1 to 100

Question 1

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

Answer 1

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 hem

Question 2

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

Answer 2

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 (though small cell carcinoma is usual cause but squamous cell carcinoma can produce ectopic ACTH as paraneoplastic syndrome also)].

Question 3

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

Answer 3

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].

Question 4

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

Answer 4

Ans. The key is B. Prostate Carcinoma. Explanation 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 leve

Question 5

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

Answer 5

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 it is not 1st choice). If SSRI cannot be used Mirtazapine is recommended as next antidepressant].

Question 6

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

Answer 6

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].

Question 7

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

Answer 7

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].

Question 8

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

Answer 8

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

Question 9

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

Answer 9

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)].

Question 10

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 negat

Answer 10

Ans. The likely key is A. Joint aspiration for cytology and culture and sensitivity. [Case of septic arthritis. 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].

Question 11

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

Answer 11

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) hormonetherapy

Question 12

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

Answer 12

Ans. The key is A. Shingles. [Here ophthalmic division of trigeminal nerve is involved. Typically shingles are unilateral].

Question 13

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

Answer 13

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 wi

Question 14

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

Answer 14

“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, smel

Question 15

15. A clinical picture of breast cancer originated from the mammary duct. Biopsy was done and 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.

Answer 15

Ans. The key is C. Small cells with round nucleus and scant indistinct cytoplasm (Lobular carcinoma)

Question 16

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

Answer 16

Ans. The key is B. Oculomotor nerve. [3rd nerve damage can cause fixed dilated pupil].

Question 17

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

Answer 17

Ans. The key is D. Universal prevention application protocol.

Question 18

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

Answer 18

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].

Question 19

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

Answer 19

“Ans. The key is B. Chicken pox. [Centripetal distribution of blisters favours chickenpox. 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].”

Question 20

20. A 64yo pt has been having freq episodes of secretory diarrhea, which is extremely watery, with large amounts 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

Answer 20

Ans. Key not given. Correct key is both C and D! [Villous adenoma can cause both hyponatremia and hypokalemia].

Question 21

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

Answer 21

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.

Question 22

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

Answer 22

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].

Question 23

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

Answer 23

Ans. The key is D. Replace morphine with oxycodone.

Question 24

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

Answer 24

Ans. The key is A. CA 125. [Ovarian ca is the likely diagnosis for which tumour marker is CA125].

Question 25

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

Answer 25

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)].

Question 26

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

Answer 26

Ans. The key is A. Capillary blood sugar. [Alcohol induced hypoglycemia can present as this case].

Question 27

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

Answer 27

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].

Question 28

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

Answer 28

Ans. The key is c. [A case of TIA. Probable cause carotid artery atherosclerosis].

Question 29

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

Answer 29

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].

Question 30

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

Answer 30

Ans. The key is B. Right abducens. [Diplopia on seeing to right indicates right lateral rectus palsy which is supplied by right abducent nerve].

Question 31

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

Answer 31

Ans. The key is B. OCD. [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].

Question 32

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

Answer 32

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].

Question 33

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

Answer 33

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.

Question 34

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

Answer 34

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].

Question 35

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

Answer 35

Ans. The key is B. Obturator nerve. [The Obturator nerve is responsible for the sensory innervation of the skin of the medial aspect of the thigh].

Question 36

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

Answer 36

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 t

Question 37

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

Answer 37

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].

Question 38

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

Answer 38

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].

Question 39

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

Answer 39

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].

Question 40

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

Answer 40

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].

Question 41

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

Answer 41

Ans. Key is B. IV NS. [It is a case of rhabdomyolysis which is initially treated with IV NS].

Question 42

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.

Answer 42

Ans. . The key is B. Low serum Na, low serum osmolarity, high urine osmolarity.

Question 43

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

Answer 43

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].

Question 44

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

Answer 44

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].

Question 45

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.

Answer 45

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].

Question 46

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

Answer 46

Ans. Key is B. Superficial inguinal LN.

Question 47

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

Answer 47

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 injury and 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 di

Question 48

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

Answer 48

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].

Question 49

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

Answer 49

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].

Question 50

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 ear. What is the most probable dx? a. Acne b. Herpes zoster c. Chicken pox d. Insect bite e. Cellulitis

Answer 50

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].

Question 51

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

Answer 51

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, ofte

Question 52

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

Answer 52

Ans. The key is A. Folic acid. [Frequently associated with neural tube defect].

Question 53

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

Answer 53

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].

Question 54

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

Answer 54

Ans. The key is A. Bronchiolitis. [Management: 1. Oxygen inhalation 2. Nasogastric feeding. DON’T USE: i) bronchodilator ii) steroid iii) antibiotics routinely.

Question 55

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

Answer 55

Ans. B. Echo. [2 mainD/D. Aortic stenosis and hypertrophic cardiomyopathy. Aortic stenosis – more likely in elderly. And hypertrophic cardiomyopathy – less likely in this age].

Question 56

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

Answer 56

Ans. The key is D. Usually occurs 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].

Question 57

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?

Answer 57

Ans. 1. Key is d. Methadone. (used in opiate abuse) Ans. 2. i) tobacco abuse: a) bupropion ii)alcohol: a) acamprosate b) disulfirum

Question 58

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?

Answer 58

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 closure of airway.

Question 59

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

Answer 59

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].

Question 60

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

Answer 60

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].

Question 61

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

Answer 61

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 l

Question 62

2. 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

Answer 62

Ans. 1. Key is b. Trigeminal neuralgia. [Electric pains in her face that starts with the jaw and moves upwards [this description indicates neurological pain of trigeminal nerve. In trigeminal neuralgia transient loss of corneal reflexs are seen just after attacks but in between attacks corneal reflexes are quite normal].

Question 63

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

Answer 63

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].

Question 64

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?

Answer 64

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

Question 65

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.

Answer 65

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].

Question 66

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

Answer 66

Ans. The key is oral oxycodon.

Question 67

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.

Answer 67

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].

Question 68

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

Answer 68

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 (12<) iii) hypotension (here lower normal) iv) miosis v) needle track marks on his arms.

Question 69

69. A 30yo man and wife present to the reproductive endocrine clinic because of infertility. The man is tall, has bilateral gynecomastia. Examination of the testes reveals bilateral small, firm testes. Which of the following inv is most helpful in dx? a. CT of pituitary b. Chromosomal analysis c. Measure of serum gonadotropins d. Measure of serum testosterone Q. 1. What is the key? Q. 2. What is t

Answer 69

Ans. 1. The key is B. Chromosomal analysis. Ans. 2. The diagnosis is Klinefelter’s syndrome. (xxy) Ans. 3. The points in favour are: i) Infertility ii) Tall stature iii) Bilateral gynaecomastia iv) Bilateral small firm testes.

Question 70

70. An 18yo female just received her A-Level results and she didn’t get into the university of her choice. She was brought into the ED after ingestion of 24 paracetamol tablets. Exam: confused and tired. Initial management has been done. Inv after 24h: normal CBC, ABG = pH7.1, PT=17s, Bilirubin=4umol/L, creatinine=83umol/L. What is the next step in management? a. Observation for another 24h b. Ref

Answer 70

Ans. 1. The key is E. Liver transplantation. Ans. 2. King’s College Hospital criteria for liver transplantation in paracetamol-induced acute liver failure. arterial pH <7.3 or arterial lactate >3.0 mmol/L after adequate fluid resuscitation, OR if all three of the following occur in a 24-hour period: Creatinine >300 μmol/L. PT >100 seconds (INR >6.5). Grade III/IV encephalopathy.

Question 71

71. A 75yo alcoholic presents with a mass up to umbilicus, urinary dribbling, incontinence, and clothes smelling of ammonia. What is the next step in management? a. Urethral catheter b. Suprapubic catheter c. Antibiotics d. Condom catheter e. Nephrostomy Q. 1. What is the key? Q. 2. What is the cause of this retention?

Answer 71

Ans. 1. The key is A. Urethral catheter. Ans. 2. Alcohol consumption [Alcoholism can cause urinary retention but it is a less common cause of retention].

Question 72

72. In CRF, main cause of Vit D deficiency is the failure of: a. Vit D absorption in intestines b. 25 alpha hydroxylation of Vit D c. Excess Vit D loss in urine d. 1 alpha hydroxylation of Vit D e. Availability of Vit D precursors

Answer 72

Ans. The key is D. 1 alpha hydroxylation of Vit D. [There are 3 steps in the synthesis of vitamin D. i) Cholecalciferol in the skin from 7-dehydrocholesterol under the action of ultraviolet light. ii)Hydroxylation in the liver of cholecalciferol to 25 hydroxycholecalciferol. iii) Hydroxylation in the kidneys (1 alpha hydroxylation by enzyme 1-alphahydroxylase) of 25-hydroxycholecalciferol to calci

Question 73

73. Pt with puffiness of face and rash showing cotton wool spots on fundoscopy. What’s the dx? a. Macular degeneration b. Hypertensive retinopathy c. Diabetic background d. Proliferative diabetic retinopathy e. SLE Q. 1. What is the key? Q. 2. Why there is puffyness of face? Q. 3. Why there is cotton wool spots on fundoscopy? What is the most common ocular manifestation of SLE?

Answer 73

Ans. 1. The key is SLE. Ans. 2. Puffiness is due to lupus nephritis. Ans. 3. SLE, can involve the retina. The classic lesion of SLE is a white fluffy appearing lesion within the retina known as a cotton wool spot. The most common ocular manifestation in SLE is Keratoconjunctivits sicca.

Question 74

74. A 35yo man presents with progressive breathlessness. He gave a hx of polyarthralgia with painful lesions on the shin. CXR: bilateral hilar lymphadenopathy. What’s the most likely dx? a. Bronchial asthma b. Cystic fibrosis c. Sarcoidosis d. Bronchiectasis e. Pneumonia Q. 1. What is the key? Q.2 . What is the specific name of this condition? What is the triad?

Answer 74

Ans. 1. The key is C. Sarcoidosis. Ans. 2. Lofgren syndrome. The triad is i) Erythema nodosum ii) Bilateral hilar lymphadenopathy iii) Arthralgia.

Question 75

75. A child presents with clean wound, but he has never been immunized as his parents were worried about it. There is no contraindication to immunization, what is the best management? a. Full course of DTP b. 1 single injection DT c. 1 single injection DTP d. Only Ig e. Antibiotic

Answer 75

Ans. The key is A. Full course of DTP.

Question 76

76. A 65yo HTN man presents with lower abdominal pain and back pain. An expansive abdominal mass is palpated lateral and superior to the umbilicus. What is the single most discriminating inv? a. Laparascopy b. KUB XR c. Pelvic US d. Rectal exam e. Abdominal US Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the points given here in favour of your diagnosis?

Answer 76

Ans. 1. The key is E. Abdominal US. Ans. 2. The diagnosis is Abdominal aortic aneurism. Ans. 3. Points in favour of AAA are i) hypertension ii) abdominal pain iii) back pain iv) expansile abdominal mass lateral and superior to the umbilicus.

Question 77

77. A 55yo man has had severe pain in the right hypochondrium for 24h. The pain comes in waves and is accompanied by nausea. Nothing seems to relieve the pain. He feels hot and sweaty but has normal temp. What is the most appropriate next inv? a. US Abdomen b. ERCP c. MRCP d. Serum amylase e. UGI endoscopy Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the points in favour of y

Answer 77

Ans. 1. The key is A. US abdomen. Ans. 2. The diagnosis is biliary colic. Ans. 3. Points in favour- i) severe right hypochondrial pain. ii) colicky nature of the pain (comes in waves) iii) nausea iv) absence of fever iv) absence of jaundice. [OHCM, 9th edition, page-637].

Question 78

78. A 67yo man has deteriorating vision in his left eye. He has longstanding COPD and is on multiple drug therapy. What single medication is likely to cause this visual deterioration? a. B2 agonist b. Corticosteroid c. Diuretic d. Theophylline Q. 1. What is the key? Q. 2. What is the cause of deteriorating vision?

Answer 78

Ans. 1. The key is B. Corticosteroid. Ans. 2. Prolonged corticostiroids [also topical i.e. eye drop] can cause cataract.

Question 79

79. A woman who returned from abroad after 3 weeks of holiday complains of severe diarrhea of 3 weeks. She also developed IDA and folic acid def. What condition best describes her situation? a. Jejunal villous atrophy b. Chronic diarrhea secretions c. Malabsorption d. Increased catabolism e. Increased secretions of acid Q. 1. What is the key? Q. 2. What are the points in favour? Q. 3. What are the

Answer 79

Ans. 1. The key is C. Malabsorption. Ans. 2. Diarrhoea, IDA and folic acid deficiency. Ans. 3.  Iron-deficiency anaemia.  Folate deficiency or vitamin B12 deficiency.  Bleeding, resulting from low vitamin K.  Oedema, which occurs in protein/calorie malnutrition.

Question 80

80. A 35yo male is bitterly annoyed with people around him. He thinks that people are putting ideas into his head. What is the single most likely dx? a. Thought block b. Thought insertion c. Thought broadcasting d. Thought withdrawal e. Reference Q. 1. What is the key? Q. 2. In which disease you will find this feature?

Answer 80

Ans. 1. The key is B. Thought insertion. Ans. 2. It is seen in schizophrenia.

Question 81

81. A 10yo girl presents with hoarseness of the voice. She is a known case of bronchial asthma and has been on oral steroids for a while. What is the most likely cause of hoarseness? a. Laryngeal candidiasis b. Infective tonsillitis c. Laryngeal edema d. Allergic drug reaction e. Ludwigs angina Q. 1. What is the key? Q. 2. What is the reason for this condition?

Answer 81

Ans. 1. The key is A. Laryngeal candidiasis. Ans. 2. Steroids predisposes to fungal infection.

Question 82

82. A lady with breast cancer has undergone axillary LN clearance. She develops arm swelling after being stung by a bee. What is the most likely mechanism responsible for the swelling? a. Lymphedema b. Cellulitis c. Hypersensitivity reaction d. DVT e. Fluid retention Q. 1. What is the key? Q. 2. What is the reason for this condition?

Answer 82

Ans. 1. The key is A. Lymphoedema. Ans. 2. Reason is compromised lymphatic drainage of arm due to axillary LN clearance. So if there is any inflammation or selling, lymph drainage is compromised further giving rise to swelling of limb of that operated side.

Question 83

83. A 34yo pt presents with 50% partial thickness burns. What should be the most appropriate management? a. IV fluids calculated from the time of hospital arrival b. IV fluids calculated from the time of burn c. No IVF d. IV dextrose stat e. Burns ointment Q. 1. What is the key? Q. 2. How the calculation of fluid is made?

Answer 83

Ans. 1. The key is B. IV fluids calculated from the time of burn. Ans. 2. Resuscitation fluids required in the first 24 hours from the time of injury. For adults: 3 ml (in partial thickness burn) of Hartmann’s solution/kg body weight/% total Body surface area. Half of this calculated volume is given in the first 8 hours and the other half is given over the following 16 hours.

Question 84

84. A 54yo man has recently been dx with moderate depression. He has hx of MI and is suffering from insomnia. What is the drug of choice for him? a. Citalopram b. Lofepramine c. ECT d. Haloperidol e. Diazepam

Answer 84

Ans. Key is A. Citalopram. [Sertraline is the drug of choice in post MI as citalopram may be a risk factor for precipitating torsades-de-pointes. But if sertraline is not in option second choice is citalopram and where SSRIs are not suitable next choice is mirtazapine].

Question 85

85. A man presented with cellulitis and swelling. He was started on flucloxacillin. What other medication do you want to add? a. Vancomycin b. Penicillin c. Metronidazole d. Ceftriaxone e. Amoxicillin Q. 1. What is the key? Q. 2. Please mention why?

Answer 85

Ans. 1. The key is B. Penicillin. Ans. 2. cellulitis is usually caused by staphylococcus and streptococcus. To cover both Flucloxacillin (for staphylococcus) and Penicillin (to cover streptococci) should be prescribed.

Question 86

86. A 24yo college student presents with nausea, vomiting, headache, neck stiffness and a fever of 38.4C. What is the most appropriate empirical antibiotic to be started? a. Ceftriaxone b. Penicillin c. Gentamicin d. Tazobactam e. Meropenem

Answer 86

Ans. The key is A. Ceftriaxone. [Cfftriaxone is the drug of choice in hospital management. Probable dx is meningitis. [In OHCM-Cefotaxime <55yrs and Cefotaxime + Ampicillin if age>55yrs (pre-hospital)].

Question 87

87. A man with prosthetic heart valve underwent hemicolectomy and after some days complains of left hypochondriac pain, fever and has a systolic murmur. What is the next inv to ascertain the cause of HF? a. CT b. Blood culture c. ECG d. MRI e. Radioactive thyroid scan Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. Why have you made this diagnosis? Q. 4. What are the important risk facto

Answer 87

Ans. 1. The key is B. Blood culture. Ans. 2. The diagnosis is infective endocarditis. Ans. 3. Fever + new murmur = endocarditis until proven otherwise. Ans. 4. Important risk factors: dermatitis, IV injections, renal failure, organ transplantation, DM, post operative wond. Risk factors for abnormal valves: aortic or mitral valve disease, tricuspid valve in IV drug users, prosthetic valves.

Question 88

88. A 45yo man with posterior gastric ulcer presented with severe excruciating pain which subsided after conservative treatment. 10 days later he developed swinging pyrexia. US shows a collection in the peritoneum. What will be the most likely location of the collection? a. Hepatorenal puch b. Left paracolic gutter c. Subphrenic d. Pelvic cavity e. Lesser sac

Answer 88

Ans. The key is E. Lesser sac.

Question 89

89. A 23yo lady was prescribed with azithromycin 1gm for her chlamydial pelvic infection. She has got a new boyfriend for the last 2 months. She has recently started contraception to avoid conception. Which of the following contraception method will be affected by azithromycin? a. Barrier b. IUCD c. POP d. COCP

Answer 89

Ans. None of them! Before it was thought that hepatic enzyme inhibitor drugs may affect COCP but later it was established that actually there is no such significant effect. Only drugs like refumpicin, rifabutin etc. can cause this. [For exam purpose if you have to choose one please choose D. COCP].

Question 90

90. An 11yo boy is being checked by the diabetic specialist nurse. His HbA1c was high and he has been skipping meals recently. He has been unhappy at school. Which single member of the clinical team would you refer him to next? a. GP b. Pediatrician c. Dietician d. Clinical psychologist

Answer 90

Ans. The key is D. Clinical psychologist. [Skipping meals, unhappy at school these are psychological issues. So he should be referred to clinical psychologist].

Question 91

91. A 35yo man who has served in the army presents with lack of interest in enjoyable activities and feeling low. He doesn’t feel like reading the news or watching movies as he believes there is violence everywhere. What is the most appropriate first line therapy? a. Citalopram b. Lofepramine c. CBT d. Chlordiazepoxide e. Desensitization Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. Wh

Answer 91

Ans. 1. The key is C. CBT Ans. 2. The diagnosis is mild depressive illness. Ans. 3. In mild depressive illness CBT is preferred option.

Question 92

92. A man has reducible bulge below the pubic tubercle, and on occlusion of the deep inguinal ring, cough impulse is present. What is the most likely dx? a. Direct inguinal b. Indirect inguinal c. Femoral d. Spigelian e. Lumbar Q. 1. What is the key? Q. 2. What are the points in favour of your answer?

Answer 92

Ans. 1. The key is C. Femoral hernia. Ans. 2. It is just below the pubic tubercle that is just below the inguinal ligament. On occlusion of deep ring cough impulse is present (means visible) as femoral hernia doesn’t come through deep ring but indirect inguinal hernia.

Question 93

93. A 48yo woman is admitted to ED with a productive cough and moderate fever. She has often central chest pain and regurgitation of undigested food most times but doesn’t suffer from acid reflux. These symptoms have been present for the last 3.5 months which affects both food and drink. A CXR shows an air-fluid level behind a normal sized heart. What is the most likely dx? a. Pharyngeal pouch b.

Answer 93

Ans. 1. The key is D. Achalasia. Ans. 2. Points in favour: Aspiration pneumonia due to retained food and fluid in oesophagus. In achalasia usually there is no acid reflux. Dysphagia for both food and drink. Air-fluid level behind heart. Why it is not hiatus hernia? Ans. Differentiating point:- i) In hiatus hernia usually you will get associatedGORD ii) Also in hiatus hernia there may be nausea or

Question 94

94. A 64yo man has been waking up in the middle of the night to go to the bathroom. He also had difficulty in initiating micturition and complains of dribbling. A dx of BPH was made after a transrectal US guided biopsy and the pt was prepared for a TURP. What electrolyte abnormality is highly likely due to this surgery? a. Hypokalemia b. Hypocalcemia c. Hyperkalemia d. Hyponatremia e. Hypernatremi

Answer 94

Ans. 1. The key is D. Hyponatremia. Ans. 2. Absorption of fluid used for bladder irrigation to flush out blood clots and IV fluids all may lead to hypervolaemia and dilutional hyponatremia.

Question 95

95. A 56yo lady has developed severe right sided headache which worsens whenever she comes to bright light since the last 4 days. She feels nauseated, but doesn’t vomit. What is the most likely dx? a. SAH b. Brain tumor c. Migraine d. Cluster headache e. Subdural headache Q. 1. What is the key? Q. 2. What is the type of the given case? Q. 3. What are the points in favour of mentioned type?

Answer 95

Ans. 1. The key is C. Migraine. Ans. 2. It is migraine without aura. Ans. 3. Criteria of migraine without aura: ≥5 headaches lasting 4-72 hours + nausea/vomiting (or photo/phono-phobia) + any 2 of: i) unilateral ii) pulsating iii) worsen by routine activity [OHCM, 9th edition, page-462].

Question 96

96. A 35yo man presented with hematuria, abdominal swelling and has a BP of 190/140. What is the most diagnostic inv? a. Cystoscopy b. USG c. CT d. Renal biopsy e. Urine analysis Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What will be the USG findings to establish diagnosis in given case?

Answer 96

Ans. 1. The key is B. USG. Ans. 2. The diagnosis is ADPKD. Ans. 3. In given case patients age is 35. So the USG diagnostic criteria is: Age 18 – 39 yrs>3 unilateral or, bilateral cysts, 40 – 59 yrs >2 cysts in each kidney, >60 yrs >4 cysts in each kidney. [OHCM, 9th edition,page- 312].

Question 97

97. A young man is brought to the ED after an RTA. His GCS on initial evaluation is 6. What is the most appropriate next step? a. CT b. MRI c. IV fluids d. Skull XR e. Secure airway

Answer 97

Ans. The key is E. Secure airway.

Question 98

98. A 65yo man presented with frank hematuria. He has no other urinary symptoms. What is the most appropriate next step that will lead to the dx? a. IVU b. US Abdomen c. Cystoscopy d. Mid-stream urine for culture e. Transrectal US Q. 1. What is the key? Q. 2. What is the diagnosis? Q. 3. What are the reasons for this diagnosis? Q. 4. If there is painless haematuria in young (say 25-30yrs) what dia

Answer 98

Ans.1. Key is C. Cystoscopy. Ans. 2. Bladder cancer. Ans. 3. Age 65, asymptomatic haematuria. Ans. 4. ADPKD [at the beginning there is very few or no symptoms].

Question 99

99. A 30yo woman had a gradual decrease of visual acuity since the last 3 years. Now she has a disability due to very low vision. What’s the dx? a. Glaucoma b. Cataract c. Macular degeneration d. Retinitis pigmentosa e. Keratitis Q. 1. What is the key? Q. 2. Why it is not the other given D/D s?

Answer 99

Ans. 1. The key is D. Retinitis pigmentosa. Ans. 2. i) It is not angle closure glaucoma as angle closure glaucoma occurs usually after the age of 50; In open angle glaucoma visual loss is not evenly gradual rather occurs a bit suddenly at its later part. It is not cataract as cataract occurs usually in elderly. In macular degeneration near blindness does not occur rather causes inability to identi

Question 100

100. A 27yo lady has had an uncomplicated pregnancy so far. She came to the hospital 2h ago after her water broke. The midwife is looking at her now. She has regular contractions. P.V exam revealed 2cm dilated cervix. Vital signs are normal. What stage of labour is she in? a. Second stage b. First stage c. Latent stage d. Third stage e. Active phase

Answer 100

Ans. The key is B. First stage. First stage starts with softening of cervix with start of opening of cervix and ends when cevix is fully dilated (i.e. 10 cm dilated).