Medicine

MCQs

1. All of the following can cause an increased anion gap EXCEPT:

A. Uremia
B. Ethylene glycol
C. Methanol
D. Type I RTA
E. Lactic acidosis
2. The most likely mechanism of breathlessness on lying down is:
A. Phrenic nerve stimulation
B. V/Q mismatch
3. Wife meets husband, one year later all of the following are possible EXCEPT:
A. Pneumocystitis carinii
B. Malaria
C. Hepatitis
D. Leishmaniasis
4. All of these drugs, following MI, reduce mortality EXCEPT
A. Aspirin
B. ACE inhibitors
C. β-blockers
D. GTN
E. Lidocaine
5. After hematemesis and gastric lavage, bleeding does NOT stop. What to do now?
A. Emergent EGD in ER
B. Octreotide
C. Call surgeon
D. H2 blocker / omeprazole
6. History of NSAID use, deep penetrating pain radiating to back:
A. Gastric ulcer
B. Duodenal ulcer
C. Atrophic gastritis
7. Patient on prednisolone is predisposed to develop:
A. Gastric ulcer
B. Erosive gastritis
8. Commonest cause of death in SLE is:
A. Infections
B. Renal failure
9. Patient, a known case of SLE, presents with fever, headache and neck rigidity:
what investigation to order?
A. ANA
B. LP
10. X-ray scan of a lady shows diffuse reticular shadowing at lung bases. She has a
history of bleomycin intake. What is the most likely cause?
A. Pulmonary fibrosis
11. A female patient from Balochistan with back pain. X-ray shows a lytic lesion on a
vertebral disc. What to do?
A. Mammography
B. ATT for 9 months
C. ATT for 18 months
Potts can cause osteolytic lesions without disc space involvement.
12. A man with a solitary brain lesion. He is unlikely to have:
A. Brain metastases
13. A patient presents with chest pain. On EKG, he has increased heart rate and ST
elevation in all leads with a decreased PR interval. The most likely cause is:
A. Pericarditis
14. Cor pulmonale: EKG will show:
A. P pulmonale
B. RAD
C. RVH
15. Allergic interstitial nephritis: all of the following are true EXCEPT:
A. Increased serum creatinine
B. Enlarged kidneys
C. Sterile pyuria
D. No eosinophilia
16. Uncontrolled HTN with CCF: post-management of MI with chronic cough: what
to give?
A. ACE inhibitors
B. CCBs
C. Thiazide
D. β-blockers
17. Dopamine vs. Dobutamine:
A. Dopamine: D+β1+α receptors; low dose ↑ RBF, high dose ↑ BP
B. Dobutamine: β1 receptors; both RBF and BP ↑ at same dose
18. Afghani man presents with fever, tachycardia and hepatosplenomegaly: what he is
NOT likely to have?
A. Tuberculosis
B. Brucellosis
C. Leishmaniasis
19. 76 years old lady complaining of severe aches and stiffness of shoulder, neck and
pelvic girdle muscles for the past 3 months. She presents with increasing
headaches and ESR of 90 mm/hr. Most appropriate investigation in her case
is:
A. Muscle biopsy
B. CT scan of brain
C. Temporal artery biopsy
D. Aortic arch arteriogram
E. ANA
20. 22 years old medical student presents with right-sided chest pain and fever for a
week. On clinical examination and CXR, a moderate pleural effusion exists. A
tap shows exudative picture with protein >5 g/dl, WBC 10,000 with
 lymphocytic predominance and glucose of 50 g/dl. The most likely diagnosis
is:
A. Uncomplicated parapneumonic effusion
B. Pulmonary infarction
C. Tuberculosis
D. Empyema
E. Rheumatoid effusion
21. A 40 years old lady presented to the pulmonology clinic with one-month history
of progressive shortening of breath, intractable dry cough, chest fullness and
fever. Clinical examination revealed crackles in left mid-zone and chest X-ray
showed evidence of alveolo-nodular infiltrate involving the lingular segment
with air bronchograms and pericardial effusion. She was diagnosed to have
carcinoma of the breast 6 months ago, which was treated with left mastectomy
followed by radiotherapy. Her present illness is most likely due to:
A. Interstitial lung disease
B. Atypical pneumonia
C. Lymphangitis carcinomatosa
D. Radiation pneumonitis
E. Cabor pneumonia
22. Mechanism of action of papilledema:
A. Interruption of axonal transport
B. Decreased arteriolar supply of optic disc
C. Decreased venous drainage of optic disc
D. Increased glial tissue at disc
23. A 72 years old man with progressive weakness, Hb 10 g/dl, macrocytosis and
reticulocytosis. Everything else is within normal range. What is the most
likely cause?
A. Iron deficiency anemia
B. Lymphoma
C. Leukemia
D. Myelodysplastic syndrome
E. Anemia of chronic disease
24. Differentials of cavity with air-fluid level on CXR:
A. Abscess
B. Bronchogenic carcinoma
C. Tuberculosis
D. Hydatid cyst
E. Rheumatoid nodule
F. All of the above
25. Which of the following anti-tuberculous drug is contraindicated in pregnancy?
A. Isoniazid
B. Rifampicin
C. Pyrazinamide
D. Ethambutol
E. Streptomycin
26. What is the most common complication of enteric fever?
 A. Carrier state
B. Intestinal perforation
C. Renal failure
27. The most common cyanotic CHD in neonates is:
A. Transposition of great vessels
28. All of the following are seen in ToF EXCEPT:
A. LVH
29. All of the following are complications of N/S administration EXCEPT:
A. Hematoma formation
30. Age assessment is possible by all of the following means EXCEPT:
A. Anterior fontanelle size
31. A 6 years old child with increasing pallor and intermittent fever. Which of the
following is NOT an essential investigation?
A. CBC
B. Chest X-ray
C. Bone marrow
D. Blood C/S
32. Thrombocytopenia is seen in all of the following EXCEPT:
A. HSP
B. ITP
C. Wiskott-Aldrich syndrome
D. Giant cell osteoclastoma
33. A 2 years old child with fever, vomiting and convulsions. Which of the following
diagnoses is unlikely?
A. Febrile seizure
B. Drug ingestion
C. Rye’s syndrome
34. Child has swallowed kerosene oil. In ER, you will give:
A. Oxygen
B. Emetic
C. Antacid
35. HUS: all of the following are symptoms EXCEPT:
A. Invariable hematoma
36. All of the following decrease theophylline metabolism EXCEPT:
A. Phenobarbital
B. Linerdil
C. Erythromycin
37. Bronchiectasis may be reliably diagnosed by:
A. History
B. Physical examination
C. Chest X-ray
D. Pulmonary function tests
E. High-resolution CT scanning
38. Atrial fibrillation may be caused by all of the following EXCEPT:
A. Mitral stenosis
B. Thyrotoxicosis
 C. Hypertension
D. Aortic stenosis
E. Ischemic heart disease
39. Alcohol toxicity to the liver includes all of the following EXCEPT:
A. Fatty liver
B. Granulomatous hepatitis
C. Cirrhosis
D. Acute hepatitis
E. Hepatocellular carcinoma
40. High anion gap metabolic acidosis is NOT caused by:
A. Lactic acidosis
B. Diabetic ketoacidosis
C. Diarrhea
D. Ethylene glycol poisoning
E. Renal failure
41. All of the following features may be found in sepsis EXCEPT:
A. Multi-organ failure
B. Peripheral vasoconstriction
C. Hemolysis
D. Coagulopathy
E. ARDS
42. A businessman develops chest pain while playing a game of tennis. The pain is
severe in intensity. On arrival in emergency room, 30 minutes after
administration of nitroglycerin, he complains of severe persistent chest pain.
He is sweaty and anxious. The patient’s electrocardiogram is shown. The
electrocardiogram of this patient shows shift of vector towards the
epicardium. Infarction most likely involves:
A. Anterior wall
B. Inferior wall
C. Lateral wall
D. Posterior wall
E. Septum
43. Which of the following agents would you choose for pain relief?
A. Aspirin and pethidine
B. Morphine and nitroglycerin
C. Paracetamol
D. Paracetamol and codeine
E. Paracetamol and piroxicam
44. After 2 hours of admission, the patient’s heart rate drops to 30 beats/min, due to
hypoxia in the territory of:
A. Left anterior descending artery
B. Left circumflex artery
C. Left internal mammary artery
D. Right coronary artery
E. Right sinus of Valsalva
45. Female with swollen DIP, PIP joints and both kness with chondrocalcinosis. She
has diabetes mellitus as revealed on biochemical labs. What is the most likely
diagnosis?
A. Osteoarthritis
B. Rheumatoid arthritis
C. Hemochromatosis
D. Pseudogout
46. 23 years old female with seizures and headache. Past history of pleuritic chest
pain and joint pains. What investigations to order?
A. Anti-dsDNA antibodies
B. ANA
47. Female with facial rash, proteinuria and edema for 3 months. The best screening
test is:
A. ANA
B. dsDNA
C. ESR
48. Female with hypertension and hypokalemia, normal sodium, on medications for
HTN. Best test is:
A. Serum renin levels
B. Serum renin levels after 20 mg furosemide
C. Saline infusion and aldosterone levels
49. Pregnant female, 1 week post-partum with dyspnea, normal SVD with no
complications. She has bilateral rhonchi in mid-chest with a 3/6 holosystolic
murmur. The most likely diagnosis is:
A. Mitral stenosis
B. Mitral stenosis with CHF
C. CHF
D. Cardiomyopathy
50. 23 years old female with history of rheumatic fever, taking prophylaxis. What
medication would you give before dental procedure?
A. Amoxicillin 2g 1 hr before and 1g 6 hrs afterwards
B. Erythromycin
C. Clindamycin
51. Patient with swollen painful joint. Joint aspirate reveals opaque fluid with
>50,000 WBCs, >75% neutrophils, C/S +ve, Glc < 25. The treatment in this
case is:
A. Rest and immobilize joint
B. Intravenous antibiotics for 2 weeks
C. Oral antibiotics for 4 weeks
D. Joint drainage
52. Nephrogenic diabetes insipidus:
A. Serum Na+ ↑, Serum Osmolarity ↑, Urinary Na+ ↓, Urinary
Osmolarity ↓
53. Enteric fever not responding to ampicillin: what to do next?
A. Get blood C/S
 Match drugs for Salmonella typhi with their mechanisms of action:
54. Ampicillin Acts on cell wall
55. Ceftriaxone Acts on cell wall
56. Azithromycin Binds to 50S subunit
57. Ciprofloxacin DNA gyrase inhibitor
58. Chloramphenicol Binds to 50S subunit
59. Septran Folate & PABA antogonist

60. A female with RA not responding to ibuprofen. What is the best treatment?
A. Increase the dose of ibuprofen
B. Methotrexate
C. Physiotherapy
D. Three NSAIDs for 2 weeks
61. Which of the following to administer to a patient with disseminated intravascular
coagulation?
A. FFP
B. Cryoprecipitate
62. Old male with 3 lesions in the right cortical area and a 4 month history of
headache. The least likely diagnosis is:
A. Primary brain cancer
B. Chronic granulomatous inflammation
63. A case history of mother with history of Sheehan syndrome. All labs show
hypopituitarism. The lesion is most likely at which site?
A. Hypothalamus
B. Pituitary gland
C. Cerebellum
D. Adrenal
64. In the above patient, what will be expected levels of anti-diuretic hormone in the
blood?
A. Increased
B. Decreased
C. Normal
D. Undetectable
65. In the above patient, what will be the cause of lactation failure?
A. Decreased prolactin
66. In the above patient, what will you give first?
A. Thyroxine
B. Cortisol
C. Minerals
D. LH
67. AV dissociation with an MI: all of the following will be administered EXCEPT:
A. Nitrates and β-blocker
B. Heparin
C. Pacemaker
68. An unstable patient with wide-complex tachycardia:
A. Cardioversion
 B. Defibrillate
69. A hypertensive with no pedal edema and JVP wnl. On auscultation of chest,
bilateral crackes are heard. How would you manage this patient?
A. Change lisinopril to hydrochlorothiazide
B. Optimize the dose of lisinopril
C. Optimize the dose of thiazide
70. ABGs of COPD patient reveal pH 7.45, pO2 ↓ and pCO2 65 mm Hg. What is the
most likely disorder?
A. Mixed acid-base disorder
71. All of the following are true about atopic asthma EXCEPT:
A. ↑ IgG
72. 8 years old male with mild jaundice:
A. Gilbert syndrome
B. Criggler-Najjar syndrome
C. Dubin-Johnson syndrome
73. Megaloblastic anemia: you will administer all of the following EXCEPT:
A. Folate
B. Vitamin E
C. Vitamin C
D. Vitamin B12
74. Pott’s disease with lytic lesion of disc: appropriate treatment would be:
A. Treat with ATT for 18 months
B. Treat with ATT for 9 months
75. A female patient on ATT for 6 months presenting with CNS signs for 3 days. MRI
shows three lesions in the brain. What is the appropriate management?
A. Continue ATT
B. Add 2 more drugs
C. Stop drugs for 2-3 days
76. A patient in septicemic shock has passed no urine in the past 2 hours. Which of
the following describes the most appropriate course of action?
A. Give dobutamine to increase cardiac output
B. Give dopamine to increase mean arterial pressure
C. Give dopamine to increase splanchnic blood flow leading to increased
kidney perfusion
77. A patient has pneumonia and massive effusion due to infection. Gram staining of
the fluid shows gram positive diplococci. What is the urgent management?
A. IV antibiotic
B. Chest tube
C. Ventilation
78. A diabetic patient with peripheral vascular disease underwent TKR. On 10th post-
operative day, he develops a pulurent discharge with swollen knee joint. The
pathophysiology of this disease includes all of the following EXCEPT:
A. Colonization of nasopharynx by causative agent
B. Defective neutrophil function
C. Ischemia due to peripheral vascular disease
D. Polyneuropathy causing sensory loss
79. A woman with abdominal pain, fever and weight loss. A barium follow-through
shows thickened terminal ileum with ulcers. What is the pathophysiology of
this condition?
A. Caseating granulomas
80. In the above patient, what will you do to confirm your diagnosis?
A. Colonoscopy, ileoscopy + biopsy
B. Tuberculin test
C. Proctoscopy
81. The most appropriate management of the above patient is:
A. Anti-tuberculous therapy
B. Steroids
82. A 68 years old woman suffering from type 2 diabetes mellitus presents with
severe pain and redness over the right leg for the last 2 days and fever for the
last 24 hours. On examination, temperature is 39.4oC. The right leg is swollen
and red from the ankle to the knee joint; also tender to palpation. There are no
other skin lesions. This patient should receive an antibiotic against:
A. Atypical bacteria
B. Gram negative rods
C. Gram negative cocci
D. Gram positive cocci
E. Mycobacteria
83. An ICU patient develops fever, purulent endotracheal secretions and a new chest
X-ray infiltrate. Pending results of cultures sent this morning. Which of the
following is the most appropriate antibiotic regimen at AKU?
A. Vancomycin plus gentamycin
B. Ceftazidime plus gentamycin
C. Vancomycin plus piperacillin-tazobactam
D. Imipenem plus erythromycin
E. Piperacillin-tazobactam plus amikacin
84. In a patient with fever and thrombocytopenia, which of the following features
clinically differentiates between malaria and Crimean-Congo hemorrhagic
fever?
A. Hepatomegaly
B. Splenomegaly
C. Leukopenia
D. Lymphocytosis
E. Abnormal liver enzymes

A 75 years old male diagnosed with Parkinson’s disease had had complaints of
difficulty starting micturition and a weak stream for the past 6 months. Today,
he presented to the ER with complaints of fever (38.6oC) with shaking chills
and pain in the left flank. Rest of the vitals is within normal limits.
85. What would be the most useful investigation to carry out at this stage?
A. D/R of midstream urine
B. D/R of suprapubic aspirate
C. Intravenous pyelography
 D. Digital rectal examination
E. Examination of left flank
86. What is the most likely reason for his 6 month long symptoms?
A. Prostatism
B. Stricture formation
C. Neurogenic bladder
D. Glomerulosclerosis
E. Psychosomatic disorder
87. Which, among the following drugs, would you prefer for controlling his
Parkinsonian tremors?
A. Benztropine
B. Bromocriptine
C. Levodopa with carbidopa
D. Selegiline
E. Tolcapone
88. Parkinson’s disease denotes a disappearance of dopaminergic neurons from the:
A. Hippocampus
B. Subthalamus
C. Striatum
D. Substantia nigra pars compacta
E. Substantia nigra pars reticulata
89. Which of the following is FALSE about the combination of levodopa and
carbidopa?
A. It reduces the incidence of hypotension
B. It reduces the incidence of peripheral side-effects
C. It crosses the blood-brain barrier
D. It increases the central availability of dopamine
E. It is administered orally
90. L-dopa is converted to dopamine by the action of:
A. Dopa decarboxylase
B. Dopa aminotransferase
C. Dopa hydroxylase
D. Dopa oxidase
E. Dopa reductase

The person above was admitted and empirically started on ceftriaxone +

amikacin. Twelve hours later, his temperature rose to 39.5oC, his BP dropped
to 90/55 mm Hg and his pulse rose to 115 bpm. The nurse’s I/O charting
records revealed oliguria. Serum creatinine was also seen to have risen above
normal limits.
91. What is the most likely reason for this deterioration?
A. Autoimmune nephrotoxicity
B. Drug-induced nephrotoxicity
C. Septic shock
D. Superinfection with a nosocomial pathogen
E. Meningoencephalitis
 [Drug-induced nephrotoxicity does not explain the new onset of fever.]

Match the following:

92. Cimetidine Gynecomastia
93. Propylthiouracil Hyperthyroidism
94. Bromocriptine Gynecomastia Acromegaly
95. Chlorpropamide Hyponatremia
96. Octreotide Acromegaly

97. Which of the following is the main reason behind the osteolytic lesions seen in
multiple myeloma?
A. Infiltration by tumor cells
B. Production of self-tolerant immunoglobulins
C. Release of cytokines
D. Secondary hyperparathyroidism
E. Expansion of the marrow
98. Secondary hyperparathyroidism is most often characterized by:
A. High serum calcium, high urinary phosphate
B. Normal serum calcium, high urinary phosphate
C. Normal serum calcium, low urinary phosphate
D. Low serum calcium, high urinary phosphate
E. Low serum calcium, low urinary phosphate

Match the following:

99. Squamous cell carcinoma Low serum PTH
100. Chronic renal failure High serum PTH
101. Thiazide diuretics Low serum PTH
102. Osteomalacia High serum PTH
103. Multiple myeloma Low serum PTH

104. An appropriate tissue biopsy of a typical patient with SLE is most likely to
show:
A. Coagulative necrosis
B. Liquefactive necrosis
C. Fat necrosis
D. Fibrinoid necrosis
E. Caseous necrosis
105. The hematologic abnormalities seen in SLE are examples of:
A. Type I hypersensitivity
B. Type II hypersensitivity
C. Type III hypersensitivity
D. Type IV hypersensitivity
E. Type V hypersensitivity
106. Choose the correct statement:
A. Langerhans cells are confined to the CNS
B. Dendritic cells are confined to the CNS
 C. Dendritic cells are confined to the skin
D. Dendritic cells are confined to the spleen
E. Langerhans cells are a subset of dendritic cells

Match the following organisms with their characteristic sites:

107. Cryptococcus CNS
108. Cryptosporidium GIT
109. Toxoplasma CNS
110. Pneumocystis Respiratory tract
111. Mycobacterium avium-intracellulare Disseminated

112. What does a raised PT signify?

A. Hepatic necrosis
B. Decreased synthetic function of liver
113. A 20 years old male with abdominal pain, vomiting, hallucinations and
agitation. A psych consult was given which further aggravated the symptoms.
What is the most likely diagnosis?
A. Acute intermittent porphyria
114. An HIV patient with painless loss of vision in one eye. Fundoscopy shows
exudates along vessels in a typical “pizza slice” appearance. What is the most
likely diagnosis?
A. CMV retinitis
115. The above condition is seen at what levels of CD4 counts in the blood?
A. CD4+ ≤ 50
B. CD4+ ≤ 100
C. CD4+ ≤ 200
116. Which of the following intervention has NOT decreased mortality in patients
with dilated cardiomyopathy?
A. Digoxin
B. Aspirin
C. Diuretics
D. Biventricular pacing
117. An 18 years old male with cough, headache and continuous high-grade fever.
On examination, his pulse is 90 bpm. He has previously used antibiotics.
Which investigation should be ordered in this case?
A. Blood culture
B. Bone marrow culture
C. MP
D. MP by ICT
E. Chest X-ray
118. Which of the following is protective against colon cancer?
A. Vitamin A
B. Vitamin E
119. All of the following are complications of massive blood transfusion EXCEPT:
A. Hyperkalemia
B. Acidosis
 C. Left-shift of O2 dissociation curve
D. Hypercalcemia
120. A patient presents with jaundice, Hb 6.5 g/dl, Hct 25%, total bilirubin 4 gm/dl,
both direct and indirect bilirubin are raised, Alk. Phos raised, PT 16/12 , aPTT
13/20, Albumin 2.0 g/dl, total protein 6.0 g/dl. After initial resuscitation, what
is the next step you will do?
A. FFPs
B. Vitamin K supplement
C. Whole blood transfusion
121. A patient had a head injury and this was followed by disorientation and coma.
The patient had hemiplegia of the left side and dilated pupil on the left. The
main reason for this is:
A. Uncal herniation onto the left side

A 3 years old male with microcytic hypochromic anemia, Hb of 5 g/dl,

dyspnea while running, enlarged liver and kidneys, respiratory insufficiency
syndrome. Father and mother are cousins and carriers. Pedigree shows that
child is homozygous.
122. Why child is suffering from dyspnea?
A. Decreased oxygen carrying capacity of blood
123. What is the causative factor?
A. Deficiency of α-chain
B. Reduced synthesis of β-chain
C. Inability to incorporate iron into heme
124. Best treatment for the above patient is:
A. Infusion of packed RBCs
125. Most important long-term complication is:
A. Secondary hemochromatosis

An obese woman with blood hormone levels shown: TSH ↑ T3 ↓ T4 ↓. On

clinical examination, her reflexes are slow and pendular with prolonged
relaxation phase.
126. Why is the woman obese in the above case?
A. Decreased metabolic rate
127. Why reflexes relax slowly?
A. K+
B. HCO3-
C. PO4-3

A 65 years old diabetic and hypertensive patient has sudden onset of chest
pain of 2 hours duration. He is brought to the emergency room. An ECG done
shows STE in leads I and V2-V4. His creatinine is 6 mg/dl.
128. ST segment elevation in above case is due to:
A. Myocardial infarction
129. Which artery is involved in the above case?
A. Left anterior descending artery
130. Why is morphine administered to the patient?
A. Analgesia
B. Euphoria
131. The best drug for long-term use in this patient is:
A. Aspirin
B. Anti-platelet drugs
132. If renal function is impaired, which drug to use?
A. ACE inhibitor
133. Why renal function is impaired in this patient?
A. Atrophy and scarring of tubules
B. Hyperplasia of glomerular cells
134. Why is the onset of chest pain sudden?
A. Ruptured atherosclerotic plaque

A 28 years old man with a history of passing stools with streaks of blood for
the past 10 years. Now, the bleeding has increased. Lab investigations show
that Hb ↓, neutrophils ↑, K+ ↓, Mg2+ ↓ with microcytic hypochromic anemia.
The patient has been taking loperamide and since last 6 months, his diet
consists of only soup and bread.
135. Why is hemoglobin low in this patient?
A. Chronic loss of blood
136. Why is the patient taking loperamide?
A. Anti-motility drug
137. Why does the patient have hypokalemia and hypomagnesemia?
A. Error in sampling
B. Loss in stool
138. Why do we plan to do colonoscopy?
A. To check for dysplasia

A child has costochondral junctional pain and nodule with cup-shaped

epiphyses at both wrist joints. The child appears emaciated and cannot walk
properly. Lab results show ↑ alkaline phosphatase, ↑↑ PTH, ↓ Ca2+ and ↓ PO4-
3
.
139. What is the fundamental problem in above case?
A. Defective mineralization
140. Why PTH has increased?
A. Decreased serum calcium
B. Secondary hyperparathyroidism
C. Parathyroid adenoma
141. Why is alkaline phosphatase elevated in blood?
A. Increased osteoclastic activity
B. Osteocalcin

A 35 years old patient had a TB-like disease a few years back with weight loss
and cough. The doctor prescribed him multiple drugs, but, he left them after 1
month. Now, he has come with worsening dyspnea for 1 day. On physical
 examination, he has muffled heart sounds, impalpable apex beat and engorged
neck veins. A chest X-ray done in the emergency room shows bilateral diffuse
infiltrates.
142. Where is the problem located in the above case?
A. Pericardium
143. If samples are sent, what type of cells will be seen?
A. Lymphocytes
144. On histopathology, what will you find in the lungs?
A. Epitheloid granulomas
145. What treatment should be given to the above patient?
A. Anti-tuberculous therapy
146. What is the main adverse effect of the above therapy?
A. Hepatotoxicity

A middle-aged lady presents with swollen hands and feet along with
involvement of metacarpophalangeal joints. Recently, she has developed pain
in her right knee with restriction of motion. The knee is tender to touch and
warm. Blood profile reveals neutrophilia and also positive for rheumatoid
factor. Knee aspirate reveals turbid synovial fluid with neutrophils. Specimen
sent for culture grows gram positive cocci which are catalase and coagulase
positive, resistant to methicillin. The patient also has weak left adductor
function and loss of sensation of lateral three-and-a-half fingers in one arm.
147. Which cells are responsible for the formation of rheumatoid factor?
A. B lymphocytes
148. Which antibiotic should be administered to the above patient?
A. Vancomycin
149. For joint pain, you will do all of the following EXCEPT:
A. GABAergic agonist
B. Systemic steroids
C. Intra-articular steroids
150. What is the most likely explanation for her tingling and sensation problems in
her left hand?
A. Carpal tunnel syndrome

65 years old Mrs. Khan, a known hypertensive and diabetic, has hemorrhage
on right side of head, conjunctival redness, proptosis and mydriasis. Her
visual acuity is severely reduced to just perception of light. She also has
swelling from right side of mouth with blackish discharge from the swelling.
151. For this swelling, what diagnostic test would you perform?
A. Kinyoun staining
B. Destroy by KOH and view under microscope
152. We can give all of the following drugs to the above patient EXCEPT:
A. Sulfonylureas

A middle-aged male presents with right upper quadrant pain, sweating and
fever. Ultrasound reveals a single hypoechoic lesion in the liver. The patient
 has mild icterus on examination. Lab results reveal ↑ ALT and ↑ total
bilirubin.
153. Why is the patient having pain in right upper quadrant?
A. Stretching of Glisson’s capsule
154. How did the patient contract this infection?
A. Ingestion of cyst
155. How did the infection reach the liver?
A. Portal vein
156. What is the source of bilirubin in this patient?
A. Liver parenchyma
B. RBCs

Match the following:

157. BT ↑ PT ↔ aPTT ↔ Platelet dysfunction
158. BT ↔ PT ↑ aPTT ↔ Extrinsic pathway defect
159. BT ↔ PT ↔ aPTT ↑ Intrinsic pathway defect
160. Aspirin use: labs normal Platelet dysfunction
161. Liver disease: PT ↑ aPTT ↑ Intrinsic, extrinsic and common
pathway defect
162. Warfarin use: PT ↑ aPTT ↑ BT ↔ Intrinsic, extrinsic and common
pathway defect
163. Heparin use: BT ↔ PT ↔ aPTT ↑ Intrinsic and common pathway
defect

164. Uncontrolled diabetes mellitus and hypertension in a 55 year old female. You
suspect that hypertension is secondary to Cushing’s syndrome. What test will
you order for this patient?
A. Low-dose dexamethasone suppression test
B. High-dose dexamethasone suppression test
C. 24-hour urinary cortisol
165. A patient with diabetes mellitus well-controlled on glibenclimide until
recently. The patient is obese. What will you do?
A. Start insulin and stop all medications
B. Add another sulfonylurea
C. Add metformin
166. ABGs of a patient show pH of 7.4, pO2 of 76 mm Hg, pCO2 of 54 mm Hg and
HCO3- of 38. What is the most likely underlying disorder?
A. Uncompensated metabolic acidosis
B. Mixed disorder of respiratory acidosis and metabolic alkalosis
167. HMG CoA reductase inhibitors decrease LDL by:
A. Lipoprotein lipase reduction
B. Reducing LDL receptors on cell membranes
C. Increasing LDL receptors on cell membranes
168. In community acquired pneumonia, all are indicators of poor prognosis
EXCEPT:
A. Age > 65 years
 B. Confusion
C. Increased urea
D. Dyspnea
E. Elevated temperature
169. In treatment of community acquired pneumonia, we have to first rule out:
A. Legionnaire’s disease
170. A patient has COPD since 2 years and can no longer be controlled by
salbutamol inhaler. What do you do?
A. Corticosteroids orally
B. I/V corticosteroids
C. Corticosteroid inhaler
D. Corticosteroid nebulizer
E. Ipratropium inhaler
171. Acute exacerbation of asthma, PEFR equals 40% of best. What do you do?
A. Give inhaled β-agonist & steroid and admit the patient
B. Do ABGs
C. Get a chest X-ray
D. Give steroids and send home
E. Give antibiotics
172. A patient has asthma for many years. He also has varicose veins, which are
progressively painful and now, he is tender around knee joints. What do you
do?
A. Doppler to rule out DVT
B. Give pain-killers
C. Involve vascular surgery
173. 65 years old female was operated on two weeks back for hip fracture. On
clinical examination, she has RR of 32/min with tachycardia, however, there
is no dyspnea or hypertension. Which of the following is the most useful
investigation to be performed?
A. D-dimer
B. Spiral CT scan of chest
C. Chest X-ray
D. Pulmonary angiography
E. V/Q scan
174. Which one of the following statements is true about bronchogenic carcinoma?
A. 75% small cell, 25% non-small cell
B. Small cell carcinoma causes SIADH
C. Surgery is the best option for small cell carcinoma
D. Sputum cytology is diagnostic
175. A young girl referred to endocrinologist for evaluation of hyperthyroidism
after spontaneous abortion. Which of the following is NOT associated with
hyperthyroidism?
A. Vitiligo
B. SLE
C. Giant cell arteritis
176. A lady with goiter: on physical examination, you would expect to see:
 A. Thinning of eyebrows
B. Myxedema
C. Pretibial myxedema
D. Ondiolysis
E. Lethargy
177. A 60 years old male farmer presents with progressive dyspnea. A chest X-ray
is ordered, which reveals bilateral nodular infiltrates. What is the most likely
diagnosis?
A. Cryptogenic fibrosing alveolitis
178. Which of the following is an action of insulin?
A. Increases glycolysis
179. A 25 years old tall lean male with no known comorbids presents to the ER
with sharp right-sided chest pain and decreased breathing sounds on right side.
What is the most likely diagnosis?
A. Tension pneumothorax
180. Which one of the following statements is true?
A. Whispering pectoriloquy is increased over an area of consolidation
181. Does the pattern of chest X-ray findings have any relation to the causative
organism of pneumonia?
A. From a chest X-ray, you cannot tell with certainity the causative agent
for pneumonia
182. In a chest X-ray, you observe mediastinal shift towards the right side. What
could be the most likely explanation?
A. Consolidation on the right side
B. Fibrosis on the right side
C. Collapse on the right side
D. Pnumothorax on the right side
E. Both B & C
183. A patient with diabetes mellitus having urine microalbumin of 180. What
should be the next step?
A. Start him on ACE inhibitor
184. Hormonal assay of a patient with Turner’s syndrome will most likely reveal:
A. Increased FSH and estradiol
B. Low FSH and estradiol
C. Decreased estradiol and increased FSH
185. Insulin does all of the following EXCEPT:
A. Inhibit lipoprotein lipase
186. Asthma is diagnosed by:
A. Improvement of PEFR by ≥15% with bronchodilators
187. In a pregnant female, we will continue all of the following anti-tuberculous
drugs EXCEPT:
A. Isoniazid
B. Rifampicin
C. Pyrazinamide
D. Ethambutol
E. Streptomycin
188. All of the following changes occur in asthma EXCEPT:
A. Increased mucus production
B. Goblet cell hypertrophy
C. Increased secretions
D. Thinning of basement membrane
189. A 61 years old male successfully treated for pneumonia has residual cough
without any fever. What is the most appropriate management plan?
A. Repeat antibiotic course
B. Continue same antibiotics for 20 days
C. Chest X-ray STAT
D. Chest X-ray and follow-up after 3 weeks
190. A patient has hirsutism and you suspect polycystic ovarian syndrome. Which
of the following investigations should be ordered for this patient?
A. Fasting insulin, TSH, pelvic U/S
191. What is the best time to administer antibiotics to a patient undergoing
cholecystectomy for cholelithiasis?
A. 1 hour pre-op
B. 24 hours pre-op
C. Intraoperatively
192. The major support of the uterus is:
A. Broad ligament
B. Infundibular ligament
C. Round ligament
D. Transverse cervical ligament
193. STEMI: ECG shows STE in leads II, III and avF with ST segment depression
in leads I, avL, V1, V2 and V3. The most likely diagnosis is:
A. Inferoposterior MI
194. Which of the following is a bad prognostic sign in febrile seizures?
A. Seizure lasting for more than 1 hour
B. EEG showing abnormal < 8 ms fall
C. Age < 1 year
195. A child with asthma under good control on inhaled steroids, however,
exacerbation occurs after exercise. What is the best advice to give to this
patient?
A. Add long-acting β2-agonist
B. Use short-acting β2-agonist before exercise
196. 10 workers in a grocery shop developed pneumonia with diarrhea, abdominal
pain and vomiting. These workers were exposed to moist environment by
cooling machine for newly arrived material. What is the most likely causative
organism?
A. Legionella pneumophila
197. Drug of choice for the above patients is:
A. Erythromycin
198. A young male from native America presents with a 4 day history of bloody
diarrhea. What is the next step?
A. U/S abdomen
 B. Culture and appropriate antibiotics
C. Drink lots of water and reassure
199. A 3 years old child while playing has sudden bouts of cough. He is brought to
the ER with suspected foreign body inhalation. What is the best management
in this case?
A. Chest X-ray and bronchoscopy if history is suspicious
B. Always do bronchoscopy in such a presentation
200. An ECG shows peaked T waves and a prolonged QT interval. Which of the
following two electrolyte disturbances can explain these findings?
A. Hyperkalemia, hypocalcemia
B. Hypokalemia, hypocalcemia
C. Hypokalemia, hypercalcemia
201. A male with left-sided weakness, arm > leg with an irregularly irregular pulse
and defect in lower quadrant of visual field with macular sparing. The most
likely location of this lesion is in the:
A. Parietal lobe
B. Temporal lobe
C. Internal capsule
202. The most likely cause of the above lesion is:
A. Embolic stroke
203. An AIDS patient being treated with zidovudine presents with complaints of
lethargy and weakness. An ECG is ordered, which shows peaked T waves.
What is the most likely cause?
A. Hyperkalemia
B. Zidovudine toxicity
C. Pericarditis
D. Hyperkalemia with inferior wall STEMI
204. A lady with a 2 year history of staghorn calculus. Now, she has presented with
flank pain and tenderness. What is the most likely cause?
A. Renal cortical abscess
B. Pyonephrosis
C. Squamous cell carcinoma of kidney
205. A 65 years old male k/c of prostate CA presents with acute retention of urine.
What is the most likely cause?
A. Radiotherapy of spine
206. A 38 years old male with 1 week history of fever, drowsiness and right
hemiparesis. On examination, he has up-going plantars and has had a seizure.
LP reveals pleocytosis, increased protein and normal glucose. What is the
most likely diagnosis?
A. HSV encephalitis
207. In the above condition, what is the most common site of involvement of the
brain?
A. Frontal lobe
B. Parietal lobe
C. Temporal lobe
D. Occipital lobe
208. What is the investigation of choice for a patient presenting with recurrent
seizures?
A. EEG
B. CT scan
C. MRA
209. A man presents with complaints of unilateral headache, lacrimation, flushing
and rhinorrhea. These symptoms are improved by 100% O2 therapy. What is
the most likely diagnosis?
A. Cluster headache
210. 82 years old male smoker k/c of HTN presents to the ER with chest pain and
extreme shortness of breath after exercise. ECG shows STE in V1-V2 and tall
R waves in V5-V6. What is the most likely diagnosis?
A. Acute myocardial infarction
B. Ischemic cardiomyopathy
C. Aortic stenosis
D. Aortic regurgitation
211. A 28 years old female patient with weight loss, night sweats and colicky
abdominal pain. What should be the most appropriate investigation to order?
A. Colonscopy & ileoscopy with biopsy
212. Which of the following will be most likely seen on histopathology of obtained
specimen for biopsy?
A. Caseating granulomas
213. What is the treatment of choice in the above case?
A. Anti-tuberculous therapy
214. Which of the following is the most lethal complication of Kawasaki disease?
A. Coronary aneurysms
215. Which of the following correctly explains the pathology in lymphocutaneous
fever?
A. Medium vessel vasculitis
216. Which of the following has an association with hepatitis B?
A. Polyarteritis nodosa
217. Which of the following is classically seen in patients with hepatitis C
infection?
A. Type II cryoglobulinemia
218. In the above patient, if a biopsy of a lymph node was taken, one would expect
to see:
A. Leukocytoclastic vasculitis
219. A 70 years old male patient with oligoarthritis, skin lesions and pitted nails
(psoariatic arthritis). An X-ray of the knee joint is likely to show:
A. Pencil-in-cup deformity
220. Which of the following vasculitides has a strong association with smoking?
A. Thrombangitis obliterans (Buerger’s disease)

Match the following:

221. Wegener’s granulomatosis cANCA
222. Churg-Strauss syndrome cANCA
223. Microscopic polyangitis pANCA

224. Which of the following correctly describes the classical findings of

bronchiectasis on physical examination?
A. Crepitations which change on coughing
225. A 30 years old female with obstructive jaundice, hepatosplenomegaly and
xanthelesmas around the eyes. She tells you that her condition has improved
on oral tablets of chenodeoxycholic acid. What is the most likely diagnosis?
A. Primary biliary cirrhosis
226. In the above patient, what specific laboratory investigation will you order?
A. Anti-mitochondrial antibody
227. Which of the following will you perform to confirm your diagnosis?
A. Liver biopsy

Match the following:

228. Dermatomyositis Anti-Jo antibodies
229. Sjögren syndrome Anti-LA (SSB) antibodies
230. SLE Anti-SM antibodies
231. Drug-induced lupus Anti-histone antibodies
232. CREST syndrome Anti-centromere antibodies
233. MCTD Anti-RNP antibodies

234. Which of the following skin lesions are classically seen in patients with
dermatomyositis?
A. Gottron’s papules and heliotrope rash
235. Which of the following investigations is required to confirm a diagnosis of
dermatomyositis?
A. Muscle biopsy
236. A 30 years old male presents with a pathologic fracture of his right femur.
During his stay in the hospital, he has an episode of hematemesis. Further
inquiry reveals that he has a long-standing headache and lethargy. What is the
most likely diagnosis?
A. Multiple endocrine neoplasia
[Pathologic fracture  PTH hyperplasia; hematemesis  gastrinoma;
headache and lethargy  pituitary adenoma]
237. The most common cause of death in patients with Paget’s disease is:
A. High output cardiac failure
238. A 5 years old boy with bilateral knee joint swelling. On examination, patellar
tap is positive. On lab investigation, he has an ESR of 90 mm/hr. What is the
best investigation?
A. Synovial fluid aspiration
B. Synovial biopsy
C. Rheumatoid factor
239. How much volume loss should occur before a systolic drop occurs?
A. <15%
B. 15-30%
 C. 30-40%
D. >40%
240. An ECG shows regular narrow-complex tachycardia with a heart rate of
300/min. What is the most likely diagnosis?
A. Atrial flutter with a 1:1 block
B. Atrial flutter with a 2:1 block
C. Atrial fibrillation
D. Sinus tachycardia
241. A 15 years old boy k/c of type I diabetes mellitus presents with diabetic
ketoacidosis. He is resuscitated in the ER and managed in hospital. Which of
the following best describes the subsequent management?
A. Continue insulin infusion until the boy starts to eat
B. Discontinue insulin infusion now
242. A baby with right localizing signs had fever for 1 week. Now, he has
generalized tonic-clonic seizures. The isolated organism is likely to
Hemophilus influenzae. Which of the following correctly describes the
condition of this baby?
A. Subdural effusion
B. Febrile seizures
243. Cilnical features of hypercapnia include all of the following EXCEPT:
A. Papilledema
B. Asterixis
C. Clubbing
244. A child had chickenpox 3 days back. He was given Dispirin by parents and
now has presented with nausea, vomiting and lethargy. The most likely
diagnosis is:
A. Reye’s syndrome
245. A known diabetic hypertensive with deranged LFTs, cholesterol 230 mg/dl,
triglycerides 130 mg/dl, HDL 45 mg/dl and family history of MI. Which of
the following drugs should be administered to this patient?
A. Niacin
B. Clofibrate
C. Simvastatin
246. A patient with CML, on chemotherapy, develops dry cough. On chest X-ray,
lower lobar reticular fibrosis is seen. What is the most likely cause?
A. Busulphan
247. A patient had a stroke: hemiplegia with slight dysarthria, no sensory loss and
normal speech. What is the most likely location of the lesion?
A. Frontal cortex
B. Medial leminiscus
C. Internal capsule
D. Cerebellum
248. A patient is on long-term steroid therapy for rheumatoid arthritis. Which of
the following lab values are NOT likely to be seen in this patient?
A. Elevated levels of ACTH
B. Leukocytosis
 C. Increased levels of cortisol

249. Heart block + murmur  aortic stenosis

250. Child with MI  Kawasaki disease
251. A patient with clubbing and coarse crepts at base  bronchiectasis
252. A patient with clubbing and fine crepts at base  ILD
253. Feature of febrile seizures  <5 months age
254. TB prophylaxis: (INH 5 mg/kg/d for 6 months)
255. Fluctuating neurologic symptoms  multiple sclerosis
256. Myotonic dystrophy  autosomal dominant
257. Restrictive PFTs  chest wall defect
258. Native valve endocarditis: new onset murmur with HF  get CT consult
259. Dessication  severe burn day-4
260. Angiodysplasia  diagnosed by arteriography
261. For diagnosis of multiple sclerosis  MRI (not CT)
262. Post-streptococcal glomerulonephritis  thiazide
263. Prophylaxis prior to dental procedure  amoxicillin
264. CSF findings of viral meningitis  ↑ protein, ↑ lymphocytes, ↔ glucose
265. Macrocytosis  myelodysplasia
266. Breast CA with mets in brain  stage IV
267. Tuberculous pericarditis  decreased ventricular filling  pericardiocentesis
268. Raised ICP mechanism  decreased CSF drainage
269. Staphylococcus aureus  β-lactamase producer
270. Post-MI ventricular arrhythmia: idioventricular  good sign of reperfusion ;
if VT 50/min, give IV lidocaine
271. Low calcium, you give bicarbonate  causes tetany
272. Pneuomcystitis carinii  seen in AIDS
273. Army athelete with hematuria  march, CMV, strep
274. Ibuprofen: proteinuria  membranous nephropathy
275. CD4+ counts <50  CMV retinitis
276. CD4+ counts <100  Toxoplasmosis
277. CD4+ counts <200  Pneumocystis juroveci pneumonia
278. Reiter’s syndrome  Keratoderma blenorrhegica
279. Polyarteritis nodosa + corneal opacity  Cogan’s syndrome
280. Patient with multiple pathologic fractures  histiocytosis X
281. Pathology in above case is  proliferation of Langerhan cells
282. Ascitic tap shows lymphocytosis  abdominal TB

283. A patient with Conn’s syndrome or primary hyperaldosteronism: (low K+)

284. A young male on antibiotics has developed diarrhea with grey-white
membranes: (pseudomembranous colitis)
285. A patient with signs and symptoms consistent with tuberculous pericarditis.
Increased JVP is due to (reduced ventricular filling)
286. Above patient comes for urgent management: (pericardiocentesis)
287. A patient with irregularly irregular pulse suddenly becomes pulseless and
cold: what has happened? (arterial embolus)
288. Post-MI auto-immune pericarditis [Dressler’s syndrome] with fever, raised
ESR and pleural effusion, chest pain, onset after 2 weeks, also known as post-
MI syndrome, treatment with NSAIDs or short course of steroids if
unresponsive
289. Ileocecal TB presents with bloody diarrhea, RIF mass and F/H of TB
290. Bronze DM seen in hemochromatosis = cirrhosis, hyperpigmentation, DM
291. Breast CA staging when size < 5 cm, lymph nodes palpable and bone scan
negative: (Stage III)
292. Treatment of breast CA: CMF (cyclophosphamide, methotrexate, 5-FU), do
not give doxorubicin, tamoxifen can be given to postmenopausal women
293. 60 years old man with shortness of breath on lying down and no cough. PFT
shows mixed restrictive and obstructive pattern: (CHF)
294. Megaloblastic anemia: get Hb/Hct, folate and serum B12 levels
295. Evan’s syndrome: autoimmune hemolytic anemia, reticulocytosis,
spherocytes, no RBC fragmentation
296. Unilateral and bilateral proptosis: (Grave’s disease)
297. Cavernous sinus thrombosis: boil on nose, Staphylococcus aureus infection,
proptosis, ophthalmoplegia
298. RV infarction: usually accompanies inferior wall MI, hypotension, raised JVP,
Kussmaul respiration, do right precordial leads, look for ST elevation in V4
299. Manage RV infarction by IV fluids so that pulmonary artery pressure is
between 15-18 mm Hg, dobutamine, IABC, do not give NTG / ACEIs /
morphine as they can precipitate hypotension
300. Initial work-up of nephrotic syndrome: urine D/R for protein, BUN/Cr, serum
albumin, lipids, serum and urine protein electrophoresis, complement levels,
ANA
301. Inferior right-sided MI: right-sided EKG, bradycardia
302. Sheehan’s syndrome: (low or normal ADH)
303. Most common cause of Sheehan’s syndrome: (postpartum hemorrhage)
304. Hepatitis C encephalopathy: (raised ammonia disturbs glutamate
metabolism in astrocytes)
305. Association of CLL with ITP: (↓ Plt, ↓ Hb)
306. Mechanism of anemia of chronic disease in RA: (iron trapped in
reticuloendothelial system by lactoferrin and not mobilized to erythroid
precursors)
307. Mechanism of cyanosis in cyanide poisoning: (↓ HbO2)
308. Mechanism of ↑ HR: (↓ TPR)
309. Post-MI complications: Immediate (day 1) ventricular arrhythmia, shock,
heart failure; days 4-7 rupture (ventricular, papillary, septal), aneurysm
formation
310. What is the best test for a patient with photosensitivity? (ANA)
311. HTN with CHF, bilateral crackles: which drug to give? (Lasix)
312. Left-sided pontine lesion: left facial weakness, right gaze preference, right
motor power +3
313. Female with pansystolic murmur and low LVEF: (mitral regurgitation)
314. Treatment of minimal change disease: (steroids)
315. Female with GTC and fever, most appropriate test to perform is (LP to rule
out meningitis)
316. Headache in a patient with raised ICP is due to (raised CSF pressure
stretches dura mater)
317. Decreased vision in above case is due to (compression of optic nerve)
318. Treatment of raised ICP: (depends on whether due to bleed or mass lesion)
319. Painful red eye in a patient with ankylosing spondylitis: (uveitis)
320. SIADH due to increased ADH secretion seen in (lung CA)
321. PT normal, aPTT deranged: all of the following EXCEPT (factor VII
deficiency)
322. Treatment of pyelonephritis: (ceftriaxone)
323. Dose-dependent hepatitis is caused by (paracetamol)
324. Antidote of above is (N-acetylcysteine)
325. Patient on ATT comes after 1 month with epigastric pain and ALT of 350.
How do you manage? (continue ATT unless ALT becomes 3-4 times the
normal limit)
326. A patient with brain mets and raised ICP: (dexamethasone)
327. Bleeding with raised ICP: which drug to reduce cerebral edema? (mannitol)
328. Most important independent prognostic marker of multiple myeloma: (β2-
microglobulin)
329. A person with HTN, hypernatremia and hypokalemia: which investigation to
order? (salt suppression test)
330. Drug of choice for cellulitis of hand: (pencillin V)
331. Mechanism of action of digoxin: (Na+/K+ ATPase inhibitor)
332. Visual gaze preference in brain lesions: (if frontal gaze center is damaged,
eyes look towards the lesion; if pontine gaze center is damaged, eyes look
away from the side of the lesion)
333. Which of the following is a risk factor for tuberculosis? (silicosis)
334. Silicosis patient is more prone to (TB)
335. In massive GI bleeding: (rule out aortoenteric fistula)
336. Asystole: (give epinephrine)
337. Bradycardia: (administer atropine)
338. A patient with halitosis and enlarged lymph nodes: (sarcoidosis)
339. IUGR associated with all of the following EXCEPT (hyperglycemia)

A 16 years old male with mental retardation, bleeding gums, fever not
responding to antibiotics, very low platelets, high WBC counts with blasts,
normochromic normocytic anemia, simian crease and HTN:
340. Risk factor for the above disease: (advanced maternal age)
341. Most likely cause of immediate problem: (neoplastic AML/ALL)
342. A 46 years old patient with incontinence, memory deficits and ataxia: (normal
pressure hydrocephalus)
[Remember wacky, wobbly and wet! (dementia, ataxia, urinary incontinence)]
343. A patient with history of anemia, achlorhydia and macrocytosis: (pernicious
anemia)
344. Old female with lower limb paresthesias, weakness, loss of vibration and
position sense in lower limbs. Blood sugar levels are normal. The most likely
diagnosis is (subacute combined degeneration)
345. Ampicillin: (morbilliform rash)
346. Young adult with easy fatiguability, worse in evening: (myasthenia)
347. Pregnant patient with malaria that is chloroquine resistant: (mefloquine)
348. On ECG, S1Q3T3 pattern with RV strain: most appropriate treatment is
(heparin)
349. Hypercalcemia with rash on extremities [erythema nodosum], bilateral hilar
lymphadenopathy: (sarcoidosis)
350. Old male, history of abdominal pain, atrial fibrillation to sinus rhythm, no
localized tenderness on examination: (mesenteric infarct)
351. What will you do in above case? (angiography)
352. HOCMP: murmur decreased with hand-grip and squatting, increases with
Valsalva, exercise and standing
353. Old patient with pancytopenia, BM shows abnormal karyotype on
chromosomes 3 and 7: (myelodysplasia)
354. Iron deficiency anemia with iron resistance: (myelodysplasia)
355. TTP: microangiopathic hemolytic anemia, fever, renal failure, CNS changes, ↑
Cr ↓ Hb ↓ Plt
356. Treatment of above is (plasmapheresis and steroids)
357. Cape like sensory loss on shoulders and back: (syringomelia)
358. Low back pain and leg pain worsening over day and morning, stiffness for 15
minutes: (osteoarthritis)
359. What investigations to do in case of aplastic anemia? (bone marrow
aspiration and trephine biopsy)
360. A patient with chronic AF: (warfarin plus metoprolol)
361. β-lactamase inhibitor added to pencillin to increase sensitivity to
(Pseudomonas)
362. Sinus rhythm after long-term AF: (splanchnic infarct)
363. Parkinson disease with early symptoms: (amantidine)
364. Treatment of a 3 mm microadenoma prolactinoma is (bromocriptine)
365. Solitary thyroid nodule in a patient with some signs of hyperthyroidism: what
test to do next? (FNAC)
366. Antimalarial for Plasmodium falciparum is (artemether plus lumefantrine)
367. Prick from a patient with chronic active hepatitis B: the risk of transmission is
(30%)
368. Prick from a patient with chronic active hepatitis C: the risk of transmission is
(3%)
369. Prick from a patient with AIDS: the risk of transmission is (0.3%)
370. Best indicator of liver functions: (PT)
371. Treatment of amebic liver abscess: (metronidazole)
372. A patient with some infection, got bloody diarrhea after using clindamycin.
What is the most likely organism? (Clostridium difficle)
373. A man with LDL 142 mg/dl, cholesterol 240 mg/dl with no risk factors. What
is the appropriate management? (life style changes)
374. Burns: right arm, whole front of trunk and right leg from knee downwards.
What is the percentage of area burnt? (36%)
375. Snake-bite: (anti-venom)
376. HBsAg positive, HBeAg negative, HBeAb negative and core IgG positive:
(carrier state)
377. A patient with HTN and K+ 6.1: (stop lisinopril, admit and give calcium
gluconate)
378. Second episode of pancreatitis, gall-stone on U/S: (refer to surgeon for
cholecystectomy)
379. Asthmatic, post-menopausal, used HRT but got DVT so stopped it, what to do
for bone health? (alandronate)
380. DKA with pH 7.21: (compensated metabolic acidosis)
381. Which statement is true about type I diabetes mellitus? (related to auto-
immune diseases)
382. A known diabetic hypertensive with CKD and mild proteinuria: (start ACE
inhibitor)
383. A patient k/c of DM, HTN, CKD is undergoing coronary angiography. Which
of the following should be given? (I/V N/S, I/V fluids plus Lasix)
384. Hypercalcemia with poor kidney function: (slow hydration)
385. A man with CKD missed dialysis and developed hyperkalemia with ECG
changes [tall T waves]. What should be first step? (give calcium gluconate,
kayexalate, dialysis)
386. Which of the following is seen in hypokalemia? (U waves)
387. 2 months history of fever, altered mental status and LP shows 88%
lymphocytes with ↓ glucose: (tuberculous meningitis)
388. Hep C reactive, but, PCR negative and LFTs normal: what to do? (repeat
LFTs in 6 months)
389. Which drug decreases mortality in CAD? (aspirin)
390. A patient with anemia, low back pain and proteinuria. Bone scan and bone
marrow given. The most likely diagnosis is (multiple myeloma)
391. Multiple sclerosis: (interferon β1b)
392. Cord compression: (X-ray, MRI)
393. Intermittent diplopia in looking up: (Tensilon test)
394. Thymoma: (mediastinal mass with increasing fatigue throughout day)
395. Cluster headache: (high flow O2)
396. Most common cause of low MCV: (iron deficiency anemia)
397. A patient with chronic blood loss from gut: (iron deficiency anemia)
398. Iron deficiency anemia in old male is supposed to be due to which pathology
unless proven otherwise? (colon CA)
399. A guy went to a friend with rash. His son had it too: (disseminated varicella)
400. Insulin self-injection: (low C-peptide)
401. AML: (CD 13, 33, MPO positive)
402. A known diabetic with UTI due to Pseudomonas: (admit and give I/V
antibiotics)
403. Howel-Jolly bodies: (sickle cell disease)
404. Whipple disease: (oculomasticatory myorhythmias)
405. Organism of whipple disease: (Tropheryma whippeli)
406. Retropharyngeal abscess: (do lateral X-ray)
407. An HIV positive girl has myositis: (zidovudine)
408. Dilated cardiomyopathy: which of the following is NOT useful? (digoxin)
409. Limotrigine adverse effect: (weight gain, alopecia, rash)
410. Increased JVP with tender hepatomegaly and pedal edema: (RVF)
411. Gestational diabetes mellitus: what do you tell her? (improvement will be
seen after 6-8 weeks)
412. Diagnosis of DM: (FBS)
413. PT ↑ aPTT ↑ BT ↔ indicates problem in (common pathway )
414. Angry patient: what is the first thing to do? (verbal)
415. Asthma with eosinophilia and cANCA positive: (Churg-Strauss syndrome)
416. Rash on arms and face, increased in sunlight and day-time, associated with
anemia and arthritis: (SLE)
417. Migraine seizures, LP shows ↑ RBCs and ↑ WBCs: what to do? (EEG, MRI,
contrast-enhanced CT, viral PCR)
418. A smoker taking lithium for bipolar disorder, serum Na+ 120, clubbing
present, urine Osmolarity 350, plasma Osmolarity 260: (SIADH)
419. A guy with pneumonia got better with pencillin but then worsened. The reason
was (pleural empyema / abscess formation)
420. A 3 day history of headache, fever and drowsiness: (meningitis, SAH)
421. 10 day history of diarrhea with small volume of mucoid stools: (Giardia, …)
422. X-ray of patient with RA: (juxta-articular osteopenia)
423. Acute renal failure after taking thiazides for HTN, no cast in urine, 20 WBCs:
(acute interstitial nephritis)
424. Right-sided infarct on ECG: what would you do to confirm? (right-sided
ECG, serial cardiac enzymes)
425. What do you NOT give in right-sided infarct? (nitrates)
426. A diabetic with pedal edema, HbA1c of 6.6: (losartan plus low-salt diet)
427. Obese diabetic with CKD, Cr 1.5 mg/dl, taking metformin and gliclazide.
What to do next? (stop metformin and add insulin)
428. TB patient taking anti-TB drugs, now got pregnant: (continue same drugs)
429. A hypertensive patient on anti-hypertensive drug therapy, however, no
improvement in symptoms. Labs show ↑ Na+ and ↓ K+. What to do? (order
renin and aldosterone levels)
430. A patient with severe asthma, respiratory acidosis on ABGs: what to do?
(intubate and I/V hydrocortisone)
431. Which of the following conditions do NOT increase prolactin?
(hyperparathyroidism)
432. A type I diabetic came with unconsciousness and fever. What to do first?
(blood glucose)
433. An HIV patient with previously treated PCP comes with S1Q3T3 pattern on
ECG: what to do? (order spiral CT scan)
434. Complex partial seizures: (give carbamezapine)
435. Heartburn post-prandial with no comorbids or weight loss: (give trial of
PPIs)
436. A boy on phenytoin has eosinophilia and developed a pruritic rash: (drug
hypersensitivity)
437. DKA: (high anion gap)
438. Newly diagnosed hypertensive in a 45 years old patient. The first anti-
hypertensive to use is (ACE inhibitor)
439. A patient with weight gain, constipation, hair loss and history of angina. Labs
reveal a TSH of 42. What dose of thyroxine to start with? (25 μg)
440. Sudden breathlessness since 3 hours in a chronic smoker: the first
investigation of choice is (CXR)
441. A policeman came with acute painful knee swelling, has history of toe
swellings: (monosodium urate crystals)
442. A 23 years old female with morning stiffness of small joints: what will
confirm the diagnosis? (bony erosions on X-ray)
443. HIV positive patient, test positive twice, what is next step? (Western blotting,
ELISA, CD4 count, viral RNA)
444. A 65 years old patient, diabetic since 10 years, sudden shortness of breath,
crackles at both lung bases, JVP wnl and no hepatosplenomegaly. What is the
diagnosis? (LVF)
445. A 30 years old male with cough and fever got splenectomy done. What is the
mediator of fever? (IL-1)
446. A patient with diabetic gastroparesis: what to give? (domperidone,
metocloperamide)
447. A lady with middle and index finger tingling and reduced pin-prick sensation.
What investigation to order? (nerve conduction studies)
448. Treatment of HSV encephalitis: (acyclovir 10 mg/kg I/V Q8H)
449. Management of chronic hyperkalemia: (kayexalate and diuresis)
450. Hemophilia: (factor VIII deficiency)
451. HS: spherocytes are also seen in (auto-immune hemolytic anemia)
452. Beck’s triad of cardiac tamponade: (jugulovenous distension, hypotension
and muffled heart sounds)
453. Jugulovenous distension in above case is caused by (reduced ventricular
filling)
454. Engorged neck veins in a lady: (SVC syndrome)
455. CSF findings of malaria patient: (↑ pressure ↓ glucose)
456. Abdominal TB, ascitic tap will reveal (lymphocytosis)
457. Patient on diuretics has decreased urine output and not feeling well: (acute
interstitial nephritis)
458. A patient with Boerhaave syndrome: what finding on clinical examination?
(Hamman’s crunch)
459. The reason for above is (pneumomediastinum)
460. A known diabetic and hypertensive with ↑ Cr ↑ BUN. The cause of CRF is
(diabetic nephropathy)
461. A patient with massive UGI bleed: immediate step is (NG)
462. Next step in above patient: (EGD)
463. A patient with aortic dissection: what to do? (rush to OR)
464. A patient with local infiltrating breast CA, nodes are negative, tumor is
positive for estrogen receptors: (give tamoxifen)
465. Obese patient with polycythaemia: (Gäisbock syndrome)
466. Treatment of hereditary spherocytosis: (splenectomy)
467. Treatment of nephrogenic diabetes insipidus: (amiloride)
468. Sickle-cell trait: (HbSA, HbSS, HbSC)
469. Treatment regimen for H. pylori is: (PPI + Klericid + Amoxyl)
470. A young female with WPW syndrome has an unstable heart rate with basal
crackles at both lung bases: (DC cardioversion)
471. An ECG shows tachycardia with a heart rate of 300/min and typical “saw
tooth” pattern: (atrial flutter)
472. ECG showing prolonged PR interval with no dropped beats: (first degree
heart block)
473. ECG shows progressively increasing PR interval followed by a dropped beat:
(Mobitz type I heart block)
474. Most common side effect of phototherapy for neonatal jaundice: (increased
insensible fluid losses)
475. A person with DVT suffered a stroke. What is the most likely explanation?
(paradoxical embolism due to patent foramen ovale)
476. Mononeuritis multiplex is seen in patients with (amyloidosis)
477. In a patient with amyloidosis, echocardiography will most likely reveal
(granular sparkling appearance)
478. What type of cardiomyopathy is seen in patients with amyloidosis?
(restrictive cardiomyopathy)
479. A patient with beaked nose, taut skin around the lips and dysphagia: (CREST
syndrome)
480. A patient with history of prolonged bleeding after delivery and failure to
lactate. Now, she has presented with ↓ FSH, ↓ LH and ↓ TSH. What is the
cause? (pituitary apoplexy)
481. A lady with history of Grave’s disease is currently euthyroid. Now, she has
presented with a palpable thyroid nodule. The best investigation to perform in
this patient is (FNAC)
482. What should be done for relief of pneumothorax? (insert chest tube in 5th
intercostal space anteriorly)
483. Chest tube is inserted at 5th intercostal space to (avoid injury to liver)
484. Safe triangle: (posterior border of pectoralis major, anterior border of
latissimus dorsi, upper border of 5th rib)
485. Most reliable way to find position of chest tube: (chest X-ray)
486. Infant with jitterness: (check serum glucose)
487. A patient with delirium has a history of urinary obstruction. He was
catheterized 2 days back for urinary retention. Now, urine bag is empty. What
will you do now? (I/V fluids and check urine output)
488. A healthy female with leukocyte esterase positive on urine D/R. What to do?
(start antibiotics and follow-up)
489. A 25 years old male carried furniture from one apartment to another. Now,
comes in with severe backache and muscle spasm. What is the appropriate
management? (reassure the patient)
490. A female with polymyalagia rheumatica complains of jaw pain [i.e. jaw
claudication]. What is the most likely cause? (giant cell arteritis)
491. A newborn with cyanosis on first day of life alongwith stridor, wheezing and
suprasternal recession. What is the most likely cause? (obstructed airway,
pneumnonia, cyanotic heart disease)
492. A baby with right middle lobar pneumonia: what drug to treat? (amoxicillin)
493. A patient with PR interval > 0.24 seconds, ↑ ESR and leukocytosis:
(rheumatic fever)
494. A patient has a high-output fistula after surgery for abdominal TB, which
involved resection of ileocecal strictures and end-to-end anastamosis. What is
the appropriate management? (TPN, skin care and antibiotics)
495. A young male with history of bloody diarrhea, weight loss and skin lesions
which turn purple. What is the most likely cause? (ulcerative colitis /
pyoderma gangrenosum)
496. The most reliable clinical sign of acute appendicitis is (rebound tenderness)
497. A patient has gross hematuria with sterile pyuria: (urinary TB)
498. A patient unstable with VT: (100 J defibrillation)
499. The most common dermatophyte infection in Pakistan is (tinea cruris)
500. Definition of anemia during pregnancy according to WHO criteria is (Hb < 11
g/dl)
501. Which of the following is NOT considered a treatment of enteric fever in
children in Pakistan? (ciprofloxacin, ceftriaxone)
502. A stroke patient is hospitalized for 5 days. Now, he has developed left-sided
chest pain and cough: (pulmonary embolism)
503. A patient with end-stage renal disease on peritoneal dialysis. He has
developed abdominal distension, pain and fever. What is the most likely
organism implicated in this case? (Staphylococcus epidermidis)
504. Partially treated meningitis: (CSF pleocytosis)
505. All of the following drugs act by causing hypoglycemia EXCEPT
(metformin)
506. Multiple bleeding points visible on colonoscopy: (ulcerative colitis)
507. ECG shows ↑ R waves in lateral leads and ST depression: (aortic stenosis)
508. Which of the following is NOT hepatotoxic? (ethambutol)
509. Which drug does NOT need adjustment in renal failure? (ethambutol)
510. Following drugs are excreted via biliary route: erythromycin, azithromycin,
doxycycline, ceftriaxone
511. Biliary sludging caused by (ceftriaxone)
512. ECG with PR interval of 0.124 seconds, tall T wave in avR, large R wave and
q wave in V6: (…) [?]
513. On a chest X-ray, air-fluid level can be seen in all of the following EXCEPT:
(hydatid cyst)
514. A 45 years old smoker with cough, chest X-ray shows right lower lobe
collapse with pleural effusion: (CT scan of chest)
 515. A 70 years old female patient with long history of steroid use. Now presents
with back pain aggravated for 1 week: (vertebral compression fracture)
516. Bloody diarrhea with friable mucosa: (ulcerative colitis)
517. A 33 years old patient with hypokalemia, BP 90/70 mm Hg and wrinkled skin:
(Addison’s disease)
518. Hyponatremia encountered in hospital settings is most likely due to (excessive
resuscitation)
519. A 9 months old boy brought by mother for complaints of fever, dry cough and
rhinorrhea. Management includes (fluids until resolve)
520. A child with easy bruising, purpura, fever and hepatosplenomegaly. On
examination, he appears pale and her labs reveal Hb of 6.4 g/dl with
pancytopenia: (ALL)
521. 27 years old male with history of missed heart beat; precordial examination is
unremarkable: (PVCs)
522. 47 years old woman with several episodes of severe chest pain: ECG reveals
STE during the episodes; administration of ergonovine during the episodes
exacerbates the pain; the diagnosis is (prinzmetal angina)
523. Most of the hospitalized AIDS patients have which electrolyte abnormality?
(hyponatremia)
524. The most common precipitating factor of epilepsy in adults is (non-
compliance)

Parameters Iron deficiency Anemia of Thalassemia Sideroblastic

chronic disease minor anemia
MCV ↓↓ ↓ or ↔ ↓↓ ↑ in acquired;
low in inherited
Serum iron ↓↓ ↓↓ ↔ ↑
Serum TIBC ↑↑ ↓↓ ↔ ↔
Serum ferritin ↓↓ ↔ or ↑↑ ↔ ↑
Serum soluble ↑↑ ↓↓ ↔ or ↑ ↔ or ↑
transferrin
receptors
Iron in BM ↓↓ Present Present Present
Iron in Absent Absent or Present In the form of
erythroblasts reduced rings

APGAR scoring 0 1 2
Appearance All blue Pink with blue limbs All pink
Pulse Absent < 100 bpm ≥ 100 bpm
Grimace None Facial grimace Cry
Activity Flaccid Some flexion Flexed limbs
Respiration Absent Gasping Regular

525. Composition of breast milk

526. Kwashiorkor vs. marasmus
527. Paroxysmal lateralized epileptiform disorder (PLED)
528. COMMON CAUSES OF METABOLIC ACIDOSIS
↑ Anion Gap (MUD PILES) ↔ Anion Gap
Methanol Mild to moderate renal failure
Uremia Acute diarrhea
Diabetic ketoacidosis High-output fistula
Paraldehyde intoxication Ileostomy
Infection Type I RTA
Lactic acidosis Type II RTA
Ethanol Type IV RTA
Salicylates Dilutional acidosis
Treated DKA

529. SIDE-EFFECTS OF ANTI-THYROID MEDICATIONS:

GENERAL: agranulocytosis, allergic dermatitis, pruritis, nausea, dyspepsia,
primary hypothyroidism

PROPYLTHIOURACIL: fulminant hepatitis, drug-induced lupus, arthritis,

aplastic anemia, thrombocytopenia
(PTU is generally considered safer in pregnant and lactating women.)

METHIMAZOLE: alopecia, serum sickness, cholestatic jaundice, nephrotic

syndrome, hypoglycemia
(Methimazole has a convenient dosing pattern.)

530. POLY-GLANDULAR AUTOIMMUNE (PGA) SYNDROMES

Also known as AUTO-IMMUNE POLY-ENDOCRINOPATHIES (APE)
TYPE I: Addison’s disease, chronic mucocutaneous candidiasis,
hypoparathyroidism
TYPE II: Addison’s disease, IDDM, thyroid disorders

531. MULTIPLE ENDOCRINE NEOPLASIA (MEN)

TYPE I: pituitary adenomas, parathyroid hyperplasia, pancreatic islet tumors
TYPE II: medullary CA of thyroid, parathyroid adenoma, pheochromocytoma
TYPE III: medullary CA of thyroid, mucosal neurommas, pheochromocytoma

532. LAMBERT-EATON MYASTHENIA: accompanies small-cell carcinoma of

lung, especially affects proximal limbs, variable weakness, patient feels better
after exertion, dysautonomia, treat with plasmapharesis and
immunosuppressants

533. MYOTONIC DYSTROPHY: CTG repeats, distal muscle weakness, males 20-
30 yrs, balding prematurely (spot diagnosis), gonadal atrophy,
cardiomyopathy, DM, anterior/posterior subcapsular stellate cataracts, mental
impairment
534. TEMPORAL ARTERITIS: especially in women, 60+ years, unilateral
headache, raised ESR, loss of vision, association with PMR, diagnose with
temporal artery biopsy and ESR, treat with steroids STAT

535. STATUS EPILEPTICUS

ABCs  100% O2 + IVI  check CBC, U/A, tox screen, drug levels 
suspected alcoholic (give thiamine 25 mg IV)  D5W @ 50 ml/hr (unless
glucose known)  bolus of lorazepam 4 mg I/V over 2 mins  infusion of
phenytoin 15 mg/kg @ ≤ 50 mg/min  midazolam and G/A if all else fails!

536. DKA (diabetic ketoacidosis) vs. HONK (hyperosmotic non-ketotic) COMA:

LABS DKA HONK
Glucose > 250 > 600
pH < 7.3 > 7.3
-
HCO3 < 10-18 > 15
Ketones +2 to +3 0 to +1
Osmolarity Variable > 320
Anion gap > 10 Variable
Neurologic status Variable Stupor/coma
DKA has a mortality of 7%

537. HYPERTHYROIDISM
CAUSES: Grave’s disease, toxic adenoma, thyroiditis, TSH secreting tumor,
miscellaneous (β-hCG secreting tumor, struma ovarii, amiodarone, T. factitia)
ANTIBODIES: TSI (not available), anti-thyroglobulin & anti-microsomal
(done at AKUH), ANA (non-specfic)
THYROTOXICOSIS: fever, palpitations, restlessness, diarrhea, vomiting
MANAGEMENT OF THYROTOXICOSIS:
IVF + NGT + sedation  order TSH, T3, T4, CBC, cultures, U/A 
metoprolol 40 mg PO  digoxin 1 mg IV over 2 hrs  after 4 hrs,
carbimazole 15-25 mg Q6H PO  Lugol’s solution 0.3 mLs Q8H PO  HC
100 mg IV Q6H (↓ T4  T3)  antibiotics if infection  fever control with
ice packs, cold baths, panadol

538. HYPOTHYROIDISM
CAUSES: Primary hypothyroidism can be with goiter (Hashimoto’s
thyroiditis, iodine deficiency) or without goiter (amiodarone, surgery,
radiation)
Secondary hypothyroidism can be due to hypothalamic or pituitary causes
HASHIMOTO’S THYROIDISM: patchy lymphocytic infiltrates, auto-
immune etiology, more common in females, Hürthle cells classically seen,
increased risk of lymphoma and Hürthle cell carcinoma
MYXEDEMA COMA:
Signs include decreased ventilation, decreased BP, mental status changes
Precipitated by trauma, infection, stroke, MI, any physiologic stress
 Management includes O2 inhalation, IV fluids, T3 5-20 µg IV slowly to
prevent MI, HC 100 mg IV Q8H, treat underlying cause; continue T3 Q4-8H
for 2 days or until improvement occurs, then give T4 50 µg/24 hrs
TREATMENT OF HYPOTHYROIDISM: check TSH 4-6 weekly, give T4 50-
100 μg QD in healthy patients; if history of CAD or advanced age, start with
25 μg Q6H; increase the dose of T4 25 μg every 1-3 weeks until euthyroid
status achieved

539. MANAGEMENT OF MITRAL STENOSIS: idea is to limit pulmonary

edema; restrict sodium intake; diurese gently; give β-blockers to increase
diastolic phase, hence, increasing ventricular filling

540. MANAGEMENT OF AORTIC STENOSIS: gentle diuresis, inotropic support

(digoxin), β-blockers / venodilators / CCBs / negative inotropic agents are
CONTRAINDICATED

541. MANAGEMENT OF AORTIC REGURGITATION

Give vasodilators (nifedipine, ACE inhibitors, hydralazine)
If patient in CHF, administer digoxin and diurese judiciously
In acute cases, IABP and vasoconstrictors are CONTRAINDICATED; give
nitroprusside, dobutamine and chronotropic support; idea is to decrease
diastolic phase, hence, decreasing regurgitation

542. GULLAIN-BARRE SYNDROME

Clinical features include ascending symmetric paralysis, hypotonia, areflexia,
normal plantars
Pathology includes demyelination with axonal injury
Labs include LP showing albuminocytologic dissociation, EMG, MRI
Management includes plasmapharesis, IV immunoglobulin, supportive care
5 As include Acute inflammatory demyelinating polyradiculopathy,
Ascending paralysis, Autonomic neuropathy, Arrhythmias,
Albuminocytologic dissociation

543. MYASTHENIA GRAVIS

Management includes pyridostigmine, methylprednisolone, plasmapharesis,
IV immunoglobulin, radical thymectomy

544. MULTIPLE SCLEROSIS

DISORDER: relapsing-remitting disease consisting of plaques of
demyelination with loss of axon turn-over throughout CNS (no effect on PNS)
PATHOGENESIS: focal disruption of blood-brain barrier with associated
immune response, myelin damage and neurodegenerative processes
PRESENTATION: usually monosymptomatic with history of prior episodes;
initially, complete remissions; accumulated disabilities as a result of numerous
relapses
 CLASSIC TRIAD: Charcot’s triad II includes nystagmus, scanning speech
and intention tremor (Charcot’s triad I is for cholangitis)
EXAMINATION: carefully look for CNS deficits than presenting symptoms
LHERMITTE’S SIGN: flexion of neck leads to paresthesias in limbs (d/d
includes cervical spondylosis, subacute combined degeneration, irradiation)
UTHOFF’S PHENOMENON: symptom precipitated by exercise due to
increase in temperature
DIAGNOSIS: clinical (based on focal neurologic lesions distributed in space
and time)
LABS: LP shows lymphocytosis, with protein < 1 g/dL and oligoclonal bands
on electrophoresis
MRI shows multiple, asymmetric, often periventricular white matter lesions
(Dawson’s fingers), especially, in the corpus callosum; active lesions enhance
with gadolinium contrast
TREATMENT: steroids for acute exacerbations, immunomodulators for
remissions; these include interferon α1a (Avonex/Rebif), interferon α1b
(Betaseron) and copolymer-1 (Copaxone); mitoxantrone given for progressive
MS; alternatives include plasmapharesis, IV immunoglobulin,
cyclophosphamide; symptomatic therapy includes baclofen for spasticity,
bethanechol for urinary retention, anti-cholinergics for urinary incontinence,
carbamezapine or amitryptyline for painful paresthesias and anti-depressants
for depression
POOR PROGNOSTIC FACTORS: old age, male gender, motor signs at onset,
many relapses early on

545. COMMUNITY ACQUIRED PNEUMONIA

Outpatient: levofloxacin
General ward: ceftriaxone ± macrolide / fluoroquinolone
ICU: cefipime / tazocin + fluoroquinolone
For aspiration pneumonia: ceftriaxone + clindamycin
For nosocomial pneumonia / HCWP: AG / FQ + ceftazidime ± vancomycin

546. OCULOMOTOR NERVE PALSY

Clinical features include eye ball goes down & out, dilated pupils and ptosis
Causes include DM / HTN (pupil-sparing), aneurysm / tumors (mydriasis)

547. PARKISON’S SYNDROME

SIGNS: pill-rolling tremors (5-6 cycles per second, more marked at rest),
rigidity (cog-wheel initially and then, lead-pipe deformity), masked facies,
bradykinesias (slow initiation of movements, progressive loss of speed in
repetitive movements, small steps with flexed trunk, decreased blinking)
PATHOLOGY: Lewy bodies
CAUSES: Parkinson’s disease (degeneration of dopaminergic fibers in
substantia nigra), arteriosclerosis, neuroleptics; rare causes include Wilson’s
disease, CO poisoning and post-encephalitis
 MANAGEMENT: L-dopa with carbidopa; anti-cholinergics for motor
symptoms and neuroleptic-induced Parkinsonism; communication between
patient, physician and attendants; objective and regular evaluation of disability

548. ACUTE CHEST SYNDROME

Seen in patients with sickle cell anemia
Have a pneumonia-like picture
CXR shows interstitial infiltrates
CBC shows leukocytosis
Management includes admission to hospital, O2 inhalation, analgesics, I/V
fluids, antibiotics including fluoroquinolones or 3rd generation cephalosporins
+ macrolides, transfusion in severe cases

549. HEMOLYSIS
EXTRAVASCULAR INTRAVASCULAR
Warm AIHA Cold AIHA
Hypersplenism PNH
Hereditary spherocytosis MAHA
Enzyme defiency anemias (G6PD, PK) Sickle cell
[AIHA=auto-immune hemolytic anemia, PNH=paroxysmal nocturnal
hemoglobinuria, MAHA=microangiopathic hemolytic anemia, PK=pyruvate
kinase]

550. CONTRAINDICATIONS TO THROMBOLYSIS

RELATIVE ABSOLUTE
SBP > 180 mm Hg Prior ICH
INR > 2.0 Internal bleeding
Pregnancy Aortic dissection
Prolonged CPR (>10 minutes) Intracranial space occupying lesion
Non-compressible vascular punctures Intracranial AVM or aneurysm
Recent trauma, major surgery or Non-hemorrhagic stroke of closed
Internal bleed (2-4 weeks old) head trauma within 3-6 months

551. VENTRICULAR TACHYCARDIA / FIBRILLATION

Defibrillate x 3 (200  300  360) and check rhythm after each defib.
Intubate and secure I/V access
Epinephrine 1 mg IV q 3-5 minutes
Defibrillate with 360 J energy
I/V amiodarone
Defibrillate 360 J energy

552. RIGHT VENTRICULAR FAILURE

50% of patients with RVF have infarction
Normal or reduced LV filling pressures
Elevated RA pressures (>10 mm Hg)
Reduced cardiac output
 Clinical signs include clear lung fields, S3 or S4 audible, Kussmaul’s sign,
jugulovenous distension and hypotension
Treatment includes dobutamine or IABP

553. ATRIAL FIBRILLATION:

Causes: thyrotoxicosis, alcohol, acute coronary syndromes, hypoxia,
hypertension, cardiomyopathy, ASD, regurgitation, drugs, ischemia, age
Management: if unstable, cardiovert; if stable, control rate, anti-coagulate and
control rhythm [in patients with lone AF, anti-coagulation not needed; if anti-
coagulation is contraindicated, give aspirin as alternative]

554. WOLF-PARKINSON-WHITE SYNDROME

Management includes amiodarone (or class Ia, Ic, III anti-arrhythmics),
accessory pathway ablation
Do NOT give agents that increase AV nodal delay; do NOT give β-blockers,
CCB or digoxin as they will increase conduction via the accessory pathway

555. CAUSES OF VENTRICULAR FIBRILLATION

Ischemia or infarction
Hypertrophic obstructive cardiomyopathy
Long QT syndrome
Hypoxia
Electrolyte disturbances
Drug toxicity

556. CAUSES OF CHRONIC LIVER DISEASE

Hepatitis B/C
Alcoholism
Hemochromatosis
Wilson’s disease
α1-antitrypsin deficiency
Primary biliary cirrhosis
Cardiac cirrhosis (may be due to CHF or constrictive pericarditis)
Osler-Weber-Rendu syndrome (hereditary hemorrhagic telangiectasia)

557. MANAGEMENT OF HEPATITIS B

Interferon-α-2b: 5 million units per day or 10 million units thrice weekly for 4
months
Lamovudine: 100 mg PO (may be required indefinitely due to relapses on
discontinuation of therapy)

558. MANAGEMENT OF HEPATITIS C

Peg-interferon 180 mg/wk for 48 weeks (genotype 1a/1b, cirrhosis, ↑ viremia)
or 24 weeks (genotype 2/3, no cirrhosis, ↓ viremia)
Also give Ribavarin daily in 2 divided doses (1 g if <75 kg, 1.2 g if >75 kg,
0.8 g if genotype 2/3, no cirrhosis, ↓ viremia)
559. STIGMATA OF CHRONIC LIVER DISEASE
Leukonychia, Terry’s nails, clubbing, palmar erythema, Dupuytren’s
contracture, jaundice, telangiectasia, spider naevi, gynecomastia, scanty body
hair

560. ASCITES
Hemorrhagic due to malignancy or trauma
Chylous due to cirrhosis, malignancy, TB, abdominal surgery, trauma,
pancreatitis, filiariasis

561. CAUSES OF CARPAL TUNNEL SYNDROME

Diabetes mellitus, obesity, rheumatoid arthritis, trauma, dialysis

562. D/D OF ERYTHEMA MULTIFORME

Drugs (sulfonamides, barbiturates), HSV, Mycoplasma pneumoniae, Poxvirus,
collagen vascular diseases, Steven-Johnson’s syndrome

563. D/D OF ERYTHEMA NODOSUM

Sarcoidosis, tuberculosis, leprosy, streptococci, IBD, drugs (sulfonamides,
dapsone, OCP)

564. MICROCYTIC ANEMIAS

Iron deficiency, thalassemia minor, anemia of chronic disease, sideroblastic
anemia, copper deficiency

565. NORMOCYTIC ANEMIAS

Acute hemorrhage, chronic renal failure, thalassemia major, aplastic anemia,
myelophthisic anemia, G6PD deficiency, PK deficiency, sickle cell anemia,
leukemias, osteopetrosis

566. MACROCYTIC ANEMIAS

Hypothyroidism, alcoholism, chronic liver disease, megaloblastic, Down’s
syndrome, Lesch-Nyhan syndrome, Fanconi’s anemia, Diamond-Blackfan
syndrome, drugs (5-fluorouracil, hydroxyurea)

567. TANNER STAGES OF DEVELOPMENT

BREAST DEVELOPMENT
Stage I Preadolescent, elevation of papilla only
Stage II Breast bud, small mound, areolar diameter enlarges
Stage III Enlargement of breast and areola, no separation of contours
Stage IV Secondary mound
Stage V Mature stage

GENITAL DEVELOPMENT
Stage I Preadolescent
 Stage II Enlargement of scrotum and testes
Stage IIIIncrease in lenght of penis; reddening of scrotal skin; change in
texture of scrotal skin
Stage IV Enlargement of penis (breadth), darkening of scrotal skin
Stage V Adult genitalia in size and shape

PUBIC HAIR
Stage I Preadolescent
Stage II Sparse, pigmented, downy hair at base of penis and along labia
Stage III Darker, coarser, curled hair; junctions of pubes
Stage IV Hair without distribution of adult type, no hair on thighs
Stage V Distrubtion along medial aspect of thigh
Stage VI Spread up linea alba: “male escutcheon”

568. CAUSES OF PANCYTOPENIA

Aplastic anemia
Myelodysplastic syndromes
Myelophthisic anemia
Hypersplenism
Alcoholism
Severe sepsis
Paroxysmal nocturnal hemoglobinuria [?]

Management of Hematological Disorders

1. Hereditary spherocytosis:
a. Folic acid 1 mg/day
b. Treatment of choice: splenectomy
2. Auto-immune hemolytic anemia:
a. Prednisolone 1-2 mg/kg/d in divided doses
b. Transfusion
c. If recurrence on tapering the steroids, do splenectomy
d. Refractory patients to these 2 modalities should be treated with:
i. Rituximab 375 mg/m2 IV weekly for 4 weeks
ii. Danazol 600-800 mg/d (low toxicity; good for long-term use)
iii. Cyclophosphamide, azathioprine, cyclosporine
iv. High-dose IV immunoglobulins (1g q 1-2 d; benefit is short-lived
and treatment expensive)
3. Cold agglutination disease:
a. Symptomatic
b. Alkylating agents like cyclophosphamide
c. Cyclosporine
d. High-dose IV immunoglobulin (temporarily)
e. Rituximab
4. Aplastic anemia:
a. Mild: supportive care; transfuse RBCs and platelets, antibiotics prn
 b. Severe: (neutrophils < 500/μL, Plt < 20,000/μL, Retics <1%, bone marrow
cellularity <20%)
i. For young adults <50 yrs, allogenic BMT from HLA matched
siblings
ii. For kids and adults <30 yrs, allogenic BMT using unrelated donor
iii. Adults over age 50 yrs or those without HLA matched siblings,
immunosuppresion with ATG and cyclosporine
iv. Use ATG in combination with steroids to avoid complications of
serum sickness (response usually partial and in 4-12 wks, but,
enough to ensure a transfusion free life)
v. High dose immunosuppression with cyclophosphamide or
refractory cases (cause: may cause pancytopenia)
vi. Androgens (low response rate e.g. oxymetholone)
5. SLE:
a. If benign, supportive care & emotional support
b. Skin lesions: corticosteroids
c. Joint symptoms: NSAIDs, hydroxychloroquine, rest
d. Thrombocytopenia: danazol
e. Corticosteroids indicated for GN, hemolytic anemia, peri/myocarditis,
alveolar hemorrhage, CNS symptoms, TTP
f. For cases resistant to steroids: immunosuppressants like
cyclophosphamide, mycophenolate mofetil, azathioprine
g. Anti-coagulation (warfarin with target INR>3.0) for APS
6. Polycythemia rubra vera:
a. Phlebotomy (weekly) to maintain Hct < 45%
b. Avoid iron supplements
c. Hydroxyurea (only when phlebotomy requirements are high,
thrombocytosis or intractable pruritis; initially myelosuppressive treatment
with alkylating agents was indicated for this, but, this increases the risk of
conversion of this disease to acute leukemia and is now avoided)
7. Myelofibrosis:
a. No specific treatment
b. Transfusion
c. Androgens
d. Allogenic BMT in younger patients
8. CML:
a. DoC is Gleevec® [imatinib mesylate] (inhibitor of tyrosine kinase activity
of bcr-abl gene product)
b. Hydroxyurea if Gleevec® not tolerated
c. α-IFN (toxicity)
d. Curative: allogenic BMT, especially, in patients <60 yrs with HLA
matched siblings
9. AML:
a. Poor prognostic factors: cytogenetics, age > 60 yrs, MPS/MPD, poor
performance
b. For cytogenetics, bone marrow on 10th and 28th days
10. CLL:
a. Smudge cells
b. Can be classified into:
i. SLL (small lymphocytic lymphoma)
ii. Richter’s syndrome i.e. DLBCL (diffuse large B-cell lymphoma)
c. Management:
i. Palliative at stage III/IV with single-agent ± vidarabine
ii. Stage II  irradiation of lymphoma
iii. Stage III  splenectomy
iv. Steroids for auto-immune hemolytic anemia / idiopathic
thrombocytopenia purpura
d. Fludarabine (new, first-line)
e. Combine with rituximab or cyclophosphamide
f. Chlorambucil (well tolerated)
g. Allogenic BMT
11. ALL:
a. Good prognostic factors: young age, WBC ≤ 30,000, early remission, Ph
negative, T-cell immnophenotype
b. Chemotherapy (daunorubicin, vincristine, prednisone, asparaginase)
c. Allogenic BMT
12. Non-Hodgkin lymphoma:
a. CHOP
13. Hodgkin lymphoma:
a. ABVD
14. ITP:
a. Plasmapheresis
15. Myelodysplastic syndrome:
a. RBC transfusion for anemia
b. G-CSF or GM-CSF for neutropenia
c. Erythropoietin (SC weekly) to reduce transfusion requirement
d. Azacitidine (improves symptoms and time to conversion to acute
leukemia)
e. Allogenic BMT
16. Multiple Myeloma:
a. VAD
b. Autologous stem cell transplant
c. Localized radiotherapy
d. Bisphosphonates
e. Treat hypercalcemia, avoid immobilization and dehydration

SAQs

1. A patient has come with 2 month history of fever, cough and left-sided chest pain.
a. Name the 2 most important abnormalities on this chest X-ray.
i. Left-sided pleural effusion
ii. Fibrotic changes in apical areas
 b. What is the most likely underlying disease responsible for the
abnormalities? (Tuberculosis)
2. A patient has 10 years history of episodic cough and wheezing. His complete
blood count showed Hb of 14 g/dl, WBC 20 with 70% neutrophils, 15%
eosinophils, 15% monocytes and no basophils.
a. Describe 2 most obvious abnormalities on the chest X-ray given.
i. Dilated bronchi left upper zone
ii. Cystic bronchiectasis near left perihilar area
iii. Finger-in-glove sign
b. What is the underlying diagnosis? (APBA)
3. A patient was brought to hospital with upper abdominal pain. His blood pressure
was found to 90/50 mm Hg.
a. What abnormalities are visible on the abdominal X-ray?
(pneumoperitoneum)
b. What is the most likely cause for the radiological abnormality? (perforated
duodenal ulcer)
4. A patient was brought to hospital with nausea and vomiting for past several hours.
His BP was found to be 90/50 mm Hg with a postural drop of 20 mm Hg. His
blood chemistry revealed a Cr of 1.2, Na+ 123 and K+ 5.9.
a. Name the three most obvious abnormalities on this chest X-ray.
i. Trachea deviated to left side, bilateral pleural thickening, fibrotic
changes with bullae in left lung
b. What is the underlying disease that could explain the X-ray findings?
(tuberculosis)
c. What is the reason for present illness? (Addison’s secondary to TB)
5. A lady with a past history of lump removed from left breast came with 3 months
complaints of cough and dyspnea on climbing stairs.
a. What abnormality is visible on the chest X-ray? (prominent bilateral
interstitial shadowing with Kerley B lines)
b. What is the underlying disease process? (lymphangitic carcinomatosis)
6. A diabetic lady brought to the ER with 2 hours history of sudden onset of dyspnea
and profuse sweating.
a. Describe the abnormalities on chest X-ray.
i. Diffuse opacification of both lungs due to alveolo-interstitial
shadowing.
ii. Possible cardiomegaly (even allowing AP projection)
b. What is the most likely explanation for abnormality? (Pulmonary edema
due to acute left ventricular failure)
7. SVC obstruction
a. Emergency management
b. Three differentials (lymphoma, bronchogenic CA, sarcoidosis)
c. Three modalities of diagnosis (CT, mediastinoscopy with biopsy)
8. DKA
a. Lab findings
b. Management
c. How much fluid to give and at what rate?
 d. What is meant by bolus?
e. What is the dose of insulin?
f. What is the risk of patient dying in the ER?
g. If he dies, what would be the cause of death?
9. SBP with grade-II PSE:
a. Diagnosis
b. Management
10. ABGs of a patient suggestive of asthma:
a. Most likely cause
b. Management
11. CBC of a patient showing hypochromic microcytic anemia:
a. Causes
b. Investigations
12. A 6 years old boy with headache, fever, vomiting and confusion:
a. Most likely diagnosis
b. Common organisms
c. Investigations
d. Drug of choice
e. What is the dose?
13. A patient with tetanic contractions of face muscles:
a. Interpret labs
b. How do you correct Ca2+ for albumin?
c. Effect of acid-base disturbances on ionized Ca2+
d. Management (give 10 mL of 10% calcium gluconate I/V infusion over 30
minutes; repeat as necessary; treat any underlying respiratory alkalosis)
14. Malar rash of SLE:
a. Diagnosis
b. Management
c. Organ involvement
15. A 75 years old patient with myxedema coma:
a. Diagnosis
b. Investigations
c. Management
16. Scleroderma with CREST syndrome:
a. What does CREST stand for?
b. What do each of the above mean?

OSCE

1. ECG for viva: S1Q3T3 with TWI – pulmonary embolism

2. Diabetic ketoacidosis – viva case
3. X-ray with abscess in lung
4. X-ray with cardiomegaly – give differentials
5. Aspiration pneumonia: mention the drugs to be given
6. Ward patient with pulmonary edema – give causes (patient had nephrotic
syndrome!)
7. Ward patient with Parkinsonism – give treatment plan
8. Physical examination of patient with CLD:
a. Look for stigmata of CLD
b. What are the causes of CLD?
c. How would you manage this patient’s ascites?
d. What are the diagnostic criteria for spontaneous bacterial peritonitis?
e. List the parameters used in Child’s classification.
f. What are the stages of hepatic encephalopathy?
9. Physical examination of a patient with murmur:
a. What are your findings?
b. How would the patient present with these murmurs?
c. What is important in the history and general physical examination?
d. What are the causes of valvular heart disease?
10. Examination of posterior thorax:
a. Differentials of bronchial breathing
i. Consolidation
ii. Atelectasis
iii. Fibrosis
iv. Pleural effusion
b. Differentials of crepitations
i. Pulmonary edema
ii. Fibrosing alveolitis
iii. Asbestosis
iv. Bronchiectasis
v. Chronic bronchitis
vi. Pneumonia
vii. Pulmonary hemorrhage/infarct
c. Differentials of decreased air entry
i. Pleural effusion
ii. Pneumothorax
iii. Atelectasis
iv. Obesity
v. Unconsciousness
vi. Silent chest (in severe asthma)
d. Differentials of rhonchi
i. Generalized (asthma, COPD, LVF)
ii. Localized (tumor, foreign body)
11. Examination of upper and lower limbs:
a. Check tone, bulk, power, reflexes, plantars, pronator drift
b. What are the root values of radial, median & ulnar nerves?
i. Radial nerve (C5-T1)
ii. Median nerve (C5-T1) esp. C6
iii. Ulnar nerve (C7-T1) esp. C8
c. What are the root values of biceps, triceps, brachioradialis, patellar and
ankle reflexes?
i. Patellar reflex (L2-L4)
 ii. Ankle jerk (S1)
d. What are your findings?
e. What is the most likely diagnosis?
12. Examination of face for neurologic signs:
a. Check CN-I to VII, IX, X and XII in detail.
b. What are the causes of optic nerve lesions?
c. Central and peripheral causes of facial nerve palsy?
13. General physical examination of patient with findings:
a. Causes of tender and non-tender cervical lymphadenopathy
b. Causes of clubbing
i. Cardiac (Eisenmenger’s syndrome, ToF, atrial myxoma)
ii. Pulmonary (bronchogenic CA, bronchiectasis, ILD, cystic fibrosis)
iii. Gastrointestinal (PBC, IBD, malignancies)
iv. Familial
v. Idiopathic
c. Causes of palmar erythema
i. Pregnancy
ii. Polycythaemia rubra vera
iii. Chronic liver disease
iv. Rheumatoid arthritis
v. Thyrotoxicosis
d. Causes of pallor
i. Microcytic anemias
ii. Normocytic anemias
iii. Macrocytic anemias
e. Causes of jaundice
i. Prehepatic (all hemolytic anemias)
ii. Hepatic (everything you can think of)
iii. Posthepatic (choledocholithiasis, CBD strictures, biliary atresia,
choledochal cyst, CA of pancreatic head)
f. Causes of pedal edema
i. CHF, CLD, CRF
ii. Filariasis
iii. Fluid overload / third spacing
iv. Protein deficiency
v. Extreme anemia
vi. DVT
vii. Prolonged bed rest
g. Causes of irregularly irregular pulse
i. Atrial fibrillation
ii. Wandering pacemaker
iii. Ventricular fibrillation
h. Indications of dialysis
i. Acidosis
ii. Drug intoxication
iii. Decreased urine output
 iv. Severe electrolyte abnormalities
v. Uremic encephalopathy
vi. Pericarditis
14. Picture of hand showing thenar atrophy:
a. Diagnosis
b. Causes
c. Management
15. A kid with spoon-shaped nails: differentials?
16. Slide of peripheral film showing anisocytosis and poikilocytosis with pencil cells:
iron-deficiency anemia
17. Slides of MM, AML, ALL, CML, sickle cell anemia
18. Picture of patient with acromegalic facies
19. Case of COPD exacerbation:
a. History
b. Management in the ER
20. Case of asthma exacerbation:
a. History
b. Management in the ER
21. Ischemic stroke:
a. Management
b. Contraindications to thrombolysis
22. Management of massive UGI bleed
23. Management of status epilepticus
24. Management of acute cord compression / cauda equina syndrome
25. A lady with rheumatoid arthritis:
a. GPE: clubbing, Boutonnière deformity in right hand, bilateral ulnar
deviation, subluxed MCP joints, pseudophakic both eyes, icteric both eyes
b. Abdominal: liver palpable 2 finger breaths below costal margin, smooth,
non-tender, non-pulsatile, shifting dullness positive
c. Differentials: RA, OA, ascites, CLD, auto-immune cirrhosis
26. ECG with following features:
a. Rate < 50/min
b. Rhythm regular
c. Axis normal
d. U waves in V3-V5
e. Sinus bradycardia
f. Most likely cause: sick sinus syndrome
27. ECG with following features:
a. Rate 200/min
b. Rhythm irregular
c. Broad complex tachycardia with LBBB
28. ECG with following features:
a. Rate 30/min
b. Rhythm irregular
c. Axis deviated to left
d. Premature atrial beats
 e. Mobitz type-II block or left anterior hemiblock
f. Heart block + murmur = aortic stenosis
29. ECG with following features:
a. Rate 60/min
b. Rhythm sinus
c. Axis normal
d. STE in V2-V6, TWI in V1, q-waves in V1-V3
e. Acute anterior wall MI
f. Management?

VIVA

1. Chest X-ray:
a. Consolidation (d/d, organisms, management)
b. Pleural effusion (causes, exudates vs. transudate, treatment)
c. Pneumothorax (causes, diagnosis, treatment)
d. Kerley B lines, cardiac failure
e. Coin lesion (d/d, management)
f. Miliary tuberculosis
2. ECG:
a. Ventricular fibrillation (diagnosis, management)
b. Ventricular tachycardia (causes, monomorphic vs. polymorphic)
c. WPW syndrome (pathology, treatment)
3. Causes of renal tubular acidosis

RANDOM FACTS

 Hirschsprung disease—associated with Down’s syndrome and Chagas disease;

NEC is the most common cause of death in such patients; toxic megacolon and
perforation can also occur
 Gynecomastia
o Normal in neonates, prepubertal boys and elderly
o If present in young adults, it may be due to a number of causes:
 Adrenal or testicular tumors
 Hyperplastic Lyedig cells in Klinefilter’s syndrome
 Decreased estrogen catabolism in cirrhosis (most common cause)
 Drugs (cimetidine, spironolactone, ketoconazole)
 Hypothalamic and pituitary disorders
 Unknown mechanisms due to digitalis & marijuana
 Volkmann’s ischemic contracture—caused by supracondylar fracture of
humerus that entraps brachial artery and median nerve; treat with fasciotomy
 Greenstick fractures—seen in children and refers to break in the cortex in the
convex side of the shaft but an intact concave side
 Pott’s fracture (bimalleolar fracture)—when foot is forced into eversion and
abduction resulting in fracture of both malleoli
 Colle’s fracture—caused by falling an outstretched hand, fracture of the distal
end of the radius at the suprastyloid level and the fracture of styloid process of
ulna, “dinner fork” deformity
 Fracture of the femoral neck—most common fracture of the femur in elderly,
most often associated with avascular necrosis and increased nonunion, also seen
in osteoporosis due to estrogen deficiency
 Finkelstein test—for the diagnosis of De Quervain’s stenosing tenosynovitis
(involves the synovial sheath of abductor hallucis longus), patient makes a tight
fist over the flexed thumb, the examiner pushes the base of the flexed thumb
towards the ulnar side and the patient feels the pain in the region of the styloid
process
 Schober test—for the diagnosis of ankylosing spondylitis, it tests for the limited
anterior flexion of the spine (characteristic finding)
 McMurray’s test—for meniscus tears in the knee joint
 Ortolani test—evaluates newborns for congenital dislocation of hip; abduction of
the affected thigh produces a palpable click as the dislocated femoral head slips
back into the acetabulum
 Beck’s triad—hypotension, distended neck vains and muffled heart sounds seen
in cardiac tamponade
 Inhalational anesthetics—to find out which agent has the most rapid recovery,
just look at the Blood Gas partition co-efficient, the agent with the lowest value
has the most rapid rate of recovery
 Hypotension & bradycardia—neurogenic shock
 Hypertension & bradycardia—Cushing reaction
 Hypotension & tachycardia—hypovolemic shock
 Hypertension & tachycardia—acute severe pain
 Cushing’s reflex—hypertension, bradycardia, falling respiratory rate as seen in
increased intracranial pressure
 Initial hematuria—urethral lesion
 Midstream or total hematuria—upper urinary tract or vesical lesion
 Terminal hematuria—prostatic lesion
 TURP—associated with high incidence of retrograde ejaculation, TURP
syndrome is volume overload
 Hemorrhoids—the rule is internal hemorrhoids bleed but do not hurt, whereas,
external hemorrhoids hurt but do not bleed
 Fogarty balloon tipped catheter—for embolectomy
 Complications of long-standing OCP use—hepatic adenomas, which may
rupture with bleeding and pain
 Volvulus in an elderly pain with no previous history of intra-abdominal
surgery—do proctosigmoidoscopy as opposed to emergency ex lap
 A 30 years old woman with headache which is gradually increasing in
intensity and worse in morning—diagnosis is brain tumor
 3rd degree burns—skin area is white, dry, painless, leathery and anesthetic;
management is immediate excision with skin grafting
 Fracture of vertebral bodies in an accident—presentation is flaccid sphincters,
loss of motor function and loss of pain & temperature sensation on both sides
distal to the injury, preservation of vibratory and positional sensation; diagnosis is
anterior cord syndrome
 A 3 weeks old infant with protracted bilious vomiting, looks acutely ill, AXR
shows two large air-fluid levels in the upper abdomen (“double bubble sign”),
diagnosis is duodenal atresia
 Differential diagnosis for severe postoperative chest pain with tachycardia and
shortness of breath is MI (seen in first 2-3 days) and PE (seen after 5-7 days)
 Three most common presenting complaints of a woman with ectopic pregnancy—
amenorrhea, abdominal pain and vaginal bleeding—first step in diagnosis is β-
hCG
 Infertility, oligomenorrhea, hirsutism and obesity is seen in polycystic ovarian
syndrome, U/S shows “string of pearls”, increased risk of endometrial CA
 History of multiple partners, early age at first intercourse, STD, HIV, genital
warts, cigarette smoking and cervical dysplasia—increased risk of cervical CA
 Investigation of clinically palpable malignant mass in a postmenopausal woman is
mammography followed by FNAC (or excisional biopsy)
 HELLP syndrome—hemolysis, elevated liver enzymes and low platelets
 Retroplacental clot with painful uterine contractions—placental abruption—most
common causes are maternal HTN, trauma and cocaine abuse
 Painful third trimester vaginal bleeding with fetal compromise (abruption)—do
emergency LSCS
 Premenstrual syndrome (PMS)—depression, insomnia, decreased appetite;
symptoms should remit shortly after menses; if the symptoms persist even after
menses, then diagnosis of depression is most likely and the patient needs thorough
psychological evaluation
 Complaints of “pimples” on vulva—multiple small (2-5 mm) dome-shaped,
flesh-colored papules with smooth flat-topped surface: molluscum contangiosum
 Young primigravida at term complains of hypotension on supine position—uterus
compressing IVC and decreasing cardiac output leading to hypotension
 When should the diaphragm be removed after intercourse? 6 hours post coitus
 Side-effects of diaphragm—bladder irritation with risk of developing cystitis, also
risk of toxic shock syndrome
 “Chocolate cysts” in ovaries, nodularity over broad ligament and “gunpowder
burns” in cul-de-sac—endometriosis
 Pelvic U/S reveals “snow storm” appearance with elevated β-hCG: hydatidiform
mole
 Atypical lymphocytosis seen in EBV and CMV mononucleosis
 Fever, profound fatigue, generalized lymphadenopathy, hepatosplenomegaly and
pharyngitis; the diagnosis is infectious mononucleosis
 Same symptoms without pharyngitis—leukemia
 A 48 years old man with complains of lower backache that radiates to the buttock
and right thigh. Pain exacerbated by applying pressure on the paravertebral region
in the lower lumbar spine and by passively raising the leg at 45o while the patient
 lies supine (Lasegue sign)—diagnosis is intervertebral disc herniation causing
compression of spinal root S1
 Treatment of above is NSAIDs and bed rest of short duration (no longer than 2
days)
 Ten minutes after blood transfusion, the patient develops severe hives: diagnosis
is selective IgA deficiency [?]
 Any skin lesion showing ABCDs (asymmetry, border irregularities, color
variation, diameter > 0.6 cm) mandates biopsy: if melanoma is confirmed then
excision should be undertaken
 Nocturnal attacks of headache lasting for 30 minutes to 2 hours, precipitated by
alcohol consumption, recurs for many weeks followed by remission for 1 year—
diagnosis is cluster headache
 Headache worse in the morning associated with other signs of depression—
diagnosis is depression headache
 Elderly patient with scalp tenderness over the affected superior temporal artery,
systemic findings of myalagias, weight loss, malaise, increased ESR—diagnosis
is giant cell arteritis in association with polymyalgia rheumatica
 Headache of early adulthood, episodic unilateral throbbing headache, associated
with nausea, photophobia, visual symptoms—migraine
 Diffuse headache with band-like character, feels worse in the back of head, pain
slowly increases, may last for hours or even days—tension headache
 A man has blisters and crusted lesions on skin-exposed skin of his face and lower
arms, plasma porphyrins are also elevated. Biopsy of the lesion reveals
supepidermal blisters, marked solar keratosis and “caterpillar bodies” in the
roof of the blister—porphyria cutanea tarda
 Right lower quadrant mimicking appendicitis—pseudoappendicitis (mesenteric
adenitis) caused by Yersinia entercolitica
 Pediatric patients with VSD are more prone to develop infective endocarditis
 Recurrent episodes of inflammatory arthritis, absence of urate crystals and
speckling (due to calcification) of the articular cartilage: diagnosis is pseudogout
(calcium pyrophosphate crystals are weakly birefringent on polarized light)
 Antimitochondrial antibodies are seen in primary biliary cirrhosis and
primary sclerosing cholangitis—these conditions can be differentiated by ERCP,
which demonstrates that the bile duct lesions extend outside the liver
(characteristic of PSC), but, extend into the liver in PBC; also, PSC is strongly
associated with UC; both conditions pose an increased risk of cholangiocarcinoma
 Drepanocytes (teardrop cells) are characteristic of thalassemia, myelofibrosis [?]
 Causes of amyloidosis—don’t forget long-standing RA and MM
 “Thumb printing” sign seen in ischemic colitis
 String sign in Crohn’s disease
 Adult with HTN and enlarged kidneys bilaterally, suspected adult polycystic
kidney disease—next step is to order U/S
 In children with acute post-streptococcal glomerulonephritis: strep throat, raised
ASO titers, decreased C3 levels, subepithelial “humps” of IgG and C3
 Treatment of HTN in children: β-blockers and diuretics in young children, ACE
inhibitors and CCBs in adolescents
 Production of surfactant is increased by maternal steroid administration,
prolonged rupture of membranes, maternal narcotic addiction, pre-eclampsia,
chronic fetal stress due to placental insufficiency, maternal hyperthyroidism and
theophylline
 Production of surfactant is reduced by hyperglycemia and hyperinsulinemia as
occurs in maternal diabetes
 Persistent pulmonary HTN of newborn (PPHN)—disorder of term or post-term
infants who experienced acute or chronic hypoxia in utero
 Term baby with pulmonary insufficiency greater than the findings on chest X-ray
—probable diagnosis is PPHN
 Total bilirubin of upto 20 mg/dl is tolerated without kernicterus
 α-fetoprotein is marker for testicular and ovarian tumors with yolk sac
components as well as hepatocellular cancers
 S-100 – malignant melanoma
 CA-125 – marker for some ovarian tumors
 LCA (leukocyte common antigen) – marker for some lymphoid neoplasms
 PSA – marker for prostatic cancer
 Homosexual man with complaints of diarrhea for 2 days and with symptoms of
flatulence and bloating appearing several days after a trip to mexico—diagnosis is
giardiasis; treatment is metronidazole
 40 years old woman with rash on her legs, epistaxis and oral bleeding—diagnosis
is ITP and treatment is prednisolone (if no active bleeding), immunoglobulins (if
active bleeding)
 Psammoma bodies and “Orphan Annie” eyes seen in papillary CA of thyroid
 Neonate or infant suffering from narcotic withdrawal syndrome—treatment is
paregoric
 VACTERL—describes the non-random association of TracheoEsophageal fistula
with Vertebral anomalies, Anal atresia, Cardiac defects, Radial Limb dysplasia
 Beckwith-Wiedemann syndrome—exophthalmos, macroglossia, gigantism,
hyperinsulinism and hypoglycemia
 Polyhydraminos—may cause duodenal atresia, omphalocele, gastroschisis
 Parvovirus is common in day-care centers
 Ductal adenocarcinoma of pancreas—most effective diagnostic method is CT
 Old man with complaints of blurred vision, describes it as curtain falling
vertically across the visual field: diagnosis is amaurosis fugax (RD?)
 Central retinal artery occlusion—sudden profound visual loss, pupils are
unreactive to direct light and there is pale retina with cherry-red spot at macula
 Central retinal vein occlusion—sudden decrease or loss of vision, pupils
sluggishly reactive to light
 Absolute neutrophil count (ANC) of less than 500 /μl is neutropenia; such patients
are susceptible to Pseudomonas infections and should be treated with I/V
ceftazidime
 Felty syndrome—rheumatoid arthritis, splenomegaly and neutropenia; these
patients have a high titer of RA factor, subcutaneous nodules and other
manifestations of rheumatoid arthritis
 The main difference between lepromatous and tuberculoid leprosy—in
lepromatous leprosy, the granulomas contain numerous AFB, while, in
tuberculoid leprosy, AFB are rarely found; bilateral ulnar neuropathy with
characteristic “Leonine facies” (loss of eyebrows, depressed nasal bridge) is
suggestive of lepromatous leprosy
 Cyst-bearing multiple daughter cysts in the liver on CT scan—diagnosis is
hydatid cyst disease caused by Echinococcus granulosis
 Biliary obstruction with granulomas in the liver—diagnosis is ascariasis
 Tender hepatomegaly with fever and eosinophilia—diagnosis is infestation
with Fasciola hepatica; can cause cholangitis and biliary fibrosis in chronic
cases
 Granulomatous hepatosplenomegaly with “pipe-stem fibrosis” and portal
hypertension—diagnosis is schistosomiasis
 On a chest X-ray, solitary nodule with “popcorn” calcification is seen in
hamartomas
 X-ray film of the abdomen shows a sentinel loop in the left upper quadrant with
colon cut-off sign—diagnosis is acute pancreatitis
 CMV can cause colitis and destructive adrenalitis in AIDS patients
 Ketoconazole may impair adrenal glucocorticoid and mineralocorticoid synthesis
 Pulmonary and CNS infections may induce SIADH
 AIDS patients with non-bloody, watery diarrhea—organism is Cryptosporidium,
Isospora belli, Cyclospora; former two are both acid-fast organisms, but, need
modified acid-fast staining to be visualized
 Focal segmental glomerulosclerosis (nephritic syndrome) is either idiopathic or
occurs in association with morbid obesity, HIV infection and heroin abuse
 Renal failure is the most common cause of acute pericarditis (uremic pericarditis),
which usually occurs when BUN exceeds 100 mg/dl (often earlier in diabetics)
 Behçét syndrome–oral ulcers, genital ulcers and arthritis
 Acanthosis nigricans—associated with visceral malignancies and also with
endocrinopathies e.g. acromegaly, Cushing’s syndrome, hyperthyroidism and
glucose intolerance