Day 11

Question 1

Q1-A 45-year-old man presents with a 1-day history of severe, excruciating pain in his right flank, vomiting and fever. He describes the pain as ‘needle-like’ and it moves towards his groin. He has tried diclofenac which has had little effect. When passing urine, the pain increased and his urine was blood-tinged. He denies any other symptoms or medical problems. The patient’s temperature is 38°C and a CT scan shows a renal staghorn calculus. The most appropriate treatment is?

A-Shock wave lithotripsy
B-Ureteroscopy
C-Percutaneous nephrolithotomy
D-Open surgery
E-Conservative management, allow stone to pass

Answer 1

Ans: C. There are a number of factors that indicate urgent intervention, they include
signs of an infection along side urinary tract obstruction, pain refractory to analgesia and/or vomiting, signs of renal failure and bilateral renal calculi. Conservative management (E) is therefore not appropriate. Percutaneous nephrolithotomy (C) uses a nephroscope with a lithotripsy or laser device attached. All fragments can be removed using suction or grasping devicesand this is the ideal treatment in large, complex stones in the kidney. Open surgery (D), although the first-line therapy in the past, has now beenreplaced by interventions that are effective and less invasive. Shock wave lithotripsy (A) utilizes shock waves in a focused manner to fragment stones,they are ideal in simple renal calculi. Ureteroscopy (B) introduces an endoscope that allows the passage of instruments that may be used forstone fragmentation. It is ideal for treating patients who are morbidly obeseor pregnant.

Question 2

Q2-A pregnant lady comes at 37 weeks with 3+ proteinuria, confusion and Blood pressure 170/110mmhg. What is the best step in her management?

A-Cesarean section
B-Hydralazine 
C-Deliver the baby immediately
D-Admit and monitor/ mgso4 
E-Send home

Answer 2

Ans: C. if sevre fetal or maternal compromises then go for CS. if mild Pre eclempsia the vaginal delivery is preferred.

Question 3

Q3-A 65year presents with dyspareunia after sex. She in menopause. She complains of bleeding after sex. What is the most probably diagnosis?

A-Cervical cancer
B-Endometrial cancer
C-Ovarian cancer
D-Breast cancer
E-Vaginal cancer

Answer 3

Ans: A.cancer cervix-post coital bleeding.

Cancer endometrium-post menopausal, intermenstrual bleeding.

Question 4

Q4-How do you diagnose pseudo membranous colitis?

A-Identification of toxin
B-Culture
C-Proctosigmoidoscopy
D-X-ray

Answer 4

Ans: A. stool assay should be done for the identification of toxin
PSEUDOMEMBRANOUS COLITIS • It is an acute diarrhoea due to toxins produced by the overgrowth of Clostridium difficile after antibiotic therapy (usually after clindamycin). • Clostridium difficile is a Gram positive, anaerobic, spore forming bacillus. It produces toxin A (enterotoxin) and toxin B (cytotoxin, more potent). • It is also often seen in immunocompromised patients and patients who are on cancer chemotherapy. • Incidence is 2%. Mortality is 30%. • Stool cytotoxin assay is highly sensitive and specific. ELISA test for toxins is also useful. • Colonoscopy is ideal as right side involvement is more common. • It can occur up to 6 weeks after stopping the drug. • Diarrhoea, toxaemia, perforation, haemorrhage also can occur

http://gi.org/guideline/diagnosis-and-management-of-c-difficile-associated-diarrhea-and-colitis/

Question 5

Q5-Which of the following is an absolute contraindication to the use of beta blockers?

A-Symptomatic bradycardia 
B-Peripheral artery disease 
C-Asthma
D-Emphysema
E-Diabetes

Answer 5

Ans: A. Symptomatic bradycardia is an absolute contraindication for the use of beta blockers. The over whelming majority of patients with peripheral artery disease can still use beta blockers. In a patient with a myocardial infarction, the mortality benefit of metoprolol far exceeds the risk of its use when asthma, emphysema, or peripheral artery disease is present. Two thirds of asthma patients can tolerate beta blockers.

Question 6

Q6-A patient with Hodgkin’s lymphoma, who is under treatment, develops high fever. His blood results show WBC -2800/cumm and Neutrophil is 10% and has a chest infection. Choose the most appropriate treatment?

A-Co-amoxiclav
B-Piperacillin+tazobactam
C-Erythromycin
D-Piperacillin+Co-amoxiclav
E-Penicillin+tazobactam

Answer 6

Ans: B. The followingantibioticsare appropriate as monotherapy in Febrile Neutropenia. Goal is to cover Pseudomonas and all of the below antibiotics cover Pseudomonas.

* Piperacillin-tazobactam 4.5 gIVq6h or.
* Cefepime 2 gIVq8h or.
* Meropenem 1 gIVq8h or.
* Imipenem-cilastatin 500 mgIVq6h.

Question 7

Q7-A patient who has recently undergone hip fracture repair develops the sudden onset of shortness of breath. His pulse is 110 per minute. The chest is clear to auscultation. Chest x-ray is normal, and the EKG shows sinus tachycardia. ABG shows pH 7.48, pCO2 28, pO2 75. What is the next best step in management?

A-Heparin
B-V/Q scan
C-Spiral CT Scan
D-D-dimers
E-Lower extremity Doppler 
F-Angiography

Answer 7

Ans: A.Its classical case of pulmonary embolism, in such case start Heparin.

Question 8

Q8-A 28year female presents with 1-week history of jaundice and 2days history of altered sleep pattern and moods. She was diagnosed with hypothyroidism for which she is receiving thyroxine. Thyroid function showed increased TSH. PT=70s. What is the most probable diagnosis?

A-Acute on chronic liver failure
B-Hyper-acute liver failure
C-Autoimmune hepatitis
D-Acute liver failure

Answer 8

Ans: C-presence of jaundice likely autoimmune hemolysis or liver disease, thyroid involvement and now liver means there is multi organ involvement commonly seen in CVD (collagen vascular dz) or autoimmune disease.

Question 9

Q9-Male patient working in the cotton field, presented with 3 weeks’ history of cough. Chest X ray showed bilateral hilar lymphadenopathy and biopsy by bronchoscopy showed non-caseating granuloma. What’s your diagnosis?

A-Sarcoidosis
B-Amylidosis
C-Histiocustosis
D-Berylliosis
E-Pneumoconiosis

Answer 9

Ans: A. Sarcoidosis is a disease of unknown cause characterized bynon-necrotizing (“non-caseating”)granulomasin multiple organs and body sites, most commonly the lungs and lymph nodes within the chest cavity. Other common sites of involvement include the liver, spleen, skin and eyes

Question 10

Q10-A 45year IV drug abuser is brought into the Emergency room with complaint of fever, shivering, malaise, dyspnea and productive cough. Exam: temp=39C, pulse=110bpm, BP=100/70mmHg. Inv: Chest x ray showed bilateral cavitating bronchopneumonia. What is the single most likely causative organism?

A-Mycoplasma
B-Staphylococcus
C-Chlamydia pneumonia 
D-Pseudomonas
E-PCP (Pneumocystis pneumonia)

Answer 10

Ans: B-Staphylococcus. Among the given causes Staphylococcus and PCP are recognized cause of cavitating pneumonia. This case is with productive cough which goes more with staphylococcus as PCP is not productive but rather associated with dry cough. Drug abuse can support both staphylococcus and PCP.

Question 11

Q11-You are seeing a child with Lymphadenopathy and fever. what is your first test from following after doing examination?

A-Chest x ray
B-Liver and renal function
C-LDH
D-CBC and differential count

Answer 11

Ans: D. best initial investigation in child with fever and lymphadenopathy is to rule out infection or Leukemia (mainly ALL).Acute Lymphoblastic leukemia is commonest cancer in childhood. so CBC and peripheral smear is best to get idea for possible diagnosis and further investigation approach too.

Question 12

Q12-Asthma not controlled on salbutamol and low dose Beudesonide. Which is the next add on drug?

A-Salmetrol
B-Oral steroid
C-Aminophylline
D-High dose budesonide (inhaled)
E-Ipratropium Bromide

Answer 12

Ans: A. From first aid USMLE –page 481 10thedition
Acute exacerbation:

■ O2, SABA (albuterol is first-line), systemic glucocorticoids. SABA/
ipratropium and magnesium can be used in severe exacerbations.

■ Never use ipratropium alone in asthma treatment.

■ Consider intubation in severe cases (cyanosis, inability to maintain
respiratory effort, altered mental status) or acutely in patients with a
Paco2 >50 mmHg or a Pao2 <50 mmHg.

Maintenance therapy: Determined by the classification of asthma severity.

■ Step 1: Inhaled SABA (albuterol) as needed for symptom control is
first-line.

■ Step 2: Add daily medication for long-term control. Low-dose inhaled
corticosteroids (ICS) are preferred. Alternatives include cromolyn, leukotriene
receptor antagonist (LTRA), or theophylline. Continue albuterol
PRN.

■ Step 3: Add long-acting β-agonist (LABA) such as salmeterol to low-dose
ICS or ↑ dose of ICS to medium-dose. Continue albuterol PRN.

■ Step 4: Medium-dose ICS + LABA. Continue albuterol PRN.

■ Step 5: High-dose ICS + LABA. Consider omalizumab (anti-IgE) or
mepolizumab (anti-IL-5) for patients with allergies (↑ IgE). Continue
albuterol PRN.
■ Step 6: High-dose ICS + LABA + oral corticosteroid. Continue albuterol
PRN.

Question 13

Q13-A patient with HIV/AIDS has repeatedly refused to disclose his HIV status to his sexual partner. The partner accompanies the patient to the office visits and is in the waiting room. The patient insists you not tell the partner.
What do you do?

A-Honor the patient’s wishes
B-Obtain a court order
C-Consult the ethics committee
D-Either the physician or the department of health can notifythe partner

Answer 13

Ans: D. You have the right to notify the partner or to disclose the patient’s HIV status to the health department so that they can notify the partner. The confidentiality of the patient is not as important as protecting the health of the partner.HIV-positive healthcare workers do not have to disclose their status to their patients or their employers.

Question 14

Q14-A 34-year woman presents with pains in both hands for the last few months and stiffness that improves as the day goes on. Multiple joints are swollen on exam. X-rays of the hands show some erosion. What is the single most accurate test?

A-Rheumatoid factor
B-Anti-cyclic citrullinated peptide (anti-CCP) 
C-Sedimentation rate
D-ANA
E-Joint fluid aspirate

Answer 14

Ans: B. Anti CCP and RA done at diagnosis of Rhumatoid Arthritis.
RA can be negative but anti CCP detects in early RA cases.
Alone RA can be present in non Rhumatoid arthritis patients.so in early disease RA can be absent but Anti CCP is present. Anti CCP high titer has prognostic value as well.

http://www.arthritisandpainclinic.com/blood-tests.html

Question 15

Q15-Elderly diabetic man with sudden unilateral visual loss. There is multiple pigmentation in retina with macular edema with hemorrhage. What is likely diagnosis?

A-Retinal detachment
B-Retinal artery occlusion
C-Retinal vein thrombosis
D-Diabetic retinopathy

Answer 15

Ans: C

Question 16

Q16-19-year-old woman presents to her primary care physician complaining of excessive bruising on her legs for the past 3 days. She denies injury. She was treated for streptococcal throat infection 10 days ago and recently completed antibiotic therapy. She has had some cramping abdominal pain, but she is premenstrual and says the pain is similar to her usual cramps. She took ibuprofen for the pain, with good relief. She has a boyfriend but is not sexually active. She denies previous history of bruising or bleeding easily. Inspection of her legs reveals diffuse tender, erythematous, indurated patches and nodules over the anterior aspects of her tibias bilaterally. Which of the following is the most likely cause of her symptoms?

A-Domestic violence 
B-Erythema nodosum 
C-Henoch-Schönlein purpura 
D-Idiopathic thrombocytopenic purpura
E-Secondary syphilis

Answer 16

Ans: B

Question 17

Q17- A 30-year woman, who is 8 weeks pregnant, presents to emergency room with PV bleeding and crampy abdominal pain. She has a past medical history of a right-sided deep vein thrombosis and two previous miscarriages. She is sent to the early pregnancy assessment unit, where ultrasound confirms miscarriage. What is the most likely underlying diagnosis?

A-Rheumatoid arthritis
B-Anti-phospholipid syndrome
C-Sjögren’s syndrome
D-Discoid lupus
E-Systemic lupus erythematosus (SLE)

Answer 17

Ans: B Anti-phospholipid syndrome (B) is recurrent miscarriages and venous or
Arterial thrombosis. This patient should have an autoantibody screen sent.
The presence of anti-cardiolipin antibodies would confirm the diagnosis.
Rheumatoid arthritis (A) is a chronic, symmetrical deforming polyarthritis
That is not associated with recurrent miscarriage and venous/arterialthrombosis. Sjögren’s disease (C) occurs due to fibrosis of the exocrineglands and presents with decreased tear production and salivation andparotid gland swelling. Discoid lupus (D) is a variant of SLE where skinmanifestations are the only feature. SLE (E) is a multisystem inflammatorydisorder where clinical manifestations are variable and occur due tounderlying vasculitis. SLE can be associated with anti-phospholipidsyndrome. However, the absence of any clinical features of SLE in thiscase means that primary anti-phopsholipid syndrome is the most likely
Diagnosis.

Question 18

Q18- A mother brings her baby to the hospital complaining that the baby has stridor only upon breast-feeding. On examination, omega shaped cartilage was seen in the neck. What is the most probable diagnosis?

A-Laryngomalacia
B-Bronchiolitis
C-Croup
D-Epiglotitis
E-Tracheooesophageal fistula

Answer 18

Ans: A.Laryngomalacia is a congenital softening of the tissues of the larynx (voice box) above the vocal cords. This is the most common cause of noisy breathing in infancy. The laryngeal structure is malformed and floppy, causing the tissues to fall over the airway opening and partially block it.

Question 19

Q19-A 62-year man comes to the physician because of a 2-month history of progressive fatigue and ankle swelling. He had an anterior myocardial infarction 3 years ago and has had shortness of breath with mild exertion since then. Current medications include labetalol and daily aspirin. He has smoked one-half pack of cigarettes daily for 30 years. His pulse is 100/min and regular, respirations are 20/min, and blood pressure is 130/75 mm Hg. There are jugular venous pulsations 5 cm above the sternal angle. Crackles are heard at both lung bases. Cardiac examination shows an S3 gallop. There is edema from the midtibia to the ankle bilaterally. Further evaluation of this patient is most likely to show which of the following findings?

A-Decreased pulmonary capillary wedge pressure
B-Impaired contractility of the left ventricle
C-Prolapse of the mitral valve
D-Thrombosis of the superior vena cava
E-Ventricular septal defect

Answer 19

Ans: B

Question 20

Q20-What is the explanation for the difference between the urinary level of protein on urinalysis and the 24-hour urine?

A-False positive 24-hour urine is common in myeloma.
B-Calcium in urine creates a false negative urinalysis.
C-Uric acid creates a false positive 24-hour urine.
D-Bence-Jones protein is not detected by dipstick.
E-IgG in urine inactivate the urine dipstick.

Answer 20

Ans: D. Bence-Jones protein is detected by urineimmunoelectrophoresis. The urine dipstick will detect only albumin.

Question 21

Q21-A 24year 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 21

Ans: A. Targeted antimicrobial therapy can begin in adults following a positive CSF Gram stain result. (Note that empiric antibiotic therapy should not be delayed pending the results of Gram stain or other diagnostic tests.) Children should not be given targeted therapy until blood culture results confirm the diagnosis, since CSF Gram stain interpretation is subject to expertise. In the meantime, they should receive empiric therapy with vancomycin plus either ceftriaxone (Rocephin) or cefotaxime (Claforan). Patients whose Gram stain result is negative also should continue with empiric therapy.
Antimicrobial therapy should be modified as soon as the pathogen has been isolated and in vitro tests have been performed. Duration of therapy depends on individual patient response, though generalized guidelines according to the responsible pathogen are as follows:Neisseria meningitidisorH. influenzae,seven days;S. pneumoniae,10 to 14 days;Streptococcus agalactiae,14 to 21 days; aerobic gram-negative bacilli, 21 days (two weeks beyond the first sterile CSF culture in neonates);Listeria monocytogenes,21 days or longer. Intravenous therapy is recommended throughout to maintain sufficient CSF concentrations.
https://www.aafp.org/afp/2005/0515/p2003.html

Question 22

Q22-A 45- year lady with breast cancer.she is about to undergo for surgery and possible adjuvant therapy. What will be the deciding fator wether she needs adjuvant therapy or not?

A-Tumor staging
B-Tumor grade
C-Homone receptor Status
D-Axillary Lymphnodes positive
E-Family history

Answer 22

Ans: D.Breast tumor size more than 1cm or axillary lymphnodes positive needs post operative (adjuvant) chemotherapy.

Question 23

Q23-A 21-year-old man presents to accident and emergency with a hot, swollen, painful right knee and feeling generally unwell. On examination, his temperature is 38.5°C and he is unable to weight bear. He cannot move his right knee joint due to the pain. A diagnosis of septic arthritis is suspected and the joint is aspirated. What
Organism is most likely to be seen on the Gram stain of the joint aspirate.

A-Neisseria meningitidis
B-Haemophilus influenzae
C-Staphylococcus aureus
D-Streptococcus pneumoniae
E-Neisseria gonorrheae

Answer 23

Ans: E This case describes the presentation of a patient with septic arthritis. In
young fit adults, the most common cause of this is Neisseria gonorrhea (E).
The most common cause overall is Staphylococcus aureus (C). The age group of this patient means that this answer is less likely than N. gonorrheae (E). Patients with meningococcal septicaemia due to infection with N.meningitidis (A) may develop septic arthritis. The absence of any features of septic arthritis make this an unlikely diagnosis in this case. Haeophilus influenzae (B) causes septic arthritis in children. Streptococci may cause septic arthritis but the age range of this patient makes this aless likely option than N. gonorrheae.

Question 24

Q24-In supine portable CXR, all the followings are expected except:

A-Cardiomegaly
B-Cephalization of veins
C-Wide mediastinum
D-Poor exposure
E-Loss of Aortic Knob

Answer 24

Ans: E

Question 25

Q25-A 24-year-old woman has been “hearing voices” and has isolated herself from her friends and family. She first noticed the voices about 2 months ago when she was feeling sad and reported sleeping poorly. She reports that her mood has since improved and denies any current sleep disturbances. What is her most likely diagnosis?

A-Schizoafective disorder
B-Major depression
C-Minor depression
D-Acute Psychotic disorder

Answer 25

Ans: A. This patient most likely has schizoaffective disorder, which is characterized by psychosis and intermittent mood symptoms. The diagnosis requires:

1) psychotic symptoms and mood symptoms, and
2) at least 2 weeks when psychotic symptoms are present without mood symptoms. Patients often have chronic psychotic symptoms, even after mood symptoms have resolved