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 TABLE OF CONTENTS

CARDIOLOGY… …. … … … …. … … …. … …. …. … … 3

RESPIRATORY… … … … …. … …. … …. … …. … … …32

DERMATOLOGY… … …. … …. … … … … …. … … … . 49

NEUROLOGY… … … … … … … … … … … …. ….. … . 74

NEPHROLOGY… … … … … … …. ….. …. …. … … … ..90

INFECTIOUS DISEASES… … … …. …. … … … … … ..101

PEDIATRICS… … … … … …. … …. … …. … … … … ..121

GERIATRIC MEDICINE… … …. … … …. … …….. ….. 158

EXTREMELY IMPORTANT MCQS… … …. …. … …. …160

PSYCHIATRY… … … … …. … … … … …. … … …. …..183

ENT… … … … … … …. …. … … …. …. … … … …. ….198

ETHICS… … …. … …. … …. … ….. …. … … …. …. … 219

PHARMACOLOGY & TEXACOLOGY… … … …. …. …. 223

FAMILY & GENERAL MEDICINE….. … … … … …. … 228

CRUCIAL POINTS…. … …. … … …. ….. …. … ….. … .241

OPHTHALMOLOGY…. … …. …. ….. ….. … …. …. … ..288

GASTROENTEROLOGY…. …. … ….. …. …. … …. ..... 320

GYN OBS…. …… … …. …. …. … …. … …. … …. …. ..336

ENDOCRINOLOGY… …. … … … …. …. …. … ….. … .366

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 HEMATOLOGY…. ……. …. …. … ….. ….. … … …. … .371

RHEUMATOLOGY… … …. ….. …. ….. … …. …. …. …378

SURGERY… …. …. … … … …. … … … … … … … … .383

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Chapter-01

CARDIOLOGY

QT Prolongation

Most likely scenario: Commonly pt presents malnutrition and arrhythmias, SOB

an ECG show QT prolongation. Note: An ECG change most typically associated
with hypomagnesaemia in QT prolongation on other hand QT shortening is more
typically seen with hypocalcaemia, QT syndrome and digoxin drug.

Reference-elentra.healthsci.queensu.ca

Treatment: IV magnesium sulphate 40 mmol over 24 hours. Avoid

pharmacologicals which cause QT prologation or shortening.

ASD (Atrial Septal Defect)

Most likely scenario: Patient presents with SOB, fixed splitting with loud P2,
ejection systolic murmur in pulmonary area is typical picture of ASD. Note: one

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 should not misdiagnose ESM in pulmonary area, SOB and loud P2 as
pulmonary hypertension though it can be develop in elderly with ASD.

Mitral Valve Stenosis

Most likely Scenario: Patient present with fatigue, exertional dyspnea and mostly
with orthopnea and this is most common valvular complication of rheumatic
fever. Note: Mitral Stenosis often presents with AF or in pregnancy.

Diagnostic investigation: Echo

Treatment: Warfarin is anticoagulation therapy

Mitral Regurgitation

Most likely Scenario: Mostly asymptomatic, Mitral regurgitation raised

pulmonary capillary pressure it causes pulmonary edema mostly when inferior
myocardial infarction causes LV remodeling, which displaces posterior papillary
muscle away from its normal position leading to ischemic mitral regurgitation.
Severe mitral regurgitation may cause left sided heart failure.

Diagnostic investigation: Echo

Treatment: If there is chronic mitral regurgitation surgery or surgical

intervention is the choice or if patient is with functional mitral regurgitation may
improve with biventricular pacing.

Mitral valve Stenosis

Most likely Scenario: Patient presents rheumatic fever without carditis with
Dyspnea on exertion, straight left border of the cardiac silhouette. To straighten
the left heart border it requires underfilling of LV and aorta which results
rheumatic mitral valve stenosis. Note AF is commonly association with
rheumatic mitral valve stenosis.

Diagnostic investigation: Echo

Treatment: Beta blockers to treat AF, avoid exertion, surgery when medical
therapy failed and if pt goes to heart failure.
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 Cardiac temponade

Most likely Scenario: Patient will presents as collection of three signs which are
called Becks traid in emergency condition where in trauma fluid accumulates
around the heart in result there is huge pressure on heart which impairs its
ability to pump so in result faint distant heart sounds and causes low arterial
blood pressure and it can cause pericarditis.

Diagnostic investigation: Echo

Treatment: Pericardiotomy and treat the cause.

Coartctation of aorta ( CoA)

Most likely Scenario: commonly patient presents with headache and could be
nose bleed, hypertension, pain in lower limb on exertion which is due to low
blood supply to legs caused Coarctation, radio femoral delay, cold legs, weak
pluses, mild systolic murmur these are all features of CoA. It’s (congenital heart
defects).

Diagnostic Investigation: CoA usually diagnosed after baby born with pale skin,
irritability, heavy sweating, and difficulty breathing. In adults Echo is most
commonly used to diagnose.

Treatment: Balloon angioplasty or cardiac catheterization.

Ventricular Septal Deffect (VSD)

Most likely Scenario: It’s a congenital defect which usually diagnosed early but
some patients show symptoms in adulthood as in early 20s not like ASD which
can be diagnosed in older people than VSD. Usually patient complains of fatigue,
dyspnea, left parasternal heave and systolic thrill with a (harsh pan systolic
murmur at left parasternal edge without cyanosis).

Diagnostic Investigation: Echo

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 Treatment: It depends on the size of hole and symptoms. If the hole is small and
narrow and can close on its own. On other hand if it’s large then an open heart
surgery or cardiac catheterization is recommended.

Aterial septal defect (ASD)

Most likely Scenario: ASD most diagnosed in adult patients with large Hole in
septum and arrhythmias are more common with cyanosis, irregularly irregular
pulse loud P2 with fixed splitting and ejection systolic murmur in left 2nd ICS.

Diagnostic investigation: Echo

Treatment: As like VSD

Dressler Syndrome

Most likely scenario: Usually Dressler syndrome occurs after few weeks of MI
(post myocardial syndrome) pericardial rub is common due to pericarditis, chest
pain with ST elevation and CXR shows loss of margin at costo vertiberal angle.

Diagnostic investigation: Echo

Treatment: NSAIDs, steroids

Dilated cardiomyopathy

Most likely Scenario: Pt will present with history of ischemia or MI (S3 gallop age
more than 40 years) and complain of chest pain with SOB on exertion edema,
rales, arrhythmias over past few days. ECG shows normal but echo shows
increase ejection fraction (EF) and decrease wall thickness which results LV
dilation and dysfunction.

Diagnostic investigation: Echo

Treatment: All types of cardiomyopathies are treated with diuretics to control the
symptoms but for long term ACEIs, ARBs, BBs, and spironolactones lowers
mortality rate.

Hypertropic Cardiomyopathy

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 Most likely scenario: Supposes Pt comes in ER likely with history of collapse. She
recalls rushing for the bus before feeling faint. Her brother recently died
suddenly due to a heart problem. O/E: She has a 'jerky' pulse, a thrusting
cardiac impulse and a mid-systolic murmur.

Note: Symptoms and signs are similar to those of aortic stenosis, except that the
character of the pulse in HCM is jerky. The age of the patient and her family
history makes HCM the likely diagnosis.

Hypertropic obstructive cardiomyopathy

Most likely scenario: Any young athlete during play feels dyspnae and sudden
fall O/E: Double peak per cardiac cycle was found, which is called pulus
bisferiens means striking double. These suggest the diagnosis of HOCM. Sudden
death is common due to ventricular arrhythmias, heart failure.

Diagnostic investigation: ECG will show typical changes in LVH and T wave
inversion.

Treatment: Beta blockers, amiodrone, CD Drugs to avoid nitrates, ACEIs and

inotropes.

Diagnostic investigation: ECHO, MRI

Treatment: start with Beta blockers, and if pt with high risk of sudden death
option is ICD. And avoid nitrates, ACEIs and diuretics as (they cause volume
depletion) as well as LVOT increase and worsen symptoms.

Pulmonary Edema

Most likely scenario: Any smoker with older age presents in OPD for a review.
She has woken during the early hours of the morning for the second time with
shortness of breath so bad that she had to fling open the windows. O/E: There
are crackles in the lung bases, S3 gallop, JVP distended. Her chest X-ray shows
bilateral fluffy perihelia shadowing. ECG reveals small anterior Q waves and a
sinus tachycardia of 105 bpm.
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 Diagnostic investigation: If BNP level is normal exclude it from PE, X-ray and
Echo is must.

Treatment: Loop diuretics, oxygen and nitrates.

Atrial fibrillation

Most likely Scenario: ECG shows that P waves are replaced with F waves with
(irregular RR intervals) diagnosis is AF.

Reference-Atrial fibralation. Wikipedia

Diagnostic investigation: ECG

Treatment: BBs commonly IV metoprolol

Atrial Flutter

Most likely Scenario: Pt with history of ICH and ECG shows (saw tooth like
waves), QRS complex of 80ms duration, ventricular rate 150 beats/min, atrial
300 beats/min and very importantly (regular RR interval). This is typical picture
of atrial flutter.

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 Diagnostic investigation: ECG

Treatment: Same as AF

Ventricular fibrillation

Most likely Scenario: In VF pt presents with heart quivers instead of pumping

due to disorganized electrical activity in ventricals. Old pts cannot breath in VF
following arrhythmia and sudden death.

Reference: Ventricular fibrillation-Wikipedia

Diagnostic investigation: ECG

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 Treatment: CPR, Pt who survives from sudden cardiac death have high incidence
of recurrence so ICD is generally indicated. MI or ischemia should be managed
with coronary revascularization.

Deep vein thrombosis (DVT)

Most likely scenario: In DVT pt founds problem in lower limbs mostly hip pain
and ulcers on medial side of ankle and result immobilization and presence of
DVT is followed by pulmonary embolism.

Diagnostic Investigation: D-Dimer testing

Treatment: Anticoagulation therapy

Pericarditis

Most likely scenario: SOB, sharp and stabbing left sided chest pain increased
with breathing and relieved by sitting forward is typical picture of pericarditis.
Some people show dull pain radiate to left shoulder and neck.

Diagnostic investigation: ECG shows (most commonly PR segment depression is

most specific ECG marker of (pericarditis) and ST elevation in all leads.

Treatment: Treat the cause if it’s viral (coxsackie) or bacterial in nature

commonly NSAIDS and colchicines.

Constrictive pericarditis

Most likely scenario: Constrictive pericarditis is mainly associated with

rheumatoid arthritis with combination of SOB, atrial fibrillation, hypertension,
lower limb edema, ascites, raised JVP and bi-atrial enlargement with normal
systolic ventricular function and calcification. CXR shows typical picture of
constrictive pericarditis.

Diagnostic investigation: First x-ray should be taken if findings are fibrosis and
calcification then Ct or MRI is accurate.

Treatment: Diuretics to relieve edema and surgical removal of pericardium.

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 Endocarditis

Most likely scenario: Pt will present low grade temperature, petechiae, cardiac
failure and new cardiac murmur. Pt might have some medical procedure as like
dental extraction recently. This is typical picture of infective endocarditis which
is defined as an infection of endocardial surface of heart which may include one
or more heart valves.

Diagnostic investigation: Two blood cultures must be positive and Echo

Treatment: Empiric antibiotics are chosen on the basis of the most likely
infecting organisms.

ST-elevation myocardial infarction (STEMI)

Most likely scenario: Typically pt shows ST elevation on ECG with SOB, chest
pain radiating to neck, jaw or left arm.

Diagnostic investigation: ECG

Treatment: Aspirin 300mg, ACEIs, oxygen, niters and morphine (MONA) and
repeat an ECG in 4 hours if there is 30-40% resolution in ST-evelation then PCI
is the option.

Non ST-Evelation myocardial infarction (NSTEMI)

Most likely scenario: An old age pt brings into ER with SOB, chest pain at rest
which lasts more than 10 minutes which radiates to left arm, jaw and neck. An
ECG shows depressed ST wave or transient ST elevation or T wave inversion and
partial blockage of coronary artery. NSTEMI is similar with unstable angina.

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 Reference BMJ.NSTEMI

Diagnostic investigation: ECG and having positive biomarkers (troponin is most

sensitive and recommended)

Treatment: Morphine, Oxygen (hypoxic), nitrates and aspirin (MONA)

Stable Angina

Most likely scenario: In Stable angina pt is mostly complaining of left sided chest
pain following an exercise or walk which lasts <30 minutes while taking rest.
Note: that stable angina is chest pain that most often occurs with activity or
emotional stress which relieved by rest or nitroglycerines. This happens due to
the blood supply to heart muscle is reduced when coronary arteries are
narrowed or blocked by atherosclerosis or by blood clot.

Unstable angina

Most likely scenario: In unstable angina pt presents chest pain, SOB, chest
tightness with sharp type of pain in rest as opposite from stable angina.
Unstable angina is part of acute coronary syndrome and may lead to MI.

Diagnostic investigation: ECG which shows transient or hemodynamic changes

with marked symmetrical T wave inversion and ST depression or elevation.

Treatment: Aspirin, nitroglycerin and oxygen final option is PCI.

Calcification

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 Most likely scenario: A 65y old male pt presents with a new onset of hypertension
and his hands turned as bluish and feeling pain. O/E: The skin was tight on her
hands and she can’t hold anything.

Note: This is the common presentation of calcification under skin.

MCQS Solving Rapid Fire (Direct targeted bullets)

1. Hypocalcaemia causes QT prolongation while hypercalcaemia causes short QT

interval.
2. Long QT syndrome or (torsades de pointes) is an inherited condition associated
with delayed repolarization of ventricles and VT and sudden death.
3. Long QT1 usually associated with exertional syncopy often during swimming.
4. Long QT2 often associated with syncope occurring following emotional stress,
exercise or auditory stimuli.
5. Long QT3 often occurs at events during night or at rest. And can cause sudden
cardiac death.
6. Inherited condition associated with delayed repolarization of the ventricles,
which leads to ventricular tachycardia is Long QT syndrome (LQTS).
7. Normal range for duration of the corrected QT interval (QTc) is 350 -430 ms.
8. Diagnosis of QTc is Holter ECG monitoring and confirmed by genetic mutation.
9. first line drug-induced LQTS is IV MgSO4
10. Long QT syn. >> usually due to loss-of-function/blockage of K+ channels.
11. Jervell - Lange-Nielsen (JLN) syndrome is caused by mutations in the KCNE1
and KCNQ1 genes. (Includes deafness and is due to an abnormal potassium
channel).
12. Romano-Ward syndrome: (no deafness).

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 13. QT shortening: caused by: >>> Hypercalcaemia, Hypermagnesaemia, Digoxin, or
Thyrotoxicosis.
14. Among SSRIs drug of choice for ischemic heart disease is = Sertraline next
choice is= Citalopram ( as other SSRIs are often case (Torsades de points and
prolonged QT interval) next choice is Mitrazapine if SSRIs cannot be used.
15. Diagnoses of exertional syncope are ( Aortic Stenosis most likely in old age) and
(Hypertropic cardiomyopathy ( HCM ) most likely in younger age) diagnostic
investigation is ECHO.
16. Features such as Hypertension, Abdominal pain, Back pain, abdominal mass
lateral and superior to the umbilicus most likely diagnose is ( Aortic Aneurism)
and single most investigation is ( Abdominal ultrasound).
17. The most common consideration of cardiac tamponade is = renal failure.
18. The most common adverse event with statin therapy is athralgia or myopathy
often with normal CPK levels.
19. Which pulse is most likely associated with Hypertrophic Obstructive
Cardiomyopathy (HOCM ) and ( Aortic Stenosis) = Pulsus Bisferiens. Bisferious
means striking twice.
20. HOCM is the most common cause of sudden cardiac death in the young.

21. Myoglobin rises first in MI.

22. HOCM is more common cause of death in youth.
23. Women who are at high risk of developing pre-eclampsia should take aspirin
75mg OD from 12 weeks until the birth of baby.
24. Definition of hypertension in pregnancy is systolic <140 mmHg and diastolic >90
mmHg.
25. Staphylococcus aureus is now most common cause of infective endocarditis.
26. Diagnosis of infective endocarditis is fever, new murmur. Risk factors are IV
injections, renal failure, dermatitis, organ transplantation, DM, post operative
wound, Dental procedures, sepsis and bronchitis.
27. Atrial fibrillation is associated with irregular irregular pulse.

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 28. Mitral valve stenosis is the most common valvular complication of rheumatic
fever.
29. DVT mostly presents swelling, warmth or redness in skin.
30. Cardiac tamponade: presents with low arterial blood pressure, JVP and distant
muffled heart sounds.
31. Long standing complication of mitral valve replacement is tricuspid
regurgitation.
32. Ischemic mitral regurgitation raised pulmonary capillary pressure results
pulmonary edema.
33. Hypertension, pain in lower limb on exertion, reduced blood supply to lower limb
due to coartation, radio-femoral delay, cold legs with weak pulses and mid
systolic murmur are all features of coartation of aorta (CoA).
34. 55y Pt came for follow up he is hypertensive now what’s targeted blood pressure
his should be answer is 130/80 mmHg
35. First line antihypertensive drug is ACEi and second line is ARB.
36. 45y old pt with high lipid profile he is on statins what exra suggestions you will
give him answer is he must follow a diet which has less than 30 mg cholesterol
or he must take total fat less than 30%.
37. Regular exercises and controlling the blood pressure can decreasing the chances
of cardiac issues and Dementia as well.
38. Suppose a drug and alcohol abuser came to ER with hypertension and
hyperlipidemia, he is on hydrochlorothiazide, lipid lowing drugs and
bromazipine. Now pt has edema in his lower extremities. What should be next
investigation? We will think that pt is on thiazides and develop edema so best
investigation is (Creatine kinase).
39. All athletes must be investigated ECG regularly.
40. Any old age hypertensive pt with pain at lower extremities or upper extremities
the initial pain management is Acetaminophen.
41. If pt has long history of abdominal pain, weight loss, non tender abdomen and
elevated Hb levels these are common features of (Mesenteric Ischemia).
42. If hypertensive pt on loop diuretics and he develops tinnitus further
management is to reduce the diuretics dose.

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 43. Dressler syndrome commonly occurs 2 to 3 weeks after MI.
44. Pleuritis is responsible for pleural effusion leading to loss of margin at costo-
vertebral angle.
45. Thiazide causes postural hypertension by volume depletion results pt falls
sudden rising from bed at mornings.
46. Dilated cardiomyopathy ejection fraction and septal wall thickness decreased if
increased EF its constrictive pericarditis.
47. Aortic dissection: Presents with cold peripheries due to reduced blood flow to
distal parts of dissection. Paraperesis or paraplegia due to spinal cord ischemia
and infarction this is presentation of aortic dissection. Usually management for
type A is surgery and for type B is conservatives.
48. SVT management: Vagal manoeuvres ( carotic sinus massage, valsalva
manoeuvre) transiently increase AV block and unmask the underlying atrial
rhythm. If unsuccessful then first choice of medicine is (adenosine).
49. Ventricular fibrillation (VF) is when heart quivers instead of pumping due to
disorganized electrical activity in ventricles. Diagnose (ECG) showing irregular
unformed QRS complexes without any clear P wave.
50. MI is only painless when autonomic neuropathy becomes well established.
51. Gingival hyperplasia is a recognized side effect of calcium channel blockers.
52. During coronary angiography, what measure will protect her kidneys from
contrast is normal saline 0.9%.
53. First choice of hypertensive lowering drug in afro-Caribbean origin is CCB.
54. High blood sugar is well known side effect of thiazide.
55. Inferior MI is frequently associated with conduction defect which usually causes
Mobitz I 2nd degree heart block.
56. Any condition that causes the walls of arteries to weaken can lead to an
aneurysm in which atherosclerosis is major cause.
57. Inferior MI presents pathological Q wave with ST elevation in leads II. III and
aVF.
58. History of surgery followed by chest pain and breathlessness suggests diagnosis
of pulmonary embolism.

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 59. Prolong use of thiazide and amlodipines are well stablished cause of postural
hypotension. So 24h BP monitoring should be done.
60. All valvular defects the best diagnostic investigation is ECHO.
61. Aortic aneurism: there is features of shock with pulse 120bpm and BP 70/40
mmHg and sudden c0llapse of the pt with pulsatile mass in abdomen. This is
likely diagnose of rupture of aortic aneurism.
62. Most common site of atherosclerotic aneurysm is (Abdomenal aorta).
63. Visceral aneurysm is most commonly seen in (splenic artery, hepatic atery).
64. Cause of stable angina is (stable atheroma).
65. Drug used for treat variant angina/prinzmeatal angina is (nitroglycerin,
nifedipine or CCBs)
66. Nocturnal angina is precipitated by (vivid dreams).
67. Investigation of choice for stable angina is ( ETT exercise tolerance test).
68. Leading cause of sudden cardiac death in young adults is (HOCM).
69. HOCM effects (left ventricle).
70. Heavy muscular and hyper contracting heart found in (HOCM).
71. Abnormal filling and outflow obstruction on ECHO is seen in (HOCM).
72. Soft flabby and hypocontracting heart seen in (dilated cardiomyopathy).
73. Diagnostic test for massive pericarditis is (ECHO).
74. Investigation of choice for constrictive pericarditis is (CT heart-pericardial
thickness >5mm).
75. Globular/ flask shaped heart/water bottled heart on CXR is seen in (massive
pericarditis).
76. Low voltage ECG is seen in (massive pericarditis).
77. Mc Callum’s patch is diagnostic of (rheumatic endocarditis).
78. ASLO titers are used in the diagnostic of ( acute rheumatic fever).
79. Autopsy finding after 12 hrs in a case of death due to MI is (coagulative
necrosis).
80. The first heart sound S1 is caused by closure of the mitral valve and tricuspid
valve.
81. S2 is due to aortic and pulmonary valve closure.
82. S3 often heart in left ventricular failure and constrictive pericarditis.

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 83. VSDs are more common than ASDs. However in adult pts ASDs are more
common as new diagnosis (they generally present later).
84. Wolff-Parkinson White syndrome (WPW) is caused by a congenital accessory
conducting pathway between the atria and ventricles leading to a
atrioventricular re-entry tachycardia (AVRT).
85. Cannon A Waves result from atrial contraction against a closed tricuspid valve
and therefore can be seen in VT when atrial and ventricular contraction is not
co-ordinated. These also be seen in complete 3rd degree heart block and atrial
flutter for the same reason.
86. Pacemaker is option when symptomatic haemodynamically unstable bradycardia
not responding to atropine.
87. Atrial flutter is a form of supraventricular tachycardia characterized by a
succession of rapid atrial depolarization waves. An ECG show sawtooth like
appearance.
88. In MI with history of hypothyroidism, what is marker of choice (troponin-I).
89. What is investigation for second MI after one week of previous MI (CK MB).
90. 7 day old MI the most sensitive biochemical marker is Troponin T.
91. Post MI day 10 which enzyme is raised (LDH).
92. In myocardial reperfusion injury the maximum effect is caused due to (free
redicals).
93. Hallmark feature of benign HTN is (hyaline arteriosclerosis).
94. Most common cause of abdominal aortic aneurysm is (Athrosclerosis).
95. The presence of stroke, peripheral vascular disease and athrosclerosis is
associated with (Insulin deficiency).
96. The enzyme of choice for diagnosing reinfarction in MI is CK MB.
97. The earliest enzyme to increase after MI is Myoglobin.
98. The most common cause of true aneurysm in aorta is atherosclerosis.
99. Disarrangement of myofibrils is found in Hypertrophic cardiomyopathy.
100. Most common cause of mitral stenosis is Rheumatic heart disease.
101. Calcification of aortic valve is seen in Syphilis.
102. Most common left sided cardiac failure is myocardial infarction.
103. Vegetations under surface of cusps are found in (Libman Sacks endocarditis).

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 104. Aschoff’s bodies are seen in acute rheumatic fever.
105. Chronic constrictive pericarditis is mostly caused by TB.
106. Most common cause of acute endocarditis (not damaged valve) is Staph. Aureus.
107. Most common cause of sub acute endocarditis (already damaged valve) is Strept
Viridans.
108. Most common cause of pprosthetic valve endocarditis is S.Epidermidis.
109. Most common cause of endocarditis in IV drug abusers is Staph. Aureus.
110. Most common heart valve involve in IV drug user endocarditis is tricuspid valve.
111. Endocarditis with colorectal carcinoma is caused by streptococcus Bovis.
112. Endocarditis in pts who have had recent tooth extraction is caused by
Staphylococcus mutans.
113. Most accurate diagnostic test for infective endocarditis is Blood culture.
114. In ECG transmural ischemia manifests as ST segment elevation.
115. The leading cause of death in diabetes mellitus is MI.
116. Histamine release lead to increased venous capacitance is the pathogenesis of
Anaphylactic shock.
117. Hypersensitivity seen in anaphylactic shock is Type -3 HSR.
118. Muffled heart sounds, elevated jugular venous pressure and a fall in the systolic
pressure known as Beck’s triad seen in Cardiac tamponade.
119. When Systolic Blood pressure declines >10 mmHg upon inspiration is Pulsus
Paradoxus.
120. Scar tissue formation in acute pericarditis can often lead to Constrictive
pericarditis.
121. Constrictive pericarditis presents with Kussmaul’s sign and a pericardial knock.
122. Cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) is often associated
with Wegener’s granulomatosis.
123. Metastasis to heart is mostly from the Breast.
124. Commonest complication of prosthetic valve is Embolism.
125. Sudden cardiac death is most commonly due to VF.
126. The plump macrophages called Anitschkow cells are pathognomonic for
Rheumatic fever.
127. Most commonly affected age group in rheumatic fever is 5-15 years.

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 128. Most commonly affected valve in rheumatic fever is Mitral valve.
129. Chaga’s disease is caused by T.cruzi, which is transmitted by the Reduviid bug.
130. A heart sound which is caused by vibration and turbulence as blood fills a
ventricle that already has excess fluid due to systolic dysfunction is S3 sound.
131. Connective tissue disorders such as Marfan’s syndrome, SLE,
mucopolysaccharidoses, hypothyroidism and Ehler’s-Danlos syndrome can
present with Mitral valve prolapsed (MVP).
132. Pulmonary regurgitation is usually due to Pulmonary artery hypertension.
133. Tricuspid stenosis is better heard at the lower sternum and increases with
inspiration.
134. The most common cardiac primary tumor in the adults is Cardiac Myxoma.
135. Arterial embolus is a thromboembolism usually arising from Mural thrombus.
136. Gas emboli are caused by the introduction of air into the blood circulation.
137. Amniotic fluid leaks into maternal circulation following of maternal fetal mixing,
most commonly after trauma or placenta abruption can lead to complication
such as (Amniotic fluid Emboli).
138. The shock which mimics an arteriovenous fistula a high flow state because all
arterioles are vasodilated, which leads to increased cardiac output is in Septic
shock.
139. Systolic ejection murmur that can radiate to the neck or shoulder and is loudest
in the second and third right intercostals space is seen in Pulmonic stenosis.
140. Patient with Wolf Parkinson White syndrome have higher risk of which type of
arrhythmia (Supra ventricular tachycardia).
141. On ECG there is no identifiable waves diagnosis is VF.
142. Six days after having myocardial infarction a pt presents with a new onset of
murmur, the murmur is called Holo systolic murmur of mitral regurgitation.
143. Drug which slow progression in renal parenchymal disease is ACEIs.
144. Triad of hypertension, hypokalemia and metabolic acidosis (increased
aldosterone, decreased rennin) is seen in Primary aldosteronism (Conn’s
syndrome).

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 145. Constriction of the aortic segment usually distal to the left subclavian artery
that leads to high BP in the upper extremities and low BP in lower extremities
and differential cyanosis is the features of Coarctation of the aorta (CoA).
146. Most frequent primary cardiac tumor in children is Rhabdomyosarcoma.
147. The most common primary cardiac tumar in adults is Myxoma.
148. Eosinophilia is seen in which vasculitis answer is Churg Strauss syndrome.
149. Pulseless disease is known as Takayasu arteritis.
150. Vasculitis is associated with heavy smokers is called Buerger’s disease
(Thromboangitis obliterans).
151. Drugs which decrease the effect of bad cholesterol are Statins.
152. Cardiac cirrhosis is caused by Right heart failure (RHF).
153. Tree bark appearance is seen in (Syphilitic heart disease).
154. Prinz metal angina shows ST elevation.
155. Artificial pacemaker is connected to which part of heart answer is Right
ventricle.
156. Principal source of energy to heart in healthy individual is (Free fatty acids).
157. Artery occluded in MI that damages the anterior interventricular septum and the
apex is LAD.
158. The crescendo-decrescendo systolic ejection murmur is seen in (AS).
159. Holosystolic blowing murmur is seen in Mitral regurgitation.
160. Continuous machine like murmur is seen in (Patent ductus arteriosus).
161. Triad of hypertension, bradycardia and respiratory depression is seen in
Cushing reflex.
162. Pulmonary vascular hypoxia cause (vasoconstriction).
163. Boot shaped heart seen on CXR in (TOF).
164. Preductal coarctation of aorta associated with (Turner syndrome).
165. Drug to close PDA is Indomethacin.
166. Hyperplasia onion skinning seen in Malignant hypertension.
167. Thoracic aortic aneurysm associated with (hypertension).
168. Autoimmune after MI is (Dressler syndrome).
169. Alcohol abuse, beriberi, cocaine use, chaga’s disease, doxorubicin and
hemochromatosis is the cause of (Dilated cardiomyopathy).

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 170. Heart valve affected in endocarditis to IV drug abusers is (tricuspid valve).
171. Infective endocarditis in colon cancer pts is due to (Strep bovis).
172. In rheumatic fever early death is caused by (Myocarditis).
173. T wave inversion may indicate (Ischemia or recent MI).
174. U wave in ECG is prominent in (Hypokalemia).
175. T tall wave in ECG is prominent in (Hyperkalemia).
176. Right to left shunt causes (early cyanosis).
177. Left to right shunt causes (Late cyanosis).
178. SA node commonly supplied by (RCA).
179. AV node commonly supplied by (PDA).
180. Contractility and stroke volume is decreased with Beta 1 blockade (dec. cAMP).
181. Venous vasodilators such as nitroglycerine are used to decrease (Preload).
182. Arterial vasodilator such as hydralazine is used to decrease (Afterload).
183. Treatment of Torsades de points is (Magnesium sulphate).
184. 18 years old male stabbed with a knife just to the right of the sternum between
the 4th and 5th rib, which cardiac structure is penetrated by the knife is (Right
atrium).
185. Acute myocardial infarctions of the inferior portion of the heart (RV) in such case
ECG findings are ST segment elevation in these leads (II, III, and aVF).
186. The node which receives input from both the sympathetic nervous system which
accelerating its rate of depolarization and parasympathetic nervous system via
vagus nerve which slowing its rate is (SA node).
187. AV nodal delay is shorten by (Sympathetic stimulation).
188. Body’s most important response to shock is by (Baroreceptors).
189. Heart block commonly seen in Lyme disease (3rd degree/complete).
190. Treatment of choice in 3rd degree heart block is (Permanent pacemaker).
191. Triad of hypertension, diaphoresis and tachycardia is seen in
(Pheochromocytoma).
192. Medial calcification of the medium sized arteries is called (Monckeberg) which
doesn’t obstruct arterial flow since the Intima is not involved.
193. Marker of inflammation as seen in unstable plaques is (C-reactive protein).
194. End diastolic volume in a normal healthy person is (50ml).

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 195. Most important cause of decreased voltage of the QRS complex is (Old MI).
196. Cannon wave is associated with (Complete heart block).
197. Pacemaker action potential occurs in (SA and AV nodes).
198. If ejection fraction is increased there will be (Decreased end systolic volume).
199. Cardiac output increases more during exercise and pregnancy.
200. Fixed splitting is seen in ASD.
201. Myxomatoys degeneration causes which valvular lesion (MVP).
202. Coronary artery occlusion most commonly seen in (LAD).
203. The most common valves which need replacing are the aortic and mitral valve.
204. There are two main options for valve replacement are two mechanical and
biological (Bioprosthetic). Note mechanical have more durability than biological
one.
205. Pulmonary arterial hypertension is defined as a sustained elevation in mean
pulmonary arterial pressure of greater than 25 mmHg at rest or 30 mmHg after
exercise.
206. One feature would indicate cardiac tamponade rather than constrictive
pericarditis is (No Y descent on JVP).
207. The ECG change most typically associated with hypomagnesaemia is QT
prolongation.
208. T wave inversion is more likely seen with coronary ischemia or left ventricular
hypertrophy.
209. QT shortening and peaked T waves are more typically seen with hypercalcaemia.
210. Dentistry in warfarinised patients - check INR 72 hours before procedure,
proceed if INR < 4.0.
211. Bendroflumethiazide - inhibits sodium reabsorption by blocking the Na+-Cl−
symporter at the beginning of the distal convoluted tubule.
212. The first-line management of SVT is vagal manoeuvres: e.g. Valsalva manoeuvre
or carotid sinus massage.
213. B-type natriuretic peptide is mainly secreted by the ventricular myocardium.
214. Statins inhibit HMG-CoA reductase, the rate-limiting enzyme in hepatic
cholesterol synthesis.

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 215. Patients with very poor dental hygiene - Viridans streptococci e.g. Streptococcus
sanguinis.
216. Primary percutaneous coronary intervention is the gold-standard treatment for
ST-elevation myocardial infarction.
217. Bosentan - endothelin-1 receptor antagonist.
218. Prostacyclins is used in the treatment of primary pulmonary hypertension.
219. JVP: giant v waves in tricuspid regurgitation.
220. Prosthetic heart valves - antithrombotic therapy:
221. bioprosthetic: aspirin
222. mechanical: warfarin + aspirin
223. Newly diagnosed patient with hypertension (> 55 years) - add a calcium channel
blocker.
224. 'Provoked' pulmonary embolisms are typically treated for 3 months.
225. Poorly controlled hypertension, already taking an ACE inhibitor and a calcium
channel blocker - add a thiazide diuretic.
226. Complete heart block following a MI? - right coronary artery lesion.
227. Endothelin receptor antagonists decrease pulmonary vascular resistance in
patients with primary pulmonary hypertension.
228. IV magnesium sulfate is used to treat torsades de pointes.
229. The two level Well's score can be used in patients presenting with signs and
symptoms suggestive of PE to guide the next investigation.
230. J-waves are associated with hypothermia.
231. HOCM is the most common cause of sudden cardiac death in the young.
232. Prosthetic valve endocarditis caused by staphylococci → Flucloxacillin +
rifampicin + low-dose gentamicin.
233. Prominent V waves on JVP → tricuspid regurgitation.
234. When treating angina, if there is a poor response to the first-line drug (e.g. a
beta-blocker), the dose should be titrated up before adding another drug.
235. Angiotensin-receptor blockers should be used where ACE inhibitors are not
tolerated.
236. Irregular cannon 'a' waves points towards complete heart block.
237. Warfarin - clotting factors affected mnemonic - 1972 (10, 9, 7, 2).

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 238. Infective endocarditis - indications for surgery:
239. severe valvular incompetence B) aortic abscess (often indicated by a lengthening
PR interval) C) infections resistant to antibiotics/fungal infections D) cardiac
failure refractory to standard medical treatment E) recurrent emboli after
antibiotic therapy
240. Gallop rhythm (S3) is an early sign of LVF.
241. Young man with AF, no TIA or risk factors, no treatment is now preferred to
aspirin.
242. Naftidrofuryl is a 5-HT2 receptor antagonist which can be used for peripheral
vascular disease.
243. Ischaemic changes in leads V1-V4 - left anterior descending.
244. Magnesium sulphate - monitor reflexes + respiratory rate.
245. Amiodarone has a very long half-life of 20-100 days - loading doses are therefore
often needed.
246. The CURB-65 score can be used for assessing the prognosis of a patient with
community acquired pneumonia.
247. Poorly controlled hypertension, already taking an ACE inhibitor, calcium
channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l - add an
alpha- or beta-blocker.
248. Prinzmetal angina - treatment = dihydropyridine calcium channel blocker.
249. Angiotensin II receptor blockers block the effects of angiotensin 2 at the AT1
receptor.
250. Women with pulmonary hypertension should avoid becoming pregnant due to
very high mortality levels.
251. Tachycardia with a rate of 150/min ?atrial flutter.
252. A single episode of paroxysmal atrial fibrillation, even if provoked, should still
prompt consideration of anticoagulation.
253. A prolonged PR interval - aortic root abscess.
254. Hypocalcemia is associated with QT interval prolongation; Hypercalcemia is
associated with QT interval shortening.
255. Infective endocarditis - streptococcal infection carries a good prognosis.
256. Ambrisentan - endothelin-1 receptor antagonist.

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 257. Nitrates should be avoided in the likely diagnosis of right ventricular myocardial
infarct due to causing reduced preload.
258. Restrictive cardiomyopathy: amyloid (most common), haemochromatosis,
Loffler's syndrome, sarcoidosis, scleroderma.
259. Erythromycin can cause a prolonged QT interval.
260. Statins + erythromycin/clarithromycin - an important and common interaction.
261. Infective endocarditis causing congestive cardiac failure is an indication for
emergency valve replacement surgery.
262. A beta-blocker or a calcium channel blocker is used first-line to prevent angina
attacks.
263. Furosemide - inhibits the Na-K-Cl cotransporter in the thick ascending limb of
the loop of Henle.
264. Poorly controlled hypertension, already taking an ACE inhibitor and a thiazide
diuretic - add a calcium channel blocker.
265. For patients of Afro-Caribbean origin taking a calcium channel blocker for
hypertension, if they require a second agent consider an angiotensin receptor
blocker in preference to an ACE inhibitor.
266. Pulmonary embolism - CTPA is first-line investigation.
267. JVP: y descent = opening of tricuspid valve.
268. Eisenmenger's syndrome - the reversal of a left-to-right shunt.
269. People with cardiac syndrome X have normal coronary angiograms despite ECG
changes on exercise stress testing.
270. Patients with recurrent venous thromboembolic disease may be considered for
an inferior vena cava filter.
271. AV block can occur following an inferior MI.
272. Aortic stenosis - S4 is a marker of severity.
273. Labetalol is first-line for pregnancy-induced hypertension.
274. Paradoxical embolus - PFO most common cause - do TOE.
275. Aortic stenosis - most common cause:
276. younger patients < 65 years: bicuspid aortic valve
277. older patients > 65 years: calcification
278. BNP - actions:

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 B) Vasodilator
A) Diuretic and natriuretic
279. suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
280. Sudden death, unusual collapse in young person - ? HOCM.
281. If high-risk of failure of cardioversion (previous failure), offer electrical
cardioversion after at least 4 weeks treatment with amiodarone.
282. Hydralazine - increases cGMP leading to smooth muscle relaxation.
283. Poorly controlled hypertension, already taking an ACE inhibitor, calcium
channel blocker and a thiazide diuretic. K+ < 4.5mmol/l - add spironolactone.
284. Risk of falls alone is not sufficient reasoning to withhold anticoagulation.
285. DVLA advice post MI - cannot drive for 4 weeks.
286. Aortic dissection
Type A - ascending aorta - control BP(IV labetalol) + surgery
Type B - descending aorta - control BP(IV labetalol)
287. Aminophylline reduces the effect of adenosine.
288. Amiodarone - MOA: blocks potassium channels.
289. Nicorandil is a potassium channel activator.
290. Right axis deviation - left posterior hemiblock.
291. Complete heart block causes a variable intensity of S1.
292. Pulmonary arterial hypertension patients with negative response to vasodilator
testing should be treated with prostacyclin analogues, endothelin receptor
antagonists or phosphodiesterase inhibitors. Often combination therapy is
required.
293. A potassium above 6mmol/L should prompt cessation of ACE inhibitors in a
patient with CKD (once other agents that promote hyperkalemia have been
stopped).
294. Hypokalaemia - U waves on ECG.
295. QT interval: Time between the start of the Q wave and the end of the T wave.
296. Rate-limiting CCBs should be avoided in patients with AF with heart failure with
reduced EF (HFrEF) due to their negative inotropic effects.
297. Dipyridamole is a non-specific phosphodiesterase inhibitor and decreases
cellular uptake of adenosine.

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 298. The main ECG abnormality seen with hypercalcaemia is shortening of the QT
interval.
299. Beta-blockers e.g. bisoprolol should not be used with verapamil due to the risk
of bradycardia, heart block, congestive heart failure.
300. HOCM - poor prognostic factor on echo = septal wall thickness of > 3cm.
301. Second heart sound (S2)
Loud: hypertension
Soft: AS
302. fixed split: ASD
303. reversed split: LBBB
304. Arrhythmogenic right ventricular cardiomyopathy is characterised by right
ventricular myocardium replaced by fatty and fibrofatty tissue.
305. ALS - give adrenaline in non-shockable rhythm as soon as possible.
306. Nicotinic acid increases HDL levels.
307. Pulmonary embolism - normal CXR.
308. Patients with stable CVD who have AF are generally managed on an
anticoagulant and the antiplatelets stopped.
309. In management of STEMI if primary PCI cannot be delivered within 120 minutes
then thrombolysis should be given.
310. Pulmonary hypertension is a cause of a loud S2 (due to a loud P2).
311. HOCM is usually due to a mutation in the gene encoding β-myosin heavy chain
protein or myosin binding protein C.
312. Ticagrelor has a similar mechanism of action to clopidogrel - inhibits ADP
binding to platelet receptors.
313. Atrial myxoma - commonest site = left atrium.
314. Patients with a suspected pulmonary embolism should be initially managed with
low-molecular weight heparin.
315. Patients with VT should not be prescribed verapamil.
316. Offer a mineralcorticoid receptor antagonist, in addition to an ACE inhibitor (or
ARB) and beta- blocker, to people who have heart failure with reduced ejection
fraction if they continue to have symptoms of heart failure.

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 317. Contrast-enhanced CT coronary angiogram is the first line investigation for
stable chest pain of suspected coronary artery disease aetiology.
318. ACE inhibitors can cause first dose hypotension.
319. Aortic regurgitation - early diastolic murmur, high-pitched and 'blowing' in
character.
320. Patients with SVT who are haemodynamically stable and who do not respond to
vagal manoeuvres, the next step is treating with adenosine.
321. Methadone is a common cause of QT prolongation.
322. Eclampsia - give magnesium sulphate first-line.
323. Symptomatic bradycardia is treated with atropine.
324. Severe pre-eclampsia - restrict fluids.
325. Atrioventricular dissociation suggests VT rather than SVT with aberrant
conduction.
326. Bisferiens pulse - mixed aortic valve disease.
327. Patients on warfarin undergoing emergency surgery - give four-factor
prothrombin complex concentrate.
328. Sotalol is known to cause long QT syndrome.
329. Aschoff bodies are granulomatous nodules found in rheumatic heart fever.
330. Streptococcus bovis endocarditis is associated with colorectal cancer.
331. Most common cause of endocarditis are:
A) Staphylococcus aureus
B) Staphylococcus epidermidis if < 2 months post valve surgery
332. Left parasternal heave is a feature of tricuspid regurgitation.
333. Adenosine main functions:
A) Dipyridamole enhances effect
B) Aminophylline reduces effect
334. S4 coincides with the P wave on ECG.
335. Inherited long QT syndrome, sensorineural deafness - Jervell and Lange-Nielsen
syndrome.
336. Left axis deviation - Wolff-Parkinson-White syndrome (right-sided accessory
pathway).
337. Hypertension in diabetics - ACE-inhibitors are first-line regardless of age.

32 | P a g e
 338. Clopidogrel inhibits ADP binding to platelet receptors.
339. New onset AF is considered for electrical cardioversion if it presents within 48
hours of presentation.
340. JVP: C wave - closure of the tricuspid valve.
341. Takotsubo cardiomyopathy is a differential for ST-elevation in someone with no
obstructive coronary artery disease.
342. Atrial fibrillation: rate control - beta blockers preferable to digoxin.
343. DVLA advice following angioplasty - cannot drive for 1 week.
344. ACE inhibitors have reduced efficacy in black patients and are therefore not
used first-line.
345. If angina is not controlled with a beta-blocker, a calcium channel blocker should
be added.
346. PCI - patients with drug-eluting stents require a longer duration of clopidogrel
therapy.
347. Pulsus alternans - seen in left ventricular failure.
348. Massive PE + hypotension – thrombolyse.
349. Major bleeding - stop warfarin, give intravenous vitamin K 5mg, prothrombin
complex concentrate.
350. Third heart sound - constrictive pericarditis.
351. Poorly controlled hypertension, already taking an ACE inhibitor - add a calcium
channel blocker or a thiazide-like diuretic.
352. Aortic stenosis management: AVR if symptomatic, otherwise cut-off is gradient of
40 mmHg.
353. Prosthetic heart valves - mechanical valves last longer and tend to be given to
younger patients.
354. Complete heart block following an inferior MI is NOT an indication for pacing,
unlike with an anterior MI.
355. An undersized blood pressure cuff may lead to an overestimation of blood
pressure.
356. Pulmonary arterial hypertension patients with positive response to vasodilator
testing should be treated with calcium channel blockers.
357. Inferior MI - right coronary artery lesion.

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 358. Pulmonary embolism and renal impairment → V/Q scan is the investigation of
choice.
359. Aortic dissection:
A) Type A - ascending B) Aorta - control BP(IV labetalol) + surgery
360. type B - descending aorta - control BP(IV labetalol)
361. Atrial fibrillation - cardioversion: amiodarone + flecainide.
362. Takayasu's arteritis is an obliterative arteritis affecting the aorta.
363. ICD means loss of HGV licence, regardless of the circumstances.
364. Staphylococci is the leading organism contributing to mortality in infective
endocarditis.
365. Dabigatran is a direct thrombin inhibitor.
366. Infective endocarditis - strongest risk factor is previous episode of infective
endocarditis.
367. Palpitations should first be investigated with a Holter monitor after initial
bloods/ECG.
368. Tricuspid valve endocarditis can cause tricuspid regurgitation, which may
manifest with a new pan-systolic murmur, large V waves and features of
pulmonary emboli.
369. Acute vasodilator testing should be used in patients with pulmonary artery
hypertension to determine which patient show a significant fall in pulmonary
arterial pressure following vasodilators and help guide treatment.
370. Asymmetric septal hypertrophy and systolic anterior movement (SAM) of the
anterior leaflet of mitral valve on echocardiogram or cMR support HOCM.
371. The recommended dose of adrenaline to give during advanced ALS is 1mg.
372. Bendroflumethiazides can worsen glucose tolerance.
373. Long QT syndrome - usually due to loss-of-function/blockage of K+ channels.
374. PCI: stent thrombosis - withdrawal of antiplatelets is a biggest risk factor.
375. Poorly controlled hypertension, already taking a calcium channel blocker - add
an ACE inhibitor or an angiotensin receptor blocker.
376. Antibiotic prohylaxis to prevent infective endocarditis is not routinely
recommended in the UK for dental and other procedures.
377. ACE-inhibitors should be avoided in patients with HOCM.

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 378. Renal dysfunction (eGFR <60) can cause a raised serum natriuretic peptides.
379. Blood pressure target (< 80 years, clinic reading) - 140/90 mmHg.
380. A stable patient presenting in AF with an obvious precipitating cause may revert
to sinus rhythm without specific antiarrhythmic treatment.
381. Witnessed cardiac arrest while on a monitor - up to three successive shocks
before CPR.
382. Ventricular tachycardia - verapamil is contraindicated.
383. Thiazide diuretics can cause hyponatraemia, metabolic alkalosis, hypokalaemia
and hypocalciuria.
384. Percutaneous mitral commissurotomy is the intervention of choice for severe
mitral stenosis.
385. Ivabradine use may be associated with visual disturbances including
phosphenes and green luminescence.
386. Myoglobin rises first following a myocardial infarction Ischaemic changes in
leads I, aVL +/- V5-6 - left circumflex.
387. JVP: x descent = fall in atrial pressure during ventricular systole.
388. Hypertension - NICE now recommend ambulatory blood pressure monitoring to
aid diagnosis.
389. Pulmonary arterial hypertension most commonly presents with exertional
dyspnoea. Patients may also experience exertional chest pain, syncope and
peripheral oedema.
390. Mechanical valves - target INR:
A) Aortic: 3.0
B) Mitral: 3.5
391. 'Unprovoked' pulmonary embolisms are typically treated for 6 months.
392. INR > 8.0 (no bleeding) - stop warfarin, give oral vitamin K 1-5mg, repeat dose of
vitamin K if INR high after 24 hours, restart when INR < 5.0.
393. VF/pulseless VT should be treated with 1 shock as soon as identified.

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 CHAPTER-02

RESPIRATORY DISEASES

36 | P a g e
 Pneumonia

Most likely scenario: An older pt came to ER with complain of persistence cough

with smoking history he now develops left sided chest pain, exacerbated by deep
breathing with fever and localized crackles.

Note: chest pain exacerbated with deep breathing, fever, smoking history and
localized crackles is highly picture of pneumonia.

Diagnostic investigation: CXR which shows middle lobe infiltrate or interstitial

infiltrates which leaves the air space empty. Sputum gram stain and culture of
sputum are best to determine micro-organisms.

Treatment: Initially start with Macrolides or doxycycline. If pt was previously on

antibiotic therapy or pt is admitted in hospital with comorbidities then Fluor
quinolones are the therapy of the choice.

Community Acquired Pneumonia

Most likely scenario: The first thing to understand is that pt. would catch CAP
from outside the hospital and came to ER with complaint of chest discomfort
with fever or hypothermia, cough dry or with sputum (purulent sputum),
tachypnea and inspiratory crackles on auscultation. Pt complains night sweats
or rigors or both.

Note: Pts usually are older in age, tobacco users, alcoholism, and
immunosuppressed and commonly with history of COPD and asthma.

Diagnostic investigation: Pt commonly admitted to hospital and advised

diagnostic tests which may guide for initial (antibiotic therapy) as like blood
culture, sputum gram stain, and urinary antigen test for S. Pneumonia and
Legionella species and Influenza antigens. CT scan is more sensitive and
diagnostic in CAP.

Treatment: Since S. pneumonia is most common cause of CAP and drug resistant
significantly affects the antibiotic choice. Most commonly used drugs are (Beta
lactams, macrolides and fluroquinolones).

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 Hospital Acquired Pneumonia (HAP)

Most likely scenario: Any pt that can presents all symptoms of Pneumonia which
develops, almost 48 hours after admission in hospital is called (HAP).

Or

Pt develops symptoms of pneumonia more than 48 hours who is on

endotracheal intubation or on mechanical ventilation is called Ventilator
associated pneumonia (VAP).

Diagnostic investigations: Same as of CAP.

Treatment: Using same method to determine sensitivity of pathogen and treat

that specific pathogen as discussed in CAP.

Pulmonary tuberculosis

Most likely scenario: Pt came to ER with complaining of continuous fever,

fatigue, weight loss, night sweats and have productive cough with blood
streaked sputum. Pt is malnourished and has few months travelling history to
Nigeria.

Diagnostic investigation: CXR shows apical pulmonary opacities. And sputum

culture positive for M. tuberculosis.

Treatment: Most common antibiotic therapy is (Isoniazid, rifampin, pyrazinamide

and ethambutol).

Pulmonary Hypertension

Most likely scenario: Pt came to ER with history of sudden fall on exertion with
complain of dyspnea, chest pain, non-productive cough and fatigue. O/E:
Findings were include jugular venous distention, pulmonary valve component of
S2 heart sound and right sided S3 heart sound, lower extremity edema,
hepatomegaly and tricuspid regurgitation, murmur was present.

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 Diagnostic investigation: Doppler Echocardiography is gold standard which
shows right ventricular strain with hypertrophy and right atrial enlargement and
elevated right ventricular systolic pressure.

Treatment: Endothelin receptors antagonists if not controlled or contraindicated

then CCB.

Asthma

Most likely scenario: Suppose a young pt attends the OPD with complain of
breathlessness on and off with cough and sputum. His sleep is disturbed and
skin is very dry in flexural areas. O/E: Pt presents tachypnea, hyper resonant
percussion and (wheezing on auscultation) this is typical scenario of asthma.

Note: Airways hyper-responsiveness to certain stimuli, recurrent variable airflow

limitation usually reversible, wheezing, breathlessness, chest tightness and
cough is typical picture of asthma. Or airway reversibility and presence of atopy
(Eczema) past history of TB and fever is also favors the diagnosis of Asthma.

Diagnostic investigation: Spirometry showing reversible airway obstruction.

Treatment: Pt’s education is must to avoid the environmental cause. If not

controlled we start from short acting beta2 agonists or long acting beta2
agonists with inhaled corticosteroids.

COPD

Most likely clinical scenario: An old age male heavy smoker came to OPD with
complain of chronic productive cough, SOB, and wheeze. Labs show PCV
increased in CBC, CXR 6th rib seen above the diaphragm in midclavicular line,
ABGs pO2 decreased.

Note: As we see in this case pt is older chronic smoker, chronic productive

cough, SOB and wheeze with raised PCV, low set diaphragm and widened
horizontal ribs and hypoxia on ABGs. This is typical case of COPD.

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 Diagnostic investigation: Most accurate test is PFT in PFT we must focus on
decreased FEV1, decreased FVC with ratio under 70%. CXR shows increased AP
diameter and flattened diaphragm.

Treatment: Oxygen therapy is must to increased saturation, short acting beta

agonists such as Albuterol, and long acting beta agonists such as salmeterol,
steroids and smoking cessation.

Pneumothorax

Most likely scenario: In pneumothorax pt should come in ER with SOB, chest

pain with smoking history, diminished breath sounds, mediastinal shift, in
tension pneumothorax pt would present with hypotension and cyanosis along
with other symptoms.

Diagnostic investigation: CXR which shows the presence of pleural air (Black
spots).

Treatment: In spontaneous pneumothorax there are many small

pneumothoraxes, which may resolve spontaneously when air absorbed from the
pleural spaces but in latrogenic and tension pneumothorax there is a need of
aspiration drainage of pleural air with angiocatheter through small or large bore.
In severe symptoms chest tube placement is must this procedure is called (tube
thoracostomy).

Sarcoidosis

Most likely scenario: Pt presence with progressive breathlessness with history of

polyarthralgia and painful lesions on the shin. Chest X ray shows bilateral hilar
lymphadenopathy.

Note: Sarcoidosis is a granulomatous inflammatory disease that affects multiple

organs in the body but mostly the lungs, skin and lymph glands. Given case is
termed as Lofgren’s syndrome which is an acute form of sarcoidosis
characterized by erythema nodosum, lupus pernio, bilateral hilar
lymphadenopathy and poluarthritis.

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 Diagnostic investigation: The chest radiographs show atypical of interstitial lung
disease in that crackles are uncommon on auscultation. Other findings may
include parotid gland enlargement, hepato-splenomegaly, lymphadenopathy and
noncaseating granulomas in biopsies.

Treatment: Corticosteroids and immune-suppressive medications such as

methotrexate, azathioprine or infliximab are used.

Bronchiectasis

Most likely scenario: 45 years old pt with history of COPD with complains of
persistent cough, SOB and copious amount of purulent sputum. He has measles
in past. O/E: Finger clubbing are found and inspiratory crepitations on
auscultation.

Note: Persistent cough, SOB with copious purulent sputum and finger clubbing
are main features of bronchiectasis. And severe lung infections, whooping
cough, pneumonia or measles could damage the airways in result bronchiectasis
may develop. Other most relatively causes are organ transplantation, connective
tissue diseases, inhalation injuries as well as post infectious and drug induced.

OR: In some cases pt represents increase volume of sputum with specks of blood
and clubbing with history of DVT. These points are also indicated towards
Bronchiectasis.

Diagnostic investigation: Spirometry and CXR.

Treatment: Corticosteroids

Interstitial Lung Disease

Most likely scenario: Pt came to ER with complaining of dyspnea, tachypnea,

small lung volume with crackles, clubbing and non productive cough.

Note: Sarcoidosis is also associated with crackles and clubbing.

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 Diagnostic investigation: CXR shows decreased lung volume and patchy
distribution of reticular, nodular and cystic opacities. CT is considered as most
diagnostic.

Treatment: Treatment is based on present cause and types of infections.

Bronchiolitis

Most likely scenario: Pt came to ER with complain of sudden onset of cough and
dyspnea with recent history of bone marrow transplantation.

Note: Bronchiolitis is most associated sudden onset of cough and SOB after
heart, lung or bone marrow transplantation or toxic fumes connective tissue
disease and any viral infections damages lungs.

Diagnostic investigations: CXR

Treatment: Corticosteroids

Cystic Fibrosis

Most likely clinical scenario: A young lady came to ER with complain of cough
with sputum. She cannot exercise and she has recurrent hemoptysis, infertility
and diarrhea. She has history of chronic lung disease and malnourished.

Note: Cystic fibrosis is commonly occurs in young people.

Diagnostic investigation: (Quantitative pilocarpine iontophoresis - sweat test) in

which sweat chloride concentration is greater than 60 mEg/L, on repetitive two
occasions.

Treatment: CFTR modulator, Genetic therapy. And antibiotics of present cause.

Pleural Effusion

Most likely scenario: A male mature Pt came to ER with SOB, cough and chest
pain with history of RTA few weeks ago and was suffering from cardiopulmonary
disease since then. There were decreased breath sounds on auscultation.

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 Diagnostic investigation: CXR shows PE. Note: Appearance of pleural fluid helps
to identify the types of PE such as Grossy purulent fluid appearance in
(empyema). Persistent turbid supernatant suggests a (chylous effusion). Where
as a mixture of blood and pleural fluid is (hemorrhagic pleural effusion). If blood
is in pleural space following chest pain due to trauma is called (hemothorax).

Treatment: Asymptomatic pts with PE there is no need of specific treatment but

in symptomatic malignant all kinds of PEs pt should have thoracotomy
drainage.

Obstructive Sleep Apnea

Most likely scenario: A middle aged young man came to OPD with complain of
fatigue and sleepiness at day time (Somnolence). He is also complaining of
morning headaches and recently weight gained and his partner describes his
loud snoring at night and thrashing movements during sleep. O/E: Oropharynx
is found to be narrowed and pt appears sleepy.

Diagnostic investigation: Polysomnography describes apneic episodes and

hypoxemia. Hypothyroidism and erythrocytosis is commonly found in labs.

Treatment: Life style modifications such as weight loss prevent alcohol use and
nasal CPAP can help. Other common procedures are (UPPP) and nasal
septoplasty.

Acute Respiratory Distress (ARDS)

Most likely scenario: We must understand the typical criteria to easily diagnose
ARDS which is based on four features 1. Acute onset. 2. pO2/FiO2 < 200
mmHg 3. Bilateral infiltrates on chest X-ray. 4. Non cardiogenic. ARDMS
commonly occurs within one week of known clinical manifestations with
worsening respiratory symptoms. This shows bilateral opacities to be evident on
CXR or on CT, which is not attributable to effusions, lobar collapse or
pulmonary nodules.

43 | P a g e
 Note: ARDS exists where respiratory failure cannot be fully explained by cardiac
failure or fluid over load. The ultrasound can further exclude hydrostatic edema
if there are no risk factors are present.

Diagnostic investigation: CXR which shows bilateral infiltrates and air Broncho
grams are common.

Treatment: No treatment is proven to reserve in ARDS so treat the underlying

cause. Low tidal volume ventilation is best initial support with 6 ml per kg of
tidal volume is recommended. PEEP is used to decrease FIO2 levels under 50%;
Because FIO2 above the 50% is toxic to the lungs.

 MCQS Solving Rapid Fire (Direct targeted bullets)

1. Pneumothorax occurs when air leaks into the space between parietal and
visceral pleura.

2. Sarcoidosis is a granulomatous inflammatory disease that affects multiple

organs, mostly lungs, skin and lymph nodes.

3. Most diagnostic criteria of asthma are (airway hyper responsiveness to certain

stimuli), (recurrent airflow reversible) and (wheezing, chest tightness, cough and
breathlessness).

4. Pneumonia is most common complication of flail chest.

5. Older age, chronic smoker, productive cough, SOB, wheeze, raised PCV
secondary to chronic hypoxia, low set diaphragm and widened ribs are most
common features of COPD.

6. Lofgren’s syndrome is triad of (erythema nodosum), (bilateral hilar

lymphadenopathy) and (arthalgia).

7. Most common features of mycoplasma pneumonia are myalgia, joint pain,

headache, bilateral patchy consolidations on CXR.
44 | P a g e
 8. Pulmonary hemorrhage causes rise in carbon monoxide transfer factor
(TLCO).

9. TLCO describes the rate of gas diffuses from alveoli into the blood.

10. Saccharopolyspora rectivirgula is responsible for Farmer’s lung.

11. Vocal cord paralysis is considered contraindication to surgical resection in

lung cancer.

12. Klabsiella pneumonia is classically presents in alcoholics.

13. Community pneumonia caused by streptococcus pneumoniae (80%).

14. Flow volume loops are the most suitable way of assessing the compression of
the upper air way.

15. Allergic bronchopulmonary aspergillosis results from an allergy to

aspergillus spores. In exam questions often present history of bronchiectasis
and eosinophilia.

16. Loeffler syndrome is associated with tropical infections as evidence and

likely with travel history.

17. DRESS syndrome is associated with eosinophilia and causes rash and fever.

18. If asthmic pt is currently on medication salbutamol inhaler 100mcg pm

combined with beclometasone dipropionate inhaler 400mcg BD, despite all this
pt is having frequent exacerbations of asthma and required a course of
prednisolone. What is most important next step in such pt’s management?
Answer is adding salmeterol.

19. Silicosis is a fibrosing lung disease which shows (Egg shell calcification of
hilar lymph nodes) which caused by inhalation of silicon dioxide the silica. Most
commonly affects workers of mining, potteries, foundries, slate workers etc. It’s
major risk factor of TB.

45 | P a g e
 20. Lung Fibrosis affects the upper zones of lung are extrinsic allergic alveolitis
which is also known as hyper sensitivity pmeumonitis, coal workers
pneumoconiosis, silicosis, sarcoidosis, tuberculosis and histiocytosis.

21. Lung fibrosis effects the lower zones includes, idiopathic pulmonary fibrosis,
asbestosis, drug induced such as amiodarone, methotrexate and bleomycin and
connective tissue disorders except ankylosing spondylitis.

22. Initially after acute PE is diagnosed management should be LMWH or

fondaparinux.

23. In massive PE where thrombolysis is being considered in such situation

unfractionated heparin should be given initially.

24. In PE the gold standard imaging test now is CPTA not V/Q scan but if
patient is with renal impairment however V/Q scans should be offered.

25. Alpha 1 antitrypsin (A1AT) deficiency is caused by lack of a protease

inhibitor (Pi) produced by the liver. (A1AT) protect cells from enzymes such as
neutrophil elastase.

26. In COPD pt what should be targeted oxygen saturations be until ABGs are
available? Answer is 88-92%.

27. In primary pneumothorax if rim air is < 2cm without SOB then considers the
discharge of pt. otherwise aspirate the pt.

28. In secondary pneumothorax if rim air is > 2cm and pt is feeling SOB then
chest drain should be inserted.

29. Latrogenic pneumothorax is less likely recurrence than spontaneous

pneumothorax.

30. Mycoplasmic pneumonia is a cause of atypical which mostly affects the

young patients.

31. Squamous cell cancer is type of lung cancer which is most commonly
associated with cavitating lesions.

46 | P a g e
 32. In RA with SOB if spirometry shows FEV1/FVC 45% in such case the cause
of SOB is (bronchiolitis obliterans) because obstructive picture of spiromatry
reveals bronchiolitis obliterans here.

33. Emergency treatment of allergic bronchopulmonary aspergillosis is oral

glucocorticoids such as prednisolone.

34. If pt came to ER with symptoms of redness and swelling on his forearms and
making harsh breathing sounds and highly irritated what will be urgent
management. This is anaphylaxis or severe allergic reaction so answer is
(adrenaline).

35. IF patient comes to OPD with SOB and emphysema, the pt is mentally fit
and aware to take medication on time but cannot manage. What is next best
option for this pt answer is discuss how to reverse this condition and how to set
proper goals to prevent further complications.

36. Most likely common features of pneumothorax are: (SOB), (pleuritic chest
pain), (hypotension), (tachycardia), (Saturation around 90%), (decreased breath
sounds on right side & wheezing on left side).

37. Asymptomatic TB pt the choice of investigation is Mantoux test (MT).

38. If patient presents noisy breathing with runny nose O/E: Suprasternal
indrawing and respiratory stridor these are common features of
(laryngotracheobronchitis).

39. Strep pneumoniae commonly causes reactivation of (herpes simplex virus)

with cold sores.

40. Pt with pregnancy has complaint of pleuritic chest pain with SOB and
continuous mild pain in her left calf for few days O/E signs were left calf deep
vein thrombosis (DVT) in such pts which is most appropriate investigation?
Answer is (compression duplex Doppler). Note DVT may provide indirect
evidence of PE.

47 | P a g e
 41. Pleural fluid with pH <7.2 in pts with suspected pleural infection indicates a
need for chest tube drainage.

42. Lambert Eaton syndrome occurs in small cell lung cancer and very least
commonly seen in squamous cell lung cancer.

43. In COPD the most useful marker to know the progression is FEV1.

44. Kartagener’s syndrome which is also known as (ciliary dyskinesia) most

frequently occurs in exams due to its association with (Dextrocardia) for example
small volume, complexes in lateral leads and quiet heart sounds.

45. Asthma diagnosis: >20% decrease in FEV1 with use of methacholine.

46. Treatment of asthma start with (SABA) short acting beta agonist with ICS. If
not controlled use (LABA) long acting beta agonist. Note: Oral corticosteroids are
added when all other therapies are not sufficient.

47. The severity of asthma exacerbation is diagnosed when there is decreased

(PEF) peak expiratory flow and ABG with increased A-a gradient.

48. All asthma pts should be given pneumococcal and flu vaccines.

49. Smoking and SOB worsened by expiration is present almost all COPD pts.

50. In COPD the best initial test is CXR.

51. Bronchiectasis is a chronic dilation of the large bronchi which is permanent

abnormality and cannot be cured.

52. The most accurate test for cystic fibrosis is an increased sweat chloride test.

53. All types of pneumonias have fever and cough.

54. Empyema and pleural effusion if infected has rapid response to the drainage
by thoracostomy and chest tube.

55. In Ventilator associated pneumonia the most accurate test is open lung
biopsy.

48 | P a g e
 56. Aspiration pneumonia occurs in upper lobe of lung when lying flat.

57. Chronic infection with large volume of sputum which (foul smells) caused by
anaerobes and weight loss are common features of lung abscess.

58. Pneumocystis pneumonia most commonly presents in pts with AIDS whose
CD4 count has dropped below 200/ul and causing agent is P. jiroveci which is
new name of P. carinii.

59. Pleural biopsy is now the most accurate diagnostic test of TB.

60. Sputum stain/culture for acid fast bacilli (mycobacteria) should be repeated
3 times to exclude tuberculosis.

61. Biopsy is must in all lung diseases where there is enlarging lesions on lungs
which are keep growing.

62. Most initial test for all lung diseases is CXR.

63. Dyspnea which worsening on exertion, loud P2 (heart sound), clubbing on

fingers and rales are features of Interstitial lung disease.

64. Pulmonary fibrosis is irreversible (incurable).

65. Inflammatory infiltration with white cells is reversible (curable).

66. Sarcoidosis is most commonly present in African origin women (key for mcq).

67. Hilar adenopathy in CXR is present in more than 95% pts with Sarcidosis.

68. PE and DVT are treated as spectrum of same disease.

69. CT angiogram is diagnostic test for PE but V/Q in pregnancy and D-dimer
when option is only for non invasive test to exclude thromboembolic disease.

70. When there is obstruction blood flow in right side of the heart and in result
pulmonary pressure rises from systolic >25 mmHg and diastolic >8 mmHg is
called pulmonary hypertension.

49 | P a g e
 71. Most common features of obstructive sleep apnea are day time drowsiness
(Somnolence) and loud snoring at night.

72. Sleep apnea is obesity and hypoventilation syndrome.

73. Most accurate test for sleep apnea is (polysomnography) which is a sleep
study.

74. The ratio below 300 in pO2/FIO2 is defined as ARDS.

75. Bronchiectasis: most common organism = Haemophilus influenza.Light's

criteria: Effusion LDH level greater than 2/3rds the upper limit of serum LDH
points to exudates.

76. COPD - still breathless despite using SABA/SAMA and asthma/steroid

responsive features → add a LABA + ICS.

77. Features of Transfer factor:

A) Raised: asthma, haemorrhage, left-to-right shunts, polycythaemia

B) Low: everything else

78. Asbestosis causes pulmonary fibrosis predominantly affecting the lower

zones.

79. Sarcoidosis CXR shows:

1 = BHL 2 = BHL + infiltrates 3 = infiltrates 4 = fibrosis

80. Adults with suspected asthma should have both a FeNO test and spirometry
with reversibility.

81. Adult with asthma not controlled by a SABA - add a low-dose ICS.

82. Unmasking of Churg-Strauss syndrome: Montelukast.

83. Leukotriene receptor antagonists may trigger eosinophilic granulomatosis

with polyangiitis (Churg-Strauss syndrome).

50 | P a g e
 84. Over rapid aspiration/drainage of pneumothorax can result in re-expansion
pulmonary edema.

85. Saccharopolyspora rectivirgula causes farmer's lung, a type of EAA.

86. PTHrP is a paraneoplastic syndrome associated with squamous cell lung

cancer.

87. Aspergillus clavatus causes malt workers' lung, a type of EAA.

88. Symptom control in non-CF bronchiectasis - inspiratory muscle training +

postural drainage.

89. COPD - LTOT if 2 measurements of pO2 < 7.3 kPa.

90. Alpha-1 antitrypsin deficiency - autosomal recessive / co-dominant.

91. Isocyanates are the most common cause of occupational asthma.

92. In around 10% of patients subsequently diagnosed with lung cancer the
chest x-ray was reported as normal.

93. Confusion in an asthma attack is a life-threatening feature.

94. Bupropion: contraindicated in epilepsy.

95. Upper zones lung fibrosis: hypersensitivity pneumonitis.

96. Calcification in lung metastases is uncommon except in the case of

chondrosarcoma or osteosarcoma.

97. COPD is the most common cause of secondary pneumothorax.

98. Management of high altitude cerebral edema (HACE) is with descent +

dexamethasone.

99. Small cell lung carcinoma secreting ACTH can cause Cushing's syndrome.

100. Contact with camels (including camel products such as milk) is a

significant risk factor for MERS-CoV.

51 | P a g e
 101. Flow volume loop is the investigation of choice for upper airway
compression.

102. Lung volume reduction surgery can be used in the treatment of alpha-1
antitrypsin deficiency.

103. COPD - reason for using inhaled corticosteroids - reduced exacerbations.

104. Chlamydia psittaci is a cause of pneumonia in bird keepers.

105. A normal pCO2 in a patient with acute severe asthma is an indicator that
the attack may classified be life-threatening.

106. Serial peak flow measurements at work and at home are used to detect
occupational asthma:

107. Asthmatic features/features suggesting steroid responsiveness in COPD:

A) previous diagnosis of asthma or atopy

B) a higher blood eosinophil count

C) substantial variation in FEV1 over time (at least 400 ml)

D) Substantial diurnal variation in peak expiratory flow (at least 20%)

108. Pulmonary arterial hypertension is defined as an elevated pulmonary

arterial pressure of greater than 25mmHg at rest or 30mmHg after exercise.

109. Erythema nodosum is associated with a good prognosis in sarcoidosis.

110. Polysomnography is diagnostic for obstructive sleep apnoea.

111. Recurrent chest infections + subfertility - think primary ciliary dyskinesia

syndrome (Kartagener's syndrome).

112. Churg-Strauss syndrome - positive pANCA serology.

113. Contraindications to lung cancer surgery include SVC obstruction, FEV <
1.5, MALIGNANT pleural effusion, and vocal cord paralysis.

52 | P a g e
 114. Paraneoplastic features of lung cancer are:

A) Squamous cell: PTHrp, clubbing, HPOA

B) Small cell: ADH, ACTH, Lambert-Eaton syndrome

115. COPD - still breathless despite using SABA/SAMA and no asthma/steroid

responsive features → add a LABA + LAMA.

116. The triangle of safety for chest drain insertion involves the base of the
axilla, lateral edge pectoralis major, 5th intercostal space and the anterior
border of latissimus dorsi.

117. Sleep apnoea causes include obesity and macroglossia.

118. Vital capacity - maximum volume of air that can be expired after a maximal
inspiration.

119. The majority of patients with sarcoidosis get better without treatment.

120. Lower zones lung fibrosis: amiodarone.

121. Following NICE 2017, patients with asthma who are not controlled with a
SABA + ICS should first have a LTRA added, not a LABA.

122. Vital capacity - 4,500ml in males, 3,500 mls in females.

123. Pott's disease (spinal TB) is an important differential in the setting of

chronic back pain, fevers and old TB.

124. Catamenial pneumothorax is the cause of 3-6% of spontaneous

pneumothoraces occurring in menstruating women.

125. Indications for corticosteroid treatment for sarcoidosis are: parenchymal

lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement.

126. Lower zones lung fibrosis: methotrexate.

127. NIV (BiPAP) is indicated in respiratory acidosis or rising PaCO2 resistant to

best medical management during an acute exacerbation of COPD.

53 | P a g e
 124. Oxygen dissociation curve:

(A). shifts Left - Lower oxygen delivery - Lower acidity, temp, 2-3 DPG - also HbF,
carboxy/methaemoglobin. (B). Shifts Right - Raised oxygen delivery - Raised
acidity, temp, 2-3 DPG

125. Shifts the oxygen dissociation curve to the left - low pCO2.

126. Basal atelectasis should be suspected in the presentation of dyspnoea and

hypoxaemia 72 hours post operatively.

127. Klebsiella most commonly causes a cavitating pneumonia in the upper

lobes, mainly in diabetics and alcoholics.

128. Before starting azithromycin do an ECG (to rule out prolonged QT interval)
and baseline liver function tests.

Chapter-03

Dermatology
Psoriasis

Most likely scenario: A young pt developed scaly and itchy patches on scalp. Pt
had a similar patch that was cleared spontaneously. Pt’s aunt has a similar
undiagnosed rash on her extensors.

54 | P a g e
 Psoriasis image source is (onHealth)

Note: Itchy, scaly patch on scalp are suggestive of (scalp psoriasis) with family
history it’s thought to be an immunological disease.

Or

Pt presents fine nail pitting, small yellow brown areas of discoloration on the nail
and it involves the nails on both hands.

Note: Characteristics such as nail changes includes pitting, nail discoloration,

subungual hyperkeratosis, crumbling of the nail plate and onycholysis are seen
in (Psoriasis). And Guttate psoriasis is commonly found in children and
adolescents caused by strep infection with tear drop papules on trunk and
limbs.

Scabies

Most likely scenario: Pt who works at nursing home or community hospital or

any unhealthy place presents with itching O/E linear tracks on the wrist. Pt
says that 2 days ago she/he come in contact with a nursing home inmate with
similar systems.

NOTE: This is allergic reaction the probable diagnose is (scabies) in which pt

presents the itching due to allergic reaction to mites commonly (mite sarcoptes
scabiei) waste products.

Treatment: First line drug id permethrin 5% and second line drug is malathion
0.5%.

55 | P a g e
 Pemphigoid Gestationis

Most likely scenario: A female pt 33 years old with 3rd trimester of her second
pregnancy, she complaints an itchy rash around her umbilicus for the first time.
O/E reveals blistering lesions in peri-umblical region and on her arms. Note:
Pemphigoid gaestationis this name itself suggests it’s a pregnancy type disorder
and PG is not associated with blistering. Other pregnancy related skin disorders
such as Polymorphic eruption of pregnancy is associated with last trimester and
first appear in abdominal striae.

Treatment: Oral corticosteroids and emollients if mild use topical steroids.

Pyoderma Gangrenosum

Most likely scenario: Old age female presents lesion over her chin. She told it
initially started as small red papule which became a red, large, nacrotic ulcer
which has violaceous border. This is a very classic presentation of (pyoderma
ganrenosum).

Malignant Melanoma

Most likely scenario: Pt came to ER with complaint of pigmented lesions

suspicious of melanoma are an irregular notched border and color variegation is
present. The most classical features of malignant melanoma are irregular
border, lack of symmetry, multiple colors and the diameter of pigment is greater
than 6 mm and bleeding and ulcerations are common signs.

56 | P a g e
 Treatement: Excision is recommended with margins dictated by the thickness of
the tumor.

Seborrheic Dermatitis

Most likely scenario: old pt complaints of developing of an itchy and red rash on
his neck, behind ears and around nasolabial folds. Pt has history of Parkinson’s
disease.

Source- Wikipedia

Note: Pt with Parkinson’s disease commonly develops seborrhoeic dermatitis.

Young pts with seborrhoeic dermatitis commonly caused by an inflammatory
reaction related a fungus called (fungus malassezia furfur).

Note: Seborrhoeic demititis creates eczematous lesions on the sebum rich areas
such as scalp and may cause dandruff, auricular, periorbital, nasolabial folds,
otitis extema and blepharitis.

Treatment: For scalp zinc pyrithione and tar Neutrogena T-gel are first line and

57 | P a g e
 for face( ketoconazole), selenium sulphide and tropical steroids.

Acne Rosacea

Most likely scenario: Matured woman comes to OPD for a review. She complains
that few months ago she developed sudden redness nose, cheeks and forehead
after she came from outdoor party and it becomes worse after drinking alcohol
and spicy food. O/E: erythematic found with pustules on the nose and
telangiecttasia on cheeks.

Source- Wikipedia

Treatment: In mild symptoms topical metronidazole and in severe cases

antibiotics are needed first line is oxytetracycline or doxicycline.

Impetigo

Most likely scenario: A young female student came to review for developing
golden, crusted lesion on the border of her lower lip which was 1cm.

Note: In impetigo Golden crusted skin lesion around the mouth is classical
presentation. Impetigo is bacterial infection either caused by staphylococcus
aureus or strep pyogenes.

58 | P a g e
 Source-Wikipedia

Treatment: First line is topical fusidic acid and second line is topical
retapamulin.

Hypes Simplex

Most likely scenario: A young male pt complaints of fatigue, low grade fever and
he developed painful ulceration of his gums and mouth. O/E his pulse was
90/bpm and submandibular lymphadenopathy.

Note: This pt has gingivostomatitis which is common characteristic of primary

herpes simplex vrus. There are two strains of herpes simplex virus (HSV-1)
which usually presents oral lesions such as cold sores and (HSV-2) usually
presents in genital herpes.

Treatment: For gingivostomatitis and genital herpes ulcerations = Oral acyclovir.

And chlorhexidine mouth wash and topical acyclovir for cold sores.

Vitiligo

Most likely scenario: A mature pt referred to Dermatologist for review. Pt has

patches of (pale skin) on hands over past few weeks. Pt told that emollients and
topical hydrocortisone has no result so far. O/E: There was hypo pigmentation
on dorsum of both hands. Past history was thyrotoxicosis which is an
autoimmune condition. This is typical picture of vitiligo.

59 | P a g e
 Source-Wikipedia

Treatment: Sun blocks, topical corticosteroids, camouflage make up and

phototherapy.

Erythema nodosum

Most likely scenario: Female pts commonly presents with purple painful lesions
on her shins.

Note: Subcutaneous fat inflammation typically causes tender erythematous

nodular lesions which commonly occurs over shins but may also develop on
forearms and thighs.

Allergic contact dermatitis

Most likely scenario: Pt usually presents rashes on neck and forehead with
weepy, vascular rash around hairline not on scalp. Pt told he/she has returned
from holidays in coastal regions. The diagnose is allergic contact dermatitis.

Alopecia Areata

Most likely scenario: A young man came for review that he is very concerned
over recent hair loss. O/E it reveals a discrete area of hair loss on left temporal
region.

Note: Alopecia areata is an autoimmune condition causing prominent patches of

60 | P a g e
 hair loss.

Treatment: Hair usually re-grows itself but it could be managed by topical

corticosteroids, topical minoxidil and phototherapy.

Pemphigus vulgaris

Most likely scenario: Old age female pt came to ER with severe mucosal
ulceration and blistering lesions over torso and arms. O/E: blistered easily
ruptured vesicles and bullae on touch as blistered are flaccid. Note: Mucosal
ulcerations are most common feature.

Treatement: Steroids

Onychomycosis

Most likely scenario: Pt in onychomycosis presents with affecting toenails

(unsightly nails are common presentation) especially lateral three nails of left
foot. O/E: Nails are brownish and break easily. Note: Nail scrapings indicate
trichophyton rubrum infection and onychomycosis is fungal infection of nails.

Treatment: Diagnosis can be confirmed by nail clippings and if infection is

present first line treatment is oral terbinafine for 12 weeks.

Acne Vulgaris

Most likely scenario: Acne vulgaris is commonly presents in youth and affects
face, neck and upper trunk. O/E commonly pts present evidence of scarring on
face and inflammation and pustules and papules.

Note: Acne has three types mild, moderate and severe.

Mild: (With or without inflammatory lesions, open or closed comedones).

Moderate (non inflammatory lesions with pustules and papules). Severe (more
severe inflammatory lesions with pitting, scarring nodules).

Treatment: Topical retinoids, benzyl peroxide or in severe conditions with use

61 | P a g e
 additionally topical antibiotic therapy along with this.

Pellagra

Most likely scenario: An alcoholic older pt comes to ER with persistent skin rash
which is red brownish in color on his arms, face and neck (especially around his
neck). Other complaints were nausea and diarrhea.

Source-Wikipedia

Note: Pellagra is condition which is caused by niacin deficiency. This condition

may be due to isoniaxid therapy and with alcoholics. Pellagra presents with 3Ds,
Dermatitis, diarrhea and dementia.

Atopic Dermatitis

Most likely scenario: Atopic dermatitis is type of scaling disorder also called
(eczema). Pt commonly presents scaly, red plaques such as xerotic, pruritic,
exudative or may be lichenified eruption affects face, neck, upper trunk, wrists
and hands and also on antecubital or popliteal folds. Pt usually presents with
family history of (asthma, allergic rhinitis or atopic dermatitis) with elevated
serum IgE.

Treatment: Emollients and topical corticosteroids.

Contact Dermatitis

62 | P a g e
 Most likely scenario: Young female pt came to ER for a review. She presents
intense pruritus, tiny vesicles, weepy and crusting red lesions on hands. She
told she was washing cloths and suddenly got this. Note: Contact dermatitis is
allergic and irritant that results from direct skin contact with (chemicals,
allergens, soaps, detergents, inorganic or organic solvents).

Treatment: Removal of causative agents, topical corticosteroids and calamine

lotion.

Herpes Zoster (shingles)

Most likely scenario: Young male pt presents painful dermatome vesicular

lesions on face and trunk. Pt has history of HIV. O/E lesions were tense and
grouped and lymph nodes were swollen and tender.

Treatment: Antiviral therapy (acyclovir, famciclovir or valaciclovir) and steroids

are contraindicated.

Cellulitis

Most likely scenario: Young female pt came to ER with fever, chills and malaise.
She got swelling and painful erythema on lower leg. O/E: lymphangitis or
lymphadenopathy were present. Blood culture was negative and leukocytosis
were present.

Note: cellulitis commonly caused by gram positive cocci.

Treatment: IV antibiotics for 2-5 days (MSSA treat with clindamycin, nafcillin,
cephalexin or doxycycline), (MRSA treat with vancomycin, clindamycin, lenozilid
etec).

Basal cell carcinoma

Most likely scenario: Old age lady presents firm rough patch on her left cheek
which is gradually getting larger in size. O/E: there was no any ulceration

63 | P a g e
 present but a firm waxy and rough area of 4 x 3 cm in size with poorly defined
edges.

Treatment: Gold standard is Mohs surgery.

MCQS solving rapid fire Direct bullets

1. Erythema ab igne is a skin disease which caused by over radiation or fire

exposure is common characteristic of Squamous cell carcinoma.

2. The granulomatous disease affecting the peripheral nerves and skin (face,
buttocks and limbs) and caused by mycobacterium leprae is called Leprosy.

3. First line treatment of leprosy is rifampicin, clofazimine and dapsone.

4. The term Erythroderma is used when more than 95% skin is involved in any
kind of rash.

5. The multisystem disorder with unknown etiology and common features of non
caseating granulomas mainly in young adults may be from African descent is
called Sarcoidosis.

6. Syndrome associated with Sarcoidosis are, Lofgen’s syndrome, Mikulicz

syndrome and Heerfordt’s syndrome.

7. The Waterlow scale is used to assess the risk of pts who are at risk of pressure
sore development as like skin type and color, nutritional status, mobility, ulcer
pressures and body mass index.

8. Seborrhoeic dermatitis in adults caused by a fungus called malassezia furfur.

9. Seborrhoeic dermatitis treatment for antifungal called ketoconazole and topical

steroids.

10. Aluminium chloride is first line drug in Hyperhidrosis which is a disorder of hyper
production of sweat.

11. Treatment of chronic plaque psoriasis is use of regular emollients plus vitamin D
analogues.

64 | P a g e
 12. Butter fly rash is seen in – SLE.

13. Icthyosis is associated with - AIDS, Hypothyroidism, Hodgkin's disease.

14. Drug causing Acanthosis negricans - Nicotinic acid.

15. Target/Iris lesions r seen in - Erythema multi forme.

16. Causative agent of Chancroid - Hemophilus Ducreyi.

17. Important feature of psoriasis is - Silver scales.

18. Most important in diagnosis of leprosy is - slit skin smears for AFB.

19. As per W.H.O minimum duration of treatment for leprosy is - 12 months.

20. If pt’s comes to OPD for an advice after having sun bath with complain of
redness on skin itching and swelling on forearms otherwise she is fine first
advice her is to stop sun exposure and apply sunscreen.

21. In infant if red or yellow scaly patches develops on his scalp is called Seborrheic
Dermatitis or commonly called (Cradle Cap).

22. Slit skin smear is negative in - Neuritic leprosy.Come dones are characteristic of
- Acne vulgaris.

23. Most common cause of pemphigus is - Pemphigus vulgaris.

24. Lesions of childhood atopic derma located in - Cubital & Popliteal fossa.

25. Melanocytes No. are reduced except – Albinism (vitiligo, piebaldism,

hypopigmentation).

26. Increased incidence of vitiligo is found in - T2DM.

27. In a patch of vitiligo - Melanocytes are absent

28. Vitiligo - genetic predisposition/PUVA(best)/Coaltar/Topical steroids

29. Sev itching over webs of fingers,> at night/e burrows - Scabies

30. Molluscum contagiosum is caused by - Virus

31. Fungus affecting hair is - Trichophyton/Microsporum

65 | P a g e
 32. Apple jelly nodules are seen in - Lupus vulgaris

33. Scabies oral drug - Ivermectin

34. Keroin is a form of - Fungal infection

35. Most common cause of cellulitis is streptococcus pyogenes

36. Flag sign in Hair is charecteristic of - PEM

37. H.Ducreyi causes - Soft chancre

38. Mycosis fungoides is a - T-cell lymphoma

39. Alopecia areata - spontaneous recovery will occur within 3-6 months in major
pts.

40. Cradle cap in babies is - seborrheic dermatitis

41. Leprosy will affect all organs except - Uterus

42. Freis test is diagnostic of - Lymphogranuloma venerium

43. Which is known as Gift spots - Leuconychia

44. Causative organism for common warts - Human papilloma virus

45. Acanthosis nigricans is most common due to carcinoma of - Colon

46. Most specific test for Syphilis - FTA-ABS

47. Photochemotherapy is useful in - Psoriasis

48. Skin condition treated with PUVA therapy is - psoriasis

49. Munro's micro abscess are seen in - Psoriasis

50. Treatment of psoriasis - PUVA/Methotrexate

51. Auspitz sign is found in - Psoriasis

52. Auspitz sign is seen in - plaque type psoriasis

53. Auspitz sign is characteristically seen n - Plaque psoriasis

54. Recurrent painful oro genital ulcers with arthritis is due to - Reiter's syndrome

55. Commonest cutaeneous eruption in SLE is - Erythema of light exposed area

66 | P a g e
 56. Pitting of nails can be seen in - Alopecia areata

57. Young female c/o of genital wart the agent implicated is - Human papilloma
virus.

58. Commonest venereal disease - Gonorrhoea

59. Tines versicolor is caused by - Malasia Furfur

60. Helitrope rash is seen on face in - Dermatomyositis

61. Lesions of pityriasis rosea are distributed mostly on - Trunk

62. PUVA therapy is used for - psoriasis/vitiligo/Atopic dermatitis

63. 5yrs/m with hypopigmented scaly macule on cheek some of his classmates also
has it

64. probable diagnosis - Pityriasis Alba

65. 10yr child- hypopigmented multiple scaly patch in face diagnosis - Pityriasis
alba

66. 3yrchild-eczematous dermatitis on extensor surface mother-BA - Atopic

dermatitis

67. Mouth lesions r seen n - Lichen planus

68. Nail changes in psoriasis - Oncholysis/pitting/subungual hyperkeratosis

69. Burrow is scabies in the - Stratum corneum

70. Itch is disease is true for - Atopic dermatitis

71. Drug producing erythema nodosum is - Sulphonamides

72. Tzank test is +ve in-Pemphigusfoliacious, P.vegetans, P.vulgaris, senear usher

syndrom

73. Tzank cell is a - Keratinocyte

74. Acantholytic bullae are found in - Burns

75. Bulla spread sign is seen in - Pemphigus vulgaris

76. DOC for dermatitis herpatiformis - Dapsone

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 77. DOC in Gonorrhoea is - Procaine penicillin

78. DOC in Chancroid - Erythromycin

79. Drug of choice in systemic candidiasis is - Amphotericin-B

80. DOC in ENL is - Steroids

81. DOC for pustular psoriasis - methotrexate

82. DOC for pustular psoriasis in pregnant lady is - Prednisolone

83. DOC for Herpes Zoster - Acyclovir

84. DOC for Granuloma venerium - Erythromycin

85. DOC for Tinea Unguam - Griseofulvin

86. DOC for systemic candidiasis - Amphotericin B

87. Koebners phenonmenon is seen in - Lichen planus

88. Most common type of scarring alopecia is - Androgenic

89. Patch test is done to document - Delayed type hypersensitivity

90. Mucosal lesion is common in - Lichen planus

91. Recurrent plaques on glans which heal with residual hyperpigmentation is-
herpes gestationalis

92. Earliest sensation to be lost in Leprosy is - Thermal

93. Degeneration of Basal cells occurs in - Lichen planus

94. Sebaceous cyst are seen in - Gardeners syndrome

95. Abscess is not a primary skin lesion

96. Acne-on drug-presents withblue black pigmentation of nails cause-

Tab.Minocycline

97. Most common side effect of retinoids - Skin rashes

98. Acne vulgaris is due to involvement of - Pilosebaceous glands

99. Apocrine gland - modified sweat gland,present in groin&axilla,

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 100. Rhinophyma (potato nose) is-Glandular form of acne rosacea/sebaceous gland

101. Anagen phase of the hair indicates - phase of activity & growth

102. Female with diffuse alopecia suffered frm typhoid 4 months back diagnosis -
Telogen effluvium

103. Correct sequence of cell cycle is - G0-G1-S-G2-M

104. Neither raised nor depressed is - Macule

105. Flat discoloration on skin as 1cm is called - Macule

106. Oil drop is seen in - psoriasis of nails

107. Felon is seen in - Nail bed

108. Tinea ungum affects - nail plate

109. Characteristic feature of atopic dermatitis - Pruritis

110. Secondary syphilis manifested by

111. painless lymphadenopathy/mucosal erosion/asymptomatic rash

112. Hypopigmented patches r seen in - Naevus anemicus

113. Fir tree type distribution is seen in - pityriasis rosea

114. Air-borne contact dermatitis is diagnosed by - patch test 104.Alopecia areata is

treated by - Minoxidil

115. School of fish appearance is shown by - Haemophilus ducreyi

116. Cicatricial alopecia-DLE/Lichen planus/SLE

117. Non cicatrical alopecia - Psoriasis/Alopecia areata

118. Rain drop pigmentation is seen in - chronic Arsenic poisoning

119. Patch test is done for - Allergic contact dermatitis

120. Fluid filled in epidermis and dermis is called - Vesicle

121. Commonest site of Atopic dermatitis is - Ante cubital fossa

122. Berloque dermatitis is due to contact with: - Cosmetics

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 123. Least common site involvement in psoriasis is - CNS involvement

124. Civatte bodies are found in - Lichen planus

125. A washer man presents with thickness erosion & discoloration of web spaces of
toes

126. diagnosis is - Candidiasis

127. Dhobi’s itch is - Tinea cruris

128. Spongiosis is seen in - Acute Eczema

129. Coin shaped eczema - Nummular Eczema

130. Atopic dermatitis is diagnosed by - Clinical examination

131. Commonest metal causing skin hypersensitivity - Nickel

132. MCC of allergic contact dermatitis in female - Detergents

133. Commonest cause of air borne contact dermatitis is - Parthenium grass

134. Pt gets recurrent urticaria while doing exercise & on exposure to sunlight cause
is Cholinergic urticaria

135. Annular herald patch is seen in - P.Rosea

136. Nummular ring is caused due to - Idiopathic

137. Darrier's sign is seen in - urticaria pigmentosa

138. Pt with recurrent swelling on face & lips due to emotional stress cause is CI
esterase inhibitor deficiency

139. Quincke's disease is popularly known as - Angioneurotic oedema

140. Bleeding spots seen on removal of scales in psoriasis is called as - Auspitz sign

141. Ash leaf maculae is found in - Tuberous sclerosis

142. the important feature of psoriasis is - Scaling

143. Patch test is a type of - Delayed type hypersensitivity

144. Patch test is read after - 2 days

145. Morbilliform eruptions r seen in - Rubella/Measles

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 146. Koebner phenonmenon is present in - Psoriasis/Lichen planus/Warts

147. Which is pruritic - Lichen planus/sunburns/Pemphigoid/psoriasis

148. Characteristic feature of lichen planus is - Wickham striae

149. Lichen planus TOC - Systemic steroids

150. Psoralen-A is used in treatment of - Vitiligo

151. Row of Tomb stones appearance is seen in – Pemphigus

152. Commonest variety of Pemphigus - Pemphigus Vulgaris

153. Associated with Pemphigus - Thymoma/CLL/Myasthenia gravis/Atrophic

gastritis

154. Blister formation in burn case is in - Subepidermal

155. Mucous lesions are seen n - Pemphigus

156. Intera cellular IgG deposition in epidermis s seen n - Pemphigus

157. Increased level of IgE is seen in - Atopy

158. Granular IgA deposits at dermal papilla r found n - Dermatitis herpetiformis

159. HLA associated with dermatitis herpatiformis - HLA B27

160. Pyoderma gangrenosum is seen in - Ulcerative colitis

161. Erythema nodosum is seen in- RA/PTB/Enteric fever/Leprosy

162. What can pt with gluten sensitive hypersensitivity consume as food -Rice,corn

163. Target or Iris lesion is seen in - Erythema multi forme

164. Causative organism of Molluscum contagiosum - Pox virus

165. Ballooning is characteristic of - Herpes Zoster

166. 156.Acantholysis is characteristic of - Pemphigus vulgaris

167. Pt c/o abd pain with vomitting, psychiatric symt & visual hallucinations,
Intermittant porphyria, Porphyria cutanea tarda can be treated by - Phlebotomy

168. Non palpable purpura is seen in - Amyloid/ITP/Drug induced vasculitis

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 169. Palpable purpura is seen n - HSP/Sr.Sickness/Wegners granulamatosis

170. Treatment for kawasaki's disease - IVIg

171. Lish nodule is seen in - von reclinghausens disease

172. IgA deposits on skin biopsy - Henoch schonlein purpura

173. Triad of Reiters syndrome include - Conjunctivitis/Urethritis/Arthritis

174. Defective DNA repair is associated - Xeroderma pigmentosa

175. Pseudo bubo is seen in - Donovanosis

176. Satellite lesions are seen in - Borderline tuberculoid leprosy

177. Dermatitis & Alopecia are due to defeciency of - Zinc

178. Tuberculoid leprosy is characterised by - Non caseating granuloma in nerve

179. Crocadile skin or sauroderma is seen in - Icthyosis vulgaris

180. Casal's necklace is caused by - pellagra

181. Rash n Measles occurs first n - Post auricular region

182. Erythema marginatum is seen in - Rheumatic fever

183. Commonest nerve involved in Leprosy is - Ulnar

184. Lupus vulgaris - Skin & Mucosa TB/Apple jelly nodules at root of nose

185. Acrodermatitis enteropathica - decreased Zinc level/autosomal recessive

186. Rose spot are seen in - Typhoid fever

187. Slapped cheek appearance is seen in - Erythema infectiosum

188. Phrynoderma - deficiency of - vitamin A

189. Virchows cells are seen in - Leprosy

190. Lepromin test is used for – prognosis

191. Features of Lepromatous leprosy - Saddle nose/Gynaecomastia/Mydriasis

192. Commonest fungal infection in female genitalia in diabetes is - Candida

193. Most potent anti leprotic drug is - Rifampicin

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 194. Permethrin is used in treatment of – Scabies

195. Leprosy do not involve - CNS

196. Leprosy affects all organs except - Uterus

197. In leprosy nerves commonly involved are - High ulnar,low median 188.Skin
hazards of swimming are - Verrucae/M.marinum infection

198. Most common type of leprosy - TT

199. Commonest skin infection in children is - Impetigo contagiosa

200. Characteristic lesions of scabies is - Burrow

201. Honey colour crusts are characteristics of - Impetigo

202. Most common organism causing Tinea capitis - Microsporum

203. Athelet's foot - 4th toe web is involved/hyperthyroidism(+)/caused by

Trichophyton

204. Tinea incognito is seen with - Steroid treatment

205. Treatment of Acne - 13 cis-retionol/Minocycline/Erythromycin

206. Multi drug therapy is given for - Leprosy

207. Tinea versicolor is caused by - Malassezia Furfur

208. Griseofulvin is useful in - T.capitis,T.cruris,T.Pedis

209. Treatment for T.Versicolor - clotrimazole/sod thiosulphate/miconazole/selenium

sulphide

210. Safety pin appearance is shown by - Donovanosis granulomatis

211. Black dot ring worm is caused by - Trichophyton

212. Washerman with thickness erosion & discolouration of web spaces & toes -
Candidiasis

213. Medically most important form of UV - UV-B

214. Rangeof light which causes max damage to skin - 290-360nm

215. Griseofulvin is not used in - T.Versicolor & Candida

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 216. Dhobi's Itch is - T.Cruris

217. Incubation period of scabies - 4 wks

218. Antidote for T.warfarrin - vit-k

219. Circlre of Hebra is associated with – Scabies

220. Vagabond's disease is - Pediculosis corporis

221. Impetigo contagiosa most commonly due to - Staphylococcus

222. Condylomata acuminata is caused by - HPV

223. LGV is caused by - Chlamydia trochamatis

224. Genital elephantiasis is caused by - Lymphogranuloma venerum

225. Sign of groove is found in - LGV

226. Frie's test is done in - LGV

227. DOC for LGV - doxycycline

228. DOC for Herpes Zoster - Acyclovir

229. DOC in primary syphilis is - Benzathine penicillin

230. Pseudo-isomorphic phenonmenon is shown by – Warts

231. Most severe form of scabies - Norwegian scabies

232. Chancroid is caused by - Hemophilus ducreyi

233. Most frequent cause of recurrent genital ulceration in sexually active male is
Herpes genitalis

234. Ivermectin is indicated in treatment of - Scabies

235. Sabre tibia is seen in - syphilis

236. Acanthosis nigricans is indicative of internal malig/endocrine dis/Blooms

synd/pigmentation of face & neck

237. Langerhans cells in skin are - Antigen presenting cells

238. Shagreen patch may be seen in - Tuberous sclerosis 230.Rodent ulcer is a type
of - basal cell CA
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 239. Hypervitaminosis A is associated with - hair loss/dry skin/hypopigmentation/#
bones.

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 240. Blue line on Gums r seen in - Acute monocytic leukemia

241. Escharotomy is done for - circumferential scars.

242. Leprosy does not affect - Uterus & ovary

243. Erythema multiforme is caused by - Virus

244. Systemic treat ment of Scabies - Ivermectin

245. Wasserman test is done for - syphilis

246. Protective from ultra violet rays - Melanocytes

247. Child born with nasal discharge & rash all over the body -
Congenital syphilis

248. 25 yr GM with urticaria,recurrent skin infection,abd cramps &

diarhea upon taking sea foods Atopic dermatitis

249. Male has painless ulcer 9 days after coitus i professional sex
worker diag - Chancre

250. Multi bacillary leprosy is -12 months

251. Pauci bacillary leprosy is - 6 months

252. Silvery scaling is an important feature of - Psoriasis

253. Melasma is seen in - Face

254. Iron deficiency anemia – Koilonychias

255. Apple jelly nodules- lupus vulgaris

256. Butterfly rashes are seen in - SLE

257. Auspitz sign is seen n - Psoriasis

258. Row of Tomb stone appearance is seen in - Pemphigus

259. Kerion is a - Fungal infection

260. Anagen is the growth phase of - Hair

261. Ashleaf spots are seen in - Tuberous sclerosis

262. Honey colored crusting seen in which Disease – Impetigo

76 | P a g e
 263. Gotrrons papule – Dermatomyositis

264. Facial angiofibroma/adenoma sebacium of Pringle -- Tuberous

sclerosis

265. Brown spots under nail plate (oil spit) -- Psoriasis

266. Burrow is seen in à Scabies

267. Hyperpituitrism à Skin discoloration

268. SLE -- Butterfly rash

269. Liver cirrhosis -- Spider angioma

270. Leprosy à Contracted face

271. Symmetrical Christmas tree skin lesion on back -- Pityriasis

rosea

272. Hypopigmented anesthetic skin lesions -- Leprosy

273. Axillary freckling/crowe's sign -- Neurofibromatosis

274. Erythema cronicum migrans -- Lyme disease

275. Pink papule with central umbilication -- Molluscum Contagiosum

276. Casal's necklace is seen in -- Pellagra

277. Wickham stria -- Lichen planus

278. Topical steroids are as follows:

A) Moderate: Clobetasone butyrate 0.05%

B) Potent: Betamethasone valerate 0.1%

C) Very potent: Clobetasol propionate 0.05%

279. Acne rosacea features:

280. nose, cheeks and forehead

281. flushing, erythema, telangiectasia → papules and pustules

282. Oral lichen planus typically presents with buccal white-lace

77 | P a g e
 pattern lesions and ulcers.

283. Acne vulgaris in pregnancy - use oral erythromycin if treatment

needed.

284. Acral lentiginous melanoma: Pigmentation of nail bed affecting

proximal nail fold suggests melanoma (Hutchinson's sign).

285. Dermatitis herpetiformis - caused by IgA deposition in the

dermis.

286. Pityriasis versicolor is caused by Malassezia furfur.

287. Blisters/bullae can be defined as:

A) no mucosal involvement (in exams at least*): bullous

pemphigoid.

B) mucosal involvement: pemphigus vulgaris.

288. Keloid scars - more common in young, black, male adults.

289. HIV is associated with seborrhoeic dermatitis.

290. Tender shin lesions - erythema nodosum.

291. Diabetic dermopathy is associated with increased age and longer

duration of diabetes.

292. Topical aluminium chloride preparations are first-line for

hyperhidrosis.

293. Urinary histamine is used to diagnose systemic mastocytosis.

294. Dry skin is the most common side-effect of isotretinoin.

295. Dermatophyte nail infections - use oral terbinafine.

296. Grave's disease, orange peel shin lesions - pretibial myxoedema.

297. Scabies - permethrin treatment: all skin including scalp + leave

for 12 hours + retreat in 7 days.

298. Management of venous ulceration - compression bandaging.

299. An itchy rash affecting the face and scalp distribution is

78 | P a g e
 commonly caused by seborrhoeic dermatitis.

300. Nodular melanoma: Invade aggressively and metastasise early.

301. Hepatitis C may lead to porphyria cutanea tarda.

302. Eczema herpeticum is a serious condition that requires IV

antivirals.

303. Porphyria cutanea tarda - photosensitive rash with blistering and

skin fragility on the face and dorsal aspect of hands.

304. Polymorphic eruption of pregnancy is not associated with

blistering.

305. Keloid scars are most common on the sternum.

306. Beta-blockers are known to exacerbate plaque psoriasis.

307. Parkinson's disease is associated with seborrhoeic dermatitis.

308. Melanoma: the invasion depth of the tumour is the single most
important prognostic factor.

309. Otitis externa and blepharitis are common complications of

seborrhoeic dermatitis.

310. Lentigo maligna melanoma: Suspicious freckle on face or scalp of

chronically sun-exposed patients.

311. Psoriasis: lithium may trigger an exacerbation.

312. Ketoconazole shampoo is used to treat pityriasis versicolor.

313. Erythema gyratum repens is a paraneoplastic eruption with a

'wood-grain' pattern and figurate erythema commonly seen in
patients with lung cancer.

314. Lichen can be defined as follows:

Planus: purple, pruritic, papular, polygonal rash on flexor

surfaces. Wickham's striae over surface. Oral involvement is
common.

315. sclerosus: itchy white spots typically seen on the vulva of elderly

79 | P a g e
 women.

316. Topical eflornithine is the treatment of choice for facial hirsutism.

317. Livedo reticularis can be caused by SLE.

318. Diabetes, waxy yellow shin lesions - necrobiosis lipoidica

diabeticorum.

319. Flexural psoriasis - topical steroid.

320. Same-day referral to a dermatologist is recommended if eczema

herpeticum is suspected.

321. An area of rapidly worsening painful eczema is an early sign of

eczema herperticum.

322. Impetigo - topical fusidic acid is first-line.

323. Hereditary haemorrhagic telangiectasia - autosomal dominant.

324. Eczema herperticum rash can be described as monomorphic

punched-out erosions (circular, depressed, ulcerated lesions)
usually 1–3 mm in diameter.

325. SCCs arising in a chronic scar are typically more aggressive and
carry an increased risk of metastasis.

326. Pompholyx eczema is a subtype of eczema characterised by an

intensely pruritic rash on the palms and soles.

327. Eczema herpeticum is a primary infection of the skin caused by

herpes simplex virus (HSV) and uncommonly coxsackievirus.

328. A non-healing painless ulcer associated with a chronic scar is

indicative of squamous cell carcinoma (SCC).

329. Pompholyx eczema may be precipitated by humidity (e.g.

sweating) and high temperatures.

330. The most common malignancy in the lower lip is a squamous cell
carcinoma.

331. Zinc deficiency caused by total parenteral nutrition (TPN) can

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 result in acrodermatitis herpetiformis.

332. Acne rosacea treatment:

A) Mild/moderate: topical metronidazole.

B) severe/resistant: oral tetracycline.

333. Deficiency of niacin (B3) causes pellagra.

334. Herpes hominis virus 7 (HHV-7) is thought to play a role in the

aetiology of pityriasis rosea.

335. Niacin (B3) deficiency is characterised by dermatitis, diarrhoea

and dementia, a condition known as pellagra.

336. Isotretinoin adverse effects are:

teratogenicity - females MUST be taking contraception

low mood

dry eyes and lips

raised triglycerides

hair thinning

nose bleeds

337. Seborrhoeic dermatitis - first-line treatment is topical

ketoconazole.

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 CHAPTER-04

NEUROLOGY

Lateral syndrome

Most likely scenario: An Old age pt after stroke now presents left
sided ptosis and constricted pupil. Pt has lost the feeling of pain
and temperature on right side of his body and face.

Note: As it’s an ischemic neurological disorder of medulla so it

cause a range of symptoms in lateral part of medulla oblongata in
the brain stem and in result the vertebral and cerebellar arteries
blockage. It causes sensory deficits that affect trunk and
extremities.

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 Oculomotor nerve

Most likely scenario: A 25 years old young male presented a fixed

dilated pupil with semi conscious level after being involved
(MVC).

Note: Third nerve (oculomotor nerve) damage can cause fixed

dilated pupil.

Radial nerve

Most likely scenario: A 34 y old pt was in OT and during surgical

procedure pt’s arms were hanging down. On waking up pt
complains of weakness and numbness in arms and have limited
wrist movements with sensory loss of hand.

Note: In this case pt’s arms were hanging down which cause
compression of radial nerve at spiral groove.

Ulner nerve

Most likely scenario: Pt will present loss of sensation in ring and

little finger.

Note: When ulner nerve compressed at the elbow is called as

(cubital tunnel syndrome) which causes numbness in 5th and half
of the 4th finger.

Right abducens nerve

Most likely scenario: A 22 years old female presents with double

vision on seeing towards right.

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 Note: Diplopia on seeing to right side is called right lateral rectus
palsy which is due to the right abducent nerve.

Obturator nerve

Most likely scenario: A female pt of 42 years old presents pain in

right thigh. She has history of benign ovarian mass on right side.

Note: (obturator nerve) is responsible for sensory innervations of

the thigh.

Radial nerve

Most likely scenario: A middle aged man came to ER with

complaint of severe pain in right arm. He said he was slipped and
fell on his hand while he was exercising. An X-ray shows fracture
of radius.

Note: Radial nerve injury at wrist caused finger drop.

Lateral peroneal nerve or superficial peroneal nerve

Most likely scenario: A wrestler or street fighter person came to

ER with deformity of upper part of leg and bruises on his body.
An X-ray shows fracture on his neck of fibula. This is typical
picture of lateral peroneal nerve damage.

Herpes simplex encephalitis

Most likely scenario: young pt came to ER with severe headache

and pyrexia for two days. Ct brain report presents (petechial
hemorrhages) in inferior frontal lobe and temporal lobe.

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 Note: In HSV encephalitis which is common exam (MCQ) only
remember the virus affects temporal lobes and results temporal
lobe signs.

Treatment: I/V acyclovir.

Migraine

Most likely scenario: Pt will present with recurrent episodes of

headache and throbbing in nature lasts around 9-12 hours and
occurs 2-3 times in a month. Medicine such as paracetamol is
very less or not affective.

Treatment: In (acute migraine 5-HT receptor agonists are first

line) and for (prophylaxis 5-HT receptor antagonists are first line).

Carpal tunnel syndrome

Most likely scenario: Middle aged woman complaining pain on her

right hand and forearm which is worsening since few days. O/E:
Pain is around index finger, thumb and there is reduction of
sensation with weak abductor pollicis brevis. Pain is relieving on
shaking her hand.

Note: CTS is caused by compression of median nerve of carpal

tunnel.

Treatment: Wrist splints, inject (corticosteroids) or surgical

decompression.

Bell’s palsy

Most likely scenario: 37 year old woman came to ER with

complaint of facial asymmetry with right side of her mouth was

85 | P a g e
 drooping. She said that she felt pain behind her right ear one day
ago and her eye became dry. O/E: Paralyzed on right side facial
nerve from forehead to mouth, nose throat and ear. PNS
(peripheral nervous system was normal.

Treatment: Steroids prednisolone is recommended dosage is

1mg/kg for 10 days. (No antiviral are recommended now).

Eclampsia

Most likely scenario: A 27 years old girl with 35 weeks of

pregnancy developed seizures and was currently on treatment of
pre-eclampsia.

Note: This issue is likely to be seen after 20 weeks of gestation

with pregnancy induced hypertension followed by proteinuria.

Treatment: I/V magnesium sulphate

Myasthenia gravis

Most likely scenario: A young woman presents with complain of

weakness of arms and has developed double vision since few
days O/E: Normal at opticians. She has history of
hypothyroidism.

Note: Myasthenia gravis is common in a female which is due to

insufficiency in acetylcholine receptors function. It creates
muscle weakness which results diplopia. If pt presents same
scenario with one change of small lung cancer then diagnose
would be (lambert-eaton syndrome).

Treatment: Steriods initially (prednisolone), long acting

anticholinesterase (pyridostigmine) or thymectomy.

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 Subarachnoid hemorrhage

Most likely scenario: A young pt came to ER with complaint of

vomiting with acute onset of occipital headache and photophobia.
Pt was conscious with subarachnoid hemorrhage in basal
cisterns in CT brain.

Treatment: treatment depends on CSF exam and first choice is

(nimodipine) to reduce the bleeding.

Subdural hemorrhage

Most likely scenario: Old male came to ER with complaint of

confusion and headache over past few days. He has history of
falls and alcohol abuse. His GCS score is 14/15 with nystagmus
on left gaze.

Treatment: Neurosurgical review.

Neurolptic malignant syndrome

Most likely scenario: In such cases young male or middle aged pt

commonly presents while taking antipsychotic medications. For
example a middle aged pt presents with history of schizophrenia
came to ER with complaint of confusion. O/E pt was found
procyclidine tablets in his bag. Pt was confused with fever, high
blood pressure and tachycardia. His GCS score was 14/15 with
increased muscle tone.

Treatment: First step is to stop antipsychotic, dopamine and

bromocriptine agonist can be used to decrease skeletal muscle
rigidity and decrease the release of calcium from sarcoplasmic
reticulum. IV/ fluids should be given.

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 Transient ischemic attack (TIA)

Most likely scenario: 55 years old woman came to ER with

complain of she lost sudden vision of left eye and with transient
leg and arm weakness for couple of hours and symptoms resolved
by itself.

Note: TIA is type of mini stroke which causes disruption due to

atherosclerosis of that part of the brain. In this scenario most
likely investigation is (Doppler USG) and cause is carotid
narrowing.

Subdural hematoma

Most likely scenario: Note: Its head injury of elderly which leads
to subdural hematoma even minor injury. A 77 years old man
had got minor head injury few weeks ago. O/E pt was drowsy,
unsteady and increasingly confused. His GCS score was 13. He
was taking warfarin atrial fibrillation medication.

Treatment: Stop warfarin as it is a risk factor of subdural

hematoma management. First line is to evacuation by burrhole
craniostomy and second line flap craniotomy if clot is organized.

Trigeminal neuralgia

Most likely scenario: Usually pt presents an electric like pain on

face which starts from jaw and moves upward with normal
corneal reflexes. This presentation is typical for trigeminal
neurological pain of trigeminal nerve.

Note: In trigeminal neuralgia pt presents normal neurological

exam.

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 Meningitis

Most likely scenario: A young pt of 23 years of age bring to ER

with vomiting, nausea, headache, fever (39 C) and neck stiffness.

Treatment: In young pt with meningitis the drug of choice in

hospital management is (Ceftriaxone).

Multiple sclerosis

Most likely scenario: A 35 years old woman came to ER with

complaining pain in eyes, blurred vision and fatigue for few
months. She has history of weakness in her right upper limb
since 3 years. O/E: Internuclear ophthalmoplegia (INO).

MRI is choice of investigation in MS.

Treatment: Steroids

Extradural hemorrhage

Most likely scenario: 32years old man hit by car and he was
unconscious and he was fine in ER but became comatose
suddenly.

Note: This person is young with head trauma and lucid interval
which is presents in both conditions like subdural and extradural
hemorrhages but more commonly and prominently in extradural
hemorrhage.

Subdural hemorrhage

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 Most likely scenario: An old age lady presents AF and is on
warfarin. Her history was progressive confusion for four days.
She was living in a care home. O/E: She has bruises on her arms
with INR 7.

Note: Subdural hemorrhage is an old age disease. In this scenario

an old age lady is living in care home and an old about 75 years.
She got injury possible due to fall and she is on warfarin and
with high INR is common risk factor of subdural hemorrhage.
Some scenarios present an old age with left pupil irresponsive to
light and is dilated and pt is confused for few days.

Intracranial hemorrhage

Most likely scenario: A teenager was admitted due to road traffic

accident (RTA). His initial GCS was 15 and after few hours at
night his GCS reduced to 12.

Note: Next step of investigation is CT scan brain is recommended.

Subdural hematoma

Most likely scenario: 45 years old man which was alcoholic

brought in ER. His attendant tells he was confused at home after
a fall and complains of headache which is worsening gradually.
O/E: His level of consciousness was fluctuating and increasing
confusion level.

Treatment: First line craniostomy via Barr twist drill and barr
hole. If there is an organized clot presents then craniotomy is
second line.

Myoclonus

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 Most likely scenario: A teenager girl had an episode of seizure in
class room with contraction of muscles of interphalangeal joints
spreads to muscles of wrist and elbow. This is typical picture of
myoclonic seizer as brief jerks of the body which is mostly seen in
limbs and facial muscles. First choice of investigation is EEG to
read brain wave activity.

Absence seizer

Most likely scenario: A child in school suddenly went blank and

up rolling his eyes and fell down and recovered immediately.

Note: An absence seizer begins in both sides of the brain and

commonly affects one’s awareness at that time and immediate
recovers from that condition.

Alzheimers

Most likely scenario: An old age person fell down and hurt his
elbow and knee while shopping. He speaks in very low voice and
answering with spaces and very slowly.

Note: Alzheimers is an old age disease which starts with

dementia and most early symptom is difficulty in remembering
most recent events.

Idiopathic intracranial hypertension

Most likely scenario: A young obese girl came to ER with major

complaint of blurred vision, headaches and apyrexia. O/E her BP
was 135/80 and bilateral blurring of optic discs there was no
other neurological signs.

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 Note: Young, obese female with optic disk swelling (papilledema)
is common picture of idiopathic intracranial hypertension which
is also known as (pseudo tumor cerebri).

Treatment: Diuretics, topiramate is used which has added

advantages like reducing weight and weight loss. Surgical
procedures: such as fenestration and optic nerve
sheathdecompression are recommended.

Essential tremor

Most likely scenario: An old woman of 68 years of age came to ER

with complaint of tremors in arms when arms are outstretched
for few days and tremor usually eased when using alcohol.

Note: Essential tremor is condition of autosomal in nature which

affects both upper limbs. But bradykinesia, postural instability
are typical present in (Parkinsons).

Treatment: First line drug is propranololnand. Perimidone is used

when first line drug is not affective.

Benign paroxysmal positional vertigo

Most likely scenario: An old man of 60 years age presents sudden

onset of dizziness, nausea and vertigo. Pt told when he moves his
head dizziness is getting worse as like room is spinning. O/E: No
any neurological findings were present.

Note: In BPPV the onset age is above 55 years and less common
in young. The main characteristic is it triggered by changing the
position of head.

Treatment: Medication has limited value it resolves

spontaneously. Best initial approach is (Epley manoeuvre has

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 80% success rate) and teach pt some exercises as like brandt-
daroff.

Parkinson’s disease

Most likely scenario: An old age pt came to neurological clinic for

review as pt was complaining of tremors in limbs while rest and
tremors were enhanced by emotional stress and progressive
postural instability.

Note: The main characteristics of Parkinson’s are that pt feels

tremors at rest. Other symptoms are rigidity and bradycardia in
severe cases.

Treatment: Tx is symptomatic amantadine is used in mild

symptoms and otherwise dopamine receptor agonists.

Dementia

Most likely scenario: 77 years old male presents with

forgetfulness for the past ten months and has started wander
around at night according to his daughter. Neurological exam is
unremarkable and his mini mental stable exam (MMSE) test
score was 17 out of 30. A full blood screen also performed.

Note: MRI is investigation of choice after (AMTS and 6CIT) along

with blood screen so it could be exclude the reversible causes
such as hypothyroidism. Alzheimer’s is most common cause of
dementia in old then vascular and lewy body dementia.

Treatment: Supportive care and (Donepezil).

Lyme disease

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 Most likely scenario: 34 years old lady presents with a facial
droop. O/E: Lower motor neuron facial nerve lesion was localized.
Pt had rash over her forearm which was settled few weeks ago.

Note: The most common findings of lyme disease is lower motor

facial nerve lesion and a rash. Lyme disease causes by tick bite
and causing organism is (spirochaete borrelia burgdorfen).

Treatment: First line is Doxycycline and alternative is amoxicillin

MCQS solving quick and Targeted bullets

1. Herpes zoster ophthalmicus occurs when varicella zoster

reactivated in the ophthalmic division of trigeminal nerve.
2. TIA caused by carotid narrowing from atherosclerosis.
3. TIA is characterized by focal ischemic cerebral neurologic deficit
which lasts for less than 24 hours.
4. Compression of ulner nerve at the elbow which is known as
cubital tunnel syndrome which causes numbness in fifth and 4th
finger.
5. Diplopia or double vision on seeing towards right is caused by
right abducens nerve damage.
6. In condition of cerebral metastasis which causes polydipsia and
polyuria is due to affect of (Diencephalon) brain part.
7. In elders head injury usually leads to subdural hematoma and in
younger it leads to extradural hemorrhage.
8. In pediatric migraine the first line drug is paracetamol.
9. (NPH) Normal pressure hydrocephalus is an abnormal build up of
cerebrospinal fluid (CSF) in brains cavities and ventricles.
10. Facial pain is caused by trigeminal nerve is most commonly
present in middle aged women.

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 11. The recurrent unprovoked seizer is called (Epilepsy) due to
abnormal paroxysmal neuronal discharge in the brain.
12. If pt has taken poison and he can’t able to walk and is drowsy
pinpoint pupils will be found on exam.
13. Partial seizer or focal onset seizer indicates the restricted one part
of cerebral hemisphere is activated.
14. Focal motor seizers consist of clonic jerking or automatism.
15. Tonic clonic seizer is a motor seizer with tonic phase and then
clonic muscle contraction with partial or complete loss of
consciousness is also known as grand mal seizer.
16. Hippocampal sclerosis is a recognized cause of focal and
generalized seizers.
17. MRI is choice for focal neurological symptoms or focal seizers.
18. After first seizer the most common laboratory investigations are
CBC, electrolytes, LFTs, calcium, magnesium and serum glucose
to exclude various causes of seizers.
19. Postural hypotension is most commonly found in
(Dysautonomia).
20. Stroke is defined as sudden onset of neurological deficit of
cerebrovascular origin.
21. Ischemic stroke is caused by vascular occlusion secondary to
thromboembolic disease.
22. Treatment of acute stroke is blood glucose, hydration,
temperature and oxygen saturation should be maintained within
normal limits. If there is no hemorrhage stroke (aspirin 300mg
orally or rectally should be given).
23. Intracerebral hemorrhage is due to presence of microaneurysms
which develops on perforating vessels in hypertensive pts.
24. Sudden severe headache, obtundation and meningeal irritation
are symptoms of (spontaneous subarachnoid hemorrhage).
25. (spinal cord vascular disease) commonly presents sudden back or
limb pain and most importantly neurological deficits in limbs.

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 26. First line drug therapy in acute migraine is oral triptan with
(NSAIDS) or paracetamol.
27. First line drug therapy in acute migraine for young pts is nasal
triptan not oral.
28. First line drug therapy in prophylaxis (acute migraine) is
propranolol or topiramate.
29. Left homonymous hemianopia means visual field defect to the left
and it causes lesion of right optic tract.
30. In parkinson’s disease treatment is delayed until onset of
disabling starts first line is dopamine receptors in young and
levodopa initially in elders.
31. Cataplexy is caused by the transient loss of muscular tone due to
any strong emotion such as laughter or being frightened.
32. Carpal tunnel syndrome is caused by compression of median
nerve in carpal tunnel.
33. Treatment of corpal tunnel is wrist splints at night, coticosteriod
injection and finally if not resolved (surgical decompression).
34. Pre eclampsia is defined as pregnancy induced hypertension,
condition seen after 20 weeks of gestation and proteinuria.
35. Eclampsia is defined as the development of seizer in association
with pre eclampsia.
36. Bell’s palsy is defined as an acute idiopathic, unilateral and facial
nerve paralysis.
37. Bell’s palsy treatment is steroids e.g prednisolone.
38. Bell’s palsy more commonly found in pregnant women.
39. Myasthenia gravis is due to the insufficient functioning of
acetylcholine receptors.
40. Post lumbar puncture headache is due to leak of CSF following
dural puncture.
41. Post lumbar puncture headache is more commonly present in
young females with low body mass index.
42. Lambert Eaton myasthenic syndrome is due to potentiating effect
with increased activity enhances muscle power.

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 43. Lambert Eaton syndrome is commonly seen in association with
small cell lung cancer.
44. Subarachnoid hemorrhage causes due to rupture of berry
aneurysms 85%.
45. Berry aneurysms are conditions which include adult polycystic
kidney disease, coarctation of the aorta and ehlers danlos
syndrome.
46. History of falls, alcohol excess, episodes of confusion, headache
and focal neurological points are commonly found in subdural
hemorrhage.
47. Neuroleptic malignant syndrome is dangerous condition in pts
taking antipsychotic drugs and commonly found in young.
48. Guillain Barre Syndrome is causes progressive weakness of all
four limbs.
49. The first line drug in consistent tonic-clonic seizers, absence
seizers and myoclonic seizers is (Sodium Valproate) and second
line is lamotrigine, carbamazepine and clonazepam.
50. The first line drug in Partial seizers is carbamazepine or
lamotrigine and second line is sodium valproate.
51. The condition classically found in young, over weight females
with papilloedema with normal neurologic findings most likely
diagnose is (Idiopathic intracranial hypertension).
52. Idiopathic intracranial hypertension is also known as
(pseudotumour cerebri).
53. Pts with Alzheimer usually have reduced production of (choline
acetyl transferase) which decreases acetylcholine synthesis
results impaired cortical cholinergic function.
54. Bradykinesia, postural instability and initial unilateral symptoms
are typical symptoms of (Parkinson’s).
55. In essential tremor symptoms eased by alcohol.
56. Essential tremor affects both upper limbs.

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 57. Sudden onset of dizziness and vertigo which triggered by
changing head position are findings of (Benign paroxysmal
positional vertigo).
58. Normal presser hydrocephalus is a reversible condition which
causes dementia seen in elderly people.
59. Pt presents visual disturbance with bitemporal hemianopia and
upper quadrants being affected is typical lesion of (Pituitary
macroadenoma).
60. Acetazolamide is used to prevent (high altitude cerebral edema)
e.g acute mountain sickness AMS.
61. Chorea and dementia are characteristics of (Huntington disease).
62. Dystonic movements or abnormal movements and postures with
normal birth and development are commonly present in
(Idiopathic Torsion Dystonia).
63. Progressive intellectual decline in elderly persons without
psychiatric disease is called (Dementia).
64. Young pt presents episodic neurologic findings and multiple foci
best visualized in MRI. These are findings of (Multiple Sclerosis).
65. Clinical findings of (MS) memory loss, optic neuritis and acute
myelitis.
66. Subacute combined degeneration of spinal cord in pernicious
anemia is due to (B12 deficiency).
67. Complete and irreversible cessation of all brain functions is called
(Brain death).
68. Disorder of the inner ear with unknown cause is called (Menier’s
disease).
69. Methylprednisolone and beta interferon reduces the acute relapse
in (MS).
70. AIDs dementia complex is caused by (HIV) virus itself.
71. Cryptococcus is most common fungal infection of (CNS).
72. A neuropsychiatric disorder which caused by thiamine deficiency
commonly found in alcoholics is (Wernick’s Encephalopathy).
73. In lewy body dementia symptoms worsen with neuroleptics.

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 74. Pts with Alzheimer’s disease presents 40% with lewy bodies.
75. In ischemic stroke pt commonly presents left hemiplegia and
initial treatment is (Aspirin).
76. Disease of central nervous system with upper motor neuron
dysfunction is typical sign of (Positive Hoffmans Sign).
77. Infection associated with Guillain Barre Syndrome is
(Campylobacter Jejuni).
78. Weber’s test tells sensorineural deafness.
79. Rinne’s test tells conductive deafness.
80. Chorea describes rapid, involuntary and jerky movements which
caused by damage of basal ganglia and moves from one body part
to another.
81. Gapapentin is first line drug in oscillopsia and neuropathy.
82. Acute confusional state is also known as (Delirium).
83. Initial first treatment choice in guillain-barre syndrome (GBS) is
IV immunoglobulins.
84. Myotonic dystrophy pt presents weakness, face reveals bilateral
ptosis, slow relaxing grip on hand shake and dysarthric speech.
85. In motor neuron disease non invasive ventilation will have
greatest effect on survival.
86. Vigabatrin is an anti-epileptic drug which causes visual field
defects.
87. Serum ferritin deficiency is most commonly cause of (secondary
restless leg syndrome).
88. Excessive copper deposition in tissues is a characteristic of
(Wilson disease).
89. The disorder of inner ear of unknown cause is characteristic of
(menieres disease).
90. Betahistine is a drug which is helpful to prevent attacks of
(Menieres disease).
91. Genetically DM1 and DM2 are two types of myotonic dystrophy.
92. TIA lasts greater than 60 minutes and scores 2 of ABCD2
prognostic scoring system.

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 93. Lesion of dorsal midbrain is called (Parinaud syndrome).
94. Impaired vertical gaze is seen in (progressive supranuclear palsy).
95. First line drug of neuropathic pain is amitriptyline and
gabapentin or pregablin.
96. Absence seizers commonly found in children.
97. Postural hypotension, inability to sweat and impotence are
characteristics of (autonomic neuropathy).
98. 5-HT receptor agonists are used in acute treatment of (Migraine).
99. 5-HT receptor antagonists are used as prophylaxix of (Migraine).
100. The major risk factor in carpal tunnel syndrome is obesity.
101. Systemic lupus erythematous is least cause raised protein levels
in CSF and conditions which are associated raised protein levels
in CSF are guillain-barre syndrome, tuberculous, bacterial and
fungal meningitis and viral encephalitis.

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 CHAPTER-05

Nephrology & Urology

Polycystic Kidneys

Most likely scenario: 35years old male came to ER with complain

of

painless hematuria. Pt is hypertensive and exam is

unremarkable. Blood test were Na+ 142 mmol/l K+ 4.2 mmol/l
Urea 18.9 mmol/l Creatinine 230 umol/l. He told his father was
on dialysis previously.The ultrasound demonstrates 3 cysts on
his right kindey and 5 cysts on left kidney.

Note: ADPKD autosomal dominant inherited polycystic kidney

disease is multisystem disorder which caused cyst formation and
enlargement in the kidney and other organs such as (spleen, liver
and pancreas). Pts with ADPKD requires renal replacement
therapy up to 50%. The renal ultrasound is choice of
investigation.

Minimal change Glomerulonephritis

Most likely scenario: A young pt of 15 years old presents with

bilateral ankle edema, his urine analysis shows protein++++ and
blood pressure was 105/70 mmHg.

Note: Points in favor of minimal change glomerulonephritis are

age 15 teenager, ankle edema, high proteinuria.

Management is steroids and second choice is cyclophosphamide.

Minimal change disease

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 Most likely scenario: 15 years old pt presents (generalized
edema). Pt’s urinalysis protein+++, eGFR is 110. Diagnose is the
minimal change disease.

Note: Here difference is generalized edema in young age. Minimal

change disease full recovers with frequent recurrent episodes.

Varicocele

Most likely scenario: 15 years old male presents painless swelling

in left scrotum and blue in color which can be compressed.
Diagnose is varicocele.

Epididymal Cyst

Most likely scenario: 35 years old man came to ER which presents

scrotal swelling and swelling is non tender like cyst. The cyst is
located the upper part of the posterior part of testis.

Note: Any abnormal finding on upper pole of posterior part of

testis is common site of epididymal pathology.

Nephrotic syndrome

Most likely scenario: 45 years old male pt presents pedal and

periorbital edema. Serum cholesterol 7mmol/l, 24 hours urine
analysis shows 8gm of protein per day. Renal biopsy has sent.

Note: Nephrotic syndrome features are proteinuria more than

3gm/24h, high cholesterol, edema and low albumin. In adults’
nephrotic syndrome commonly caused by (Membranous
Glomerulonephritis & focal segmental glomerulosclerosis).

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 Renal Artery disease

Most likely scenario: A 40 years old pt came to ER with chest

pain. His ECG shows anterior ST elevation and pt was
thrombolized with high blood pressure. Pt’s was on aspirin,
bisoprolol, ramipril and atrorvastatin. His blood screen reveals
Urea 22mmol/l Creatinine 277umol/l.

Or

A 65-year-old with type 2 diabetes mellitus and a heavy smoking

history is started on (ACEI) for high blood pressure.

His creatinine subsequently doubles from 100 µmol/l to 200

µmol/l.

Note: Renal artery disease is most common pts with

atherosclerotic ischemic renal disease main cause is the
hypertension and rise in creatinine to recognize.In young pts
commonly presents fibromuscular dysplasia especially in young
women. MR angiography is now the choice of investigation.

Renal stones

Most likely scenario: A 55 years old female pt presents with 3rd

episode of urinary tract infection (UTI) and right loin pain. She
has history of hypertension and she told that a month ago her
creatinine was elevated at 147 mmol/l. An ultrasound of urinary
tract reveals right staghorn calculus.

Note: Kidney stones formed by the urea splitting bacteria in

which proteus is common. Staghorn calculi are form of large
calculi which may have significant impact on renal function.

Treatment is to treat the UTI and consult to urologist to remove

the larger stones.

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 Hemolytic uraemic syndrome

Most likely scenario: A 30 year old man presents to hospital

feeling unwell with a few days history of diarrhoea and abdominal
pain. He reports having eaten at a (burger shop) a few days ago.

He has no previous hospitalisations. His initial laboratory tests

show new onset renal impairment, anaemia and low platelets. His
clotting is normal.

Note: Hemolytic uraemic syndrome is a syndrome composing of

the triad of:

Microangiopathic haemolytic anaemia 2. Low platelets 3. Renal

failure

Main pathogen which causes hemolytic uraemia is Escherichia

coli.

Rhabdomyolysis

Most likely scenario: An old homeless male was found stuporous

and smelling of alcohol.

Observations in the emergency department reveal a core

temperature of 34°C, a pulse of 50 bpm and blood pressure of
116/80 mmHg. Dipstick urine analysis shows blood +++.

Some of his investigations are listed:

Creatinine 320 µmol/l (60-110)

Gamma GT 40 U/l (10-40)

AST 550 U/l (1-40)

LDH 1500 U/l (10-250)

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 Urine microscopy no cells or organisms

Note: Rhabdomyolysis is strongly suggested by the fact that

urinalysis is strongly positive for blood, whereas urine
microscopy is negative for red blood cells. Here pt was
unconscious with elevated serum creatinine is most likely due to
rhabdomyolysis.

IgA nephropathy

Most likely scenario: A 60 years old man with longstanding

hypertension was found to have a serum creatinine concentration
of 275 µmol/L (60- 110).

Urinalysis showed blood ++ and protein >1 g/L. Renal ultrasound

showed the left kidney to be 9.2 cm long, the right to be 8.9 cm
long (normal range for both kidneys 10-12 cm), and neither
kidney was obstructed.

Note: The presence of long standing hypertension, haematuria,

significant non-nephrotic proteinuria is highly suspicious of
glomerular abnormality such as IgA nephropathy which is best
characterised by a renal biopsy.

Membranous nephropathy

Most likely scenario: A 45y old woman patient presents to the

medical intake with bilateral leg swelling.

Urine dipstick shows 4+ proteins and serum albumin is 14 g/l

(normal range 35-50 g/l). Renal function is within normal range.

Further urinalysis indicates nephrotic-range proteinuria. Further

to this a renal biopsy is performed which shows thickened
glomerular capillary loops.

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 Note: Infectious causes of membranous nephropathy include:

Hepatitis B, Hepatitis C, Syphilis and Malaria.

Membranous glomerulonephritis

Most likely scenario: A 65y old man with a history of (non-small

cell lung cancer) was treated with a right lower lobectomy 12
months ago.

He had an abdominal CT scan one month ago which revealed

hepatic mass lesions and hilar lymphadenopathy. He now
presents with malaise and fatigue.

His results show:

Urinalysis Protein +++

24 hour urine protein 2.7 g/24hr

Serum urea 30 mmol/L (2.5-7.5)

Serum creatinine 450 µmol/L (60-110)

A renal biopsy shows focal deposition of IgG and C3 with a

granular pattern.

Note: Just remember that Membranous GN is associated most

important with malignancy and elderly pts males are more
common than females.

Systemic lupus erythematosu (SLE)

Most likely scenario: A 23y old female presents with joint pains
and rash. On examination her blood pressure was 140/100
mmHg. Investigations reveal: Creatinine 90 µmol/l (60-110), Anti

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 dsDNA antibodies strongly positive (0-73), 24 hour urinary
protein excretion 1.7 g (<0.2).

Note: The renal manifestations of SLE are highly variable, ranging

from mild asymptomatic proteinuria or haematuria to rapidly
progressive uraemia.

Goodpasture’s Syndrome

Most likely scenario: A young pt 26y old male presents

hemoptysis. Pt is non smoker no respiratory history. Pt was
lethargic and anorexic. Bronchoscopy sent and Blood tests
reveals as: Na 141mmol/l K 5.3mmol/l Urea
16.7mmol/l Creatinine 271umol/l

A renal biopsy shows (linear IgG deposits) along basement

membrane.

OR

A 25 years old male presents worsening renal function so a renal

biopsy advised which reveal (linear IgG deposits) along with the
basement membrane.

Note: Just remember the renal biopsy with linear IgG deposits
with basement membrane this is major hint here. Goodpasture’s
syndrome is associated with two conditions one is pulmonary
hemorrhage and the other is progressive glomerulonephritis. The
cause of this condition is (anti GBM).

Amyloidosis

Most likely scenario: A 65y old woman presents ankle swelling

and leg edema. She has history of rheumatoid arthritis since 10
years and she was previously diagnosed with type DM. she is

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 taking metformin and methotrexate. Her 24 hours urinary
protein is 4.9g.

Note: In amyloidosis pt develops inflammatory at lower limb and

rheumatoid arthritis. This pt has developed nephrotic syndrome
secondary to amyloidosis.

MCQS Solving Quick targeted bullets

1. Thrombocytopenic purpura (TTP) is combination of renal failure,

thrombocytopenia and pyrexia.
2. Hemolytic uremic syndrome usually seen in youngers with triad
of acute renal failure, thrombocytopenia and hemolytic anemia.
3. IgA nephropathy is also called Bergers desease or
mesangioproliferative glomerulonephritis which commonly causes
glomerulonephritis and typically presents in youngers with
hematuria.
4. Peritoneal dialysis (PD) is kind of renal replacement therapy
which is most commonly caused by staph epidemidis and
another causes is staph aureus.
5. Primary hyperaldosteronism is caused by an aldosterone
adenoma producing and known as (conn’s syndrome).
6. Allopurinol reduces the formation of uric acid stones.
7. Pyridoxine and cholestyramine reduces the oxalate stone
formation.
8. Calcium stones formation occurs due to hypercalciuria and can
be reduced by thiazide diuretics.
9. Cystinuria is a risk factor for renal stone formation.
10. Nephrotic syndrome commonly presents with hematuria and
hypertension.
11. When prescribing fluids, the potassium requirement per day is 1
mmol/kg/day
12. Renal stones on x-ray are as follows:

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 13. A). cystine stones: semi-opaque
14. B). urate + xanthine stones: radio-lucent
15. Membranoproliferative glomerulonephritis (mesangiocapillary)
types
16. Type 1: cryoglobulinaemia, hepatitis C
17. Type 2: partial lipodystrophy
18. Alfacalcidol is used as a vitamin D supplement in end-stage renal
disease because it does not require activation in the kidneys.
19. The time taken for an arteriovenous fistula to develop is 6 to 8
weeks.
20. Minimal change disease is the most common cause of nephrotic
syndrome in a child.
21. Tolvaptan is a vasopressin receptor 2 antagonist.
22. Proteus mirabilis infection predisposes to struvite kidney stones.
23. Stag-horn calculi are composed of struvite and form in alkaline
urine (ammonia producing bacteria therefore predispose).
24. Young female, hypertension and asymmetric kidneys →
fibromuscular dysplasia.
25. CKD on haemodialysis - most likely cause of death is IHD.
26. Calciphylaxis lesions are intensely painful, purpuric patches with
an area of black necrotic tissue that may form bullae, ulcerate,
and leave a hard, firm eschar.
27. Prevention of contrast-induced nephropathy: volume expansion
with 0.9% saline.
28. Nephrotic syndrome is associated with a hypercoagulable state
due to loss of antithrombin III via the kidneys.
29. ADPKD type 1 = chromosome 16 = 85% of cases.
30. Cytomegalovirus is the most common and important viral
infection in solid organ transplant recipients.
31. Coagulase-negative Staphylococcus is the most common cause of
peritonitis secondary to peritoneal dialysis.
32. Other causes of HUS include S. pneumoniae, Shigella (type 1 and
3), HIV and Coxsackie virus.

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 33. Haemolytic uraemic syndrome - classically caused by E coli
0157:H7.
34. Goodpasture's syndrome - IgG deposits on renal biopsy - anti-
GBM antibodies.
35. Nephrotic syndrome - malignancies cause membranous
glomerulonephritis.
36. Micturating cystography is the investigation of choice for reflux
nephropathy.
37. hCG is associated with testicular seminomas.
38. Ultrasound is the screening test for adult polycystic kidney
disease.
39. Antimuscarinic drugs are useful in patients with an overactive
bladder.
40. ADPKD type 2 = chromosome 4 = 15% of cases.
41. Arteriovenous fistulas are the preferred method of access for
haemodialysis.
42. Renal transplant HLA matching - DR is the most important.
43. Alport's syndrome - type IV collagen defect.
44. Nephrogenic diabetes insipidus may be caused genetic
mutations.
45. The more common form affects the vasopression is (ADH)
receptor
46. The less common form results from a mutation in the gene that
encodes the aquaporin 2 channel.
47. Contrast-induced nephropathy occurs 2 -5 days after
administration.
48. In Ascites - use spironolactone.
49. Guidelines continue to recommend the use of IM diclofenac in the
acute management of renal colic.
50. Renal cell carcinoma can cause liver dysfunction in particular
cholestasis and hepatosplenomegaly.
51. Urine output of < 0.5 ml/kg/hr over 6 consecutive hours
constitutes an acute kidney injury.

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 52. Uric acid nephrolithiasis are radiolucent, requiring
ultrasonography or CT KUB (without contrast).
53. Mesangiocapillary glomerulonephritis (membranoproliferative).
54. Type 1: cryoglobulinaemia, hepatitis C
55. Type 2: partial lipodystrophy
56. Urine dip can be used to differentiate acute tubular necrosis from
acute interstitial nephritis in AKI.
57. The mainstay of rhabdomyolysis treatment is rapid IV fluid
rehydration.
58. Flash pulmonary oedema, U&Es worse on ACE inhibitor,
asymmetrical kidneys → renal artery stenosis - do MR
angiography.
59. Rapidly progressive glomerulonephritis, causes:
A) Goodpasture's
B) ANCA positive vasculitis
60. Chronic Kidney Disease often leads to anaemia due to reduced
levels of erythropoietin.
61. Eplerenone can be used in patients with troublesome
gynaecomastia on spironolactone.
62. PSGN develops 1-2 weeks after URTI. IgA nephropathy develops
1-2 days after URTI.
63. Sterile pyuria and white cell casts in the setting of rash and fever
should raise the suspicion of acute interstitial nephritis, which is
commonly due to antibiotic therapy.
64. ADPKD is associated with hepatomegaly (due to hepatic cysts).
65. ATN or prerenal uraemia? In prerenal uraemia think of the
kidneys holding on to sodium to preserve volume.
66. Diffuse proliferative glomerulonephritis is the most common and
severe form of renal disease in SLE patients.
67. Diffuse proliferative glomerulonephritis, causes:
A) post-streptococcal
B) SLE

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 68. Fanconi syndrome is a reabsorptive defect in PCT where there is
increased excretion of nearly all amino acids, glucose,
bicarbonate and phosphate.
69. Gentamicin causes an intrinsic AKI.
70. In AKI, hyperkalaeamia which is refractory to medical
management is an indicator for renal replacement therapy.
71. ADPKD is associated with mitral valve prolaspe.
72. Rhabdomyolysis should always be considered in the setting of
lactic acidosis, hyperkalaemia and features of acute tubular
necrosis.
73. Amyloidosis biopsy findings - Congo red stain shows apple-green
birefringence under polarised light.
74. Spironolactone acts on the cortical collecting ducts as a diuretic.
75. eGFR variables - CAGE - Creatinine, Age, Gender, Ethnicity.
76. Idiopathic membranous glomerulonephritis is related to anti-
phospholipase A2 antibodies.
77. Alport's syndrome - X-linked dominant (in the majority).
78. Finasteride treatment of BPH may take 6 months before results
are seen Stag-horn calculi.
79. composed of Struvite (ammonium magnesium phosphate, triple
phosphate).
80. form in alkaline urine (ammonia producing bacteria such as
Ureaplasma urealyticum and Proteus. therefore predispose).
81. Ureterosigmoidostomy - normal anion gap metabolic acidosis.
82. A common complication of plasma exchange is hypocalcaemia.
83. The presence of upper respiratory tract signs points towards
granulomatosis with polyangiitis in a patient with rapidly
progressive glomerulonephritis.
84. Minimal change glomerulonephritis – prednisolone.
85. NSAIDs and ACE-inhibitors/ARB cause prerenal acute kidney
injury by decreasing the glomerular filtration.
86. Nephrotic syndrome in children / young adults - minimal change
glomerulonephritis.

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 87. Rhabdomyolysis can cause parenchymal acute kidney injury and
is characterised by elevated plasma creatine kinase (CK).
88. Consider fibromuscular dysplasia in young female patients who
develop AKI after the initiation of an ACE inhibitor.
89. NSAIDs should be stopped in AKI except aspirin at cardio-
protective dose.
90. Renal tubular acidosis causes a normal anion gap.
91. Use of 0.9% Sodium Chloride for fluid therapy in patients
requiring large volumes = risk of hyperchloraemic metabolic
acidosis.
92. Patients who have received an organ transplant are at risk of skin
cancer (particularly squamous cell carcinoma) due to long-term
use of immunosuppressants.
93. CKD: only diagnose stages 1 & 2 if supporting evidence to
accompany eGFR.
94. Renal cell carcinoma can metastasise to the lungs, and remains
an important differential in the setting of hypertension,
hypercalcaemia and haematuria.

Chapter–06
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 Infectious Diseases

Chicken Pox

Most likely scenario: A 45yrs old male has developed blisters on

his trunk and has temperature 39C. Pt is delirious. Few days ago
He travelled to Nigeria. Pt is feeling well and not on any
medication.

Note: Distribution of blisters and travelling to third world country

favors (chicken pox). In chicken pox adults develop general brain
inflammation called encephalitis whose symptoms can be
delirium or seizers. Remember in adults after exposure to
varicella or herpes zoster rash chicken pox has incubation period
of 10-21 days.

Erythema migrans

Most likely scenario: A 35y old male pt developed an itchy scaly

annular rash on his thigh after a walk in a park near by sea.

Note: Developing an itchy scaly annular rash after a walk in park

commonly indicates erythema migrans which transmitted by bite
of pinhead sized ticks leading to lyme disease caused by
(spirochete borrelia burgdorferi).

Treatment is doxycycline.

Plasmodium ovale or vivex infection

Most likely scenario: A 45y Asian male presents long history of

fever with rigors and chills for last one year on and off. His blood
test reveals ring form plasmodium with schuffners dots inside
RBCs.

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 Note: Schuffners dots in RBCs indicate plasmodium ovale or
vivex infection. Premaquine is the drug of choice which can
eradicate this plasmodium from liver cycle.

Tuberculosis

Most likely scenario: A 35 years old female presents with weight

loss, cough, fever and enlarged cervical lymph nodes. O/E:
Caseating granulomata found in lymph nodes. She recently
travelled to India.

Note: weight loss, night sweats, fever, cough, cervical

lymphadenopathy, caseating granulomata and travelling to
populated developing country indicates diagnosis of TB. And
causing organism is mycobacterium tuberculosis.

Sepsis

Most likely scenario: A 65y old woman presents to ER with fever,

hypotension and tachycardia. Pt has no any medical history but
she had reports rashes and lips swelling due to penicillin.

Note: Pt has severe sepsis as she presents fever, tachycardia and

hypotension. The diagnostic test is blood culture and current
guidelines suggest that severe sepsis most commonly cause is
Staph aureus and treatment regimen must cover MRSA if
penicillin is allergic. Here is recommended treatment is IV
vencomycin and low dosage of gentamicin.

Chlamydia

Most likely scenario: A 22y young man presents with (Dysuria)

along with watery discharge from (urethal meatus). Urethral swab

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 reveals urethritis (non specific) and urine has sent to lab for
Gonococcus/Chlamydia.

Note: As Chlamydia commonly presents dysuria in men and in

women cervicitis & dysuria. Here swab shows non-specific
urethritis most likely diagnose is Chlamydia. The causative is
gram negative diplococcic and treatment is doxycyline or
azithromycin.

Legionella

Most likely scenario: A 35y old woman presents to ER with fever,

flu like symptoms, dry cough and confusion. She has recent
travelling history from Cyprus. Blood test shows hyponatremia
and deranged LFTs; CXR shows patchy alveolar infiltrates with
consolidation in right lung lobe.

Note: legionella presents severe pneumonia like symptoms and is

caused by (intracellular bacterium legionella) which commonly
colonizes in water tanks or pools. Here indication is foreign
holidays.

Diagnostic test is urinary antigen and recommended treatment is

erythromycin.

Shigella

Most likely scenario: 23 people are on a Nile boat cruise and five
people present one week into their cruise with diarrhea.

Note: The most likely organism from this history is Shigella which
accounts for approx 15% of all traveler’s diarrhea.

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 Leishmaniasis

Most likely scenario: A 30y old pt soldier who returned from

Afghanistan few months ago. Pt develops a large painless ulcer
on his back of hand. O/E: he has 3.5cm ulcer with central
depression. He is well and has no other medical issues.

Note: As given travel history to and painless single lesion this is

common presentation of cutaneous leishmaniasis which
transmitted by sand flies commonly presents as papule or an
erythematous patch which slowly enlarges and becomes an ulcer.

Hepatitis B

Most likely scenario: A 35y old male pt presents with

decompensate liver disease of unknown etiology. Liver screen
shows Anti-Hbs positive, Anti-Hbc negative, Hbs antigen
negative.

Note: surface antigen is very 1st marker to appear and it produce

(Anti-Hbs) which implies immunity and negative in chronic
disease. If HbsAg presents for one to six months it implies acute
disease. So therefore diagnose is hepatitis B.

Lyme disease

Most likely scenario: A 21y old man presents with an annular

rash along with polyarthralgia and pyrexia. He returns from
woods and remembers being bitten by tick.

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 Note: Lyme disease is caused by tick bite which transmitted
(spirochaete borrelia burgdorferi).

Malaria

Most likely scenario: A 34 year old man returned from Ghana and
presents cyclical fever and headache. O/E: splenomegaly was
found. A blood for MP was suggested which shows plasmodium
ovale malaria.

Note: Plasmodiumovale is typically found from Africa and

plasmodium vivax found from central America and South Asia e.g
India. These both types should be treated with primaquine
following chloroquine.

Meningitis

Most likely scenario: A 46y old male pt presents three days

history of fever and headache otherwise pt is normal and fit with
no any medical history. O/E: Nuchal rigidity found. His serum
glucose level is 3.9 mmol/l. Pt sent for lumbar puncture.

Note: If CSF shows low glucose, high protein and high

polymorphs. Simply recall if there is low glucose and high protein
it means bacterial meningitis and if there is high glucose and low
protein its viral meningitis. In this age group which is given in
scenario (streptococcus pneumonia and Neisseria meningitis) is
most likely causes bacterial meningitis.

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 Neisseria meningitis

Most likely scenario: A 19y old female was admitted with

suspected meningitis. The initial lumbar puncture microscopy of
culture tells that there is gram negative Diplococci is growing.

Note: Here in this age group Neisseria meningitis and

Streptococcus pneumoniae is most commonly found.

And remember Neisseria meningitis is gram negative diplococcic.

Strep. Pneumoniae is gram positive diplococcic.

E. coli is gram negative bacilli.

H. Influenza is gram negative coccobacilli.

L. monocytogenes is gram positive rod.

Meningitis age related causes are as follows

0 to 3 months= most common cause here is streptococcus in

(neonates) while E. coli and Listeria monocytogenes are rare.

3 months to 6 years= Neisseria meningitis is very common and on

second are Strep. Pneumonia and Hemophilus influenza.

6 to 60 years= N. meningitis and strep. Pneumonia.

60 + years= Strep. Pneumonia and N. meningitis.

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 Immunosuppressed individuals= Listeria monocytogenes.

Herpes Simplex

Most likely scenario: A 22y old man presents multiple painful

ulcers on the shaft of his penis. O/E: He has tender and enlarged
inguinal lymph nodes bilaterally. Pt tells he has had a new sexual
partner recently but she has no any symptoms. Pt denies
dysuria.

Note: Here pt has changed sexual partner recently and has

painful genital ulcers is indicates herpes simples. While in
Syphilis, donovanosis(granuloma inguinal) and
Lymphogranuloma venereum cause painless genital ulcers.

Bacterial Vaginosis

Most likely scenario: 32y old female pt presents with white

(Malodorous vaginal discharge). Pt has no itch or dyspareunia.

Note: BV is defined as an outgrowth of anaerobic organism such

as (Gardnerella vaginalis), this cause fall in lactic acid producing
aerobic lactobacilli which results raised in vaginal pH >4.5, with
white homogenous discharge. BV is not a STD and management
is oral metronidazol for a week.

Tetanus

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 Most likely scenario: A 30y old male presents with fever,
headache and lethargic with trismus (lock jaw). Pt told he had
injured few months ago.

Note: Tetanus presents in soil and can be transmit into body

from a wound and caused by clostridium tetani.The management
is IV metronidazol.

Cellulitis

Most likely scenario: A 45y old female pt presents with a rash on

his left shin, which is growing in size and have painful, hot
erythematous area on her left shin and skin has been infalmmed.
Pt has T2DM since 10 years.

Note: Cellulitis is described as an inflammation of skin or

subcutaneous tissues, which commonly occurs in shins and
caused by Strep. Pyogenes or Strep. Aureus. The first line drug is
Flucloxacillin.

Dengue fever

Most likely scenario: A 27y old female pt presents with onset of

fever, joint pain, headache and rash on her limbs. Pt came from
Dominica. CBC shows low platelets.

Note: Dengue fever is commonly present in South America also in

East Asia and presents with arthralgia, rashes, low platelets and
in severe cases Dangue hemorrhagic fever.

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 Myocarditis

Most likely scenario: A 35y old African decent admitted to ER

following a collapse in his bed room. Pt is known to have a
Chagas disease.

Note: Chagas disease is known to cause cardiac deaths. There are

2 main protozoa one is called African trypanosomiasis (sleeping
sickness) second is American trypanosomiasis (chagas disease).

Cerebral Toxoplasmosis

Most likely scenario: A 45y old HIV positive pt presents confusion

and drowsiness. Pt was complaining of headache for many days.
O/E: Blood pressure 105/75mmHg, Heart rate 95/minute and
temp is 37.2 C. his GCS score is 14. There is no neck stiffness or
photophobia. CT brain shows multiple hypodense regions in the
basal ganglia which indicates ring enhancement, no mass effect
with minimal edema.

Note: The cerebral toxoplasmosis is most commonly found

neurological infection in HIV. Symptoms are confusion,
drowsiness and headache. CT shows multiple ring enhancing
lesions.

Treatment: Sulfadiazine and pyrimethamine.

Staphylococcal toxic shock syndrome

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 Most likely scenario: A 45y old male famer presents with high
temp and confusion. O/E: His BP was 84/56 mmHg, pulse was
120 bpm and temp 39.8 C. He has generalized erythematous
rash on his palms and a paronychial infection on his left
fingernail.

Note: STSS is a severe systemic reaction to staphylococcal

exotoxins. The main fever, temp, hypotension, erythematous
rash, especially on palms and soles.

Necrotising fascilitis

Most likely scenario: A 47y old male pt presents severe pain in

the perineal area for few hours. O/E: Cellulitis on skin tender
and hemorrhagic bullae are seen.

Note: Necrotising fasciitis is a medical emergency that is difficult

to recognize and surgical referral is single most initial step. Type
1 is caused by mixed anaerobes and aerobes often occurs post
surgeical diabetics. Type 2 is caused by (Streptococcus
pyogenes).

Methicillin-resistant Staphylococcus Aureus (MRSA)

Most likely scenario: There was a call of meeting to all medical

staff in hospital management. The meeting motto is how to tackle
with a sudden an increased incidence of MRSA septicemia in
hospital. What is the single most step to reduced the MRSA
incidence.

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 Note: MRSA is one of first organisms which were noticed as the
danger of hospital acquired infections and hand hygiene is the
single most important step to reduce it.

Chikungunya

Most likely scenario: A 35y old male presents with high grade
fever, headache and severe joint pain. Pt recently came from
Kenya. Pt is on malarial pills. His blood reports shows Hb 180g/l,
platelates 300 * 10/l, WBC 6 * 10/l.

Note: Here indication is severe joint pain, high fever and

travelling history to Africa. These are main features of
Chikungunya.

Gonorrhea

Most likely scenario: A young 25y old man complains of purulent

urethral discharge. A sample of discharge has taken which
results (Gram negative diplococcus).

Note: The main features of gonorrhea are in male is dysuria and

urethral discharge and in females (cervicitis) which leads to
vaginal discharge. In gonorrhea rectal or pharyngeal infections
are asymptomatic.

Streptococci

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 Most likely scenario: Teenagers female presents with complain of
sore throat. O/E: There were seen inflamed tonsils covered in
white patches, cervical lymphadenopathy and low grade fever.

Note: Here causative organism is Strep. Pyogenes. Streptococci

are gram positive which can be divided into two types Alpha and
beta hemolytic types.

Alpha hemolytic streptococci a (partial hemolysis)

In this chain of alpha hemolytic streptococcus the main

important organism is pneumococcus or strep. Pneumonae which
commonly cause (pneumonia), (meningitis) and (otitis media).

Beta hemolytic Streptococci (complete hemolysis)

In beta hemolyctic streptocci the main organism is Streptococci

pyogenes, which is responsible for impetigo, erysipelas, cellulitis,
pharyngitis/tonsillitis and type two necrotizing fasciitis. While
the Strep. Agalactae is commonly caused neonatal meiningitis
and septicemia.

Staphylococci

Most likely scenario: A 45y old male was admitted in ICU

following acute pancreatitis episode and pyrexia. The culture and
sepsis screen ordered which shows a bacterial infection of
Staphylococcus epidermidis. The CXR shows no any infection.

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 Note: Staphylococci are gram positive bacteria and main types of
staphylococci we need to know which are Staph. Aureus and
Staph. Epidermidis.

The Staph. Aureus causes skin infections such as (cellulitis),

abscesses, osteomyelitis and toxic shock symdrome.

Quick MCQ solving Bullets

1. Chlamydia infection in the non-pregnant pt is usually treated

with a tetracycline or ezythromycin.

2. Chlamydia with pregnant pt is usually treated amoxicillin.

3. Cattle are a major reservoir of Escherichia coli O157:H7 and

contaminated meat is the most commonly implicated source of
outbreaks of diarrhea.

4. A white cell count of 50 in CSF findings would exclude partially

treated meningitis.

5. Non-sputum producing patients are commonly non-infectious

with (Mycobacterium tuberculosis).

6. Gonorrhoea the first line therapy is ceftriaxone or cefixime.

7. Brucellosis is a recognized cause of spondylitis.

8. Brucellosis is a zoonosis, spreading from infected animals

particularly cattle.

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 9. Chlamydia psittaci is endemic in birds including psittacine birds,
canaries, finches, pigeons and poultry.

10. Oral clindamycin is recommended for penicillin allergic patients

where prophlyaxis is required against infective endocarditis.

11. Acyclovir is a synthetic purine nucleotide analogue and as such

is a specific inhibitor of herpesvirus DNA polymerase.

12. Giardia lambdia infection causes steatorrhoea.

13. Whooping cough (pertussis) is caused by the bacterium

Bordetella pertussis which may lead to hemiplegia.

14. Varicella-Zoster infection causes Herpes Zoster and Chicken Pox.

15. If an old age person needs immunization booster now (herpes

zoster) is must recommended as an additional vaccine.

16. Anti-tuberculous therapy that included isoniazid which may

increase the risk of (hepatitis).

17. Man returns from trip abroad with maculopapular rash and flu-
like illness - think HIV seroconversion.
18. Infectious mononucleosis is generally a self-limiting condition.
19. The Jarisch-Herxheimer reaction is a known phenomenon
following syphilis treatment that does not require any specific
treatment or investigations other antipyretics.
20. Haematuria + bladder calcification → schistosomiasis.
21. IV ceftriaxone should be used as first-line treatment of Lyme
disease with disseminated or central nervous system
involvement.

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 22. Disseminated gonococcal infection triad = tenosynovitis,
migratory polyarthritis, dermatitis.
23. All patients with a CD4 count lower than 200/mm3 should
receive prophylaxis against Pneumocystis jiroveci pneumonia.
24. Eikenella is notable as a cause of infections following human
bites.
25. False positive VDRL/RPR: antiphospholipid syndrome can cause
a false positive syphilis test due to cardiolipin antibodies.
26. Staphylococcus aureus is associated with cavitating lesions when
it causes pneumonia.
27. Pneumocystis jiroveci penumonia is treated with co-trimoxazole,
which is a mix of trimethoprim and sulfamethoxazole.
28. Lassa fever is contracted by contact with the excreta of infected
African rats (Mastomys rodent) or by person-to-person spread.
29. Ciprofloxacin promotes acquisition of MRSA.
30. Mycoplasma is associated with erythema multiforme.
31. HIV antibody testing is most reliable 3 months post exposure.
32. HIV, neuro symptoms, widespread demyelination - progressive
multifocal leukoencephalopathy.
33. The BCG vaccine is unreliable in protecting against pulmonary
tuberculosis.
34. Streptococcus pneumoniae is associated with cold sores.
35. Granuloma inguinale - Klebsiella granulomatis.
36. Animal bite - co-amoxiclav.
37. Post-exposure prophylaxis for HIV: oral antiretroviral therapy for
4 weeks.
38. Diabetes is the strongest risk factor for the development of
melioidosis.
39. Bilateral conjunctivitis, bilateral calf pains and high fevers in a
sewage worker suggests leptospirosis.
40. If a sexually active patient presents with genital chlamydia and
bowel symptoms, LGV proctocolitis should be considered.
41. Listeria monocytogenes - Gram-positive rod.

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 42. Non specific (non gonococcal) urethritis is a common
presentation where inflammatory cells but no gonococcal bacteria
are seen on swab; it requires treatment with doxycycline or
azithromycin.
43. Asymptomatic bacteriuria should not be treated except in
pregnancy, children younger than 5 years or immunosuppressed
patients due to the risk of complications.
44. Hookworms may cause an iron deficiency anaemia in patients
returning from travel to endemic areas e.g. the Indian
subcontinent.
45. Schizonts and late stages of trophozoites are typically sequested
in Plasmodium falciparum infection and their presence on the
peripheral smear indicates severe disease.
46. Patients with peritonsillar abscesses can develop Lemierre's
syndrome (thrombophlebitis of the IJV)- this can present with
neck pain, and can result in septic pulmonary embolism.
47. Kaposi's sarcoma - caused by HHV-8 (human herpes virus 8).
48. Immune reconstitution inflammatory syndrome can occur in HIV
positive patients when starting anti-retrovirals; this is an
immune phenomenon that results in the clinical worsening of a
pre- exisiting opportunistic infection.
49. Schistosoma haematobium causes haematuria.
50. Severe falciparum malaria - intravenous artesunate.
51. Dengue is transmitted by the Aedes aegypti mosquito.
52. One of the sequelae of diphtheria is cardiovascular disease;
notably heart block.
53. Trypanosomiasis: African-form causes sleeping sickness and
American-form causes Chagas' disease.
54. Chikungunya can present with debilitating joint pain.
55. Legionella pneumophilia is best diagnosed by the urinary antigen
test.
56. Leptospirosis - give penicillin or doxycycline.
57. Tetracyclines can cause photosensitivity.

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 58. Human bites, like animal bites, should be treated with co-
amoxiclav.
59. HIV: anti-retrovirals - P450 interaction = 1. Nevirapine (a
NNRTI): induces P450 2. Protease inhibitors: inhibits P450.
60. Bacterial vaginosis: oral metronidazole.
61. Atypical lymphocytes - glandular fever.
62. Amoebiasis should be considered in the presentation of dysentery
after a long incubation period.
63. HIV, neuro symptoms, multiple brain lesions with ring
enhancement – toxoplasmosis.
64. Rabies - following possible exposure give immunglobulin +
vaccination.
65. Primaquine is used in non-falciparum malaria to destroy liver
hypnozoites and prevent relapse Live attenuated vaccines = A)
BCG B) MMR C) oral polio D) yellow fever E) oral typhoid.
66. Clostridium - Gram-positive rod.
67. Macrolides such as clarithromycin are used to treat Legionella.
68. Gonorrhoea is a gram-negative diplococci that can be identified
on gram staining.
69. Benznidazole is used in the acute phase of Chagas' disease to
manage the illness.
70. Yellow fever - live attenuated.
71. HIV drugs, rule of thumb: = 1. NRTIs end in 'ine' 2. Pis: end in
'vir' 3. NNRTIs: nevirapine, efavirenz.
72. Staphylococcus saprophyticus can commonly cause UTI in
sexually active young women.
73. Immunocompetent patients with toxoplasmosis don't usually
require treatment.
74. Intramuscular ceftriaxone is the treatment of choice for
Gonorrhoea.
75. Animal bites are generally polymicrobial but the most common
isolated organism is Pasteurella multocida.
76. Hepatitis C - 55-85% become chronically infected.

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 77. Leprosy leads to skin hypopigmentation.
78. Renal transplant + infection? CMV.
79. Heterophile antibodies - infectious mononucleosis.
80. Staphylococcus aureus is a gram+ve bacterium, catalase +ve,
coagulase +ve organism.
81. Kaposi's sarcoma is caused by HHV-8 infection in HIV positive
individuals.
82. Stereotypical features of Legionella include flu-like symptoms and
a dry cough, relative bradycardia and confusion. Blood tests may
show hyponatraemia.
83. Supportive therapy is the mainstay of treatment in
Cryptosporidium diarrhea.
84. EBV: associated malignancies: = 1. Burkitt's lymphoma 2.
Hodgkin's lymphoma 3. Nasopharyngeal carcinoma.
85. Aspergilloma on x-ray may show a fungal ball cavity with a
crescent sign.
86. Azithromycin, erythromycin or amoxicillin may be used to treat
Chlamydia in pregnancy.
87. Coxiella presents may present with culture-negative endocarditis.
88. Cat scratch disease - caused by Bartonella henselae.
89. Amphotericin B binds with ergosterol, a component of fungal cell
membranes, forming pores that cause lysis of the cell wall and
subsequent fungal cell death.
90. Mycoplasma? - Serology is diagnostic.
91. ELISA is the first-line investigation for suspected Lyme disease in
patients with no history of erythema migrans.
92. HIV, neuro symptoms, single brain lesions with homogenous
enhancement - CNS lymphoma.
93. Treatment for invasive amoebiasis should be followed by a
luminal amoebicide to eradicate the cystic stage which is
resistant to metronidazole and tinidazole (which are used against
the invasive stage).
94. Schistosomiasis is treated with praziquantel.

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 95. Cryptosporidium can be diagnosed by modified Ziehl-Neelsen
staining of stool to reveal red cysts.
96. Enterococci - Gram-positive cocci.
97. Painless black eschar – anthrax.
98. Parasitaemia > 2% is a feature of severe malaria.
99. Japanese encephalitis can present with Parkinsonism- this is a
sign of basal ganglia involvement.
100. Bacillus cereus characteristically occurs after eating rice that has
been reheated.
101. Acute toxoplasmosis in the immunocompetent patient can mimic
acute EBV infection (low-grade fever, generalised
lymphadenopathy with prominent cervical lymph nodes and
malaise) and should be suspected with negative EBV serology.
102. Pregnancy testing and counselling is paramount due to the risk
of congenital toxoplasmosis.
103. False positive VDRL/RPR: 'SomeTimes Mistakes Happen' (SLE,
TB, malaria, HIV).
104. P. knowlesi has the shortest erythrocytic replication cycle,
leading to high parasite counts in short periods of time.
105. Shigella infection is usually self limiting and does not require
antibiotic treatment; antibiotics are indicated for people with
severe disease, who are immunocompromised or with bloody
diarrhea.
106. Chickenpox exposure in pregnancy - first step is to check
antibodies.
107. A ‘hot stool’ (a stool examined within 15 minutes of passage, or
kept warm) is required to make a microscopic diagnosis of
intestinal amoebiasis as once cooled Entamoeba histolytic
returns to its cystic state and becomes indistinguishable from the
non-pathogen Entamoeba dispar.
108. Amantadine - inhibits uncoating (M2 protein) of virus in cell. Also
releases dopamine from nerve endings.

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 109. Ribavirin - guanosine analog which inhibits inosine
monophosphate (IMP) dehydrogenase, interferes with the capping
of viral mRNA.
110. A-6 years - 60 years age group are at risk from meninigitis
caused by Streptococcus pneumonia.
111. Botulinum toxin inhibits the release of acetylcholine at synapses.
112. Anthrax presents with a black eschar that is typically painless; it
is treated with ciprofloxacin.
113. Latent syphilis (i.e asymptomatic syphilis) can occur at an early
and a late stage and requires the same antibiotic treatment.
114. Chancroid causes painful genital ulcers.
115. Severe manifestations of enteric fever include bowel perforation
and neurological complication. If these occur it is typically in the
third week of illness.
116. Mycoplasma pneumonia - treat with doxycycline or a macrolide.
117. Schistosomiasis is a risk factor for Squamous cell bladder cancer.
118. Genital wart treatment = 1. multiple, non-keratinised warts:
topical podophyllum 2. Solitary, keratinised warts: cryotherapy.
119. Aciclovir is much more specific for viral than mammalian DNA
polymerase.
120. Parvovirus is a common cause of fetal hydrops during pregnancy
and can be treated with fetal transfusion.
121. Mumps meningitis is associated with a low CSF glucose.
122. Anti-retroviral therapy for HIV is now started at the time of
diagnosis, rather than waiting for the CD4 count to drop to a
particular level.
123. Quinine is no longer recommended as a first-line treatment for
complicated/severe falciparum malaria.
124. First line treatment for early Lyme disease is a 14-21 day course
of oral doxycycline.
125. Tampon use is a risk factor for staphylococcal toxic shock
syndrome.

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 126. The Jarisch-Herxheimer reaction, unlike an anaphylactic
reaction, will not present with hypotension and wheeze.
127. Clostridium botulinum presents with flaccid paralysis, whereas
Clostridium tetani presents with spastic paralysis.
128. M. tuberculosis can cause hypoadrenalism.
129. URTI symptoms + amoxicillin → rash? Glandular fever.
130. Genital warts - 90% are caused by HPV 6 & 11.
131. Trimethoprim and co-trimoxazole should be avoided in patients
on methotrexate.
132. Aciclovir - guanosine analog, phosphorylated by thymidine kinase
which in turn inhibits the viral DNA polymerase.
133. Fever and the presence of a eschar in a patient returning from
South East Asia is strongly suggestive of scrub typhus (caused by
Orientia tsutsugamushi) and necessitates urgent treatment with
doxycycline.
134. Cutaneous leishmaniasis acquired in South or Central America
merits treatment due to the risk of mucocutaneous leishmaniasis
whereas disease acquired in Africa or India can be managed more
conservatively.
135. p24 testing can be used 4 week after an exposure and is often
used in combination with the HIV antibody test in clinical
practice.
136. Strongyloides stercoralis gains access to the body by penetrating
the skin.
137. Live vaccines given by injection may be either given
concomitantly or a minimum interval of 4 weeks apart to prevent
risk of immunological interference.
138. Moraxella catarrhalis - Gram-negative cocci.
139. Pneumocystis jiroveci pneumonia - pneumothorax is a common
complication.
140. Necrotising fasciitis should be suspected in the setting of a
rapidly worsening cellulitis with pain out of keeping with physical
features.

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 141. Dexamethasone improves outcomes in the treatment of bacterial
meningitis.
142. Chlamydia - treat with azithromycin or doxycycline.
143. Yellow fever typically presents with flu like illness → brief
remission→ followed by jaundice and haematemesis.
144. Thick blood films check for parasite burden, thin films allow for
speciation.
145. Chickenpox exposure in pregnancy - if not immune give VZIG.
146. Bacterial vaginosis - overgrowth of predominately Gardnerella
vaginalis.
147. Terbinafine inhibits the fungal enzyme squalene epoxidase,
causing cellular death.
148. Non-falciparum malaria (acute infection) , treatment of choice:
artemisinin-based combination therapy (ACT) or chloroquine.
149. Severe hepatitis in a pregnant woman - think hepatitis E.
150. Mucocutaneous ulceration following travel? - Leishmania
brasiliensis.
151. Telbivudine is a synthetic thymidine nucleoside analogue.
152. Nucleic acid amplification tests (NAATs) are the investigation of
choice for Chlamydia.
153. In the UK all HIV positive women should be advised not to
breastfeed.
154. Staph aureus is a coagulase positive Staph.
155. Neisseria gonorrhoeae - Gram-negative cocci.
156. Lymphogranuloma venereum - Chlamydia trachomatis.
157. Salmonella typhi infection can cause rose spots on the abdomen.
158. Following treatment for syphilis: TPHA remains positive, VDRL
becomes negative.
159. Aerosolized pentamidine is an alternative treatment for
Pneumocystis jiroveci pneumonia but is less effective with a risk
of pneumothorax.

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 160. Genital ulcers = 1). Painful: herpes much more common than
chancroid. 2). Painless: syphilis more common than
lymphogranuloma venereum.
161. E. coli is the most common cause of travellers' diarrhea.
162. Amoxicillin is an alternative to treat early Lyme disease if
doxycycline is contraindicated such as in pregnancy.
163. Pubic lice can be treated with either malathion or permethrin.
164. Exchange transfusion should be considered in cases of severe
parasitaemia (>10%).
165. Pneumonia in an alcoholic – Klebsiella.
166. Recurrent herpes outbreaks in pregnancy should be treated with
suppressive therapy; risk of transmission to the baby is low and
aciclovir is safe to use in pregnant women.
167. Cephalosporins are a type of beta-lactam.

Chapter-07

Pediatrics

Bronchiolitis

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 Most likely scenario: A 7 month old child presents in ER with
fever and cough. O/E: temperature is 39C. mother told child is
feeding poorly and baby has difficulty in breathing.

Note: This scenario is typical in children and diagnosis is

bronchiolits. If there is same scenario in adult we will diagnose
bronchitis because it’s very common in young. The management
of this pt will be oxygen inhalation and nasogastric feeding. There
is no need of bronchodilators, steroids or antibiotics in routinely
because chest congestion has not been described in question.
Reference: OHCS, 9th edition, page 160.

When to call anesthesiologist

Most likely scenario: A 16 month old child presents with sore

throat, drooling, loss of voice and have fever.

Note: Here we needed urgent intubation to secure airway so call

to anesthesiologist for the procedure.

What to do when child is not immunized

Most likely scenario: A child presents with clean wound, but child
has never been immunized as his parents were worried about it
and there is no any contraindication to immunization. The best
management option here is to have full course of DTP.

Which child we must refer to Psychologist

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 Most likely scenario: A 10 years old boy is being checked by the
diabetic specialist nurse staff. The level of HbA1c is relatively
high and child has been skipping meals recently. He told that he
has been unhappy at school. Which single member of clinical
team you would refer. Answer is clinical Psychologist.

Breath holding spells

Most likely scenario: A 3 years old boy fell off his cycle and hurt
his arm. Child got up to start crying but there was no sound and
he went pale, rigid and unconscious. Child recovered after 2-3
minutes but remained pale and after an hour he has back to
normal. Mother told that she was afraid he was going to die and
child had similar episode few months back when after falling
down from stairs.

Note: the breath holding spells are the occurrence of episodic

apnea in children. Which is likely associated with loss of
consciousness and changes in postural tone. The breath holding
spells are most commonly present in children under 5 years of
age and usually not present after that age.

Infantile pyloric stenosis

Most likely scenario: A 4 months old baby girl presents with

recurrent episodes of vomiting. Mother noticed some of vomits is
blood strained which is like coffee ground appearance.

Note: In pyloric stenosis which usually affects babies between two

or eight weeks of age but can occur anytime from birth to 6

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 months. The hematemesis is of either bright red flecks or coffee
ground appearance is sometimes observed. The choice of
investigation here is ultrasound then barium meal. If both are
non diagnostic we go for endoscopy. The diffence in between
pyloric stenosis and duodenal atresia is PS is very common than
DA. In duodenal atresia vomits contains bile not blood.

Breast milk jaundice

Most likely scenario: A 5 weeks baby girl has been diagnosed of

having breast milk jaundice. Baby is otherwise well. What is
single most management here?

Note: Here baby is well so mother has to continue breast feed, if

jaundice lasts past 1st week of her life in a breastfed baby. Who’s
otherwise healthy. This condition is called breast milk jaundice
and it’s predominantly uncojugated hyperbilirubinemia.

Honey bee/Insect bite

Most likely scenario: An 11y old boy accidentally stepped on a

hive and was bitten several times, while he was playing in
garden. He has several wheals on his body and complaining of
severe itching.

Note: In such cases we will treat with an oral antihistamine.

While I/V antihistamines are used as an adjunct to adrenaline in
only emergency treatment of anaphylaxis and angioedema. The
common indications of adrenaline in anaphylaxis are included

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 horseness of voice, SOB, shock, stridor, wheez, swelling of tongue
and cheek and facial swelling.

Rh incompatibility

Most likely scenario: A term baby born to a 35y old female. Her
blood group is A–ve and she develops severe jaundice within first
24 hours of birth.

Note: RH incompatibility is a condition that occurs during

pregnancy if a women has Rh -ve blood and her baby has Rh+ve
blood.

Patent Ductus Arterious (PDA)

Most likely scenario: A 5y old baby girl is found to have bounding

pulse and continuous machinery murmur. What is diagnose here?

Note: PDA is a condition in which the ductus arteriosus fails to

close after birth. So this causes a portion of oxygenated blood
from the left heart to flow back to lungs by flowing from aorta,
which has higher pressure towards pulmonary artery. The
continous mechinary murmur is well known feature of PDA other
common feature is bounding pulse.

Tetralogyn of fallot (TOF)

Most likely scenario: An 11y old child presents with episodes of

sudden bluish coloration and loss of consciousness O/E: Central

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 cyanosis, clubbing, systolic thrill with systolic ejection murmur
in 2nd left ICS.

Note: The TOF usually does not become symptomatic at early

infancy and given features of (Central cyanosis and clubbing with
murmur of right ventricular outflow obstruction e ejection
systolic murmur in 2nd left ICS are known features of TOF).

Septic arthritis

Most likely scenario: A 4y old boy presents sudden onset of pain

in his knee of three days duration and child present mild fever on
2nd day. The child can walk but with a limp. O/E: There is
painful restriction in his right hip.

Note: The feature which favors diagnosis of septic arthritis is

painful joints like hips and knee with fever and painful restricted
movement of joint. Please note that in osteomyelitis there is no
pain in joints but in other parts of bone.

Celiac disease

Most likely scenario: A 4y old boy presents with on and off

diarrhea. The mother told that his stool is frothy, bulky and hard
to flush.

OR

One year old child presents with poor weight gain since child is
on solid food recently and has history of loose stools.

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 Note: The anti-endomysial antibody causes this problem and it’s
not cystic fibrosis as there is no any lung problem has been
described in scenario which is most likely seen with GI problems.

Glandular fever

Most likely scenario: A 5y old child presents with easy bruising in

different places whenever child falls. The childs CBC shows WBC
25, Hb 10.7, platelets 45 and his (Paul bunnel) test is positive.

Note: The Glandular fever commonly presents with leucocytosis,

normal Hgb levels, thrombocytopenia, positive Paul bunnel test
and child get easy bruises.

Minimal change glomerulonephritis

Most likely scenario: A 6y old child was referred to ER but his

mother wanted to get some medicine and go home. O/E: Boy was
tired and irritable with swelling around eyes. His renal biopsy
shows podocyte fusion on electron microscopy.

Note: The most common feature of minimal change

glomerulonephritis is (podocyte fusion on electron microscopy).

Febrile convulsion

Most likely scenario: A 5y old child baby presents with

generalized tonic-clonic seizer and his temp was 39.5C. Her
mother described that seizer happened 2-3 times before.

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 Note: The main point here is to consider that seizer happened
with fever which is not a feature of epilepsy. As we know that
febrile convulsions doesn’t reoccur but it can recur as well.

Congenital hypothyroidism

Most likely scenario: A 7m old infant presents with failure to

thrive (FTT) and constipation. O/E: There was long tongue
noticed and infant has prolonged history of neonatal jaundice.

Note: Failure to thrive FTT, macroglossia, prolonged jaundice and

constipation are common features of CH.

Measles

Most likely scenario: A 5y old boy has high grade fever for five
days. O/E: There were rashes on buccal mucosa and around the
mouth.

Note: High grade fever and (koplicks spot) rash on buccal mucosa
are common features of measles in children.

Tricuspid atresia

Most likely scenario: A 5 week old infant presents with

progressive cyanosis, poor feeding, holosystolic murmur and
tachypnea over first two weeks of life.

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 Note: the tricuspid atresia is a congenital defect and is causes
cyanosis with left ventricular hypertrophy which creates
holosystolic murmur.

Patent ductus arteriosus

Most likely scenario: A 34 weeks baby born with murmur and

cyanotic. Baby was kept in incubator for almost 2 weeks and on
discharge there was no any murmur.

Note: PDA is also a cyanotic congenital defect. We must

remember PDA is more common in (premature births).

Diurnal enuresis

Most likely scenario: A 5y old baby girl was presents to GP. Her
mother complains that girl is getting wet herself up to 7 times per
day.

Note: This is diurnal enuresis not docturnal enuresis and

management is (behavioral training).

Supraventricluar tachycardia (SVT)

Most likely scenario: A 1m infant presents in ER. The baby is

conscious but with cool peripheries and HR is 223bpm. Baby is
irritable for last 24hours. Chest x-ray shows borderline enlarged

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 heart with clear lung fields. An ECG shows regular narrow
complex tachycardia and difficult to identify p wave.

Note: The main features here are cold peripheries due to low
blood pressure and inadequate oxygen. Next step to this pt is DC
cardio version.

Non accidental injury (NAI)

Most likely scenario: A 5y old child brought by her mother with

multiple bruises, fever and fractures. The child is living with his
step father.

Note: Here history of living with stepfather multiple bruises,

fracture and fever are suggestive of non accidental injury.

Sleep terror disorder

Most likely scenario: A 7y old baby girl presents with sudden

screaming and waked up from deep sleep. Now she is feeling like
confused. When parents try to ask her in the morning about the
event she totally forgets.

Note: The typical features of sleep terror disorder are screaming

and waking up from deep sleep without remembrance of event in
morning.

Mumps

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 Most likely scenario: A 15y old male presents acute pain and
earache on his right side of face. O/E: Temp 38.6C, swelling on
right side and bilateral tenderness on palpation.

Note: The main features to recognize mumps are malaise

increased temp and painful parotid swelling.

Cushing’s syndrome

Most likely scenario: An 11y old boy presents obese and with
short stature. Boy had renal transplantation last year. Mother
was worried of he was being bullied.

Note: Here we will think of boy is immunosuppressant indication

is renal transplant. Here short stature is due to steroid use in
early age cause premature fusion of growth plate or calcification.

Tourette’s syndrome

Most likely scenario: An 11y old boy presents with behavioral

problems. His parents told that he admitted to an special school
due to inappropriate behavior. O/E: boy shouts loudly in an
inappropriate words like barking and repeating words while
jumping bending or twisting.

Note: The tourette’s syndrome usually has motor tics like sniffing,
touching objects, barking, jumping, repeating words and bending
or twisting.

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 Acute epiglottitis

Most likely scenario: A 5 y old child presents with severe stridor

and drooping saliva. Child was febrile and sick looking. CXR
shows thumb sign.

Note: The drooping of saliva, stridor along with thumb sign in

CXR are common features of acute epiglottitis.

Henoch-Schonlein purpura (HSP) or IgA vasculitis

Most likely scenario: A 5y old boy presents with cough and

arthritis which followed by a rash on his legs which arenon-
blenching on glass test. His blood test shows PT 13, APTT31, Hb
12.5, WBC 6.5 and platelets 300.

Note: HSP usually occurs below ten years of age. Most common
features are purple rash on lower legs with vasculitis.

Nephrotic syndrome

Most likely scenario: A 9y old boy presents with bilateral

periorbital edema, ankle swelling and increased body weight.

Note: above described are all common features of nephrotic

syndrome.

Eczema

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 Most likely scenario: An 11y old boy presents with itching in
hands. O/E: Shows dry and red skin. His family history is his
mother is asthmatic and old sister has hay fever.

Note: When you find like itchiness and family history of asthma
and hay fever always favors the diagnosis of eczema.

Foreign body aspiration

Most likely scenario: A mother brings her 2.5y old baby boy with
1hour complain of noisy breathing. Her mother told that her son
had mild coryza over last week so they went on to nursery
children’s picnic. During picnic she found that her child is
coughing and stridoring, and ever since his breathing is noisy.
O/E: boy is seems well in ER but respiratory rate is raised and
saturation is 91%.

Note: Foreign body aspiration occurs mainly under 3y of age in

children. The main complain is noisy breathing with cough and
stridor.

Mastoiditis

Most likely scenario: A 3yrs old child presents with fever and
severe pain in left ear. O/E: There is swelling and tenderness
behind the ear.

Note: This is typical picture of (Mastoiditis).

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 Lymphangioma

Most likely scenario: A 2y old boy bring by her mother with

complain of swelling in the right side of his neck which extends
from the angle of his mouth to middle 1/3 of sternocleidomastoid
muscle. The swelling was on anternolateral side which was
brilliantly transilluminant.

Note: 90% lymphangioma occur in children less than 2y of age.

Both lymphangioma and brancheal cyst are lateral neck mass
both the difference between the two is that brancheal cyst
usually doesn’t transilluminate where as lymphangioma does it
brilliantly.

Pneumonia

Most likely scenario: A 3y old baby girl presents with a four day
history of fever that initiate with cough. Her respiratory rate is
45bpm, saturation 94% and capillary refill time is 1 second. O/E:
crepitations on left base, urine shows negative dipstick and CXR
was uninterpretable.

Note: In children the diagnose of pneumonia on basis of CXR is

sometimes difficult to diagnose as main feature in CXR is
consolidation or infiltration which sometimes doesn’t show clear
results but still the diagnose is pneumonia.

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 MCQs solving rapid fire

1. If mother of breast feeding infant came for an advice to start solid

food to infant to decrease his breast feeding habits answer is she
must continue breastfeeding along with solids.

2. If four years old boy has fallen from stairs and had got injury in
arm O/E: There was flexion on trunk and with painful swelling
elbow answer is subluxation on head of the radius.
3. The height of a child is double the birth height at the age of: 6
years
4. Height of children in 2-10 years of age is increased by: 6 cm/year
5. Infant body weight is tripled by age of: 11 months
6. A mother comes with her 3 year old female child with complain of
that child is not eating anything. Her weight is 11 kg (50th
percentile) and height is 88 cm. (75th percentile). What should be
done next: Nothing should be done actively and assure the parent
7. Pincer grasp is attained at: 10th months
8. A female child has recently learned to eat with spoon without
spilling, to dress and undress herself with supervion and to
understand that she is a girl. These skills are first mastered
between the ages of: 2 and 3 years
9. 10 month old child can do: Change cube from one hand to
another, Can pull and stand and Pincer grasp
10. A baby has recently developed mouthing but has not developed
stranger anxiety. Likes and dislikes for food.
11. What is the most appropriate age of this baby: 5 months
12. A child is able to build blocks of 5 Cubes: 18 months

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 13. A normal child develops the ability to use 10 words with meaning
at the age of: 18months
14. A child is able to say short sentences of 6 words: 6 years
15. 1st permanent teeth to appear: Molor
16. Delayed Eruption of teeth is characteristics of: Hypothyroidism >
Down’s syndrome
17. Nails is formed in which week of IUL: 10th to 12th weeks
18. 90% of brain growth is achieved by the age of: 2nd year
19. The maximum age for growth of lymphoid tissue: 5-7 years
20. Increase in height in first year is by: 50%
21. Birth weight of a child doubles at five months of age while the
birth length doubles at the age of: 4 years
22. A newborn baby has a head circumference of 35 cms, at birth,
His optimal head circumference will be 43 cms at: 6 months of
age
23. In a healthy child, the head and chest circumference equal each
other around the age of: 9-12 months
24. A normal healthy child has a height of 100 cm and weighs 16 kg,
his most likely age: 4 years
25. A child draws circle at: 36months (3 years)
26. The age by which most of the normal babies know their gender is:
3 years
27. A child can ride a tricycle, copy a circle and knows age sex by the
age of: 3 years
28. In a child, one should be worried if: Social smile absent by 10
weeks
29. Handedness develops at: 3 years

30. Milestones in Children (Try to Memorize as Much as Possible)

» Social smile: 2 months

» Recognizes mother: 3 months

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 » Holds object and takes it to mouth: 4 months

» Sitting on slight support: 5 months

» Enjoys mirror: 6 months

» Sits alone momentarily: 5–6 months

» Transfers object from head to hand: 6 months

» Rolls over: 7 months

» Sits steadily: 7–8 months

» Crawls in bed: 8 months

» Monosyllabic words (Mama, Dada) : 9 months

» Creeps: 10 months

» Cruises around furniture: 10 months

» Builds a tower of 2 cubes and pincer grasp: 12 months

» Can turn two or three pages of a book: 13 months

» Walks alone: 13–14 months

» Walks sideways and backwards: 15 months

» Builds a tower of three cubes: 18 months

» Feeds self: 18 months

» Can drop and draw a horizontal or vertical line: 2 years

» Can turn one page at a time: 2 years

» Able to wear socks or shoes: 2 years

» Can remove his pants: 2½ years

» Can draw a circle: 3 years

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 » Can dress or undress completely and buckle his shoes: 3 years

» Knows age and sex: 3 years

» Can copy and draw a cross (Plus Sign): 4 years

» Can draw a rectangle: 4 years

» Can draw a tilted cross (Multiplication sign): 5 years

» Can draw a triangle: 5 years

» Bladder control—Diurnal: 12–16 months

» Nocturnal: 2½ to 3 years

» Draws a horizontal or vertical line: 2 years

» Draws a circle: 3 years

» Draws a cross: 4 years

» Draws a rectangle: 4 years

» Draws a triangle: 5 years

31. A 2-month-old infant can lift its head to 45 degrees, eyes follow to
the midline, vocalize, smiles and has a state of half- waking
consciousness
32. A 6-month-old infant can roll over, grasp a rattle, turn to voice,
feed self and separate the world into a ‘parent’ and ‘not parent’
world
33. A 12-month-old child can sit without support, pull to stand, use
a pincer grasp, babble, indicate wants, and have stranger anxiety
34. An 18-month-child can walk well, make a tower of 2 blocks, say 3
words, use a spoon and a cup, have temper tantrums, and bridge
gaps by bringing objects to the caregiver.
35. The most common cause of short stature is: Constitutional

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 36. Short stature is seen in: Maternal deprivation syndrome,
Hypothyroidism and IUGR
37. Fetal growth is maximally affected by: Insulin
38. A child is below the third percentile for height. His growth
velocity is normal, but chronologic age is more than skeletal age.
The most likely diagnosis is: Constitutional delay in growth
39. Infantile proportion in adult is seen in: Achondroplasia and
Hypothyroidism
40. A 9 year old child is restless. He is hyperactive and his teacher
complaints that he does not listen to the teachings. Disturbs
other students, he also shows less interest in playing. The likely
diagnosis is: Attention deficit hyperactive child
41. A10 year old child is always restless, inattentive to study and
always wants to play outside, Parents are extremely distressed.
What would you advise: Behaviour therapy
42. Essential features of attention deficit hyperactive disease (ADHD):
Lack of concentration, Impulsivity and Hyperactivity
43. Drugs used in ADHD are: Atomoxetine, Methylphenidate and
Dextro-amphetamine
44. A 9 year old child disturbs other people, is destructive interferes
when two people are talking, does not follow instructions and
cannot wait for his turn while playing a game. He is likely to be
suffering from: Attention deficit hyperactive child
45. A 3 year old boy with normal developmental milestones with
delayed speech and difficulty in communication and
concentration. He is not making friends. Most probable diagnosis
is: Autism
46. A 6 year old child has history of birth asphyxia does not
communicate well, has slow mental and physical growth, does
not mix with people, has limited interest, gets widely agitated if
disturbed, diagnosis is: Autistic disorder
47. A 2 year old girl child is brought to the outpatient with features of
hand wringing stereotype movements, impaired language and

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 communication development, breath holding spells, poor social
skills and deceleration of head growth after 6 months of age. The
most likely diagnosis is: Rett’s syndrome
48. Nasal spray which is very effective in control of enuresis:
Desmopressin
49. The behaviour therapeutic falls in management of enuresis, the
pharmacological drug of choice for this case is: Imipramine
50. Cretinism is: Disproportionate dwarfism
51. Best treatment for enuresis is: Imipramine > Desmopressin
52. Early strict toilet training can result in: Encopresis

53. An 18-month old baby presents with recurrent episodes of

excessive crying followed by cyanosis, unconsciousness and
occasional seizures since 9 months of age. The most likely
diagnosis is: Breath holding spells
54. A new born is noted to have a large head and short limbs. On
further examination, short broad fingers, a small face, and low-
normal length are noted. The trunk appears long and narrow, to
confirm the diagnosis you should: Obtain skeletal radiographs
55. WHO defines adolescent age between: 10-19 years
56. Peak growth velocity in adolescent girls is seen just After:
Appearance of pubic & axillary hair
57. First sign of puberty in girls: Thelarchy
58. Thelarchy: Hormone related breast enlargement in girls
59. Pubarche: refers to appearance of pubic hair
60. Adrenarche: refers to stage of maturation of adrenal cortex
61. Order of puberty: Telarchy
62. Order of development of secondary sexual characteristic in male:
Testicular development =pubic hair =axillary hair =beard
63. Peak growth velocity in adolescent girl is indicated: Just before
commencement of menarche
64. Maximum growths spurts seen in girls at time: menarchy

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 65. Growth spurt occurs: Just before menarche
66. Correct order of events at puberty in a girl: Thelarchy-pubarchy-
growth spurt-menarche
67. First sign of puberty in girls: Increase in breast size
68. Deficit in weight for height in a 3 year old child indicates: Acute
malnutrition
69. Best indicator for nutritional status for a child is: Rate of increase
of height and weight
70. Acute malnutrition is manifested by: Weight for height
71. The best indicator of long term nutritional status: Height for age
72. Common to both acute and chronic malnutrition is: Weight for
age
73. Indicator of moderate to severe malnutritions is: Albumin 2.1
g/dl
74. The amount of calories required at 1 year of age are: 1200
Kcal/day
75. The normal calorie requirement for a 5 year old child is: 1500
Kcal/day
76. Kwashiorkar is diagnosed in growth retarded children along with:
edema and mental changes
77. In Kwashiorkor, which immunoglobulin is most affected: IgA
78. Flaky paint appearance of skin is seen in: Kwashiorkor
79. The current recommendation for breast feeding that: Exclusive
breast feeding should be continued till 6 month of age followed by
supplementation with additional foods
80. The protective effects of breast milk are known to be associated
with: IgA antibodies
81. The important fatty acid present in breast milk which is
important for growth is: Docosahexaenoeic acid
82. Compared with Cow’s milk, mother’s milk has more: Lactose
83. » Cow’s milk has more proteins than breast milk
84. » Cow’s milk has more calcium than breast milk
85. » Cow’s milk has more Vitamin K than breast milk

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 86. Breast Milk: Can transmit tuberculosis
87. An absolute contraindication to breastfeeding: Galactosemia
88. Breastfed infant can be deficient in:

» Vitamin B1

» Vitamin B12

» Vitamin D

» Vitamin K

» Folic acid

89. Human colostrum contains more of the following Nutrients than

mature human milk: Lactose, Proteins and Vitamin A
90. Cupping of metaphysis and Defective Mineralization are seen in:
Rickets
91. Deficient mineralization in epiphyseal growth cartilage is seen in:
Rickets
92. Wind swept deformity is seen in: Rickets
93. Earlier manifestation of Rickets is: Craniotabes
94. Rachitic rosary, Splaying and Cupping of the metaphysis is seen
in: Rickets
95. Rickety rosary seen in: Rickets, Scurvy and Chondrodystrophy
96. Winberger sign is present in: Scurvy
97. Hypervitaminosis of which of the following will cause bony
abnormalities: Vit A and D
98. A child with alopecia, hyperpigmentation psoriatic dermatitis in
genitals & mouth and hypogonadism is likely to be suffering
from: zinc deficiency
99. Shakir tape is used for: Measurement of midarm circumference
100. Dosage of Vitamin-A for children between 1-3 years: 1333IU

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 101. Child with frog like position and resistance to move the limbs:
Scurvy
102. Pseudoparalysis is seen in: Scurvy
103. Calorie requirement per day of a child weighing 15kg would be:
1250 kcal
104. Neonatal period extends: 28 days of life
105. Persistent Moro’s reflex at 6-7 months indicates: Brain damage
106. New born babies are able to breathe and suck at the same time
due to: High larynx
107. Common sites for mongolian spot are: Lumbosacral area, Leg and
Thigh
108. A baby on examination shows unilateral moro’s reflex with
positive palmar grasp reflex. The site of lesion is: C5C6
109. Reflex which never reappears is: Moro’s
110. Moro’s Reflex disappears at: 6 months
111. Palmomental reflex is seen in lesions of: Frontal lobe
112. Small for date baby is: < 10 percentile for the gestational age
113. Low birth weight is defined as: Weight <2.5 kg
114. Most common cause of Neonatal sepsis in hospital: Klebsiella
115. Most common cause of sepsis in Pakistan within 2 months: E.coli
116. Neonatal septicemia is most commonly caused by: Group B
Streptococci
117. Neonatal sepsis and meningitis most common cause:
Streptococcus agalactiae
118. A 2-year-old boy was admitted to a pediatric hospital with a 7-
day history of high fever, lymphadenopathy, conjunctivitis and an
erythematous exfoliative rash affecting his trunk and extremities:
Kawasaki Disease
119. In Kawasaki disease, coronary artery aneurysms seen in: 25% of
patients
120. A 3-month-old male infant developed otitis media for which he
was given a course of Co-trimoxazole. A few days later, he
developed extensive peeling of the skin; there were no mucosal

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 lesions and the baby was not toxic. The most likely diagnosis is:
Staphylococcal Scalded Skin Syndrome (SSS)
121. 1st day disease: Measles
122. 2nd day disease: Scarlet fever
123. 3rd day disease: Rubella
124. 5th day disease: Erythema infectiosum
125. 6th day disease: Roseola infantum
126. 8th day disease: Tetanus
127. A four-week-old boy is brought to the pediatric emergency
department by his father who states that he has been vomiting
after being fed for the past several days. She describes the
vomitus as nonbilious, and he has had normal stools with no
blood in them. On examination, the infant appears to be mildly
dehydrated, his abdomen is soft, and there is a palpable, olive-
sized, firm movable mass in the right upper quadrant: Pyloric
Stenosis
128. An 8-year-old girl has chickenpox. A week after the onset of the
rash, she begins vomiting and becomes lethargic and comatose.
Laboratory examination is significant for elevated liver enzymes
and ammonia. Which of the following is, the most likely
diagnosis: Reye’s syndrome
129. Secondary hypertension in children is most commonly caused by:
Renal disease
130. Sustained severe hypertension in children is most commonly
suggestive of: Renal parenchymatous disease 125. ln X-ray
batwing appearance is seen in: Cardiogenic pulmonary edema
131. The treatment of choice for a case of congestive failure with
hypertension is: ACE inhibitors
132. Coarctation of the aorta: Most common site is distal to the origin
of the left subclavian artery
133. Patent ductus arteriosus: May cause a machinery murmur due to
its patency

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 134. Left axis deviation with left ventricular hypertrophy not seen:
TOF
135. Congenital heart disease, which causes death in the first week of
life: Hypoplastic left ventricle syndrome
136. Emergency treatment of TGV: Balloon Septostomy
137. Pott's shunt is: Connection between descending aorta to left
pulmonary artery
138. Condition which worsens with prolonged infusion of
prostaglandin E: Obstructed TAPVC
139. Most commonly associated cardiac anomaly with coarctation of
aorta: Bicuspid aortic valve
140. Pentalogy of Fallot: ASD in addition to tetralogy of fallot.
141. Infective endocarditis is least common with: Atrial Septal Defect
142. Ebstein's anomaly is seen with intake of: Lithium
143. NADA’s criteria are used for: Assessment of child for presence of
heart disease
144. Commonest type of congenital heart disease is: VSD
145. Functional closure of ductus arteriosus occurs: Within 24 hrs of
birth
146. Oxygenated blood to the fetus is carried by: Umbilical vein
147. Anatomical closure of ductus arteriosus occurs at: 10th day after
birth
148. Most common manifestation of rheumatic fever: Arthritis
149. Earliest valvular lesion in a case of acute rheumatic fever is:
Mitral regurgitation (MR)
150. In a patient of rheumatic carditis steroids are given for: 12
weeks
151. A 10-year-old girl with pulmonary flow systolic murmur and fixed
split second hear sound: ASD
152. A 3-year-old girl with failure to thrive has pansystolic murmur on
left sternal border with prominent pulmonary vascular markings:
VSD

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 153. A 5-day-old girl with machinery-like heart murmur and bounding
peripheral pulses PDA
154. A 6-year-old with clubbing, cyanosis improved by squatting,
systolic ejection murmur in 3rd intercostal space with right
ventricular hypertrophy: Tetralogy of Fallot
155. Carey Coombs Murmur: Transient Soft middiastolic murmur of
acute rheumatic fever due to mitral valvulitis, low- pitched
156. Austin Flint Murmur: Murmur of mitral stenosis at apex
157. Graham Steell Murmur: Early diastolic murmur of Pulmonary
Regurgitation
158. Means Murmur: Pulmonary Systolic murmur in Thyrotoxicosis
159. Seagull’s Murmur: Aortic regurgitation murmur.
160. Umbilical cord contains: Two arteries and one vein.
161. Oxygenated blood to fetus is carried by: Umbilical vein.
162. In fetal circulation: Brain and heart (coronary) circulation receive
blood with higher oxygen saturation.
163. In fetal circulation: IVC has more oxygen saturation than SVC;
pressure in right and left ventricle is equal. 159. Anatomic
closure of doctor arteriosus occurs: Between 10 to 25 days after
birth. Functional closure of ductus
164. arteriosus occurs: Immediately (within 15 hours) after birth.
165. Epstein’s anomaly is seen with intake of: Lithium.
166. Strongest familial tendency in CHDs is known for: Holt-orate
syndrome (ASD with bany abnormalities).
167. CHDs in congenital rubella: PDA (most common), PS, VSD, ASD
(least common).
168. NAD’s criteria is used for: Assessment of child for presence or
absence of heart disease.
169. Important cyanotic CHDs with pulmonary oligemia: Tricuspid
atresia, TOF, Eisenmenger's syndrome, Ebstein anomaly.
170. Important cyanotic CHDs with pulmonary plethora TGA, TAPVR,
persistent truncus arteriosus, single ventricle, hypoplastic left
heart.

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 171. Important acyanotic CHOs with pulmonary plethora: PDA, VSD,
ASD, PAPVR
172. Important CHDs with pulmonary plethora: TGA, TAPVR, PDA,
VSD, ASD, PAPVR, persistent truncus arteriosus, single ventricle.
173. Cyanotic CHD with left ventricle hypertrophy: Tricuspid atresia.
174. Important CHDs with right ventricular hypertrophy (right axis
deviation): ASD (with RBBB), PAPVR, PS, MS, COA (in Infant),
TOF, Eisenmenger’s syndrome, Epstein’s anomaly.
175. Important CHDs with left ventricular hypertrophy (left axis
deviation): VSD, PDA, AS, AR, COA, MR, tricuspid atresia,
pulmonary atresia.
176. Commonest CHD: VSD. 172.Commonest cyanotic CHO: TOF.
177. Recurrent chest infections are seen in ASD, VSD, PDA, TGA,
TAPVR

178. Recurrent chest infections is not a feature of: COA, TOF,

pulmonary atresia, Tricuspid atresia, PS, AS.
179. Cyanotic CHO which does not develop cardiomegaly or CHF: TOF.
180. Left atrium is not enlarged in: ASD.
181. ASD may be associated with: Halt-Oram syndrome, TAR
syndrome, Down syndrome, Ellis-Van crevald syndrome, EDH,
fetal alcohol syndrome.
182. Seen in ASD: Hypertrophy of right atrium & right ventricle,
pulmonary plethora, pulmonary hypertension, left to right shunt,
wide split & fixed S2.
183. Not seen in ASD: Left atrial enlargement, CHF, right to left shunt,
shunt murmur, infective endocarditis.
184. Most common ASD: Ostium secundum type.
185. In ASD, aorta is: Small.
186. ASD with mitral stenosis Lutembacher syndrome.
187. True about VSD: Membranous mast common, left to right shunt,
Pansystolic murmur, wide split S2, left atrial & left ventricle

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 hypertrophy, CHF, endocarditis common, pulmonary plethera,
small defects close spontaneously.
188. Improvement of CHF in a large VSD is due to: Development of
vascular changes in pulmonary circulation. 185. Clubbing in a
patient with VSD suggests: Infective endocarditis.
189. Differentiating feature between ASD and VSD on chest X-ray:
Size of left atrium (enlarged in VSD but not in ASD). 187.In PDA
connection is between: Aorta and pulmonary artery.
190. Ductus arteriosus forms: Ligamentum arteriosum in post-natal
life.
191. Potency of ductus arteriosus causes: Machinery murmur.
192. Symptoms of PDA are similar to: Aortopulmonary window.
193. PDA is more common in: Females.
194. Important features of PDA: Continuous (machinery) murmur,
pulmonary plethora, left atrial and left ventricle enlargement,
paradoxical split of S2.
195. Complications of PDA: CHF, infective endocarditis, pulmonary
hypertension, chest infection, Eisenmenger’s syndrome,
aneurysm of PDA.
196. Most common cause of death in PDA: CHF (most common)
followed by infective endocarditis.
197. Mediators which maintain potency of ductus arteriosus:
Prostaglandins.
198. Drugs used to maintain potency of PDA: Prostaglandin E,
(misoprost, rioprostil).
199. Closure of PDA is stimulated by: Prostaglandin Inhibitors, i.e.
NSAIDs (most commonly indomethacin).
200. Constituents of TOF: VSD, overriding/dextroposed aorta, right
ventricular hypertrophy, pulmonic stenosis (infundibular
stenosis).
201. Constituents of Pentalogy of Fallot: Components of TOF plus ASD
202. Most common site of pulmonic stenosis (right ventricular outflow
obstruction) in TOF: Infundibular stenosis.

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 203. True about Ebstein anomaly: Downward displacement of
tricuspid valve, right atrial dilatation, systolic and diastolic
murmur won scratchy character.
204. CHD which may be associated with WPW syndrome: Ebstein
anomaly
205. Position of aorta in transposition of great arteries (TGA): Anterior
and right to pulmonary artery.
206. True about TGA: Cyanosis at birth, intact septum or VSD, CHF,
single S2, pulmonary plethora, 'Egg on side' on X-ray.

207. Treatment of TGA includes: PGE, Rashkind atrial septostomy,

arterial switch procedures (Mustard & senning or Jatene).
208. Most common conotruncal defect: TGA
209. Most common type of TAPVC: Supra-cardiac (Type 1).
210. In TAPVC: Oxygen saturation is higher in pulmonary artery,
infracardiac type is always obstructive, pulmonary venous blood
reaches in right atrium, blood from right atrium to left atrium
flows through patent foramen ovale or ASD (but not VSD).
211. Figure of '8' configuration or snowman appearance on chest X-
ray: TAPVC (supracardiac type).
212. Eisenmenger’s complex is common in: VSD.
213. Sequence of events in development of Eisenmenger’s complex in
VSD: Left to right shunt = right ventricle hypertrophy =
pulmonary hypertension = right to left shunt.
214. Important signs of impending Eisenmenger's syndrome Loud P2
single S2, parasternal heave, pulmonary ejection click, Grahm
steel Murmur.
215. Important features of Eisenmenger’s syndrome: Dilation of
central pulmonary artery with peripheral prunning, no dilatation
of pulmonary veins.
216. CHD with risk of MI in a neonate: Anomalous origin of coronary
artery.

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 217. Coarctation of aorta (CoA) is common with: Turner syndrome.
218. Coarctation is associated with Bicuspid aortic valve most
common), Aortic stenosis, ASD, VSD, MR
219. CoA is not associated with: Pulmonary stenosis
220. Most common site of CoA: Just below origin of left subclavian
artery.
221. Rib notching in CoA is seen at: Inferior border.
222. Rib notching is due to: Enlargement of collateral vessels
(especially intercostal vessels).
223. Collateral vessels involved in Cod: Internal thoracic, intercostal,
subclavian, superior & inferior epigastric, axillary
224. CoA is characterized by: Weak/absent pulses in lower limb
(femoral artery) compared to upper limb (brachial artery).
225. Common presentation of CoA Intermittent claudication,
headache, dizziness, hypotension, dyspnea on exertion, weak
pulse in femoral vessels.
226. Important causes of death in CoA: CHF, aortic dissection,
cerebral hemorrhage, infective endocarditis, hypertension, aortic
rupture.
227. Ductus dependent CHDs: PS without VSD, TOF, CoA, TGV,
Hypoplastic left heart, congenital aortic stenosis, and Tricuspid
atresia.
228. Ductus independent CHDs: TAPVR, Truncus arteriosus,
anomalous origin of left coronary artery from pulmonary artery.
229. Acyanotic heart disease with ejection systolic murmur: ASD,
VSD, PDA, CoA.
230. Right aortic arch is associated with: truncus arteriosus, TOF.
231. Double aortic arch commonly present as: Compression of
trachea. 230.Commonest cause of CHF in infants: Congenital
heart disease.
232. Commonest cause of CHF in older children: Rheumatic heart
disease.

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 233. Important causes of CHF in first week of life:
Pulmonary/mitral/aortic atresia’s, TGA, hypoplastic left and
right heart syndromes.
234. Treatment of choice for CHF in children: ACE inhibitors.
235. Rheumatic fever is: Not a communicable disease (it is an immune
mediated damage)
236. True about RF: Occurs after streptococcal pharyngitis, affect 5-15
years old in low socioeconomic status.
237. Major criteria in RF diagnosis: Carditis, arthritis, chorea,
subcutaneous nodule, erythema marginatum.
238. Minor criteria in RF diagnosis: Fever, arthralgia, previous RF,
increased ESR, leukocytosis, increased CRP, prolonged PR
interval on ECG.
239. Most common valve involved in RF: Mitral valve
240. Most common valvular defect in RF: Mitral regurgitation
240.Most common major manifestation in RF: Arthritis
241. Carey-Coombs murmur: Soft (low-pitched) mid-diastolic murmur
in RF due to mitral regurgitation.
242. Sydenham's chorea of RF: Occurs in isolation; aggravated by sex
hormones (estrogen) and pregnancy.
243. Subcutaneous nodules in RF: Non-tender, on extensor surface,
often seen in association with carditis.
244. Erythema marginatum in RF: Spares face and involves trunk and
proximal part of extremities.
245. Arthritis in RF: Migratory polyarthritis, no residual damage,
dramatic relieve by salicylates.
246. Drug of choice for treatment of RF: Penicillin.
247. Drug of choice for RF in penicillin allergic patients: Erythromycin.
248. Corticosteroids are indicated in RE: In presence of carditis.
249. Duration of corticosteroids treatment in rheumatic carditis: 12
weeks.
250. Most common cause of bacterial endocarditis: Staphylococcus
aureus.

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 251. Infective endocarditis is not seen in ASD.
252. Most common cause of hypertension in children: Renal
parenchymal disease (especially chronic GN).
253. Most common cause of renovascular hypertension in children:
Renal artery stenosis.
254. Average BP in 1 year old child: 93/65
255. Differential cyanosis is seen in RDA, TGA, and preductal CoA.
256. Pulsatile varicose veins in lower limb is seen in Klippel
Trenaunay syndrome.
257. The most common cause of CHF in infants: congenital heart
disease
258. The most common cause of CHF in the older children: Rheumatic
fever & rheumatic heart disease
259. Pedigree analysis chart is used for: illustrating the inheritance of
genes in a family.
260. Chances of having unaffected baby when both parents have
autosomal dominant disease: 25%
261. Chances of being affected if one parents has autosomal dominant
disorder: 50%
262. Chance having disease if one parent is having autosomal
recessive disorder and other parents is carrier: 50% 263.
Chances of having diseases if both parents are carrier of
autosomal recessive disease: 25%
263. Chances of having diseases if both parents are affected by
autosomal recessive disease: 100%
264. Chance having disease if one parent is carrier for autosomal
recessive disease and other is normal: 0% (50% will be carrier)
265. Only males are affected: X-linked recessive
266. Only males are affected and females act as carrier: X-linked
recessive
267. Fathers not transmit the disease to son: X-linked
268. Mothers not transmit the disease to daughter: X-linked recessive

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 269. Fathers transmitting the disease to all daughters: X-linked
dominant
270. Mothers transmitting the disease to all sons: X-linked recessive
271. Mothers transmitting the disease to half son: X-linked dominant
272. Differential expression of same gene depending on parent of
origin: Genomic imprinting
273. Functional gene is inherited from one Parent: Genomic
imprinting.
274. Paternal 15 deletion or Maternal 15 disomy: Prader Willi
syndrome.
275. Maternal 15 deletion or Paternal 15 disomy: Angleman syndrome.
276. Obesity with mental retardation: Prader will syndrome.
277. Mother transmitting disease to all children: Mitochondrial
disorders.
278. Both males and females are affected but males do not transmit
the disease: Mitochondrial disorders.
279. Common ocular finding in trisomy 13 (Patau syndrome): Bilateral
microphthalmos
280. Multiple defects with cleft lip, cleft palate, microcephaly,
microphthalmos and scalp defect: Trisomy 13.
281. Cat eye syndrome: Partial trisomy
282. Most common chromosomal disorder is: Trisomy 21 (Down
syndrome)
283. Not seen in Down's syndrome: Decreased nuchal thickness,
hyper tonicity, Pigmented birth mark.
284. Robertsonian translocation is seen in Down syndrome: 13-15/21,
22/21; Mosaic 21.
285. Most common cause of trisomy 21 in Down syndrome: Maternal
nondisjunction in meiosis 1.
286. Most common CHD in Down syndrome: Endocardial cushion,
ASD, VSD.

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 287. Triple test for Down's syndrome includes: Estriol (decreased),
alpha fetoprotein (decreased), HCG (raised). 289. Quadruple test
for Down's syndrome: Triple test + inhibin A.
288. PAPA levels in Down syndrome: Decreased.
289. Commonest cause of intestinal obstruction in Down syndrome:
Duodenal atresia.
290. Chromosomes in Turner syndrome: 45 (45X0).
291. Features of turner syndrome with normal karyotype: Noonan
syndrome.
292. Edema of hands and feet in an infant: Turner syndrome.
293. Most common cardiac anomaly in Turner syndrome: Bicuspid
aortic valve (MC) and COA (2nd MC)
294. Most common cardiac anomaly in Turner syndrome Bicuspid
aortic valve (MC) and COA (2nd MC)
295. Patau syndrome: Trisomy 13
296. Edward syndrome Trisomy 18 299.Down syndrome: Trisomy 21
297. Klinefelter syndrome is diagnosed by: Karyotyping 301.Barr body
is present in: Normal female (46XX)
298. Female with absent Barr body: Turner syndrome (45 XO)
299. Male with present Barr body: Klinefelter syndrome (47XXY)
300. Most common birth defect in Pakistan: Neural tube defect (spina
bifida)
301. Skull in Down's syndrome: Brachiocephaly
302. Distinguishing feature of Edward syndrome (Trisomy 18): Rocker
bottom fect
303. Not seen in Turner syndrome: Mental retardation
304. Not a feature of Noonan syndrome: Chromosomal abnormality.
305. Mutation in a single gene produces effect on more than one
characteristic: Pleiotropy
306. Child resembles grand-parents: Atavism
307. MC Pediatric malignancy: Leukemia > Lymphoma
308. MC Neoplasm in children < 2 years: ALL

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 309. MC Solid tumor in children: Brain tumors 314.MC Renal
neoplasm in children: Wilms’ tumor
310. MC Soft-tissue tumor in children: Rhabdomyosarcoma
316.Commonest cause of convulsions in childhood is febrile
seizures
311. The commonest type of seizures in newborn: Subtle seizures
318.DOC for neonatal convulsions: Phenobarbitone
312. DOC for status epilepticus in childhood: Diazepam
313. 320. Fungal ball in lung cavity: Aspergillosis 321.Bronchiolitis in
children: Respiratory Syncytial virus
314. Croup: Parainfluenza virus
315. Viral pneumonia in adults/children: Influenza/Resp syncytial
virus
316. Tropical hemoptysis: Paragonimus westermanii
317. Meningitis in less than 2 months old: E Coli, Beta Hemolytic
Streptococci
318. Meningitis in 2 months to 12 years: H. Influenzae
319. Meningitis after 12 years: Meningococcus
320. Meningitis in recurrent CSF leaks: Streptococcus pneumonia
321. Endemic hematuria: Schistosoma haematobium
322. Infection in burns: Pseudomonas
323. MCC of impetigo: Staphylococcus 332.Parotitis: Staphylococcus
324. Boil: Staphylococcus
325. Cherry-red spot on macula ‘without’ hepatosplenomegaly: Tay-
Sachs disease
326. Cherry-red spot on macula ‘with’ hepatosplenomegaly: Niemann-
Pick’s disease
327. Bronze skin: Hemochromatosis
328. Heliotrope rash: Dermatomyositis
329. Salty tasting infant: Cystic fibrosis
330. Honey ingestion: Infant botulism
331. Currant jelly stool: Intussusception
332. Currant jelly sputum: Klebsiella Pneumoniae

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 333. Lowe’s syndrome: Hypophosphatemic rickets + aminoaciduria +
CNS and eye defects
334. Potter’s syndrome: Pulmonary hypoplasia + renal hypoplasia +
ear deformities
335. Cat eye syndrome: Partial trisomy 22
336. Floppy baby syndrome: Due to clostridium botulinum
337. Dandy-Walker syndrome: Due to obstruction of Foramina of
Luschka and Megendie
338. McLeod syndrome: Unilateral pseudoemphysema occurring in
childhood
339. William’s syndrome: Infantile hypercalcemia
340. Caudal regression syndrome seen in: diabetics
341. Important features of neonatal airway: Small & narrow, large
tongue, omega shaped & large epiglottis, larynx extends from C2
to 4, subglottic region narrowest, more compliant chest wall.
342. Important causes of wheeze in children: Asthma, foreign body,
infection, hypersensitivity pneumonitis, external compression by
mediastinal lymphadenopathy.
343. Important causes of stridor in children: Croup, epiglottitis,
laryngornalacia, vascular ring, vocal cord palsy, subglottic
hemangioma or stenosis.
344. Most common cause of stridor in infant and young children:
Laryngomalacia.
345. Most common congenital abnormality of larynx: Laryngomalacia.
346. Features of laryngomalacia: Inspiratory intermittent stridor more
prominent in supine position and relieved in prone position.
347. Omega shaped epiglottis is seen in: Laryngomalacia.
348. Treatment of laryngomalacia: Only reassurance that it is a self-
limiting condition.
349. Acute onset of cough, dyspnea and stridor in a child is mostly
due to: Foreign body aspiration.
350. Commonest sign of intrabronchial foreign body in child: Cough.

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 351. Immediate management of foreign body aspiration in lower
respiratory tract (e.g. lung/bronchi: Rigid bronchoscopic removal.
352. Most common cause of stridor shortly after birth:
Laryngomalacia.
353. Seal barking like croupy cough is characteristic of:
Laryngotracheobronchitis (croup)
354. Most common cause of croup (Laryngotracheobronchitis):
Parainfluenza virus type 1.
355. Other causes of croup: RSV, influenza virus, adenovirus,
rhinovirus
356. Typical presentation of croup: History of URTI for 1-3 days
followed by barking cough, inspiratory stridor which is
aggravated by crying
357. Treatment of choice for croup: Dexamethasone
358. Other measures in treatment of croup: Oxygen, hydration,
nebulized epinephrine, hellos (helium plus 02).
359. Drugs which have no role in croup: Antibiotics, sedatives, opioids
(morphine).
360. X-ray sign of croup: Steeple sign
361. Most common cause of epiglottitis: H. Influenzae
362. Radiological signs of epiglottitis: Thumb sign, vallecula sign.
363. Most common cause of bronchiolitis: RSV
364. Dyspnea, wheezing, bilateral crepitation with bilateral
hyperinflation on chest x-ray is seen in: Bronchiolitis 374.
Treatment of bronchiolitis includes: Humid atmosphere, 02,
bronchodilators, antipyretics, aerosolized ribavirin (drug
365. of choice).
366. Aerosolized ribavirin is drug of choice for: Acute bronchiolitis
(caused by RSV).
367. Drug with no role in treatment of bronchiolitis: Morphine
368. Most common cause of pneumonia in children: RSV (MCC)
followed by influenza virus (as 2nd MCC)

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 369. Commonest cause of bacterial pneumonia in children:
Streptococcus pneumoniae (Pneumococcus).
370. Virus causing pneumonia in children: RSV, influenza virus,
adenovirus, Parainfluenza virus, rhinovirus
371. Not a cause of viral pneumonia: Mumps virus.
372. Pneumatocele is seen in pneumonia with: Staphylococcus aureus
(most common), less commonly by E. coli and klebsiella.
373. Primary giant cell pneumonia (Hecht’s pneumonia) is caused by:
Measles.
374. Important causes of lung abscess: Staphylococcus,
pneumococcus, klebsiella, E. coli, H-Influenzae, pseudomonas.
375. Most common cause of pneumothorax, emphysema, lung
abscess, Pneumatocele as complications of pneumonia:
Staphylococcus
376. Drug of choice for mycoplasma pneumonia: Macrolides
(erythromycin, azithromycin)
377. Lobe of lung most commonly involved in aspiration: Posterior
segment of right apical lobe.
378. Important features of childhood asthma: Raised IgE,
family/personal history of atopic dermatitis, improvement in
wheezing with mild exercise.
379. Most characteristic clinical feature of asthma: Wheezing
380. Most common indication of liver transplantation in children:
Biliary atresia
381. Most common cause of bleeding per rectum in infants: Anal
fissures
382. Most common cause of vomiting in neonate: Aerophagy
383. Skip lesions are seen in: Crohn's disease.
384. Pseudocyst and toxic megacolon are features of: Ulcerative colitis
385. Lead pipe appearance on barium enema is seen in: Crohn disease
386. Absence of stomach bubbles on antenatal USG: Fetal esophageal
atresia

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 387. Causes of bloody vomitus in neonates: Stress gastritis,
hemorrhagic disease of newborn, swallowed maternal blood
388. Double bubble sign in children: Duodenal atresia, Ladds band,
annular pancreas, pancreatic head tumor, pancreatic pseudocyst
389. Childhood cholelithiasis is seen in: Niemann Pick's disease
390. Most common cause pancreatic pseudocyst in children: Acute
pancreatitis due to trauma.
391. Most common GI malignancy in children: Lymphoma
392. Drug of choice for asthma in children: Short acting inhaled B2-
agonist.
393. Drug of choice for exercise induced asthma: Inhaled B2-agonist.
394. Drugs not used in the treatment of asthma: Sedatives, opioids.
395. Typical presentation of bronchiolitis obliterans: Moderate fever,
mild dyspnea and nonproductive cough which improve initially,
but later developing high fever, severe dyspnea, productive cough
with hyperluceny on X-ray and obstructive PFT.
396. Infants with cystic fibrosis most likely to develop:p Meconium
ileus
397. Cystic fibrosis is: An autosomal recessive disorder due to
mutation in CFTR gene on long arm of chromosome 407. Most
common infecting organism in cystic fibrosis: Non-mucoid
pseudomonas
398. Diagnostic test of choice in cystic fibrosis: Trans-epithelial nasal
membrane potential difference.
399. Blood supply of lung sequestration: Aorta or Its branches
400. Venous drainage of pulmonary sequestration: IVC
(extrapulmonary sequestration), pulmonary veins
(intrapulmonary sequestration)
401. In pulmonary sequestration: Lesion does not fill on
bronchography
402. Components of Kartagener's syndrome: (i) Bronchiectasis, (ii)
Sinusitis, (iii) Situs invert us, (iv) Infertility.

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 403. Kartagener's syndrome 'so subgroup of: Primary ciliary
dyskinesia
404. Most common posterior mediastinal moss in children: Neurogenic
tumor
405. Most common cause of ASOM in children: Streptococcus
pneumoniae
406. Most common cause of acute bronchitis (not bronchiolitis) in
children: Influenza virus
407. Cyanosis and respiratory symptoms improve on crying: Choanal
atresia
408. Most common pulmonary tumor in children: Carcinoid.
409. Dribbling and regurgitation after feed, respiratory distress,
frothing & bubbling at mouth in a neonate: Tracheo- esophageal
fistula.
410. Congenital hypertrophic pyloric stenosis (CHPS) usually presents:
After 3 weeks (but may be as early as 1 week)
411. Metabolic derangement in CHPS: Hypochloremic alkalosis with
paradoxical aciduria and hyponatremia.
412. Non-bilious vomiting with palpable mass in epigastrium:
Congenital hypertrophic pyloric stenosis
413. Ramstedt operation is done in: Congenital hypertrophic pyloric
stenosis (CHPS)
414. Ramstedt operation (pyloromyotomy) - longitudinal incision
through the anterior wall of the pyloric canal to the level of the
submucosa, to treat hypertrophic pyloric stenosis.
415. Most common cause of acquired megacolon: Chaga's disease
416. Hirschsprung disease is due to: Defective migration of neural
crest cells into mesodermal layer of gut
417. Most commonly affected region in Hirschsprung disease:
Rectosigmoid region
418. Typical presentation of Hirschsprung disease: Delayed passage of
meconium

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 419. Initial (screening) test of choice for Hirschsprung disease: Rectal
manometry
420. Definitive diagnosis of Hirschsprung disease is made by: Rectal
biopsy
421. Biopsy findings in Hirschsprung disease: Absence of ganglia &
ganglionic cells with thickening & hypertrophy of nerve trunk
422. Dilatated segment of bowel in Hirschsprung disease is: Proximal
to affected (contracted) segment.
423. Most common cause of intestinal obstruction In a neonate:
Jejunoileal atresia (MC) followed by duodenal atresia (2nd MC)
424. Most common cause of intestinal obstruction in children:
Intussusception
425. Most common symptom of small bowel obstruction in a neonate:
Bilious vomiting
426. Most common cause of abdominal distension in intestinal
obstruction : Swallowed air
427. Investigation of choice of volvulus neonatorum with suspected
perforation: Plain X-ray
428. Likely cause of Intussusception in a child: Payer’s patch
hypertrophy
429. Bloody currant jelly stool, abdominal distension, sausage shaped
palpable mass in child screaming with severe abdominal pain:
Intussusception
430. Inflammatory bowel diseases (IBDs) in children: Crohn disease
(regional ileitis), ulcerative colitis
431. Commonest site of involvement in CD: Distal ileum, followed by
distal ileum with colon
432. Important features of necrotizing enterocolitis: Abdominal
distension, diminished bowel sound, pneumatosis intestinalis,
pneumoperitoneum, metabolic acidosis
433. Treatment of choice for perforated necrotizing enterocolitis:
Paracentesis (peritoneal drainage) followed by definitive surgery

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 434. Definitive diagnostic test for cause of chronic malabsorption:
Intestinal biopsy
435. Features of coeliac disease: Villous atrophy, crypt hyperplasia,
inflammatory cells in lamina propria, maintained mucosal
thickness.
436. Cereals which should be avoided in Coeliac disease: Wheat, oat,
barley, rice (but not maize).
437. Celiac disease is associated with: HLA-DQ2 (MC), HLA-DQ8
(2nd), HLA-B8, HLA-DR3, HLA-DR7.
438. Most common enzyme deficiency after infectious enteritis:
Lactose
439. Test for lactose deficiency and lactose intolerance: Hydrogen
(F12) breath test
440. Most common cause of cholestatic jaundice in newborn:
Idiopathic neonatal hepatitis (MC), extrahepatic biliary atresia
(2nd MC)
441. Important features of extrahepatic cholestasis (e.g. biliary
atresia): Raised alkaline phosphatase, 5-nucleotidase and GGT
442. Giant cells are seen in: Neonatal hepatitis, EHBA, a1-antitrypsin
deficiency, viral infections, Niemann-Pick disease
443. Diagnostic procedure for extrahepatic biliary atresia (EHBA):
Percutaneous liver biopsy.
444. Most common cause of portal hypertension in children:
Extrahepatic portal venous obstruction (EHPVO).
445. Most common cause of massive hematemesis in a child: Portal
hypertension
446. Most common cause of diarrhea in children: Rotavirus
447. Important viral causes diarrhea in children: Rotavirus, calcivirus
adenovirus, astrovirus, norwalk virus (but not reovirus)
448. Most common bacterial cause of diarrhea in children: ETEC
449. Parasites causing diarrhea in immunocompromised child:
Giardia, cryptosporidium.

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 450. Commonest cause of abdominal pain in children: Behavioral
(functional) pain
451. Most common cause of abdominal pain in an infant: Colic
(evening colic)
452. Evening colic usually disappears at the age of: 3-4 months.
453. Most common abdominal mass is a neonate: Multicystic renal
dysplasia.
454. Most common abdominal mass in 1 months to 3 years: Wilms
tumor or Multicystic renal dysplasia.
455. Most common renal problem in j to 6years: Minimal change
disease causing nephrotic syndrome.
456. Most common renal problem in 6 to 14 years: Acute post-
streptococcal GN.
457. Most common renal cystic disease in infancy: Multicystic
dysplastic kidney (Unilateral renal dysplasia).
458. Childhood polycystic kidney disease (CPKD) is acquired as:
Autosomal dominant
459. Important associations of CPKD: Maternal Oligohydromnios,
pulmonary hypoplasia, hepatic cysts & fibrosis, biliary atresia,
Portter’s syndrome.
460. Unilateral renal agenesis is associated with: Single umbilical
artery.
461. Most common site of opening of ectopic ureter in males: Posterior
(prostatic) urethra.
462. Important features of nephrotic syndrome: Proteinuria (>3.5
gm/d), hypoalbuminemia, edema, hyperlipidemia, lipiduria.
463. Cause of edema in nephrotic syndrome: Hypoalbuminemia.
464. Cause of edema in nephrotic syndrome: Salt {sodium) and water
retention.
465. Finnish type of congenital nephrotic syndrome is due to mutation
in: Nephrin protein coded by NPHS1 gene.
466. Genes involved in congenital steroid resistant nephrotic
syndrome: NPHS2 which codes for protein podocin.

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 467. Most common cause of nephrotic syndrome in children: Minimal
change disease (Lipoid nephrosis)
468. Best response to steroid is seen in: Minimal change disease
(lipoid nephrosis).
469. Characteristic feature of nephritic syndrome in children: RBC
casts in urine.
470. Marker for renalvasculitis in children: IgA level
471. Hematuria with dysmorphic RBCs in urine 2 days after an attack
of upper respiratory tract infection: IgA nephropathy.
472. Triad of hemolytic uremic syndrome: Anemia, renal failure
(Increased BUN, Increase creatinine, oliguria) and
473. thrombocytopenia.
474. Most common cause of HUS gastroenteritis by E. coli (EHEC)
475. Most common cause of urinary tract obstruction in a male infant:
Posterior urethral valve
476. A full term neonate can concentrate urine to: 700-800 mOsm/kg.
486.An older child can concentrate urine upto: 1200-1400
mOsm/kg.
477. Concentrating ability reaches equal to adult level at: 1 year of
age.
478. A newborn can dilute urine upto: 50 mOsm/kg (similar to older
children)
479. Most common infection in nephrotic syndrome: Spontaneous
bacterial peritonitis
480. Most common cause of recurrent UTI in a child: Vesicoureteric
reflux (VUR).
481. Vesicoureteric reflux (VUR) is more common in: Newborn females
482. Most common cause of renal scarring in a 3 year old child: VUR
induced pyelonephritis
483. Most common cause of UTI in children: E.coli.
484. Most appropriate method for collection of urine specimen for
culture in infant: Suprapubic aspiration
485. Chronic pyelonephritis is more common in Females.

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 486. Infant/baby with umbilical bleeding — Injection vitamin K

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