PLAB 1700A Flashcards

Question 1

Q

A 65yo man presents with painless hematuria, IVU is normal, prostate is mildly enlarged with mild frequency. What is the most appropriate next step?

a. US Abdomen
b. Flexible cystoscopy
c. MRI
d. Nuclear imaging
e. PSA

Answer

A

Ans. The key is B. Flexible cystoscopy. [Painless hematuria in an elderly (here 65 years old man) indicates carcinoma bladder for which flexible cystoscopy is done.

Here BEP is not advanced to cause hemorrhage. There is mild enlargement of prostate and mild symptoms of prostration and hemorrhage is unlikely at this initial stage of BEP which makes Bladder cancer as the likely cause of painless hematuria. It is also less likely to be prostate cancer as symptoms of prostration are mild (indicates disease is not advanced). Moreover bleeding in cancer prostate is much more less common].

Question 2

Q

A 74yo smoker presented to his GP with cough and SOB. Exam revealed pigmentation of the oral mucosa and also over the palms and soles. Tests show that he is diabetic and hypokalemic. What is the most probable dx?

a. Pseudocushing syndrome
b. Conns disease
c. Ectopic ACTH
d. Cushings disease

e. Hypothyroidism

Answer

A

The key is C. Ectopic ACTH. [The patient is smoker and probably developed squamous cell lung cancer which is working as a tumour producing ectopic ACTH causing pigmentation. Resulting raised cortisole is leading to diabetes and hypokalemia].

Question 3

Q

A 44yo woman has lost weight over 12 months. She has also noticed episodes where her heart beats rapidly and strongly. She has a regular pulse rate of 90bpm. Her ECG shows sinus rhythm. What is the most appropriate inv to be done?

a. Thyroid antibodies
b. TFT
c. ECG
d. Echocardiogram
e. Plasma glucose

Answer

A

Ans. The key is B. TFT. [The patient has paroxysmal atrial fibrillation That is why there is no arrhythmia in between attacks. From the given option TFT is the appropriate test as thyrotoxycosis is a leading cause of paroxysmal atrial fibrillation and this ladies weight loss also makes thyrotoxycosis as the probable cause here]

Question 4

Q

A 79yo anorexic male complains of thirst and fatigue. He has symptoms of frequency, urgency

and terminal dribbling. His urea and creatinine levels are high. His serum calcium is 1.9 and he is anemic. His BP is 165/95 mmHg. What is the most probable dx?

a. BPH
b. Prostate carcinoma
c. Chronic pyelonephritis
d. Benign nephrosclerosis

Answer

A

Ans. The key is B. Prostate Carcinoma.

Explanation for Question no. 4:

First to say in this case (almost all features goes in favour of prostatic carcinoma like- frequency, urgency and terminal dribbling are features of prostatism; Age, anorexia and anaemia are constitutional features of carcinoma prostate and it would be accurate presentation if it was hypercalcaemia. But given calcium level is of hypocalcaemic level and it is the main cause of discrepancy of this question). Renal failure can be an association of malignant disease and can cause high BP. Thirst is a feature of hypercalcaemia (here may be erroneously calcium level is given in hypocalcaemic level ; probably a bad recall). Prostate biopsy is the confirmatory diagnosis and others like PSA is suggestive.

***There are some suggestion that Renal Failure may be the cause of hypocalcemia.

Question 5

Q

A 64yo man has recently suffered from an MI and is on aspirin, atorvastatin and ramipril. He has been having trouble sleeping and has been losing weight for the past 4 months. He doesn’t feel like doing anything he used to enjoy and has stopped socializing. He says he gets tired easily and can’t concentrate on anything.
What is the most appropriate tx?

a. Lofepramine
b. Dosulepin
c. Citalopram
d. Fluoxetine
e. Phenelzine

Answer

A

Ans. The key is C. Citalopram. [Among SSRIs Sertraline is the drug of choice for ischemic heart disease. Next choice is citalopram (as it is often related to torsades de pointes). If SSRI cannot be used Mirtazapine is recommended as next antidepressant].

Question 6

Q

A 67yo man after a stroke, presents with left sided ptosis and constricted pupil. He also has loss of pain and temp on the right side of his body and left side of his face. Which part of the brain is most likely affected?

a. Frontal cortex
b. Cerebellum
c. Pons
d. Medulla
e. Parietal cortex

Answer

A

Ans. The key is D. Medulla. [The name of the condition is “Lateral medullary syndrome” [ipsilateral Horner syndrome and contralateral loss of pain and temperature sense].

Question 7

Q

A 60yo man presents with dysphagia and pain on swallowing both solids and liquids. A barium meal shows gross dilatation of the esophagus with a smooth narrowing at the lower end of the esophagus. What is the SINGLE most likely cause of dysphagia?

a. Achalasia
b. Myasthenia gravis
c. Esophageal carcinoma
d. Esophageal web
e. Systemic sclerosis

Answer

A

Ans. The key is A. Achalasia. [Dysphagia for both solid and liquid or prominently liquid suggest achalasia where dysphagia to solid suggest stricture. Also gross dilatation of oesophagus with smooth narrowing at lower end is seen in achalasia. In achalasia dysphagia is usually described as progressive].

Question 8

Q

A man undergoes a pneumonectomy. After surgery, invs show hyponatremia. What could be the cause of the biochemical change?

a. Removal of hormonally active tumor
b. Excess dextrose
c. Excess colloid
d. Excessive K+
e. Hemodilution

Answer

A

Ans. The key is A. Removal of harmonically active tumour. [Ectopic ACTH secreting tumour causes hypernatremia and body’s homeostatic mechanism try to lower the level of high sodium and do a lesser degree though sodium remains in hypernatremic level or even it may be normal (this question does not mention any preoperative hypernatremia). Removal of that tumour results in negative sodium balance for time being which results hyponatremia while gradually it tends to rise again to normal level].

Question 9

Q

A pregnant lady came with pain in her calf muscle with local rise in temp to the antenatal clinic. What tx should be started?

a. Aspirin
b. LMWH
c. Paracetamol
d. Cocodamol
e. Aspirin and heparin

Answer

A

Ans. The key is B. LMWH. [Injections with low molecular weight heparin (LMWH) are usually used to treat pregnant women with DVT. LMWH is an anticoagulant, which means it prevents the blood clot getting bigger. It does not affect the developing baby (www.nhs.uk)]

Question 10

Q

A 53yo female presents with an acute painful hot knee joint. She is a known case of RA. On examination, the knee is red, tender and swollen. The hamstring muscles are in spasm. Her temp is 38.5C and BP is 120/80mmHg. What is the SINGLE best next inv?

a. Joint aspiration for cytology and culture and sensitivity
b. Joint aspiration for positive birefrengent crystals
c. Joint aspiration for negative birefrengent crystals
d. Blood culture
e. Serum uric acid

Answer

A

Ans. The likely key is A. Joint aspiration for cytology and culture and sensitivity. [Any chronically arthritic joint is predisposed to infection. Moreover chronic use of steroid in Rh. arthritis is one of the important predisposing factor. In this age group likely organism is Staphylococcus. In younger age group Neisseria gonorrhea is more common].

Question 11

Q

An 80yo man presented with pain in his lower back and hip. He also complains of waking up in the night to go to the washroom and has urgency as well as dribbling. What is the most likely dx?

a. BPH
b. Prostatitis
c. UTI
d. Prostate carcinoma
e. Bladder carcinoma

Answer

A

Ans. The key is D. Prostate carcinoma. [Age, nocturia, urgency and dribbling points towards prostate pathology. Pain of lower back and hip points towards bony metastases from prostate cancer. Blood test for PSA; Prostate biopsy; MRI (if initial biopsy is negative, to decide repeat biopsy).

Treatment options: 1. Active treatment [i) radical prostatectomy ii) radical radiotherapy iii) hormone therapy iv) brachytherapy v) pelvic radiotherapy vi) orchidectomy

Active surveillance
Watchful waiting
Palliative care (Source: NICE)].

Question 12

Q

An 18yo female has peri-orbital blisters. Some of them are crusted, others secreting pinkish fluid. What is the most likely dx?

a. Shingles
b. Chicken pox
c. Varicella
d. Rubella
e. Measles

Answer

A

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

Question 13

Q

A 29yo lady who is a bank manager is referred by the GP to the medical OPC due to a long hx of tiredness and pain in the joints. An autoimmune screen result showed smooth muscle antibodies positive. What is the most appropriate next inv?

a. ECG
b. TFT
c. LFT
d. Serum glucose
e. Jejunal biopsy

Answer

A

Ans. The key is C. LFT. [A case of autoimmune hepatitis. Autoimmune hepatitis is an uncommon cause of chronic hepatitis which if untreated can lead to cirrhosis. However with treatment outlook is very good. Smooth muscle antibody is positive in autoimmune hepatitis. Definitive investigation is liver biopsy. Treated with steroid [start with high dose prednisolone]. Azathioprine is commonly added with steroid to reduce its dose as steroid has more side effects than azathioprine]

Question 14

Q

A 5yo with recurrent chest pain, finger clubbing with offensive stool. Choose the single most likely inv?

a. Endomyseal/Alpha glidin antibody
b. Sweat test
c. Barium meal
d. ECG
e. Glucose tolerance test

Answer

A

Ans. The key is B. Sweat test. [Recurrent chest pain from frequent lung infections including pneumonia or bronchitis.”Clubbing” of the fingers is a classic features of Cystic Fibrosis, although not present in many patients. The digestive enzymes are not being produced, food is not adequately digested (malabsorption) and excess fat and protein is lost in the stools, making them bulky, oily, smelly and difficult to flush away].

Question 15

Q

A clinical picture of breast cancer originated from the mammary duct. Biopsy was done and there were neoplastic cells found. Choose the histological picture of the cancer.

a. Neoplastic cells are arranged in small clusters occupying a space between collagen bundles (Seirrhous carcinoma)
b. Spindle cell neoplasms with margins, which infiltrate adjacent structure, fat invaded (Breast sarcoma)
c. Small cells with round nucleus and scant indistinct cytoplasm (Lobular carcinoma)

Answer

A

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

Question 16

Q

A 22yo man has a reduced conscious level and a fixed dilated pupil after being involved in a MVC. Choose the single most appropriate option?

a. Facial nerve
b. Oculomotor nerve
c. Olfactory nerve
d. Optic nerve
e. Trigeminal nerve

Answer

A

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

Question 17

Q

A man with suspected active TB wants to be treated at home. What should be done to prevent the spread of disease?

a. Immediate start of the tx with Anti-TB drugs
b. All family members should be immediately vaccinated with BCG vaccine
c. Patient should be isolated in a negative pressure chamber in his house
d. Universal prevention application protocol

Answer

A

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

Question 18

Q

A 7yo child is brought to the ED with a 1 day hx of being listless. On examination, the child is drowsy with an extensive non-blanching rash. What advice would you give the parents?

a. All family members need antibiotic therapy
b. Only the mother should be given rifampicin prophylaxis
c. All family members need isolation
d. All family members should be given rifampicin prophylaxis

Answer

A

Ans. The key is D. All family members should be given rifampicin prophylaxis. [Meningococcal disease. Diagnosis is done with blood or CSF PCR. Initial prehospital management: Benzyl penicillin or cefotaxime].

Question 19

Q

A 47yo man has a temp of 39C and is delirious. He has developed blisters mainly on his trunk, which appeared a few hours ago. He is well and not on any medications. He last travelled 5 months ago to Italy. Which of the following is the most likely dx?

a. Shingles
b. Chicken pox
c. Pemphigoid
d. Bullous pemphigus

Answer

A

Ans. The key is B. Chicken pox. [Adults more commonly develop a more generalized brain inflammation (“encephalitis”) whose symptoms may include delirium and seizures. Incubation period of chicken-pox is 10-21 days. So this travel history is not significant].

Question 20

Q

A 64yo pt has been having freq episodes of secretory diarrhea, which is extremely watery, with large amts of mucus. A dx of villous adenoma was made after endoscopy. What electrolyte abnormality is most likely in this pt?

a. Hyperkalemia
b. Hypernatremia
c. Hyponatremia
d. Hypokalemia

Answer

A

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

Question 21

Q

A pt with an acute gout attack came to the ED.
What drug should be given to relieve symptoms?

a. NSAIDs
b. Allopurinol
c. Ibuprofen

Answer

A

Ans. The key is A. NSAIDs. [Oral NSAIDs commenced immediately and continue for 1 – 2 weeks; Colchicine can be effective alternative but is slower to work than NSAIDs. Intra articular corticosteroids are highly effective in acute gouty monoarthritis.

Question 22

Q

A pt was lying down on the operating table in a position with his arms hanging down for 3 hours. Soon after he woke up, he complains of numbness and weakness in that hand and has limited wrist movement/wrist drop and sensory loss over dorsum of that hand, weakness of extension of the fingers and loss of sensation at the web of the thumb. What structure is likely to bedamaged?

a. Radial nerve
b. Median nerve
c. Ulnar nerve
d. Axillary nerve
e. Suprascapular nerve

Answer

A

Ans. The key is A. Radial nerve. [Here arm hanging down compressing the radial nerve at the spiral groove is the cause of given scenario]

Question 23

Q

A pt who was previously on 120mg slow release oral morphine has had his dose increased to 200mg. He is still in significant pain. He complains of drowsiness and constipation. What is the next step in the management?

a. Increase slow release morphine dose
b. Fentanyl patch
c. Replace morphine with oral hydromorphone
d. Replace morphine with oxycodone
e. Subcutaneous morphine

Answer

A

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

Question 24

Q

A 40yo woman notices increasing lower abdominal distention with little/no pain. On examination, a lobulated cystic mass is felt and it seems to be arising from the pelvis. What is the most appropriate inv?

a. CA 125
b. CA 153
c. CA 199
d. CEA
e. AFP

Answer

A

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

Question 25

Q

A resident of a nursing home presented with rashes in his finger webs and also on his abdomen, with complaints of itching which is severe at night. He was dx with scabies. What the best tx for his condition?

a. 0.5% permethrin
b. Doxycycline
c. 5% permethrin
d. Reassure
e. Acyclovir

Answer

A

Ans. The key is C. 5% permethrin. [Scabies outbreaks in nursing homes and cases of crusted scabies may require combination therapy consisting of topical application of permethrin and 2 oral doses of ivermectin at 200 mcg/kg (administered 1 wk apart)].

Question 26

Q

A 34yo alcoholic is found passed out in front of a local pub. The ambulance crew informs you that he was sweating when they found him and there were cans of cider lying empty around him. What is the initial stage of inv?

a. Capillary blood sugar
b. CT head
c. MRI head
d. ABG
e. MCV

Answer

A

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

Question 27

Q

A young boy fell on his outstretched hand and has presented with pain around the elbow. He has absent radial pulse on the affected hand. What is the most likely dx?

a. Dislocated elbow
b. Angulated supracondylar fx
c. Undisplaced fx of radial head
d. Posterior dislocation of shoulder

Answer

A

Ans. The key is B. Angulated supracondyllar fx. [Damage or occlusion of the bracheal artery is the cause of absent radial pulse. Often closed reduction results in restoration of normal anatomy and correction of occlusion of bracheal artery and establishes circulation again but in few instances open reduction is required to fix the occluded artery].

Question 28

Q

A 65yo woman presented with transient arm and leg weakness as well as a sudden loss of vision in the left eye. Her symptoms resolved within the next couple of hours. What is the most appropriate next inv?

a. CT brain
b. Echo
c. Doppler USG
d. Arteriography
e. 24h ECG

Answer

A

Ans. The key is c. [A case of TIA. Probable cause carotid artery narrowing. Treated with Aspirin 300 mg daily for 2 weeks then aspirin + modified release dipiridamole daily [NICE guidelines].

Question 29

Q

A man complains of loss of sensation in his little and ring finger. Which nerve is most likely to be involved?

a. Median nerve
b. Ulnar nerve
c. Radial nerve
d. Long thoracic nerve
e. Axillary nerve

Answer

A

Ans. The key is B. Ulner nerve. [Compression of ulner nerve at the elbow, known as cubital tunnel syndrome, causes numbness in the 5th (pinky) finger, along the half (lengthwise) of the 4th (ring) finger closest to the 5th finger, and the back half of the hand over the 5th finger].

Question 30

Q

A young man complains of double vision on seeing to the right. Which nerve is most likely to be involved?

a. Left abducens
b. Right abducens
c. Left trochlear
d. Right trochlear
e. Right oculomotor

Answer

A

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

Question 31

Q

A 45yo man keeps having intrusive thoughts about having dirt under the bed. He can’t keep himself from thinking about these thoughts. If he tries to resist, he starts having palpitations. What is the most likely dx?

a. OC personality
b. OCD
c. Schizophrenia
d. Panic disorder
e. Phobia

Answer

A

Ans. The key is B. [Here patients thoughts are obsession and though no compulsive act is described (like repeated cleansing of dirt) but his nature of thought like inability to resist the thinking or getting palpitation on trying to avoid thinking can be regarded as compulsion of thought. CBT 1st line. SSRIs].

Question 32

Q

A 33yo man presents with an itchy scaly annular rash on his thigh after a walk in the park. Which of the following drugs will treat his condition?

a. Erythromycin
b. Doxycycline
c. Penicillin
d. Amoxicillin

Answer

A

Ans. The key is B. Doxycycline. [Itchy scaly annular rash after a walk in the park indicates erythema migrans caused by the spirochete Borrelia Burgdorferi transmitted by bite of pinhead-sized ixodes ticks leading to lyme disease].

Question 33

Q

A pt with cerebral mets has polyuria and polydipsia.
What part of the brain would be affected?

a. Cerebral cortex
b. Cerebellum
c. Diencephalon
d. Pons
e. Medulla

Answer

A

Ans. The key is C. Diencephalon. [Diencephalon is the caudal (posterior) part of the forebrain, containing the epithalamus, thalamus, hypothalamus, and ventral thalamus and the third ventricle. Hypothalamus produce ADH and hens lesion of diencephalon (hypothalsamus) may produce cranial diabetes insipidus.

Question 34

Q

A 32yo man presented with painless hematuria. He is hypertensive but the rest of the exam is unremarkable.
What is the most likely dx?

a. Polycystic kidneys
b. Ca bladder
c. Ca prostate
d. TTP
e. HUS

Answer

A

Ans. The key is A. Polycystic kidneys. [Painless haematuria at an younger age with hypertension is suggestive of polycystic kidney disease. Renal ultrasound is used to diagnose the condition].

Question 35

Q

A 45yo female complains of pain in the inner side of her right thigh. She was dx with benign ovarian mass on the right. Which nerve is responsible for this pain?

a. Femoral nerve
b. Obturator nerve
c. Iliohypogastric nerve
d. Ovarian branch of splanchic nerve
e. Pudendal nerve

Answer

A

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

Question 36

Q

A 37yo lady strongly believes that a famous politician has been sending her flowers every day and is in love with her. However, this is not the case. What is the most likely dx?

a. Erotomania
b. Pyromania
c. Kleptomania
d. Trichotillomania
e. Grandiosity

Answer

A

Ans. 1. The key is A. Erotomania. [Erotomania is a type of delusion in which the affected person believes that another person, usually a stranger, high-status or famous person, is in love with them].

Pyromania is an impulse control disorder in which individuals repeatedly fail to resist impulses to deliberately start fires, in order to relieve tension or for instant gratification.

Kleptomania is the inability to refrain from the urge to steal items.
Trichotillomania is an impulse disorder characterized by the compulsive urge to pull out one’s hair, leading to noticeable hair loss and balding.

Grandiosity refers to an unrealistic sense of superiority.

Question 37

Q

A 3yo child has been brought with facial lacerations. On examination he has some cuts over his right cheek and under the eye. The GCS on initial evaluation is 15. What is the appropriate next inv?

a. Skull XR
b. Facial XR
c. CT scan
d. MRI
e. Observation

Answer

A

Ans. The key is B. Facial X-ray. [Normal GCS makes intracranial lesion less likely. As there is facial injury to exclude any facial bone fracture we can do facial X-ray].

Question 38

Q

A 73yo woman has lymphadenopathy and splenomegaly. She feels well but has had recurrent chest infections recently. Choose the single most likely blood film findings?

a. Atypical lymphocytes
b. Excess of mature lymphocytes
c. Plasma cells
d. Multiple immature granulocytes with blast cells
e. Numerous blast cells

Answer

A

Ans. The key is B. Excess of mature lymphocytes. [Dx is CLL. Age of patient (usually above 50 yrs), lymhadenopathy and splenomegaly, appearance of lymphocytes (mature lymphocytes – but functionally not normal). Repeated chest infection points towards abnormal function of lymphocytes against infection].

Question 39

Q

A lady presents with itching around the breast and greenish foul smelling discharge from the
nipple. She had a similar episode before. What is the most likely dx?

a. Duct papilloma
b. Duct ectasia
c. Breast abscess
d. Periductal mastitis
e. Mammary duct fistula

Answer

A

Ans. The key is B. Duct ectasia. [Duct ectasia of the breast or mammary duct ectasia or plasma cell mastitis is a condition in which the lactiferous duct becomes blocked or clogged. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age].

Question 40

Q

A young male whose sclera was noted to be yellow by his colleagues has a hx of taking OTC drugs for some pain. Tests showed raised bilirubin, ALT and AST normal. The provocation test with IV nicotinic acid is positive and produces further rise in the serum bilirubin levels. What is the most likely dx?

a. Acute hepatitis
b. Drug hypersensitivity
c. Gilberts syndrome
d. Acute pancreatitis

Answer

A

Ans. The key is C. Gilbert’s syndrome. [Only bilirubin is increased but not the liver enzymes. Also positive nicotinic acid provocation test is in its favour].

Question 41

Q

A 24yo biker has been rescued after being trapped under rocks for almost 12h. He complains of
reddish brown urine. His creatinine is 350umol/L and his urea is 15mmol/L. What is the most imp step in the management of this patient?

a. Dialysis
b. IV NS
c. IV dextrose
d. IV KCl
e. Pain relief

Answer

A

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

Question 42

Q

A 74yo man who has been a smoker since he was 20 has recently been dx with SCLC. What serum electrolyte picture will confirm the presence of SIADH?

a. High serum Na, low serum osmolarity, high urine osmolarity
b. Low serum Na, low serum osmolarity, high urine osmolarity
c. Low serum Na, high serum osmolarity, high urine osmolarity
d. High serum Na, low serum osmolarity, low urine osmolarity
e. High serum Na, high serum osmolarity, low urine osmolarity

Answer

A

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

Question 43

Q

A man brought into the ED after being stabbed in the chest. Chest is bilaterally clear with muffled heart sounds. BP is 60/nil. Pulse is 120bpm. JVP raised. What is the most likely dx?

a. Pulmonary embolism
b. Cardiac tamponade
c. Pericardial effusion
d. Hemothorax
e. Pneumothorax

Answer

A

Ans. The key is B. Cardiac tamponade. [chest is clear, so there is no pneumothorax or pleural effusion. Muffled heart sound is due to fluid in pericardial space, low BP from reduced chamber expansion due to pericardial fluid’s pressure and restricted right heart expansion causes raised JVP].

Question 44

Q

A 50yo pt is admitted for elective herniorraphy. Which of the following options will lead to a postponement of the operation?

a. SBP 110mmHg
b. MI 2 months ago
c. Hgb 12g/dl
d. Pain around hernia
e. Abdominal distention

Answer

A

Ans. The key is B. MI 2 months ago. [After MI elective surgery should not be done before 6 months post MI, as operation in earlier than this time has significant increase in mortality].

Question 45

Q

A 32yo woman of 39wks gestation attends the antenatal day unit feeling very unwell with sudden onset of epigastric pain associated with nausea and vomiting. Her temp is 36.7C. Exam: she is found to have RUQ tenderness. Her blood results show mild anemia, low platelets, elevated liver enzymes and hemolysis. What is the most likely dx?

a. Acute fatty liver of pregnancy
b. Acute pyelonephritis
c. Cholecystitis
d. HELLP syndrome
e. Acute hepatitis

Answer

A

Ans. The key is D. HELLP syndrome. [The main treatment is to deliver the baby as soon as possible [as early as after 34 weeks if multisystem disease is present].

Question 46

Q

A woman comes with an ulcerated lesion 3 cm in the labia majorum. What is the lymphatic drainage of this area?

a. External iliac
b. Superficial inguinal LN
c. Para-aortic
d. Iliac
e. Aortic

Answer

A

Ans. Key is B. Superficial inguinal LN.

Question 47

Q

A man post-cholecystectomy presented with jaundice, fever and dark urine. What is the most diagnostic inv?

a. ERCP
b. USG Abdomen
c. CT Scan
d. MRCP
e. MRI

Answer

A

Ans. The key is A. ERCP [Post operative US will not give good results. We shall not go for ercp first as it has complications like pancreatitis. Acceptable options are CT, MRI and MRCP among which most easiest and less time consuming but with very good test result is CT scan. So CT is most appropriate! But as the Question wants most diagnostic it is ERCP (though not practical)!!! The diagnosis here is choledocolithiasis with cholangitis].

Question 48

Q

A 79yo stumbled and sustained a minor head injury 2 weeks ago. He has become increasingly confused, drowsy and unsteady. He has a GCS of 13. He takes warfarin for Afib.

What is the most likely dx?

a. Extradural hemorrhage
b. Cerebellar hemorrhage
c. Epidural hemorrhage
d. Subdural hemorrhage
e. Subarachnoid hemorrhage

Answer

A

Ans. 1. The key is D. Subdural hematoma. [In elderly head injury usually leads to subdural hematoma even if head injury is minor or trivial and extradural hematoma in elderly is extremely uncommon even in more severe head injury. Management: 1st line: Evacuation by barr hole craniostomy. 2nd line: Craniotomy if the clot is organized].

Question 49

Q

A 25yo female complains of intermittent pain in her fingers. She describes episodes of numbness and burning of the fingers. She wears gloves whenever she leaves the house. What is the most probable dx?

a. Kawasaki disease
b. Takayasu arteritis
c. Buerger’s disease
d. Embolism
e. Raynaud’s phenomenon

Answer

A

Ans. The key is E. Raynaud’s phenomenon. [Intermittent nature points towards some triggers and wearing of gloves during going out indicates cold weather. Also female sex makes the diagnosis of Raynaud’s phenomenon more likely].

Question 50

Q

A 22yo lady has been unwell for some time. She came to the hospital with complaints of fever and painful vesicles in her left ear. What is the most probable dx?

a. Acne
b. Herpes zoster
c. Chicken pox
d. Insect bite
e. Cellulitis

Answer

A

Ans. The key is B. Herpes Zoster. [This is a case of Herpes zoster oticus and if facial nerve is also involved then it is called Ramsay Hunt syndrome].

Question 51

Q

A 5yo girl had earache and some yellowish foul smelling discharge, perforation at the attic and conductive hearing loss. She has no past hx of any ear infections. What is the most appropriate dx?

a. Acute OM
b. OM with effusion
c. Acquired cholesteatoma
d. Congenital cholesteatoma
e. Otitis externa

Answer

A

Ans. The key is c. Acquired cholesteatoma. [Acquired cholesteatomas develop as a result of chronic middle ear infection and are usually associated with perforation of the tympanic membrane at the attic (mass is seen in attick with perforation at pars flaccida- in contrast to medial to tympanic membrane which is in congenital). Clinical presentation usually consists of conductive hearing loss, often with purulent discharge from the ear].

In congenital:
• mass medial to the tympanic membrane
• normal tympanic membrane
• no previous history of ear discharge, perforation or ear surgery.
[discrepancy like no previous infection is the only point in favour of congenital here and may be due to a bad recall!!!]

Question 52

Q

A female with T1DM would like to know about a deficiency of vitamins in pregnancy that can
be harmful. A deficiency of which vitamin can lead to teratogenic effects in the child?

a. Folic acid
b. Vit B12
c. Thiamine
d. Riboflavine.
e. Pyridoxine

Answer

A

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

Question 53

Q

A 23yo woman has been having pain at the base of her thumb, the pain is reproduced when lifting her 3 month old baby or changing diapers and also with forceful abduction of the thumb against resistance. What is the likely cause?

a. Avascular necrosis of scaphoid
b. Trigger finger.
c. De Quervain’s tenosynovitis

Answer

A

Ans. The key is c. De Quervain’s tenosiovitis. [Can be diagnosed by Finkelstein’s test: The physician grasps the thumb and the hand is ulnar deviated sharply. If sharp pain occurs along the distal radius (top of forearm, about an inch below the wrist), de Quervain’s syndrome is likely].

Question 54

Q

A 6m child presents with fever and cough. His mother has rushed him to the ED asking for help. Exam: temp=39C and the child is feeding poorly. Dx?

a. Bronchiolitis
b. Asthma
c. Bronchitis

Answer

A

Ans. The key is A. Bronchiolitis. [Management: 1. Oxygen inhalation 2. Nasogastric feeding. DON’T USE: i) bronchodilator ii) steroid iii) antibiotics routinely. [OHCS, 9th edition, page-160]

Question 55

Q

A 75yo man collapsed while walking in his garden. He recovered fully within 30 mins with BP 110/80 mmHg and regular pulse of 70bpm. He has a systolic murmur on examination. His activities have been reduced lately which he attributes to old age. What is the definitive diagnostic inv that will assist you with his condition?

a. ECG
b. Echo
c. 24h ECG monitoring
d. 24h BP monitoring
e. Prv CIN

Answer

A

Ans. B. Echo. [Aortic stenosis – more likely in elderly. And hypertrophic cardiomyopathy – less likely in this age, presentation may be in an earlier age].

Question 56

Q

A 35yo man with a hx of schizophrenia is brought to the ER by his friends due to drowsiness. On examination he is generally rigid. A dx of neuroleptic malignant syndrome except:

a. Renal failure
b. Pyrexia
c. Elevated creatinine kinase
d. Usually occurs after prolonged tx
e. Tachycardia

Answer

A

Ans. The key is D. Usually after prolonged tx. [Malignant neuroleptic syndrome usually occurs SOON after start or in increasing dose of antipsychotic drugs! All others mentioned are seen in this syndrome like renal failure, pyrexia, elevated creatinine kinase, tachycardia etc].

Question 57

Q

A 33yo drug addict wants to quit. She says she is ready to stop the drug abuse. She is supported by her friends and family. What drug tx would you give her?

a. Benzodiazepines
b. Diazipoxide
c. Lithium
d. Methadone
e. Disulfiram

Q.1. What is the key.
Q.2. What drugs should you use in i) tobacco abuse and in ii) alcohol abuse?

Answer

A

Ans. 1. Key is d. Methadone. (used in opiate abuse)

Ans. 2. i) tobacco abuse: a) bupropion ii) alcohol: a) acamprosate b) disulfirum

Question 58

Q

A 16m child presents with drooling, sore throat and loss of voice. He has fever with a temp of 38.2C. What is your next step towards management?

a. Direct pharynoscopy
b. Call ENT surgeon
c. Call anesthesiologist
d. IV fuilds
e. Start antibiotics

Q. 1. What is the key?
Q. 2. What is the diagnosis?
Q. What is the urgent management?

Answer

A

Ans. 1.The key is C. Call anesthesiologist. [As an expert to intubate].

Ans. 2. Diagnosis is Acute epiglottitis.

Ans. 3. In given case urgent intubation is needed to secure airway to prevent blockage of respiration.

Question 59

Q

A 62yo woman complains of unsteadiness when walking. On examination she has pyramidal weakness of her left lower limb and reduced pain and temp sensation on right leg and right side of trunk up to the umbilicus. Joint position sense is impaired at her left great toe but is normal elsewhere. She has a definite left extensor plantar response and the right plantar response is equivocal. Where is the lesion?

a. Left cervical cord
b. Midline mid-thoracic cord
c. Right mid-thoracic cord
d. Left mid-thoracic cord
e. Left lumbo-sacral plexus

Q. 1. What is the key?
Q. 2. What is the name of this condition?

Answer

A

Ans. 1. The key is d. Left mid-thoracic cord.

Ans. 2. Brown-sequard syndrome. [In brown-sequard syndrome paralysis and loss of proprioception on the same (or ipsilateral) side as the injury or lesion, and loss of pain and temperature sensation on the opposite (or contralateral) side as the lesion].

Question 60

Q

A 26yo man presents to ED with increasing SOB on left side and chest pain. He has been a heavy smoker for the past 4 years. He doesn’t have any past med hx.
What is the likely dx?

a. Pulmonary embolism
b. MI
c. Asthma
d. Pleural effusion
e. Pneumothorax

Answer

A

Ans. The key is e. Pneumothorax. [Increased shortness of breath and chest pain with no past medical history favours the dx of pneumothorax. Heavy smoking or tobacco is a risk factor for spontaneous pneumothorax].

Question 61

Q

A pt with hepatocellular ca has raised levels of ferritin. What is the most probable cause?

a. Hemochromatosis
b. A1 antitrypsin def
c. Cystic fibrosis

Answer

A

Ans. The key is A. Haemochromatosis. [Hemochromatosis itself is a cause of hepatocellular carcinoma and associated with raised level of ferritin. Serum ferritin levels elevated higher than 200 mcg/L in premenopausal women and 300 mcg/L in men and postmenopausal women indicate primary iron overload due to hemochromatosis, especially when associated with high transferrin saturation and evidence of liver disease. Ferritin concentration higher than 1000 mcg/L suggests liver damage with fibrosis or cirrhosis].

Question 62

Q

A woman has electric pains in her face that start with the jaw and move upwards. Her corneal reflexes are normal.

What is the most likely dx?

a. Atypical face pain
b. Trigeminal neuralgia
c. Tempero-mandibular joint dysfunction
d. GCA
e. Herpes zoster

Answer

A

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

Question 63

Q

A 32yo man presented with slow progressive dysphagia. There is past hx of retro-sternal discomfort and he has been treated with prokinetics and H2 blockers.

What is the probably dx?

a. Foreign body
b. Plummer vinson syndrome
c. Pharyngeal puch
d. Peptic stricture
e. Esophageal Ca

Answer

A

Ans. 1. The key is D. Peptic stricture. [Progressive dysphagia to mostly solid is suggestive of peptic stricture which is supported here by the use of prokinetic drugs and H2 blockers which are used for reflux oesophagitis].

Question 64

Q

A 56yo man comes with hx of right sided weakness & left sided visual loss. Where is the occlusion?

a. Ant meningeal artery
b. Mid meningeal artery
c. Mid cerebral artery
d. Carotid artery
e. Ant cerebral artery
f. Ant communicating artery

Q. 1. What is the key?
Q. 2. How will you differentiate between middle cerebral artery occlusion from anterior cerebral artery occlusion?

Answer

A

Ans. 1. The key is d. Carotid artery. [Carotid artery divides to internal and external carotid of which internal continues as middle cerebral ultimately. But just before it becomes middle cerebral internal carotid gives rise to ophthalmic branch. So middle cerebral occlusion may give partial visual loss but not complete mono-ocular blindness. For complete mono-ocular blindness occlusion should be proximal to ophthalmic artery i.e. either in internal carotid or more proximally to carotid artery].

Ans. 2.

i) Middle cerebral artery occlusion: paralysis or weakness of contralateral face and arm (faciobracheal). Sensory loss of the contralatera face and arm.
ii) Anterior cerebral artery occlusion: paralysis or weakness of the contralateral foot and leg. Sensory loss at the contralateral foot and leg.

Answer 65

A

Ans. 1. Key is B. Cocaine overdose.

Ans. 2. Points in favour: i) Tachyrhythmia ii) High fever iii) perforated nasal septum iv) unconsciousness

Ans. 3. Other findings of cocaine toxicity: i) Psychiatric: anxiety, paranoia ii) Tachypnoea iii) Increased energy and talking rapidly iv) Dilated pupils. Also: [rhabdomyolysis, metabolic acidosis, convulsion].

Answer 66

A

Ans. The key is oral oxycodon.

Answer 67

A

Ans. 1. The key is A. Branchial cyst.

Ans. 2. i) Branchial cyst is anterior triangular lump. [parotid is also anterior triangular lump but parotitis regresses with appropriate treatment i.e. becomes normal in size]. ii) pharyngeal pouch is posterior triangular lump. iii) Thyroglossal is midline lump. iv) thyroid swelling moves with swallowing].

Answer 68

A

Ans.1. The key is B. Naloxone.

Ans. 2. The diagnosis is opiate overdose.

Ans. 3. Points in favour are: i) reduced consciousness ii) RR 8/min (12

Answer 69

A

Ans. 1. The key is B. Chromosomal analysis.

Ans. 2. The diagnosis is Klinefelter’s syndrome. (xxy)

Ans. 3. The points in favour are: i) Infertility ii) Tall stature iii) Bilateral gynaecomastia iv) Bilateral small firm testes.

Answer 70

A

Ans. 1. The key is E. Liver transplantation.

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

Answer 71

A

Ans. 1. The key is A. Urethral catheter.

Ans. 2. Alcohol consumption [Alcoholism can cause urinary retention but it is a less common cause of retention].

Answer 72

A

Ans. The key is D. 1 alpha hydroxylation of Vit D.

Answer 73

A

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

Answer 74

A

Q. 1. What is the key?
Q.2 . What is the specific name of this condition? What is the triad?

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

Answer 75

A

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

Answer 76

A

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

Answer 77

A

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

Answer 78

A

Ans. 1. The key is B. Corticosteroid.

Ans. 2. Prolonged corticostiroids [also topical i.e. eye drop] can cause cataract.

Answer 79

A

Ans. 1. The key is C. Malabsorption.

Ans. 2. Diarrhoea, IDA and folic acid deficiency.

Ans. 3.
• Iron-deficiency anaemia.
• Folate deficiency or vitamin B12 deficiency.
• Bleeding, resulting from low vitamin K.
• Oedema, which occurs in protein/calorie malnutrition.

Answer 80

A

Ans. 1. The key is B. Thought insertion.

Ans. 2. It is seen in schizophrenia.

Answer 81

A

Ans. 1. The key is A. Laryngeal candidiasis.

Ans. 2. Steroids predisposes to fungal infection.

Answer 82

A

Ans. 1. The key is A. Lymphoedema.

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

Answer 83

A

Ans. 1. The key is B. IV fluids calculated from the time of burn.

Ans. 2. Resuscitation fluids required in the first 24 hours from the time of injury.

For adults: 3 ml (in partial thickness burn) of Hartmann’s solution/kg body weight/% total
Body surface area.
Half of this calculated volume is given in the first 8 hours and the other half is given over the following 16 hours.

Answer 84

A

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

Answer 85

A

Ans. 1. The key is B. Penicillin.

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

Answer 86

A

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

Answer 87

A

Ans. 1. The key is B. Blood culture.

Ans. 2. The diagnosis is infective endocarditis.

Ans. 3. Fever + new murmur = endocarditis until proven otherwise.

Ans. 4. Important risk factors: dermatitis, IV injections, renal failure, organ transplantation, DM, post operative wond. Risk factors for abnormal valves: aortic or mitral valve disease, tricuspid valve in IV drug users, prosthetic valves.

Answer 88

A

Ans. The key is E. Lesser sac.

Answer 89

A

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

Answer 90

A

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

Answer 91

A

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

Answer 92

A

Ans. 1. The key is C. Femoral hernia.

Ans. 2. It is just below the pubic tubercle that is just below the inguinal ligament.

Answer 93

A

Ans. 1. The key is D. Achalasia.

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

Answer 94

A

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

Answer 95

A

Ans. 1. The key is C. Migraine.

Ans. 2. It is migraine without aura.

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

Answer 96

A

Ans. 1. The key is B. USG.

Ans. 2. The diagnosis is ADPKD.

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

Answer 97

A

Ans. The key is E. Secure airway.

Answer 98

A

Ans.1. Key is C. Cystoscopy.

Ans. 2. Bladder cancer.

Ans. 3. Age 65, asymptomatic haematuria.

Ans. 4. ADPKD [at the beginning there is very few or no
symptoms].

Answer 99

A

Ans. 1. The key is D. Retinitis pigmentosa.

Ans. 2. i) It is not angle closure glaucoma as angle closure glaucoma occurs usually after the age of 50; In open angle glaucoma visual loss is not evenly gradual rather occurs a bit suddenly at its later part. It is not cataract as cataract occurs usually in elderly. In macular degeneration near blindness does not occur rather causes inability to identify face or cannot read small prints; otherwise peripheral vision is not that depressed. In keratitis will be pain, redness, photophobia and vision is ok.

Answer 100

A

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

Answer 101

A

Ans. 1. The key is D. None.

Ans. 2. Diagnosis is breath holding spell.

Answer 102

A

Ans. 1. The key is B. DIC.

Ans. 2. Pregnancy itself is a risk factor for DIC. Placental abruption is a more common cause of DIC.
Other causes of pregnancy related DIC are: eclampsia, retention of a dead fetus, amniotic fluid embolism, retained placenta or bacterial sepsis.

Answer 103

A

Ans. The key is B. Cervical/vaginal trauma. [complication of forceps delivery].

Answer 104

A

Ans. The key is C. IM morphine. [Some post operative pain is severe pain which needs strong opioid analgesic].

Answer 105

A

Ans. 1. The key is D. Mature lymphocytes.

Ans. 2. The diagnosis is CLL.

Ans. 3. It is CLL because of his age (73 yrs), cervical lymphadenpathy, recurrent infections (mature but functionally defective lymphocytes), and pale conjunctiva (anaemia).

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