PLAB 1700J Flashcards
A 23yo man sprained his right ankle 6wks ago while playing football. He was tx with a below knew walking cast. On removal of the cast, the pt noted to have right foot drop. He has weakness of extensors of the ankle and toes and diminished pin prick sensation over the dorsum of the foot. The ankle jerk is present and plantar reflex is flexor. What is the most likely cause of the foot drop?
a. Compression of common peroneal nerve
b. Compression of the tibial nerve
c. Compression of the S1 nerve root
d. Rupture of Achilles tendom
e. Tx of the medial collateral lig of the ankle
Ans. The key is A. Compression of common peronial nerve. [Foot drop, weakness of extensors of the ankle and toes and diminished pin prick sensation over the dorsum is sugestive of compression of common peroneal nerve].
A young man was knocked down during a fight in the waiting room of the ED. He is now unconscious and unresponsive. What is the 1st thing you would do?
a. Turn pt and put in recovery position
b. Put airway
c. Endotracheal intubation
d. Assess GCS
e. Start CPR
Ans. The key is B. Put airway. [ABC protocol].
A 52yo man underwent a hemicolectomy. After a few days he complains of left ventricular pain and fever. ECHO has been done and shows a systolic murmur. What is the next appropriate inv?
a. CT
b. US
c. CXR
d. Blood culture
e. LFT
Ans. The key is D. Blood culture. [Dx a case of infective endocarditis. Therefore the next appropriate investigation is blood culture].
A 19yo man has exercised induced asthma and is using a salbutamol inhaler as req and beclamethasone 400ug BD. He complains that he has to wake up at night for his inhaler. What is the single most appropriate tx?
a. Beclo
b. Regular salbutamol and budesonide
c. Sodium cromoglycate
d. Oral steroid
e. Inhaled steroid
Ans. The key is C. Sodium cromoglycate. [the patients current complaint is nocturnal asthma for which next step is long acting beta blocker!! This question is probably a bad recall].
Pt with a long hx of smoking is now suffering from bronchial ca. histology reveals there are sheets of large polygonal or giant MNC. What is the most likely dx?
a. Squamous cell ca
b. Small cell ca
c. Adenocarcinoma
d. Large cell ca
e. Oat cell ca
Ans. No key is given!! Correct answer is D. Large cell ca. [Large cell carcinoma is, by definition, a poorly differentiated malignant epithelial tumor. It consists of sheets or nests of large polygonal or giant multinuclear cells and probably represents SCC .”]
A 27yo man presents with chest pain and respiratory distress. Exam: tachycardia, hypotension and neck vein distension. Trachea is deviated to the left side, breathing sounds on right side are absent and diminished on left side. What is the next appropriate management?
a. CXR
b. Right side aspiration (16G)
c. Left side aspiration (16G)
d. Right side drain with a small tube (12F)
e. Left side drain with a small tube (12F)
Ans. The key is B. Right side aspiration (16G). [The features described is diagnostic of right sided tension pneumothorax. Next appropriate management is To remove the air, insert a large-bore (14–16G) needle with a syringe, partially filled with 0.9% saline, into the 2nd intercostal interspace in the midclavicular line on the side of the suspected pneumothorax. Remove plunger to allow the trapped air to bubble through the syringe (with saline as a water seal) until a chest tube can be placed. Alternatively, insert a large-bore Venfl on in the same location OHCM, 9th edition, page 824].
A 16wk pregnant pt who was exposed to a child with chicken pox came to GP for help. She was tested –ve for varicella antibody. What is the next most imp step in management?
a. Reassurance
b. Ig
c. Ig + vaccine
d. Vaccine only
e. Acyclovir
Ans. The key is B. Ig. [If you are pregnant, come contact with chicken pox case, found antibody negative on blood test you have to take injection Ig. Ref: patient.info].
A 68yo woman dx with T2DM and BMI=33. Lab: GFR=29, urea=13, creatinine=390mmol/L. what is the next appropriate management?
a. Biguanide
b. Sulfonylurea
c. Insulin
d. Glitazone
e. Sulfonylurea receptor binder
Ans. The key is C. insulin. [Insulin is devoid of significant side effect than Glitazones (like fluid retention). In renal failure there is reduced GFR and some fluid retention. It is not desirable that glitazone to cause more fluid retention by causing oedema. The oral agents that are thought to be relatively safe in patients with nondialysis CKD include short-acting sulfonylureas (eg, glipizide) and repaglinide. If an oral agent is used, the short-acting sulfonylurea, glipizide, is the preferred agent among nondialysis CKD patients who have an estimated glomerular filtration rate (eGFR) <30 mL/min/1.73. The dose for glipizide is 2.5 to 10 mg/day. Glyburide and other long-acting sulfonylureas are generally not recommended in any CKD patient with type 2 diabetes, because of the risk of hypoglycemia. Some clinicians recommend the use of the meglitinide repaglinide (starting with a dose of 0.5 mg) for nondialysis CKD patients since these agents are not renally cleared. Nondialysis CKD patients with type 2 diabetes may be treated with an oral agent, although many patients end up on insulin therapy because it is more effective. So it may be that we can go for insulin as the answer!!].
A 5yo boy was brought to GP with high temp and many vesicles on his back. What is the most appropriate management?
a. Topic acyclovir
b. Oral acyclovir
c. Oral antibiotics
d. Topical steroids
e. None
Ans. The key is E. None. [A case of chickenpox. None of the given treatment is used in chickenpox. Symptomatic treatment like, acetaminophen if fever, antihistamine and calamine lotion is given].
A woman came with the complaint of pain in her right arm when she abducts it. She has recently moved to a new house. There is no hx of trauma. What is the likely cause of her pain?
a. Rupture of the long head of biceps
b. Sprain of the acromio-clavicular ligament
c. Tendinitis of the abductor sheat
d. Supraspinatus tendinitis
e. Shoulder dislocation
Ans. The key is D. Supraspinatus tendinitis. [Tendinitis and partial tears in the supraspinatus tendon causes a ‘painful arc’ since as the person elevates his arm sideways, the tendon begins to impinge under the acromion throught the middle part of the arc, and this is usually relieved as the arm reaches 180 degrees (vertical)].
An 83yo man with longstanding COPD has become progressively breathless over the last 2yrs. He is on salbutamol, ipratropium, salmetarol, beclomethasone and theophylline. His FEV1<30%. What is the next appropriate management?
a. Lung transplant
b. Trial of CPAP
c. Trial of non-invasive ventilation
d. Assessment for long term O2 therapy
e. Short course of O2 therapy
Ans. The key is D. Assessment for long term O2 therapy. [Patient is progressively breathless with present FEV1 of <30%. So his respiratory deterioration indicates progressive respiratory failure for which he should be assessed for long term O2 therapy. Long-term oxygen therapy (LTOT) for more than 15 h/day improved mortality and morbidity in a well-defined group of patients with chronic obstructive pulmonary disease. Requirement of condition to proceed to LTOT is patient should be stable and on appropriate optimum therapy (as in given case) and having stopped smoking tobacco. Patient should be shown to have a PaO2 less than 7.3 kPa and/or a PaCO2 greater than 6 kPa on two occasions at least 3 weeks apart. FEV1 should be less than 1.5 litres, and there should be a less than 15% improvement in FEV1 after bronchodilators. Patients with a PaO2 between 7.3 and 8 kPa who have polycythaemia, right heart failure or pulmonary hypertension may gain benefit from LTOT].
A 49yo man complains of fullness in his left ear, recurrent vomiting and tinnitus. What is the most appropriate med?
a. Buccal prochlorperazine
b. Oral chlorpheniramine
c. Oral flupenphenazine
d. Buccal midazolam
e. IV rantidine
Ans. The key is A. Buccal prochlorperazine. [Meniere’s disease Dilatation of the endolymphatic spaces of the membranous labyrinth causes vertigo for ~12h with prostration, nausea/vomiting, a feeling of fullness in the ear; uni- or bilateral tinnitus, sensorineural deafness (eg fluctuating). Attacks occur in clusters (<20/month). Cause: A mystery! Electrocochleography; endolymphatic space MRI. Prochlorperazine as BuccastemR 3mg/8h PO (1st-line if vomiting) or betahistine 16mg/8h PO or chlorthalidone may help. Ref: OHCS, 9th edition, page 554].
A man had a soft mass on his mandible. Mass is freely mobile and has started growing progressively over the past 6m. The mass still moves freely. What is the best inv for this pt?
a. FNAC
b. CT
c. XR
d. MRI
e. ESR
Ans. The key is A. FNAC.
A 63yo man has been brought to the hosp after collapsing during a wedding. His ECG is below.
What is the most likely dx?
a. VT
b. A-fib
c. VF
d. A-flutter
e. SVT
Ans. The key is C. VF. [QRS complex is chaotic, wide, bizarre and irregular which is characteristic of ventricular fivrillation].
A 75yo war veteran complains of loss of appetite and says he has lost weight over the past few months. He says that he has passed some blood in his urine, however, he had no pain. A recent report shows that PSA >5.5ng/ml. how will you manage this pt?
a. Radical prostatectomy
b. TURP
c. Cryosurgery
d. Brachytherapy
e. Irradiation
Ans. The key is A. Radical prostatectomy. This answer is controversial. [Though PSA is a bit higher than normal it is not confirmatory of carcinoma! But loss of appetite and weight loss are highly suggestive of cancer in this 75yrs old man. Active Surveillance is offered first for Low Gleason score. esp at age of 75. and any other treatment depending on extension of tumor will be offered after excluding mets].
A 19yo boy comes to the ED with pain, swelling and tenderness 2cm distal to Lister’s tubercle of radius. Exam: proximal pressure on the extended thumb and index finger is painful. XR: no fx. What is the next appropriate management for the pt?
a. Immobilization with cast
b. Repeat XR
c. MRI
d. Surgery
e. None
Ans. The key is A. Immobilization with cast. This is wrong key! Correct key is C. MRI. [Imaging: Request a dedicated ‘scaphoid’ series. If –ve, and fracture is suspected MRI has been shown to be sensitive and cost-eff ective. CT is an alternative. If neither is available, cast and re-x-ray in 2 weeks. Ref: OHCS, 9th edition, page-744].
A 71yo man with a hx of 50yrs of smoking presents with cough, hemoptysis, dyspnea and chest pain. He also has anorexia and weight loss. The dx of lung cancer has been stabilized. Which electrolyte abnormality can be seen?
a. Hyperkalemia
b. Hypocalcemia
c. Hyponatremia
d. Hypernatremia
e. Hypomagnesemia
Ans. The key is C. Hyponatremia. [Likely diagnosis is squamous cell lung cancer (as the patient is smoker) causing SIADH and resulting hyponatremia].
A 56yo man who is hypertensive recently underwent a change in meds. 2days later he developed wheezing. Which drug can cause this?
a. Atenolol
b. Ramipril
c. Bendroflumethiazide
d. Verapamil
e. Furosemide
Ans. The key is A. Atenolol. [Beta blockers can precipitate asthma attacks].
A 33yo man has a temp=38.5C, cough and chest pain on the right side on inspiration. He also has purulent sputum. What is the most likely organism to cause pneumonia in this pt?
a. Gram +ve diplococcic
b. Coagulase +ve cocci
c. PCP cold agglutinins
d. AFB
e. Gram –ve diplococcic
Ans. The key is C. PCP cold agglutinins. It is wrong key! Correct key should be A. Gram +ve diplococci. [It is a case of community acquired pneumonia caused by streptococcus pneumoniae].
A young man’s arm was caught in a machine. XR showed no fx but arm is very swollen. What is
the best tx?
a. Plaster cast
b. Wide splint with upward position
c. Analgesics
d. Antibiotics
e. Tetanus prophylaxis
Ans. The key is B. Wide splint with upward position. [If the limb is kept hanging it will aggravate the swelling as fluid shifts to dependant part. Here wide splint with upward position will help the accumulated blood or fluid to move down and will improve the swelling].
A child was brought in to ED by his parents for taking his grand-dad’s meds. There is an extra systole in the ECG. Which drug was taken?
a. Digoxin
b. Amitryptiline
c. Atenolol
d. Ramipril
e. Bendroflumethiazide
Ans. The key is A. Digoxin. [Both digoxin and amitryptiline can cause extrasystole].
A 5yo child came from Ghana 6wks ago. 2d ago he developed fever, vomiting and neck stiffness. He had taken malaria prophylaxis and had no rash. What is the dx?
a. Cerebral abscess
b. Cerebral malaria
c. Meningococcal meningitis
d. SAH
e. Cerebral tumor
f. Pneumonia
Ans. The key is B. Cerebral malaria. [Incubation period of malaria is 7 – 30 days. Malaria prophylaxis cannot give confirmed protection and there is often failure of prophylaxis. Fever, vomiting, neck stiffness are consistent with cerebral malaria].
A HTN pt on bendroflumethiazide 2.5mg/d has come for his routine checkup. Exam: BP=145/85mmHg. Lab: K+=5.9, Na+=137. What is the most appropriate management for this pt?
a. Stop meds
b. Continue same dose
c. Increase the dose
d. Decrease the dose
e. Repeat the blood test
Ans. The key is E. Repeat the blood test [Bendroflumethiazide causes hyponatremia and hypokalemia. But the findings are opposite which is probably error of test. Hence blood test should be repeated to confirm the level of potassium and sodium].
A 65yo man presents with significant weight loss and complains of cough, SOB and chest pain. Exam: left pupil constricted, drooping of left eyelid. What is the most likely dx?
a. Pancoast tumor
b. Thoracic outlet syndrome
c. Cervical rib
d. Pneumonia
e. Bronchogenic ca
Ans. The key is A. Pancoast tumor. [Pancoast tumour is the apical lung cancer that is associated with destructive lesions of the thoracic inlet and involvement of the brachial plexus and cervical sympathetic nerves (the stellate ganglion) leading to horner’s syndrome].
A 4yo boy presents with fever, sore throat and lymphadenopathy. The dx of tonsillitis has been
made. He had 3 episodes last yr. What is the most appropriate management for this pt?
a. Tonsillectomy
b. Paracetamol/ibuprofen
c. Oral penicillin V
d. IV penicillin
e. None
Ans. The key is B. Paracetamol/ibuprofen.
[Explanation: Drugs:
• Antipyretic analgesics such as paracetamol and ibuprofen are of value.
• For most patients, antibiotics have little effect on the duration of the condition or the severity of symptoms. The National Institute for Health and Care Excellence (NICE) suggests that indications for antibiotics include:[1]
Features of marked systemic upset secondary to the acute sore throat.
Unilateral peritonsillitis.
A history of rheumatic fever.
An increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency).
Acute tonsillitis with three or more of the following Centor criteria present:
History of fever
Tonsillar exudates
No cough
Tender anterior cervical lymphadenopathy. [Source: patient.info].
Indications for tonsillectomy:
• The child has five or more episodes of acute sore throat per year, documented by the parent or clinician.
• Symptoms have been occurring for at least a year.
• The episodes of sore throat have been severe enough to disrupt the child’s normal behaviour or day-to-day functioning.
A pt had passed a 4mm stone in his urine. He has a 3mm stone in the renal pelvis found on US. What is the management?
a. ESWL
b. None
c. Dormier basket
d. Surgery
e. PCNL
Ans. The key is B. None.
• [Stones less than 5 mm in diameter pass spontaneously in up to 80% of people.
• Stones between 5 mm and 10 mm in diameter pass spontaneously in about 50% of people.
• Stones larger than 1 cm in diameter usually require intervention (urgent intervention is required if complete obstruction or infection is present).
• Two thirds of stones that pass spontaneously will do so within four weeks of onset of symptoms]. Ref: patient.info
A 4yo boy presents with fever, severe ear ache, vomiting and anorexia. He also has mod tonsillitis. Exam: tympanic membrane bulging. He came to the GP a few days ago and was dx with URTI. What is the most appropriate dx?
a. OE
b. Acute OM
c. Serous otitis
d. Chronic suppurative OM
e. Mastoiditis
Ans. The key is B. Acute OM. [High fever, severe earache, vomiting, bulging tympanic membrane and H/O associated URTI is highly suggestive of acute OM].
A 3yo girl presents with complains of sudden right facial weakness and numbness and pain around her ear. There are no symptoms. What is the most appropriate dx?
a. SAH
b. Bell’s palsy
c. Stroke
d. TIA
e. Subdural hemorrhage
Ans. The key is B. Bell’s palsy.
A 6yo boy fell in the playground and has been holding his forearm complaining of pain. Exam: no sign of deformity or swelling. However, there is minimal tenderness on exam. What is the dx?
a. Fx mid radius
b. Fx mid ulnar
c. Fx neck of humerus
d. Fx shaft of humerus
e. Green stick fx of distal radius
Ans. The key is E. Green stick fx of distal radius.
A 62yo man has been smoking about 15 cigarettes/day for 45yrs, and has been working as a builder since he was 24yo. He presents with chest pain, SOB, weight loss. CXR shows bilateral fibrosis and left side pleural effusion. What is the best inv that will lead to dx?
a. CXR
b. Pleural fluid aspiration of cytology
c. MRI
d. Pleural biopsy
e. CT
Ans. The key is D. Pleural biopsy. [There is asbestos exposure in builders and associated smoking greatly increases the possibility of developing mesothelioma and the given presentation is typical of mesothelioma. Best investigation is pleural biopsy].
During a basketball match, one of the players suddenly collapsed to the ground with coughing and SOB. What is the inv of choice?
a. CXR
b. CT
c. MRI
d. V/Q scan
e. CTPA
Ans. The key is A. CXR. [Likely diagnosis is pneumothorax. So investigation of choice is CXR].
A 57yo man having HTN on oral anti-HTN. However, he is finding it difficult to mobilize as he feels dizzy whenever he tries to get up. What is the most appropriate inv for him?
a. Ambulatory BP
b. ECG
c. MRI
d. CXR
e. CT
Ans. The key is A. Ambulatory BP. [Ambulatory BP to document low BP as cause of presenting symptom. The case seems to be of postural hypotension and low BP as a result of given anti hypertensive].
A 33yo female complains of diplopia on upright gaze. Exam: ptosis can be seen. There are no other complains or any significant PMH. What is the most appropriate inv for him?
a. Ophthalmoscopy
b. Visual field test
c. TFT
d. CT
e. Checking red reflex
Ans. The key is E. Checking red reflex. This is a wrong key. Right key should be D. CT. [A case of 3rd nerve palsy. So to delineate the cause CT should be done].
A tall rugby player was hit in the chest by a player of the opponent team. He developed breathlessness and his face went blue and purple. You have been called to look at him, how will you manage him?
a. Insert a needle in the 2nd ICS in the mid-clavicular line
b. Insert a needle in the 5th ICS in the mid-axillary line
c. Intubate the pt
d. Start CPR
e. Give oxygen
Ans. The key is E. give oxygen.
A young woman fell and hit her knee. Exam: valgus test +ve. What ligament was most probably injured?
a. Ant cruciate
b. Medial collateral
c. Lateral collateral
d. Post cruciate
e. Meniscus
Ans. The key is B. Medial collateral. [The valgus stress test involves placing the leg into extension, with one hand placed as a pivot on the knee. With the other hand placed upon the foot applying an abducting force, an attempt is then made to force the leg at the knee into valgus. If the knee is seen to open up on the medial side, this is indicative of medial collateral ligament damage].
A 75yo man comes in complaining of difficulty in passing urine, poor stream and dribbling at the end of voiding and anorexia. US shows bilateral hydronephrosis. What is the cause of these findings?
a. BPH
b. Renal stones
c. Bladder stones
d. Prostatic ca
e. UTI
Ans. The key is D. Prostatic ca. [Elderly patient of 75yrs with obstructive symptoms of lower urinary tract, bilateral hydronephrosis all can occur in BPH or ca prostate. Anorexia is clincher here. It is a feature of carcinoma rather than BPH].
2h after an appendectomy, a pt complains of a rapid HR and fever. He says there is also abdominal pain and pain in the shoulder area. What is happening to this pt?
a. Intra-abdominal bleeding
b. Anastomotic leak
c. Sepsis
d. Intestinal obstruction
Ans. The key is A. Intra-abdominal bleeding.
A 50yo man presents with the complaints of recurrent UTI and occasional blood in the urine. Some unusual cells have been seen in urine on routine exam. Which os the following inv would you like to carry out now?
a. Cystoscopy
b. Urine C&S
c. XR KUB
d. US
e. CBC
Ans. The key is D. US. It is wrong key! Correct key is A. Cystoscopy. [Likely diagnosis is bladder cancer. Occasional blood in urine and unusual cells (suggestive of malignant cells) suggests the diagnosis. It is also true that in bladder cancer there occurs frequent uti like symptoms].
A 28yo drug user presents to ED collapsed and anuria. His serum K+=7.5mmol/l. CXR shows early pulmonary edema. What is the next appropriate management for this pt?
a. Urgent hemodialysis
b. IV calcium gluconate
c. IV insulin + dextrose
d. Furosemide
e. IV 0.9% NS
Ans. The key is B. IV calcium gluconate. [In severe hyperkalemia IV calcium gluconate is given to protect the heart from cardiac arrest or life-threatening arrhythmias till definitive treatments are arranged].
DM man feels hot, painful lump near the anal region. What is the most probable dx?
a. Anal fissure
b. Abscess
c. Hematoma
d. Wart
e. External hemorrhoids
Ans. The key is B. Abscess. [DM patients are much prone to infection].
