1001 to 1100

Question 1

1001. An 82yo man has woken up with incoherent speech and difficulty in finding the right words. Exam: otherwise normal, good comprehension. Which anatomical site is most likely to be affected? a. Broca’s area b. Wernicke’s area c. Midbrain d. Parietal cortex e. Pons

Answer 1

Ans. The key is A. Brocha’s area. [A person with expressive aphasia will exhibit halting and effortful speech. Speech may only include important content words. Word comprehension is preserved. The person may still be understood, but sentences will not be grammatical. This contrasts with receptive or Wernicke’s aphasia, which is distinguished by a patient’s inability to comprehend language or speak

Question 2

1002. A 25yo woman has a recent cough, hoarseness and swelling in the neck. There are several nontender swellings on both sides of her neck. She has lost 13kgs. She takes recreational drugs. What is the most probable dx? a. Thyrotoxicosis b. Hyperthyroidism c. Vocal cord nodules d. Carcinoma bronchus e. TB

Answer 2

Ans. The key is E. TB. [Cough, wt. loss, non-tender cervical lymphadenopathy, and immunodeficient state as a result of recreational drug use all these favours the diagnosis of TB. Laryngeal involvement may be the cause of horseness].

Question 3

1003. A 30yo woman presents with acute headache. She complains of seeing halos especially at night. What is the single most likely defect? a. Paracentral scotoma b. Mono-ocular field loss c. Tunnel vision d. Central scotoma e. Cortical blindness

Answer 3

Ans. The key is C. Tunnel vision. [The diagnosis is glaucoma (headache and haloes especially at night). In glaucoma there occurs tunnel vision].

Question 4

1004. A 35yo man presents with a headache that worsens on bending his head forward. What is the most likely dx? a. Chronic sinusitis b. SAH c. Migraine d. Cluster headache e. Tension headache

Answer 4

Ans. The key is A. Chronic sinusitis.

Question 5

1005. A 20yo man presents with painful swallowing. Exam: trismus and unilateral enlargement of his tonsils. The peritonsilar region is red, inflamed and swollen. What is the most appropriate tx? a. Oral antibiotics b. IV antibiotics and analgesics c. I&D with antibiotics d. Analgesics with antipyretics e. Tonsillectomy

Answer 5

Ans. The key is C. I&D with antibiotics. [The dx is peritnsillar abscess and tx is I&D with antibiotics].

Question 6

1006. A 40yo manual worker presents with a swelling in the groin. Exam: mass is found to be just above and lateral to the pubic tubercle. It is reducible. On applying pressure on the internal ring there is no cough impulse seen. What is the most probable dx? a. Direct inguinal hernia b. Indirect inguinal hernia c. Femoral hernia d. Strangulated hernia e. Femoral aneurysm

Answer 6

Ans. The key is B. Indirect inguinal hernia. [Swelling in the groin; mass just above and lateral to the pubic tubercle means inguinal hernia. It is reducible. On applying pressure on the internal ring there is no visible cough impulse; it means the hernia enters through deep ring, and enters scrotum passing through the superficial ring. That means it is indirect inguinal hernia].

Question 7

1007. A 34yo male presents with headache and vomiting. Exam: temp=38.5C, neck stiffness, discharge from left ear and right sided hyper-reflexia with an extensor plantar response. What is the most likely dx? a. Cerebral tumor b. Meningitis c. Cerebellar tumor d. Cerebral abscess e. Normal pressure hydrocephalus

Answer 7

Ans. The key is D. Cerebral abscess. [Otitis media can lead to cerebral abscess].

Question 8

1008. A 26yo male presents with speech difficulties. Exam: nystagmus. Which anatomical site is most likely to be affected? a. Midbrain b. Pons c. Cerebellum d. Cerebrum e. Vestibule cochlear nerve

Answer 8

Ans. The key is C. Cerebellum. [Difficulty speech (cerebellar dysarthria) and nystagmus are suggestive of cerebellar lesion].

Question 9

1009. A 75yo man presents with Bell’s palsy. His PMH is significant for late onset asthma and heart failure. He also reports to have consulted his GP for generalized rash prv. CXR: multiple soft shadows and CBC: eosinophilia. What is the single most likely positive antibody? a. P ANCA b. C ANCA c. Anti Ro d. Anti DS DNA e. Anti centromere

Answer 9

Ans. The key is A. p-ANCA. [The dx is Charg Strauss Syndrome (CSS). There are six criteria for dx of CSS: 1. Asthma (wheezing, expiratory rhonchi). 2. Eosinophilia of more than 10% in peripheral blood. 3. Paranasal sinusitis. 4. Pulmonary infiltrates (may be transient). 5. Histological confirmation of vasculitis with extravascular eosinophils. 6. Mononeuritis multiplex or polyneuropathy. The prese

Question 10

1010. A 50yo man complains of visual prbs and dull pain in the left eye. Fundoscopy reveals papilloedema. He was dx with MS 2yrs ago. There is no consensual light reflex of the right eye. What is the single most likely defect? a. Paracentral scotoma b. Mono-ocular field loss c. Homonymous upper quadrantanopia d. Central scotoma e. Homonymous lower quadrantanopia

Answer 10

Ans. The key is B. Mono-ocular field loss.

Question 11

1011. A 54yo pt wakes up with right sided weakness. His current medication is bendroflumethiazide for HTN. Pulse=92bpm, BP=160/90mmHg. CT shows left cerebral infarct. What is the most appropriate tx? a. Alteplase b. Aspirin c. Clopidogrel d. Dipyridamole e. Simvastatin

Answer 11

Ans. The key is A. Alteplase. It is a wrong key! Correct option is B. Aspirin. [In stroke window period to use alteplase is 4.5 hours. In the given history we can no way certain the time of stroke and we can not proceed for alteplase unless window period is confirmed. Hence we cannot give alteplase but Aspirin].

Question 12

1012. A 33yo man presented to the GP with hx of headaches and photophobia. The GP examines him and finds a rash and is now ringing you at the hospital for advice. What would you advice the GP? a. Send pt home b. Start IV benzylpenicillin c. Conduct LP d. Start IV ceftriaxone

Answer 12

Ans. The key is B. Start IV benzylpenicillin. [Before hospitalization IV benzylpenicillin. In hospital Ceftriaxone can be given but not in calcium containing fluid instead give Cefotaxime (NICE). According to OHCM hospital management is Cefotaxime if <55yrs and Cefotaxime + Ampicillin if >55yrs ].

Question 13

1013. An 89yo pt has lung cancer. His Na+=122mmol/l. What is the tx for this? a. Demeclocycline b. Vasopressin c. Restrict fluids d. Reassure

Answer 13

Ans. There are two keys. A. Demeclocycline and C. Restrict fluids. *both are correct!![• Asymptomatic chronic hyponatraemia fluid restriction is often sufficient if asymptomatic, although demeclocycline (ADH antagonist) may be required. Ref: OHCM, 9th edition, page 686].

Question 14

1014. A 25yo woman who is 11wks pregnant had central abdominal pain for 36h. The pain is now colicky. There is no vaginal bleeding. She has vomited once and has had an episode of loose motion. She looks ill, temp=37.8C and there is rebound tenderness in the RIF. What is the most probable dx? a. Salpingitis b. PID c. Appendicitis d. Ovarian torsion e. Uterine fibroid

Answer 14

Ans. The key is C. Appendicitis. [No vaginal bleeding and pain above pelvis makes pregnancy complication less likely. Loose motion, low grade temperature and positive Mc Burney’s sign makes the diagnosis of appendicitis more probable].

Question 15

1015. A 42yo man presents with stroke. He is not able to walk straight and his speech is slurred. What is the initial appropriate inv? a. CT brain b. PET brain c. MRI brain d. Carotid angiography e. Monitor for 24h

Answer 15

Ans. The key is C. MRI brain. [Ataxia and slurred speech are features of cerebellar lesion which is posterior fossa organ. For posterior fossa lesion MRI is the investigation of choice! So key is correct. It is C. MRI brain].

Question 16

1016. A 24yo woman has severe depression 3m after the birth of her first child. She is breastfeeding but is otherwise unable to look after the baby and is convinced that her family is likely to kill her. She has no interest in anything and keeps crying. What is the most appropriate tx? a. Fluoxetine b. Citalopram c. CBT d. ECT e. Haloperidol

Answer 16

Ans. The key is D. ECT. [ [In question it is mentioned she has severe depression. In severe depression the tx is ECT]

Question 17

1017. A 20yo woman with no prv hx of ear complains, presents with 1d hx of severe pain in the right ear which is extremely tender to examine. What is the single most likely dx? a. Chondromalasia b. Furuncle c. Myringitis d. OE e. OM

Answer 17

Ans. The key is D. OE. [Extreme tenderness to examine indicate otitis externa].

Question 18

1018. A couple has just finished their detox regime and wants a drug with a pharmacological action to serve as a deterrent when they take alcohol. What drug is the appropriate choice? a. Disulfiram b. Acamprosate c. Vitamin supplement d. Naloxone e. Naltrexone

Answer 18

Ans. The key is B. Acamprosate. This is a wrong key! Correct key is A. Disulfiram. [Acramposate is not a deterrent (which keeps away from drinking by making it unpleasant) but Disulfirum!]

Question 19

1019. A 68yo woman presents to the ED with confusion. Temp=39.3C and productive cough. Sputum is rusty colored after 2 days. CXR shows right lower lobe consolidation. What is the most likely organism? a. Streptococcus pneumonia b. Staphylococcus aureus c. Coxiella burnetti d. Mycoplasma pneumonia

Answer 19

Ans. The key is A. Streptococcus pneumonia. [Typical presentation of streptococcal pneumonia].

Question 20

1020. A 70yo man with prostatic cancer has had severe acute back pain waking him up at night for 6wks. What is the most appropriate inv? a. MRI spine b. Radionuclide bone scan c. DEXA scan d. Serum ALP concentration e. Serum calcium concentration

Answer 20

Ans. The key is B. Radionuclide bone scan. [[MRI is good for soft tissue but not for bone. If it was radiculopathy, spinal cord compression or prolapsed disc creating pressure on nerve MRI would be fine but not for bony metastasis. Here investigation of choice is radionuclide bone scan]

Question 21

1021. An asymptomatic 56yo man who has never consumed alcohol came for a routine checkup. Exam: increased skin pigmentation, spider angioma, cardiomegaly, S3 gallop, liver firm with 8cm span, no ascites. He is in the risk of which condition? a. Cerebellar degeneration b. Werniecke’s encephalopathy c. Renal failure d. Hepatoma e. Hepatic vein thrombosis

Answer 21

Ans. The key is D. Hepatoma. [Increased skin pigmentation, features of chronic liver disease (spider angioma), Cardiomyopathy (cardiomegaly, S3 gallop), Enlarged liver these are suggestive of Haemochromatosis. (OHCM: Slate-grey skin pigmentation; signs of chronic liver disease; hepatomegaly; cirrhosis; dilated cardiomyopathy; osteoporosis; also endocrinopathies are features of haemochromatosis). I

Question 22

1022. A 39yo male presents with visual symptoms. Ophthalmoscopy shows papilloedema. Which anatomical site is most likely to be affected? a. Optic nerve b. Optic disc c. Optic radiation d. Occulomotor nerve e. Optic chiasma

Answer 22

Ans. The key is B. Optic disc.

Question 23

1023. A 75yo man has been attending the clinic for lower urinary tract symptoms. His mood is very low and he says he feels unhappy, anxious and unable to sleep. He has been dx with moderate depression. What tx would be most effective for this pt? a. Amitriptyline b. Citalopram c. CBT d. Dosulepin e. Diazepam

Answer 23

Ans. The key is B. Citalopram. [Mild depression = CBT, Moderate depression = Antidepressant, Severe depression & Psychotic depression = ECT, Amitryptiline and Dosulepine causes urinary retention (which is comperatively less in citalopram) so not suitable in a patient with lower urinary symptoms. Hence Citalopram is the preferred option].

Question 24

1024. A 48yo pt after surgical removal of mandibular ca presents with perioral paresthesia and severe pain which is not relieved by oral morphine. What is the next step in treating this pt? a. Oral amitryptiline (2nd line) b. Oral oxycodone c. PCA d. IV morphine e. Fentanyl patch f. Gabapentine (1st line)

Answer 24

Ans. The key is F. Gabapentine. [This pain is likely due to nerve injury during operation and both amitryptilin

Question 25

1025. A 34yo man was slapped over his right ear in a fight. There is blood coming from his external auditory canal and he has pain, deafness and ringing in his ears. What is the most appropriate initial inv? a. CT b. MRI c. Otoscopy d. Skull XR e. Facial XR

Answer 25

Ans. The key is A CT. It is a wrong key! Correct key is C. Otoscopy. [Traumatic perforation of the tympanic membrane (TM) can cause pain, bleeding, hearing loss, tinnitus, and vertigo. Diagnosis is based on otoscopy. Treatment often is unnecessary. Antibiotics may be needed for infection. Surgery may be needed for perforations persisting > 2 mo, disruption of the ossicular chain, or injuries affec

Question 26

1026. A 45yo man has developed an annular rash with a scaly edge on his thigh. The rash has been spreading over the last 3wks. He has some general aches and pains. What is the single most useful investigation? a. ANA b. Biopsy lesion c. Lyme antibodies d. Skin scrap for mycology e. Skin swab for bacteria

Answer 26

Ans. The key is C. Lyme antibodies. [Spreading annular rash suggests erythema migrans of lyme disease].

Question 27

1027. A 80yo man with prostatic cancer has confusion, thirst, abdominal pain and an abnormal ECG. What is the most appropriate inv? a. MRI spine b. Radionuclide bone scan c. DEXA scan d. Serum ALP concentration e. Serum calcium concentration

Answer 27

Ans. The key is E. Serum calcium concentration. [Confusion, thirst, abdominal pain and ECG changes (marked shortening of QT interval) are features of hypercalcemia. So E. Serum calcium concentration is the likely option].

Question 28

1028. A 27yo lady after C-section developed epigastric pain after 8h. What is the appropriate inv? a. ABG b. Coag profile c. Liver enzyme d. Liver biopsy

Answer 28

Ans. The key is C. Liver enzyme. [Epigastric pain is a warning sign of HELLP syndrome. So to rule out HELLP syndrome Liver enzymes should be done].

Question 29

1029. A 35yo woman presents with visual problems. CT brain reveals pituitary tumor. What is the single most likely defect? a. Homonymous hemianopia b. Homonymous upper quadrantopia c. Bitemporal hemianopia d. Cortical blindness e. Homonymous lower quadrantopia

Answer 29

Ans. The key is C. Bitemporal hemianopia. [pitutary tumour by pressing optic chiasma causes bitemporal hemianopia].

Question 30

1030. A 45yo heroin addict was involved in a car crash and is now paraplegic. During the 1st week of hospital stay he cried everyday because he couldn’t remember the accident. What is the most likely dx? a. PTSD b. Severe depression c. Organic brain damage

Answer 30

Ans. The key is C. organic brain damage.

Question 31

1031. A pt with T1DM has a fundus showing micro-aneurysm and hard exudate. What is the single most likely dx? a. Macular degeneration b. Hypertensive retinopathy c. MS d. Diabetic background e. Proliferative DM retinopathy

Answer 31

Ans. The key is D. Diabetic background retinopathy. [Microenurism, hard exudates are seen in background diabetic retinopathy].

Question 32

1032. A 62yo man has multiple liver mets due to adenocarcinoma with an unknown primary. He is deeply jaundiced and has ascites with edema upto the buttocks. He is now drowsy and his family are worried that he is not drinking enough. His meds include: haloperidol 1.5mg, lactulose 10ml. Bloods taken 3d ago: electrolytes normal, urea=6.5mmol/l, creatinine=89mmol/l, calcium=2.04mmol/l, albumin=17g/L,

Answer 32

Ans. The key is A. Albumin infusion. [Here serum albumin is 17. So the patient developed ascites and oedema secondary to reduced plasma colloidal osmotic pressure. Albumin infusion can help rise the colloidal osmotic pressure and improve the patients condition].

Question 33

1033. A 2yo with atrophy of the buttocks, distended abdomen with frequent offensive smelly stool. Choose the single most likely inv? a. Upper GI endoscopy b. Endomyseal/alpha glidin antibody c. Sweat test d. Colonscopy e. Stool culture

Answer 33

Ans. The key is B. Endomyseal/alphagliadin antibody. [Atrophy of buttock due to fat malabsorption and distended abdomen (sometimes with everted umbilicus) with frequent offensive smelly stools are seen in coeliac disease. Hence endomyseal/alpha gliadin antibody should be done].

Question 34

1034. A 78yo woman is brought to the hospital complaining of back pain and is referred to the surgeon. She has been saying that her mother is due to visit her today and that somebody must have broken her lower back as she is in agony. Labs: creatinine=295mmol/l, calcium=3.03mmol/l. Which inv is most likely to lead to a dx? a. US KUB b. XR Spine c. IVU d. Bence-Jones Protein e. Mental state exam

Answer 34

Ans. The key is D. Bence-Jones protein. [Severe back pain, high calcium level and renal impairment are typical of multiple myeloma].

Question 35

1035. A 40yo woman presents with dysphagia. Exam: febrile with erythema and middle neck swelling. What is the best management strategy? a. IV antibiotics and drainage b. Antipyretics c. XR neck d. Endoscopic diverticulectomy e. I&D

Answer 35

Ans. The key is A. IV antibiotics and drainage. [Neck abscess. Treated with IV antibiotics and drainage].

Question 36

1036. A young lady presents with gradually worsening headaches, visual disturbance, and lack of energy. MRI shows 15mm tumor in the pituitary fossa. What is the tx of choice? a. Radiotherapy b. Octreotide c. Reassurance and f/u after 6m d. Surgery e. Chemotherapy

Answer 36

Ans. The key is D. Surgery. [Hormonically active tumour, tumour causing pressure symptoms (like headache, visual disturbance) and large size of tumour are indications for surgical removal].

Question 37

1037. A man with dementia has an ulcerative lesion on his forehead. He wants it removed so ‘it can help improve his memory’. Wife says he is not fit to give consent. What will you do? a. Get letter signed from the GP b. Get letter signed from the wife c. Get letter signed from the pt d. Refer to psychiatrist to assess the mental capacity to give consent

Answer 37

Ans. The key is D. Refer to psychiatrist to assess the mental capacity to give consent

Question 38

1038. A pt with flame shaped hemorrhage on long term tx with nifedipine. What is the single most likely dx? a. Macular degeneration b. HTN retinopathy c. MS d. DM background e. Proliferative DM retinopathy f. SLE

Answer 38

Ans. The key is B. HTN retinopathy. [Stages of hypertensive retinopathy: 1. Grade 1: Silver wiring 2. Grade 2: 1 + AV nipping 3. Grade 3: 2 + flame shaped hemorrhage 4. Grade 4: 3 + optic disc edema + macular star].

Question 39

1039. A pt whose pain is not relieved by oral codeine. What is the best management? a. Oral oxycodone b. Co-codamol c. PCA d. IV morphine e. Oral morphine

Answer 39

Ans. The key is E. Oral morphine.

Question 40

1040. A 6wk baby with vomiting, irritability and palpable mass in the abdomen on feeding. Choose the single most likely inv? a. Upper GI endoscopy b. Barium meal c. US d. CT abdomen e. Barium enema

Answer 40

Ans. The key is C. US. [Palpable mass in the abdomen “ON FEEDING” (just after feeding the mass becomes more prominent and can be palpated more easily) is suggestive of pyloric stenosis. US is used to diagnose this].

Question 41

1041. A 79yo man who is being treated with GnRH antagonist for proven adenocarcinoma of the prostate attends a follow up session. What is the most appropriate inv? a. Serum AFP b. Serum PSA c. Serum acid phosphates conc d. Serum ALP isoenzyme conc e. Trans rectal US

Answer 41

Ans. The key is B. Serum PSA. [Serum PSA is used to assess the progress of treatment. (If a man’s PSA level rises after prostate cancer treatment, his doctor will consider a number of factors before recommending further treatment. Additional treatment based on a single PSA test is not recommended. Instead, a rising trend in PSA level over time in combination with other findings, such as an abnorma

Question 42

1042. A middle aged woman has some weakness of hand after an injury. Which vertebra will be the lowest to be included on cervical XR to dx the injury? a. C7/T1 b. C8/T1 c. C5/C6 d. C6/C7

Answer 42

Ans. The key is A. C7/T1.

Question 43

1043. A 50yo man with a known hx of stroke. He can’t remember anything about his life. What is the single most likely defect? a. Homonymous hemianopia b. Homonymous upper quadrantanopia c. Bitemporal hemianopia d. Binasal hemianopia e. Homonymous lower quadrantanopia

Answer 43

Ans. The key is B. Homonymous upper quadrantanopia. [Memory processing occur in temporal lobe. So as the patient lost memory his temporal lobe is involved. We know temporal lobe lesion causes “homonymous upper quadrantanopia” which is the key here!]

Question 44

1044. An 18yo girl has been dx with anorexia nervosa and has mild depressive symptoms. She has cut down her food intake for the last 18m and exercises 2h everyday. Her BMI=15.5, BP=90/60mmHg. What would be the single most appropriate management? a. Refer to eating disorder clinic b. Refer to psychodynamic therapy c. Refer to acute medical team d. Prescribe antidepressant

Answer 44

Ans. The key is C. Refer to acute medical team. This is a wrong key! Correct key is A. Eating disorder unit. [Anorexia nervosa is moderate when BMI is 15-17.5 as in given case. In moderate anorexia (BMI 15– 17.5, no evidence of system failure) routine referral can be to the local community mental health team (CMHT)/adolescent unit or Eating Disorder Unit (EDU) if available. So the key is A. Eating

Question 45

1045. A 36yo woman has an injury to the right external laryngeal nerve during a thyroid surgery. What symptom would be expected in this pt? a. Stridor b. Hoarseness c. Aphonia d. Dysphonia e. Aphasia

Answer 45

Ans. The key is D. Dysphonia. [External laryngeal nerve (smaller, external branch of the superior laryngeal nerve) lesion causes mono toned voice (loss of ability to produce pitched sound) that is dysphonia].

Question 46

1046. A 75yo woman has weakness of the left side of her face. She has had a painful ear for 48h. There are pustules in the left ear canal and on the eardrum. What is the single most likely dx? a. Chronic serous OM b. Herpes zoster infection c. Impacted earwax d. Perforation of eardrum e. Presbycusis

Answer 46

Ans. The key is B. Herpes zoster infection. [A case of Ramsay Hunt syndrome defined as an acute peripheral facial neuropathy associated with erythematous vesicular rash of the skin of the ear canal, auricle (also termed herpes zoster oticus), and/or mucous membrane of the oropharynx caused by Herpes zoster infection].

Question 47

1047. An 8wk baby boy is noted to be jaundiced. He is breast-feeding well and has gained 300g since birth. His stools are yellow and his urine is pale straw colored. What is the most likely dx? a. Galactosemia b. Biliary atresia c. G6PD deficiency d. Breast milk jaundice e. Congenital viral infection

Answer 47

Ans. The key is A. Galactosemia. [Biliary atresia causes obstructive picture where stools are pale and urine becomes dark. Hemolytic disorder like G6PD or spherocytosis causes appearance of jaundice in 1st 24 hours. In breastmilk jaundice, jaundice develops in 2nd week. Also congenital viral infection (TORCH) occurs in 1st 24 hours. Here there is failure to thrive also. So likely cause in the pres

Question 48

1048. A lady developed breast abscess after delivery. What is the most likely organism? a. Staph aureus b. Staph albus c. GBS d. Strep pyogenes e. Strep faecalis

Answer 48

Ans. The key is A. Staphylococcus aureus

Question 49

1049. A 32yo man suffering from MS presents with blurring of vision. Ophthalmoscopy shows pallor of the optic disc. Which anatomical site is most likely to be affected? a. Optic nerve b. Optic disc c. Optic radiation d. Trigeminal e. Oculomotor nerve

Answer 49

Ans. The key is A. Optic nerve. [ MS–optic neuropathy which affects optic nerve and long standing optic neuropathy can be seen as pallor of optic disc in opthalmoscope].

Question 50

1050. A 23yo man presents with severe pain in the right flank radiating to his groin. He is rolling about on the floor. An IVU confirms a stone in the ureter which is 8mm in size. Which tx modality will be most effective? a. Fluids and alpha blockers b. ESWL c. CCB d. Dormier basket e. PCNL

Answer 50

Ans. The key is B. ESWL. [Though for 8 mm stone we can use medical expulsive therapy but for this patient with agonizing pain “most effective” therapy seems to be ESWL].

Question 51

1051. A 37yo woman believes that her neighbours have been using her shower while she is away from home. Her 42yo partner is convinced about this and calls the police. What term best describes this situ? a. Capgras syndrome b. Cotard syndrome c. Delusion of persecution d. Folie a deux e. Munchausen syndrome

Answer 51

Ans. The key is D. Folie a deux. [Folie a deux is symptoms of a delusional belief and hallucinations that are transmitted from one individual to another as here from wife to husband].

Question 52

1052. A 45yo woman has dull pain in her right ear which has been present for several weeks. There is no discharge. Chewing is uncomfortable and her husband has noticed that she grinds her teeth during sleep. The eardrum appears normal. What is the single most likely dx? . Dental caries b. Mumps c. OM d. Temporomandibular joint pain e. Trigeminal neuralgia

Answer 52

Ans. D. Temporomandibular joint pain. [Temporomandibular joint pain may cause pain in ear and teeth grinding is a recognized cause of this symptom].

Question 53

1053. A 42yo lady had corrective surgery for cyanotic congenital heart disease at the age of 3y, after a palliative operation during infancy. There is a parasternal impulse and an early diastolic murmur. What is the most probable dx? a. Aortic regurgitation b. Ischemic mitral regurgitation c. Aortic stenosis d. Pulmonary stenosis e. Pulmonary regurgitation

Answer 53

Ans. The key is E. Pulmonary regurgitation. [In the present day, some patients with tetralogy of Fallot have survived for longer than 15-20 years after their first operation. The major problem encountered by these individuals is the development of pulmonary valvular regurgitation. It appears that a number of these individuals require pulmonary valve replacement

Question 54

1054. A 45yo lady presents with hx of double vision and facial numbness. Which anatomical site is most likely to be affected? a. Cerebral cortex b. Trigeminal nerve c. Oculomotor nerve d. Brain stem e. Basal ganglia

Answer 54

Ans. The key is D. Brain stem. [Cerebral cortex will not cause features of cranial nerve lesions. Trigeminal nerve: ophthalmic and maxillary divisions are pure sensory hence it is also not the answer. Oculomotor does not cause facial numbness. These features are not of basal ganglia lesion also. These features only can be explained by cranial nerve involvement in brainstem lesion].

Question 55

1055. A 30yo woman has experienced restlessness, muscle tension and sleep disturbance on most days over the last 6m. She worries excessively about a number of everyday events and activities and is unable to control these feelings which are impairing her ability to hold down her job. What is the most likely dx? a. Panic disorder b. GAD c. Pheochromocytoma d. Acute stress disorder e. Social phobia

Answer 55

Ans. The key is B. GAD. [In GAD patient is worried about different number of events every day. Almost everything triggers the anxiety].

Question 56

1056. Which of the following is not a degenerative corneal disease? a. Band keratopathy b. Marginal dystropathy c. Fatty/lipid degeneration d. Mooren’s ulcer e. Keratoconus

Answer 56

Ans. The key is D. Moorens ulcer. [All other options are degenrative disease of cornea except Mooren’s ulcer which is a type of ulcerative keratitis].

Question 57

1057. A 30yo man presents to hosp complaining that his urine has been very dark recently, resembling coffee at worst. He has been under the weather 2wks back and had taken a few days off work with a sore throat and coryzal symptoms. Urine dipstick in hosp returns highly positive for blood and protein. He is admitted for supportive management and is scheduled for a renal biopsy, which shows mesangi

Answer 57

Ans. The key is D. Post- strep GN. [Nephritic picture, H/O sorethroat 2 weeks before presentation and biopsy reports are suggestive of post streptococcal glomerulonephritis].

Question 58

1058. A 65yo lady presents with a 6h hx of facial droop and weakness in the left side of her body. What single agent will she be prescribed for her whole life? a. Clopidogrel b. Altepase c. Aspirin d. Labetalol

Answer 58

Ans. The key is A. Clopidogrel. [Ongoing symptoms are considered as stroke (unless completely resolved within 24 hours). Hence Clopidogrel is the answer here as they want life long!].

Question 59

1059. A 10yo boy is brought to the hosp with a rash over his buttocks a/w abdominal pain and vomiting. In the ED, he is accompanied by his mother and stepfather. His mother had left him for the weekend with the stepfather and was called to come back from holiday as he started to have some hematuria with the rash. Social services had been notified on arrive to hospital. What is the most probably dx

Answer 59

Ans. The key is C. HSP. [Rash over buttock, abdominal pain and vomiting, blood in urine or stool suggest HSP].

Question 60

1060. A man with hx of fall had confusion and laceration mark on the head. Which is the most appropriate vessel affected? a. Basiliary artery b. Middle meningeal artery c. Vertebral artery d. Diploic vein

Answer 60

Ans. The key is B. Middle meningeal artery. [Considerable head injury and lucid interval (several episodes of transient confusion)points towards extradural hematoma which occurs frequently from bleeding from middle meningeal artery. Subdural hematoma usually occur due to bleeding vein].

Question 61

1061. A 72yo lady is drowsy and her relatives want to take her home. She has been prescribed diazepam 2.5mg. What is the best delivery route? a. Oral b. IV c. IM d. Per rectal e. SC

Answer 61

Ans. The key is D. Per rectal.

Question 62

1062. A nonsmoker who has worked in coal mines for 20yrs presents with gradually increasing SOB, limited exercise tolerance and a dry cough. His CXR shows round fibrotic tissue demonstrating a mixed restrictive and obstructive ventilator defect with irreversible airflow limitation and reduced gas transfer. What is the single most appropriate dx? a. Churg-strauss syndrome b. Cryptogenic organizing

Answer 62

Ans. E. Progressive massive fibrosis. [Coal miners pneumoconiosis].

Question 63

1063. A pt was complaining of pain within 6h after his appendectomy for gangrenous appendix. What med is the best option for his pain relief? a. IV morphine b. Diclofenac per rectal c. PCA d. Tramadol

Answer 63

Ans. The key is D. Tramadol.

Question 64

1064. A 62yo farmer presents with a persistent firm irregular lesion on upper part of pinna which grew over the last few months. What is the most appropriate dx? a. Basal cell b. Squamous cell c. Keratocanthoma

Answer 64

Ans. The key is A. Basal cell. [Any ulcer which is located above the neck is always basal cell carcinoma until proven otherwise. (samson note)].

Question 65

1065. A 24yo schizophrenic has been under antipsychotic tx for the last 1 yr and now complains of ED Erectyl Dysfunction). Which drug is most likely to have caused this? a. Fluoxetine b. Citalopram c. Clozapine d. Haloperidol e. Risperidone

Answer 65

Ans. The key is D. Haloperidol. This is a wrong key. Correct key is E. Risperidone. [Haloperidol, raises serum prolactin levels to 20~40 ng/ml in therapeutic doses but risperidone causes around 171 ng/ml].

Question 66

1066. What is the most likely dx based on this ECG a. Normal b. VT c. Sinus Tachycardia d. WPW syndrome e. A-fib

Answer 66

Ans. The key is C. Sinus Tachycardia.

Question 67

1067. A 45yo woman has recently been dx with MS and has been started on oral steroids. She is brought to the hosp after having ingested 100 paracetamol tablets 4h ago. She is refusing all med tx. What is the next best step? a. Observe b. Refer to psychiatrist to assess pts ability to refuse tx c. Gastric lavage d. Activated charcoal e. Refer to social worker

Answer 67

Ans. The key is B. Refer to psychiatrist to assess pt’s ability to refuse tx.

Question 68

1068. A 44yo obese pt with findings: FBS=6mmol/l, OGTT=10mmol/l. What is the most likely dx? a. Impaired glucose tolerance b. Diabetes insipidus c. T1DM d. T2DM e. MODY

Answer 68

Ans. The key is A. Impaired glucose tolerance. [Impaired glucose tolerance is 2-hours glucose level 140-199 mg/dl (7.8 to 11.0 mmol/l) on the 75-g oral glucose tolerance test].

Question 69

1069. A child distressed with fever, stridor and unable to swallow saliva. His RR=40bpm. What is the initial step that needs to be taken? a. Examine throat b. Secure airway c. Keep him laid flat d. IV penicillin

Answer 69

Ans. The key is B. Secure airway. [Probable epiglottitis. So airway should be secured].

Question 70

1070. A pt presents with hemoptysis 7d after tonsillectomy and adenoidectomy. What is the next step of management? a. Explore again b. Pack it c. Oral antibiotics and discharge d. Admit and IV antibiotics e. Ice cream and cold fluid

Answer 70

Ans. The key is D. Admit and IV antibiotics. [secondary hemorrhage can occur due to infection causing sloughing out of part of arterial wall due to infection. It is managed by iv antibiotics folloing admitting the patient to hspital].

Question 71

1071. A 55yo man presents with swelling at the angle of the mandible which is progressively increasing in size and it’s mobile for 6m. What is the most probable dx? a. Benign parotid b. Mandible tumor c. Tonsillar carcinoma

Answer 71

Ans. The key is A. Benign parotid. [Mandibular tumour or tonsillar carcinoma would not be so mobile after such time period and Benig parotid is likely diagnosis].

Question 72

1072. A 61yo man, known smoker, comes to the hospital with complaints of painless hematuria, urgency and dysuria. He has been worried about his loss of weight and reduced general activity. Which inv would be diagnostic of his condition? a. Urine microscopy b. IVU c. CT d. Cystoscopy e. US abdomen f. KUB g. Cystoscopy with biopsy h. Mid stream urine for culture i. Trans rectal US

Answer 72

Ans. The key is G. Cystoscopy with biopsy. [Painless hematuria in elderly man is due to Ca of bladder usually and in bladder cancer there are UTI like symptoms like urgency, dysuria. Also constitutional symptom like weight loss and reduced genral activity is feature of carinoma].

Question 73

1073. An 8wk pregnant lady is brough to the ED due to severe vomiting. She was administered IV fluids and oral anti-emetics. She still can’t tolderate anything orally. What is the next best tx? a. IV feeding b. IV antiemetics c. Termination of pregnancy d. PPI e. IV steroid

Answer 73

Ans. The key is IV antiemetics. [If oral antiemetics are not tolerated IV antiemetics are tried].

Question 74

1074. A 48yo man presents with bone pain. Labs: ALP=high, phosphate=normal. What is the most likely dx? a. Osteoporosis b. Osteomalacia c. Paget’s disease d. Fx e. Myeloma

Answer 74

Ans. The key is C. Paget’s disease. [Bone pain, high ALP and normal phosphate are suggestive of pagets disease. In osteoporosis Ca+, PO4³- and ALP are normal. In osteomalacia Ca+ low, PO4³- low and ALP is high. In Pagets disease Ca+ and PO4³- normal and ALP markedly raised].

Question 75

1075. A 54yo lady presents with sudden severe pain in the left half of her skull. She also complains of pain around her jaw. What is the most likely next step? a. CT b. MRI c. Fundoscopy d. ESR e. Temporal artery biopsy

Answer 75

Ans. The key is D. ESR. [Elderly lady with severe pain in the left half of her skull and pain around jaw is suspicious of Giant cell or Temporal arteritis. ESR if markly raised supports the diagnosis of temporal arteritis].

Question 76

1076. A 7yo school boy has been dx with meningococcal meningitis. What is the advice for schoolmates and staff? a. Rifampicin for the whole class and family b. Rifampicin for the whole school and family c. Meningococcal vaccine for the family d. Benzylpenicillin e. IV cefotaxime

Answer 76

Ans. The key is A. Rifampicin for the whole class and family. [In contacts of meningococcal meningitis chemoprophylaxis is given with Rifampicin].

Question 77

1077. A pt came with dyskaryosis to the OPD. She is a heavy smoker and alcoholic. Cervical smear shows abnormal cells. What is the best advice for her? a. Colposcopy b. Biopsy c. Endocervical sample d. Repeat after 4m e. None f. Cone biopsy

Answer 77

Ans. The key is A. Colposcopy. [Patient with dyscariosis should go for colposcopy].

Question 78

1078. Pt with pain and swelling in left leg and thigh up to the level of inguinal ligament. Where is the level of occlusion? a. Femoro-popliteal artery b. Left common iliac artery c. Aortoiliac artery d. Femoral artery e. Profound femoral artery

Answer 78

Ans. There are two keys B. Left common iliac artery. and D. Femoral artery. Correct key is B. Left common iliac artery. [General rule is occlusion occurs in proximal bifarcation. So the correct key is B. Left common iliac artery. That is occlusion in the bifarcation of left common iliac artery (as femoral artery bifarcates more distally to superficial and deep branches)].

Question 79

1079. A 65yo man presents with dyspnea 3d after an MI. On auscultation he has a pansystolic murmur at the apex radiating to the axilla. What is the most likely dx? a. Ruptured papillary muscle b. Ventricular aneurysm c. Pericarditis d. Pericardial effusion e. VSD

Answer 79

Ans. The key is A. Ruptured papillary muscle. [Pansystolic murmur in apex radiating to axilla may be due to mitral regurgitation secondary to papillary muscle rupture].

Question 80

1080. A 64yo man with multiple myeloma has been vomiting since the past 2days. Labs: Ca2+=3.2mmol/l, K+=5mmol/l, Na+=149mmol/l and PCV=55%. What is the most appropriate next step? a. IV insulin b. IV calcium gluconate c. IV fluids d. IV bisphosphonates e. Oral bisphosphonates

Answer 80

Ans. The key is C. IV fluids. [Multiple myeloma itself is a cause of vomiting and also associated hypercalcemia can cause sickness. As the patient is vomiting for 2 days there may be considerable dehydration and also the hypercalcemia needs treatment with IV fluid].

Question 81

1081. A 30yo man from Australia returned from a business trip to Indonesia 6d ago presenting with complaints of fever, joint and muscle ache and headache, in particular behind the eye for the past 2 days. What is the most probable dx? a. Malaria b. Chicken pox c. TB d. Lyme’s disease e. Dengue

Answer 81

Ans. The key is E. Dengue. [Fever, arthralgia, myalgia, headache these are common in dengue fever. Particularly retro-orbital pain is well recognized feature of dengue fever].

Question 82

1082. A lady came for OBGYN assessment unit with hx of 8wk pregnancy and bleeding per vagina for last 2 days. On bimanual exam, uterus =8wks in size. On speculum exam, cervical os is closed. How do you confirm the viability of the fetus? a. Transvaginal US b. Serum BHCG c. Urinary BHCG d. Abdominal US e. Per speculum exam

Answer 82

Ans. The key is A. Transvaginal US. [Viability of the fetus is better assessed with transvaginal US. TVU can be done throught pregnancy. It should be avoided once the membrane is ruptured to avoid chance of fetal infection].

Question 83

1083. A 24yo lady has been low after the death of her husband and had stopped contacting her family. She was started on SSRI tx and starts feeling better after a few months. On discontinuating the meds she starts feeling that she has developed cancer just like her husband. What is the most appropriate next step? a. Continue SSRI b. Add TCA c. Neuropsychiatric analysis d. CBT e. Antipsychotics

Answer 83

Ans. The key is C. Neuropsychiatric analysis.

Question 84

1084. A 24yo male who is sexually active with other males with hx of discharge per urethra. Dx of chlamydia has been made. What is the possible complication if left untreated? a. Orchitis b. Balanitis c. Epididymo-orchitis d. Acute abdomen

Answer 84

Ans. The key is C. Epididymo-orchitis.

Question 85

1085. A person doesn’t go outside the home because he thinks that people will look at him and talk about him. He finds it difficult to associate with his peers in a restaurant or under social settings. What is the most likely dx? a. Agoraphobia b. GAD c. Panic disorder d. Adjustment disorder e. Social phobia

Answer 85

Ans. The key is E. Social phobia.

Question 86

1086. A 63yo man presented with sudden onset of severe dyspnea, orthopnea, raised JVP and bilateral basal crackles 3d after an episode of MI. A dx of acute congestive cardiac failure was made and IV furosemide was started for this pt. What electrolyte abnormality is expected? a. High Na+, Low K+ b. Low Na+, High K+ c. Low Na+, Low K+ d. High Na+, High K+ e. Low Na+, Normal K+

Answer 86

Ans. The key is C. Low Na+, Low K+. [Frusemide causes hyponatremia, hypochloremic alkalosis, hypokalemia, hypomagnesemia and hypocalcemia].

Question 87

1087. A 70yo hypertensive white british man on thiazide diuretics needs a 2nd drug to control his BP. Which one of the following is the best choice for him? a. Amlodipine (CCB) b. Enapril (ACEi) c. Propranolol (BB) d. Increase dose of diuretic e. Prazocin (Alpha blocker)

Answer 87

Ans. The key is B. Enalapril. [In patients >55 yrs CCB. If CCB not suitable (oedema, heart failure) thiazide is preferred. In patients <55yrs ACEI or ARB. Now if patient is on CCB or Thiazide 2nd drug should be added it should be one of ACEI or ARB and not one from CCB or Thiazide].

Question 88

1088. A 74yo lady who has had a stroke in the past has an indwelling catheter for 10m. She presents with bluish-purple discoloration of the catheter bag. What is the most likely explanation for this? a. Normal change b. Catheter degradation c. Acidic urine d. Alkaline urine e. Bacterial colonization of the urinary tract

Answer 88

Ans. The key is E. Bacterial colonization of the urinary tract. [Purple Urine Bag Syndrome].

Question 89

1089. A 62yo man has slow palpitations and the following ECG. What is the most likely dx? a. Sinus bradycardia b. 1st degree heart block c. Mobitz type 1 block d. Mobitz type 2 block e. Complete heart block

Answer 89

Ans. The key is C. Mobitz type 1 block. [Gradual prolongation of PR interval followed by a drop beat].

Question 90

1090. A 29yo woman presents with lid lag, lid retraction and diplopia. What is the most appropriate next step? a. TFT b. Tensilon test c. Fundoscopy d. Autoantibodies e. EMG

Answer 90

Ans. The key is A. TFT. [Features are suggestive of Grave’s disease hence TFT].

Question 91

1091. A 41yo man presents with longstanding foul smelling ear discharge and progressive hearing loss. Otoscopy showed perforation of the pars flacida and a mass in the upper part of the middle ear. What is the most likely dx? a. ASOM b. CSOM c. Acquired cholesteatoma d. Congenital cholesteatoma e. Barotrauma

Answer 91

Ans. The key is C. Acquired cholesteatoma. [In congenital cholesteatoma there is usually no perforation. In acquired cholesteatoma perforation is in pars flaccida].

Question 92

1092. A 9yo child presented with a rash on his skin which didn’t respond to antibacterial ointment. What med should be added next? a. Corticosteroid b. Antifungal c. Emollient d. Permethrin e. Coal tar

Answer 92

Ans. The key is B. Antifungal. [If a lesion is suspected to be infected should be given antibiotic. but if no response next step is to add an antifungal].

Question 93

1093. A young boy has a hx of epistaxis. CBC=normal, except APTT=47s. What is the most likely dx? a. Hemophilia b. ITP c. Sickle cell d. HUS e. Thalassaemia

Answer 93

Ans. The key is A. Hemophilia. [A young boy with epistaxis and prolonged APTT is a probable case of hemophilia. Factor VIII and IX should be offerred to confirm the diagnosis].

Question 94

1094. A 29yo young man presents with complaints of recurrent attacks of diarrhea. He says his stools contain blood and mucos. Sometimes he has low grade fever. What is the most appropriate inv for his condition? a. Stool culture b. Plain abdominal XR c. Per rectal exam d. Barium enema

Answer 94

Ans. The key is D. Barium enema. [Features are suggestive of IBD, so barium enema is the most relevant investigation among the given options].

Question 95

1095. A 26yo young man presents with hx of passing loose stools for the past 2m. He says his stools contain blood and mucus and are a/w abdominal pain. He undergoes a colonscopy after which he was started on tx. What is the most appropriate tx for his condition? a. Mesalazine b. Corticosteroids c. Infliximab d. Cyclosporine

Answer 95

Ans. The key is A. Mesalazine. [Features and tx after colonoscopy suggests dx of ulcerative colitis for which initial treatment option is mesalazine].

Question 96

1096. A 52 yo male with poorly controlled DM has now presented to his GP with pain in the ear. Exam: skin around the ear is black in color and there was foul smelling discharge from the ear. Pt also had conductive hearing loss. What is the most probable dx? a. Carbuncle b. Folliculitis c. Malignant OE d. Cholesteatoma e. Furuncle

Answer 96

Ans. The key is C. Malignant OE. [In some cases, otitis externa can spread to the outer ear and surrounding tissue, including the bones of the jaw and face. This infection is known as malignant otitis externa. Thogh the term malignant is used it is not a cancer].

Question 97

1097. A 55yo male has been admitted for elective herniorraphy. Which among the following can be the reason to delay his surgery? a. Controlled asthma b. Controlled A-fib c. DVT 2yrs ago d. DBP 90mmHg e. MI 2m ago

Answer 97

Ans. The key is E. MI 2m ago. [Following MI at least 6 months should be elapsed for elective operation. Prior this time surgery is associated with increased mortality].

Question 98

1098. A 21yo female in her first pregnancy at 38wks was brought to the ED with generalized tonic clonic seizure. IV MgSO4 was given but fits was not controlled. She is having fits again. What is the single most imp immediate management of this pt? a. IV MgSO4 b. IV diazepam c. Immediate C-section d. IV phenytoin e. MgSO4 bolus f. IV lorezepam

Answer 98

Ans. The key is A. IV MgSO4. It is a wrong key! Correct key is E. MgSO4 bolus. [Treat a first seizure with 4g magnesium sulfate in 100mL 0.9% saline IV .if respiratory rate <14/min or tendon reflex loss, or urine output <20mL/h. Have IV calcium gluconate ready in case of MgSO4 toxicity: 1g (10mL) over 10 min if respiratory depression. –10mg slowly IV). If seizures continue, ventilate and consider

Question 99

1099. A 24yo lady with BMI=30 complains of facial hair growth and hx of amenorrhea. FSH=10.9, prolactin=400IU, estradiol=177.8mmol/l, progesterone=normal, LH=33.2. What is the most probable dx? a. PCOS b. Pregnancy c. Cushing’s disease d. CAH e. POF

Answer 99

Ans. The key is A. PCOS. [Clinical features (obesity, hirsutism, amenorrhea etc.)are consistent with PCOS. We know in PCOS LH:FSH ratio is 2:1 or 3:1. Here LH is 33.2 and FSH is 10.9 which also supports diagnosis of PCOS].

Question 100

1100. A 17yo girl with a lump in her breast was seen in the clinic. Exam: the lump was free and mobile and not attached to the skin. Her mother wants further tests done. What should be the next step? a. CT b. US breast c. Punch biopsy d. Reassure and send home e. Stereotactic biopsy

Answer 100

Ans. The key is B. US breast. [Described lump is fibroadenoma. Next investigation is either US breast or mammography].