Dr. Khalid's Explanation of 1700 MCQ PDF

1700 files explained by Dr. Khalid Saifullah (Question 1 to question 1707) 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 Ans. The key is B. Flexible cystoscopy. [Painless hematuria in an elderly (here 65 years old man) indicates carcinoma bladder for which flexible cystoscopy is done. Here BEP is not advanced to cause hemorrhage. There is mild enlargement of prostate and mild symptoms of prostration and hemorrhage is unlikely at this initial stage of BEP which makes Bladder cancer as the likely cause of painless hematuria. It is also less likely to be prostate cancer as symptoms of prostration are mild (indicates disease is not advanced) and no constitutional or other features suggesting cancer and moreover bleeding in cancer prostate is much more less common]. 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 Ans. The key is C. Ectopic ACTH. [The patient is smoker and probably developed squamous cell lung cancer which is working as a tumour producing ectopic ACTH causing pigmentation. Resulting raised cortisole is leading to diabetes and hypokalemia]. 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 Ans. The key is B. TFT. [The patient has paroxysmal atrial fibrillation That is why there is no arrhythmia in between attacks. From the given option TFT is the appropriate test as thyrotoxycosis is a leading cause of paroxysmal atrial fibrillation and this ladies weight loss also makes thyrotoxycosis as the probable cause here]. 4. A 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 Ans. The key is B. Prostate Carcinoma. Explanation for 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 are constitutional features of carcinoma prostate 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. ***There are some suggestion that Renal Failure may be the cause of hypocalcemia. 5. A 64yo man has recently suffered from an 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. [Among SSRIs Sertraline is the drug of choice for ischemic heart disease. Next choice is citalopram (as it is often related to torsades de pointes). If SSRI cannot be used Mirtazapine is recommended as next antidepressant]. 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 Ans. The key is D. Medulla. [The name of the condition is “Lateral medullary syndrome” [ipsilateral Horner syndrome and contralateral loss of pain and temperature sense]. 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. [Dysphagia for both solid and liquid or prominently liquid suggest achalasia where dysphagia to solid suggest stricture.also gross dilatation of oesophagus with smooth narrowing at lower end is seen in achalasia. In achalasia dysphagia is usually described as progressive]. 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 harmonically active tumour. [Ectopic ACTH secreting tumour causes hypernatremia and body's homeostatic mechanism try to lower the level of high sodium and do a lesser degree though sodium remains in hypernatremic level or even it may be normal (this question does not mention any preoperative hypernatremia). Removal of that tumour results in negative sodium balance for time being which results hyponatremia while gradually it tends to rise again to normal level]. 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. [Injections with low molecular weight heparin (LMWH) are usually used to treat pregnant women with DVT. LMWH is an anticoagulant, which means it prevents the blood clot getting bigger. It does not affect the developing baby (www.nhs.uk)]. 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 Ans. The likely key is A. Joint aspiration for cytology and culture and sensitivity. [Any chronically arthritic joint is predisposed to infection. Moreover chronic use of steroid in Rh. arthritis is one of the important predisposing factor. In this age group likely organism is Staphylococcus. In younger age group Neisseria gonorrhea is more common]. 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 Ans. The key is D. Prostate carcinoma. [Age, nocturia, urgency and dribbling points towards prostate pathology. Pain of lower back and hip points towards bony metastases from prostate cancer. Blood test for PSA; Prostate biopsy; MRI [if initial biopsy is negative, to decide repeat biopsy. 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 peri-orbital 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 Ans. The key is A. Shingles. [Here ophthalmic division of trigeminal nerve is involved. Typically shingles are unilateral]. 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 Ans. The key is C. LFT. [A case of autoimmune hepatitis. Autoimmune hepatitis is an uncommon cause of chronic hepatitis which if untreated can lead to cirrhosis. However with treatment outlook is very good. Smooth muscle antibody is positive in autoimmune hepatitis. Definitive investigation is liver biopsy. Treated with steroid [start with high dose prednisolone]. Azathioprine is commonly added with steroid to reduce its dose as steroid has more side effects than azathioprine]. 14. A 5yo with recurrent chest pain, finger clubbing with offensive stool. Choose the single most likely inv? a. Endomyseal/Alpha glidin antibody b. Sweat test c. Barium meal d. ECG e. Glucose tolerance test Ans. The key is B. Sweat test. [Recurrent chest pain from frequent lung infections including pneumonia or bronchitis."Clubbing" of the fingers is a classic features of Cystic Fibrosis, although not present in many patients. The digestive enzymes are not being produced, food is not adequately digested (malabsorption) and excess fat and protein is lost in the stools, making them bulky, oily, smelly and difficult to flush away]. 15. A clinical picture of breast cancer originated from the mammary duct. Biopsy was done ad there were neoplastic cells found. Choose the histological picture of the cancer. a. Neoplastic cells are arranged in small clusters occupying a space between collagen bundles (Seirrhous carcinoma) b. Spindle cell neoplasms with margins, which infiltrate adjacent structure, fat invaded (Breast sarcoma) c. Small cells with round nucleus and scant indistinct cytoplasm (Lobular carcinoma) Ans. The key is C. Small cells with round nucleus and scant indistinct cytoplasm (Lobular carcinoma) 16. A 22yo man has a reduced conscious level and a fixed dilated pupil after being involved in a MVC. Choose the single most appropriate option? a. Facial nerve b. Oculomotor nerve c. Olfactory nerve d. Optic nerve e. Trigeminal nerve Ans. The key is B. Oculomotor nerve. [3rd nerve damage can cause fixed dilated pupil]. 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. The key is D. Universal prevention application protocol. 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 Ans. The key is D. All family members should be given rifampicin prophylaxis. [Meningococcal disease. Diagnosis is done with blood or CSF PCR. Initial prehospital management: Benzyl penicillin or cefotaxime]. 19. A 47yo man has a temp of 39C and is delirious. He has developed blisters mainly on his trunk, which appeared a few hours ago. He is well and not on any medications. He last travelled 5 months ago to Italy. Which of the following is the most likely dx? a. Shingles b. Chicken pox c. Pemphigoid d. Bullous pemphigus Ans. The key is B. Chicken pox. [Adults more commonly develop a more generalized brain inflammation ("encephalitis") whose symptoms may include delirium and seizures. Incubation period of chicken-pox is 10-21 days. So this travel history is not significant]. 20. A 64yo pt has been having freq episodes of secretory diarrhea, which is extremely watery, with large amts of mucus. A dx of villous adenoma was made after endoscopy. What electrolyte abnormality is most likely in this pt? a. Hyperkalemia b. Hypernatremia c. Hyponatremia d. Hypokalemia 21. A pt with an acute gout attack came to the ED. What drug should be given to relieve symptoms? a. NSAIDs b. Allopurinol c. Ibuprofen Ans. The key is A. NSAIDs. [Oral NSAIDs commenced immediately and continue for 1 – 2 weeks; Colchicine can be effective alternative but is slower to work than NSAIDs. Intra articular corticosteroids are highly effective in acute gouty monoarthritis. 22. A pt was lying down on the operating table in a position with his arms hanging down for 3 hours. Soon after he woke up, he complains of numbness and weakness in that hand and has limited wrist movement/wrist drop and sensory loss over dorsum of that hand, weakness of extension of the fingers and loss of sensation at the web of the thumb. What structure is likely to be damaged? a. Radial nerve b. Median nerve c. Ulnar nerve d. Axillary nerve e. Suprascapular nerve Ans. The key is A. Radial nerve. [Here arm hanging down compressing the radial nerve at the spiral groove is the cause of given scenario]. 23. A pt who was previously on 120mg slow release oral morphine has had his dose increased to 200mg. He is still in significant pain. He complains of drowsiness and constipation. What is the next step in the management? a. Increase slow release morphine dose b. Fentanyl patch c. Replace morphine with oral hydromorphone d. Replace morphine with oxycodone e. Subcutaneous morphine Ans. The key is D. Replace morphine with oxycodone. 24. A 40yo woman notices increasing lower abdominal distention with little/no pain. On examination, a lobulated cystic mass is felt and it seems to be arising from the pelvis. What is the most appropriate inv? a. CA 125 b. CA 153 c. CA 199 d. CEA e. AFP Ans. The key is A. CA 125. [Ovarian ca is the likely diagnosis for which tumour marker is CA 125]. 25. A resident of a nursing home presented with rashes in his finger webs and also on his abdomen, with complaints of itching which is severe at night. He was dx with scabies. What the best tx for his condition? a. 0.5% permethrin b. Doxycycline c. 5% permethrin d. Reassure e. Acyclovir Ans. The key is C. 5% permethrin. [Scabies outbreaks in nursing homes and cases of crusted scabies may require combination therapy consisting of topical application of permethrin and 2 oral doses of ivermectin at 200 mcg/kg (administered 1 wk apart)]. 26. A 34yo alcoholic is found passed out in front of a local pub. The ambulance crew informs you that he was sweating when they found him and there were cans of cider lying empty around him. What is the initial stage of inv? a. Capillary blood sugar b. CT head c. MRI head d. ABG e. MCV Ans. The key is A. Capillary blood sugar. [Alcohol induced hypoglycemia can present as this case]. 27. A young boy fell on his outstretched hand and has presented with pain around the elbow. He has absent radial pulse on the affected hand. What is the most likely dx? a. Dislocated elbow b. Angulated supracondylar fx c. Undisplaced fx of radial head d. Posterior dislocation of shoulder Ans. The key is B. Angulated supracondyllar fx. [Damage or occlusion of the bracheal artery is the cause of absent radial pulse. Often closed reduction results in restoration of normal anatomy and correction of occlusion of bracheal artery and establishes circulation again but in few instances open reduction is required to fix the occluded artery]. 28. A 65yo woman presented with transient arm and leg weakness as well as a sudden loss of vision in the left eye. Her symptoms resolved within the next couple of hours. What is the most appropriate next inv? a. CT brain b. Echo c. Doppler USG d. Arteriography e. 24h ECG Ans. The key is c. [A case of TIA. Probable cause carotid artery narrowing. Treated with Aspirin 300 mg daily for 2 weeks then clopidogrel 75 mg daily [newer recommendation (OHCM 9th edition, page 480]. 29. A man complains of loss of sensation in his little and ring finger. Which nerve is most likely to be involved? a. Median nerve b. Ulnar nerve c. Radial nerve d. Long thoracic nerve e. Axillary nerve Ans. The key is B. Ulner nerve. [Compression of ulner nerve at the elbow, known as cubital tunnel syndrome, causes numbness in the 5th (pinky) finger, along the half (lengthwise) of the 4th (ring) finger closest to the 5th finger, and the back half of the hand over the 5th finger]. 30. A young man complains of double vision on seeing to the right. Which nerve is most likely to be involved? a. Left abducens b. Right abducens c. Left trochlear d. Right trochlear e. Right oculomotor Ans. The key is B. Right abducens. [Diplopia on seeing to right indicates right lateral rectus palsy which is supplied by right abducent nerve]. 31. A 45yo man keeps having intrusive thoughts about having dirt under the bed. He can’t keep himself from thinking about these thoughts. If he tries to resist, he starts having palpitations. What is the most likely dx? a. OC personality b. OCD c. Schizophrenia d. Panic disorder e. Phobia Ans. The key is B. [Here patients thoughts are obsession and though no compulsive act is described (like repeated cleansing of dirt) but his nature of thought like inability to resist the thinking or getting palpitation on trying to avoid thinking can be regarded as compulsion of thought. CBT 1st line. SSRIs]. 32. A 33yo man presents with an itchy scaly annular rash on his thigh after a walk in the park. Which of the following drugs will treat his condition? a. Erythromycin b. Doxycycline c. Penicillin d. Amoxicillin Ans. The key is B. Doxycycline. [Itchy scaly annular rash after a walk in the park indicates erythema migrans caused by the spirochete Borrelia Burgdorferi transmitted by bite of pinhead-sized ixodes ticks leading to lyme disease]. 33. A pt with cerebral mets has polyuria and polydipsia. What part of the brain would be affected? a. Cerebral cortex b. Cerebellum c. Diencephalon d. Pons e. Medulla Ans. The key is C. Diencephalon. [Diencephalon is the caudal (posterior) part of the forebrain, containing the epithalamus, thalamus, hypothalamus, and ventral thalamus and the third ventricle. Hypothalamus produce ADH and hens lesion of diencephalon (hypothalsamus) may produce cranial diabetes insipidus. 34. A 32yo man presented with painless hematuria. He is hypertensive but the rest of the exam is unremarkable. What is the most likely dx? a. Polycystic kidneys b. Ca bladder c. Ca prostate d. TTP e. HUS Ans. The key is A. Polycystic kidneys. [Painless haematuria at an younger age with hypertension is suggestive of polycystic kidney disease. Renal ultrasound is used to diagnose the condition]. 35. A 45yo female complains of pain in the inner side of her right thigh. She was dx with benign ovarian mass on the right. Which nerve is responsible for this pain? a. Femoral nerve b. Obturator nerve c. Iliohypogastric nerve d. Ovarian branch of splanchic nerve e. Pudendal nerve Ans. The key is B. [The Obturator nerve is responsible for the sensory innervation of the skin of the medial aspect of the thigh]. 36. A 37yo lady strongly believes that a famous politician has been sending her flowers every day and is in love with her. However, this is not the case. What is the most likely dx? a. Erotomania b. Pyromania c. Kleptomania d. Trichotillomania e. Grandiosity Ans. 1. The key is A. Erotomania. [Erotomania is a type of delusion in which the affected person believes that another person, usually a stranger, high-status or famous person, is in love with them]. Pyromania is an impulse control disorder in which individuals repeatedly fail to resist impulses to deliberately start fires, in order to relieve tension or for instant gratification. Kleptomania is the inability to refrain from the urge to steal items. Trichotillomania is an impulse disorder characterized by the compulsive urge to pull out one's hair, leading to noticeable hair loss and balding. Grandiosity refers to an unrealistic sense of superiority. 37. A 3yo child has been brought with facial lacerations. On examination he has some cuts over his right cheek and under the eye. The GCS on initial evaluation is 15. What is the appropriate next inv? a. Skull XR b. Facial XR c. CT scan d. MRI e. Observation Ans. The key is B. Facial X-ray. [Normal GCS makes intracranial lesion less likely. As there is facial injury to exclude any facial bone fracture we can do facial X-ray]. 38. A 73yo woman has lymphadenopathy and splenomegaly. She feels well but has had recurrent chest infections recently. Choose the single most likely blood film findings? a. Atypical lymphocytes b. Excess of mature lymphocytes c. Plasma cells d. Multiple immature granulocytes with blast cells e. Numerous blast cells Ans. The key is B. Excess of mature lymphocytes. [Dx is CLL. Age of patient (usually above 50 yrs), lymhadenopathy and splenomegaly, appearance of lymphocytes (mature lymphocytes – but functionally not normal). Repeated chest infection points towards abnormal function of lymphocytes against infection. 39. A lady presents with itching around the breast and greenish foul smelling discharge from the nipple. She had a similar episode before. What is the most likely dx? a. Duct papilloma b. Duct ectasia c. Breast abscess d. Periductal mastitis e. Mammary duct fistula Ans. The key is B. Duct ectasia. [Duct ectasia of the breast or mammary duct ectasia or plasma cell mastitis is a condition in which the lactiferous duct becomes blocked or clogged.This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age]. 40. A young male whose sclera was noted to be yellow by his colleagues has a hx of taking OTC drugs for some pain. Tests showed raised bilirubin, ALT and AST normal. The provocation test with IV nicotinic acid is positive and produces further rise in the serum bilirubin levels. What is the most likely dx? a. Acute hepatitis b. Drug hypersensitivity c. Gilberts syndrome d. Acute pancreatitis Ans. The key is C. Gilbert’s syndrome. [Only bilirubin is increased but not the liver enzymes. Also positive nicotinic acid provocation test is in its favour]. 41.A 24yo biker has been rescued after being trapped under rocks for almost 12h. He complains of reddish brown urine. His creatinine is 350umol/L and his urea is 15mmol/L. What is the most imp step in the management of this patient? a. Dialysis b. IV NS c. IV dextrose d. IV KCl e. Pain relief Ans. Key is B. IV NS. [It is a case of rhabdomyolysis which is initially treated with IV NS]. 42. A 74yo man who has been a smoker since he was 20 has recently been dx with SCLC. What serum electrolyte picture will confirm the presence of SIADH? a. High serum Na, low serum osmolarity, high urine osmolarity b. Low serum Na, low serum osmolarity, high urine osmolarity c. Low serum Na, high serum osmolarity, high urine osmolarity d. High serum Na, low serum osmolarity, low urine osmolarity e. High serum Na, high serum osmolarity, low urine osmolarity Ans.. The key is B. Low serum Na, low serum osmolarity, high urine osmolarity. 43. A man brought into the ED after being stabbed in the chest. Chest is bilaterally clear with muffled heart sounds. BP is 60/nil. Pulse is 120bpm. JVP raised. What is the most likely dx? a. Pulmonary embolism b. Cardiac tamponade c. Pericardial effusion d. Hemothorax e. Pneumothorax Ans. The key is B. Cardiac tamponade. [chest is clear, so there is no pneumothorax or pleural effusion. Muffled heart sound is due to fluid in pericardial space, low BP from reduced chamber expansion due to pericardial fluid’s pressure and restricted right heart expansion causes raised JVP]. 44. A 50yo pt is admitted for elective herniorraphy. Which of the following options will lead to a postponement of the operation? a. SBP 110mmHg b. MI 2 months ago c. Hgb 12g/dl d. Pain around hernia e. Abdominal distention Ans. The key is B. MI 2 months ago. [After MI elective surgery should not be done before 6 months post MI, as operation in earlier than this time has significant increase in mortality]. 45. A 32yo woman of 39wks gestation attends the antenatal day unit feeling very unwell with sudden onset of epigastric pain associated with nausea and vomiting. Her temp is 36.7C. Exam: she is found to have RUQ tenderness. Her blood results show mild anemia, low platelets, elevated liver enzymes and hemolysis. What is the most likely dx? a. Acute fatty liver of pregnancy b. Acute pyelonephritis c. Cholecystitis d. HELLP syndrome e. Acute hepatitis Ans. The key is D. HELLP syndrome. [The main treatment is to deliver the baby as soon as possible [as early as after 34 weeks if multisystem disease is present]. 46. A woman comes with an ulcerated lesion 3 cm in the labia majorum. What is the lymphatic drainage of this area? a. External iliac b. Superficial inguinal LN c. Para-aortic d. Iliac e. Aortic Ans. Key is B. Superficial inguinal LN. 47. A man post-cholecystectomy presented with jaundice, fever and dark urine. What is the most diagnostic inv? a. ERCP b. USG Abdomen c. CT Scan d. MRCP e. MRI Ans. The key is A. ERCP [Post operative US will not give good results. We shall not go for ercp first as it has complications like pancreatitis. Acceptable options are CT, MRI and MRCP among which most easiest and less time consuming but with very good test result is CT scan. So CT is most appropriate! But as the Question wants most diagnostic it is ERCP (though not practical)!!! The diagnosis here is choledocolithiasis with cholangitis]. 48. A 79yo stumbled and sustained a minor head injury 2 weeks ago. He has become increasingly confused, drowsy and unsteady. He has a GCS of 13. He takes warfarin for Afib. What is the most likely dx? a. Extradural hemorrhage b. Cerebellar hemorrhage c. Epidural hemorrhage d. Subdural hemorrhage e. Subarachnoid hemorrhage Ans. 1. The key is D. Subdural hematoma. [In elderly head injury usually leads to subdural hematoma even if head injury is minor or trivial and extradural hematoma in elderly is extremely uncommon even in more severe head injury. Management: 1st line: Evacuation by barr hole craniostomy. 2nd line: Craniotomy if the clot is organized]. 49. A 25yo female complains of intermittent pain in her fingers. She describes episodes of numbness and burning of the fingers. She wears gloves whenever she leaves the house. What is the most probable dx? a. Kawasaki disease b. Takayasu arteritis c. Buerger’s disease d. Embolism e. Raynaud’s phenomenon Ans. The key is E. Raynaud’s phenomenon. [Intermittent nature points towards some triggers and wearing of gloves during going out indicates cold weather. Also female sex makes the diagnosis of Raynaud’s phenomenon more likely]. 50. A 22yo lady has been unwell for some time. She came to the hospital with complaints of fever and painful vesicles in her left hear. What is the most probable dx? a. Acne b. Herpes zoster c. Chicken pox d. Insect bite e. Cellulitis Ans. The key is B. Herpes Zoster. [This is a case of Herpes zoster oticus and if facial nerve is also involved then it is called Ramsay Hunt syndrome]. 51. A 5yo girl had earache and some yellowish foul smelling discharge, perforation at the attic and conductive hearing loss. She has no past hx of any ear infections. What is the most appropriate dx? a. Acute OM b. OM with effusion c. Acquired cholesteatoma d. Congenital cholesteatoma e. Otitis externa Ans. The key is c. Acquired cholesteatoma. [Acquired cholesteatomas develop as a result of chronic middle ear infection and are usually associated with perforation of the tympanic membrane at the attic (mass is seen in attick with perforation at pars flaccida- in contrast to medial to tympanic membrane which is in congenital). Clinical presentation usually consists of conductive hearing loss, often with purulent discharge from the ear]. In congenital: mass medial to the tympanic membrane normal tympanic membrane no previous history of ear discharge, perforation or ear surgery. [discrepancy like no previous infection is the only point in favour of congenital here and may be due to a bad recall!!!] 52. A female with T1DM would like to know about a deficiency of vitamins in pregnancy that can be harmful. A deficiency of which vitamin can lead to teratogenic effects in the child? a. Folic acid b. Vit B12 c. Thiamine d. Riboflavine. e. Pyridoxine Ans. The key is A. Folic acid. [Frequently associated with neural tube defect]. 53. A 23yo woman has been having pain at the base of her thumb, the pain is reproduced when lifting her 3 month old baby or changing diapers and also with forceful abduction of the thumb against resistance. What is the likely cause? a. Avascular necrosis of scaphoid b. Trigger finger. c. De Quervain’s tenosynovitis Ans. The key is c. De Quervain’s tenosiovitis. [Can be diagnosed by Finkelstein’s test: The physician grasps the thumb and the hand is ulnar deviated sharply. If sharp pain occurs along the distal radius (top of forearm, about an inch below the wrist), de Quervain's syndrome is likely]. 54. A 6m child presents with fever and cough. His mother has rushed him to the ED asking for help. Exam: temp=39C and the child is feeding poorly. Dx? a. Bronchiolitis b. Asthma c. Bronchitis Ans. The key is A. Bronchiolitis. [Management: 1. Oxygen inhalation 2. Nasogastric feeding. DON’T USE: i) bronchodilator ii) steroid iii) antibiotics routinely. [OHCS, 9th edition, page-160] 55. A 75yo man collapsed while walking in his garden. He recovered fully within 30 mins with BP 110/80 mmHg and regular pulse of 70bpm. He has a systolic murmur on examination. His activities have been reduced lately which he attributes to old age. What is the definitive diagnostic inv that will assist you with his condition? a. ECG b. Echo c. 24h ECG monitoring d. 24h BP monitoring e. Prv CIN Ans. B. Echo. [Aortic stenosis – more likely in elderly. And hypertrophic cardiomyopathy – less likely in this age as presentation may be in an earlier age]. 56. A 35yo man with a hx of schizophrenia is brought to the ER by his friends due to drowsiness. On examination he is generally rigid. A dx of neuroleptic malignant syndrome except: a. Renal failure b. Pyrexia c. Elevated creatinine kinase d. Usually occurs after prolonged tx e. Tachycardia Ans. The key is D. Usually after prolonged tx. [Malignant neuroleptic syndrome usually occurs SOON after start or in increasing dose of antipsychotic drugs! All others mentioned are seen in this syndrome like renal failure, pyrexia, elevated creatinine kinase, tachycardia etc]. 57. A 33yo drug addict wants to quit. She says she is ready to stop the drug abuse. She is supported by her friends and family. What drug tx would you give her? a. Benzodiazepines b. Diazipoxide c. Lithium d. Methadone e. Disulfiram Q.1. What is the key. Q.2. What drugs should you use in i) tobacco abuse and in ii) alcohol abuse? Ans. 1. Key is d. Methadone. (used in opiate abuse) Ans. 2. i) tobacco abuse: a) bupropion ii) alcohol: a) acamprosate b) disulfirum 58. A 16m child presents with drooling, sore throat and loss of voice. He has fever with a temp of 38.2C. What is your next step towards management? a. Direct pharynoscopy b. Call ENT surgeon c. Call anesthesiologist d. IV fuilds e. Start antibiotics Q. 1. What is the key? Q. 2. What is the diagnosis? Q. What is the urgent management? Ans. 1.The key is C. Call anesthesiologist. [As an expert to intubate]. Ans. 2. Diagnosis is Acute epiglottitis. Ans. 3. In given case urgent intubation is needed to secure airway to prevent blockage of respiration. 59. A 62yo woman complains of unsteadiness when walking. On examination she has pyramidal weakness of her left lower limb and reduced pain and temp sensation on right leg and right side of trunk up to the umbilicus. Joint position sense is impaired at her left great toe but is normal elsewhere. She has a definite left extensor plantar response and the right plantar response is equivocal. Where is the lesion? a. Left cervical cord b. Midline mid-thoracic cord c. Right mid-thoracic cord d. Left mid-thoracic cord e. Left lumbo-sacral plexus Q. 1. What is the key? Q. 2. What is the name of this condition? Ans. 1. The key is d. Left mid-thoracic cord. Ans. 2. Brown-sequard syndrome. [In brown-sequard syndrome paralysis and loss of proprioception on the same (or ipsilateral) side as the injury or lesion, and loss of pain and temperature sensation on the opposite (or contralateral) side as the lesion]. 60. A 26yo man presents to ED with increasing SOB on left side and chest pain. He has been a heavy smoker for the past 4 years. He doesn’t have any past med hx. What is the likely dx? a. Pulmonary embolism b. MI c. Asthma d. Pleural effusion e. Pneumothorax Ans. The key is e. Pneumothorax. [Increased shortness of breath and chest pain with no past medical history favours the dx of pneumothorax. Heavy smoking or tobacco is a risk factor for spontaneous pneumothorax]. 61. A pt with hepatocellular ca has raised levels of ferritin. What is the most probable cause? a. Hemochromatosis b. A1 antitrypsin def c. Cystic fibrosis Ans. The key is A. Haemochromatosis. [Hemochromatosis itself is a cause of hepatocellular carcinoma and associated with raised level of ferritin. Serum ferritin levels elevated higher than 200 mcg/L in premenopausal women and 300 mcg/L in men and postmenopausal women indicate primary iron overload due to hemochromatosis, especially when associated with high transferrin saturation and evidence of liver disease. Ferritin concentration higher than 1000 mcg/L suggests liver damage with fibrosis or cirrhosis]. 62. A woman has electric pains in her face that start with the jaw and move upwards. Her corneal reflexes are normal. What is the most likely dx? a. Atypical face pain b. Trigeminal neuralgia c. Tempero-mandibular joint dysfunction d. GCA e. Herpes zoster Ans. 1. Key is b. Trigeminal neuralgia. [In trigeminal neuralgia transient loss of corneal reflexs are seen just after attacks but in between attacks corneal reflexes are quite normal]. 63. A 32yo man presented with slow progressive dysphagia. There is past hx of retro-sternal discomfort and he has been treated with prokinetics and H2 blockers. What is the probably dx? a. Foreign body b. Plummer vinson syndrome c. Pharyngeal puch d. Peptic stricture e. Esophageal Ca Ans. 1. The key is D. Peptic stricture. [Progressive dysphagia to mostly solid is suggestive of peptic stricture which is supported here by the use of prokinetic drugs and H2 blockers which are used for reflux oesophagitis]. 64. A 56yo man comes with hx of right sided weakness & left sided visual loss. Where is the occlusion? a. Ant meningeal artery b. Mid meningeal artery c. Mid cerebral artery d. Carotid artery e. Ant cerebral artery f. Ant communicating artery Q. 1. What is the key? Q. 2. How will you differentiate between middle cerebral artery occlusion from anterior cerebral artery occlusion? Ans. 1. The key is d. Carotid artery. [Carotid artery divides to internal and external carotid of which internal continues as middle cerebral ultimately. But just before it becomes middle cerebral internal carotid gives rise to ophthalmic branch. So middle cerebral occlusion may give partial visual loss but not complete mono-ocular blindness. For complete mono-ocular blindness occlusion should be proximal to ophthalmic artery i.e. either in internal carotid or more proximally to carotid artery]. Ans. 2. i) Middle cerebral artery occlusion: paralysis or weakness of contralateral face and arm (faciobracheal). Sensory loss of the contralatera face and arm. ii) Anterior cerebral artery occlusion: paralysis or weakness of the contralateral foot and leg. Sensory loss at the contralateral foot and leg. 65. A young college student is found in his dorm unconscious. He has tachyarrhythmia and high fever. He also seems to be bleeding from his nose, which on examination shows a perforated nasal septum. What is the most likely dx? a. Marijuana OD b. Cocaine OD c. Heroin OD d. Alcohol OD e. CO poisoning Q. 1. What is the key? Q. 2. What are the points that favours the diagnosis in given question? Q. 3. What are other important findings? Ans. 1. Key is B. Cocaine overdose. Ans. 2. Points in favour: i) Tachyrhythmia ii) High fever iii) perforated nasal septum iv) unconsciousness Ans. 3. Other findings of cocaine toxicity: i) Psychiatric: anxiety, paranoia ii) Tachypnoea iii) Increased energy and talking rapidly iv) Dilated pupils. Also: [rhabdomyolysis, metabolic acidosis, convulsion]. 66. A 56yo pt whose pain was relieved by oral Morphine, now presents with progressively worsening pain relieved by increasing the dose of oral morphine. However, the pt complains that the increased morphine makes him drowsy and his is unable to carry out his daily activities. What is the next step in his management? a. Oral oxycodone b. Oral tramadol c. PCA d. IV Fentanyl e. Diamorphine Ans. The key is oral oxycodon. 67. A 30yo man presents with a 5cm neck mass anterior to the sternocleido-mastoid muscle on the left side in its upper third. He states that the swelling has been treated with antibiotics for infection in the past. What’s the most likely cause? a. Branchial cyst b. Parotitis c. Pharyngeal pouch d. Thyroglossal cyst e. Thyroid swelling Q. 1. What is the key? Q. 2. Justify your answer. Ans. 1. The key is A. Branchial cyst. Ans. 2. i) Branchial cyst is anterior triangular lump. [parotid is also anterior triangular lump but parotitis regresses with appropriate treatment i.e. becomes normal in size]. ii) pharyngeal pouch is posterior triangular lump. iii) Thyroglossal is midline lump. iv) thyroid swelling moves with swallowing. 68. An 18yo man is rushed into the ER by his friends who left him immediately before they could be interviewed by staff. He is semiconscious, RR=8/min, BP=120/70mmHg, pulse=60bpm. He is noted to have needle track marks on his arms and his pupils are small. What is the single best initial tx? a. Insulin b. Naloxone c. Methadone d. Gastric lavage Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the points in favour of the diagnosis? Ans.1. The key is B. Naloxone. Ans. 2. The diagnosis is opiate overdose. Ans. 3. Points in favour are: i) reduced consciousness ii) RR 8/min (1235; urine output negligible. 137. A 67yo man presents with palpitations. ECG shows an irregular rhythm and HR=140bpm. He is otherwise stable, BP=124/80mmHg. What is the most appropriate management? a. Bisoprolol b. ACEi c. Ramipril d. Digoxin Ans. The key is A. Bisoprolol. [In acute AF (48h) rate control with beta-blocker or rate limiting CCB; OHCM, 9th edition, page-124]. 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. [This is much too a controversial question!! Patient is neglecting himself and is in a measerable state. His son can’t deal with the patient! So it seems impossible for care home staff to deal with him and social worker as well. If son move in with father will be of no benefit as he can not deal with the patient. So voluntary admission to psychiatry ward is the only option to which we can look but still with doubt as whether he is able to understand or give consent for voluntary admission. Even though A seems to be the likely option!!] 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. [The picture is of pneumonia and bilateral cavitating consolidation favours staphylococcus as the causative agent]. Ans. 2. Name of organism is Staphylococcus aureus. [Both coagulase positive and coagulase negative cocci are staphylococci. Gram positive diplococcic is pneumococcus and gram negative nisseria, moraxella catarrhalis and hemophilus influenza. For AFB there should be low grade evening fever with night sweats, weight loss, anorexia etc]. 140. A 67yo man had successful thrombolysis for an inf MI 1 month ago and was discharged after 5days. He is now readmitted 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. [ischaemic mitral regurgitation > raised pulmonary capillary pressure > pulmonary oedema]. [ Inferior myocardial infarction causes left ventricular remodeling, which displaces posterior papillary muscle away from its normal position, leading to ischemic mitral regurgitation]. 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. 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) not embolism as no pain (rest pain), no numbness, no redness or itching or rash, no ulceration of skin. 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. [It is not cystic fibrosis as lung problem is most commonly seen in cystic fibrosis along with GI problem like indigestion]. 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. It is probably a wrong key and correct key should be C. MRCP. [Post operative US of abdomen does not give good result for hepatobiliary system. ERCP is invasive procedure and it has its considerable complications like cholangitis, injury, pancreatitis etc. Among given options MRCCP is most appropriate. We shall go for ERCP after making the dx confirm. For this MRCP is preferred. If the question asks which is the “DEFINITIVE” or the “MOST DIAGNOSTIC” then the option will be ERCP]. Ans. 2. Diagnosis is choledocolithiasis. 145. A 53yo woman presented with pain in the eye, blurry vision and clumsiness for 3 months. She has a hx of difficulty in swallowing and weakness in her right upper limb 2y ago. What is the inv of choice? a. CSF analysis b. EEG c. EMG d. MRI brain e. Visual evoked response test Q. What is the key? Q. What is the diagnosis? Ans. 1. The key is D. MRI brain. Ans. 2. Diagnosis is multiple sclerosis. 146. A 55yo male presents with malaise and tiredness. Exam: spleen approaching RIF, no lymphadenopathy. Choose the single cell type? a. Helmet shaped cell b. Sickle cell c. Granulocyte without blast cells d. Blast cells Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the diagnostic features? Ans. 1. The key is C. Granulocyte without blast cells. Ans. 2. The diagnosis is CML. Ans. 3. Diagnostic features are i) increased number of mature granulocytes ii) huge splenomegaly. [* Helmet shaped cells (or shistocytes) = hemolytic or Microangiopathic hemolytic anemia * Sickle cell = sickle cell anemia * Blast cells (immature cells) = in acute leukemia]. 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. 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. [Done by interventional radiologist expert in arterial embolization technique. Particles are placed in uterine artery to block circulation to uterine body. No operation or GA is required]. 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]. 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] 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.] 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. These features are common for both hemothorax and tension pneumothorax and tracheal deviation is common to both! But chance of tension pneumothorax is more in stab wond and no tracheal deviation is controversial. This is probability of bad recall!! 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]. 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. Theakey is Cardiac tempoade. 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. 155. A 15yo boy has a soft painless swelling in the left scrotum, blue in color and can be compressed. What is the most appropriate next step? a. Analgesia b. Antibiotic c. Biopsy d. Immediate surgery e. Reassurance Q. 1. What is the key? Q.2. What is the name of this condition? Ans. 1. The key is E. Reassurance. Ans. 2. Name of the condition is Varicocele. 156. A 12yo pt presents with copious diarrhea. Exam: urine output=low, mucous membrane=dry, skin turgor=low. What is the most appropriate initial management? a. Antibiotic b. Antimotility c. Anti-emetic d. Fluid replacement e. Reassurance Q. 1. What is the key? Q. 2. What is the diagnosis and why? Ans. 1. The key is D. Fluid replacement. Ans. 2. Diagnosis is severe dehydration. Points in favour: i) low urine output ii) dry mucous membrane and iii) low skin turgor. 157. A 60yo smoker presents with cramp-like pain in the calves relived by rest and non-healing 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), 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 angeoedema usually manifest after the age of 40 yrs. 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. 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]. 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. [Sciatic nerve injury though may occur but rare!] 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] 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, radio-femoral delay, cold legs with week pulse, mid-systolic murmur are all features of coarctation of aorta]. 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 low blood glucose 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]. 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. 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, 9th edition, page- 142]. 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]. 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]. 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. MI b. DM c. HF d. PE 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. 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. 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. 172. A 44yo pt has sudden onset of breathlessness and stridor few minutes after extubation for thyroidectomy. The pat had longstanding goiter for which he had the surgery. What is the most likely dx? a. Thyroid storm b. Hematoma c. Unilateral recurrent laryngeal nerve injury d. External laryngeal nerve injury e. Tracheomalacia Ans. The key is tracheomalacia. [Prolonged pressure over trachea by goiter is a cause of tracheomalacia following thryroidectomy]. 173. A 15yo boy presents with generalized edema. His urinalysis reveals protein +++, eGFR =110. What is the most likely dx? a. IgA nephropathy b. Membranous nephropathy c. Minimal change disease d. PSGN e. Lupus nephritis Ans. The key is C. Minimal change disease. [Points in favour: i) Age 15 yrs ii) Generalized oedema iii) Protein in urine +++ vi) Normal eGFR of 110 (Normal range- 90 to 120 mL/min)]. 174. A 72yo man is receiving chemotherapy for SCLC. He has his 4th tx 8 days ago. He has a cough with some green sputum but feels well. Temp=37.6C. Chest exam = few coarse crepitations in the right base. HR=92bpm. CBC: Hgb=12.5g/dL, WBC=1.1, Neutrophils=0.6, Plt=89. Sputum, urine and blood culture sent to microbiology. What is the most appropriate management? a. Broad spectrum antibiotics IV b. Broad spectrum antibiotics PO c. GCSF d. Postpone tx until bacteriology results available e. Reassure and send home Q. 1. What is the key? Q. 2. What is the Diagnosis? Q. 3. What is the treatment of low WBC count? Ans. 1. The key is A. Broad spectrum antibiotics IV Ans. 2. The diagnosis is lower respiratory tract infection. Ans. 3. GCSF subcutaneously. [it is the treatment of chemotherapy induced leucopenia] 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. *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. **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 [Many like to chose the key to be febrile convulsion but febrile convulsion does not usually recur!] 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. Probably wrong key as mefloquine can not eradicate hepatic cycle! Primaquine is the drug that can eradicate hepatic cycle. Ans. 2. Shuffners dot indicates, it is plasmodium ovale or plasmodium vivex infestation. *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. *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. 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. 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? Ans.1. The key is E. Congenital hypothyroidism. Ans. 2. Points in fevour:i) FTT (failure to thrive) 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 [Infections are common in children due to problems with the immune system's T-cell-mediated response that in some patients is due to an absent or hypoplastic thymus]. [in newborne can be recognized by convulsions from hypocalcaemia due to malfunctioning parathyroid glands and low level of parathyroid hormones]. 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. It is a wrong key!! According to UK greenbook correct key is A. Human Ig only. 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. 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. 187. A 19yo boy complains of itching on the site of insect bite. What is the single most appropriate management? a. Penicillin oral b. Doxycycline oral c. Oral antihistamine d. Oral ciprofloxacin e. Reassurance Ans. The key is C. Oral antihistamine. 188. A man presents with scrotal swelling, the swelling is cystic and is non-tender. It is located in the upper pole of the posterior part of the testis. What is the most likely dx? a. Epididymal cyst b. Testicular ca c. Hydrocele d. Teratoma e. Testicular torsion Ans. The key is A. Epididymal cyst. [the location of upper pole of the posterior part of testis is the common site for epididymal pathology]. 189. A young footballer has collapsed during a game. During initial evaluation: RR=14/min, pulse=88bpm, BP=110/70mmHg. He seems to be sweating and muttering some incomprehensible words. What is the most imp next step? a. CT b. MRI c. Blood sugar d. Body temp e. IV fluids Ans. The key is C. Blood sugar. 190. A 45yo waitress complains of pelvic pain which worsens pre-menstrually and on standing and walking. She also complains of post-coital ache. Select the most likely cause leading to her symptoms? a. PID b. Endometritiosis c. Pelvic congestion syndrome d. Adenomyosis e. Premature ovarian failure Ans. The key is C. Pelvic congestion syndrome. 191. A 37yo female had a fall with outstretched hand, presented with dinner fork deformity and tenderness over the right arm. What is the single most associated nerve injury? a. Axillary nerve b. Radial nerve c. Musculocutaneous nerve d. Median nerve e. Ulnar nerve Ans. The key is D. Median nerve. [Median nerve is the nerve injured in Colle’s fracture]. 192. A mother comes with her 15m child. Which of the following will bother you? a. Shies away from strangers b. Can walk but not run c. Vocabulary consists of only 2 meaningless words d. She can’t make a sentence e. None Q. 1. What is the key? Q. 2. How many words is told clearly by a 15 month old child? Ans. 1. The key is C. Vocabulary consists of only 2 meaningless words. Ans. 2. At 15 months the child can clearly say 5 words and his first meaningful clear word he says at 12 months. 193. A 35yo lady who has been using IUCD for one year now complains of pelvic pain and heavy painful periods. Select the most likely cause leading to her symptoms? a. PID b. Endometriosis c. Adenomyosis d. Fibroids e. Asherman syndrome Q. 1. What is the key? Q. 2. What points favour your diagnosis? Ans. 1. The key is A. PID. Ans. 2. The given picture may have D/D of PID or fibroid. As IUCD is a risk factor for PID, it is the most likely diagnosis of given picture. 194. The dx cells of Hodgkin disease are: a. T-cells b. R-S cells c. B-cells d. Macrophages e. Auer rods Ans. The key is B. R-S cells. [Diagnostic cell in Hodgkins disease is Reed-Sternberg cells]. 195. A 16yo girl is admitted after taking a paracetamol OD 4 h ago. She has consumed lare amounts of alcohol. Her plasma paracetamol conc is just below the conc that would suggest tx. What should be the tx option for her? a. Refer to psychiatry ward b. Refer to medical ward c. N-acetylcystine d. Serum plasma paracetamol e. No further investigation Ans. The key is A. Refer to psychiatry ward. [Short term acute alcohol consumption causes enzyme inhibition as in present case and even then paracetamol level is under tx level. So the patients drug level is in safe side but simultaneous drug overdose and alcohol consumption needs psychiatric evaluation and hence the option here is A]. 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). 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, 9th Eition, page-462 where NSAIDS like ketoprophen or dispersible aspirin 900 mg/6 hr are recommended as treatment in acute stage]. 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, woozing of blood from drain; all these goes in favour of reactionary haemorrhage]. 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]. 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]. 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. 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]. 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]. 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]. 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. X 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. 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). 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 feature like fistula is a common association of CD]. 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. 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. 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. 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 invasiv is preferred so laparoscopic rather than laparotomy. 214. In a man who is neglected and alcohol dependent, whith high suicidal risk, which factor can increase this risk further? a. Alcohol dependence b. SSRI c. S]moking d. Agoraphobia e. Court involvement Ans. The key is A. Alcohol dependence. This is considered a wrong key by previous plabbers and suggested correct key is B. SSRI. 215. A 71 yo man presents with coarse tremor. He is on some meds. Which one can be the reason for the tremor? a. Lithium b. Diazepam c. Fluoxetine d. Imipramine e. Haloperidol Ans. The key is A. Lithium. Actually in therapeutic dose lithium causes fine tremor but in toxic dose it causes coarse tremor. So the probable answer is lithium. 216. A young woman complains of diarrhea, abdominal cramps and mouth ulcers. AXR shows distended transverse colon with globet cell depletion on rectal biopsy. What is the most probable dx? a. CD b. UC c. Bowel Ca d. Bowel obstruction e. IBS Q. 1. What is the key? Q. 2. What are points in favour? Ans. 1. The key is B. UC. Ans. 2. In UC there is goblet cell depletion and less mucous production in contrast with CD where there may be goblet cell hyperplasia and mucous secretion is not reduced. 217. After eating a cookie at a garden party, a child began to cough and went blue. The mother also noticed that there were swollen patches on the skin. What is the dx? a. Allergic reaction b. Aspiration of food c. Cyanotic heart disease d. Trachea-esophageal fistula e. Achalasia cardia Ans. The key is A. Allergic reaction. 218. A 70 yo man presents with balance difficulties, vomiting and nausea. Which of the following is the best inv? a. MRI cerebellum b. CT cerebellum c. Skull XR d. LP e. Blood culture Ans. The key is A. MRI cerebellum. [In posterior fossa lesion MRI is preferred]. 219. A 2 yo pt presents with colicky pain which radiates from loin to groin. He complains of similar episodes in the past. Inv has been done and 7mm stone was found in the ureter. What is the most appropriate management? a. Percutaneous nephrolithiotomy b. Open surgery c. Ureteroscopy or laser d. Conservative tx e. ESWL Q. 1. What is the key? Q. 2. What treatments are recommended for different sized stones? Ans. 1. The key is E. ESWL. Probably a wrong key! Upto 10mm stone conservative tx. So correct key should be D. conservative tx. Ans. 2. Stones < 5mm: pass spontaneously, Increase fluid intake. Stones 5mm-10mm /pain not resolving: medical expulsive therapy---> Nifedipine or Tamsulosin(and/or prednisolone). Stones 10mm-2cm: ESWL or Ureteroscopy using dormia basket. Stones > 2cm/large/multiple/complex: Percutaneous nephrolithotomy. 220. A footballer has been struck in the groin by a kick and a presents with severe pain and mild swelling in the scrotum. What is the most appropriate next step? a. USG b. Doppler c. Exploratory surgery d. IV fluids e. Antibiotics Ans. The key is C. Exploratory surgery. [To exclude torsion]. 221. A 47 yo ex-soldier suffers from low mood and anxiety. He can’t forget the images he faces before and has always had flashbacks. He is not able to watch the news because there are usually some reports about war. What is he suffering from? a. Depression b. PTSD c. Panic attack d. Agoraphobia e. GAD Ans. The key is B. PTSD. [repeated flashbacks and tendency to avoid the thoughts of stressor is diagnostic of PTSD]. 222. A 36 yo woman has recently spent a lot of money on buying clothes. She goes out almost every night with her friends. She believes that she knows better than her friends, so she should choose the restaurant for eating out. She gave hx of having low mood at 12 yo. What’s the dx? a. Mania b. Depression c. Bipolar affective disorder d. Borderline personality disorder e. Dysthymia Ans. The key is C. Bipolar affective disorder. [Initial depressive episode (may be befor a long) followed by mania is bipolar affective disorder]. 223. A 28 yo female presents with a 3m hx of diarrhea. She complains of abdominal discomfort and passing stool 20x/day. Exam=febrile. Barium enema shows cobblestone mucosa. What is the most likely dx? a. Ameoba b. Colon Ca c. GE d. CD e. UC Ans. The key is D. CD. [Hx of diarrhea, abdominal discomfort, and patient being febrile indicate gut inflammation and cobblestone appearance on barium enema is suggestive of CD]. 224. A child is brought in with high grade fever, runny nose and bark-like cough. He is also drooling. What is the most appropriate tx for this child? a. Corticosteroids b. Paracetamol c. Adrenaline nebulizer d. IV antibiotics e. Intubation under GA Ans. The key is E. Intubation under GA. This is a wrong key! In epiglottitis there is no cough and bark like cough is diagnostic of croup! So the correct key should be a. Corticosteroids. [high fever, bark-like cough, drooling in a child suggest croup which is treated with corticosteroids]. 225. A 78yo lady on warfarin for atrial fibrillation lives in a care home. She presents with hx of progressive confusion for three days. She was also noticed to have bruises on her arms. INR = 7. What is the most probable dx? a. Alzheimers b. Delirium c. Subdural hemorrhage d. Vascular dementia e. Pick’s dementia Ans. The key is C. Subdural haemorrhage. [Age 78 yrs, living in a care home where unnoticed trivial injury is possible (like fall), warfarine and high INR is potential risk factor of subdural haemorrhage suggested by bruises on arms also]. 226. A 28 yo drug user presents to the ED with collapse and anuria. His serum K+ = 7.5mmol/L. CXR = early pulmonary edema. What is the next appropriate management? a. Urgent hemodialysis b. IV calcium gluconate c. IV insulin + dextrose d. Furosemide e. IV NS 0.9% Ans. The key is B. IV calcium gluconate. [To correct hyperkalemia to prevent cardiac arrhythmia]. **227. A 32 yo woman suffers an episode of severe occipital headache with vomiting and loss of consciousness. She is brought to the hospital where she is found to be conscious and completely alert. Exam: normal pulse & BP. No abnormal neurological signs. What is the next step in management? a. Admission for observation b. CT brain c. MRI head d. Reassurance and discharge e. XR skull Ans. The key is B. CT brain. [basilar migraine can cause severe headache and LOC. But there occurs no neurological deficit and on recovering from unconsciousness becomes completely alert. But to diagnose basilar migraine there should at least history of two migraine attacks with aura. As here diagnostic criteria of basilar migraine is not fulfilled we can not discharge the patient without neuroimaging like CT or MRI]. 228. A 25 yo woman was brought to the ED by her boyfriend. She has many superficial lacerations on her forearm. She is so distressed and constantly says her boyfriend is going to end the relationship. She denies trying to end her life. What is the most likely dx? a. Acute psychosis b. Severe depression c. Psychotic depression d. Borderline personality disorder e. Schizophrenia Ans. The key is D. Borderline personality disorder. [ Borderline personality disorder: Act impulsively and develop intense but short-lived emotional attachment to others. They are usually attention seekers but not suicidal]. 229. A young woman was brought to the hospital. On exam she has low temperature and tremor. She says when she closes her eyes, she can see colors. What drug has been used? a. Amphetamines b. LSD c. Cocaine d. Heroine e. Ecstasy Ans. The key is B. LSD. *230. A lady comes in severe liver disease and hematemesis. Her INR is >10. What should she be given? a. FFP b. Steroids c. Whole blood d. IV fluids e. Vit K Ans. The key is A. FFP. 231. After eating a cookie at a garden party, a child began to cough and went blue. The mother also noticed that there were swollen patches on the skin. What is the initial management? a. OTC antihistamine b. Oxygen c. Bronchodilators d. Epinephrine IM e. Nebulized epinephrine Ans. The key is D. Epinephrine IM [anaphylaxis with partially blocked airway]. 232. A 63 yo female is noted to have left pupil irresponsive to light and is dilated. What is the most probably dx? a. Pontine hemorrhage b. Subdural hemorrhage c. Cerebellar hemorrhage d. Extradural hemorrhage e. Subarachnoid hemorrhage Ans. The key is D. Extradural hemorrhage. It is a wrong key. In a 63 year old extradura hemorrhage is extremely unlikely. As no clinical picture is described in question except 3rd nerve palsy E. SAH is more logical answer! 233. A 28yo business executive presents at the GP asking for some help because she has been arguing with her boyfriend frequently. She is worried about her weight, and she thinks she may be fat. She has been on a diet and lost 7 kgs in the last 2 months on purpose. She is eating less. She used to do a lot of exercise. Now she says she’s feeling down, has some insomnia and feels tired and without energy. She has not showed up at work. She is worried because recently she got a loan to buy a luxury car. She can’t be fired. She complains about her low mood. She thinks this is weird because she used to be extremely productive. She used to work showing an excellent performance at the office. She even received compliments from her boss. How, she says her boyfriend is angry because her apartment is a chaos. Usually she spends a lot of time cleaning it, even upto 3 AM. She liked it to be perfect, but not it’s a mess. On exam: BMI=23, no other signs. What is the most probably dx? a. Anorexia nervosa b. Bipolar disease c. Binge eating disorder d. Hyperthyroidism e. Schizophrenia Ans. The key is B. Bipolar disease. 234. A woman brought her husband saying she wants the ‘thing’ on his forehead removed. The husband is refusing tx saying it improves his thinking. What is the most appropriate next step? a. Assess his mental capacity to refuse tx b. Remove lesion c. Refer to ED d. Mini-mental state exam e. Refuse surgery and send pt back Ans. The key is A. Assess his mental capacity to refuse treatment. 235. A 37 yo man who has many convictions and has been imprisoned many times has a hx of many unsuccessful relationships. He has 2 boys but doesn’t contact them. What is the most probable dx? a. Borderline personality disorder b. Schizophrenia c. Avoidant personality disorder d. Histrionic personality disorder e. Antisocial behavior disorder Ans. The key is E. Antisocial behavior disorder. 236. A 60 yo man has a pathological rib fx. He also complains of recurrent infection. BMA is done. Labs: Ca2+ = 3.9mmol/L and ALP = 127u/L. what type of cell would be found in abdundance in the marrow smear? a. Plasma cell b. Myeloid cell c. Bence-jones protein d. Megakaryocytes e. Reticulocytes Q. 1. What is the key. Q. 2. What is the diagnosis? Q. What are the points in favour of diagnosis? Ans. 1. The key is A. Plasma cell. Ans. 2. The diagnosis of multiple myeloma. Ans. 3. Points in favour: i) age 60 yrs ii) pathological rib fracture (from metastases) iii) recurrent infection (due to B cell dysfunction (manifested as hypogammaglobulinemia), numerical and functional abnormalities of T cells, and dysfunction of natural killer cells), iv) raised calcium level. 237. A child presents with blue marks on the sclera, short stature and heart murmur. What is the dx? a. Osteogenesis imperfect b. Hypopituitarism c. VSD d. Achondrogenesis e. Dwarfism Ans. The key is A. Osteogenesis imperfecta. 238. A 5month child can’t speak but makes sounds. She can hold things with palm, not fingers. Can’t sit independently but can hold her hand and sit when propped up against pillows. How’s the childs development? a. Normal b. Delayed speech c. Delayed sitting d. Delayed motor development Ans. The key is A. normal 239. A 27 yo woman has hit her neck in an RTA without complains of tingling or motor loss. What is the next most appropriate inv? a. MRI b. XR c. CT cervical d. Diagonal XR Ans. The key is B. X-ray. [As there is no neurological deficit we can exclude any fracture by x-ray first]. [Diagonal x ray means ,oblique view of cervical spine. By this view we can assess facet joint arthopathy. This doesn't related to RTA]. 240. A young female who has many superficial lacerations was brought into the ED by her boyfriend for superficially lashing her upper arm. She is adamant and screaming that she is not suicidal but scared her boyfriend wants to leave her. What is the dx? a. Acute psychosis b. Severe depression c. Obsessive d. Bipolar e. Borderline personality f. Schizophrenia Ans. The key is acute psychosis. Probably this is wrong key! Correct key should be E. Borderline personality disorder. 241. A 22yo woman was brought by her boyfriend with multiple superficial lacerations. There are scars of old cuts on her forearms. She is distressed because he wants to end the relationship. She denies suicide. What is the most likely dx? a. Acute psychosis b. Borderline personality disorder c. Severe depression d. Schizoid personality e. Psychotic depression Ans. The key is B. Borderline personality. 242. A 31yo single man lives with his mother. He usually drives to work. He always thinks when the traffic lights change, his mother is calling him, so he drives back home. What is the dx? a. OCD b. GAD c. Schizophrenia d. Bipolar e. Cyclothymia Ans. The key is C. Schizophrenia. [ delusion of reference - he thinks that the changing traffic lights are giving message to him]. 243. A 56yo woman is known case of pernicious anemia. She refuses to take hydroxycobalamin IM as she is needle shy. She asks for oral medication. Why will oral meds be not effective? a. Intrinsic factor def b. Malabsorption c. Irritated gastric mucosa d. Lack of gastric acidity Ans. The key is A. Intrinsic factor def. 244. An 11m baby had an apnea event. The parents are worried that if something like this happens in the future, how they are to deal. Advise them about infant CPR. a. Index and middle finger compression b. Compression with palm of one hand c. Compression with palm of two hands d. Compression with rescue breaths 30:2 e. Compression with rescue breaths 15:2 Ans. The key is A. Index and middle finger compression. 245. A teacher brings in a child who says she fell down after hitting a table. On probing further, you decide that it was most probably an absence seizure. What led you to this dx? a. The child had not eaten since morning b. The child suddenly went blank and there was up-rolling of eyes c. The child started moving his fingers uncontrollably before he fell d. The child’s body became rigid and then started to jerk Ans. The key is B. The child suddenly went blank and there was up-rolling of eyes. 246. A man has discharge from his left ear after a fight. Where is the discharge coming from? a. CSF b. Inner ear c. Outer ear d. Brain Ans. The key is A. CSF. [probable fracture base of skull]. 247. A 40 yo manic depressive is noted to have high serum levels of lithium and profound hypokalemia. His GP had started him on anti-HTNs. Choose the single most likely cause? a. Verapamil b. Amiodarone c. Ranitidine d. Lithium e. Thiazide Ans. The key is E. Thiazide. [Thiazide was prescribed for Hpt and when lithium was prescribed its level increased due to thiazide and thiazide also caused hypokalemia resulting the given picture]. 248. A 74yo man presents with weakness in his arm and leg from which he recovered within a few days and short term memory loss. He has an extensor plantar response. He has similar episodes 2 years ago and became unable to identify objects and to make proper judgment. What is the most appropriate dx? a. Alcoholic dementia b. Pick’s dementia c. Huntington’s disease d. Alzheimer’s disease e. Vascular dementia Ans. The key is E. Vascular dementia. [hemiparesis, memory impairment, extensor planter reflex, inability to identify objects, poor judgment are features of vascular dementia]. 249. A nurse comes to you saying that she has recently developed the habit of washing her hands after every 15-20 mins. She is unable to conc on her work and takes longer than before to finish tasks as she must constantly wash her hands. What is the most appropriate management? a. CBT b. SSRI c. ECT d. Antipsychotics e. Desensitization Q. 1. What is the key? Q. 2. What is the diagnosis? Ans. 1. The key is A. CBT. Ans. 2. The diagnosis is OCD. 250. A 61yo man underwent a surgery in which ileal resection had been done. He complains of fatigue, headache, and heart racing. Labs: MCV=108fL, Hgb=8.9g/dL. What is the most likely dx? a. Vit B12 def b. Iron def c. Folate def d. Hemolytic anemia e. Anemia of chronic disease Q. 1. What is the key? Q. 2. What are the points in favour? Ans. 1. The key is Vit. B12 deficiency. Ans. 2. Vit B12 is absorbed mostly in ileum. Megaloblastic anaemia. 251. A 7yo is brought by his mother who says that he was well at birth but has been suffering from repeated chest and GI infections since then. She also says that he is not growing well for this age. What is the likely condition of this child? a. CF b. SCID c. Primary Tcell immunodeficiency d. Primary Bcell immunodeficiency e. Malabsorption Q. 1. What is the key? Q. 2. What are the points in favour? Ans. 1. The key is A. cystic fibrosis. Ans. 2. CF involved in production of sweat, digestive fluid and mucous. These secretion becomes thick than normal predisposing to lung and GI infections since birth. 252. A 3yo child has a high temp for 4 days and he had not seen a doctor. Then mother notices rashes on buccal mucosa and some around the mouth. What is the most appropriate dx? a. Measles b. Roseola infectiosum c. Rubella d. Chicken pox e. Impetigo Ans. The key is B. Roseola infectiosum. It is a wrong key! The correct key should be A. Measles! [As the rash developed after 4 days fever the dx is measles!]. 253. A 70yo lady presents with fever for 3d and confusion. There is no significant PMH. What is the most probable dx? a. Delirium b. Hypoglycemia c. Alzheimers d. DKA Ans. The key is A. Delirium. Delirium is an acute confusional state and declined cognitive function which involves changes in arousal (hyperactive, hypoactive or mixed), perceptual deficits, altered sleep-wake cycle, and psychotic features such as hallucinations and delusions. 254. An obese mother suffers from OSAS. Which of the following inv is best for her? a. ABG b. Overnight pulse-oximetry c. Polysomnography d. EEG Ans. The key is B. Overnight pulse-oxymetry. [It is already a diagnosed case of OSAS. So no need for polysomnography rather if like to know the current status or monitor overnight pulse oxymetry is good]. 255. A 28yo business man came to the sexual clinic. He was worried that he has HIV infection. 3 HIV tests were done and all the results are negative. After a few months, he comes back again and claims that he has HIV. What is t

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