PLAB 1 QBank 2020 PDF

HAEMATOLOGY a) discharge; 1. Abnormal blood film b) inversion; a) Peripheral blood film (red cell, white cell and platelets) c) Paget's b) Dif...

HAEMATOLOGY a) discharge; 1. Abnormal blood film b) inversion; a) Peripheral blood film (red cell, white cell and platelets) c) Paget's b) Differential white cell count 5. Request for reduction/augmentation c) Pancytopenia d) Bone marrow failure CARDIOVASCULAR e) ESR 1. Chest Pain f) Hyperviscosity syndrome a) Acute myocardial infarction, acute coronary syndrome and angina g) Spleen and splenectomy b) Acute myocardial infarction (MI) 2. Haematological malignancies and myeloproliferative disorders c) Acute coronary syndrome (ACS) a) Leukaemia d) Angina pectoris b) Myeloma e) Electrocardiogram (ECG) – normal and abnormal c) Paraproteinemia f) Investigations (cardiac catheterisation; echocardiography; nuclear d) Amyloidosis cardiology; ECG: exercise/ ambulatory) 3. Bruising/ bleeding/ purpura g) Complications of MI (arrhythmias; hypertension) a) Intrinsic and extrinsic pathways (clotting) h) Atherosclerosis b) Any cause including 2. Heart Murmur: any cause c) Bleeding disorder 3. Hypertension: all, including risk fator d) Anticoagulants 4. Palpitations e) Thrombophilia a) Bradycardia 4. Immunosuppressive drugs b) Narrow complex tachycardia 5. Inherited bleeding disorders Anaemia of any cause c) Atrial fibrillation and flutter a) Iron deficiency anaemia d) Broad complex tachycardia b) Refractory anaemia e) Pacemakers c) Anaemia of chronic disease 5. Peripheral arterial disease d) Sideroblastic anaemia a) Aneurisms e) Macrocytic anaemia (all causes) b) Ischaemic limb f) Pernicious anaemia c) Occlusions g) Haemolytic anaemia 6. Peripheral oedema and Heart failure including valvular heart disorder and h) Sickle cell anaemia rheumatic heart disease i) Thalassaemia anaemia a) Rheumatic fever j) Transfusion (safety & procedures) b) Mitral valve disease k) (Myeloproliferative disorders) c) Aortic valve disease 6. Generalised enlarged lymph nodes: any cause d) Right heart valve disease e) Indications for cardiac surgery BREAST LUMP AND/OR PAIN f) Infective endocarditis 1. Cancer g) Diseases of heart muscle including myocarditis 2. Infection h) Pericardial disease a) abscess; i) Dyspnoea in heart failure b) puerperal mastitis 7. Peripheral Venous problems 3. Benign a) VTE a) fibro-adenoma; b) DVT b) fibro-adenosis; c) Risk Factors c) fat necrosis; cysts) d) Varicose Veins 4. Nipple https://afkebooks.com DEVELOPMENTAL PROBLEMS e) Inflammatory conditions (including diverticulitis; appendicitis, pancreatitis) 1. Congenital Abnormalities f) Colic: ureteric (see also under Renal), Biliary/ gallbladder (see also under a) Ventricular septal defect Jaundice) b) Atrial septal defect 3. Anorexia and weight loss c) Patent ductus arteriosus a) Cancer d) Aortic stenosis b) Metabolic causes including diabetes (see under Endocrine/ Abnormal e) Pulmonary stenosis blood sugar); f) Coarctation of the aorta c) thyroid (see under Endocrine/ Thyroid abnormalities) g) Fallot's tetralogy d) Malabsorption h) Transposition of the great arteries e) Physical causes of anorexia i) Tricuspid atresia f) Psychological causes of anorexia (see also under Mental health/ Eating j) Total anomalous pulmonary venous return problems k) Persistent truncus arteriosus 4. Facial Swelling l) Hypoplastic left heart a) Cancer m) Pulmonary atresia b) Sinusitis n) Ebstein's anomaly c) Salivary glands o) Polycystic kidneys d) Teeth p) Congenital adrenal hyperplasia e) Oral cavity q) Chromosomal abnormalities (including Turner's; Down's; Tay Sachs') f) Lymph nodes (see also under Blood and lymph) r) Inherited conditions (cystic fibrosis; PKU) 5. Jaundice s) Acquired conditions (including caused by drugs/alcohol) a) Pre-hepatic (including haemolysis) t) Neural tube defects (including spina bifida) b) Hepatic (including drug-induced) u) Developmental abnormalities of the musculoskeletal system (including c) Post-hepatic (including biliary obstruction) talipes) 6. Lower GI Problems 2. Developmental Delay/ Failure to thrive a) Including faecal incontinence a) Endocrine problems/ Metabolic disorders b) Spurious diarrhoea and encopresis b) Malabsorption (see also under Digestive) c) Cancer c) Inadequate diet d) Ulceration 3. Psychological and Social e) Bleeding a) Non-accidental injury f) Abnormal anatomy (fissures, piles, prolapse) b) Sexual abuse g) Masses (including polyps) c) Emotional deprivation h) Altered bowel habit (constipation, diarrhoea) d) Bullying i) Rectal pain e) Manifestations of neglect j) Pruritis ani k) Inflammation (including IBD) DIGESTIVE 7. Upper GI Problems 1. Abdominal Mass a) Including nausea and vomiting a) Organomegaly b) Infections (including food poisoning, UTI, gastroenteritis) b) Hernias c) Pyloric stenosis (see also under Developmental) c) Ascites d) Drug-induced 2. Abdominal Pain e) Raised intracranial pressure a) Perforation f) Pregnancy (see also under Reproductive) b) Obstruction g) Constipation c) Ischaemia h) Cancer d) Aneurysm (see also under Cardiovascular/ Peripheral arterial disease) i) Ulceration https://t.me/afkebooks  j) GORD 4. Pituitary gland k) Bleeding a) Hypopituitarism l) Dysphagia (including tumours; benign; neurological causes; congenital; b) Pituitary tumours acquired) c) Hyperprolactinaemia; hypoprolactinaemia 8. Nutrition d) Acromegaly a) Recognises nutritional disorders are common in patients with long-term e) Diabetes insipidus conditions f) Hypopituitary coma b) Performs basic nutritional screen and recognises patients with potential for 5. Thyroid Disorders nutritional deficiencies and considers this in planning care a) Cancer c) Formulates a plan for investigation and management of weight loss or b) Hyperthyroidism weight gain c) Thyroid eye disease d) Demonstrates the knowledge, skills, attitudes and behaviours to assess d) Hypothyroidism patients’ basic nutritional requirements e) Thyroid disease in pregnancy (see also under Reproductive/ Problems in e) Recognises major nutritional abnormalities and eating disorders and pregnancy) establishes a management plan, where relevant with other healthcare f) Goitre; nodules professional input g) Thyroid emergency f) Works with other healthcare professionals in addressing nutritional needs and communicating these during care planning ENT g) Makes nutritional care part of daily practice 1. Earache any cause h) Considers the additional effects of long-term ill-health on nutritional status a) Cancer and the effect of poor nutrition on long-term health. b) Infection c) Eustachian tube dysfunction ENDOCRINE 2. Hearing Problems: any cause 1. Diabetes Mellitus a) Foreign body (including wax) a) Type 1 diabetes b) Conductive and nerve deafness b) Type 2 diabetes 3. Hoarseness and stridor any cause c) Complications (including diabetic retinopathy; neuropathy; arterial disease) a) Cancer d) Diabetic foot care b) Infection (including epiglottitis) e) Hypoglycaemia/ hyperglycaemia c) Voice misuse (including nodules) f) Patient with diabetes undergoing surgery d) Nerve injury (including palsies) g) Diabetes in pregnancy (see also under Reproductive) e) Stridor (see also under Thyroid abnormalities/ Goitre) 2. General 4. Nasal Symptons a) Hyperparathyroidism a) Cancer b) Hypoparathyroidism b) Bleeding c) Multiple endocrine neoplasia (MEN 1 and MEN 2) c) Nasal obstruction (including polyps; allergic rhinitis) 3. Adrenal d) Infections a) Adrenal gland e) Trauma (including fractures) b) Addisonian crisis 5. Vertigo any cause c) Addison’s disease a) Ménières disease d) Hyperaldosteronism b) Labyrinthitis e) Phaeochromocytoma c) Cancer f) Virilism d) Cerebellar lesions (see also under Neurological) g) Gynaecomastia (see under Breast) e) Benign positional h) Impotence (see under Reproductive/ Fertility problems) f) Toxins (including alcohol) i) Cushing’s syndrome https://afkebooks.com EYE e) Foreign body 1. Eye Pain f) Child sexual abuse (see also under Developmental problems) a) Cancer b) Sinusitis (see also under ENT) HOEMOSTATIC c) Glaucoma 1. Acid-base imbalance and blood gas abnormalities d) Migraine (see also under Neurological/ Headache a) Metabolic and respiratory acidosis or alkalosis e) Foreign body b) Kidney function (tubular dysfunction, low GFR, chronic renal failure) 2. Orbital Swelling 2. Electrolyte abnormalities a) Cancer a) Sodium, b) Infection (including cellulitis; blepharitis) b) potassium, c) Thyroid disease (see under Endocrine) c) glucose, d) Cysts: congenital and acquired d) calcium e) Eyelid Disorder e) SIADH 3. Red eye f) Magnesium a) Infection g) Zinc b) Conjunctivitis h) Selenium c) Iritis i) Water d) Trauma (including foreign body) e) Scleritis/ episcleritis INFECTIOUS DISEASE f) Glaucoma 1. Hospital Acquired inefction g) Subconjunctival haemorrhage a) Infection Control h) Polycythaemia b) MRSA 4. Visual impairment c) C. diff a) Tumours (including pituitary) d) Manages sepsis b) Arterial and venous a. Understands the seriousness of sepsis c) Lens (including cataract; dislocation) b. Understands and applies the principles of managing a patient with d) Degenerative sepsis e) Hereditary c. Involves the infection control team at an appropriate early stage f) Systemic conditions: including connective tissue; diabetes (see also under d. Takes appropriate microbiological specimens in a timely fashion Endocrine) e. Follows local guidelines/protocols for antibiotic prescribing. g) Drug-induced 2. Serious infection h) Infections a) HIV i) Detached retina b) AIDS j) Vitreous haemorrhage (including floaters) c) Hep B d) And Tb GENITOURINARY 3. Travel Medicine and Tropical infections: any cause 1. Uretrhal Discharge any cause a) Malaria a) Infection (including STI) b) Bilharzia b) Cancer c) Dengue fever c) Foreign body d) Lyme disease 2. Vaginal Discharge any cause e) Toxoplasma a) Pruritis vulvae f) Rabies b) Normal physiological g) Yellow fever c) Cancer 4. Viral Infections d) Infection (including STI) a) Exanthemata https://t.me/afkebooks  b) Mumps b) Delusional disorders c) Measles d) Rubella MUSCULOSKELETAL e) Herpes simplex 1. Back and Neck f) Herpes zoster 2. Connective tissue Disorders g) Viral meningitis 3. Foor and Ankle h) Influenza 4. Hand and Wrist 5. Hip MENTAL HEALTH 6. Knee 1. Alcohol and drug misuse and dependence 7. Rheumatological problemas a) Including co-morbidity and withdrawal a) Rheumatoid b) Substitution therapy b) Osteoarthrosis c) Acute intoxication c) Psoriatic d) Harmful use d) Lupus 2. Anxiety e) Polymyalgia rheumatica a) Including generalised anxiety disorder, phobias and OCD f) Gout b) Panic attack 8. Upper limb c) Obsessive compulsive disorder 9. Skeletal 3. Deliberate self harm a) Disorders of calcium homeostasis (osteoporosis, osteomalacia, Paget's) a) Overdose, poisoning and other self-harm b) Infections b) Suicidal risk c) Tumours (benign, malignant, secondaries) 4. Eating Problems d) Fractures of long bones a) Anorexia 10. Fractures b) Bulimia nervosa 5. Learning and communication problems Any cause NEUROLOGICAL a) Intellectual disability 1. Blackouts and Faints b) Acquired brain injury a) Loss of consciousness of any cause 6. Medically-unexplained physical symptons b) Vasovagal syncope a) Including psychosomatic disorders, c) Cough syncope b) somatisation disorders d) Effort syncope 7. Mood/ affective problems e) Micturition syncope a) Depressive disorders f) Carotid sinus syncope b) Bipolar disorders g) Epilepsy c) Suicidal risk h) Stokes Adams attacks 8. Organic Brain Sybdrome i) Hypoglycaemia a) Delirium j) Orthostatic hypotension b) Dementia k) Drop attacks c) Encephalopathy 2. Cranial Nerve Problems 9. Personallity and behavioural disorders a) Any cause including visual field defects a) Emotionally unstable personality disorder b) Multiple sclerosis (MS) b) Antisocial personality disorder c) Space occupying lesions c) Pathological gambling d) Bell’s palsy d) Pyromania 3. Falls 10. Psychosis a) Complications including subdural, extradural a) Schizoaffective disorder b) Any cause including environmental https://afkebooks.com  c) Dizziness g) Meningitis d) Vertigo (benign positional vertigo) h) Guillain-barre e) Ménières disease i) Cord infarction f) Ototoxicity j) Spinal artery thrombosis g) Vestibular nerve problems (Acoustic neuroma, vestibular neuronitis, k) Trauma herpes zoster, brain stem) l) Dissecting aortic aneurism 4. Headache m) Cauda equina lesions a) Any cause including environmental n) Management of paralysed patient b) Dizziness o) Leg weakness (spastic paraparesis, flaccid paraparesis, unilateral foot c) Vertigo (benign positional vertigo) drop, weak legs with no sensory loss, absent knee jerks and extensor d) Ménières disease plantars) e) Ototoxicity p) Recognition of different gait disorders f) Vestibular nerve problems (Acoustic neuroma, vestibular neuronitis, q) Stroke (mimics, risk factors, site of lesion, investigation management and herpes zoster, brain stem) treatment, rehabilitation, TIA, SAH) 5. Movment Disorder including tremor and gait r) Myopathy a) Abnormalities of the motor nervous system s) Myaesthenia gravis b) Chorea c) Athetosis RENAL d) Hemiballismus 1. Urine Abnormalitis e) Tics, myoclonus, dystonia and tardive dyskinesia a) Blood, protein, pH, volumes f) Parkinson’s disease b) Renal calculi g) Parkinsonism c) Renal tract obstruction 6. Peripheral nerve problem d) Retroperitoneal fibrosis a) Testing peripheral nerves e) Glomerulonephritis b) Dermatomes f) Nephrotic syndrome c) Including neuropathies of any cause g) Renal vein thrombosis d) Autonomic neuropathy 2. Renal Problems e) Mononeuropathy’s a) Urinary tract imaging f) Polyneuropathy’s b) Renal biopsy g) Bulbar palsy c) Acute renal failure h) MND d) Chronic renal failure, renal replacement therapy, renal transplantation i) Cervical spondylosis e) Interstitial nephritis j) Neurofibromatosis f) Nephrotoxins k) Syringomyelia g) Renal vascular disease 7. Seizure h) Renal tubular disease a) Epilepsy i) Inherited kidney diseases b) Convulsion j) Renal manifestations of systemic disease 8. Speech and Language 3. Urinary excretion 9. Weakness and Fatigue a) Oliguria and polyuria including renal failure; a) Cerebral artery territories b) urate b) Upper motor neurone vs lower motor neurone 4. Urinary Symptons c) Muscle weakness grading a) Pyelonephritis d) Cord compression b) Acute and chronic urinary tract infection (UTI) e) Transverse myelitis c) Frequency f) Carcinomatosis d) Incontinence https://t.me/afkebooks  e) Enuresis a) Endometriosis b) PID REPRODUCTIVE c) Dyspareunia 1. Contraception 8. Vulval and vaginal lump/lesions a) Oral contraceptive pill b) Intrauterine contraceptive devices (IUCDs) RESPIRATORY c) Implants 1. Breathlessness 2. Fertility Problems a) Pulmonary fibrosis a) Both male and female; b) Any infection, inflammation, including COPD, asthma, occupational lung b) including normal development in puberty disease, sleep apnoea and cyanosis 3. Normal Pregnancy and care c) Respiratory system examination, age related changes, chest x-ray a) Including prenatal diagnosis d) Pneumonia including CURB 65 b) Role of folic acid e) Chronic obstructive pulmonary disease (COPD), acute respiratory distress c) Risks to fetus including smoking, alcohol, food issues syndrome 4. Problems in Pregnancy f) Respiratory failure a) Including antepartum haemorrhage, postpartum haemorrhage and g) Pulmonary embolus miscarriage h) Pneumothorax b) Ectopic pregnancy i) Pleural effusion c) Pre-eclampsia, eclampsia and hyperemesis j) Extrinsic allergic alveolitis d) Thyroid disease in pregnancy k) Cryptogenic fibrosing alveolitis e) Epilepsy l) Industrial dust diseases f) Anticoagulation m) Obstructive sleep apnoea g) Prematurity n) Cor pulmonale h) Low birth weight 2. Chest Pain 5. Irregular vaginal bleeding a) Including any pleuritic cause a) Including antepartum haemorrhage, postpartum haemorrhage and b) Mesothelioma miscarriage c) Pneumothorax b) Ectopic pregnancy 3. Cough and Haemoptiasis c) Pre-eclampsia, eclampsia and hyperemesis a) Cough and haemoptysis d) Thyroid disease in pregnancy b) Bronchiectasis e) Epilepsy c) Cystic fibrosis f) Anticoagulation d) Fungi g) Prematurity e) Lung cancer h) Low birth weight f) Sarcoidosis 6. Pelvic mass 4. Wheeze/ Stridor a) Including antepartum haemorrhage, postpartum haemorrhage and a) Asthma – acute and chronic miscarriage b) Bronchodilators and steroids b) Ectopic pregnancy c) Pre-eclampsia, eclampsia and hyperemesis SERIOUSLY ILL PATIENT d) Thyroid disease in pregnancy 1. Collapse e) Epilepsy a) Subdural, extradural, intracerebral haemorrhage including subarachnoid f) AnticoagulationBreath haemorrhage (SAH) g) Prematurity b) Hypertensive encephalopathy h) Low birth weight c) Epilepsy 7. Pelvic Pain d) Addisonian crisis https://afkebooks.com  e) Drug poisoning c) hyperthermia f) Hypoglycaemia d) hypothermia g) Hyperglycaemia 5. Itchy ando r scaly rashes h) Hypoxia a) Excess hair i) Hypothermia b) Hair loss j) Encephalopathy c) Nail changes in systemic diseases 2. Fever/Infection d) Psoriasis a) Including pyrexia of unknown origin, septicaemia, meningitis and e) Fungal infections of nails neutropaenic sepsis 6. Hair and nail b) Bacterial viral meningitis a) Including eczema, c) Pneumonia b) dermatoses (psoriasis etc.) d) Acute severe asthma c) reactions (drugs/food) e) PE 7. Infections 3. Multiple Trauma a) Including viral, a) Including head injury and intra-abdominal injury b) bacterial and 4. Schock c) fungal infections a) Paracetamol overdose 8. Lumps b) Salicylate overdose a) Nodular lesions c) Any cause including blood loss b) Skin tumour d) Acute myocardial infarction (MI) c) BCC e) Intra abdominal blood loss d) Ganglion f) Massive pulmonary embolus 9. Moles and Pingmented lesios g) Burns a) Benign b) Vitiligo SKIN c) Malignant including melanoma 1. Bites and Stings 10. Ulcers a) Including infestations a) Arterial b) Insect b) Venous c) Fish c) Neuropathic d) Scorpion d) Malignant e) Snake f) Dog/cat bites UROLOGICAL g) Human bite 1. Groin scrotal pain and or swelling h) Scabies a) Torsion of testis i) Lice b) Hernias 2. Bullous c) Hydrocele a) Pemphigus d) Tumour b) Pemphigoid e) Orchitis 3. Dermatological manifestations of systemic disease f) Infection a) Endocrine 2. Urinary tract obstruction b) Cancer a) Calculus c) Connective tissue b) Tumours (benign and malignant) 4. Extreme of Temperature c) Strictures a) Burns, d) Bladder neck obstruction b) frostbite, e) Enuresis https://t.me/afkebooks  ANATOMY Questions&Answers Q-1 A 31 year old female with known gallstones undergoes a cholecystectomy. Unfortunately, she continues to have pain, and her liver function tests suggest an obstructive jaundice. An ERCP is performed which demonstrates a calculus lodged in the second part of the duodenum. What is the SINGLE most likely place that the stone was lodged? A. Hepatic duct B. Cystic duct C. Accessory pancreatic duct D. Hepatocellular ampulla E. Common hepatic duct ANSWER: Hepatopancreatic ampulla EXPLANATION: This question is purely testing your knowledge of the biliary tree anatomy. The Hepatopancreatic ampulla, otherwise known as the Ampulla of Vater, is formed from the pancreatic duct and the common bile duct. It opens into the second part of the duodenum. https://afkebooks.com Q-2 Which of the following is located at the level of the first lumbar vertebra (L1)? A. Mcburney’s point B. Stellate ganglion C. Deep inguinal ring D. Xiphoid process E. Transpyloric plane ANSWER: Transpyloric plane EXPLANATION: The first lumbar verebra is level with the anterior end of the ninth rib. This level is also called the important transpyloric plane, since the pylorus is at this level. Other important structures are also located at this level, they include; fundus of the gall bladder, coeliac trunk, superior mesenteric artery, termination of spinal cord, and hilla of kidneys. The Transpyloric plane, also known as Addison’s Plane, is an upper transverse line, located halfway between the jugular notch and upper border of the pubic symphysis. The plane in most cases cuts through the pylorus of the stomach, the tips of the ninth costal cartilages and the lower border of the first lumbar vertebra. Q-3 What anatomical structure or landmark lies just above the midpoint of the inguinal ligament? https://t.me/afkebooks A. Femoral artery pulse felt B. McBurney’s point C. Stellate ganglion D. Deep inguinal ring E. Transpyloric plane ANSWER: Deep inguinal ring EXPLANATION: The deep inguinal ring is located about 2.5 cm above the midpoint of the inguinal ligament Q-4 Which landmark or anatomical structure is located at the midpoint between the suprasternal notch and pubic symphysis? A. Fundus of the gallbladder B. McBurney’s point C. Stellate ganglion D. Deep inguinal ring E. Transpyloric plane ANSWER: Transpyloric plane EXPLANATION: The suprasternal notch (fossa jugularis sternalis) is also known as the jugular notch. The Transpyloric plane, also known as Addison’s Plane, is an upper transverse line, located halfway between the jugular notc and the upper border of the pubic symphysis. The plane in most cases cuts through the pylorus of the stomach, the tips of the ninth costal cartilages and the lower border of the first lumbar vertebra While it is true that the transpyloric plane passes through the fundus of the gall bladder, the fundus of the gallbladder is NOT at the midpoint between the suprasternal notch and pubic symphysis. It is on the same plane but it is more lateral nearer to the midclavicular line rather than midsternal line. https://afkebooks.com Q-5 A 24 year old patient 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 on his left hand and has a wrist drop. There is a loss of sensation over a small area between the dorsal aspect of 1st and 2nd metacarpals. What is the SINGLE most likely structure to be damaged? A. Radial nerve B. Median nerve C. Ulnar nerve D. Axillary nerve E. Suprascapular nerve ANSWER: Radial nerve EXPLANATION: Radial nerve (C5-T1) Motor to Extensor muscles (forearm, wrist, fingers, thumb) If damaged leads to wrist drop Sensory to If damaged – Sensory loss is variable, but always includes the dorsal aspect of the root of the thumb. Usually leads to loss to small area between the dorsal aspect of 1st and 2nd metacarpals https://t.me/afkebooks It is important to remember the key phrases for nerve damage during PLAB. There are certain phrases you need to memorise to relate it to a specific nerve damages. Examples Wrist drop – Radial nerve Foot drop – Either common peroneal nerve or sciatic nerve Claw hand – Ulnar nerve Paraesthesia of thumb, index and middle finger – Median nerve Numbness on superior aspect of upper arm just below shoulder joint – Axillary nerve Fibular neck fracture – Common peroneal nerve Femur neck fracture or Acetabular fractures – Sciatic nerve Fracture of humeral shaft – Likely Radial nerve Fracture of humeral neck – Likely Axillary nerve Monteggia fracture – Radial nerve Paraesthesia and impaired sensation in both hands (glove distribution) – Peripheral neuropathy Q-6 A 35 year old man sat cross-legged for 30 minutes after which he found himself unable to dorsiflex his left foot and had loss of sensation in the web space between the big toe and the second toe. What is the SINGLE most likely anatomical structure to be affected? https://afkebooks.com A. Femoral nerve B. Sural nerve C. Sciatic nerve D. Deep peroneal nerve E. Superficial peroneal nerve ANSWER: Deep peroneal nerve EXPLANATION: Deep peroneal nerve (Deep fibular nerve) Motor functions The deep peroneal nerve innervates the muscles in the anterior compartment of the leg which are responsible for dorsiflexion of the foot at the ankle joint. Sensory functions The deep peroneal nerve innervates the webbed space of skin between the great toe (hallux) and the second toe. Clinical relevance The deep peroneal nerve can become entrapped or compressed during its course through the anterior compartment of the leg, and so a patient loses the ability to dorsiflex the foot. With unopposed plantarflexion, their foot drops. There are two main reasons why the deep fibular nerve could be compressed. The first is that the anterior leg muscles have been excessively used and so are compressing the nerve with the anterior compartment. The patient will experience pain in the anterior leg. The other common cause is tight-fitting shoes, compressing the nerve beneath the extensor retinaculum. This commonly occurs with wearing tight ski boots (referred to as ski boot syndrome). The patient will experience pain in the dorsum of the foot. Q-7 A 55 year old man with a history of a stroke a year ago has severe difficulty remembering events in his life. This includes important events like the year he married his wife. Along with the long term memory impairment, he has altered sexual behaviour which has been seen after the stroke. He is also noted to have a visual defect after the stroke. What is the SINGLE most likely visual defect? A. Homonymous hemianopsia B. Upper homonymous quadrantanopias C. Lower homonymous quadrantanopias D. Binasal hemianopsia https://t.me/afkebooks E. Bitemporal hemianopsia ANSWER: Upper homonymous quadrantonopias EXPLANATION: This man has had a stroke affecting his temporal lobe. It is important to note that the most common cause of temporal lobe lesions is a cerebrovascular event (CVE). Several neural structures found in the temporal lobe are proposed to be involved in memory. This also includes structures closely related to it such as the amygdala, the hippocampus, and the rhinal cortes in the temporal lobe. Once you know that the temporal lobe is affected, you would be able to ansewr the question. The optic radiation passes through the temporal lobes. Damage to this can cause an upper homonymous quadrantanopias. Q-8 A 37 year old man has a nonhealing ulcer on the skin of the right medial malleolus. Which SINGLE lymph node is likely to be involved? A. Axillary lymph nodes B. Pre-aortic lymph node C. Aortic lymph node D. Inguinal lymph node E. External iliac lymph nodes ANSWER: Inguinal lymph node EXPLANATION: The skin at the medial malleolus drains into inguinal lymph nodes. Q-9 A 60 year old man was screwing his cupboard to the wall when he suddenly felt a rupture at the cubital fossa resulting in a swollen elbow with weakness on flexion and supination. A lump in the distal arm is seen. What is the SINGLE most likely diagnosis? A. Hand flexor tendon rupture B. De Quervain’s disease C. Biceps tendon rupture D. Tennis elbow E. Golfer’s elbow ANSWER: Biceps tendon rupture https://afkebooks.com EXPLANATION: The weakness and lump at distal arm are characteristic for a biceps tendon rupture. There are two types of biceps tendon rupture which are proximal and distal. Thankfully, this question does not require you to differentiate the two. Proximal biceps tendon rupture Ruptures of the proximal biceps tendon make up nearly all biceps ruptures Presents with the biceps muscle bunches up in the distal arm, causing the characteristic ‘Popeye muscle’ appearance. There is minimal loss of function. Distal biceps tendon rupture Distal biceps tendon rupture is usually caused by a single traumatic event involving flexion against resistance, with the elbow at right angle. Presents with a sudden tearing sensation resulting in a painful swollen elbow with weakness of flexion and supination. Q-10 What important landmark is found above the 5th intercostal space and anterior to the mid axillary line? A. Apex beat B. Chest drain insertion C. Stellate ganglion D. Transpyloric plane E. Vena cave opening into the diaphragm ANSWER: Chest drain insertion EXPLANATION: This landmark is especially important when attempting to insert a chest drain. Always look for the safe triangle when inserting chest drains. Insert the drain in an area anterior to mid axillary line, posterior to pectoral groove, and above the 5th intercostal space. Q-11 A camel rider sustained an injury to the lateral side of his right leg just below the knee caused by the camel stick. The site is slightly bruised and tender to touch. He is unable to either dorsiflex or evert the foot. There is loss of sensation over the front and outer half of the leg and dorsum of the foot. What is the SINGLE most likely anatomical structure to be affected? A. Sural nerve B. Common peroneal nerve C. Tibial nerve D. Lateral plantar nerve E. Medial plantar nerve https://t.me/afkebooks ANSWER: Common peroneal nerve EXPLANATION: This is actually called a peroneal strike. A peroneal strike is a temporarily disabling blow to the common peroneal nerve of the leg, just above the knee which causes a temporary loss of motor control of the leg, accompanied by numbness and a painful tingling sensation from the point of impact all the way down the leg, usually lasting anywhere from 30 seconds to 5 minutes in duration. Q-12 A 32 year man presents to A&E with a fracture dislocation of his right elbow. He complains of loss of sensation in his little finger and ring finger. Which is the SINGLE most likely nerve to be involved? A. Median nerve B. Radial nerve C. Superficial branch of radial nerve D. Axillary nerve ANSWER: Ulnar nerve EXPLANATION: Ulnar nerve (C8-T1) Sensory loss is over the little finger and a variable area of the ring finger (palmar & dorsal) This is the nerve of finger abduction and adduction. Injury level determins severity of the claw deformity. In a distal lesion of the ulnar nerve, there will be more clawing of the 4th and 5th fingers compared with a proximal, more complete lesion at the elbow. Q-13 A 75 year old woman was referred by her general practitioner to the same day ophthalmology clinic because of a 4 hour history of sudden painless loss of vision affecting her right eye. Her medical history includes hypertension and heavy smoking. Ophthalmic assessment showed visual acuity of light perception only in the right eye and 6/9 in the left eye. Apart from early questioning, the patient admitted that she had previously experienced episodes of vision loss in the same eye, which lasted for a few seconds to a few minutes. What is the most likely artery involved in this scenario? A. Anterior communicating artery B. Anterior cerebral artery C. Middle cerebral artery https://afkebooks.com D. Central retinal artery E. Posterior inferior cerebellar artery ANSWER: Central retinal artery EXPLANATION: Patients with central retinal artery occlusion have sudden painless loss of vision, usually within initial visual acuity of counting fingers or worse. Urgent management is required. The short episodes of previous vision loss is termed amaurosis fugax. This temporary painless type of vision loss procees loss of vision in up to 10% of patients with central artery occlusion. Amaurosis fugax is usually caused by emboli coming from atherosclerotic carotid artery resulting in a fleeting loss of vision when the emboli pass through the retinal circulation. Any temporary reduction in the retinal artery blood flow would cause retinal hypoxia which includes any emboli arising from vasculature preceding the retinal artery. The anatomy of the arterial supply of the eye is complicated. It is provided by several branches of the ophthalmic artery, which derives from the internal carotid artery. These branches include the central retinal artery, the short and long posterior ciliary arteries and the anterior ciliary arteries. The retina is mainly supplied by the central retinal artery and its branches which is a site of emboli. The other arteries are less likely to be involved as they present with additional symptoms. Anterior and middle cerebral artery occlusions have features of contralateral hemiparesis and sensory loss. Posterior inferior cerebellar artery has features of ipsilateral facial pain and temperature loss, contralateral limb/torso pain and temperature loss, ataxia and nystagmus Anterior communicating artery is a common site for brain aneurysms and if large enough to compress the optic chiasm visual defects such as bitemporal hemianopsia may occur Key points to remember Amaurosis fugax is the temporary loss of vision due most commonly to ischaemia Embolism is the most common cause of central retinal artery occlusion with the major source of this being atherosclerotic plaques of the carotid artery (as opposed to transient ischaemic attacks (TIA) involvind the cerebral hemispheres where emboli usually originates from heart disease instead of carotid stenosis) Q-14 A 45 year old man has been informed by his doctors that he has a carcinoma of https://t.me/afkebooks the head of the pancreas. Which SINGLE structure is in close proximity with the head of pancreas? A. Pylorus B. Aorta C. Left kidney D. Splenic artery E. Common bile duct ANSWER: Common bile duct EXPLANATION: The Common Bile Duct lies in close relation to the head of the pancreas. The initial presentation on about 70% of patients with carcinoma of the head of the pancreas is jaundice due to obstruction of the CBD by the tumour. Q-15 A 58 year old man underwent surgery for varicose veins of the leg. He is now complaining of numbness on the medial side of his foot. What is the SINGLE most likely nerve involved? A. Common peroneal nerve B. Tibial nerve C. Sural nerve D. Saphenous nerve E. Medial plantar nerve ANSWER: Saphenous nerve EXPLANATION: The Saphenous nerve is the largest cutaneous branch of the femoral nerve and is a strictly sensory nerve with no motor functions. Surgery for varicose veins, saphenous vein cutdown and orthopedic surgery can result in damage to the saphenous nerve, resulting in loss of cutaneous sensation in the medial leg. It can also be damaged during vein harvest for bypass surgery and during trocar placement during knee arthroscopy. Remember: Loss of sensationss in medial foot: Saphenous Nerve Loss of snesations in lateral foot: Sural nerve Foot drop: Common peroneal nerve Q-16 https://afkebooks.com A 33 year old man suffered a mandibular fracture and now has loss of sensation over the chin and mucosal surface of the lower lip. Which SINGLE nerve is most likely to be involved? A. Mandibular nerve B. Inferior alveolar nerve C. Buccal nerve D. Lingual nerve E. Facial nerve ANSWER: Inferior Alveolar Nerve EXPLANATION: The Inferior Alveolar Nerve is a branch of the Mandibular nerve, which is the third branch of the Trigeminal Nerve. The nerve supplies sensation to the lower teeth and via the mental nerve, sensation to the chin and lower lip. Damage can occur commonly during dental procedures especially wisdom teeth removal as well as due to mandibular trauma. Q-17 A 24 year old man is hit by a baton just above the knee on his right leg. This is followed by loss of motor control of the leg. His foot drops and is unable to dorsiflex his foot. There is loss of sensation over the front and outer half of the leg and dorsum of the foot. What is the SINGLE most anatomical structure to be affected? A. Sural nerve B. Common peroneal nerve C. Tibial nerve D. Lateral plantar nerve E. Medial plantar nerve ANSWER: Common peroneal nerve EXPLANATION: This is actually called a peroneal strike. A peroneal strike is a temporarily disabling blow to the common peroneal nerve of the leg, just above the knee which causes a temporary loss of motor control of the leg, accompanied by numbness and a painful tingling sensation from the point of impact all the way down the leg, usually lasting anywhere from 30 seconds to 5 minutes in duration. Q-18 A 32 year old woman has weakness of both her hands and neck pain immediately after a fall down a flight of stairs. She was brought in by a scoop stretcher by the https://t.me/afkebooks paramedics with a hard cervical collar, adhesive tape and sandbags to immobilize the neck. An X-ray was ordered. Which is the SINGLE lowest vertebrae that needs to be seen in a lateral cervical X-ray to help diagnose the injury? A. C4/C5 B. C5/C6 C. C6/C7 D. C7/T1 E. C8/T1 ANSWER: C7/T1 EXPLANATION: Hand weakness involves either median nerve which has contributions from C5-T1 or ulnar nerve which originates from the C8-T1 nerve roots. Remember, a C8 vertebrae does not exist and so the option for C8/T1 is clearly wrong. There are seven cervical vertebrae (C1-C7) and a total of eight cervical nerves C1-C8. All cervical nerves except C8 emerge above their corresponding vertebrae, while the C8 nerve emerges below the C7 vertebra that is between C7 and T1 vertebrae. When you request for a cervical X-ray for any severe injury of the neck, you would like the film to extend up to C7/T1 as you would be able to see the cervical vertebrae (C1- C7). This applies for any trauma including road traffic accidents. The patient should not try to move her neck and she should continue to have the cervical collar and immobilization of the neck until the cervical X-ray is performed to rule out cervical fractures. In this case, there should be at least 3 X-ray views taken. AP cervical spine view which shows the pedicles, facets and lateral masses Lateral cervical spine view Open-mouth odontoid view also called the peg view as would demonstrate peg fractures In some cases where the patient’s neck is short, the X-ray film would not show the C7/T1 junction. The radiographsers would then ask for a swimmers lateral view. This involves repositioning the patient in such a way that the arm closest to the sensor is placed above the patient’s head much like a swimming position. This would likely provide a clear visualisation of C7/T1 junction. If again, this does not capture that junction, then we would need to request a CT scan to rule out fractures Q-19 A 62 year old male comes to the GP complaining of double vision when climbing down the stairs. Which is the SINGLE most likely nerve to be affected? https://afkebooks.com A. Abducens nerve B. Trochlear nerve C. Oculomotor nerve D. Optic nerve E. Trigeminal nerve ANSWER: Trochlear nerve EXPLANATION: Trochlear nerve innervates the superior oblique muscle. It only causes diplopia on downgaze like looking downwards to walk. This is a high yield question in PLAB. Please remember the nerves involving the eye and how they present NERVES INVOLVING THE EYE Functions CN III – Oculomotor nerve Controls most of eye muscle Constriction of pupil Levator palpebrae suprioris CN IV – Trochlear nerve Innervates a single muscle – Superior oblique CN VI – Abducens nerve Lateral rectus muscle Palsies The simple method to remember for the exam is: CN III – Oculomotor nerve Will have features of either ptosis and/or a dilated pupil on the nerve on the same side as the affected eye Mnemonic: Letter “O” for oculomotor which with good imagination can represent a dilated pupil CN IV – Trochlear nerve Diplopia on downward gaze If looks right and sees double, then lesion is on the left (Opposite to gaze) CN VI – Abducens nerve If looks left and sees double, then lesion is on the left. (same side as gaze) Another mnemonic is: LR6(SO4)O3 https://t.me/afkebooks  Lateral rectus – 6th Nerve Superior oblique – 4th Nerve Others – 3rd Nerve Q-20 A 33 year old man complains of double vision when he looks to the right. Which is the SINGLE most likely nerve to be involved? A. Left abducens B. Right abducens C. Left trochlear D. Right trochlear E. Right oculomotor ANSWER: Right abducens nerve EXPLANATION: His right eye is unable to abduct thus he sees double. The nerve involved here would be the right abducens nerve. Q-21 A 32 year old patient presents to Accident & Emergency with a deep cut on the surface of her palm and the surface of the back of her wrist. She has an inability to extend the distal phalanx of her ring finger. What is the SINGLE most likely structure affected? A. Extensor digitorum B. Branch of ulnar nerve C. Flexor digitorum profundus D. Palmaris brevis E. Branch of median nerve ANSWER: Extensor digitorum EXPLANATION: Unfortunately, this is just something that you have to memorize Some other important clinchers for anatomy questions: Ulnar nerve (C8-T1) Sensory loss is over the little finger and a variable area of the ring finger (palmar & dorsal) This is the nerve of finger abduction and adduction. Injury level determines severity of https://afkebooks.com the claw deformity. In a distal lesion of the ulnar nerve, there will be more clawing of the 4th and 5th fingers compared with a proximal, more complete lesion at the elbow. The short saphenous vein is the only one which travels on the lateral aspect of the ankle. Note that the great or long saphenous vein travels on the medial aspect of the ankle. The left anterior descending (LAD, interventricular artery appears to be a direct continuation of the left coronary artery which descends into the anterior interventricular groove. The skin at the medial malleolus drains into inguinal lymph nodes. The first lumbar vertebra is level with the anterior end of the ninth rib. This level is also called the important transpyloric plane, since the pylorus of the stomach is at this level. The deep inguinal ring is located about 2.5 cm above the midpoint of the inguinal ligament. Full extension of right thumb is achieved by extensor pollicis longus The fundus of the gall-bladder approaches the surface behind the anterior end of the ninth right costal cartilage close to the lateral margin of the Rectus abdominis. The extensor digitorum communis extends the phalages, then the wrist, and finally the elbow. It tends to separate the fingers as it extends them. The suprasternal notch (fossa jugularis sternalis) is also known as the jugular notch The extensor pollicis brevis extends the thumb at the metacarpophalangeal joint. Whenever you see the word “foot drop” or “unable to dorsiflex: pick peroneal nerve. Radial nerve (C5-T1) Motor to Extensor muscles (forearm, wrist, fingers, thumb) If damaged – leads to wrist drop Sensory to If damaged – Sensory loss is variable, but always includes the dorsal aspect of the root of the thumb. Usually leads to loss to small area between the dorsal aspect of 1st and 2nd metacarpals. Facial nerve lesion leads to facial weakness and loss of taste sensation of anterior two third of tongue. https://t.me/afkebooks Vagus nerve lesion results in weak cough, vocal cord paralysis with dysphonia. There is also parasympathetic loss of innervation to respiratory, gastrointestinal and cardiovascular systems. Trigeminal nerve lesion presents with signs depending upon the level of lesion. Usually there is weakness of muscles of mastication, jaw deviates to side of weak pterygoid muscle and there is also loss of sensation on the face. Glossopharyngeal nerve lesion presents with loss of gag reflex, loss of taste sensation from posterior third of the tongue, loss of general sensation from posterior pharynx, tonsils and soft palate. Hypoglossal nerve is the twelfth cranial nerve XII, and innervates muscles of the tongue. Q-22 Which artery descends into the anterior interventricular groove? A. Acute marginal branch B. Left anterior descending artery C. Septal branches D. Circumflex artery E. Right coronary artery ANSWER: Left anterior descending artery EXPLANATION: The left anterior descending (LAD, interventricular) artery appears to be a direct continuation of the left coronary artery which descends into the anterior interventricular groove. Q-23 A 45 year old man presents to the clinic with herpes zoster over the dermatome of the maxillary branch of the trigeminal nerve. Which SINGLE type of mucosa will be affected along with the dermatome? A. Palate B. Cheek C. Conjunctiva D. Anterior 1/3 of the tongue E. Upper lip ANSWER: Palate EXPLANATION: To choose the correct answer, one should remember the maxillary nerve and the https://afkebooks.com structures that it supplies. The maxillary nerve carries sensory information from the lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses and parts of the meninges. The maxillary division of the facial nerve innervates both cheek and the palate (along with the upper lip, upper teeth, gums, nasal mucosa, roof of the pharynx, and the maxillary ethmoid and sphenoid sinuses). But pay attention, the question asks about which MUCOSA the maxillary branch of the trigeminal nerve innervates so the best answer will therefore be palate as it is a mucous membrane. Q-24 A 73 year old woman with rheumatoid arthritis is unable to extend the fingers of her right hand at the metacarpophalangeal joint and interphalangeal joints following a fall. What is the SINGLE most likely tendon to have been damaged? A. Extensor carpi radialis B. Extensor carpi ulnaris C. Extensor digitorum D. Extensor indicis E. Flexor digitorum profundus ANSWER: Extensor digitorum EXPLANATION: The extensor digitorum communis extends the phalanges, then the wrist, and finally the elbow. It tends to separate the fingers as it extends them. Q-25 A 46 year old man is being treated for a pleural effusion. A chest drain has been sited just below the 4th rib, anterior to the mid-axillary line on his right side. What SINGLE structure is at particular risk of injury? A. Azygous vein B. Diaphragm C. Intercostal artery D. Internal thoracic artery E. Liver ANSWER: Intercostal artery EXPLANATION: When inserting a chest drain, one needs to be aware of the intercostal neurovascular bundle. This is located at the inferior aspects of the ribs. https://t.me/afkebooks The intercostal neurovascular bundle contains structures in a specific order which can be remembered as “VAN”. This stands for V – Vein A – Artery N – Nerve This order is from top to bottom The options in this question only have onf of the structures of the intercostal neurovascular bundle which is the intercostal artery. Hence that is the answer. Having this knowledge of the location of the intercostal neurovascular bundle would help you remember to insert the needle directly above the upper margin of the relevant rib. Chest drain Insertion technique Chest insertion should be performed within the “safe triangle” In the exam, it is important to remember the borders of the “Safe triangle” which is used in clinical practice for chest drain insertions. It is bounded anteriorly by pectoralis major, posteriorly by latissimus dorsi, inferiorly by the fifth intercostal space, and superiorly by the axilla. By inserting at the safe triangle, we avoid major vessels and muscles. It is important to note that the intercostal vessels and nerves run below the inferior border of the ribs. Thus, the drain track should be directed ove the top of the lower rib to avoid the intercostal vessels lying below each rib. Q-26 A 53 year old man has reduced sensation on the medial and posterior aspect of his lower left forearm and tingling described as “pins and needles” in his left hand. He also has weakness of thumb extension and wrist ulnar deviation. There is wasting of the muscles of the left hand. What is the SINGLE most likely structure affected? A. Ulnar nerve at elbow B. Median nerve at elbow C. Median nerve at wrist D. C8 nerve root E. T1 nerve root ANSWER: C8 nerve root EXPLANATION: The C8 nerve root exits the spinal cord at the C7-T1 spinal segment. If the C8 nerve https://afkebooks.com becomes compressed or irritated for any reason, then C8 radiculopathy will occur. Symptoms of a C8 radiculopathy include weakness of thumb extension and wrist ulnar deviation. Paresthesias in the little finger is also a finding in C8 radiculopathy. The test to perform to identify C8 radiculopathy is to have the patient hold their extended fingers together against the examiner’s attempts to open the fingers. It is important in this question to differentiate between pure ulnar neuropathy and C8-T1 radiculopathies. The ulnar nerve provides sensation to the fourth and fifth fingers and medial border of the hand. The ulnar nerve innervates all intrinsic hand muscles, except the abductor and flexor pollicis brevis, opponens pllicis, and lateral two lumbricals, which are innervated by C8 and T1 via the median nerve. By examining these five muscles, one can clinically differentiate cubital tunnel syndrome from C8-T1 radiculopathies. The ulnar nerve does not provide sensation to the medial forearm, which is innervated by the medial antebrachial cutaneous nerve which is supplied by C8 and T1 via the medial cord of the brachial plexus. Therefore, an ulnar lesion at the elbow which is a common site of compression or trauma would result in anaesthesia of the ulnar hand and fingers but not the forearm. Q-27 A 64 year old woman has difficulty in moving her right shoulder on recovering from surgery of the posterior triangle of her neck. What is the SINGLE most likely anatomical structure to be affected? A. Accessory nerve B. Glossopharyngeal nerve C. Hypoglossal nerve D. Vagus nerve E. Brachial plexus ANSWER: Accessory nerve EXPLANATION: The accessory nerve is a cranial nerve that controls the sternocleidomastoid and trapezius muscles. Injury to the spinal accessory nerve can cause an accessory nerve disordre or spinal accessory nerve palsy, which results in diminished or absent function of the sternocleidomastoid muscle and upper portion of the trapezius muscle. Q-28 A 55 year old man presents with an ulcer of the scrotum. Which is the SINGLE most likely lymph node involved in it’s lymphatic drainage? https://t.me/afkebooks A. External iliac lymph node B. Pre-aortic lymph node C. Aortic lymph node D. Inguinal lymph node E. Cervical lymph node ANSWER: Inguinal lymph node EXPLANATION: The superficial inguinal lymph nodes receive afferents lymphatic vessels from the scrotum. Q-29 A 72 year old woman has had a stroke a month ago. Since then she has had left upper and left lower limbs which are paralyzed and she has difficulty in speaking. Which is the SINGLE most likely anatomical site to be affected? A. Thalamus B. Cerebellum C. Internal capsule D. Hippocampus E. Brainstem ANSWER: Internal capsule EXPLANATION: For the exam, know these three general areas of infarct. Cerebral infarct Contralateral sensory loss/hemiplegia, dysphasia, homonymous hemianaopia. Brainstem infarct Quadriplegia, locked-in syndrome, vertigo, diplopia Lacunar infarcts Ataxic hemiparesis, pure motor loss, pure sensory loss, sensorimotor loss, dysarthria Although this patient is having difficulty in speaking, the most likely area of infact is still the internal capsule (which is part of the lacunes). Q-30 A 35 year old man is due for a surgery to attempt to removal of a glioma. What is the SINGLE most likely anatomical structure to be opened durign the surgery? https://afkebooks.com A. Cricoid cartilage B. Rectus sheath muscle C. Dura Mater D. Conjoined tendon E. Intercostal muscles ANSWER: Dura Mater EXPLANATION: Gliomas are tumours arising from glial cells andmay occur in the spinal cord or the brain. The dura mater, which is a thick membrane of the outermsot three layers of the meninges that surround the brain and spinal courd would need to be opened for the surgery to take place. Q-31 A 69 year old woman has been diagnosed with left ovary carcinoma. What lymph nodes are likely to be removed? A. Superficial inguinal nodes B. Deep inguinal nodes C. Sacral nodes D. Para-aortic nodes E. Iliac nodes ANSWER: Para-aortic nodes EXPLANATION: The lymphatic drainage of the ovaries are into the para-aortic nodes. Q-32 A 68 year old woman is unable to extend the interphalangeal joint of her right thumb six weeks following a fracture of the right radius. The other fingers and thumb movements are unaffected. What is the SINGLE most likely tendon to be damaged? A. Abductor pollicis longus B. Extensor pollicis brevis C. Extensor pollicis longus D. Flexor digitorum profundus E. Flexor pollicis longus https://t.me/afkebooks ANSWER: Extensor pollicis longus EXPLANATION: Full extension of right thumb is achieved by extensor pollicis longus. Q-33 A 12 year old boy presents with a painful swollen knee after a sudden fall on his right knee. The pain is localized below the knee cap. Which SINGLE anatomical structure is most likely to be affected? A. Semimembranous bursa B. Prepatellar bursa C. Pretibial bursa D. Suprapatellar bursa E. Pes anserine bursa ANSWER: Prepatellar bursa EXPLANATION: Prepatellar bursa The prepatellar bursa is a frontal bursa of the knee joint. It is a superficial bursa with a thin synovial lining located between the skin and the patella. Prepatellar bursitis classically occurred in housmaids, hence the nickname ‘housemaid’s knee’. It is commonly seen in people who knee such as plumbers. Friction caused by repeated kneeling can cause it. It is a common cause of swelling and pain over the anterior inferior patella. Symptoms Redness Inability to flex the knee Pain and swelling is localized over site of bursa (e.g. below patella) Rest usually relieves symptoms. Q-34 A 34 year old man has a white patch on the margin of the mid-third of his tongue. Which is the SINGLE most likely lymph node involved? A. External iliac lymph node B. Submandibular lymph node C. Submental lymph node D. Deep cervical lymph node E. Aortic lymph node https://afkebooks.com ANSWER: Submandibular lymph node EXPLANATION: The anterior 2/3 of the tongue is supplied by the submandibular lymph nodes. The posterior 1/3 of the tongue is supplied by the jugulo-omohyoid lymph nodes The tip of the tongue is supplied by the submental lymphnodes Q-35 A 45 year old man has a cancer of the posterior oropharynx. What is the SINGLE most likely lymph node to be involved? A. Submental nodes B. Submandibular nodes C. Deep cervical nodes D. Occipital nodes E. Axillary nodes ANSWER: Deep cervical nodes EXPLANATION: The posterior oropharynx predominantly drains into the jugular nodes. The jugular nodes are also known as the deep cervical nodes though that is an outdated terminology. Q-36 A 36 year old male involved in a street fight presents to Accidents and Emergency with bruises and deformity of his lower right knee. He was given pain relief and an X-ray was ordered. The X-ray shows a fracture of the neckof the fibula. What is the SINGLE most associated nerve injury? A. Sciatic nerve B. Femoral nerve C. Musculocutaneous nerve D. Common peroneal nerve E. Tibial nerve ANSWER: Common peroneal nerve EXPLANATION: Peroneal nerve injury https://t.me/afkebooks  The common peroneal nerve crosses the fibular neck and is susceptible to injury from a fibular neck fracture, the pressure of a splint or during surgical repair. Peroneal nerve injury mayresult in foot drop and sensation abnormalities. Q-37 You are observing a medical student perform a neurological examination on a patient. They forget to perform the reflexes so you decide to quiz them on their neuroanatomy. Which of the following reflexes and innervating spinal nerves are correctly paired? A. Anal reflex – S1 B. Ankle jerk – L5 C. Biceps jerk reflex – C7 & C8 D. Knee jerk reflex – L3 & L4 E. Triceps jerk reflex – T1 ANSWER: Knee jerk reflex – L3 & L4 EXPLANATION: It is important to understand the nerve root innervation of the common reflexes. This is not always exact science, and there may be slight variations depending on which textbook you read. Damage to the associated nerves can also lead to diminished reflexes. REFLEX ACTION INNERVATION Anal (anal wink) reflex Contraction of external anal sphincter S2-S4 muscle on stroking the skin around the anus Ankle reflex The Achilles tendon is struck causing S1&S2 plantar flexion of the foot Sciatic nerve Knee (patella) reflex The patellar ligament is struck L3 & L4 causing contraction of the quadriceps Femoral nerve muscle Biceps reflex The biceps brachii tendon is struck C5 & C6 causing flexion at the elbow Musculocutaneous nerve Brachioradialis The brachioradialis is struck causing C6 & C7 (supinator reflex) wrist extension with radial deviation Radial nerve Triceps reflex The triceps brachii tendon is struck C6 & C7 causing extension Radial nerve Q-38 A 23 year old man is having difficulty in speaking following a stab wound to the right of his neck. On tongue protrustion test, the tip of tongue is deviated to the right. Which of the following nerve is the SINGLE most likely to be affected in https://afkebooks.com this patient? A. Facial nerve B. Hypoglossal nerve C. Vagus nerve D. Trigeminal nerve E. Glossopharyngeal nerve ANSWER: Hypoglossal nerve EXPLANATION: The hypoglossal nerve is the twelfth cranial nerve XII, and innervates muscles of the tongue. The following are the common causes of this nerve injury: a. Lower motor neuron lesions – Polio, syringomyelia b. Stroke c. Bulbar Palsy d. Neck trauma e. Surgery – Carotid endarterectomy Symptoms often show deviation of the tongue towards the paralyzed side when it is stuck out. This is because of the weaker genioglossal muscle. Other lesions: Facial nerve lesion leads to facial weakness and loss of taste sensation of anterior two third of tongue. Vagus nerve lesion results in weak cough, vocal cord paralysis with dysphonia. There is also parasympathetic loss of innervation to respiratory, gastrointestinal and cardiovascular systems. Trigeminal nerve lesion presents with loss of gag reflex, loss of taste sensation from posterior third of the tongue, loss of general sensation from posterior pharynx, tonsils and soft palate. Q-39 What SINGLE anatomical landmark correlates to the tip of the 9th costal cartilage? A. Fundus of the gallbladder B. Deep inguinal ring C. Termination of the spinal cord D. Stellate ganglion E. Inferior vena cava passing through the caval opening https://t.me/afkebooks ANSWER: Fundus of the gallbladder EXPLANATION: The fundus of the gall-bladder approaches the surface behind the anterior end of the ninth right costal cartilage close to the lateral margin of the Rectus abdominis. Q-40 A 63 year old woman presents to the Emergency Department with an inability to flex the proximal interphalangeal joint of her fingers of the left hand. Upon further questioning, she reveals that she has broken a wine glass and caused a cut on the surface of her left hand. She also had no previous procedure done to her hand. On examination, there was 2x2 cm clean cut on the left hand. Extension at wrist joint was normal with no problem in adduction and abduction of the hand. However, she was unable to flex her first metacarpophalangeal joint. An X-ray of the left hand was done which was normal. What structure is most likely to be injured in her case? A. Flexor digitorum profundus B. Flexor digitorum superficialis C. Lumbrical muscles D. Flexor digiti minimi E. First dorsal interossei ANSWER: Flexor digitorum superficialis EXPLANATION: The correct answer is Flexor digitorum superficialis because it causes flexion at metacarpophalangeal joints (MCP), as well as at the interphalangeal joint (IP) There is no doubt that flexor pollicis brevis flexes MCP joint of thumb but here we do not have that as an option. Moreover, the patient is also unable to flex proximal interphalangeal joints of her left hand. Hence, flexor digitorum superficialis flexes both, the MCP JOINT as well as the IP JOINTS of the hand so the best answer here is flexor digitorum superficialis. Flexor digitorum profundus, causes flexion of the distal interphalangeal joint (DIP), therefore, this is not correct. Lumbrical muscles are intrinsic muscles of the hand that simultaneously flex the https://afkebooks.com metacarpophalangeal joints and extend the interphalangeal joints. The flexor digiti minimi is a hypothenar muscle that causes flexion of the 5 th digit (the little finger) at the metacarpophalangeal joint. The dorsal interosseous muscles arise between the metacarpal bones and are abductors of the fingers. Q-41 A 63 year old lady with a BMI of 32 has pigmentation on her legs. Dilated veins could be seen on the lateral aspect of her ankles. Which SINGLE structure would be involved? A. Short saphenous vein B. Long saphenous vein C. Deep venous system D. Popliteal veins E. Sapheno-femoral junction ANSWER: Short saphenous vein EXPLANATION: The short saphenous vein is the only one which travels on the lateral aspect of the ankle. Note that the great or long saphenous vein travels on the medial aspect of the ankle. Q-42 A 15 year old boy complains of double vision when climbing down the stairs. This has occurred since he was hit in the face. The images that he sees appear one above the other. He also notices double vision when he looks to the right. What is the SINGLE most likely nerve to be affected? A. Left abducens nerve B. Left trochlear nerve C. Left oculomotor nerve D. Right trochlear nerve E. Right abducens nerve ANSWER: Left trochlear nerve https://t.me/afkebooks EXPLANATION: Trochlear nerve innervates the superior oblique muscle. It only causes diplopia on downgaze like looking downwards to walk. It is a trochlear nerve lesion on the left side because he sees double when looking on the right side. This is a high yield question in PLAB. Please remember the nerves involvingthe eye and how they present. Q-43 What is the lymphatic drainage of the testes? A. Superficial inguinal nodes B. Internal iliac lymph nodes C. Deep inguinal nodes D. External iliac lymph nodes E. Para-aortic nodes ANSWER: Para-aortic nodes EXPLANATION: The lymphatic drainage of the testes is into the para-aortic nodes. Both the male and female gonads drain into the para-aortic nodes. Remember, the testes drain into the para-aortic node but the scrotum drains into the superficial inguinal nodes. Q-44 A 48 year old main with a known posterior gastric ulcer presents with excruciating pain which subsides after analgesia. 8 days later, he becomes unwell and has a temperature of 38.5 C. A collection in the peritoneum is suspected. Where is the SINGLE most likely location of the collection? A. Lesser sac B. Inferior diaphragm C. Paracolic gutter D. Pouch of Douglas E. Greater sac ANSWER: Lesser sac EXPLANATION: Posterior gastric ulcers arising from the fundus or body of the stomach erode into the lesser sac behind the stomach. The lesser sac is a potential space and is less effective in sealing off the perforation. This results in accumulation of gastric contents and pus https://afkebooks.com resulting in the formation of an abscess which will then pass into the peritoneal cavity through the Foramen of Winslow leading to generalized peritonitis. In contrast, posterior perforation of pyloric and duodenal ulcers result in a retroperitoneal abscess. Q-45 A 45 year old man was hit on his back by a chair during a fight. He presents with back pain and bruising. The back pain is specifically at the midpoint of the spine at the level of the iliac crest. Which vertebrae is likely to be affected? A. L2 B. L3 C. L4 D. L5 E. S1 ANSWER: L4 EXPLANATION: L4 is at the level of the iliac crest. Most anaesthetist would know this as the supracristal plane which is the highest point of the iliac crest typically sits at the level of L4 vertebrae which is a landmark for identification of L4/5 where a lumbar puncture can be performed. Q-46 A 55 year old man with rheumatoid arthritis struck his hand against a door. On examination, he could extend the interphalangeal joint of his right thumb but the metacarpophalangeal joint of the thumb remained flex. What is the SINGLE most likely tendon to have been damaged? A. Extensor carpi ulnaris B. Exensor digitorum C. Extensor indicis D. Extensor pollicis brevis E. Extensor pollicis longus ANSWER: Extensor pollicis brevis EXPLANATION: The extensor pollicis brevis extends the thumb at the metacarpophalangeal joint. Q-47 A 33 year old man presents with outward gaze and ptosis of his right eye. He also complains of seeing double. Which is the SINGLE most likely nerve to be affected? https://t.me/afkebooks A. Left trochlear B. Left oculomotor C. Right trochlear D. Right abducens E. Right oculomotor ANSWER: Right oculomotor EXPLANATION: The nerve involved here would be the right oculomotor nerve. This is a high yield question in PLAB. Please remember the nerves involving the eye and how they present. Q-48 What is the SINGLE most likely anatomical structure to be pierced when inserting a drain in the mid-axillary line? A. External iliac muscle B. Linea alba C. Rectus sheath muscle D. Conjoined tendon E. Intercostal muscles ANSWER: Intercostal muscles EXPLANATION: Please see Q-25 for Chest Drain Insertion Technique Q-49 A 32 year old man has complaints of pain on the medial side of his left forearm. There was also associated weakness of finger abduction and finger adduction, as well weakness upon adduction of his thumb. Finger flexion was normal. On inspection, atrophy of the muscles of his left hand was noted. What is the SINGLE most likely associated injury? A. T1 nerve root injury B. C8 vertebral injury C. Median nerve injury D. Ulnar nerve injury E. C6 nerve root injury ANSWER: T1 nerve root injury https://afkebooks.com EXPLANATION: A T1 lesion presents with movement disorders that affect the intrinsic muscles of the hand such as adduction or abduction of the digits. Paraesthesiae and pain can also occur along the affected nerve. The cervical spine is comprised of seven vertebrae only. A C8 vertebral injury is physically impossible and hence cannot be the right answer. A C8 nerve root lesion presents with abnormalities of thumb movement primarily, as well as an ainablity to extend the elbow against resistance. T1 radiculopathy have similarities of clinical findings to C8 radiculopthy, so be thankful that the option was C8 vertebral injury and not nerve root injury. The ulnar nerve originates from the C8-T1 nerve roots. Ulnar nerve injury leads to the classic ‘claw hand’ deformity. Since the ulnar nerve provides sensory innervation to the medial side of the hand, fifth digit and the medial half of the fouth digit, injury to it will cause loss of sensation or paraesthesiae in those areas. A C6 lesion affects the sensation of the thumb, flexion of the elbow and rotation of the forearm. It usually occurs in conjunction with C5 injury. One may see this during delivery of a baby which is known as Erb’s palsy. Here aree some easy points to remember regarding motor function for cervical roots Flex elbow – C5 Extend wrist – C6 Extend elbow – C7 Flex fingers – C8 Adduct and abduct fingers – T1 Try to do the above sequence like a strange dance to help you memorise it. https://t.me/afkebooks  CARDIOLOGY Questions & Answers Q-1 A 66 year old man presents to the hospital with palpitations. An ECG taken shows atrial fibrillation. He has no history of any ischaemic heart diseases. His blood pressure is 110/70 mmHg, heart rate is 130 beats/minute and respiratory rate is 20 breaths/minute. He looks sweaty on examination. His chest is clear clinically on auscultation. What is the SINGLE most approprite management? A. Adenosine B. Metoprolol C. Electrical cardioversion D. Amiodarone E. Digoxin ANSWER: Metoprolol EXPLANATION: Rate control medications such as metoprolol should be given first as he is hemodynamically stable. If rate control medications fail, then we could try rhythm control. Digoxin as part of rate control should not be used as first line unless there is evidence of congestive heart failure. Remember, the most important part of management for atrial fibrillation is preventing strokes and controlling patient’s symptoms. Converting patients back to sinus rhythm is not always the main goal. Atrial fibrillation management The clinical presentation of atrial fibrillation can vary. Some patients are asymptomatic; others may have life-threatening complications (e.g. heart failure or angina). The management depends on the underlying cause and the presence of symptoms. There are two wide categories for management: 1. Rhythm control (cardioversion) 2. Rate control https://afkebooks.com Rhythm Control If the patient has signs of shock, syncope, acute cardiac failure, or ischaemia then perform electrical cardioversion under sedation. This is rarely necessary. There is also the option of chemically cardioverting with flecainide or amiodarone. If the patient has had symptoms for more than 48 hours, there is a risk of cardiac thromboembolism when cardioverted. So in these cases, rate control medications and low molecular weight heparin are better choices. Rate control Rate control medications include beta blockers (metoprolol), rate limiting calcium channel blockers (diltiazem or verapamil) and digoxin. For rate control, beta blockers or rate limiting calcium channel blockers are first choice. Digoxin 500 mcg is usually the choice of drug if the patient suffers from congestive heart failure. Example of how rate control is performed: 1. Either a beta-blocker (metoprolol 2.5 mg up to 5 mg IV over 5 min, which can be repeated at intervals of 10 min to a maximum of 10 mg, or 50 mg orally) or a rate-limiting calcium blocker (verapamil 2.5 mg IV over 2 min, which can be repeated at intervals of 5 min to a maximum of 10 mg) but not both 2. If rate does not fall sufficiently, add digoxin 3. Where heart failure is a clinical issue, start with digoxin. 4. Also give thromboprophylaxis. Persistent AF is considered AF that is not self-terminating lasting longer than 7 days, or prior cardioversion. This is a general idea of when we should use rhythm control and rate control. Factors towards rhythm control first for patients with persistent AF Who are symptomatic Who are younger Presenting for the first time with lone AF Factors towards rate-control first for patients with persistent AF: Over 65 If patient is stable and AF started more than 48 hours ago Who are unstable for cardioversion such as o A long history of AF (usually > 12 months) o A history of multiple failed attempts at cardioversion and/or relapses Q-2 A 55 year old man has sudden onset of central chest pain and shortness of breath 3 hours ago. He looks pale and sweaty. An ECG was done in the https://t.me/afkebooks Emergency Department and is seen below: What is the SINGLE most likely diagnosis based on this ECG? A. Left bundle branch block B. Right bundle branch block C. Second degree heart block D. Third degree heart block E. Supraventricular tachycardia ANSWER: Left bundle branch block EXPLANATION: This could be potentially a case of a myocardial infarction. A new LBBB in the context of cardiac chest pain is traditionally considered part of the criteria for thrombolysis. It is extremely important to recognise a LBBB on an ECG. Q-3 Which of the following may cause the abnormalities of the QRS axis shown on this ECG? https://afkebooks.com A. Inferior myocardial infarction B. Pulmonary embolism C. Anterolateral myocardial infarction D. Right ventricular hemiblock E. Chronic lung disease ANSWER: Inferior myocardial infarction EXPLANATION: The first step is to recognise that there is left axis deviation on this ECG. https://t.me/afkebooks The easiest method to recognise this is to: 1. Find the lead with smallest or equiphasic deflection. In this case it would be lead aVR. 2. Look for the leads which are at right angles to the first lead you picked. This would be lead III. 3. Look at the net deflection at the second lead (which in this ECG your eyes would be looking at lead III. Since lead III has a negative net deflection (seen on yellow circle on ECG), this is a left axis deviation. This can be confirmed by looking at lead aVL where you would see a positive net deflection (seen on blue circle on ECG). To recap: Lead with smallest deflection is aVR Lead at right angles to aVR is lead III Net deflection in lead III is negative Thus AXIS is -60 which falls under left axis deviation A common cause of left axis deviation is inferior myocardial infarction Remember, this question is not asking if this is an inferior myocardial infarction hence the ECG does not show the typical ST elevation in leads II, III, and aVF. This question is asking, what abnormalities could represent a left axis deviation of which inferior myocardial infarction is the only option. ECG causes of axis deviation https://afkebooks.com Common causes of left axis deviation (LAD) Left ventricular hypertrophy (LVH) Left anterior fascicular block (or hemiblock) Inferior myocardial infarction Less common causes of left axis deviation (LAD) Obesity Wolff Parkinson White syndrome Causes of right axis deviation Right ventricular hypertrophy Thin tall Chronic lung disease Pulmonary embolism Left posterior hemiblock Lateral myocardial infarction Lateral wall of the left ventricle is supplied by left anterior descending. Infarction here would cause an axis deviation away from site of infarction. Causes of extreme right axis deviation (Also known as “no man’s land” or “northwest axis”) Congenital heart disease Left ventricular aneurysm Rules of Thumbs for Determining Cardiac Axis Deviation on ECG Look at lead I and Lead III A positive deflection means thumbsup and a negative deflection means thumbsdown Q-4 A 60 year old man had a myocardial infarction 2 weeks ago. He now presents with dyspnoea and pleuritic chest pain. A pericardial friction rub was noticed on examination. ECG shows widespread ST elevation. A chest x-ray shows an enlarged, globular heart. His pulse rate is 95 beats/minute and his respiratory rate is 24 breaths/minute. What is the SINGLE most likely cause of his symptoms? A. Cardiac tamponade B. Mitral regurgitation C. Dressler’s syndrome D. Atrial fibrillation E. Pulmonary embolism ANSWER: Dressler’s syndrome EXPLANATION: The widespread ST elevation and pericardial friction rub is seen in pericarditis. The chest X-ray showing an enlarged, globular heart points towards pericardial effusion. Dressler’s syndrome would explain all the findings. https://t.me/afkebooks Dressler’s syndrome tends to occur around 2-6 weeks following an MI. The underlying pathophysiology is thought to be an autoimmune reaction against antigenic proteins formed as the myocardium recovers. It is characterised by a combination of fever, pleuritic pain, pericardial effusion and a raised ESR. It is treated with NSAIDs. Q-5 A 62 year old man has a routine ECG pre-operatively for an elective osteoarthritic knee replacement. He is in sinus rhythm, and the WRS complex is not prolonged. There is a gradual prolongation of the PR interval, followed by a dropped beat every 3 or 4 QRS complexes. The ECG machine is unable to calculate the PR interval. The patient does not complain of any palpitations. What is the SINGLE most likely diagnosis? A. Sinus bradycardia B. 1st degree heart block C. Mobitz type 1 block D. Mobitz type 2 block E. Complete heart block ANSWER: Mobitz type 1 block EXPLANATION: Mobitz type 1 block→Gradual prolongation of PR interval followed by a dropped beat. 1st degree heart block is a prolongation of the PR interval (beyond 0.2 seconds). It is a benign condition that does not require additional follow up or management. It is not usually associated with symptoms and doe