Day 2

Question 1

Q1-A 49-year-old man presents witha painful, swollen big toe after anight of heavy drinking. His homemedications are lansoprazole, ASA, sildenafil, and psyllium. Which medication should he temporarily discontinue?

A-Lansoprazole
B-ASA
C-Sildenafil
D-Psyllium

Answer 1

Ans: B.ASA (aspirin). This patient is having an acute gout attack, and ASA can cause ↓ excretion of uric acid by the kidney

Question 2

Q2-75 -year old man presents with enlarged cervical lymphnode. He has had recurrent infection over the past year.his conjunctiva is pale. Choose the single cell type you will find on the peripheral blood film?

A-Granulocyte without blast cells
B-Myelofibroblasts
C-Plasma cell
D-Mature Lymphocyte

Answer 2

Ans: D. The diagnosis is CLL(Chronic Lymphoblastic Leukemia).

Question 3

Q3-Child was presented with Erythema, and swelling in his hand after 18 hours of bee sting, what is your management in this case?

A-Epinephrine
B-Antihistaminic drugs
C-Hospitalization
D-All of the above

Answer 3

Ans: B. 18 hours is a long duration so it’s unlikely to be anaphylactic shock & more likely a regular reaction to bee stings so antihistaminics is the best solution.

Question 4

Q4- A 65 y/o man presents with a 3-month history of intermittent bilateral knee pain, which suddenly worsened for the past 3 days and has now disappeared. Symptoms were worsened with walking and alleviated with rest and NSAIDs. He has a 4-5-year history of smoking and alcohol use. P/E finds warm knees with mild tenderness. Serum chemistry reveals low Mg and phosphate, and normal uric acid. Xray shows linear radiodense deposits in joint menisci. Synovial fluid analysis (SFA) has confirmed the Dx. What’s the best next treatment?

A-Low-dose colchicine 
B-Indomethacin 
C-High-dose colchicine 
D-Steroids 
E-Ibuprofen 
F-Allopurinol

Answer 4

Ans: A. It’s most likely pseudogout, usually caused by CPPD crystal deposition in joints with preexisting damage in elderly patients. Dx is confirmed by positively birefringent crystals on SFA. Since now it’s during a break, ‘A’ is the best to prevent frequent recurrences. ‘B’ is the best for acute gout or pseudogout attack; ‘C’ is the 2nd choice. “D and E” are not very effective. ‘F’ is for long-term effects (to decrease urate production).

Question 5

Q5-A 64-year man presents with a 2-days history of abdominal pain which he
Describes as constant, dull and around his umbilicus and occasionally migrating to
His groin. He has a body mass index (BMI) of 27 and a past medical history of
Poorly controlled hypertension. Abdominal examination reveals a pulsatile and
Expansile mass just below the umbilicus. Which of the following is most appropriate screening investigation?

A-Abdominal ultrasound
B-Abdominal x-ray
C-Computed tomography (CT) scans of the abdomen
D-Abdominal Magnetic Resonance Imaging (MRI) scans
E-Angiography

Answer 5

Ans: A This patient is suffering from a suspected abdominal aortic aneurysm (AAA), these most commonly occur infrarenally and predominantly affect males. There is close association with atherosclerosis and genetic abnormalities such as Marfan’s and Ehlers–Danlos syndrome. Althoughmost aneurysms are asymptomatic, patients can present with renal coliclikesymptoms, diverticular-like pain, umbilical pain and groin pain. Apusatile and expansile mass is strongly indicative of an abdominal aneurysm. In order to screen for an AAA an abdominal ultrasound scan
(A) is the least invasive and safest screening investigation. In obese patients, it can be difficult to differentiate the entire aortic structure. Anabdominal x-ray (B) would not be able to provide enough detail of theabdominal aorta to determine an aneurysm. An abdominal CT scan (C) provides the most accurate visualization of an AAA, especially withcontrast, however due to the availability of resources and invasiveness itis not appropriate as a first-line screening investigation. An abdominalMRI scan (D) is comparable to a CT scan if enhanced with contrast material, however, patients are unlikely to remain motionless during scanning and
the modality is not as reliable when compared to CT and US scanning. Angiography (E) is an invasive procedure and the true size of the aneurysm
Cannot always be ascertained and so this modality is more appropriatewhen preparing the patient for surgical intervention.

Question 6

Q6-A 53-year female present with acute painful hot knee joint. She is known case of Rhumatoid Arthritis.on examination knee is red, tender and swollen.the hamstring muscles are in spasm. Her Temp-39C, BP is 120/80mmof hg. What is the single best next investigation?

A-Joint aspiration for cytology and culture and sensitivity
B-Joint aspiration for positive birefringent crystals
C-Joint aspiration for negative birefringent crystals
D-Blood culture
E-Serum uric acid

Answer 6

Ans: A. any chronically arthritic joint predispose to infection. Moreover, chronic use of steroid in Rhumatoid Arthritis is one of the predisposing factor. Staphylococcus is organism in old middle and old age group and Nisseria Gonorrhea is organism in Younger age group.

Question 7

Q7-Which of the following indicates good prognosis in schizophrenia?

A-Family history of schizophrenia
B-Gradual onset
C-Flat mood
D-Prominent affective symptoms
E-No precipitating factors

Answer 7

Ans: D. Schizophrenia is a serious mental disorder in which people interpret reality abnormally. Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning, and can be disabling. People with schizophrenia require lifelong treatment
In general, females have a better prognosis and respond better to treatment than males
When the case describes any of the following features, the prognosis is poor
-Early age of onset
-Negative symptoms
-Poor premorbid functioning
-Family history of schizophrenia

Question 8

Q8-Pregnant woman with suspected DVT (Deep Vein Thrombosis), which is the best initial investigations?

A-Duplex ultrasound
B-D dimer
C-Plethysmography
D-Venogram

Answer 8

Ans: A. Duplex ultrasoundsuccessfully identifies 95 percent of deep vein thromboses that occur in the large veins above the knee. The ability ofduplex ultrasoundto detectDVTin the large veins above the knee is so good that when the test is positive, no further testing is necessary and treatment may be started.

Question 9

Q9-Patient is known case of cervical spondylolysis, presented with parasthesis of the little finger with atrophy of the hypothenar muscles, EMG (Electro Myography) showed cubital tunnel compression of the ulnar nerve, what is your action now:

A-Ulnar nerve decompression
B-Steroid injection
C-CT scan of the spine
D-Anti inflammatory and pregabalin

Answer 9

Ans: A

Question 10

Q10-Known case of Sickle cell disease, presented with plueritic chest pain, fever, tachypnea, and respiratory rate of 30/min, oxygen saturation is 90 %. What is the diagnosis?

A-Acute chest syndrome
B-Pericarditis
C-Vaso occlusive crisis

Answer 10

Ans: A. A- SCD painful crisis: May occur alone and be precipitated by hypoxia, fever, infection, dehydration, and acidosis. The acute chest syndrome is common–severe chest pain, fever, leukocytosis, hypoxia, and pulmonary infiltrates (by CXR) and is hardly distinguishable from pneumonia. Life-threatening sickling and stroke may occur. With hemolysis in a child, concomitant G6PD or splenic sequestration should be considered. Sudden drops in hematocrit (caused by acute aplasia, not hemolysis) may be associated with Parvovirus B19 (PVB19) infection or folate deficiency.

Question 11

Q11-A 82-year-old woman presents to the Emergency department with a 2-day history of difficulty speaking and weakness in her right face and arm. During the interview, she speaks in two- to three-word choppy sentences but can follow commands. She cannot repeat what you say. Where is her lesion?

A-Posterior frontal cortex
B-Temopral Cortex
C-Occipital Cortex
D-Cerebellar Cortex

Answer 11

Ans: A, This patient presents with Broca aphasia. In Broca aphasia, the lesion is in the posterior frontal cortex of the dominant side of the brain, in this case the left

Question 12

Q12-During routine P/E a 10 y/o girl is found to have lateral curvature and rotation of the spine during a forward bending test. Spinal Xray (2-positional views) confirms 30o lateral curvature. The girl does not experience difficulty with daily activities. What’s the best next step?

A-Observation 
B-Spinal bracing 
C-Surgical correction 
D-Programmed exercise 
E-Further examinations

Answer 12

Ans: B. Scoliosis is defined as a lateral curvature of the spine of > 10 degrees (mostly in the thoracic and/or lumbar). Treatment: (1) < 20o curvature: observation; (2) 20-45o curvature: spinal bracing; (3) > 50o curvature: surgical correction.

Question 13

Q13-A young woman complains of diarrhea, abdominal cramps and mouth ulcers. Abdominal X ray showsdistended transverse colon with goblet cell depletion on rectal biopsy. What is the most probable diagnosis?

A-Chron’s disease
B-Ulcerative colitis
C-Bowel Cancer
D-Bowel obstruction
E-Irritable bowel syndrome

Answer 13

Ans: B. They have give you a clinical presentation with some features to resembling crohns to confuse you, but included information about a biopsy which is definitive for UC.
Histologic Features
CROHNS
Transmural distribution with skip lesions
Focal inflammation ± noncaseating granulomas,
Deep fissuring + aphthous ulcerations, strictures
Glands intact (e.g. goblet cells)

ULCERATIVE COLITIS
Mucosal distribution, continuous disease (no skip lesions)
Granulomas absent,
Crypt abscess
Gland destruction (e.g. goblet cells)

N.b rectal bleeding a feature of UC but initial presentation is usually with non bloody diarhea
UC can occur anywhere in the lower bowel, from rectum to entire colon…CD: most common location is ileum and ascending colon.

Question 14

Q14-Patient with ischemic stroke present after 6 hours, the best treatment is?

A-ASA
B-TPA (tissue plasminogen activator)
C-Clopidogril
D-IV heparin

Answer 14

Ans: A.
1-TPA: administered within 3hours of symptoms onset (if no contraindication)
2-ASA: use with 48hours of ischemic stroke to reduce risk of death.
3-Clopidogrel: can be use in acute ischemic
4-Heparin & other anticoagulant: in patient has high risk of DVT or AF

Aspirin: Best initial therapy for those coming too late for thrombolytics. Also indicated after the use of thrombolytics. • Clopidogrel: Switch to clopidogrel if the patient has developed a stroke on aspirin. • Dipyridamole: If the patient is already on aspirin when a new stroke or TIA occurs, add dipyridamole or switch to clopidogrel.

Question 15

Q15-The treatment of choice for recurrent transient ischemic attacks in a patient on aspirin with new-onset atrial fibrillation?

A-Anticoagulation
B-Carotid endarterectomy
C-Clopidogrel
D-Corticosteroid treatment
E-Carotid stent

Answer 15

Ans: A

Question 16

Q16-Single thyroid nodule with feature of thyrotoxicosis, thyroid scan showed hot nodule, what is the best treatment?

A-Radio Active Iodine
B-Regular followup
C-Antithyriod medication
D-FNAC

Answer 16

Ans: A.
http://www.aafp.org/afp/2003/0201/p559.html
Radioactive iodine.
Doctors useradioactive iodineto treat hyperthyroidism. Taken as a capsule or in liquid form,radioactive iodineis absorbed by yourthyroidgland. This causes thenodulesto shrink and signs and symptoms of hyperthyroidism to subside, usually within two to three months

Question 17

Q17- An 18 y/o boy presents with progressive pain around the right knee for the past month. He has no other symptoms except occasional headache. P/E shows a swelling with tenderness around the right knee. Lab tests reveal increased serum Ca, phosphate, and AKP. X-ray shows a focal osteolytic lesion beneath the knee with periosteal reaction. What’s the most likely Dx?

A-Paget’s disease of bone (Osteitis deformans)
B-Osteitis fibrosa cystica (Osteitis fibrosa)
C-Hyperparathyroidism
D-Giant cell tumour of bone (Osteoclastoma)
E-Osteosarcoma (Osteogenic sarcoma)

Answer 17

Ans: E. Osteosarcoma is the most common primary bone cancer (20%); alkaline phosphatase (ALP) is often increased; bone X-ray typically shows a ‘sunburst’ pattern of neoplastic bone or “Codman’s triangle”. Giant cell tumor (osteoclastoma) is a benign but sometimes malignant osteolytic tumor; X-ray often shows “soap bubble” sign in the epiphyseal end.

Question 18

Q18-An 18-year-old man presents with a 3-day history of fever, vomiting and headaches on waking in the morning. He has recently started at university and denies taking any illicit substances prior to or during his time at university. He has tried paracetamol but they have not helped. He decided to see a doctor when his neck became painful and stiff to move. On further examination, a non-blanching
Petechial rash is discovered. The most appropriate management is?

A-Intravenous ceftriaxone
B-Fundoscopy
C-Lumbar puncture
D-Intravenous cephalexin
E-Blood culture

Answer 18

Ans: A. This patient is likely to be suffering from meningococcal septicaemia and
Has the classic symptom of fever, headache, non-blanching rash and neckstiffness along side his new environment at university. Once meningitis is suspected, rapid management is required to prevent precipitation. The British Infection Society splits management dependent on whether the patient has predominantly septicaemic symptoms, as in this patient, or meningitic symptoms. In septicaemia, immediate antiobiotics must be started and this is usually IV ceftriaxone (A) or cefotaxime. Intravenous cephalexin (D) is not appropriate to provide enough safe cover. In suspected bacterial meningitis a lumbar puncture (C) is appropriate if there are no signs of raised intracranial pressure (ICP). Senior advice must always be sought and if there are any suspicions of raised ICP the critical care team should be called. A blood culture (E) in either pathway would take too longby which the patient may decompensate without any other treatment or intervention .Fundoscopy (B) would be useful in a patient with suspected meningitis to assess for raised ICP which would negate a lumbar puncture, however, this patient is suffering from septicaemic symptoms and so this is not appropriate.

Question 19

Q19-Young female with whitish grey vaginal discharge, KOH test done. Smell of discharge like fish. What is the likely diagnosis?

A-Gonorrhea
B-Bacterial Vaginosis
C-Trachomanous Vaginalis

Answer 19

Ans: B. Bacterial vaginosis(BV) is adiseaseof thevaginacaused by excessive growth ofbacteria. Common symptoms include increasedvaginal dischargethat often smells like fish. The discharge is usually white or gray in color. Burning with urinationmay occur.Itching is uncommon. Occasionally, there may be no symptoms. Having BV approximately doubles the risk of infection by a number ofsexually transmitted infections, includingHIV/AIDS.It also increases the risk ofearly deliveryamong pregnant women.
BV is caused by an imbalance of the naturally occurring bacteria in the vagina. There is a change in the most common type of bacteria and a hundred to thousandfold increase in total numbers of bacteria present. Typically, bacteria other thanLactobacillibecome more common. Risk factors includedouching, new ormultiple sex partners,antibiotics, and using anintrauterine device, among others.However, it is not considered a sexually transmitted infection.Diagnosis is suspected based on the symptoms, and may be verified by testing the vaginal discharge and finding a higher than normal vaginalpH, and large numbers of bacteria. BV is often confused with avaginal yeast infectionorinfection with Trichomonas

Question 20

Q20-One of the Anti-psychotics drug causes ECG changes, Leukopenia, drooling?

A-Risperidone
B-Clozapine
C-Amisulpride

Answer 20

Ans: B.

Question 21

Q21-A 70 y/o man is brought to the ER for fever, headache, and confusion for the past 2 days. He lives alone with poor living conditions. P/E results: Alert, T = 38oC, HR = 88/min, RR and BP are normal; neck is stiff; Kernig’s sign is (+/-). Eye examination is normal. CBC: WBC = 15 x 103/uL, with 50% lymphocytes (LC). CSF: Opening pressure = 200 mmH2O, lymphocytes = 60%, neutrophils = 40%, protein = 55 mg/dL, and glucose = 30 mg/dL. This patient most likely has

A-Pneumococcal meningitis 
B-viral meningitis
C-TB meningitis 
D-TB encephalitis 
E-viral encephalitis 
F-Fungal meningitis

Answer 21

Ans: C. In general, only TB and fungal meningitis have these clinical features and CSF results. Fungal meningitis is rare, typically occurring only in the setting of a chronic or immunodeficient disease. ‘A’ is the #1 common meningitis, usually presenting with more severe manifestations and a predominance of neutrophils in the CSF. Encephalitis is less likely given the symptoms and CSF results.

Question 22

Q22-A 45 y/o female presents with fever and a painful mass in the front of her neck for the past week, accompanied with anxiety, sweating, tremor, and a “pounding heart.” Now she complains of lethargy, fatigue, and “always feeling cold.” P/E finds normal results except for mild bradycardia and an enlarged thyroid with tenderness. Lab tests show mild TSH increase and T4 decrease. The best initial treatment is

A-aspirin 
B-corticosteroids 
C-T4 supplement 
D-propranolol 
E-observation

Answer 22

Ans: A. This is typical subacute thyroiditis–URI and brief hyperthyroidism followed by hypothyroidism. Treatment is Anti-inflammation or symptomatic, with aspirin as the best option for this patient. The disease eventually returns to normal state over months. ‘B’ is best for Riedel thyroiditis–hypothyroidism caused by idiopathic fibrosis of the thyroid (painless, non-toxic goiter). T4 is best for Hashimoto’s thyroiditis–an autoimmune inflammatory disease of the thyroid causing a painless goiter with hypothyroidism mostly in children. ‘D’ is best for lymphocytic thyroiditis–a self-limited episode of thyrotoxicosis (painless goiter).

Question 23

Q23-Erythroderma is described as a chronic inflammatory skin condition characterized by scaling affecting greater than 50 per cent of the total body. Which one of the following cutaneous malignancies would you expect erythroderma to be associated with?

A-T-cell lymphoma
B-Squamous cell carcinoma (SCC)
C-Basal cell carcinoma (BCC)
D-Malignant melanoma
E-Kaposi’s sarcoma

Answer 23

Ans: A Cutaneous T-cell lymphomas (A) have been known to be associated with
the development of erythroderma. SCC (B), BCC (C), malignant melanoma(D) and Kaposi’s sarcoma (E) have not been known to be associated with erythroderma

Question 24

Q24-A woman comes to the emergency department with a severe headache starting one day prior to admission. On physical examination she has a temperature of 103°F, nuchal rigidity, and photophobia. Her head CTscan is normal. Lumbar Puncture shows CSF with 1250 white blood cells and 50,000 Red blood cells. What is the most appropriate next step in the management of this patient?

A-Angiography
B-Ceftriaxone and vancomycin
C-Nimodipine
D-Embolization
E-Surgical clipping
F-Repeat the CT scan with contrast
G-Neurosurgical consultation

Answer 24

Ans: B. The number of WBCs in the CSF in this patient far exceeds the normal ratio of 1 WBC to each 500 to1000 RBCs. With 50,000 RBCs, there should be no more than 50 to 100 WBCs. The presence of 1250 WBCs indicates an infection, and ceftriaxone and vancomycin are the best initial therapy for bacterial meningitis. Contrast is not useful when looking for blood. Try never to answer “consultation” for anything. FROM MTB-2.

Question 25

Q25-A 55 y/o man presents with lethargy, weakness, headache, irritability, polydipsia, and polyuria with about 5 L of dilute urine per day for the past 2 days. He has a history of a mood disorder, which is recently unstable. Because of this, the patient is on a newly prescribed medicine. P/E is mostly Nl. Serum Na, K, and Cl levels are all elevated, plasma osmolality is 400 mOsm/kg, and urine osmolality is 290 mOsm/kg. After water deprivation for 5 hours with ADH challenge, his urine osmolality is 300 mOsm /kg with similar volume. What’s the best next step?

A-Head MRI 
B-Desmopressin 
C-Hydrochlorothiazide 
D-Water intake increase 
E-Water deprivation again

Answer 25

Ans: C. A case of nephrogenic DI caused by lithium intake. It can be treated effectively by stopping lithium, restricting salt, increasing water intake, and adding a thiazide. ‘A’ is for central DI, to search a potential pituitary or hypothalamic tumor. It would be treated with ‘B’ +/- surgery. In central DI: Water deprivation with ADH challenge test will decrease urine output and increase urine osmolality. ‘E’ is for psychogenic polydipsia, in which urine osmolality before and after an ADH analogue should be the same high level (about 700 mOsm/kg), and serum NaCl is low.