lightly over the median nerve at the wrist causes a
distal paraesthesia in the median nerve distribution.
Positive carpal tunnel compression test: pressure over the proximal edge of
the carpal ligament (proximal wrist crease) with thumbs causes paraesthesia to
develop or increase in the median nerve distribution.

Electroneurography (ENG) - This is the gold standard investigation for CTS.

591. A 58yo pt presents with altered bowel habits and bleeding per rectum. Exam and
sigmoidoscopy showed an ulcer. What is the single most likely dx?
a. Colorectal carcinoma
b. Celiac disease
c. Crohn's disease
d. UC
e. IBS
a. Colorectal carcinoma
Older patient. Altered bowel habits and bleeding PR is Ca unless proven otherwise.
Alter bowl habbit+ bleeding are a red flag for CA colon>>>> colonoscopy >>>> one ulcer >>> CA. UC
Usually there is no alteration in bowel habit, usually boodly diarrhoea >>> colonoscopy >>>>
multiple ulceration

third most common cancer in the UK


second most common cause of cancer death in the UK.
Presentation:
Right colon cancers: weight loss, anaemia, occult bleeding, mass in right iliac
fossa, disease more likely to be advanced at presentation.
Left colon cancers: often colicky pain, rectal bleeding, bowel obstruction,
tenesmus, mass in left iliac fossa, early change in bowel habit, less advanced
disease at presentation.
The most common presenting symptoms and signs of cancer or large polyps are
rectal bleeding, persisting change in bowel habit and anaemia.
Colonoscopy is the gold standard for diagnosis of colorectal cancer.

592. A mother is concerned that her 18m son has a vocabulary of ten words but cant
form a
sentence. What is the best management strategy?
a. Arrange hearing test
b. Assess developmental milestones
c. Reassurance
d. Refer to speech therapist
e. MRI brain
c. Reassurance

Age

Milestone

3 months

Quietens to parents voice


Turns towards sound
Squeals

6 months

Double syllables 'adah', 'erleh'

9 months

Says 'mama' and 'dada'


Understands 'no'

12 months

Knows and responds to own name

12-15 months

Knows about 2-6 words (Refer at 18 months)


Understands simple commands - 'give it to mummy'

2 years

Combine two words


Points to parts of the body

2 years

Vocabulary of 200 words

3 years

Talks in short sentences (e.g. 3-5 words)


Asks 'what' and 'who' questions
Identifies colours
Counts to 10 (little appreciation of numbers though)

4 years

Asks 'why', 'when' and 'how' questions

593. A 55yo man has weight loss, dyspnea and syncope. He smokes 20 cigarettes/day.
Inv confirms squamous cell carcinoma in the left bronchus. What is the single most likely
biochemical
abnormality to be a/w the condition?
a. Hypercalcemia
b. Hyperkalemia
c. Hypoernatremia
d. Hypocalcemia
e. Hypomagnesium
a. Hypercalcemia
Squamous cell ca causes hypercalcemia...whereas small cell ca causes SIADH
paraneoplastic syndrome causing ectopic production of parathyroid hormone-related protein (PTHrP),
resulting in "hypercalcemia"

There are three main subtypes of non-small cell lung cancer:


Squamous cell cancer
typically central

associated with parathyroid hormone-related protein (PTHrP) secretion


hypercalcaemia
strongly associated with finger clubbing

Adenocarcinoma
typically peripheral
most common type of lung cancer in non-smokers, although the majority of
patients who develop lung adenocarcinoma are smokers
Large cell lung carcinoma
typically peripheral
anaplastic, poorly differentiated tumours with a poor prognosis
may secrete -hCG
594. A 72yo man presents with intermittent difficulty in swallowing with regurgitation of
stale food
materials. Sometimes he wakes up at night with a feeling of suffocation. Choose the
single most
likely cause of dysphagia?
a. Benign structure
b. Esophageal carcinoma
c. Esophageal spasm
d. Pharyngeal pouch
e. Systemic sclerosis
d. Pharyngeal pouch
Pharyngeal
pouch

More common in older men


Represents a posteromedial herniation between thyropharyngeus
and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that
gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and
chronic cough. Halitosis may occasionally be seen

595. A 9m child is brought to the ED with an irreducible firm swelling which descended
into the left
groin when the child has been crying. Exam: both testicles are palpable in the scrotum.
What is
the most appropriate management strategy?
a. Reassurance
b. Emergency herniotomy
c. Elective herniotomy
d. Emergency herniotomy + orchidopexy
e. Elective herniotomy + orchidopexy

c. Elective herniotomy
As the swelling descended into the left scrotum when the child was crying so probably it is no more
irreducible
So elective herniotomy
strangulated hernia:

Examination reveals a firm lump in the groin of a crying child, which may extend into the
scrotum. The child may have vomited but is usually well.
Paediatric surgeons will undertake repair soon after diagnosis, regardless of age
or weight, in healthy full-term infant boys with asymptomatic reducible inguinal
hernias. Emergency surgery is twenty times more likely to cause complications
than an elective procedure.
Immediate surgery is not always necessary in a case of strangulation: four out of
five can be reduced manually.
Tachycardia, fever or signs or obstructions are indications for surgery.
596. A 37yo woman was admitted for femur fx repair after a RTA. On the 4th post-op
day she became confused and starts picking on her bed sheets and complains of seeing
spiders all over. What is the most likely dx?
a. Delirium tremens
b. Wernickes encephalopathy
c. Korsakoffs psychosis
d. Psychotic depression
a. Delirium tremens
Delirium tremens usually begins 24-72 hours after alcohol consumption has been
reduced or stopped.
The symptoms/signs differ from usual withdrawal symptoms in that there are
signs of altered mental status. These can include:
o Hallucinations (auditory, visual, or olfactory).
o Confusion.
o Delusions.
o Severe agitation.
Seizures can also occur.
Examination may reveal signs of chronic alcohol abuse/stigmata of chronic liver
disease. There may also be:
o Tachycardia.
o Hyperthermia and excessive sweating.
o Hypertension.
o Tachypnoea.
o Tremor.
o Mydriasis.
o Ataxia.
o Altered mental status.
o Cardiovascular collapse.

Withdrawal symptoms:

Symptoms typically present about eight hours after a significant fall in blood
alcohol levels. They peak on day 2 and, by day 4 or 5, the symptoms have
usually improved significantly.
Minor withdrawal symptoms (can appear 6-12 hours after alcohol has stopped)
Alcoholic hallucinosis (can appear 12-24 hours after alcohol has stopped):[6]
o Includes visual, auditory or tactile hallucinations.
Withdrawal seizures (can appear 24-48 hours after alcohol has stopped):
o These are generalised tonic-clonic seizures.
Alcohol withdrawal delirium or 'delirium tremens' (can appear 48-72 hours
after alcohol has stopped)

597. A 36yo pt came with diarrhea, bleeding, weight loss and fistula. What is the single
most likely dx?
a. Celiac disease
b. Crohns disease
c. UC
d. IBS
b. Crohns disease
fistula due to transmural involvement, weight loss in crohns.
598. A 72yo woman who is taking look diuretics is suffering from palpitations and muscle
weakness.
What is the electrolyte imbalance found?
a. Na+ 130mmol/l, K+ 2.5mmol/l
b. Na+ 130mmol/l, K+ 5.5mmol/l
c. Na+ 140mmol/l, K+ 4.5mmol/l
d. Na+ 150mmol/l, K+ 3.5mmol/l
e. None
a. Na+ 130mmol/l, K+ 2.5mmol/l
Hypokalaemia can occur with loop or thiazide diuretics.

599. A 60yo diabetic pt on anti-diabetic medication developed diarrhea. What is the most
likely cause for his diarrhea?
a. Autonomic neuropathy
b. Infective
c. Celiac disease
d. Crohns disease
a. Autonomic neuropathy
In general people no autonomic neuropathy usually. Once a diabetic develop autonomic neuropathy he gets
diarrhea off and on due to his autonomic neuropathy and it becomes the most comon cause for his diarrhea.
So most likely cause in this case would be Autonomic neuropathy.
Autonomic neuropathy{GI tract} causes dysfunctional motility / secretions /absorption. ..leads to
gasteroparesis(damage to vagus nerve ), ch: diarrhea(neuronal damage to small intestine)
,,/constipation(colon nerves damage )...

>diarrhea can be due to metformin] it has very common GI side effects ..

Autonomic neuropathy

Risk factors include hypertension and dyslipidaemia. It is more common in


females.
May present with:
o Cardiac autonomic neuropathy, which has been linked to:[5]
Resting tachycardia, postural hypotension, orthostatic bradycardia
and orthostatic tachycardia.
Exercise intolerance.
Decreased hypoxia-induced respiratory drive.
Increased incidence of asymptomatic myocardial ischaemia,
myocardial infarction, decreased rate of survival after myocardial
infarction.
Congestive heart failure.
o Genitourinary:
Impotence, retrograde ejaculation, urinary hesitancy, overflow
incontinence.
At least 25% of men with diabetes have problems with sexual
function.
There is often no association with glycaemic control, duration or
severity of diabetes.
Risk factors for erectile dysfunction include increasing age,
alcohol, initial glycaemic control, intermittent claudication and
retinopathy.
o Gastrointestinal:
Nausea and vomiting.
Abdominal distension.
Dysphagia.
Diarrhoea.
o Gustatory sweating, anhidrosis.

600. Which artery runs in the anterior inter-ventricular groove?


a. Acute marginal branch
b. Left ant descending artery
c. Septal branches
d. Circumflex artery
e. Right coronary artery
b. Left ant descending artery
601. A mother presents with her 12m daughter. The child has no meaningful words, is
unable to sit unaided and cant play with her toys. She doesnt laugh and has poor
interaction with her
siblings. What is the best management strategy?
a. Arrange hearing test
b. Assess developmental milestones
c. Reassure
d. Refer to speech therapist

e. MRI brain
b. Assess developmental milestones
1st we will do assessment of all developmental milestones thn will go for ct or mri

602. A pt presents with progressive visual deterioration. Exam: large, multiple cotton
wool spots in
both eyes. What is the single most likely dx?
a. Kaposis sarcoma
b. Cryptosporidium
c. CMV infection
d. Pneumocystis carinii infection
e. Cryptococcal infection
c. CMV infection
Retinitis:
Retinitis is the most common manifestation of CMV disease in patients who are
HIV positive.
It presents with decreased visual acuity, floaters, and loss of visual fields on one
side.
Ophthalmological examination shows yellow-white areas with perivascular
exudates. Haemorrhage is present. Lesions may appear at the periphery of the
fundus, but they progress centrally.
It begins as a unilateral disease, but in many cases it progresses to bilateral
involvement. It may be accompanied by systemic CMV disease.

Ganciclovir has been used to treat retinitis, but it only slows the progression of
the disease. The optimal treatment is using ganciclovir implants in the vitreous,
accompanied by intravenous ganciclovir therapy.
Oral ganciclovir may be used for prophylaxis of CMV retinitis. It should not be
used for treatment.

603. A 53yo had a dental extraction after which he recently had a mitral valve prolapse,
high temp of 39C, cardiac failure and new cardiac murmur. What is the single most likely
dx?
a. Atheroma
b. Congenital
c. Regeneration
d. Infection
e. Neoplastic
d. Infection
infective endocarditis?

604. A 12yo boy with a hx of fall on an outstretched hand was brought to the ED with
swelling and
pain around the elbow. His radial nerve was affected. What is the type of fx?
a. Angulated fx
b. Epiphyseal fx
c. Compound fx
d. Spiral fx
d. Spiral fx

Humeral shaft fractures


Complications

Radial nerve injury: occurs in 11.8% of fractures. It is most common in distal third
fractures.It is more common in transverse or spiral fracture. Spontaneous
recovery occurs in 70.7% treated conservatively. Initial expectant treatment may
avoid unnecessary operations.
Brachial artery injury.
Non-union.

605. A 32yo lady complains that she hears everyone saying that she is an evil person.
What type of hallucinations is she suffering from?
a. 2nd person auditory hallucinations
b. 3rd person auditory hallucinations
c. Echo de la pense
d. Gedankenlautwerden

b. 3rd person auditory hallucinations


She hears everyone
talking ABOUT her. So it's third person hallucination. If she had been hearing
everyone talking TO her, it would've been second person hallucination.

606. A 65yo woman had an excision of colonic tumor 3yrs ago. Now she is losing weight
and feels
lethargic. Exam: pale but no abdominal findings. What is the most appropriate inv?
a. CA 125
b. CA 153
c. CA 199
d. CEA
e. AFP
d. CEA
607. A 46yo African-Caribbean man is found to have BP=160/90mmHg on 3 separate
occasions. What is the best initial tx?
a. ACEi
b. Beta-blockers
c. ARBs
d. None
e. CCB
e. CCB
Step 1 treatment
patients < 55-years-old: ACE inhibitor (A)
patients > 55-years-old or of Afro-Caribbean origin: calcium channel blocker
Step 2 treatment
ACE inhibitor + calcium channel blocker (A + C)
Step 3 treatment
add a thiazide diuretic (D, i.e. A + C + D)
NICE now advocate using either chlorthalidone (12.5-25.0 mg once daily) or
indapamide (1.5 mg modified-release once daily or 2.5 mg once daily) in
preference to a conventional thiazide diuretic such as bendroflumethiazide
608. A 39yo woman will undergo tubal sterilization and she wants to know the failure
rate of this
type of sterilization.
a. 1:50
b. 1:200
c. 1:500
d. 1:1000
e. 1:5000

b. 1:200
Male sterilisation - vasectomy
failure rate: 1 per 2,000*
semen analysis needs to be performed twice following a vasectomy before a
man can have unprotected sex (usually at 16 and 20 weeks)
Female sterilisation
failure rate: 1 per 20