2015

Question 1

This patient came with retrosternal chest pain and fever
1. What is the diagnosis?
2. What are two complications?

Answer 1

1. Acute pericarditis
2. Cardiac tamponade, constrictive pericarditis, atrial fibrillation

Question 2

1. What are two symptoms the patient may present with?
2. How would you treat the patient ?

Answer 2

1. Palpitations, dizziness, syncope, convulsions
2. Permanent pacemaker

Question 3

A case of rheumatic heart disease ..
1. What is the diagnosis ?
2. What will happen to the JVP?

Answer 3

1. Atrial fibrillation
2. Absent a wave

Question 4

A diabetic patient with sudden increased sweating, nausea, and vomiting (the idea is that diabetic patients don’t have the typical pic of MI, no chest pain or orthopnea)
1. Which artery is affected?
2. On auscultation what 2 murmurs will you hear?

Answer 4

1. Left anterior descending artery
2. Pansystolic murmur (MR) and pansystolic murmur of VSD

Question 5

The patient had sudden onset of palpitations → sudden stop
1. What is the cause of these changes?
2. What is the definitive treatment ?

Answer 5

1. The cause of the change is supraventricular tachycardia (WPW was marked correct but it is not the right answer for the cause of change – Dr. Babu)
2. Radiofrequency or cryoablation of the accessory pathway

Question 6

50 year old Patient developed retrosternal chest pain radiating to the neck associated with palpitation and sweating.
1. What murmur would you hear on auscultation?
2. Why does this murmur develop?

Answer 6

1. Pansystolic murmur heard over the apex radiating to the axilla
2. One of the complications of acute MI is the rupture of papillary muscles which produces acute mitral regurgitation.

Question 7

Patient was experiencing palpitations and felt faintness with syncope
1. What is your immediate management?
2. What is the diagnosis?

Answer 7

1. Immediate synchronized cardioversion with DC shock
2. Ventricular tachycardia

Question 8

A patient developed sudden onset of severe retrosternal chest pain associated with palpitations.
1. What artery would be totally occluded?
2. What is the pathophysiology of the disease?

Answer 8

1. Left Anterior descending coronary artery, a branch of the left coronary artery.
2. An atherosclerotic plaque develops on the wall of the left coronary artery, if this plaque has a thin fibrous cap, it is more likely to rupture, triggering platelet aggregation and formation of a platelet-rich clot that totally occludes the vessel. Vasoconstriction also occurs due to platelet release of serotonin and thromboxane. This all results in ischemia and eventually infarction of the myocardial tissue.

Question 9

A patient took salbutamol and developed palpitations. His ECG in the emergency department is shown on the right.
1. What is the diagnosis?
2. Mention two systemic complications.

Answer 9

1. Atrial fibrillation
2. Stroke and Heart failure

Question 10

A 65 year old man had a dull pain in the middle of his chest and lasted for four hours.
1. Explain the pathophysiology behind the patient’s presentation.
2. What is the definitive treatment?

Answer 10

1. Rupture of atherosclerotic plaque, leading to thrombus formation that occluded the left coronary artery and caused tissue necrosis and death. (This artery is divided into left anterior descending artery and left circumflex artery).
2. Primary percutaneous intervention (PCI), thrombolytics if not feasible

Question 11

A 38 year old man presented with dyspnea and chest pain.
1. What is the diagnosis?
2. Two other signs seen in clinical examination?
3. What is the immediate management?

Answer 11

1. Tension pneumothorax of right lung (trachea is mildly deviated to the opposite side)
2. Deviated trachea, hyperresonant, absent breath sounds
3. Needle decompression in the second intercostal space in the midclavicular line, followed by chest tube insertion

Question 12

1. What is the diagnosis?
2. What is the most important next diagnostic step for diagnosis?

Answer 12

1. Right-sided pleural effusion
2. Pleural tap for lights criteria and cell count etc.. (if the history indicates TB, you should mention pleural biopsy)

Question 13

1. What is the most likely causative organism?
2. What is the treatment?

Answer 13

1. S.pneumonia
2. Oral antibiotics e.g. amoxicillin or cephalosporin

Question 14

1. What is the structure pointed at with the arrow?
2. In which condition would this be enlarged?

Answer 14

1. Right Atrium
2. Pulmonary Hypertension Right ventricular failure Tricuspid regurgitation

Question 15

The patient had anemia leukocytosis and hypercalcemia he lost 3kg in 6 weeks
1. What is the diagnosis?
2. What is the mechanism of the hypocalcemia?

Answer 15

1. Bronchogenic carcinoma
2. Parathyroid like hormone production (paraneoplastic syndrome) (or bone mets)

Question 16

A 15 year-old south-Asian patient developed fever and chest pain, associated with weight- loss.
1. What is the finding on chest X-ray?
2. What is the most likely diagnosis?

Answer 16

1. An opacity occupying the middle zone of the right lung with air bronchogram
2. Right upper lobe pneumonia ( no silhouette sign).

Question 17

This patient came with productive cough and fever
1. Mention 2 signs in physical exam?
2. What is good for long-term management?

Answer 17

1. (the picture had tracheal deviation) Reduced chest expansion and dullness on percussion
2. Azithromycin +/- chest physiotherapy and postural drainage

Question 18

A 22 year old patient presents with sudden onset of SOB. His chest x-ray is shown.
1. What is the diagnosis based on the chest x-ray, specify on which side.
2. Mention 3 findings on physical examination.

Answer 18

1. Right sided pneumothorax.
2. Hyperresonant percussion of right side. Decreased breath sounds on the right side. Decreased vocal resonance on the right side.

Question 19

patient presented with fever, productive cough, and shortness of breath.
1. What is seen in this chest x-ray?
2. What is the diagnosis?

Answer 19

1. An ill-defined white opacity occupying the middle zone of the right lung (consolidation).
2. Right middle lobar pneumonia.

Question 20

A patient came with fever and breathlessness.
1. Describe the patient’s x-ray?
2. What is the diagnosis?

Answer 20

1. Obliteration of the left costophrenic angle by a homogenous opacity and meniscus sign
2. Pleural effusion in the left lung

Question 21

A 32 year old female patient developed progressive breathlessness and cough with hemoptysis. She denied having a history of acute rheumatic fever. Intracardiac pressures are shown.
1. What added sound would you search for on auscultation?
2. What medications would you treat the patient with?

Answer 21

1. An opening snap and loud S1
2. Diuretics for fluid overload, Beta-blockers for palpitations (atrial fibrillation), and long term anticoagulation is indicated in underlying rheumatic mitral stenosis for atrial fibrillation

Question 22

A patient complaining of breathlessness of 3 months duration, he developed cough with hemoptysis.
1. What is the murmur heard on auscultation?
2. What is the most likely etiology?

Answer 22

1. Mid-diastolic murmur.
   (An opening snap followed by low pitched mid-diastolic rumble best heard over the apex over the left lateral decubitus position with the bell of the diaphragm).
2. Rheumatic heart disease (a complication of acute rheumatic fever).

Question 23

A patient developed fever and weight loss of 3 weeks duration. She suddenly developed pulmonary edema.
1. What is the name of this lesion?
2. What is the likely diagnosis?

Answer 23

1. Vegetation over the aortic root due to bacterial infection.
2. Infective endocarditis.

Question 24

A 24 year old patient complained of a 1 week history of fever and then developed progressive shortness of breath and orthopnea.
1. Mention two findings in this chest x-ray.
2. What is the diagnosis?

Answer 24

1. Increase in cardiothoracic ratio, indicating cardiomegaly, Bilateral haziness in both lung fields
2. Viral myocarditis

Question 25

A 32 year old pregnant female with a history of pre-eclampsia and diabetes. Her diabetes is well controlled with medications. She came to the outpatient clinic as she could not wear her shoes.
1. What is this physical sign?
2. What are findings in physical examination that indicates a cardiac cause?

Answer 25

1. Pitting edema
2. Raised JVP, S3 sound Displaced apex beat

The patient got dilated cardiomyopathy that may occur in peri- or postpartum periods. The patient may present with, ascites, pitting edema, and pulmonary edema.

Question 26

A 21 year old women presented with history of fever, joint pain and swelling, and breathlessness of one week duration. She had a history of sore throat three weeks before her current presentation. The picture below shows a lesion on her elbow.
1. What is the diagnosis?
2. How would you treat her?

Answer 26

1. Acute rheumatic fever
2. Penicillin for 10 years or until age of 40 (whichever is longer)

Question 27

A 35 year old male presented with history of central chest pain, radiating to the neck and relieved by leaning forward. He was also noted to have a low grade fever on admission.
1. What is the diagnosis?
2. What physical sign will you be looking for during your cardiovascular examination?

Answer 27

1. Acute pericarditis
2. Pericardial rub

Question 28

Patient presented with progressive SOB and non-productive cough. He has negative occupational history. CT scan shown:
1. Describe the finding of CT scan?
2. Mention two symptoms the affect the patient the most?
3. What are the treatment methods/what is the definitive management ?

Answer 28

1. Honeycomb appearance with traction bronchiectasis
2. SOB & dry cough?
3. O2, specialized therapy such as pirfenidone/nintedanib (not steroids)

(if the question was definitive management then the answer is lung transplant)

Question 29

An asthmatic patient was complaining of a cough and chest tightness
1. What percent improvement in FEV1% is considered to be significant?/*What is the percentage change in FEV1 after the administration of bronchodilator to consider the diagnosis of asthma?
2. If the previous test is inconclusive and you still suspect asthma، what test is used to diagnose it?
3. You gave the patient inhaled corticosteroids and the symptoms were not improving, what is the next step?

Answer 29

1. 12% and 200 ml
2. Methacholine challenge test.
3. LABA (long acting beta adrenergic agonists)

Question 30

A 50 year old patient is complaining of non-productive cough and increasing breathlessness of 10 months duration. High resolution CT scan of the chest is shown.
1. What are the findings on CT scan?
2. What is the diagnosis?

Answer 30

1. Traction bronchiectasis with honeycomb appearance of the lung
2. Interstitial lung disease most probably idiopathic pulmonary fibrosis.

Question 31

A PFT of a patient is shown
1. Comment on the result of this patient’s PFT.
2. Why is the residual volume increased in this case?

Answer 31

1. Obstructive irreversible pattern
2. Due to air trapping

Question 32

A PFT of a patient is shown
1. What is the most probable disease based on PFT?
2. What treatment would be beneficial for this patient?

Answer 32

1. The PFT’s show moderately severe reversible obstructive ventilatory defect with air trapping suggestive of bronchial asthma.
2. 1-Inhaled corticosteroids (as a part of maintenance therapy).
   2-Short acting beta adrenergic agonists (salbutamol) 3- Long acting beta adrenergic agonists (salmeterol) 4- Oral corticosteroids are occasionally necessary in patients not controlled on inhaled steroids

Question 33

Patient is a case of Parkinson’s and has a pill rolling tremor
1. What are the cardinal features of Parkinson’s disease?
2. What is the mainstay treatment of Parkinson’s disease?

Answer 33

1. ● Bradykinesia: slowing of movements or difficulty initiating movements.
   ● Tremor: Resting tremor usually most obvious in the hands improved by voluntary movement and worsens with anxiety.
   ● Rigidity: increase in tone with resistance to passive extension throughout movement.
   ● Postural changes: a stoop,
2. Dopamine replacement improves the motor symptoms and is the basis of:
3. Pharmacological therapy ( levodopa, dopamine agonists, monoamine oxidase Inhibitors etc.. ).
   Other treatments include physiotherapy to improve gait and prevent falls. Deep Brain stimulation has proved to be a major therapeutic advance in selected patients.

Question 34

Patient came to the ER with this vision.
1. What is the finding?
2. Why is the macula spared in this case?

Answer 34

1. Left homonymous hemianopia with sparing of the macula.
2. The lesion is in the visual cortex, the part that represents macular vision has dual blood supply by the Posterior cerebral artery and middle cerebral artery.

Question 35

A patient complained of nocturnal paresthesia affecting the thumb, index and middle finger.
1. What are the main findings?
2. How would you confirm the diagnosis?

Answer 35

1. Atrophy of the thenar muscles.
2. It is mainly a clinical diagnosis positive tinel and phalen test but nerve conduction studies can be used to confirm the diagnosis.

Question 36

A Patient with Horner syndrome
1. What are the main pathological features ?
2. Mention two causes of this condition

Answer 36

1. Ptosis and miosis
2. ● Pancoast tumor of the apex of the lung
   ● Carotid artery dissection

Question 37

Weber’s test
1. How would you explain and conduct this test on the patient?
2. How would you interpret the test?

Answer 37

1. Place the heel of the vibrating tuning for in the center of the patient’s forehead , ask the patient if he hears the sound more on the left or the right, or just in the middle of the head.
2. If for example, the sound lateralizes to the left ear, it is either conductive hearing loss in the left ear, or sensorineural hearing loss in the right ear. Rinne test should be conducted in order to assess the air and bone conduction for both ears.

Question 38

A patient who is diabetic and hypertensive developed an ischemic stroke in the MCA territory
1. Why is the leg not affected in this type of stroke?
2. Give two preventive measures for stroke?

Answer 38

1. The Middle cerebral artery supplies the motor cortex (motor homunculus) which gives off corticospinal fibers that synapse with lower motor neurons innervating the muscles of the body above the knee. A Stroke affecting The anterior cerebral artery on the other hand, would cause profound weakness of muscles below the knee because it supplies medial surface of the cerebral cortex which is a representation of the legs and knees as well as muscles responsible for micturition and defecation within the motor homunculus.
2. • Control of hypertension is the most important preventable risk factor for stroke.
     - Control of hyperlipidemia with lipid lowering drugs (statins)
     - Aspirin, which is an antiplatelet drug that prevents clot formation

Question 39

1. How do you differentiate between a traumatic tap and subarachnoid hemorrhage with lumbar puncture?
2. What is the classical presentation of subarachnoid hemorrhage?

Answer 39

1. You should take 3 consecutive samples. A decreasing concentration of red blood cells from bottles one to three indicates a traumatic tap rather than blood in the CSF.
2. Thunderclap headache that reaches maximum intensity within seconds of onset and described as being the worst ever.

Question 40

A 50 year old man with uncontrolled diabetes presented to the outpatient clinic as shown in the picture.
1. Why is the eye directed down and out?
2. Why is the pupil spared in this patient?

Answer 40

1. The patient has oculomotor (CN III) nerve palsy. Lateral rectus and superior oblique are unopposed.
2. In CN III, the parasympathetic fibers are on the periphery, while the motor is centrally located. With diabetes, the vasa vasorum supplying CN III is impaired and the central part is more affected. This causes the down and out presentation with no mydriasis.

Question 41

This patient has this problem while going down the stairs:
1. What is the problem with this patient?
2. Why does the patient tilt his head to the opposite shoulder?

Answer 41

1. He has left trochlear (CN IV) nerve palsy. This nerve innervates the superior oblique muscle responsible for depression, intrusion, and abduction of the eye. The loss of its function causes the eye to be elevated, extorted, and adducted.
2. It is a way of compensation to bring the fields back together (the extorted left eye comes to a position that the healthy right eye can match by intorsion).

Question 42

A 51 year old women presented with headache and diplopia. The patient is looking forward:
1. Why is the left eye turned in (adducted)?
2. Name two causes of this condition.

Answer 42

1. The patient has abducens (CN VI) nerve palsy, normally responsible for abduction (lateral rectus). Unopposed medial rectus causes the eye to turn inward.
2. Stroke, Acoustic neuroma and multiple sclerosis

Question 43

1. How do you differentiate between UMN lesion and LMN lesion affecting the facial nerve?
2. In case of pontine lesion, why will hemiparesis be contralateral?

Answer 43

1. UMN lesion causes contralateral weakness of the lower part of the face, but the frontalis is spared due to dual cortical innervation. LMN lesion causes ipsilateral weakness of all facial muscles, including the frontalis.
2. Because motor decussation occurs in the lower part of the medulla (located in a level below the pons).

Question 44

1. What are the afferent and efferent of this reflex?
2. What is relative afferent pupillary defect (RAPD)?

Answer 44

1. Afferent: optic nerve
   Efferent: oculomotor nerve
2. Incomplete damage to one optic nerve relative to the other (eg. optic neuritis). The patient’s pupil constricts less, therefore appearing to dilate when a bright light is swung from the unaffected eye to the affected eye.

Question 45

A patient suffering from nuchal rigidity. His CSF analysis is shown on the right.
1. What is the meaning of nuchal rigidity? What does it indicate?
2. What is the diagnosis?

Answer 45

1. It is increased resistance to passive flexion of the neck. It indicates meningeal irritation (meningitis, subarachnoid hemorrhage, etc).
2. Bacterial meningitis

Question 46

Performing the test in the picture yielded negative result in a patient.
1. Name two abnormalities that can be seen in this patient?
2. Describe Brown-Sequard syndrome?

Answer 46

1. Positive Romberg’s test and abnormal proprioception
2. Hemi-section of the spinal cord. It is characterized by contralateral pain and temperature loss (spinothalamic) with ipsilateral weakness and loss of vibration & joint position (dorsal column and corticospinal) below the lesion. There is also a LMNL at the level of the lesion.

Question 47

Patient developed ventricular fibrillation, was suddenly sweating and then collapsed.
1. What is the classical presentation preceding syncope?
2. What are the classical symptoms following seizures?

Answer 47

1. A prodrome of nausea, headache, lightheadedness and sweating occurs. Rapid recovery from the attack and the absence of jerking movements suggest a faint rather than a fit.
2. A period of post-ictal flaccid unresponsiveness followed by confusion and drowsiness lasting for several hours.

Question 48

A patient was complaining of abdominal pain, weight loss and watery diarrhea. She has a recent travel history to Lebanon. The picture shows a biopsy from the small bowel
1. What is the diagnosis/ what is the organism?
2. What is the mode of transmission?

Answer 48

1. Giardiasis caused by giardia lamblia (giardia intestinalis).
2. It is transmitted by contaminated water and via feco-oral route.

Question 49

Patient developed right epigastric pain radiating to the back. He was also hypotensive and tachycardic.
1. What is this sign and what does it indicate?
2. What does this mean with regards to morbidity and mortality?

Answer 49

1. Cullen sign, a sign of peritoneal hemorrhage, in this case it is most likely due to acute hemorrhagic (necrotizing) pancreatitis
2. It is associated with higher risk of morbidity and mortality as it indicates severe necrotizing pancreatitis.

(this may not be exact question but you have to know that Cullen and gray-turner sign are signs of severe acute pancreatitis and carry a poor prognosis).

Question 50

A 40 year old female with 15 years history of Ulcerative colitis. Her liver enzymes are shown. The patient underwent ERCP
1. What is the diagnosis?
2. Mention 2 complications?

Answer 50

1. Primary sclerosing cholangitis
2. Liver cirrhosis Cholangiocarcinoma

Question 51

An old man presented fatigue and exertional dyspnea. CBC and colonoscopy is done and the result is shown:
1. Explain the lab findings:
2. What is the diagnosis?

Answer 51

1. The patient developed microcytic (low MCV) and hypochromic (low MCH) anemia
2. Colorectal cancer

Question 52

A female presented with watery diarrhea and abdominal pain. She also suffers from itching in her abdomen as shown in this picture.
1. What is this sign? What is it associated with?
2. Mention two diagnostic tests.
3. How can you manage the patient?

Answer 52

1. Dermatitis herpetiformis. It is associated with celiac disease
2. Serology (anti-tissue transglutaminase, anti-endomysial antibodies, and anti- deaminated gliadin) and Duodenal biopsy
3. Gluten restriction

Question 53

1. Name the signs shown in A & B.
2. Give two differential diagnoses.

Answer 53

1. A. Aphthous ulcer
   B. Erythema nodosum
2. Crohn’s and Behcet’s disease

Behcet’s disease is characterized by recurrent oral ulceration and skin lesions, like erythema nodosum.

Question 54

A Patient with type 2 diabetes Mellitus
1. What are the circled lesions called, and how do they develop?
2. Name another microvascular complication and ways to screen for it.

Answer 54

1. Hard exudates. Capillary leaks of plasma rich in lipids and protein.
2. Diabetic nephropathy. The urine of all patients should be checked at least once a year by dipsticks for the presence of protein and microalbuminuria. Meticulous control of blood sugar and treatment with ACEI would delay frank proteinuria and end-stage renal disease.

Note from Kumar:
Hard exudates have a bright yellowish white color and are often irregular in outline with sharply define margin.
Cotton wool spots are greyish white, have indistinct margins and a dull matt surface unlike the glossy appearance of hard exudates.

Question 55

1. What are the 2 signs?
2. What is the diagnosis?

Answer 55

1. Heberden and Bouchard nodes
2. Osteoarthritis

Question 56

A 36 year old man presented to you with chronic lower back pain. His x-ray is shown below.
1. Mention two findings on the x-ray.
2. What is the possible diagnosis?

Answer 56

1. Squaring of vertebral bodies
   Fusion of vertebrae (bamboo spine)
2. Ankylosing spondylitis

Question 57

34 year old female complained of fatigue and joint pain for more than 12 weeks.
1. Mention two initial investigations you would request.
2. What other bedside examination would you perform beside MSK?

Answer 57

1. CBC and ANA
2. Cardiovascular system (looking for pericardial effusion and pericarditis)

Question 58

A patient with severe metastatic bone disease due to breast cancer
1. In which category the patient would lie?
2. Explain you answer.

Answer 58

1. D
2. In metastatic bone disease, there is bone destruction as a result of release of osteoclastic factors from malignant cells, this results in bone resorption and hypercalcemia. The normally functioning parathyroid gland would be suppressed by negative feedback inhibition due to hypercalcemia.

Question 59

This patient has pituitary adenoma as shown in the coronal MRI imaging.
1. Mention 2 systemic manifestation in this patient.
2. Mention 2 mass effect of the lesion.

Answer 59

1. Diabetes mellitus and cardiomyopathy
2. Bitemporal hemianopia and cranial nerve palsies (cavernous sinus compression)

Question 60

18 year old patient with splenomegaly and microcytic anemia
1. What does the peripheral blood smears show, and what are the cells seen on blood film?
2. What is the diagnosis and basis of management?

Answer 60

1. Microcytic anemia with basophilic stippling and teardrop cells
2. Sideroblastic anemia is one of the causes of refractory anemia
   Treatment is to withdraw the causative agents and some cases respond to pyridoxine (Vitamin B6)

Question 61

A post-menopausal women presented with GI bleeding
1. Explain what you see in the blood smear
2. How would you confirm the diagnosis?

Answer 61

1. Microcytic hypochromic anemia with pencil cells ( elliptocytes ) and anisocytosis
3. Iron study which includes: - Serum ferritin.
   - Serum Iron.
   - Transferrin and its saturation. 2. Colonoscopy

Question 62

A patient came with tiredness, palpitation and dyspnea upon exertion. A peripheral smear and iron study is shown on the right.
1. Describe the findings on the smear.
2. What is the diagnosis?

Answer 62

1. basophilic stippling of RBCs, tear drop cells, and central pallor of RBCs
2. Sideroblastic anemia

Question 63

A patient presented with fatigue, abdominal pain, and bloody diarrhea. He also has a red sore tongue.
1. What is the main cause of presence of this cell on the right?
2. Which part of GI system is affected?

Answer 63

1. Vitamin B12 deficiency
2. Terminal ileum (Crohn’s disease)

Question 64

A 28 year old patient with weakness and fatigability.
1. What is the acid base status?
2. What is the most likely diagnosis?

Answer 64

1. Partially compensated normal anion gap metabolic acidosis
2. Diarrhea (GI losses of HCO3)

Question 65

A patient presented with dehydration and vomiting. He was hyperventilating:
1. What is the next step after giving normal saline IV fluid? Justify.
2. Calculate the anion gap and comment on it.

Answer 65

1. Correct the hypokalemia (as per ECG and labs) before administering insulin since insulin will cause intracellular K+ shift and more hypokalemia.
2. (Na + K)-(Cl + HCO3) = (128 + 2.8)-(99 + 14.9) = 16.9 High anion gap metabolic acidosis due to DKA

Question 66

A patient developed fever, chills and a rash.
1. What is the diagnosis?
2. What is the treatment?
3. What is the other disease that affects a specific dermatome?

Answer 66

1. Chickenpox
2. -
3. Shingles (herpes zoster).

Question 67

A patient presented with left-sided pain one week ago, and then developed a rash shown in the picture 3-4 days
1. What is the diagnosis?
2. Name one systemic agent used to treat this patient.

Answer 67

1. Shingles (VZV)
2. IV Acyclovir

Question 68

A patient had a facial rash after wearing her new glasses three days ago.
1. What is the type of metal she is sensitive to?
2. What is the type of this hypersensitivity?

Answer 68

1. Nickel
2. Delayed (Type IV) hypersensitivity (This is a case of contact dermatitis)

Question 69

A 16 year old boy accidently ingested a peanut butter cookie. Soon after, he developed an anaphylactic reaction.
1. Mention two symptoms of anaphylaxis.
2. Explain the pathophysiology of anaphylaxis.

Answer 69

1. Angioedema and wheezing
2. Allergens cross-link with IgE presented on mast cells, leading to its degranulation and production of mediators, like histamine. This causes increased capillary permeability and bronchoconstriction.

Question 70

This patient came with retrosternal chest pain and fever
1. What is the diagnosis ?
2. What are two complications?

Answer 70

1. Acute pericarditis
2. Cardiac tamponade,
   constrictive pericarditis, atrial fibrillation
   (confirmed by dr. Babu)

Question 71

1. What are two symptoms the patient may present with?
2. How would you treat the patient ?

Answer 71

1. Palpitations, dizziness, syncope, convulsions
2. Permanent pacemaker

Question 72

A case of rheumatic heart disease ..
1. What is the diagnosis ?
2. What will happen to the jvp ?

Answer 72

1. Atrial fibrillation
2. Absent a wave

Question 73

A diabetic patient with sudden increased sweating, nausea, and vomiting ( the idea is that diabetic patients don’t have the typical pic of MI, no chest pain or orthopnea)
1. Which artery is affected?
2. on auscultation what 2 murmurs will you hear?

Answer 73

1. Left anterior descending artery
2. Pan-systolic murmur (MR) and pansystolic murmur of VSD
   (MI affect valves with papillary muscles only – so it results in MR, TR, VDS – confirmed by dr Babu)

Question 74

The patient had sudden onset of palpitationsàsudden stop
1. What is the cause of these changes ?
2. What is the definitive treatment ?

Answer 74

1. The cause of the change is supraventricular tachycardia
   (WPW was marked correct but it is not the right answer for the cause of change – Dr. Babu)
2. Radiofrequency or cryo ablation of the accessory pathway

Question 75

1. What is the diagnosis ?
2. What is the most important next diagnostic step for diagnosis?

Answer 75

1. Rt Sided pleural effusion
2. Pleural tap for lights criteria and cell count etc.. (if the history indicates TB, you should mention pleural biopsy)

Question 76

A 26 year old Patient with cough, fever and tiredness
1. What is the most likely causative organism?
2. What is the treatment?

Answer 76

1. S.pneumonia
2. Oral antibiotics e.g. amoxicillin or cephalosporin

Question 77

This patient came with progressive shortness of breath and non-productive cough
1. What can you see?
2. What are the treatment methods/what is the definitive management ?

Answer 77

1. Honeycombing with traction bronchiectasis
2. O2, specialized therapy such as pirfenidone/nintedanib (not steroids)
   (if the question was definitive management then the answer is lung transplant)

Question 78

The patient had anemia leukocytosis and hypercalcemia helost3kgin6weeks
1. What is the diagnosis ?
2. What is the mechanism of the hypocalcemia ?

Answer 78

1. Bronchogenic carcinoma
2. Parathyroid like hormone production (paraneoplastic syndrome) (or bone mets)

Question 79

This patient came with productive cough and fever
1. Mention 2 signs in physical exam? (the picture had tracheal deviation)
2. What is good for long-term management?

Answer 79

1. Reduced chest expansion and dullness on percussion
2. Azithromycin +/- chest physiotherapy and postural drainage