Dr. Rabia 1700 Plab Material Mcqs

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

Diagnosis : Bladder CA. (1 in 10,000) Most common : Transistional cell CA. 3x in MEN of 50+ age. Inc factors : Smoking, schistosomiasis, rubber dye industries, White ppl, recurrent infections. Symptoms : Painless hematuria (on and off) Pain in lower abdomen

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

Ans. 1. The key is C. Ectopic ACTH. Ans. 2. The patient is smoker and probably developed small cell lung cancer which is working as a tumour producing ectopic ACTH resulting in pigmentation. Resultant raised cortisol is leading to diabetes and hypokalemia. the features can be explained by increased levels of ACTH and adrenocortical hormones. So the question is : ectopic or pituitary ACTH excess? It seems to be from an ectopic source since the patient is smoker and has SOB and cough ( Lung tumor whether small cell CA bronchus or carcinoid tumor- both may

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

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

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

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

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

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

Calcium

2.1-2.6 mmol/l

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

5. A 64yo man has recently suffered from a MI and is on aspirin, atorvastatin and ramipril. He has been having trouble sleeping and has been losing weight for the past 4 months. He doesn’t feel like doing anything he used to enjoy and has stopped socializing. He says he gets tired easily and can’t concentrate on anything. What is the most appropriate tx? a. Lofepramine b. Dosulepin c. Citalopram d. Fluoxetine e. Phenelzine Ans. The key is C. Citalopram. [Citalopram is the antidepressant of choice in IHD] Citalopram is associated with dose-dependent QT interval prolongation and is contraindicated in patients with known QT interval prolongation or congenital long QT syndrome. Sertraline can also be used in patients with IHD for depression. sertraline is considered the drug of choice post-MI 1. Depression with obesity=fluoxetine (It helps without weight loss) 2. Depression with sexual dysfunction=mirtazapine 3. Post stroke depression use nortriptyline (TCA) 4. Depression with obsessive compulsive disorder=clomipramine (TCA) 5. Depression with ischemic heart disease=SSRI e. g citalopram

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

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ipsilateral: dysphagia, facial numbness, cranial nerve palsy e.g. Horner's contralateral: limb sensory loss

Lateral medullary or Wallenberg's syndrome:    

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

o o o o o o o

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

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

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

CXR: wide mediastinum, fluid level Gold standard - Manometry

Treatment

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intra-sphincteric injection of botulinum toxin Heller cardiomyotomy for fit young patients. balloon dilation for old unwell patients.

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

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

Dysphagia may be associated with weight loss, anorexia or vomiting during eating Oesophageal cancer

Oesophagitis

Past history may include Barrett's oesophagus, GORD, excessive smoking or alcohol use

May be history of heartburn Odynophagia but no weight loss and systemically well

Oesophageal candidiasis

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

Achalasia

Dysphagia of both liquids and solids from the start Heartburn Regurgitation of food - may lead to cough, aspiration pneumonia etc

Pharyngeal pouch

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

Systemic sclerosis

Other features of CREST syndrome may be present, namely Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia

As well as oesophageal dysmotility the lower oesophageal sphincter (LES) pressure is decreased. This contrasts to achalasia where the LES pressure is increased

Myasthenia gravis

Other symptoms may include extraocular muscle weakness or ptosis

Dysphagia with liquids as well as solids

Globus hystericus

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

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

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

Wells' diagnostic algorithm[1] Score one point for each of the following:  Active cancer (treatment ongoing or within the previous six months, or palliative).  Paralysis, paresis or recent plaster immobilisation of the legs.  Recently bedridden for three days or more, or major surgery within the previous 12 weeks, requiring general or regional anaesthesia.  Localised tenderness along the distribution of the deep venous system (such as the back of the calf).  Entire leg is swollen.  Calf swelling by more than 3 cm compared with the asymptomatic leg (measured 10 cm below the tibial tuberosity).  Pitting oedema confined to the symptomatic leg.  Collateral superficial veins (non-varicose).  Previously documented DVT. Subtract two points if an alternative cause is considered at least as likely as DVT. The risk of DVT is likely if the score is two or more, and unlikely if the score is one or less. invs : initial - Duplex USG Gold standard - invasive venography

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

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

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

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

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

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

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

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

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

Signs    

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

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

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

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

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

Choice of antibiotics in hospital : o Ceftriaxone is usually given to those over 3 months o Cefotaxime and amoxicillin are usually given to those under 3 months.

o

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Vancomycin is given in addition, to those who have recently travelled outside the UK or have had prolonged or multiple exposure to antibiotics. CHEMOPROPHYLAXIS : To close contacts of cases, irrespective of vaccination status - for example, those who have had prolonged close contact with the case in a household-type setting during the seven days before onset of illness Ciprofloxacin and rifampicin are both recommended by Public Health England (PHE) but ciprofloxacin is the preferred choice for most individuals. Ciprofloxacin can be used in all ages and in pregnancy; it is easily available in a single dose and does not interfere with oral contraceptives (but is contraindicated if there has been previous sensitivity): o Adults and children aged >12 years - 500 mg orally stat. o Children aged 5-12 years - 250 mg orally stat. o Children aged 60 minutes

2

10-59 minutes

1

height, pectus deformity, scoliosis, pes planus. Minor signs: Mitral valve prolapse, high-arched palate, joint hypermobility. Diagnosis is clinical. DANGER IS AORTIC DISSECTION. Surgery is done when aorta >5cm Can also cause pneumothorax. 122. A 4yo child presents with pain of spontaneous onset in his knee of 2 days duration. He has developed mild fever in the 2nd day. He can walk but has a limp. Exam: painful restriction in the

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

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

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

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

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

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

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

Risks: Antenatal • Previous PPH or retained placenta BMI>35kg/m2 • Maternal Hb100mmHg, Transfuse blood. Is the placenta delivered? If it is, is it complete? If not, explore the uterus. • If the placenta is complete, put the patient in the lithotomy position with adequate analgesia and good lighting. Check for and repair trauma. • If the placenta has not been delivered but has separated, attempt to deliver it by controlled cord traction after rubbing up a uterine contraction. If this fails, ask an experienced obstetrician to remove it under general anaesthesia.Beware renal shut down. 129. A 32yo woman in tears describing constant irritability with her 2 small children and inability to relax. She describes herself as easily startled with poor sleep and disturbed nightmares following a house fire a year ago, while the family slept. What is the single best tx? a. Rassurance b. Relaxation therapy c. Quetiapine d. Lofepramine e. Fluoxetine Q. 1. What is the key Q. 2. What is the diagnosis? Q. 3. What are the points in favour of your diagnosis? Ans. 1 The key is E. Fluoxetine. The key is probably a wrong key. Likely correct key is B. Relaxation therapy Ans. 2. The diagnosis is post traumatic stress disorder. Ans. 3. Points in favour of PTSD: i) H/O stressor (house fire a year ago) ii) Nightmares of the stressor iii) Hyper arousal (very anxious and inability to relax (leading to irritability) iv) associated depression (poor sleep, tearful). Note: Fluoxetin and peroxetin are the drugs of choice in PTSD. CBT is the nonpharmacological treatment. PTSD: Symptoms: Fearful; horrified; dazed • Helpless; numb, detached • Emotional responsiveness • Intrusive thoughts • Derealization • Depersonalization • Dissociative amnesia • Reliving of events • Avoidance of stimuli • Hypervigilance • Lack of Concentration • Restlessness• Autonomic arousal: pulse; BP; sweating • Headaches; abdo pains Signs: Suspect this if symptoms become chronic, with these signs (may be delayed years): difficulty modulating arousal; isolated-avoidant modes of living; alcohol abuse; numb to emotions and relationships; survivor guilt; depression; altered world view in which fate is seen as untamable, capricious or absurd, and life can yield no meaning

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

Anal fissures: Acute If less than 6weeks, >6wks chronic. Causes: Most are due to hard faeces. Spasm may constrict the inferior rectal artery, causing ischaemia, making healing difficult and perpetuating the problem. History of constipation almost always present. Examination is almost impossible due to severe pain. Treatment: Acute: Increase fluid intake, fiber diet. Bulk forming laxatives are first line. Topical anesthetics are used. Lactulose can be tried. Chronic: Topical GTN is the first line and mainstay of treatment. If ineffective for >8wks surgical referral for use of botulinum toxin. 131. A 20yo student attends the OPD with complaint of breathlessness on and off, cough and sputum. His sleep is disturbed and skin is very dry in flexural areas of the body. Exam: tachypnea, hyperresonant percussion and wheezing on auscultation. What is the most likely dx? a. Extrinsic allergic alveolitis b. Asthma c. Wegener’s granulomatosis d. COPD e. Cystic fibrosis Q. What is the key? Q. What are the diagnostic criteria? Ans. The key is B. Asthma. Ans. 2. Diagnostic criteria of asthma: i) Airway hyper-responsiveness to certain stimuli ii) Recurrent variable airflow limitation usually reversible iii) presents as wheezing, breathlessness, chest tightness and cough. ASTHMA. Symptoms: Dyspnea, wheeze, cough (with or without sputum), chest tightness (4 most important) particularly if symptoms are worse at night or early morning and in response to certain triggers like cold, exercise, allergens. Symptoms exacerbated by use of

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

Management: CHRONIC (LONG TERM)

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

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

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

136. A butcher stabbed accidently his groin. He bled so much that the towel was soaked in blood and BP=80/50mmHg, pulse=130bpm. What % of circulatory blood did he lose? a. 50% Q. 1. What is the key? Q. 2. What is the classification of blood loss according to vital sign? Ans. 1. The key is C. 30-40% Ans. 2. Hypovolemic shock Classification: 1. Class 1 up to 15% of blood volume lost: pulse 140; systolic BP decreased; pulse pressure decreased’ respiratory rate >35; urine output negligible.

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

In the given question since the patient is above the age of 65 so rate control is done! For which either a beta blocker or calcium channel blocker is used! 138. A 78yo man is depressed after his wife’s death. He has been neglecting himself. His son found him in a miserable state when he went to visit. The son can’t deal with his father. What is the appropriate management? a. Voluntary admission to psychiatry ward b. Hand over to social worker c. Request son to move in with father d. Send pt to care home Ans. The key is A. Voluntary admission to psychiatry ward. 139. An old alcoholic presents with cough, fever, bilateral cavitating consolidation. What is the most probable cause? a. Gram +ve diplococcic b. Coagulase +ve cocci c. Gram –ve cocci d. AFB e. Coagulase –ve cocci Q. 1. What is the key? Q. 2. What is the organism? Ans. 1. The key is B. Coagulase +ve cocci. Ans. 2. Name of organism is Staphylococcus aureus. • Legionella: hotel stay, foreign travel, flu like symptoms, hyponatremia, pleural effusion. TEST: urinary antigen. CXR shows bi-basal consolidation • Mycoplasma Pneumonae: Rash (erythema multiforme), unusual symptoms (abd pain, dry cough), long duration of symptoms, hyponatremia, Diagnosis by serology. CXR: reticularnodular shadowing or patchy consolidation

• Staphylococcal pneumonia may complicate influenza infection and is seen most frequently in the elderly and in intravenous drug users or patients with underlying disease. Shows bilateral cavitations. • Pneumonia associated with COPD: H.influenze (more likely) or P.aeruginosa • P.aeruginosa: Common in bronchiectasis or CF. Also causes hospital acquired infection. • Klebsiella pneumoniae is classically in alcoholics • Strept pneumonia: Associated with herpes labialis. commoner in the elderly, alcoholics, post-splenectomy, immunosuppressed and patients with chronic heart failure or pre-existing lung disease • Pneumocystis pneumonia (PCP) causes pneumonia in the immunosuppressed (eg HIV). CXR may be normal or show bilateral perihilar interstitial shadowing. Diagnosis: visualization of the organism in induced sputum, bronchoalveolar lavage, or in a lung biopsy specimen

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

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

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

This patient has intermittent claudication due to atherosclerosis,

Symptoms Cramping pain is felt in the calf, thigh, or buttock after walking for a given distance (the claudication distance) and relieved by rest. Ulceration, gangrene, and foot pain at rest—eg burning pain at night relieved by hanging legs over side of bed—are the cardinal features of critical ischaemia. Fontaine classification for peripheral arterial disease: 1. Asymptomatic 2. Intermittent claudication 3.Ischaemic rest pain 4. Ulceration/gangrene (critical ischaemia) Signs: Absent femoral, popliteal or foot pulses; cold, white leg(s); atrophic skin; punched out ulcers (often painful); postural/dependent colour change; a vascular (Buerger’s) angle of 15s are found in severe ischaemia Imaging: Colour duplex USS is 1st line (non-invasive and readily available). If considering intervention then MR/CT angiography MANAGEMENT: Stop smoking, exercise, treat HTN, antiplatelet (clopidogrel). Advise exercise until maximum tolerable pain. Vasoactive drugs may be used. If PAD is advancing consider: Percutaneous transluminal angioplasty (PTA) is used for disease limited to a single arterial segment. Surgical reconstruction: arterial bypass Amputation. If all fail. Knee should be saved if possible. 143. A 3yo child who looks wasted on examination has a hx of diarrhea on and off. The mother describes the stool as bulky, frothy and difficult to flush. What is the single inv most likely to lead to dx? a. Sweat chloride test b. Anti-endomysial antibodies c. LFT d. US abdomen e. TFT Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. The key is B. Anti-endomysial antibody Ans. 2. The diagnosis is celiac disease. Coeliac Disease: Suspect this in all those with diarrhoea + weight loss or anaemia (esp. if iron or B12). It is a T-cell-mediated autoimmune disease of the small bowel in which prolamin (alcohol-soluble proteins in wheat, barley, rye ± oats) intolerance causes villous atrophy and malabsorption (including of bile acids)

Investigations: FBC, Dec feritin, dec vit.B12 Antibodies: alpha -gliadin, transglutaminase and anti-endomysial 95% specific. Duodenal biopsy shows subtotal villous atrophy.

Treatment Lifelong gluten-free diet 144. A 45yo woman has had severe epigastric and right hypochondrial pain for a few hours. She has a normal CBC, serum ALP is raised, normal transaminase. 3 months ago she had a cholecystectomy done. What is the most appropriate inv? a. US abdomen b. ERCP c. MRCP d. CT abdomen e. Upper GI endoscopy Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. The key is B. ERCP. Ans. 2. Diagnosis is choledocolithiasis. Right upper quadrant pain… think of gall stones. And since the LFTs here show obstructive picture ALP increased with normal transaminases the obstruction is most probably in the biliary tract CBD. ERCP: Endoscopic retrograde cholangiopancreatography (ERCP) Indications: No longer routinely used for diagnosis, it still has a significant therapeutic role: sphincterotomy for common bile duct stones; stenting of benign or malignant strictures and obtaining brushings to diagnose the nature of a stricture. MRCP: MRCP (magnetic resonance cholangiopancreatography) gives detail of the biliary system and the pancreatic duct. MRCP has excellent sensitivity and specificity for diagnosing common bile duct stones—when these are >6mm both are 99% (although accuracy is lower for stones 100mL, teach intermittent selfcatheterization; if 80% of those with CML t(9:22) Symptoms Mostly chronic and insidious: weightloss, tiredness, fever, sweats. There may be features of gout (due to purine breakdown), bleeding (platelet dysfunction), and abdominal discomfort (splenic enlargement). ~30% are detected by chance. Signs Splenomegaly (>75%)—often massive. Hepatomegaly, anaemia, bruising (fi g 2). Tests WBC increased (often >100≈109/L) with whole spectrum of myeloid cells, ie increased neutrophils, myelocytes, basophils, eosinophils. Hb dec or normal, platelets variable. Urate increased B12increased. Bone marrow hypercellular. Treatment: is by chemotherapy or stem cell transplantation. 147. A 6yo pt comes with easy bruising in different places when she falls. CBC: WBC=25, Hgb=10.9, Plt=45. Her paul brunnel test +ve. What is the most likely dx? a. Glandular fever b. ITP c. Trauma d. NAI e. Septicemia Q. 1. What is the key? Q. 2. What are the lab. Values that suggests the diagnosis here? Ans. 1. The key is A. Glandular fever. Ans. 2. Suggestive lab. Values: WBC=25 (leucocytosis), Hgb=10.9 (usually patient is not anaemic), Plt=45 (thrombocytopenia-leading to easy bruising), Positive paul bunnel test.

INFECTIOUS MONONUCLEOSIS Caused by EBV, spread by saliva or droplets. EBV also causes certain cancers (Hogdkin’s, burkitts and nasopharyngeal CA) Symptoms: Sore throat, inc T°, anorexia, malaise, lymphadenopathy (esp. posterior triangle of neck), palatal petechiae, splenomegaly, fatigue/mood Blood film Lymphocytosis and atypical lymphocytes (large, irregular nuclei)

Heterophil antibody test (Monospot, Paul– Bunnell) 90% show heterophil antibodies by 3wks, disappearing after ~3 months PCR may also be done. Treatment: None usually needed.Avoid contact sports for 8 weeks. Avoid alcohol. Steroid or acyvlovir may be given but there is not much benefit. Never give ampicillin or amoxicillin for sore throats as they often cause a severe rash in those with acute EBV infection 148. A 41yo woman who has completed her family, has suffered from extremely heavy periods for many years. No medical tx has worked. She admits that she would rather avoid open surgery. After discussion, you collectively decide on a procedure that wouldn’t require open surgery or GA. Select the most appropriate management for this case. a. Endometrial ablation b. Hysterectomy c. Fibroid resection d. Myomectomy e. Uterine artery embolization Ans. The key is uterine artery embolization. Treating menorrhagia Drugs Progesterone-containing IUCDs, eg Mirena should be considered 1st line treatment for those wanting contraception. effective for bleeding and also reduce the size of fibroid uterus. 2nd line recommended drugs are antifibrinolytics, antiprostaglandins or the Pill. Antifibrinolytics Taken during bleeding these reduce loss (by 49%)—eg tranexamic acid CI: thromboembolic disease— Antiprostaglandins eg mefenamic acid 500mg/8h PO pc (CI: peptic ulceration) taken during days of bleeding particularly help if there is also dysmenorrhoea. COCP can also be used if they are not contraindicated.. 3rd line recommendation is progestogens IM or norethisterone Rarely gonadotrophin (LHRH) releasing hormones are used Surgery Endometrial resection is suitable for women who have completed their families and who have 10wk size and fibroids >3cm may benefit from hysterectomy, vaginal hysterectomy being the preferred route. 149. A girl with hx of allergies visited a friend’s farm. She got stridor, wheeze and erythematous rash. What is the most appropriate tx? a. 0.25ml IM adrenaline b. 0.25ml PO adrenaline c. 0.25ml IM adrenaline d. IV chlorphearamine Ans. The key is A. 0.25 ml IM adrenaline [Presence of stridor and wheeze are suggestive of anaphilaxis and treatment option is adrenaline]. Consider anaphylaxis when there is compatible history of rapid-onset severe allergictype reaction with respiratory difficulty and/or hypotension, especially if there are skin changes present and the treatment of anaphylaxis is IM adrenaline not anti histamine

Treatment:ABCDE, Oxygen, IM Adrenaline. 12 yrs 0.5ml 1:1000 Since the age of the girl is not mentioned here and options A & C are the same so A or C could be the answers supposing the girl was 6-12 yrs of age. 150. A 5yo boy is referred to the hospital and seen with his father who is worried that he has been listless. He is not sure why his GP suggested he should come to the ED and is keen to get some tablets and go home. Exam: tired and irritable, swelling around eyes. Renal biopsy: remarkable for podocyte fusion on EM. What is the most probable dx? a. NAI b. Myelodysplastic disease c. HSP d. Membranous GN e. Minimal change GN Ans. The key is E. Minimal change glomerulonephritis. [Podocyte fusion on electron microscopy] Most common cause of nephrotic in children is minimal change disease. There will be hypoalbuminemia and peripheral edema too. Electron microscopy shows effacement of podocyte foot processes.. MCD has albumin selective proteinuria. Treatment is with steroids. 151. A 6yo boy is brought to the hospital for a 3rd episode of sore throat in 1 month. He is found bleeding from gums and nose and has pale conjunctiva. What’s the single cell type? a. Clumped platelets b. Microcytes c. Granulocyte without blast cells d. Blast cells e. Mature lymphocytes Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the points that favour diagnosis? Ans. 1. The key is D. Blast cells. Ans. 2. The diagnosis is ALL Ans. 3. Points in favour: i) Age-6yrs ii) recurrent infection (sorethroat) due to neutrpenia and abnormal lymphoblasts which cannot protect from infection iii) thrombocytopenia causing gum and nose bleeding. Iii) anaemia (pale conjunctiva) due to reduced red cell production from marrow occupation by blast cells. [Here debate came why it is not aplastic anaemia? There is no risk factor mentioned for this patient for aplastic anaemia. There may be congenital aplastic anaemia but again it would present earlier in life. So it goes more with leukaemia but it cannot be confirmed unless we do bone marrow aspiration.] ALL: This is a malignancy of lymphoid cells, affecting B or T lymphocyte cell lines, arresting maturation and promoting uncontrolled proliferation of immature blast cells, with marrow failure and tissue infiltration.

Causes: Genetic susceptibility, environmental factors (ionizing radiations) Down’s syndrome. Commonest cancer of childhood.

Signs and symptoms: • Marrow failure: Anaemia (Hb), infection (WCC), and bleeding (platelets). • Infiltration: Hepatosplenomegaly, lymphadenopathy—superficial or mediastinal, orchidomegaly, CNS involvement—eg cranial nerve palsies, meningism. INVESTIGATIONS: Characteristic blast cells on blood film and bone marrow CXR and CT scan to look for mediastinal and abdominal lymphadenopathy. Lumbar puncture should be performed to look for CNS involvement. TREATMENT: Blood transfusions, prophylactic antibiotics, IV antibiotics in case of infection. Main stay of treatment is chemotherapy. Prognosis Cure rates for children are 70–90%; for adults only 40% 152. A 23yo man has been stabbed in the back and has SOB. The trachea is not deviated, he has engorged neck veins and absent breath sounds on the right. What is the most appropriate dx? a. Tension pneumothorax b. Cardiac tamponade c. Simple pneumothorax d. Hemothorax e. Pleural effusion Q. 1. What is the key? Q. 2. What are the point in favour of your answer? Ans. 1. The key is A. Tension pneumothorax. Ans. 2. Points in favour: i) Stab wound in the back ii) SOB iii) Engorged neck vein iv) Absent breath sound. 153. A 44yo pt comes with right hemiparesis. Exam: left sided ptosis and left dilated pupil. Where is the lesion? a. Cerebral infarct b. Cerebellar infarct c. Medulla oblongata d. Pons e. Midbrain Q. 1. What is the key? Q. 2. What is the name of this condition? Ans. 1. The key is E. Midbrain. Ans. 2. Weber syndrome [presence of ipsilateral oculomotor nerve palsy and contralateral hemiparesis or hemiplagia]. Ptosis + miosis = horners syndrome CN3 nucleus lies in the midbrain. Fore brain: CN 1,2 Mid brain: CN 3,4 Pons: CN 5,6,7,8 Medulla: CN 9,10,12

Ptosis + mydriasis= oculomotor nerve palsy.

Weber’s syndrome (superior alternating hemiplegia) Ipsilateral oculomotor nerve palsy with contralateral hemiplegia, due to infarction of one-half of the midbrain,

after occlusion of the paramedian branches of the basilar or posterior cerebral arteries 154. A 50yo man has a stab wound to his left anterior chest at the level of the 4th ICS. He has a BP 80mmHg, pulse=130bpm. His neck veins are dilated and his heart sounds are faint. His trachea is central. What is the most appropriate dx? a. Cardiac tamponade b. Diaphragmatic rupture c. Fractured ribs d. Tension pneumothorax e. Traumatic rupture of aorta Q. 1. What is the Key? Q. What are the points in favour of your answer? Ans. 1. The key is Cardiac tamponade. Ans. 2. Points in favour: i) Systolic BP 80 mmHg ii) Pulse 130 bpm iii) Engorged neck vein iv) Faint heart sounds v) Trachea is central. Essence:Pericardial fluid collects intrapericardial pressure rises heart cannot fill pumping stops. Causes: Trauma, lung/breast cancer, pericarditis, myocardial infarct, bacteria, eg TB. Signs: Falling BP, a rising JVP, and muffled heart sounds (Beck’s triad); JVP on inspiration (Kussmaul’s sign); pulsus paradoxus (pulse fades on inspiration) (also in severe asthma). Echocardiography may be diagnostic. CXR: globular heart; left heart border convex or straight; right cardiophrenic angle 10%: The above, but worse, with: shock, drowsiness, and hypotension. MANAGEMENT Mild: Treated at home by oral rehydrating therapy. Moderate: Oral fluids, via NG or IV fluids can be used. ‘Rapid rehydration’ involves 4 hours of 10mL/kg/h 0.9% NaCl then maintenance after if needed. Monitor U & Es Severe: If not in shock oral or NG route can be used. If in shock. 0.9% saline 20mL/kg IVI bolus, while calculations are performed. Continuously monitor pulse, BP, ECG. • Continue with boluses until the signs of shock ease. • Then give the daily requirement + fluid deficit 157. A 60yo smoker presents with cramp-like pain in the calves relieved by rest and nonhealing ulcers. Exam: cold extremities with lack of hair around the ankles, absent distal pulses. What is the most probable dx? a. Intermittent claudication b. Chronic ischemia of the limbs c. Buerger’s disease d. DVT e. DM Q. 1. What is the key? Q. 2. Points that support your diagnosis. Ans. 1. The key is B. Chronic ischaemia of the limb. Ans. 2. Intermittent claudication is a symptom not diagnosis. It is not buerger’s disease as buerger occur in more younger heavy smoker (before the age of 50yrs) mostly limited

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

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

Pointers to a diagnosis of HAE are:  Family history.  Recurrent episodes of non-urticarial swelling lasting >24 hours, and unresponsive to antihistamines.  Laryngeal oedema.

 

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

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

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

Shooting pain mostly neuropathic pain.

Proctalgia fugax Idiopathic (could be because of spasm of muscles) , intense, brief, stabbing/crampy rectal pain,often worse at night. Very short lived pain. The mainstay of treatment is reassurance. Inhaled salbutamol or topical GTN (0.2–0.4%) or topical diltiazem (2%) may help. 161. A 78yo male, DM and HTN, had a fall and since then is unable to walk. He presents with deformity and tenderness over the right hip area. XR=fx of femur neck. What is the single most associated nerve injury? a. Sciatic nerve b. Gluteal nerve c. Lateral peroneal nerve d. Tibial nerve e. Femoral nerve Ans. The key is A. Sciatic nerve. Fractures of the femoral neck are far more common in the elderly but fractures of the femoral shaft and supracondylar fractures most often occur in adolescents and young adults. Hip fracture is the most common reason for admission to an orthopaedic trauma ward. Intertrochanteric fractures affect the base of the femoral neck, May disrupt the blood supply to the femoral head, leading to avascular necrosis.

Posterior dislocation of the hip 

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

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

Anterior dislocation of the hip   

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

Complications

These include damage to the femoral nerve, artery and vein:  Injury to the femoral nerve may occur, resulting in paralysis and numbness in the femoral nerve distribution.  Injury to the femoral artery may produce arterial insufficiency in the leg

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

  

To determine the gradient across the coarctation (with a gradient in excess of 20 mm Hg considered to be significant). To assess other abnormalities and the overall haemodynamic picture when considering therapeutic options in more detail. Therapeutically using balloon angioplasty with or without stent implantation.

Treatment: Surgery or balloon dilatation ± stenting. 164. A 23yo male has a tonic clonic seizure whilst at college. His GCS is 12, BP=120/77mmHg, HR=99bpm. What is the most appropriate inv for his condition? a. CT b. MRI c. Serum blood glucose d. Serum drug levels Ans. The key is C. Serum blood glucose [it is also possible that he may have taken drug, even though first we have to do serum glucose as its presence can be very easily managed and it needs urgent management to save life. If it is excluded then we can look for other causes which may be not fatal in short time as hypoglycaemia]. This case will be treated as status epilepticus. Normally status occurs in a patient with known epilepsy but here no such history is given. Even in a person who presents with his first seizure we need to look for hypoglycemia first before going onto later tests. Status epilepticus: This means seizures lasting for >30min, or repeated seizures without intervening consciousness. Also consider eclampsia in mind if the patient is female and the abdomen is distended. Investigations • Bedside glucose, the following tests can be done once treatment has started: lab glucose, ABG, U&E, Ca2+, FBC, ECG. • Consider anticonvulsant levels, toxicology screen, LP, culture blood and urine, EEG, CT, carbon monoxide level. • Pulse oximetry, cardiac monitor. Treatment: Try to control seizure in less than 20mins as there could be permanent brain damage. 1. IV lorazepam:0.1mg/kg. Repeat if no response in 10mins. Be careful about respiratory depression. If there is no IV access give PR Diazepam. 2.Buccal midazolam: Alternative oral route. squirt half the volume between the lower gum and the cheek on each side. 3.Phenytoin infusion: 15–20mg/kg IVI (roughly 1g if 60kg, and 1 . 5g if 80kg; max 2g. 2nd line! Dont use if bradycardic or hypotensiv. ECG monitoring is recommended. Diazepam infusion: eg 100mg in 500mL of 5% dextrose. It is most unusual for seizures to remain unresponsive following this. If they do, allow the idea to pass through your mind that they could be pseudoseizures, particularly if there are odd features (pelvic thrusts; resisting attempts to open lids and your attempts to do passive movements; arms and legs flailing around).

4. Dexamethasone: 10mg IV if vasculitis/cerebral oedema (tumour) possible. 5. General anaesthesia: For refractory status: get anaesthetist/ICU involved early

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

Clinical diagnosis. No investigations required. Management: Find the cause and avoid/treat it. Antihistamines:  Non-sedating H1 antihistamines are the mainstay of treatment  In pregnancy chlorphenamine is often the first choice of antihistamine.

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

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

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

• Proliferative retinopathy: New vessels form. Needs urgent referral. • Maculopathy: (hard to see in early stages). Suspect if acuity. Prompt laser, intra vitreal steroids or anti-angiogenic agents may be needed in macular oedema. 168. A 2m baby who has ambiguous genitalia presents to the ED with vomiting. Labs: Na+=125mmol/L, K+=6mmol/L. What is the most likely dx? a. Fragile X syndrome b. Turners syndrome c. Noonan syndrome d. Congenital adrenal hyperplasia Q. 1. What is the key? Q. 2. What are the points in favour? Ans. 1. The key is D. Congenital adrenal hyperplasia Ans. 2. Points in favour: i) ambiguous genitalia ii) salt wasting manifested as hyponatremia and hyperkalemia (In mild forms of salt-wasting adrenal hyperplasia, salt wasting may not become apparent until an illness stresses the child). [here hyperkalaemia inspite of vomiting is indicating the disease]. Congenital adrenal hyperplasia (From secretion of androgenic hormones deficiency of 21-hydroxylase, 11-hydroxylase, or 3--hydroxysteroid dehydrogenase). Cortisol is inadequately produced, and the consequent rise in ACTH leads to adrenal hyperplasia and overproduction of androgenic cortisol precursors. CAH is a leading cause of male pseudohermaphroditism. Signs: Vomiting, dehydration, and ambiguous genitalia. Girls may be masculinized. Boys may seem normal at birth, but have precocious puberty, or ambiguous genitalia (androgens in 17-hydroxylase deficiency), or incomplete masculinization (hypospadias with cryptorchidism from 3-hydroxysteroid dehydrogenase). Hyponatraemia and hyperkalaemia are common. Plasma 17-hydroxyprogesterone Increased in 90%; Increased urinary 17ketosteroids (not in 17-hydroxylase deficit). Management of adrenocortical crisi: Urgent treatment is needed 0.9% saline IVI (3–5g Na+/day), glucose, fludrocortisone and hydrocortisone in neonate IV stat then maintanance dose. CAH can lead to addison’s disease later in life due to delayed onset. 169. A 40yo man collapsed at home and died. The GPs report says he suffered from T2DM and BMI=35. What is the most likely cause of death? a. Myocardial Infarction b. Diabetes mellitus c. Heart failure d. Pulmonary embolism e. Renal failure Q. 1. What is the key? Q. 2. Why the patient’s death was unnoticed? Ans. 1. The key is A. MI. Ans. 2. In diabetics MI become painless when the patient develop autonomic neuropathy (till there is no autonomic neuropathy diabetic patients will feel MI pain). In this case the disease was unnoticed as it was a painless attack. It is one of the complications of Diabetes. Vascular disease Chief cause of death. MI is 4-fold commoner in DM and is more likely to be ‘silent’. Stroke is twice as common. Women are at high risk.

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

Treatment

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

COPD: COPD is a common progressive disorder characterized by airway obstruction (FEV1 1h apart, or the patient is toxic, assume septicaemia and start blind combination therapy—eg piperacillin–tazobactam—(+ vancomycin,if Gram +ve organisms suspected or isolated, eg Hickman line sepsis). Check local preferences. Continue until afebrile for 72h or 5d course, and until neutrophils >0.5≈109/L. If fever persists despite antibiotics, think of CMV, fungi (eg Candida; Aspergillus) and central line infection.

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

Causes: uterine atony (90%), genital tract trauma (7%), clotting disorders—(3%) Risks: Antenatal • Previous PPH or retained placenta BMI>35kg/m2 • Maternal Hb100mmHg, Transfuse blood. Is the placenta delivered? If it is, is it complete? If not, explore the uterus. • If the placenta is complete, put the patient in the lithotomy position with adequate analgesia and good lighting. Check for and repair trauma. • If the placenta has not been delivered but has separated, attempt to deliver it by controlled cord traction after rubbing up a uterine contraction. If this fails, ask an experienced obstetrician to remove it under general anaesthesia.Beware renal shut down. 176. A 23yo lady presents with headache. Exam: photophobia and generalized rash that doesn’t blanch on pressure. What must be done immediately? a. IV benzylpenicillin

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

Examination: Find any infection; if any neck stiffness consider meningitis. : Management: Put in recovery position; if fit is lasting >5min: lorazepam IV, buccal midazolam or diazepam PR. Tepid sponging if hot; paracetamol syrup Labs: Consider FBC, U&E, Ca2+, glucose, MSU, CXR, ENT swabs. Avoid LP in the postictal period. If you suspect meningitis, then treat now. Parental education: Allay fear (a child is not dying during a fit). For the 30% having recurrences, teach carers to use buccal midazolam or rectal diazepam 0.5mg/ kg Further prevention: Diazepam PR during fevers has a role; other anticonvulsants are ‘never’ needed. Explain that all fevers (eg vaccination-associated) should prompt oral antipyretics. Prognosis: In typical febrile convulsions there is no progress to epilepsy in 97%. 178. A middle aged Asian presents with episodes of fever with rigors and chills for last 1y. Blood film: ring form plasmodium with schaffners dots in RBCs. What is the drug to eradicate this infection? a. Doxycycline b. Mefloquine c. Proguanil d. Quinine e. Artesonate Q. 1. What is the key? Q. 2. What does Shuffner’s dot in RBC indicate? Ans. 1. The key is B. Mefloquine. Ans. 2. Shuffners dot indicates, it is plasmodium ovale or plasmodium vivax infestation. MALARIA: Plasmodium vivax and ovale: cyclical fever every 48 hours. P.malariae: Cyclical fever every 72 hours. Can cause glomerulonephritis. Rarely fatal. P. falciparum: fevr 36-48hrs cyclical. Fulminant disease. Presentation: 3 phases: 1 Shivering (1h): “I feel so cold.” 2 Hot stage (2–6h): T ≈ 41°C, flushed, dry skin; nausea/vomiting; headache. 3 Sweats (~3h) as T° falls Also malaise, fatigue, anorexia, myalgias... Signs: Anaemia, jaundice, and hepatosplenomegaly. No rash or lymphadenopathy Protective factors: G6PD lack; sickle- cell trait; melanesian ovalocytosis; Complications: Hemolytic anemia can occur. 5 grim signs: 1 dec Consciousness/coma (cerebral malaria) 2 Convulsions 3 Coexisting chronic illness 4 Acidosis (eg esp bad if HCO3 – 35kg: 4 tabs stat, then 4 tablets at 8, 24, 36, 48 and 60h. • Artesunate-amodiaquine; if a fixed combination pill is available. Dihydroartemisinin-naphthoquine • Dihydroartemisinin piperaquine. • Atovaquoneproguanil. can be used. In pregnancy: Artemisinins are OK in children and pregnancy from 13 weeks; (use quinine + clindamycin in 1st trimester). In addition give symptomatic treatment for fever, blood transfusion if required.

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

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

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

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

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

Congenital Hypothyroidism: Thyroid hormone is necessary for growth and neurological development. Signs: May be none at birth—or prolonged neonatal jaundice, widely opened posterior fontanelle, poor feeding, hypotonia, and dry skin are common. Inactivity, sleepiness, slow feeding, little crying, and constipation may occur. Look for coarse dry hair, a flat nasal bridge, a protruding tongue, hypotonia, umbilical hernia, slowly relaxing reflxes, pulse, and poor growth and mental development if it has not been picked up. Other later signs: dec IQ, delayed puberty (occasionally precocious), short stature, delayed dentition. Universal neonatal screening: Cord blood or filter paper spots (at ~7 days, from heel prick) allow early diagnosis (the‘Guthrie card’). Tests: Decreased T4, Increased TSH (but undetectable in secondary hypothyroidism), Decreased I131 uptake, dec Hb. Bone age is less than chronological age. As it is unwise to X-ray the whole skeleton, the left wrist and hand are most commonly used. Treatment: Levothyroxine (LT4): Start neonates with ~15μg/kg/day; adjust by 5μg/kg every 2 weeks to a typical dose of 20–50μg/day. Avoid high TSH levels.

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

DiGeorge’s syndrome A deletion of chromosome 22q11.2 causes absent thymus, fits, small parathyroids ( decreased Ca2+), anaemia, lymphopenia, dec growth hormone, dec T-cell-immunity. It is related to velo-cardiofacial syndrome: characteristic face, multiple anomalies, eg cleft palate, heart defects, cognitive defects Management: Cardiac defects are the usual focus of clinical management. Hypocalcaemia should be screened for by checking calcium levels three-monthly in infancy and then annually. Low calcium and high phosphate levels should prompt further testing of parathyroid hormone and vitamin D levels. All patients should have baseline immunological testing and annual blood count Cleft palates may be submucous. In particular, they should be sought if feeding difficulties are encountered in the neonatal period. Gastro-oesophageal reflux needs to be managed appropriately with feed thickeners and antireflux medication. Nasogastric tube feeding and occasionally gastrostomy may be needed to deal with feeding issues.

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

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

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

Transbronchial biopsy can demonstrate the presence of non-caseating granulomata, giving a more accurate diagnosis Bronchioalveolar lavage may also be done 186. A neonate’s CXR shows double bubble sign. Exam: low set ears, flat occiput. What is the most likely dx? a. Downs syndrome b. Fragile X syndrome c. Turner’s syndrome d. DiGeorge syndrome Q. 1. What is the key? Q. 2. What double bubble sign indicate? Ans. 1. The key is A. Down’s syndrome. Ans. 2. Double bubble sign indicate duodenal atresia. Down’s syndrome: Causes: Non-disjunction of chromosome >88% Mosaicism 150mg/kg or 12 total PRESENTATION: Hepatic damage shown by deranged LFTs occurs after 24hrs. Patients may develop encaph, hypoglycemia, ARF

INVESTIGATIONS: Paracetamol levels: 4hrs post ingestion, if time is >4hr or staggered overdose Any alcohol taken (acute alcohol ingestion will inhibit liver enzymes and may reduce the production of the toxin NAPQI, whereas chronic alcoholism may increase it)

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

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

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

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

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

197. A

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

Migraine: Symptoms Classically: •Visual or other aura lasting 15–30min followed within 1h by unilateral, throbbing headache. Or: •Isolated aura without headache; •Episodic severe headaches without aura, often premenstrual, usually unilateral, with nausea, vomiting ± photophobia/phonophobia (‘common migraine’). There may be allodynia—all stimuli produce pain: “I can’t brush my hair, wear earrings or glasses, or shave, it’s so painful”. Signs: None. Aura: • Visual: chaotic cascading, distorting, ‘melting’ and jumbling of lines, dots, or zigzags, scotomata or hemianopia; • Somatosensory: paresthesia spreading from fingers to face; • Motor: dysarthria and ataxia (basilar migraine), ophthalmoplegia, or hemiparesis; • Speech: (8% of auras) dysphasia or paraphasia, eg phoneme substitution.

Criteria for diagnosis if no aura ≥5 headaches lasting 4–72h + nausea/vomiting (or photo/phonophobia) + any 2 of: • Unilateral • Pulsating • Impairs (or worsened by) routine activity. Partial triggers Seen in 50%: CHOCOLATE or: Chocolate, Hangovers, Orgasms, Cheese, Oral contraceptives, Lie-ins, Alcohol, Tumult, or Exercise. Treatment: Acute:

.

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

Use early in the attack to avoid gastric stasis. Use soluble aspirin 600-900 mg (not in children) or ibuprofen 400-600 mg. Use prochlorperazine 3 mg buccal tablet if there is nausea and vomiting.

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

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

Haemorrhage

occurring

within

first

24

hrs

following

The causes Reactionary Haemorrhage: 1) 2) 3) 4)

Slipping away of Ligatures Dislodgement of Clots Cessation of Reflex vasospasm Normalization of Blood Pressure

Secondary Haemorrhage: Haemorrhage occurring after 7 -14 days after Trauma/Surgery. The attributed cause is infection and sloughing away of the blood vessels. The symptoms tell us that the patient is in hypovolemic shock one of the causes of which is haemorrhage and Since here the patient is still in the recovery room this type of haemorrhage is reactionary. 199. A 33yo man is hit by a car. He loses consciousness but is found to be fine by the paramedics. When awaiting doctors review in the ED he suddenly becomes comatose. What is the most likely dx? a. SAH b. Subdural hemorrhage c. Intracerebral hemorrhage d. Extradural hemorrhage Ans. The key is D. Extradural haemorrhage. [Age 33 (younger age), considerable head trauma, and lucid interval (present in bothe extradural and subdural) are the points in favour]. Lucid interval can occur both ins Subdural and extra dural haemorrhage. The difference is that the presentation of the lucid interval (that is the gain of consciousness and the LOC) in extra dural occurs within hours or 1-2 days while in subdural it can take days to weeks upto 9 months. Epidural (extradural) haemorrhage: Suspect this if, after head injury, conscious level falls or is slow to improve, or there is a lucid interval. Extradural bleeds are often due to a fractured temporal or parietal bone causing laceration of the middle meningeal artery and vein, typically after trauma to a temple just lateral to the eye. Any tear in a dural venous sinus will also result in an extradural bleed. Blood accumulates between bone and dura. Presentation: Increasingly severe headache, vomiting, confusion, and fits follow, ± hemiparesis with brisk reflexes and an upgoing plantar. If bleeding continues, the ipsilateral pupil dilates, coma deepens, bilateral limb weakness develops, and breathing becomes deep and irregular (brainstem compression). Death follows a period of coma and is due to respiratory arrest. Bradycardia and raised blood pressure are late signs. Tests CT scan shows a haematoma (often biconvex/lens-shaped; the blood forms a more rounded shape compared with the sickle-shaped subdural haematoma. Skull X-ray may be normal or show fracture lines crossing the course of the middle meningeal

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

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





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

Signs  

Pyramidal tract signs may be present. Reflexes may be brisk.



Papilloedema is absent (but there has been found to be an association with glaucoma, so glaucomatous optic disc changes may be noticed).

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

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

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

202. A 5yo child presents with fever. He looks pale. His parents say he always feels tired. On exam: orchidomegaly & splenomegaly. Labs: WBC=1.7, Hgb=7.1, Plt=44. What is the dx? a. ALL b. CLL c. AML d. CML e. Hodgkins Ans. The key is A. ALL. [normally in ALL CBC shows raised WBC, low RBC and low platelet; but it is also possible to all cell lines to be depressed, as is the presented case]. ALL: This is a malignancy of lymphoid cells, affecting B or T lymphocyte cell lines, arresting maturation and promoting uncontrolled proliferation of immature blast cells, with marrow failure and tissue infiltration. Causes: Genetic susceptibility, environmental factors (ionizing radiations) Down’s syndrome. Commonest cancer of childhood.

Signs and symptoms: • Marrow failure: Anaemia (Hb), infection (WCC), and bleeding (platelets). • Infiltration: Hepatosplenomegaly, lymphadenopathy—superficial or mediastinal, orchidomegaly, CNS involvement—eg cranial nerve palsies, meningism. INVESTIGATIONS: Characteristic blast cells on blood film and bone marrow CXR and CT scan to look for mediastinal and abdominal lymphadenopathy. Lumbar puncture should be performed to look for CNS involvement. TREATMENT: Blood transfusions, prophylactic antibiotics, IV antibiotics in case of infection. Main stay of treatment is chemotherapy. Prognosis Cure rates for children are 70–90%; for adults only 40% 203. A 6wk child is brought in with vomiting, constipation and decreased serum K+. What is the dx? a. Pyloric stenosis b. Duodenal atresia c. Hirschsprung disease d. Achalasia cardia e. Tracheo-esophageal fistula Ans. The key is A. Pyloric stenosis. [why not duodenal atresia? Pyloric stenosis is much more commoner than duodenal atresia; in duodenal atresia the vomitus should contain bile, which is not the case in pyloric stenosis].

Pyloric stenosis Symptoms: Presents at 3–8 weeks) with vomiting which occurs after feeds and becomes projectile (eg vomiting over far end of cot). Pyloric stenosis is distinguished from other causes of vomiting by the following:

• The vomit does not contain bile, as the obstruction is so high. • No diarrhoea: constipation is likely (occasionally ‘starvation stools’). • Even though the patient is ill: he is alert, anxious, and always hungry—and possibly malnourished, dehydrated. • The vomiting is extremely large volume and within minutes of a feed. Try to palpate the olive-sized pyloric mass There may be severe water & NaCl deficit. The picture is of hypochloraemic, hypokalaemic metabolic alkalosis Imaging: Ultrasound detects early, hard-to-feel pyloric tumours, but is only needed if examination is –ve. Barium studies are ‘never’ needed. Management: Correct electrolyte disturbances. Before surgery (Ramstedt’s pyloromyotomy/ endoscopic surgery) pass a wide-bore nasogastric tube. 204. A 17 yo girl had an episode of seizure. Contraction of muscles started from around the interphalangeal joints, which spread to the muscles of wrist and elbow. Choose possible type of seizure? a. Grand mal b. Tonic clonic c. Myoclonic d. Absent Ans. The key is C. Myoclonic. [seizers associated with contraction of specific muscle group is seen in myoclonic seizers]. Types of seizures:

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

• Tonic–clonic seizures: Loss of consciousness. Limbs stiffen (tonic), then jerk (clonic). May have one without the other. Post-ictal confusion and drowsiness. • Myoclonic seizures: Sudden jerk of a limb, face or trunk. The patient may be thrown suddenly to the ground, or have a violently disobedient limb: one patient described it as ‘my flying-saucer epilepsy’, as crockery which happened to be in the hand would take off . • Atonic (akinetic) seizures: Sudden loss of muscle tone causing a fall, no LOC. Infantile spasms/West syndrome: Peak age: 5 months. Clusters of head nodding (‘Salaam attack’) and arm jerks, every 3–30sec. IQ decrease in ~70%. EEG is characteristic (hypsarrythmia). 205. 46yo man, known case of chronic GN presents to OPD. He feels well. BP = 140/90mmHg. Urine dipstick: protein ++, blood ++ and serum creatinine=106mmol/L. Which medication can prevent the progression of this dx? a. ACEi b. Diuretics c. Cytotoxic meds d. Longterm antibiotics

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

Anxiety: Symptoms: Tension, agitation; feelings of impending doom, trembling; a sense of collapse; insomnia; poor concentration; ‘goose flesh’; ‘butterflies in the stomach’; hyperventilation (so tinnitus, tetany, tingling, chest pains); headaches; sweating; palpitations; poor appetite; nausea; ‘lump in the throat’ unrelated to swallowing (globus hystericus); difficulty in getting to sleep; excessive concern about self and bodily functions; repetitive thoughts and activities Children’s symptoms: Thumb-sucking; nail-biting; bed-wetting; foodfads. Causes Genetic predisposition; stress (work, noise, hostile home), events (losing or gaining a spouse or job; moving house). Others: Faulty learning or secondary gain (a husband ‘forced’ to stay at home with agoraphobic wife). Treatment: Symptom control: Listening is a good way to reduce anxiety. Explain that headaches are not from a tumour, and that palpitations are harmless. Regular (non-obsessive!) exercise: Beneficial effects appear to equal meditation or relaxation. Meditation: Intensive but time-limited group stress reduction intervention based on ‘mindfulness meditation’ can have long-term beneficial effects. Cognitive–behavioural therapy and relaxation appear to be the best specific measures with 50–60% recovering over 6 months. Behavioural therapy employs graded exposure to anxiety-provoking stimuli. Drugs augment psychotherapy: 1 Benzodiazepines (eg diazepam) 2 SSRI eg paroxetine in social anxiety). 3 Azapirones (buspirone, 5HT1A partial agonist; ess addictive/sedating than diazepam, and few withdrawal issues). 4 Old-style antihistamines (eg hydroxyzine). 5. Beta blockers.6 Others: pregabalin and venlafaxine. Progressive relaxation training: Teach deep breathing using the diaphragm, and tensing and relaxation of muscle groups, eg starting with toes and working up the body. Practice is essential. Hypnosis

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

Panic attacks must be associated with >1 month's duration of subsequent, persisting anxiety about recurrence of the attacks, the consequences of the attacks, or significant behavioural changes associated with them. A panic attack is defined as a discrete episode of intense subjective fear, where at least four of the characteristic symptoms, listed below, arise rapidly and peak within 10 minutes of the onset of the attack: · Attacks usually last at least 10 minutes but their duration is variable. ·

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

medical conditions or other psychiatric disorders, in order to satisfy the diagnostic criteria. Panic disorder manifests as the sudden, spontaneous and unanticipated occurrence of panic attacks, with variable frequency, from several in a day to just a few per year: · Palpitations, pounding heart or accelerated heart rate. ·

Sweating.

·

Trembling or shaking.

·

Dry mouth.

·

Feeling short of breath, or a sensation of smothering.

·

Feeling of choking.

·

Chest pain or discomfort.

·

Nausea or abdominal distress.

·

Feeling dizzy, unsteady, light-headed or faint.

·

Derealisation or depersonalisation (feeling detached from oneself).

·

Fear of losing control or 'going crazy'.

·

Fear of dying.

·

Numbness or tingling sensations.

·

Chills or hot flushes.

Signs: No specific signs Investigations: Just to rule out any physical illness. Management: Involve the family, find and avoid any triggers. Find out if the symptoms are because of alcohol use and treat that. CBT is the first line. ·

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

indicated. ·

Consider imipramine or clomipramine if there is no improvement after 12

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

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

208. A 2yo child is very naughty. His teacher complains that he is easily distracted. His parents say that he can’t do a particular task for a long time. He sometimes hurts himself and breaks many things. This causes many troubles at home. What is the dx? a. ASD

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

Attention deficit & hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. It has prevalence of 3–5% in Western nations ADHD is commoner in learning-disabled children, and if prenatal cannabis exposure. The core diagnostic criteria are: impulsivity, inattention and hyperactivity. Not all those with ADD are hyperactive. There is no diagnostic test Most parents first note hyperactivity at the toddler stage, Family association is often present. These children are at increased risk of self harm and suicide. Management: 1st line treatment for pre-school children and school age children with moderate ADHD/moderate impairment is parent training/education programmes. Older children may benefit from cognitive behavioural therapy. Drugs may be useful in school age children if non-drug treatments fail (eg methylphenidate atomoxetine: Severe ADHD in school age children methylphenidate and atomoxetine are 1st line treatments so ensure referral 209. A 79 yo lady who is otherwise well recently started abdominal pain. She is afebrile and complains that she passed air bubbles during urination. A urethral catheter showed fecal leakage in the urinary bag. What is the likely pathology? a. Diuretics b. CD c. Rectosigmoid tumor d. Large bowel perforation e. UC Ans. The key is B. CD. [debate came that Crohn’s disease cannot occur in 79 yrs but this is not the case! “Crohn’s disease can occur at any age, but is most frequently diagnosed in people ages 15 - 35. About 10% of patients are children under age 18”. [http://www.nytimes.com/health/guides/disease/crohns-disease/risk-factors.html]. So I think it can occur in this age also and the features support the diagnosis of CD.

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

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

months. Towards the end, often but not invariably, patients become sedentary, taking little interest in anything. Associations: environmental and genetic factors both play a role. Accumulation of beta-amyloid peptide, neurofibrillary tangles, increased numbers of amyloid plaques, and loss of the neurotransmitter acetylcholine—the hippocampus, amygdala, temporal neocortex and subcortical nuclei (eg nucleus basalis of Meynert) are most vulnerable. Vascular effects are also important—95% of AD patients show evidence of vascular dementia

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

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

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

Gall Stones: Pigment stones: (60

1

Blood pressure

BP>140 systolic and/or >90 diastolic

1

Clinical features

Unilateral weakness

2

Speech disturbance without weakness

1

Other

0

>60 minutes

2

10-59 minutes

1

400,000 platelets/mm3). o Leukocytosis (>12,000/mm3). o Leukocyte alkaline phosphatase (>100 units in the absence of fever or infection).

Investigation 

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

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

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

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

o

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 

For people older than 75 years of age: first-line is hydroxycarbamide; second-line is radioactive phosphorus or busulfan. Pruritus can be quite disabling: o Taking baths or showers at lower temperatures and patting the skin dry, to avoid rubbing, may help. o Antihistamines, including H2 receptor antagonists (H2RAs), are useful in refractory cases. o Selective serotonin reuptake inhibitors (SSRIs) - eg, paroxetine or fluoxetine. Elevated uric acid may require allopurinol. It may be necessary to consider splenectomy when there is painful splenomegaly or there are repeated episodes of splenic infarction.

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

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

Presentation

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

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

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

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

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



Two-dimensional echocardiography may demonstrate asymptomatic valve thickening, vegetations or valvular insufficiency.

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

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

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

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

o





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

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

Presentation        

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

Investigations

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There needs to be a high index of clinical suspicion in order to avoid diagnostic delay and improve outcome. Haemolysis with fragmented red cells on the blood film Raised LDH >600 IU/L with a raised bilirubin. Liver enzymes are raised with an AST or ALT level of >70 IU/L. Levels of AST or ALT >150 IU/L are associated with increased maternal morbidity and mortality.

Management     

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

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

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

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

Management of severe pre-eclampsia[1]

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

Management of eclampsia 

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

Complications 

 

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

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

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

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

Epidemiology[3]  



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

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





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

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

Management[10] Medical management 

 

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



Any patient needing significant medical management should be referred for surgical assessment.

Surgical management     

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

Catheter closure 



 

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

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

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

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

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

prognosis : Squamous cell carcinomas detected at an early stage and removed promptly are almost always curable and cause minimal damage]. basal cell carcinoma is usually on face with inverted margins malignant melanoma is on sun exposed parts and is dark (black colored) ulcer 353. A

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

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

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

The key is E. Alpha 1 antitrypsin deficiency. REASON. Unexplained liver disease with respiratory symptoms are very suggestive of AATD. liver disease occurs because of the accumulation AAT in it where as d/t inability to be transported out of liver AATD causes emphysema hence the resp problems 358. A 35yo construction worker is dx with indirect inguinal hernia. Which statement below best describes it? a. Passes through the superficial inguinal ring only b. Lies above and lateral to the pubic tubercle c. Does not pass through the superficial inguinal ring d. Passes through the deep inguinal ring Ans. The key is D. Passess through the deep inguinal ring. direct hernia passes directly through the posterior wall of inguinal canal whereas indirect can only do so via deep ring

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

364. A 22yo sexually active male came with 2d hx of fever with pain in scrotal area. Exam: scrotal skin is red and tender. What is the most appropriate dx? a. Torsion of testis b. Orchitis c. Inguinal hernia d. Epididymo-orchitis D Epididymo-orchitis. In orchitis there should be fever, elevation of testes reduces pain (positive prehn sign), In torsion testis lies at a higher level. In torsion urinalysis negative but in orchitis it is positive. Orchitis usually occurs in sexually active man. X 365. A man on warfarin posted for hemicolectomy. As the pt is about to undergo surgery. What option is the best for him? a. Continue with warfarin b. Continue with warfarin and add heparin c. Stop warfarin and add aspirin d. Stop warfarin and add heparin e. Stop warfarin D Stop warfarin and add heparin 5 DAYS BEFORE SURGERY WARFARIN MUST BE REPLACED BY HEPARIN, 366. A 65yo known alcoholic is brought into hospital with confusion, aggressiveness and ophthalmoplegia. He is treated with diazepoxide. What other drug would you like to prescribe? a. Antibiotics b. Glucose c. IV fluids d. Disulfiram e. Vit B complex E Vitamin B complex. [confusion and ophthalmoplegia points towards the diagnosis of Wernicke’s encephalopathy]. which occurs d/t thiamine def. 367. A 32yo woman has severe right sided abdominal pain radiating into the groin which has lasted for 3h. She is writhering in pain. She has no abdominal signs. What is the most likely cause of her abdominal pain? a. Appendicitis b. Ruptured ectopic pregnancy c. Salpingitis d. Ureteric colic e. Strangulated hernia D Ureteric colic. It indicate stone at lower ureter. [i) Pain from upper ureteral stones tends to radiate to the flank and lumbar areas. ii) Midureteral calculi cause pain that radiates anteriorly and caudally. This midureteral pain in

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

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

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

B 18m of PTU alone. Other drug option i.e Carbamazepine is teratogenic [can cause i) spina bifida ii)cardiovascular malformations ETC . PTU is on the other hand relatively safe in pregnancy. 370. A child living with this stepfather is brought by the mother with multiple bruises, fever and fractures. What do you suspect? a. NAI b. Malnutrition c. Thrombocytopenia d. HIV Ans. The key is A. NAI. [H/O living with stepfather, multiple bruises, fever and fractures are suggestive of NAI]. OTHER possible points can include hx not matching with bruises, wounds which are a day or two older at the time of presentation.

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

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

B. Bronchial carcinoma. [Asbestos exposure is a risk factor for lung cancer and also has a synergistic effect with cigarette smoke].

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

B. Glaucoma. . Cataract is unlikely at this age. Nothing in the history suggests retinopathy. Uveitis and iritis doesn’t have such degree of vision loss and iritis and anterior uveitis have pain, redness and photophobia. Open angle glaucoma is likely cause. 379. A child during operation and immediately after showed glycosuria, but later his urine sugar was normal. Choose the most probable dx. a. Pre-diabetic state b. Normal finding c. Low renal tubular threshold d. DM B Normal finding. Stress during operation can cause transient hyperglycemia causing glycosuria secondary to stress induced rise of cortisol which becomes normal after some time. 380. A pt presented with hx of swelling in the region of the sub-mandibular region, which became more prominent and painful on chewing. He also gave hx of sour taste in the mouth, the area is tender on palpation. Choose the most probable dx? a. Chronic recurrent sialadenitis b. Adenolymphoma c. Mikulicz’s disease d. Adenoid cystic carcinoma e. Sub-mandibular abscess A Chronic recurrent sialadenitis. [pain, swelling, more pain on chewing, tenderness, and submandibular region suggests diagnosis of submandibular chronic recurrent sialadenitis, usually secondary to sialolithiasis or stricture]. 381. ECG of an 80yo pt of ICH shows saw-tooth like waves, QRS complex of 80ms duration, ventricular rate=150/min and regular R-R interval. What is the most porbable dx? a. Atrial fib b. Atrial flutter c. SVT d. Mobitz type1 second degree heart block e. Sinus tachycardia

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

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

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

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

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

Nodosum is in diseases like Tb, sarcoidosis, IBD Marginatum is the rash of acute rheumatic fever

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

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

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

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

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

Ans. 1. The Key is D. Retinal detachment. #Causes of sudden painless loss of vision: 1. 2. 3. 4. 5. 6.

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

remember retinal detachment has vision loss as if curtain is coming down 399. A child was woken up from sleep with severe pain in the testis. Exam: tenderness on palpation and only one testis was normal in size and position. What would be your next step? a. Analgesia b. Antibiotics c. Refer urgently to a surgeon d. Reassurance e. Discharge with analgesics

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

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

To evaluate chest pain not reproduced with exercise testing

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

·

To identify arrhythmias or palpitations

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

·

To assess the function of an implanted pacemaker

·

To determine the effectiveness of therapy for complex arrhythmias

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

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

   

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

The key is B. Beta blockers [the probable arrhythymia is AF secondary to thyrotoxicosis(heat intolerance). So to rapid control the symptoms of thyrotoxicosis Beta blocker should be used]. 410. A T2DM is undergoing a gastric surgery. What is the most appropriate pre-op management? a. Start him in IV insulin and glucose and K+ just before surgery b. Stop his oral hypoglycemic on the day of the procesure c. Continue regular oral hypoglycemic d. Stop oral hypoglycemic the prv night and start IV insulin with glucose and K+ before surgery e. Change to short acting oral hypoglycemic The key is D. Stop oral hypoglycemic the prv night and start IV insulin with glucose and K+ before surgery. 411. A 19yo boy is brought by his mother with complaint of lack of interest and no social interactions. He has no friends, he doesn’t talk much, his only interest is in collecting cars/vehicles having around 2000 toy cars. What is the most appropriate dx? a. Borderline personality disorder b. Depression c. Schizoaffective disorder d. Autistic spectrum disorder The key is D. Autistic spectrum disorder. Autism spectrum disorders affect three different areas of a child's life: Social interaction Communication -- both verbal and nonverbal Behaviors and interests In some children, a loss of language is the major impairment. In others, unusual behaviors (like spending hours lining up toys) seem to be the dominant factors. 412. A 45yo man who is diabetic and HTN but poorly compliant has chronic SOB, develops severe SOB and chest pain. Pain is sharp, increased by breathing and relieved by sitting forward. What is the single most appropriate dx? a. MI b. Pericarditis c. Lung cancer d. Good pastures syndrome e. Progressive massive fibrosis The key is B. Pericarditis. [Nature of pain i.e. sharp pain increased by breathing and relieved by sitting forward is suggestive of pericarditis]. Nature of pericardial pain: the most common symptom is sharp, stabbing chest pain behind the sternum or in the left side of your chest. However, some people with acute pericarditis describe their chest pain as dull, achy or pressure-like instead, and of varying intensity. · · ·

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

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

1. 2. 3. 4.

1. 2.

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

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

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

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

nd

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

   

tonsillitis (probably caused by group A streptococcus). There are four main signs that tonsillitis is caused by a bacterial infection rather than a viral infection. They are: a high temperature white pus-filled spots on the tonsils no cough swollen and tender lymph nodes (glands). 423. A man with a fam hx of panic disorder is brought to the hosp with palpitations, tremors, sweating and muscles tightness on 3 occasions in the last 6 wks. He doesn’t complain of headache and his BP is WNL. What is the single most appropriate long-term tx for him? a. Diazepam b. Olanzapine c. Haloperidol d. Fluoxetine e. Alprazolam Ans. The key is D. Fluoxetine. [Recommended treatment for panic disorder is i) CBT ii) Medication (SSRIs or TCA). NICE recommends a total of seven to 14 hours of CBT to be completed within a four month period. Treatment will usually involve having a weekly one to two hour session. When drug is prescribed usually a SSRI is preferred. Antidepressants can take two to four weeks before becoming effective]. 424. A 28yo man presents with rapid pounding in the chest. He is completely conscious throughout. The ECG was taken (SVT). What is the 1st med to be used to manage this condition? a. Amiodarone b. Adenosine c. Lidocaine d. Verapamil e. Metoprolol Ans. The key is B. Adenosine. [Management of SVT: i) vagal manoeuvres (carotid sinus message, valsalva manoeuvre) transiently increase AV-block, and unmask the underlying atrial rhythm. If unsuccessful then the first medicine used in SVT is adenosine, which causes transient AV block and works by i) transiently slowing ventricles to show the underlying atrial rhythm ii) cardioverting a junctional tachycardia to sinus rhythm. OHCM]. 425. A 56yo woman who is depressed after her husband died of cancer 3m ago was given amitryptaline. Her sleep has improved and she now wants to stop medication but she still speaks about her husband. How would you manage her? a. CBT b. Continue amitryptaline c. Psychoanalysis d. Bereavement counselling e. Antipsychotic

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

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

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

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

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

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

The key is E. Alpha 1 antitrypsin deficiency. REASON. Unexplained liver disease with respiratory symptoms are very suggestive of AATD. liver disease occurs because of the accumulation AAT in it where as d/t inability to be transported out of liver AATD causes emphysema hence the resp problems 358. A 35yo construction worker is dx with indirect inguinal hernia. Which statement below best describes it? a. Passes through the superficial inguinal ring only b. Lies above and lateral to the pubic tubercle c. Does not pass through the superficial inguinal ring d. Passes through the deep inguinal ring Ans. The key is D. Passess through the deep inguinal ring. direct hernia passes forectly through the posterior wall of inguinal canal whereas indirect can only do so via deep ring 359. A woman has numerous painful ulcers on her vulva. What is the cause? a. Chlamydia b. Trichomonas c. Gardenella d. HSV e. EBV Ans. The key is D. HSV. reason has been explained in q 351

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

In orchitis there should be fever, elevation of testes reduces pain (positive prehn sign), In torsion testis lies at a higher level. In torsion urinalysis negative but in orchitis it is positive. Orchitis usually occurs in sexually active man. X 365. A man on warfarin posted for hemicolectomy. As the pt is about to undergo surgery. What option is the best for him? a. Continue with warfarin b. Continue with warfarin and add heparin c. Stop warfarin and add aspirin d. Stop warfarin and add heparin e. Stop warfarin D Stop warfarin and add heparin 5 DAYS BEFORE SURGERY WARFARIN MUST BE REPLACED BY HEPARIN, 366. A 65yo known alcoholic is brought into hospital with confusion, aggressiveness and ophthalmoplegia. He is treated with diazepoxide. What other drug would you like to prescribe? a. Antibiotics b. Glucose c. IV fluids d. Disulfiram e. Vit B complex E Vitamin B complex. [confusion and ophthalmoplegia points towards the diagnosis of Wernicke’s encephalopathy]. which occurs d/t thiamine def. 367. A 32yo woman has severe right sided abdominal pain radiating into the groin which has lasted for 3h. She is writhering in pain. She has no abdominal signs. What is the most likely cause of her abdominal pain? a. Appendicitis b. Ruptured ectopic pregnancy c. Salpingitis d. Ureteric colic e. Strangulated hernia D Ureteric colic. It indicate stone at lower ureter. [i) Pain from upper ureteral stones tends to radiate to the flank and lumbar areas. ii) Midureteral calculi cause pain that radiates anteriorly and caudally. This midureteral pain in particular can easily mimic appendicitis on the right or acute diverticulitis on the left. iii) Distal ureteral stones cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female.

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

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

B 18m of PTU alone. Other drug option i.e Carbamazepine is teratogenic [can cause i) spina bifida ii)cardiovascular malformations ETC . PTU is on the other hand relatively safe in pregnancy. 370. A child living with this stepfather is brought by the mother with multiple bruises, fever and fractures. What do you suspect? a. NAI b. Malnutrition c. Thrombocytopenia d. HIV Ans. The key is A. NAI. [H/O living with stepfather, multiple bruises, fever and fractures are suggestive of NAI]. OTHER possible points can include hx not matching with bruises, wounds which are a day or two older at the time of presentation. 371. A young man who was held by the police was punched while in custody. He is now cyanosed and unresponsive. What is the 1st thing you would do? a. IV fluids b. Clear airway c. Turn pt and put in recovery position d. Give 100% oxygen e. Intubate and ventilate B. Clear airway. [ABC protocol].

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

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

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

B. Glaucoma.

. Cataract is unlikely at this age. Nothing in the history suggests retinopathy. Uveitis and iritis doesn’t have such degree of vision loss and iritis and anterior uveitis have pain, redness and photophobia. Open angle glaucoma is likely cause. 379. A child during operation and immediately after showed glycosuria, but later his urine sugar was normal. Choose the most probable dx. a. Pre-diabetic state b. Normal finding c. Low renal tubular threshold d. DM B Normal finding. Stress during operation can cause transient hyperglycemia causing glycosuria secondary to stress induced rise of cortisole which becomes normal after some time. 380. A pt presented with hx of swelling in the region of the sub-mandibular region, which became more prominent and painful on chewing. He also gave hx of sour taste in the mouth, the area is tender on palpation. Choose the most probable dx? a. Chronic recurrent sialadenitis b. Adenolymphoma c. Mikulicz’s disease d. Adenoid cystic carcinoma e. Sub-mandibular abscess A Chronic recurrent sialadenitis. [pain, swelling, more pain on chewing, tenderness, and submandibular region suggests diagnosis of submandibular chronic recurrent sialadenitis, usually secondary to sialolithiasis or stricture]. 381. ECG of an 80yo pt of ICH shows saw-tooth like waves, QRS complex of 80ms duration, ventricular rate=150/min and regular R-R interval. What is the most porbable dx? a. Atrial fib b. Atrial flutter c. SVT d. Mobitz type1 second degree heart block e. Sinus tachycardia B Atrial flutter. [Saw-tooth like waves, normal QRS comples of 80 ms (normal range 70100 ms), ventricular rate of 150/min and regular R-R interval is diagnostic of atrial flutter]. FOR AFIB THERE WD BE IRREGULARARLY IRREGULAR RHYTHM 382. A 50 yo woman who was treated for breast cancer 3 yrs ago now presents with increase thirst and confusion. She has become drowsy now. What is the most likely metabolic abnormality? a. Hypercalcemia b. Hyperkalemia c. Hypoglycemia d. Hyperglycemia e. Hypercalcemia. E HYPERCALCEMIA

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

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

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

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

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

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

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

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

Ans. 1. The Key is D. Retinal detachment. #Causes of sudden painless loss of vision: 1. 2. 3. 4. 5. 6.

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

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

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

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

To evaluate chest pain not reproduced with exercise testing

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

·

To identify arrhythmias or palpitations

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

·

To assess the function of an implanted pacemaker

·

To determine the effectiveness of therapy for complex arrhythmias

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

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

   

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

The key is E. Blood sugar. [Age at presentation and class1 obesity favours the diagnosis of type2 DM]. since culture is -ve for nitrates, so uti is ruled out 408. A pt from Africa comes with nodular patch on the shin which is reddish brown. What is the most probable dx? a. Lupus vulgaris b. Erythema nodosum c. Pyoderma gangrenosum d. Erythema marginatum e. Solar keratosis The key is B. Erythema nodosum. [Causes of erythema nodosum: MOST COMMON CAUSES- i) streptococcal infection ii) sarcoidosis. Other causes- tuberculosis, mycoplasma pneumonia, infectious mononucleosis, drugs- sulfa related drug, OCP, oestrogen; Behcet’s disease, CD, UC; lymphoma, leukemia and some others]. #Nodes are mostly on anterior aspect of shin 409. A 29yo lady came to the ED with complaints of palpitations that have been there for the past 4 days and also feeling warmer than usual. Exam: HR=154bpm, irregular rhythm. What is the tx for her condition? a. Amiadarone b. Beta blockers c. Adenosine d. Verapamil e. Flecainide The key is B. Beta blockers [the probable arrhythymia is AF secondary to thyrotoxicosis(heat intolerance). So to rapid control the symptoms of thyrotoxicosis Beta blocker should be used]. 410. A T2DM is undergoing a gastric surgery. What is the most appropriate pre-op management? a. Start him in IV insulin and glucose and K+ just before surgery b. Stop his oral hypoglycemic on the day of the procesure c. Continue regular oral hypoglycemic d. Stop oral hypoglycemic the prv night and start IV insulin with glucose and K+ before surgery e. Change to short acting oral hypoglycemic The key is D. Stop oral hypoglycemic the prv night and start IV insulin with glucose and K+ before surgery. 411. A 19yo boy is brought by his mother with complaint of lack of interest and no social interactions. He has no friends, he doesn’t talk much, his only interest is in collecting cars/vehicles having around 2000 toy cars. What is the most appropriate dx? a. Borderline personality disorder b. Depression c. Schizoaffective disorder

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

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

1. 2. 3. 4.

1. 2.

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

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

nd

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

   

Ans. The key is B. Acute follicular tonsillitis. [Tonsillitis is usually caused by a viral infection or, less commonly, a bacterial infection. The given case is a bacterial tonsillitis (probably caused by group A streptococcus). There are four main signs that tonsillitis is caused by a bacterial infection rather than a viral infection. They are: a high temperature white pus-filled spots on the tonsils no cough swollen and tender lymph nodes (glands). 423. A man with a fam hx of panic disorder is brought to the hosp with palpitations, tremors, sweating and muscles tightness on 3 occasions in the last 6 wks. He doesn’t complain of headache and his BP is WNL. What is the single most appropriate long-term tx for him? a. Diazepam b. Olanzapine c. Haloperidol d. Fluoxetine e. Alprazolam Ans. The key is D. Fluoxetine. [Recommended treatment for panic disorder is i) CBT ii) Medication (SSRIs or TCA). NICE recommends a total of seven to 14 hours of CBT to be completed within a four month period. Treatment will usually involve having a weekly one to two hour session. When drug is prescribed usually a SSRI is preferred. Antidepressants can take two to four weeks before becoming effective].

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

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

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

428. A 55yo man presents with hx of weight loss and tenesmus. He is dx with rectal carcinoma. Which risk factors help to develop rectal carcinoma except following? a. Smoking b. Family hx c. Polyp d. Prv carcinoma e. High fat diet f. High fibre diet KEY- F All options except High fiber diet are risk factors for developing rectal carcinoma. *Other risk factors for Rectal Carcinoma are: -IBD -Nulliparity and early menopause -Diet rich in meat and fat, poor in folate and Calcium -Sedentary lifestyle, obesity, smoking and high alcohol intake. -Diabetes -Radiation and asbestos exposure

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

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

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

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

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

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

restoration of respiration and reduction of ICP. Berry aneurysms are often associated with APCKD.

436. A schizophrenic pt hears people only when he is about to fall asleep. What is the most likely dx? a. Hypnopompic hallucinations b. Hyponogogic hallucinations c. Hippocampal hallucinations d. Delirious hallucinations e. Auditory hallucinations KEY- B Hypnopompic hallucinations- While waking up. Hyponogogic hallucinations- While falling asleep. Hippocampal hallucination- Photographic, animated or film-like clarity of people, animals, faces, flowers, insects etc. Auditory hallucinations- hearing voices that aren’t present. 437. A pt who came from India presents with cough, fever and enlarged cervical LN. Exam: caseating granulomata found in LN. What is the most appropriate dx? a. Lymphoma b. TB adenitis

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

VTach- Sequence of 3 or more ventricular beats. Atrial rate 60-100. Ventricular rate 110-250. Regular. Can progress to VFib and cardiac arrest. Ttt if pulse present, cardioversion. If pulseless, defibrillation. 440. A 65yo man with difficulty in swallowing presents with an aspiration pneumonia. He has a bovine cough and fasciculating tongue. Sometimes as he swallows food it comes back through his nose. Choose the single most likely cause of dysphagia from the given option? a. Bulbar palsy b. Esophageal carcinoma c. Pharyngeal pouch d. Pseudobulbar palsy e. Systemic sclerosis KEY- A Bulbar palsy - Relates to medulla. Affection of lower cranial nerves (VIIXII). Dysphagia, dysphonia, dysarthria, tremulous lips, FASICULATIONS. Pseudobulbar palsy - Affection of corticobulbar tracts. Dysphagia, dysphonia. Donald duck speech, unable to protrude tongue. NO FASICULATIONS 441. A 16yo teenager was brought to the ED after being stabbed on the upper right side of his back. Erect CXR revealed homogenous opacity on the lower right lung, trachea was centrally placed. What is the most probable explanation for the XR findings? a. Pneumothorax b. Hemothorax c. Pneumonia d. Tension pneumothorax e. Empyema KEY- B Sharp stabbing wound- Hemothorax. Clincher- homogenous opacity; not seen with pneumothorax. Also since trachea is not displaced from the centre, it is simple, not tension hemothorax. Treatment- Chest drain insertion in the 5th intercostal space, mid-axillary line. For tension hemo/pneumothorax, needle thoracostomy insertion in the 2nd intercostal space, mid-clavicular line. 442. A 55yo woman complains of retrosternal chest pain and dysphagia which is intermittent and unpredictable. The food suddenly sticks in the

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

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

fluconazole for atleast 21 days or atleast 14 days after disappearance of symptoms. **Oesophageal carcinoma- Dysphagia to colod foods then later to liquids. Weight loss, hoarseness of voice(if involving the recurrent laryngeal nerve), hematemesis, hemoptysis, nausea and vomiting. Risk factors- smoking and unhealthy diet. Diagnosis- Endoscopy and biopsy. Treatment- Surgery, radio and chemotherapy depending on stage. **Pharyngeal pouch (Zencker’s diverticulum)- Common above 70. M:F is 5:1. Presentation: Dysphagia, regurgitation, aspiration, chronic cough and weight loss.Neck lump that gurgles on palpation. Halitosis from food decaying in the pouch. Investigation: Barium swallow shows residual contrast pool within the pouch. Aspiration from the pouch might cause inhalation pneumonia. Ttt cricopharyngeal myotomy. 443. A 38yo female presents with sudden loss of vision but fundoscopy is normal. She a similar episode about 1 y ago which resolved completely within 3m. Exam: mild weakness of right upper limb and exaggerated reflexes. What is the single most appropriate tx? a. Pan retinal photo coagulation b. Pilocarpine eye drops c. Corticosteroids d. Peripheral iridectomy e. Surgical extraction of lens KEY- C > This is a case of optic neuritis caused by Multiple sclerosis. Steroids are the answer here. They are given during acute symptomatic attacks of MS. During relapse or remission, disease modifying agents like interferons are given. > Pan retinal photocoagulation is done for diabetic retinopathy where parts on the retina are burned in order to reduce the Oxygen demand. Lens extraction is done mainly for cataract to remove the opacified lens that disturbs the vision > Peripheral iridectomy is done by making a hole in the iris for open angle glaucoma in order to provide an alternative drainage for the fluid accumulating inside the eye, thus decreasing the IOP.

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

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

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

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

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

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

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

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

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

454. A 65yo male presents with dyspnea and palpitations. Exam: pulse=170bpm, BP=120/80mmHg. Carotid massage has been done as first instance. What is the next step of the management? a. Adenosine b. Amilodipine c. DC cardioversion d. Lidocaine e. Beta blocker KEY- A Likely diagnosis SVT. Initially, vagal manoeuvres, if fails iv adenosine. • Vagal manoeuvres (carotid sinus massage, Valsalva manoeuvre) transiently increase AV block, and may unmask an underlying atrial rhythm. • If unsuccessful, give adenosine, which causes transient AV block. 455. A 48yo farmer presented with fever, malaise, cough and SOB. Exam: tachypnea, coarse end-inspiratory crackles and wheeze throughout, cyanosis. Also complaint severe weight loss. His CXR shows fluffy nodular shadowing and there is PMN leukocytosis. What is the single most appropriate dx? a. Ankylosing spondylitis b. Churg-strauss syndrome c. Cryptogenic organizing d. Extrinsic allergic alveolitis e. Progressive massive fibrosis KEY- D Dx- Farmer’s lung/ Hypersensitivity penumonitis/ Extrinsic allergic penumonitis. It is diffuse granulomatous inflammation of the lung in patients who are allergic to organic antigens present in dust particles. On chest X-ray, diffuse nodular opacities are seen. 456. A 35yo lady is admitted with pyrexia, weight loss, diarrhea and her skin is lemon yellow in color. CBC = high MCV. What is the most probably dx? a. Aplastic anemia b. Pernicious anemia c. Leukemia d. ITP e. Lymphoma KEY- B

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

a. Ankylosing spondylitis b. Churg-strauss syndrome c. Good pasture syndrome d. Motor neuron disease e. Progressive massive fibrosis f. Spinal cord compression KEY- D Involvement of respiratory muscles in Motor Neuron Disease is associated with poor respiration causing sleep apnoea. 460. A 55yo man presents with mild headache. He has changed his spectacles thrice in 1 yr. there is mild cupping present in the disc and sickle shaped scotoma present in both eyes. What is the single most appropriate tx? a. Pan retinal photo coagulation b. Pilocarpine eye drops c. Corticosteroids d. Scleral buckling e. Analgesics alone KEY- B > Sickle-shaped scotoma or siedel sign is often seen in glaucoma. That along with the fact that he keeps changing his spectacles denotes that this is a case of progressive open angle glaucoma. It can also present with nausea, vomiting, headache and ocular pain. Treated with Carbonic anhydrase inhibitors like acetazolamide, Miotic agents (parasympathomimetics) such as pilocarpine, Alpha2-adrenergic agonists like brimonidine, or Prostaglandin analogs like latanoprost. > Pan retinal photocoagulation is done for diabetic retinopathy where parts on the retina are burned in order to reduce the Oxygen demand. > Scleral buckling is done for retinal detachment to put the retina back in place. 461. A 55yo woman was found collapsed at home, paramedics revived her but in the ambulance she had a cardiac arrest and couldn’t be saved. The paramedic’s report tells that the woman was immobile lately due to hip pain and that they found ulcers on the medial side of ankle. She had DM and was on anti-diabetics. What is the cause of her death? a. Acute MI b. DKA c. Pulmonary embolism d. Acute pericarditis

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

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

pulse=100bpm, temp=37.5C. CXR: bilateral patchy consolidation. What is the single most likely causative organism? a. Pneumococcal pneumonia b. Legionella c. Mycoplasma d. Klebsiella e. Chlamydia pneumonia KEY- C > Mycoplasma pneumonia- Atypical pneumonia. Slow onset, dry cough, pleuritic pain, myalgia, arthralgia, malaise. > Legionella- history of travel and stay in hotel- atypical symptoms plus GI manifestations. > Klebsiella- commonly associated with alcohol. 465. A 46yo man is being investigated for indigestion. Jejunal biopsy shows deposition of macrophages containing PAS (Periodic acid-schiff) +ve granules. What is the most likely dx? a. Bacterial overgrowth b. Celiac disease c. Tropical sprue d. Whipple’s disease e. Small bowel lymphoma KEY- D Periodic acid-schiff positive granules containing macrophages in jejunal biopsy is diagnostic of whipple’s disease. Coeliac disease is gluten sensitivity. 466. A 32yo woman of 38wks gestation complains of feeling unwell with fever, rigors and abdominal pains. The pain was initially located in the abdomen and was a/w urinary freq and dysuria. The pain has now become more generalized specifically radiating to the right loin. She says that she has felt occasional uterine tightening. CTG is reassuring. Select the most likely dx? a. Acute fatty liver of pregnancy b. Acute pyelonephritis c. Round ligament stretching d. Cholecystitis e. UTI KEY- B This is a case of UTI followed by ascending infection leading to pyelonephritis. Fever, rigors and abdominal pain are typical symptoms.

467. A 32yo pt presents with cervical lymphadenopathy and splenomegaly. What is the single most appropriate option? a. Hemophilus b. Streptococcus c. Toxoplasmosis d. NHL e. Pneumocystis jerovcii KEY- D Non Hodgkin’s lymphoma is the only option here that will have both lymphadenopathy and splenomegaly (although splenomegaly is not a common presentation). Pneumocystis jerovici and Toxoplasmosis are common in HIV patients. 468. A 62yo man who was admitted for surgery 3days ago suddenly becomes confused. His attn span is reduced. He is restless and physically aggressive and picks at his bed sheets. What single aspect of the pt’s hx recovered in his notes is most likely to aid in making the dx? a. Alcohol consumption b. Head trauma c. Hx of anxiety d. Prescribed med e. Obvious cognitive impairment KEY- A This is a typical case of Delirium tremens. It appears [48-72 hours after alcohol has stopped]. Altered mental status in the form of confusion, delusions, severe agitation and hallucinations. We should ask alcohol history. Examination might reveal stigmata of chronic alcoholic liver disease. 469. A 10yo girl presents with pallor and features of renal failure. She has hematuria as well as proteinuria. The serum urea and creat are elevated. These symptoms started after an episode of bloody diarrhea 4 days ago. What is the most probable dx? a. TTP b. HUS c. ITP d. HSP e. ARF KEY- B

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

472. A 71yo woman looks disheveled, unkempt and sad with poor eye contact. She has recently lost her husband. Which of the following describes her condition? a. Anxiety b. Hallucination c. Mania d. High mood e. Low mood KEY- E Dx- Depression. Disheveled and unkempt because she doesn’t take care of herself, plus the loss of her husband, points towards depression. 473. A 62yo male comes to the GP complaining of double vision while climbing downstairs. Which of the following nerve is most likely involved? a. Abducens nerve b. Trochlear nerve c. Oculomotor nerve d. Optic nerve e. Trigeminal nerve KEY- B This is a lesion in the Trochlear nerve affecting the Superior oblique muscle. All extrinsic muscles of the eye are supplied by the Oculomotor nerve except the Lateral rectus by the Abducens nerve and the Superior oblique by the trochlear (mnemonic LAST). Oculomotor nerve affection causes palsy of inferior rectus, medial rectus and superior rectus manifesting as double vision in multiple gaze. But trochlear involving superior oblique only causes diplopia in downgaze only.

474. L1 level, what is the most appropriate landmark? a. Mcburney’s point b. Stellate ganglion c. Deep inguinal ring d. Termination of the spinal cord e. Transpyloric plane

KEY- E

475. A 32yo woman presents to the ED with headache and vomiting. She was decorating her ceiling that morning when the headache began, felt mainly occipital with neck pain. Some 2hs later she felt nauseated, vomited and was unable to walk. She also noticed that her voice had altered. She takes no reg meds and has no significant PMH. Exam: acuity, field and fundi are normal. She has upbeat nystagmus in all directions of gaze with normal facial muscles and tongue movements. Her uvulas deviated to the right and her speech is slurred. Limb exam: left arm past-pointing and dysdiadochokinesia with reduced pin prick sensation in her right arm and leg. Although power is normal, she can’t walk as she feels too unsteady. Where is the most likely site of lesion? a. Right medial medulla b. Left medial pons c. Left cerebellar hemisphere d. Right lateral medulla e. Left lateral medulla KEY- E Lateral medullary syndrome affects: -Contralateral spinothalamic tract (loss of pain and temperature on the opposite side of the body) -Ipsilateral Sympathetic tract- Horner’s syndrome. -Ipsilateral Spinal trigeminal nucleus (loss of pain,temperature and corneal reflex on same side of the face) -Nucleus ambigous- Dysphagia and Dysarthria -Inferior cerebellar peduncle- Ataxia Ipsilateral Cranial nerves- IX, X and XI (dysphagia, loss of gag reflex, palate paralysis) Cause- Occlusion of PICA (posterior inferior cerebellar artery) Medial medullary syndrome affects: Contralateral corticospinal tract/pyramids- weakness of arms and legs opposite side. Contralateral Medial lemniscus/dorsal column- loss of proprioception and vibration. Ipsilateral hypoglossal nerve- weakness of tongue on the same side. [Hypoglossal nerve affection manifests as protrusion of the tongue to the side of the weakness while at rest, it deviates to the contralateral side) Cause- Occlusion of Anterior spinal artery. 476. A 28yo female presents with 1 wk hx of jaundice and 2d hx of altered sleep pattern and moods. She was dx with hypothyroidism for which

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

479. A 30yo man presents to the ED with difficulty breathing. He has returned from India. Exam: throat reveals grey membranes on the tonsils and uvula. He has mild pyrexia. What is the single most relevant dx? a. Diphtheria b. IM c. Acute follicular tonsillitis d. Scarlet fever e. Agranulocytosis KEY- A Clinchers- History of travel to India, and greyish membrane. Infectious mononucleosis will typically present in a teenager, with enlarged cervical lymphadenopathy and fever. Acute follicular tonsillitis as the name suggests, will have follicles on the tonsils. Scarlet fever presents with rash and strawberry tongue 480. A 23yo man comes to the ED with a hx of drug misuse. He recognizes that he has a prb and is willing to see a psychiatrist. Which of the following terms best describes this situation? a. Judgement b. Thought insertion c. Thought block d. Mood e. Insight KEY- E Insight is the patient's awareness and understanding of the origins and meaning of his attitudes, feelings, and behavior and of his disturbing symptoms, basically, he is aware that he has a problem. 481. A pt with hodgkins lymphoma who is under tx develops high fever. His blood results show WBC Complications of Meningitis: *Immediate: septic shock, DIC, coma with loss of protective airway reflexes, cerebral oedema and raised ICP, septic arthritis, pericardial effusion and haemolytic anaemia (H. influenzae). Subdural effusions: reported in 40% of children aged 1-18 months with bacterial meningitis. Syndrome of inappropriate antidiuretic hormone secretion (SIADH). Seizures *Delayed: decreased hearing, or deafness; other cranial nerve dysfunction, multiple seizures, focal paralysis, subdural effusions, hydrocephalus, intellectual deficits, ataxia, blindness, Waterhouse-Friderichsen syndrome and peripheral gangrene. 491. A primiparous woman with no prv infection with herpes zoster is 18wk pregnant. She had recent contact with a young 21yo pt having widespread chicken pox. What is the most suitable management for the pregnant lady? a. Acyclovir PO b. Acyclovir IV +IVIG c. Acyclovir IV d. Reassure e. IVIG

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

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

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

VTach- Sequence of 3 or more ventricular beats. Atrial rate 60-100. Ventricular rate 110-250. Wide QRS complex (>120ms). Regular. Can progress to VFib and cardiac arrest. Ttt- if pulse present, cardioversion. If pulseless, defibrillation. SVT and AFib will have narrow QRS complexes.

499. A pt presents with purple papular lesions on his face and upper trunk measuring 1-2 cm across. They aren’t painful or itchy. What is the single most likely dx? a. Kaposi’s sarcoma b. Hairy leukoplakia c. Cryptosporidium d. CMV infection e. Cryptococcal infection KEY- A Kaposi’s sarcoma is a spindle-cell tumour derived from capillary endothelial cells or from fibrous tissue, caused by human herpes virus. It presents as non painful purple papules (½ to 1 cm) or plaques on skin and mucosa (any organ). It is not itchy, and it metastasizes to nodes. Associated with AIDS infection. OHCM 9th edition, page 716. 500. A 6yo boy is clinically obese, his BMI >95 centile. He has no other medical prbs, examination is unremarkable. His mother says that she has tried everything to help him lose weight. What is the most probable dx? a. Cushing’s syndrome b. Congenital hypothyroidism c. Down’s syndrome d. Lawrence moon biedel syndrome e. Primary obesity KEY- E Features support primary childhood obesity. No other associated signs or symptoms except obesity. It’s not cushing (No moon face, pigmentation, hyperglycaemia) etc. It’s not congenital hypothyroidism, (No weight loss despite increased appetite), not Down syndrome (No features of Down) or Lawrence moon biedel syndromes (No learning difficulties). th

501. A 20yo boy is brought by his parents suspecting that he has taken some drug. He is agitated, irritated and can’t sleep. Exam: perforated nasal septum. Which of the following is the most likely to be responsible for his symptoms? a. Heroine b. Cocaine c. Ecstasy/MDMA/amphetamine d. Alcohol

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

  

hyperthermia metabolic acidosis rhabdomyolysis

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

probably wise to choose it.

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

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

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

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

Pericarditis chest pain: may be pleuritic. Is often relieved by sitting forwards Pulmonary embolism pleuritic chest pain, dyspnoea and haemoptysis Costochondritis Chest wall pain with a history of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture) is common

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

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

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

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

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Laparoscopy has become a routine procedure in the management of acute abdominal disease

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

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

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

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

509. What is the most appropriate antibiotic to treat uncomplicated chlamydial infection in a 21yo female who isn’t pregnant? a. Erythromycin b. Ciprofloxacin c. Metronidazole d. Cefixime e. Doxycycline e. Doxycycline Chlamydia is the most prevalent sexually transmitted infection in the UK. Management  doxycycline (7 day course) or azithromycin (single dose). The 2009 SIGN guidelines suggest azithromycin should be used first-line due to potentially poor compliance with a 7 day course of doxycycline  if pregnant then erythromycin or amoxicillin may be used. Potential complications       

epididymitis pelvic inflammatory disease endometritis increased incidence of ectopic pregnancies infertility reactive arthritis perihepatitis (Fitz-Hugh-Curtis syndrome)

510. A 45yo manual worker presented with a 2h hx of chest pain radiating to his left arm. His ECG is normal. What is the single most appropriate inv? a. Cardiac enzymes b. CXR c. CT d. ECG e. V/Q scan a. Cardiac enzymes to rule out NSTEMI.

Non-ST-elevation ACS (NSTE-ACS): patients present with acute chest pain but without persistent ST-segment elevation. The ECG shows persistent or transient ST-segment depression or T-wave inversion, flat T waves, pseudo-normalisation of T waves, or no ECG changes at presentation. Management: All patients should receive  aspirin 300mg  nitrates or morphine to relieve chest pain if required

Antithrombin treatment. Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a patients creatinine is > 265 mol/l unfractionated heparin should be given.

Clopidogrel 300mg should be given to all patients and continued for 12 months.

Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban) should be given to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.

Coronary angiography should be considered within 96 hours of first admission to hospital to patients who have a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in patients who are clinically unstable.

511. A 26yo woman had bipolar disorder for 10yrs and is on Lithium for it. She is symptom free for the past 4 years. She is now planning her pregnancy and wants to know whether she should continue taking lithium. What is the single most appropriate advice? a. Continue lithium at the same dose and stop when pregnancy is confirmed b. Continue lithium during pregnancy and stop when breast feeding c. Reduce lithium dosage but continue throughout pregnancy d. Reduce lithium gradually and stop when pregnancy is confirmed e. Switch to sodium valproate d. Reduce lithium gradually and stop when pregnancy is confirmed symptom free for last 4 years. Lithium is teratogenic. Adverse effects      

nausea/vomiting, diarrhoea fine tremor polyuria (secondary to nephrogenic diabetes insipidus) thyroid enlargement, may lead to hypothyroidism ECG: T wave flattening/inversion weight gain

Monitoring of patients on lithium therapy  inadequate monitoring of patients taking lithium is common - NICE and the National Patient Safety Agency (NPSA) have issued guidance to try and address this. As a result it is often an exam hot topic  lithium blood level should 'normally' be checked every 3 months. Levels should be taken 12 hours post-dose  thyroid and renal function should be checked every 6 months  Pregnancy: avoid in first the trimester (teratogenic). Only use in the second and third trimester if considered essential, ie a severe risk to the patient, and monitor levels closely, as dose requirements may alter.  Breast-feeding: avoid, as present in milk, and there is risk of toxicity in an infant. Bottle-feeding is advisable.

Withdrawal Abrupt withdrawal (both because of poor compliance or rapid change in dose) can precipitate relapse. Withdraw lithium slowly over several weeks, watching for relapse.

512. A pt presents with dysphagia and pain on swallowing. He has sore mouth and soreness in the corners of the mouth. What is the single most likely dx/ a. Kaposi’s sarcoma b. Molluscum contagiosum c. CMV infection d. Candida infection e. Toxoplasma abscess d. Candida infection Pain on swallowing is classic for candida. Kaposi's sarcoma  caused by HHV-8 (human herpes virus 8)  presents as purple papules or plaques on the skin or mucosa (e.g. gastrointestinal and respiratory tract)  skin lesions may later ulcerate  respiratory involvement may cause massive haemoptysis and pleural effusion  radiotherapy + resection Molluscum contagiosum The majority of cases occur in children (often in children with atopic eczema), with the maximum incidence in preschool children aged 14 years.characteristic pinkish or pearly white papules with a central umbilication, which are up to 5 mm in diameter. Lesions appear in clusters in areas anywhere on the body (except the palms of the hands and the soles of the feet).

CMV infection Infection is worldwide and usually asymptomatic . The most common disease manifestation is gastrointestinal disease. CMV pneumonia is the most serious complication, but has become less common with prevention strategies for at-risk patients. Rare manifestations include retinitis and encephalitis.

ToxoplasmaThis is asymptomatic in most cases.Toxoplasmic chorioretinitis.Toxoplasmic encephalitis.Pneumonitis.Multiorgan involvement with respiratory failure and shock.

513. A 30yo lady has epistaxis for 30mins. Her Hgb is normal, MCV normal, WBC normal, PT/APTT/Bleeding time are normal. Where is the defect? a. Plts b. Coagulation factor c. Sepsis d. Anatomical e. RBC d. Anatomical All labs normal.

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Trauma to the nose (the most common cause) - especially nose picking! Insertion of foreign bodies and excessive nose blowing may also be seen as trauma. The latter is likely to occur with a cold when the nasal mucosa is congested. Sinusitis causes nasal congestion. Disorders of platelet function - thrombocytopenia and other causes of abnormal platelets, including splenomegaly and leukaemia. Waldenström's macroglobulinaemia may present with nosebleeds. Idiopathic thrombocytopenic purpura (ITP) can occur in children and young adults. Drugs - aspirin and anticoagulants. Disorders of platelets are more likely to be a problem than clotting factor deficiency. Abnormalities of blood vessels in the elderly arteriosclerotic vessels prolong bleeding. Hereditary haemorrhagic telangiectasia (Osler-Rendu-Weber syndrome) causes recurrent epistaxis from nasal telangiectases. Malignancy of the nose may present with bleeding - juvenile angiofibroma is a highly vascular benign tumour that typically presents in adolescent males. Cocaine use - if the septum looks sloughed or atrophic ask about use of cocaine. Other conditions - Wegener's granulomatosis and pyogenic granuloma can present as an epistaxis.

514. Midpoint between the suprasternal notch and pubic symphysis. What is the single most appropriate landmark? a. Fundus of the gallbladder b. Mcburney’s point c. Stellate ganglion d. Deep inguinal ring e. Transpyloric plane e. Transpyloric plane An upper transverse, the transpyloric, halfway between the jugular notch and the upper border of the symphysis pubis; this indicates the margin of the transpyloric plane, which in most cases cuts through the pylorus, the tips of the ninth costal cartilages and the lower border of the first lumbar vertebra;

Fundus located at the tip of the 9 costal cartilage th

Mcburney’s point one-third of the distance from the anterior superior iliac spine to the umbilicus

Stellate ganglion located at the level of C7 (7th cervical vertebrae), anterior to the transverse process of C7, superior to the neck of the first rib, and just below the subclavian artery

Deep inguinal ring immediately above the midpoint of the inguinal ligament (midway between the anterior superior iliac spine and the pubic tubercle)

Structures crossed The transpyloric plane is clinically notable because it passes through several important abdominal structures. These include:  lumbar vertebra 1 and hence passes just before the end of the spinal cord in adults.  the fundus of the gallbladder  the end of the spinal cord  the Neck of pancreas

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the origin of the superior mesenteric artery from the abdominal aorta and termination of the superior mesenteric vein at the hepatic portal vein the left and right colic flexure hilum of the kidney on the left hilum of the kidney on the right the root of the transverse mesocolon duodenojejunal flexure the 1st part of the duodenum the upper part of conus medullaris the spleen the pylorus of the stomach which will lie at this level approximately 5 cm to the right of the midline. cisterna chyli (which drains into the thoracic duct)

515. Tip of the 9th costal cartilage. What is the single most appropriate landmark? a. Fundus of the gallbladder b. Deep inguinal ring c. Termination of the spinal cord d. Transpyloric plane e. Vena cava opening in the diaphragm a. Fundus of the gallbladder spinal cord around the L1/L2 vertebral level, forming a structure known as the conus medullaris.

Apertures through the diaphragm 1. Vena caval hiatus (vena caval foramen)  at the level of T8 and transmits the IVC and occasionally the phrenic nerve. 2. Esophageal hiatus  at the level of T10 and transmits the esophagus and vagus nerves. 3. Aortic hiatus  at the level of T12 and transmits the aorta, thoracic duct, azygos vein, an occasionally greater splanchnic nerve.

516. A child complains of RIF pain and diarrhea. On colonoscopy, granular transmural ulcers are seen near the ileo-cecal junction. What should be the management? a. Sulfasalazine b. Oaracetamol c. Ibuprofen d. Metronidazole a. Sulfasalazine Crohns disease-transmural ulcers

metronidazole is often used for isolated peri anal disease Remission glucocorticoids (oral, topical or intravenous) are generally used to induce remission. 5-ASA drugs (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective

stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) Maintenance azathioprine or mercaptopurine is used first-line to maintain remission methotrexate is used second-line 517. A 60yo woman presents with acute onset of bone and back pain following a rough journey in a car. Exam: tenderness at mid-thoracic vertebra with spasm, she feels better once she bends forward. What is the single most probable dx? a. Osteoporotic fx verterbra b. Myofacial pain c. Whiplash injury d. MI e. Pancreatitis b. Myofacial pain  Myofascial pain syndrome typically occurs after a muscle has been contracted repetitively.  Only myofascial pain/muscle sprain relieves on change of position.  Whiplash is only for cervical vertebrae  osteoporotic fx has dull pain and persistent or even worse on movement. After repeated contraction of a muscle there occur spasm of the muscle and often the pain may felt in some other part (referred pain). Here rough journey and associated spasm is clincher. In vertebral fracture you will find neurological features which is absent here. Spinal Stenosis pain also Relieved by sitting down, leaning forwards and crouching down

518. A 70yo woman presents with recurrent episodes of parotid swelling. She complains of difficulty in talking and speaking and her eyes feel gritty on waking in the morning. What is the single most likely dx? a. C1 esterase deficiency b. Crohns disease c. Mumps d. Sarcoidosis e. Sjogrens syndrome e. Sjogrens syndrome main symptoms of xerophthalmia (dry eyes), xerostomia (dry mouth) and enlargement of the parotid glands.  Difficulty eating dry food, typically cracker biscuits.  Difficulty with dentures.  Complaint of the tongue sticking to the roof of the mouth.  Speaking for long periods of time causes hoarseness.  Oral candidiasis and angular cheilitis. Dry eyes tend to cause a gritty sensation. There is a predisposition to blepharitis and the eyes may be sticky in the morning.

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There may be recurrent parotitis, usually bilateral. Glands are usually enlarged but this is not often the presenting feature. Dryness of the mucosa of the trachea and bronchi may present as a dry cough. Dryness of the pharynx and oesophagus may cause difficulty in swallowing, and lack of saliva and secretions may predispose to gastro-oesophageal reflux. There can be dry skin and vaginal dryness causing dyspareunia Disease of the pancreas can lead to malabsorption and even acute pancreatitis or chronic pancreatitis but a more likely cause of elevated serum amylase is parotitis. Fatigue is a common feature. About 20% have Raynaud's phenomenon.

Associated diseases There may be a number of associated autoimmune conditions, such as the variant of scleroderma: calcinosis, Raynaud's phenomenon, (o)esophageal motility disorder, sclerodactyly and telangiectasia (CREST). There may be joint pain, swelling and fatigue rrecurrent miscarriage with antiphospholipid syndrome.

Investigations   

Rheumatoid factor Antinuclear antibodies Schirmer test

519. A 39yo woman has not had her period for 10months. She feels well but is anxious as her mother had an early menopause. Choose the single most appropriate initial inv? a. Serum estradiol conc. b. Serum FSH/LH c. Serum progesterone conc. d. None e. Transvaginal US b. Serum FSH/LH Premature Menopause (ovarian faililure)shoud be ruled out.So FSH and LH(very high) Premature Ovarian Failure (menopause before 40 years of age).

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climacteric symptoms: hot flushes, night sweats infertility secondary amenorrhoea raised FSH, LH levels serum estradiol reflects primarily the activity of the ovaries. useful in the detection of baseline estrogen in women with amenorrhea or menstrual dysfunction, and to detect the state of hypoestrogenicity and menopause. Serum progesterone: indicates if failure to ovulate 7 days prior to expected next period 520. A 50yo man with DM suddenly develops persistent crushing central chest pain radiating to the neck. What is the single most appropriate dx? a. Angina b. Costochondritis (tietz’s disease)

c. Dissecting aneurysm d. MI e. Pulmonary embolism c. Dissecting aneurysm Pain can radiate to back (classically described in questions) or to the neck as well. MI is an important differential but usually MI in diabetics is silent one. Angina does not radiate, costochondritis mostly have localised pain In aortic dissection, pain is abrupt in onset and maximal at the time of onset. In contrast, the pain associated with acute myocardial infarction starts slowly and gains in intensity with time. It is usually more oppressive and dull. Although tearing is the classical description, the pain is described as sharp more often than tearing, ripping, or stabbing.

Investigations Often the first problem is to distinguish aortic dissection from myocardial infarction. Both conditions may exist if the dissection involves the coronary ostium. For this reason, the electrocardiogram (ECG) is very important.

Best: MRI 521. A 22yo man has rushed into the ED asking for help. He describes recurrent episodes of fearfulness, palpitations, faintness, hyperventilation, dryness of the mouth with peri-oral tingling and cramping of the hands. His symptoms last 5-10 mins and have worsened since their onset 3months ago. He is worried he may be having a heart attack. An ECG shows sinus tachycardia. What is the single most appropriate immediate intervention? a. High flow oxygen b. IV sedation c. Rebreathe into a paper bag d. Refer for anxiety management course e. Refer for urgent cardiology opinion c. Rebreathe into a paper bag

Characteristic symptoms experienced during panic attacks Panic disorder manifests as the sudden, spontaneous and unanticipated occurrence of panic attacks, with variable frequency, from several in a day to just a few per year:  Palpitations, pounding heart or accelerated heart rate.  Sweating.  Trembling or shaking.  Dry mouth.  Feeling short of breath, or a sensation of smothering.  Feeling of choking.  Chest pain or discomfort.  Nausea or abdominal distress.

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Feeling dizzy, unsteady, light-headed or faint. Derealisation or depersonalisation (feeling detached from oneself). Fear of losing control or 'going crazy'. Fear of dying. Numbness or tingling sensations. Chills or hot flushes.

522. An 8yo boy has longstanding asthma. He has admitted with a severe episode and is tired and drowsy. He has not improved on oxygen, inhaled B2 agonist and IV hydrocortisone. CXR shows bilateral hyperinflation. He is too breathless to use a peakflow meter and is O2 sat 125 in those aged over 5 years or >140 in 2- to 5-year-olds.  Respiratory rate >30 in those aged over 5 and >40 in 2- to 5-year-olds.

Life-threatening  Silent chest.  Cyanosis.  Poor respiratory effort.  Hypotension.  Exhaustion.  Confusion.  Coma.

523. A man was operated for colorectal ca. His pain is relieved with morphine 60mg bd PO but now he can’t swallow medications. What will be the next regimen of analgesic administration? a. Oxycodone b. Fentanyl patch c. Morphine 60mg IV/d d. Morphine 240mg IV/d b. Fentanyl patch

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A regular 4-hourly starting dose for opioid-naive patients is usually 5-10 mg morphine.  Once pain relief is at a satisfactory and stable level, sustained-release preparations can be substituted to allow od or bd dosing  Any breakthrough pain not associated with unusual activity should be treated with morphine elixir or ordinary tablets at 1/6 total daily dose.  the breakthrough dose of morphine is one-sixth the daily dose of morphine  When increasing the dose of opioids the next dose should be increased by 3050%.  If vomiting, dysphagia or increasing weakness prevent patients from taking oral morphine then usual practice is to convert to a subcutaneous infusion of opioid via a device such as a syringe driver.( in whom oral opioids are not suitable and analgesic requirements are unstable) Injection site should be changed every 2-3 days. An alternative to both oral morphine and subcutaneous diamorphine in patients with stable pain is transdermal fentanyl or buprenorphine patches. (in whom oral opioids are not suitable and analgesic requirements are stable) They can be useful in ambulatory patients where the following exist: -Problems with the oral route. -Intractable constipation or subacute obstruction. -Morphine intolerance. Consider if agitated confusion is due to opioid toxicity rather than uncontrolled pain before giving further opioids. Consider switching to an alternative strong opioid. Alternatives include hydromorphone, methadone and oxycodone Consider changing the route of administration - eg where gastrointestinal absorption is poor, consider switching to skin patches. opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred

Oral to oral route conversions[2]

Converting

Converting to:

Divide 24-hour dose of current opioid by figure below to calculate initial 24-hour dose of new opioid

from: (new opioid) (current opioid)

oral codeine

oral morphine

Divide by 10

oraltramadol

oral morphine

Divide by 5

oral morphine

oral oxycodone

Divide by 2

oral morphine

oralhydromorphone

Divide by 7.5

524. Just above the mid-inguinal point. What is the single most appropriate landmark? a. Femoral artery pulse felt b. Mcburney’s point c. Stellate ganglion d. Deep inguinal ring e. Transpyloric plane d. Deep inguinal ring

525. 5th ICS in the ant axillary line. What is the single most appropriate landmark? a. Apex beat b. Chest drain insertion c. Stellate ganglion d. Transpyloric plane e. Vena cava opening into the diaphragm b. Chest drain insertion Surface anatomy of Apex beat is left 5th ICS midclavicular line.

526. A 34yo man with MS has taken an OD of 100 tablets of paracetamol with intent to end his life. He has been brought to the ED for tx but is refusing all intervention. a. Assessment b. Evaluate pt’s capacity to refuse tx c. Establish if pt has a prv mental illness b. Evaluate pt’s capacity to refuse tx

Urgent treatment

Consent not needed when urgent treatment is required:    

To save the patient's life. To prevent a serious deterioration in the patient's condition, so long as the treatment is not irreversible. To alleviate serious suffering so long as the treatment is neither irreversible nor hazardous. To prevent the patient from behaving violently or being a danger to self or others so long as the treatment is neither irreversible nor hazardous, and represents the minimum interference necessary.

527. A 23yo woman with painless vaginal bleeding at 36wks pregnancy otherwise seems to be normal. What should be done next? a. Vaginal US b. Abdominal US c. Vaginal exam d. Reassurance b. Abdominal US to assess fetal being and check placenta previa vaginal US is more accurate but not initial when bleeding. No PV until no PP Placenta previa Painless bleeding starting after the 28th week (although spotting may occur earlier) is usually the main sign.

Acute bleeding Admit the patient to hospital. DO NOT PERFORM A VAGINAL EXAMINATION, as this may start torrential bleeding in the presence of placenta praevia.   

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Blood loss is assessed and cross-matched for possible transfusion. Resuscitation if indicated; the mother is the priority and should be stabilised prior to any assessment of the fetus. Appropriate surgical intervention may be required: o In severe bleeding the baby is delivered urgently whatever its gestational age. o Hysterectomy should also be considered in severe cases. If immediate delivery is not likely, maternal steroids may be indicated in order to promote fetal lung development and reduce the risk of respiratory distress syndrome and intraventricular haemorrhage.

528. A 29yo lady admitted with hx of repeated UTI now developed hematuria with loin pain. What is the most probable dx? a. Acute pyelonephritis b. Chronic pyelonephritis c. UTI d. Bladder stone a. Acute pyelonephritis

Presentation Onset is usually rapid with symptoms appearing over a day or two. There is unilateral or bilateral loin pain, suprapubic or back pain. Fever is variable but can be high enough to produce rigors. Malaise, nausea, vomiting, anorexia and occasionally diarrhoea occur. There may or may not be accompanying lower urinary tract symptoms with frequency, dysuria, gross haematuria or hesitancy. Gross haematuria occurs in 30-40% of young women. The patient looks ill and there is commonly pain on firm palpation of one or both kidneys and moderate suprapubic tenderness without guarding. Investigation of choice: Contrast-enhanced helical/spiral CT (CECT) scan is the best investigation in adults In children, the choice is between ultrasound and CT scanning. CT is more sensitive but the exposure to radiation may make ultrasound a safer option. Treatment: ciprofloxacin for seven to ten days

529. A 45yo chronic smoker attends the OPD with complaints of persistent cough and copious amount of purulent sputum. He had hx of measles in the past. Exam: finger clubbing and inspiratory crepitations on auscultation. What is the single most likely dx/ a. Interstitial lung disease b. Bronchiectasis c. Asthma d. COPD e. Sarcoidosis b. Bronchiectasis Bronchiectasis -(clubbing is not present in pure COPD) Plus all the signs and symptoms are characteristic of bronchiectasis. - Copious and purulent sputum - Finger clubbing - Post infective occurrence (as can be noted with pertussis, measles, recurrent childhood bronchiolitis etc) That being said, he probably has underlying COPD owing to the history of chronic smoking, which makes him susceptible to repeated viral infections of the respiratory tract and consequently bronchiectasis. If COPD ever presents with finger clubbing, we investigate for underlying bronchogenic Ca or bronchiectasis.

Interstitial lung disease The most common symptom of all forms of interstitial lung disease is shortness of breath. dry nonproductive cough. Asthma wheeze, breathlessness, chest tightness and cough, particularly if:  symptoms worse at night and in the early morning  symptoms in response to exercise, allergen exposure and cold air

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symptoms after taking aspirin or beta blockers

COPD patients over 35 years of age who are smokers or ex-smokers and have symptoms such as exertional breathlessness, chronic cough or regular sputum production.

Bronchiectasis  Bronchiectasis describes a permanent dilatation of the airways secondary to chronic infection or inflammation.  Post-infection - eg, childhood respiratory viral infections (measles, pertussis, influenza, respiratory syncytial virus), tuberculosis, bacterial pneumonia. Infection is the most common cause.  persistent daily expectoration of large volumes of purulent sputum.  dyspnoea, chest pain and haemoptysis. Bronchiectasis may progress to respiratory failure and cor pulmonale.  Coarse crackles are the most common finding  The gold standard for diagnosis is HRCT of the chest.  first-line treatment is amoxicillin 500 mg three times a day or clarithromycin 500 mg twice daily  All children and all adults up to the age of 40, presenting with bronchiectasis, should have investigations for cystic fibrosis.

530. A 68yo man has had malaise for 5 days and fever for 2 days. He has cough and there is dullness to percussion at the left lung base. What is the single most appropriate inv? a. Bronchoscopy b. CXR c. CT d. MRI e. V/Q scan b. CXR If a person is sufficiently sick to require hospitalization, a chest radiograph is recommended. A CT scan can give additional information in indeterminate cases.

Pneumonia Presentation  Symptoms: cough, purulent sputum which may be blood-stained or rustcoloured, breathlessness, fever, malaise.  Diagnosis is unlikely if there are no focal chest signs and heart rate, respiratory rate and temperature are normal.  The elderly may present with mainly systemic complaints of malaise, fatigue, anorexia and myalgia.  Signs: tachypnoea, bronchial breathing, crepitations, pleural rub, dullness with percussion. CURB-65 criteria of severe pneumonia  Confusion (abbreviated mental test score 7 mmol/L  Respiratory rate >= 30 / min  BP: systolic 3 weeks requires investigation to exclude malignancy:  Carcinomas of larynx and lung must be considered, so CXR and/or laryngoscopy are indicated.  National Institute for Health and Care Excellence (NICE) guidance on suspected cancer states that for patients with hoarseness persisting for >3 weeks, particularly smokers aged ≥50 years and heavy drinkers: o Arrange urgent CXR. o Refer patients with positive findings urgently to a team specialising in the management of lung cancer. o Refer patients with a negative finding urgently to a team specialising in head and neck cancer.

544. A 52yo man whose voice became hoarse following thyroid surgery 1 wk ago shows no improvement. Which anatomical site is most likely affected?

a. Bilateral recurrent laryngeal nerve b. Unilateral recurrent laryngeal nerve c. Unilateral external laryngeal nerve d. Bilateral external laryngeal nerve e. Vocal cords b. Unilateral recurrent laryngeal nerve bilateral injury of the RLN leads to aphonia. In unilateral damage, the patient voice is still preserved but it's harsh ( hoarse ) due to unilateral paralysis of the vocal cords. Direct injury to the vocal cords is unlikely in thyroid procedures since the larynx isn't opened. The external laryngeal nerves are more frequently damaged than the RLN , but they cause only minor changes in voice quality ( pitch changes). Bilateral rln palsy will cause emergency airway obstruction and stridor Vocal cord inj should be transient and improving External laryngeal inj doesnt cause hoarseness B due to close relation of the inferior thyroid artery to the recurrent laryngeal nerve the clamping of artery during surgery might accidentally injured the nerve causing hoarseness of voice if bilaterally affected the nerve it will most likely causing acute respiratory distress

545. A 73yo male presents with a 12m hx of falls. His relatives have also noticed rather strange behavior of late and more recently he has had episodes of enuresis. Exam: disorientation to time and place, broad-based, clumsy gait. What is the most probable dx? a. Dementia b. Pituitary adenoma c. CVD d. Syringomyelia e. Normal pressure hydrocephalus e. Normal pressure hydrocephalus clincher: Gait, dementia and enuresis the wet, wobbly and wacky grandpa It is a reversible cause of dementia. Seen in elderly patients. Secondary to reduced CSF absorption at the arachnoid villi. Classical triad of features:1. Urinary incontinence 2. Dementia 3. Bradyphrenia 4. Gait abnormality Imaging: Hydrocephalus with an enlarged 4th ventricle Management: Ventriculoperitoneal shunting one in which person talks vulgar things---> frontotemporal dementia One in which dementia fluctuates---> lewy body dementia One asso with parslysis---> vascular dementia One with stepwise deterioration---> Alzheimer's disease

546. A 75yo nursing home resident complains of headache, confusion and impaired vision for 4days. She has multiple bruises on her head. What is the most likely cause of confusion in this pt/ a. Alcohol intoxication

b. Infection c. Subdural hematoma d. Hypoglycemia e. Hyponatremia c. Subdural hematoma multiple bruises on her head Subdural haematoma

Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. Risk factors include old age, alcoholism and anticoagulation. Slower onset of symptoms than a epidural haematoma.

547. A 50yo woman returned by air to the UK from Australia. 3days later she presented with sharp chest pain and breathlessness. Her CXR and ECG are normal. What is the single most appropriate inv? a. Bronchoscopy b. Cardiac enzymes c. CT d. MRI e. Pulse oximetry f. V/Q scan g. CTPA g. CTPA Long flight and sharp chest pain along with breathlessness points towards PE As per NICE guidelines the most appropriate investigation is CTPA if ur suspecting PE. V/Q scan is preferred in only few situation like pregnancy, Ckd patients, or ctpa n/a. U have to do wells scoring of the patient and if its > 4, u straight away do CTpa .. Dont even wait for d dimer. Definitely CTPA in this case

medical student textbook triad of pleuritic chest pain, dyspnoea and haemoptysis. computed tomographic pulmonary angiography (CTPA) is now the recommended gold standard Management: Low molecular weight heparin (LMWH) or fondaparinux should be given initially after a PE is diagnosed.An exception to this is for patients with a massive PE where thrombolysis is being considered. In such a situation unfractionated heparin should be used.  a vitamin K antagonist (i.e. warfarin) should be given within 24 hours of the diagnosis  the LMWH or fondaparinux should be continued for at least 5 days or until the international normalised ratio (INR) is 2.0 or above for at least 24 hours, whichever is longer, i.e. LMWH or fondaparinux is given at the same time as warfarin until the INR is in the therapeutic range  warfarin should be continued for at least 3 months.

 

NICE advise extending warfarin beyond 3 months for patients with unprovokedPE. for patients with active cancer NICE recommend using LMWH for 6 months

Thrombolysis  thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension). Other invasive approaches should be considered where appropriate facilities exist

548. A tall thin young man has sudden pain in the chest and becomes breathless while crying. What is the single most appropriate inv? a. Cardiac enzymes b. CXR c. CT d. ECG e. V/Q scan b. CXR spontaneous pneumothorax .most often in young thin male ..due to rupture of bullous emphysema patient may have marfans syndrome or alpha-1 antitrypsin deficiency

Secondary pneumothorax Recommendations include:  if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.  otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours  if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours 549. A 21yo woman has had several sudden onset episodes of palpitations, sweating, nausea and overwhelming fear. On one occasion she was woken from sleep and feared she was going insane. There is no prv psychiatric disorder. What is the most probable dx? a. Pheochromocytoma b. Panic disorder c. GAD d. Phobia e. Acute stress disorder b. Panic disorder panic attack is MORE likely... it can be pheochromocytoma but "overwhelming fear" makes panic attack look more fitting... It cant be phobia, because the attacks are just random without any known trigger

Pheochromocytoma pressure symptoms

Treatment in primary care  NICE recommend either cognitive behavioural therapy or drug treatment  SSRIs are first-line. If contraindicated or no response after 12 weeks then imipramine or clomipramine should be offered 550. A 55yo woman with a persistent cough and hx of smoking develops left sided chest pain exacerbated by deep breathing with fever and localized crackles. What is the single most appropriate dx? a. Dissecting aneurysm b. Pericarditis c. Pneumonia d. Pneumothorax e. Pulmonary embolism c. Pneumonia dissec aneurysm will have a sharp pain radiating to the back. pericarditis has similiar features , but i dont see a cardiac cause. pneumothorax is seen in smokers , as a complication to COPD , but it wont have fever and above features. ( reduced air entry is seen in it, with hyper resonance on percussin ). pulm embloism also seems unlikely , should have travel history . looks like pneumonia then - pain on inspiration ( pleural pain ), fever , cough, and crackles !

Klebsiella pneumoniae is classically in alcoholics Streptococcus pneumoniae (pneumococcus) is the most common cause of communityacquired pneumonia Characteristic features of pneumococcal pneumonia  rapid onset  high fever  pleuritic chest pain  herpes labialis Management CURB-65 criteria of severe pneumonia  Confusion (abbreviated mental test score 7 mmol/L  Respiratory rate >= 30 / min  BP: systolic 160/110 mm Hg or mean arterial pressure >125 mm Hg) is essential to reduce the risk of cerebrovascular accident. Treatment may also reduce the risk of further seizures.

o

 

Intravenous hydralazine or labetalol are the two most commonly used drugs. Both may precipitate fetal distress and therefore continuous fetal heart rate monitoring is necessary. Fluid therapy: o Close monitoring of fluid intake and urine output is mandatory. Delivery: o The definitive treatment of eclampsia is delivery. o However, it is unsafe to deliver the baby of an unstable mother even if there is fetal distress. Once seizures are controlled, severe hypertension treated and hypoxia corrected, delivery can be expedited. o Vaginal delivery should be considered but Caesarean section is likely to be required in primigravidae, well before term and with an unfavourable cervix. o After delivery, high-dependency care should be continued for a minimum of 24 hours

558. A 27yo woman had pre-eclampsia and was delivered by C-section. She is now complaining of RUQ pain different from wound pain. What inv will you do immediately? a. Coagulation profile b. LFT c. Liver US d. MRCP e. None b. LFT HELLP syndrome

Presentation       

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

Investigations    

There needs to be a high index of clinical suspicion in order to avoid diagnostic delay and improve outcome. Haemolysis with fragmented red cells on the blood film Raised LDH >600 IU/L with a raised bilirubin. Liver enzymes are raised with an AST or ALT level of >70 IU/L.

Definitive treatment of HELLP syndrome requires delivery of the fetus and is advised after 34 weeks of gestation if multisystem disease is present.

559. A 10yo girl has been referred for assessment of hearing as she is finding difficulty in hearing her teacher in the class. Her hearing tests show: BC normal, symmetrical AC threshold reduced bilaterally, weber test shows no lateralization. What is the single most likely dx? a. Chronic perforation of tympanic membrane b. Chronic secretory OM with effusion c. Congenital sensorineural deficit d. Otosclerosis e. Presbycusis b. Chronic secretory OM with effusion B/L conductive deafness glue ear/ OM e effusion Bc normal means no sn deafness .. there is conductive deafness .. otosclerosis has cd but it usually appears in 3rd decade of life n associated with tinnitus .. perforation on both sides is uncommon .. so we're left with csom with effusion which is most common cause of cd in school going age Glue Ear/ otitis media with effusion: recurrent ear infections, poor speech development, and failing performances at school, typically in children between the ages of 2 and decreasing with advancement of age.. .Causes conductive hearing loss. The clincher also is 'child finding difficulty in hearing in classroom/turning up the volume of Tv'

Chronic suppurative otitis media (CSOM) is a chronic inflammation of the middle ear and mastoid cavity. Clinical features are recurrent otorrhoea through a tympanic perforation, with conductive hearing loss of varying severity.    

CSOM presents with a chronically draining ear (>2 weeks), with a possible history of recurrent AOM, traumatic perforation, or insertion of grommets. The otorrhea should occur without otalgia or fever. Fever, vertigo and otalgia should prompt urgent referral to exclude intratemporal or intracranial complications. Hearing loss is common in the affected ear

Treatment options include:  grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months  adenoidectomy 560. A thin 18yo girl has bilateral parotid swelling with thickened calluses on the dorsum of her hand. What is the single most likely dx? a. Bulimia nervosa b. C1 esterase deficiency c. Crohn’s disease d. Mumps e. Sarcoidosis a. Bulimia nervosa Clincher for a is calluses over dorsum; (chronic inducing vomiting) ,parotid swelling

Thickened calluses at back of hand (Russel's sign -tooth mark on finger for induced vomiting) +parotid enlargment Bulimia

C1 esterase deficiency autosomal dominant condition associated with low plasma levels of the C1 inhibitor (C1-INH) protein. attacks may be proceeded by painful macular rash  painless, non-pruritic swelling of subcutaneous/submucosal tissues  may affect upper airways, skin or abdominal organs (can occasionally present as abdominal pain due to visceral oedema) Mumps can be asymptomatic.fever, headache, malaise, myalgia and anorexia, can precede parotitis.Parotitis is usually bilateral although it can be unilateral. Sarcoidosis  acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia  insidious: dyspnoea, non-productive cough, malaise, weight loss  skin: lupus pernio(chronic raised hardened, often purple lesion)  hypercalcaemia  Heerfordt's syndrome (inflammation of submaxillary/parotid glands with uveitis and facial nerve palsy) may accompany constitutional presentation.

Bulimia nervosa Presentation 



The history often dates back to adolescence. o Regular binge eating. o Attempts to counteract the binges - eg, vomiting, using laxatives, diuretics, dietary restriction and excessive exercise. o Preoccupation with weight, body shape, and body image. o low self-esteem, and self-harm. o Periods may be irregular. Physical examination is usually normal and is mainly aimed at excluding medical complications such as dehydration or dysrhythmias (induced by hypokalaemia). o Examination must include height and weight (and calculation of the BMI) and blood pressure. o Salivary glands (especially the parotid) may be swollen. o There may be oedema if there has been laxative or diuretic abuse. o Russell's sign may be present (calluses form on the back of the hand, caused by repeated abrasion against teeth during inducement of vomiting).

561. A 48yo presents with severe chest pain since the last 40mins. In the ED he is given oxygen, GTN, morphine. ECG=ST elevation. Bloods=increased troponin levels. What is the next step of management? a. Beta blockers b. Percutaneous angiography c. Anticoagulant & heparin d. Clopidogrel e. Aspirin

b. Percutaneous angiography Technically speaking trops are raised which means 2-3 hours have passed. PCI is indicated within 120 mins. It should be E PCI is more appropriate as the clinch is the time 40 mins that's why i went for B. I would go for B In case of ST elevation MI.. mx include aspirin at first usually given by GP or paramedic then morphine with metoclopramide. GTN not used routinely except in case of HTN or severe LVF. Next step is PCI if available within 120mins of hospital contact. If not available .fibrinolysis done if no CI and later proceed for PCI. As here time frame of 4o mins mentioned..i guess its PCI..B Its B. ST elevation MI means that the thrombus clot has already been stabilized and occluded the vessel...that is why we give t-PA (thrombolytic) in ST elevation MI only... aim is to break down the thrombus, not stop it from forming...aspirin only stops it from forming it doesn't break it down... smile emoticon also raised troponin levels mean that the patient has a previous infarct at most 10 days before (since it raised in only 40 minutes, not 4 hours), having previous infarct means has 2 or 3 vessel disease and not 1 vessel disease, he is high risk patient and should have angioplasty as soon as possible...answer is B, angiography is done right before angioplasty

Acute Myocardial Infarction

Pre-hospital management first line management is MONA (Morphine, O2, Nitrates and Aspirin) Sublingual glyceryl trinitrate and intravenous morphine + metoclopramide should be given to help relieve the symptoms. Aspirin 300mg should be given to all patients (unless contraindicated) Pre-hospital thrombolysis is indicated if the time from the initial call to arrival at hospital is likely to be over 30 minutes.

Primary percutaneous coronary intervention (PCI) Door (or diagnosis) to treatment time should be less than 90 minutes, or less than 60 minutes if the hospital is PCI ready and symptoms started within 120 minutes If they cannot be transferred to a larger hospital for PCI within 120 minutes then fibrinolysis should be given. If the patient's ECG taken 90 minutes after fibrinolysis failed to show resolution of the ST elevation then they would then require transfer for PCI. PCI should be considered if there is an ST elevation acute coronary syndrome, if symptoms started up to 12 hours previously

562. A 34yo female presents with a foul smelling discharge. What set of organisms are we looking for to be treated here? a. Chlamydia, gonorrhea b. Chlamydia, gardenella c. Chlamydia, gonorrhea, gardenella d. Gonorrhea, gardenella e. Gardenella only e. Gardenella only

Chlamydia is usually asymptomatic (no odour) and generally goes with gonorrhea. BV will give the grey fishsmelling discharge Bacterial vaginosis and Trichomonas vaginalis give foul smelling discharge. In BV its grey white fishy and in TV it can be greenish frothy fihy alongwith vulvovginitis i-e strawberry cervix. The discharge of Chlamydia and Gonorrhea is not foul smelling but gives dysuria.

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present  thin, white homogenous discharge  clue cells on microscopy: stippled vaginal epithelial cells  vaginal pH > 4.5  positive whiff test (addition of potassium hydroxide results in fishy odour) Management  oral metronidazole for 5-7 days

563. A 6wk formula fed baby boy is found at the child health surveillance to be deeply jaundiced. His weight gain is poor and his stools are pale. What is the most likely dx? a. Galactosemia b. Biliary atresia c. G6PD deficiency d. Rh incompatibility e. Congenital viral infection b. Biliary atresia pale stools , dark urine- biliary atresia pale stools, straw urine - galactosemia galactosemia presents with vomitting,diarrhea,failure to thrive and jaundice...progressive n deep jaundice is biliary atresia

Biliary atresia presents shortly after birth, with persistent jaundice, pale stools and dark urine. All term infants who remain jaundiced after 14 days (and preterm infants after 21 days) should be investigated. Galactosemia There is often feeding difficulty, with vomiting and failure to gain weight, with poor growth in the first few weeks of life. G6PD deficiency  neonatal jaundice is often seen  intravascular haemolysis  gallstones are common  splenomegaly may be present  Heinz bodies on blood films

564. A 45yo man with colon cancer now develops increased thirst, increased frequency in urination and weight loss. His fasting blood glucose=9mmol/L. what is the most appropriate management? a. Oral hypoglycemic b. Insulin long acting c. Short acting insulin before meal d. IV insulin e. Subcutaneous insulin a. Oral hypoglycemic colon cancer is assoc with hyperinsulinemia or insulin resistance..so oral hypoglycemics preferred because oral hypoglycemic (metformin) has anticancerogenic effect. A.. first line treatment dont get confused by colon cancer.. Metformin is the first drug of choice for the management of type 2 diabetes. It has two main antidiabetic mechanisms of action, both of which have also been implicated as anticarcinogenic mechanisms. Firstly, metformin inhibits hepatic glucose production through an LKB1/AMP-activated protein kinase–mediated mechanism which has been shown to adversely affect the survival of cancer cell lines. Secondly, metformin improves insulin sensitivity in peripheral tissues reducing hyperinsulinemia. Insulin resistance and hyperinsulinemia have been associated with increased risk of several types of neoplasm and specifically with colorectal cancer.

565. A 34yo man from Zimbabwe is admitted with abdominal pain to the ED. An AXR reveals bladder calcification. What is the most likely cause? a. Schistosoma mansoni b. Sarcoidosis c. Leishmaniasis d. TB e. Schistosoma haematobium e. Schistosoma haematobium Schistosoma Hematobium (Bilhaarziasis). CA urinary bladder and vesicolithiasis are the two main concern here

S. haematobium causes urinary schistosomiasis, and is the most prevalent and widespread species in Africa and the Middle East. Schistosomiasis is associated with anaemia, chronic pain, diarrhoea, exercise intolerance, and malnutrition. The first sign may be swimmer's itch  Fever.  Hepatosplenomegaly.  Right upper quadrant pain or tenderness.  Urticaria may be seen occasionally.  Lymphadenopathy. Praziquantel is the drug of choice Oxamniquine is the only alternative Complications:  renal stones  increased risk of squamous cell carcinoma of bladder that has been noticed especially in Egypt. It is possible that the infestation and the carcinogens in tobacco smoke have a synergistic effect.

   

Hydronephrosis renal failure may occur iron-deficiency anaemia Portal hypertension

566. A 6yo came with full thickness burn. He is crying continuously. What is the next step of management? a. Refer to burn unit b. IV fluid stat c. Antibiotic d. Analgesia e. Dressing d. Analgesia In NHS,, making comfortable to patient is vital. Here question ask for initial management, hence analgesia is the most here then after treat accordingly, either refer to burn unit or give if fluids using parklands. D. Then iv fluids then refer to burn unit.

Referral to secondary care  all deep dermal and full-thickness burns.  superficial dermal burns of more than 10% TBSA in adults, or more than 5% TBSA in children  superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck  any inhalation injury  any electrical or chemical burn injury  suspicion of non-accidental injury Management of burns  initial first aid as above  review referral criteria to ensure can be managed in primary care  superficial epidermal: symptomatic relief - analgesia, emollients etc  superficial dermal: cleanse wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours 567. A 78yo nursing home resident is revived due to the development of an intensely itchy rash. Exam: white linear lesions are seen on the wrists and elbows and red papules are present on the penis. What is the most appropriate management? a. Topical permethrin b. Referral to GUM clinic c. Topical betnovate d. Topical ketoconazole e. Topical selenium sulfide hyoscine a. Topical permethrin

Red papule on penis typical with wrist and elbow lesion goes with Scabies, topical permethrin once wk and repeat if symptoms remain.

white linear lesions Features  widespread pruritus  linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist  Nodules may develop. These occur particularly at the elbows, anterior axillary folds, penis, and scrotum.  in infants the face and scalp may also be affected  secondary features are seen due to scratching: excoriation, infection Management  permethrin 5% is first-line  malathion 0.5% is second-line  give appropriate guidance on use  pruritus persists for up to 4-6 weeks post eradication

568. A 4yo has earache and fever. Has taken paracetamol several times. Now it’s noticed that he increases the TV volume. His preschool hearing test shows symmetric loss of 40db. What is the most likely dx? a. OM with effusion b. Otitis externa c. Cholesteatoma d. CSOM e. Tonsillitis a. OM with effusion see Q. 559 569. A pt presents with gradual onset of headache, neck stiffness, photophobia and fluctuating LOC. CSF shows lymphocytosis but no organism on gram stain. CT brain is normal. What is the single most likely dx? a. Hairy leukoplakia b. TB c. CMV infection d. Candida infection e. Cryptococcal infection b. TB TB as there is lymphocytosis and no organism on gram staining Zn staining or AFB can detect mycobacterium TB

Viral meningitis may be clinically indistinguishable from bacterial meningitis but features may be more mild and complications (eg, focal neurological deficits) less frequent. Any person presenting with suspected meningitis should therefore be managed as having bacterial meningitis until proved otherwise.

classic triad of fever, neck stiffness and a change in mental status was present in only 44% of adults presenting with community-acquired acute bacterial meningitis. However, 95% had at least two of the four symptoms of headache, fever, neck stiffness and altered mental status. Most patients with viral meningitis present with subacute neurological symptoms developing over 1-7 days. Chronic symptoms lasting longer than one week suggest meningitis caused by some viruses as well as TB, syphilis or fungi.

Bacterial

Viral

Tuberculous

Appearance

Cloudy

Clear/cloudy

Slight cloudy, fibrin web

Glucose

Low (< 1/2 plasma)

60-80% of plasma glucose*

Low (< 1/2 plasma)

Protein

High (> 1 g/l)

Normal/raised

High (> 1 g/l)

White cells

10 - 5,000 polymorphs/mm�

15 - 1,000 lymphocytes/mm�

10 - 1,000 lymphocytes/mm�

570. An 18m boy has been brought to the ED because he has been refusing to move his left arm and crying more than usual for the past 24h. He has recently been looked after by his mother’s new bf while she attended college. Assessment shows multiple bruises and a fx of the left humerus which is put in plaster. What is the single most appropriate next step? a. Admit under care of pediatrician b. Discharge with painkillers c. Follow up in fx clinic d. Follow up in pediatric OPD e. Follow up with GP a. Admit under care of pediatrician Non accidental injury The most common manifestation of abuse is bruising An estimated 15-25 % of pediatric burns are the result of abuse. Fractures are the second most common manifestation of child abuse after soft tissue injuries. Any fracture in a young child should be concerning, especially if the child is not ambulating. Abusive head trauma, also known as shaken baby syndrome, is the most common cause of child abuse death, usually occurring during the first year of life.

571. A 74yo female presents with headache and neck stiffness to the ED. Following a LP the pt was started on IV ceftriaxone. CSF culture = listeria monocytogenes. What is the appropriate tx? a. Add IV amoxicillin b. Change to IV amoxicillin + gentamicin c. Add IV ciprofloxacin d. Add IV co-amoxiclav e. Continue IV ceftriaxone as mono-therapy b. Change to IV amoxicillin + gentamicin Meningitis caused by meningococci  Intravenous ceftriaxone for at least seven days is usually used..  Prevention of secondary case of meningococcal meningitis is usually with rifampicin or ciprofloxacin. Meningitis caused by pneumococci Vancomycin and a third-generation cephalosporin (either cefotaxime or ceftriaxone)  Benzylpenicillin may be given if the organism is penicillin-sensitive but penicillin resistance is becoming an increasing problem. Meningitis caused by H. influenzae type b  Children aged 3 months and older and young people - intravenous ceftriaxone for 10 days. Meningitis caused by group B streptococci  This mainly occurs in babies between the ages of 7-90 days. Intravenous cefotaxime for at least 14 days should be given. Meningitis caused by listeriosis  For children under the age of 3 months, intravenous amoxicillin or ampicillin for 21 days in total, plus gentamicin for at least the first seven days.

572. A pt presents with fever, dry cough and breathlessness. He is tachypneic but chest is clear. Oxygen saturation is normal at rest but drops on exercise. What is the single most likely dx? a. CMV infection b. Candida infection c. Pneumocystis carinii infection d. Cryptococcal infection e. Toxoplasma abscess c. Pneumocystis carinii infection This kind of history about oxygen desaturation on exercise is typical for PCP. Dry cough along with that supports that. patient is immunocompromised. Mostly in HIV patients we see that pt becomes breathless after a walk or exercise. Also fever with dry cough is there. Most likely pathogen is PCP. CMV affects retina n brain Toxoplasmosis..brain Candida. .mouth and esophagus Cryptococcus..meningitis

Whilst the organism Pneumocystis carinii is now referred to as Pneumocystis jiroveci, the term Pneumocystis carinii pneumonia (PCP) is still in common use

PCP is the most common opportunistic infection in AIDS all patients with a CD4 count < 200/mm³ should receive PCP prophylaxis Features: dyspnoea dry cough fever very few chest signs Pneumothorax is a common complication of PCP. Extrapulmonary manifestations are rare (1-2% of cases), may cause hepatosplenomegaly lymphadenopathy choroid lesions Investigation CXR: typically shows bilateral interstitial pulmonary infiltrates but can present with other x-ray findings e.g. lobar consolidation. May be normal exercise-induced desaturation sputum often fails to show PCP, bronchoalveolar lavage (BAL) often needed to demonstrate PCP (silver stain shows characteristic cysts) Management co-trimoxazole IV pentamidine in severe cases steroids if hypoxic (if pO2 < 9.3kPa then steroids reduce risk of respiratory failure by 50% and death by a third)

573. A 14yo boy fell and hit his head in the playground school. He didn’t lose consciousness. He has swelling and tenderness of the right cheek with a subconjuctival hemorrhage on his right eye. What is the most appropriate initial inv? a. CT brain b. EEG c. MRI d. Skull XR e. Facial XR e. Facial XR there's no indication of CT scan here- he is conscious and has not vomited

The difference between Skull and facial x ray is view. Skull PA view is done in prone position for seeing Skull bones. Facial is simply reverse i.e AP view done in supine position and gives more clear view of facial bones. Suspected injury to facial bones is a

CONTRAINDICATION for PA view as patient cannot be asked to lie down in prone position/ or to lean forward with face down. A facial or sinus X-ray may be done to:  Find problems of the sinuses of the face and nose, such as sinusitisor abnormal growths (polyps or tumors).  Find fractures of the facial bones and nose.  Check the bones around the eye (orbital cavity).  Check the sinuses before surgery.  Check for metal objects around the eyes before a magnetic resonance imaging (MRI) test.  Look for the cause of pain in the face. 574. A 15m child is due for his MMR vaccine. There is a fam hx of egg allergy. He is febrile with acute OM. What is the single most appropriate action? a. Defer immunization for 2wks b. Don’t give vaccine c. Give half dose of vaccine d. Give paracetamol with future doses of the same vaccine e. Proceed with standard immunization schedule a. Defer immunization for 2wks egg allergy is not contraindication for MMR ...therefore if pt is febrile then wait for the next two weeks until he is afebrile and give the normal dose of immunization

Children in the UK receive two doses of the Measles, Mumps and Rubella (MMR) vaccine before entry to primary school. This currently occurs at 12-15 months and 3-4 years as part of the routine immunisation schedule Contraindications to MMR  severe immunosuppression  Acute illness  allergy to neomycin  children who have received another live vaccine by injection within 4 weeks  pregnancy should be avoided for at least 1 month following vaccination  immunoglobulin therapy within the past 3 months (there may be no immune response to the measles vaccine if antibodies are present) Adverse effects  malaise, fever and rash may occur after the first dose of MMR. This typically occurs after 5-10 days and lasts around 2-3 days Note that the following are NOT contra-indications:  Family history of any adverse reactions following immunisation.  Previous history of infection with pertussis, measles, rubella or mumps.  Contact with an infectious disease.  Asthma, eczema, hay fever or rhinitis.  Treatment with antibiotics or locally acting (eg, topical or inhaled) steroids.  The child's mother being pregnant.  The child being breast-fed.  History of jaundice after birth.  Being over the age recommended in the immunisation schedule.

   

'Replacement' corticosteroids. Allergy to eggs Neurological conditions are not a contra-indication although, if the condition is poorly controlled (eg, epilepsy), immunisation should be deferred. MMR should ideally be given at the same time as other live vaccines, such as BCG. However, if live vaccines cannot be administered simultaneously, a fourweek interval is recommended.

575. A 33yo lady with Hodgkin’s lymphoma presents with temp=40C, left sided abdominal pain and lymphadenitis. Blood was taken for test. What will you do next? a. Wait for blood test b. Start broad spectrum IV antibiotics c. Oral antibiotics d. CBC e. Monitor pyrexia b. Start broad spectrum IV antibiotics the patient has an immune compromising disease ,you cant wait until you get lab results or give oral antibiotics, you shuld give systemic antibiotic to treat any possible infectons Chemotherapy causes imunosuppresion so increased chance of infections,as in this case temp 40,and lymphadenitis so broad spectrum antibiotics

576. A 40yo man with marked weight loss over the preceding 6m has bilateral white, vertically corrugated lesion on the lateral surfaces of the tongue. What is the single most likely dx? a. C1 esterase deficiency b. Crohns disease c. HIV disease d. Sarcoidosis e. Sjogren’s syndrome c. HIV disease

'Hairy' leukoplakia This is associated with Epstein-Barr virus (EBV) and occurs mostly in people with HIV, both immunocompromised and immunocompetent. The natural history of hairy leukoplakia is variable. Lesions may frequently appear and disappear spontaneously. Hairy leukoplakia is often asymptomatic and many patients are unaware of its presence. Some patients with hairy leukoplakia do experience symptoms including mild pain, dysaesthesia, alteration of taste and the psychological impact of its unsightly cosmetic appearance.  Systemic antiviral therapy, which usually achieves resolution of the lesion within 1-2 weeks of therapy.  Topical therapy with podophyllin resin 25% solution, which usually achieves resolution after 1-2 treatment applications.  Topical therapy with retinoic acid (tretinoin), which has been reported to resolve hairy leukoplakia.  Ablative therapy, which can also be considered for small hairy leukoplakia lesions. Cryotherapy has been reported as successful but is not widely used.

577. A 3m baby was miserable and cried for 2h following his 1st routine immunization with DTP, HiB and meningitis. What is the single most appropriate action? a. Defer immunization for 2wks b. Don’t give vaccine c. Give half dose of vaccine d. Give paracetamol with future doses of the same vaccine e. Proceed with standard immunization schedule e. Proceed with standard immunization schedule General contraindications to immunisation  confirmed anaphylactic reaction to a previous dose of a vaccine containing the same antigens  confirmed anaphylactic reaction to another component contained in the relevant vaccine (e.g. egg protein) Situations where vaccines should be delayed  febrile illness/intercurrent infection Contraindications to live vaccines  pregnancy  immunosuppression Specific vaccines  DTP: vaccination should be deferred in children with an evolving or unstable neurological condition Not contraindications to immunisation  asthma or eczema  history of seizures (if associated with fever then advice should be given regarding antipyretics)  breastfed child  previous history of natural pertussis, measles, mumps or rubella infection  history of neonatal jaundice  family history of autism  neurological conditions such as Down's or cerebral palsy  low birth weight or prematurity  patients on replacement steroids e.g. (CAH) 578. A 65yo man with HTN develops gingival hyperplasia. What is the single most likely dx? a. ACEi b. Beta blockers c. Crohns disease d. Nifedipine e. Sarcoidosis d. Nifedipine

Side effect of CCB also due to cyclosporin, phenytoin, AML.

579. A 65yo woman is undergoing coronary angiography. What measure will protect her kidneys from contrast? a. Furosemide b. Dextrose c. 0.45% saline d. 0.9% saline d. 0.9% saline post contrast nephropathy due to contrast induced or cholesterol embolisation. adequately hydrated pt prior to procedure reduces the complications.

580. An 83yo woman who is a resident in a nursing home is admitted to hospital with a 4d hx of diarrhea. She has had no weight loss or change in appetite. She has been on analgesics for 3wks for her back pain. She is in obvious discomfort. On rectal exam: fecal impaction. What is the single most appropriate immediate management? a. Codeine phosphate for pain relief b. High fiber diet c. Oral laxative d. Phosphate enema e. Urinary catheterization d. Phosphate enema Codiene Laxative Fiber will increase gut motility Where as Phosphate enema will act locally Helpful in clearing Fecal impaction too

Bulk producers:  Increase faecal mass, which stimulates peristalsis.  They must be taken with plenty of fluid  Contra-indications: difficulty in swallowing; intestinal obstruction; colonic atony; faecal impaction. Stool softeners:  Side-effects can include: anal seepage, lipoid pneumonia, malabsorption of fatsoluble vitamins Stimulants:  Increase intestinal motility and should not be used in intestinal obstruction.  Prolonged use should be avoided, as it may cause colonic atony and hypokalaemia (but there are no good, long-term follow-up studies). Osmotic agents:

 Retain fluid in the bowel. Enemas and suppositories - useful additional treatment.

581. A 26yo woman being treated for a carcinoma of the bronchus with steroids presents with vomiting, abdominal pain and sudden falls in the morning. What is the most specific cause for her symptoms? a. Steroid side effects b. Postural hypotension c. Adrenal insufficiency d. Conn’s disease e. Cushing’s disease c. Adrenal insufficiency Streoids causing suppression of acth. In turn causing mineralcorticoid deficiency so adrenal insufficiency high dose sterods suppresss adrenals...cause hyponatraemia..hypotension..hypoglycaemia..hyperkalaemia Exogenous steroids can suppress the pituitary adrenal axis leading to adrenal insufficiency. Symptoms include weakness, anorexia, dizzy, Faints,nausea,vomiting,abd pain Steroid does not cause vomit or falls so A can be excluded. Postural hypotension does not cause abd. Pain so B excluded . Conn's syndrome is hyperaldosteronism which would cause hypernatremia and hypokalemia and hypertension. So D excluded Cushing causes hypertension so E Excluded C is the right answer cuz adrenal insufficiency due to prolonged steroid intake would cause addison syndrome which is hyponatremia hypotension abdominal pain .

582. A 78yo woman presents with unilateral headache and pain on chewing. ESR=70mm/hr. She is on oral steroids. What is the appropriate additional tx? a. Bisphosphonates b. HRT c. ACEi d. IFN e. IV steroids a. Bisphosphonates She getting treated for temporal arteritis, therefore steroid will cause osteoporosis. So additional therapy is A It appears GCA. We first do ESR and start steroids. If symptoms are not resolved then we up the dose of steroids. Additional treatment would be bisphosphonate to reduce risk of osteoporosis.

Bisphosphonates Bisphosphonates decrease demineralisation in bone. They inhibit osteoclasts. Clinical uses  prevention and treatment of osteoporosis  hypercalcaemia

 

Paget's disease pain from bone metatases

Adverse effects  oesophagitis, oesophageal ulcers  osteonecrosis of the jaw  increased risk of atypical stress fractures of the proximal femoral shaft. 583. A 30yo man is suffering from fever, rash and photophobia. Doctors are suspecting he is suffering from meningitis. Which is the best medication for this condition? a. Ampicilling b. Cefotaxime c. Tetracycline d. Acyclovir e. Dexamethasone b. Cefotaxime Initial 'blind' therapy  Children 3 months and older and young people should be given intravenous ceftriaxone as empirical treatment before identification of the causative organism. If calcium-containing infusions are required at the same time, cefotaxime is preferable. 584. A 15yo girl was admitted with anemia, chest infection and thrombocytopenia. She was treated and her symptoms had regressed. She was brought again with fever and the same symptoms a few days later. She also seems to have features of meningitis. What is the most likely dx? a. AML b. ALL c. Aplastic anemia d. CML e. CLL b. ALL Young, anemia, thrombocytopenia, recurrent infectionswith/without cns involvement and testicular swelling... always go for All..if not treated completed can appear again...in aplastic anemia the cell count of all cell types is low with a mention of some predisposing factor..like drugs, radiation or a dry tap of bone marrow. Patients with ALL frequently have meningeal leukaemia at the time of relapse (50-75% at one year in the absence of CNS prophylaxis) and a few have meningeal disease at diagnosis ( 80% ( Restrictive lung disease) If FEV1/FVC < 80% ( obstructive lung disease) If reversible > 12% after brochochodilator ( reversibilty test) its asthma otherwise copd

Spirometry With older children with an intermediate probability of asthma, diagnostic tests such as PEFR and forced expiratory volume in one second (FEV1) can provide objective measures of airways obstruction but these may be normal between episodes of bronchospasm and provide poor discrimination with other conditions that also cause airways obstruction.Spirometry is usually possible from about 5 years old, although there

is wide variation, and is dependent on the child's co-operation and comprehension of the task. Where there is evidence of airways obstruction, looking for changes in PEFR or FEV1 10 minutes after the use of a bronchodilator (reversibility usually taken as >12% subsequent improvement in lung function). Also, look for response to a treatment trial over a defined time period, as this adds further weight to the diagnosis of asthma.

615. A 45yo man had recently started taking anti-HTN therapy. 6m later his RBS=14mmol/l. Which single drug is most likely to have caused this? a. Amlodipine b. Bendroflumethiazide c. Doxazosin d. Losartan e. Ramipril b. Bendroflumethiazide Pt was not diabetic, but he develops DM after taking medication...Thiazide and B-blockers increases risk of DM OHCM-134 The connection between diuretics and hyperglycemia involves intracellular K+ levels. Intracellular K+ is involved in the secretion of a lot of hormones...including insulin. Some diuretics cause hypokalemia, (decrease inK+) like thiazides. This inhibits insulin secretion and can lead to hyperglycemia.

Common adverse effects  dehydration  postural hypotension  hyponatraemia, hypokalaemia, hypercalcaemia  gout  impaired glucose tolerance  impotence Amlodipine Flushing, headache, ankle swelling Doxazosin postural hypotension, drowsiness, dyspnoea, cough Losartan Like ACE inhibitors they should be used with caution in patients with renovascular disease. Side-effects include hypotension and hyperkalaemia. Ramipril cough, angioedema, hyperkalaemia, first-dose hypotension.

616. A 27yo waitress has pelvic pain, dysmenorrhea and increasingly heavy periods. She also complains of dyspareunia. There is generalized pelvic tenderness without peritonism. Pelvic US is normal. What is the most likely dx? a. Endometriosis b. Uterine fibroid c. Pelvic congestion syndrome d. PID e. Tubal pregnancy c. Pelvic congestion syndrome (or A?)

Here, Profession , Waitress, is the clue , prolonged standing is the risk factor for pelvic congestion syndrome! It is pelvic venous congestion, dilated pelvic veins cause cyclic dragging pain, worse menstrually and after prolonged standing,walking. Dyspareunia. Air hostess, waiters. Also pelvis us free suggest absent of endometriosis plus waitress !! But if didn't mentioned pelvic us it will be typically endometriosis

Ultrasound examination may be useful (US). This imaging test uses sound waves to detect the abnormal veins. It is good at showing the blood flow through the veins and is non-invasive. However, sometimes the veins in the pelvis are difficult to see through the abdomen, therefore a special ultrasound where a small probe is placed into the vagina to see the veins, called a transvaginal ultrasound may be required. Duplex ultrasound scanning =golden standard diagnosis

617. A 14yo girl is clinically obese. She has not started her periods yet and has severe acne. Among her inv, a high insulin level is found. What is the most probable dx? a. Cushing’s syndrome b. Grave’s disease c. Acquired hypothyroidism d. PCOS e. Addison’s disease d. PCOS 14 yr...primary amenorrhea, severe acne ,high insulin. ...All favours PCOS. obesity hyperandrogenism(acne) hyperinsulinemia and amenorrhea P' AM + Insulin Resistance. Both Cushing n PCOS have hyperglycaemia but in Cushing's $, it's due to high glucocorticoids lvl, not coz of Insulin Resistance.

Features  subfertility and infertility  menstrual disturbances: oligomenorrhea and amenorrhoea  hirsutism, acne (due to hyperandrogenism)  obesity  acanthosis nigricans (due to insulin resistance) Investigations  pelvic ultrasound: multiple cysts on the ovaries  FSH, LH, prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes  check for impaired glucose tolerance 618. An 18yo girl with primary amenorrhea complains of severe abdominal pain every 48weeks which is now getting worse. Exam: lower abdominal mass is felt. What is the most probable dx? a. Ectopic pregnancy b. Ovarian carcinoma c. Hematometrium

d. Biliary colic e. Renal carcinoma c. Hematometrium hematometrium, may be septate vagina She has cyclical bleed every month as scenario tells. Examination shows lower abdmonal mass likely blood accumulation everytime. Cause is likely imperforate hymen or transvaginal septum

619. A 14yo boy with asthma suddenly developed chest pain and increasing breathlessness during a game of football. When seen in the ED he was not cyanosed. He has reduced breath sounds on the right side. His oxygen saturation is 94% on air. What is the single most appropriate inv? a. Capillary blood gases b. CXR c. CT chest d. Exercise challenge e. MRI chest b. CXR spontaneous pneumothorax young pt, sudden cp, sob, decreased breath sounds -> spont pneumothorax on rt. side ... CXR- if >2cm...do aspiration

  

if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered otherwise aspiration should be attempted if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted

620. A 36yo woman was recently admitted to a psychiatric ward. She believes that the staff and other pts know exactly what she is thinking all the time. What is the most likely symptom this pt is suffering from? a. Thought insertion b. Thought withdrawal c. Thought block d. Though broadcasting e. Hallucination d. Though broadcasting Thought insertion, removal or interruption - delusions about external control of thought Thought broadcasting - the delusion that others can hear one's thoughts

thought withdrawal is the delusional belief that thoughts have been 'taken out' of the patient's mind, and the patient has no power over this. It often accompanies thought blocking. Thought blocking is a thought condition usually caused by a mental health condition such as schizophrenia. During thought blocking, a person stops speaking suddenly and without explanation in the middle of a sentence. hallucination is a perception in the absence of external stimulus that has qualities of real perception. 621. A 60yo woman is admitted to the hospital after a fall. She is noted to have poor eye contact. When asked how she is feeling, she admits to feeling low in mood and losing enjoyment in all her usual hobbies. She has also found it difficult to concentrate, feels that she is not good at anything, feels guilty over minor issues and feels very negative about the future. What is the most likely dx? a. Mild depression b. Moderate depression c. Severe depression d. Psychosis e. Seasonal depression a. Mild depression NICE use the DSM-IV criteria to grade depression:  1. Depressed mood most of the day, nearly every day  2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day  3. Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day  4. Insomnia or hypersomnia nearly every day  5. Psychomotor agitation or retardation nearly every day  6. Fatigue or loss of energy nearly every day  7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day  8. Diminished ability to think or concentrate, or indecisiveness nearly every day  9. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide Subthreshold depressive symptoms Mild depression

Fewer than 5 symptoms Few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment

Moderate depression

Symptoms or functional impairment are between 'mild' and 'severe'

Severe depression

Most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms

622. A 70yo woman lives in a nursing home following a stroke has developed reddish scaly rash on her trunk. She has many scratch marks on her limbs and trunk with scaling lesions on her hands and feet. What is the single most appropriate initial tx? a. Aqueous cream b. Chlorphenaramine c. Coal tar d. 1% hydrocortisone ointment e. Permethrin e. Permethrin Nursing home, multiple scratch marks :scabies

Features  widespread pruritus  linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist  Nodules may develop. These occur particularly at the elbows, anterior axillary folds, penis, and scrotum.  in infants the face and scalp may also be affected  secondary features are seen due to scratching: excoriation, infection Management  permethrin 5% is first-line  malathion 0.5% is second-line  give appropriate guidance on use (see below)  pruritus persists for up to 4-6 weeks post eradication 623. A 16yo boy following a RTA was brought to the ED with a swelling and deformity in his right thigh. Exam: airway is patent and is found to have a pulseless leg. Which structure is involved in this fx? a. Femoral artery b. Posterior tibial artery c. Common peroneal nerve d. Dorsalis pedis a. Femoral artery

624. A man sat cross-legged for about 30mins. After this he was unable to dorsiflex his left foot and had loss of sensation in the web space between the big toe and the 2nd toe. He also has sensory loss on the same side of the foot after 2h. Which of the following was affected? a. Femoral nerve b. Sural nerve c. Peroneal nerve d. Sciatic nerve c. Peroneal nerve Chronic peroneal neuropathy can result from, among other conditions, bed rest of long duration, hyperflexion of the knee, peripheral neuropathy, pressure in obstetric stirrups, and conditioning in ballet dancers. The most common cause is habitual leg crossing that compresses the common peroneal nerve as it crosses around the head of the fibula.Transient trauma to the nerve can result from peroneal strike. Damage to this nerve typically results in foot drop, where dorsiflexion of the foot is compromised and the foot drags (the toe points) during walking; and in sensory loss to the dorsal surface of the foot and portions of the anterior, lower-lateral leg.

625. A 25yo woman is presenting with diarrhea and abdominal bloating over the last 4m. Exam: she has blistering rash over her elbows. Biochemistry: low serum albumin, calcium and folate conc. On jejunal biopsy, there is shortening of the villi and lymphocytosis. What is the most likely dx? a. Celiac disease b. Whipple’s disease c. Crohn’s disease d. Tropical sprue e. Giardiasis f. Cystic fibrosis a. Celiac disease Patient with chronic diarrhoea, villus atrophy, lymphocytosis, Dermatitis herpetiformis. All with Celiac disease. Coeliac Disease ( Endoscopic small bowel biopsy- subtotal villus atrophy and lymphocytic infiltration ) The blistering rash is dermatitis herpetiformis..associated with coeliac

Coeliac disease is caused by sensitivity to the protein gluten. Repeated exposure leads to villous atrophy which in turn causes malabsorption. Conditions associated with coeliac disease include dermatitis herpetiformis (a vesicular, pruritic skin eruption) and autoimmune disorders (type 1 diabetes mellitus and autoimmune hepatitis). Signs and symptoms       

Chronic or intermittent diarrhoea Failure to thrive or faltering growth (in children) Persistent or unexplained gastrointestinal symptoms including nausea and vomiting Prolonged fatigue ('tired all the time') Recurrent abdominal pain, cramping or distension Sudden or unexpected weight loss Unexplained iron-deficiency anaemia, or other unspecified anaemia

Conditions     

Autoimmune thyroid disease Dermatitis herpetiformis Irritable bowel syndrome Type 1 diabetes First-degree relatives (parents, siblings or children) with coeliac disease

Complications  anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)  hyposplenism  osteoporosis, osteomalacia  lactose intolerance  enteropathy-associated T-cell lymphoma of small intestine  subfertility, unfavourable pregnancy outcomes

Immunology  tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE  endomyseal antibody (IgA)  anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE  anti-casein antibodies are also found in some patients Jejunal biopsy  villous atrophy  crypt hyperplasia  increase in intraepithelial lymphocytes  lamina propria infiltration with lymphocytes Whipple’s disease diarrhea, steatorrhea, abdominal pain, weight loss, migratory arthropathy, fever, and neurological symptoms. duodenal endoscopy, which reveals PAS-positive macrophages 626. A 19yo man presents for the 1st time with a firm and unshakable belief that he is being followed by terrorists who are plotting against him. What is the single best term for this man’s condition? a. Delusion of persecution b. Delusion of grandeur c. Delusion of control d. Delusion of reference e. Delusion of nihilism a. Delusion of persecution most common types of delusions, centering around a person's fixed, false belief that others aim to obstruct, harm, or kill him/her. Delusion of grandeur fixed, false belief that one possesses superior qualities such as genius, fame, omnipotence, or wealth. Delusion of control false belief that another person, group of people, or external force controls one's general thoughts, feelings, impulses, or behavior. Delusion of reference A neutral event is believed to have a special and personal meaning. For example, a person with schizophrenia might believe a billboard or a celebrity is sending a message meant specifically for them. Delusion of nihilism the delusion that things (or everything, including the self) don't exist. a sense that everything is unreal. 627. A 19yo female is brought in by her parents. They are concerned about her BMI which is 12. She is satisfied with it. What is the next step? a. Psychiatric referral for admission b. Family counselling

c. Social service d. Start antidepo e. Medical admission e. Medical admission bmi s 12..so next step s medical admission.

The defining clinical features are:  Refusal to maintain a normal body weight for age and height.  Weight below 85% of predicted. This means in adults a body mass index (BMI) below 17.5 kg/m2.  Having a dread of gaining weight.  Disturbance in the way weight or shape is experienced, resulting in overevaluation of size.  Amenorrhoea for three months or longer  fatigue, hypothermia, hypotension, peripheral oedema, gaunt face, lanugo hair, scanty pubic hair, acrocyanosis (hands or feet are red or purple), and bradycardia  Enhanced weight loss by over-exercise, diuretics, laxatives and self-induced vomiting need for urgent referral and appropriate medical intervention      

Nutrition: BMI below 14; weight loss more than 0.5 kg per week. Circulation: systolic BP below 90; diastolic BP below 70; postural drop greater than 10 mm Hg. Squat test: unable to get up without using arms for balance or leverage. Core temperature below 35°C. Blood tests: low potassium, sodium, magnesium or phosphate. Raised urea or LFTs. Low albumin or glucose. ECG: pulse rate below 50; prolonged QT interval.

628. A lady who works at a nursing home presents with itching. Exam: linear tracks on the wrist. She says that 2d ago she had come in contact with a nursing home inmate with similar symptoms. What is the mechanism of itching? a. Infection b. Destruction of keratinocytes c. Allergic reaction d. Immunosuppression e. None c. Allergic reaction Scabies. pruritis due to allergic reaction. 629. A teacher had a respiratory infection for which she was prescribed antibiotics. After the antibiotic course when she rejoined school, she lost her voice completely. What is the single most appropriate dx? a. Recurrent laryngeal nerve palsy b. Angioedema c. Laryngeal obstruction by medication d. Laryngitis

e. Functional dysphonia/vocal cords e. Functional dysphonia/vocal cords Can't be recurrent laryngeal nerve because major reasons are it's either trauma via surgery for thyroid or any neck surgery, tumour of neck,tumour superior vena cava, tumour of mediastinal,metastasis etc. can't b angioedema because it presents acutely with in minutes and usually superficial ie visible sites though also involve deeper respiratory structures. Drug's notorious to cause angioedema are A.C.E.i and in rare cases A.R.B.s and very rarely antibiotics antifungals and can be any drug acute reaction. Can't be laryngeal obstruction because it will eventually block your respiratory intake ie breathing which this patient seems to having no problem with. Similarly Laryngitis is an infection for which doctors do prescribe antibiotics but main treatment is voice rest and gargles and further question says after use of antibiotics in laryngitis voice hoarseness or loss is pre treatment mostly. Antibiotics rarely cause voice loss. Where no organic cause is found - a diagnosis of exclusion. A common cause of hoarseness. There are various forms (below). Infections Acute laryngitis (common), often with upper respiratory infection. Usually viral (may have secondary infection with staphylococci or streptococci). Other infections - fungal or tuberculous. Benign laryngeal conditions Voice overuse - common. Benign lesions of the vocal cords - eg, nodules (singer's nodes), polyps and papillomas. 630. A 43yo lady is admitted with pyrexia, arthropathy, breathlessness and syncope. She was recently dx with pulmonary emboli. There is an early diastolic sound and a mid-diastolic rumble. Her JVP is elevated with prominent a-waves. What is the most likely cause? a. Mitral regurgitation b. Ventricular ectopics c. Pulmonary regurgitation d. Atrial myxoma e. Complete heart block d. Atrial myxoma Atrial Myxoma presents mostly with signs and symptoms of mitral stenosis if in left atrium, so there's mid diastolic murmur and the other early diastolic sound is called tumour plop which is characteristic to the impact of the tumour on the mitral valve in diastole as the valves in systole were closed and holding the

tumour above but when they open the Myxoma falls on the valve producing early diastolic plop.On top we have extra cardiac symptoms depending upon location,if myxoma obstructs the valve, then its diastolic rumble...if leaflets r damaged, then its a systolic rumble(due to regurgitation)

Jugular venous pressure may be elevated, and a prominent A wave may be present. A loud S1 is caused by a delay in mitral valve closure due to the prolapse of the tumor into the mitral valve orifice (mimicking mitral stenosis). P2 may be delayed. Its intensity may be normal or increased, depending on the presence of pulmonary hypertension. In many cases, an early diastolic sound, called a tumor plop, is heard. This sound is produced by the impact of the tumor against the endocardial wall or when its excursion is halted. An S3 or S4 may be audible. A diastolic atrial rumble may be heard if the tumor is obstructing the mitral valve. If there is valve damage from the tumor, mitral regurgitation may cause a systolic murmur at the apex. A right atrial tumor may cause a diastolic rumble or holosystolic murmur due to tricuspid regurgitation. General examination may reveal fever, cyanosis, digital clubbing, rash, or petechiae.

631. A 28yo man presents with a maculopapular rash over his trunk and palms. He also has numerous mouth ulcers. He had a penile ulcer which healed 2wks ago. What will you do to confirm the dx? a. PCR for treponemal and non-treponemal antibiodies b. Dark ground microscopy from mouth ulcer c. Blood culture for treponema d. Dengue fever a. PCR for treponemal and nontreponemal antibodies because it has now progressed to secondary syphilis and the investigation of choice is PCR Dark ground microscopy is done from the chancre fluid and not from mouth ulcers stage 1/ primary= dark field microscopy. 2= treponeme specific and non- antibodies, treponemes r seen in the lesions too. Late secondary= organisms can no longer be seen but the AB tests are still +. tertiary= look for FTA and TPHA antibodies in CSF. PCR is the best for confirmation of any diagnosis??

Management  benzylpenicillin  alternatives: doxycycline  the Jarisch-Herxheimer reaction is sometimes seen following treatment. Fever, rash, tachycardia after first dose of antibiotic. It is thought to be due to the release of endotoxins following bacterial death and typically occurs within a few hours of treatment.

632. A 34yo man complains of arthralgia, abdominal pain and vomiting, a facial rash that is worse in the summer and hematuria. Urea and creatinine are slightly elevated with urinalysis demonstrating red cell casts. PMH is remarkable for childhood eczema. Which inv is most likely to lead to a dx? a. US KUB b. Joint aspiration c. Auto antibodies d. IVU e. Renal biopsy c. Autoantibodies HSP mostly in children after a viral infection and with a palpable purpura on buttocks and extensor surfaces. Si can't be HSP. SLE yes I agree a lot of presentations going in favour of SLE. arthralgias rash photosensitivity renal involvement. I don't recall abdominal pain and vomiting in SLE. SLE - Facial Rash, worsen by sunlight, arthralgia, Nephritis, Other immune problems ( eczema )

General features  fatigue  fever  mouth ulcers  lymphadenopathy Skin  malar (butterfly) rash: spares nasolabial folds  discoid rash: scaly, erythematous, well demarcated rash in sun-exposed areas. Lesions may progress to become pigmented and hyperkeratotic before becoming atrophic  photosensitivity  Raynaud's phenomenon  livedo reticularis  non-scarring alopecia Musculoskeletal  arthralgia  non-erosive arthritis Cardiovascular  myocarditis Respiratory  pleurisy  fibrosing alveolitis Renal  

proteinuria glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)

Neuropsychiatric  anxiety and depression

 

psychosis seizures

Autoantibodies:  ANA: screening test with a sensitivity of 95% but not diagnostic in the absence of clinical features.  Anti-dsDNA: high specificity but sensitivity is only 70%. 633. A 56yo woman has had severe abdominal pain for 24h radiating to her back and is accompanied by nausea and vomiting. She appears to be tachycardic and in shock. She was found to have gallstones, 2yrs ago. What is the most likely inv to confirm dx? a. US abdomen b. LFT c. Serum lipase d. Angiography e. CT abdomen c. Serum lipase lipase is done for diagnosing pancreatiitis.... CT is done to find the complications of pancreatitis..

Serum amylase 3 or more times normal is the traditional way of diagnosing acute pancreatitis. However, lipase levels are more sensitive and more specific.

634. A 32yo female with axillary freckles and café au lait spots wants to know the cahnces of her child also having similar condition. a. 1:2 b. 1:4 c. No genetic link d. 1:16 e. Depends on the genetic make up of the partner a. 1:2 (or E)? neurofibromatosis..autosomal dominant..so 1:2 if her partner has also same condition than there 75 %chances while he is normal than 50 % chances we cant tell her for sure that there is 50 % of getting her baby affected when he husband is diseased. So i think option E is correct answer in such scenerio

635. A 40yo man has pain, redness and swelling over the nasal end of his right lower eyelid. The eye is watery with some purulent discharge. The redness extends on to the nasal peri-orbital area and mucoid discharge can be expressed from the lacrimal punctum. What is the single most appropriate clinical dx? a. Acute conjunctivitis b. Acute dacrocystitis c. Acut iritis d. Retrobulbar neuritis e. Scleritis b. Acute dacryocystitis Dacryocystitis is infection of the lacrimal sac Features  watering eye (epiphora)  swelling and erythema at the inner canthus of the eye Management is with systemic antibiotics. Intravenous antibiotics are indicated if there is associated periorbital cellulitis

636. A 60yo lady has severe chest pain. ECG shows changes of inferior wall MI. ECG also shows progressive prolongation of PR interval until a QRS complex is dropped. What is the most probable dx? a. Atrial fibrillation b. VT c. SVT d. Mobitz type I 2nd degree heart block e. Mobitz type II 2nd degree heart block d. Mobitz type I 2nd degree heart block First degree heart block  PR interval > 0.2 seconds Second degree heart block  type 1 (Mobitz I, Wenckebach): progressive prolongation of the PR interval until a dropped beat occurs  type 2 (Mobitz II): PR interval is constant but the P wave is often not followed by a QRS complex Third degree (complete) heart block  there is no association between the P waves and QRS complexes 637. A 52yo woman speaks rapidly without any pause and ignores interruptions. She doesn’t even pause to take enough breaths. What term best describes this kind of speech? a. Flight of ideas b. Broca’s aphasia c. Wernicke’s aphasia d. Pressure of speech e. Verbal dysphasia d. Pressure of speech Flight of ideas a nearly continuous flow of rapid speech that jumps from topic to topic Broca’s aphasia When a stroke injures the frontal regions of the left hemisphere, different kinds of language problems can occur. This part of the brain is important for putting words together to form complete sentences. Injury to the left frontal area can lead to what is called Broca’s aphasia. Wernicke’s aphasia People with serious comprehension difficulties have what is called Wernicke’s aphasia.

638. A 30yo woman has been feeling low and having difficulty in concentrating since her mother passed away 2m ago. She feels lethargic and tends to have breathlessness and tremors from time to time. What is the most likely dx? a. Adjustment disorder

b. PTSD c. Panic disorder d. GAD e. Bereavement a. Adjustment disorder Adjustment disorder is a short-term condition that occurs when a person has great difficulty coping with, or adjusting to, a particular source of stress, such as a major life change, loss, or event. Unlike major depression, however, an adjustment disorder doesn't involve as many of the physical and emotional symptoms of clinical depression (such as changes in sleep, appetite and energy) or high levels of severity (such as suicidal thinking or behavior). adj disorder starts within 3 m of the stress and does not last more than 6 m while bereavement starts w the stress and does not last more than 2 months It is not PTSD as in aetiology death of near one is not included and given case doesn't have the diagnostic feature of repeated memory flashbacks or dream. Panic disorder does not occur in response to any external or internal stress! So it is not panic disorder. Similarly GAD is chronic anxiety which is not directly related to any object or situation. Which also does not explain death as a point in its favour! Beyond 2 months bereavement is considered to be either pathological bereavement or major depression. So given time period of 2 months indicates it is no more normal bereavement. So by exclusion I think it is a case of adjustment disorder (of which death of near one is considered as an etiologic factor). Bereavement is the time spent adjusting to loss. It has four stages accepting that your loss really happened experiencing the pain that comes with grief trying to adjust to life without the person who died putting less emotional energy into your grief and finding a new place to put it i.e. moving on. Since this woman is not able to adjust to the loss and is having physical symptoms I think that's the reason it's adjustment disorder.

639. A 32yo man on psychiatric medications complains of inability to ejaculate. Which drug is most likely to cause these symptoms? a. Lithium b. Haloperidol c. Chlorpromazine d. Fluoxetine e. Clozapine d. Fluoxetine SSRI's ( fluoxetine ) cause sexual dysfunction

gastrointestinal symptoms are the most common side-effect

640. A 4yo boy is brought by his parents with complains of wetting his bed at night and whenever he gets excited. What would be the most appropriate management for this child? a. Desmopressin b. Oxybutynin c. Behavioural therapy d. Tamsulosin e. Restrict fluid intake c. Behavioural therapy Children below 7yrs : sleep alarms or behavioural therapy

Children above 7yrs : Desmopressin

Alarm training is a first-line treatment for nocturnal enuresis and is the most effective longterm strategy Desmopressin should be offered first-line to children aged over 7 where rapid control is needed or an alarm is inappropriate. Otherwise it should be used second-line after an alarm has been tried. It may be used in children aged 5-7 if treatment is required under the same circumstances.

641. A 34yo DM pt is undergoing contrast radiography. What measure should be taken to prevent renal damage with contrast dye? a. Reduce contrast dye b. Plenty of fluids c. NSAIDS d. ACEi e. IV dextrose b. Plenty of fluids 642. A 75yo woman presents to the breast clinic having noticed that she has had a blood stained discharge from the left nipple, together with dry skin over the left areola. Exam: blood stained discharge with dry flaky skin noted on the left areola. The nipple was noted to be ulcerated. Wht is the most appropriate inv? a. FNAC b. MRI c. Punch biopsy d. Open biopsy e. Stereotactic biopsy c. Punch biopsy Paget’s disease A punch biopsy is when the doctor removes a small circle of skin tissue to biopsy. You might have this type of biopsy if your doctor thinks you could have inflammatory breast cancer or Paget's disease of the nipple.

643. A 50yo man presents with low mood, poor concentration, anhedonia and insomnia. He has had 2 episodes of increased activity, promiscuity and aggressive behavior in the past. He was arrest 8m ago for trying to rob a bank claiming it as his own. Which drug is most likely to benefit him? a. Haloperidol b. Citalopram c. Desipramine d. Carbamazepine e. Ethosuximide d. Carbamazepine bipolar disorder

  



Lithium should be considered first-line, with the addition of valproate if ineffective. Valproate or olanzapine should be considered for patients intolerant of lithium or who are not prepared to undergo regular monitoring. If symptoms still continue then the patient should be referred to a mental health specialist. Medications that might be used in this situation are lamotrigine (especially in bipolar II disorder) or carbamazepine. If medication is stopped, patients should be made aware of early warning symptoms of recurrence. Medication should be tailed off gradually

644. A 25yo woman complains of dizziness, nausea, vomiting, visual disturbances and anxiety which keep coming from time to time. Most of the attacks are a/w sudden change in posture. What is the most likely dx? a. Panic disorder b. Carotid sinus syncope c. BPPV d. Vertebrobasilar insufficiency e. Postural hypotension c. BPPV    

vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards) may be associated with nausea each episode typically lasts 10-20 seconds positive Dix-Hallpike manoeuvre

BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by:  Epley manoeuvre (successful in around 80% of cases)  teaching the patient exercises they can do themselves at home, for example Brandt-Daroff exercises Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.

645. A 56yo man was recently put on anti-HTN meds and recent biochemistry on 2 occasions showed: Na+=132, K+=7.6, Urea=11.3, Creat=112. Which of the following drugs is responsible for this result? a. Amlodipine b. Bendroflumethiazide c. Doxazosin d. Atenolol e. Ramipril e. Ramipril no Angiotensin II >> no Aldosterone >> hyponatremia, hyperkalemia.

Side-effects:

   

cough: occurs in around 15% of patients and may occur up to a year after starting treatment. Thought to be due to increased bradykinin levels angioedema: may occur up to a year after starting treatment hyperkalaemia first-dose hypotension: more common in patients taking diuretics

Cautions and contraindications  pregnancy and breastfeeding - avoid  renovascular disease - significant renal impairment may occur in patients who have undiagnosed bilateral renal artery stenosis  aortic stenosis - may result in hypotension  patients receiving high-dose diuretic therapy (more than 80 mg of furosemide a day) - significantly increases the risk of hypotension  hereditary or idiopathic angioedema 646. A 46yo woman has offensive yellow discharge from one nipple. She had a hx of breast abscess 3yrs ago. What is the possible dx? a. Duct papilloma b. Duct ectasia c. Duct fistula d. Breast cancer c. Duct fistula as there is H/O abscesses which might have led to fistula formation. Clincher here is previous H/O abscess In cancer n papilloma discharge is blood stained mainly and ectasia it is greenish clear discharge from multiple ducts

Breast cancer Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering Paget's disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the skin/areola Mammary duct ectasia Dilatation of the large breast ducts Most common around the menopause May present with a tender lump around the areola +/- a green nipple discharge If ruptures may cause local inflammation, sometimes referred to as 'plasma cell mastitis' Duct papilloma Local areas of epithelial proliferation in large mammary ducts Hyperplastic lesions rather than malignant or premalignant May present with blood stained discharge Breast abscess More common in lactating women Red, hot tender swelling

647. A 35yo woman undergoing tx for TB presents with malar rash, photosensitivity and hematuria. What is the single most likely positive antibody? a. Anti Ds DNA b. Anti Sm c. Anti Histone d. Anti La e. Anti centromere

c. Anti Histone drug induced lupus. Most common causes  procainamide  hydralazine Less common causes  isoniazid  minocycline  phenytoin 648. A 6wk child with profuse projectile vomiting. What is the first thing you will do? a. US b. Check serum K+ level c. ABG d. NG tube e. IV fluids b. Check serum K+ level vomiting causes metabolic alkalosis.initially hypokalemia and later hyponatremia This seems a case of Pyloric stenosis Definitive diagnosis is done by US showing olive like But on blood tests it shows low blood levels of potassium and chloride in association with an increased blood pH and high blood bicarbonate level due to loss of stomach acid (which contains hydrochloric acid) from persistent vomiting. 6 weeks is the typical age for pyloric stenosis presentation

649. A 55yo woman who attends the clinic has recently been dx with a depressive episode. She complains of unintentionally waking early in the morning, a recent disinterest in sex and a loss of appetite, losing 5kg weight in the last month. She feels that her mood is worse at the beginning of the day. What is the most likely dx for this pt? a. Mild depression b. Moderate depression c. Severe depression d. Low mood e. Pseudo depression b. Moderate depression Physical symptoms like weight loss and early morning insomnia makes it moderate as opposed to mild Pseudodepression "A condition of personality following frontal lobe lesion in which apathy, indifference and a loss of initiative are apparent symptoms but are not accompanied by a sense of depression in the patient."

Q.621 for more 650. An employer sent his worker to the ED after having hit his head on a machine. Exam: normal. What is the single most likely inv you would do?

a. Skull XR b. CT head c. MRI head d. Reassure a. Skull XR CT head only if Loss of consciousness more than 5 minutes, More than two episodes of vomiting, Signs of base of skull fracture ( peri orbital haematoma, bleeding or CSF leak from nose or ears), Fits, Double vision, Headache not easing off with paracetamol or ibuprofen, Unusual drowsiness/lOW GCS, If none of the above discharge with head injury advise which means if any of the above develop in next 24 he pt should come back to A&E, This is current NICE head injury guideline.

651. A lady with fam hx of ovarian carcinoma has a pelvis US that fails to reveal any abnormality. What is the single most appropriate inv? a. Pelvic CT b. CA 125 c. CA 153 d. Laparoscopy e. MRI b. CA 125 Pelvic usg is not as sensitive as ca 125. So even if pelvic usg fails to detect a small lesion, it can still be detected by a rise in ca 125.

652. A 10yo boy is taken to his GP by his parents with behavioural prbs. He attends a special school due to inappropriate behavior and during the interview with his parents the boy barks at infrequent episodes and shouts expletives. What is the most likely dx? a. Asperger syndrome b. Cotard syndrome c. Rett syndrome d. Ekbom syndrome e. Tourette’s syndrome e. Tourette’s syndrome tourette syndrome (multiple motor tics + vocal / phonetic tics)

Asperger syndrome: autism spectrum disorder (autism: a mental condition, present from early childhood, characterized by great difficulty in communicating and forming relationships with other people and in using language and abstract concepts.) The main difference from classic autism is a lack of delayed or retarded cognition and language. Those with AS are also more likely to seek social interaction and share activities and friendships. In classic autism, children tend to be spotted earlier (18-30 months) because of impaired communication. In Asperger's syndrome (AS), the diagnosis comes later - usually at school entry, when socialisation becomes necessary. Many people with AS may learn to mask their problems. They may present as patients with no

serious mental health problem, but who are anxious, lonely, have a poor employment record and just don't seem to fit in.

Cotard syndrome: afflicted person holds the delusion that he or she is dead, either figuratively or literally.

Rett syndrome: small feet ,hands & head ,no speech no walking, repeated hand movement. Onset occurs between 6 and 18 months of age. deceleration of the rate of head growth

ekbom syndrome: delusional parasitosis delusional belief that they are infested with parasites, whereas in reality no such parasites are present. Wittmaack-Ekbom syndrome: a synonym of restless legs syndrome

Tourette’s syndrome Tics can be defined as sudden, purposeless, repetitive, non-rhythmic, stereotyped movements or vocalisations - eg, eye twitching or blinking. Examples of vocal tics are throat clearing, grunting and barking.

Other features that may be seen in Tourette's syndrome      

Echolalia - involuntary copying of other's' words. Palilalia - repeating one's own words. Coprolalia - compulsory saying of dirty words, which is pathognomonic of the syndrome and is seen in about 10% of patients. Copropraxia - making obscene gestures. Echopraxia - involuntary copying of other's movements. Difficulty concentrating or easily distracted.

653. A 52yo male presents with sudden complete loss of vision from right eye. He also had been complaining of right sided headaches which would come up more on chewing. On fundoscopy, the retina was pale and a cherry red spot could be seen in the macular region. What caused this vision loss? a. CRAO b. CRVO c. Branch RAO d. Branch RVO e. Circumciliary vein occlusion a. CRAO pale optic disc, cherry red spot on macula

The most common causes of a sudden painless loss of vision are as follows:  ischaemic optic neuropathy (e.g. temporal arteritis or atherosclerosis)  occlusion of central retinal vein  occlusion of central retinal artery  vitreous haemorrhage  retinal detachment

Ischaemic optic neuropathy  may be due to arteritis (e.g. temporal arteritis) or atherosclerosis (e.g. hypertensive, diabetic older patient)  due to occlusion of the short posterior ciliary arteries, causing damage to the optic nerve  altitudinal field defects are seen Central retinal vein occlusion  incidence increases with age, more common than arterial occlusion  causes: glaucoma, polycythaemia, hypertension  severe retinal haemorrhages are usually seen on fundoscopy Central retinal artery occlusion  due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis)  features include afferent pupillary defect, 'cherry red' spot on a pale retina Vitreous haemorrhage  causes: diabetes, bleeding disorders  features may include sudden visual loss, dark spots Retinal detachment  features of vitreous detachment, which may precede retinal detachment, include flashes of light or floaters

654. A 48yo woman presents with left-sided severe headache. She also has a red, watering eye and complains of seeing colored haloes in her vision. What is the most appropriate next step? a. Measure IOP b. Relieve pain with aspirin c. 100% oxygen d. CT e. Relieve pain with sumatriptan a. Measure IOP Red watery eye point to cluster headache but that's occur in young males...all other points to glaucoma haloes seen in glaucoma. Measure iop

Features  severe pain: may be ocular or headache  decreased visual acuity  symptoms worse with mydriasis (e.g. watching TV in a dark room)  hard, red eye  haloes around lights  semi-dilated non-reacting pupil  corneal oedema results in dull or hazy cornea  systemic upset may be seen, such as nausea and vomiting and even abdominal pain

Management  urgent referral to an ophthalmologist  management options include reducing aqueous secretions with acetazolamide and inducing pupillary constriction with topical pilocarpine

655. A 31yo woman presents with 7-10days following childbirth, with loss of feeling for the child, loss of appetite, sleep disturbance and intrusive and unpleasant thoughts of harming the baby. What is the best tx for this pt? a. Fluoxetine b. Haloperidol c. CBT d. Reassurance e. ECT e. ECT Antipsychotics are given taking into account the breastfeeding factor. Usually lithium is given but ECT is better way to go. Why we need ECT? As this is psychosis and there is danger to both mother and child we need to control the situation rapidly with high intensity psychological intervention

Postpartum psychosis is a psychiatric emergency. It requires urgent assessment, referral, and usually admission, ideally to a specialist mother and baby unit.[8] Management is primarily pharmacological, using the same guidance as for other causes of psychosis. Medication would normally involve an antipsychotic and/or mood stabilising drug. However, choice of medication must take breastfeeding into account. Mothers requiring lithium treatment should be encouraged not to breast-feed, due to potential toxicity in the infant. Most antipsychotics are excreted in the breast milk, although there is little evidence of it causing problems. Where they are prescribed to breast-feeding women, the baby should be monitored for side-effects. Clozapine is associated with agranulocytosis and should not be given to breast-feeding women. Electroconvulsive therapy (ECT) may also be considered in some cases

656. A 56yo male pt presents with intermittent vertigo, tinnitus and hearing loss. What is the best drug tx for this pt? a. Buccal prochlorperazine b. Oral flupenphenazine c. TCA d. Gentamicin patch on the round window e. No med tx available a. Buccal prochlorperazine meiners disease-t/t oral percholperazine

Features  recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom  a sensation of aural fullness or pressure is now recognised as being common  other features include nystagmus and a positive Romberg test  episodes last minutes to hours  typically symptoms are unilateral but bilateral symptoms may develop after a number of years Natural history  symptoms resolve in the majority of patients after 5-10 years  the majority of patients will be left with a degree of hearing loss  psychological distress is common Management  ENT assessment is required to confirm the diagnosis  patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved  acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required  prevention: betahistine may be of benefit

657. An 82yo woman has developed painful rash on one side of her forehead and ant scalp. Lesions have also affected her cornea. What is the single most appropriate option? a. Accessory nerve b. Facial nerve c. Olfactory nerve d. Optic nerve e. Trigeminal nerve e. Trigeminal nerve Corneal involvement. Forehead n scalp. All are area of supply of trigeminal

658. A 24yo woman presents with episodes of peri-oral tingling and carpo pedal spasms every time she has to give a public talk. This also happens to her before interviews, exams and after arguments. What is the best management strategy for this pt? a. Diazepam b. Rebreathe in a paper bag c. Desensitization d. Buspirone e. Propranolol b. Rebreathe in a paper bag??? many confusing answers She has co2 washout which results in hypocalcemia hence the Peri oral tingling and carpo pedal spasms

Desensitization is for phobias...like arachnophobia buspirone is for smoking cessation For acute attack.. Rebreathe into paper bag For prophylaxis just like when a pt has to give a public talk or appear in an interview..beta blocker. .propanolol. Best Mx is CBT. Desensitization If CBT doesn't help we go for medical Mx.. SSRI questions mentions all the events she is worried about and get symptoms from. What I think is that this is panic disorder which starts at the time public speaking and ends after its over. As opposed to GAD which is persistent and long lasting. And if we go according to management of panic attack. Step 1 is education Step 2 is cbt or ssri. So i think in this case cbt is the best answer. If it would be that the patient needs something to calm down while an exam then propranolol would be best. I mean for one time event. And if it would be acute and first time episode then rebreathing would be way to go.

659. A 32yo woman P3 of 39wks gestation reports having spontaneous ROM 4days ago. She didn’t attend the delivery suite as she knew that would happen and had already decided on a home birth. Today she feels very hot and sweaty. She thought that she was starting to have labour pains but she describes the pain as more constant. Exam: uterus is tender throughout. Blood tests show raised CRP and WBC. Select the most likely dx? a. Round ligament stretching b. Chorioamnionitis c. Uterine rupture d. Labor e. DIC b. Chorioamnionitis The characteristic clinical signs and symptoms of chorioamnionitis include the following:

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Maternal fever (intrapartum temperature >100.4°F or >37.8°C): Most frequently observed sign Significant maternal tachycardia (>120 beats/min) Fetal tachycardia (>160-180 beats/min) Purulent or foul-smelling amniotic fluid or vaginal discharge Uterine tenderness Maternal leukocytosis (total blood leukocyte count >15,000-18,000 cells/μL)

The standard drug treatment in the mother with chorioamnionitis includes ampicillin and an aminoglycoside (ie, usually gentamicin), although clindamycin may be added for anaerobic pathogens. Clindamycin may also be used if the mother is allergic to penicillin

660. A 63yo man continues to experience chest pain and has a temp of 37.8C 2 days after an acute MI. His ECG shows widespread ST elevation with upward concavity. What is the single most likely explanation for the abnormal inv? a. Acute pericarditis

b. Cardiac tamponade c. Atrial thrombus d. Left ventricular aneurysm e. Dressler syndrome a. Acute pericarditis Pericarditis in the first 48 hours following a transmural MI is common Features  chest pain: may be pleuritic. Is often relieved by sitting forwards  other symptoms include non-productive cough, dyspnoea and flu-like symptoms  pericardial rub  tachypnoea  tachycardia Causes       

viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism

ECG changes  widespread 'saddle-shaped' ST elevation  PR depression: most specific ECG marker for pericarditis

Dressler's syndrome tends to occur around 2-6 weeks following a MI. The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs.

661. A 55yo man presents with an ulcer of the scrotum. Which of the following LN is involved? a. External iliac LN b. Pre-aortic LN c. Aortic LN d. Inguinal LN e. Iliac LN f. Submental LN g. Submandibular LN h. Deep cervical LN D. Inguinal LN

662. A 35yo woman has butterfly rash on her face and she suffers symmetrical joint pains on knee and elbow, ESR is raised. What is the most discriminative inv for dx? a. Anti DNA antibodies b. Anti Jo1 antibodies c. Anti nuclear antibodies

d. Anti centromere antibodies e. Anti la antibodies a. Anti DNA antibodies in diagnostic critera for SLE,we have four antibody.Among them most specific is anti double stranded DNA antibody.So answer is a.

Immunology  99% are ANA positive  20% are rheumatoid factor positive  anti-dsDNA: highly specific (> 99%), but less sensitive (70%)  anti-Smith: most specific (> 99%), sensitivity (30%)  also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La) Monitoring  ESR: during active disease the CRP is characteristically normal - a raised CRP may indicate underlying infection  complement levels (C3, C4) are low during active disease (formation of complexes leads to consumption of complement)  anti-dsDNA titres can be used for disease monitoring (but note not present in all patients)

663. Pt had a fight following which he developed bleeding, ringing and hearing loss from one ear. What is the inv of choice? a. CT b. XR skull c. Otoscopy d. MRI vestibule e. Coagulation study a. CT CT scan to rule out basilar skull fracture esp when there is history of fight, bleeding from ear (hemotympanum) If bleeding and tinnitus is present it is almost certain that the patient has a traumatic perforation... So now our main aim is to rule out fracture base of skull which can be best done by a CT scan.

Selection of adults for CT scan

CT scan of the brain within one hour (with a written radiology report within one hour of the scan being undertaken):  Glasgow Coma Scale (GCS) memory is usually normal> pick's dementia

670. A 55yo man returns for routine follow up 6wks after a MI. He gets breathless when walking uphill. His ECG shows ST elevation in leads V1, V2, V3 and V4. What is the single most likely explanation for the abnormal investigation? a. Heart block b. Right ventricular strain c. Atrial thrombus d. Left ventricular aneurysm e. Dressler’s syndrome d. Left ventricular aneurysm S t elevation 6 weeks after mi...with no other major symptoms... Also a continuous St elevation and a history of mi points towards an aneurysm persistent ST elevation after few months of acute MI,D/D-1.ventricular aneurysm 2.underkinetic wall motion disorder. N.B -contrary to sounding fatal,there is neither predisposition nor any association of cardiac rupture in ventricular aneurysm. Ventricular aneurysm occurs at the site of previous STEMI. V1-V4 involvement indicates previous anteroseptal MI ( caused by LAD obstruction ) . This localized involvement of leads almost excludes Dressler's syndrome where pericarditis causes ST elevation in all but aVR leads.

Left ventricular aneurysm The ischaemic damage sustained may weaken the myocardium resulting in aneurysm formation. This is typically associated with persistent ST elevation and left ventricular failure. Thrombus may form within the aneurysm increasing the risk of stroke. Patients are therefore anticoagulated. Dressler's syndrome tends to occur around 2-6 weeks following a MI. The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs.

671. A 4m girl has severe FTT and increasing jaundice which was 1st noticed at 1wk of age. She has an enlarged liver and scratches on her skin. Her parents have been unable to seek medical care. What is the most likely dx? a. Biliary atresia b. G6PD deficiency c. Hep B

d. Spherocytosis a. Biliary atresia gradual increasing of jaundice with obstructive jaundice indicate this. so USG to confirm this.G6PD def is hereditary disease of XLR inheritance and always presented when aggravating factor present (some medication) and otherwise asymptomatic. congenital spherocytosis not presented with this early stage upto development of gallstone due to haemolysis. hepB not possible due to it causes hepatocellular picture. Galactosemia: Poor weight gain, poor feeding, irritable, jaundice. B. Atresia: Jaundice noticed usually at 1 wk, progressive, pale stools, dark urine. G6PD Def: Jaundice comes usu after/ during illness, off and on.

672. A 76yo man suddenly collapsed and died. At post mortem exam, a retroperitoneal hematoma due to ruptured aortic aneurysm was noted. What is the most likely underlying cause of the aortic aneurysm? a. Atheroma b. Cystic medial necrosis c. Dissecting aneurysm d. Polyarteritis nodosa e. Syphilis a. Atheroma

risk factors include:         

Severe atherosclerotic damage of the aortic wall; however, new evidence suggests this is not the only factor, and aneurysmal disease is probably a distinct arterial pathology. Family history - there are probably strong genetic factors. About 15% of firstdegree relatives of a patient with an AAA, mainly men, will develop an aneurysm.[6] Tobacco smoking is an important factor. Male sex. Increasing age. Hypertension. Chronic obstructive pulmonary disease. Hyperlipidaemia. In population-based studies, people with diabetes have a lower incidence of aneurysms than people without diabetes.

673. A 33yo male came to the hospital with complaint of occasional left sided chest pain that lasts lights off ----> pupil fully dilated----> angle closed--->obstruction of fluid flow from anterior chamber---> increased pressure in anterior chamber---> AACG Diagnosis is Acute Angle Closure glaucoma. It is based on the finding of two symptoms of ocular pain, nausea/vomiting, and a history of intermittent blurring of vision with haloes and at least three signs of the following: IOP greater than 21 mm Hg, conjunctival injection, corneal epithelial oedema, mid-dilated nonreactive pupil and shallower chamber in the presence of occlusion.

Features  severe pain: may be ocular or headache  decreased visual acuity  symptoms worse with mydriasis (e.g. watching TV in a dark room)  hard, red eye  haloes around lights  semi-dilated non-reacting pupil  corneal oedema results in dull or hazy cornea  systemic upset may be seen, such as nausea and vomiting and even abdominal pain Management  urgent referral to an ophthalmologist  management options include reducing aqueous secretions with acetazolamide and inducing pupillary constriction with topical pilocarpine

682. An 82yo male suddenly becomes unconscious and fell down. He recovered completely within minutes. What is the best inv you to to dx the case? a. ECG b. EEG c. Blood glucose level d. CT e. CXR a. ECG in old age arrhythmias are common like stokes adam..so ecg

Sudden loss of consciousness with sudden gain is always cardiac until proved otherwise (except in diabetics ) The immediate recovery is the trick. If it was hypoglycemia or head injury, the patient would not wake up quickly. The only condition where the patient gets loss of conscious and recover quickly is in cardiac conditions If hypoglycemia recovery without glucose would be difficult. There would be some other features like palpitation sweating etc. For exam purposes.. A pt in hypo won't recover until glucose is administered

A classic Stokes-Adams attack is a collapse without warning, associated with loss of consciousness for a few seconds. Typically, complete (third-degree) heart block is seen on the ECG during an attack (but other ECG abnormalities such as tachy-brady syndrome have been reported)

683. A child admitted with progressive muscle weakness and frequent falls. What is the most probable dx? a. Duchenne’s MD b. Becker’s MD c. Polymyositis d. Dermatomyositis e. Polymyalgia rheumatic a. Duchenne’s MD Duchenne is an x linked recessive disorder where muscle degeneration occurs and present at a very early age ( before 6 yrs usually) with proximal limb and pelvis muscle weakness..later progressing to the arms etc. Beckers is same as duchenne but a much milder form so present at a later age. Duchene ...starts early in life 5-6 years. B...starts later after 10 years b is almost same but less severe,c and d are inflammatory but there is rash involved in d..and e is entirely different related to giant cell arteritis

There is progressive proximal muscular dystrophy with characteristic pseudohypertrophy of the calves. All patients have symptoms by age 3 years, but diagnosis is often delayed. Presenting features are:     

Motor milestones delayed Inability to run - waddling gait when attempting to do so Other gait signs - no spring in the step, cannot hop or jump; toe walking; falls Gower's sign - 'climbing up legs' using the hands when rising from the floor Hypertrophy of calf muscles (and possibly other muscles too, including the deltoid, quadriceps, tongue and masseters)

Non-locomotor presenting symptoms:     

Speech delay or global developmental delay Failure to thrive Abnormal LFTs (raised AST or ALT) Anaesthetic complications - eg, myoglobinuria, rhabdomyolysis or malignant hyperthermia after certain anaesthetics Fatigue - this is common

The initial investigation is serum CK The precise diagnosis is best achieved by a combination of:  Genetic analysis - can identify most (but not all) of the DMD mutations.  Muscle biopsy - with assay for dystrophin protein.  Clinical observation of muscle strength and function.

684. A 56yo man presents to the ED with chest pain. The following ECG was taken. What is the most likely dx?

a. Anterior MI b. Inferior MI c. Lateral MI d. Posterior MI e. NSTEMI a. Anterior MI

ECG changes

Coronary artery

Anteroseptal

V1-V4

Left anterior descending

Inferior

II, III, aVF

Right coronary

Anterolateral

V4-6, I, aVL

Left anterior descending or left circumflex

Lateral

I, aVL +/- V5-6

Left circumflex

Posterior

Tall R waves V1-2

Usually left circumflex, also right coronary

685. A schizophrenic says: life is unfair. I like fairs. Fairs have food. It must be good. What term describes this pt’s speech? a. Neologism b. Flight of ideas c. Broca’s aphasia d. Wernicke’s aphasia e. Clang association e. Clang association rhytmic speech is Clang association association of words based upon sound rather than concepts Neologism: is the name for a relatively new or isolated

term, word, or phrase that may be in the process of entering common use, but that has not yet been accepted into mainstream language 686. A man comes to the ED with hx of pulsatile swelling in the abdomen, he has hx of HTN and exam: pulse=120bpm, BP=70/40mmHg. He is restless and in shock. What emergency management should be done on priority basis? a. Urgent abdominal CT b. Urgent abdominal US c. IV fluids 0.9% NS crystalloids to bring SBP to 90mmHg d. IV fluids 0.9% NS crystalloids to bring SBP to 120mmHg e. Dopamine inj c. IV fluids 0.9% NS crystalloids to bring SBP to 90 mmHg Aortic aneurism rupture with hypovolemic shock.. first step is to give crystalloids for resus to bring the systolic bp up to a min of 90 our target sbp should be 4s b. HR >90bpm c. Increased RR d. Stool >10x/d e. Weight of child = 10kgs nd

784. A 44yo woman with breast cancer had an extensive removal and LN clearance. She needs an adjunctive tx. Her mother had cancer when she was 65. Which of the following factors will be against the tx? a. Famhx b. Tumor grading c. LN involvement d. Her age adjunctivetx is given in LN involvement. Tumor grading should also be done to stage it.

785. A 45yo man presents with hearing loss and tinnitus in the right ear. Exam: weber test lateralizes to the left. Audiometry: AC > BC in both ears. What is the next best inv? a. CT b. MRI brain c. Angiogram d. Otoscopy Unilateral sensorineural hearing loss and loss of corneal reflex indicate involvement of facial, trigeminal and vestibulocochlear nerve which is common in acoustic neuroma. MRI of internal auditory meatus and CP angle would show the tumour. Acoustic Neuroma: Presentation: progressive ipsilateral tinnitus, sensorineural deafness. Big tumours may cause ipsilateral cerebellar signs or raised ICP. 5, 6, 7 cranial nerves at risk. Investigations: MRI TREatment: surgery 786. A 74yo lady called an ambulance for an acute chest pain. She has ahx of DM and HTN, and is a heavy smoker. Paramedics mentioned that she was overweight and recently immobile because of a hip pain. She collapsed and died in the ambulance. What is the most likely cause of death? a. Pulmonary embolism b. MI c. Stroke d. Cardiac arrhythmia e. Cardiac failure acute onset of chest pain and hx of immobility point towards pul embolism. Causes: DVT After long bone fracture

Amniotic fluid Air embolism Immobility Risk factors for venous thromboembolism 3] [

Major risk factors: relative risk of 5-20

Minor risk factors: relative risk of 2-4

Cardiovascular: Surgery:

·

Major abdominal/pelvic

surgery or hip/knee replacement (risk lower if prophylaxis used). ·

Postoperative intensive care.

Obstetrics:

·

Congenital heart disease.

·

Congestive cardiac failure.

·

Hypertension.

·

Paralytic stroke.

Oestrogens: ·

Pregnancy (but see major risk

factors for late pregnancy and puerperium).

·

Late pregnancy.

·

Combined oral contraceptive.

·

Puerperium.

·

Hormone replacement

·

Caesarean section.

therapy.

Lower limb problems:

Haematological:

·

Fracture.

·

·

Varicose veins - previous

detailed list is available)

varicose vein surgery;

Thrombotic disorders (a

Consider this in cases of PE aged 3.5g/24h (ACR >250 mg/mmol) • Hypoalbuminemia (10 mmol/L) is often present causes: It can be due to primary renal disease or secondary to a number of systemic disorders.

• Primary causes: Minimal change disease, membranous nephropathy, focal segmental glomerulosclerosis (FSGS), mesangiocapillary GN (MCGN). • Secondary causes: Hepatitis B/C (usually membranous, hep C can cause MCGN), SLE (class V lupus nephritis causes a membranous pattern), diabetic nephropathy, amyloidosis, paraneoplastic (usually membranous pattern) or drug related (again usually membranous—NSAIDS, penicillamine, anti-TNF, gold). Treatment: (In children the peak incidence is between 2 and 5 years of age. Around 80% of cases in children are due to a condition called minimal change glomerulonephritis. The condition generally carries a good prognosis with around 90% of cases responding to high-dose oral steroids.)

Reduce oedema: Loop diuretics, eg furosemide are used, often high doses are needed. Reduce proteinuria: ACE-i or ARB should be started in all patients. Reduce risk of complications Treat underlying condition. 795. A 53yo man with prv hx of COPD presents with breathlessness and purulent sputum. O2 stat=85% on air. ABG: PaO2=7.6, PaCOS=7. What is the appropriate management for his condition? a. 24% oxygen b. Mechanical ventilation c. 100% oxygen d. Nebulized salbutamol Answer= A. 24% oxygen. this is acute exacerbation of copd so 24% oxygen is given first.

796. A 34yo man was involved in a RTA and whilst in the ambulance his GCS deteriorated and RR increased from 30-48. What is the most appropriate management for this pt? a. IV fluid b. Needle thoracocentesis c. 100% oxygen d. Portable XR Answer= C. 100% oxygen. RTA case so we will follow ABC protocol. The ATLS programme uses the ABCDE mantra. It prioritizes direct treatment according to the most life-threatening injury identified and avoids delay. Remember to act immediately… Primary survey →A=Airway + O2 + cervical spine. Approach the patient with arms ready to immobilize Assess the airway; jaw thrust can be used to help maintain patency. Give 100% 02 to all patients. →B=Breathing + ventilation. Check air entry with auscultation; also auscultate the heart; inspect, palpate and percuss the chest wall for further evidence of injury. Check RR. →C=Circulation + haemorrhage control. Check GCS/AVPU, skin perfusion, BP & pulse. Control any visible haemorrhage with local pressure, and consider possible sources of occult haemorrhage if no source identified but the patient is shocked, ie examine abdo, pelvis, femoral.

Get 2L of warmed Ringer’s lactate solution/Hartmann’s solution/0.9% saline running stat via 2 separate points of venous access →D=Disability. Check GCS (if not already done), pupillary reflexes, gross evidence of a lateralizing injury or spinal cord level. →E=Exposure. Check and maintain body temperature using rewarming methods. Totally undress the patient, cutting all clothes off if necessary. Adjuncts to the primary survey can add life-saving information: CXR, lateral C Spine X-ray and pelvic X-ray . urinary catheter to accurately assess urine output (exclude urethral injury first); NGT insertion, O2 sats and then ABG to accurately assess oxygenation. Secondary survey: Now the patient is stabilized. More focused imaging can take place. Includes more focused examination (eg PR exam, otoscopy) and tests (eg limb x-ray, full C-spine series). 797. A 44yo lady who has PCKD is concerned because her 38yo brother has just died of an intracranial insult. She knows he was not hypertensive. What was the most likely cause of her brother’s death? a. Subdural hematoma b. Subarachnoid hemorrhage c. Cerebral infarct d. Epidural hematoma Answer: B. subarachnoid hemorrhage. subarachnoid hemorrhage is mainly due to rupture of berry aneurysm ( which is associated with adult polycystic kidney disease, ehler danlos syndrome and coarctation of aorta) SUBARACHNOID HEMORRHAGE Causes  85% are due to rupture of berry aneurysms (conditions associated with berry aneurysms include adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta)

  

AV malformations trauma tumours

Investigations  CT: negative in 5%  lumbar puncture: done after 12 hrs (allowing time for xanthochromia to develop) Complications  rebleeding (in 30%)  obstructive hydrocephalus (due to blood in ventricles)  vasospasm leading to cerebral ischaemia Management  neurosurgical opinion: no clear evidence over early surgical intervention against delayed intervention  post-operative nimodipine (e.g. 60mg / 4 hrly, if BP allows) has been shown to reduce the severity of neurological deficits but doesn't reduce rebleeding.

798. A 36yo male dx with glioblastoma since last 5m has cerebral edema and is on dexamethasone. He has diarrhea and vomiting for the last 3 days. He has been suffering from repeated falls today. What could be the possible cause for his falls? a. Adrenal insufficiency b. Dehydration c. Dexamethasone therapy d. Raised ICP Answer: A. Adrenal insufficiency. diarrhea, vomiting, falls (d/t postural hypotension) all point towards diagnosis. It is because of the steroid resistance and these exogenous steroids would have caused atrophy of adrenal glands. Adrenal insufficiency is a condition in which there is destruction of the adrenal cortex and subsequent reduction in the output of adrenal hormones, ie glucocorticoids (cortisol) and/or mineralocorticoids (aldosterone). There are two types of adrenal insufficiency: Primary insufficiency (Addison's disease) - there is an inability of the adrenal glands to produce enough steroid hormones. The most common cause for this in the developed world is autoimmune disease. Secondary insufficiency - there is inadequate pituitary or hypothalamic stimulation of the adrenal glands. Presentation: Often diagnosed late: lean, tanned, tired, tearful ± weakness, anorexia,dizzy, faints, fl u-like myalgias/arthralgias. Mood: depression, psychosis, low self esteem. GI: nausea/vomiting, abdominal pain, diarrhoea/constipation. Think of Addison’s in all with unexplained abdominal pain or vomiting. Pigmented palmar creases & buccal mucosa

(ACTH; cross-reacts with melanin receptors). Postural hypotension.Vitiligo. Signs of critical deterioration: Shock (↓BP, tachycardia),T°↑, coma. investigations: In a patient with suspected Addison's disease the definite investigation is a ACTH stimulation test (short Synacthen test).If a ACTH stimulation test is not readily available (e.g. in primary care) then sending a 9 am serum cortisol can be useful: > 500 nmol/l makes Addison's very unlikely < 100 nmol/l is definitely abnormal 100-500 nmol/l should prompt a ACTH stimulation test to be performed Associated electrolyte abnormalities are seen in around one-third of undiagnosed patients:    

hyperkalaemia hyponatraemia hypoglycaemia metabolic acidosis

management: Patients who have Addison's disease are usually given both glucocorticoid and mineralocorticoid replacement therapy. This usually means that patients take a combination of: 

hydrocortisone: usually given in 2 or 3 divided doses. Patients typically require 20-30 mg per day, with the majority given in the morning dose 

fludrocortisone

799. A 2yo child is brought by his mother. The mother had hearing impairment in her early childhood and is now concerned about the child. What inv would you do? a. Audiometry b. Distraction testing c. Scratch test d. Tuning fork Answer: A. Audiometry. Family history of deafness so audiometry should be done. 800. An 8yo child presents with recurrent abdominal pain, occasional headaches but maintains a good appetite. Exam: normal. CBC, BUE, etc are normal. What would you do for her next? a. US abdomen b. CT head c. Reassure d. Analgesics

Answer: C reassure. This is the case of abdominal migraine. Reassurance is the most important treatment in it. Abdominal migraine. This presents typically as recurrent bouts of generalised abdominal pain associated with nausea and vomiting but no headache, followed by sleep and recovery. Typical migraines may occur separately. pain is mostly periumbilical and lasts 1 to 4 hrs sometimes interfering with normal physical activity and routine. Diagnosis: clinical. assess triggers like sleep pattern, missing meals etc. children with abdominal migraine have tendency to develop migraine when they grow up. Treatment: Reassurance is the most important treatment. For headaches in children paracetamol can be given.

Muniba / Samar: 814-845 Chishti: 856-865 Hamza: 866-875 Wajiha: 876-950 801. A 78yo gentleman suddenly collapsed. His HR=120bpm, BP=70/40mmHg. Exam: pulsatile mass in abdomen. What is the most appropriate dx? a. Aortic aneurysm b. Mesenteric cyst c. Umbilical hernia Key is A aortic aneurysm. Clincher: Pulsatile mass in abdomen is most likely to be an aortic aneurysm. It’s actually a burst aortic aneurysm which can be predicted by collapsed, tachycardic patient presenting with hypotension. ABDOMINAL AORTIC ANEURYSM:

An aneurysm is a permanent and irreversible dilatation of a blood vessel by at least 50% of the normal expected diameter. An aneurysm is caused by degradation of the elastic lamellae, a leukocytic infiltrate, enhanced proteolysis and smooth muscle cell loss. The dilatation affects all three layers of the arterial wall. A false aneurysm (pseudoaneurysm) is caused by blood leaking through the arterial wall but contained by the adventitia or surrounding perivascular tissue. The 'normal' diameter of the abdominal aorta is approximately 2 cm; it increases with age. An abdominal aneurysm is usually defined as an aortic diameter of 3 cm or greater. Most abdominal aortic aneurysms (AAAs) arise from below the level of the renal arteries.

Presentation Unruptured AAA   

Most patients with unruptured AAA have no symptoms. AAA may be an incidental finding on clinical examination, or on scans ultrasound, CT or MRI. It may sometimes be visible on a plain X-ray film. Possible symptoms and signs are: o Pain in the back, abdomen, loin or groin:  This may be due to pressure on nearby structures. Back pain may be due to erosion of the vertebral bodies.  NB: severe lumbar pain of recent onset may indicate impending rupture. o The patient or doctor may find a pulsatile abdominal swelling o Distal embolisation may produce features of limb ischaemia. The appearance of micro-embolic lower limb infarcts in a patient with easily palpable pedal pulses suggests a popliteal or abdominal aneurysm. o Ureterohydronephrosis can also occur with AAA. o Inflammation or retroperitoneal fibrosis can complicate AAA and may cause symptoms - eg, back pain, weight loss and symptoms related to entrapment of adjacent structures.

Ruptured AAA 



NB: the diagnosis may not be obvious. Ruptured AAA should be considered in any patient with hypotension and atypical abdominal symptoms. Similarly, abdominal pain in a patient with a known aneurysm or pulsatile mass must be considered as a possible ruptured or rapidly expanding aneurysm and treated accordingly. Ruptured AAA may present with: o Pain in the abdomen, back or loin - the pain may be sudden and severe. o Syncope, shock or collapse:



The degree of shock varies according to the site of rupture and whether it is contained - eg, rupture into the peritoneal cavity is usually dramatic, with death before reaching hospital; whereas rupture into the retroperitoneal space may be contained initially by a temporary seal forming.

802. A woman prv in good health presents with sudden onset of severe occipital headache and vomiting. Her only physical sign on exam is a stiff neck. Choose the most likely dx.

a. b. c. d. e.

Subarachnoid hemorrhage Subdural hematoma Cerebellar hemorrhage Migraine Cerebral embolus

Key is A Any Severe headache of Sudden onset in previously well patient is Subarachnoid hemorrhage unless proven otherwise. It may also be described as “worst headache of my life.” Subdural hematoma usually presents with history of falls in an alcoholic or elderly patient and may also shows signs of confusion. Cerebellar hemorrhage may present with signs and symptoms of cerebellar lesion like lack of balance , nystagmus e.t.c. Migraine presents with unilateral severe throbbing pain with photophobia and phonophobia. It lasts for about 4-72 hours and may occur along with nausea and vomiting and aura. Cerebral embolus rarely cause headache and presents with focal neurological deficits. SUBARACHNOID HEMORRHAGE:

Presentation The most characteristic feature is a sudden explosive headache. This may last a few seconds or even a fraction of a second.  

     



Sudden explosive headache may be the only symptom in a third of patients. Of patients who present with a sudden explosive headache as the only symptoms, around 10% have SAH. It is difficult to suspect SAH without sudden headache, but with seizure or confusional state - there are many other more common causes of these presentations, but SAH should be on the list of differential diagnoses. Vomiting may occur; although this does not distinguish it from other causes of headache. Seizures, occur in about 7%. When they do, they are highly suggestive of a haemorrhage. 1-2% of patients with SAH present with an acute confusional state. Neck stiffness and other signs of meningism may be present, although it usually presents around six hours after onset of SAH. Trauma may be confused with SAH if trauma has also occurred. Patients may also cause a motor vehicle accident as a result of SAH. SAH needs to be on the differential diagnostic list for patients with altered consciousness, headache or seizure after trauma, particularly if there is disproportionate headache or neck stiffness. SAH following head injury causes headache, decreased level of consciousness and hemiparesis. SAH is a frequent occurrence in traumatic brain injury, and carries a poor prognosis if it is associated with deterioration in the level of consciousness.

Investigations CT scanning 

If SAH is suspected, CT scanning (without contrast) is the first line in investigation because of the characteristically hyperdense appearance of blood in the basal cisterns.

Lumbar puncture  



CT is negative in 2% of patients with SAH. If the CT scan is negative but the history is suggestive, lumbar puncture should be undertaken, providing the scan shows no contra-indications. Around 3% of patients with a negative CT scan will prove, on lumbar puncture, to have had an SAH. Lumbar puncture to remove a CSF sample from the lumbar sac should ideally take place over 12 hours after the onset of the headache because if there are red cells in the CSF, sufficient lysis will have taken place during that time for bilirubin and oxyhaemoglobin to have formed

Angiography  

Further investigation should follow immediately acute SAH is confirmed. After an SAH is confirmed, its origin needs to be determined. If the bleeding is likely to have originated from an aneurysm, the choice is between cerebral angiography (injecting radiocontrast through a catheter to the brain arteries) and CT angiography (visualising blood vessels with radiocontrast on a CT scan) to identify aneurysms. Catheter angiography also offers the possibility of coiling an aneurysm.

803. A 34yo housemaid presents with headaches in the back of her head for several days and pain on flexing her neck. What is the most likely cause? a. Subdural hemorrhage b. Cervical spondylosis c. Subarachnoid hemorrhage d. Meningitis e. Cluster headache Key is B Clincher is 34 year old housemaid which shows that patient has to work with flexed neck for longer time of the day. pain on flexion of neck shows nerve root irritation due to compression,herniation or osteophytic outgrowth. Subarachnoid hemorrhage is usually sudden in onset and does not prevail for several days. Migraine is a unilateral throbbing pain and is not associated with neck flexion Cluster headache presents with unilateral headache with unilateral autonomic signs like rhinorrhea, lacrimation and ptosis CERVICAL SPONDYLOSIS: Cervical spondylosis is chronic cervical disc degeneration with herniation of disc material, calcification and osteophytic outgrowths. As with simple back pain, it is multifactorial in origin, reflecting poor posture, muscle strain, sporting and occupational activities as well as psychological factors. Cervical spondylosis undoubtedly contributes to this burden, but may also cause:  Radiculopathy due to compression, stretching or angulation of the cervical nerve roots.  Myelopathy due to compression, compromised blood supply or recurring minor trauma to the cord.

Symptoms      

Cervical pain worsened by movement. Referred pain (occiput, between the shoulder blades, upper limbs). Retro-orbital or temporal pain (from C1 to C2). Cervical stiffness - reversible or irreversible. Vague numbness, tingling or weakness in upper limbs. Poor balance.

Signs   

Limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides). Minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy). Poorly localised tenderness.

Investigations Most patients do not need further investigation and the diagnosis is made on clinical grounds alone.  

Plain X-ray of cervical spine showing formation of osteophytes, narrowing of disc spaces with encroachment of intervertebral foraminae. This is not diagnostic as these findings are common in normal middle-aged patients. Patients with neurological abnormality will need magnetic resonance imaging (MRI) of the cervical spine at an early stage, particularly if they have progressive myelopathy, radiculopathy or intractable pain.

804. A 40yo man complains of thirst and lethargy. His BP=140/90mmHg, corrected Ca2+=3.7mmol/l. What is the most appropriate management at this stage? a. IV fluids b. Prednisolone c. IV hydrocortisone d. Calcium prep KEY is A This is Hypercalcemia since CA2+ levels are increased (normal range 2.252.5mmol/l). Increasing the circulating volume with 0.9% saline, helping to increase the urinary output of calcium

Presentation Presentation of Hypercalcaemia At levels >>> gut perforation mostly peptic ulcer because of RA drugs Indications of plain abdominal x-ray Renal colic: • A 'KUB' picture is requested. This is a large film that is designed to take in the kidneys, ureters and bladder. • About 90% of renal stones are radio-opaque. Uric acid stones may be missed. • False positives may occur from phleboliths that are most common in the pelvic veins. False negatives may arise, especially if stones are small. • Calcification may represent gallstones but only a minority of gallstones are radio-opaque. Gallstones become more frequent with age and are often asymptomatic.[4] • Doctors in A&E tend to be poor at identifying stones on plain films but, if urinalysis is negative, the diagnosis is unlikely to be renal colic. Intestinal obstruction: • Erect and supine films are used to confirm the diagnosis. • Obstruction of the small bowel shows a ladder-like series of small bowel loops but this also occurs with an obstruction of the proximal colon. Fluid levels in the bowel can be seen in upright views. • Distended loops may be absent if obstruction is at the upper jejunum. • Obstruction of the large bowel is more gradual in onset than small bowel obstruction. The colon is in the more peripheral part of the film and distension may be very marked. • Fluid levels will also be seen in paralytic ileus when bowel sounds will be reduced or absent rather than loud and tinkling as in obstruction. • In an erect film, a fluid level in the stomach is normal as may be a level in the caecum. Multiple fluid levels and distension of the bowel are abnormal.

Perforation of the intestine: • If the bowel has been perforated and a significant amount of gas has been released it will show as a translucency under the diaphragm on an erect film. • Gas will also be found under the diaphragm for some time after laparotomy or laparoscopy. Appendicitis • An appendicolith may be apparent in an inflamed appendix in 15% of cases but as a diagnostic point in the management of appendicitis, the plain X-ray is of very limited value.[6] • It may be of value in infants. Intussusception: • Intussusception occurs in adults and children. • A plain abdominal X-ray may show some characteristic gas patterns.[8] • A sensitivity and specificity of 90% adds to this rather difficult diagnosis but ultrasound is vastly superior.[9] • Detection of swallowed foreign bodies: • Plain X-ray will detect the presence of radiopaque foreign bodies. • A plain abdominal X-ray will show 90% of cases of 'body packing' (internal concealment of drugs to avoid detection) but there will be false positives in 3%. 833. A 44yo man went on holiday to Sudan 5wks ago. He now presents with red urine and fever. Exam: hepatomegaly. What is the most likely dx? a. Malaria b. Brucellosis c. Leptospirosis d. Schistosomiasis key : d Schistosomiasis Presentation • Infection can be acute or chronic. • Physical findings vary with the stage of illness, worm burden, worm location, and organs involved. • Schistosomiasis is associated with anaemia, chronic pain, diarrhoea, exercise intolerance, and malnutrition.[2] • Acute syndrome (Katayama syndrome)

• The acute reaction is due to the sudden release of highly antigenic eggs. • The most common acute syndrome is Katayama fever. It usually occurs in children or young adults with no past exposure to the disease and is most likely with S. japonicum. • As travellers present several weeks after contact with infested water, it is necessary to obtain a careful travel history, including drinking water sources and activities such as swimming. Symptoms: • Most acute infections are asymptomatic. • The first sign may be swimmer's itch in which there is an urticarial response for a few days after the parasite has penetrated the skin. • Malaise. • Arthralgia or myalgia. • Cough. • Diarrhoea. • Right upper quadrant pain. Signs: • Fever. • Hepatosplenomegaly. • Right upper quadrant pain or tenderness. • Urticaria may be seen occasionally. • Lymphadenopathy. • Initial invasion of skin and infection with non-human species may cause itching and rash. Chronic disease • Chronic schistosomiasis can present months to years after exposure, making diagnosis difficult. • It is endemic in poor, rural areas. • Many patients have not had an acute syndrome. • Symptoms may be few or mild. They may be nonspecific or reflect the site of egg production in the mesentery or bladder wall, the extent of damage to liver or spleen, the degree of lung involvement, and possibly other sites including the central nervous system (CNS). Symptoms: • Bloody diarrhoea. • Abdominal pain, right upper quadrant pain, cramps. • Haematemesis, which can occur from oesophageal varices with portal hypertension. • Haematuria, dysuria:

• The first feature may be frequency of micturition. • Initially, haematuria is only terminal but, as it becomes more severe, the blood produces red urine throughout the stream. • There is proteinuria. • Pulmonary hypertension may produce: • Fatigue. • Dyspnoea on exertion. • Cough. • Atypical chest pain. • Hepatosplenomegaly. Signs: • Abdominal tenderness. • Ascites with portal hypertension. • Seizures and/or altered mental state (with cerebral infection). Investigations • Microscopic examination of stool or urine is the gold standard for diagnosis but requires the adult worms to be producing eggs. • Serology can diagnose less advanced infections • FBC shows eosinophilia and anaemia. • Renal function may be impaired if the urinary tract is obstructed. Management • Praziquantel is the drug of choice in most cases. • The World Health Organization (WHO) believes that praziquantel is safe in pregnancy, lactation and in children under the age of 24 months. • Oxamniquine is the only alternative • In acute Katayama fever, corticosteroids are very important to subdue the hypersensitivity reaction. • Corticosteroids and anticonvulsants may be needed as adjuvants to praziquantel in neuroschistosomiasis. Surgical • Endoscopy and sclerotherapy can treat oesophageal varices. • A ventriculoperitoneal shunt and corticosteroids are required to treat hydrocephalus and raised intracranial pressure in cerebral schistosomiasis. Complications Urinary tract • Secondary bacterial infection and renal stones may occur. • There is an increased risk of squamous cell carcinoma of bladder that has been noticed especially in Egypt. It is possible that the infestation and the carcinogens in tobacco smoke have a synergistic effect.

• Hydronephrosis may occur but will reverse if the disease is treated, suggesting that the renal parenchyma is compressed but not destroyed and renal function is not markedly impaired. • Schistosomal nephropathy leading to renal failure may occur. • Female urogenital schistosomiasis may be a risk factor for HIV infection. Alimentary canal • Gastrointestinal complications include gastrointestinal bleeding, gastrointestinal obstruction, malabsorption and malnutrition. • Lesions tend to bleed and there is loss of blood and protein, causing iron-deficiency anaemia and hypoproteinaemia. These lesions are mostly in the colon and rectum. • Fibrosis of the liver occurs, producing portal hypertension. S. mansoni infection invariably results in liver fibrosis. • Portal hypertension can produce oesophageal varices that may bleed, and ascites. • Portocaval shunting predisposes to pulmonary infestation and problems of pulmonary hypertension. • Co-infection with hepatitis, HIV, and malaria can increase the risk of hepatocellular carcinoma and increase the risk of mortality. Other complications • Chronic septicaemic salmonellosis (prolonged fever with enlargement of the liver and spleen) may occur in schistosoma-infected individuals who are co-infected with salmonella. • Pulmonary hypertension. • Cor pulmonale. • Neuroschistosomiasis (includes increased intracranial pressure, myelopathy and radiculopathy). 834. A 32yo homosexual comes with hx of weight loss. Fundoscopy reveals retinal hemorrhages. What is the single most appropriate option? a. Mycobacterium avium b. CMV c. Hemophilus influenze d. NHL e. Pneumocystic jerovici key : B reason : homosexual +wt loss >>> HIV >>> CMV Cytomegalovirus and HIV infection CMV can cause very serious infection in HIV infection. Retinitis:

• Retinitis is the most common manifestation of CMV disease in patients who are HIV positive. • It presents with decreased visual acuity, floaters, and loss of visual fields on one side. • Ophthalmological examination shows yellow-white areas with perivascular exudates. Haemorrhage is present. Lesions may appear at the periphery of the fundus, but they progress centrally. • It begins as a unilateral disease, but in many cases it progresses to bilateral involvement. It may be accompanied by systemic CMV disease. • Ganciclovir has been used to treat retinitis, but it only slows the progression of the disease. The optimal treatment is using ganciclovir implants in the vitreous, accompanied by intravenous ganciclovir therapy. • Oral ganciclovir may be used for prophylaxis of CMV retinitis. It should not be used for treatment. CMV pneumonia in patients who are HIV positive is uncommon. The reason for this is unknown. Gastrointestinal tract: • In the upper gastrointestinal tract, CMV has been isolated from oesophageal, gastric and duodenal ulcers. Patients with oesophageal disease may present with painful dysphagia. • In the lower gastrointestinal tract, patients with CMV may present with diarrhoea due to colitis. CMV may cause disease in the peripheral and central nervous system. 835. A 30yo man comes with hx of early morning back pain and stiffness. Exam: red eyes. What is the single most appropriate option? a. Iris b. Ciliary body c. Cornea d. Conjunctivitis e. Sclera key : A reason : male pt with early morning back pain and stiffness >> AS >>>uvitits Presentation AS usually presents before the age of 30 years. Most patients have mild chronic disease or intermittent flares with periods of remission. Systemic features are common. Fever and weight loss may occur during periods of active disease. Fatigue is also prominent. Morning stiffness is characteristic.

Inflammatory back pain which Often improves with moderate physical activity. The spinal disease starts in the sacroiliac joints (bilateral lumbosacral region) and may be felt as diffuse nonspecific buttock pain. Peripheral enthesitis: Occurs in approximately a third of patients. Common sites - behind the heel (Achilles tendonitis), the heel pad (plantar fasciitis) and the tibial tuberosity. Lesions tend to be painful, especially in the morning. There may be associated swelling of the tendon or ligament insertion. Peripheral arthritis: Also occurs in about a third of patients. Joint involvement is usually asymmetric, involving the hips, shoulder girdle (glenohumeral, acromioclavicular, and sternoclavicular joints), joints of the chest wall (costovertebral joints, costosternal junctions) and symphysis pubis. Other peripheral joints are less often and less severely affected, usually as asymmetrical oligoarthritis. In children, AS tends to commence with arthritis prior to spinal disease developing. Temporomandibular joints are occasionally involved. Extra-articular manifestations of AS Eye involvement Acute anterior uveitis occurs in 20-30% of patients. Of all patients presenting with acute anterior uveitis, a third to a half have or will go on to develop AS. Acute anterior uveitis presents with an acutely painful red eye and severe photophobia and requires emergency treatment to prevent visual loss. Cardiovascular involvement This occurs in >> no blisters yet 838. A 12yo boy presented with itching in his hands. Exam: skin is dry and red. His mother is asthmatic and older brother has hay fever. What is the single most likely causative factor? a. Dermatitis herpitiformis b. Scabies c. Eczema d. Uremia e. Drug induced key : c Eczema Diagnostic criteria • Must have an itchy skin condition (or report of scratching or rubbing in a child) plus three or more of the following: • History of itchiness in skin creases such as folds of the elbows, behind the knees, fronts of ankles, or around the neck (or the cheeks in children aged 18 months or under). • History of asthma or hay fever (or history of atopic disease in a first-degree relative in children aged under 4 years). • General dry skin in the preceding year. • Visible flexural eczema (or eczema affecting the cheeks or forehead and outer limbs in children aged under 4 years). • Onset in the first two years of life (not always diagnostic in children aged under 4 years). • If it does not itch it is very unlikely to be eczema. management : emolient + topical steroids

839. A 45yo man presented with pruritic purple papules on the flexor surface of his wrist and some white lacy markings on his buccal mucosa. What is the single most likely causative factor? a. ALL b. Lymphoma c. Polycythemia d. IDA e. Lichen planus key : e Lichen planus Presentation Onset is usually acute, affecting the flexor surfaces of the wrists, forearms and legs. The typical lesion is an intensely itchy 2-5 mm red or violet shiny flattopped papule with white streaks ('Wickham's striae'). Mucous membranes are commonly affected >>> Classically, white slightly raised lesions with a trabecular, lacy appearance on the inside of the cheeks 840. A known DM was admitted with sudden LOC. What is the initial inv? a. CT scan b. RBS c. MRI d. ECG e. ABG key : B reason : diabetic pt >>> hypogycemia is common >>> RBS is the initial inv 841. A 36yo lady comes with hx of early morning stiffness of her small joints and with red and painful eye. What is the single most appropriate option? a. Iris b. Ciliary body c. Cornea d. Conjunctivitis e. Sclera f. Lichen planus key : E reason :female pt with early morning stiffness of her small joints >>> RA >>> scleritis Scleritis

Scleritis often appears in association with other inflammatory diseases such as rheumatoid arthritis and granulomatosis - the histopathological changes are characteristic of a chronic granulomatous disease. 842. A 23yo man comes with 2d hx of sticky greenish discharge from the eyes with redness. What is the single most appropriate option? a. Iris b. Ciliary body c. Cornea d. Conjunctivitis e. Sclera key : D Bacterial conjunctivitis Presentation Symptoms Discomfort - burning or gritty but not sharp. Pain is minimal; significant pain suggests a more serious diagnosis. Vision is usually normal, although 'smearing', particularly on waking, is common. Discharge tends to be thick rather than watery. There may be mild photophobia. Significant photophobia suggests severe adenoviral conjunctivitis or corneal involvement. History Ask about contact lens wear: establish whether this could be (or lead to) a problem of the (vulnerable) cornea. Time course: onset, duration - in chronic cases consider venereal disease in people at a sexually active age. Use of over-the-counter medication: consider whether this could be a reaction to previously administered drops or ointment. Social aspect: establish whether anybody else has had it (family, school, work). Determine whether there are concerns about working during the course of the illness. Findings 'Red eye' with uniform engorgement of all the conjunctival blood vessels. Bacterial conjunctivitis may often be distinguished from other types of conjunctivitis by the presence of a yellow-white mucopurulent discharge. Eyes may be difficult to open in the morning, glued together by discharge.

There is also usually a papillary reaction (small bumps on the palpebral conjunctiva, appearing like a fine velvety surface). The presence of follicles is more likely to indicate viral conjunctivitis. Bacterial conjunctivitis is usually bilateral (but often sequential). Check visual acuity - this should be normal, other than the mild and temporary blur secondary to the discharge which can be blinked or wiped away. 843. A pt was admitted with erectile dysfunction, reduced facial hair and galactorrhea. What is the most probable dx? a. Hyperprolactinemia b. Cushing’s syndrome c. Pheochromocytoma d. Hyperthyroidism e. Hypoparathyroidism key : A reason : galactorrhea + with erectile dysfunction + reduced facial hair hyperprolactinaemia Presentation Women: Common symptoms of are amenorrhoea, oligomenorrhoea and galactorrhoea. They may also have infertility, hirsutism and reduced libido. Men: The hormonal effects of raised prolactin levels are subtle and develop slowly. Endocrine symptoms are reduced libido, reduced beard growth and erectile dysfunction. Children: Growth failure and delayed puberty are possible presentations in children. Symptoms due to tumour size (usually macroprolactinomas): Headache. Visual disturbances (classically, a bitemporal hemianopia (lateral visual fields) or upper temporal quadrantanopia). Cranial nerve palsies. Symptoms and signs of hypopituitarism. Rarely, cerebrospinal fluid (CSF) leak or secondary meningitis. Investigations Initial investigations TFTs.

Exclude pregnancy. Basal serum prolactin: If prolactin is mildly elevated (eg 400-1000 mU/L, normal range 5000 mU/L usually indicates a true prolactinoma. Further investigations Visual field testing. Pituitary imaging (preferably MRI). Assessment of pituitary function 844. A 32yo man has been repeatedly admitted to hospital for what was described as anxiety or panic attacks and palpitations. On occasions he is found to be tremulous and hypertensive. A persistent weight loss is noted. What is the most probable dx? a. Hyperthyroidism b. Panic attacks c. Pheochromocytoma d. Cushing’s disease e. GAD key : c reason :male young age + anxiety + palpitation +wt loss +HTN Pheochromocytoma signs and Symptoms Headache Profuse sweating Palpitations Tremor Nausea Weakness Anxiety Sense of doom Epigastric pain Flank pain Constipation Weight loss Hypertension but it may be paroxysmal in 50%. Postural hypotension.

symptoms are intermittent and may vary from once a month to several times a day with duration from seconds to hours. Investigations Blood tests Blood glucose is often raised. Calcium may be elevated. Haemoglobin is elevated Plasma catecholamines and plasma metanephrines (the o-methylated metabolites of catecholamines) have both been used in diagnosis Urine 24-hour urine collection is required for creatinine , total catecholamines, vanillylmandelic acid (VMA) and metanephrines. Imaging After biochemical confirmation of a tumour, imaging is necessary to locate it.[9] 90% of phaeochromocytomas are in the adrenal glands and 98% within the abdomen. Common locations for extra-adrenal phaeochromocytomas include close to the origin of the inferior mesenteric artery, bladder wall, heart, mediastinum and carotid and glomus jugulare tumours. MRI can locate all tumours within the adrenals. CT is less sensitive and detects around 85-95% of tumours in excess of 1 cm in diameter. management : Surgical resection of the tumour is the treatment of choice and usually results in cure of the hypertension. Pre-operative treatment with alphablockers and beta-blockers is required to control blood pressure and prevent intraoperative hypertensive crises. 845. A 35yo man with T1DM is dehydrated with BP of 90/50mmHg. What is the single most appropriate initial inv? a. ABG b. CBC c. HbA1c d. LFT e. Serum Urea key: a reason : T1DM suspected to have DKA>>> ABG will show acidosis DKA DKA is characterised by hyperglycaemia, acidosis, and ketonaemia

DKA is normally seen in type 1 diabetics and may be a presenting feature of undiagnosed type 1 diabetes, particularly in children. However DKA may rarely occur in type 2 diabetics Check capillary blood glucose and blood gases promptly. If these suggest diabetic ketoacidosis (DKA) then immediately begin resuscitation and management. management: • Immediate resuscitation as required • Correct dehydration >>> 0.9% sodium chloride solution is the recommended fluid of choice • Insulin therapy >>> A fixed-rate IV insulin infusion calculated on 0.1 units/ per kilogram infusion is recommended. • Metabolic treatment • Treat any precipitating illness 846. In OGTT what is the glucose venous plasma level 2h after glucose intake which indicates impaired glucose tolerance? a. >11.1mmol/l b. Between 7.8-11.0mmol/l c. Between 8.0-10.9mmol/l d. Between 10.0-11.0mmol/l e. Between 7.1-11.0mmol/l ANSWER is B.

847. A young man who has no PMH presented with jaundice, low Hgb, retics 8% and other indices WNL but occasional spherocytes were seen on blood film. What is the single most appropriate inv? a. G6PD enzyme assay b. Direct coombs test c. Repeat blood film d. Indirect coombs test e. BMA Normal retic count is 1%. Increased reticulocyte count always indicates hemolysis. Since there are spherocytes on the blood film it means this patient either has autoimmune hemolytic anemia or hereditary spherocytosis. Direct coombs test will be positive in autoimmune hemolytic anemia. For HS Flow cytometric analysis of eosin-5-maleimide (EMA) binding to red cells, and cryohaemolysis test have replaced osmotic fragility tests.

848. A 22yo man came to the hosp after an injury in his hand while playing basketball. Exam: avulsion of extensor tendon from the distal phalanx. What is the single most probable deformity? a. Dinner fork deformity b. Game keeper thumb c. Mallet finger d. Gun-stock deformity e. Garden spade deformity A Colles' fracture (dinner fork deformity) is a fracture of the distal radius in the forearm with dorsal and radial displacement of the wrist and hand. Game keeper’s thumb: This is injury to the ulnar collateral ligament (UCL) of the MCP joint (on the medial side of the thumb) due to forced abduction of the MCP. Mallet Finger: There is avulsion of the extensor tendon causing the finger to be stuck in moderate flexion. Gunstock deformity: Also known as cubitus varus. Cubitus varus (varus means a deformity of a limb in which part of it is deviated towards the midline of the body) is a common deformity in which the extended forearm is deviated towards midline of the body . Garden spade deformity: This is the Smith’s fracture. Reverse of colles. The definition is a fracture of the distal radius, with or without ulnar involvement, that has volar (anterior) displacement of the distal fragments So the ANSWER here is C.

849. A 28yo man is inv for recurrent lower back pain. A dx of Ankylosing Spondylitis is suspected. Which of the following inv is most useful? a. ESR b. XR sacro-iliac joints c. HLA B27 d. XR thoracic spine e. CT lumbar spine

Tests: Diagnosis is clinical, supported by imaging (MRI is most sensitive and better at detecting early disease). Sacroiliitis is the earliest X-ray feature, but may appear late. In later stages, calcification of ligaments with ankylosis lead to a ‘bamboo spine’ appearance. Also: FBC (normocytic anaemia), ESR, CRP, HLA B27+ve (not diagnostic) Treatment: Exercise, NSAIDs, TNF blockers etanercept, adalimumab and golimumab are indicated in severe active AS if NSAIDS fail 850. A 4yo girl is taken by her mother to the ED and complains of feeling unwell, urinary urgency and temp=39C. What is the single next best inv? a. Catheter catch of urine b. Clean catch of urine c. US d. IVU e. Suprapubic catch of urine ANSWER B. Recommended way of getting a urine sample: Dipstick all ward urines. If nitrites or WCC +ve, get a clean catch (or a suprapubic aspirate or catheter sample; bag urines have many false positives from vulvitis or balanitis). Wash the genitals gently with water, and tap repeatedly in cycles of 1min with 2 fingers just above the pubis, 1h after a feed, and wait for a clean voided urine (CVU) sample, avoiding the stream’s 1st part 851. A 2yo girl presents with a 4d hx of fever that started with a cough. Her RR=45bpm, sat=94%, temp=38.9C, capillary refill time=1s. There are crepitations at the left base on auscultation. Urine shows negative dipstick. What is the single inv most likely to lead to dx? a. Blood for C&S b. ESR c. CXR d. Urine for C&S e. CSF analysis ANSWER C. The main presenting symptoms here are Cough, fever and tachypnea. Which means some respiratory problem is present. A cause of fever has been ruled out by giving the negative urine test which rules out UTI. Plus there are crepitations at the base of lung. So we will first do a chest X-ray to look for

the cause possibly pnuemonia. Blood C & S takes times. ESR is raised in sooo many diseases and will not point towards any specific diagnosis. Urine dipstick is negative so no need to culture that. No signs of neurological involvement so no need to do CSF analysis. 852. A 3yo girl presents with fever for 2d. She is drowsy and had a seizure causing twitching of the right side of the body for 4mins. Her RR=30 bpm, sat=90%, temp=38.9C, capillary refill time=2s. Urine negative on dipstick. What is the single inv most likely to lead to dx? a. Blood for C&S b. ESR c. CXR d. Urine for C&S e. CSF analysis This question is similar to the one given above. But here the patient is ‘drowsy and had a seizure’ which shows CNS involvement so we would go for CSF analysis to rule out meningitis most probably. 853. A 6m boy is admitted with persistent irritability. He is lethargic and is not feeding as well as usual. His RR=30bpm, sat=97%, temp=38.0C, capillary refill time=2s. Urine reveals leucocytes on dipstick. What is the single inv most likely to lead to dx? a. Blood for C&S b. ESR c. CXR d. Urine for C&S e. CSF analysis Again a similiar sort of a scenario. Only abnormal sign is the temperature with symptoms of irritability, lethargy and not taking feed. Here the urine analysis reveals leucocytosis pointing towards a possible diagnosis of UTI so we go for urine culture and sensitivity to know about the particular organism and the specific antibiotic for it. All other inv here will be useless until UTI has been ruled out. 854. A 3yo boy presents with a 1d hx of being unwell. He appears shocked and has 3h old rash made up of urticarial and purpural spots. His RR=30bpm, sat=94%, temp=39C, capillary refill time=1s. Urine is clean on dipstick. What is the single inv most likely to lead to dx? a. Blood for C&S

b. c. d. e.

ESR CXR Urine for C&S CSF analysis

Patient with fever and rash could lead to meningitis. In a previous question when meningitis was suspected we went for CSF analysis but here since there is a rash LP is contraindicated so we go for Blood C & S. Contraindications of LP: DIC; purpura or brain herniation is near (odd posture or breathing; glascow coma scale 25 and life style modifications have failed, start biguanides If BMI is < 25, start sulfonylurea 903. A pt presents with progressive dyspnea. He complains of cough, wheeze and a table spoonful of mucopurulent sputum for the last 18m. Spirometry has been done. FEV1/FVC=2.3/3.6. After taking salbutamol, the ratio=2.4/3.7. What is the most likely dx? a. Chronic bronchitis b. Asthma c. Bronchiectasis d. Lung fibrosis e. Sarcoidosis Key : a Clincher : table spoonful of mucopurulent sputum, FEV1/FVC ratio being medical therapy ( nifedipine ,alpha blocker ) if not passed , go for ESWL ( If < 1cm ) or dormia basket... PCNL ---> when stone is large ,multiple or complex.. Percutaneous nephrostomy ---> presence or infection or obstruction , to safe the kidney from reflux damage and save the person from Sepsis ( if pus collected ) 932. A 4yo boy presents with fever, severe ear ache, vomiting and anorexia. He also has mod tonsillitis. Exam: tympanic membrane bulging. He came to the GP a few days ago and was dx with URTI. What is the most appropriate dx? a. OE b. Acute OM c. Serous otitis d. Chronic suppurative OM e. Mastoiditis b. Acute OM Complications of tonsillitis include:

  

otitis media quinsy - peritonsillar abscess rheumatic fever and glomerulonephritis very rarely antibiotics are not routinely recommended. NICE recommends however that they should be considered in the following situations:  children younger than 2 years with bilateral acute otitis media  children with otorrhoea who have acute otitis media

933. A 3yo girl presents with complaints of sudden right facial weakness and numbness and pain around her ear. There are no symptoms. What is the most appropriate dx? a. SAH b. Bell’s palsy c. Stroke d. TIA e. Subdural hemorrhage b. Bell’s palsy Bell's palsy may be defined as an acute, unilateral, idiopathic, facial nerve paralysis. The aetiology is unknown although the role of the herpes simplex virus has been investigated previously. The peak incidence is 20-40 years and the condition is more common in pregnant women. Features  lower motor neuron facial nerve palsy - forehead affected*  patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis Management  in the past a variety of treatment options have been proposed including no treatment, prednisolone only and a combination of aciclovir and prednisolone  following a National Institute for Health randomised controlled trial it is now recommended that prednisolone 1mg/kg for 10 days should be prescribed for patients within 72 hours of onset of Bell's palsy. Adding in aciclovir gives no additional benefit  eye care is important - prescription of artificial tears and eye lubricants should be considered 934. A 6yo boy fell in the playground and has been holding his forearm complaining of pain. Exam: no sign of deformity or swelling. However, there is minimal tenderness on exam. What is the dx? a. Fx mid radius b. Fx mid ulnar c. Fx neck of humerus d. Fx shaft of humerus

e. Green stick fx of distal radius e. Green stick fx of distal radius Greenstick fractures common in children

Paediatric both-bone forearm fractures Fractures may be of greenstick type (incomplete) or complete. A greenstick fracture can occur in one bone with a complete fracture in the other. Complete fractures may be undisplaced, minimally displaced or overriding. Fractures of the proximal third are relatively rare. Middle third fractures account for about 18% of both-bone fractures and distal third fractures for about 75%.  Mechanism of injury: usually an indirect injury following a fall on to an outstretched hand. Occasionally caused by a direct trauma.  Presentation: pain, swelling and deformity at the fracture site.  Investigation: X-rays of the wrist, elbow and whole forearm should be taken.  Management: unlike the management of these fractures in adults, conservative management is still the first line of treatment for paediatric forearm fractures, especially in children less than 10 years old. [6]

935. A 62yo man has been smoking about 15 cigarettes/day for 45yrs, and has been working as a builder since he was 24yo. He presents with chest pain, SOB, weight loss. CXR shows bilateral fibrosis and left side pleural effusion. What is the best inv that will lead to dx? a. CXR b. Pleural fluid aspiration of cytology c. MRI d. Pleural biopsy e. CT d. Pleural biopsy Only biopsy confirms carcinoma Ct is the next step not the best step towards the diagnosis. The best work up leading to diagnosis should b pleural biopsy, Asbestosis predisposing to mesothelioma and therefore pleural biopsy Pleural fluid: straw coloured or blood stained. Cytological analysis occasionally leads to the diagnosis but a pleural biopsy is usually required.

936. During a basketball match, one of the players suddenly collapsed to the ground with coughing and SOB. What is the inv of choice? a. CXR b. CT c. MRI d. V/Q scan e. CTPA a. CXR

case of spontaneous pneumothorax...xray chest ...first Basketball player... tall height.... more chances of apical subpleural blebs... its SPONTANEOUS PNEUMOTHORAX.. so CXR is best

937. A 57yo man having HTN on oral anti-HTN. However, he is finding it difficult to mobilize as he feels dizzy whenever he tries to get up. What is the most appropriate inv for him? a. Ambulatory BP b. ECG c. MRI d. CXR e. CT a. Ambulatory BP

Who should be referred for ambulatory blood pressure monitoring? 

The National Institute for Health and Care Excellence (NICE) recommends that if a clinic blood pressure is 140/90 mmHg or higher, ABPM should be offered to confirm the diagnosis of hypertension. If a person is unable to tolerate ABPM, home blood pressure monitoring (HBPM) is a suitable alternative to confirm the diagnosis of hypertension.  Poorly controlled hypertension - eg, suspected drug resistance.  Patients who have developed target organ damage despite control of blood pressure.  Patients who develop hypertension during pregnancy.  High-risk patients - eg, those with diabetes mellitus, those with cerebrovascular disease, and kidney transplant recipients.  Suspicion of white coat hypertension - high blood pressure readings in clinic which are normal at home.  Suspicion of reversed white coat hypertension, ie blood pressure readings are normal in clinic but raised in the patient's own environment.  Postural hypotension.  Elderly patients with systolic hypertension. 938. A 33yo female complains of diplopia on upright gaze. Exam: ptosis can be seen. There are no other complains or any significant PMH. What is the most appropriate inv for him? a. Ophthalmoscopy b. Visual field test c. TFT d. CT e. Checking red reflex [5]

d. CT ptosis can be due to neurological causes of muscle weakness in this case , but there is associated diplopia so it’s better to exclude any nerve lesion through ct. 3rd nerve palsy

939. A tall rugby player was hit in the chest by a player of the opponent team. He developed breathlessness and his face went blue and purple. You have been called to look at him, how will you manage him? a. Insert a needle in the 2nd ICS in the mid-clavicular line b. Insert a needle in the 5th ICS in the mid-axillary line c. Intubate the pt d. Start CPR e. Give oxygen a. Insert a needle in the 2nd ICS in the mid-clavicular line Tension pneumothorax

940. A young woman fell and hit her knee. Exam: valgus test +ve. What ligament was most probably injured? a. Ant cruciate b. Medial collateral c. Lateral collateral d. Post cruciate e. Meniscus b. Medial collateral Medial collateral: Valgus stress test

Lateral collateral: Varus stress test Anterior Cruciate: Anterior drawer test, Lachman’s test, pivot shift test. Posterior cruciate: Posterior drawer test, posterior sag test. 941. A 75yo man comes in complaining of difficulty in passing urine, poor stream and dribbling at the end of voiding and anorexia. US shows bilateral hydronephrosis. What is the cause of these findings? a. BPH b. Renal stones c. Bladder stones d. Prostatic ca e. UTI d. Prostatic ca bph is common and BOO signs are present with it earlier but here the anorexia is given which points to carcinoma    

bladder outlet obstruction: hesitancy, urinary retention haematuria, haematospermia pain: back, perineal or testicular digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus

942. 2h after an appendectomy, a pt complains of a rapid HR and fever. He says there is also abdominal pain and pain in the shoulder area. What is happening to this pt? a. Intra-abdominal bleeding b. Anastomotic leak c. Sepsis d. Intestinal obstruction a. Intra-abdominal bleeding rapid HR due to haeg, shoulder pain due to diaphragmatic irritation following intraabdominal bleeding and fever for tissue reaction following surgery following appendicitis, gut anastomosis not needed and gut anastomosis is needed following large or small gut ischaemic necrosis or gangrene. Sepsis in 2 hours very unlikely post op h'age : primary- immediate or as a continuation of intraop bleed. reactionary : within 24hrs. secondary: upto 10 days. Mx: 1. fluid replacement - crystalloids upto 1000ml bolus and then maintain. 2.direct compression to control superficial bleeding if any. 3. cross match blood. 4. emergency surgery 943. A 50yo man presents with the complaints of recurrent UTI and occasional blood in the urine. Some unusual cells have been seen in urine on routine exam. Which os the following inv would

you like to carry out now? a. Cystoscopy b. Urine C&S c. XR KUB d. US e. CBC d. US the unusual cells may indicate malignancy , which in turn can be the cause of recurrent UTI .US followed by cystoscopy seems to be the appropriate approach. unusual cell points towards possible malignancy! may be bladder cancer or renal cell carcinoma. So we have two options, for bladder cystoscopy and for renal cell ca US. Before going to more invasive procedure we can think first noninvasive procedure. So US is more logical i think. for uti we can do c/s but that is not the major issue. 944. A 28yo drug user presents to ED collapsed and anuria. His serum K+=7.5mmol/l. CXR shows early pulmonary edema. What is the next appropriate management for this pt? a. Urgent hemodialysis b. IV calcium gluconate c. IV insulin + dextrose d. Furosemide e. IV 0.9% NS b. IV calcium gluconate cardioprotective Stabilisation of the cardiac membrane  intravenous calcium gluconate Short-term shift in potassium from extracellular to intracellular fluid compartment  combined insulin/dextrose infusion  nebulised salbutamol Removal of potassium from the body  calcium resonium (orally or enema)  loop diuretics  dialysis

945. DM man feels hot, painful lump near the anal region. What is the most probable dx? a. Anal fissure b. Abscess c. Hematoma d. Wart e. External hemorrhoids b. Abscess Perianal abscess: the most common (60%)

High-risk groups include those with diabetes, immunocompromised patients, people who engage in receptive anal sex and patients with inflammatory bowel disease. Symptoms include painful, hardened tissue in the perianal area, discharge of pus from the rectum, a lump or nodule, tenderness at the edge of the anus, fever, constipation or pain associated with bowel movements.  Prompt surgical drainage.  Medication for pain relief.  Antibiotics are usually not necessary unless there is associated diabetes or immunosuppression. 946. A 65yo lady with T1DM for the last 20y comes with a tender lump near the anal opening. She says she also has a fever. What tx should she get? a. I&D + antibiotics b. IV antibiotics c. C&S of aspirate from swelling d. Painkillers e. Cautery of swelling a. I&D + antibiotics see q 245

947. An 80yo DM lady presents with redness and swelling over her right foot. It is tender to touch, warm and glossy. What are the complications this pt might develop? a. Meningitis b. Sepsis c. Ulcer d. Gangrene d. Gangrene Cellulitis to wet gangrene In clinical setting in diabetics it's usually cellulitis then gangrene then sepsis.

Complications of cellulitis Complications are uncommon but may include:  Abscess formation.  Gangrene.  Thrombophlebitis/lymphangitis.  Chronic leg oedema (a late complication which may predispose to further episodes of infection). Less common complications (occurring in 5% INvestigations : PT,BT,fibrinogen and Von willebrand Normal APTT) - usually prolonged, Factor VIII:C - is reduced Treatment: Children with severe haemophilia (ONce weekly prophylaxis with FActor VIII) Recombinant factor VIII preferred. Fresh frozen plasma and cryoprecipitate should only be used in an emergency when the concentrates are not available Desmopressin boosts Factor VIII activity. 962. A 53yo lady presents with hot flash and night sweats. Her LMP was last year. She had MI recently. What is the most appropriate management for her? a. Raloxifene b. Estrogen c. COCP d. Evening primrose e. Clonidine Ans : Correct Answer is Clonidine .Clonidine has cardiac uses like antihypertensive and diagnosis of pheochromocytoma (by reducing nor epinephrine) And non cardiac uses like post menopausal vasomotor symptoms ,opioid withdrawal,diabetic diarrhoea,smoking cessation, and analgesia

HRT contraindicated in pts with recent MIs or ischemic episodes. Contraindications:  

pregnancy undiagnosed abnormal vaginal bleeding

   

active thromboembolic disorder or acute-phase myocardial infarction suspected or active breast or endometrial cancer active liver disease with abnormal liver function tests porphyria cutanea tarda

As transdermal oestrogen is associated with fewer risks than oral HRT, a transdermal route may be preferable for many women. This route is also advantageous for women with diabetes, hypertension and other cardiovascular risk factors, and also especially with advancing age 963. A 73yo man who was a smoker has quit smoking for the past 3yrs. He now presents with hoarseness of voice and cough since past 3wks. XR: mass is visible in the mediastinum. What is the best inv to confirm the dx? a. Bronchoscopy b. Thoracoscopy c. US d. CT thorax e. LN biopsy Ans: E Reason : the patient seems to be affecting from Bronchogenic Carcinoma, The Key diagnosis as rccomended by NICE Xray CT Bronchoscopy with Biopsy Biopsy of a convenient metastatic site should be performed if this is easier than biopsy of a primary site . (Biopsy remains the best investigation to confirm the diagnosis) NICE strongly recommends a new imaging test,18F-deoxyglucose positron emission tomography (FDG-PET), to help stage tumours Treatment Small cell tumours are usually treated with 4-6 cycles of multi-drug platinum-based chemotherapy with the possibility of added radiotherapy in limited stage disease. Most Rapidly Growing+Worst Prognosis Staging of the disease and the patient’s overall fitness and exercise ability will determine the type of treatment chosen Surgery , Radiotherapy, Radical Radiotherapy , RADIO+ Chemo 964. A 52yo man known DM presents to ED with sudden onset of pain in the left loin and hematuria. Inv: 8mm stone in left lower ureter. Nifedipine with steroids was prescribed as initial tx with supportive therapy. He

returned complaining of worsening pain, vomiting with passing of 2 stones. Renal function tests indicate impending ARF. How will you manage this pt? a. Continue same tx b. Start alpha blocker c. ESWL d. Percutaneous nephrolithotomy e. Percutaneous nephrostomy f. Open surgery Ans: E Reason : Emergency Treatment with percutaneous nephrostomy and or ureteric stent insertion is necessary if either pain or obstruction is persistent. 95% of those 2-4 mm in diameter pass spontaneously but passage may take as long as 40 days (ESWL) - shock waves are directed over the stone to break it apart. The stone particles will then pass spontaneously.(Acute urinary tract infection or urosepsis Contraindication for ESWL) Percutaneous nephrolithotomy (PCNL) - used for large stones (>2 cm), staghorn calculi and also cystine stone Open surgery reserved for multiple stone/complicated cases

965. A lady who is alcohol dependent wants to quit but wants someone to encourage her. What would you do? a. Medication b. Refer to social services c. Refer to psychology d. CBT ANS: B She should be Advised to join a Support Group to Help her Quit. 966. A young girl presented to OBGYN assessment unit with lower abdominal pain and per vaginal bleeding after a hx of hysterosalpingograph as a part of her infertility tx. Observation: BP=90/50mmHg, pulse=120bpm, exam revealed rigid abdomen. What is the most appropriate next inv? a. CT b. XR erect and supine c. US abdomen

d. e.

Coag profile CXR

ANS: C Reason : USG abdomen will confirm the presence of blood in the abdominal cavity, infections can occur after Hysterosalpingography along with vaginal bleeding, fever and foul smelling discharge. TEST RISKS  allergic reaction to contrast dye  endometrial (uterine lining) or fallopian tube infection  injury to the uterus, such as perforation 967. A 21yo woman who is on COCP had to take azithromycin. What should be advised for her contraception? a. Using 7d condoms after antibiotics and avoid pill free break b. Using 14d condoms after antibiotics and avoid pill free break c. Using 7d condoms after antibiotics d. No extra precaution e. Using 14d condoms after antibiotics ANS: D REASON : NON enzyme inducing antibiotics no extra precaution necessary. Type of medication

Advice given

Non-enzyme-inducing antibacterial.

Women should be advised that no additional contraception is required.

Short course of enzyme-inducing antibacterials rifampicin or rifabutin.

Women are advised to continue taking the COCP and use additional precautions. Monophasic 21day pills should be taken either as an extended regimen (continue packets without a break until 3-4 days of BTB occurs, then have 4-day pill-free interval) or a tricycling regimen (three packets without a break then a 4-day pill-free interval). Additional contraception should be continued for 28 days after stopping the rifampicin/rifabutin.

Long-term course of Should be advised to use an alternative, nonenzyme-inducing hormonal method where possible (very potent antibacterials enzyme inducers). rifampicin or rifabutin. Other enzymeinducing drugs, including anticonvulsants, St John's wort, etc.

Short course: advice is as per that above for rifampicin/rifabutin. Long course: women should be encouraged to use alternative methods of contraception. If, having considered alternatives, they still choose the COCP, the patient should be advised of the increased risk of pregnancy. Should use a preparation containing at least 50 micrograms of oestrogen. Tricycling or extended regimens as above should be used. If BTB occurs on 50 micrograms, the dose should be increased to a maximum of 70 micrograms.

Lamotrigine.

Women should be advised not to take lamotrigine with the COCP and should seek another form of contraception (unless also taking a non-enzymeinducing anticonvulsant such as sodium valproate).

Antiretroviral therapies.

Those women on ritonavir-boosted protease inhibitors should be advised to use alternative methods of contraception.

Ulipristal acetate.

Women should use additional contraceptive precautions for 14 days after taking ulipristal acetate as ellaOne® for emergency contraception (16 days for Qlaira®). Those taking ulipristal in a higher dose as Esmya® for fibroids should not be advised to use alternative contraception.

968. A 60yo woman presented with radial fx and had a colle’s fx and supracondylar fx in the past. What inv is req to detect her possibility of having the same prb later? a. Dexa scan b. MRI c. Nuclear bone scan d. CT

e.

Bone biopsy

ANS: A Reason: Increasing Age is associated with osteoporosis and increasing incidence of fractures, DEXA scan measures the density of the bone and chances of bone fracture. 969. A 43yo woman presents with low mood, loss of libido, sleep disturbance, tiredness, palpitation, chest discomfort, irritability and recurrent worries. What is the most likely dx? a. Seasonal Affective Disorder b. Mod depression c. Dysthymia d. GAD e. Bipolar disorder And: moderate depression Typical features of depression , season affective disorder mostly affects during specific time of the year mostly in winters ,patient tend to be low ,loss of interest and increased somnolence. dysthymia is a serious state of chronic depression, which persists for at least two years 970. Which of the following is true for tamoxifen? a. Increased incidence of endometrial carcinoma b. Increased risk of breast ca c. Increased risk of osteoporosis d. Increased risk of ovarian ca Ans: A Tamoxifen is associated with increased risk of endometrial cancer . 971. A 45yo male complains of tremors in hands. Exam: tremors are absent at rest but present when arms are held outstretched and persist on movement. What is the most probable dx? a. Parkinsonism b. Benign essential tremor c. Cerebellar disease d. Liver failure

e.

Stroke

Ans: B Reason . the patient is suffering from postural tremors , no tremors at rest ,present on persisted posture and movement . Causes : Benign Essential Tremor Rest tremor: abolished on voluntary movement. Cause: parkinsonism. Intention tremor: irregular, large-amplitude, worse at the end of purposeful acts, eg finger-pointing or using a remote control. Cause: cerebellar damage (eg MS, stroke). Postural tremor: absent at rest, present on maintained posture (arms out-stretched) and may persist (but is not worse) on movement. Causes: Benign essential tremor (autosomal dominant; improves with alcohol), thyrotoxicosis, anxiety, β-agonists. 972. Pregnant lady had her antenatal screening for HIV and Hep B. what more antenatal inf should she be screened for? a. Rubella and syphilis b. Toxoplasma and rubella c. Syphilis toxoplasma d. Hep C & E e. Hep A & C ANs : A Reason: Routine ANtenatal INfectious Screen .. Rubella, Syphilis, HIV, HEP B Hep C offered if Patient thinks she may be infected. 973. A young man has been found in the park, drunk and brought to the ED by ambulance. He recently lost his job and got divorced. He thinks nurses are plotting against him. What is the most likely dx? a. Schizoid personality b. Borderline personality c. Schizophrenia d. Psychotic depression e. Paranoid personality Ans: C Reason : delusional, history of unstable job and family life.

974. An elderly man who used to work in the shipyard industry presented with cough and SOB few weeks to months. He was given salbutamol nebulization and antibiotics and admitted to the ward. He died 3d later. CT: patchy infiltrates, pleural thickening and pleural effusion. Why is this a coroner’s case? a. Pt got wrong dx or management b. Pt died soon after admission c. Death could be due to occupational illness Ans: C Reason: history suggests this could be a case of asbestosis. 975. A 26yo lady came with abdominal pain, vaginal discharge and low grade fever. What is the most likely dx? a. HELLP syndrome b. Acute PID c. Ectopic pregnancy d. Appendicitis Ans: B Reason : typical cilinical picture of PID. S/S lower abdominal pain, deep dyspareunia , abnormal vaginal or cervical discharge often purulent .lower abdominal tenderness, fever. Diagnosis : testing for gonorrhea and chlamydia in lower genital tract. Elevated ESR ,C reactive protein D/D .ectopic pregnancy , appendicitis Management : broad spectrum antibiotics to cover gonorrhea and chlamydia. Cefoxitin/ceftriaxone followed by doxycline showed good outcome . Oral ofloxacin 400 mg bd + mteronodalzole 400 mg bd 14 days 976. A new screening test has been devised to detect early stages of prostate ca. However, the test tends to dx a lot of ppl with no cancer, although they do have cancer as dx by other standard tests. What is this flaw called? a. False +ve b. True +ve c. False –ve

d. True –ve e. Poor specificity ans: C Reason : diagnosing disease positive patients as no disease present known as false negative . 977. A 26yo political refugee has sought asylum in the UK and complains of poor conc. He keeps getting thoughts of his family whom he saw killed in a political coup. He is unable to sleep and feels hopeless about his survival. Because of this he is afraid to go out. What is the most likely dx? a. Acute stress disorder b. PTSD c. Social phobia d. OCD e. GAD Ans: B Reason : post traumatic stress disorder is delayed or prolonged response to stressful situation. E.g Sexual abuse, War, Road traffic accident, human disaster . 978. A 2yo boy presented with gradual swelling of feet and poor feeding. He has gained weight and has dark urine. What is the single most appropriate inv? a. Serum albumin b. 24h urinary protein c. Serum calcium d. BUE e. Serum glucose Ans: the clinical features correlate with loss of protein , it could be due to any underlying disease presenting itself as nephrotic syndrome . 979. A 26yo lady presents with high fever, lower abdominal pain and purulent vaginal discharge. She looks very unwell. What is the most appropriate management? a. Tetracycline 250mg QD b. Doxycycline 100mg BD and metronidazole 400mg BD c. IV Ceftriaxone 2g with doxycycline 100mg

d. e.

IV ceftriaxone 2g with doxycycline 500mg Ofloxacin 400mg BD and metronidazole 400mg BD

Ans: C Reason : patient seems to be suffering from acute PID and the recommended management is broad spectrum antibiotics therapy to cover chlamydia and gonorrhea. First line in inpatient patients severe infection is Iv Ceftriaxone 2g + doxycline 100 mg bd. 980. A 39wk pregnant woman came to labor suite 3d after an obstructed labour presents with pain and swelling of one leg. Exam: leg has blue mottling and is cold. What is the dx? a. DVT b. Post phlebitis syndrome c. Embolus d. Varicose vein e. Herpes gladiatorum Ans:C Reason : clinical features of limb ischemia suggestive of thromboembolic phenomena , S/S The affected part becomes pale, pulseless, painful, paralysed, paraesthetic and 'perishing with cold' ('the 6 Ps').[1] The onset of fixed mottling of the skin implies irreversible changes INV: Hand held Doppler , Blood Tests , identify Source ( ECG,Echo,Aortic USG, Popliteal femoral artery USG) Treatment :- emergency , urgent heparinization If occlusion embolic : embolectomy with Fogarty catheter , bypass graft ( post op heparinization required) If occlusion thrombotic : I) intra arterial thrombolysis II) Angioplasty III) bypass surgery After thrombolysis or amputation if ischemia progressed treat underlying cause .

981. An 8yo boy has his tonsils and adenoids removed. On the 7 post-op day, he comes back to the ED with hemoptysis and fever. What is the most appropriate management? a. Admit for IV antibiotics b. Prescribe oral antibiotics and discharge c. Packing d. Surgery e. Reassurance Ans A Hemorrhage between 1 to 2 weeks post op is called secondary hemorrhage and is due to infection , depending on the severity of the condition the patient should be admitted and managed on iv antibiotics . th

982. A 50yo female had swelling in her ankles. She is a known alcoholic. Now she presented with breathlessness and palpitations. What is the most likely cause of her condition? a. VT b. SVT c. A-flutter d. A-fib e. V-ectopics Ans D Holiday Heart Syndrome : Holiday heart syndrome is an irregular heartbeat pattern presented in individuals who are otherwise healthy. Coined in 1978 the term is defined as arrhythmias sometimes following excessive alcohol consumption; usually temporary" .

Holiday heart syndrome can be the result of stress, dehydration, and drinking alcohol. It is sometimes associated with binge drinking common during the holiday season Most Common Arryhtmias : Afib , Aflutter sometimes SVts. Increased alcohol promotes alcoholic cardiomyopathy, heart failure and arrhythmias. S/S Alcoholic Cardiomyopathy  shortness of breath  swelling of the legs  rapid and irregular heartbeat

   

rapid and irregular pulse fatigue, weakness, dizziness, fainting an enlarged liver cough that produces a frothy, pink mucus

983. A young boy has acute scrotal pain for a few hours. Exam: one testis is very painful to touch. He had this kind of pain before but it was mild and resolved itself within 30mins. What would you do next? a. Urgent exploration b. US c. Antibiotics d. IV fluids e. Doppler US Ans: A Reason Testicular Torsion , usually affects unilaterally.typically sudden, severe pain in one testis.abdominal pain , often comes during sports or physical injury, history of previous, brief episodes of similar pain (presumably a torsion that corrected itself ) nausea vomiting, Diagnosis: most important investigation is ultrasound integrated with colour Doppler. A very significant finding is the detection of presence/absence of intratesticular blood flow for the early identification of testicular torsion. An acute scrotum in a child requires surgical exploration for a definitive diagnosis Management : It may be possible to reduce torsion manually , But the Prefered option is always exploration. 984. An 8wk pregnant woman presents with persistent vomiting and weight loss. Exam: HR=110bpm. Dehydration was corrected with NS infusion and K+. The condition didn’t improve so IM cyclizine was given. She is still vomiting. What is the next appropriate management? a. IV fluids b. IV antiemetics c. IV steroids d. Terminate pregnancy e. Thiamine

Ans: C Hyperemesis Gravidarum intractable vomiting associated with weight loss of more than 5% of prepregnancy weight, dehydration, electrolyte imbalances, ketosis, and the need for admission to hospital. Usually Occurs before 12 weeks of gestation. Treatment: Fluid Resuscitation with potassium replacement should be done Vitamins should be routinely given , thiamine , pyridoxine Nutritional support thromboprophylaxis Antiemetics to control vomiting Corticosteroids to control intractable cases 985. A 28yo lady presents with dyspareunia and dysmenorrhea. She is very obese. She now wants reversible contraceptive method. Which of the following will be most suitable for her? a. Minera b. COCP c. POP d. Copper T e. Barrier method Ans: A Mirena preferred in Obese,diabetes,epilepsy,migraine and in women with contraindication to oestrogens.Reduced menstrual loss and Dysmenorrhea , rapid return of fertility with removal. Other Users: Menorrhagia and HRT (prevention of endometrial hyperplasia during oestrogen therapy) 986. A young lady who is 28wks pregnant presents with vaginal bleeding. She has lost about 200 ml of blood. Exam: uterus is tender. Resuscitation has been done. What is the most imp inv to establish the dx? a. US b. CT c. D-dimer d. Clotting profile e. None Ans: A

USG abdomen can easily visualize underlying cause of bleeding. To see fetal status and uterus. 987. A 14yo girl presents with primary amenorrhea and a short stature. What is the most likely dx? a. Down’s syndrome b. Klinefeltner’s syndrome c. Turner’s syndrome d. Fragile X syndrome e. Normal finding ANs: C most likely it is Turner, which is associated with impaired pubertal growth spurt and ovarian dysgenesis. D/D Constitutional Growth failure 988. A 32yo woman wants reversible form of contraception. She has one child delivered by emergency C-section. She also suffers from migraine and heavy periods. What is the most suitable form of contraception for this lady? a. COCP b. Mini pill c. IUCD d. Barrier method e. Abstinence Ans: C Reason : Mirena preferred in Obese,diabetes,epilepsy,migraine and in women with contraindication to oestrogens.Reduced menstrual loss and Dysmenorrhea , rapid return of fertility with removal. Other Users: Menorrhagia and HRT (prevention of endometrial hyperplasia during oestrogen therapy) 989. A 45yo known hypertensive man presents with hematuria, proteinuria and edema. What is the definitive dx test for him? a. Urine protein b. Renal biopsy c. Renal function test d. Urine microscopy e. Serum protein Ans: B

Pt seems to be suffering from nephritic syndrome , the definitive diagnosis can be made on renal biopsy. 990. A 47yo man presents with proteinuria, BP=160/95 mmHg, small kidneys that have smooth renal pelvis. What is the most probable dx? a. GN b. Chronic pyelonephritis c. Unilateral renal artery stenosis d. Multiple myeloma e. ARF ANS : A Reason : GN is a common cause of CKD, presenting with proteinuria, hypertension and small kidneys. 991. You are the HO in the hospital and the lab report of a pt shows glucose=4mmol/l, K+=5.2mmol/l, Na+129mmol/l. what is the most appropriate management? a. NS 0.9% b. NS 0.45% c. NS 0.9% and insulin d. Insulin e. Dextrose ANS: A Reason: The immediate concern is correction of hyponatremia. 992. A 27yo man presents with abdominal pain. He says his urine is dark. Exam: BP=160/105mmHg. What is the most appropriate inv? a. US b. Renal biopsy c. CT d. Urine protein e. Urine microscopy Ans:A USG will confirm Abdominal pain, hematuria and hypertension are classic feature of autosomal dominant polycystic kidney disease. The disease process usually

begins before the age of 30 yrs and renal failure are evident at about 60 yrs of age 993. A 12m child with AIDS is due for his MMR vaccination. What is the single most appropriate action? a. Defer immunization for 2wks b. Don’t give vaccine c. Give half dose of vaccine d. Give paracetamol with future doses of the same vaccine e. Proceed with standard immunization schedule ANS: B Reason: Measles, mumps and rubella (MMR) vaccine is a freeze-dried preparation containing live attenuated measles, mumps and rubella viruses HIV-positive individuals. Severely immunocompromised patients should not be given the vaccine but it is indicated for patients with mild-to-moderate immunosuppression. The degree of immunosuppression is estimated using the patient's age and CD4 count 994. A young man presents with sudden, severe pain and swelling in the scrotum. Exam: one testis seems higher than the other. What is the most probable dx? a. Varicocele b. Hematocele c. Testicular tumor d. Epidiymo-orchitis e. Testicular torsion ANS: E Reason: History: Testicular Torsion , usually affects unilaterally.typically sudden, severe pain in one testis.abdominal pain , often comes during sports or physical injury, history of previous, brief episodes of similar pain (presumably a torsion that corrected itself ) nausea vomiting EXAM:usually reddening of the scrotal skin.There is a swollen, tender testis retracted upwards.Lifting the testis up over the symphysis increases pain, whereas in epididymitis this .usually relieves pain.testes on both sides are characteristically in the 'bell-clapper position' with a horizontal long axis.

995. A 24yo male involved in RTA with XR: fx neck of humerus. What is the single most associated nerve injury? a. Axillary nerve b. Radial nerve c. Median nerve d. Ulnar nerve ANS:A Most common nerve injury associated with Humerus neck fracture is Axillary Nerve injury. 996. A 64yo man complains of increasing SOB and cough for the past 18m. He coughs up a Tbsp of mucopurulent sputum with occasional specks of blood. What is the most likely underlying cause? a. Acute bronchitis b. Bronchiectasis c. Chronic bronchitis d. Lung cancer e. Pneumonia ANS: B

It is usually accompanied by a chronic cough, mucopurulent sputum production and recurrent infections presentation:daily expectoration of large volumes of purulent sputum. symptoms including dyspnoea, chest pain and haemoptysis suspect bronchiectasis ,presents with Persistent productive cough, especially if any one of the following: Young age at presentation.History of symptoms over many years.Absence of smoking history.Daily expectoration of large volumes of very purulent sputum.Haemoptysis.Sputum colonisation with P. aeruginosa Diagnosis: CXR normal or show ring or tubular opacities, tramlines and fluid levels. HRCT gold standard for diagnosis Sputum Exam Management: Physiotherapy

Antibiotic therapy in Acute Exacerbation. Amoxicillin, Clarithromycin, Ciprofloxacin in P.aeruginosa. Long term Antibiotic : pts having three or more exacerbations per year. NOT RECOMMENDED Corticosteroids - inhaled or oral - unless there is co-existent asthma. Mucolytics.Leukotriene receptor antagonists. Surgery:Lung resection surgery may be considered in patients with localised disease in whom symptoms are not controlled by medical treatment 997. A 55yo man who is hypertensive suddenly lost his vision. The retina is pale and fovea appears as a bright cherry red spot. What is the single most appropriate tx? a. Pan retinal photocoagulation b. Corticosteroids c. Scleral buckling d. Surgical extraction of lens e. Pressure over eyeball ANSS: E Reason: Presentaion in Central Retinal Artery occlusion is painless loss of vision unilaterally over a few seconds.Can be a HX of Amaurosis Fugax. Exam:afferent pupillary defect, a pale retina with attenuation of the vessels. segmentation of the blood column in the arteries ('cattle-trucking') and the centre of the macula (supplied by the intact underlying choroid) stands out as a cherry-red spot Management: Presentation within 90-100 min Occular massage can be tried. Paracentesis and acetazolamide to reduce intraocular pressure Sublingual isosorbide dinitrate. Oral pentoxyphylline 998. A 32yo man with schizophrenia and a hx of violence and distressing auditory hallucinations was admitted to the ward with aggressive behavior and has already smashed his room. He is refusing any oral meds. What is the single most appropriate injection? a. Flupenthixol b. Fluphenazine c. Haloperidol d. Paraldehyde

e.

Risperidone

ANS: C Haloperidol indicated acute psychosis and violent settings,hyperactivity aggression,hyperactive delirium, Haloperidol can be used to treat acute psychosis and has proven efficacy for agitation.benzodiazepines can decrease agitation and have efficacy similar to Haloperidol but cause more sedation , Benzodiazepines other than lorazepam and midazolam should not be administered IM because of erratic absorption. Ziprasidone, 20 mg IM, is well tolerated and has been shown to be effective in decreasing acute agitation symptoms in patients with psychotic disorders. Olanzapine is as effective as haloperidol in decreasing agitation in patients with schizophrenia, with lower rates of EPS.Both IM ziprasidone and olanzapine have a relatively rapid onset of action (within 30 minutes), which makes them reasonable choices in the acute setting. Olanzapine has a long half-life (21 to 50 hours); therefore, patients’ comorbid medical conditions, such as cardiac abnormalities or hypotension, must be considered.If parenteral medication is required, IM olanzapine or IM ziprasidone is recommended. IM haloperidol with a benzodiazepine also can be considered. 999. A 65yo man complains of hematuria, frequency, hesistancy and nocturia. He reports that on certain occasions he finds it difficult to control the urge to pass urine. Urine microscopy confirms the presence of blood but no other features. What is the most porbable dx? a. BPH b. Bladder ca c. Prostatic ca d. Pyelonephritis e. Prostatitis ANS: C Reason: Prostatic CA, presents with symptoms of LUTS initially and in locally invasive disease there can be hematuria,dysuria,incontinence. 1000. A 60yo man presents with mass in the groin. Exam: mass lies below the midpoint of the inguinal ligament and is pulsatile. What is the most probable dx? a. Direct inguinal hernia

b. c. d. e.

Saphenavarix Femoral hernia Irreducible hernia Femoral aneurysm

ANS: E Femoral aneurysms: These are the second most common peripheral aneurysm.Patients present with local pressure symptoms, thrombosis, or distal embolisation.A pulsatile mass can be felt in the groin 1001. An 82yo man has woken up with incoherent speech and difficulty in finding the right words. Exam: otherwise normal, good comprehension. Which anatomical site is most likely to be affected? a. Broca’s area b. Wernicke’s area c. Midbrain d. Parietal cortex e. Pons ANS: A Reason: Broca’s area is associated with motor part of speech, incoherent speech, though the patient is able to understand speech. Wernicke area is associated with sensory part of speech ,it affects understanding and as well as speech production 1002. A 25yo woman has a recent cough, hoarseness and swelling in the neck. There are several non-tender swellings on both sides of her neck. She has lost 13kgs. She takes recreational drugs. What is the most probable dx? a. Thyrotoxicosis b. Hyperthyroidism c. Vocal cord nodules d. Carcinoma bronchus e. TB ANS: TB History and clinical picture suggests pulomonary TB spread locally and distantly into lymph nodes.( non tender matted rubbery lymph nodes).Wt

loss cough. Immunocompromised , HIV, drug abusers are at increased risk of developing active TB. Treatment Active Respiratory TB: 2month initial phase Isoniazid+Rifampicin+erhambutol+pyrizinamide 4month continuition with Isoniazid+rifamipicin Meningeal TB treated for 12 months : 2months Isoniazid+Rifampicin+erhambutol+pyrizinamide 10 months Isoniazid+rifamipicin Glucocorticoid with gradual withdrawal. LTBI: 3month treatment with rifampicin + isoniazid 1003. A 30yo woman presents with acute headache. She complains of seeing halos especially at night. What is the single most likely defect? a. Paracentral scotoma b. Monocular field loss c. Tunnel vision d. Central scotoma e. Cortical blindness This is glaucoma paracentral scotoma first, f/b a SEIDEL'S scotoma, f/b an arcuate and a double arcuate scotoma and finally a tunnel vision leading to blindness.

1004. A 35yo man presents with a headache that worsens on bending his head forward. What is the most likely dx? a. Chronic sinusitis b. SAH c. Migraine d. Cluster headache e. Tension headache Ans : A Reason : None of the other type of headaches have any effect on bending. 1005. A 20yo man presents with painful swallowing. Exam: trismus and unilateral enlargement of his tonsils. The peritonsillar region is red, inflamed and swollen. What is the most appropriate tx? a. Oral antibiotics

b. c. d. e.

IV antibiotics and analgesics I&D with antibiotics Analgesics with antipyretics Tonsillectomy

Ans:C/E ( Both Answers considered Equally Acceptable , But tonsillectomy should offer better treatment)

Reason: The Patient Seems to be suffering from peritonsillar abscess IV fluids and IV antibiotics along with analgesics should be prescribed.Medical treatment alone is no longer considered sufficient,Needle aspiration, incision and drainage and quinsy tonsillectomy are all considered acceptable for the surgical management of acute peritonsillar abscess.Some surgeons advocate acute (immediate) tonsillectomy as a treatment for peritonsillar abscess. 1006. A 40yo manual worker presents with a swelling in the groin. Exam: mass is found to be just above and lateral to the pubic tubercle. It is reducible. On applying pressure on the internal ring there is no cough impulse seen. What is the most probable dx? a. Direct inguinal hernia b. Indirect inguinal hernia c. Femoral hernia d. Strangulated hernia e. Femoral aneurysm Ans: B Ring occlusion done to confirm it 1007. A 34yo male presents with headache and vomiting. Exam: temp=38.5C, neck stiffness, discharge from left ear and right sided hyperreflexia with an extensor plantar response. What is the most likely dx? a. Cerebral tumor b. Meningitis c. Cerebellar tumor d. Cerebral abscess e. Normal pressure hydrocephalus Ans: D

Reason: unilateral (Right Sided)hyperreflexia and extensor plantar response indicates upper motor type palsy, due to space occupying lesion( tumour/abscess) on the left side. Headache & vomiting indicates raised intracranial pressure but raised temperature and neck stiffness favours abscess/ meningitis. in meningitis the aforementioned unilateral focal signs (hyperreflexia) usually absent. left sided ear discharge indicates origin of abscess from left middle ear. so roughly all symptoms indicates Left sided brain abscess S/S Fever, headache, and neurological problems, while classic, only occur in 20% of people. The symptoms of brain abscess are caused by a combination of increased intracranial pressure due to a space-occupying lesion (headache, vomiting, confusion, coma), infection (fever, fatigue etc.) and focal neurologic brain tissue damage (hemiparesis, aphasia etc.). The most frequent presenting symptoms are headache, drowsiness, confusion,seizures, hemiparesis or speech difficulties together with fever with a rapidly progressive course. The symptoms and findings depend largely on the specific location of the abscess in the brain Diagnosis: Ct brain , shows space occupying lesion after a few days there is ring enhancement . Management: IV antibiotics , sensitivity should be done . hyperbaric oxygen therapy .

1008. A 26yo male presents with speech difficulties. Exam: nystagmus. Which anatomical site is most likely to be affected? a. Midbrain b. Pons c. Cerebellum d. Cerebrum e. Vestibule cochlear nerve ANS: C Scanning speech , nystagmus, ataxia, dysdiadochokinesia, tremors,past pointing.loss of balance.

1009. A 75yo man presents with Bell’s palsy. His PMH is significant for late onset asthma and heart failure. He also reports to have consulted his GP for generalized rash prv. CXR: multiple soft shadows and CBC: eosinophilia. What is the single most likely positive antibody? a. P ANCA b. C ANCA c. Anti Ro d. Anti DS DNA e. Anti centromere Ans: A Reason: Churg Straus Syndrome A rare diffuse vasculitic disease affecting coronary, pulmonary, cerebral, abdominal visceral and skin circulations. The vasculitis affects small- and medium-sized arteries and veins and is associated with asthma. Presentation: Allergic rhinitis, Pulmonary Symp(ASthmna, granulomatous infiltrates). Cardiac S/S (cardiac failure, myocarditis). Skin Manfestations ( Purpura , nodules, livedo reticularis). Glomerulonephritis, Peripheral neuropathy,myositis.Bowel Ischemia,bleeding,perforation. Investigations: Antineutrophil cytoplasmic antibodies (ANCA): 70% of patients are perinuclear staining (p-ANCA) positive (anti myeloperoxidase antibodies). eosinophilia and anaemia on the FBC; elevated ESR and CRP; elevated serum creatinine; increased serum IgE levels, hypergammaglobulinemia; proteinuria, microscopic haematuria and red blood cell casts in the urine.Chest X-ray: pulmonary opacities, transient pulmonary infiltrates, pleural effusions. Treatment: High dose steroids usually enough. Cyclophosphamide and azathioprine in severe cases. IV immune globulins +Plasma exchange Overall prognosis good 1010. A 50yo man complains of visual prbs and dull pain in the left eye. Fundoscopy reveals papilloedema. He was dx with MS 2yrs ago. There is no consensual light reflex of the right eye. What is the single most likely defect?

a. b. c. d. e.

Paracentral scotoma Mono-ocular field loss Homonymous upper quadrantanopia Central scotoma Homonymous lower quadrantanopia

ANS: B Reason : As the Pt wa diagnosed with M.S, M.S mostly affects vision unilaterally, with optic neuritis,papilloedema ,painful eye , decreased vision, blindness or hemianopia.thus loss of consensual light reflex in the opposite eye. 1011. A 54yo pt wakes up with right sided weakness. His current medication is bendroflumethiazide for HTN. Pulse=92bpm, BP=160/90mmHg. CT shows left cerebral infarct. What is the most appropriate tx? a. Alteplase b. Aspirin c. Clopidogrel d. Dipyridamole e. Simvastatin Ans: A Reason:Reason : If a patient with ischemic stroke presents within 4.5 hours of ischemic episode thrombolysis can be tried. Do a CT 24 hrs Post thrombolysis.after that patients are prescribed Aspirin 300 mg for 2 weeks.( ischemic stroke is a gradual process and episodes might take place during sleep) CI: major infarct or hemorrhage mild deficit Recent Birth,Surgery,Trauma Past CNS bleed Seizures at presentation platelets 220/130

1012. A 33yo man presented to the GP with hx of headaches and photophobia. The GP examines him and finds a rash and is now ringing you at the hospital for advice. What would you advise the GP?

a. b. c. d.

Send pt home Start IV benzylpenicillin Conduct LP Start IV ceftriaxone

ANS: B Reason: Headache,photophobia and skin rash points towards developing Meningococcal meningitis due to N.Meningitidis, the patient should be immediately started on Iv Benzylpenicillin. 1013. An 89yo pt has lung cancer. His Na+=122mmol/l. What is the tx for this? a. Demeclocycline b. Vasopressin c. Restrict fluids d. Reassure ANS C Common paraneoplastic syndrome due to small cell lung cancer is SIADH, Treatment: Always treat the underlying cause Hyponatremia is generally defined as a serum sodium level of less than 135 mEq/L and is considered severe when the serum sodium level is below 125 mEq/L Midl hyponatremia present with suble unrecognized symptoms (131 mmol or above ) change of gait,posture . Neurological S/S develop below 115 mmol/L , seizures ,coma. The development of S/S also depends upon how fast or severe the sodium change is , sometimes in chronic settings pts are even able to handle severe diminished sodium levels due to adaptation . In asymptomatic Chronic setting : Fluid Restriction is firstline, If it is not sufficient move towards drugs, DEMECLOCYCLINE (potent inhibitor of vasopressin) In acute not so severe Hypovolemic : 0.9%/saline replacement . Normovolemic: Fluid restrict (500-1000 ml/day) if inadequate consider NaCl tablets or 3% saline . Furosemide,demeclocycline,vaptans

In Acute (Symptomatic Patients) emergency : 3% NS should be given, the target should be to increase serum NA 3.5: all prev and abd pain, vomiting, dehydration, arrhythmia, pancreatitis, coma. Nephrocalcinosis. Causes: malignancy and prim hyper PTH, sarcoisosis, TB, Endocrine conditions, thiazide, vit D, Familial FHH, prolonged immobilization. Investigations: Corrected Ca levels. Rx: rehydrate with Normal Saline, furosemide. IV Bisphosphonates after hydration . 1028. A 27yo lady after C-section developed epigastric pain after 8h. What is the appropriate inv? a. ABG b. Coag profile c. Liver enzyme d. Liver biopsy symptom is pointing towards liver abnormality. So C is most likely. Could be because of HELLP syndrome characterized by hemolysis, elevated liver enzymes, low platelets. Usually occurs in pregnant females of pre eclampsia and eclampsia. May present in last half of pregnancy or shortly after delivery. Initial symptoms are non specific. Like malaise, fatigues, epigastric pain, nausea Investigation: CBC with peripheral smear, raised serum LDH, Bilirubin, liver enzymes. Rx: deliver as soon as possible If post partum then give steroids and plasma exchange. Complications: DIC, pulmonary edema, renal failure, liver hemorrhage and failure. Retinal detachment 1029. A 35yo woman presents with visual problems. CT brain reveals pituitary tumor. What is the single most likely defect?

a. Homonymous hemianopia b. Homonymous upper quadrantopia c. Bitemporal hemianopia d. Cortical blindness e. Homonymous lower quadrantopia dx: pituitary adenoma. Which presses on optic chiasm leading to bitemporal hemianopia. Optic chiasm contains nasal fibres from both eyes. If optic nerve is damaged it will lead to complete blindness in eye of same side. If lesion is at optic chiasm, then bitemporal hemianopia If the lesion is at optic tract, then contralateral homonymous hemianopia If the Lesion is at temporal fibres of optic radiation, then contralateral upper quadrant hemianopia. If parietal fibres are involved, then lower quadrant hemianopia. Lesions in primary visual cortex then contralateral homonymous hemianopia with macular sparing. Cortical blindness is blindness with intact pupillary reflexes. 1030. A 45yo heroin addict was involved in a car crash and is now paraplegic. During the 1st week of hospital stay he cried everyday because he couldn’t remember the accident. What is the most likely dx? a. PTSD b. Severe depression c. Organic brain damage symptoms are pointing towards brain damage. It is a brain injury resulting from a medical cause and not a psychiatric cause. For eg trauma, hemorrhage, concussion, hypoxia, hypercapnia, stroke, heart infections, Alzhiemers, degenerative disorders, metabolic causes, kidney liver disease, drug and alcohol. Inv and Rx depend on underlying disorder. Symptoms: agitation, confusion, dementia, delirium. 1031. A pt with T1DM has a fundus showing micro-aneurysm and hard exudate. What is the single most likely dx? a. Macular degeneration b. Hypertensive retinopathy c. MS d. Diabetic background e. Proliferative DM retinopathy different stages of diabetic retinopathy: Background retinopathy: microaneurysm, hemorrhagic blots, hard exudates Pre proliferative: cotton wool spots, hemorrhage, venous bleeding Proliferative: neo vascularisation Maculopathy: visual acuity decreased, new vessels on optic disc, retinal detachment 1032. A 62yo man has multiple liver mets due to adenocarcinoma with an unknown primary. He is deeply jaundiced and has ascites with edema upto the buttocks. He is now drowsy and his family are worried that he is not drinking enough. His meds include: haloperidol 1.5mg, lactulose 10ml. Bloods taken 3d ago: electrolytes normal, urea=6.5mmol/l, creatinine=89mmol/l, calcium=2.04mmol/l, albumin=17g/L, total bilirubin=189mmol/l. What is the single most appropriate management of his fluid intake? a. Albumin infusion b. Crystalloids IV

c. Crystalloids SC d. Fluids via NGT e. Fluids PO scenario of decompensated liver disease as indicated by ascites, jaundice and drowsiness. Fluid restriction should be done because of edema and ascites. His albumin levels are low as normal value of albumin is 35-50g/L. ascites is to be managed with fluid restriction, low salt, diuretics and daily weighing. 1033. A 2yo with atrophy of the buttocks, distended abdomen with frequent offensive smelly stool. Choose the single most likely inv? a. Upper GI endoscopy b. Endomyseal/alpha glidin antibody c. Sweat test d. Colonscopy e. Stool culture Dx: celiac disease: Immune mediated inflammatory systemic disorder provoked by gluten and prolamines in genetically susceptible people. Gluten in wheat rye and barley. Associated with HLA DQ2 and DQ8. May present at any age. Babies and yung present after weening. Symptoms: malabsorption, weight loss, failure to thrive, vomiting, anorexia, abd distension. Older child presents with anemia, abd pain, malabsorption, mouth ulcers. Dermatitis herpetiformis classic manifestation of skin Involvement. INV: Anti TTG, Anti endomysial, anti gliadin antibodies. IgA anti TTG preferred. Antibodies used to monitor disease. Confirmation by duodenal biopsy. Rx: gluten restriction 1034. A 78yo woman is brought to the hospital complaining of back pain and is referred to the surgeon. She has been saying that her mother is due to visit her today and that somebody must have broken her lower back as she is in agony. Labs: creatinine=295 mmol/l, calcium=3.03mmol/l. Which inv is most likely to lead to a dx? a. US KUB b. XR Spine c. IVU d. Bence-Jones Protein e. Mental state exam points in favour of myeloma: Age, low back pain, increased creatinine and hypercalcemia. XRAY spine would not lead to diagnosis and MSE would have been done if the labs were normal. Myeloma is due to abnormal proliferation of a single clone of plasma cells leading to secretion og Ig immunoglobulin ot Ig fragment. Symptoms: bone lesions, anemia, neutropenia, thrombocytopenia, recurrent infection, renal impairment. Dx made on: serum or urine electrophoresis. Plasma cells increased on marrow biopsy End organ damage or bone lesion Complications: hypercalcemia Spinal cord compression Hyperviscosity Acute renal injury

Rx: supportive and chemotherapy. Allogenic tx. 1035. A 40yo woman presents with dysphagia. Exam: febrile with erythema and middle neck swelling. What is the best management strategy? a. IV antibiotics and drainage b. Antipyretics c. XR neck d. Endoscopic diverticulectomy e. I&D presentation is that of a neck abscess. IV abx and InD forms the basis of Rx for neck abscess. 1036. A young lady presents with gradually worsening headaches, visual disturbance, and lack of energy. MRI shows 15mm tumor in the pituitary fossa. What is the tx of choice? a. Radiotherapy b. Octreotide c. Reassurance and f/u after 6m d. Surgery e. Chemotherapy pituitary tumor: almost always benign and incurable. May be associated with MEN 1 syndrome. Types of tumors include adenoma prolactinoma GH secreting ACTH secreting TSH, FSH, LH secreting Symptoms depend on the hormone tht is being produced. Local effects of tumor includes:: retro orbital headache, worse on waking up. Obstruction of CSF resulting in hydroceph Ocular nerve palsy causing squint Disorder of thirst, appetite, temperature regulation if extended to hypothalamus. INV: MRI Rx: depends on type of tumor. Surgery in most cases Bromocriptine in Prolactin secreting tumors. Somatostatin analogues in GH secreting tumors Small non functioning adenomas in asymptomatic pts don’t require any Rx. 1037. A man with dementia has an ulcerative lesion on his forehead. He wants it removed so ‘it can help improve his memory’. Wife says he is not fit to give consent. What will you do? a. Get letter signed from the GP b. Get letter signed from the wife c. Get letter signed from the pt d. Refer to psychiatrist to assess the mental capacity to give consent According to OHCM, consent in incapacitated requires a formal assessment to be documented in medical notes. No one is able to give consent on behalf of any adult even if he is incapacitated. So he should be referred to a psychiatrist. 1038. A pt with flame shaped hemorrhage on long term tx with nifedipine. What is the single most likely dx? a. Macular degeneration b. HTN retinopathy

c. MS d. DM background e. Proliferative DM retinopathy f. SLE pt is on Ca channel blocker indicating he is hypertensive. Fundoscopic findings in hypertensive retinopathy: Grade 1: tortuous arteries with thick shiny walls, silver copper wiring Grade 2: AV nipping Grade 3: flame hemorrhages, dot and blot, hard soft exudates Grade 4: papilledema Rx. Control BP 1039. A pt whose pain is not relieved by oral codeine. What is the best management? a. Oral oxycodone b. Co-codamol c. PCA d. IV morphine e. Oral morphine pain management steps: 1. Non opiods: paracetamol, NSAID, 2. if not controlled with above, use weak opioids ie codeine and tramadol 3. Still not controlled then strong opioids like morphine, dimorphine, oxycodone, fentanyl. Points in favour of morphine: First line for severe pain in palliative care Beneficial effect such as euphoria and detachment 4. IV morphine, pethidine and fentanyl patch if all of the above fail 1040. A 6wk baby with vomiting, irritability and palpable mass in the abdomen on feeding. Choose the single most likely inv? a. Upper GI endoscopy b. Barium meal c. US d. CT abdomen e. Barium enema scenario of infantile hypertrophic pyloric stenosis. Presents at 3-8 weeks with vomits esp after feed, large volume and projectile. Differentiating point btw other causes of vomiting is that vomitus doesn’t contain bile, no diarrhea but constipation. Alert, anxious. Hungry o/e: left to right LUQ peristalsis during a feed. Olive sized pyloric mass present in RUQ labs: water and NACL deficit, hypochloremic, hypo kalemic metabolic alkalosis. Dx. Clinical. US may be done Rx ramsdeth’s pyloromyotomy ot endoscopic surgery 1041. A 79yo man who is being treated with GnRH antagonist for proven adenocarcinoma of the prostate attends a follow up session. What is the most appropriate inv? a. Serum AFP b. Serum PSA c. Serum acid phosphates conc d. Serum ALP isoenzyme conc e. Trans rectal US urologists rely on rising PSA results to signal that a radical intervention (usually either chemotherapy or radiotherapy) is necessary. This is particularly appropriate for older patients with comorbidities, on the basis that they are likely to die of some other cause before a slow-growing prostate tumour has an effect on their lifespan. Such 'active

monitoring' is also appropriate for any patient who wishes to avoid the side-effects of interventional management. Most prostate cancers are adenocarcinomas arising in the peripheral zone of the prostate gland Risk factors: Age Black-african Family hx · · Factors such as food consumption, pattern of sexual behaviour, alcohol consumption, exposure to ultraviolet radiation, chronic inflammation and occupational exposure have all been considered as possible risk factors * Local disease: o Raised PSA on screening. o Weak stream, hesitancy, sensation of incomplete emptying, urinary frequency, urgency, urge incontinence. o Urinary tract infection. * Locally invasive disease: o Haematuria, dysuria, incontinence. o Haematospermia. o Perineal and suprapubic pain. o Obstruction of ureters, causing loin pain, anuria, symptoms of acute kidney injury or chronic kidney disease. o Impotence. o Rectal symptoms - eg, tenesmus. * Metastatic disease: o Bone pain or sciatica. o Paraplegia secondary to spinal cord compression. o Lymph node enlargement. o Loin pain or anuria due to ureteric obstruction by lymph nodes. o Lethargy (anaemia, uraemia). o Weight loss, cachexia * Abdominal palpation may demonstrate a palpable bladder due to outflow obstruction. * DRE may reveal a hard, irregular prostate gland. Indications of possible prostate cancer are: o Asymmetry of the gland. o A nodule within one lobe. o Induration of part or all of the prostate. o Lack of mobility - adhesion to surrounding tissue. o Palpable seminal vesicles. Differential diagnosis * All other causes of haematuria (eg, urinary tract infection) and urinary tract obstruction. * Benign prostatic hyperplasia. * Prostatitis. * Bladder tumours. INV: PSA Transrectal needle biopsy · Urinalysis to exclude renal and bladder pathology. Urine sent for microscopy, culture and sensitivities. · Renal function tests to help exclude renal disease. MRI should be considered for men with a negative TRUS core biopsy to determine whether another biopsy is needed MRI for staging Bone scan for mets The National Institute for Health and Care Excellence (NICE) referral guidelines for suspected cancer state:[11]

* Men presenting with symptoms suggesting prostate cancer should have a DRE and PSA test after counselling. Symptoms will be related to the lower urinary tract and may be inflammatory or obstructive. Prostate cancer is also a possibility in male patients with any of the following unexplained symptoms: erectile dysfunction, haematuria, lower back pain, bone pain or weight loss, especially in the elderly. * Urinary infection should be excluded before PSA testing, especially in men presenting with lower tract symptoms. The PSA test should be postponed for at least one month after treatment of a proven urinary infection. * If a hard, irregular prostate typical of a prostate carcinoma is felt on DRE, then the patient should be referred urgently. The PSA should be measured and the result should accompany the referral. * Patients do not need urgent referral if the prostate is simply enlarged and the PSA is in the age-specific reference range. * In a man with or without LUTS and in whom the prostate is normal on DRE but the age-specific PSA is raised or rising, an urgent referral should be made. Symptomatic patients with high PSA levels should be referred urgently. * If there is doubt about whether to refer an asymptomatic man with a borderline level of PSA, the PSA test should be repeated after an interval of one to three months. If the second test indicates that the PSA level is rising, the patient should be referred urgently. Rx: low risk localized tumor: active surveillance/surgery (personal preference) Intermediate to high risk: · Men with intermediate and high-risk localised prostate cancer should be offered a combination of radical radiotherapy and androgen deprivation therapy, rather than radical radiotherapy or androgen deprivation therapy alone. · Men with intermediate and high-risk localised prostate cancer should be offered 6 months of androgen deprivation therapy before, during or after radical external beam radiotherapy. · Continuing androgen deprivation therapy for up to 3 years should be considered for men with high-risk localised prostate cancer. · High-dose rate brachytherapy in combination with external beam radiotherapy should be considered for men with intermediate and high-risk localised prostate cancer. Brachytherapy alone should not be offered to men with high-risk localised prostate cancer. Locally advanced: pelvic radiotherapy Metastasis: bilateral orchidectomy · Urinary tract obstruction, acute kidney injury, chronic kidney disease. · Sexual dysfunction: erectile dysfunction, loss of libido. · Metastatic spread: bone pain, pathological fractures, spinal cord compression. 1042. A middle aged woman has some weakness of hand after an injury. Which vertebra will be the lowest to be included on cervical XR to dx the injury? a. C7/T1 b. C8/T1 c. C5/C6 d. C6/C7 weakness of hand shows brachial plexus routes involvement ie C5-T1, so in Cervical Xray, lowest vertebra included should be C7/T1 which will include all the nerve roots of brachial plexus.

1043. A 50yo man with a known hx of stroke. He can’t remember anything about his life. What is the single most likely defect? a. Homonymous hemianopia b. Homonymous upper quadrantanopia c. Bitemporal hemianopia d. Binasal hemianopia e. Homonymous lower quadrantanopia Memory storing site is in the temporal lobe. Lesion of the temporal lobe leads to homonymous upper quadrantanopia. 1044. An 18yo girl has been dx with anorexia nervosa and has mild depressive symptoms. She has cut down her food intake for the last 18m and exercises 2h everyday. Her BMI=15.5, BP=90/60mmHg. What would be the single most appropriate management? a. Refer to eating disorder clinic b. Refer to psychodynamic therapy c. Refer to acute medical team d. Prescribe antidepressant Answer should be A, according to OHCM. As the pt has moderate anorexia. Hence should be referred to EDU rather than a medical unit as there are no severe symptoms at present. mild anorexia BMI >17.5: focus on building a trusting relationship and encourage use of self help books and food diary. If no response within 8 wks, then consider referral to sec care moderate anorexia (BMI 15-17.5) routine referral to mental health team or adolescent unit or eating disorder unit severe anorexia (BMI 2 cm), staghorn calculi and also cystine stones. Stones are removed at the time of the procedure using a nephroscope. 1051. A 37yo woman believes that her neighbours have been using her shower while she is away from home. Her 42yo partner is convinced about this and calls the police. What term best describes this situ? a. Capgras syndrome b. Cotard syndrome c. Delusion of persecution d. Folie a deux e. Munchausen syndrome Folie a duex is defined as a delusion or mental condition shared by two people in close association. Munchausen syndrome is when a person feigns illness to gain attention and sympathy.

Capgras syndrome is the irrational belief that a familiar person or place has been replaced with an exact duplicate. Cotards syndrome is the delusion where the patient believes that he/she is literally or figuratively dead. Delusion of persecution is a delusion where a person falsely believes that they are being persecuted by someone who intends to do them harm. Thus since both partners believe in the neighbors using their shower, the answer is folie a duex. 1052. A 45yo woman has dull pain in her right ear which has been present for several weeks. There is no discharge. Chewing is uncomfortable and her husband has noticed that she grinds her teeth during sleep. The eardrum appears normal. What is the single most likely dx? a. Dental caries b. Mumps c. OM d. Temporomandibular joint pain e. Trigeminal neuralgia Dx. Temporomandibular joint pain Earache, facial pain, and joint clicking/popping related to malocclusion, teeth-grinding (bruxism) or joint derangement. Stress making this a biopsychosocial disorder which may become a chronic pain syndrome Signs: Joint tenderness exacerbated by lateral movement of the open jaw, or trigger points in the pterygoids. Imaging: MRI. Associations: Depression; Ehlers Danlos Rx: NSAIDs (PO or topical, eg Diclofenac); Stabilizing orthodontic occlusal prostheses; cognitive therapy; physiotherapy; biofeedback; Reconstructive Surgery; acupuncture. 1053. A 42yo lady had corrective surgery for cyanotic congenital heart disease at the age of 3y, after a palliative operation during infancy. There is a parasternal impulse and an early diastolic murmur. What is the most probable dx? a. Aortic regurgitation b. Ischemic mitral regurgitation c. Aortic stenosis d. Pulmonary stenosis e. Pulmonary regurgitation Dx is pulmonary regurgitation. 42 yo lady has parasternal impulse and early diastolic murmur. Received corrective surgery for cyanotic congenital heart disease (pulmonary hypertension, Eisenmenger syndrome) Early diastolic murmur only in aortic regurgitation or pulmonary regurgitation. Causes of pulmonary hypertension also cause pulmonary regurgitation. {Graham steell murmur if mitral stenosis+ pulmonary hypertension} 1054. A 45yo lady presents with hx of double vision and facial numbness. Which anatomical site is most likely to be affected? a. Cerebral cortex b. Trigeminal nerve c. Oculomotor nerve d. Brain stem

e. Basal ganglia Dx is brain stem. Vertibobasilar circulation. Supplies the cerebellum, brainstem, occipital lobes. Occlusion causes signs relating to any or all 3: hemianopia; cortical blindness; diplopia; vertigo; nystagmus; ataxia; dysarthria; dysphasia; hemi- or quadriplegia; unilateral or bilateral sensory symptoms; hiccups or coma. 1055. A 30yo woman has experienced restlessness, muscle tension and sleep disturbance on most days over the last 6m. She worries excessively about a number of everyday events and activities and is unable to control these feelings which are impairing her ability to hold down her job. What is the most likely dx? a. Panic disorder b. GAD c. Pheochromocytoma d. Acute stress disorder e. Social phobia Dx is GAD. GAD is anxiety and +3 somatic symptoms present over a course of 6 months. Panic disorder is the experience of intense anxiety along with 4 symptoms of autonomic hyperactivity lasting less than 30 mins. Acute stress disorder is the experience of symptoms by a person under a maximum period of 1 month following exposure to a traumatic event. Social phobia is the fear of a situation where something potentially embarrassing might happen. Causes of GAD are genetic predisposition, stress and events involving stress. Treatment of GAD is through symptom control, exercise, meditation, behavioural therapy, hypnosis and various drugs such as benzodiazepines, ssris, azapirones, beta blockers and antihistamines. Prognosis gets better by age 50 years. 1056. Which of the following is not a degenerative corneal disease? a. Band keratopathy b. Marginal dystropathy c. Fatty/lipid degeneration d. Mooren’s ulcer e. Keratoconus Dx is Mooren’s ulcer. Band keratopathy is characterized by the appearance of a band across the central cornea, formed by the precipitation of calcium salts on the corneal surface (directly under the epithelium). This form of corneal degeneration can result from a variety of causes, either systemic or local, with visual acuity decreasing in proportion to the density of the deposition. Pellucid marginal degeneration is a degenerative corneal condition, often confused with keratoconus. Keratoconus is a degenerative disorder of the eye in which structural changes within the cornea cause it to thin and change to a more conical shape than the more normal gradual curve. Mooren’s ulcer is a chronic, painful peripheral corneal ulcer of unknown cause that easily leads to loss of vision. Severe pain, red, tearing and photophobic. Fatty/lipid degeneration is degenerative. In mooren’s ulcer severe pain is common and eye(s) may be very red, photophobic, and tearing. It is more common in southern and central Africa, China, and India. Treatments tried: steroidal and nonsteroidal anti-infl ammatory drops, cytotoxics (topical and

systemic), conjunctivectomy, and cornea debridement (superficial keratectomy). None is known to be superior 1057. A 30yo man presents to hosp complaining that his urine has been very dark recently, resembling coffee at worst. He has been under the weather 2wks back and had taken a few days off work with a sore throat and coryzal symptoms. Urine dipstick in hosp returns highly positive for blood and protein. He is admitted for supportive management and is scheduled for a renal biopsy, which shows mesangial proliferation with a positive immune-flurescence pattern. What is the most probable dx? a. Membranous glomerulonephropathy b. SLE c. Wegener’s granulomatosis d. Post – strep GN e. IgA nephropathy Dx is Post strep GN History of sore throat, mesangial proliferation and immune flouresence pattern point to post strep GN. Presentation is usually nephritic syndrome. Renal biopsy isn’t performed unless atypical presentation. IF shows IgG and C3 deposits Serology shows inc ASOT and inc C3 Supportive treatment with more than 95% function recovered 1058. A 65yo lady presents with a 6h hx of facial droop and weakness in the left side of her body. What single agent will she be prescribed for her whole life? a. Clopidogrel b. Altepase c. Aspirin d. Labetalol Rx is clopidogrel. 65 yo lady with facial droop and weakness on left side is suggestive of a stroke. 1059. A 10yo boy is brought to the hosp with a rash over his buttocks a/w abdominal pain and vomiting. In the ED, he is accompanied by his mother and stepfather. His mother had left him for the weekend with the stepfather and was called to come back from holiday as he started to have some hematuria with the rash. Social services had been notified on arrive to hospital. What is the most probably dx? a. NAI b. ITP c. HSP d. ALL e. HUS HSP is a Small vessel vasculitis with purpura (non blanching purple papules)-buttocks and extensor surfaces. Young. Glomerulonephritis, arthritis, abd pain (+_ intussusception) may mimic an acute abdomen. Rx is supportive.

1060. A man with hx of fall had confusion and laceration mark on the head. Which is the most appropriate vessel affected? a. Basilar artery b. Middle meningeal artery c. Vertebral artery d. Diploic vein The history of fall and laceration mark suggests an extradural hemorrhage. Therefore, artery affected would be middle meningeal. Test : CT scan to confirm hemorrhage. Stabilize and transfer urgently (with skilled medical and nursing escorts) to a neurosurgical unit for clot evacuation ± ligation of the bleeding vessel. Care of the airway in an unconscious patient and measures to ICP often require intubation and ventilation (+ mannitol IVI Prognosis Excellent if diagnosis and operation early. Poor if coma, pupil abnormalities, or decerebrate rigidity are present pre-op 1061. A 72yo lady is drowsy and her relatives want to take her home. She has been prescribed diazepam 2.5mg. What is the best delivery route? a. Oral b. IV c. IM d. Per rectal e. SC Delivery is Per rectal. Diazepam is not absorbed properly via the oral or IM route. The IV route presents difficulties for non-medical carers. The SC route is contraindicated in old people. 1062. A nonsmoker who has worked in coal mines for 20yrs presents with gradually increasing SOB, limited exercise tolerance and a dry cough. His CXR shows round fibrotic tissue demonstrating a mixed restrictive and obstructive ventilator defect with irreversible airflow limitation and reduced gas transfer. What is the single most appropriate dx? a. Churg-strauss syndrome b. Cryptogenic organizing c. Extrinsic allergic alveolitis d. Good pasture’s syndrome e. Progressive massive fibrosis f. Molluscum Key: E Page 192, Industrial Dust Disease; Chest Medicine; OHCM 9TH Edition. Coal Worker’s Pneumonia (CWP): Underground Coal Mines. Over 15-20 years. Fibrosisround opacities (1-10 mm) esp in upper zone. Clinical features: asymptomatic (co existing chronic bronchitis common) PMF: Due to progression of CWP, which causes progressive dyspnoea, fibrosis, and, eventually, cor pulmonale. CXR: upper-zone fibrotic masses (1–10cm). Management: Avoid exposure to coal dust; claim compensation. [In Extrinsic AA: farmer- mushroom worker, bird fancier, malt worker, sugar or bagassosis worker 4-6h post exposure: Fever, rigors, myalgia, dry cough, dyspnoea, crackles In IPF (CFA): Dry cough, exertional dyspnea, dec weight, arthralgia, cyanosis, clubbing]

1063. A pt was complaining of pain within 6h after his appendectomy for gangrenous appendix. What med is the best option for his pain relief? a. IV morphine b. Diclofenac per rectal c. PCA d. Tramadol Rx is Tramadol Who Pain Ladder Rung 1 Non-opioid Paracetamol; NSAIDS Rung 2 Weak opioid Codeine; dihydrocodeine; tramadol Rung 3 Strong opioid Morphine; diamorphine; hydromorphone; oxycodone; fentanyl; buprenorphine (± adjuvant analgesics) Tramadol as pain is of moderate severity. Morphine is for severe pain. Diclofenac is for mild pain. PCA is not a drug. 1064. A 62yo farmer presents with a persistent firm irregular lesion on upper part of pinna which grew over the last few months. What is the most appropriate dx? a. Basal cell b. Squamous cell c. Keratocanthoma Dx is basal cell Basal cell is most common. Squamous and keratocanthoma are less common and similar in presentation. GOLJAN PATHOLOGY it says that such lesions above the upper lip is basal cell. And below that is SCC- if on face. 1065. A 24yo schizophrenic has been under antipsychotic tx for the last 1 yr and now complains of Erectile Dysfunction. Which drug is most likely to have caused this? a. Fluoxetine b. Citalopram c. Clozapine d. Haloperidol e. Risperidone The answer here should be E Risperidone. C,D and E are the antipsychotics from the options. OHCS states that atypical antipsychotics cause erectile dysfunction so haloperidol goes out of the race. Since there are great chances of agranulocytosis by using clozapine and the first choice is risperidone for schizo so the patient would have been advised Risperidone which has caused ED. 1066. What is the most likely dx based on this ECG? a. Normal b. VT c. Sinus Tachycardia d. WPW syndrome e. A-fib Key: C No other apparent abnormality 1067. A 45yo woman has recently been dx with MS and has been started on oral steroids. She is brought to the hosp after having ingested 100 paracetamol tablets 4h ago. She is refusing all med tx. What is the next best step?

a. Observe b. Refer to psychiatrist to assess pts ability to refuse tx c. Gastric lavage d. Activated charcoal e. Refer to social worker Key says B. Not a very clear answer though something like this given on: Page 403, Psychiatry; OHCS 9TH Edition. 1068. A 44yo obese pt with findings: FBS=6 mmol/l, OGTT=10 mmol/l. What is the most likely dx? a. Impaired glucose tolerance b. Diabetes insipidus c. T1DM d. T2DM e. MODY Dx is IGT IGT: fasting 7.8 but 7 and random >11.1 * Raised venous fasting >7 and random >11.1- on 2 separate occasions or OGTT> 11.1 * HB 1Ac> 48mmol/L (6.5%) 1069. A child distressed with fever, stridor and unable to swallow saliva. His RR=40bpm. What is the initial step that needs to be taken? a. Examine throat b. Secure airway c. Keep him laid flat d. IV penicillin Key: B Page 158, URTI; Paeds; OHCS 9TH Edition. DD for Stridor is Epiglotitis, bacterial tracheitis and Viral Croup. Based on symptomology its epiglotitis [croup has barking cough and hoarseness, Bac Tracheitis has mucopurulent exudates not cleared by coughing] Cause of risk of obstruction in both tracheitis and epiglotittis, we first call the anesthetist to secure the airway. [after first laryngoscopy that shows cherry red swollen epiglottis ] Then 3rd generation Cefotaxime. For tracheitis, give additional flucloxacillin. 1070. A pt presents with hemoptysis 7d after tonsillectomy and adenoidectomy. What is the next step of management? a. Explore again b. Pack it c. Oral antibiotics and discharge d. Admit and IV antibiotics e. Ice cream and cold fluid Key: D Page 565, Tonsillectomy; ENT; OHCS 9TH Edition. Primary: within 24 hr needs return to theatre. Secondary: from after 24 hrs to 5-10 days post surgery is due to infections. Needs admission and IV antibiotics [along with HO gargles and vasoconstrictors] When severe hemorrhage- Admit, O2, IVI, crossmatch, antibiotics (co-amoxiclav) 1071. A 55yo man presents with swelling at the angle of the mandible which is progressively increasing in size and it’s mobile for 6m. What is the most probable dx?

a. Benign parotid b. Mandible tumor c. Tonsillar carcinoma Key: A Page 578, Salivary Gland Tumours; ENT; OHCS 9TH Edition. 80% - benign pleomorphic adenoma, parotid gland and in superficial lobe. Middle aged, man, parotid gland, slow growth and mobile: all favoring a benign parotid swelling like Pleomorphic Adenoma. Rx: Removal by superficial parotidectomy or Enucleation. 1072. A 61yo man, known smoker, comes to the hospital with complaints of painless hematuria, urgency and dysuria. He has been worried about his loss of weight and reduced general activity. Which inv would be diagnostic of his condition? a. Urine microscopy b. IVU c. CT d. Cystoscopy e. US abdomen f. KUB g. Cystoscopy with biopsy h. Mid stream urine for culture i. Transrectal US Key: G Page 648, Bladder Tumors; Surgery; OHCM 9TH Edition. Transitional Cell Carcinoma: painless hematuria, frequency urgency and dysuria ; UTI; UTO plus Smoking is considered one of the important causative factors to TCC. Cystoscopy with Biopsy is confirmatory 1073. An 8wk pregnant lady is brought to the ED due to severe vomiting. She was administered IV fluids and oral anti-emetics. She still can’t tolerate anything orally. What is the next best tx? a. IV feeding b. IV antiemetics c. Termination of pregnancy d. PPI e. IV steroid Tx is IV anti emetics. Woman may be progressing towards Hyperemesis Gravidarum. IV feeding, IV steroids and PPIs are options if IV antiemetics fail to work Termination is only the last option. 1074. A 48 yo man presents with bone pain. Labs: ALP=high, phosphate=normal. What is the most likely dx? a. Osteoporosis b. Osteomalacia c. Paget’s disease d. Fx e. Myeloma Key: C Page 699, Clinical Chemistry; OHCM 9TH Edition. Also known as osteitis Deformans. There is Inc bone turnover ass with osteoclastic and osteoblastic activity causing brittle bones and bone pain. Mostly pts over 40 and Ca and PO4 are normal. ALP is raised

1075. A 54yo lady presents with sudden severe pain in the left half of her skull. She also complains of pain around her jaw. What is the most likely next step? a. CT b. MRI c. Fundoscopy d. ESR e. Temporal artery biopsy Key: D Page 558, Vasculitis; Rheumatology; OHCM 9TH Edition. Giant cell arteritis (GCA)= cranial or temporal arteritis. Common in the elderly—consider Takayasu’s if under 55yrs. It is associated with PMR in 50% Symptoms: Headache, temporal artery and scalp tenderness (eg when combing hair), jaw claudication, amaurosis fugax, or sudden blindness, typically in one eye. Extracranial symptoms may include dyspnoea, morning stiffness,and unequal or weak pulses. If you suspect GCA, do ESR and start prednisolone 60mg/d PO immediately then go for temporal artery biopsy which is definitive. 1076. A 7yo school boy has been dx with meningococcal meningitis. What is the advice for schoolmates and staff? a. Rifampicin for the whole class and family b. Rifampicin for the whole school and family c. Meningococcal vaccine for the family d. Benzylpenicillin e. IV cefotaxime Key is A Prophylaxis: household contacts in droplet range or Those who have kissed the patient's mouth. Give rifampicin (600 mg 12 hrly PO for 2 days). 1077. A pt came with dyskaryosis to the OPD. She is a heavy smoker and alcoholic. Cervical smear shows abnormal cells. What is the best advice for her? a. Colposcopy b. Biopsy c. Endocervical sample d. Repeat after 4m e. None f. Cone biopsy If there is class 3 mild moderate or class 4 severe dyskaryosis on smear, the next step is ro refer the lady for colposcopy, and if needed punch biopsy. Class 1 Normal pap smear: repeat in 3 years Class 2 Inflammatory pap smear: Take swab and treat infection. Repeat in 6 months. Colposcopy after 3 abnormal smears Mild atypia: repeat in 4 months. Colposcopy after 2 abnormal smears Class 3 Mild dyskaryosis: HPV test +/- colposcopy Moderate dyskaryosis: colposcopy Class 4 Severe dyskaryosis: colposcopy

Class 5 Suspected invasion and abnormal glandular cells: urgent colposcopy 1078. Pt with pain and swelling in left leg and thigh up to the level of inguinal ligament. Where is the level of occlusion? a. Femoro-popliteal artery b. Left common iliac artery c. Aortoiliac artery d. Femoral artery e. Profound femoral artery The location of the pain in patients with peripheral arterial occlusive disease (PAOD) is determined by the anatomic location of the arterial lesions. PAOD is most common in the distal superficial femoral artery (located just above the knee joint), a location that corresponds to claudication in the calf muscle area (the muscle group just distal to the arterial disease). When atherosclerosis is distributed throughout the aortoiliac area, thigh and buttock muscle claudication predominates. In this scenario, there is pain in left leg and thigh, so femoral artery is more likely to be occluded in this patient. Risk factors:Smoking, Diabetes mellitus. Hypertension. Hyperlipidaemia: high total cholesterol and low high-density lipoprotein (HDL) cholesterol are independent risk factors. Physical inactivity. Obesity. The most common symptom is muscle pain in the lower limbs on exercise (intermittent claudication): * Walking impairment - eg, fatigue, aching, cramping or pain in the buttock, thigh, calf or foot, particularly when symptoms are quickly relieved at rest. Pain comes on more rapidly when walking uphill than on the flat. Claudication can occur in both legs but is often worse in one leg. * Similar pain may occur in the buttocks and thighs, associated with absent femoral pulses and male impotence (Leriche's syndrome; caused by aorto-iliac obstruction). * The differential diagnosis of pain in the lower limb when walking includes sciatica and spinal stenosis, deep vein thrombosis, entrapment syndromes and muscle/tendon injury. * The main method to confirm the diagnosis is Doppler ultrasonography (duplex scanning). The ratio of systolic blood pressure at the ankle and in the arm - anklebrachial pressure index (ABPI) - provides a measure of blood flow at the level of the ankle (as a general guide, normal = 1, claudication 0.6-0.9, rest pain 0.3-0.6, impending gangrene 0.3 or less). The ABPI is a strong marker of cardiovascular disease and is predictive of cardiovascular events and mortality * Treatment includes reduction and modification of risk factors, medical management with anti platelets and peripheral vasodilators. Surgical procedures such as endovascular revascularization and bypass surgery. 1079. A 65yo man presents with dyspnea 3d after an MI. On auscultation he has a pansystolic murmur at the apex radiating to the axilla. What is the most likely dx? a. Ruptured papillary muscle b. Ventricular aneurysm c. Pericarditis d. Pericardial effusion e. VSD Complications post MI Cardiac arrest, unstable angina, bradycardia or heart block, tachyarrhythmias, right ventricular failure, pericarditis, DVT and PE, systemic embolism, cardiac tamponade, mitral regurgitation, VSD, late malignant vent arrhythmia, dresslers syndrome, left ventricular aneurysm.

In this scenario, patient has presented to us post MI with complains of dysnea (pulmonary edema). Auscultation reveals a pansystolic murmur at apex radiating to axilla characteristic of MR murmur. MR post MI occurs as a result of papillary muscle dysfunction (mild MR) or papillary muscle or chordal rupture or ischemia (severe MR). Vsd will also present with pansystolic murmur but at lower left sternal edge. Pericarditis and pericardial effusion with muffled heart sounds and pericardial pain relieved by sitting forward. Ventricular aneurysm occurs late after 4-6 weeks. Presents with LVF, angina, recurrent VT or systemic embolization. Persistent ST segment elevation. Treatment is excise and coagulate. 1080. A 64yo man with multiple myeloma has been vomiting since the past 2days. Labs: Ca2+=3.2mmol/l, K+=5mmol/l, Na+=149mmol/l and PCV=55%. What is the most appropriate next step? a. IV insulin b. IV calcium gluconate c. IV fluids d. IV bisphosphonates e. Oral bisphosphonates Multiple myeloma, vomiting point toward diagnosis of hypercalcemia indicated by raised serum calcium and dehydration indicated by raised sodium, potassium and increased pcv. There has been inadequate water replacement as a result of vomiting. Treatment is to give IV fluids initially Iv bisphosphonates may be used later Iv furosemide may also be used after rehydration. Acute hypercalcaemia[11] Treatment should be initiated in hospital on the advice of a specialist and should include: * Increasing the circulating volume with 0.9% saline, helping to increase the urinary output of calcium. * A loop diuretic such as furosemide. This is occasionally used where there is fluid overload but it does not reduce serum calcium . * After rehydration, bisphosphonates (which act by reducing bone turnover) should be administered intravenously. Pamidronate and zoledronic acid are commonly used. Salmon calcitonin may also be given. It has fewer side-effects than bisphosphonates but is less effective in reducing hypercalcaemia. * Glucocorticoids are useful for hypercalcaemia due to vitamin D toxicity, sarcoidosis and lymphoma. * Gallium was identified as a useful drug when it was found that patients with malignancy having gallium scans did not develop hypercalcaemia. It may be given intravenously to patients with malignant hypercalcaemia who do not respond to bisphosphonates.[14] * Cinacalcet hydrochloride is a calcimimetic (= mimicking the action of calcium) agent that effectively reduces parathyroid levels in patients with secondary hyperparathyroidism.[12] * A new experimental approach to malignancy-associated hypercalcaemia involves the blockade of receptor activator of nuclear factor kappa-B ligand, usually abbreviated as RANKL. RANKL is a key element in the differentiation, function and survival of osteoclasts, which plays an essential role in removing calcium ions from the bone in response to PTH stimulation.[15] Denosumab, a human monoclonal antibody that acts in this manner, is licensed for the prevention of osteoporotic fractures but is also useful for patients with persistent or relapsed hypercalcaemia of malignancy.[16] * Haemodialysis or peritoneal dialysis may be relevant in patients with severe hypercalcaemia secondary to renal failure.

Non-PTH-mediated hypercalcaemia Treatment depends on the underlying condition. PTH-mediated hypercalcaemia[8] * Asymptomatic patients may be treated conservatively with regular monitoring of bone density, renal function and serum and urinary calcium levels. * For symptomatic patients, dietary calcium should be reduced - eg, minimise the intake of dairy products and leafy vegetables. This approach has been questioned for asymptomatic patients, in whom 1000-1200 mg calcium daily has been recommended.[17] * Bed-bound patients should be mobilised if possible. Symptomatic patients will respond well to having the affected part of the parathyroid gland removed. * There is no consensus on the operative treatment of asymptomatic patients. In general, it tends to be reserved for patients who have impaired renal function, hypercalciuria, low bone mineral density or severe hypercalcaemia 1081. A 30yo man from Australia returned from a business trip to Indonesia 6d ago presenting with complaints of fever, joint and muscle ache and headache, in particular behind the eye for the past 2 days. What is the most probable dx? a. Malaria b. Chicken pox c. TB d. Lyme’s disease e. Dengue a. Dengue Fever, joint and muscle ache and headache behind eye, hx of travel to Indonesia all point towards diagnosis of Dengue fever. Symptoms * Haemorrhagic fever syndromes begin with abrupt onset of fever and myalgia. * Fever is associated with frontal or retro-orbital headache accompanied by onset of a generalised rash. * Symptoms regress for a day or two but may recur, although fever is rarely as high as at the onset. * Dengue fever cases experience severe bony and myalgic pain in legs, joints and lower back which may last for weeks (hence, breakbone fever). * Nausea, vomiting, cutaneous hyperaesthesia, taste disturbance and anorexia are common. * Abdominal pain may occur and, if severe, suggests possible DHF. 1082. A lady came for OB GYN assessment unit with hx of 8wk pregnancy and bleeding per vagina for last 2 days. On bimanual exam, uterus =8wks in size. On speculum exam, cervical os is closed. How do you confirm the viability of the fetus? a. Transvaginal US b. Serum BHCG c. Urinary BHCG d. Abdominal US e. Per speculum exam Transabdominal ultrasound will provide a panoramic view of the abdomen and pelvis and is noninvasive, whereas transvaginal ultrasound provides a more limited pelvic view and requires insertion of a probe into the vagina. Transabdominal ultrasound cannot reliably diagnose pregnancies that are less than 6 weeks gestation. Transvaginal ultrasound, by contrast, can detect pregnancies earlier, at

approximately 4 ½ to 5 weeks gestation. Prompt diagnosis made possible by transvaginal ultrasound can, therefore, result in earlier treatment. Scenario is that of threatened miscarriage. Serum and urine b hcg maybe raised a few days until after death of fetus, per speculum exam is not done for miscarriage. 1083. A 24yo lady has been low after the death of her husband and had stopped contacting her family. She was started on SSRI tx and starts feeling better after a few months. On discontinuing the meds she starts feeling that she has developed cancer just like her husband. What is the most appropriate next step? a. Continue SSRI b. Add TCA c. Neuropsychiatric analysis d. CBT e. Antipsychotics Delusion of hypochondriasis is the diagnosis. Lady requires a neuropsychiatric analysis. All the other options are wrong. Hypochondriasis This is a disorder where people fear that minor symptoms may be due to a serious disease. For example, that a minor headache may be caused by a brain tumour, or a mild rash is the start of skin cancer. Even normal bodily sensations such as 'tummy rumbling' may be thought of as a symptom of serious illness. People with this disorder have many such fears and spend a lot of time thinking about their symptoms. This disorder is similar to somatisation disorder. The difference is that people with hypochondriasis may accept the symptoms are minor but believe or fear they are caused by some serious disease. Reassurance by a doctor does not usually help, as people with hypochondriasis fear that the doctor has just not found the serious disease. 1084. A 24yo male who is sexually active with other males with hx of discharge per urethra. Dx of chlamydia has been made. What is the possible complication if left untreated? a. Orchitis b. Balanitis c. Epididymo-orchitis d. Acute abdomen Chlamydia genital tract infection in men can lead to epididymo-orchitis and infertility if left untreated. Other causes are e.coli, mumps, gonorrhea and tb CHLAMYDIA is common in males 35 years and above. Doxycycline 100 mg bd for 10 days is treatment. 1085. A person doesn’t go outside the home because he thinks that people will look at him and talk about him. He finds it difficult to associate with his peers in a restaurant or under social settings. What is the most likely dx? a. Agoraphobia b. GAD c. Panic disorder d. Adjustment disorder e. Social phobia Agoraphobia is fear of open spaces. Panic disorder or panic attack consists of episodes in which patient feels as if they are going to die. Last for 10 mins. Phobic disorders: anxiety in special situations.

Social phobia: phobia of situations in which a person may be closely minutely observed. Such as in this scenario. * Social anxiety is a fear of being around people and having to interact with them. Sufferers fear being watched and criticised. Normal activities such as working, shopping, or speaking on the telephone are marked by persistent feelings of anxiety and selfconsciousness. They feel dread as a situation approaches and afterwards they analyse or ruminate on how they could have done better. Hence, it may be seen as a fundamentally normal response but exaggerated to the point of being pathological. * Physical symptoms include trembling, blushing, sweating and palpitations. * They often experience chronic insecurity about their relationships with others, excessive sensitivity to criticism, and profound fears of being judged negatively, mocked, or rejected by others. * There are two forms of the condition: * Generalised social anxiety which affects most, if not all areas of life. This is the more common type and affects around 70% of sufferers. * Performance social anxiety, where these feelings only occur in a few specific situations such as public speaking, eating in public or dealing with figures of authority. * Treatment is CBT Generalized anxiety disorder: * Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a wide range of events or activities (such as work or school performance). * The person finds it difficult to control the worry. Adjustment disorder is a group of symptoms, such as stress, feeling sad or hopeless, and physical symptoms that can occur after you go through a stressful life event. The symptoms occur because you are having a hard time coping. Your reaction is stronger than expected for the type of event that occurred. 1086. A 63yo man presented with sudden onset of severe dyspnea, orthopnea, raised JVP and bilateral basal crackles 3d after an episode of MI. A dx of acute congestive cardiac failure was made and IV furosemide was started for this pt. What electrolyte abnormality is expected? a. High Na+, Low K+ b. Low Na+, High K+ c. Low Na+, Low K+ d. High Na+, High K+ e. Low Na+, Normal K+ Furosemide is a loop diuretic which inhibits transport of na/k/2cl in the thick ascending limb of loop of henle. Diuresis usually occurs 4 hr after a dose. Effects is a massive nacl excretion. Calcium secrestion also increased. Used in treatment of edema in heart failure, ascites and pulmonary edema. Also used in severe hypercalcemia. Hypokalemic metabolic alkalosis, hypovolemia, ototoxicity and allergic reactions are side effects. 1087. A 70yo hypertensive white british man on thiazide diuretics needs a 2nd drug to control his BP. Which one of the following is the best choice for him? a. Amlodipine (CCB) b. Enapril (ACEi) c. Propranolol (BB) d. Increase dose of diuretic e. Prazocin (Alpha blocker) Key is b. Hypertension management

If age is greater than 55, or black patient of any age: ca channel blocker or thiazide (C/D) If age is less than 55: ace inhibitor(A) B blocker to be considerd in young, pregnancy or if increased sympathetic drive Combination therapy Ace inhibitor plus ca channel blocker or thiazide(A+C/D) 3 drugs needed: ace inhibitor plus ca channel blocker plus diuretic (A+C+D) 4th drug needed. Add higher dose diuretic or b blocker or alpha blocker(A+C+D+B) 1088. A 74yo lady who has had a stroke in the past has an indwelling catheter for 10m. She presents with bluish-purple discoloration of the catheter bag. What is the most likely explanation for this? a. Normal change b. Catheter degradation c. Acidic urine d. Alkaline urine e. Bacterial colonization of the urinary tract Explained in Samson notes. Renal section. 1089. A 62yo man has slow palpitations and the following ECG. What is the most likely dx? a. Sinus bradycardia b. 1st degree heart block c. Mobitz type 1 block d. Mobitz type 2 block e. Complete heart block Progressive prolongation of PR interval followed by missed beat is indicative of MOBITZ type 1 block. Bradycardia is to be treated with atropine. If not controlled, then temporary pacing may be required. 1090. A 29yo woman presents with lid lag, lid retraction and diplopia. What is the most appropriate next step? a. TFT b. Tensilon test c. Fundoscopy d. Autoantibodies e. EMG Scenario suggestive of Graves disease, hyperthyroidism. Graves' disease:[9] * This is the most common cause of hyperthyroidism and has an autoimmune basis. It is mediated by B and T lymphocytes, characterised also by the presence of thyroidstimulating immunoglobulins (TSIs). These are directed at four different thyroid antigens: * Thyroglobulin. * Thyroid peroxidase (or antimicrosomal antibodies). * Sodium-iodide symporter. * TSH receptor. * The condition is characterised by a small to moderate diffuse, firm goitre with 50% of these showing ophthalmopathy. * There may be a personal or family history of autoimmune disease. * >> fibroadenoma Triple assesment for breast lump 

clinical examination



imaging :mamography if older than 35 years or u/s for younger patients



FNAC

THIS is a case of fibroadenoma and examination was done so the next step is imaging (pt is 17 so u/s) Fibroadenoma This is a benign tumour that is common in young women, mostly aged under 40 years. They are the most common tumour of the breast in those under 30 years old, but overall they are second to breast cancer. Assessment often includes examination, imaging studies and fine-needle aspiration. Ultrasound >>> in younger women with dense breasts, as mammograms are more difficult to interpret in this group. Routine mammography, as a population screening tool, is not performed below the age of 50 years. - The initial examination depends upon the age of the patient. Ultrasound for 35 years old. - Ultrasound is best for dense breast tissue, whereas Mammography is best for less dense breast tissue; eg, after menopause. - CT is not done for breast lesions. - Stereotactic Biopsy is the investigation of choice only when there are no palpable masses. - You cannot reassure and send home as it might be a Fibroadenoma since the patient is young. 1101. A lady comes with a missing IUCD thread. Her LMP was 2wks ago. What is the single most appropriate next step in management? a. Abdominal US

b. Prescribe contraceptives c. CT d. Serum BHCG e. Vaginal exam key: A cause: in case of lost thread we advise the pt with extra contraception like condom then we start managing the case by : pregnancy test but in this case her LMP was two weeks ago so no need for than , so the next step is to locate the IUCD using imaging studies ( us first then xray) lost thread : OCS pg 298 the IUCD may have been expelled, so advise extra contaception and exclude pregnancy seek coil on u/s ; if missing arrange x-ray to exclude extra-uterine coils ( surgical retrieval is advised)

- In case of a lost thread, a number of measures should be taken. They are: - If threads are not visible, or if they are but the stem of the device is palpable, the woman should be advised to use condoms or abstain from intercourse until the site of the device (if present) can be determined. - Perform a speculum examination to ensure the device is not in the posterior fornix. - Determine whether the woman is already pregnant. - With consent, explore the lower part of the endocervical canal with narrow artery forceps: threads which have been drawn a little way up are usually found by this method. - An experienced operator may, after appropriate analgesia (eg, mefenamic acid 500 mg) explore the uterine cavity with a retriever hook. - Hormonal emergency contraception may be indicated. - Ultrasound should be arranged to locate the device. - If ultrasound does not locate the device and there is no definite history of expulsion then abdominal X-ray should be performed to look for an extrauterine device. - Expulsion should not otherwise be assumed. - Hysteroscopy can be helpful if ultrasound is equivocal. - Surgical retrieval of an extrauterine device is advised.

- The question asks for the most appropriate next step in the management of this case. That step would be to exclude pregnancy via an abdominal ultrasound. IUCDs increase the risk of ectopic pregnancy, for which again, the next step would be an abdominal ultrasound.

1102. A 32yo woman presents with hx of lower abdominal pain and vaginal discharge. She had her menses 4wk ago. She has a temp of 38.6C. What is the most suitable dx? a. Acute appendicitis >>> (nausia,vomiting,RIF pain) b. Acute PID c. Endometriosis>>> dysparaunia d. Ectopic pregnancy>>> missed period,abnormal vaginal bleeding e. UTI>>>urinary symptoms key: B cause: clinical signs and symptoms fit ( fever above 38 + bilatral lower abdominal pain + vaginal discharge) PID Diagnosis of acute PID made only on clinical signs signs & symptoms 

Bilateral lower abdominal pain.



Deep dyspareunia.



Abnormal vaginal bleeding (postcoital, intermenstrual or menorrhagia).



Vaginal or cervical discharge that is purulent.



Fever above 38°C

Investigations: 

Pregnancy test (pregnant women with PID should be admitted; ectopic pregnancy may be confused with PID).



Cervical swabs for chlamydia and gonorrhoea



Endocervical swabs for C. trachomatis and N. gonorrhoeae

Treatment:



Mild or moderate disease can be managed in primary care or outpatients, whereas clinically severe disease requires hospital admission for intravenous (IV) antibiotics.



The current outpatient treatment recommendation is ceftriaxone 500 mg as a single (IM) dose, followed by doxycycline 100 mg orally twice daily and metronidazole 400 mg twice daily for 14 days



Initial treatment is with doxycycline, single-dose IV ceftriaxone and IV metronidazole, then change to oral doxycycline and metronidazole to complete 14 days of treatment.

- Symptoms of PID - Bilateral Lower/Pelvic abdominal pain that ranges from mild to severe. - Pain during sex - Abnormal vaginal discharge - Abnormal vaginal bleeding (1 in 4 cases) - Risk Factors - A recent change of sexual partner. The risk goes up with the number of partners. - A previous episode of PID or sexually transmitted disease. - A recent abortion. - A recent operation or procedure on the womb (uterus). - A contraceptive coil inserted recently. - Tests to be done - Endocervical Swab is the investigation of choice. High vaginal swab can also be taken. - If the above doesn’t show anything, an U/S can be done to look for inflamed fallopian tubes. - Complications - Infertility - Ectopic Pregnancy - Miscarriage and Still Births - Persistent pain (including pain during sex) - Reiter’s Syndrome - Abscess formation - Treatment

- Antibiotics - The partner must also be treated 1103. A 40yo female was on COCP which she stopped 6m ago. But she has not had her periods since then. Labs: FSH=22, LH=24, prolactin=700, estradiol=80. What is the most appropriate dx? a. Hypothalamic amenorrhea b. Post pill amenorrhea c. Prolactinoma d. Pregnancy e. Premature ovarian failure key: E reason: this is a case of secondary amenorrhea with elevated gonadotropins indicating ovaian failure and the patient is 40 years so it's premature ovarian failure causes of secondary amenorrhea: 

with no androgen excess:

1-pregnancy(the most common cause of secondary amenorrhea),lactation,menopause. 2-premature ovarian failure: this is a poorly understood condition that may represent an autoimmune phenomenon. It can also follow radiotherapy or chemotherapy. With all these causes, menstruation and fertility can sometimes resume spontaneously. Ovarian failure will cause elevation of gonadotrophins and so hot flushes are likely. Premature menopause is defined as occurring before the age of 40. 3-depot and implant contraception 4-cevical stenosis and intrauterine adhessins >>> Asherman's syndrome 5-wt loss >>> especially if rapid 6-pitutary disease and hyperprolactinaemia 7-sheehan syndrome >>> the pituitary may be damaged by tumours, trauma, cranial irradiation, sarcoidosis or tuberculosis 8- post pill amenorrhea with androgen excess :

PCOS Premature Ovarian Failure – Secondary Amenorrhea (E) - Causes - Hyperprolactinemia - PCOS - Premature Ovarian Failure - Post-pill Amenorrhea - Asherman’s Syndrome - Investigations - Pregnancy test (if appropriate) - Follicle-stimulating hormone (FSH) and luteinising hormone (LH) - PRL - Total testosterone and sex hormone-binding globulin - TSH - A pelvic ultrasound may be useful in patients with suspected PCOS - Treatment Treatment is related to cause. Premature Ovarian Failure is irreversible but hormone replacement is necessary for controlling the symptoms of Estrogen deficiency and protection against Osteoporosis. Pregnancy can be achieved by oocyte donation or in vitro fertilization techniques. - What to look for in the question - Secondary amenorrhea before or at the age of 40 (The age is 40 in this question) - A raised Gonadotropin level

1104. A 25yo woman presents with a single lump in the breast and axilla. The lump is mobile and hard in consistency. The US, mammogram and FNA turn out to be normal. What is the most appropriate inv to confirm the dx? a. FNAC

b. MRI c. Punch biopsy d. Genetic testing and counselling e. Core biopsy key: E reason : in palpable mass we do triple assessment : clinical examination,imaging,FNAC >>>if not conclusive we do core biopsy then excional biopsy if still non conclusive Breast lump triple assessment 

examination



imaging: mamogaraphy,u/s



biopsy

* non palpable lesion: 1-core biopsy(image -guided) 2- open biopsy(needle localisation >>> radio opaque needles are used to guide the boipsy0 *palpable lesion: 1-FNAC 2-core biopsy 3-excision biopsy (entire lesion is removed) 4-incision biopsy (part of the lesion) All patients with breast lumps must undergo triple assessments. 1st Assessment: Clinical examination of the breast including axillary lymph nodes 2nd Assessment: Imaging - U/S for 35 years old patient. 3rd Assessment: Cytology - If it is a cyst, perform FNAC -Clear Fluid? Reassure the patient - Blood-stained aspirate? Send to lab for Cytology

- Clear fluid but residual mass? Perform core biopsy In this particular question: The patient is a young woman with a single lump in the breast and the axilla. The lump is hard and mobile which points towards Fibroadenoma but a swollen lymph node in the axilla points towards a carcinoma. To find out which one it is, we need a core biopsy since an ultrasound, a Mammogram and an FNAC turned out to be normal. The usual typical order of investigations in such cases is: - Ultrasound/ Mammogram depending upon the age. - Mammogram - FNAC - Core Biopsy

1105. A 37yo lady stopped taking COCP 18m ago and she had amenorrhea for 12m duration. Labs: FSH=8, LH=7, prolactin=400, estradiol=500. What is the cause? a. Hypothalamic amenorrhea b. PCOS c. Prolactinoma d. Post pill amenorrhea e. POF key:D reason :this is a case of secondary amenorrhea following COCP use,,, decreased gonadotropins >>> so it's not POF,, and there are no symptoms of increased androgens>>> so it's not PCOS ,, NO increased prolactin >>>so not prolactinoma,,, the history of amenorrhea after COCP use + decreased gonadotropins fit with >>> post pill amenorrhea Post-pill amenorrhoea this is when stopping oral contraceptives does not lead to a resumption of a normal menstrual cycle. It usually settles spontaneously in around three months but, if not, it requires

investigation. The condition is probably not a true entity but the cause of amenorrhoea started whilst taking the contraceptives that induced an artificial cycle until they were stopped. Post pill amenorrhea is described as the loss of menstrual periods for at least 6 months after stopping birth control pills. The incidence of post-pill amenorrhea ranges from 0.2% to 3%. - Cause of Post-pill Amenorrhea Post-pill amenorrhea is believed to be due to suppression of the pituitary gland by the birth control pills. - Investigations - The diagnosis of post-pill amenorrhea is usually made when there is loss of periods after a prolonged history of taking birth control pills. - Ultrasonography will reveal ovaries with no signs of developing follicles and ovulation even after having stopped the pills for 6 months. - Blood tests showing a low level of FSH, LH and estrogen is usually sufficient to confirm the diagnosis. - Treatment - The first line of treatment in case of post-pill amenorrhea is waiting for a spontaneous remission of the amenorrhea and a spontaneous occurrence of periods. - The time limit is usually six months. But if the woman is anxious to get her periods, active treatment may be started after waiting for only three months. - The standard treatment of post-pill amenorrhea is by stimulating the pituitary to produce FSH and LH. This is done by the drug clomiphene citrate. 1106. A lady with a firm smooth breast lump in outer quadrant had a FNAC done. Results showed borderline benign changes. She also has a fam hx of breast cancer. What is the your next? a. Mammography b. US c. Core biopsy d. Genetic testing and counselling e. Punch biopsy key : D reason: assessment of the case is complete (borderline benign change),,,next step is genetic testing and counselling. breast lump >>>discussed earlier

In this question a lady underwent an FNAC and the results have showed benign breast changes. She also has a risk for developing breast cancer because of her family history. All options but one are investigations, which we don’t need at this point because we got all we could get from the investigations. What needs to be done now is to assess the risk of breast cancer in this patient. Also, the patient needs to be counselled about the disease. Therefore, we should for genetic testing and counselling. 1107. A pt presents with mild dyskaryosis. 1y ago smear was normal. What is the most appropriate next step? a. Cauterization b. Repeat smear c. Swab and culture d. Cone biopsy e. Colposcopy key: E Cervical screening Cervical cancer is the third or fourth most common female malignancy worldwide The screening process is done using LBC (liquid based cytology) or older method (PAP) Interpreting smear results: Cells are analysed to look for abnormalities in the appearance of the nucleus and other aspects of cell morphology (dyskaryosis) 

Negative (normal) >>> treat incidental findings eg,infection & recall as appropriate



inadequate : insufficient or unsuitable material sampled >>>>Repeat sample immediately after treating any infection,,Repeat sample as soon as convenient if technically inadequate,,,if persistent (three inadequate samples), advise assessment by colposcopy



Borderline changes and mild dyskaryosis>>>> HPV testing ,,if positive >> colopscopy,,



if negative >>> normal recall



if unreliable >>> repeat HPV in six month and if +ve >> colopscopy



moderate and severe dyskaryosis >>>> refer to colopscopy

Cervical Cancer – When to refer for Colposcopy (E)

- Any smear showing mild, moderate or severe Dyskaryosis - Any suggestion of malignancy - 3 consecutive inflammatory smears - 2 consecutive atypical smears - 3 consecutive borderline smears - 3 consecutive inadequate smears - Post-coital bleeding 1108. An African lady presents with heavy but regular periods. Her uterine size correlates to 14wks pregnancy. What is the most appropriate dx? a. Blood dyscrasia b. Hematoma c. Fibroids d. Adenomyosis e. Incomplete abortion key: C reason: fibroids are three times more common in African americans than white american+ enlarged uterus + heavy menses Fibroids 

-age :commonly 30-50 ys



- more common in : obese, early menarche , African Americans ,



-protective factors: exercise, increased parity , may be smoking



types>> submucosal,,intramural,,subserosal



*presentation:



.. excessive or prolonged bleeding,,pelvic pain



..enlarged uterus>>pressure symptoms>>heaviness,constipation,urinary symptoms



..submucosal>>infertility,miscarriage,intermenstrual bleeding



..during pregnancy>>red degeneration

Investigations: 

pelvic u/s



TVUS >> more accurate



saline infusion u/s is superior to TVUS and hysteroscopy in detection of submucosal fibroids



MRI>>if myomectomy is considered and u/s is not conclusive



Endometrial sampling>>>in abnormal uterine bleeding



combination LDH, LDH isoenzyme 3 and gadolinium-enhanced MRI is highly accurate in diagnosing leiomyosarcoma pre-operatively, if sarcoma is suspected clinically

Treatment : 

only required if symptomatic

Medical: 

NSAIDs (ibuprofen)



Antifibrinolytic (tranexamic acid)



Combined hormonal contraception ( CHC)



Merina,,danazol,,GnRH agonists,,Mifepristone,,ulipristal acetate,,aromatase inhibitor>>letrozole

Surgical: 

indications>>failure of medical treatment,,infertility,,pressure symptoms,,excessively enlarged uterine size



*myomectomy>> for those who want to maintain fertility



abdominal myomectomy : safe alternative to hysterectomy + risk of blood loss



laparoscopic myomectomy: less pain, shorter hospital stay and reduced recovery time,subserous fibroid



hysteroscopic myomectomy : established surgical procedure for women with submucosal fibroids and excessive uterine bleeding, infertility or repeated miscarriages.



laparoscopic laser myomectomy >> not recommended by NICE



* TOTAL hysterectomy



laparotomy



laparoscopic assisted hysterectomy >> urinary tract injury+severe bleeding



* uterine artery embolization UAE



*MRI-guided transcutaneous focused ultrasound

- Notice that the question mentions an African female with regular but heavy periods. This is because fibroids are mostly common in Afro-Caribbean females. - Fibroids are responsive to estrogen and therefore increase in size, which in turn increases the size of the uterus. E.g., in this patient, her uterine size correlates to 14 weeks pregnancy. - Other symptoms - Pelvic pain (Compression on to adjacent structures) - Infertility/Recurrent Miscarriages - Pelvic Mass - The investigation of choice is an U/S - Management - Mirena Coil is the first choice if the fibroids are not big enough to restrict its insertion. - If < 3 cm - Trial of pharmacologic treatment first (Tranexamic Acid) first - If it fails and uterus is not bigger than 10-week pregnancy, do endometrial ablation - If the above fails, perform a hysterectomy - If > 3 cm and wishes to retain uterus and/or wants to avoid surgery - Go for Uterine Artery Embolization - If > 3 cm and wishes to retain uterus, go for a hysteroscopic myomectomy or a myomectomy

1109. A 29yo at 38wks GA presents with a 2h hx of constant abdominal pain. She then passes 100 ml of blood per vagina. What is the next appropriate inv? a. USS b. CTG c. Clotting screen d. Hgb

e. Kleihauer Betke test key: A reason : in case of antenatal bleeding we do u/s to investigate the cause of bleeding Antenatal bleeding 

never perform PV >> might increase bleeding



dangerous causes: Abruption,placenta praevia,vasa praevia



other caused:circumvallate placenta,placental sinuses cervical polyps,erosions and carcinoma,cervicitis,vaginitis,vulvar varicosities



placental abruption>>>> part of placenta becomes detached ,, the outcome depends on the amount of detachment and blood loss,,bleeding might be concealed



associations>>> preeclampsia,smoking,cocaine,IUGR,PROM,abdominal trauma,multiple pregnancy,polyhydramnios,increased maternal age,non vertex presentation,assisted reproductive techniques



placenta praevia>>>placenta is in the lower uterine symptoms,,bleeding is always revealed

Management: 

in severe bleeding>>> admission,,IV lines , O2 mask,, blood transfusion if in shock,,catheterize,,if severe bleeding >> CS



in mild cases>>> IVI,,Hb , cross match,check vitals >> establish dx by u/s >>if placenta praevia >>>cs

Bleeding During Third Trimester – APH (A) - Bleeding during the third trimester is either painful or painless bleeding. - Painful bleeding points to Placental Abruption while painless bleeding points to Placenta Previa - In this case, the patient is experiencing painful vaginal bleeding in the third trimester, so this appears to be the case of Placental Abruption - The investigation of choice in this case is an Ultrasound - Risk Factors for Abruption - Hypertension - Smoking - Multiple Pregnancy - Cocaine/Amphetamine Use

- Increased Maternal Age - Trauma to the abdomen - Polyhydramnios - Investigation - Diagnosis is clinical but U/S is done to exclude Placenta Praevia and to check the well-being of the baby. - Management - Always admit the patient to hospital for assessment and management. Phone 999/112/911 if there are any major concerns regarding maternal or fetal well-being. - The mainstays of management are resuscitation and accurate diagnosis of the underlying cause. - Severe bleeding or fetal distress: urgent delivery of the baby, irrespective of gestational age. - Admit to hospital, even if bleeding is only a very small amount. There may be a large amount of concealed bleeding with only a small amount of revealed vaginal bleeding. - No vaginal examination should be attempted, at least until a placenta praevia is excluded by ultrasound. It may initiate torrential bleeding from a placenta praevia. - Resuscitation can be inadequate because of underestimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs. - Take blood for FBC and clotting studies. Crossmatch, as heavy loss may require transfusion. - Gentle palpation of the abdomen to determine the gestational age of the fetus, presentation and position. - Fetal monitoring. - Arrange urgent ultrasound. - With every episode of bleeding, a rhesus-negative woman should have a Kleihauer test and be given prophylactic anti-D immunoglobulin - Complications - Premature Labour - DIC - Renal Tubular Necrosis - PPH

- Placenta Accreta - Points to look for diagnosis of Abruption - Shock is out of proportion from visible blood loss - Constant pain - Tender tense uterus - Fetal heart sounds absent/distressed - Coagulation problems like DIC

1110. A 26yo woman had amenorrhea for 10wks and is pregnant. She experiences hyperemesis. Now she presents with vaginal bleed. Exam: uterus=16wks, closed os. What is the most probable dx? a. Thyrotoxicosis b. Hyperemesis gravidarum c. Twins d. Wrong dates e. Molar pregnancy key : E reason: increased uterine size for date + hyperemesis + vaginal bleeding Molar pregnancy 

complete mole >>> MRI-guided transcutaneous focused ultrasound,,the most common



partial mile >>>the trophoblast cells have three sets of chromosomes (triploid)



risk factors>>> mother over 45ys,,previous molar pregnancy,multiple pregnancy,menarche over 12 ys ,asian women , oral contraceptive pills



presentation >>>vaginal bleeding in the first trimester , hyperemesis, abnormal uterine enlargement, hyperthyroidism, anaemia, respiratory distress and preeclampsia are now rare as a result of routine use of ultrasound in early pregnancy

Investigations 

Urine and blood levels of hCG >>> for follow up after evacuation



histology>>>> Definitive diagnosis is made by histological examination of the products of conception.



u/s>>>>Ultrasound in the first trimester may not be reliable. The typical 'snowstorm' appearance occurs mainly in the second trimester

treatment : 

Suction curettage is the method of choice of evacuation for complete molar pregnancies.



Suction curettage is the method of choice of evacuation for partial molar pregnancies except when the size of the fetal parts deters the use of suction curettage and then medical evacuation can be used.



follow up :



A urinary pregnancy test should be performed three weeks after medical management of failed pregnancy if products of conception are not sent for histological examination.



complications: choriocarcinoma >>> follows a molar pregnancy and should always be considered when a patient has continued vaginal bleeding after the end of a pregnancy. It has the ability to spread locally, as well as metastasise.

Molar Pregnancy - Tumor consists of chorionic villi which have swollen and degenerated - It makes a lot of HCG and therefore gives rise to exaggerated pregnancy symptoms, e.g. Hyperemesis Gravidarum - Signs - Exaggerated pregnancy symptoms - A larger for dates uterus - Hyperthyroidism - Most present with early pregnancy failure - Investigation - Snowstorm appearance on U/S - Management - Suction and curettage is the method of choice for evacuation - Give anti-D prophylaxis - Monitor HCG levels every two weeks until they are normal

- Monitor monthly for six months after they return to normal - Pregnancy should be avoided for a year while HCG levels are being monitored - Measure HCG 6-8 weeks after any future pregnancy regardless of the outcome

1111. A pregnant woman of G2, GA 11wks presents with heavy vomiting, headache and reduced urine output. Urine analysis shows ketonuria. Choose the next best step? a. US b. Oral fluid replacement c. Serum BHCG d. Parental anti-emetics e. IV fluids key: E reason : the pt has reduced urine output,vomiting ,headache ,ketonuria >>which indicates hypovolemia >>> IV fluids Vomiting in pregnancy Presentation 

Symptoms usually start between 4 and 7 weeks of gestation and resolve by 16 weeks in about 90% of women. Check for signs of dehydration

Management 

Most cases are mild and do not require treatment



Diet >>> Advise the patient to rest; eat small, frequent meals that are high in carbohydrate and low in fat



Anti-emetic drug treatment>>> This should only be given when symptoms are persistent, severe and preventing daily activities( cyclizine, metoclopramide, prochlorperazine, promethazine, chlorpromazine, domperidone and ondansetron )



Proton pump inhibitors and histamine H2-receptor antagonists may be used in women who also have dyspepsia



Hyperemesis gravidarum:



intractable vomiting associated with weight loss of more than 5% of pre-pregnancy weight, dehydration, electrolyte imbalances( hyponatremia,hypokalemia), ketosis, and the need for admission to hospital.



management:



dietary advice



Fluid and electrolyte replacement >>> intravenous fluid and electrolyte replacement



Nutritional support (enteral or parenteral)



Vitamin supplements >>> thiamine



Thromboprophylaxis >>> LMWH



Anti-emetic drugs



Corticosteroids: may be used for intractable (failure to respond to conventional treatment) cases of severe hyperemesis gravidarum in secondary care.



In cases of hyperemesis gravidarum: renal function and electrolytes, LFTs, midstream urine and ultrasound (exclude multiple or molar pregnancy).

Treating Dehydration due to Heavy Vomiting (E) - This patient has heavy vomiting which causes dehydration. - The immediate next step here would be fluid correction through IV route. 1112. A pt had inflammatory changes on cervical smear. There is no vaginal discharge, no pelvic pain and no fever. What is the next step? a. Repeat smear in 6m b. Take swab c. Treat with antibiotics d. Colposcopy e. Cone biopsy key : b reason : if inaccurate repeat the test ( full topic discussed earlier ) Inflammatory Changes on Cervical Smear (A) - OHCS on encountering inflammatory changes: Take swab. Treat infection. Repeat in 6 months. Colposcopy after 3 abnormal.

1113. A 37yo infertile lady with 5 cm subserosal and 3 cm submucosal fibroid is trying to get pregnant. Which is the most suitable option? a. Clomiphene therapy b. IVF c. Myomectomy d. Hysterectomy e. IU insemination key : c reason : submucosal fibroids cause infertility >> myomectomy ( full topic discussed earlier) - Refer to 1108. It is explained in detail over there.

1114. A young tall man and his wife are trying for babies and present at the infertility clinic. On inv the man has primary infertility and azoospermia. What other inv should be done? a. Testosterone b. LSH c. FSH d. Estradiol e. Karyotyping key : e reason : in primary azoospermia + tall man >>> karyotyping >>> klinefelter's syndrome Klinefelter's syndrome karyotype XXY is associated with hypogonadism and disorders of spermatogenesis. The classic clinical description 

Infertility and small firm testes are present in about 99% of individuals ,decreased facial and pubic hair; loss of libido; impotence.



Tall and slender, with long legs, narrow shoulders, and wide hips.



Gynaecomastia or history of gynaecomastia during puberty; decreased libido; history of undescended testes.



Learning disability; delayed speech development; behavioural problems; psychosocial disturbances.



tiredness, reduced muscle power and stamina, and truncal obesity



Investigations



XXY males may be diagnosed before birth, through amniocentesis or chorionic villus sampling.



Later, serum testosterone is low or low normal. FSH and LH are elevated (FSH >LH).



Diagnosis is confirmed by chromosomal analysis. The most common indications for karyotyping are hypogonadism and infertility.

Management 

testosterone replacement



fertility treatment : ICSI



Surgical treatment : for gynaecomastia

- Young tall man with primary infertility and Azoospermia points in the direction of Klinefelter’s Syndrome. - The definitive diagnosis is chromosomal analysis also known as karyotyping.

1115. A woman who is on regular COCP presented to you for advice on what to do as she has to now start to take a course of 7d antibiotics. What would you advice? a. Continue regular COC b. Continue COCP and backup contraception using condoms for 2d c. Continue COCP and backup contraception using condoms for 7d d. Continue COCP and backup contraception using condoms for 2wks key : D reason : There are many commonly used medications which can affect the efficacy of the pill INTERACTIONS : 

*Non-enzyme-inducing antibacterial >>> Women should be advised that no additional contraception is required.



*Enzyme-inducing antibacterials rifampicin or rifabutin , and anticonvulsants, St John's wort, (Short course two months or less ) >>> Women are advised to continue taking the COCP ,use additional precautions AND should be continued for 28 days after stopping the rifampicin/rifabutin.



*Enzyme-inducing antibacterials rifampicin or rifabutin,and anticonvulsants, St John's wort (Long-term course) >>> Should be advised to use an alternative, nonhormonal method



*Lamotrigine >>> Women should be advised not to take lamotrigine with the COCP and should seek another form of contraception (unless also taking a non-enzymeinducing anticonvulsant such as sodium valproate)



*Antiretroviral therapies>>> women on ritonavir-boosted protease inhibitors should be advised to use alternative methods of contraception.



*Ulipristal acetate>>>Women should use additional contraceptive precautions for 14 days after taking ulipristal acetate

- Antibiotics like Rifampicin and Griseofulvin increase the breakdown of estrogen and therefore can cause unwanted pregnancy. - In such cases, backup contraception using condoms for two weeks should be advised.

1116. A lady presents with hot flashes and other symptoms of menopause. What is the tx option? a. Raloxifene b. HRT c. Bisphosphonate d. COCP e. Topical estrogen key :B reason : HRT is the gold standard treatment for hot flushes. MENOPAUSE The menopause is a natural phenomenon occurs in all women when the number of ovarian follicles are depleted. oestrogen & progesterone fall, and LH &FSH increase in response. Menstruation becomes erratic and eventually stops PRESENTATION



Menstrual irregularity >>> which may last for up to four years,The cycle may lengthen or shorten,A slight increase in the amount of menstrual blood loss,10% of women have an abrupt cessation of periods.



Hot flushes and sweats



Urinary and vaginal symptoms >>> dyspareunia, vaginal discomfort and dryness, recurrent lower urinary tract infection and urinary incontinence



Sleep disturbance , Loss of libido AND Mood changes

Management 

Healthy lifestyle >>> Stopping smoking, losing weight and limiting alcohol



Hormone replacement therapy (HRT) >>> the most effective treatment to completely relieve the symptoms particularly Vasomotor symptoms (hot flushes/night sweats) ,Mood swings ,Vaginal and bladder symptoms caused by the menopause. It also prevents and reverses bone loss.



Alternatives to HRT >>> Herbal or complementary treatments



Other drugs >>> GABA , SSRI

1116. Menopause (B) - Permanent cessation of menstruation for a minimum of 12 months in the absence of other causes of Amenorrhea. - Usually occurs between 45-55 years; average age is 52. - Symptoms - Hot flushes - Depression - Anxiety - Irritability - Mood swings - Vaginal dryness - Atrophic Vaginitis leading to dyspareunia - Treatment - Hormone-Replacement Therapy is the gold standard. - Estrogen-only HRT is suitable for candidates who have had a hysterectomy - Combined HRT is suitable for patients with a uterus

- Vaginal dryness and atrophic vaginitis should be treated with topical estrogen - Long-term Complications - Osteoporosis - Cardiovascular disease - Urogenital Atrophy – Atrophic Vaginitis - HRT Contraindications - Estrogen-dependent cancer - Past pulmonary embolus - Undiagnosed PV bleeding - Increased LFTs - Pregnancy - Breastfeeding - Phlebitis 1117. A 28yo woman at 34wks GA for her first pregnancy attends antenatal clinic. Her blood results: Hgb=10.6, MCV=95, MCHC=350. What do you do for her? a. Folate b. Dextran c. Ferrous sulphate d. None e. IV FeSO4 f. Explain this physiologic hemodynamic anemia g. Blood transfusion key : F reason : normal MCV,MCHC + in the second and third trimester anemia is considered when Hb is less than 10.5 Anemia in pregnancy

definition >>> Hb level > NOT usually recommended >>> continuation of COCP, the combined contraceptive patch, and combined contraceptive vaginal ring -WITHOUT AURA ( ≥35 years of age) >>> don't use COCP 

DM >>> Methods that should not usually be used: progestogen-only injectables. COCP, the combined contraceptive patch and the combined contraceptive vaginal ring



Hypertension >>> Methods that are not usually recommended: COCP, the combined contraceptive patch and combined contraceptive vaginal ring.



Irregular menses >>> COCP



Smoking >>> Methods that should not be used: COCP, combined contraceptive patch and combined contraceptive vaginal ring.



Multiple risk factors for cardiovascular disease>>> Methods that should not be used: COCP, combined contraceptive patch and combined contraceptive vaginal ring AND POP are not usually recommended



Venous thromboembolism or risk of thromboembolism>>> Methods that should not be used: COCP, the combined contraceptive patch, and the combined contraceptive vaginal ring.



Sickle cell disease >>> intrauterine devices are not recommended, as they may be associated with uterine bleeding and infection , Depot contraceptive (DepoProvera®) is safe and has been found to improve the blood picture and reduce pain crises.



Women taking anticoagulants for VTE >>> Methods that should not be used: COCP, combined contraceptive patch and combined contraceptive vaginal ring AND POP are not usually recommended



Sexually transmitted infection or pelvic inflammatory disease >>> insertion of a cu-IUCD or the LNG-IUS is not recommended.



Contraception for those with learning disabilities >>> use of injectable contraceptives and IUCDs is high



Contraception for those also taking enzyme enhancers >>>COCP - all women should be advised to switch to a contraceptive method unaffected by enzyme inducers (eg progestogen-only injectable, copper IUCD (Cu-IUCDs) or LNG-IUS).or to cover with another method eg. condoms

POP>>> Advise alternative contraceptive methods

Progestogen-only implants >>> May continue with progestogen-only implants with additional contraceptive protection, such as condoms, when taking liver enzyme-inducers and for four weeks after they are stopped. drugs which induce liver enzymes include: Antifungals: griseofulvin. Antibiotics: rifampicin and rifabutin. Anti-epileptics: carbamazepine, eslicarbazepine, phenytoin, phenobarbital, primidone, oxcarbazepine, topiramate. Central nervous system stimulant: modafinil. Antiretroviral drugs: nelfinavir, nevirapine, ritonavir. St John's wort. - Mirena, also known as Intrauterine System, is a Levonorgestril-containing coil which is inserted into the uterus. - Local effect: reversible endometrial atrophy, makes implantation less likely and periods lighter (20% reversible amenorrhea) - Less risk of ectopic pregnancy - Risk of STDs is reduced - May benefit women with endometriosis, adenomyosis, fibroids or endometrial hyperplasia - NOTE: Avoid if breast cancer.

1120. A 32yo woman comes with intermenstrual bleeding. Her last cervical smear was 1y ago and was negative. What test would you recommend for her initially? a. Colposcopy b. Cervical smear c. Endocervical swab d. Transvaginal US e. Pelvic CT key : b reason : to exclude cervical carcinoma

- In this patient there is no indication for colposcopy. Indications for colposcopy include: - Smear showing mild, moderate or severe Dyskaryosis - Any suggestion of malignancy - 3 consecutive inflammatory smears - Glandular abnormal cells - 2 consecutive atypical smears - 3 consecutive borderline or inadequate smears - Post-coital bleeding - Endocervical Swab is not advisable at this point due to absence of any signs of infection - Initially, a cervical smear should be taken as the previous one was negative one year ago (25-50 years, take cervical smear every 3 years)

1121. A 20yo woman has had abdominal pain in the LIF for 6wks duration. Over the past 48h, she has severe abdominal pain and has a fever of 39.1C. Pelvic US shows a complex cystic 7 cm mass in the LIF. What is the most likely dx? a. Endometriosis b. Dermoid cyst c. Ovarian ca d. Tubo-ovarian abscess e. Ectopic pregnancy key : D reason : fever 39.1 +cystic pelvic mass + localized abdominal pain Tubo-ovarian abscess A tubo-ovarian abscess is one type of pelvic abscess which is found in women of reproductive age, and may be a complication of pelvic inflammatory disease. In this case it is an inflammatory mass which involves the ovary and Fallopian tube Presentation 

Systemic features of toxicity: fever, malaise, anorexia, nausea, vomiting, pyrexia.



Local effects: eg, pain, deep tenderness , diarrhoea, tenesmus, mucous discharge per rectum, urinary frequency, dysuria, vaginal bleeding or discharge.

Investigations 

FBC >>> raised white cell count often but not invariably



Ultrasound



CT/MRI scanning may be more effective at identifying the origin of the abscess

Management: 

Hospital admission



Drainage of the abscess along with antibiotic treatment



Antibiotics used alone are occasionally effective for very early, small abscesses



Procedures used for drainage of the pelvic abscess >>> Ultrasound-guided aspiration and drainage----CT-guided aspiration and drainage----Endoscopic ultrasound-guided drainage ----Laparotomy or laparoscopy with drainage of abscess



Definitive surgery may be required after initial drainage for some causes of pelvic abscess, such as salpingo-oophorectomy for tubo-ovarian abscess.

-General symptomatology of pelvic infections - Systemic features of toxicity: fever, malaise, anorexia, nausea, vomiting, pyrexia. - Local effects: eg, pain, deep tenderness in one or both lower quadrants, diarrhoea, tenesmus, mucous discharge per rectum, urinary frequency, dysuria, vaginal bleeding or discharge. - Rectal or vaginal examination: may reveal tenderness of the pelvic peritoneum and bulging of the anterior rectal wall. - Partial obstruction of the small intestine: this may sometimes occur. -Investigations - FBC showing increased WBC count - U/S - CT/MRI scanning may help in tracing the origin of the abscess - Management - Arrange urgent admission to hospital. - Management is usually by drainage of the abscess along with antibiotic treatment. Antibiotics used alone are occasionally effective for very early, small abscesses

- Antibiotic choice is guided by the likely cause and local resistance patterns and guidelines, but usually needs to be broad-spectrum until the pathogens are determined. - Points in favour of Tubo-Ovarian Abscess - Fever - Pain in the LIF - Severe abdominal pain - U/S showing a cystic mass in the LIF

1122. A woman is 16wk pregnant and she is worried about abnormal chromosomal anomaly in her child. What is the definitive inv at this stage? a. Amniocentesis b. CVS c. Parents karyotyping d. Coomb’s test e. Preimplantation genetic dx key : A Prenatal diagnosis 

Amniocentesis : This is normally carried out from 15 weeks of gestation. A needle is inserted into the amniotic cavity and amniotic fluid is sampled, allowing culture and assessment of fetal cells.the most invasive prenatal diagnostic procedure.



Chorionic villus sampling : carried out at 11-13 weeks. Risk of miscarriage may be slightly higher than for amniocentesis. sampling of the developing placenta and the same type of analysis of fetal cells to detect chromosomal, genetically inherited and endocrine or metabolic conditions.



Fetoscopy : This allows visualisation of the fetus, using endoscopic techniques. at 18-20 weeks of gestation



Cordocentesis/percutaneous umbilical blood sampling : at 18 weeks.ultrasound guidance to obtain fetal blood cells from the umbilical cord.It enables karyotyping/chromosome analysis, Intrauterine blood transfusions, Fetal viral infection confirmation.



Fetal radiology : in suspected skeletal dysplasia, ultrasound (2D and 3D) and MRI are now the investigations of choice



Ultrasound-guided percutaneous skin and organ biopsy : This can also be carried out to allow skin, muscle, liver and other fetal organ analysis



Maternal blood tests : eg. Maternal serum alpha-fetoprotein levels can be measured to aid the diagnosis of neural tube defects between 15-22 weeks

- Definitive tests - Pre-implantation Genetic Diagnosis (earliest possible diagnosis; available to couples at risk of having a child with specific genetic or chromosomal disorder such as CF, Thalassemia and Huntington’s etc) - Chorionic Villous Sampling (done between 10 and 13 weeks; enables early detection and provides the mother with a choice to either continue or terminate pregnancy) - Amniocentesis (done between 14-18 weeks; carries a very low risk of miscarriage) - The patient is 16 weeks pregnant, so the best definitive testing that can be carried out at this stage would be Amniocentesis.

1123. A 28yo lady with a fam hx of CF comes for genetic counselling and wants the earliest possible dx test for CF for the baby she is planning. She is not in favor of termination. What would you recommend for her? a. CVS b. Amniocentesis c. Pre-implantation genetic dx d. Chromosomal karyotyping e. Maternal serum test f. Reassure key : C reason :pre-implantation genetic dx is the earliest diagnostic test Pre-implantation prenatal diagnosis This is a technique that allows the analysis of oocytes or embryos conceived through in vitro fertilisation (IVF). This information then informs the choice of optimal embryos to be transferred

back to the mother. This is an accepted technique for avoiding the birth of affected children from parents with a known genetic abnormality - There is a positive family history of CF, therefore the earliest possible diagnosis can be made via Pre-implantation genetic testing. - See above for further details 1124. A 39yo woman in her 36th week GA with acute abdominal pain is rushed for immediate delivery. Her report: BP=110/60mmHg, Hgb=low, bilirubin=22, AST=35, Plt=60, APTT=60, PT=30, Fibrinogen=0.6. What is the cause? a. Pregnancy induced hypertension b. DIC c. HELLP syndrome d. Acute fatty live e. Obstetric cholestasis key : B reason : low fibrinogen,increased bilirubin ,normal AST , prolonged PT,PTT DIC The diagnosis of DIC should include both clinical and laboratory information: 

(PT) elevated.



(aPTT) elevated.



Platelet counts in DIC are typically low



Fibrinogen level low.

Confirmatory tests : 

The D-dimer test gives strong evidence of DIC.



Fibrin degradation products (FDPs) are helpful but can occur in other conditions such as deep vein thrombosis (DVT)



In acute DIC, PT and aPTT are prolonged, and the platelet count and fibrinogen decrease. D-dimer, FDP, and fibrin monomer levels are elevated

Management :

The cornerstone of the the management of DIC is treatment of the underlying condition. Thus, infection will need antibiotics, and obstetric complications may need intervention plasma and /or platelet transfusion Conditions that may be complicated by DIC include: * Infections, especially septicaemia, Escherichia coliO157, typhoid fever, Rocky Mountain spotted fever and parasites. The rash of meningococcal septicaemia is classical. * Malignancy, especially leukaemias. * Major trauma including crush syndrome and, occasionally, burns. * Some connective tissue disorders including antiphospholipid syndrome. * Complications of pregnancy including the placental problem of placental abruption, amniotic fluid embolism, severe hypertension of pregnancy with fulminating pre-eclampsia and HELLP syndrome. A retained dead fetus tends to produce a thrombotic rather than a haemorrhagic state. * Incompatible blood transfusion. * Heat stroke. * Dissecting aortic aneurysm. * Some snake bites If DIC is suspected then clotting screen tests are followed by confirmation: - Prothrombin time (PT) elevated. - Activated partial thromboplastin time (aPTT) elevated. - Platelet counts in DIC are typically low, especially in acute sepsis-associated DIC, but may be increased in malignancy-associated chronic DIC. - Fibrinogen level low. If two results are positive,DIAGNOSIS is possible; if three are positive, it is likely; if all four are positive, it is extremely likely. - Confirmatory tests look for evidence of the simultaneous formation of thrombin and plasmin. - The D-dimer test gives strong evidence of DIC. - Fibrin degradation products (FDPs) are helpful but can occur in other conditions such as deep vein thrombosis (DVT) and, in severe disease, they may be negative. - In acute DIC, PT and aPTT are prolonged, and the platelet count and fibrinogen decrease. Ddimer, FDP, and fibrin monomer levels are elevated.

1125. A 36wk pregnant woman presents with sudden onset of uterine pain and bleeding, uterus is

tender, no prv LSCS. What is the most appropriate cause? a. Preeclampsia b. DIC c. Placental abruption d. Placental previa e. Ectopic pregnancy f. Missed abortion g. Ectropion key : C reason : a case of antepartum haemorrhage in the third trimester >>> pain + bleeding >>> abruptin ( pain is common with abruption) ( full topic discussed earlier) - Bleeding during the third trimester is either painful or painless bleeding. - Painful bleeding points to Placental Abruption while painless bleeding points to Placenta Previa - In this case, the patient is experiencing painful vaginal bleeding in the third trimester, so this appears to be the case of Placental Abruption - The investigation of choice in this case is an Ultrasound - Risk Factors for Abruption - Hypertension - Smoking - Multiple Pregnancy - Cocaine/Amphetamine Use - Increased Maternal Age - Trauma to the abdomen - Polyhydramnios - Investigation - Diagnosis is clinical but U/S is done to exclude Placenta Praevia and to check the well-being of the baby. - Management

- Always admit the patient to hospital for assessment and management. Phone 999/112/911 if there are any major concerns regarding maternal or fetal well-being. - The mainstays of management are resuscitation and accurate diagnosis of the underlying cause. - Severe bleeding or fetal distress: urgent delivery of the baby, irrespective of gestational age. - Admit to hospital, even if bleeding is only a very small amount. There may be a large amount of concealed bleeding with only a small amount of revealed vaginal bleeding. - No vaginal examination should be attempted, at least until a placenta praevia is excluded by ultrasound. It may initiate torrential bleeding from a placenta praevia. - Resuscitation can be inadequate because of underestimation of blood loss and misleading maternal response. A young woman may maintain a normal blood pressure until sudden and catastrophic decompensation occurs. - Take blood for FBC and clotting studies. Crossmatch, as heavy loss may require transfusion. - Gentle palpation of the abdomen to determine the gestational age of the fetus, presentation and position. - Fetal monitoring. - Arrange urgent ultrasound. - With every episode of bleeding, a rhesus-negative woman should have a Kleihauer test and be given prophylactic anti-D immunoglobulin - Complications - Premature Labour - DIC - Renal Tubular Necrosis - PPH - Placenta Accreta - Points to look for diagnosis of Abruption - Shock is out of proportion from visible blood loss - Constant pain - Tender tense uterus - Fetal heart sounds absent/distressed - Coagulation problems like DIC

1126. A 28wk pregnant woman presents with uterine bleeding after sexual intercourse. What is the most appropriate cause? a. Preeclampsia b. DIC c. Placental abruption d. Placental previa e. Ectopic pregnancy f. Missed abortion g. Ectropion key : G reason :postcoital bleeding >>> mostly ectropion Causes of postcoital bleeding 

Infection,Trauma.



Cervical ectropion - especially in those women taking the combined oral contraceptive pill (COCP).



Cervical or endometrial polyps. 

Vaginal cancer , Cervical cancer - usually apparent on speculum examination. Ectropion



It is most commonly seen in teenagers, during pregnancy and in women on combined hormonal contraception.



It is generally an asymptomatic condition but patients occasionally present with bleeding or excessive discharge.



Once a normal cervical smear has been confirmed, it is actively managed only if there are symptoms. Over time, vaginal acidity promotes metaplasia to squamous epithelium when the symptoms will disappear.



After stopping any oestrogen-containing contraceptive, treatment options are controversial but include diathermy, cryotherapy, surgery with laser treatment and microwave therapy.

- The cervix enlarges under the influence of oestrogen and as a result the endocervical canal is everted. It is seen on examination as a red ring around the os and is so common as to be regarded as normal. - It is most commonly seen in teenagers, during pregnancy and in women on combined hormonal contraception. - This seems to be the most appropriate among the given options because the patient is 28 weeks pregnant and had sex at this point. - There are no signs of pre-eclampsia, DIC, Placental abruption and Placenta Praevia. Ectopic pregnancy and missed abortion do not present at this stage. 1127. A 6wk pregnant woman presents with abdominal pain. She has prv hx of PID. What is the most likely dx? a. Preeclampsia b. DIC c. Placental abruption d. Placental previa e. Ectopic pregnancy f. Missed abortion g. Ectropion key : E reason : hx of PID + early pregnancy + abdominal pain Ectopic pregnancy The majority of ectopic pregnancies occur in the ampullary or isthmic portions of the Fallopian tubes Risk factors 

IUCD



PID



in tubes that have been divided in a sterilisation operation and where they have been reconstructed to reverse on

Presentation :  

30% of ectopic pregnancies present before a period has been missed. Abdominal pain.



Pelvic pain.



Amenorrhoea or missed period.



Vaginal bleeding (with or without clots)

Investigations: 

The most accurate method to detect a tubal pregnancy is transvaginal ultrasound.



hCG levels are performed in women with pregnancy of unknown location who are clinically stable

Management : 

Medical management: systemic methotrexate is offered first-line to those women who are able to return for follow-up and who have the following:



No significant pain,Unruptured ectopic pregnancy with an adnexal mass > preeclampsia Pre-eclampsia Pre-eclampsia is pregnancy-induced hypertension in association with proteinuria (>0.3 g in 24 hours) with or without oedema. Severe pre-eclampsia is defined as diastolic blood pressure of at least 110 mm Hg, or systolic blood pressure of at least 160 mm Hg, and/or symptoms, and/or biochemical and/or haematological impairment Presentation: 

New hypertension ,New and/or significant proteinuria.



Other clinical features of severe pre-eclampsia include:

Severe headache - usually frontal. Platelet count falling to below 100 x 109/ Abnormal liver enzymes (ALT or AST rising to above 70 IU/L). HELLP syndrome: H (haemolysis) EL (elevated liver enzymes) LP (low platelets). Investigations : 

Urinalysis



Frequent monitoring of FBC, LFTs, renal function, electrolytes and serum urate



Clotting studies if there is severe pre-eclampsia or thrombocytopenia



24-hour urine collections for protein quantification and creatinine clearance.



Assessment of fetus -ultrasound

Management: 

Control Blood pressure



Prevention of seizures >>> Magnesium sulfate



Fluid balance



Delivery

- Pre-eclampsia: BP > 140/90 and 300 mg proteinuria in 24-hour urine collection - Mild to moderate: BP 160/110 with significant proteinuria or if maternal complications occur - Risk factors - Previous history of pre-eclampsia - Maternal age > 40 years - Family History - DM, HTN, Renal Disease - This is a case of severe pre-eclampsia as the BP of the patient in question suggests. This should be managed along the following lines. - Anti-hypertensives to bring BP down to less than 160/110 - IV Hydralazine is the first choice - Labetolol - MgSO4 to prevent eclampsia - CTG and U/S to monitor the baby NOTE: If less than 34 weeks gestation, give steroids to help production of surfactant. - Complications - Eclampsia - HELLP Syndrome - DIC - Renal Failure

- Placental Abruption

1130. A 32yo woman has a hx of spontaneous abortions at 6wks, 12wks, and 20wks. She is now keen to conceive again. Which of the following would you prescribe for the next pregnancy? a. MgSO4 b. Aspirin c. Warfarin d. Mefenamic acid e. Heparin key : B reason : antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage >>>> Rx >>> Asprin recurrent miscarriage def. >>> the loss of three or more consecutive pregnancies Aetiology : 

Antiphospholipid syndrome >> investigation : anticardiolipin antibodies , lupus anticoagulant >>> Rx : Aspirin



structural >>> uterine anomalies , fibroids , cervical incompetence ( late miscarriage) >>> investigation : pelvic u/s >>> Rx in cervical incompetence : cerclage (complication : uterine rupture)



endocrine >>> PCOS , uncontrolled diabetes



immune



thrombophilia



genetic abnormality



infection >>> bacterial vaginosis in the first trimester is a risk of second trimester miscarriage and preterm delivery

- Recurrent miscarriage is defined as the loss of three or more consecutive pregnancies. Miscarriage, the most common complication of pregnancy, is the spontaneous loss of a pregnancy before the fetus has reached viability. The term therefore includes all pregnancy

losses from the time of conception until 24 weeks of gestation in the UK. - Antiphospholipid syndrome (APS): - This is the most important treatable cause of recurrent miscarriage. - Investigations - Antiphospholipid antibodies: The presence of these is associated with early miscarriages and maternal morbidity and is referred to as primary APS. There is requirement for two tests at least six weeks apart showing either lupus anticoagulant or anticardiolipin antibodies at significant levels. - Women with recurrent first-trimester miscarriage and all women with one or more secondtrimester miscarriages should be screened for antiphospholipid antibodies before pregnancy. - Women with second-trimester miscarriage should be screened for inherited thrombophilias including factor V Leiden, factor II (prothrombin) gene mutation and protein S. - All women with recurrent first-trimester miscarriage and all women with one or more secondtrimester miscarriages should have pelvic ultrasound to assess uterine anatomy. - If uterine anomalies are detected then further investigations, such as hysteroscopy and/or laparoscopy, may be required. - Management - General advice - Reassurance should be given about the high probability of a successful outcome. In a large trial that included women with 4.2 consecutive miscarriages and an average age of 32.7 years, the placebo group was shown to have a live birth rate of 65%. Pharmacological treatment - In primary APS patients, heparin combined with low-dose aspirin improves live birth rate to 70%.[5] There ARE only limited data supporting the use of heparin in women without APS - There is some evidence suggesting that use of metformin during pregnancy is associated with a reduction in the miscarriage rate in women with polycystic ovarian syndrome - However, the RCOG DOES NOT recommend its use in pregnancy at present until further randomised prospective study results are available to provide adequate evidence of safety and efficacy of its use. - A Cochrane review found evidence of benefit for progestogen therapy in women with a history of recurrent miscarriage. There was no statistically significant difference in rates of adverse effects. - However, there is currently a large randomised, double-blind, placebo-controlled multicentre trial underway - the Progesterone in recurrent miscarriage (PROMISE) study - which aims to provide a definitive answer regarding progesterone use in women with recurrent miscarriages.

Surgical - Cervical cerclage is used where cervical incompetence is suspected. However, it is overdiagnosed as a cause of second-trimester miscarriage. The cerclage procedure also carries a risk of stimulating uterine contractions. - Cerclage benefit increases as the cervix shortens to less than 25 mm. It has also been shown to be beneficial in those women with a shortened cervical length of less than 25 mm.

1131. A 6yo child presents with hx of recurrent jaundice. Between the episodes he is totally fine. Mother gives hx of jaundice being brought about by ongoing infections. What is the most likely dx? a. Hereditary spherocytosis b. G6PD deficiency c. Thalassemia d. Sickle cell disease e. Congenital storage disorder key : B reason : hemolytic attack triggered by infection + normal in between attacks >> G6PD deficiency haemolytic anemia DDx Genetic   

Red cell membrane abnormalities: hereditary spherocytosis, elliptocytosis. Haemoglobin abnormalities: sickle cell anaemia, thalassaemia. Enzyme defects: glucose-6-phosphate dehydrogenase (G6PD), pyruvate kinase deficiency.

Acquired 

Immune:

- Isoimmune: haemolytic disease of newborn, blood transfusion reaction. 

Autoimmune:

-Warm antibody : SLE

-Cold antibody type : -Drug-related : 

Non-immune: trauma ,infection , hypersplenism, membrane disorders, paroxysmal nocturnal haemoglobinuria, liver disease. G6PD

PRESENTATION : Most are asymptomatic,, History of drug or infection induced haemolysis,,Gallstones are common, history of neonatal jaundice ,During a crisis jaundice occurs, investigations : G6PD enzyme activity - is the definitive test FBC : anemia ,macrocytosis , reticulocytosis during the attack Blood film in acute attack : Heinz bodies Haemolysis - reduced levels of haptoglobin and elevated levels of bilirubin; haemoglobinuria. Ultrasound examination of the abdomen may reveal splenomegaly and gallstones. Management of acute haemolysis : blood transfusion may be needed,Dialysis may be required in acute kidney injury. Infants - more susceptible to neonatal jaundice, especially if premature, and exchange transfusion may be required. Management of chronic haemolysis : Splenectomy may help ,Supplementation with folic acid Avoid : precipitating drugs, broad beans and naphthalene - found in mothballs. - X-linked disease with about 300 variants reported - Precipitating factors - Certain drugs like Primaquine, Methylthioninium, Nitrofurantoin, Sulfonamides including coTrimoxazole, Dapsone etc. - Certain foods like broad beans - Severe infection - DKA - Acute Kidney Injury

- Presentation - Pallor of anemia - Jaundice during crisis - Back or abdominal pain - Splenomegaly may occur - Investigations * FBC - anaemia. * Macrocytosis - due to reduced folic acid which is required for erythropoiesis. * Reticulocyte count - raised; gives indication of the bone marrow activity (bone marrow sampling thus not needed). * Blood film - acute haemolysis from G6PD deficiency can produce Heinz bodies, which are denatured haemoglobin and bite cells (cells with Heinz bodies that pass through the spleen have part of the membrane removed). * Haemolysis - reduced levels of haptoglobin and elevated levels of bilirubin; haemoglobinuria. * Direct antiglobulin test - to look for other causes of haemolysis; should be negative in G6PD deficiency. * Renal function - to ensure no renal failure as a precipitant. * LFTs - to exclude other causes of raised bilirubin. * G6PD enzyme activity - is the definitive test (as opposed to the amount of G6PD protein). * Performing assays for G6PD during haemolysis and reticulocytosis may affect levels and not reflect baseline values. * Ultrasound examination of the abdomen may reveal splenomegaly and gallstones. - Management Avoidance of substances that may precipitate hemolysis is essential. Usually no further management is required, although if hemolysis is marked there may be benefit from folate supplementation. Management of acute haemolysis * Seek specialised advice. * Blood transfusions may be needed. * Dialysis may be required in acute kidney injury.

* Infants - more susceptible to neonatal jaundice, especially if premature, and exchange transfusion may be required. Management of chronic haemolysis or stable disease * Splenectomy may help. * Supplementation with folic acid. * Avoidance of precipitating drugs, and broad beans (usually favism occurs in the Mediterranean variety of the disease). * Avoid naphthalene - found in mothballs.

1132. A 42yo woman who smokes 20 cigarettes/d presents with complaints of heavy bleeding and prolonged menstrual period. What is the most appropriate tx for her? a. Tranexamic acid b. COCP c. Mefenamic acid d. IUCD e. Norethisterone key : D reason : smoker >>> so no use of COCP ,,, heavy bleeding >>> IUCD ( FULL TOPIC DICUSSED EARLIER) The key says IUCD (D) but it is not the first choice in heavy/prolonged menstrual periods. Mirena Coil is. The second line is Tranexamic Acid. Third line is COCPs. Fourth line is Endometrial ablation or Hysterectomy (If there is no desire to conceive). IUCD, according to patient.info actually causes heavy or painful periods. The logical choice in this case would be Tranexamic Acid since Mirena is not mentioned in the given options. 1133. A 17yo senior schoolgirl with complain of prolonged irregular menstrual period and heavy blood losses. What is the most appropriate tx for her? a. Mefenamic acid b. COCP

c. POP d. IUCD e. Mirena KEY : B reason : irregular menses + heavy bleeding >>> COCP can treat both (Full topic discussed earlier) - COCPs are widely used for irregular menstrual periods. - They also carry the advantage of causing a decrease in bleeding and menstrual pain (can be used for dysmenorrhea and menorrhagia) 1134. A 32yo presents with heavy blood loss, US: uterine thickness>14mm. What is the most appropriate tx for her? a. Mefenamic acid b. COCP c. POP d. IUCD e. IU system (mirena) key :E reason : heavy bleeding >>> IUS is the first line (full topic discussed earlier) - Mirena, also known as Intrauterine System, is a Levonorgestrel-containing coil which is inserted into the uterus. - Local effect: reversible endometrial atrophy, makes implantation less likely and periods lighter (20% reversible amenorrhea) - Less risk of ectopic pregnancy - Risk of STDs is reduced - May benefit women with endometriosis, adenomyosis, fibroids or endometrial hyperplasia - NOTE: Avoid if breast cancer.

1135. A 37yo woman presents with heavy bleeding. Inv show subserosal fibroid=4 cm and intramural

fibroid=6cm. Which is the most appropriate tx? a. UAE b. Abdominal hysterectomy c. Hysteroscopic Myomectomy d. Vaginal Hysterectomy e. Abdominal myomectomy key : e reason : abdominal myomectomy is the best alternative for hysterectomy in patients who want to keep their fertility ,, pt is 37 ys and this procedure can treat both intramural and subserosal fibroids (full topic discussed earlier) - Fibroids are responsive to estrogen and therefore increase in size, which in turn increases the size of the uterus. - Other symptoms - Pelvic pain (Compression on to adjacent structures) - Infertility/Recurrent Miscarriages - Pelvic Mass - The investigation of choice is an U/S - Management - Mirena Coil is the first choice if the fibroids are not big enough to restrict its insertion. - If < 3 cm - Trial of pharmacologic treatment first (Tranexamic Acid) first - If it fails and uterus is not bigger than 10-week pregnancy, do endometrial ablation - If the above fails, perform a hysterectomy - If > 3 cm and wishes to retain uterus and/or wants to avoid surgery - Go for Uterine Artery Embolization - If > 3 cm and wishes to retain uterus, go for a hysteroscopic myomectomy or a myomectomy NOTE: This patient has a subserosal fibroid so an abdominal approach should be adopted. 1136. A woman with sickle cell disease complains of heavy menstrual blood loss. What is the most

appropriate tx? a. COCP b. Mirena c. Depot provera d. Copper IUS e. Transdermal patch key : c reason : sickle cell disease : intrauterine devices are not recommended, as they may be associated with uterine bleeding and infection. Combined hormonal methods are not recommended , because of the risk of thromboembolism in sickle cell patients Depot contraceptive (Depo-Provera®) is safe and has been found to improve the blood picture and reduce pain crises.[15] The choice of contraceptive method needs to be considered carefully. The coil (intrauterine contraceptive device) may cause particularly heavy painful periods. The use of injectable contraceptives (such as Depo-Provera) has been reported to provide some protection against sickling episodes. 1137. A 70yo woman is admitted with diarrhea, vomiting and dehydration. Exam: yellow visual halos in her eyes, ECG=bradycardia. She has a hx of chronic A-fib. Which drug causes the above mentioned side effects? a. Nifedipine b. Ramipril c. Atenolol d. Lithium e. Digoxin key : e reason : symptoms are classic for digoxin toxicity

Features suggestive of toxicity include nausea, vomiting, diarrhoea, dyspnoea, confusion, dizziness, headache, blurred vision and diplopia ( yellow halos),bradycardia, skin rash, renal dysfunction and hypokalaemia Plasma concentrations is helpful when initiating therapy, checking compliance or detecting toxicity. Levels above 2 nmol/L suggest toxicity. - Adverse Effects of Digoxin - Diarrhea - Nausea - Vomitting - Dizziness - Headache - Maculopapular rash - Cardiac dysrhythmia - Arrhythmia in children - Visual disturbances (Blurred or yellow vision) - Heart Block - Asystole 1138. A 33yo lady who is a drug addict wants to quit. She says she is ready to stop the drug abuse. She is supported by her friends and family. What drug tx would you give her? a. Benzodiazepines b. Diazipoxide c. Lithium d. Methadone e. Disulfiram key : D reason :methadone is used to treat opioid withdrawal symptoms Methadone or buprenorphine can be used in opioid dependance treatment

NICE recommends that, if both drugs are equally suitable, methadone should be prescribed as first choice - Methadone is used as a pain reliever and as part of drug addiction detoxification and maintenance programs. - For detoxification during withdrawals Methadone is the first choice. - Methadone is also used for maintenance. - Benzodiazepines, Diazepoxide and Disulfiram are specifically used in alcohol withdrawal. - Lithium is used in Mania and Bipolar Affective Disorder.

1139. A 50yo lady has been suffering from chronic RA and is on methotrexate and naproxen. Her CBC shoes microcytic anemia. What is the most likely cause? a. Anemia of chronic disease b. GI hemorrhage c. Menorrhagia key : B reason: because of use of NSAIDs >>> naproxen anemia of chronic illness is normocytic normochromic microcytic anemia >>> iron deficiency due to chronic blood loss >>> GI hrg - There is a history of chronic NSAID use, this leads to weakening of defense mechanism of the mucosa of the stomach. - This leads to exposure of the mucosa to gastric acid and causes ulcers. - Bleeding from these ulcers can lead to anemia.

1140. A 15yo male noticed swelling on the left knee following a fall while playing. The swelling has not subsided in spite of rest and analgesia. Exam: full knee movement with slight tenderness. He has painless palpable mass in left inguinal region. What is the most probable dx? a. Osteosarcoma b. Ewing’s sarcoma

c. Chondrosarcoma d. Lymphangiosarcoma e. Osteodosteoma key : A reason : age ( highest in 15-19 years) + site ( around knee) + LN metastasis Osteosarcoma 

The most common primary bone malignancy in children. The incidence is highest in 15-19 ys



The male:female ratio is 1.4:1.



The most common sites are around the knee (75%), or proximal humerus.



Often presents as a relatively painless tumour.



Rapidly metastasises to the lung >>associated with a poorer prognosis



X-ray shows combination of bone destruction and formation. Soft tissue calcification produces a 'sunburst' appearance.



Disease-free survival has increased to 55-75% with surgery and effective chemotherapy ,Chemotherapy alone is not as effective.

Presentation pain, swelling and localised tenderness,Rapid growth and erythema ,pathological fractures Investigations : Plain X-ray ,MRI and CT scan ,Biopsy Treatment : surgery + chemotherapy Osteosarcoma This is the most common type of primary bone cancer but even this is rare. It only affects around 150 people a year in the UK. It arises from bone-forming cells. Most cases occur in young people between the ages of 10 to 25. It can, however, occur at any age. It typically develops in the growing ends of the bone in young people, most commonly in bones next to the knee and the upper arms. However, any bone can be affected. Ewing's sarcoma The cells of this cancer look different to the more common osteosarcoma. It only affects around 100 people a year in the UK. Most cases occur in young people between the ages of 10 to 20, but it can occur at any age. It most commonly affects the hips (pelvis) and long bones in the leg. - The age and symptoms fit both the above conditions.

1141. A 45yo female looking pale has bluish discoloration of hands whenever she goes out in the cold. She has also noticed some reddish spots on her body. She has symmetrical peripheral arthropathy for the last yr. What is the most probable dx? a. RA b. Osteosarcoma c. Limited systemic sclerosis d. Diffuse systemic sclerosis e. Chondrosarcoma key : C reason : classic picture of limited SSc it's a disease of connective tissue disease like as RA, SLE. so arthritis here and symmetrical arthritis. two variety of Systemic sclerosis. LCSS- Involvement distal to the knee and elbows with CREST syndrome, DCSS- involvement proximal to knee and elbows with renal involvement (scleroderma renal crisis ). presence of telangiectasia and Raynaud pheno indicates LCSS.in RA, arthritis present but not raynauds pheno. Raynaud's also present in SLE.

scleroderma Common presenting symptoms are Raynaud's phenomenon, skin hardening in hands or face, and oesophageal symptoms. types of SSC Limited scleroderma >>> Generally a milder disease, with less skin involvement, slow onset and slow progression. 70% of SSc cases. Affects only the face, forearms and lower legs up to the knee. The older term for limited scleroderma is CREST syndrome (= Calcinosis, Raynaud's disease, (O)Esophageal dysmotility, Sclerodactyly, Telangiectasia). Diffuse scleroderma >>> Usually a more rapid onset, with skin thickening and Raynaud's phenomenon occurring together or within a short interval 30% of SSc cases ,, Involves also the upper arms, thighs or trunk - Formerly known as the CREST Syndrome - C: Calcinosis - R: Raynaud’s Phenomenon

- E: Esophageal and Gut dysmotility - S: Sclerodactyly - T: Telangiectasias (Reddish Spots)

1142. A 60yo female has pain and stiffness in her right hip joint. Pain is not severe in the morning but increases as the day progresses. She has noticed some nodules in her hands. Inv: Hgb=low. What is the most probable dx? a. RA b. Osteoarthritis c. Gout d. Pseudogout e. Multiple myeloma key : B reason : A diagnosis of OA can be made clinically without investigations if a person: 

Is aged 45 years or over; and



Has activity-related joint pain; and



Has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes. osteoarthritis

Symptoms Joint pain that is exacerbated by exercise and relieved by rest. Rest and night pain can occur in advanced disease. Knee pain due to OA is usually bilateral and felt in and around the knee. Hip pain due to OA is felt in the groin and anterior or lateral thigh. Hip OA pain can also be referred to the knee and, in males, to the testicle on the affected side. Joint stiffness in the morning or after rest. Signs Pain and Reduced range of joint movement. Joint swelling/synovitis (warmth, effusion, synovial thickening).

Bony swelling and deformity due to osteophytes - Commonest joint condition - Usually monoarthritis - Usually affects females 50 years and above - Commonly affects the weight-bearing joints e.g, Hip and knee joints. (Notice the joint involved) - Pain on movement and worsening towards the end of the day - Bouchard’s nodes and Heberden’s nodes are usually present. - Investigations - X-ray - Treatment -Advise exercise and activity, and physiotherapy - Paracetamol - Topical NSAIDs - Intra-articular steroids - Low-dose of tricyclic antidepressants for pain at night - Weight reduction - Joint replacement in end-stage Osteoarthritis

1143. A 30yo female has chronic diarrhea, mouth ulcers and skin tags. She complains of visual prbs, low back pain and morning stiffness. Inv: ESR and CRP=raised, Hgb=10 mg/dl. What is the most probable dx? a. SLE b. Reactive Arthritis c. Gout d. Pseudogout e. Seronegative arthritis key : B

reason : the symptoms fits ( GIT or urinary tract symptoms >> diarrhea + law back pain + visual problems >> uveitis + lab >> anemia and inreased ESR & CRP ) Reactive arthritis or Reiter's syndrome >>> is a form of seronegative spondyloarthritis clinically associated with inflammatory back pain, GIT symptoms . The presence of large joint oligoarthritis, urogenital tract infection and uveitis characterises Reiter's syndrome as a clinical subtype of reactive arthritis. Presentation 

develops 2-4 weeks after a genitourinary or gastrointestinal infection.



The onset is most often acute, with malaise, fatigue, and fever.



An asymmetrical, predominantly lower extremity, Low back pain often occurs.



The complete Reiter's triad of urethritis, conjunctivitis, and arthritis may occur.



Skin ,nails and mucous membranes (mouth ulcers) may all be affected.



Eyes: uveitis, episcleritis, keratitis, and corneal ulcerations.



Gastrointestinal: abdominal pain and diarrhoea

Investigations : **Once arthritis is observed, microbial tests and blood or synovial fluid cultures are negative, and only serum antibodies are detected. 

ESR and CRP are usually very high.



FBC: normocytic normochromic anaemia



HLA-B27 is positive

Management 

In the acute phase, rest affected joints, aspirate synovial effusions.



Physiotherapy.



Non-steroidal anti-inflammatory drugs (NSAIDs).



Corticosteroids

Antibiotics to treat an identified causative organism

1144. A 28yo woman has been on tx for RA for 3yrs. She has gradual loss of vision in both eyes. Her IOP is normal. Red reflex is absent in both eyes. What is the single most likely dx?

a. Cataract b. DM retinopathy c. Hypermetropia d. Macular degeneration e. HTN retinopathy key : A reason : absent red reflex + tx for RA for 3yrs+ gradual loss of vision in both eyes. the treatment plan of rheumatoid arthritis includes : corticosteroids which induce cataract formation with long term use - Cataracts are cloudy (opaque) areas that develop in the lens of an eye and affects vision - Vision becomes gradually worse over the years. - Most affected people develop a cataract for no apparent reason. Factors that may increase the chance of developing cataracts include: - Having a poor diet. - Smoking. - Being exposed to a lot of ultraviolet light. - Diabetes. - Steroid medicines. - Having a family history of cataracts - There are no medicines, eye drops or lasers that can treat cataracts. The only way of treating cataracts is with an operation. This is a very common operation.

1145. An elderly man with recently dx HF has been treated with diuretics. He now develops severe joint pain in his left ankle with swelling and redness. What is single most likely inv? a. XR of bone b. Plasma RF c. Joint fluid uric acid crystals d. ESR

key : c reason : both thiazides and loop diuretics can precipitate or worsen pre-existing gout. If a diuretic is unavoidable, consider prophylaxis with allopurinol. Gout Primary gout occurs mainly in men aged 30-60 years presenting with acute attacks. secondary gout is due to chronic diuretic therapy. It occurs in older subjects, both men and women, and is often associated with osteoarthritis. Risk factors : Male sex ,Meat ,Seafood ,Diuretics ,Obesity ,Hypertension ,Coronary heart disease ,Diabetes mellitus ,Chronic renal failure, High triglycerides Presentation: 50% of all attacks and 70% of first attacks affect the first metatarsophalangeal joint. Other sites often affected are: Knee, Midtarsal joints ,Wrists, Ankles ,Small hand joints ,Elbows Management : colchicine and/or NSAIDs as the first-line option for acute gout. - There is a clear history of diuretic use which causes Hyperuricemia in almost 40% of the patients. - Hyperuricemia can lead to development of gout (Notice the redness, severe pain, swelling and involvement of a single joint). - Gout is usually precipitated by Trauma, Tumor Lysis Syndrome, Surgery, Infection, Diuretics, Polycythemia, Leukemia, Cytotoxic Drugs and Alcohol Abuse - Investigation - Joint aspiration for microscopy, C/S, which shows negatively birefringent crystals - Treatment - NSAIDs - If contraindicated, give Colchicine - If there is renal failure, then both NSAIDs and Colchicine are problematic, so use steroids.

1146. A 60yo lady with a hx of HTN and suffering from RA since the last 10y now presents with hot,

swollen and tender knee joint. What inv would you do for her? a. XR b. C&S of joint aspirate c. US d. MRI e. CT key : B reason : septic arthritis is the most important diagnosis to exclude as, if left untreated, the sequelae include permanent joint damage, impairment of function and even death DDx of hot swollen tender joint Infection: 

Septic arthritis >> acute onset , monoarthritis, mostly knee in adults and hip in children , plus constitutional symptoms ( fever , malaise)



Neisseria gonorrhoeae



Lyme disease >> erythema migrans

Rheumatoid arthritis >>> insidious onset ,polyarthritis Crystal arthropathies - gout and pseudogout >>> acute onset , monoarthritis mostly, 70% of attacks first occur in the big toe in gout Reactive arthritis (now considered synonymous with Reiter's syndrome). >>> polyarthritis , Hx of gastrointestinal or genitourinary infection Trauma >>> Hx of trauma - History of Rubor, Erythema and swelling in a single joint is Septic Arthritis until proven otherwise. - Therefore the investigation of choice would be C/S of joint aspirate. - Rest of the investigations do not help in making the diagnosis or exclusion of septic arthritis. 1147. A 34yo man after an RTA was brought to the ED. He has BP=50/0mmHg and chest wall with asymmetrical movement, RR=34bpm. What would be the initial action? a. IV fluid infusion

b. Intubation and ventilation c. CT chest d. Transfer to ITU key : B reason : in trauma patient we follow : Airway ,Breathing ,Circulation ,Disability , Exposure>> and that patient has asymmetrical chest movement and increased RR>>> we have to secure the air way and ventilate the pt Initial assessment the 'ABCDE' principles : Airway maintenance with cervical spine protection Breathing and ventilation Circulation with haemorrhage control Disability: neurological status Exposure/environmental control

1148. A 7yo presented with chronic cough and is also found to be jaundiced on exam. What is the most likely dx? a. Congenital diaphragmatic hernia b. Congenital cystic adenomatoid malformation c. Bronchiolitis d. RDS e. Alpha 1 antitrypsin deficiency key : E reason : clinical picture fits >>> The organs most commonly involved are the lungs and the liver. Alpha 1 antitrypsin deficiency 

A1AT deficiency is an inherited condition.



In A1AT deficiency, the protein is still produced but the A1AT molecule configuration is changed. As a result, it cannot pass out of the liver into the bloodstream and so cannot pass to the lungs and the rest of the body



Some people with A1AT deficiency develop liver disease. This results from the congestion of A1AT in the liver cells, leading to cell destruction.



If there is a deficiency of A1AT then elastase can break down elastin unchecked; in the lungs this can lead to the destruction of alveolar walls and emphysematous change >>> COPD



Neonates with A1AT deficiency may present with neonatal jaundice and hepatitis; older children may develop hepatitis, cirrhosis and liver failure due to A1AT deficiency.

Investigations 

Serum levels of alpha-1 antitrypsin



Phenotyping



CXR and lung function testing ,CT scanning of the chest.



LFTs and possibly liver biopsy.

- It is an autosomal recessive inherited disorder - It commonly affects lungs (Emphysema) and liver (Cirrhosis and Hepatocellular Carcinoma) - Investigation - Serum alpha 1 antitrypsin levels - Management - Supportive treatment for Emphysema and Liver disease may be sufficient for some. - Among the given options no condition can explain the involvement of lungs and liver at the same time.

1149. A 65yo man had a bowel resection 5d ago. He is anuric and breathless. His BP=150/110 mmHg. He has crackles at both lung bases and sacral edema. Bloods: K+=6.8mmol/l, urea=58 mmol/l, creatinine=600 umol/l. What is the single most appropriate immediate management? a. Bolus of 20U insulin b. Calcium resonium enema c. Dextrose-saline infusion d. 5% dextrose infusion

e. 10U insulin, 50ml of 50% dextrose infusion key : e reason : this is a case of acute kidney injury following major surgery ( increased urea and creatinine + hyperkalemia ( normal range 3.5-5 ) >>> to treat hyperkalemia >>> Shift potassium into cells using 10U insulin, 50ml of 50% dextrose infusion Hyperkalaemia normal k+ 3.5-5 mmol/L Mild Hyperkalaemia - 5.5-5.9 mmol/L Moderate Hyperkalaemia - 6.0-6.4 mmol/L Severe Hyperkalaemia - >6.5 mmol/L Causes:  

Renal causes: eg. Acute kidney injury (AKI) ,Chronic kidney disease (CKD) Increased circulation of potassium: Exogenous - eg, potassium supplementation. Endogenous - eg, tumour lysis syndrome, rhabdomyolysis, trauma, burns.



A shift from the intracellular to the extracellular space: Acidosis - eg, diabetic ketoacidosis (DKA). Medications - eg, digoxin toxicity, suxamethonium, beta-blockade, theophylline.

ECG changes in hyperkalemia : Peaked T waves ,prolonged PR interval ,Wide QRS,bradycardia. Management : 

Stop further potassium accumulation: Stop any potassium supplements stop digoxin and beta-blockers,Decrease potassium in the diet



Protect cardiac membrane: Give 10 ml 10% calcium gluconate



Shift potassium into cells: Insulin-glucose IV >> usually 10 units of Actrapid® are added to 50 ml of glucose 50% and infused over 30 minutes.



Remove potassium from the body : Calcium polystyrene sulfonate resin (Calcium Resonium®) with regular lactulose will remove potassium via the gastrointestinal tract.

** in resistant hyperalaemia Haemodialysis may be required but is invasive.

1150. A 25yo woman presents with a painful shallow ulcer on the vulva. What inv has to be done? a. HSV antibodies b. Syphilis serology c. Swab for haemophilus ducreyi d. Urine culture e. Blood culture key : c reason : shallow painful ulcer >> chancroid chancroid: Chancroid is a sexually transmitted disease (STD) caused by haemophilus ducreyi characterized by painful shallow with soft ragged margins necrotizing genital ulcers that may be accompanied by inguinal lymphadenopathy. - The symptoms point towards the causative organism being Haemophilus Ducreyi as it causes painful shallow ulcers. - Mnemonic: YOU CRY WITH DUCREYI - The other conditions cannot explain the symptoms above as they do not cause painful shallow ulcers. HSV cause vesicles while Syphilis causes painless ulcers. - Urine and Blood Culture are not required for the same reason as stated above.

1151. A child was admitted with fever, generalized skin lesion, some of them are weeping lesions and some of them are crusted. What is the most probable dx? a. Varicella b. Impetigo c. Drug reaction d. Contact dermatitis e. Scabies Impetigo (B) -Infection due to Staph. Aureus.

- Usually on the face with honey-coloured fluid in an erythematous base. - Common in children. - Children should be kept off school or nursery until there is no more blistering or crusting or until 48 hours after antibiotic treatment has been started. -Treatment - Flucloxacillin 1152. A pt comes with 6m hx of painless bilateral swelling of the face which has been progressively increasing in size. On routine CXR, he is found to have perihilar lymphadenopathy. What is the most probable dx? a. Chronic sialadenitis b. Thyroid adenoma c. Carcinoma of salivary gland d. Adenoid cystic carcinoma e. Mikulicz’s disease Mikulicz’s Disease (E) - Bilateral parotid and lacrimal gland enlargement was characterized by the term Mikulicz's disease if the enlargement appeared apart from other diseases. - In 80% of cases, the parotid gland is affected. Lacrimal glands are also affected. - The gland affected has a diffuse swelling. The swelling can be asymptomatic, but mild pain can also be associated. - A biopsy is needed to distinguish benign lymphoepithelial lesions from sialadenosis (sialosis). - Treatment - Treatment usually consists of observation unless the patient has concern, there is pain, drainage, or other symptoms related to the lesion. Surgical removal of the affected gland would be recommended in those cases.

1153. A woman has widespread metastasis from a carcinoma. She presented with severe back pain. Where do you expect the cancer to be? a. Lungs b. Cervix

c. Ovary d. Uterus e. Breast E - Breast. - Occasionally, breast cancer presents as metastatic disease—that has spread beyond the original organ. The symptoms caused by metastatic breast cancer will depend on the location of metastasis. Common sites of metastasis include bone, liver, lung and brain. - Bone is the commonest site of metastasis in Breast Cancer

1154. A 10yo child has got progressive bilateral hearing loss. He has started to increase the TV volume. All other examination is normal. What is the most likely dx? a. Wax b. Foreign body c. Bilateral OM with effusion d. SNHL e. Meningitis due to meningococcus Progressive Bilateral Hearing Loss in a Child (C) - Otitis media is an inflammation in the middle ear (the area behind the eardrum) that is usually associated with the buildup of fluid. The fluid may or may not be infected. - Symptoms, severity, frequency, and length of the condition vary. At one extreme is a single short period of thin, clear, non-infected fluid without any pain or fever but with a slight decrease in hearing ability. At the other extreme are repeated bouts with infection, thick "glue-like" fluid and possible complications such as permanent hearing loss. - Fluctuating conductive hearing loss nearly always occurs with all types of otitis media. In fact it is the most common cause of hearing loss in young children. Management General advice * Give written information about OME to the parents. * Advise parents or carers not to expose the child to tobacco smoke. NICE recommends hearing aids for children with bilateral OME and hearing loss where surgery is not acceptable or is contra-indicated. Each case needs to be considered on its own merits: the

need to assist hearing during a period of active observation, for example, has to be weighed against evidence that the use of aids in children can increase anxiety.

1155. A child had a patchy rash following tx for sore throat & cervical LN enlargement. Which is the most appropriate antibiotic? a. Ampicillin b. Erythromycin c. Cefuroxime d. Metronidazole e. Tetracycline EBV infection (A) NOTE: The question here is not asking for appropriate treatment. It is actually trying to ask about the drug that has caused a rash in a child with the given symptoms. - A child with a sore throat and Cervical Lymphadenopathy has an active EBV infection until proven otherwise. - Ampicillin and amoxicillin are contraindicated during acute Epstein–Barr virus infection since the vast majority of patients treated with them develop a diffuse nonallergic rash.

1156. A child with a hx of asthma is brought to ED with a cut on knee and sprained on her left wrist. Which is the best analgesic for her? a. Paracetamol b. NSAIDs c. Co Codamol d. Ibuprofen A - Paracetamol Paracetamol. paracetamol should only be given in this patient to relieve pain. NSAIDS should not be given as the child has h/o asthma as nsaids may increase the risk of acute bronchospasm and co codamol has codeine which can cause respiratory depression.

1157. A 15m baby girl presented to the ED with difficulty in breathing. Exam: she has intercostal

recessions and a wheeze. Temp=normal. What is the most likely dx? a. URTI b. Pneumonia c. Bronchiolitis d. RDS e. Alpha 1 antitrypsin deficiency key : c reason : age : (younger than 2 years (most common between 2 and 6 month) + wheezy chest + intercostal recession + normal temp ) Bronchiolitis is an acute infectious disease of the lower respiratory tract that occurs primarily in the very young, most commonly infants between 2 and 6 months old. It is a clinical diagnosis based upon: Breathing difficulties , Cough , Decreased feeding ,Irritability ,Apnoeas in the very young ,Wheeze or crepitations on auscultation the causative organism : 

Respiratory syncytial virus (RSV) : the most common cause



Human metapneumovirus (hMPV) - the second most common cause

Investigations: 

Pulse oximetry.



Nasopharyngeal aspirate for: RSV rapid testing



Viral cultures for RSV, influenza A and B, parainfluenza and adenovirus

Management: Most infants with acute bronchiolitis will have mild, self-limiting illness and can be managed at home. Supportive measures , with attention to fluid input, nutrition and temperature control. 1158. An 8yo boy develops a seizure affecting his right arm, seizure lasts for several mins. He doesn’t remember anything what happened. On his CT: lesion in left hemisphere. What is the most probable dx? a. Epilepsy b. Space occupying lesion

c. Dementia d. Huntington’s chorea e. Intracranial HTN key : b reason : CT lesion >>> Space occupying lesion brain tumors in children the most common subtype >>> astrocytoma followed by the second most common >>> embryonal tumours ( primitive neuroectodermal tumours and medulloblastoma) Presentation: 

increased intracranial pressure : Headache, nausea and vomiting, abnormalities of gait and coordination, and papilloedema.



frontal lobe tumours are associated with personality change and occipital lobe tumours are associated with visual deficits



Brainstem tumours: Abnormal gait and coordination, cranial nerve palsies, pyramidal signs, headache and squint.



Central brain tumours: Headache, abnormal eye movements, squint, and nausea and vomiting



Supratentorial tumours: Unspecified symptoms and signs of raised intracranial pressure, seizures and papilloedema.



Posterior fossa tumours: Nausea and vomiting, headache, abnormal gait and coordination, and papilloedema

investigations : 

MRI , CT : MRI is better , it provides better images and there is no radiation involved.



excision biopsy

1159. A 28yo female presented with complains of difficulties in swallowing liquids only. She also suffers from recurrent chest infection in the past few months. What is the most probable dx? a. Foreign body b. Plummer vinson syndrome c. Achalasia cardia

d. Peptic stricture e. Esophageal carcinoma key : c reason : liquid dysphagia + recurrent chest infection ( due to regurgitation) Achalasia is a motility disorder of the lower oesophageal or cardiac sphincter. The smooth muscle layer of the oesophagus has impaired peristalsis and failure of the sphincter to relax causes a functional stenosis presentation : 

The most common presenting feature is dysphagia. This affects solids more than soft food or liquids.



Regurgitation , Chest pain , Heartburn ,



Nocturnal cough and even inhalation of refluxed contents >> recurrent chest infection

Investigations : Manometry is the gold standard for diagnosis of achalasia. 

CXR : The classical picture of a CXR in achalasia shows a vastly dilated oesophagus behind the heart



Barium swallow : the bird beak appearance



Endoscopy : can detect approximately a third of achalasia



lowe oesophogeal PH monitoring >> to exclude GERD

MANAGEMENT : 

the Heller myotomy is the best treatment for those who are fit



Pneumatic dilatation is the preferred option for older unfit patients



Calcium-channel blockers and nitrates may be used for those who are unable to tolerate other forms of treatment



Endoscopic injection of botulinum toxin >>> recurrence

1160. Mother having 2 children with CF. What is the risk of getting another baby? a. 1:2 b. 1:8 c. 1:4

d. 1:16 e. 1:1 key : c reason : cystic fibrisis is autosomal recessive gene so :

Cc CC

Cc Cc

normal

Cc carrier

cc diseased

1161. A 14yo boy has been dx with nephrotic syndrome. 5d later he presents with flank pain, hematuria and fluctuating urea levels. A dx of renal vein thrombosis is made. What is the most likely cause for renal vein thrombosis? a. Protein C deficiency b. Vasculitis c. Loss of antithrombin III d. High estrogen levels e. Stasis key : c Complications of nephrotic syndrome include: 

Decreased resistance to infections, due to urinary immunoglobulin loss.



Increased risk of arterial and venous thrombosis, due to loss of antithrombin III and plasminogen in the urine, combined with an increase in hepatic synthesis of clotting factors. Adults with membranous nephropathy are at particular risk



Acute kidney injury



Chronic kidney disease may occur as a result of an underlying cause - eg, amyloidosis or diabetes.



Increased risk of osteitis fibrosa cystica and osteomalacia due to loss of vitamin Dbinding protein

1162. A 36yo woman presented with massive bleeding from multiple sites. Lab: fibrin degradation products: +++, plt=30, bleeding time=prolonged, PT=prolonged, APTT=prolonged. What is the

most likely dx? a. Hemophilia b. DIC c. ITP d. Factor V leiden e. Warfarin key : B cause : lab criteria ( decreased fibrinogen and platelets +increased PTT,PT ) full topic discussed earlier 1163. A study was done amongst 2 hosp for the equal number of cancer pts. It was noted that hosp A had the higher rate of mortality than hosp B for treated cancer pts. What is the study done here classified as? a. Retrospective b. Observational c. Cohort d. Case study key : c Longitudinal or cohort studies: 

A group of people is followed over many years to ascertain how variables such as smoking habits, exercise, occupation and geography may affect outcome.



Prospective studies are more highly rated than retrospective ones, although the former obviously take many years to perform. Retrospective studies are more likely to produce bias.

1164. A 17yo girl comes to see her GP after having unprotected sex 2d ago. She asks if her GP can explain to her how this prescribed procedure would work by helping her not to get pregnant. a. It helps to prevent implantation b. It helps in preventing or delaying ovulation c. It causes an early miscarriage

d. It releases progesterone and stops ovulation e. It causes local enzymatic reaction key:A reason : CU IUD prevents implantation emergency contraception: 

Progestogen-only - levonorgestrel >>> early in the cycle inhibits ovulation. later in the cycle, it is unclear how it has its effect. use within 72 hours of UPSI



ulipristal acetate >>> inhibits ovulation. effective up to 120 hours after UPSI. Pregnancy or suspected pregnancy should be excluded before use



IUCD >>> inhibitory effect on both fertilisation and implantation ( direct toxicity effects of the copper on both ovum and sperm). up to five days after UPSI

1165. A 2d baby’s mother is worried about the baby’s hearing. Mother has a hx of conductive hearing loss. What is the most appropriate test? a. Brain stem evoked response b. CT c. Fork test d. MRI e. Reassure KEY :A Neonatal hearing screening tests 

Automated otoacoustic emissions (AOAE) test >>> measures the integrity of the inner ear



Automated auditory brainstem responses (AABR) test >>> measures not only the integrity of the inner ear, but also the auditory pathway.

1166. A healthy 8yo boy had antibiotic tx for meningitis. Initially he wasn’t resuscitated. What will be the outcome if he receives full tx? a. He will recover fully to his prv health b. He will have hearing impairment

c. He will have brain abscess d. He will have encephalitis key : a 1167. A pt presented with jaundice, fever and upper abdominal pain within 24h after removal of gallstone by ERCP. The cholangiography was done and it was patent. What is the possible cause of his complaints? a. Biliary infection b. Acute pancreatitis c. Perforation key : b cause : post ERCP pancreatitis 

ERCP Complications



Pancreatitis - 2-9% of patients will develop pancreatitis , perioperative indomethacin or diclofenac reduce the incidence of pancreatitis.



Infection may occur - although rates are low.



Bleeding may occur - although severe haemorrhage is rare.



Perforation of the duodenum with development of an acute abdomen.



Failure of gallstone retrieval - may need to revert to open or more invasive procedures.



Prolonged pancreatic stenting is associated with stent occlusion, pancreatic duct obstruction and pseudocyst formation.

1168. A mother presents with her 14m child. He holds furniture and other things to help him stand and walk. He can say ‘mama’ and ‘papa’. He makes eye contact and smiles. He can transfer objects from one hand to another. He responds to his name. what do you interpret from his development? a. Delayed gross motor development b. Delayed fine motor development c. Dela

yed verbal development d. Normal development e. Delayed social development KEY : D

1169. A young child, 3yo, has presented with vomiting for 3d. Exam: mild-mod dehydration. What is his ABG profile likely to show? a. pH low, PCO2 low b. pH low, PCO2 high c. pH high, PCO2 low d. pH high, PCO2 high e. pH normal, PCO2 normal key : d reason : vomiting causes metabolic alkalosis ( high ph ), and it is compansated by increased PCO2 1170. A 68yo woman has been admitted with poor appetite, weight loss, poor concentration and self neglect for 3wks. She has not been eating or drinking adequately and has rarely left her bed. She is expressive suicidal ideas and is convinced that people are out to kill her. She has been on antidepressant therapy for the past 3m with no improvement. What is the most appropriate tx? a. Antidepressants b. CBT c. Interpersonal therapy d. ECT e. Antipsychotics KEY : D REASON : suicidal thought is an indication of ECT specially after treatment failure Indications of ECT 

Severe depressive illness or refractory depression.



Catatonia.

 

A prolonged or severe episode of mania. It should only be used if other treatment options have failed or the condition is potentially life-threatening (eg, personal distress, social impairment or high suicide risk).



ECT is not useful in schizophrenia

1171. A 78yo retired teacher was admitted for a hernioplasty procedure. After the operation he became agitated, aggressive and confused. What is the most appropriate management? a. Diazepam b. Chlordiazepoxide c. Vit B d. Clozapine e. Thiamine key : b reason :delirium tremens >>> first line >>> chlordiazepoxide second line >>> diazepam Delirium tremens: Delirium tremens usually begins 24-72 hours after alcohol consumption has been reduced or stopped,,there are signs of altered mental status eg, Hallucinations ,Confusion, Delusions ,Severe agitation , Seizures can also occur. 1172. A 25yo girl saw a tragic RTA in which a young boy was killed. The night of the event she couldn’t sleep and the day after she suddenly lost her vision. She was prv fine and there was no hx of medical or psychological prbs. What is the dx? a. Conversion b. Somatization c. PTSD d. Dissociation e. GAD key : a

reason : sudden lost her vision after she saw the accident >>> physical symptom after psychological trauma >>> conversion somatization >>> This is a chronic condition in which there are numerous physical complaints. These complaints can last for years and result in substantial impairment. 1173. A 25yo man has been suffering from breathlessness and wheeze for 3m. He has been taking salbutamol 2puffs as required. In the last 2 wks his symptoms have worsened and he has to take salbutamol more frequently during the day time. He also complains of excessive dyspnea at night. What drugs or regimen would you like to add? a. Prednisolone b. Fluticasone + salbutamol inhaled c. Beclomethasone inhaled d. Montelukast PO e. Salmetrol PO key : c reason : asthma management in adults : 

Step 1: mild, intermittent asthma >>> inhaled short-acting beta2 agonist



Step 2: introduction of regular preventer therapy >>> Inhaled steroids ( beclomethasone )are the most effective preventer drugs

indications : A recent exacerbation ,Nocturnal asthma , Daytime symptoms or use of an inhaled shortacting beta2 agonist more than three times per week. 

Step 3: add-on therapy >>> inhaled long-acting beta2 agonists (LABAs) such as salmeterol or formoterol.



Step 4: poor control on moderate dose of inhaled steroid plus add-on therapy >>> Trial an additional fourth drug over six weeks (eg, leukotriene receptor antagonist, sustained-release theophylline or beta2 agonist tablet) and increase the inhaled steroid to high-dose ranges.



Step 5: continuous or frequent use of oral steroids >>> he use of daily steroid tablet in the lowest dose providing adequate control is suggested

1174. A 64yo man who was exposed to asbestos for 40yrs presents with weight loss and chest pain. The dx of mesothelioma has been made. He develops SOB and XR=pleural effusion. What is the most appropriate management? a. Thoracocenthesis b. Chest drain c. Radiation therapy d. Pneumonectomy e. Chemotherapy key : e chemotherapy in mesothelioma: 

promising results have been achieved with pemetrexed and raltitrexed in combination with cisplatin and other combinations, including cisplatin and gemcitabine.



Single-agent therapy with vinorelbine may provide useful palliation with low toxicity



(NICE) has recommended pemetrexed as a possible treatment for malignant pleural mesothelioma in people:



With advanced disease.



Whose cancer is not suitable for surgical resection.



Who have (WHO) performance status of 0 (able to carry out all normal activity without restriction) or 1 (restricted in strenuous activity but able to move around and carry out light work).

1175. A 72yo presents with polyuria and polydipsia. The fasting blood sugar is 8 and 10mmol/l. BP=130/80 mmHg and the level of cholesterol=5.7mmol. There is microalbuminuria. What is the single most appropriate next management? a. ACEi and sulfonylurea b. Statin and biguanide c. Statin and glitazone d. Insulin and ACEi e. Statin and ACEi

key : e 

reason : ACEi for microalbuminuria + statin for hyperlipidemia + Medication to control hyperglycaemia may be required at the time of diagnosis of type 2 diabetes or soon after.

Initial treatment for newly diagnosed diabetes : 

Advice on diet and exercise



Prevention of coronary heart disease: blood pressure control , cholesterol-lowering drugs , low dose aspirin and stop smoking



All patients with microalbuminuria or proteinuria should start (ACE) inhibitor, if there are no contra-indications



Medication to control hyperglycaemia may be required at the time of diagnosis of type 2 diabetes or soon after.



insulin therapy should be started immediately in those who are ill at presentation or who have a high level of ketones in their urine. Insulin should also be considered, regardless of age, if one or more of the following are present:

Rapid onset of symptoms. Substantial loss of weight. Weakness. A first-degree relative who has type 1 diabetes

1175. A 72yo presents with polyuria and polydipsia. The fasting blood sugar is 8 and 10mmol/l. BP=130/80 mmHg and the level of cholesterol=5.7mmol/l. There is microalbuminuria. What is the single most appropriate next management? a. ACEi and sulfonylurea b. Statin and biguanide c. Statin and glitazone d. Insulin and ACEi e. Statin and ACEi e. Statin and ACEi ACEI should be considered in diabetic patients , especially in those with renal complications. A statin is considered in all diabetic patients above the age of 40 years ( BNF ) . An oral hypoglycemic drug does not seem to be needed since the sugar levels aren't that high and may respond to lifestyle and dietary modifications alone.

when microalbuminuria is present , the target BP is 125/75. therefore , ACE-i should be given. Cholesterol is also raised , so statins Diabetic pt, target BP 70% according ECST** criteria or > 50% according to NASCET*** criteria

1255. The artery that runs along the left AV groove. What is the single most appropriate option? a. Left internal mammary artery b. Left anterior descending artery c. Circumflex artery d. Left main stem (LMS) post descending artery e. Diagonal branch Answer: C. Circumflex Artery. Left Anterior Descending artery descends into interventricular groove. 1256. A 26yo man presents with painless hematuria. He has no other complaints and on examination no other abnormality is found. What is the most appropriate initial inv to get to a dx? a. Cystoscopy b. Midstream urine for culture c. Abdominal US d. MRI spine e. Coag screening Answer:C.Abdominal US. As the patient is young so we can't go for cystoscopy. The initial investigation in this patient should be abdominal US to exclude any pathology in the genitourinary tract. PKD can also be suspected here so US should be done to exclude that aswell first. 1257. A pt, 50yo smoker and heavy drinker, presents with complaints of racing heart. A 24h EKG comes out normal. What is your next step in management? a. Echo b. Reassure c. Stress test Answer: B.Reassure. Everything is normal in this patient so reassure the patient. If there would have been chest pain or past h/o chest pain then stress test could be a viable option. 1258. A 36yo woman came with uterine bleeding. Vaginal US reveals uterine thickness=12mm. what is the most probable dx? a. Cervical ca b. Endometrial ca

c. Ovarian ca d. Breast ca e. Vaginal ca Answer: B.Endometrial CA. The increased uterine thickness points towards the diagnosis. Endometrial cancer is classically seen in postmenopausal women but around 25% of cases occur before the menopause. It usually carries a good prognosis due to early detection The risk factors for endometrial cancer are as follows*:  obesity  nulliparity  early menarche  late menopause  unopposed oestrogen. The addition of a progesterone to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously  diabetes mellitus  tamoxifen  polycystic ovarian syndrome Features  postmenopausal bleeding is the classic symptom  pre-menopausal women may have a change intermenstrual bleeding  pain and discharge are unusual features Investigation  first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value  hysteroscopy with endometrial biopsy Management  localised disease is treated with total abdominal hysterectomy with bilateral salpingooophorectomy. Patients with high-risk disease may have postoperative radiotherapy  progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

1259. A 30yo woman has PID which was treated with metronidazole and cephalosporin. It is getting worse. What is the next best inv? a. Endocervical swab b. US c. Laparotomy d. High vaginal swab Answer: B. US. US is done to rule out tubo ovarian abscess. Pelvic inflammatory disease (PID) is a term used to describe infection and inflammation of the female pelvic organs including the uterus, fallopian tubes, ovaries and the surrounding peritoneum. It is usually the result of ascending infection from the endocervix Causative organisms

   

Chlamydia trachomatis - the most common cause Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis

Features  lower abdominal pain  fever  deep dyspareunia  dysuria and menstrual irregularities may occur  vaginal or cervical discharge  cervical excitation Investigation  screen for Chlamydia and Gonorrhoea Management  due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment  oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole  RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ' Removal of the IUD should be considered and may be associated with better short term clinical outcomes' Complications  infertility - the risk may be as high as 10-20% after a single episode  chronic pelvic pain  ectopic pregnancy  perihepatitis  tubo ovarian abscess  reiter's syndrome

1260. A pregnant woman had hit her chest 3wks ago. Now she is 24wks pregnant and presents with left upper quadrant mass with dimpling. What is the most probable dx? a. Breast ca b. Carcinoma c. Fibroadenoma d. Fibroadenosis e. Fatty necrosis of breast Answer:E. Fatty necrosis of breast. H/o of trauma to the breast and lump with dimpling point towards the diagnosis. Fat necrosis It tends to be large, fatty breasts in obese women that have this problem:

  

It usually follows trauma. The lump is usually painless and the skin around it may look red, bruised or dimpled. Biopsy may be required, but if the diagnosis is confirmed, no further management is indicated.

1261. A pregnant pt with Rh –ve who hasn’t been prv sensitized delivers her first baby without any prbs. What would be the latest time to administer anti-sensitization? a. 6h PP b. 24h PP c. 48h PP d. 72h PP e. 5d PP Answer: D.72h pp. Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:  delivery of a Rh +ve infant, whether live or stillborn  any termination of pregnancy  miscarriage if gestation is > 12 weeks  ectopic pregnancy  external cephalic version  antepartum haemorrhage  amniocentesis, chorionic villus sampling, fetal blood sampling 1262. A 30yo primigravida who is 30wks GA presents to the L&D with absent fetal movements. She also complains of severe headache, heartburn and seeing floaters before her eyes for the last few days. Exam: BP=170/110 mmHg, urine protein=++++, rock hard uterus, no visible signs of fetal movements. Choose the single most likely dx? a. Abruption of placenta 2nd pre-eclampsia b. Antepartum hemorrhage c. Placenta previa d. Primary PPH e. IUFD f. Abruption of placenta due to trauma Answer: A. Abruption of placenta secondary to preeclampsia. Maternal Hypertension is the most important cause of placental abruption.

Rigid abdomen/ hard rock uterus here indicates peritoneal irritation due to bleeding (concealed haemorrhage) exclusion: IUFD: We need a lot more to conclude IUFD and cannot be based on just rock hard uterus and no visible signs of fetal movements (such as auscultation, cardiotocography, real time ultrasonography etc) ABRUPTION OF PLACENTA Abruption is the premature separation of a normally placed placenta before delivery of the fetus, with blood collecting between the placenta and the uterus. It is one of the two most important causes of antepartum haemorrhage (the other being placenta praevia), accounting for 30% of all cases of antepartum haemorrhage.

There are two main forms:  

Concealed (20% of cases) - where haemorrhage is confined within the uterine cavity and is the more severe form. The amount of blood lost is easily underestimated. Revealed (80%) - where blood drains through the cervix, usually with incomplete placental detachment and fewer associated problems.

Risk factors There are recognised factors that increase the risk - these include:   

         

Previous abruption carries the highest risk of abruption in current pregnancy. Multiple pregnancy: twice as common with a twin pregnancy than with a singleton. Trauma: o Road traffic accident. o Domestic violence. o Iatrogenic - eg, external cephalic version. Threatened miscarriage earlier in current pregnancy. Pre-eclampsia and maternal hypertension (most imp risk factor accounting for approx: 44% of cases) Multiparity. Previous caesarean section. Non-vertex presentations. Smoking. Cocaine or amphetamine use during pregnancy. Thrombophilia. Intrauterine infections. Polyhydramnios.

The clinical features of placental abruption depend on the size and site of the bleeding. The grades of haemorrhage described are:

 



mild - in this case there is only a small area of placental separation and the blood loss is usually less than 200 ml. There may be abdominal discomfort and the uterus may be tender moderate - up to a 1/3 of the placenta separates. There is more severe bleeding (200600 ml). The patient complains of abdominal pain. On examination the patient may have tachycardia but does not have signs of hypovolemia. The uterus is tender. Fetal heart sounds are present severe - in this condition more than half of the placenta separates. The abdominal pain is more severe. On examination the uterus is tender and rigid (hard) - it may be impossible to feel the fetus. Fetal heart sounds are reduced or absent. The patient may be in a state of hypovolaemic shock

Diagnosis Abruption is a clinical diagnosis with no available sensitive or reliable diagnostic tests.

Management: Guidance from the Royal College of Obstetricians and Gynaecologists for moderate or severe placental abruption is to follow ABCD of resuscitation:   

Assess Airway and Breathing: high-flow oxygen. Evaluate Circulation: Access fetus and Decide on Delivery

1263. A 38yo woman, 10d post partum, presents to her GP with a hx of passing blood clots per vagina since yesterday. Exam: BP=90/40 mmHg, pulse=110 bpm, temp=38C, uterus tender on palpation and fundus is 2 cm above umbilicus, blood clots +++. Choose the single most likely dx? a. Abruption of placenta 2nd preeclampsia b. Concealed hemorrhage c. Primary PPH d. Secondary PPH e. Retained placenta f. Scabies Answer:D. Secondary PPH. The 10day post partum, signs of shock and blood clots all point towards the diagnosis of secondary pph.

Post-partum haemorrhage Post-partum haemorrhage (PPH) is defined as blood loss of > 500mls and may be primary or secondary Primary PPH  occurs within 24 hours  affects around 5-7% of deliveries  most common cause of PPH is uterine atony (90% of cases). Other causes include genital trauma and clotting factors Risk factors for primary PPH include*:  previous PPH  prolonged labour  pre-eclampsia  increased maternal age  polyhydramnios  emergency Caesarean section  placenta praevia  macrosomia  ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis) Management  ABC  IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms  IM carboprost

 

other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Secondary PPH  occurs between 24 hours - 12 weeks**  due to retained placental tissue or endometritis *the effect of parity on the risk of PPH is complicated. It was previously thought multiparity was a risk factor but more modern studies suggest nulliparity is actually a risk factor

1264. A 22yo lady who is in her last trimester of pregnancy comes with hx of exposure to a child dx with chicken pox 1d ago. She was investigated and was +ve for varicella antibody. What is the single most appropriate management? a. Give varicella I/g b. Quarantine c. Give varicella vaccination d. Oral acyclovir e. Reassure, Answer: E. Reassure. Lady is +ve for varicella antibody so no need to give varicella zoster Igs, just reassure the patient.

Chickenpox exposure in pregnancy Chickenpox is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion. In pregnancy there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome Risks to the mother  5 times greater risk of pneumonitis Fetal varicella syndrome (FVS)  risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation  studies have shown a very small number of cases occurring between 20-28 weeks gestation and none following 28 weeks  features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities Other risks to the fetus  shingles in infancy: 1-2% risk if maternal exposure in the second or third trimester  severe neonatal varicella: if mother develops rash between 5 days before and 2 days after birth there is a risk of neonatal varicella, which may be fatal to the newborn child in around 20% of cases

Management of chickenpox exposure  if there is any doubt about the mother previously having chickenpox maternal blood should be urgently checked for varicella antibodies  if the pregnant women is not immune to varicella she should be given varicella zoster immunoglobulin (VZIG) as soon as possible. RCOG and Greenbook guidelines suggest VZIG is effective up to 10 days post exposure  consensus guidelines suggest oral aciclovir should be given if pregnant women with chickenpox present within 24 hours of onset of the rash

1265. A 22yo woman who is 20wk pregnant came with pain and bleeding per vagina. Exam: os is not open. What is the single most likely dx? a. Threatened abortion b. Missed abortion c. APH d. Miscarriage e. Inevitable abortion Answer. A. Threatened Abortion. Pain and bleeding per vagina and os closed all point towards the diagnosis. MISCARRIAGE Miscarriage is defined as the loss of a pregnancy before 24 weeks of gestation. Classification of miscarriage is as follows:  Threatened miscarriage: mild symptoms of bleeding. Usually little or no pain. The cervical os is closed.  Inevitable miscarriage: usually presents with heavy bleeding with clots and pain. The cervical os is open. The pregnancy will not continue and will proceed to incomplete or complete miscarriage.  Incomplete miscarriage: this occurs when the products of conception are partially expelled. Many incomplete miscarriages can be unrecognised missed miscarriages.  Missed miscarriage: the fetus is dead but retained. The uterus is small for dates. A pregnancy test can remain positive for several days. It presents with a history of threatened miscarriage and persistent, dirty brown discharge. Early pregnancy symptoms may have decreased or gone.  Habitual or recurrent miscarriage: three or more consecutive miscarriages.

1266. A 32yo lady G1, 28wks GA came to her ANC with a concern about pain relief during labour. She has no medical illnesses and her pregnancy so far has been uncomplicated. She wishes to feel her baby being born but at the same time she wants something to work throughout her labour. What method of pain relief best matches this lady’s request? a. C-section b. Pudendal block c. Entonox d. TENS e. Pethidine C. Entonox.

Pain Relief In Labor: 1. Transcutaneous electrical nerve stimulation (TENS) Randomised controlled trials provide no compelling evidence for TENS having any analgesic effect during labour. so it is not recommended by NICE. 2. Acupuncture and hypnosis may be beneficial for the management of pain during labour; 3. Water/birthing pool: Immersion in water during labour is claimed to increase maternal relaxation and reduce analgesic requirements. It is supported by the Royal College of Obstetricians and Gynaecologists (RCOG) for healthy women with uncomplicated pregnancies. 4. Nitrous oxide and oxygen (Entonox®) This is a 50:50 mixture inhaled during painful contractions during the first and second stages of labour. It is often used as a supplement to pethidine.  

The main advantages are that it is under the patient's control, it takes effect within seconds and wears off quickly with no side-effects. Inhaled analgesia appears to be effective in reducing pain intensity and in giving pain relief in labour



5. Intramuscular opiate: Parenteral opioids provide some relief from pain in labour but are associated with adverse effects - eg, maternal nausea, vomiting and drowsiness. 6. Epidural analgesia: Epidural analgesia is a central nerve block technique achieved by injection of a local anaesthetic close to the nerves that transmit pain. It is widely used as a form of pain relief in labour. Advantages: It is the most effective way of relieving pain in labour - providing complete relief in 95% of cases. It also has the benefit of avoiding need for greater analgesia/general anaesthetic if forceps, vacuum extraction or caesarean section are required. It is not associated with increase in symptoms related to perineal trauma and pelvic floor muscle weakness.

7. Ambulatory epidural: This is a low-dose epidural that relieves pain, but allows women to walk about during labour. 8. Local analgesia: This is used for women who have not had an epidural but require forceps or vacuum extraction delivery. It is also used for repair of episiotomy or perineal tear. Pudendal nerve block: using lidocaine behind each ischial spine of the pelvis via the vagina. 1267. A primipara at full term in labor has passed show and the cervix is 3cm dilated. What is the single most appropriate management for her labor? a. Repeat vaginal examination in 4h b. CTG c. IV syntocin drip

d. Repeat vaginal examination in 2h e. Induction of labour It is the first stage of labor since the cervix is only 3cm dilated. First stage of labour ends when the cervix is 10cm dilated. The first stage of labour Latent phase (not necessarily continuous): there are painful contractions, the cervix initially effaces (becomes shorter and softer) then dilates to 4cm. Established phase: contractions with dilatation from 4 cm. A satisfactory rate of dilatation from 4 cm is 0.5cm/h. The 1st stage generally takes 8–18h in a primip, and 5–12h in a multip. During the first stage check maternal BP, and T° 4-hourly, pulse hourly; assess the contractions every 30min, their strength and their frequency (ideally 3–4 per 10min, lasting up to 1 min). Offer vaginal examination e.g every 4h to assess the degree of cervical dilatation, the position and the station of the head. Auscultate fetal heart rate (if not continuously monitored), by Pinard or Doppler every 15min, listening for 1min after a contraction.

1268. A 36yo pregnant woman comes for evaluation with her husband. Her husband has been complaining of morning sickness, easy fatigability and even intermittent abdominal pain. What is the husband suffering from? a. Ganser syndrome b. Couvade syndrome c. Pseudo-psychosis d. Stockholm syndrome e. Paris syndrome

Ganser syndrome is a type of factitious disorder, a mental illness in which a person deliberately and consciously acts as if he or she has a physical or mental illness when he or she is not really sick. Couvade syndrome, also called sympathetic pregnancy, is a proposed condition in which a partner experiences some of the same symptoms and behavior of an expectant mother. These most often include minor weight gain, altered hormone levels, morning nausea, and disturbed sleep patterns. Stockholm syndrome, or capture-bonding, is a psychological phenomenon in which hostages express empathy and sympathy and have positive feelings toward their captors, sometimes to the point of defending and identifying with the captors.

Pseudo Psychosis: As the name itself says, pseudo (psychosis), which means false, is not a form of psychosis, but instead, pseudo psychosis is when someone is convinced that they are suffering from psychosis when they are not. This doesn’t mean that the person is pretending or faking the symptoms of psychosis such as hallucinations, “hearing voices” or other forms of being completely detached from reality. Paris Syndrome: is a transient psychological disorder exhibited by some individuals visiting or vacationing in Paris or elsewhere in Western Europe. It is characterized by a number of psychiatric symptoms such as acute delusional states, hallucinations, feelings of persecution (perceptions of being a victim of prejudice, aggression, or hostility from others), derealization, depersonalization, anxiety, and also psychosomatic manifestations such as dizziness, tachycardia, sweating, and others

1269. A woman comes to the ED complaining of pain in the right side of the abdomen, she has 7wks amenorrhea. Her pregnancy test is +ve and US scan shows an empty uterus. What is the next step? a. Laparoscopy b. HCG measurements c. US d. Laparotomy e. Culdo-centhesis Answer is B. This is a case of ectopic pregnancy. Always think of an ectopic in a sexually active woman with abdominal pain; bleeding; fainting; or diarrhoea and vomiting. There is generally ~8 weeks’ amenorrhoea but an ectopic may present before a period is missed. An early sign is often dark blood loss (‘prune juice’, as the decidua is lost from the uterus) or fresh. Diagnosis: Early diagnosis is vital. Dipstix testing for HCG (human chorionic gonadotrophin) is sensitive to values of 25IU/L. do ultrasound. If HCG >6000IU/L and an intrauterine gestational sac is not seen, ectopic pregnancy is very likely, as is the case if HCG 1000– 1500IU/L and no sac is seen on transvaginal ultrasound. 1270. A 23yo woman who has had several recent partners has experienced post-coital bleeding on gentle contact. What is the single most likely cause of her vaginal discharge? a. Cervical ca b. Cervical ectropion c. CIN d. Chlamydial cervicitis e. Gonococcal cervicitis Answer is D

Causes of postcoital bleeding  

Infection. Cervical ectropion - especially in those women taking the combined oral contraceptive pill (COCP).

   

Cervical or endometrial polyps. Vaginal cancer. Cervical cancer - usually apparent on speculum examination. Trauma.

In this case the history of several recent partners points towards a sexually transmitted disease so it is chlamydial cervicitis as chlamydia is transmitted sexually. Chlamydial cervicitis:

Risk factors  Age mycoplasma, In legionella questions u ll mostly find some water related hints or outdoor activity near water or air conditioning system mention and most of the times GI symptoms along with respiratory symptoms

Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects younger patients. It is associated with a number of characteristic complications such as erythema multiforme and cold autoimmune haemolytic anaemia. Epidemics ofMycoplasma pneumoniae classically occur every 4 years. It is important to recognise atypical pneumonias as they may not respond to penicillins or cephalosporins due to it lacking a peptidoglycan cell wall. Features    

the disease typically has a prolonged and gradual onset flu-like symptoms classically precede a dry cough bilateral consolidation on x-ray complications may occur as below

Complications       

cold agglutins (IgM) may cause an haemolytic anaemia, thrombocytopenia erythema multiforme, erythema nodosum meningoencephalitis, Guillain-Barre syndrome bullous myringitis: painful vesicles on the tympanic membrane pericarditis/myocarditis gastrointestinal: hepatitis, pancreatitis renal: acute glomerulonephritis

Investigations  

diagnosis is generally by Mycoplasma serology positive cold agglutination test

1343. A 10yo boy is brought to the ED 10h after injury to the foot. It was punctured with a metal spike that passed through his shoe. What is the next best step? a. Ig b. Ig and vaccine c. Vaccine only d. Clean the wound e. Antibiotics Initial step is always to clean the wound in order to get rid of source. 1344. A 56yo male presents with persistent watery diarrhea. What is the most likely dx? a. Treponema pallidum

b. Nesseria meningitides c. Cryptosporidium d. Staph aureus e. Pseudomonas aeruginosa It should be c. C coz T pallidum...syphilis...not diarrhoea N menigitidis....menigitis S aureus...also not organisms for diarrhea P aeruginosa....again not causing diarrhoea

1345. A 2yo girl has frequency, urgency and burning micturition. She has some supra pubic tenderness. Which one of the following is the most appropriate initial inv? a. Supra pubic aspiration of urine for C&S b. Clean catch of urine for C&S c. USG d. IVU e. MCUG Ans is clean catch Urinary tract infections (UTI) are more common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood Presentation in childhood depends on age:    

infants: poor feeding, vomiting, irritability younger children: abdominal pain, fever, dysuria older children: dysuria, frequency, haematuria features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness

NICE guidelines for checking urine sample in a child   

if there are any symptoms or signs suggestive or a UTI with unexplained fever of 38�C or higher (test urine after 24 hours at the latest) with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)

Urine collection method    

clean catch is preferable if not possible then urine collection pads should be used cotton wool balls, gauze and sanitary towels are not suitable invasive methods such as suprapubic aspiration should only be used if noninvasive methods are not possible

Management

 





infants less than 3 months old should be referred immediately to a paediatrician children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs

1346. An 89yo man presents with carcinoma of posterior oropharynx. Which is the single most appropriate LN involved? a. Pre-aortic LN b. Aortic LN c. Submental LN d. Submandibular LN e. Deep cervical LN Oropharyngeal Lumphatics >>> Retropharyngeal Ln >> Deep cervical LN 1347. A young boy presented to the OPD 12wks after renal transplantation with fever and pain in lower abdomen. Renal functions were deranged. Renal biopsy showed immune cell infiltrate and tubular damage. What is the most probable dx? a. Pyelonephritis b. Chronic graft rejection c. Acute rejection d. Drug toxicity e. Graft vs host disease Hyperacute rejection : Within minutes of transplant Acute: After one week upto months Chronic : After years due to fibrosis 1348. A 56yo lady presents with a pathological fx of T11 vertebra. There is found to be an underlying metastatic lesion. What is her most common primary ca? a. Lung b. Breast c. Uterine d. Brain Breast CA is most notorious for bony mets. 1349. A 6m infant has breast milk jaundice. He is otherwise feeding well and is not dehydrated. What would his LFTs look like? a. Total bilirubin:40, conjugated bilirubin85% d. Total bilirubin:400, conjugated bilirubin 12 years

500 micrograms (0.5ml 1 in 1,000)

200 mg

10 mg

Adrenaline can be repeated every 5 minutes if necessary. The best site for IM injection is the anterolateral aspect of the middle third of the thigh. Common identified causes of anaphylaxis   

food (e.g. Nuts) - the most common cause in children drugs venom (e.g. Wasp sting)

1390. A 7yo boy presents with proptosis and periorbital edema. What is the immediate action that needs to be taken? a. IV morphine and immediate ophthalmoscopy b. IV morphine c. Observation only Seems to be an incomplete recall. Considering the age, and unilateral problem, diagnosis may be unilateral orbital cellulitis. Ans seems to be A Presentation :  Sudden onset of unilateral swelling of conjunctiva and lids.  Proptosis (bulging of the eye).  Pain with movement of the eye, restriction of eye movements.  Blurred vision, reduced visual acuity, diplopia.  Pupil reactions may be abnormal - relative afferent pupillary defect (RAPD); see the separate article on Examination of the Eye.  Fever, severe malaise. Management :  Hospital admission under the joint care of the ophthalmologists and the ENT surgeons is mandatory.  Intravenous antibiotics are used (eg, cefotaxime and flucloxacillin) in addition to metronidazole in patients over 10 years old with chronic sinonasal disease.[3]



Clindamycin plus a quinolone such as ciprofloxacin are used where there is penicillin sensitivity. Vancomycin is also an alternative.  Optic nerve function is monitored every four hours (pupillary reactions, visual acuity, colour vision and light brightness appreciation).  Treatment may be modified according to microbiology results and lasts for 7-10 days.  Surgery is indicated where there is CT evidence of an orbital collection, where there is no response to antibiotic treatment, where visual acuity decreases and where there is an atypical picture which may warrant a diagnostic biopsy. Surgery often concurrently warrants drainage of infected sinuses 1391. A schizophrenic man complains that he can hear voices talking about him and telling him to end his life by cutting his throat. He only hears them when he wakes up from sleep and not at other times. What type of hallucinations is he having? a. Somatic b. Kinesthetic c. Hypnogogic d. Hypnopompic e. Lilliputian Hypnagogic - occur on falling asleep and are harmless. Hypnopompic - occur on waking up and are harmless. Auditory - of one or more talking voices; seen commonly in schizophrenia. · Charles Bonnet's syndrome - visual hallucinations that blind persons experience · · ·

1392. A 28yo woman complains of hearing strange voices in her bedroom as she is falling asleep in the night. She says there is no one in the room except her. On evaluation she has no other problems. What is she suffering from? a. Delusion of persecution b. Cotard syndrome c. Hypnogogic hallucinations d. Lilliputian hallucinations e. Schizophrenia Types of Hallucinations :  Hypnagogic - occur on falling asleep and are harmless.  Hypnopompic - occur on waking up and are harmless.  Auditory - of one or more talking voices; seen commonly in schizophrenia.  Charles Bonnet's syndrome - visual hallucinations that blind persons experience

1393. A 32yo man on psychiatric meds presents with coarse tremors and diarrhea. What is the most likely altnernate to the drug causing the prb? a. Lithium b. Diazepam c. Haloperidol d. Valproate e. Citalopram Seems that Lithium has caused the symptoms. Its adverse effects are : G I upset. Coarse tremors Hypo/hyper thyroidism Diabetes insipidus Ebstein anomaly(in foetus) Lithium is used for bipolar disorder, alternatively we can give valproate (2nd line) 1394. A man is brought to the ED after he was stabbed in the best. Chest is clear bilaterally with muffled heart sounds. BP=60/0mmHg, pulse=120bpm, JVP is raised. What is the most probable dx? a. Pulmonary embolism b. Cardiac tamponade c. Pericardial effusion d. Hemothorax e. Pneumothorax

Cardiac tamponade Features  dyspnoea  raised JVP, with an absent Y descent - this is due to the limited right ventricular filling  tachycardia  hypotension  muffled heart sounds  Kussmaul's sign (much debate about this)  ECG: electrical alternans  Pulsus Paradoxus 1395. A 64yo alcoholic who has been dx with liver cirrhosis presents with a massive ascites. What is the mechanism of fluid accumulation in a pt with liver disease? a. Cirrhosis b. Portal HTN c. Hypoalbuminemia d. Liver failure e. Hepatic encephalopathy This question asks about the cause of a broader term - fluid accumulation which is mainly mediated by hypoalbuminemia. Liver cirrhosis is the final

stage of liver disease and hypoalbuminemia can be noticed prior to that stage. 1396. A 38yo man presented to ED with severe pain in upper abdomen. He has already taken course of triple therapy and now had elective endoscopy 2d ago. He is in shock. What is the most probable dx? a. Ca esophagus b. Barret’s esophagus c. Mediastinitis d. Ca stomach Always suspect mediastinitis in a pt with shock and fever after a hx of - Recent cardiothoracic surgery or instrumentation. - Upper GI endoscopy. - Bronchoscopy. - Recent dental or oropharyngeal infection. - Upper respiratory tract infection - Ingestion of a foreign body (particularly button batteries by young children, which may cause oesophageal rupture). other signs may include edema of the neck and face , and crunching sound when auscultation of the heart Surgical referral is urgent Boerhaave's syndrome

The term Boerhaave's syndrome is reserved for the 10% of esophageal perforations which occur due to vomiting

This can occur due to with Alcoholics who drink a lot and then vomit forcefully , this may cause esophageal perforation thereafter mediastinitis followed by death ..... Mallory–Weiss , also known as , gastro-esophageal laceration syndrome refers to bleeding from tears ... rather than perforation ..... 1397. A 68yo man who is a known case of liver cirrhosis has developed ascites. What is the mechanism for the development of ascites? a. Portal HTN b. Hypoalbuminemia c. Congestive heart failure d. Liver failure Ans can be A or B. Trigger factor for ascities is splancnic vasodilation due to PHT. Hypoalbuminemia plays a vital role too. According to ohcm pg 260, Portal HTN is mentioned as a cause of ascities. Mechanism of "fluid accumulation" (BROADER TERM ) is hypoalbuminaemia and ascites is portal HTN

1398. A man feels mild discomfort in the anal region and purulent discharge in underpants. What is the most likely dx? a. Feacal incontinence b. Anal abscess c. Fistula in ano

d. Anal tags e. Rectal Ca Fistula in ano is commonly seen in otherwise fit, young males. Associations: crohn's, diabetes, obesity Causes : perianal sepsis, crohn’s. TB, Rectal CA. Immunocompromise Inv : Endoanal USS In anal abscess- there would be severe pain & fever. Abscess is confined in the cavity and is very painful. Rectal ca would have been presented with bleeding or feeling of imcomplete defecation. . Some fistulla are painless specially if old. 1399. A 38yo female presents with difficulty in looking upward and on examination she was found to have lid lag as well. She also complains of her heart racing at times. Which test will help in dx? a. Tensilon test b. 24h ECG c. TFT d. Schimmer test e. Young Helmholtz ophthalmoscopy Hyperthyroidism Causes  Graves' disease  toxic nodular goitre  subacute (de Quervain's) thyroiditis  post-partum thyroiditis  acute phase of Hashimoto's thyroiditis (later results in hypothyroidism)  toxic adenoma (Plummer's disease)  amiodarone therapy Investigation  TFT’S (TSH down, T4 and T3 up)  thyroid autoantibodies  other investigations are not routinely done but includes isotope scanning

1400. A young anxious mother of a 10m boy comes to you and requests a test for CF. What is the most appropriate inv? a. Sweat test b. Heel prick test c. Breath test d. CXR CF is an autosomal recessive disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene, on chromosome 7. The only risk factor is a family history of the condition.

Signs These may include: · · · · ·

Finger clubbing. Cough with purulent sputum. Crackles. Wheezes (mainly in the upper lobes). Forced expiratory volume in one second (FEV1) showing obstruction.

Babies diagnosed with CF will usually have no signs or symptoms.

Investigations Sweat testing confirms the diagnosis and is 98% sensitive. Chloride concentration >60 mmol/L with sodium concentration lower than that of chloride on two separate occasions. · Molecular genetic testing for CFTR gene. · Sinus X-ray or CT scan - opacification of the sinuses is present in almost all patients with CF. · CXR or CT of thorax. · Lung function testing - spirometry is unreliable before 6 years. · Sputum microbiology - common pathogens include Haemophilus influenzae,Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia, Escherichia coli and Klebsiella pneumoniae. · Various blood tests including FBC, U&Es, fasting glucose, LFTs and vitamin A, D and E levels are usually performed. ·

Management of cystic fibrosis involves a multidisciplinary approach Key points 

    

regular (at least twice daily) chest physiotherapy and postural drainage. Parents are usually taught to do this. Deep breathing exercises are also useful high calorie diet, including high fat intake* vitamin supplementation pancreatic enzyme supplements taken with meals heart and lung transplant

1400. A young anxious mother of a 10m boy comes to you and requests a test for CF. What is the most appropriate inv? a. Sweat test b. Heel prick test c. Breath test d. CXR Answer= A- sweat test (Sweat testing confirms the diagnosis of cystic fibrosis and is 98% sensitive) exclusion of other options: Heel prick test= this test is usually done on the 5th to 6th day of life. A blood spot is taken from baby’s heel it is done for screening diseases like sickle cell disease, cystic fibrosis, congenital hypothyroidism, phenylketonuria, homocystinuria etc.In cystic fibrosis the heel prick test detects a chemical called immunoreactive trypsinogen. CXR=not diagnostic in CF Cystic Fibrosis: CF is an autosomal recessive disease caused by mutations in the CF transmembrane conductance regulator (CFTR) gene, on chromosome 7. CFTR is an ATP-responsive chloride channel that also affects other cellular activities, such as sodium transport across the respiratory epithelium, composition of cell surface glycoprotein and antibacterial defences. Clinical features: neonates= failure to thrive,meconium ileus,rectal prolapse children and adults= respiratory: recurrent chest infections ( recurrent lower respiratory tract infection (LRTI) with chronic sputum production is the most common presentation) GIT: pancreatic insufficiency, gallstones, cirrhosis etc others= male infertility,vasculitis,nasal polyps,arthritis,osteoporosis,hypertrophic pulmonary osteoarthropathy Signs= finger clubbing,cyanosis,bilateral coarse crackles Investigations= DIAGNOSIS by SWEAT TEST= . Chloride concentration >60 mmol/L with sodium concentration lower than that of chloride on two separate occasions. Molecular genetic testing for CFTR gene Sputum microbiology - common pathogens include Haemophilus influenzae,Staphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia, Escherichia coli and Klebsiella pneumoniae. Treatment= Patient care is most effective when provided in specialist centres by multidisciplinary teams. symptomatic treatment for instance, respiratory= chest physiotherapy GIT= pancreatic enzyme replacement, fat sol vitamin supplementation etc

1401. A 22yo Greek man presents with rapid anemia and jaundice following tx of malaria. He is noted to have Heinx bodies. Choose the single most likely cause from the given options? a. G6PD deficiency b. Anemia of chronic disease c. Pernicious anemia d. IDA e. Vit B12 deficiency

Answer= Glucose 6 phosphate dehydrogenase deficiency (G6PD). Acute haemolysis from G6PD deficiency can produce HEINZ BODIES which are denatured haemoglobin and bite cells. it is precipitated by drugs such as primaquine (antimalarial),sulfonamides,aspirin. exclusion of other causes= anemia of chronic disease: commonest anemia in hospital patients.common causes include Chronic infection,Inflammation - including connective tissue disorders,Neoplasia. pernicious Anemia=type of megaloblastic anemia due to impaired absorption of vitamin b12 deficiency.it is caused by autoimmune atrophic gastritis leading to acchlorhydria and lack of intrinsic factor secretion. Iron def Anemia=microcytic hypochromic anemia caused by iron deficiency d/t blood loss, poor diet,malabsorption etc. blood film shows anisocytosis and poikilocytosis vit b12 def= macrocytic anemia caused by vit b12 deficiency d/t dietary def,pernicious anemia,ileal resection,gastrectomy.Blood film will show hypersegmented polymorphs G6PD is x linked chief rbc enzyme defect disorder. it mainly affects males. it is percipitated by drugs like primaquine,sulfonamides and aspirin.Usually asymptomatic.In attacks,there is rapid anemia and jaundice. tests: fbc= anemia Blood film= heinz bodies G6PD enzyme activity - is the definitive test (as opposed to the amount of G6PD protein). Treatment= Avoidance of the substances that may precipitate hemolysis is essential. If severe then transfuse. if severe hemolysis, folate supplementation may be beneficial.

1402. A 65yo has terminal cancer and his pain is relieved by a fentanyl patch but he now complains of shooting pain in his arm. Which of the following will add to his pain relief? a. Gabapentin b. Radiotherapy c. Amitriptyline d. Morphine answer=A. Gabapentin. it is the neuropathic pain and the first line treatment for neuropathic pain according to recent nice guidelines is amitriptyline, duloxetine, gabapentin,pregabalin.if the first line drug treatment doesn't work try one of the other 3 drugs Gabapentin is 1st line for neuropathic pain. Amitriptyline is 1st line for diabetic neuropathy but it is off license so now the first line for diabetic neuropathy is duloxetine. . Neuropathic pain is defined as pain arising as a direct consequence of a lesion or disease affecting the somatosensory system. it is often difficult to treat and responds poorly to standard analgesia. The discomfort is usually of a chronic nature and may be described by the patient as a burning sensation, a sharp, stabbing or shooting pain, or 'like an electric shock'. examples include= diabetic neuropathy,trigeminal neuralgia,post herpetic neuralgia, prolapsed intervertebral discs. There are various causes of it including infections like guillain barr syndrome, hiv etc, drugs like isoniazid, vincristine, cisplatin,nitrofurantoine etc, malignancy.

treatment= pharmacological All neuropathic pain (except trigeminal neuralgia): Offer a choice of amitriptyline, duloxetine, gabapentin or pregabalin as initial treatment for neuropathic pain (except trigeminal neuralgia). If the initial treatment is not effective or is not tolerated, offer one of the remaining three drugs, and consider switching again if the second and third drugs tried are also not effective or not tolerated.

1403. A 45yo male alcoholic presents after a large hematemesis. He has some spider naevi on his chest, BP=100/76mmHg, pulse=110bpm. He has a swollen abdomen with shifting dullness. a. Gastric ca b. Mallory-weiss tear+ c. Esophageal ca d. Esophageal varices e. Esophagitis f. Peptic ulceration Answer= esophageal varices. The most common causes of upper GI bleeding are peptic ulcer and oesophago-gastric varices.Factors that increase the risk of variceal bleeding are the decompensation of liver disease (ascites,bleeding esophageal varices,oedema etc),alcohol intake,aspirin,nsaids etc spider naevi is also one of the signs of chronic liver disease. exclusion of other causes: peptic ulceration= although the most common causes of upper GI bleeding are peptic ulcer and oesophago-gastric varices but Helicobacter pylori infection is associated with about 95% of duodenal ulcers and 80% of gastric ulcers.other causes may include nsaids,pepsin,smoking,alcohol etc.symptoms commonly include epigastric pain,nausea,dyspepsia etc mallory weiss tear= Mallory-Weiss syndrome (MWS) is characterised by upper gastrointestinal bleeding (UGIB) from mucosal lacerations in the upper gastrointestinal tract, usually at the gastroesophageal junction or gastric cardia. Mallory Weiss tears account for 48% of cases of UGIB. Haematemesis due to a Mallory Weiss tear usually occurs after a prolonged or forceful bout of retching, vomiting, coughing, straining or even hiccupping. Acute treatment of variceal haemorrhage  ABC  correct clotting: FFP, vitamin K  vasoactive agents: terlipressin is currently the only licensed vasoactive agent and is supported by NICE guidelines. Octreotide may also be used.  prophylactic antibiotics reduce mortality in patients with liver cirrhosis  endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation  Sengstaken-Blakemore tube if uncontrolled haemorrhage  Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail

Prophylaxis of variceal haemorrhage  propranolol: reduced rebleeding and mortality compared to placebo  endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration

1404. A 23yo woman presents with a 1cm small smooth, firm, mobile mass in her left breast. She is very anxious. What is the most appropriate inv? a. Mammography b. US breast c. FNAC d. Mammography and US Answer= US breast. In triple assessment for breast lump, ultrasound is done for 35ys old Diagnosis= Fibroadenoma: it usually presents 4.5 in men is usually asymptomatic but may cause urethritis investigations= microscopy of a wet mount shows motile trophozoites

1410. A 35yo man has been given a dx of allergic rhinitis and asthma. Exam: peripheral neuropathy with tingling and numbness in a ‘glove and stocking’ distribution. Skin lesions are present in the form of tender subcutaneous nodules. The pt is responding well to corticosteroids. What is the single most appropriate dx? a. AS b. Churg-strauss syndrome c. Cryptogenic organizing d. Extrinsic allergic alveolitis e. Tropical pulmonary eosinophilia Answer= B. churg- strauss syndrome. allergic rhinitis with asthma points towards the diagnosis of churg strauss syndrome. mnemonic : BEAN SAP BE: Blood Eosinophilia A : Asthma N : Neuropathy (mononeuritis multiplex) - usually common peroneal nerve S : Sinus abnormality A : Allergies P : Perivascular eosinophils / vasculitis Churg Strauss Syndrome A triad of adult-onset asthma, eosinophilia, and vasculitis (± vasospasm ± MI ± DVT), affecting lungs, nerves, heart, and skin. A septic-shock picture/systemic inflammatory response syndrome may occur (with glomerulo nephritis/ renal failure, esp. if ANCA +ve). Presentation: The physical findings are specific to organ system involvement. There are three phases:  Allergic rhinitis and asthma.  Eosinophilic infiltrative disease, such as eosinophilic pneumonia or gastroenteritis.  Systemic medium and small vessel vasculitis with granulomatous inflammation. Investigations: Antineutrophil cytoplasmic antibodies (ANCA): 70% of patients are perinuclear staining (p-ANCA) positive (anti myeloperoxidase antibodies).Other likely findings include eosinophilia and anaemia on the FBC; elevated ESR and CRP; elevated serum creatinine; increased serum IgE levels

Treatment= Steroids; biological agents if refractory disease, eg rituximab. 1411. A 28yo woman comes with sudden onset vomiting and pain per abdomen. Exam: mobile swelling in the right iliac fossa. What is the most probable dx? a. Ectopic pregnancy b. Tubo-ovarian abscess c. Acute appendicitis d. Ovarian torsion

e. Diverticulitis Answer= D Ovarian Torsion. Mobile swelling in rif sudden pain vomiting in female exclusion of other options: ectopic pregnancy= history of amenorrhea and pv bleeding and it won't be palpable tubo- ovarian abscess= history of fever present acute appendicitis= mass wont be mobile in it rather will be fixed diverticulitis= pain on the left side OVARIAN TORSION

Ovarian torsion (adnexal torsion) is an infrequent but significant cause of acute lower abdominal pain in women. This condition is usually associated with reduced venous return from the ovary as a result of stromal edema, internal hemorrhage, hyperstimulation, or a mass. The ovary and fallopian tube are typically involved.

ETIOLOGY Pregnancy is associated with, and may be responsible for, torsion in approximately 20% of adnexal torsion cases Ovarian tumors, both benign and malignant, are implicated in 50-60% of cases of torsion. Dermoid tumors are most common. patients with a history of pelvic surgery (principally tubal ligation) are at increased risk for torsion.

Features; Classically, patients present with the sudden onset (commonly during exercise or other agitating movement) of severe, unilateral lower abdominal pain that worsens intermittently over many hours. The pain usually is localized over the involved side, often radiating to the back, pelvis, or thigh Nausea and vomiting Fever may occur as a late finding as the ovary becomes necrotic.

Investigations: Diagnostic ultrasonography should be the first examination performed; typically, the affected ovary is enlarged, with multiple immature or small follicles along its periphery. Ultrasonography with color Doppler analysis is the method of choice for the evaluation of adnexal torsion

Treatment: Outpatient care has no role in the treatment of ovarian torsion. Patients with either a suspected or confirmed diagnosis of ovarian torsion should be admitted and either operated on or observed by a gynecologist. Laparoscopy can be used for both confirmation of the diagnosis and treatment.

(source medscape)

1412. A 68yo man on tx for an irregular heart beat comes to the ED. He has palpitations for the last 3h. Exam: pulse=regular, 154bpm. Carotid sinus massage settled his pulse down to 80bpm. What is the most likely rhythm disturbance? a. SVT b. V-fib c. VT d. V-ectopics e. A-fib

Answer= A.SVT Palpitations and dizziness, which are the most common symptoms reported in svt. During an attack, tachycardia may be the only finding if the patient is otherwise healthy and there is no cardiac dysfunction. During an episode of SVT the pulse rate is 140-250 beats per minute (bpm).In haemodynamically stable regular narrow QRS-complex tachycardia, vagal manoeuvres - eg, Valsalva, carotid massage, facial immersion in cold water. 1413. A 43yo man with a hx of hospital admissions talk about various topics, moving from one loosely connected topic to another. What is the most likely dx? a. Psychosis b. Mania c. Schizophrenia d. Pressured speech e. Verbal diarrhea Answer= B. Mania. rapid flit from one subject to another ('flight of ideas') and pressured speech (speech is rapid and copious) both are features of mania.. The presence of psychotic symptoms differentiates mania from hypomania Psychotic symptoms  delusions of grandeur  auditory hallucinations The following symptoms are common to both hypomania and mania Mood  

predominately elevated irritable

Speech and thought  pressured  flight of ideas  poor attention Behaviour  insomnia  loss of inhibitions: sexual promiscuity, overspending, risk-taking  increased appetite

1414. An 18yo girl presents with rahs on her trunk, abdominal pain, arthritis, proteinuria and hematuria. What is the most probable dx? a. TTP b. ITP c. HSP d. HUS e. Measles

Answer= C. HSP. Henoch-Schönlein purpura (HSP) is an IgA-mediated, autoimmune hypersensitivity vasculitis of childhood. The main clinical features are skin purpura, arthritis, abdominal pain, gastrointestinal bleeding, orchitis and nephritis. In classic cases palpable purpuric rash (with localized oedema) over buttocks and other sites are extensor surfaces of arms and legs and trunk. Features of IgA nephropathy may occur e.g. haematuria, renal failure. exclusion of other causes: HUS=Haemolytic uraemic syndrome is generally seen in young children and produces a triad of:acute renal failure, microangiopathic haemolytic anaemia and thrombocytopenia. Typical (or infection-induced) HUS is most commonly associated with Escherichia coli with somatic (O) antigen 157 and flagella (H) antigen 7 - hence the designation O157:H7.The classical presenting feature is profuse diarrhoea that turns bloody 1 to 3 days later.

Henoch-Schönlein purpura (HSP) is an IgA-mediated, autoimmune hypersensitivity vasculitis of childhood. The main clinical features are skin purpura, arthritis, abdominal pain, gastrointestinal bleeding, orchitis and nephritis. In classic cases palpable purpuric rash (with localized oedema) over buttocks and other sites are extensor surfaces of arms and legs and trunk. Features of IgA nephropathy may occur e.g. haematuria, renal failure. Treatment: analgesia for arthralgia treatment of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants Prognosis: usually excellent, HSP is a self-limiting condition, especially in children without renal involvement around 1/3rd of patients have a relapse HSP = 10 P's PALPABLE PURPURA PLATELETS OK -- DDx from ITP PRURITUS -- URTICARIA PAIN -- ABDOMEN and LEGS POSITIVE +guaiac -- FECES PRESSURE -- increased blood pressure PROTEINURIA PREDNISONE = Tx

1415. A pt is on loop diuretics. What effect do loop diuretics produce? a. Low Na+, low K+

b. Low Na+, normal K+ c. Normal Na+, normal K+ d. High Na+, low K+ e. High Na+, high K+ Answer= A. low na+, Low K+ Loop Diuretics loop diuretics act by inhibiting the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle, reducing the absorption of NaCl. There are two variants of NKCC; loop diuretics act on NKCC2, which is more prevalent in the kidneys. Indications= heart failure: both acute (usually intravenously) and chronic (usually orally), resistant hypertension, particularly in patients with renal impairment. Adverse effects= hypotension, hyponatremia, hypokalemia,hypocalcemia,hypochloremic alkalosis, hyperglycemia (less common with thiazides), renal impairment( from dehydration+direct toxic effect) and gout

1416. A 6yo girl is being investigated for renal failure. She is found to have a congenital abnormality of the insertion of the ureters into the urinary bladder. What is the single most likely cause for renal failure in this pt? a. SLE b. PKD c. Wilm’s tumor d. Acute tubular necrosis e. Reflux nephropathy Answer= Reflux Nephropathy 1417. A 76yo man is in the CCU 2d after an acute MI. He tells you that he had an episode of rapid pounding in the chest lasting for about 2mins. He remains conscious throughout. What is the most likely rhythm? a. SVT b. VF c. VT d. V-ectopics e. A-fib Answer= C. Ventricular tachycardia. Palpitations (pounding chest) or arrhythmias 48hrs post MI is almost always Ventricular tachycardia until proven otherwise. Ventricular tachycardia (VT) is broad-complex tachycardia originating from a ventricular ectopic focus. It has the potential to precipitate ventricular fibrillation and hence requires urgent treatment. There are two main types of VT:  monomorphic VT: most commonly caused by myocardial infarction  polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval. Management: If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure or rate >

150 beats/min) then immediate cardioversion is indicated. In the absence of such signs antiarrhythmics may be used. If these fail, then electrical cardioversion may be needed with synchronised DC shocks. Drug therapy:   

amiodarone: ideally administered through a central line lidocaine: use with caution in severe left ventricular impairment procainamide

Verapamil should NOT be used in VT If drug therapy fails  

electrophysiological study (EPS) implantable cardioverter-defibrillator (ICD) - this is particularly indicated in patients with significantly impaired LV function

1418. A 49yo man comes with hx of cough and SOB. His CD4 count is measured as 350. CXR shows lobar consolidation. What is the single most appropriate option? a. Mycobacterium avium intracellulare b. CMV c. Streptococcus d. Toxoplasmosis e. Pneumocystis jiroveci Answer= C Streptococcus. The patient presents with h/o cough. SOB and cxr shows lobar consolidation. these point towards the diagnosis of pneumonia and streptococcus is the most common cause of community acquired pneumonia. exclusion of other options: pneumocystis Jiroveci (PCP): PCP is the most common opportunistic infection in AIDS which usually occur when CD4 count 100 (PBC is a major indication) - recurrence in graft can occur but is not usually a problem

1444. A 60yo man complains of tiredness, lethargy and itching that is severe after a hot bath. He also has nocturia, polyuria and nausea and vomiting. Exam: pallor, pigmentation and generalized edema. What is the single most likely dx? a. Hyperthyroidism b. Lichen planus c. Lymphoma d. Eczema e. Liver failure f. CRF Answer: F. CRF (Chronic Renal Failure), tiredness, lethargy, itching, nocturia, polyuria,pigmentation, generalized edema all point towards the diagnosis. CHRONIC RENAL FAILURE Impaired renal function for >3 months based on abnormal structure or function, or GFR 3 months with or without evidence of kidney damage. Symptoms usually only occur once stage 4 is reached (GFR 10mL/min/1.73m2 within 5yrs) • BP poorly controlled despite ≥4 antihypertensive drugs at therapeutic doses • Known or suspected rare or genetic causes of CKD • Suspected renal artery stenosis Management of patients can be split into four main approaches: investigations, limiting progression/complications, symptom control and preperation for renal replacement therapy.

1445. A 30yo man complains of vague pain in the loin with BP=140/90mmHg. He is found to have proteinuria and hematuria. What is the inv to confirm the dx? a. Abdominal US

b. ANCA c. ANA d. Urine microscopy and culture e. Stool culture Answer= A. Abdominal US. Pain in the loin with hematuria and proteinuria and with high blood pressure points towards the Polycystic Kidney Disease. so investigation of choice in this case would be Abdominal US to confirm the diagnosis. ADULT POLYCYSTIC KIDNEY DISEASE It is an autosomal dominant condition. 85% of patients have mutations in PKD1 (chromosome 16) and Remainder have mutation in PKD2 (chromosome 4) Features= Loin pain is the most common symptom. Hypertension is a common presenting feature Bilateral kidney enlargement - abdominal examination may reveal enlarged and palpable kidneys. Gross haematuria following trauma (haemorrhage into a cyst) is a classic presenting feature of ADPKD. It occurs in 30-50%. Cyst infection, renal calculi, progressive renal failure. Extrarenal: liver cysts, intracranial aneurysm, SAH (subarachnoid haemorrhage), mitral valve prolapse, ovarian cysts and diverticular disease Investigations= routine blood tests: fbc, urea,cr and electrolytes, GFR etc urine analysis Imaging is used to establish the diagnosis and to monitor disease progression USS screening offers good sensitivity and specificity depending on age. Management= Monitor U&E. BP should be treated aggressively, with target levels of 25; if immunocompromised: 10 mg/kg/8h slowly IVI for 10d; alternative: famciclovir or valaciclovir If conjunctiva affected, use 3% acyclovir ointment Beware iritis; test acuity often.

1452. An 87yo woman with a hx of HTN has acute breathlessness. She has a RR=32bpm, widespread lung crackles, pulse=120bpm, BP=160/90mmHg and elevated venous pressure. Her peripheral O2 sat=85%. What is the single most appropriate initial management? a. IV antibiotics b. IV furosemide c. Nitrate infusion d. Neb. Salbutamol e. 100% oxygen Answer= E. 100% oxygen. the pt is hypertensive with acute breathlessness and raised JVP pointing towards the diagnosis of Acute Heart Failure. Management of acute heart failure Sit the patient upright ↓ Oxygen 100% if no pre-existing lung disease ↓ IV access and monitor ECG Treat any arrhythmias, eg AF ↓ Investigations whilst continuing treatment ↓ Diamorphine 1.25–5mg IV slowly Caution in liver failure and COPD ↓

Furosemide 40–80 mg IV slowly Larger doses required in renal failure ↓ GTN spray 2 puffs SL or 2 ≈ 0.3mg tablets SL Don’t give if systolic BP 35 kg, 4 tablets stat and then a further 4 tablets at 8, 24, 36, 48 and 60 hours. the WHO revised their treatment guidelines in 2010. These recommend that artemisinin-based combination therapies should be used first-line in preference to quinine. complicated or severe Falciparum malaria treatment: IV quinine dihydrochloride is the first-line antimalarial drug. Oral quinine sulfate 600 mg tds should be substituted once the patient is well enough to complete a 5- to 7-day course in total. Artesunate regimen - for named adult patient use only, on expert advice A second drug should always accompany these regimes.

1484. A pt is unresponsive and cyanosed. What is the most definitive 1st step in management? a. Chest compressions b. Check airway c. Call 999 d. Mouth to mouth e. Recovery position Answer= B. check airway

1485. A man was bitten by a drug addict and comes to the hosp with a wound. What inv should be undertaken? a. Hep C b. Lyme disease c. Hep B d. Syphilis

e. Hep A Answer= C.Hep B. Hepatitis B spreads via blood products, IV drug abusers, direct contact. Hepatitis B virus (HBV, a DNA virus.) Spread: Blood products, IV drug abusers (IVDU),sexual, direct contact. Risk groups: IV drug users and their sexual partners/carers; health workers; haemophiliacs; job exposure to blood ; haemodialysis (and chronic renal failure); close family members of a carrier or case; staff or residents of institutions/prisons; babies of HBSAg +ve mothers Incubation= 1- 6 months Signs: Resemble hepatitis A but arthralgia and urticaria are commoner. Tests: HBSAg (surface antigen) is present 1–6 months after exposure. HBeAg (e antigen) is present for 1½–3 months after acute illness and implies high infectivity. HBSAg persisting for >6 months defi nes carrier status and occurs in 5–10% of infections; Antibodies to HBCAg (anti-HBc) imply past infection; Antibodies to HBSAg (anti-HBs) alone imply vaccination. HBV PCR allows monitoring of response to therapy. Vaccination: Passive immunization (specific anti-HBV immunoglobulin) may be given to non-immune contacts after high-risk exposure. Treatment: Avoid alcohol. Immunize sexual contacts. Refer all with chronic liver inflammation (eg ALT 30iu/L) for antivirals, eg pegylated (PEG) interferon alfa-2a, lamivudine, entecavir, adefovir. The aim is to clear HBSAg and prevent cirrhosis and HCC (risk is if HBSAg and HBeAg +ve). Other complications: fulminant hepatic failure, cholangiocarcinoma, cryoglobulinemia. 1486. An 18yo woman says that she can’t walk around as she is very big for that room. What is the most likely hallucination? a. Extracampine visual hallucinations b. Lilliputian visual hallucinations c. Alice in wonderland syndrome d. Hypnagogic hallucinations Answer= B. lilliputian visual hallucinations.These are hallucinations seen in Alice in wonderland syndrome. there is altered perception in size and shape of body parts or objects ± an impaired sense of passing time. Alice in Wonderland Syndrome (also known as Todd's syndrome, or lilliputian

hallucinations) is a disorienting neurological condition that affects human perception. People experience micropsia, macropsia, pelopsia, teleopsia, or size distortion of other sensory modalities. It is often associated with migraines, brain tumors, and the use of psychoactive drugs. It can also be the initial symptom of the Epstein–Barr virus. 1487. A middle aged lady presented with fever, altered sensorium, bleeding gums and jaundice. Labs:deranged renal function tests, normal PT/APTT, fragmented RBCs and low plts. What’s the most likely dx? a. Cholesterol emboli b. HUS c. TTP d. Hepatorenal syndrome e. Sepsis Answer= C. TTP. altered sensorium, jaundice, low plts all point towards the diagnosis. exclusion of other causes: Haemolytic uraemic syndrome (HUS) Though it has same features as TTP but it is usually common in children. HUS is characterized by microangiopathic haemolytic anaemia (MAHA): intravascular haemolysis + red cell fragmentation. Causes: 90% are from E. coli strain O157 This typically affects young children in outbreaks (more common than sporadically) after eating undercooked contaminated meat. Signs: Abdominal pain, bloody diarrhoea, and AKI. Tests: Haematuria/proteinuria. Blood film: fragmented RBC (schistocytes, platelets, Hb. Clotting tests are normal. treatment: Seek expert advice. Dialysis for AKI may be needed. Plasma exchange is used in severe persistent disease.

TTP (THROMBOTIC THROMBOCYTOPENIC PURPURA) There is an overlap between TTP and HUS, and many physicians consider them a spectrum of disease. All patients have MAHA (severe, often with jaundice) and low platelets. Other features can include AKI, fluctuating CNS signs (eg seizures, hemiparesis, consciousness, vision) and fever. The classic description included the full ‘pentad’ of features, but with the advent of plasma exchange this is rarely seen. Mortality is higher than childhood HUS and can be >90% if untreated, though reduced to ~20% with plasma exchange. Pathophysiology: There is a genetic or acquired deficiency of a protease (ADAMTS13) that normally cleaves multimers of von Willebrand factor (VWF). Causes: Idiopathic (40%), autoimmunity (eg SLE), cancer, pregnancy, drug associated (eg quinine), bloody diarrhoea prodrome (as childhood HUS) Tests: As HUS treatment: Urgent plasma exchange may be life-saving. Steroids are the mainstay for non-responders. . 1488. A child came to the ED with severe asthma and not responding to salbutamol nebulizer and vomiting many times. What is the most appropriate management? a. Salmeterol

b. Montelukast c. Prednisolone d. Budesonide inhaler e. Oxygen f. IV salbutamol Answer= F. IV Salbutamol. it is a severe attack where optimum treatment is failed.

1489. A 73yo woman with skeletal and brain mets from breast ca has worsening low back pain and blurring of vision. She has weakness of her legs, minimal knee and absent ankle tendon reflexes, a palpable bladder, a power of 2/5 at the hip, 3/5 at the knee and ankle, and tenderness over the 2nd lumbar vertebra. There is reduced sensation in the perineum. She has been started on dexamethasone 16mg daily.What is the single most likely cause of her weakness? a. Paraneoplastic neuropathy b. Progression of brain tumor c. PID at L2/L3 d. Spinal cord compression e. Steroid induced myopathy Answer= D. spinal cord compression. Spinal cord compression (as probably at L2/L3 region associated cauda equina syndrome). Here blurring of vision can be explained by raised intracranial pressure causing papilloedema (due to brain metastasis) which excludes blurring of vision from "Paraneoplastic neuropathy". In progressive brain tumour you will get upper motor neurone lesions which is not evident here. rather lower motor neurone type features and bladder involvement and reduced perineal sensation justifies spinal cord compression associated with cauda equina syndrome. 1490. A 78yo woman presents with unilateral headache and pain on chewing. ESR=70mm/hr. She is on oral steroids. What is the appropriate additional therapy? a. Bisphosphonates b. HRT c. ACEi d. IFN e. IV steroids Answer= A. Bisphosphonates. unilateral headache and pain on chewing with raised ESR all points towards the diagnosis of GIANT CELL ARTERITIS the management of which is high dose steroids. so osteoporosis prophylaxis is given in these patients, thus

bisphosphonates are given. Giant cell arteritis (GCA) = cranial or temporal arteritis It is common in the elderly—consider Takayasu’s if under 55yrs. It is associated with PMR (polymyalgia Rheumatica) in 50% Symptoms: Headache, temporal artery and scalp tenderness (eg when combing hair), jaw claudication, amaurosis fugax, or sudden blindness, typically in one eye. Extracranial symptoms may include dyspnoea, morning stiffness, and unequal or weak pulses. If you suspect GCA, do ESR and start prednisolone 60mg/d PO immediately. The risk is irreversible bilateral visual loss, which can occur suddenly if not treated. Tests: ESR & CRP↑↑ , ↑ platelets,↑ alk phos, Hb↓. Get a temporal artery biopsy within 7 days of starting steroids. Prognosis: Typically a 2-year course, then complete remission. Reduce prednisolone once symptoms have resolved and↓ ESR;↑ dose if symptoms recur. The main cause of death and morbidity in GCA is long-term steroid treatment so consider risks and benefits! Give gastric and bone protection (PPI & bisphosphonate).

1491. A 48yo woman is admitted to the ED with a productive cough and mod fever. She often has central chest pain and she regurgitates undigested food most of the time but doesn’t suffer from acid reflux. These symptoms have been present for the last 3.5m which affects her daily food intake. CXR: air-fluid level behind a normal sized heart. What is the single most likely dx? a. Pharyngeal pouch b. Hiatus hernia c. Bulbar palsy d. Achalasia e. TB Answer= D.Achalasia. Regurgitation of undigested foods, respiratory infection, absence of acid reflux, air fluid level on chest x ray all point towards the diagnosis. exclusion of other options: Hiatal hernia=Hiatus hernia is a risk factor for GORD,in GORD patient will have regurgitation of digested food particles and acid reflux. ACHALASIA CARDIA Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus

above dilated. Achalasia typically presents in middle-age and is equally common in men and women. Clinical features  dysphagia of BOTH liquids and solids  typically variation in severity of symptoms  heartburn  regurgitation of food - may lead to cough, aspiration pneumonia etc  malignant change in small number of patients Investigations  manometry: excessive LOS tone which doesn't relax on swallowing - considered most important diagnostic test  barium swallow shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance  CXR: wide mediastinum, fluid level Treatment  intra-sphincteric injection of botulinum toxin  Heller cardiomyotomy  balloon dilation  drug therapy has a role but is limited by side-effects

1492. A retired ship worker has pleural effusion and pleural thickening on right side with bilateral lung shadowing. What would you do to improve his symptoms? a. Aspiration b. Chest drain c. Chemotherapy d. Diuretic Answer= C, Chemotherapy. ship worker developing pleural effusion and pleural thickening points towards the diagnosis of Mesothelioma for which Chemotherapy is definite treatment. Malignant mesothelioma is a tumour of mesothelial cells that usually occurs in the pleura, and rarely in the peritoneum or other organs. It is associated with occupational exposure to asbestos, Clinical features: Chest pain, dyspnoea, weight loss, finger clubbing, recurrent pleural effusions. Signs of metastases: lymphadenopathy, hepatomegaly, bone pain/tenderness, abdominal pain/obstruction (peritoneal malignant mesothelioma). Tests: CXR/CT: pleural thickening/effusion. Bloody pleural fluid. Treatment:

Patients are usually offered palliative chemotherapy (Pemetrexed + cisplatin) and there is also a limited role for surgery and radiotherapy.

1493. An 88yo woman is a known smoker. She had an attack of MI 2y back and is known to have peripheral vascular disease. She presents with an irreducible herniation over the incision region of a surgery which she underwent in her childhood. What is the most appropriate tx? a. Truss b. Elective herniorrhaphy c. Urgent herniorrhaphy d. Elective herniotomy e. Reassure Answer= B. Elective herniorrhaphy. Incisional hernia is a risk of any abdominal surgery and is estimated to occur in 15% of abdominal operations.  

They are caused essentially by failure of the wound to heal but are probably the result of multiple patient and technical factors. Advances in technique and materials have not removed this problem.

Management  They require urgent repair with reinforcing mesh used in large hernias. This is required particularly where the patient is obese.  Recurrence occurs in up to 50% of large hernias.

1494. A 72yo woman who is taking loop diuretics for left ventricular failure. She now is suffering from palpitations and muscle weakness. What is the electrolyte imbalance found? a. Na+=130mmol/L, K+=2.5mmol/L b. Na+=130mmol/L, K+=5.5mmol/L c. Na+=140mmol/L, K+=4.5mmol/L d. Na+=150mmol/L, K+=3.5mmol/L e. None Answer= A. Na+=130mmol/L, K+=2.5mmol/L Loop Diuretics loop diuretics act by inhibiting the Na-K-Cl cotransporter (NKCC) in the thick ascending limb of the loop of Henle, reducing the absorption of NaCl. There are two variants of NKCC; loop diuretics act on NKCC2, which is more prevalent in the kidneys. Indications= heart failure: both acute (usually intravenously) and chronic (usually orally), resistant hypertension, particularly in patients with renal impairment.

Adverse effects= hypotension, hyponatremia, hypokalemia,hypocalcemia,hypochloremic alkalosis, hyperglycemia (less common with thiazides), renal impairment( from dehydration+direct toxic effect) and gout

1495. A young woman who is a marathon runner comes with secondary amenorrhea. Inv: normal LH, FSH and estradiol, prolactin=600. What is the most likely dx? a. Hypothalamic amenorrhea b. Pregnancy c. PCOS d. Prolactinoma e. Anorexia Answer= A. Hypothalamic Amenorrhea. patient is a marathon runner and LH,FSH may be normal if weight loss or excessive exercise are the cause. prolactins levels can also be increased by stress. Hypothalamic amenorrhea : excessive exercise can impair the pulsatile release of GnRH from the hypothalamus. Although in most of such cases LH and FSH are low , a normal level can be present depending on the timing of the test with regards to the menstrual cycle. In general , prolactin levels can be interpreted in the following way : 5000 : macroprolactinoma. During pregnancy and lactation :750-8000 mU/L. Hypothalamic–pituitary–ovarian causes are common (34% of cases) as control of the menstrual cycle is easily upset, eg by stress (emotions, exams), exercise, weight loss. Up to 44% of competitive athletes have amenorrhoea. Tests • HCG (eg urinary) to exclude pregnancy. • FSH/LH (low if hypothalamic pituitary cause but may be normal if weight loss or excessive exercise the cause. Raised eg FSH>20 IU/L if premature menopause • Prolactin (↑by stress, hypothyroidism, prolactinomas and drugs, eg phenothiazines, domperidone, metoclopramide). Treatment is related to cause. Hypothalamic–pituitary axis malfunction: If mild (eg stress, moderate weight loss) =there is sufficient activity to stimulate enough ovarian oestrogen to produce an endometrium (which will be shed after a progesterone challenge, eg medroxyprogesterone acetate 10mg/24h for 10 days), but the timing is disordered so cycles are not initiated. If the disorder is more severe the axis shuts down (eg in severe weight loss)= Reassurance and advice on diet or stress management, or psychiatric help if appropriate. she should be advised to use contraception as ovulation may occur at any time. 1496. A 4yo child comes with a sprain in his foot. Hx reveals that the child has had recurrent admissions to the hosp due to severe asthma. What is the most appropriate analgesic?

a. Diclofenac sodium b. Ibuprofen. c.Paracetamol d. Codeine Answer= C.Paracetamol. paracetamol should only be given in this patient to relieve pain. NSAIDS should not be given as the child has h/o asthma as nsaids may increase the risk of acute bronchospasm and codeine can cause respiratory depression. 1497. A 34yo pregnant woman, 38wk GA is in labor. She had a long 1st stage and troublesome 2nd stage, has delivered a baby. After her placenta was delivered she had a convulsion. What is the most probable management? a. MgSO4 IV b. Diazepam IV c. IV fluid d. Hydralazine IV e. Anti-epileptic Answer= MGSO4 IV. whenever a woman develops a fit few days after delivery, it is always eclampsia until proven otherwise. Treatment of hypertension: If BP >160/110 mmHg or mean arterial pressure >125 mmHg, use labetalol 20mg IV increasing after 10min intervals to 40 mg then 80 mg until 200mg total is given. Aim for BP 150/80–100 mmHg. Alternative is hydralazine. Give prophylactic H2 blockers until normal postnatal care starts. Restrict fluids to 80 mL/h. Hourly urine output. Renal failure is rare. Maintain fluid restriction until postpartum diuresis. Fluid restriction is inappropriate if there is haemorrhage. Treatment of seizures (eclampsia): Treat a first seizure with 4g magnesium sulfate in 100 mL 0.9% saline IVI over 5min + maintenance IVI of 1g/h for 24h. Beware respiration. If recurrent seizure give 2g IV magnesium sulfate over 5 min. Check tendon reflexes and respiratory rate every 15min. Stop magnesium sulfate IV if respiratory rate patient got HIV inf ( immunocompromised)---> developed TB --> HIV induced dementia The use of plasma-derived factor VIII, before the availability of recombinant products, led to infection with HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) in many haemophiliacs. One case of likely transmission of variant Creutzfeldt-Jakob disease (vCJD) by UK factor VIII concentrates has been reported in an elderly haemophilic patient in the UK. The recent report of a blood test that may be used to detect vCJD has raised the possibility of a new way to identify infected individuals, perhaps even before the onset of clinical symptoms. 1517. An 18yo girl has menorrhagia and dysmenorrhea and requires contraception. What drug will you give her? a. COCP b. Mirena coil c. Copper T d. UAE e. Depo provera Answer: i think it should be B but in key it's A

Menorrhagia+dysmenorrhea------give COCP Acc to nice guidelines the management steps of menorrhagia are: When a first pharmaceutical treatment has proved ineffective then a second pharmaceutical treatment should be considered rather than immediate referral to surgery. If there is iron deficiency it should be corrected with oral iron. First-line treatment This is the levonorgestrel-releasing intrauterine system (IUS) - Mirena®. This is longterm treatment and should be left in situ for at least 12 months. One recent study has shown that women with menorrhagia reported more improvement in bleeding and quality of life with the levonorgestrel-releasing IUS than with other treatments available in primary care. In addition, they were more likely to continue with this treatment. However, the rate of discontinuation of Mirena® treatment has been shown to be relatively high - 16% at 12 months and 28% by 2 years. Second-line treatment This includes tranexamic acid, mefenamic acid or the combined oral contraceptive pill (COCP): Mefenamic acid works by inhibiting prostaglandin synthesis. It reduces menstrual loss by around 25% in three quarters of women and is better tolerated than tranexamic acid. Tranexamic acid is a plasminogen-activator inhibitor. It inhibits the dissolution of thrombosis that leads to menstrual flow. It can reduce flow by up to 50%. It is most effective at reducing menstrual loss associated with IUCDs, fibroids and bleeding diathesis. Other non-steroidal anti-inflammatory drugs (NSAIDs) may also be used. Side-effects include nausea, vomiting and diarrhoea. If there is disturbance in colour vision then it should be discontinued. The COCP suppresses production of gonadotrophins and reduces menstrual blood loss by around 50%. It can improve dysmenorrhoea, lighten periods, regulate the cycle, improve premenstrual symptoms, reduce the risk of PID and protect the ovaries and endometrium against cancer. Third-line treatment This is with norethisterone. The dose is 15 mg daily, from day 5 to 26 (or injected long-acting progestogens). This can result in a significant reduction in menstrual blood loss, although women tend to find the treatment less acceptable than intrauterine levonorgestrel. This regimen of progestogen may have a role in the short-term treatment of menorrhagia. However, there are very limited data regarding the use of progestogens and of oestrogens and progestogens in combination in the treatment of irregular menstrual bleeding associated with anovulation. There is still no consensus about which regimens are the most effective.[9] In secondary care 3-4 months of a gonadotrophin-releasing hormone (GnRH) analogue may be offered before hysterectomy or myomectomy, where the uterus is enlarged or distorted by fibroids. It is also a reasonable choice of therapy if other methods are contra-indicated - but 'add-back' hormone therapy will be needed if continued for >6 months. In the acute situation, a bleeding episode may be so disabling for the woman that treatment with high-dose norethisterone (30 mg daily) needs to be used. This is

continued until bleeding is controlled, but is then tailed off. Surgical options The choice of treatment will depend on both the uterine size and the patient's desire to retain her uterus. 1518. A pt of tuberculous abscess with the hx of prv abscess drainage presented with fever and tenderness between L2/L3 vertebra. Which is the best inv for this pt? a. XR b. CT c. US d. MRI e. Blood culture Answer: D Investigations for pott's disease: MRI scanning may demonstrate the extent of spinal compression and can show changes at an early stage. Bone elements visible within the swelling, or abscesses, are strongly suggestive of Pott's disease rather than malignancy. CT scans and nuclear bone scans can also be used but MRI is best to assess risk to the spinal cord. 1519. A 4yo child presents with repeated chest infections. He has yellow discoloration of sclera and the mother gives a hx of diarrhea as well. What is the single inv most likely to lead to a dx? a. Sweat chloride test b. Anti-endomysial antiboides c. LFT d. Jejunal biopsy e. TFT Answer: A Features of cystic fibrosis: High sodium sweat Primary secretion of sweat duct is normal but CFTR does not absorb chloride ions, which remain in the lumen and prevent sodium absorption. Pancreatic insufficiency Production of pancreatic enzymes is normal but defects in ion transport produce relative dehydration of pancreatic secretions, causing their stagnation in the pancreatic ducts. Biliary disease Defective ion transfer across the bile duct causes reduced movement of water in the lumen so that bile becomes concentrated, causing plugging and local damage. Gastrointestinal disease Low-volume secretions of increased viscosity, changes in fluid movement across both the small and large intestine and dehydrated biliary and pancreatic secretions cause intraluminal water deficiency.

Respiratory disease Dehydration of the airway surfaces reduces mucociliary clearance and favours bacterial colonisation, local bacterial defences are impaired by local salt concentrations and bacterial adherence is increased by changes in cell surface glycoproteins. Increased bacterial colonisation and reduced clearance produce inflammatory lung damage due to an exuberant neutrophilic response involving mediators such as IL8 and neutrophil elastase. 1520. An 82yo woman has been admitted from a nursing home with dense hemiplegia and homonymous hemianopia. She is dysphasic. What vessel is most likely to be involved? a. Ant cerebral artery b. Mid cerebral artery c. Post cerebral artery d. Internal carotid artery e. Post inf cerebellar artery Answer: B Areas supplied by the middle cerebral artery include: The bulk of the lateral surface of the hemisphere; except for the superior inch of the frontal and parietal lobe (anterior cerebral artery), and the inferior part of the temporal lobe. Superior division supplies latero inferior frontal lobe (location of Broca's area i.e. language expression) Inferior division supplies lateral temporal lobe (location of Wernicke's area i.e. language comprehension) Deep branches supply the basal ganglia as well as the internal capsule. Occlusion of the middle cerebral artery results in Middle cerebral artery syndrome, potentially showing the following defects: Paralysis (-plegia) or weakness (-paresis) of the contralateral face and arm (faciobrachial) Sensory loss of the contralateral face and arm. Damage to the dominant hemisphere (usually the left hemisphere) results in aphasia i.e. Broca's or Wernicke's Damage to the non-dominant hemisphere (usually the right hemisphere) results in contralateral neglect syndrome Large MCA infarcts often have déviation conjuguée, a gaze preference towards the side of the lesion, especially during the acute period. Contralateral homonymous hemianopsia is often present. 1521. A pt is dx with SIADH. Choose the appropriate biochemical change. a. Plasma Na+ decrease and urine osmolarity increase b. Plasma Na+ decrease and urine osmolarity decrease c. Plasma Na+ increase and urine osmolarity decrease d. Plasma Na+ increase and urine osmolarity increase Answer: A Syndrome of inappropriate ADH secretion (SIADH)[8][9]

Inappropriate ADH secretion from posterior pituitary or from ectopic source despite low serum osmolality. Major diagnostic features Hyponatraemia. Plasma hypo-osmolality proportional to hyponatraemia. Inappropriately elevated urine osmolality (>100 mOsmol/kg) commonly > plasma osmolarity. Persistent urine [Na+] >40 mmol/L with normal salt intake. Euvolemia. Normal thyroid and adrenal function. Extra features include an elevated ADH level and low blood uric acid level. 1522. A newborn that is electively intubated at birth and is due for surgery 48h after birth. The condition was suspected on antenatal US on CXR. What is the most likely dx? a. CF b. Congenital diaphragmatic hernia c. Congenital cystic adenomatoid malformation d. RDS e. Alpha 1 antitrypsin deficiency Answer: B (Many infants are now diagnosed in utero by ultrasound scan. CXR or ultrasound scan will confirm the diagnosis in a neonate who has not previously been diagnosed.) Congenital diaphragmatic hernia is produced by the failure of the diaphragm to fuse properly during fetal development, allowing the abdominal organs to migrate up into the chest cavity. This results in the two primary problems underpinning congenital diaphragmatic hernias: pulmonary hypertension and pulmonary hypoplasia. This is compounded by dysfunction of the surfactant. Associated diseases, notably cardiac abnormalities, are frequent. Congenital diaphragmatic hernia occurs in 1 in 2,500 births. It accounts for 8% of all major congenital defects. Males are more commonly affected than females with a ratio of 3:2. Right-sided lesions are rare (10-15%) compared with left-sided (85%) as the liver plugs the opening. Right congenital diaphragmatic hernia carries a disproportionately high mortality and morbidity.[4][5] Many cases are now diagnosed prenatally on routine ultrasound scans or scans following the discovery of polyhydramnios in the mother.[7] This allows for detailed planning of the delivery and immediate aftercare of the neonate. Previously undiagnosed cases still occur and these will usually present at or very soon after birth, depending on the severity of the hernia. Signs include: Cyanosis soon after birth. Tachypnoea. Tachycardia. Asymmetry of the chest wall. Absent breath sounds on one side of the chest, usually the left with the heart shifted to the right. Bowel sounds audible over the chest wall. The abdomen possibly feels 'less full' on palpation.

Management: Children born without a prior diagnosis of congenital diaphragmatic hernia, present a paediatric emergency and the initial management must be aimed at reducing the pressure in the chest and increasing oxygenation. If bowel sounds are heard in the chest of a neonate who has respiratory distress, the child should be resuscitated in a 'head up', rather than the more usual 'head down', position. Endotracheal intubation and mechanical ventilation are required for all infants with severe disease who present in the first hours of life. Avoid bag-and-mask ventilation in the delivery room because the stomach and intestines become distended with air and further impair lung function. Passage of an orogastric tube will facilitate location of the stomach on X-ray, as well as permitting decompression of the stomach. Use of surfactant at an early stage may be beneficial. Blood gases should be monitored and an indwelling arterial catheter is advantageous. An indwelling venous catheter will enable administration of drugs (eg, inotropic agents and hypertonic solutions). Surgery consists of replacing the abdominal organs within the abdominal cavity and repairing the diaphragmatic defect. It used to be performed early, in the first 24 hours of life. Some suggest that repair 24 hours after stabilisation is ideal but delays of up to 7 or 10 days are often well tolerated. Many surgeons now prefer to operate when echocardiography has shown normal pulmonary arterial pressures maintained for at least 24 to 48 hours. Therefore, delayed surgical repair is now usual, performed as an elective procedure, and rarely as an out-of-hours procedure.

1523. A 63yo male undergoes abdominal surgery. On Monday morning, 3d post-op, repeat samples confirm serum K+=7.1mmol/l. His ECG shows broad QRS complexes. Which one of the following can be used as an effective tx for this pt’s hyperkalemia? a. Calcium chloride IV b. Calcium gluconate IV c. Insulin subcutaneously d. Furosemide IV Answer: B When arrhythmias occur, or when potassium levels exceed 6.5 mmol/l, emergency lowering of potassium levels is needed. Several agents are used to transiently lower K+ levels. To treat myocardial excitability caused by hyperkalemia, Calcium (calcium chloride or calcium gluconate) increases threshold potential through a mechanism that is still unclear, thus restoring normal gradient between threshold potential and resting membrane potential, which is elevated abnormally in hyperkalemia. Other agents used to shift K in the cells are insulin or salbutamol. They control Hyperkalemia temporarily. 1524. A 25yo man attended in urological OPD has single testis. He was inv and other testis was located in the abdomen. What is the best management plan for this pt? a. Short trial of HCG b. Orchidectomy

c. Orchidopexy d. Reassurance Answer: C (should be B: Before 2 years of life, Orchidopexy may be done. But after that, tissue usually atrophy, if it doesn't, there is a high probability of it developing into a tumour. Some Urologists use 12-18 months to do Orchidopexy in Cryptorchidism, others have 912 months as reference age for pexy.) An undescended testicle (testis) is more common in boys who are born prematurely. Although in the majority of cases the testis descends by the age of 6 months, some boys will need an operation. This is called an orchidopexy. This operation brings the testis down from the tummy (abdomen) into the testes' sac (scrotum). There is an increased risk of infertility and also cancer if the testis remains in the abdomen. 1525. A 56yo male who presented with epilepsy like symptoms has been dx with an intracranial space occupying lesion. He now complains of thirst and mild dehydration. His blood glucose is also increased. What is the single most appropriate immediate tx? a. Insulin b. IV fluids c. Stop dexamethasone d. Stop sodium valproate and change to another anti-epileptic Answer:B Diabetes insipidus is a condition in which your ability to control the balance of water within your body is not working properly. Your kidneys are not able to retain water and this causes you to pass large amounts of urine. Because of this, you become more thirsty and want to drink more. There are two different types of diabetes insipidus: cranial and nephrogenic.Treatment includes drinking plenty of fluids so that you do not become dehydrated. Treatment with medicines may be also needed for both types of diabetes insipidus. 1526. A mother brings her newborn to the hosp concerned about a blue patch on the buttocks. The newborn is of mixed race and was delivered normally. What is the most appropriate management? a. Reassurance b. CBC c. XR d. Plt count Answer: A A Mongolian spot, also known as Mongolian blue spot, congenital dermal melanocytosis,[1] and dermal melanocytosis is a benign, flat, congenital birthmark with wavy borders and irregular shape. It normally disappears three to five years after birth and almost always by puberty.[6] The most common color is blue, although they can be blue-gray, blue-black or even deep brown. 1527. The ECG of a 65yo shows absent P waves, narrow QRS complex, ventricular rate of 120bpm and irregular R-R interval. What is the most probable dx? a. A-fib b. A-flutter c. SVT d. Mobitz type 1 2nd degree heart block

e. Sinus tachycardia Answer: A Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, characterised by irregularly irregular ventricular pulse and loss of association between the cardiac apex beat and radial pulsation. Loss of active ventricular filling is associated with: Stagnation of blood in the atria leading to thrombus formation and a risk of embolism, increasing the risk of stroke. Reduction in cardiac output (especially during exercise) which may lead to heart failure. 1528. The ECG of an 80yo pt of IHD shows sawtooth like waves, QRS complex of 80ms, ventricular rate of 150bpm and regular R-R interval. What is the most probable dx? a. A-fib b. A-flutter c. SVT d. Mobitz type 1 2nd degree heart block e. Sinus tachycardia Answer: B The common form of type I atrial flutter has saw-tooth flutter waves, best seen in leads II, III, and aVF, with atrial rates of 240-340. A 12-lead ECG is gold standard for diagnosis.[4] ATRIAL FLUTTER In Atrial flutter, Pulse may be irregular or regular, but is usually rapid. Arteriovenous conduction is usually 2:1, making the ventricular rate approximately 150 bpm. 1:1 atrioventricular (AV) conduction may lead to haemodynamic collapse. Carotid massage may decrease the ventricular rate 1529. A man brings his wife into the ED after finding her unconscious at home. He says at breakfast time she had complained of sudden severe headache. What is the most appropriate inv? a. MRI b. XR c. CT brain d. Carotid Doppler Answer: C The most characteristic presentation of subarachnoid hemorrhage is a sudden explosive headache. This may last a few seconds or even a fraction of a second. If SAH is suspected, CT scanning (without contrast) is the first line in investigation because of the characteristically hyperdense appearance of blood in the basal cisterns. Every patient in whom SAH is suspected should have a CT scan at the earliest opportunity. This should be done immediately if the patient presents with sudden severe headache and as soon as possible in all other cases. Treatment of SAH: Rebleeding is the most imminent danger; a first aim is therefore occlusion of the aneurysm. Endovascular obliteration by means of platinum spirals (coiling) is now the preferred mode of treatment, but some patients require a direct neurosurgical approach (clipping).

1530. A 68yo lady with T2DM. Which drug should be prescribed? a. Biguanides b. Sulphonyl urea c. Insulin d. Lifestyle modifications Answer: A Pharmacologic Therapy Early initiation of pharmacologic therapy is associated with improved glycemic control and reduced long-term complications in type 2 diabetes. Drug classes used for the treatment of type 2 diabetes include the following: Biguanides Sulfonylureas Meglitinide derivatives Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) Glucagonlike peptide–1 (GLP-1) agonists Dipeptidyl peptidase IV (DPP-4) inhibitors Selective sodium-glucose transporter-2 (SGLT-2) inhibitors Insulins Amylinomimetics Bile acid sequestrants Dopamine agonists Metformin is the only biguanide in clinical use.Metformin lowers basal and postprandial plasma glucose levels. Its mechanisms of action differ from those of other classes of oral antidiabetic agents; metformin works by decreasing hepatic gluconeogenesis production. It also decreases intestinal absorption of glucose and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. Unlike oral sulfonylureas, metformin rarely causes hypoglycemia. 1531. In a laparoscopic mesh repair for hernia, when the trocar is inserted at midpoint between umbilicus and ischial spine. What structure will be pierced? a. Linea alba b. Rectus muscle c. Conjoint tendon d. External and internal oblique muscles e. Inguinal ligament Answer: D Structures in Anterior Abdominal Wall In human anatomy, the layers of the abdominal wall are (from superficial to deep): Skin Subcutaneous tissue Fascia Camper's fascia - fatty superficial layer. Scarpa's fascia - deep fibrous layer. Muscle External oblique muscle Internal oblique muscle

Rectus abdominis Transverse abdominal muscle Pyramidalis muscle Fascia transversalis Peritoneum 1532. A 48yo man has intermittent left sided lower abdominal pain and feels generally unwell. He has lost his appetite and has lost weight. Temp=38.3C and he has BP=190/100mmHg. What is the single inv most likely to lead to dx”? a. Colonoscopy b. Endomysial antibodies c. Fasting serum glucose conc d. TFT e. US abdomen Answer: E Investigations recommended for left iliac fossa pain on patient.co. These should be tailored to the patient's symptoms and the examination findings. In the GP setting there are a number of bedside tests that can be done to aid diagnosis: Dip urine for pus cells, leukocytes and/or nitrites if urinary tract infection (UTI) is suspected. Microscopic haematuria is usually present in ureteric colic. It can also occur in abdominal aortic aneurysm. Perform a pregnancy test if ectopic pregnancy or miscarriage is suspected. If the pain is non-acute and can be managed in the GP setting, further investigations may be requested: Blood tests may include FBC, renal function, LFTs. Vaginal swab tests can help to exclude pelvic infection. Ultrasound scanning can show ovarian or other mass. Referral for further bowel investigations may be necessary - eg, referral under the twoweek wait rule if bowel carcinoma is suspected. 1533. A man with DM comes to the ED after he collapsed at home. His GCS=10. What should be the next initial inv for this man? a. Capillary blood sugar b. MRI head c. CT head d. Serum electrolytes Answer: A Diabetic coma is a reversible form of coma found in people with diabetes mellitus. It is a medical emergency. Three different types of diabetic coma are identified: 1. Severe low blood sugar in a diabetic person 2. Diabetic ketoacidosis advanced enough to result in unconsciousness from a combination of a severely increased blood sugar level, dehydration and shock, and exhaustion 3. Hyperosmolar nonketotic coma in which an extremely high blood sugar level and

dehydration alone are sufficient to cause unconsciousness. A quick look, and a glucose meter to determine the cause of unconsciousness in a patient with diabetes. Laboratory confirmation can usually be obtained in half an hour or less. Other conditions that can cause unconsciousness in a person with diabetes are stroke, uremic encephalopathy, alcohol, drug overdose, head injury, or seizure. 1534. A 60yo DM pt presented with easy fatigability, weakness and numbness of hands and swollen feet. Exam: pedal edema, sensory neuropathy and palpable liver and spleen. Urine: proteinuria. US abdomen: enlarged kidney. Renal biopsy: amorphous homogenous substance that stained red with congo-red. What is the dx? a. DM retinopathy b. Sarcoidosis c. Wilms tumor d. Amyloidosis e. Glycogen storage disease Answer: D (Aggregation of the congo-red dye and binding to amyloid fibrils tends to redshift the absorption spectrum, whereas binding to cellulose fibers has the opposite effect.) Apple-green birefringence of Congo red stained preparates under polarized light is indicative for the presence of amyloid fibrils. Amyloidosis is a rare disease that results from accumulation of inappropriately folded proteins. These misfolded proteins are called amyloids. When proteins that are normally soluble in water fold to become amyloids, they become insoluble and deposit in organs or tissues, disrupting normal function. The type of protein that is misfolded and the organ or tissue in which the misfolded proteins are deposited determines the clinical manifestations of amyloidosis. Amyloid deposition in the kidneys can cause nephrotic syndrome, which results from a reduction in the kidney's ability to filter and hold on to proteins. In AA amyloidosis the kidneys are involved in 91-96% of people,symptoms ranging from protein in the urine to nephrotic syndrome and rarely renal insufficiency. 1535. A 75yo man has urinary symptoms of hesitancy, frequency and nocturia. Rectal exam: large hard prostate. What is the most appropriate inv? a. CA 125 b. CA 153 c. CA 199 d. CEA e. PSA Answer: E Prostate-specific antigen (PSA) Cancer type: Prostate cancer Tissue analyzed: Blood PSA is produced exclusively by epithelial prostatic cells, both benign and malignant. It is also found in the serum. Serum PSA is currently the best method of detecting localised prostatic cancer and monitoring response to treatment but it lacks specificity, as it is also increased in most patients with benign prostatic hyperplasia.

1536. A child suffering from CF developed pneumonia. Which organism is responsible for this pneumonia? a. H. influenza b. Klebsiella c. S. aureus d. S. pneumonia E. Pseudomonas Answer: E Chronic infections in cystic fibrosis,. Thick mucus in the lungs and sinuses provides an ideal breeding ground for bacteria and fungi. People with cystic fibrosis may have frequent bouts of bronchitis or pneumonia Pseudomonas aeruginosa: Typical pneumonia aspiration or inhalation green sputum, abscess formation, Common cause of pneumonia in cystic fibrosis patients and those with severely compromised respiratory defenses. 1537. An obese woman with hx of migraine presented with heavy bleeding during menstruation which is painful and needs contraception too. What is the best possible management for this pt? a. COCP b. Mirena coil c. Copper T d. UAE e. Depo provera Answer: B Management of menorrhagia: First-line treatment This is the levonorgestrel-releasing intrauterine system (IUS) - Mirena®. This is longterm treatment and should be left in situ for at least 12 months.[2] Second-line treatment This includes tranexamic acid, mefenamic acid or the combined oral contraceptive pill (COCP): Mefenamic acid works by inhibiting prostaglandin synthesis. It reduces menstrual loss by around 25% in three quarters of women and is better tolerated than tranexamic acid. Tranexamic acid is a plasminogen-activator inhibitor. It inhibits the dissolution of thrombosis that leads to menstrual flow. It can reduce flow by up to 50%.[8] It is most effective at reducing menstrual loss associated with IUCDs, fibroids and bleeding diathesis. Other non-steroidal anti-inflammatory drugs (NSAIDs) may also be used. Side-effects include nausea, vomiting and diarrhoea. If there is disturbance in colour vision then it should be discontinued. The COCP suppresses production of gonadotrophins and reduces menstrual blood loss by around 50%. It can improve dysmenorrhoea, lighten periods, regulate the cycle, improve premenstrual symptoms, reduce the risk of PID and protect the ovaries and endometrium against cancer. Third-line treatment This is with norethisterone.

The dose is 15 mg daily, from day 5 to 26 (or injected long-acting progestogens). This can result in a significant reduction in menstrual blood loss, although women tend to find the treatment less acceptable than intrauterine levonorgestrel. This regimen of progestogen may have a role in the short-term treatment of menorrhagia. However, there are very limited data regarding the use of progestogens and of oestrogens and progestogens in combination in the treatment of irregular menstrual bleeding associated with anovulation. There is still no consensus about which regimens are the most effective. 1538. A 2yo fell on outstretched hand on playground. He presents with pain on base of the thumb. XR=no fx. What is the single most likely dx? a. Colles fx b. Head of radius c. Mellet finger d. Scaphoid fx e. No fx Answer: D The scaphoid bone is one of the carpal bones in your hand around the area of your wrist. It is the most common carpal bone to break (fracture). A scaphoid fracture is usually caused by a fall on to an outstretched hand. Symptoms can include pain and swelling around the wrist. Diagnosis of a scaphoid fracture can sometimes be difficult, as not all show up on X-rays. Treatment is usually with a cast worn on your arm up to your elbow for 8 to 12 weeks. Sometimes surgery is advised. Correct diagnosis and prompt treatment of a scaphoid fracture can help to reduce complications. 1539. A pt was admitted with increased frequency of passing urine, increased thirst, weakness and muscle cramps. What is the most probable dx? a. Conn’s syndrome b. Cushing’s syndrome c. Pheochromocytoma d. Hyperthyroidism e. Hypoparathyroidism Answer: A Classic presentation of hyperaldosteronism include: Hypertension. Hypokalaemia (usually 2 antihypertensive agents d. Impaired growth hormone response to glucose loading e. Unilateral adrenal enlargement Key is E: Unilateral adrenal enlargement Cushing’s disease Bilateral adrenal hyperplasia from an ACTH secreting pituitary adenoma. Peak age 30-50 years, male female ratio 1:1 A low dose dexamethasone test leads to no change in plasma cortisol but 8 mg may be enough

1658. Which finding, on clinical examination of the pulse, suggests a diagnosis of hypertrophic obstructive cardiomyopathy (HOCM)? a. Irregularly irregular pulse suggesting A-fib b. Pulsusalternans c. Pulsusbigeminus d. Pulsusbisferiens e. Pulsusparadoxus Key is C Pulsusbisferiens pulsusbisferiens, is a sign where, onpalpation of the pulse, a double peak per cardiac cycle can be appreciated. Bisferious means striking twice. Classically, it is detected when aortic insufficiency exists in association with aortic stenosis, but may also be found hypertrophic obstructive cardiomyopathy. Hypertrophic Cardiomyopathy: · Hypertrophic cardiomyopathy (HCM) is an autosomal dominant genetic disorder characterised by left ventricular hypertrophy (LVH), impaired diastolic filling, and abnormalities of the mitral valve. These features can cause dynamic obstruction of the left ventricular outflow tract, diastolic dysfunction, myocardial ischaemia, and an increased risk of supraventricular and ventricular tachyarrhythmias. · HCM is the most common genetic cardiovascular disease. · Epidemiology:The prevalence of HCM is about one in 500 and it tends to affect men and black people more often. The obstructive form is seen in 25% of cases. · Hypertrophy can occur in any part of the left ventricle, although it is most common in the anterior ventricular septum. · The presentation: is variable and includes dyspnoea (the most common presenting symptom), chest pain, palpitations and syncope. · Examination: Classic examination findings are a forceful apex beat, with double impulse(pulsusbisferiens) if the left ventricular outflow tract is obstructed and a late ejection systolic murmur, which can be augmented by standing or Valsalvamanoeuvre and diminished by squatting. · Investigation: Electrocardiogram (ECG): most patients have an abnormal ECG, although electrocardiographic features are nonspecific and include LVH, ST segment changes and T-wave inversion. 1659. A 60yo male is admitted with a 2d hx of lower abdominal pain and marked vomiting. On examination he has abdominal swelling, guarding and numerous audible bowel sounds. What is the likely dx? a. Gallstone ileus b. Ischemic colitis c. Large bowel obstruction d. Sigmoid volvulus e. Small bowel obstruction Key is D: sigmoid volvulus History is not suggestive of ischemic colitis. There are no bowel sounds heard in gallstone ileus, large bowel obstruction and small bowel obstruction, hence it is sigmoid volvulus. Sigmoid Volvulus: [1]

[2]

In sigmoid volvulus, a large sigmoid loop full of faeces and distended with gas twists on its mesenteric pedicle to create a closed-loop obstruction. Risk factors: · The elderly. · Chronic constipation. · Megacolon, large redundant sigmoid colon and excessively mobile colon. · It is more common in men. Presentation: · lower abdominal pain associated with gross abdominal distension and a failure to pass either flatus or stool. · Abdominal examination reveals a tympanitic, distended (but usually nontender) abdomen and a palpable mass may be present. Investigation and Management: · Characterstic Abdominal X-Ray with an inverted U loop of bowel that looks a bit like a coffee bean. · Often managed by sigmoidoscopy and insertion of a flatus tube. Sigmoid colectomy is sometimes required 1660. A 17-year-old boy is diagnosed with scabies. Which of the following statements regarding scabies is correct? a. Is best treated by salicylate emulsion b. It can be spread by a droplet infection c. It causes itchiness in the skin even where there is no obvious lesion to be seen d. It is caused by Staphylococcus aureus e. Typically affects the face Key is C: It causes itchiness in the skin even where there is no obvious lesion to be seen Excluded Points: a. The usual scabies treatment is with permethrin cream. Permethrin is an insecticide that kills the mites b. You need close skin-to-skin contact with an infected person to catch scabies. This is because the scabies mite cannot jump or fly d. Scabies is caused by a mite (like a tiny insect) called Sarcoptesscabiei. The mite is a parasite, meaning it lives off the host (a human) with no benefit to the host e. Itching is often severe and tends to be in one place at first (often the hands) Scabies: · Scabies is caused by a mite (like a tiny insect) called Sarcoptesscabiei. The mite is a parasite, meaning it lives off the host (a human) with no benefit to the host. · Scabies is common. In the UK, about 1 in 1,000 people develop scabies each month. Scabies is more common in town (urban) areas, in women and children, in the winter, and in the North of the country. · The skin-to-skin contact needs to be for a reasonable time to catch the mite. You usually need to be in skin contact for 15-20 minutes to catch scabies. · Scabies symptoms usually take 2-6 weeks to occur after you are first Treatment: Scabies can stay in your skin for ever if not treated. Treatment is needed for: · Anybody who has scabies; AND · All household members, close contacts, and sleeping/sexual partners of the affected person - even if they have no symptoms. This is because it can [2]

·

take up to six weeks to develop symptoms after you become infected. Close contacts may be infected, but have no symptoms, and may pass on the mite. Apply 5% permethrin over whole body including scalp, face (avoid eyes), neck and ears. Do not forget the soles; wash off after 8-12 h, repeat after 7 days.

1661. An anemic young man is found to have a macrocytosis of 90%. The most likely cause is? a. Zieve’s syndrome b. Thalassemia minor c. Chronic renal disease d. IDA e. Folate def f. Chronic liver disease g. HUS h. Cytotoxic chemotherapy i. Phenytoin Ans: Floate Def Zieve's syndrome is an acute metabolic condition that can occur during withdrawal from prolonged alcohol abuse. It is defined byhemolytic anemia (with spur cells and acanthocytes), hyperlipoproteinaemia (excessive blood lipoprotein), jaundice, and abdominal pain.[1] The underlying cause is liver delipidization

1662. An association with HPV is a most characteristic feature of? a. Torus b. Exotosis c. Pleomorphic adenoma d. Verruca vulgaris e. Fibroma f. Epulis fissuratum g. Mucocele h. Pyogenic granuloma i. Parulis j. Ranula Ans.D, it is most commonly associated with warts or verruca vulgaris. Exotosis:benign outgrowth cartilaginous tissue Plemorphic Adenoma: A Locally invasive benign tumor Fibroma: benign tumors composed of fibrous tissue Epulis Fissuratum:benign hyperplasia of fibrous connective tissue which develops as a reactive lesion to chronic mechanical irritation produced by the flange of a poorly fitting denture Mucocele: a benign swelling containing mucin. pyogenic granuloma: Pyogenic granulomata are common benign vascular lesions of the skin and mucosa.a reactive inflammatory mass of blood vessels and a few fibroblasts within the dermis of the skin. Parulis: an elevated nodule at the site of a fistula draining a chronic periapical ABSCESS

Ranula: A ranula is a type of mucocele found on the floor of the mouth 1663. For the following type of surgery what is the most likely agent that may cause post-operative infection -- aorto-iliofemoral reconstruction with a Dacron vascular prosthesis? a. Proteus b. E.coli c. Bacteroides fragilis d. Staphylococcus aureus e. Staphylococcus epidermis f. C.perfringens g. Pseudomonas aeruginosa h. Streptococcus fecalis i. Streptococcus pneumonia j. Brucella melitensis Ans: Staph epidermidis is most common cause of infections in prosthesis. 1664. A primigravida in the 17th week of her symptomless gestation is found, on US, to have evidence of placental tissue covering the cervical os. By the end of her pregnancy she is likely to develop? a. Placental migration b. Uterine myoma c. Uterine rupture d. Choriocarcinoma e. Chorangioma f. Vasa previa g. Subplacental abruption placenta h. Subchorionic abruption placenta i. Placenta accrete j. Placenta previa Ans: A

In 90% of pregnancies, an initial low lying placenta will be pulled upwards by the growing uterus and assume a normal position in the upper segment. This phenomenon is referred to as Migration 1665. An elderly lady with COPD has chronic SOB. She is listed for cataract extraction. What is the anaesthetic of choice? a. Facial nerve block b. Bupivacaine infiltration of the peri-orbital skin c. IV midazolam d. Peribulbar acupuncture

e. Peribulbar lignocaine infiltration f. Topical xylocaine g. IV alfentanil h. Epidural anesthesia i. General anesthesia j. Retrobulbar xylocaine Inj Ans:E

The most used mode of anaesthesia in ophthalmic feild is peribulbar using lingocaine 1666. A 55yo chronic alcoholic with known hepatic cirrhosis has been on a heavy bout of alcohol the night before and was brought home by friends after falling several times in the pub. While being taken up the stairs to his bedroom he falls down the flight of 5 steps but sustains no obvious injuiry. His wife calls the ED the next day because she could not rouse him in the morning. He is brought in in a comatose state and both pupils appear dilated. Skull vault XR appears normal. a. Hepatic encephalopathy b. Intracerebral hematoma c. Brain stem injury d. Extradural hematoma e. Chronic subdural hemorrhage f. Despressed skull fx g. Vertibrobasilar ischemia h. Acute subdural hematoma i. SAH j. Severe migraine attack ANS: H Acute subdural hemotoma, typical history of alcholics, falls and usually debilliated or elderly, hepatic cirrhosis increases coagulopathy and chances for bleed. 1667. A 58yo man complains of nose disfigurement. He has a hx of facial erythema particularly of the cheeks and nose. Papules and pustules have been erupting at intervals over the last 10yrs. He admits to a moderate regular consumption of alcohol. Exam: noted to have rhinophyma. The most likely dx is? a. Eczema b. Herpes simplex c. Epidermolysis bullosa d. Dermatomyositis e. Tinea versicolor f. Pemphigus vulgaris

g. Acne rosacea h. Malignant melanoma i. Psoriasis j. Atopic dermatitis Ans: Acne Rosacea Reason: Acne Rosacea is characterised by recurrent episodes of facial flushing with persistent erythema, telangiectasia, papules and pustules.It is a chronic acneform disorder of the facial pilosebaceous glands with an increased reactivity of capillaries to heat, causing flushing and eventually telangiectasia.Rhinophyma is an enlarged nose associated with rosacea which occurs almost exclusively in men. Management: Reassurance, benign disease, sunscreens, facial massage reduces oedema.avoid topical steroids, avoid astringents. Topical .75% MTZ firstline. Azaleic Acid 15% gel. Oral oxytetracyline, doxycyline or erythromycin. 1% Ivermection cream (better than MTZ) Topical Brimonidine for flushing

1668. A 60yo man who presented with metastatic adenocarcinoma of unknown source. He developed rapidly progressive weakness of his arms and was found to have a deposit of tumour in his cervical spine. This was emergently treated with radiation. He developed considerable nausea and vomiting during his therapy and at the end of the course began to have bloody vomiting. Following rescusitation with 6 units of blood, what is the next test of choice? a. Apt test b. Neck, chest, abdominal XR c. 24h esophageal pH probe test d. CT abdomen e. US abdomen f. MRI abdomen g. Barium swallow h. Angiography i. Nuclear scan j. Endoscopy Ans: Endoscopy Reason: whenever there hemetemesis endoscopy should be carried out immediately if the patients condition allows or it should be delayed till resucitation ,Underlying cause for hemetemesis needs to be sorted out.( High dose radiation is a cause Ulceration and any active bleeders must be treated) 1669. A pt has fine nail pitting, small yellow-brown areas of discoloration in the nailbed involving the nails on both hands. These findings a re commonly associated with? a. Yellow nail syndrome

b. Leukonychia c. Onychomycosis d. Lichen planus e. Pellagra f. Thallium toxicity g. Contact dermatitis h. Zinc deficiency i. Hypoalbuminemia j. Psoriasis Ans: Psoriasis Characteristic nail changes include pitting, discolouration,subungual hyperkeratosis, crumbling of the nail plate, and onycholysis. Oil drop or salmon patch: translucent yellow-red discoloration in the nail bed. Leukonychia: areas of white nail plate due to foci of parakeratosis within the body of the nail plate. 1670. A young man develops nonfluent, effortful speech with dysarthria. He is able to undertsand speech. He fails to repeat the sentence. What would you do next? a. XR skull b. Non-contrast CT brain c. Contrast CT brain d. Contrast MRI optic nerves e. 4-vessel cerebral angiogram f. Single vessel cerebral angiogram g. Cerebral angiography h. MRI frontal lobe i. MRI pituitary gland j. MRI temporal lobe Ans: MRI Frontal lobe (Brocas area) Production (Broca's) dysphasia/aphasia - lesions are located in the left pre-central areas. This is a non-fluent or expressive aphasia since there are deficits in speech production, prosody and syntactic comprehension. Patients will typically exhibit slow and halting speech but with good semantic content. Comprehension is usually good. Unlike Wernicke's aphasia, Broca's patients are aware of their language difficulties. Prosody is the study of the meter of verse. Here it means the rhythm of speech Sensory (Wernicke's) dysphasia/aphasia - lesions are located in the left posterior perisylvian region and primary symptoms are general comprehension deficits, word retrieval deficits and semantic paraphasias. Lesions in this area damage the semantic content of language while leaving the language production function intact. The consequence is a fluent or receptive aphasia in which speech is fluent but lacking in content. Patients lack awareness of their speech difficulties. Semantics is the meaning of words. Semantic paraphrasia is the substitution of a semantically related but incorrect word.

1671. A pt being sedated with fentanyl develops severe respiratory depression. This is best reversed using? a. Ethanol b. Naloxone c. Phyostigmine d. Atropine e. Methylene blue f. Diphenhydramine g. Calcium disodium ethylene diamine tetra-acetic acid h. Deferoxamine mesylate i. Flumazenil j. Folic acid Ans: Naloxone Opioid Antagonist, reverses the effects of fentanyl, though it has to be administeres for a longer period of time due long half life of fentanyl. 1672. A pt presented with the following blood work, MCV: Decreased Serum ferritin: Decreased Total iron binding capacity: Increased Serum iron: Decreased Marrow iron: Absent. What is your dx? a. Thalassemia trait b. Hypoparathyroidism c. Hereditary sideroblastic anemia d. Protein energy malnutrition e. Chronic renal failure f. Anemia of chronic disease g. Acute blood loss h. IDA i. Oral contraceptives j. Megaloblastic anemia H: Iron deficiency Anemia Reason: S/S pallor, koilonychia,angular cheilitis, atrophic glossitis, IN marked Anemia ( Cardiac enlargemnet,Flow Murmurs,ankle oedema and heart failure) Inv: FBC : shows microcytic hypochromic anemia Serum ferrtitin Level reduced, normal 12-15 mcg/L, ( serum ferritin is falsely raised during infections) Anisocytosis and poikilocytosis Total iron binding capacity is increased Treatment: Iron supplememtation with B12 and folic acid 1673. A 20yo prv healthy woman presents with general malaise, severe cough and breathlessness which has not improved with a seven day course of amoxycillin. There is nothing significant to find on examination. The x-ray shows patchy shadowing throughout the lung fields. The blood

film shows clumping of red cells with suggestion of cold agglutinins. a. Mycobacterium avium complex b. Coxiella burnetii c. Escherichia coli (Gram -ve) d. Haemophilus influenza e. Legionella pneumophila f. Strep pneumococcus g. TB h. Mycoplasma pneumonia i. PCP j. Staph aureus Ans: Mycoplasma pneumonia Reason : inablity to respond to a seven day course of amoxicillin suggests atypical pneumonia, patchy shadows throughout lung fields and cold agglutination points towards mycoplasma. M. pneumoniae:[9] Vague and slow-onset history over a few days or weeks of constitutional upset, fever, headache, dry cough with tracheitic ± pleuritic pain, myalgia, malaise and sore throat. This is like many of the common viral illnesses but the persistence and progression of symptoms is what helps to mark it out. In otherwise healthy individuals, it usually resolves spontaneously over a few weeks. The hacking, dry cough can be very persistent. Extra-respiratory features include rashes such as erythema multiforme, erythema nodosum and urticaria; neurological complications like Guillain-Barré syndrome, transverse myelitis, cerebellar ataxia and aseptic meningitis; haematological complications such as cold agglutinin disease and haemolytic anaemia; joint symptoms like arthralgia and arthritis; cardiac complications such as pericarditis and myocarditis; rarely, may cause pancreatitis

TReatment: Macrolides, Fluroquinolones 1674. An 18yo male works in a company where lunches are often catered. One day, the water at the company facility is not working, but they manage to have the lunch anyway. 2wks later, he becomes sick. He develops anorexia, nausea, malaise and jaundice. During the course of the next 4wks, 7 people who shared in the lunch become ill with similar symptoms. After a few wks, each of the 7 people completely recovers and they replace their caterer. What is a likely dx? a. Pancreatic ca b. Hemochromatosis c. Laennec’s cirrhosis d. Hep A

e. HCC f. Rotor’s syndrome g. Primary biliary cirrhosis h. Gilbert’s syndrome i. Hep B j. Hemolysis Ans: Hepatitis A Symptoms of Hepatitis A range from mild nauseas to liver failure (very rare).Spread is normally by the faecal-oral route although there are occasional outbreaks through food sources.Hand washing and good hygiene around food and drink prevent spread of infection.Increasing age is a direct determinant of disease severity. S/S The incubation period is 2-6 weeks with a mean of 4 weeks. There is a prodrome of mild flu-like symptoms (anorexia, nausea, fatigue, malaise and joint pain) preceding the jaundice. Smokers often lose their taste for tobacco. Diarrhoea can occur, particularly in children. This can progress to the icteric phase with:Dark urine (appears first).Pale stools (not always). Jaundice occurring in 70-85% of adults with acute HAV infection. Abdominal pain occurring in 40% of patients. Itch or pruritus. Arthralgias and skin rash.Tender hepatomegaly, splenomegaly, and lymphadenopathy Inv:IgM antibody to HAV is positive with onset of symptoms (usually about 3 to 4 weeks after exposure but up to 6 weeks). The test is sensitive and specific. It remains positive for between 3 and 6 months (up to 12 months). It remains positive in relapsing hepatitis. IgG antibody to HAV appears soon after IgM and persists for many years. In the absence of IgM it indicates past infection or vaccination rather than acute infection. IgG remains detectable for life LFTs Mangement: Supportive, avoid alcohol.

1675. A 35yo 1st time donor suddenly passes out as she is donating blood. Which of the following steps would be least useful in managing this adverse event? a. Ensure donor is adequately hydrated and has not skipped a meal b. Elevating the donor's legs as this is usually due to a vasovagal syncope c. Haemoglobin of the donor meets the minimum requirement for donation d. The donation is usually continued along with simultaneous normal saline infusion e. The donor should be encouraged to mobilise after they have recovered Ans: C Option C has no role after such an event has occured.

1676. An infant is being examined as part of a routine examination. The child can hold its head up and lifts its chest off a table. He has a palmer and rooting reflex as well as a social smile. He is not afraid of strangers. What is the most likely age of this child? a. neonate b. 2 months c. 6 months d. one year e. one and a half years f. two years g. four years h. seven years i. ten years j. fourteen year Ans:6 months Reason : holding head and raising chest upto 90 degrees from a surface while prone (4months) social smile 6 weeks, becomes increasingly socially responsive. palmer and rooting reflexes are primitive reflexes 1677. A mother is concerned because her 1m boy has a swelling in his scrotum. He was born prematurely. On examination the swelling is seen to transilluminate. The likely cause is? a. Lymphogranuloma Venereum b. Testicular Torsion c. Hydrocele d. Epididymitis e. Seminoma f. Mature teratoma g. Varicocele h. Lymphoma i. Orchitis j. Spermatocele Ans: Hydrocele Reason: 1-2% neonates present with congenital hydrocele which disappears by 1-2 years. Spermatoceles:Smooth, extratesticular, spherical cysts in the head of the epididymis are not uncommon in adult men. They are benign and do not usually require treatment.Epididymal cysts usually develop in adults around the age of 40. Epididymal cysts are rare in children and when they occur, usually present around puberty. 1678. A 2m girl has an ante-natal diagnosis of right hydronephrosis. Postnatal serial US exams revealed increasing dilatation of the right pelvicalyceal system. No reflux was demonstrated on a MUCG. Appropriate management should include?

a. Surgical repair b. Intermittent catheterization c. Diuresis renography d. Anticholinergic agents e. Phenylpropanolamine f. Gellhorn pessary g. Biofeedback-assisted behavioral treatment h. Oral Estrogen therapy i. Vaginal Estrogen therapy j. Ring pessary 1679. Jean is a 72yo woman with recurrent bowel cancer following a hemi-colectomy 2y ago. She is known to have both local recurrence and liver mets and her pain has been under control on MST 90mg bd. She has had quite severe pain in the RUQ for the past hour despite having taken her normal dose of MST. You find that she has an enlarged liver which is hard and irregular. There is marked localised tenderness over the right lobe of her liver. Her abdomen is otherwise soft and non-tender and the bowel sounds are normal. She is apyrexial. The tx of choice would be? a. Oral NSAIDs b. TENS c. radio therapy to the liver d. IM diamorphine e. Paracetamol f. Prednisolone g. Physiotherapy h. epidural anaesthetic i. Pitocin j. Aspirin Ans: I/M diamorphine . Pain ladder 1680. Titubation is a feature of disease involving the? a. Cerebellum b. Basal ganglia c. Corpus callosum d. Pons e. Temporal lobe f. Occipital lobe g. Optic chiasma h. 3rd ventricle i. Hypothalamus j. Pituitary gland Ans: Cerebellum titubations mostly occur due to cerebellar lesions.

1681. A 50yo farmer complains of pain in his left arm. Exam: he appears to have a neuropathy affecting isolated nerves in multiple, random areas of his left arm. He also has a palpable purpura and tender nodules on both of his upper and lower limbs. A likely diagnosis is? a. Carpal tunnel syndrome b. Polyarteritis nodosa c. Angina Pectoris d. Gout e. Cellulitis f. Rheumatoid arthritis g. Erysipelas h. Fascitis i. Reiter's Syndrome j. Polymyalgia Rheumatica Ans: PAN PAN is necrotising arteritis of medium or small arteries without glomerulonephritis or vasculitis in arterioles, capillaries, or venules, and not associated with antineutrophil cytoplasmic antibodies (ANCAs).It can affect any organ but, for unknown reasons, it spares the pulmonary and glomerular arteries.

Presentaion:Peripheral nerves and skin are the most frequently affected tissues. PURPURA,LIVEDOID,SUBCUTANEOUS NODULES and NECROTIC ULCERS. Neurologically, MONONEURITIS MULTIPLEX>...involvemnet of CNS,Git,kidneys and heart means higher mortality.RENAL INVOLVEMENT:hypertension,AKI, GIT:necrosis,perforation.Myalgia

Investigations: Hepatitis B surface antigen is positive in 30%.  The p-ANCA test is usually negative in PAN.  There is a prominent acute phase response but this is nonspecific.  FBC shows leukocytosis with raised neutrophils.  Hypergammaglobulinemia occurs in 30%.  Biopsy Arteriography shows aneurysms TREATMENT: Corticosteroids..RELAPSE add Cyclophosphamide.=> Azathioprine useful in maintenance therapy. (IV-Ig) and aspirin are effective in childhood PAN.

1682. A patient with chronic neutropenia develops a chronic cough. A CXR reveals a cavitating intrapulmonary lesion containing a movable rounded ball lesion. A likely dx is? a. Tuberculosis b. Bronchiectasis c. Cystic fibrosis

d. Pulmonary hemosiderosis e. Mitral stenosis f. Aspergillosis g. Wegener’s granulomatosis h. Goodpasture’s syndrome i. Pulmonary embolism j. Non-SCLC Ans: Aspergillosis. mostly affects people with reduced immunity, reduced neutrophil count is also predilection for aspergillosis. five clinical types of Aspergillosis APBA Severe Asthma with fungal sensitization Aspergilloma : (fungal ball in already caivitated space due to TB, Sarcoidosis) Invasive aspergillosis Chronic Necrotizing Pulmonary Aspergillosis. Aspergilloma usually presents with massive hemoptysis, cough and fever are rare, Discovered occasionally in asymptomatic patiets on xray showing a mass in upper lobe surrounded by air border. CT demonstrated fungal structure more accurately. Surgical removal Long term itraconazole therapy Instillation of amphotericin hemoptysis needs to be treated with bronchial artery embolization. 1683. A mother brings her 1yo infant to her pediatrician. She describes that following a common cold her child's voice has become hoarse and has developed a cough that sounds harsh and brassy and was worse at night. Exam: the child was noted to have trouble drawing air into its lungs between coughs and had trouble drawing air into its lungs. There was visible stridor on inhalation. The cause is most likely to be? a. EBV b. Rhinovirus c. Parainfluenza d. Flavivirus e. HIV f. Rotavirus g. CMV h. Kemerovo i. Creutzfeld-Jacob j. Rubella Ans: Parainfuenza Parainfluenza virus causes several respiratory problms, laryngitis, bronchitis, pneumonia and bronchiolitis, A rough barking cough with croup hoarsness and wheezing

labored breathing runny nose, fever, cough decreased appetitie, diarrhea. Investigation: Viral culture of secretions. Treatment: Symptoatic supportive treatment Antibiotics incase of secondary infection. 1684. INR:Normal, APTT:Elevated, Thrombin time:Elevated, Plt count:Normal, Bleeding time: Normal. A likely aetiology is? a. Waldenström's macroglobulinaemia b. Heparin c. Sézary cell leukaemia d. Pelger-Hüet anomaly e. von Willebrand's disease f. Haemophilia g. HIV infection h. DIC i. Acanthocytosis j. Vit K deficiency Ans: Heparin PT-test for extrinsic system INR- 0.9-1.2 (PT Control), Increased INR in warfarin, Vitamin K and liver disease APTT- intrinsic system, increased PTT (Heparin,Haemophillia (Factor 8 affected)) THrombin Time- 10-15 seconds, increased in heparin, increasedd in DIC Bledding Time (normal 7 min) - commonest ccause Von willlbrand disease

1685. An infant has diarrhea for 3d with weight loss from 10 kg to 9 kg. Exam: he is noted to have dry mucous membranes, poor skin turgor, markedly decreased urine output, and tachycardia. His BP=normal and compression-release of the nail beds shows satisfactory refilling. Appropriate treatment would include? a. Plasmapheresis and plasma infusion b. 0.5% Normal Saline c. Lactated Ringer's injection d. Packed cells e. Whole blood f. Platelets g. FFP h. double strength Normal Saline i. 5% dextrose in 0.5N saline

solution j. IV heparin ANS: C 1-5% body weight loos Mild dehydration skin turgor decreassed, mucous membrane dry, urine low, HR raissed, BP normal,perfusion normal,skin colour pale,irritable GIVE ORS 5-10% body weight loss Moderate Dehydration skin turgor decreased,mucous menbrane very dry,urine oligouric,HR raised,BP normal,Perfusion prolonged capilllary refill,skin colour grey, lethargic, GIVE ORS 50-100 mL/kg body weight over 2-4 hours,again starting with 5 mL every 5 minutes. if ors fails then give IV Bolus of 20 ml/kg Isotonic solution. 10-15% body weight loss Severe Dehydration skin turgor poor,m ucous membrane parched,urine anuric,HR raised, Bp Decreased, perfusion prolonged , skin colour mottledd, Comatose. intravenous isotonic fluid boluses (20-60 mL/kg) until perfusion improves.

EXAMPLES OF ISOTONIC SOLUTIONS     

0.9% Saline (aka Normal Saline) Ringer’s Solution Lactated Ringers 5% Dextrose in 0.225% Saline 5% Dextrose in Water (technically, Isotonic, but physiology hypotonic

1686. A 4yo boy has the sudden onset of bone pain. He begins experiencing bleeding of his gums and frequent bloody noses. His mother takes him to his pediatrician. Exam: he is pale and has numerous petechiae over his body, with lymphadenopathy and hepatosplenomegaly. He has WBC=100,000mm and numerous circulating blast cells. He is admitted to the hospital. A bone marrow biopsy=35% blast cells. Which of the following is most likely? a. Mantle cell lymphoma b. Infectious lymphocytosis c. Waldenstrom’s macroglobulinemia d. CML e. CLL f. Burkitt lymphoma g. ALL h. Mycosis fungoides i. Hairy cell leukemia

j. AML 1687. A 63yo male has anal canal carcinoma with no evidence of spread to the pelvic wall, pelvic muscles or lymph nodes. This is typically managed by? a. Resection of the sigmoid colon b. Right hemicolectomy c. Left hemicolectomy d. Transverse colectomy e. Internal sphincterotomy f. CT guided drainage g. Diverticulectomy h. Transverse colostomy i. Chemotherapy and radiatherapy j. Abdominal perineal resection 1688. A 2m baby develops a life-threatening anemia. Blood tests show a normal serum iron, ferritin and TIBC. Hemoglobin electrophoresis reveals a markedly decreased Hemoglobin A content and an increased hemoglobin F content. This baby's anemia is likely to be secondary to? a. Failure of alpha chain production b. Failure of beta chain production c. Deficiency of B12 d. Lead poisoning e. IDA f. Presence of hemoglobin S g. Presence of hemoglobin M h. Deficiency of folate i. Bone marrow failure j. Inability to manufacture heme 1689. A 30yo caucasian man presented with a 2wk hx of gradually worsening vision in his left eye. The patient had been seen once by a neurologist 2yrs prv for flashes. At that time a head CT was normal. The patient was lost to follow up with the neurologist, but the flashes had continued for the 2yr period. The patient did not experience visual changes with activity or movement. The patient reported continued decreasing vision. Goldmann visual fields were done and showed a central scotoma. A MRI was done at this time and showed inflammation of the left optic nerve. A likely diagnosis is? a. Pseudotumor b. Orbital teratoma c. Optic neuritis d. Sarcoidosis e. Optic glioma f. Lymphangioma g. Rhabdomyosarcoma

h. Retinal vascular shunts i. Retinoblastoma j. Mucormycosis 1690. A pregnant woman in an early stage of labour expresses the wish to have pain relief during labour. The anesthetist describes that if the patient wishes he can use medication as a local anesthetic to block the pain sensations of labour. Into which space should the local anaesthetic be normally injected? a. Anterior pararenal space b. Aryepiglottic space c. Vestibule space d. Epidural space e. Sub-arachnoid space f. Space of Disse g. Middle ear h. Posterior pararenal space i. Supraglottic space j. Lesser sac 1691. A 29yo Afro-Caribbean man presents with a non-productive cough mild aches in the ankles. The symptoms have been present for 2m. His ESR is elevated. Ca: 2.69 mmol/l; PO43-: 1.20 mmol/l; ALP: 80 iu/L. Serum 25(OH) D: 180 nmol/l. Normal values for Calcium: 2.12-2.65mmol/l; Phosphate: 0.8-1.45mmol/l; ALP 30300iu/L; Serum 25(OH) D: 20-105nmol/l; Urea: 2.5-6.7mmol/l; Creatinine: 70-120μmol/l a. Osteoporosis b. Thiazide diuretics c. Skeletal metastases d. Primary hyperparathyroidism e. Hypoparathyroidism f. Osteomalacia g. Multiple myeloma h. Paget's disease of bone i. Sarcoidosis j. Hyperthyroidism 1692. A 22yo has had recent chickenpox. He now presents with confusion. He is noted to have low urine output and large petechiae all over his body. CXR: a large patch of consolidation is seen. The management of choice should be : a. Ventilatory support b. Open surgical debridement c. Resection of superficial petechiae with wide margin d. Booster vaccine e. TENS f. Lontophoresis g. Nephrostomy h. Oral Corticosteroids

i. Brivudin j. IV acyclovir 1693. A young girl with a psychiatric hx on med tx is brought to the dermatologist by her mother because of recurrent patchy hair loss. Exam: the hair shafts revealed twisting and fractures. This suggests the following pathology: a. Infection with Trichophyton tonsurans b. Infection with Microsporum canis c. Alopecia areata d. Telogen Effluvium e. Androgenetic Alopecia f. Lichen planus g. Traction Alopecia h. Alopecia totalis i. Trichorrhexis nodosa j. Trichotillomania 1694. Syphilis typically causes a. Lymphogranuloma Venereum b. Testicular Torsion c. Hydrocele d. Epididymitis e. Seminoma f. Mature teratoma g. Varicocele h. Lymphoma i. Orchitis j. Spermatocele 1695. A middle aged woman has severe collapse of the right femoral head requiring replacement. The removed femoral head is sent for pathology and is found to contain enlarged fat cells. The pathologist explains that this is the likely cause of the patient's femoral head collapse. A likely aetiology is a. Septic emboli b. Impaired venous drainage c. Hgb SS disease d. Steroid use e. Alcoholism f. Gaucher's disease g. missed fracture h. Cushing's disease i. Radiation j. Vasculitis 1696. A 7yo boy with frequent episodic asthma is on tx with sodium cromoglycate. His physician wants to add a non-steroid preventer. The mother of the boy, a teacher, has just read about a nonsteroidal

medication which acts on the mast cells, stopping them from releasing harmful chemicals. Her physician agrees to add this medication to the boy's drug regimen. Which medication is the physician most likely to add to the boy's treatment? a. Inhaled short acting bronchodilator b. SC adrenaline c. Nedocromil Sodium d. Inhaled long acting bronchodilator e. Inhaled sodium cromoglycate f. Inhaled steroids g. Inhaled SABA h. Oral steroids i. Nebulised bronchodilators j. Oral theophylline key)C Investigations for asthma Spirometry: FEV1:FVC ratio, A low value indicates that you have narrowed airways which are typical in asthma Therefore, spirometry may be repeated after treatment. An improvement in the value after treatment with a bronchodilator to open up the airways is typical of asthma. PEFR:morning readings are usualy lower than evening readings in asthmatics

1697. A 3yo boy is playing with his brother when he falls. He cries immediately and refuses to walk. His mother carries him to hospital. He had a full term NVD with no neonatal complications. His immunisations are up to date. Exam: looks well and well-nourished, no dysmorphic features. He has slight swelling, warmth and discomfort on the lower 1/3 of the left tibia, and refuses to weight bear. AP and lateral x rays of the tibia are normal. What is the most likely dx? a. Ankle fx b. Ankle sprain c. Fibular fx

d. Knee dislocation e. Tibial fx

Key)E Ans)Toddler's fracture  Undisplaced spiral fractures of the tibial shaft in children under 7 years old often follow minimal trauma and may not be visible on initial Xray.[8]  Can be difficult to diagnose but should be suspected whenever a child presents with a limp or fails to bear weight on the leg.  Treatment consists of immobilisation for a few weeks to protect the limb and to relieve pain.  Subperiosteal bone formation is usually apparent on X-rays by two weeks. 1698. Which one of the following electrocardiographic changes is found in hypercalcaemia? a. Increased QRS interval b. Prolonged Q-T interval c. Short P-R interval d. Short Q-T interval key)D Ans)Fact 1699. An elderly male pt with prior hx of hematemesis is having hx of long term use of aspirin and other drugs, now presents with severe epigastric pain, dysphagia and vomiting. He was connected to vital monitors which were not reassuring. What is the management? a. Oral antacids b. IV PPI c. Oral PPI d. Endoscopy e. Analgesia key)D Ans) long term use of an nsaid predisposes to peptic ulcers. the symptoms described are of a possibly perforated peptic ulcer or acute upper Gi bleed caused by the ulcer. The guidelines suggest that Endoscopy is the primary diagnostic investigation in patients with acute UGIB  

Endoscopy should be undertaken immediately after resuscitation for unstable patients with severe acute UGIB. Endoscopy should be undertaken within 24 hours of admission for all other patients with UGIB.

1700. A 68yo man presents with bruising and hx of falls. He is found to have a mask-like face, pillrolling tremor and shuffling gait. EEG=normal. Which of the following conditions is he most likely

being treated for? a. HTN b. DM c. Psychosis d. TIA e. Complex partial seizure key) C Ans) features are classic for parkinson’s disease. and people with PD usualy go on to develop parkinson related dementia or psychosis. Symptoms of Parkinsons:  Slowness of movement (bradykinesia). For example, it may become more of an effort to walk or to get up out of a chair. This is a 'shuffling' walk with some difficulty in starting, stopping, and turning easily.  Stiffness of muscles (rigidity), and muscles may feel more tense. Also, your arms do not tend to swing as much when you walk.  Shaking (tremor) is common, but does not always occur. It typically affects the fingers, thumbs, hands, and arms, but can affect other parts of the body. It is most noticeable when you are resting. It may become worse when you are anxious or emotional. It tends to become less when you use your hand to do something such as picking up an object. it is diagnosed clinically and treatment includes 1. 2. 3. 4.

levodopa plus a dopa decarboxylase inhibitor dopamine agonists anticholinergics (tremor) MAO inhibitors